A comparative study of governmental financial support and resilience of self-employed people in Sweden and Canada during the COVID-19 pandemic

Globally, self-employed people were among the hardest hit by the repercussions of the COVID-19 pandemic and faced hardships such as financial decline, restrictions, and business closures. A plethora of financial support measures were rolled out worldwide to support them, but there is a lack of research looking at the effect of the policy measures on self-employed people. To understand how different governmental financial support measures enhanced the resilience of the self-employed and improved their ability to manage the pandemic, we conducted a mixed-method study using policy analysis and semi-structured interviews. The documents described policies addressing governmental financial support in Sweden and Canada during the pandemic, and the interviews were conducted with Swedish and Canadian self-employed people to explore how they experienced the support measures in relation to their resilience. The key results were that self-employed people in both countries who were unable to telework were less resilient during the pandemic due to financial problems, restrictions, and lockdowns. The interviews revealed that many self-employed people in hard-hit industries were dissatisfied with the support measures and found them to be unfairly distributed. In addition, the self-employed people experiencing difficulties running their businesses reported reduced well-being, negatively affecting their business survival.

The intersection of social and Indigenous determinants of health for health system strengthening: a scoping review

The COVID-19 pandemic exposed long-standing gaps in health service systems and realities of environmental changes impacting Native nations and Indigenous communities in the US and circumpolar regions. Despite increased awareness and funding, there is limited research and few practical resources available for the work. This is a scoping review of the current literature on social determinants of health (SDOH) impacting Indigenous peoples, villages, and communities in the US and circumpolar region. The review used the York methodology to identify research questions, chart, and synthesize findings. Thirty-two articles were selected for full review and analysis. The articles were scoping reviews, evaluations, and studies. The methods used were 44% mixed (n = 14), 31% quantitative (n = 10) and 25% qualitative (n = 8). The synthesis identified four areas for discussion: 1) systemic and structural determinant study designs, 2) strengthening Indigenous health systems, 3) mapping the relationship of co-occurring health conditions and SDOH, and 4) emergent areas of inquiry. While the scoping review has limitations, it provides a snapshot of broad SDOH and shared Indigenous social determinants of health (ISDOH) to create tailored frameworks for use by tribal and urban Indigenous health organisations, with their partners, in public health and system strengthening.

Health harms that discourage alcohol consumption: A randomized experiment of warning messages

BACKGROUND

Health warnings about alcohol consumption could inform consumers and discourage alcohol consumption, but little is known about what topics these warnings should address. We sought to identify promising topics for alcohol warnings.

METHODS

In January 2024, we recruited a convenience sample of 2,522 US adults ages ≥ 21 years. In an online within-subjects experiment, participants viewed messages about 6 topics (5 warning topics selected from a pool of 16 topics [e.g., liver disease, liver cancer] and 1 control topic [i.e., recycling or reselling products]) shown in random order. For each topic, participants viewed and rated 2 statements about that topic on perceived message effectiveness (primary outcome) and reactance (secondary outcome).

RESULTS

The 16 warning topics elicited higher perceived message effectiveness than the control topic (ps < 0.001). Among the warning topics, liver disease, most cancer types, dementia or mental decline, and hypertension elicited the highest perceived message effectiveness, while breast cancer, sleep, and drinking guidelines elicited the lowest. Fourteen of the 16 warning topics (all except for fetal harms and impaired driving) elicited more reactance than the control topic (ps < 0.001). Warning topics that elicited high perceived message effectiveness generally elicited high reactance, except for messages about liver disease and liver cancer, which elicited high perceived message effectiveness but only moderate reactance.

DISCUSSION

Warning messages about a variety of topics hold promise for discouraging alcohol consumption. Messages about liver disease, most cancer types, dementia or mental decline, and hypertension are perceived as especially effective; however, none of these topics are included in the current US alcohol warning.

Organophosphate ester flame retardant chemicals and maternal depression during pregnancy

BACKGROUND

Depression substantially contributes to pregnancy-related morbidity, and pregnancy is increasingly recognized as a vulnerable window for exposure effects on maternal mental health. Exposures to organophosphate esters (OPEs) are ubiquitous and may have neurotoxic effects; however, their impacts on prenatal depression remain unknown. We evaluated associations of third trimester OPE metabolites on maternal depressive symptoms during pregnancy.

METHODS

This study included 422 participants in the Maternal and Developmental Risks from Environmental and Social Stressors (MADRES) cohort, a prospective pregnancy cohort of primarily low-income and Hispanic participants residing in Los Angeles, California. We measured concentrations of nine OPEs in third trimester spot urine samples (mean gestational age = 31.5 ± 2.0 weeks). Using the Center for Epidemiologic Studies-Depression (CES-D) scale, we classified participants as having probable depression during pregnancy (N = 137) or not (N = 285) if one or more CES-D scores administered at each trimester met the suggested cutoff score for clinically significant depressive symptoms (≥16). We estimated associations of prenatal OPE metabolite concentrations in tertiles and risk of prenatal depression using modified Log-Poisson regression. We examined associations of the OPE mixture on depression during pregnancy using Bayesian kernel machine regression (BKMR).

RESULTS

Participants with the highest tertiles of DPHP and BDCIPP exposure had a 67% (95% CI: 22%, 128%) and 47% (95% CI: 4%, 108%) increased risk of maternal depressive symptoms during pregnancy, respectively. No associations between other OPE metabolites and maternal depression symptoms were observed. In mixture analyses, we observed a positive and linear association between higher exposure to the OPE metabolite mixture and odds of prenatal maternal depression, primarily driven by DPHP.

CONCLUSIONS

Our findings provide new evidence of associations between frequently detected OPE metabolites on maternal depression symptoms during pregnancy. Results could inform future intervention efforts aimed at reducing perinatal maternal depression.

Enrollment and associated factors of the national health insurance program of Nepal: Further analysis of the Nepal Demographic and Health Survey 2022

The focus of this study was on the current enrollment status of the government-funded health insurance (HI) program in Nepal, which is necessary to achieve universal health coverage by 2030. Despite the government's commitment, the program faces challenges of low enrollment and high dropout rates, hindering progress towards this goal. With a purpose to find out the associated factors for enrollment in HI, the cross-sectional study employs secondary data obtained from the Nepal Demographic and Health Survey 2022. A multi-stage sampling method yielded a representative sample of 14,280 households, and an interview was conducted with 14,845 females and 4,913 males aged 15-49. A weighted sample was employed and subsequently analyzed through the use of R. The analysis reveals a concerningly low enrollment rate, with only 10% of the surveyed population possessing government HI. Furthermore, significant geographical disparities were found to exist-Koshi Province had the highest coverage (21.8% men and 20.4% women), while Madhesh Province lagging far behind (3.1% men and 2.7% women). Additionally, the enrollment rates correlated positively with urban residence, higher socioeconomic statuses, and employment, with no subgroup surpassing 30% coverage, though. The study demonstrates a positive association between HI and healthcare utilization, with insured individuals exhibiting a higher likelihood of visiting health facilities and reporting fewer access-related issues. Respondents with higher levels of education and greater wealth were significantly more likely to enroll in HI than those with basic education and middle-level wealth, respectively. This pattern holds consistently for both males and females. These findings suggest that the program, aiming for 60% coverage by 2023/24, is currently off-track. Policymakers should interpret these data as a call for action, prompting the development and implementation of the targeted interventions to address enrollment disparities across Nepal. By focusing on the low-coverage areas and the vulnerable populations, the program can be strengthened and contribute meaningfully to achieving universal health coverage by 2030.

What is the best strategy for iron deficiency anemia prevention and control in Iran? a policy analysis study protocol

BACKGROUND

The present study is a type of exploratory qualitative studies and applied research. The approach of this study is a prospective policy analysis in which we will formulate appropriate policy options to prevent and control iron deficiency anemia in Iran.

METHODS AND MATERIALS

Current study is a multi-method research with an analysis for policy approach containing three phases. First, through a literature review study, policies, programs and interventions of different countries to control and prevent anemia caused by iron deficiency will be identified. Then, in the qualitative phase of the study, the challenges, barriers, facilitators of the policies and programs implemented and ongoing in Iran will be examined. The content and policy-making process, as well as the context and role of stakeholders and actors will be analyzed using the framework of the policy triangle and analysis of the policy process using the Kingdon's multiple streams model. Then, the proposed initial policy options will be developed. In the next phase, an expert panel contain experts, authorities and policymakers will be formed and the proposed options will be reviewed and categorized. In order to prioritize policy options and evaluate their feasibility in Iran, the Delphi technique and the policy options analysis framework of the Centers for Disease Control and Prevention (CDC) will be used. At the end, policy options will be selected based on the highest score and will be presented as appropriate policy options.

CONCLUSION

Prospective policy analysis allows the selection of potentially practical and effective policy options to control iron deficiency anemia. The findings of current study will be presented as reports and research articles for policy makers.

Drug development in LMICs: could the emerging Indian model usher the southeast Asian region?

