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Background Undocumented migrants experience multiple institutional and legal barriers when trying to access healthcare services. Due to such limitations, healthcare workers often experience ethical dilemmas when caring for undocumented migrants. This article aims to understand how individual healthcare workers who regularly take care of undocumented migrants deal with these dilemmas in practice. So far, the role of healthcare workers in this context has mainly been theorized through the lens of biopolitics, conceiving of healthcare workers as merely obedient instruments of humanitarian government or gatekeeping. Methods Based on semi-structured, in-depth interviews and ethnographic observations with healthcare workers in Belgium, we explore how they ascribe meaning, reflect upon and give shape to care practices in relation to undocumented migrants. We use Foucault’s later work on care of the self to interpret the accounts given by the healthcare workers. Results Healthcare workers in clinical roles exercise a certain degree of freedom in relation to the existing limitations to healthcare access of undocumented migrants. They developed techniques such as purposefully being inattentive to the undocumented status of the migrants. They also try to master their affective responses and transform their bodily attitude towards undocumented patients. They perform practical mental exercises to remind themselves of their role or position in the wider healthcare system and about their commitment to treat all patients equally. These techniques and exercises are inspired by colleagues who function as role models, inspiring them to relate in an ethical way to limitations in healthcare access. The developed care practices sometimes reproduce, sometimes transform the legal and institutional limitations to care for undocumented migrants. Conclusions The findings nuance the biopolitical analysis regarding the role of healthcare workers in healthcare delivery to undocumented migrants that has been dominant so far. Theoretically this article provides a reconceptualization of healthcare ethics as care of the self, an ethical practice that is somewhat independent of the traditional professional ethics. Trial Registration Medical ethics committee UZ Jette, Brussels, Belgium – Registration date: 18/05/2016 – Registration number: B.U.N. 143201628279.

Background Engaging patients and family members as partners in research studies has become a widespread practice in healthcare. However, relatively little has been documented about what happens after the research study ends. For example, is patient and family engagement embedded in the wider infrastructure of organizations, and if so how? What are the long-term effects of engaging parents on research teams on the culture of how research is conducted? This study seeks to address these two gaps by examining how a culture of family engagement has been built over time at CanChild Centre for Childhood Disability Research at McMaster University in Ontario, Canada. Methods This study is based on ethnographic research methodology and combines elements of organizational ethnography, interviews, and collaborative auto-ethnography with parent partners, researchers, staff, and trainees. Results Since the inception of CanChild Centre for Childhood Disability Research at McMaster University in 1989, parents have been involved in research studies. Over time, this involvement evolved from being consulted on research studies to undertaking decision-making roles as partners and most recently as co-principal investigators. A growing infrastructure fosters a community of engagement that goes beyond the individual research study, and often beyond CanChild. This infrastructure consists of training, knowledge mobilization and social networking. In addition, the “softer” building blocks of CanChild’s culture of engagement are an openness to learning from others, a commitment to relationship building, and a drive to grow and improve. These values are espoused by the leadership and are instilled in the next generation of researchers to inform both research and clinical work. While some challenges should be acknowledged when researchers and family partners work together on research studies, we identify a number of strategies that we have used in our studies to foster authentic and meaningful family–researcher partnerships. Conclusion Engaging patients and families as partners in research constitutes a culture shift in health research, whereby studies about patients and families are carried out with them. Developing a community of engagement that transcends an individual research study is a step towards creating a culture of research that is truly shaped by the people about whom the research is being done., Plain English summary More and more patients and family members are getting involved in health research studies as partners. However we do not know much about what happens after the research study ends. This article looks at how parents have been involved in research studies at CanChild Centre for Childhood Disability Research at McMaster University in Ontario, Canada. CanChild researchers, staff, students and parents were asked about their experiences of working together on research studies. One of the researchers then pooled together all of these stories, shared them with everyone to get their feedback, and wrote the initial draft of this article. All the people interviewed were invited to read the article and to add their thoughts and opinions until everyone was satisfied with the final product. Our shared stories show that a lot has changed since CanChild was established in 1989. At first, researchers consulted with parents when they were doing a study. Now, many parents are partners and co-principal investigators on research studies. CanChild has also developed opportunities for parents and researchers to get training in patient-family engagement and to network with each other outside of research studies. Researchers, staff, students and parents talked about what makes research partnerships successful, including: being open to learning from each other; taking the time to get to know each other as people; and always trying to do better. They also shared some of the challenges that come up on research studies and suggested strategies for working through them.

The chiropractic profession is 125 years old and has evolved a culture beset with internal conflict. The internal ructions have been particularly noticeable during the last 20 years. The recent resignation of the entire World Federation of Chiropractic Research Committee has again focussed the conflicting views and goals of the “wellness” and “evidence” factions within the profession. These polarising viewpoints are worsening to the degree that there are calls for the profession to break into two separate entities. Key to the recognition of the differences within the profession is the recognition of title for particular sub populations of patients presenting to chiropractors. For many of the sub populations such as sport or paediatrics there has grown appropriate post professional specialist educational training sometimes leading to a protected title. However, this is not occurring in that group of practitioners that choose to focus on wellness care. A recommendation is made that wellness chiropractic be viewed as a post professional specialty program within chiropractic, as it is in medicine and elsewhere, and that recognition follow after appropriate post professional educational programs have been completed, as is customary in the other special interest groups. In order to do so, consensus will be required from all stakeholders within the profession on the level, scope and depth of such programs. Furthermore, it is possible that different jurisdictions around the world may require different post graduate educational levels based on local competitive, legal and professional circumstances. In such cases, transitioning to the higher level over a period of time may be undertaken. Recognition of the wellness specialty by the profession would allow for vertical integration with other healthcare providers as well as help bridge a gap between the entrepreneur and academic groups that would be responsible for creating these programs at tertiary education institutions. Finally, should these programs acquire evidence to underpin them, a process that would be taught within the programs, it is likely that recognition of an extended scope of practice would occur increasing the appeal of chiropractic to the public.

