Increasing confidence for pediatric COVID-19 and influenza vaccines using messages affirming parental autonomy: A randomized online experiment

OBJECTIVES

To test the effects of autonomy-affirming pediatric vaccine messages for U.S. parents on overall vaccine confidence and intention to vaccinate against COVID-19 and flu while examining potential moderation effects of political ideology.

METHODS

We conducted an online randomized messaging experiment with 1718 parents, balanced across political ideology (31 % conservative, 37 % moderate, 31 % liberal). We compared four types of vaccine messages: 2 (autonomy-confirming vs authoritarian tone) x 2 (COVID-19 or flu). Parents viewed three messages within a single condition and rated their overall vaccine confidence and intentions to vaccinate their children.

RESULTS

Adjusted for covariates, we found significant interactions between autonomy-confirming language and ideology. Conservative parents who saw COVID-19 messages increased vaccine confidence in response to autonomy-confirming messages, compared to both moderate and liberal parents. For flu messages, we found that autonomy-confirming messages increased confidence and intention to vaccinate for conservative parents only.

DISCUSSION

Messages promoting pediatric COVID-19 and flu vaccination were generally more effective at increasing overall confidence toward vaccines for conservative parents when using autonomy-confirming language.

CONCLUSIONS

Pediatric vaccinations are politicalized in the United States, and messaging strategies targeting parents must consider this. Public health agencies serving conservative parents can use autonomy-confirming messaging to positively influence parents' confidence in giving their children vaccines.

How do restrictions on opioid prescribing, harm reduction, and treatment coverage policies relate to opioid overdose deaths in the United States in 2013-2020? An application of a new state opioid policy scale

BACKGROUND

Identifying the most effective state laws and provisions to reduce opioid overdose deaths remains critical.

METHODS

Using expert ratings of opioid laws, we developed annual state scores for three domains: opioid prescribing restrictions, harm reduction, and Medicaid treatment coverage. We modeled associations of state opioid policy domain scores with opioid-involved overdose death counts in 3133 counties, and among racial/ethnic subgroups in 1485 counties (2013-2020). We modeled a second set of domain scores based solely on experts' highest 20 ranked provisions to compare with the all-provisions model.

RESULTS

From 2013 to 2020, moving from non- to full enactment of harm reduction domain laws (i.e., 0 to 1 in domain score) was associated with reduced county-level relative risk (RR) of opioid overdose death in the subsequent year (adjusted RR = 0.84, 95 % credible interval (CrI): 0.77, 0.92). Moving from non- to full enactment of opioid prescribing restrictions and Medicaid treatment coverage domains was associated with higher overdose in 2013-2016 (aRR 1.69 (1.35, 2.11) and aRR 1.20 (1.11, 1.29) respectively); both shifted to the null in 2017-2020. Effect sizes and direction were similar across racial/ethnic groups. Results for experts' highest 20 ranked provisions did not differ from the all-provision model.

CONCLUSIONS

More robust state harm reduction policy scores were associated with reduced overdose risk, adjusting for other policy domains. Harmful associations with opioid prescribing restrictions in 2013-2016 may reflect early unintended consequences of these laws. Medicaid coverage domain findings did not align with experts' perceptions, though data limitations precluded inclusion of several highly ranked Medicaid policies.

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

OBJECTIVE

Suicide risk identified via universal screening in health care 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 were 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 were 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.

From stigma to solutions: harnessing local wisdom to tackle harms associated with menstrual seclusion (chhaupadi) in Nepal

In Nepal, menstrual practices, and particularly chhaupadi, impose restrictive norms affecting women's daily lives. Chhaupadi is a tradition that involves isolating women and girls during menstruation and after childbirth, along with following other restrictions, which have physical and mental health implications. To date, interventions have yet to fully and sustainably address harms associated with chhaupadi across the country. This two-phase study conducted in Dailekh, Nepal facilitated the development of community-created solutions to mitigate chhaupadi's adverse impacts on women's health. Using Human Centred Design and a community-engaged approach, the discovery phase identified key stakeholders and contextualised chhaupadi, while the subsequent design phase facilitated the development of five community-created interventions. These included leveraging female community health volunteers (FCHVs) for counselling and awareness, targeting mothers to drive behavioural change, engaging the wider community in behaviour change efforts, empowering fathers to catalyse change at home, and training youth for advocacy. The FCHV intervention concept was selected as the most promising intervention by the women co-design team, warranting broader exploration and testing. Additionally, while it is imperative for interventions to prioritise tackling deleterious aspects of chhaupadi, interventions must also acknowledge its deep-rooted cultural significance and history and recognise the positive aspects that some women may wish to preserve.

Legal residency status and its relationship with health indicators among Syrian refugees in Lebanon: a nested cross-sectional study

BACKGROUND

Failure to possess or renew legal residency permits increases the burden on a vulnerable refugee population. It risks detention or deportation, and hinders access to basic services including healthcare. This study aimed to examine the association between legal residency status and health of Syrian refugees living in Lebanon.

METHODS

Data were from two independent nested cross-sectional studies collected in 2022 through telephone surveys. In the first study, all Syrian refugees aged 50 years or older from households that received humanitarian assistance were invited to participate. The second included all adult Syrian refugees residing in a suburb of Beirut. The exposure was self-reported possession of a legal residency permit in Lebanon. The self-reported health outcomes were mental health status, COVID-19 vaccine uptake, and access to needed healthcare services. Separate logistic regression models examined the association between lacking a legal residency permit and each health outcome, adjusted for age, length of stay in Lebanon, education, employment, wealth index and receipt of assistance.

RESULTS

The first sample included 3357 participants (median age 58 years (IQR: 54-64), 47% female), of whom 85% reported lacking a legal residency permit. The second sample included 730 participants (median age 34 years (IQR: 26-42), 49% female), of whom 79% lacked a legal residency permit. In both studies, lacking a legal residency permit increased the odds of having poor mental health (adjusted odds ratio (aOR): 1.46 (95% CI: 1.07 to 1.99); aOR: 1.62 (95% CI: 1.01 to 2.60)) and decreased the odds of COVID-19 vaccine uptake (aOR: 0.66 (95% CI: 0.54 to 0.80); aOR: 0.51 (95% CI: 0.32 to 0.81)). In the subsample who needed primary healthcare, lacking a legal residency permit decreased the odds of access to primary healthcare, which was statistically significant in the second study (aOR: 0.37 (95% CI: 0.17 to 0.84)).

CONCLUSIONS

The majority of Syrian refugees from these two samples reported lacking a legal residency permit in Lebanon. This was associated with poor mental health and lower uptake of COVID-19 vaccination, potentially originating from fear of detention or deportation. These findings call for urgent action to support access to legal documentation for refugees in Lebanon.

Life events triggered frailty-related eating behaviors of older adults

BACKGROUND & AIMS

Support to improve eating behavior could be an effective strategy for preventing frailty, if support is provided at the appropriate time. This study aimed to explore the life events that affect the eating behaviors associated with frailty.

METHODS

A cross-sectional, web-based survey was conducted in 2023, and 1200 older adults aged 65-74 years participated. The Kihon Checklist was used to assess frailty status: robustness, prefrailty, or frailty. Thirteen potential frailty-related eating behaviors, adapted from a previous qualitative study, were evaluated for associations with frailty status using ordinal logistic regression models with adjustments. Life events that affected frailty-related behaviors were summarized.

RESULTS

Overall, the proportions of individuals with robustness, prefrailty, and frailty were 40.5 %, 39.1 %, and 20.4 %, respectively. The men with frailty were more likely to have light lunches (adjusted odds ratio (aOR) [95 % confidence interval]: 2.13 [1.26-3.60]) and were less likely to have Westernized meals (aOR: 0.52 [0.30-0.90]), eat together (aOR: 0.39 [0.18-0.85]), go shopping (aOR: 0.44 [0.20-0.97]), and habituate to clean-up (aOR: 0.47 [0.26-0.86]), which were affected mainly by being married or retired. The women with frailty were less likely to have protein-rich foods (aOR: 0.10 [0.02-0.41]), eat together (aOR: 0.43 [0.20-0.93]), and go shopping (aOR: 0.19 [0.06-0.58]), which were affected mainly by getting married.

CONCLUSION

Nutritional support at retirement and changes in marital status may be effective ways to prevent unfavorable eating behaviors that contribute to frailty. Further studies are needed to capture the whole picture of the life events that affect frailty-related eating behaviors.