Low-income and middle-income countries (LMICs) of southeast Asia are passing through a similar phase as India in their tryst with the development of novel drugs. They are beginning to break away from their dependency on the institutions of our developed world. Over the past few years, Tata Memorial Centre-India's premier cancer centre-has shown the tenacity to develop drugs within the national frontiers. By collaborating with the domestic pharmaceutical industries, it has been able to have a steady pipeline of drugs under development, with two of them receiving marketing authorization recently. Lately, Indonesia and Vietnam have also shown an inclination towards public-private partnerships for similar motives. However, due to prolonged innovative stagnation, the entire drug development machinery faces challenges stretching all the way from arranging funds to persuading regulatory bodies. In this Viewpoint, we have tried to address a few of those issues and their potential solutions, with the intention to share our own experience which might be useful to other LMICs in connecting some adamant dots.

Barriers to calling emergency services amongst people who use substances in the event of overdose: A scoping review

BACKGROUND

North America is grappling with an ongoing drug overdose crisis. While harm reduction measures like take-home naloxone kits, and supervised consumption sites, have helped reduce mortality, other strategies to address this public health emergency are required. Good Samaritan Laws (GSLs) offer legal protection for individuals who report overdoses, yet people who use substances (PWUS) may still hesitate to seek help due to concerns about existing legislation. This scoping review explores barriers preventing PWUS from calling emergency services for overdoses, along with potential solutions and facilitators to address this challenge.

METHODS

PRISMA-ScR was used as a guide to conduct this study. Health sciences librarians searched Medline, Embase, PsychINFO, CINAHL, and SCOPUS to identify relevant articles. Six reviewers contributed to screening and extracting the articles through Covidence. Two reviewers performed thematic analysis using NVivo software to identify key barriers and facilitators.

RESULTS

An initial search found 6275 articles for title and abstract screening, resulting in 48 studies meeting the inclusion criteria. The primary barrier to calling 911 pertained to concerns about police arrivng with other first responders, especially regarding their presence and involvement at the scene of overdose. This was followed by legal repercussions, including fear of arrest, incarceration, and fear of eviction, amongst others. Some studies noted the lack of knowledge or trust in GSLs as a deterrent to seeking medical assistance. Additional barriers included concerns about privacy and confidentiality, preference to manage an overdose alone/receive help from another peer, confidence in naloxone effectiveness, limited access to cell phones, peer pressure to not call for help, and identifying as Black, Indigenous, or a Person of Colour (BIPOC). Facilitators include increased GSL awareness among PWUS and law enforcement, expanded legal safeguards for 911 callers, reduced police intervention in overdose cases, and enhanced naloxone availability at key access points.

CONCLUSION

Despite the good intentions of GSLs, PWUS continue to experience significant barriers to calling emergency services in the event of an overdose. Understanding these barriers and key facilitators is necessary to inform future drug policy and advocacy efforts.

Social Disparities and Critical Illness during the Coronavirus Disease 2019 Pandemic: A Narrative Review

The coronavirus disease 2019 (COVID-19) pandemic raised new considerations for social disparities in critical illness including hospital capacity and access to personal protective equipment, access to evolving therapies, vaccinations, virtual care, and restrictions on family visitation. This narrative review aims to explore evidence about racial/ethnic and socioeconomic differences in critical illness during the COVID-19 pandemic, factors driving those differences and promising solutions for mitigating inequities in the future. We apply a patient journey framework to identify social disparities at various stages before, during, and after patient interactions with critical care services and discuss recommendations for policy and practice.

Information Seeking and Avoidance in the COVID-19 Pandemic as a Function of Political Ideology and National Context: A Survey Comparing the US and Germany

The COVID-19 pandemic sparked a globally heightened need for scientific information. At the same time, the abundance of information led to tendencies of media fatigue and information avoidance. Both information seeking and avoidance are embedded in a specific national context, in which conditions of and measures against the pandemic may differ dramatically. In addition, the pandemic quickly became entangled with political ideology. Using the Risk Information Seeking and Processing Model (RISP) as a theoretical background, we investigate the role of national context and political ideology for information seeking and avoidance in a comparative survey in the U.S. and Germany during the early phase of the pandemic. Results show that the factors predicting information behavior are effective in both countries with only few differences: In both countries, perceived hazard characteristics, information norms and perceived information gathering capacity were related to higher information seeking and lower information avoidance. Ideology too is an important influence: Right-leaning ideology was associated with lower levels of information norms in both countries; but only in the US was right-leaning ideology connected to less perceived hazard characteristics and less negative affective responses. Results are discussed regarding their implications for the RISP model.

A scoping review of the impact of ageing on individual consumers' insurance purchase intentions

Recently, the phenomenon of population ageing and its impact on the insurance industry has garnered increasing global attention. However, a notable gap in scholarly research persists in understanding the nuanced effects of ageing on consumer behaviour and insurance purchase intentions. This study maps the current academic evidence on how ageing influences individual consumers' insurance decisions. Using a scoping review methodology aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews and Joanna Briggs Institute guidelines, 44 articles out of 1082 from four databases-Web of Science, Scopus, ScienceDirect, and Emerald Insight-are reviewed. The results reveal a rising interest in this research area, with China emerging as a significant contributor. The focus is predominantly on Theory of Planned Behavior, quantitative methods, questionnaire survey, regression analysis, older population, and general health insurance. Variables capturing the impact of ageing, beyond demographic information, include family-related, risk-related, and expectation-related factors. This study highlights the current state of research on ageing's effect on insurance purchase intentions and offers valuable insights and directions for future research.

The Effect on Travel Distance of a Statewide Regionalization Policy for Initial Breast Cancer Surgery

PURPOSE

Reimbursement strategies to regionalize care can be effective for improving patient outcomes but may adversely affect access to care. We sought to determine the effect on travel distance for surgical treatment of a 2009 New York State (NYS) policy restricting Medicaid reimbursement for breast cancer surgery at low-volume hospitals.

PATIENTS AND METHODS

From a linked data set merging the NYS tumor registry with hospital discharge data, we identified women younger than 65 years with stage I-III first breast tumors from pre- and post-policy periods. We classified patients by urbanicity of their residence into four geographic areas (New York City, other large urban core, suburban/large town, and small town/rural). A multivariable difference-in-difference-in-differences model was used to estimate the policy effect on the distance traveled by Medicaid and non-Medicaid insured patients before and after the policy, by area of residence.

RESULTS

Among the 46,029 study sample, 13.5% were covered by Medicaid. Regardless of insurance, women treated more recently traveled longer distances to their surgical facility than those in the prepolicy period. Regardless of time period, Medicaid beneficiaries drove fewer miles to treatment than women with other insurance. Although all women traveled greater distances postpolicy, the increase was not significantly different by insurance status (Medicaid or not), except for those living in suburban areas in which Medicaid patients traveled further postpolicy (+7.7 miles compared with +3.4 miles for non-Medicaid; P = .007).

CONCLUSION

After a policy regionalizing surgical care, only suburban Medicaid patients experienced a statistically significant (albeit small) increase in travel distance compared with non-Medicaid patients. In the state of NY, regionalization of breast cancer care yielded improved outcomes with minimal decrease in access.

Modern contraceptive utilization among women of reproductive age in Ghana: a multilevel mixed-effect logistic regression model

BACKGROUND

Worldwide, sexual and reproductive health remains a prominent public health concern for women of reproductive age. Modern contraceptive methods play a crucial role in enabling individuals and families to regulate fertility, thereby reducing unintended pregnancies, abortions, pregnancy-related complications, and mortality. Due to the scarcity of reliable and current data regarding the factors affecting the adoption of modern contraceptives among women of reproductive age at the national level in Ghana, this research aimed to explore the determinants of modern contraceptive usage among reproductive age women.

METHODS

The study analyzed data from the 2022 Ghana Demographic and Health Survey, including a weighted sample of 6,839 reproductive-age women. By employing a multilevel logistic regression model, the study sought to determine factors associated with the utilization of modern contraceptives. Associations between explanatory variables and the outcome were evaluated using adjusted odds ratios (AORs) along with 95% confidence intervals (CIs). Statistical significance was established using a p-value threshold of less than 0.05. All statistical analyses were conducted using STATA version 17 software.

RESULTS

The study found that 26.36% (95% CI: 25.33-27.34%) of women of reproductive age in Ghana used modern contraceptives. Secondary education (AOR = 1.26, 95% CI = 1.03-1.53), poorer household (AOR = 1.30, 95% CI = 1.05-1.61), women's marital status, i.e. married (AOR = 1.46, 95% CI = 1.16-1.83), living with a partner (AOR = 1.65, 95% CI = 1.32-2.06), divorced (AOR = 2.53, 95% CI = 1.48-4.31), and separated (AOR = 1.70, 95% CI = 1.21-2.37), multipara (AOR = 1.39, 95% CI = 1.04-1.87), were the factors that promote modern contraceptive utilization. Women's age in years, i.e. 35-39 (AOR = 0.71, 95% CI = 0.52-0.97), 40-44 (AOR = 0.63, 95% CI = 0.44-0.90), and 45-49 (AOR = 0.45, 95% CI = 0.25-0.79), history of pregnancy loss (AOR = 0.86, 95% CI = 0.76-0.98), region, i.e. Greater Accra (95% CI = 0.42-0.92), Bono East (95% CI = 0.32-0.81), Northern (95% CI = 0.28-0.67), Savannah (95% CI = 0.28-0.81), and North East (95% CI = 0.20-0.63), were all associated with a lower use of modern contraceptives.