Background Individuals experiencing chronic illnesses face many physical, emotional, and social strains as a result of their illnesses, all the while trying to navigate unfamiliar territory in the healthcare system. Navigation is a strategy that can help people facing complex care needs and barriers to care in finding and accessing needed supports in the health care system. Navigators provide a patient-centred service, guiding individuals through their care plans and overcoming barriers to care. Navigation supports for individuals experiencing complex care needs have shown significant promise and have been gaining traction across Canada. Methods The Canadian Healthcare Navigation Conference was the first event of its kind in Canada to bring together navigation researchers, service providers, students, decision makers, and individuals with lived experience to share lessons learned, promising practices, and research findings. This event was co-hosted by the Family Navigation Project at Sunnybrook Health Sciences Centre and NaviCare/SoinsNavi at the University of New Brunswick, and took place virtually on April 15–16, 2021. Results This event spanned two days, which both began with a keynote address, one from a researcher and medical professional in navigation, and another from an individual with lived experience involved in advocacy in Canadian healthcare. Concurrent oral presentations by a variety of presenters were held following each keynote presentation. A poster session was held at the end of the first day, and a panel presentation rounded out the second day. Concurrent and poster presentations covered a range of topics pertaining to approaches to navigation, navigator roles, evaluation and quality improvement, lived experience in navigation, and navigation in the context of the COVID-19 pandemic. The panel presentation focused on identifying how the navigation field has progressed in Canada and identifying crucial next steps in navigation. These next steps were determined to be: 1) agreement on navigation-related definitions, 2) regulation and training, 3) equity, diversity, inclusion, and accessibility, 4) integrating lived experience, and 5) regional coordination. Conclusion This conference was an important first step to creating a shared national conversation about navigation services so that we can continue to develop, implement, and share best evidence and practices in the field.

This short report describes the development of a COVID-19 module for Round 10 of the European Social Survey (ESS). The module is formed of 20 items, including 10 agreed with ESS National Coordinators and 10 developed by two academic teams following an external call for content. The majority of ESS participating countries will field the module for Round 10 fieldwork in 2020–2021. This report provides the rationale for the module, presents challenges of developing such a module for ESS, and gives an overview of the question development and testing process. The two external sub-modules—Government authority and legitimacy in the age of a pandemic and COVID-19 conspiracy beliefs and government rule compliance—are also introduced. Supplementary Information The online version contains supplementary material available at 10.1186/s42409-021-00029-4.

Background After its landfall in Puerto Rico in 2017, Hurricane Maria caused the longest blackout in United States history, producing cascading effects on a health care system that had already been weakened by decades of public sector austerity and neoliberal health reforms. This article addresses how health care professionals and administrators experienced the health care system’s collapse and the strategies used by them to meet their communities' health needs. Methods Data were collected between September 2018 and February 2020. Ethnographic observations in health care facilities and semi-structured qualitative interviews with representatives of the health care system were conducted. This paper focuses on data from interviews with health care providers (n = 10) and administrators (n = 10), and an ethnographic visit to a pop-up community clinic. The analysis consisted of systematic thematic coding of the interview transcripts and ethnographic field notes. Results Results provide insight on how participants, who witnessed first-hand the collapse of Puerto Rico’s health care system, responded to the crisis after Maria. The prolonged power outage and lack of a disaster management plan were partly responsible for the death of 3,052 individuals who experienced extended interruptions in access to medical care. Participants reported a sense of abandonment by the government and feelings of mistrust. They also described the health sector as chaotic and lacking clear guidelines on how to provide services or cope with personal crises while working under extreme conditions. In such circumstances, they developed resilient responses to meet communities’ health needs (e.g., itinerant acupuncture services, re-locating physicians to local pharmacies). Conclusions Participants’ narratives emphasize that the management of Hurricane Maria was fraught with political and economic constraints affecting Puerto Rico. Ineffective planning and post-Maria responses of the local and federal governments were determinants of the disaster’s impact. The findings contribute to a growing scientific literature indicating that Hurricane Maria revealed ‘the collapse before the collapse,’ alluding to the structural deficiencies that presaged the catastrophic event. In the context of governmental abandonment, the authors argue for the importance of developing alternative strategies in post-disaster health care provision among health professionals and administrators who work at the front lines of recovery.

Background Partnerships between charitable food systems and healthcare systems have been forming across the country to support individuals and families experiencing food insecurity, yet little research has focused on these partnerships, particularly from a food bank perspective. The objective of this exploratory pilot study was to identify implementation challenges and facilitators of charitable food system and healthcare partnerships from the food bank perspective. Method Texas food banks with existing food bank/healthcare partnerships were identify through website review and support from Feeding Texas. Interview questions were tailored to each interview, but all focused on identify program components of the food bank/healthcare partnership and implementation barriers/facilitators of the partnership. In total, six interviews were conducted with food bank/healthcare partnership leaders (n = 4) and charitable food system experts (n = 2) about their experiences of working with food bank/healthcare partnerships. All interviews were completed via Zoom and took between 30 and 60 min to completed. Detailed notes were taking during each interview, and immediately discussed with the complete research time to formulate broad implementation themes. Results Interviews suggest unique implementation challenges exist at all levels of food bank/healthcare partnerships including the partnership, program, and system levels. Partnership-level implementation challenges focused on issues of partnership scale and data collection, sharing, and analysis. Program-level implementation challenges focused on food and produce expectations. Structural-level implementation challenges included issues of food safety, subsidized food regulations, and patient privacy. Implementation facilitators included leadership support, mission compatibility/organizational readiness, food insecurity training, and identify of partnership champions. Conclusions This study adds to the growing interest in food bank/healthcare partnership as it highlights unique implementation challenges and facilitators for cross-sector partnerships between healthcare systems and community-based charitable food systems. Ultimately, we believe that collaborative discussion among leaders of charitable food systems and healthcare systems is needed to overcome outlined implementation challenges to better facilitate sustainable, equitable implementation of food bank/healthcare partnerships.