American Indian Adolescent Perspectives on COVID-19 Impacts Within Great Plains Area Reservations

INTRODUCTION

COVID-19 created unprecedented disruption for school-age children and adolescents across the United States. This educational disruption was significant for American Indian/Alaska Native (AI/AN) students. Our study's purpose was to understand COVID-19's impact on AI/AN adolescents' education and their physical, emotional, mental, social, and spiritual well-being, as well as their coping mechanisms.

METHODOLOGY

We employed a qualitative descriptive design with 14 AI/AN adolescents aged 14 to 18 years among three Tribes in the Great Plains in August 2023.

RESULTS

Our participants reported several disruptions, yet they found unique ways to stay connected. The themes identified were social network, physical activity, emotional well-being, gaming, responses of reservation schools to COVID-19, and challenges of virtual learning.

DISCUSSION

There is a lack of focus on the resilience and protective factors among rural AI/AN adolescents. Understanding how these factors may enhance AI/AN well-being is essential for providing culturally responsive care and promoting healthy growth and development.

Contextual factors influencing implementation of tuberculosis digital adherence technologies: a scoping review guided by the RE-AIM framework

INTRODUCTION

Digital adherence technologies (DATs) may enable person-centred tuberculosis (TB) treatment monitoring; however, implementation challenges may undermine their effectiveness. Using the reach, effectiveness, adoption, implementation and maintenance framework, we conducted a scoping review to identify contextual factors informing 'reach' (DAT engagement by people with TB) and 'adoption' (DAT uptake by healthcare providers or clinics).

METHODS

We searched eight databases from 1 January 2000 to 25 April 2023 to identify all TB DAT studies. After extracting qualitative and quantitative findings, using thematic synthesis, we analysed common findings to create meta-themes informing DAT reach or adoption. Meta-themes were further organised using the Unified Theory of Acceptance and Use of Technology, which posits technology use is influenced by perceived usefulness, ease of use, social influences and facilitating conditions.

RESULTS

66 reports met inclusion criteria, with 61 reporting on DAT reach among people with TB and 27 reporting on DAT adoption by healthcare providers. Meta-themes promoting reach included perceptions that DATs improved medication adherence, facilitated communication with providers, made people feel more 'cared for' and enhanced convenience compared with alternative care models (perceived usefulness) and lowered stigma (social influences). Meta-themes limiting reach included literacy and language barriers and DAT technical complexity (ease of use); increased stigma (social influences) and suboptimal DAT function and complex cellular accessibility challenges (facilitating conditions). Meta-themes promoting adoption included perceptions that DATs improved care quality or efficiency (perceived usefulness). Meta-themes limiting adoption included negative DAT impacts on workload or employment and suboptimal accuracy of adherence data (perceived usefulness); and suboptimal DAT function, complex cellular accessibility challenges and insufficient provider training (facilitating conditions). Limitations of this review include the limited studies informing adoption meta-themes.

CONCLUSION

This review identifies diverse contextual factors that can inform improvements in DAT design and implementation to achieve higher engagement by people with TB and healthcare providers, which could improve intervention effectiveness.

Experiences and reflections of doctors on the operations of designated clinics during the COVID-19 pandemic in Hong Kong: a qualitative study

BACKGROUND

The conversion of General Out-patient Clinics (GOPC) into COVID-19 designated clinics played a crucial role in combating COVID-19 pandemic in Hong Kong in 2022. This qualitative research aimed to contribute valuable perspectives from doctors on the operations of designated clinics for the preparedness of future outbreaks and health emergencies.

METHODS

This research adopted an interpretive phenomenological approach. Participants were purposively recruited from the doctors who worked in designated clinics during the COVID-19 pandemic in the Cluster of New Territories West, Hong Kong. Individual semi-structured interviews were conducted using an interview guide informed by the researchers' past experiences and the Donabedian framework. The verbatim transcripts were imported into NVivo 12 for data organizing, coding and thematic analysis.

RESULTS

Sixteen participants were recruited and interviewed until data sufficiency. Eight themes were elicited and grouped under the three domains of the Donabedian framework: structure (availability of facilities, supportive training and education, and flexible manpower allocation), process (challenges in clinical practices, communication and collaboration, and effectiveness of operations), and outcome (patient outcomes and impact to healthcare workers).

CONCLUSIONS

Overall, participants thought that the operations in the designated clinics were smooth, efficient, and achieving satisfactory outcomes. However, improvements could be made in upgrading facilities to better manage more severe future outbreaks, enhancing government roles in information centralization and public communication and improving collaboration between designated clinics and ambulance services. This research provided valuable insights for the preparedness of future outbreaks and health emergencies.

Invasive Meningococcal Disease in the Post-COVID World: Patterns of Disease Rebound

Invasive meningococcal disease (IMD) is a global health threat with an unpredictable epidemiology that varies regionally and over time. During the COVID-19 pandemic, the Invasive Respiratory Infection Surveillance Consortium reported widespread reductions in bacterial diseases transmitted via the respiratory route, including IMD, that were associated with the stringency of COVID-19 measures implemented in each country. Here, we report the epidemiology of IMD from the United States, England, France, Australia, and Chile during and after the COVID-19 pandemic. There was a consistent trend in which IMD incidence declined throughout 2020 and into 2021 but began to increase in 2021 (England and Chile) or 2022 (United States, France, and Australia). Case numbers of IMD in France and the United States surpassed pre-pandemic levels by December 2022 and 2023, respectively, whereas in other countries examined, overall cases in 2021/2022 or 2023 approached but did not exceed pre-pandemic levels. Except for the United States, meningococcal serogroup B was the prominent serogroup of post-pandemic re-emergence, although substantial increases in serogroup Y and W disease in France in 2022 and serogroup W disease in Chile in 2023 were also observed. In the United States, where meningococcal vaccination coverage did not decline during the pandemic, the rebound in cases was predominantly due to serogroups C, Y, and nongroupable serogroups. The data indicate that surveillance of IMD cases, associated serogroups, and vaccination uptake is essential for monitoring the effectiveness of disease prevention strategies and guiding future public health policy.

Testing the unintended cost effects of health policies for generic substitutions: the case of China's National Volume-Based Procurement (NVBP) policy

Generic substitutions are globally considered to contain health expenditures. Yet it is uncertain whether the costs spill over to other medicines or health services. Contextualizing China's National Volume-Based Procurement (NVBP) policy, which promoted generic substitution, this study tests the changes in patients' utilization of generic medicines and whether the costs shift to other pharmaceutics or health services post-policy. This population-based, matched, cohort study uses claims data from Tianjin, China in 2018-2020. We focus on amlodipine, the most commonly used calcium channel blocker with the largest procurement volume. We build comparable post-policy cohorts: Non-switchers who kept using originator amlodipine, Pure-switchers who loyally switched to generic amlodipine, and Back-switchers who switched back-and-forth; and compare between each matched pair, respectively, their annual healthcare costs and that broken down by components, and patients' use of and adherence to amlodipine post-policy. In all, 1185 Pure-switchers, 1398 Back-switchers, and 2330 Non-switchers were identified (mean age: 63.0 years; 58.5% men). For the matched pairs, Pure-switchers (n = 772) incurred annual total medical costs of CNY 9213.5, 12.2% lower than Non-switchers [n = 1544, absolute difference CNY -1309.3, 95% confidence interval (-2645.8, -19.6)]. The cost reduction only results from amlodipine prescriptions in outpatient encounters and are equally borne by health plans and the enrolees. The costs for Pure-switchers and Non-switchers are not different from other medicines, nor from other items including tests, surgeries, beds, and medical consumables for hypertension-related encounters/admissions. Pure-switchers also had higher daily dosage and better adherence to amlodipine than Non-switchers. The differences between Back-switchers and Non-switchers show similar trends but are less profound. China's NVBP policy is effective in controlling pharmaceutical costs. No unintended cost effects have yet been identified in the short run. Other countries may learn from China on a comprehensive set of auxiliary policies, including listing, bidding, purchasing, and reimbursing, to better promote generic substitutions.

