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It is widely acknowledged in hospitals that the quality of design and environment can influence the quality of patient care, the sense of therapeutic security and the experience of staff. This women's PICU collaborated with the charity Hospital Rooms to realise the valuable role of art within the clinical environment. Experienced artists were commissioned to work in genuine partnership with patients and staff to re-envision the physical environment with the installation of eight imaginative, inventive and PICU compliant art works. The implementation, and both patient and staff perspectives were evaluated. There was no disruption to clinical care and engagement and participation was enthusiastic. There were 35 patient encounters and 32 staff encounters, including creative workshops and an exhibition. Patient Experience Data Intelligence Centre (PEDIC) reports showed an improvement following artwork installation. Patients were more likely to recommend the ward, felt more involved in their care and that the ward was comfortable. The art transformed clinical spaces creating opportunity for patients to have exceptional experiences: 'being here feels like sitting in the park'. Staff evaluation through a 'visual matrix' method that explores shared experience, revealed that the art has introduced further possibility of 'respite and escape' for both patients and staff. There is a sense that 'you feel like it is leading you to somewhere, you feel like there is something more'. It has also engendered 'ownership and pride': it 'feels like pushing boundaries, things you thought could never be considered at all, are now being considered'.

Communities are powerful and necessary agents for defining and pursuing their health, but outside organizations often adopt community health promotion approaches that are patronizing and top-down. Conversely, bottom-up approaches that build on and mobilize community health assets are often critiqued for tasking the most vulnerable and marginalized communities to use their own limited resources without real opportunities for change. Taking into consideration these community health promotion shortcomings, this article asks how communities may be most effectively and appropriately supported in pursuing their health. This article reviews how community health is understood, moving from negative to positive conceptualizations; how it is determined, moving from a risk-factor orientation to social determination; and how it is promoted, moving from top-down to bottom-up approaches. Building on these understandings, we offer the concept of ‘resourcefulness’ as an approach to strengthen positive health for communities, and we discuss how it engages with three interrelated tensions in community health promotion: resources and sustainability, interdependence and autonomy, and community diversity and inclusion. We make practical suggestions for outside organizations to apply resourcefulness as a process-based, place-based, and relational approach to community health promotion, arguing that resourcefulness can forge new pathways to sustainable and self-sustaining community positive health.

Background There has been substantial progress in research on preventing violence against women and girls (VAWG) in the last 20 years. While the evidence suggests the potential of well-designed curriculum-based interventions that target known risk factors of violence at the community level, this has certain limitations for working in partnership with communities in low- and middle-income (LMIC) countries, particularly when it comes to addressing the power dynamics embedded within north-south research relationships. Methods As an alternative approach, we outline the study design for the EVE Project: a formative research project implemented in partnership with community-based researchers in Samoa and Amantaní (Peru) using a participatory co-design approach to VAWG prevention research. We detail the methods we will use to overcome the power dynamics that have been historically embedded in Western research practices, including: collaboratively defining and agreeing research guidelines before the start of the project, co-creating theories of change with community stakeholders, identifying local understandings of violence to inform the selection and measurement of potential outcomes, and co-designing VAWG prevention interventions with communities. Discussion Indigenous knowledge and ways of thinking have often been undermined historically by Western research practices, contributing to repeated calls for better recognition of Southern epistemologies. The EVE Project design outlines our collective thinking on how to address this gap and to further VAWG prevention through the meaningful participation of communities affected by violence in the research and design of their own interventions. We also discuss the significant impact of the COVID-19 pandemic on the project in ways that have both disrupted and expanded the potential for a better transfer of power to the communities involved. This article offers specific strategies for integrating Southern epistemologies into VAWG research practices in four domains: ethics, theories of change, measurement, and intervention design. Our aim is to create new spaces for engagement between indigenous ways of thinking and the evidence that has been established from the past two decades of VAWG prevention research and practice.