Co-design as a participatory method aims to improve health service design and implementation. It is being used more frequently by researchers and practitioners in various health and social care settings. Co-design has the potential for achieving positive outcomes for the end users involved in the process; however, involvement of diverse ethnic minority population in the process remains limited. While the need to engage with diverse voices is identified, there is less information available on how to achieve meaningful engagement with these groups. Ethnic minorities are super-diverse population and the diversity between and within these groups need consideration for optimising their participation in co-design. Based on our experience of working with diverse ethnic minority groups towards the co-design of consumer engagement strategies to improve patient safety in cancer services as part of the two nationally-funded research projects in Australia, we outline reflections and practical techniques to optimise co-design with people from diverse ethnic backgrounds. We identify three key aspects of the co-design process pertinent to the involvement of this population; 1) starting at the pre-commencement stage to ensure diverse, seldom heard consumers are invited to and included in co-design work, 2) considering logistics and adequate resources to provide appropriate support to address needs before, during and beyond the co-design process, and 3) supporting and enabling a diversity of contributions via the co-design process.

Background A variety of policies have been implemented around the world in response to the COVID-19 pandemic. This study originally aimed to identify and compare policy responses of different countries and their effects on the pandemic. It quickly evolved into an identification of the heterogeneity among existing policies and the challenges in making meaningful comparisons of the impact of these policies. Methods The process of collecting and comparing data from different sources was analysed through inductive thematic analysis to understand the obstacles that impede research designed to compare COVID-19 data and related policies. Results We identified the following obstacles: (1) no single reputable source of information and too much noise; (2) a lack of standards for how to measure and report data across countries; (3) variations in the content, implementation and enforcement of policies; and (4) politics, instead of science, leading the efforts in pandemic management. Conclusion Heterogeneity in existing policies makes it challenging to compare the effects of various policies worldwide on the COVID-19 pandemic. Our findings call for an automatically updated informatics infrastructure across the globe for collecting and maintaining standardized data from multiple sources. There is a strong need for steadfast utilization of scientific and technical experts to inform and influence health policy. Increased investment in public health and emergency planning is essential to overcome the current pandemic, as well as future public health emergencies. Focused leadership and collaboration from world leaders in a unified mission to decrease the mortality and morbidity of the COVID-19 pandemic is imperative.

Background Numerous reports have demonstrated the disproportionate impact that COVID-19 has had on vulnerable populations. Our purpose is to describe our health care system’s response to this impact. Methods We convened a Workgroup with the goal to mitigate the impact of COVID-19 on the most medically vulnerable people in Springfield, Massachusetts, USA, particularly those with significant social needs. We did this through (1) identifying vulnerable patients in high-need geographic areas, (2) developing and implementing a needs assessment/outreach tool tailored to meet cultural, linguistic and religious backgrounds, (3) surveying pharmacies for access to medication delivery, (4) gathering information about sources of food delivery, groceries and/or prepared food, (5) gathering information about means of travel, and (6) assessing need for testing. We then combined these six elements into a patient-oriented branch and a community outreach/engagement branch. Conclusions Our highly intentional and methodical approach to patient and community outreach with a strong geographic component has led to fruitful efforts in COVID-19 mitigation. Our patient-level outreach engages our health centers’ clinical teams, particularly community health workers, and is providing the direct benefit of material and service resources for our at-risk patients and their families. Our community efforts leveraged existing relationships and created new partnerships that continue to inform us—healthcare entities, healthcare employees, and clinical teams—so that we can grow and learn in order to authentically build trust and engagement.

Background Healthcare quality measurements in the United States illustrate disparities by racial/ethnic group, socio-economic class, and geographic location. Redressing healthcare inequities, including measurement of and reimbursement for healthcare quality, requires partnering with communities historically excluded from decision-making. Quality healthcare is measured according to insurers, professional organizations and government agencies, with little input from diverse communities. This community-based participatory research study aimed to amplify the voices of community leaders from seven diverse urban communities in Minneapolis-Saint Paul Minnesota, view quality healthcare and financial reimbursement based on quality metric scores. Methods A Community Engagement Team consisting of one community member from each of seven urban communities —Black/African American, Lesbian-Gay-Bisexual-Transgender-Queer-Two Spirit, Hmong, Latino/a/x, Native American, Somali, and White—and two community-based researchers conducted listening sessions with 20 community leaders about quality primary healthcare. Transcripts were inductively analyzed and major themes were identified. Results Listening sessions produced three major themes, with recommended actions for primary care clinics. #1: Quality Clinics Utilize Structures and Processes that Support Healthcare Equity. #2: Quality Clinics Offer Effective Relationships, Education, and Health Promotion. #3: Funding Based on Current Quality Measures Perpetuates Health Inequities. Conclusion Community leaders identified ideal characteristics of quality primary healthcare, most of which are not currently measured. They expressed concern that linking clinic payment with quality metrics without considering social and structural determinants of health perpetuates social injustice in healthcare.