Bridging inequity gaps in healthcare through tailored support: implementation perspectives of the Social Health Bridge-Building Programme

BACKGROUND

Equity in access to and outcomes from healthcare is a fundamental pillar of universal healthcare systems. However, these systems have not eliminated social inequities in health. Significant socio-economic disparities persist in access to and utilisation of healthcare services, as well as in the quality and outcomes of care. The Social Health Bridge-Building Programme aims to enhance health equity by addressing multi-level barriers to healthcare. In this programme, healthcare student volunteers accompany individuals in a socially vulnerable situation to healthcare appointments, providing support before, during, and after these encounters. This reciprocal arrangement not only enhances the healthcare experience for the individuals involved but also offers student volunteers unique insights into the social determinants of health while fostering the development of essential communication skills. This study explores implementation perspectives of the programme, focusing on those accompanied to appointments.

METHODS

Individuals accompanied to a healthcare appointment from August 2021 to June 2022 were asked to complete a web-based questionnaire covering socio-demographics, health literacy, physical and mental health, and satisfaction with the support provided. The frequency of accompaniments over six months were collected through telephone calls.

RESULTS

A total of 187 users of the programme responded. The Individuals were characterised by short educational attainment, limited social support, unemployment, as well as poor physical and mental health. The majority reported difficulties comprehending health information and engaging with healthcare professionals. Forty percent of the accompaniments were to hospital visits and 23% to GP consultations, with most requesting multiple types of support such as emotional, transportation, communication, and way-finding. Most users (96%) reported that the student-volunteer accommodated their need for support. The additional number of accompaniments over six months ranged from 0 to 21.

CONCLUSIONS

The programme is successfully implemented for individuals in a socially vulnerable situation and succeeded in the delivery of a tailored programme that adresses the individuals' specific needs and request. High satisfaction rates and the positive impact on healthcare experiences highlight the programme's potential to bridge existing inequity gaps in healthcare.

Decision-making under epistemic, strategic and institutional uncertainty during COVID-19: findings from a six-country empirical study

BACKGROUND

Uncertainty is defined as limited knowledge or lack of predictability about past, present or future events. The COVID-19 pandemic management was significantly impacted by uncertainty, as the gaps between existing information and the necessary knowledge hindered decision-making. Current uncertainty literature primarily focuses on natural disasters, leaving a gap in understanding decision-making under uncertainty in times of public health emergencies. Analysing strategies for making decisions under uncertainty during the pandemic is crucial for future pandemic preparedness.

METHODS

Using a comparative research design, we study the strategies governments used to make decisions under uncertainty during the COVID-19 pandemic. We collected data through desk reviews, stakeholder interviews and focus group discussions with stakeholders from government, academia and civil society from six purposefully selected countries: Nigeria, Singapore, South Africa, Bangladesh, Jordan and the UK.

RESULTS

Regardless of political, geographic and economic context, all six countries adopted common strategies to make decisions under three types of uncertainties. Decision-making under epistemic uncertainty involved seeking expert advice and collecting evidence from other countries and international organisations. Decision-making under strategic uncertainty involved coordination, collaboration and communication. Decision-making under institutional uncertainty involved using or adapting pre-existing experiences, structures and relationships and establishing new institutions and processes.

CONCLUSIONS

We contribute to the theory and practice of public health crisis decision-making by presenting a unified national-level applied decision-making framework for events involving uncertainty. We provide practical guidance for approaches to enhance decision-making in future health crises that could also be used for other emergencies.

A scoping review on the impact of women's global leadership: evidence to inform health leadership

INTRODUCTION

The documented benefits of gender parity in leadership are emerging-women leaders have been shown to have a positive impact on maternal and health care policies, strengthen health facilities, and reduce health inequalities. More research is needed, however, to document their impact on global health. We go beyond the well-documented barriers that uphold the lack of gender parity by identifying areas where women leaders are making an impact to inform investment, programming, and policy.

METHODS

We conducted a scoping review of peer-reviewed literature, following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, to map evidence on the impact of women's leadership in organisations in low- and middle-income countries. As many leadership outcomes are cross-disciplinary, outcomes were explored across sectors with particular attention paid to the relevance of these outcomes for global health.

RESULTS

137 articles were included in the review. Studies found women leaders' positive influence on six areas of impact: (1) financial performance, risk, and stability, (2) innovation, (3) engagement with ethical initiatives, (4) health, (5) organisational culture and climate outcomes, and (6) influence on other women's careers and aspirations. Articles reporting mixed results focused on multiple indicators and still largely pointed to positive results, particularly when modified by other factors including increased education, increased experience, and opportunities to work with other women across the organisation. In all sectors, across leadership roles, and across geographies, women's leadership can produce positive results. Women leaders' success, however, cannot be separated from the contexts in which they work, and unsupportive environments can affect the extent to which women leaders can have an impact.

CONCLUSION

Increased and sustained investment in women's leadership within the health sector can lead to improved outcomes for organisations and their clients. Such investments must not only target individual women, but also seek to foster organisational cultures that promote and retain women leaders and support their independent decision-making.

How is process tracing applied in health research? A systematic scoping review

Complex health system questions often have a case study (such as a country) as the unit of analysis. Process tracing, a method from policy studies, is a flexible approach for causal analysis within case studies, increasingly used in applied health research. The aim of this study was to identify the ways in which process tracing methods have been used in health research, and provide insights for best practice. We conducted a systematic scoping review of applied studies purporting to use process tracing methods in health research contexts. We examined the range of studies and how they conducted and reported process tracing. We found 84 studies published from 2011 to 2023. Studies were categorised into two groups: those with greater methodological description (n = 19 studies) and those with less methodological description (n = 65 studies). A majority of studies were focused on public health and health policy with around half of studies focused on low and middle income countries. Of those 19 studies that provided greater methodological description eight studies featured four areas of good practice: (1) reporting the development of a mechanistic theory and making it explicit; (2) linking empirical material collected to the mechanistic theory; (3) clearly presenting the causal mechanism tracing; and (4) reporting how consideration of counterfactuals or evidence of alternatives within the study were analysed in practice. The review demonstrates the rapid take-up of process tracing to generate theory and evidence to support a better understanding of causal mechanisms in complex health research. To support future studies in conducting and reporting process tracing, we provide emergent recommendations.

COVID-19 Case, Death, and Vaccination Rate Disparities by Race and Ethnicity in Virginia

This paper tracks trends in COVID-19 case, death, and vaccination rate disparities by race and ethnicity in Virginia during the COVID-19 pandemic. COVID-19 case, death, and vaccination rates were obtained from electronic state health department records from March 2020 to February 2022. Rate ratios were then utilized to quantify racial and ethnic disparities for several time periods during the pandemic. The Hispanic population had the highest COVID-19 case and age-adjusted death rates, and the lowest vaccination rates at the beginning of the pandemic in Virginia. These disparities resolved later in the pandemic. COVID-19 case and death rates among the Black population were also higher than those of the White population and these disparities remained throughout the pandemic. Racial and ethnic disparities changed over time in Virginia as vaccination coverage and public health policies evolved. Year 2 of the analysis saw lower case and death rates, and higher vaccination rates for non-White populations in Virginia. Public health strategies need to be addressed during the pandemic and developed before the next pandemic to ensure that large racial and ethnic disparities are not again present at the outset.

The association between tobacco use and COVID-19 diagnoses in three Nordic countries: a pooled analysis

Previous research has suggested an unexpected negative association between smoking and susceptibility to COVID-19. This study, drawing on population-based data from three Nordic countries-Sweden, Norway, and Finland-aims to investigate this association further, capitalizing on diversity introduced by different containment measures. The objective of this research was to examine the association between cigarette smoking and snus (smokeless tobacco) use and the risk of confirmed COVID-19 infection. A pooled analysis integrating original data from 547,685 participants across three countries. We used a multiple imputation approach based on conditional probabilities to impute the systematically missing covariates. The associations between tobacco use and COVID-19 infection were assessed, controlling for potential confounding factors. Current cigarette smokers had a lower risk of a confirmed COVID-19 case, whereas there was an increased risk among snus users. Our sensitivity analysis confirmed that the associations between tobacco use and COVID-19 infection risk are robust, remaining consistent regardless of whether covariate imputation was applied. Findings support a negative association between smoking and SARS-CoV-2 infection, but not the hypothesis that nicotine may be protective against the risk of contracting SARS-CoV-2 infection.