Objectives: To undertake an descriptive analysis of the health needs, healthcare practices and barriers to accessing healthcare faced by women in Lower Napo River Region, Peru, and to understand health literacy regarding cervical cancer and the need for more effective cervical cancer screening services. Methods: We performed a community-based needs assessment adapting Demographic and Health survey methodology with additional questions determining female health literacy on cervical cancer and assessing the availability and need for cervical cancer screening services. We surveyed women (N = 121) across all households in six communities along the Lower Napo River, Loreto, Peru, in May 2015. Data were collected as part of the larger Amazon Community Based Participation Cervical Cancer Screen-and-Treat Programme. Survey data were compared to national results from ENDES 2014. Results: Comparison between our findings and the ENDES 2014 survey highlighted considerable inequality between indigenous or mixed indigenous, rural populations in Loreto, Peru, and national population data averages over level of formal education, literacy, barriers to accessing healthcare and maternal and sexual health. Even though only 5.9% (N = 7/117) of women had no formal health insurance coverage, money was reported as the leading barrier accessing healthcare (N = 88/117, 75.2%). Health literacy regarding cervical and breast cancer was poor. A high proportion of women highlighted fear of screening processes (70.8%, N = 80/113) and lack of available services (53.6%, N = 60/112) as barriers to cervical cancer screening. Conclusion: Although progress has been made in improving healthcare access in Peru, such gains have not been experienced equitably and women living in remote communities face persistent marginalization regarding their health. There is a significant need for education related to and screening for cervical cancer in this region that is tailored to the reality of women’s lives in remote communities in Loreto.

Background The feminisation of the global health workforce presents a unique challenge for human resource policy and health sector reform which requires an explicit gender focus. Relatively little is known about changes in the gender composition of the health workforce and its impact on drivers of global health workforce dynamics such as wage conditions. In this article, we use a gender analysis to explore if the feminisation of the global health workforce leads to a deterioration of wage conditions in health. Methods We performed an exploratory, time series analysis of gender disaggregated WageIndicator data. We explored global gender trends, wage gaps and wage conditions over time in selected health occupations. We analysed a sample of 25 countries over 9 years between 2006 and 2014, containing data from 970,894 individuals, with 79,633 participants working in health occupations (48,282 of which reported wage data). We reported by year, country income level and health occupation grouping. Results The health workforce is feminising, particularly in lower- and upper-middle-income countries. This was associated with a wage gap for women of 26 to 36% less than men, which increased over time. In lower- and upper-middle-income countries, an increasing proportion of women in the health workforce was associated with an increasing gender wage gap and decreasing wage conditions. The gender wage gap was pronounced in both clinical and allied health professions and over lower-middle-, upper-middle- and high-income countries, although the largest gender wage gaps were seen in allied healthcare occupations in lower-middle-income countries. Conclusion These results, if a true reflection of the global health workforce, have significant implications for health policy and planning and highlight tensions between current, purely economic, framing of health workforce dynamics and the need for more extensive gender analysis. They also highlight the value of a more nuanced approach to health workforce planning that is gender sensitive, specific to countries’ levels of development, and considers specific health occupations.

Background Interlocking planetary health crises can reveal the complex nature of human and environmental interactions and highlight the importance of broader health ecosystems. Reductionist approaches to human health overlook broader systems factors, such as informal economies and environmental factors. However, these systems play an key role in the promotion of health and prevention of infectious diseases such as HIV and malaria. To better understand these factors, we applied a community and health asset ecosystem approach to infectious disease prevention, drawing on systems thinking and asset-based methods. Methods We did a systematic review and qualitative synthesis, including English-language literature from community and participatory programmes in low-income and middle-income countries worldwide that were focused on Sustainable Development Goal 3.3, with no date restrictions. We applied a systems-minded, asset-based approach to analysis, to construct a community and health asset ecosystem and understand how community and health systems assets come together to prevent infectious diseases in dynamic, multilevel, and non-linear ways. Findings We included eight papers in the final review, which were original qualitative and quantitative research articles and systematic reviews from community-based HIV and malaria prevention interventions. Systems of health assets spanned micro, meso, and macro levels, and were identified across the informal community setting and the formal health system setting. Community assets represented primary (those inherent to the individual or community), secondary (knowledge, technologies, and rules to harness primary resources), and tertiary (higher-level community processes promoting quality and stewardship of local assets) resources. Process factors driving the success of community programmes involved partnerships, engagement, sufficient resource availability, and community leadership. Interpretation Beyond identifying systems of local assets for health, our approach emphasises the process of how these assets are best converted into meaningful outcomes. The community and health asset ecosystem reflects the complex human–environmental interface and sheds light on how individuals or communities can effectively and sustainably place a claim on assets necessary to achieve health. Funding None.