Background This is the eighth in our series of 11 papers on “CHWs at the Dawn of a New Era”. Community health worker (CHW) incentives and remuneration are core issues that affect the performance of individual CHWs and the performance of the overall CHW programme. A better understanding of what motivates CHWs and a stronger awareness of the social justice dimensions of remuneration are essential in order to build stronger CHW programmes and to support the professionalization of the CHW workforce. Methods We provide examples of incentives that have been provided to CHWs and identify factors that motivate and demotivate CHWs. We developed our findings in this paper by synthesizing the findings of a recent review of CHW motivation and incentives in a wide variety of CHW programmes with detailed case study data about CHW compensation and incentives in 29 national CHW programmes. Results Incentives can be direct or indirect, and they can be complementary/demand-side incentives. Direct incentives can be financial or nonfinancial. Indirect incentives can be available through the health system or from the community, as can complementary, demand-side incentives. Motivation is sustained when CHWs feel they are a valued member of the health system and have a clear role and set of responsibilities within it. A sense of the “do-ability” of the CHW role is critical in maintaining CHW motivation. CHWs are best motivated by work that provides opportunities for personal growth and professional development, irrespective of the direct remuneration and technical skills obtained. Working and social relationships among CHWs themselves and between CHWs and other healthcare professionals and community members strongly shape CHW motivation. Conclusion Our findings support the recent guidelines for CHWs released by WHO in 2018 that call for CHWs to receive a financial package that corresponds to their job demands, complexity, number of hours worked, training, and the roles they undertake. The guidelines also call for written agreements that specify the CHW’s role and responsibilities, working conditions, remuneration, and workers’ rights.

Background This is the ninth paper in our series, “Community Health Workers at the Dawn of a New Era”. Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs. This paper focuses on the quality of CHW relationships with actors at the local level of the national health system and with communities. Methods The authors conducted a selective review of journal articles and the grey literature, including case study findings in the 2020 book Health for the People: National CHW Programs from Afghanistan to Zimbabwe. They also drew upon their experience working with CHW programmes. Results The space where CHWs form relationships with the health system and the community has various inherent strengths and tensions that can enable or constrain the quality of these relationships. Important elements are role clarity for all actors, working referral systems, and functioning supply chains. CHWs need good interpersonal communication skills, good community engagement skills, and the opportunity to participate in community-based organizations. Communities need to have a realistic understanding of the CHW programme, to be involved in a transparent process for selecting CHWs, and to have the opportunity to participate in the CHW programme. Support and interaction between CHWs and other health workers are essential, as is positive engagement with community members, groups, and leaders. Conclusion To be successful, large-scale CHW programmes need well-designed, effective support from the health system, productive interactions between CHWs and health system staff, and support and engagement of the community. This requires health sector leadership from national to local levels, support from local government, and partnerships with community organizations. Large-scale CHW programmes should be designed to enable local flexibility in adjusting to the local community context.

Background Various governments in Ghana have tried to improve healthcare in the country. Despite these efforts, meeting health care needs is a growing concern to government and their citizens. Short term medical missions from other countries are one of the responses to meet the challenges of healthcare delivery in Ghana. This research aimed to understand Ghanaian perceptions of short-term missions from the narratives of host country staff involved. The study from which this paper is developed used a qualitative design, which combined a case study approach and political economy analysis involving in-depth interviews with 28 participants. Result Findings show short term medical mission programs in Ghana were largely undertaken in rural communities to address shortfalls in healthcare provision to these areas. The programs were often delivered free and were highly appreciated by communities and host institutions. While the contributions of STMM to health service provision have been noted, there were challenges associated with how they operated. The study found concerns over language and how volunteers effectively interacted with communities. Other identified challenges were the extent to which volunteers undermined local expertise, using fraudulent qualifications by some volunteers, and poor skills and lack of experience leading to wrong diagnoses sometimes. The study found a lack of awareness of rules requiring the registration of practitioners with national professional regulatory bodies, suggesting non enforcement of volunteers’ need for local certification. Conclusion Short Term Medical Missions appear to contribute to addressing some of the critical gaps in healthcare delivery. However, there is an urgent need to address the challenges of ineffective utilisation and lack of oversight of these programs to maximise their benefits.

Background The onset of the COVID-19 pandemic has sparked heated debate among scholars on the relevance of lockdowns. There are those in favor of the lockdown and others who are critical of it. However, despite the increased interest in understanding the relevance of lockdowns, there still has not been much focus on its relevance in countries like Zambia. Thus, with the help of the Social Representation Theory (SRT), we set out to explore and document the local characterization of the lockdown by residents of Lusaka, Zambia. Methods We recruited our participants through convenient and purposive sampling techniques. This was done through the use of the ZAMTEL public phone records. Initial contact was made to potential participants, and they were asked of their availability and willingness to participate in the interview. Upon agreeing to participate, they were included in the sample. A total of 68 people were selected to take part in this study. Their age ranged from 20 to 76 years old. 33 of them were male and 35 females. After this, we conducted interviews with the 68 participants. Due to COVID-19 restrictions, our interviews were conducted via telephone in conformity with the recommendations from the IRB in Lusaka and the advice of the ministry of health. We anonymized the demographic characteristics and responses from our participants. Later, thematic analysis was used to analyze the data. Results The lockdown was on one hand lauded for slowing down the incidence rates, preventing fatalities, and protecting the healthcare system from collapse. On the other hand, it was criticized for exacerbating poverty levels, unemployment rates, increasing the rate of mental health problems, aiding gender-based violence, and intensifying political repression and corruption. The results speak to the complexity in the characterization of the lockdown as a response to COVID-19 in Lusaka, Zambia. This observation demonstrates the folly of viewing, applying and characterizing the COVID-19 lockdown as a ‘one-size-fits-all’ approach in Lusaka, Zambia. Conclusion Rather than establishing the lockdown as an incontestable good, as it is depicted by some scholars or as useless by its critics, our findings instead demonstrate the diversity and complexity in how it is locally viewed by Lusaka residents. The study provides grounds for caution on simplistic and binary characterization of lockdowns. It indicates the need for careful dialog between the designers of lockdowns and citizens in order to tailor such interventions to local realities in context-specific ways. It also shows that though the development of such interventions, all the various and complex elements it embodies must be taken into account in order to realize optimum outcomes.