"I Saw it Incidentally but Frequently": Exploring the Effects of Online Health Information Scanning on Lung Cancer Screening Behaviors Among Chinese Smokers

In China, lung cancer is the most common cancer with high mortality. While prior research suggests that health information scanning influences cancer screening within the general population, a deeper exploration of the underlying mechanisms is imperative. This study specifically targets smokers, aiming to investigate whether online health information scanning can effectively encourage lung cancer screening and elucidate the mechanisms driving this association. Data were extracted from a Chinese national survey conducted between January and September 2023, exclusively involving current smokers (N = 992). A moderated mediation model was employed to examine a cognitive-affective sequential chain of mediation through risk perceptions and cancer worry. Results showed that 99.1% of Chinese smokers reported online health information scanning, which possessed significant influence. Online health information scanning was positively associated with effective lung cancer screening among smokers directly (OR = 1.927, p < .01) and indirectly (OR = .065, p < .001). The perceived threat of smoking and cancer worry served as the cognitive and affective mediating mechanisms. Furthermore, a moderating effect of eHealth literacy was observed (OR = 6.292, p < .05). Smokers with higher eHealth literacy are more inclined to undergo effective lung cancer screening. Based on these findings, public health sectors should leverage online platforms to disseminate tailored cancer screening education and implement initiatives to enhance public eHealth literacy.

Understanding the effects of alcohol policies on treatment admissions and birth outcomes among young pregnant people

BACKGROUND

This study examines whether state-level alcohol policy types in the United States relate to substance use disorder treatment admissions and birth outcomes among young pregnant and birthing people.

METHODS

We used data from the Treatment Episode Data Set: Admissions (TEDS-A) and Vital Statistics birth data for 1992-2019. We examined 16 state-level policies, grouped into three types: youth-specific, general population, and pregnancy-specific alcohol policies. Using Poisson and logistic regression, we assessed policy effects for those under 21 (aged 15-20) and considered whether effects differed for those just over 21 (aged 21-24).

RESULTS

Youth-specific policies were not associated with treatment admissions or preterm birth. There were statistically significant associations between family exceptions to minimum legal drinking age (MLDA) policies and low birthweight, but findings were in opposite directions across possession-focused and consumption-focused (MLDA) policies and did not differentially apply to people 15-20 versus 21-24. Most pregnancy-specific policies were not associated with treatment admissions, and none were significantly associated with birth outcomes. A few general population policies were associated with improved birth outcomes and/or increased treatment admissions. Specifically, both government spirits monopolies and prohibitions of spirits and heavy beer sales in gas stations were associated with decreased low birthweight among people 15-20 and among people 21-24. Effects of Blood Alcohol Concentration (BAC) limits varied by age, with slight reductions in adverse birth outcomes among people 15-20, as BAC limits get stronger, but slight increases for those 21-24. Although treatment admissions rates across ages were similar when BAC limits were in place, treatment admissions were greater for pregnant people 21-24 than for 15-20 when there were no BAC limits.

CONCLUSIONS

General population policies also appear effective for reducing the adverse effects of drinking during pregnancy for young people, including those under 21. Policies that target people based on age or pregnancy status appear less effective.

Cognitive functions in COVID-19 survivors, approaches strategies, and impact on health systems: a qualitative systematic review

Post-COVID syndrome has been defined as signs and symptoms that develop after an infection consistent with COVID-19 and continue for more than 12 weeks, including neurocognitive signs and symptoms that have an impact on the functioning and quality of life of middle-aged adult and older survivors. This systematic review describes the current knowledge of long-term cognitive impairments in COVID-19 survivors, approaches strategies, and their impact on public and private health services worldwide. The systematic review was conducted under the criteria and flowchart established in the PRISMA statement, considering studies from the PubMed, Scopus, and Web of Science databases between 2020 and 2023. The included studies considered participants over 40 years of age, COVID-19 survivors. A total of 68 articles were included, most of which had high to excellent quality. The analysis showed the presence of heterogeneous cognitive symptoms in COVID survivors, persistent for at least 12 weeks from the onset of infection, mostly unsystematized and nonspecific approaches strategies, and a lack of methods for monitoring their effectiveness, with a significant economic and logistical impact on health systems. Specific protocols are required for the rehabilitation of persistent cognitive dysfunction in COVID-19 survivors, as well as longitudinal studies to evaluate the effectiveness of these interventions.

Temporal trends in the incidence and case severity of COVID-19 cases among the Syrian refugees in Azraq camp in Jordan: A retrospective observational study

BACKGROUND

Azraq Syrian refugee camp, located in Jordan, is where the challenges of managing the COVID-19 epidemic meet the vulnerabilities of displaced people. This study aimed to investigate the epidemiological characteristics, incidence, risk factors, and outcomes of COVID-19 among Azraq camp residents.

METHODS

COVID-19 data from Azraq camp were collected by International Medical Corps clinics and analyzed retrospectively from August 1, 2020, to August 31, 2022. Data included demographics, risk factors, testing history, contact tracing, and vaccination profiles. We estimated COVID-19 incidence and analyzed risk factors using Poisson and multilevel logistic regression.

RESULTS

A total of 2,468 confirmed COVID-19 cases were identified, with a prevalence of 5.6 per 100 residents. The camp's monthly incidence rate was more than 50% lower than the national rate, with a 1.7% monthly decrease. Females had a higher incidence than males (6.4% vs. 4.9%, p < 0.001), while the elderly bore the greatest disease burden. Home-based isolation was the main strategy, except during the second wave. Vaccination coverage reached 31.6%, primarily with Pfizer (49.8%). Symptomatic cases made up 44.0% of confirmed cases, with 10.4% requiring hospitalization. Factors independently associated with hospitalization included age, comorbidity, and vaccination status.

CONCLUSION

The study highlights the need for robust surveillance, targeted healthcare interventions, equitable resource allocation, and vaccination campaigns to manage COVID-19 and future epidemics in refugee camps.

The Effect of Wildfires on Asthma and Allergies

Climate change is a major driver of the frequency and severity of wildfires caused by extended periods of drought and hotter, drier weather superimposed on the legacy of fire suppression in the Mountain West of the United States. In recent years, increased wildfire smoke has negated the improvements in air quality made by clean energy transitions. Wildfire smoke is a complex mixture of gases and solids, a chief constituent of which is fine particulate matter (PM2.5). Exposure to PM2.5 is associated with adverse respiratory outcomes, including exacerbations of asthma and chronic obstructive pulmonary disease. In the face of increasing wildfire smoke exposures, it is critical that adaptation and mitigation strategies be put in place to minimize health effects. Individual strategies include modifying behavior and creating clean air spaces in homes to avoid wildfire smoke exposure. Community strategies include regulations promoting fire-resistant buildings and landscaping; establishing wildfire monitoring and alert systems; providing safe clean spaces where individuals can minimize wildfire smoke exposure and find evacuation routes; and creating health care response teams. Mitigation to prevent wildfires includes forest management and establishing monitoring systems and protocols to control forest fires in the wildland urban interface before they increase in size and intensity. Research into understanding the mechanism by which wildfire smoke mediates adverse health effects can inform guidelines to mitigate its health effects further.

Associated Factors in Terms of Having Multiple Sex Partners in Nepal: A Cross-Sectional Study

Background and Aims

A sex partner is considered to someone with whom a person engages in sexual activity. This could be casual partner or interpersonal relationship, depending on the context. An individual who engages in a sexual relationship with more than one partner, either simultaneously or consecutively, is considered to have multiple sex partners. This study aims to determine the factors and behaviors that lead to having multiple sex partners in Nepal.

Methods

This study utilized secondary data from a nationally representative "Nepal Demographic and Health Survey (NDHS) 2022." A multistage, probability proportional sampling, cross-sectional method was used. A total of 4913 men between the ages of 15 and 49 years from 476 different clusters were surveyed. Bivariate and multivariate analyses were carried out using SPSS 25 version, and (p < 0.05) was considered statistically significant.

Results

In this study, it was found that 55.2% of the population had multiple sexual partners based on the reported number of sexual partners a men has had since becoming sexually active. Significant factors associated with having multiple sexual partners included the age of the respondents, province, level of education, religion, ethnicity, use of the internet, occupation, wealth index combined, ecological region, current working status, and area of residence. Respondents aged between 20 and 24 years and those between 25 and 29 years are more likely to have multiple sex partners (crude Odds Ratio (cOR) = 1.570; 95% confidence interval (CI): 1.113-2.215) and (cOR = 1.505; 95% CI: 1.076-2.112), even after adjusting for other all compounding variables, than those from other age groups, keeping all other variables constant. After age, province, ethnicity, occupation, and area of residence of the respondents were significant predictors linked to having multiple sex partners.

