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Background High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries? Methods We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines. Results Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines. Conclusions Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a ‘one-size-fits-all’ approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies. Systematic review registration PROSPERO CRD42020178166

A secure parent-infant relationship lays the foundations for children’s development, however there are currently no measurement tools recommended for clinical practice. We evaluate the clinical utility of a structured assessment of the parent-infant relationship (the Maternal Postnatal Attachment Scale, MPAS) in a deprived, multi-ethnic urban community in England. This paper answers the question: what are health visitors’ views on the parent-infant relationship, and experiences of piloting the MPAS? It explores the barriers and facilitators to implementation, and complements the paper on psychometric properties and representativeness reported in Dunn et al (submitted).Semi-structured interviews were conducted with 11 health visitors and data were analysed using thematic analysis. Health visitors stressed the importance of the parent-infant relationship and reported benefits of the MPAS, including opening conversation, and identifying and reporting concerns. Challenges included timing, workload, the appropriateness and understanding of the questions and the length of the tool. Suggestions for improvements to the tool were identified.Our findings help to explain results in Dunn et al, and challenges identified would hinder routine assessment of the parent-infant relationship. Further work with health professionals and parents has been undertaken to co-produce an acceptable, feasible and reliable tool for clinical practice.Key findings and points for practitionersHealth visitors saw identification and support of the parent-infant relationship as an important part of their role, however there are currently no recommended tools for this.Health visitors report some benefits to using the MPAS, but also several challenges to using this tool in practice, including the length of time required, the complexity of the language, potential to trigger distress and perceived intrusiveness of some questions.Further work in collaboration with health professionals and parents is needed to develop an acceptable, feasible and reliable tool to assess the parent-infant relationship.Statement of relevance to the field of infant and early childhood mental healthA secure parent-infant relationship lays the foundations for children’s development, and identification of concerns and provision of support is a priority in the UK and internationally. However, no tools are currently recommended for assessing the relationship in clinical practice. Our findings on experiences, benefits and challenges of piloting a tool to assess the parent-infant relationship provide important directions for development of a short, clinically relevant and valid tool in clinical practice.Statement explaining how the research reflects an appreciation for diversity and an anti-racist approachThis pilot was conducted with a diverse, multi-ethnic community (half of new mothers are from Asian/Asian British Pakistani backgrounds, a quarter White British, and a quarter from other ethnic backgrounds). The health visiting service engages with the whole population in a culturally sensitive way, including ensuring staff speak key community languages and using interpreters. None of the authors spoke community languages, but we purposively selected the health visitors to include experience of using the MPAS in community languages. Our findings reflect experiences implementing the tool with women from different ethnic backgrounds, and we report detailed findings on language. We hope our findings can inform appropriate and equitable implementation of tools in diverse communities.

Purpose Participation in community programmes by the Roma community is low, whilst this community presents with high risk of poor health and low levels of wellbeing. To improve rates of participation in programmes, compatibility must be achieved between implementation efforts and levels of readiness in the community. The Community Readiness Model (CRM) is a widely used toolkit which provides an indication of how prepared and willing a community is to take action on specific issues. The purpose of this paper is to present findings from a CRM assessment for the Eastern European Roma community in Bradford, UK, on issues related to nutrition and obesity. Design/methodology/approach The authors interviewed key respondents identified as knowledgeable about the Roma community using the CRM. This approach applies a mixed methodology incorporating readiness scores and qualitative data. A mean community readiness score was calculated enabling researchers to place the community in one of nine possible stages of readiness. Interview transcripts were analysed using a qualitative framework analysis to generate the contextual information. Findings An overall score consistent with vague awareness was achieved, which indicates a low level of community readiness. This score suggests that there will be a low likelihood of participation in currently available nutrition and obesity programmes. Originality/value To our knowledge, this is the first study to apply the CRM in the Roma community for any issue. The authors present the findings for each of the six dimensions that make up the CRM together with salient qualitative findings.

Greenspace is important for physical and mental health. Low-income, multi-ethnic populations in deprived urban areas experience several barriers to using greenspace. This may exacerbate health inequalities. The current study explored structural and individual determinants of greenspace use amongst parents of young children in an urban, deprived, multi-cultural area situated in the North of England, UK. Semi-structured in-depth interviews and focus group discussions were conducted with 30 parents of children aged 0-3 between December 2016 and May 2017 from a range of ethnic groups. Thematic analyses were informed by the Human Health Habitat Map and the Theoretical Domains Framework. The results show that whilst all families recognised the benefits of greenspaces, use was bounded by a variety of structural, community, and individual determinants. Individual determinants preventing use included lack of knowledge about where to go, or how to get there and confidence in managing young children whilst outdoors. Fear of crime, antisocial behaviour and accidents were the overriding barriers to use, even in high quality spaces. Social and community influences both positively encouraged use (for example, positive social interactions, and practical support by others) and prevented use (antisocial or inappropriate behaviours experienced in greenspace). The built environment was a key barrier to use. Problems related to unsuitable or unsafe playgrounds, no gardens or safe areas for children's play, poor accessibility, and lack of toilets were identified. However, the value that parents and children placed on natural blue and green features was an enabler to use. Contextual influences included external time pressures, difficulties of transporting and caring for young children and poor weather. Multi-sectoral efforts are needed to tackle the uneven playing field experienced by multi-ethnic, urban, deprived communities. Initiatives to increase use should tackle structural quality issues, addressing fears about safety, whilst simultaneously encouraging communities to reclaim their local greenspaces.