Background There is a strong policy impetus for the One Health cross-sectoral approach to address the complex challenge of zoonotic diseases, particularly in low/lower middle income countries (LMICs). Yet the implementation of this approach in LMIC contexts such as India has proven challenging, due partly to the relatively limited practical guidance and understanding on how to foster and sustain cross-sector collaborations. This study addresses this gap by exploring the facilitators of and barriers to successful convergence between the human, animal and environmental health sectors in India. Methods A mixed methods study was conducted using a detailed content review of national policy documents and in-depth semi-structured interview data on zoonotic disease management in India. In total, 29 policy documents were reviewed and 15 key informant interviews were undertaken with national and state level policymakers, disease managers and experts operating within the human-animal-environment interface of zoonotic disease control. Results Our findings suggest that there is limited policy visibility of zoonotic diseases, although global zoonoses, especially those identified to be of pandemic potential by international organisations (e.g. CDC, WHO and OIE) rather than local, high burden endemic diseases, have high recognition in the existing policy agenda setting. Despite the widespread acknowledgement of the importance of cross-sectoral collaboration, a myriad of factors operated to either constrain or facilitate the success of cross-sectoral convergence at different stages (i.e. information-sharing, undertaking common activities and merging resources and infrastructure) of cross-sectoral action. Importantly, participants identified the lack of supportive policies, conflicting departmental priorities and limited institutional capacities as major barriers that hamper effective cross-sectoral collaboration on zoonotic disease control. Building on existing informal inter-personal relationships and collaboration platforms were suggested by participants as the way forward. Conclusion Our findings point to the importance of strengthening existing national policy frameworks as a first step for leveraging cross-sectoral capacity for improved disease surveillance and interventions. This requires the contextual adaptation of the One Health approach in a manner that is sensitive to the underlying socio-political, institutional and cultural context that determines and shapes outcomes of cross-sector collaborative arrangements.

Background For evidence-based decision-making, there is a need for quality, timely, relevant and accessible information at each level of the health system. Limited use of local data at each level of the health system is reported to be a main challenge for evidence-based decision-making in low- and middle-income countries. Although evidence is available on the timeliness and quality of local data, we know little about how it is used for decision-making at different levels of the health system. Therefore, this study aimed to assess the level of data use and its effect on data quality and shared accountability at different levels of the health system. Methods An implementation science study was conducted using key informants and document reviews between January and September 2017. A total of 21 key informants were selected from community representatives, data producers, data users and decision-makers from the community to the regional level. Reviewed documents include facility reports, district reports, zonal reports and feedback in supervision from the district. Thematic content analysis was performed for the qualitative data. Results Respondents reported that routine data use for routine decision-making was low. All health facilities and health offices have a performance monitoring team, but these were not always functional. Awareness gaps, lack of motivating incentives, irregularity of supportive supervision, lack of community engagement in health report verification as well as poor technical capacity of health professionals were found to be the major barriers to data use. The study also revealed that there are no institutional or national-level regulations or policies on the accountability mechanisms related to health data. The community-level Health Development Army programme was found to be a strong community engagement approach that can be leveraged for data verification at the source of community data. Conclusion The culture of using routine data for decision-making at the local level was found to be low. Strengthening the capacity of health workers and performance monitoring teams, introducing incentive mechanisms for data use, engaging the community in data verification and introducing accountability mechanisms for health data are essential to improve data use and quality.

BackgroundsThis study examined the dynamic association between risk communication and the public’s risk perception and action across the COVID-19 outbreak timeline in China.MethodsThis study collected publicly available information on COVID-19 released on official channels (e.g., government websites and official media) by the Parehub tool. Also, the study used the Zhongyun Big Data Platform to search public datasets about released COVID-19 information on Chinese social media, such as TikTok and Weibo. An online survey was conducted via WeChat to Chinese citizens using a snowball sampling method. The questionnaire assessed changes in participants’ risk perception and action against COVID-19. The data analysis examined information content and release-time trajectories against the public’s risk perception and actions over time.ResultsAltogether, the collected data includes 1477 pieces of authorized information and 297,000 short videos on COVID-19. Of 1362 participants recruited from 33 provinces and municipalities of China, 1311 respondents (25–60 years, 42% male) were valid for future analysis. The study indicated that 85.7% of participants mainly relied on official channels to obtain information. Alongside the outbreak’s progress, there was a gradual rise in information quantity, publishing frequency, and content variation. Correspondingly, the public’s risk perception that “take it seriously” rose from 13 to 80%, 87.1% of those who took “multiple actions” compared to 25.9% initially.ConclusionsOur findings indicated that insufficient information freely-accessible at the early stages of the outbreak might lead to the lack of risk awareness and the public’s inadequate protective actions. Given the current global situation of COVID-19, the study highlights authorized, transparent, and timely two-way risk communication is vital to guide public perception and actions. Furthermore, our study provides risk communication recommendations and may contribute to developing full measures to address future crises.

BackgroundPublic health (PH) practitioners have a strong moral commitment to health equity and social justice. However, PH values often do not align with health systems values, making it challenging for PH practitioners to promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and prevention of harms of substance use.MethodsAs part of a broader program of public health systems and services research, we interviewed 32 PH practitioners.ResultsUsing constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control.ConclusionsNaming these tensions provides insights into the daily ethical challenges of PH practitioners and an opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as a promising approach for developing ethical frameworks for PH practice.

Background The 2014–2015 Ebola epidemic in West Africa became a humanitarian crisis that exposed significant gaps in infection prevention and control (IPC) capacity in primary care facilities in Sierra Leone. Operational partners recognized the national gap and rapidly scaled-up an IPC training and infrastructure package. This prompted us to carry out a mixed-methods research study which aimed to evaluate adherence to IPC practices and understand how to improve IPC at the primary care level, where most cases of Ebola were initially presenting. The study was carried out during the national peak of the epidemic. Discussion We successfully carried out a rapid response research study that produced several expected and unexpected findings that were used to guide IPC measures during the epidemic. Although many research challenges were similar to those found when conducting research in low-resource settings, the presence of Ebola added risks to safety and security of data collectors, as well as a need to balance research activities with the imperative of response to a humanitarian crisis. A participatory approach that attempted to unify levels of the response from community upwards helped overcome the risk of lack of trust in an environment where Ebola had damaged relations between communities and the health system. Conclusion In the context of a national epidemic, research needs to be focused, appropriately resourced, and responsive to needs. The partnership between local academics and a humanitarian organization helped facilitate access to study sites and approvals that allowed the research to be carried out quickly and safely, and for findings to be shared in response forums with the best chance of being taken up in real-time.