Conclusion

To be engaged with just one or more partners in sexual activity is a personal choice; however, the risks associated with having multiple sexual partners should be taken into account.

Mental Health After COVID-19 Death-Related Loss in Individuals With Eating Disorders: A Multi-Country Nested Matched Case-Control Study

OBJECTIVE

The COVID-19 pandemic caused millions of deaths worldwide and significantly impacted people with eating disorders, exacerbating symptoms and limiting access to care. This study examined the association between COVID-19 death-related loss-defined as the death of a family member, friend, or acquaintance due to COVID-19-and mental health among people with preexisting eating disorders in the United States (US), the Netherlands, and Sweden.

METHOD

Participants with a history of eating disorders completed a baseline survey early in the pandemic (US: N = 511; Netherlands: N = 510; Sweden: N = 982) and monthly (US, the Netherlands) or biannual (Sweden) follow-ups from April 2020 to May 2021. The surveys assessed pandemic impact on eating disorder-related behaviors and concerns, anxiety, depression, sleep disturbances, and COVID-19-related deaths. A matched nested case-control design was used to compare individuals experiencing a death-related loss with matched controls.

RESULTS

A substantial proportion experienced a COVID-19 death-related loss (US: 33%; Netherlands: 39%; Sweden: 17%). No significant differences were found between cases and controls on eating disorder, anxiety, depression, or sleep outcomes.

DISCUSSION

Despite the expected influence of COVID-19 death-related loss on mental health, our study found no significant association. Reactions to pandemics may be highly individual, and practitioners may want to consider broader losses-such as bereavement, missed educational experiences, relationship disruptions, financial instability, and employment challenges-when addressing patients' needs. Future research should continue to explore how death-related loss impacts eating disorder risk and progression.

A Narrative Persuasion Approach to Promoting COVID-19- Related Policy Support

Communication scholars warn against focusing on individual behaviors when discussing health issues, arguing that doing so can reduce affect and policy support. Although COVID-19 outcomes are linked to structural barriers to treatment, policy interventions appear to improve outcomes for vulnerable groups. Thus, strategic messages must promote public understanding of social determinants and policy support related to COVID-19. Using concepts from attribution theory and narrative persuasion, we employed an experiment (N = 435) testing the effects of personal responsibility (high, moderate, and low) on affective engagement and COVID-19 policy support. Namely, the manuscript examines (a) affective responses to characters displaying varying levels of personal responsibility for COVID-19 prevention, (b) the impact of these affective responses on policy support, and (c) the moderating role of audience political ideology on these effects. Analyses revealed that a highly responsible protagonist elicited empathy and perceived similarity, increasing policy support. While participants' political ideology moderated protagonist responsibility on perceived similarity, a more responsible protagonist evoked empathy independently of political leaning. Theoretical and practical implications are offered.

Low-Cost Strategies for the Development of Neurocritical Care in Resource-Limited Settings

This review explores low-cost neurocritical care interventions for resource-limited settings, including economical devices, innovative care models, and disease-specific strategies. Devices like inexpensive ventilators, wearable technology, smartphone-based ultrasound, brain4care, transcranial Doppler, and smartphone pupillometry offer effective diagnostic and monitoring capabilities. Initiatives such as intermediate care units, minimally equipped stroke units, and tele-neurocritical care have demonstrated benefits by reducing hospital stays, preventing complications, and improving clinical and economic outcomes. The review emphasizes locally applicable tailored approaches for diagnosing and managing conditions such as traumatic brain injury, neuroinfections, status epilepticus, autoimmune neurological disorders, and acute stroke as viable and affordable solutions.

Mass Casualty Incident Training in Immersive Virtual Reality: Quasi-Experimental Evaluation of Multimethod Performance Indicators

BACKGROUND

Immersive virtual reality (iVR) has emerged as a training method to prepare medical first responders (MFRs) for mass casualty incidents (MCIs) and disasters in a resource-efficient, flexible, and safe manner. However, systematic evaluations and validations of potential performance indicators for virtual MCI training are still lacking.

OBJECTIVE

This study aimed to investigate whether different performance indicators based on visual attention, triage performance, and information transmission can be effectively extended to MCI training in iVR by testing if they can discriminate between different levels of expertise. Furthermore, the study examined the extent to which such objective indicators correlate with subjective performance assessments.

METHODS

A total of 76 participants (mean age 25.54, SD 6.01 y; 45/76, 59% male) with different medical expertise (MFRs: paramedics and emergency physicians; non-MFRs: medical students, in-hospital nurses, and other physicians) participated in 5 virtual MCI scenarios of varying complexity in a randomized order. Tasks involved assessing the situation, triaging virtual patients, and transmitting relevant information to a control center. Performance indicators included eye-tracking-based visual attention, triage accuracy, triage speed, information transmission efficiency, and self-assessment of performance. Expertise was determined based on the occupational group (39/76, 51% MFRs vs 37/76, 49% non-MFRs) and a knowledge test with patient vignettes.

RESULTS

Triage accuracy (d=0.48), triage speed (d=0.42), and information transmission efficiency (d=1.13) differentiated significantly between MFRs and non-MFRs. In addition, higher triage accuracy was significantly associated with higher triage knowledge test scores (Spearman ρ=0.40). Visual attention was not significantly associated with expertise. Furthermore, subjective performance was not correlated with any other performance indicator.

CONCLUSIONS

iVR-based MCI scenarios proved to be a valuable tool for assessing the performance of MFRs. The results suggest that iVR could be integrated into current MCI training curricula to provide frequent, objective, and potentially (partly) automated performance assessments in a controlled environment. In particular, performance indicators, such as triage accuracy, triage speed, and information transmission efficiency, capture multiple aspects of performance and are recommended for integration. While the examined visual attention indicators did not function as valid performance indicators in this study, future research could further explore visual attention in MCI training and examine other indicators, such as holistic gaze patterns. Overall, the results underscore the importance of integrating objective indicators to enhance trainers' feedback and provide trainees with guidance on evaluating and reflecting on their own performance.

Body Fat and Obesity Rates, Cardiovascular Fitness, and the Feasibility of a Low-Intensity Non-Weight-Centric Educational Intervention Among Late Adolescents: Quasi-Experimental Study

Background

Obesity rates among Saudi adolescents are increasing, with regional variations highlighting the need for tailored interventions. School-based health programs in Saudi Arabia are limited and often emphasize weight and body size, potentially exacerbating body image dissatisfaction. There is limited knowledge on the feasibility of non-weight-centric educational programs in Saudi Arabia and their effects on health behaviors and body image.

objectives

This study aimed to (1) assess the prevalence of obesity using BMI-for-age z score (BAZ) and fat percentage among Saudi adolescents; (2) evaluate key health behaviors, cardiovascular fitness, and health literacy; and (3) assess the feasibility and impact of a low-intensity, non-weight-centric educational intervention designed to improve knowledge of macronutrients and metabolic diseases, while examining its safety on body image discrepancies.

Methods

A quasi-experimental, pre-post trial with a parallel, nonequivalent control group design was conducted among 95 adolescents (58 boys and 37 girls; mean age 16.18, SD 0.53 years) from 2 public high schools in Medina City, Saudi Arabia. Participants were randomly assigned to either the weight-neutral Macronutrient + Non-Communicable Diseases Health Education group or the weight-neutral Macronutrient Health Education group. Anthropometry (BAZ and fat percentage), cardiovascular fitness, physical activity, and eating behaviors were measured at baseline. Independent t tests and χ² tests were conducted to compare group differences, and a 2-way mixed ANOVA was used to evaluate the effect of the intervention on macronutrient knowledge and body image discrepancies. A total of 69 participants completed the postintervention assessments.

Results

The prevalence of overweight and obesity based on BAZ was 37.9% (36/95), while 50.5% (48/95) of participants were classified as overfat or obese based on fat percentage. Students with normal weight status were significantly more likely to have had prior exposure to health education related to metabolic diseases than students with higher weight status (P=.02). The intervention significantly improved macronutrient-metabolic knowledge (F1,64=23.452; P<.001), with a large effect size (partial η²=0.268). There was no significant change in students' body image from pre- to postintervention (P=.70), supporting the safety of these weight-neutral programs. The intervention demonstrated strong feasibility, with a recruitment rate of 82.6% and a retention rate of 72.6%.

