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Background: Healthcare workers (HCWs) in the United Kingdom (UK) have faced many challenges during the COVID-19 pandemic, some of these arising out of their social positions. Existing literature explicating these challenges (e.g., lack of appropriate PPE, redeployment, understaffing) have highlighted inequities in how these have been experienced by HCWs based on ethnicity, gender or, job role. In this paper, we move a step ahead and examine how the intersection of these social positions have impacted HCWs’ experiences of challenges during the pandemic. Methods: We collected qualitative data, using interviews and focus groups, from 164 HCWs from different ethnicities, gender, job roles, migration statuses, and regions in the United Kingdom (UK) between December 2020 and July 2021. Interviews and focus groups were conducted online or by telephone, and recorded with participants’ permission. Recordings were transcribed and a hybrid thematic analytical approach integrating inductive data-driven codes with deductive ones informed by an intersectional framework was adopted to analyse the transcripts. Results: Thematic analysis of transcripts identified disempowerment, disadvantage and, discrimination as the three main themes around which HCWs’ experiences of challenges were centred, based on their intersecting identities (e.g., ethnicity gender, and/or migration status). Our analysis also acknowledges that disadvantages faced by HCWs were linked to systemic and structural factors at the micro, meso and macro ecosystemic levels. This merging of analysis which is grounded in intersectionality and considers the ecosystemic levels has been termed as ‘intrasectionalism’. Discussion: Our research demonstrates how an intrasectional lens can help better understand how different forms of mutually reinforcing inequities exist at all levels within the healthcare workforce and how these impact HCWs from certain backgrounds who face greater disadvantage, discrimination and disempowerm

Introduction: Ethnic minority populations experience significant health and social care disparities; despite experiencing a greater burden of diseases, these groups are underrepresented in health and social care research. Consequently, related research can be less applicable to these population groups. The REPRESENT study aims to explore the health and social care experiences of ethnic minorities and other minoritised populations, their research interests and appropriate research practices. Methods: Focus groups and semistructured interviews were conducted between May and September 2022 with members of a number of ethnic minority communities in England. Data were audio recorded, transcribed and thematically coded using NVivo 12. Rigour was determined through extensive sampling, iterative data collection and analysis. Findings: Fifty-two ethnic minority members were engaged in group interviews and one-to-one interviews. Participants included representatives of the following groups: African Caribbean, Eastern European, Gypsy Travellers, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual+, Refugee/Asylum Seekers, Somali and South Asian communities. Interviews were also conducted with ethnic minority healthcare providers and researchers. Three overarching categories were identified: health information, medical service experiences, health and social care concerns and health research. Health and social care services challenges were mostly attributed to discrimination, delayed services, poor cultural relevance and language and cultural barriers. The most influential information sources were local community organisations and word-of-mouth. The main health and social care concerns were chronic long-term health conditions, mental health, maternal health and child development. Recommendations for research involved understanding the motivations for participation, improving communication and empowering communities. Top research priorities were long-term health cond

Introduction: During the COVID-19 pandemic, pregnant women were regarded as vulnerable to poor health outcomes if infected with the SARS-CoV-2 (COVID-19) virus. To protect the United Kingdom’s (UK) National Health Service (NHS) and pregnant patients, strict infection control policies and regulations were implemented. This study aimed to understand the impact of the COVID-19 policies and guidelines on maternal and reproductive health services during the pandemic from the experiences of healthcare workers (HCWs) caring for these patients. Methods: This qualitative study involved HCWs from the United Kingdom Research study into Ethnicity and COVID-19 outcomes in Healthcare workers (UK-REACH) project. Semi-structured interviews and focus groups were conducted online or by telephone with 44 diverse HCWs. Transcripts were thematically analyzed following Braun and Clarke’s principles of qualitative analysis. Results: Three key themes were identified during analysis. First, infection control policies impacted appointment availability, resulting in many cancellations and delays to treatment. Telemedicine was also used extensively to reduce risks from face-to-face consultations, disadvantaging patients from minoritized ethnicities. Secondly, staff shortages and redeployments reduced availability of consultations, appointments, and sonography scans. Finally, staff and patients reported challenges accessing timely, reliable and accurate information and guidance. Conclusions: COVID-19 demonstrated how a global health crisis can impact maternal and reproductive health services, leading to reduced service quality and surgical delays due to staff redeployment policies. Our findings underscore the implications of policy and future health crises preparedness. This includes tailored infection control policies, addressing elective surgery backlogs early and improved dissemination of relevant vaccine information.