CONCLUSIONS

Modern contraceptive utilization was low in this study. Factors such as women's education, socioeconomic status, and marital status were associated with increased modern contraceptive utilization, whereas women's age and regional disparities were linked to lower usage rates. These findings emphasize the need for targeted interventions to address socioeconomic barriers and regional disparities in access to family planning services across Ghana.

Racial and Ethnic Disparities and the National Burden of COVID-19 on Inpatient Hospitalizations: A Retrospective Study in the United States in the Year 2020

BACKGROUND

Since January 2020, COVID-19 has affected more than 100 million people in the U.S. Previous studies on racial and ethnic disparities related to characteristics and outcomes of COVID-19 patients have been insightful. However, appropriate epidemiologic age-standardization of the disease burden and disparities for hospitalization data are lacking.

OBJECTIVE

To identify and describe racial and ethnic disparities for primary COVID-19 hospitalizations in the U.S. in 2020.

METHODS

In this nationally representative observational study, we use the National Inpatient Sample to quantify racial and ethnic disparities in COVID-19 hospitalizations. Descriptive statistics for patient characteristics, common comorbidities, age-standardized hospitalization rates, inpatient complications, and mortality among COVID-19 hospitalizations were contrasted by race and ethnicity.

RESULTS

There were 1,058,815 primary COVID-19 hospitalizations in 2020. Of those, 47.2% were female, with median age of 66 (IQR, 54, 77). Overall inpatient mortality rate was 11.1%. When compared to White patients, Black, Hispanic, and Native American patients had higher age-standardized hospitalization rate ratios of 2.42 (95% CI 2.40-2.43), 2.26 (2.25-2.28), and 2.51 (2.46-2.56), respectively. Non-White patients had increased age-adjusted rates for procedures and complications. Factors associated with inpatient mortality include age, male sex, Hispanic or Native American race or ethnicity, lower income, Medicaid, heart failure, arrhythmias, coagulopathy, and chronic liver disease.

CONCLUSIONS

Marginalized populations in the U.S. had over twice the COVID-19 hospitalization rate relative to White patients. Age-adjusted mortality rates were highest for Black, Hispanic, and Native American patients. Careful consideration for vulnerable populations is encouraged during highly communicable respiratory pandemics.

Social isolation and loneliness among people living with experience of homelessness: a scoping review

Social isolation and loneliness (SIL) are public health challenges that disproportionally affect individuals who experience structural and socio-economic exclusion. The social and health outcomes of SIL for people with experiences of being unhoused have largely remained unexplored. Yet, there is limited synthesis of literature focused on SIL to appropriately inform policy and targeted social interventions for people with homelessness experience. The aim of this scoping review is to synthesize evidence on SIL among people with lived experience of homelessness and explore how it negatively impacts their wellbeing. We carried out a comprehensive literature search from Medline, Embase, Cochrane Library, PsycINFO, CINAHL, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index for peer-reviewed studies published between January 1st, 2000 to January 3rd, 2023. Studies went through title, abstract and full-text screening conducted independently by at least two reviewers. Included studies were then analyzed and synthesized to identify the conceptualizations of SIL, measurement tools and approaches, prevalence characterization, and relationship with social and health outcomes. The literature search yielded 5,294 papers after removing duplicate records. Following screening, we retained 27 qualitative studies, 23 quantitative studies and two mixed method studies. SIL was not the primary objective of most of the included articles. The prevalence of SIL among people with homelessness experience varied from 25 to 90% across studies. A range of measurement tools were used to measure SIL making it difficult to compare results across studies. Though the studies reported associations between SIL, health, wellbeing, and substance use, we found substantial gaps in the literature. Most of the quantitative studies were cross-sectional, and only one study used health administrative data to ascertain health outcomes. More studies are needed to better understand SIL among this population and to build evidence for actionable strategies and policies to address its social and health impacts.

Surveillance strategies for SARS-CoV-2 infections through one health approach

Coronavirus disease-2019 (COVID-19), caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), is an emergent disease that threatens global health. Public health structures and economic activities have been disrupted globally by the COVID-19 pandemic. Over 556.3 million confirmed cases and 6.3 million deaths have been reported. However, the exact mechanism of its emergence in humans remains unclear. SARS-CoV-2 is believed to have a zoonotic origin, suggesting a spillover route from animals to humans, which is potentially facilitated by wildlife farming and trade. The COVID-19 pandemic highlighted the importance of the One Health approach in managing threats of zoonosis in the human-animal-environment interaction. Implementing vigilant surveillance programs by adopting the One Health concept at the interfaces between wildlife, livestock, and humans is the most pertinent, practical, and actionable strategy for preventing and preparing for future pandemics of zoonosis, such as COVID-19 infection. This review summarizes the updated evidence of CoV infections in humans and animals and provides an appropriate strategy for preventive measures focused on surveillance systems through an On Health approach.

Examining the risk factors of chronic pelvic pain and its effect on the quality of life in refugee and non-refugee women

BACKGROUND

This study aimed to determine the prevalence of chronic pelvic pain(CPP) in refugee and non-refugee women, determine the factors associated with CPP, and evaluate the effect of CPP on life quality.

METHODS

This was a cross-sectional study conducted among 283 non-refugee and 278 refugee women in Turkey. A questionnaire including questions assessing chronic pelvic pain and related factors, World Health Organization Quality of Life Scale Short Form(WHOQOL-BREF), Depression Anxiety Stress Scale-21, were administered to the participants. Chi-square test, Mann-Whitney U test and multiple logistic regression analysis were used for statistical analysis.

RESULTS

The prevalence of chronic pelvic pain was 41.0% in refugee women and 19.1% in non-refugee women (p< 0.001). The prevalence of CPP was 1.68 times higher in refugee women than in non-refugee women (OR;95%CI:1.68;1.01-2.81). In the multivariate analysis performed in the study group, refugee status, low family income status(OR;95%CI:2.09;1.26-3.46), low back pain(OR;95%CI:2.02;1.21-3.35), dyspareunia (OR; 95%CI:2.96;1.75-4.99), number of three or more miscarriages (OR;95%CI:3.07;1.18-8.01), history of gynaecological surgery (OR;95%CI:2.44;1.33-4.50), diarrhea (OR;95%CI:2.01;1.07-3.76), urinary tract infections(OR; 95%CI:1.66;1.02-2.71) and anxiety(OR; 95%CI:1.17;1.10-1.24) were found to be risk factors for CPP. In the refugee and non-refugee groups, those with CPP had lower scores in all subdomains of the WHOQOL-BREF scale than those without CPP (p < 0.05).

CONCLUSIONS

Refugee status independently contributes to the risk of developing CPP. Targeted interventions to address CPP and its associated risk factors are needed, particularly in vulnerable refugee populations, to improve their quality of life.

Interplay between sanctions, donor conditionality, and food insecurity in complex emergencies: the case of Syria

Thirteen years into conflict, Syria remains one of the world's major humanitarian crises. Food insecurity has reached unprecedented levels in the country, with millions of civilians facing starvation and hunger. The key drivers of this are conflict-related, nature-induced, and, importantly, man-made policies. Semi-comprehensive sanctions against the country and donor conditionality vis-à-vis humanitarian operators' work are prime examples of the latter. These policies are inextricably linked with food insecurity in Syria and have direct and indirect impacts on it. Understanding the ongoing crisis as a complex emergency, this paper examines the interplay between sanctions, donor conditionality, and food insecurity, an understudied subject in the Syrian context. It explores how sanctions and donor conditionality influence three key dimensions of food security, namely, availability, affordability and economic access, and utilisation, and subsequently worsen the conditions confronting the Syrian population. The paper contributes to discussions on food security in conflict settings and how sanctions negatively affect civilians in targeted countries.

Associations of Individual Characteristics and Socioeconomic Status With Heated Tobacco Product Harmfulness Perceptions in Japan: A Nationwide Cross-sectional Study (INFORM Study 2020)

BACKGROUND

In Japan, heated tobacco products (HTPs) are promoted by the tobacco industry as reduced-risk tobacco products despite the lack of evidence for this claim. This study determined the distribution of HTP-harmfulness perception and identified the explanatory factors associated with the perception of HTP as less harmful than conventional cigarettes.