Conclusions

This study reveals a high prevalence of obesity among Saudi adolescents, particularly when measured using fat percentage. The significant improvement in knowledge and the nonimpact on body image suggest that a non-weight-centric intervention can foster better health outcomes without exacerbating body image dissatisfaction. Region-specific strategies that prioritize metabolic health and macronutrient education over weight-centric messaging should be considered to address both obesity and body image concerns in adolescents.

Focus Groups With Guatemalan Community Leaders About Barriers to Cervical Cancer Prevention and Control

Cervical cancer is the leading cause of cancer-related death among Latin American women, including Guatemalans. This is troubling, given we have a vaccine, screening tool, and treatment for this preventable disease. Human papillomavirus (HPV) causes most cervical cancer. HPV self-testing is a viable option for women in low-resource areas, such as Guatemala. More information is needed about barriers to HPV self-testing. We conducted four focus groups (N = 43) in three locations in San Raymundo with female community leaders to assess the lived experience of their attitudes, practices, and knowledge about cervical cancer. Participants shared barriers they face receiving Pap tests, the HPV vaccine, and self-testing for HPV. We concluded culturally targeted information is needed about cervical cancer prevention, screening, and treatment. Policies should include outreach to marginalized populations in remote areas with low-literacy indigenous Mayans. Practices should include partnerships with lay midwives and health promoters to help Guatemalan women self-test for HPV.

Psychosocial determinants of the willingness to pay for social health insurance among workers at a commercial bank in Dessie, Ethiopia: a multi-setting study

Background

A lack of health insurance is a major barrier to the "health for all" agenda, where out-of-pocket (OOP) spending is the primary healthcare funding mechanism, a characteristic of Ethiopia's healthcare sector, leading it to plan to fully implement social health insurance (SHI) by 2014, but not yet, owing to significant opposition from public employees. The objective of this study was to look into the psychosocial determinants of the willingness to pay (WTP) for SHI among employees at a commercial bank in Dessie, Ethiopia.

Methods

We employed a cross-sectional study (October to December 2023) design. A self-administered questionnaire was used to collect the data. We used SPSS 27 to analyze the data. The relationship between dependent and independent variables was determined using the odds ratios at a p value less than 0.05 with a 95% CI.

Results

Of 396 samples, 264 (66.7%) responded, of which 93.9% had information about SHI, mainly from broadcast media (71.0%). More than three-fourths (75.8%) and two-thirds (64.4%), respectively, had poor knowledge and a negative perception regarding SHI. More than half (50.4%) of the participants were willing to pay, of which 88.5% (40.5% of the total participants) were interested in paying the 3.0% premium set by the government. The main reason for the WTP was to help those who could not afford medical costs, while the primary reason for not paying was the scheme's limited benefit packages. The WTP was found to be significantly affected by being female (AOR = 0.50, 95% CI: 0.26-0.98), being affiliated with orthodox Christianity (AOR = 0.48, 95% CI: 0.23-0.99), the presence of ≥5 family members in the household (AOR = 0.17, 95% CI: 0.06-0.52), experience of illness in the last 6 months (AOR = 4.95, 95% CI: 2.23-11.00), and perception toward it (AOR = 4.07, 95% CI: 2.03-8.17).

Conclusion

The WTP for the scheme was suboptimal, attributed to limited benefit packages, lack of medicines and equipment, and poor healthcare quality, and significantly influenced by being female, being affiliated with orthodox Christianity, family size, experience of illness in the last 6 months, as well as perceptions toward it.

Addressing cardiovascular health risk factors in American Indian/Alaska Native Children: A narrative review

BACKGROUND

Cardiovascular disease (CVD) is common in American Indian/Alaska Native (AI/AN) adults and represents the leading cause of mortality. Risk factors for CVD in AI/AN adults are well-described, and a growing body of evidence reports the inequitable prevalence of factors associated with the development of CVD in AI/AN children, including obesity, physical inactivity, and diabetes mellitus (DM).

OBJECTIVE

This article organizes and summarizes the evidence describing CVD risk factors in AI/AN children, discusses the social drivers of health impacting these risks, and highlights several programs that have demonstrated effectiveness in improving AI/AN child health.

RESULTS

Fortunately, multiple community- and Tribal-based programs have aimed to mitigate the impact of obesity, diabetes, and physical activity in AI/AN youth, given that nascent CVD begins in the pediatric years. These efforts include screening, lifestyle choices, including diet and exercise, and, importantly, culturally relevant programming to promote cardiovascular health in AI/AN children.

DISCUSSION

Though at a disproportionate risk for CVD based on biological and social drivers of health, AI/AN children are being prioritized by their communities, and there are many ongoing efforts to support their cardiovascular health. However, further investigation and investment is warranted to protect this population and address ongoing disparities in AI/AN CVD.

The association of the four social vulnerability themes and COVID-19 mortality rates in U.S. Counties

The purpose of this study was to examine the relationship between social vulnerability and COVID-19 mortality rates during the whole outbreak in U.S. counties. COVID-19 deaths were gleaned from the USA Facts. Independent variables were gleaned from the CDC's Social Vulnerability Index. Spatial autoregressive models were used for data analysis. Results show that counties with more social vulnerability (socioeconomic) were positively associated with higher COVID-19 mortality rates. Counties with more social vulnerability (household composition & disability) were positively associated with higher COVID-19 mortality rates. Counties with more social vulnerability (minority status & language) were negatively associated with higher COVID-19 mortality rates. Counties with more social vulnerability (housing type & transportation) were negatively associated with higher COVID-19 mortality rates. In conclusion, county-level social vulnerability provides an useful framework for identifying unequal distribution of deaths from COVID-19 in the United States.

Exploring public support for novel tobacco and alcohol control policies in Great Britain 2021-2023: A population-based cross-sectional survey

Objective and rationale

This study assessed support for novel tobacco compared with alcohol control policies among adults in Great Britain in 2021-2023. Objectives were to assess 1) overall level of support for tobacco compared to alcohol control policies; 2) level of support for tobacco compared to alcohol control policies among people who smoke tobacco or who consume alcohol at increasing and higher risk levels, or who do both; 3) level of support for tobacco compared to alcohol control policies among different sociodemographic groups?

Methods

Data were collected in September/October 2021-2023 in a monthly population-based survey on smoking and drinking behaviour of adults across Great Britain (N = 6311), weighted to match the overall population. Outcome measure was level of support for each seven tobacco and alcohol control policies.

Results

More people were in support of tobacco than alcohol control policies (e.g., 57 % vs. 51 % for tax-related policies). This trend was apparent across all sociodemographic subgroups. With one exception, the policies included in this study were supported by more than half of the participants. The exception was decreasing the visibility of alcohol products in shops, which received 41 % of support. People who engaged in the behaviour targeted by policies (tobacco more so than alcohol use) were generally less supportive.

Conclusion

Overall, public support for tobacco and alcohol control policies is high in Great Britain. With one exception, the policies were supported by over half of participants, suggesting that the public is in favour of government regulations to reduce smoking and drinking prevalence in Great Britain.

Visible and invisible cultural patterns influencing women's use of maternal health services among Igala women in Nigeria: a focused ethnographic study

BACKGROUND

Explicit and implicit cultural patterns are critical cultural norms, beliefs, and practices that determine women's health-seeking behaviour. These cultural patterns could limit women's use of maternal health services, resulting in maternal health complications. The study aims to provide an in-depth understanding of explicit and implicit cultural patterns, their meanings and how they influence women's use of maternal health services among Igala women in Nigeria.

METHODS

Roper and Shapira's (2000) focused ethnography was employed with 43 women aged 18-43 years recruited using the purposive and snowballing technique. The study was conducted with 21 women for one-on-one interviews and two focus group discussions with six women in the rural area and seven women in the urban area. In addition, participant observation of nine women from the third trimester to birth was conducted, yielding 189 h of observation in two primary healthcare facilities in rural and urban areas. Data analysis was conducted using Roper and Shapira's (2000) method.