Background: Aboriginal people in rural and remote areas of the Northern Territory of Australia have suffered longstanding issues of homelessness and profound health and social inequities. The town and region of Katherine are particularly impacted by such inequities and have the highest rates of homelessness in Australia, composed almost entirely of Aboriginal people who represent 51% of the total population of 24,000 people. The region is serviced by a 60-bed hospital, and a small cohort of frequent attenders (FAs) represent 11% of the Emergency Department (ED) case load. The vast majority of FAs are Aboriginal and have very high burdens of social inequity and homelessness. FAs are a challenge to efficient and effective use of resources for most hospitals around the world, and investment in programs to address underlying social and chronic health issues contributing to frequent attendance have been demonstrated to be effective. Methods: These are the interim findings of a prospective cohort study using five sources of linked health and related data to evaluate a community-based case management pilot in a culturally competent framework to support frequent attenders to the Katherine Hospital ED. FAs were defined as people with six or more presentations in 12 preceding months. The intervention composed of a community-based case management program with a multi-agency service delivery addressing underlying vulnerabilities contributing to ED presentations. Results: Among this predominantly Aboriginal cohort (91%), there were high rates of homelessness (64%), food insecurity (60%) and alcohol misuse (64%), limited access to transport, and complex comorbidities (average of 2.8 chronic conditions per client). Following intervention, there was a statistically significant reduction in ED presentations (IRR 0.77, 95% CI 0.69&ndash, 0.85), increased engagement with primary health care (IRR 1.90, 95% CI 1.78&ndash, 2.03), and ambulance utilisation (IRR 1.21, 95% CI 1.07&ndash, 1.38). Reductions in hospital admissions (IRR 0.93, 95% CI 0.77&ndash, 1.10) and aeromedical retrievals (IRR 0.67, 95% CI 0.35&ndash, 1.20) were not statistically significant. Conclusions: This study demonstrates the short-term impacts of community-led case management extending beyond the hospital setting, to address causes of recurrent ED presentations among people with complex social and medical backgrounds. Improving engagement with primary care is a particularly important outcome given the national impetus to reduce preventable hospital admissions.

The original article [1] contained an error in the presentation of all figures and tables; each figure and table is now set out and designated appropriately in the original article.

Background: The Base of the Pyramid (BoP) project is a public–private partnership initiated by Novo Nordisk that aims to facilitate access to diabetes care for people at the base of the economic pyramid in low- and middle-income countries (LMICs). In Kenya, the BoP, through a partnership model, aims to strengthen five pillars of diabetes care: increased awareness of diabetes; early diagnosis of diabetes; access to quality care by trained professionals; stable and affordable insulin supply; and improved self-management through patient education. Objectives: This study evaluates the extent to which BoP Kenya is scalable and sustainable, whether stakeholders share in its value, and whether BoP Kenya has improved access to diabetes care. Method: The Rapid Assessment Protocol for Insulin Access (RAPIA), an approach developed to provide a broad situational analysis of diabetes care, was used to examine health infrastructure and diabetes care pathways in Kenya. At the national level, the RAPIA was applied in a SWOT analysis of the BoP through in-depth interviews with key stakeholders. At individual and county health system levels, RAPIA was adapted to explore the impact of the BoP on access to diabetes care through a comparison of an intervention and control county. Results: The BoP was implemented in 28 of 47 counties in Kenya. Meru, a county where BoP was implemented, had 35 of 62 facilities (56%) participating in the BoP. Of the five pillars of the BoP, most notable progress was made in achieving the fourth (stable and affordable insulin supply). A price ceiling of 500KSh (US$5) per vial of insulin was established in the intervention county, with greater fluctuation and stock-outs in the non-intervention county. Despite reduced insulin costs, many patients with diabetes could not afford the additive expenses of monitoring, medicines, and travel. Less progress was made over the other pillars, which also faced challenges to sustainability and scalability. Conclusion: In the context of the rising prevalence of non-communicable diseases in LMICs, cross-sector approaches to improving access to care are increasingly needed. Public–private partnerships such as the BoP are necessary but not sufficient to ensure access to health care for people with diabetes at the base of the economic pyramid in Kenya.