METHODS

A nationwide cross-sectional survey was conducted with Japanese people aged 20 years or older (INFORM Study 2020) using a self-administered questionnaire. We performed descriptive analysis and weighted logistic regression analysis to examine the relationship between explanatory factors (eg, individual characteristics, socioeconomic status, and trusted sources of cancer information) and the perception of HTPs as less harmful.

RESULTS

Among 3,420 participants, the proportions of those who perceived HTPs as less harmful were 40.3% and 18.3% for users and non-users of tobacco, respectively. For participants aged 20-39 years, the proportions were 49.9% and 30.4%, respectively. Among 1,160 tobacco non-users who were familiar with HTPs, male, aged under 39 years, and having lower education were associated with the perception of HTPs as less harmful. Trusted sources of cancer information were not associated with the perception of HTPs as less harmful.

CONCLUSION

This study showed that, among tobacco non-users, being male, aged under 39 years, and having lower education were associated with a perception of HTPs as less harmful. Public health stakeholders should provide the latest evidence about HTP harmfulness in their daily practice and strengthen the regulations on HTP marketing directed at both tobacco- and tobacco non-users.

Insect frass fertilizer as a regenerative input for improved biological nitrogen fixation and sustainable bush bean production

Bush bean (Phaseolus vulgaris L.) production is undermined by soil degradation and low biological nitrogen fixation (BNF) capacity. This study evaluated the effect of black soldier fly frass fertilizer (BSFFF) on bush bean growth, yield, nutrient uptake, BNF, and profitability, in comparison with commercial organic fertilizer (Phymyx, Phytomedia International Ltd., Kiambu, Kenya), synthetic fertilizer (NPK), and rhizobia inoculant (Biofix, MEA Fertilizers, Nairobi, Kenya). The organic fertilizers were applied at rates of 0, 15, 30, and 45 kg N ha-1 while the NPK was applied at 40 kg N ha-1, 46 kg P ha-1, and 60 kg K ha-1. The fertilizers were applied singly and in combination with rhizobia inoculant to determine the interactive effects on bush bean production. Results showed that beans grown using BSFFF were the tallest, with the broadest leaves, and the highest chlorophyll content. Plots treated with 45 kg N ha-1 BSFFF produced beans with more flowers (7 - 8%), pods (4 - 9%), and seeds (9 - 11%) compared to Phymyx and NPK treatments. The same treatment also produced beans with 6, 8, and 18% higher 100-seed weight, compared to NPK, Phymyx, and control treatments, respectively. Beans grown in soil amended with 30 kg N ha-1 of BSFFF had 3-14-fold higher effective root nodules, fixed 48%, 31%, and 91% more N compared to Phymyx, NPK, and rhizobia, respectively, and boosted N uptake (19 - 39%) compared to Phymyx and NPK treatments. Application of 45 kg N ha-1 of BSFFF increased bean seed yield by 43%, 72%, and 67% compared to the control, NPK and equivalent rate of Phymyx, respectively. The net income and gross margin achieved using BSFFF treatments were 73 - 239% and 118 - 184% higher than the values obtained under Phymyx treatments. Our findings demonstrate the high efficacy of BSFFF as a novel soil input and sustainable alternative for boosting BNF and improving bush bean productivity.

Suicide Risk Identified among Transgender and Gender Diverse Youth in the Emergency Department (2019-2022)

BACKGROUND AND OBJECTIVES

Suicide risk identified via universal screening in healthcare settings is associated with subsequent suicidal behavior and is an important prevention strategy. The prevalence of positive suicide risk screening among transgender and gender diverse (TGD) youth in the emergency department (ED) has not been described. The current study examined the association between gender identity and suicide risk screening results, adjusted for other demographic and clinical characteristics.

METHODS

Retrospective cross-sectional study of electronic medical record data from ED visits November 2019-August 2022 in an urban academic children's hospital. Participants were youth ages 8-25 who received the Ask Suicide-Screening Questions suicide risk screening tool.

RESULTS

Of 12,112 ED visits with suicide risk screening performed (42% male, median age 14 [12, 16]), 24% had positive screens. Of 565 visits by TGD youth, 78.1% had positive screens and 9.5% had active suicidal ideation. Compared to visits by cisgender females, the adjusted odds of positive screens was 5.35 times higher (95% CI 3.99, 7.18) among visits by TGD youth and 0.45 times lower (95% CI 0.40, 0.52) among visits by cisgender males. Compared to visits by cisgender females, the adjusted odds of active suicidal ideation was higher for cisgender males (aOR 1.34, 95% CI 1.07, 1.68) but did not significantly differ for TGD youth.

CONCLUSIONS

TGD youth have high rates of positive suicide risk screening in the ED, demonstrating substantial mental health needs. Opportunities may be available to improve detection, evidence-based brief interventions, and linkage to mental health services for this population.

An incomplete picture: A scoping review of how scholars account for race and ethnicity in family homelessness research

Families of color in the United States experience homelessness at a disproportionately higher rate than White families; however, little is known about how scholars account for race and ethnicity in family homelessness research. This scoping review analyzes how researchers examine race and ethnicity in conceptual frameworks, methods, and analysis. Following PRISMA-ScR reporting standards, I searched PubMed, PsycINFO, Scopus, and ERIC for quantitative studies including a housing outcome for homeless service-involved families. I used Covidence to screen for inclusion and extract data, and QuADS to evaluate study quality. Fourteen studies met inclusion criteria. Researchers' articles lacked theory and the context of racism, lacked detail on how race and ethnicity were conceptualized and operationalized, and most (71%) did not disaggregate results. Without putting data within the context of systemic racism and disaggregating outcomes, research will produce incomplete knowledge on family homelessness, leading to ineffective interventions for families of color.

Additive Orthodiagonal Rhytidoplasty of the Ergotrid: A Novel Treatment Technique for Severe Dynamic Lip Lines

SUMMARY

Dynamic lip lines pose a challenge in perioral rejuvenation despite the availability of numerous hyaluronic acid dermal filler products and techniques. In this article, the authors introduce additive orthodiagonal rhytidoplasty of the ergotrid, or ADORE, a novel technique for the treatment of severe dynamic lip lines. Based on an objective analysis of treatment outcomes, the authors' technique demonstrates the ability to confer substantial improvement in dynamic lip line severity, with a median reduction in lip line intensity of 79% (average, 70%; SD, 19%) at 1 month and 72% (average, 61%; SD, 21%) at 6 months, and a high degree of patient satisfaction.

Impact of a school-based food assistance program on household food insecurity in Greece, 2012-2019: a multi-year evaluation of the DIATROFI program

Background

Childhood food insecurity can persist among low socioeconomic areas in high-income countries. Universal Free School Meal (UFSM) programs are designed to respond to this pressing issue. This study aimed to conduct a multi-year evaluation of the DIATROFI Program's impact on household food insecurity in Greece.

Methods

This study utilized data from 18,716 students (618 kindergarten to high schools), from low socioeconomic areas participating in the school-level UFSM Program DIATROFI between 2012 and 2019. Parents of students completed annual baseline and follow-up paper-based self-completed questionnaires. The primary outcome was household food insecurity, measured using the Food Security Survey Module (FSSM) at both questionnaires, and evaluated through mixed linear and logistic regression models with repeated measurements.

Findings

Students' median age was 9 years old (Interquartile range (IQR): 6.5, 12.0), 51.6% (n = 9658) were girls, and 82.2% (n = 15,382) lived in low/medium socioeconomic affluence households. Households with food insecurity reduced from 51.5% (n = 9630) to 47.6% (n = 8901) after one school year. Food insecurity score declined steadily for four years of consecutive participation, compared to baseline score (one-year b:-0.26; 95% Confidence Interval (CI):-0.30, -0.22, and four-year -1.28; -1.53, -1.03). The likelihood of retaining food insecure status reduced from 17% after one-year participation (Odds Ratio (OR): 0.83; 95% CI: 0.79, 0.87) to 36% after four-year participation (0.64; 0.49, 0.82). The Program's impact on household food insecurity alleviation was greater among households with low parental education and low socioeconomic affluence.

Interpretation

The DIATROFI Program effectively improved household food security during and after the Greek socioeconomic crisis. School-level UFSM programs targeting underprivileged students can improve household food insecurity, with a more pronounced effect with increased years of participation, and among economically disadvantaged households.

Funding

The DIATROFI Program was funded through various national and private organizations, including national prefecture authorities, Greek payment authorities, philanthropic/charitable organizations, and private companies.

Development of Indian Council of Medical Research (ICMR) Standard Treatment Workflows for Skin Diseases: A Step Toward Universal Health Coverage

Background

Skin conditions form a major bulk of diseases in the community. With a disproportionately low number of dermatologists in the country, and a greatly unequal distribution between urban versus rural areas, ineffective treatment and mismanagement of skin conditions are, however, commonplace.

Objective

To develop standard treatment workflows (STWs) for certain skin diseases for use by clinicians at primary, secondary, and tertiary care centers.