RESULT

Three themes were generated using the PEN3 cultural model: perceptions, enabler, and nurturers. Subthemes generated under the theme of perception were, Belief in witchcraft, Pregnancy announces itself, I cannot tell people I am in labour, and Unspoken acquiescence to the culture. Under the theme of nurturer, Home birth was found to limit access to maternal health services. The theme of enabler yielded subthemes such as You are not woman enough; I want my placenta and Rising matriarchs.

CONCLUSION

Implicit and explicit cultural patterns significantly influence women's use of maternal health services. Given the complexity of culture and its influence on women's use of maternal health services, multifaceted strategies tailored to the cultural needs of communities are needed to enhance the realization of Sustainable Development Goal #3:1 in Nigeria.

Estimated prevalence of post-intensive care cognitive impairment at short-term and long-term follow-ups: a proportional meta-analysis of observational studies

OBJECTIVE

Evidence of the overall estimated prevalence of post-intensive care cognitive impairment among critically ill survivors discharged from intensive care units at short-term and long-term follow-ups is lacking. This study aimed to estimate the prevalence of the post-intensive care cognitive impairment at time to < 1 month, 1 to 3 month(s), 4 to 6 months, 7-12 months, and > 12 months discharged from intensive care units.

METHODS

Electronic databases including PubMed, Cochrane Library, EMBASE, CINAHL Plus, Web of Science, and PsycINFO via ProQuest were searched from inception through July 2024. Studies that reported on cognitive impairment among patients discharged from intensive care units with valid measures were included. Data extraction and risk of bias assessment were performed independently for all included studies according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. Newcastle-Ottawa Scale was used to measure risk of bias. Data on cognitive impairment prevalence were pooled using a random-effects model. The primary outcome was pooled estimated proportions of prevalence of the post-intensive care cognitive impairment.

RESULTS

In total, 58 studies involving 347,940 patients were included. The pooled post-intensive care cognitive impairment prevalence rates at the follow-up timepoints < 1 month, 1-3 month(s), 4-6 months, 7-12 months, > 12 months were 49.8% [95% Prediction Interval (PI), 39.9%-59.7%, n = 19], 45.1% (95% PI, 34.8%-55.5%, n = 23), 47.9% (95% PI, 35.9%-60.0%, n = 16), 28.3% (95% PI, 19.9%-37.6%, n = 19), and 30.4% (95% PI, 18.4%-43.9%, n = 7), respectively. Subgroup analysis showed that significant differences of the prevalence rates between continents and study designs were observed.

CONCLUSIONS

The prevalence rates of post-intensive care cognitive impairment differed at different follow-up timepoints. The rates were highest within the first three months of follow-up, with a pooled prevalence of 49.8% at less than one month, 45.1% at one to three months, and 47.9% at three to six months. No significant differences in prevalence rates between studies that only included coronavirus disease 2019 survivors. These fundings highlight the need for further research to develop targeted interventions to prevent or manage cognitive impairment at short-term and long-term follow-ups.

Preventing zoonotic spillover through regulatory frameworks governing wildlife trade: A scoping review

Wildlife trade can create adverse impacts for biodiversity and human health globally, including increased risks for zoonotic spillover that can lead to pandemics. Institutional responses to zoonotic threats posed by wildlife trade are diverse; understanding regulations governing wildlife trade is an important step for effective zoonotic spillover prevention measures. In this review, we focused on peer-reviewed studies and grey literature conducted on regulatory approaches that govern domestic and international wildlife trade in order to assess the role of local, national and global-level institutions in the prevention of zoonotic spillover and infection transmission between humans. The five-stage scoping review protocol described by Arksey and O'Malley to map key concepts and main sources and types of evidence available was followed to understand and analyze empirical evidence from peer-reviewed studies and grey literature conducted on regulatory approaches that govern domestic and international wildlife. Sources were included if they discuss at least one of three points: regulatory approaches governing the wild animal trade, including wild animal markets, traditional medicine or exotic pets; regulatory approaches governing importation of wild animals and the international wildlife supply chain; or the role of local, national, and global-level institutions in regulating wild animal trade for food, traditional medicine or exotic pets. A total of 1598 sources were retrieved, from which 32 sources were included in the final review (30 studies + 2 grey literature reports). Based on published literature, regulations governing wildlife trade are inconsistent within and between countries. Organizations regulating wildlife trade may have competing interests, which can lead to fragmentation and a lack in coordination and oversight. National compliance with international regulations can be an issue. Reducing the probability of spillover events in wildlife trade is key to prevent future pandemics. Our results indicate a need for enhanced regulatory harmonization within and between national and supranational regulations. Coordination and collaboration for prevention of zoonotic infection and spillover may be enhanced through future research focused on the effectiveness of timely Information sharing and global- and national- level harmonization of wildlife trade regulations.

The impact of multidimensional poverty on antenatal care service utilisation in Malawi

BACKGROUND

Poverty remains a key barrier to accessing essential maternal health services, particularly in low- and middle-income countries like Malawi. Despite the recognised importance of antenatal care (ANC) in ensuring healthy pregnancies as well as improving maternal and child health outcomes, ANC services remain underutilised by many women living in poverty. This underutilisation is not solely driven by a lack of financial resources but also by a range of non-monetary factors that constitute multidimensional poverty, such as limited access to education, healthcare services, and infrastructure. While much of the existing literature focuses on monetary poverty, this study explores how multidimensional poverty impacts ANC utilisation. By examining how various deprivations intersect to limit access to ANC, this research contributes to understanding the broader issue of healthcare inequality.

AIM

We assess the impact of multidimensional poverty (non-monetary) on antenatal care use in Malawi.

METHOD

Multidimensional poverty was constructed using the Forster-Akire method of the Oxford Poverty and Human Initiative (OPHI). We use data from the 2015-16 Demographic Health Survey (DHS), which includes information on women aged 15-49 who gave birth within five years of the survey. To mitigate selection bias, we use Propensity Score Matching (PSM) techniques for our principal analysis.

RESULTS

Our findings reveal that 52% of women adequately utilised ANC services. About 8,428 women were identified as multidimensionally poor, and 4,685 were classified as non-poor. The results of our PMS analysis show a significant negative relationship between ANC utilisation and multidimensional poverty (B = 0.52; P < 0.008), indicating that multidimensionally poor women are less likely to use ANC services. Similarly, the timing of ANC visits also showed a negative relationship with multidimensional poverty (B = 0.26; P < 0.04), highlighting that multidimensionally poor women are less likely to attend ANC visits within the recommended first trimester.

CONCLUSION

The findings suggest that there is a need for sustainable investments in poverty alleviation programs to address and reduce multidimensional poverty as well as raise awareness of sexual and reproductive health concerns among adolescents and women in Malawi to improve maternal health outcomes.

Non-utilisation of postpartum services in northwestern Nigeria: analyses of trend and social determinants from 2003 to 2018

OBJECTIVE

To assess the prevalence of non-utilisation of postpartum services in northwestern Nigeria from 2003 to 2018 and to identify and estimate the influence of social determinants, a crucial step in improving maternal and child health in the region.

DESIGN

The 2003, 2008, 2013 and 2018 Nigeria Demographic and Health Survey rounds were used. Descriptive, trend and multivariable logistic regression analyses were used to show the trend and assess the influence of social determinants. The sample consisted of 17 294 women aged 15-49 who responded to questions on postpartum attendance during the period.

SETTING

Northwestern geographical subregion of Nigeria.

OUTCOME

The non-use of postpartum services.

RESULTS

The non-utilisation of postpartum services has increased from 77% in 2003 to 87% in 2018, with an overall prevalence of 88% of all women not using the services. The odds of not using postpartum services were higher for women with no education (adjusted OR (AOR): 1.27; CI: 1.03 to 1.58), those with no knowledge of contraceptives (AOR: 1.72; CI: 1.35 to 2.19), those who never used contraceptives (AOR: 1.71; CI: 1.39 to 2.09), those with parity of four or more births (AOR: 1.58; CI: 1.34 to 1.86), those in polygynous marriage (AOR: 1.16; CI: 1.03 to 1.30) and those from the poorest (AOR: 2.34; CI: 1.67 to 3.28) and poorer (AOR: 2.05; CI: 1.50 to 2.78) households. The odds were lower for women who wanted to delay pregnancy (AOR: 0.74; CI: 0.55 to 0.99) and those with full (AOR: 0.56; CI: 0.42 to 0.75) or joint (AOR: 0.67; CI: 0.53 to 0.83) autonomy in healthcare decisions.