A key challenge of preconception healthcare is identifying how it can best be delivered at a population level. To review current strategies of preconception healthcare, explore methods of preconception healthcare delivery, and develop public health models which reflect different preconception healthcare pathways. Preconception care strategies, programmes and evaluations were identified through a review of Medline and Embase databases. Search terms included: preconception, pre-pregnancy, intervention, primary care, healthcare, model, delivery, program, prevention, trial, effectiveness, congenital disorders OR abnormalities, evaluation, assessment, impact. Inclusion criteria for review articles were: (1) English, (2) human subjects, (3) women of childbearing age, (4) 1980–current data, (5) all countries, (6) both high risk and universal approaches, (7) guidelines or recommendations, (8) opinion articles, (9) experimental studies. Exclusion criteria were: (1) non-human subjects, (2) non-English, (3) outside of the specified timeframe, (4) articles on male healthcare. The results of the literature review were synthesised into public health models of care: (1) primary care; (2) hospital-based and inter-conception care; (3) specific preconception care clinics; and, (4) community outreach. Fifteen evaluations of preconception care were identified. Community programmes demonstrated a significant impact on substance use, folic acid supplementation, diabetes optimization, and hyperphenylalaninemia. An ideal preconception visits entail risk screening, education, and intervention if indicated. Subsequently, four public health models were developed synthesizing preconception care delivery at a population level. Heterogeneity of risk factors, health systems and strategies of care reflect the lack of consensus about the best way to deliver preconception care. The proposed models aim to reflect differing aspects of preconception healthcare delivery.

Background: Researchers evaluated the progress of Millennium Development Goal Three, which promotes gender equity and empowering women, by assessing the targets for education, employment, and government, and their relation to women's health in South Asia. Methods: Researchers obtained data from the United Nations, Inter-Parliamentary Union, International Labor Organization, World Bank, and World Health Organization. First, they performed a literature review including manuscripts that quantified a Millenium Development Goal Three outcome in South Asia and were published after 1991. They derived women's health outcomes from World Health Organization databases. Spearman's rank test was used to evaluate the relationship between change in gender parity and change in women's health outcomes. Results: South Asia's average primary education Gender Parity Index (defined as the ratio of girls to boys enrolled in primary, secondary, and tertiary education and expressed as a value between 0 and 1.0) improved from 0.73 (SD 0.34) to 0.92 (SD 0.13) between 2000 and 2008. Secondary and tertiary education had a lower Gender Parity Index (average 2008 Gender Parity Index 0.87 (SD 0.21) and 0.59 (SD 0.23), respectively), but had also improved from 2000 (average Gender Parity Index = 0.77, SD 0.38) to 2008 (average Gender Parity Index = 0.52, SD 0.11). An average proportion of 22.1% (SD 12.58) of women participated in waged, non-agricultural employment and 16.6% (SD 10.3) in national parliaments. No clear association was found between change in gender equity and women's health in South Asia between 2000 and 2008. Conclusion: Some progress has been made toward gender equity in South Asia, although the results have been mixed and inequities persist, especially in employment and government. While gender equity does not appear to have been related to female health outcomes, both must be addressed simultaneously as priority development targets and remain prerequisites to achieving the overall Millennium Development Goals. [Supplementary material is available for this article. Go to the publisher's online edition of Women & Health for the following resource: addition tabulated data and statistical analysis]