The hemoglobin A1c (A1C) test is increasingly used as a diagnostic and screening test for type 2 diabetes. With an estimated 8.8% of adults globally having diabetes, effective screening, diagnosis, and monitoring is of major global importance (1). The biomarker of A1C refers to glycated hemoglobin A molecules and has gained prominence in the diagnosis of type 2 diabetes because it offers certain advantages over plasma glucose testing regimens (2). It is well established that some of the hundreds of hemoglobin (Hb) variants, including the clinically relevant HbS, HbE, HbC, and HbD (3,4), may interfere with the validity of A1C results. Thus, testing strategies and tools employing A1C should ideally identify variants when they are present. Incidental findings of Hb variants present several ethical challenges for laboratories, health care providers, patients, and their families. These challenges have, to date, received little attention. This article reviews some of the advantages of detecting sickle cell trait, identified by the routine A1C test, but also several related ethical dilemmas. We explore issues such as whether informed consent is necessary, how the results should be communicated, how patients may be affected by knowing their carrier status, the timing of communications, complications caused by partial results, and the circumstance of being a “healthy carrier” while potentially experiencing symptoms. A multidisciplinary team and a patient diagnosed as a sickle cell carrier through the A1C test worked together to explore these ethical challenges to produce this article. We hope it will instigate discussion around the issues presented and ultimately lead to the development of appropriate international guidelines. Sickle Hb (HbS) is one of the most common Hb variants. Worldwide, an estimated 300 million people have sickle cell trait (SCT) and ∼4.4 million people have sickle cell disease (SCD), the overall name for a group …

Children living in cold homes experience worse outcomes. This paper considers some of the findings from the Warm Well Families (WWF) study, which aimed to explore factors influencing the abilities of households including children with asthma to keep warm at home in winter. Individual and group interviews with children, families and professionals were conducted and home temperature and humidity measurements were taken. The experience, knowledge, beliefs and attitudes of adults living in households with children with asthma affect the choices they make. The concept of a ‘trade-off’ is used, to describe the complex process by which families in fuel poverty are juggling competing priorities in order to make decisions. The paper explores three participant families in detail, through the use of case studies, to illustrate the trade-offs made and the impact of those trade-offs on a family’s ability to keep warm and well at home. It is argued that policy initiatives and interventions need to engage with the full range of decisions families make, and the constraints on these decisions, in order to reduce the impact of fuel poverty on the wellbeing of families.

Sickle cell disorders are a complex multisystem inherited genetic blood disorders that affect millions of people worldwide and complications of the disorders can include anaemia, pain episodes and organ damage. Medical advances, early detection, intervention in infancy and specialised care across the life-course are transforming these genetic blood disorders into chronic conditions, with longer life expectancies and better quality of life, yet public health debates continue to view sickle cell disorders as purely biomedical problems that need to be prevented. We argue that adopting a social determinants of health approach to sickle cell disorders can help to move the policy focus from viewing sickle cell disorders as burdens to be prevented, to a more holistic perspective that would ensure better health and well-being across the life-course. The social determinants of health promotes a socially just and ethical framing of health and well-being in all policies, that are fundamental to achieving the United Nations Sustainable Development Goals (SDGs), including SDG 10—of reducing health inequalities within and between countries.

Contemporary epidemiological methods testing the associations between green space and psychological well-being treat all vegetation cover as equal. However, there is very good reason to expect that variations in ecological "quality" (number of species, integrity of ecological processes) may influence the link between access to green space and benefits to human health and well-being. We test the relationship between green space quality and restorative benefit in an inner city urban population in Bradford, United Kingdom. We selected 12 urban parks for study where we carried out botanical and faunal surveys to quantify biodiversity and assessed the site facilities of the green space (cleanliness, provision of amenities). We also conducted 128 surveys with park users to quantify psychological restoration based on four self-reported measure of general restoration, attention-grabbing distractions, being away from everyday life, and site preference. We present three key results. First, there is a positive association between site facilities and biodiversity. Second, restorative benefit is predicted by biodiversity, which explained 43% of the variance in restorative benefit across the parks, with minimal input from other variables. Third, the benefits accrued through access to green space were unrelated to age, gender, and ethnic background. The results add to a small but growing body of evidence that emphasize the role of nature in contributing to the well-being of urban populations and, hence, the need to consider biodiversity in the design of landscapes that enhance multiple ecosystem services.

Objectives To report the findings of a literature review of the concept of wellbeing and consider its operational and heuristic potential within a range of disciplines. Design A literature review to examine the philosophical roots of wellbeing and the contributions of the main disciplines uncovered by the review; economics, psychology, health studies, sociology, anthropology and biomedicine. Setting 'Wellbeing' is a concept of increasing interest to those working in health promotion, social and public health medicine and medical sociology. Despite its popularity, wellbeing lacks a clear conceptual base and there is little consensus about how it may be identified, measured and achieved. Method Although conducted rigorously this was more of a scoping exercise than a systematic review. The reviewer was given a fairly broad exploratory brief including qualitative and quantitative dimensions. The search was restricted to articles in the English Language between the years 1980-2001. Results Most disciplines tended to be biased towards one or two aspects of the three major aspects of physical, social and psychological Wellbeing, with the main exception of child wellbeing studies. Those working in economics made a significant contribution to understanding conceptual elements of wellbeing. The fields of psychology and biomedicine were more concerned with negative than positive affect. There was a particular lack of consensus and research around social wellbeing. Conclusion Although wellbeing may indeed be extremely useful as a unifying concept for all those involved in health improvement or health research,at present it is being used unreflectively, thus potentially masking differences.

Although it is gratifying to see updates to the National Institute for Health and Care Excellence (NICE) clinical guideline on feverish illness in children,1 we would like to redress the balance for concern about altered thermoregulation in sick children. Fever is a cardinal sign of inflammation, infection, and trauma, but low body temperature is also a …