CONCLUSION

The findings are crucial for understanding and addressing the non-utilisation of postpartum services in northwestern Nigeria. Policymakers should aim to address the impacts of the identified social determinants to promote the use of postpartum services, prevent maternal deaths and meet the SDG-3.1 target.

Association of children's electronic media use with physical activity, cognitive function, and stress

OBJECTIVE

Electronic media is constantly evolving and has become an integral part of people's lives, especially among youth. This cross-sectional observational study assessed the association between electronic media use, health behaviors and outcomes, specifically, physical activity, stress and cognitive function among youth from an under-resourced community.

METHODS

Participants ages six-sixteen were recruited from a Federally Qualified Health Center to participate in a study to promote park prescriptions with data collection between 2020 and 2024. At baseline, both intervention and control participants were asked to wear an accelerometer for one week and complete surveys about their electronic media time, stress, and cognitive function. We estimated the associations between electronic media use and health outcomes using cross-sectional multiple regressions.

RESULTS

Among the 441 participants, the average amount of electronic media use was 48.6 h per week (95 % CI: 46.0, 51.1), with children ages 6-9 engaging in 37.3 h per week (95 % CI: 34.5, 40.2) and youth ages 10-16 engaging in 56.4 h per week of electronic media time (95 % CI: 52.9, 59.9). Average daily MVPA was 16.6 min (95 % CI: 15.4, 17.8). Electronic media use time was negatively associated with MVPA and with cognitive function for all age groups. Electronic media time was only associated with stress for youth over age 10.

CONCLUSION

The associations among electronic media, MVPA, cognitive function and stress were statistically significant, but relatively modest. Future research should examine whether reducing time on electronic media will have a positive impact on physical activity and mental health outcomes.

CLINICAL TRIALS REGISTRY NUMBER

#NCT04114734.

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.

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.

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.

Enforcement of COTPA in India- current status, challenges and solutions

INTRODUCTION

The key for public health programs to succeed is their successful implementation to achieve the desired outcomes. For integrating legislative measures such as the Cigarette and Other Tobacco Products Act (COTPA), which needs a component of enforcement, unless there is optimal engagement and empowerment of the assigned agencies, the outcomes are likely to be weak and incomplete at best.

CURRENT STATUS

Enforcement of COTPA under the National Tobacco Control Programme (NTCP) has succeeded only partly despite the best efforts of State Tobacco Control Cells (STCCs) countrywide. The lack of an execution plan, irregularity in the training schedules of the assigned agencies which lack ownership, suboptimal engagement of the stakeholders, including civil societies (CSOs), missing monitoring and evaluation of their outputs until recently and, above all, an absence of an accountability clause in COTPA for non-performance have led to varied but mostly poor compliance.

SOLUTIONS

For successful enforcement of COTPA, the Ministry of Health & Family Welfare (MoHFW), besides integrated solutions proposed by several studies, should consider amending COTPA and strengthening the existing measures to control tobacco, such as setting of a dedicated COTPA-enforcement Police Unit at the State-level, a National Tobacco Control Organization (NTCO) or entrust it entirely to a third-party.

CONCLUSION

In India, the strictest enforcement of COTPA is critical to reduce the burden of tobacco. The MoHFW, besides amending COTPA at the earliest, should specifically focus on adopting the proposed outcome-oriented strategies. Or else, it should consider working for an endgame of tobacco in India by the year 2030.

Racial/ethnic inequality in homelessness and drug overdose deaths in US States

PURPOSE

This study examined whether state-level racial disproportionality in homelessness is associated with racial disproportionality in overdose mortality.

METHODS

Counts of individuals experiencing homelessness (2015-2017; by state and racial/ethnic group) were obtained from the US Department of Housing and Urban Development; population estimates and counts of drug overdose deaths (2018-2021; by state and racial/ethnic group) were obtained from the National Center for Health Statistics. Homelessness and overdose mortality disproportionality scores were calculated to indicate the extent to which each racial group was over- or under- represented among those experiencing homelessness, or among overdose deaths, respectively (relative to each racial group's proportional share in the general population). For each racial group examined, ordinary least squares regression models with robust standard errors (SEs) examined associations between state-level disproportionality in homelessness and disproportionality in overdose mortality, adjusting for percent aged 18-64 and US Census Region, as well as disproportionality in educational attainment and unemployment.

RESULTS

State-level racial disproportionality in homelessness was significantly and positively associated with racial disproportionality in overdose mortality for Black (b = 0.16 [SE = 0.05]; p < .01), American Indian/Alaska Native (b = 0.71 [SE = 0.23]; p < .01), and Hispanic populations (b = 0.17 [SE = 0.05]; p < .01), in models adjusting for region and percent aged 18-64. The significant positive associations in these three populations persisted after adjusting for educational attainment disproportionality, yet the association was no longer significant in the Black population after adjusting for unemployment disproportionality.

CONCLUSION

States with the highest levels of racial/ethnic minority overrepresentation in homelessness generally also had relatively higher levels of racial/ethnic minority overrepresentation in overdose deaths.

Timing of Infection as a Key Driver of Racial/Ethnic Disparities in Coronavirus Disease 2019 Mortality Rates During the Prevaccine Period

Disparities in coronavirus disease 2019 mortality are driven by inequalities in group-specific incidence rates (IRs), case fatality rates (CFRs), and their interaction. For emerging infections, such as severe acute respiratory syndrome coronavirus 2, group-specific IRs and CFRs change on different time scales, and inequities in these measures may reflect different social and medical mechanisms. To be useful tools for public health surveillance and policy, analyses of changing mortality rate disparities must independently address changes in IRs and CFRs. However, this is rarely done. In this analysis, we examine the separate contributions of disparities in the timing of infection-reflecting differential infection risk factors such as residential segregation, housing, and participation in essential work-and declining CFRs over time on mortality disparities by race/ethnicity in the US state of Michigan. We used detailed case data to decompose race/ethnicity-specific mortality rates into their age-specific IR and CFR components during each of 3 periods from March to December 2020. We used these estimates in a counterfactual simulation model to estimate that that 35% (95% credible interval, 30%-40%) of deaths in black Michigan residents could have been prevented if these residents were infected along the timeline experienced by white residents, resulting in a 67% (61%-72%) reduction in the mortality rate gap between black and white Michigan residents during 2020. These results clearly illustrate why differential power to "wait out" infection during an infectious disease emergency-a function of structural racism-is a key, underappreciated, driver of inequality in disease and death from emerging infections.

Characterizing and responding to stimulant overdoses: Findings from a mixed methods study of people who use cocaine and other stimulants in New England

PURPOSE

To explore people who use stimulants' (PWUS) stimulant overdose experiences and identify factors associated with calling 911 for personal and witnessed stimulant overdoses.

METHODS

From 2022-2023, 222 people in Massachusetts and Rhode Island with past-30-day illicit stimulant use were surveyed. Adjusted multivariable logistic regression models examined the association between sociodemographics, substance use, and stimulant overdose history and whether 911 was called for participants' last personally experienced and witnessed stimulant overdoses.

RESULTS

Overall, 42.2 % of PWUS witnessed- and 34.5 % personally overdosed on stimulants. Nearly half (48.7 %) of participants who overdosed used crack cocaine prior, 35.5 % reported extremely severe symptoms (e.g., heart attack, stroke, seizure, loss of consciousness), and 34.2 % said 911 was called at their last overdose. Among those who last witnessed a stimulant overdose, 41.5 % reported crack cocaine involvement, and 47.9 % said 911 was called (20.0 % personally called). Higher educational attainment and experiencing extremely severe symptoms were positively associated with 911 being called at participants' last stimulant overdose, whereas the number of overdoses witnessed and crack cocaine use by the person overdosing were negatively associated with 911 being called at participants' last witnessed stimulant overdose (all p-values<.05).

CONCLUSION

Stimulant overdoses were common. Most participants reported moderate-to-severe symptoms, yet 911 was called in less than half of personal or witnessed stimulant overdoses. Emergency help-seeking also varied by symptom severity, stimulant type, and the sociodemographics of the person overdosing. Research is needed to understand barriers to formal help-seeking and the practices PWUS engage in to prevent fatal stimulant overdoses.