Methodology

Seven members, from various academic institutes across the country, were selected for formulation of the STWs. They were provided logistic and technical support by the ICMR, Department of Health Research (DHR), and WHO India office. Multiple rounds of online and physical discussions were performed to identify topics that would be most useful in the management of skin diseases for the health care personnel (HCP) and subsequently to frame the STW content.

Results

The selected diseases included acne and rosacea, alopecia, bacterial skin infections, cutaneous adverse drug reactions, dermatophytosis, eczema/dermatitis, immunobullous dermatoses, psoriasis, scabies, varicella and herpes, vitiligo, and urticaria. There was one separate module on rational use of topical corticosteroids. The STWs for these conditions have been finalised and are available as physical posters in health centers and can also be accessed online and through mobile applications.

Conclusion

Thirteen STW modules have been prepared with a view to optimize management of skin diseases at various levels of health care system of the country.

San Raymundo: Focus Group About Comadronas' Response to Obstetrical Emergencies in Urban Guatemala

INTRODUCTION

Comadronas attend most births in rural and urban Guatemala where the maternal mortality rate (MMR) is highest in Latin America. Information has been published regarding rural comadronas' response to obstetrical emergencies. Understanding urban comadronas' response to obstetrical emergencies is essential to addressing Guatemala's MMR.

METHODS

A total of 17 urban comadronas participated in one, 34-min focus group to share their knowledge, practices, and attitudes regarding obstetrical emergencies. We used the long table to analyze the content to develop a matrix of themes.

RESULTS

Five themes emerged. Urban comadronas receive consistent training, have hospital transportation, and feel confident in their knowledge, but they lack equipment and feel hospital providers disrespect them. Still, the joy of attending births outweighs the challenges they face.

DISCUSSION

Urban comadronas described a different experience of responding to obstetrical emergencies than rural comadronas. Distinct approaches are needed to provide culturally congruent support for urban and rural comadronas when responding to obstetrical emergencies.

Examining the effects of voluntary avoidance behaviour and policy-mediated behaviour change on the dynamics of SARS-CoV-2: A mathematical model

Background

Throughout the SARS-CoV-2 pandemic, policymakers have had to navigate between recommending voluntary behaviour change and policy-driven behaviour change to mitigate the impact of the virus. While individuals will voluntarily engage in self-protective behaviour when there is an increasing infectious disease risk, the extent to which this occurs and its impact on an epidemic is not known.

Methods

This paper describes a deterministic disease transmission model exploring the impact of individual avoidance behaviour and policy-mediated avoidance behaviour on epidemic outcomes during the second wave of SARS-CoV-2 infections in Ontario, Canada (September 1, 2020 to February 28, 2021). The model incorporates an information feedback function based on empirically derived behaviour data describing the degree to which avoidance behaviour changed in response to the number of new daily cases COVID-19.

Results

Voluntary avoidance behaviour alone was estimated to reduce the final attack rate by 23.1%, the total number of hospitalizations by 26.2%, and cumulative deaths by 27.5% over 6 months compared to a counterfactual scenario in which there were no interventions or avoidance behaviour. A provincial shutdown order issued on December 26, 2020 was estimated to reduce the final attack rate by 66.7%, the total number of hospitalizations by 66.8%, and the total number of deaths by 67.2% compared to the counterfactual scenario.

Conclusion

Given the dynamics of SARS-CoV-2 in a pre-vaccine era, individual avoidance behaviour in the absence of government action would have resulted in a moderate reduction in disease however, it would not have been sufficient to entirely mitigate transmission and the associated risk to the population in Ontario. Government action during the second wave of the COVID-19 pandemic in Ontario reduced infections, protected hospital capacity, and saved lives.

'We're at war.' Healthcare workers' experience with organisational change, uncertainty and vaccine hesitancy in 2021 and 2022 during the COVID-19 vaccination programe in Poland

This article analyses the organisation of the mass COVID-19 vaccination programme in Poland and its consequences for various aspects of the social identity of healthcare workers (HCWs). Based on 31 in-depth interviews with HCWs, our study reveals the following: (1) Certain elements of the programme (inclusion of other healthcare professionals like pharmacists and laboratory diagnosticians as vaccinators) and the provision of additional infrastructure (pharmacies and shopping malls) may prompt scepticism and criticism in physicians and nurses who feel challenged about their professional autonomy and hierarchies; (2) Given the high levels of professional uncertainty, the implementation of the COVID-19 vaccination is forcing HCWs to revise their attitude to medical standards, resulting in specific responses and adaptation strategies (ranging from the active involvement in the programme due to the sense of mission, to more or less evident scepticism); and (3) Confronting vaccine hesitancy, both among patients and other HCWs, contributes to the feeling of helplessness, leading to criticism of policymakers.

A Scoping Review to Identify Community- and Societal-Level Strategies Evaluated from 2013 to 2023 for Their Potential Impact on Child Well-Being in the United States

There is increased recognition for solutions that address the social determinants of health (SDOHs)-the context in which families are raising children. Unfortunately, implementing solutions that address inequities in the SDOHs has proven to be difficult. Many child and family serving systems and communities do not know where to start or do not have the capacity to identify and implement upstream SDOH strategies. As such, we conducted a scoping review to assess the status of evidence connecting strategies that address the SDOHs and child well-being. A total of 29,079 records were identified using natural language processing with 341 records meeting inclusion criteria (e.g., outcomes focused on child well-being, interventions happening at a population level, and evaluations of prevention strategies in the United States). Records were coded, and the findings are presented by the SDOH domain, such as strategies that addressed economic stability (n = 94), education access and quality (n = 17), food security (n = 106), healthcare access and quality (n = 96), neighborhood and built environment (n = 7), and social and community context (n = 12). This review provides an overview of the associations between population-level SDOH strategies and the impact-good and bad-on child well-being and may be a useful resource for communities and practitioners when considering equitable solutions that promote thriving childhoods.

Changes in School-Age Children's Well-being and School-Related Needs Post COVID-19 Pandemic

COVID-19 highlighted the importance of schools for child health, as emerging data suggest that pandemic-related school closures may have led to worsening child health and exacerbated health disparities. This study examines school-aged children's well-being, and characterizes changes in school-related needs, from 2021 to 2022. This is a secondary analysis of a longitudinal cohort study, where a nationally representative sample of parents of school-aged children were surveyed in June 2021 and 2022. The percentage of children with deficits in total difficulties, hyperactivity, and prosocial behavior decreased at follow-up, while a high percentage of children continued to experience peer problems. At least one school-related need remained for most parents. Highest priority needs were academic enrichment, socialization, physical activity, tutoring, and coping with stress. Academic support and social-emotional well-being remained major parental concerns, with social development showing significant deficit. Improvements in child well-being were experienced unequally across demographic groups.

Workplace Exposures Vary Across Neighborhoods in the US: Implications on Social Vulnerability and Racial/Ethnic Health Disparities

Ignoring workplace exposures that occur beyond the local residential context in place-based risk indices like the CDC's Social Vulnerability Index (SVI) likely misclassifies community exposure by under-counting risks and obscuring true drivers of racial/ethnic health disparities. To investigate this hypothesis, we developed several place-based indicators of occupational exposure and examined their relationships with race/ethnicity, SVI, and health inequities. We used publicly available job exposure matrices and employment estimates from the United States (US) Census to create and map six indicators of occupational hazards for every census tract in the US. We characterized census tracts with high workplace-low SVI scores. We used natural cubic splines to examine tract level associations between the percentage of racial/ethnic minorities (individuals who are not non-Hispanic White) and the occupational indicators. Lastly, we stratified each census tract into high/low occupational noise, chemical pollutant, and disease/infection exposure to examine racial/ethnic health disparities to diabetes, asthma, and high blood pressure, respectively, as a consequence of occupational exposure inequities. Our results show that racial/ethnic minority communities, particularly those that are also low-income, experience a disproportionate burden of workplace exposures that may be contributing to racial/ethnic health disparities. When composite risk measures, such as SVI, are calculated using only information from the local residential neighborhood, they may systematically under-count occupational risks experienced by the most vulnerable communities. There is a need to consider the role of occupational justice on nationwide, racial/ethnic health disparities.

Risk Factors for Food Insecurity among Early Childhood Education Providers: Time for a Solution

The COVID-19 pandemic exacerbated challenges in the child care industry, leading to closures and financial strain. Early care and education (ECE) providers faced reduced income, increased debt, and material hardships such as food insecurity. Using survey data collected through the Child Care Resource Center (CCRC), this study examines the association between food insecurity risk, sociodemographic factors, and pandemic-related service changes among ECE providers in California. The results showed that income, race, and increased food costs were significantly associated with a higher risk of food insecurity among ECE providers. Compared to incomes greater than USD 60,000, those earning USD 40,000-USD 49,999 and USD 50,000-USD 59,999 had higher odds of food insecurity (OR: 1.94, 95% CI: 0.683-1.86; OR: 2.12, 95% CI: 0.623-1.81, respectively). Black (OR: 1.89, 95% CI: 1.21-2.94) and multi-racial respondents (OR: 1.71, 95% CI: 1.1-2.65) had higher odds of food insecurity than white respondents. Lastly, respondents experiencing increased food costs had greater odds of food insecurity (OR: 4.52, 95% CI: 2.74-7.45). These findings suggest the need for policies and interventions aimed at increasing food access among vulnerable ECE providers. Such interventions will better protect them from financial shocks and the risk of food insecurity, and will support their crucial role in healthy child growth and development.