Background As Arab countries seek to implement the ‘Guideline on Good Pharmacovigilance Practice (GVP) for Arab countries’, understanding policy implementation mechanisms and the factors impacting it can inform best implementation practice. This study aimed to explore the mechanisms of and factors influencing pharmacovigilance policy implementation in Arab countries with more established pharmacovigilance systems (Jordan, Oman), to inform policy implementation in a country with a nascent pharmacovigilance system (Kuwait). Results Matland’s ambiguity-conflict model served to frame data analysis from 56 face-to-face interviews, which showed that policy ambiguity and conflict were low in Jordan and Oman, suggesting an “administrative implementation” pathway. In Kuwait, policy ambiguity was high while sentiments about policy conflict were varied, suggesting a mixture between “experimental implementation” and “symbolic implementation”. Factors reducing policy ambiguity in Jordan and Oman included: decision-makers’ guidance to implementors, stakeholder involvement in the policy’s development and implementation, training of policy implementors throughout the implementation process, clearly outlined policy goals and means, and presence of a strategic implementation plan with appropriate timelines as well as a monitoring mechanism. In contrast, policy ambiguity in Kuwait stemmed from the absence or lack of attention to these factors. Factors reducing policy conflict included: the policy’s compliance with internationally recognised standards and the policy’s fit with local capabilities (all three countries), decision-makers’ cooperation with and support of the national centre as well as stakeholders’ agreement on policy goals and means (Jordan and Oman) and adopting a stepwise approach to implementation (Jordan). Conclusions Using Matland’s model, both the mechanism of and factors impacting successful pharmacovigilance policy implementation were identified. This informed recommendations for best implementation practice in Arab as well as other countries with nascent pharmacovigilance systems, including increased managerial engagement and support, greater stakeholder involvement in policy development and implementation, and undertaking more detailed implementation planning.

Background In developing countries, health information system (HIS) is experiencing more and more difficulties to produce quality data. The lack of reliable health related information makes it difficult to develop effective health policies. In order to understand the organization of HIS in African countries, we undertook a literature review. Methods Our study was conducted using the PubMed and Scopus bibliographic search engines. The inclusion criteria were: (i) all articles published between 2005 and 2019, (ii) articles including in their title the keywords "health", "information", "systems", "system", "africa", "developing countries", "santé", "pays en développement", "Afrique", (iii) articles that are written in English or French, (iv) which deals with organizational and technical issues about HIS in African countries. Results Fourteen retrieved articles out of 2492 were included in the study, of which 13 (92.9%) were qualitative. All of them dealt with issues related to HIS in 12 African countries. All 12 countries (100.0%) had opted for a data warehouse approach to improve their HIS. This approach, supported by the DHIS2 system, has enabled providing reliable data. However, 11 out of the 12 countries (92.0%) frameworks were aligned with funding donors’ strategies and lacked any national strategy. Conclusion This study suggests that the lack of a national health information management strategy will always be a threat to HIS performance in African countries. Ideally, rigorous upstream thinking to strengthen HIS governance should be undertaken by defining and proposing a coherent conceptual framework to analyze and guide the development and integration of digital applications into HIS over the long term.

Background There could be various stakeholders who influencing multidrug-resistant tuberculosis (MDR-TB) policy development and implementation, yet their attributes and roles remain unclear in practice. This study aimed to identify key stakeholders in the process of policy-making for MDR-TB control and prevention and to analyse the attributes and relationships of the stakeholders, providing evidence for further policy research on MDR-TB control. Methods This study was conducted from October 2018 to March 2019 and applied the stakeholder analysis guidelines and domestic stakeholder analysis. An initial candidate stakeholder list was developed by policy scanning. Ten experts were invited to identify these candidate stakeholders. The major attribute of these stakeholders were analysed using the Michell scoring method. Based on these results, the intertwined relationships among groups of stakeholders were analysed and mapped through a systematic scan of the policy and literature on MDR-TB control, as well as information obtained from the interviews. Results A list of 21 types of candidate stakeholders was developed after a literature review and policy scanning, of which 11 received 100% approval. After expert evaluation and identification (the total expert authority was 0.80), 19 categories of stakeholders were approved and included in the stakeholder analysis. We categorized all of the stakeholders into three groups: (i) definitive stakeholders who are mainly involved in administrative departments and the Provincial Center for Disease Control and Prevention (CDC); (ii) expectant stakeholders who are mainly involved with MDR-TB patients, clinical departments of TB hospitals at different levels, community health care facilities, prefectural CDC and charity organizations; and (iii) latent stakeholders who mainly involved family members and neighbours of MDR-TB patients and TB related products manufacturers. Government departments and higher-level CDCs have strong decision-making power in developing MDR-TB control policies whereas the recommendations from service providers and the concerns of patients should be considered. Conclusions The MDR-TB prevention system was a multistakeholder cooperation system that was mainly led by government stakeholders. Enhancing communications with front-line service providers and patients on their unmet needs and evidence-based suggestions would highly benefit policy-making of MDR-TB prevention and control. Graphical abstract