Globally, health inequities between Indigenous and non-Indigenous populations exist. The disparity in health outcomes between Indigenous and non-Indigenous Australians is exemplified by cervical cancer. Current evidence suggests that Indigenous women have higher age standardised incidence and mortality than non-Indigenous women when adjusted for stage at diagnosis and co-morbidities; however, there is little information pertaining to national estimates of cervical cancer in Indigenous women. In this paper we review available evidence on the difference in occurrence and case fatality of cervical cancer among Indigenous and non-Indigenous Australian women. The Australian Bureau of Statistics, Australian Institute of Health and Welfare, and State- or Territory-based Cancer Registries were utilised to collect surveillance data. To corroborate existing data, further available journal literature was identified through Medline and Embase. All papers selected for review were cross-referenced to identify further relevant studies. The most recent national estimate of age-standardised cervical cancer incidence rate was 16.9 and 7.1 per 100,000 women-years in Indigenous and non-Indigenous women respectively (incidence ratio 2.4). The Indigenous age-standardised mortality rate was 9.9 per 100,000 women years (95% CI 7.1-13.3), over 5 times the non-Indigenous rate. Cervical cancer incidence, in both Indigenous and non-Indigenous women, has decreased since 1991. Despite the decline, age-standardised incidence among Indigenous women is still higher than non-Indigenous women. The pattern of cervical cancer incidence and survival corroborates the health inequities that exist in Australia. Indigenous women are more likely than non-Indigenous women to develop cervical cancer and are less likely to survive it. Similar patterns exist in Indigenous populations worldwide, such as New Zealander Maoris and Canadian Aboriginals, suggesting that high rates of cervical cancer incidence and mortality may be a symptom of social and economic inequity.

Congenital disorders are a leading cause of global burden of disease; the birth prevalence remains constant at 6%. Initiating preconception care before pregnancy may be an effective strategy to reduce congenital disorders and improve the health of reproductive-age women. Our objectives are: (1) To identify components of preconception interventions, (2) to assess the effectiveness of preconception interventions in reducing the burden of congenital disorders, and (3) to prioritize these interventions. Medline and Science Direct search terms included: preconception, pre-pregnancy, childbearing, reproduction, care, intervention, primary care, healthcare, model, program, prevention, trial, efficacy, effectiveness, congenital disorders OR abnormalities. Inclusion criteria were: (1) English, (2) human subjects, (3) women of childbearing age, (4) 1980-current data, (5) all countries, (6) experimental studies, (7) systematic reviews or meta-analysis, (8) program reports/evaluations. Data was collected and abstracted by two independent reviewers. To prioritize preconception interventions likely to have the largest impact at a population level, a ranked scoring system was created incorporating the following: (1) quality of evidence supporting the intervention, (2) effect size of the intervention, and (3) global burden of the specific congenital disease. Preconception interventions include risk screening, education, motivational counseling, disease optimization and specialist referral. The most effective interventions, based on the strength of evidence, size of impact of intervention, and disease burden are: folic acid fortification/supplementation, diabetic control, smoking and alcohol interventions, HIV management, thrombophillia screening, obesity prevention and epilepsy management. Although multiple conditions require preconception attention, only nine interventions have evidence to support their effect on congenital disorders through a randomised control trial, systematic review or meta-analysis. There is a need for more high-level research in evaluating certain preconception interventions. These findings have significant implications on planning and implementation of preconception care.