One Health Ethics and the Ethics of Zoonoses: A Silent Call for Global Action

This paper presents a critical review of key issues related to the emergence of new networks for the spread of zoonotic diseases amid the mass extinction of species. Zoonotic and infectious diseases account for approximately 70% of new and existing diseases affecting humans and animals. The initial section argues that the term "zoonoses" should not be confined to single-cause events within veterinary medicine. Instead, zoonoses should be viewed as complex, systemic phenomena shaped by interrelated factors, including environmental, sociocultural, and economic elements, influenced by anthropogenic climate change. The second section presents bioethical principles and potential strategies for those engaged in zoonotic disease prevention. The third section uses the slaughter of animals in disaster settings as a case study to illustrate the need for further clarification of normative and interspecies justice conflicts in One Health ethics. This section concludes with an outlook on "zoonoethics". Section four develops the analysis of the interlinked elements that trigger zoonoses and examines antimicrobial resistance (AMR) from an ethical and political standpoint, concluding with policy recommendations for addressing AMR. Section five offers a critical reflection, integrating contributions from zoonoethics, human ecology, and the ecotheological turn. Finally, section six concludes with a call to action and policy recommendations for an inclusive, intercultural, and gender-sensitive One Health approach.

Problems accessing health care and under-5 mortality: a pooled analysis of 50 low- and middle-income countries

BACKGROUND

Access to health care remains suboptimal in low- and middle-income countries (LMICs) and continues to hinder survival in early childhood. We systematically assessed the association between problems accessing health care (PAHC) and under-five mortality (U5M).

METHODS

Child mortality data on 724 335 livebirths came from the latest Demographic and Health Surveys of 50 LMICs (2013-2021). Reasons for PAHC were classified into three domains: 'money needed for treatment' (economic), 'distance to health facility' (physical), 'getting permission' or 'not wanting to go alone' (socio-cultural). Multivariable logistic regression was used to estimate the association between PAHC (any and by each type) and U5M.

RESULTS

In our pooled sample, 47.3 children per 1000 livebirths died before age of 5, and 57.1% reported having experienced PAHC (ranging from 45.3% in Europe & Central Asia to 72.7% in Latin America & Caribbean). Children with any PAHC had higher odds of U5M (OR: 1.05, 95% CI: 1.02, 1.09), and this association was especially significant in sub-Saharan Africa. Of different domains of PAHC, socio-cultural PAHC was found to be most significant.

CONCLUSIONS

Access to health care in LMICs needs to be improved by expanding health care coverage, building health facilities, and focusing more on context-specific socio-cultural barriers.

Sensitivity assessment of optimal control strategies and cost-effectiveness analysis of a novel Candida Auris environmental transmission model in intensive care facilities

Candida Auris is an emerging fungal pathogen flagged by CDC as a serious global health threat among nosocomial infections in the recent times. As an evolving pathogen that often goes misidentified or unidentified under standard laboratory tests, it has the ability to cause fatal infections among the target population involving patients with serious medical conditions admitted to intensive care facilities, due to its capacity to resist anti-fungal treatment and the ability to persist in the hospital environment for long periods. The subject of this paper is to develop a deterministic model to study the transmission nature of Candida Auris wherein measures like apt admission screening methods with weekly screening follow-ups, transmission prevention, proper treatment protocols and environmental disinfection procedures are introduced as constant mitigating controls into the model initially which are later redefined as variable control functions during the optimal control analysis. The theory of optimal control implemented into the model helps us to understand the sensitivity of each control strategy upon the behaviour of each state variable. Further, cost-effectiveness analysis is rigorously conducted using incremental cost-effectiveness ratio (ICER) to identify and rank the control strategies involved based on their economic efficiency. Numerical simulation for the optimal control analysis is performed in MATLAB using the Forward-Backward Sweep Method and the findings are illustrated graphically.

Effects of Resource Sharing Networks on Community Anti-Drug Coalitions' Outcomes: A Social Network Analysis

Substance use-related problems continue to be a national public health crisis despite years of prevention efforts. Community anti-drug coalitions are well positioned to address substance use at local levels. Coalitions often rely on their members to connect to resources they need to address community issues and plan for sustainability over time. Such capacity building occurs through voluntary cooperation among members, making it essential to understand the role network connections play. This study sought to determine whether structural characteristics of coalitions' resource sharing networks impact members' perceptions of community improvement and coalition sustainability. Surveys at two timepoints collected data from 68 coalitions in Pennsylvania and Missouri on members' connections or ties to share information, personnel, money, or other types of collaboration. Analyses examined how coalition-level measurements of sectoral diversity, density, and resource sharing centralization, respectively, were associated with members' perceptions of community improvement, sustainability planning, and coalition sustainability. Sectoral diversity and centralization were unrelated to study outcomes. Density was also unrelated with perceived community improvement and sustainability planning. However, two facets of cooperative density were positively associated with perceived coalition sustainability: the density of ties to share information and the density of multiple types of collaborative ties. This study suggests that both information and other collaborative ties foster perceived coalition sustainability, although not community improvement.

Evaluating Multi-Jurisdictional Enteric Illness Outbreak Messaging in Canada: A Content Analysis of Public Health Notices

Effective risk communication during enteric illness outbreaks requires the provision of clear and consistent information to diverse audiences to reduce risk of exposure, inform behavior changes, and prevent illness. Most enteric illnesses are caused by pathogens transmitted through consumption of contaminated food or water, contact with animals, or person-to-person contact. When multi-jurisdictional outbreaks occur, the Public Health Agency of Canada posts web-based Public Health Notices (PHNs) to inform Canadians. This study evaluated the comprehensibility of PHNs to optimize federal risk communication approaches. Publicly available web-based PHNs (n = 42) from 2014-2022 were obtained. A codebook was developed using the Centers for Disease Control and Prevention's (CDC) Clear Communication Index (CCI) and Health Belief Model (HBM) and systematically applied. A SMOG readability calculator was used to determine reading grade level. Descriptive statistics were calculated to summarize coded data. The average reading grade level was above Grade 12 (13.9 ± 1.1). PHNs communicated the nature of the risk (100%) and behavioral recommendations (96.5%) clearly. An active voice was sometimes used (61.9%), but numerical information was less commonly presented using best practices (38.1%). The HBM was fully incorporated in seven PHNs, with most PHNs using five of six constructs (66.7%). PHNs shared similar information in a consistent order (75.0%). Aligning PHNs to best practices in risk communication is recommended, including writing content at a reading grade level that supports comprehension by diverse audiences, following the CCI to increase clarity, including all HBM constructs to promote behavior change, and maintaining message consistency.

Performance evaluation of Mexico's health system at the national and subnational level, 1990-2019: an analysis of the Health Access and Quality Index

OBJECTIVES

This study aimed to comprehensively evaluate Mexico's health system performance from 1990 to 2019 utilising the Health Access and Quality Index (HAQI) as a primary indicator.

STUDY DESIGN

A retrospective ecological analysis was performed using data from the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) study and the National Population Council (CONAPO).

METHODS

HAQI values for 1990, 2000, 2010, 2015, and 2019 were examined for each state in Mexico and three age groups (young, working, and post-working). Additionally, the marginalisation index was employed to assess inequalities in the HAQI distribution across states. The concentration index of the HAQI for each year was estimated, and the efficiency of states in producing the HAQI was evaluated using a data envelopment approach.

RESULTS

Through the analysis of national and subnational data, results indicated an overall improvement in healthcare access and quality during the study period. Although differences in the HAQI value related to state marginalisation decreased from 1990 to 2015, by 2019, the inequality had returned to a level comparable to 2000. Efficiency in producing health (HAQI values) exhibited substantial heterogeneity and fluctuations in the ranking order over time. States such as Nuevo León consistently performed well, while others, such as Guerrero, Chihuahua, Mexico City, and Puebla, consistently underperformed.

CONCLUSIONS

The findings from this study emphasise the necessity for nuanced strategies to address healthcare disparities and enhance the overall system performance. The study provides valuable insights for ongoing discussions about the future of Mexico's healthcare system, aiming to inform evidence-based policy decisions and improve the nationwide delivery of healthcare services.