Background: GRT communities are disadvantaged minority groups in Europe and experience some of the poorest health outcomes, including maternal and child health. This systematic review aimed to assess the maternal, perinatal and infant health outcomes of women from GRT communities and the factors associated with the reported outcomes. Methods: Database searches were conducted from inception to June 2023 in 4 bibliographic databases supplemented with an additional Google Scholar search. Studies with quantitative data on maternal outcomes published in English were considered. A narrative synthesis was performed, and data were presented in text, figures and tables. Findings: Forty-five studies from 13 European countries were included. Outcome factors related to mothers showing low healthcare engagement, high fertility rates and shorter gestation periods among GRT women. Child wantedness was also noted to influence pregnancy completeness, which included abortion and miscarriage. More negative infant outcomes were seen in GRT infants than non-GRT infants; this included higher preterm births, lower birth weight, higher rates of intrauterine growth restriction and infant mortality. Risk factors of poorer maternal outcomes were early reproduction, education, smoking, alcohol consumption, deprivation, poor nutrition and perinatal care. Conclusion: This review provides evidence that GRT women and children experience more negative outcomes than general populations. It also highlights the gaps in ethnicity and health inequalities more broadly. The significant importance of this research is the need for increased focus on reducing health inequalities, especially among the GRT community.

Vaccination has a significant impact on morbidity and mortality. High vaccination coverage rates are required to achieve herd protection against vaccine-preventable diseases. However, limited vaccine access and hesitancy among specific communities represent significant obstacles to this goal. This review provides an overview of critical factors associated with vaccination among disadvantaged groups in World Health Organisation European countries. Initial searches yielded 18,109 publications from four databases, and 104 studies from 19 out of 53 countries reporting 22 vaccine-preventable diseases were included. Nine groups representing the populations of interest were identified, and most of the studies focused on asylum seekers, refugees, migrants and deprived communities. Recall of previous vaccinations received was poor, and serology was conducted in some cases to confirm protection for those who received prior vaccinations. Vaccination coverage was lower among study populations compared to the general population or national average. Factors that influenced uptake, which presented differently at different population levels, included health service accessibility, language and vaccine literacy, including risk perception, disease severity and vaccination benefits. Strategies that could be implemented in vaccination policy and programs were also identified. Overall, interventions specific to target communities are vital to improving uptake. More innovative strategies need to be deployed to improve vaccination coverage among disadvantaged groups.

While chronic lung disease causes substantial global morbidity and mortality, global estimates have primarily been based on broad assumptions. Specific country data from low-income countries such as Nepal are limited. This review assessed primary evidence on chronic respiratory disease burden among adults in Nepal. A systematic search was performed in June 2019 (updated May 2020) for studies through nine databases. High levels of heterogeneity deemed a narrative synthesis appropriate. Among 27 eligible studies identified, most were low-moderate quality with cross-sectional and retrospective study design. Chronic lung diseases identified were chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis and restrictive lung diseases. Studies were categorised as: (i) community-based, (ii) hospital-based and (iii) comorbidity-related and disease burden. Reported disease prevalence varied widely (COPD, 1.67–14.3%; asthma, 4.2–8.9%). The prevalence of airflow obstruction was higher among rural dwellers (15.8%) and those exposed to household air pollution from domestic biomass burning as opposed to liquid petroleum gas users (Odds Ratio: 2.06). Several comorbidities, including hypertension and diabetes mellitus added to the disease burden. The review shows limited literature on lung disease burden in Nepal. Publications varied in terms of overall quality. Good quality research studies with prospective cohorts related to respiratory conditions are required.

Background: Community health workers (CHWs) have proven to be successful in mobilizing rural populations to utilize primary health services where they can be supported by skilled health workers. This study assessed the cost-effectiveness of three CHW models implemented in northern Nigeria. Method: Using a quasi-experimental design, we compare the costs and health outcomes for communities where CHW models were implemented versus those where no CHW models were implemented. The three CHW models were Community Volunteer (CV), Nigeria Subsidy Reinvestment and Empowerment Programme for Maternal and Child Health Village Health Worker (VHW), and the Junior Community Health Extension Worker providing community based service delivery (JCHEW-CBSD). The unit costs, consultation patterns, benefit-cost ratios, and cost-effectiveness ratios were calculated for the three CHW models. Results: Compared to the CVs, the VHWs and the JCHEW-CBSDs had the highest levels of interactions in the community, each helping to educate 120-130 pregnant women each year. JCHEW-CBSDs made the most referrals for antenatal care (220) and facility births (122); however, women who interacted with the VHWs increased their antenatal care visits the most, with 92% of the women having made at least one and 70% having made 4+ ANC visits. The unit cost of the CVs was lowest, compared to the other two models, at $127 versus $3176 for the VHW model and $4443 for the JCHEWCBSD model. The outcomes per unit cost ratios were highest for the VHW model. For every $1000 invested in the VHW, there were 54 ANC 4+ visits and 95.9 deliveries attended by a skilled birth attendant. The Incremental Cost-Effectiveness Ratios for the VHW model were also lower than for the JCHEW-CBSD model, ranging from a low of an additional $25 per incremental ANC visits to $152 for increments in attended deliveries, the latter amount three times lower than for the JCHEW-CBSD model. Conclusion: This cost-effectiveness study of CHW models in No