Objective This study aims to model the impact of preconception care on births with congenital disorders at a national level. Design Mathematical cross-sectional model based on life-table methodology. Setting Research conducted in Cambridge, United Kingdom. Population Women aged 15-45 years in England, 2001. Methods A mathematical model was constructed based on cross-sectional data from women aged 15-45 years in England undertaking one of three interventions, so as to reflect different strategies of preconception care: folic acid SUPPL.ementation and fortification (representing national, universal interventions); alcohol intervention (reflecting primary care strategies); and diabetes management (targeting a population of high-risk women with a known chronic disease). Main outcome measure Reduction in the prevalence of congenital disorders at birth. Results Between 585 (lower estimate) and 1085 (upper estimate) congenital disorders could be prevented with a national preconception programme, based on a single-year national cohort in England. This represents an 8-15% reduction in annual notifications of congenital disorders in live births annually. According to modelled estimates, folic acid fortification or SUPPL.ementation, alcohol intervention, and diabetic management may result in a 46, 32-62, 53, and 54% reduction in the live birth prevalence of specific congenital disorders, respectively. In an ideal scenario, the application of this model decreases the total annual number of congenital disorder notifications by approximately one-sixth. Conclusion A preconception care programme comprising three different strategies potentially can reduce the number of infants born with congenital disorders at a national level. This model provides strong support for preconception care to become a healthcare priority, and has major implications for healthcare planning. © 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.

To determine the clinical and environmental variables associated with frequent presentations by adult patients to a remote Australian hospital emergency department (ED) for reasons other than chronic health conditions.Unmatched case-control study of all adult patients attending Katherine Hospital ED between 1 January and 31 December 2012.Cases were defined as frequent attenders (FAs) without a chronic health condition who presented to the ED six or more times during the 12-month period. A single presentation was randomly selected for data collection. Controls were patients who presented on only one occasion.Basic demographic data were collected, including clinical outcomes, Indigenous status, living arrangements, and whether alcohol and violence contributed to the presentation. Environmental variables were extracted from the Bureau of Meteorology database and mapped to each presentation.FAs were much more likely to be homeless (odds ratio [OR], 16.4; P0.001) and to be Aboriginal (OR, 2.16; P0.001); alcohol as a contributing factor was also more likely (OR, 2.77; P = 0.001). FAs were more likely to present in hotter, wetter weather, although the association was statistically weak. Clinical presentations by cases and controls were similar; the annual death rates for both groups were high (3.6% and 1.5%, respectively).There was a strong association between FA and Aboriginal status, homelessness and the involvement of alcohol, but alcohol was more likely to contribute to presentation by non-Aboriginal FAs who had stable living conditions. FAs and non-FAs had similar needs for emergency medical care, with strikingly higher death rates than the national average in both groups. As a result of this study, Katherine Hospital has initiated a Frequent Attender Pathway that automatically triggers a dedicated ED service for those at greatest clinical risk. Homelessness is a serious problem in the Northern Territory, and is associated with poor health outcomes.

had wide local excision and one vulvectomy. Four recurrences occurred. The vulvectomy and two of the three local excisions (one unstated) did not recur. Recurrence can occur as late as 11 years after initial excision. Vulvar leiomyomas are rare and may be misdiagnosed if the clinician is not aware. Even rarer still is combined vulvar and oesophageal leiomyomas, which may represent a specific syndrome. Treatments for isolated or syndromal vulvar leiomyoma are the same and should generally involve a marginal excision. Regular follow-up is warranted as late recurrence may occur.

There is growing interest in preconception health as a crucial period for influencing not only pregnancy outcomes, but also future maternal and child health, and prevention of long-term medical conditions. Successive national and international policy documents emphasise the need to improve preconception health, but resources and action have not followed through with these goals. We argue for a dual intervention strategy at both the public health level (eg, by improving the food environment) and at the individual level (eg, by better identification of those planning a pregnancy who would benefit from support to optimise health before conception) in order to raise awareness of preconception health and to normalise the notion of planning and preparing for pregnancy. Existing strategies that target common risks factors, such as obesity and smoking, should recognise the preconception period as one that offers special opportunity for intervention, based on evidence from life-course epidemiology, developmental (embryo) programming around the time of conception, and maternal motivation. To describe and monitor preconception health in England, we propose an annual report card using metrics from multiple routine data sources. Such a report card should serve to hold governments and other relevant agencies to account for delivering interventions to improve preconception health.