Intersecting social-ecological vulnerabilities to and lived experiences of sexually transmitted infections among Syrian refugee women in Lebanon: A qualitative study

Conflict-affected women and girls living in protracted forced displacement settings are vulnerable to sexually transmitted infections (STIs). Yet, little is known about the risk factors for and lived experiences of STIs in complex humanitarian settings, particularly in the Middle East and North Africa, where STIs have long been understudied. This qualitative study adapts the social ecological model to characterize the multi-level risks for and lived experiences of STIs among Syrian refugee women resettled in an urban refugee camp in Beirut, Lebanon. Adopting a community-based sampling strategy, community health workers, who were refugee women from the camp, recruited and conducted in-depth interviews (IDIs) with 30 adult Syrian refugee women. Data were analyzed using an interpretative phenomenological approach and thematically organized according to the levels of the social ecological model. We identified a confluence of individual, interpersonal, community-based, and societal vulnerabilities to STIs, including extreme poverty and insecurity, patriarchal gender norms, stigma, sexual exploitation and trafficking, poor healthcare accessibility, intimate partner violence, including marital rape, transactional sex, sexual harassment, social isolation, and internalized stigma. Participants described experiencing bothersome symptoms and sequelae of advanced and untreated STIs in the setting of limited access to health services and challenges with engaging their partners in STI treatment, largely due to STI stigma. These novel findings suggest dynamic, interrelated social and health disparities across all social ecological levels influencing refugee women's sexual health, including their risk of STIs. Comprehensive, multi-sectorial interventions, which transcend traditional public health methods and which adopt a sexual well-being approach, are urgently needed to address systemic and intrapersonal violence against refugee women, examine and mitigate the burden of STIs, and ensure sexual justice and health equity in this protracted forced displacement setting.

Balancing acts: The dual faces of fentanyl in medicine and public health

Fentanyl is a potent synthetic opioid widely used in medicine for its effective analgesic properties, particularly in surgical procedures and in the treatment of severe, chronic pain. In recent decades, however, there has been a worrying increase in the illicit use of fentanyl, particularly in North America. This rise in illicit use is concerning because fentanyl is associated with polydrug abuse, which adds layers of complexity and dangerous. This review provides a comprehensive examination of fentanyl, focusing on its synthesis and medical use. It also discusses the significance of the piperidine ring in medicinal chemistry as well as the critical role of fentanyl in pain management and anesthesia. Furthermore, it addresses the challenges associated with the abuse potential of fentanyl and the resulting public health concerns. The study aims to strike a balance between the clinical benefits and risks of fentanyl by advocating for innovative uses while addressing public health issues. It examines the chemistry, pharmacokinetics and pharmacodynamics of fentanyl and highlights the importance of personalized medicine in the administration of opioids. The review underscores the necessity of continuous research and adaptation in both clinical use and public health strategies.

Circadian disruptions and their role in the development of hypertension

Circadian fluctuations in physiological setpoints are determined by the suprachiasmatic nucleus (SCN) which exerts control over many target structures within and beyond the hypothalamus via projections. The SCN, or central pacemaker, orchestrates synchrony between the external environment and the internal circadian mechanism. The resulting cycles in hormone levels and autonomic nervous system (ANS) activity provide precise messages to specific organs, adjusting, for example, their sensitivity to approaching hormones or metabolites. The SCN responds to both photic (light) and non-photic input. Circadian patterns are found in both heart rate and blood pressure, which are linked to daily variations in activity and autonomic nervous system activity. Variations in blood pressure are of great interest as several cardiovascular diseases such as stroke, arrhythmias, and hypertension are linked to circadian rhythm dysregulation. The disruption of normal day-night cycles, such as in shift work, social jetlag, or eating outside of normal hours leads to desynchronization of the central and peripheral clocks. This desynchronization leads to disorganization of the cellular processes that are normally driven by the interactions of the SCN and photic input. Here, we review autonomic system function and dysfunction due to regulation and interaction between different cardiorespiratory brain centers and the SCN, as well as social, lifestyle, and external factors that may impact the circadian control of blood pressure.

Post-Traumatic Epilepsy: Observations from an Urban Level 1 Trauma Center

There are approximately 2.5 million cases of traumatic brain injury (TBI) in the U.S. each year. Post-traumatic epilepsy (PTE), a sequela of TBI, has been shown to occur in approximately 15% of TBI patients. Pre-disposing risk factors for the development of PTE include severe TBI and penetrating head injury. PTE is associated with poor functional outcomes, increased negative social factors, and mental illness. We conducted a retrospective chart review with a 5-year timeframe at an urban Level 1 Trauma Center. Patients with ICD-10-CM codes associated with TBI were identified. Patients were coded as TBI with or without PTE by the presence of codes associated with PTE. Datapoints collected included risk factors for PTE and encounters with neurologists. A total of 1886 TBI patients were identified, with 178 (9.44%) classified as TBI with PTE. The most significant risk factor associated with PTE was severe brain injury, with an odds ratio (OR) of 2.955 (95% CI [2.062,4.236]; p < 0.0001). Only 19 of 178 patients (10.7%) visited a neurologist beyond 6 months after TBI. Our results suggest the presence of a significant population of patients with PTE and the need for better follow-up.

Social-Economic Backgrounds to US County-Based COVID-19 Deaths: PLS-SEM Analysis

A complex interplay of social, economic, and environmental factors drove the COVID-19 epidemic. Understanding these factors is crucial in explaining the racial disparities observed in COVID-19 deaths. This research investigated various hypotheses, including ecological, racial, demographic, economic, and political party factors, to determine their impact on COVID-19 deaths. The study utilized data from the National Center for Health Statistics (NCHS), specifically focusing on COVID-19 deaths categorized by race and Hispanic origin in US counties, with over 100 recorded deaths as of July 11, 2022.

METHOD

To analyze the data, the study employed partial least squares (PLS) as the statistical approach, considering the presence of multicollinearity in the county-level socioeconomic data. SmartPLS4 software was utilized to illustrate paths depicting variance and covariance and to conduct significance tests. The analysis encompassed overall COVID-19 deaths and deaths among White, Black, and Hispanic Americans, utilizing the same latent variables and paths.

RESULTS

The results revealed that the number of residents aged 65 years or older in a county was the most influential predictor of COVID-19 deaths, irrespective of race. Economic factors emerged as the second strongest predictors. However, when considering each racial group separately, distinct factors aligned with the five hypotheses emerged as significant contributors to COVID-19 deaths. Furthermore, the diagrams illustrating the relationships between these factors (covariates) varied among racial groups, indicating that the underlying social influences differed across races.

DISCUSSION

In light of these findings, it becomes evident that a "one-size-fits-all" approach to prevention strategies is suboptimal. Instead, targeted prevention efforts tailored to specific racial and social classes at high risk of COVID-19 death could have provided more precise messaging and necessitate direct engagement.

Singapore's COVID-19 crisis decision-making through centralization, legitimacy, and agility: an empirical analysis

Background

Decision-making during health crises differs from routine decision-making and is constrained by ambiguity about evolving epidemiological situations, urgency of response, lack of evidence, and fear. Recent analyses of governance and decision-making during COVID-19, focusing on leadership qualities, involvement of specific stakeholders, and effective resource management, do not adequately address a persisting gap in understanding the determinants of decision-making during health crises at the national level.

Methods

We undertook a study to understand the processes and characteristics of decision-making during the COVID-19 pandemic in Singapore. We used a case study approach and collected empirical evidence about public health decision-making, using a combination of key informant interviews and focus group discussions with stakeholders from government, academia and civil society organizations.

Findings

We argue that administrative centralization and political legitimacy played important roles in agile governance and decision-making during the pandemic in Singapore. We demonstrate the role of the Singapore government's centralization in creating a unified and coherent governance model for emergency response and the People's Action Party's (PAP) legitimacy in facilitating people's trust in the government. Health system resilience and financial reserves further facilitated an agile response, yet community participation and prioritization of vulnerable migrant populations were insufficient in the governance processes.

Interpretation

Our analysis contributes to the theory and practice of crisis decision-making by highlighting the role of political and administrative determinants in agile crisis decision-making.

Funding

This study is funded by the U.S. Centers for Disease Control and Prevention through a Cooperative Research Agreement (NU2HGH2020000037).

Developing an alcohol strategy for the Northwest Territories: Evaluating global research evidence against rural and remote realities

OBJECTIVES

This paper outlines the engagement process that was used to develop the Northwest Territories Alcohol Strategy, based on a recommendation by the developers of the Canadian Alcohol Policy Evaluation report, and how this informed the final actions in the strategy.

METHODS

A literature review, four targeted engagement activities, and iterative validation by advisory groups and community and Indigenous leadership were used to evaluate, modify, or reject the original recommendations and develop the final actions that were included in the NWT Alcohol Strategy.

RESULTS

There are fourteen original CAPE recommendations, four of which had already been implemented in the Northwest Territories before the development of the strategy. On completion of the process, four recommendations had already been implemented in the NWT. Two recommendations were included in the strategy without changes, two were adapted for use in the strategy, and six were not included. One stand-alone alcohol policy measure was created and included.

CONCLUSION

Alcohol strategies are dependent on a variety of contextual factors. Developers need to take into consideration the unique geography, political climate, and cultural context of the region for which they are being developed, in order to produce a strategy that is applicable, acceptable, and feasible at the community level.