Background Research partnerships in conflict-affected and humanitarian settings can reveal complex power hierarchies between academics and NGOs. During the process of research, decision-making may skew in favour of more powerful actors, who often direct the scope of the research, hold the budget and lead the analysis. Co-production is increasingly emerging as a helpful approach that attempts to equalise power dynamics during research. The aim of this paper is to draw attention to the main challenges associated with a “research as usual” approach to research partnerships in humanitarian settings, as power hierarchies may be particularly magnified in these settings. Methods This paper is based on a comprehensive literature review and 32 semi-structured interviews with academics and practitioners from non-government organisations. Participants were selected purposively based on their experience in co-producing research or working within research partnerships. Some participants had worked in humanitarian settings while others had experience co-producing research in non-humanitarian contexts. We used Nvivo to thematically code data. Results This paper documents the problems with “research as usual” partnerships in humanitarian settings, specifically: the burden on communities as merely sources of data, certain forms of knowledge being valued over others, lack of reflection on the power hierarchies structuring research partnerships, top-down decision-making and lack of transparency, one-way “capacity-building”, lack of mutual benefit, and rigid research processes and timeframes. Conclusion This paper highlights key challenges with standard research practices in humanitarian settings and identifies seven key principles of co-production that can be helpful in attempting to equalise power dynamics within research partnerships, specifically in conflict-affected and humanitarian settings.

Two tendencies have emerged in environmental epidemiology that hamper the translation of research findings into prevention of environmental hazards. One is the increased focus on highlighting weaknesses of epidemiology research that is clearly meant to explain away the research conclusions and weaken their possible implications for interventions to control environmental hazards. Another is the voluminous amount of information sharing that involves a substantial amount of misinformation, as part of the ongoing infodemic. In this light, the appearance of the catalogue of doubt-raising strategies, indeed the worst practices of scientific inference, is good news. Collected under the auspices of the International Network for Epidemiology in Policy, it serves to illustrate the range of possible (and impossible) forms of critique that may be raised on behalf of vested interests or other groups who for some reason disagree with the epidemiological conclusions. We believe that this systematic list will be useful in our field and help to identify critiques of policy options that are hidden and sometimes suppressed in weighing the epidemiological evidence.

Background Pandemics such as COVID-19 are a serious public health risk for Australian Aboriginal and Torres Strait Islander communities, yet primary healthcare systems are not well resourced to respond to such urgent events. At the start of the COVID-19 pandemic, a federal government advisory group recommended a rapid, tailored Indigenous response to prevent predicted high morbidity and mortality rates. This paper examines the efforts of one ACCHO, which in the absence of dedicated funding, pivoted its operations in response to COVID-19. Gurriny Yealamucka Health Service (Gurriny) is the only primary healthcare service in the discrete Indigenous community of Yarrabah, Far North Queensland. Methods The research was conducted at the request of the Chief Executive Officer of Gurriny. Using grounded theory methods, thirteen Gurriny staff and five Yarrabah and government leaders and community members were interviewed, transcripts of these interviews and 59 documents were imported into NVIVO-12 and coded, and key concepts were compared, organised into higher order constructs, then structured into a theoretical framework. Results Gurriny responded to COVID-19 by leading with local solutions to keep Yarrabah safe. Four key strategies were implemented: managing the health service operations, realigning services, educating and supporting community, and working across agencies. These strategies were enabled or hindered by five conditions: the governance and leadership capacity of Gurriny, relying on the health taskforce, locking the door, “copping it”, and (not) having resources. A year after the first case was experienced in Australia and on the eve of vaccine rollout to Indigenous communities, there have been no COVID-19 cases in Yarrabah. Discussion The success of the locally led, holistic, comprehensive and culturally safe response of Gurriny suggests that such tailored place-based approaches to pandemics (and other health issues) are appropriate, but require dedicated resourcing. Key challenges were the fragmented and rapidly changing government processes, poorly coordinated communication and resource allocation channels, and bottlenecks in hierarchical funding approval processes. Conclusions The COVID-19 response in Yarrabah demonstrates the need for governance reform towards greater resourcing and support for local decision making by Aboriginal community-controlled health organisations.