Introduction: The study objective was to assess the potential of using midwives as skilled birth attendants in providing access to maternal health services in rural Nigeria using the Subsidy Reinvestment and Empowerment programme on Maternal and Child Health (SURE P MCH). Method: Baseline survey of 1000 primary health care (PHC) facilities located across all states in the country was conducted before the programme started in 2012. Improvements made on the core indicators for maternal health services were assessed after a follow-up survey. The survey results were also compared to data from rural areas from the 2013 National Demographic Health Survey (NDHS) report. Findings: Total number of antenatal care (ANC) visits at follow-up survey increased by 42%, new ANC visits increased by 39% and four or more ANC visits increased by 30%. Births by skilled birth attendants were up by 56%, postnatal visits increased by 33% and number of women using contraceptive methods increased by 66%. When compared to data from the 2013 NDHS, access to skilled birth attendant and use of modern contraceptives were significant at p<0.0001. Access to antenatal and postnatal services were not significant. The median scores for the core indicators from the geographical zones were significant at p<0.05. Key Conclusions and Implications for practice: Women are more likely to have more supervised births and use more contraceptives in rural facilities when midwifery services are present. The programme model has the potential to strengthen and improve access to maternal health services in rural communities where the need is greatest. Keywords: Midwives; Rural health facilities; Maternal health

Background: Armed conflict in Nigeria resulted in more than 2 million internally displaced persons (IDPs). IDPs live in poor conditions lacking basic resources with variable provision across different locations. This audit aimed to determine the health-related resources available to IDPs in camp-like settings in Nigeria and whether these met international standards. Methods: Using a cross-sectional study approach, information was collected in 9 camps across 7 states from camp managers, and direct observation in September-October 2016. The Sphere minimum standards in humanitarian crises were used as the audit standards. Findings: Five of 15 assessed standards were met to some extent, including the availability of water and shelter. Sanitation and vaccination were unmet in 5 camps, with severe overcrowding in 5 camps, and inadequate waste disposal in all camps. Health programme implementation was uneven, and especially poor in self-settled and dispersed settlements. Conclusion: Inequality in distribution of humanitarian support was observed across different settings, which could lead to a higher likelihood of water, food and air related diseases and thereby, a poorer quality of life for IDPs. Ensuring standardised health assessments could promote a more even distribution of resources across IDP locations.

Background Since 2011, Nigeria has experienced major conflicts from the Boko Haram terrorist group in the north-east region. Over 20 million people have been affected and about two million were forced out of their homes to other countries as refugees or remained in the country as Internally Displaced Persons (IDPs). As of December 2015, the majority of IDPs had settled across 13 of the 37 states in the country, and about 19% (~418,000) lived in camps or camp-like settings. Prior to this conflict, the northern regions had very poor health indices including poor immunisation coverage of 14.2% compared to the national average of 51%. Among the IDPs, the most common health conditions and causes of deaths were related to infectious diseases and severe acute malnutrition. Limited evidence existed on the availability of health-related resources and the IDP health management processes. Also little was known on the perceptions of IDPs in respect to their health. This thesis aimed to review the accessibility and provision of essential health services available to IDPs living in camp-like settings in Northern Nigeria, from both user and provider perspectives. Observed practices were assessed in relation to the IDP health issues and internationally recommended standards. Methods A systematic review was conducted to appraise the essential health interventions implemented among conflict-induced IDP locations in low and middle-income countries from year 2000 to 2017. Primary data were collected in Nigeria, using a cross-sectional mixed-methods study approach, from nine camps across seven states between September and October 2016. Camp audits were performed through direct observations and interviews with camp managers (CMs) and the findings were assessed against 15 of the 40 Sphere minimum standards. A survey was conducted with 2,253 IDPs using an interviewer-administered questionnaire, which included questions on displacement history, living conditions, personal health history, an