Do school Water, Sanitation, and Hygiene facilities affect students' health status, attendance, and educational achievements? A qualitative study in Nepal

Background and Aims

Access to safe and sufficient drinking Water, Sanitation, and good Hygiene (WASH) facilities in schools play a crucial role in preventing students from numerous Neglected Tropical Diseases, improving the learning environment in schools, and creating resilient communities living in a healthy environment. This study aims to explore the impact of combining WASH facilities on students' health status, school attendance, and educational achievements.

Methods

Four schools, two with improved and two without improved WASH facilities, were selected purposively from Dhanusha and Chitwan districts of Nepal. A total of 24 participants, 16 students, and eight teachers were also purposively selected based on the Theory of Data Saturation. The participants were interviewed face-to-face using study guidelines; Key Informants Interview for teachers and In-depth Interview for students. The data were audio recorded and analyzed thematically using Dedoose 9.0.17 qualitative data management and analysis software.

Results

School WASH facilities have a significant impact on students' health and well-being. Poor school-WASH facilities hindered students' school attendance, particularly for menstruating girls. School without separate toilets for girls, including menstruation hygiene facilities, lack of water and soap, sanitary pad, and secure toilet's door often have higher rates of absenteeism among girls. Poor teacher and students' relationships, students' low interest in education, household chores, and participation in social customs also contribute to students' absence from school and low educational performance. It is important to note that inadequate WASH facilities affect not only students, but also teachers in the same school.

Conclusion

The lack of safe and sufficient drinking water, unimproved sanitation, and poor hygiene facilities were seen by students and teachers as reducing their health and well-being, school attendance, and academic performance. Thus, schools need prioritize and promote the provision of improved WASH facilities for the betterment of students' health, attendance, and educational proficiency.

Drugs, crime, and racial disparities in the homeless population gathered from a sample of police reports: Evidence from Brazil

Brazil is one of the most unequal democracies in the world. Although the number of homeless individuals in our country has increased due to the reproduction of people living in extreme poverty, little has been discussed about their welfare and rights. In the present study, we provide analysis with a theoretical-methodological approach directed at homeless people living in the wealthy neoliberal middle-sized southeast city of São Paulo, Brazil's richest state. Data was acquired from police reports with prior permission from the Civil Police of São Paulo and the São Paulo Interior Judiciary Police Department. Our results illustrate that the homelessness phenomenon in Franca appears to be comparable to that of other large urban cities, where Blacks, a minority of the population, make up the bulk of homeless individuals. It also denies that homeless activity increases criminality, emphasizes the difference between Blacks and Whites drug users' criminal behavior, with Whites being more active in theft and robbery and Blacks in trafficking, and extends the idea that drug use by homeless people is stress-related and hence an indicator of a health condition.

Association of socioeconomic vulnerability with outcomes after emergency general surgery

PURPOSE

Social determinants of health are increasingly recognized to shape health outcomes. Yet, the effect of socioeconomic vulnerability on outcomes after emergency general surgery remains under-studied.

METHODS

All adult (≥18 years) hospitalizations for emergency general surgery operations (appendectomy, cholecystectomy, laparotomy, large bowel resection, perforated ulcer repair, or small bowel resection), within 2 days of non-elective admission were tabulated in the 2016 to 2020 Nationwide Readmissions Database. Socioeconomic vulnerability was defined using relevant diagnosis codes and comprised economic, educational, healthcare, environmental, and social needs. Patients demonstrating socioeconomic vulnerability were considered Vulnerable (others: Non-Vulnerable). Multivariable models were constructed to evaluate the independent associations between socioeconomic vulnerability and key outcomes.

RESULTS

Of ∼1,788,942 patients, 177,764 (9.9%) were considered Vulnerable. Compared to Non-Vulnerable, Vulnerable patients were older (67 [55-77] vs 58 years [41-70), P < .001), more often insured by Medicaid (16.4 vs 12.7%, P < .001), and had a higher Elixhauser Comorbidity Index (4 [3-5] vs 2 [1-3], P < .001). After risk adjustment and with Non-Vulnerable as a reference, Vulnerable remained linked with a greater likelihood of in-hospital mortality (adjusted odds ratio 1.64, confidence interval 1.58-1.70) and any perioperative complication (adjusted odds ratio 2.02, confidence interval 1.98-2.06). Vulnerable also experienced a greater duration of stay (β+4.64 days, confidence interval +4.54-4.74) and hospitalization costs (β+$1,360, confidence interval +980-1,740). Further, the Vulnerable cohort demonstrated increased odds of non-home discharge (adjusted odds ratio 2.44, confidence interval 2.38-2.50) and non-elective readmission within 30 days of discharge (adjusted odds ratio 1.29, confidence interval 1.26-1.32).

CONCLUSION

Socioeconomic vulnerability is independently associated with greater morbidity, resource use, and readmission after emergency general surgery. Novel interventions are needed to build hospital screening and care pathways to improve disparities in outcomes.

Postintensive care syndrome in patients and family members. Analysis of COVID-19 and non-COVID-19 cohorts, with face-to-face follow-up at three months and one year

OBJECTIVE

Compare prevalence and profile of post-intensive care patient (P-PICS) and family/caregiver (F-PICS) syndrome in two cohorts (COVID and non-COVID) and analyse risk factors for P-PICS.

DESIGN

Prospective, observational cohort (March 2018-2023), follow-up at three months and one year.

SETTING

14-bed polyvalent Intensive Care Unit (ICU), Level II Hospital.

PATIENTS OR PARTICIPANTS

265 patients and 209 relatives. Inclusion criteria patients: age > 18 years, mechanical ventilation > 48 h, ICU stay > 5 days, delirium, septic shock, acute respiratory distress syndrome, cardiac arrest. Inclusion criteria family: those who attended.

INTERVENTIONS

Follow-up 3 months and 1 year after hospital discharge.

MAIN VARIABLES OF INTEREST

Patients: sociodemographic, clinical, evolutive, physical, psychological and cognitive alterations, dependency degree and quality of life. Main caregivers: mental state and physical overload.

RESULTS

64.9% PICS-P, no differences between groups. COVID patients more physical alterations than non-COVID (P = .028). These more functional deterioration (P = .005), poorer quality of life (P = .003), higher nutritional alterations (P = .004) and cognitive deterioration (P < .001). 19.1% PICS-F, more frequent in relatives of non-COVID patients (17.6% vs. 5.5%; P = .013). Independent predictors of PICS-P: first years of the study (OR: 0.484), higher comorbidity (OR: 1.158), delirium (OR: 2.935), several reasons for being included (OR: 3.171) and midazolam (OR: 4.265).

CONCLUSIONS

Prevalence PICS-P and PICS-F between both cohorts was similar. Main factors associated with the development of SPCI-P were: higher comorbidity, delirium, midazolan, inclusion for more than one reason and during the first years.

Understanding the Use of Mobility Data in Disasters: Exploratory Qualitative Study of COVID-19 User Feedback

BACKGROUND

Human mobility data have been used as a potential novel data source to guide policies and response planning during the COVID-19 global pandemic. The COVID-19 Mobility Data Network (CMDN) facilitated the use of human mobility data around the world. Both researchers and policy makers assumed that mobility data would provide insights to help policy makers and response planners. However, evidence that human mobility data were operationally useful and provided added value for public health response planners remains largely unknown.

OBJECTIVE

This exploratory study focuses on advancing the understanding of the use of human mobility data during the early phase of the COVID-19 pandemic. The study explored how researchers and practitioners around the world used these data in response planning and policy making, focusing on processing data and human factors enabling or hindering use of the data.

METHODS

Our project was based on phenomenology and used an inductive approach to thematic analysis. Transcripts were open-coded to create the codebook that was then applied by 2 team members who blind-coded all transcripts. Consensus coding was used for coding discrepancies.

RESULTS

Interviews were conducted with 45 individuals during the early period of the COVID-19 pandemic. Although some teams used mobility data for response planning, few were able to describe their uses in policy making, and there were no standardized ways that teams used mobility data. Mobility data played a larger role in providing situational awareness for government partners, helping to understand where people were moving in relation to the spread of COVID-19 variants and reactions to stay-at-home orders. Interviewees who felt they were more successful using mobility data often cited an individual who was able to answer general questions about mobility data; provide interactive feedback on results; and enable a 2-way communication exchange about data, meaning, value, and potential use.

CONCLUSIONS

Human mobility data were used as a novel data source in the COVID-19 pandemic by a network of academic researchers and practitioners using privacy-preserving and anonymized mobility data. This study reflects the processes in analyzing and communicating human mobility data, as well as how these data were used in response planning and how the data were intended for use in policy making. The study reveals several valuable use cases. Ultimately, the role of a data translator was crucial in understanding the complexities of this novel data source. With this role, teams were able to adapt workflows, visualizations, and reports to align with end users and decision makers while communicating this information meaningfully to address the goals of responders and policy makers.