Background Involving patients and communities with health research in low- and middle-income countries (LMICs) contributes to increasing the likelihood that research is relevant in local context and caters to the needs of the population, including vulnerable and marginalised groups. When done right, it can also support empowerment of wider communities in taking ownership of their own health, lead to increased access and uptake of health services and generally improve the wellbeing of individuals. However, the evidence base of how to undertake successful community engagement and involvement (CEI) activities in LMICs is sparse. This paper aims to add to the available literature and describes how the Global Health Research Unit on Global Surgery’s (GSU) team in Ghana worked collaboratively with the Unit’s team in the UK and a UK-based Public Advisory Group to involve community stakeholders in rural Ghana with surgical research. The aim was to explore ways of reaching out to patients and community leaders in rural Ghana to have conversations that inform the relevance, acceptability, and feasibility of a clinical trial, called TIGER. Methods As this kind of larger scale involvement of community stakeholders with research was a novel way of working for the team in Ghana, a reflective approach was taken to outline step-by-step how the GSU team planned and undertook these involvement activities with 31 hernia patients, two Chiefs (community leaders), a community finance officer and a local politician in various locations in Ghana. The barriers that were experienced and the benefits of involving community stakeholders are highlighted with the aim to add to the evidence base of CEI in LMICs. Results GSU members from the UK and Ghana planned and organised successful involvement activities that focused on establishing the best way to talk to patients and other community stakeholders about their experiences of living with hernias and undergoing hernia repairs, and their perceptions of the impact of hernias on the wider community. The Ghanaian team suggested 1:1 conversations in easily accessible locations for rural patient contributors, creating a welcoming environment and addressing contributors in their local dialects. A UK-based Public Advisory Group helped in the initial stages of planning these conversations by highlighting potential barriers when approaching rural communities and advising on how to phrase questions around personal experiences. Conversations mainly focused on understanding the needs of hernia patients in rural Ghana to then incorporate these in the design of the TIGER trial to ensure its relevance, acceptability and feasibility. When talking to patient contributors, the GSU teams found that they were more likely to open up when they knew members of the team and the opportunity to speak to local leaders only arose because of the Ghanaian team members being well-respected amongst communities. The experiences of the patient and community contributors led to changes in the study protocol, such as including women in the patient cohort for the trial, and allowed the GSU teams to confirm the relevance and acceptability of this trial. These conversations also taught the team a lot about perceptions of health in rural communities, allowed the Ghanaian team to establish relationships with community leaders that can be utilised when future studies need input from the public, and has changed the minds of the Ghanaian research team about the importance of involving patients with research. Conclusion This paper contributes to the evidence base on successful CEI activities in LMICs by providing an example of how CEI can be planned and organised, and the benefits this provides. The conversations the teams had with patient contributors in Ghana are an example of successful patient consultations. Even though there are certain limitations to the extent of these involvement activities, a solid foundation has been built for researchers and community stakeholders to establish relationships for ongoing involvement. Supplementary Information The online version contains supplementary material available at 10.1186/s40900-021-00270-5., Plain English summary Evidence in the literature shows that research that was designed and implemented with the help of patients or other members of the community affected by the study, is more likely to be relevant to the needs of the end user. This can have positive effects on the quality and impact of the study. However, working collaboratively with patient or public contributors can have certain challenges, especially in low- and middle- income countries. For example, factors such as different languages or dialects, religious beliefs, health beliefs, level of literacy, understanding of research, and poverty can potentially make it more difficult for researchers to reach, communicate and involve relevant members of the public. On top of this, the evidence base for successfully implementing these so-called community engagement and involvement activities is sparse, making it more challenging for researchers to learn from others’ experiences. Members of the Global Surgery Unit, who are based in Ghana, proposed a clinical trial to address the shortfall of specialist surgeons at rural hospitals. This will be achieved by training medically qualified doctors, who have not yet gone through the specialist training to become qualified surgeons, to perform inguinal hernia repairs proficiently. Before the study gets funded and a protocol can be designed, the researchers need to ensure its relevance, acceptability, and feasibility. This is usually done by getting the opinion and thoughts of key stakeholders, mainly individuals who will be affected by the research. To achieve this, the team in Ghana worked together with Global Surgery Unit members in the UK to identify the best ways to approach and have conversations with 31 inguinal hernia patients who either previously had surgery or currently live with hernias, two Chiefs (community leaders), a community finance officer and a local politician in a variety of locations in Ghana that are representative of the patient cohort for the study. The intention was to understand the impact of hernias on individual patients, their families, and entire communities to inform the relevance, acceptability and feasibility of the clinical trial, and ensure that relevant aspects are captured in the study protocol. A UK-based public advisory group provided initial input to help eliminate potential barriers of addressing patient contributors in rural Ghana. This paper states in detail how these conversations were planned and organised, the challenges the team had to overcome, and what they learned and gained from talking to community members - which goes far beyond just informing a study. Supplementary Information The online version contains supplementary material available at 10.1186/s40900-021-00270-5.

Background Only three of twenty Caribbean Community (CARCICOM) countries have mandatory school nutrition policies despite one third of the region’s children being overweight or obese. In Barbados, there are nutrition guidelines which lack the legal mandate of a formal policy. We aim to assess the comprehensiveness of current national nutrition guidelines and to understand the factors operating in the inner and outer school setting that may influence the implementation of a mandatory school nutrition policy from the perspectives of school administrators. Methods A documentary analysis of existing nutritional guidelines was conducted along with qualitative semi-structured interviews in primary (elementary) and secondary (high) schools in Barbados. We purposively sampled six primary and four secondary school administrators (principals, deputy principals or senior teachers) to explore their knowledge and views on the National School Nutrition Guidelines. The deterministic implementation paradigm, Consolidated Framework for Implementation (CFIR), was used to explore the complexities within the inner and outer settings of schools. Documentary analysis used a theory-based framework informed by the Wellness School Assessment Tool—school policy analysis questionnaire. Interview transcripts were team coded using thematic analysis with constant comparison facilitated by NVIVO software version12. Results School administrators were unaware of the existing National School Nutrition Guidelines which documentary analysis found to be restrictive and weak for implementation. Administrators envisioned a government-led (outer setting), whole of society approach as the most effective strategy for the development and implementation of a proposed mandatory school nutrition policy. School administrators identified lack of financial and human resources as barriers to nutrition policy implementation. Formal and informal food vendors are institutionalized in schools and are influential determinants of the school food environment. Schools have individually reached into the outer setting to work with civil society organizations and private individuals to provide financial support and nutrition expertise to their institutions. Mass media campaigns in the outer setting may influence child and parental food choices. Conclusion School administrators describe that government-led, CSO supported policy development using a whole-of-society approach has implications for improving nutrition policy implementation. Our findings demonstrate the use of a deterministic implementation framework in the pre-implementation phase of school nutrition policy development.

Background A range of services within Australia and internationally have been developed that are focused on the engagement of individuals who are of refugee background to work as a liaison between their communities and mental health services. The Community Liaison Worker (CLW) role at the Victorian Foundation for Survivors of Torture (VFST) was developed in 2008 in order to engage in such capacity-building initiatives. Aims To review and document the establishment, evolution and current status of the VFST CLW role, and examine the perspectives of CLWs on their role in trauma-informed community capacity-building. Methods The study comprised of two stages: a historical case study of the development of the CLW role, and a qualitative research study based on interviews with CLWs in order to identify key themes regarding various aspects of their role and understand the facilitators and barriers to their work of trauma-informed capacity-building with their respective communities. Results The CLW role has evolved from the provision of direct services through joint work with Counsellor Advocates at VFST to a broader role that is focused on building the capacity of community members. Thematic analysis of interviews with the seven current CLWs identified the complexity of their dual role as members of their community and employees of VFST, their role in addressing short-term goals to meet community needs, and the long-term objective of empowering their community to become integrated and self-sufficient. Conclusions CLWs at VFST demonstrate important work of liaison workers in facilitating trauma-informed capacity-building initiatives that are of benefit to members of their communities and also to service providers.