Sex differences in the relationship between childhood sexual abuse and adult homelessness among underserved bipolar outpatients

BACKGROUND

Childhood sexual abuse (CSA) and homelessness are major public health problems with elevated prevalence among people diagnosed with bipolar disorder (BD). While CSA is a known risk factor for homelessness, little research has examined sex differences in the relationship between CSA and adult homelessness among people with BD.

METHODS

This study tested whether sex moderates the CSA-homelessness relationship such that greater CSA severity predicts higher risk of adult homelessness for females but not males. Data were collected from 201 outpatients at a bipolar outpatient clinic in the Southeastern U.S., most of whom identified as female and Black/African American and reported low income. Self-report data were collected at one clinic visit and analyzed using moderated logistic regression.

RESULTS

CSA was reported by 76.3 % of females and 43.5 % of males. Sex moderated the CSA-homelessness relationship (p < .01). CSA severity was significantly associated with adult homelessness for females (OR = 1.08, 95 % CI: [1.02, 1.15]) but not for males.

LIMITATIONS

Internal and external validity were constrained by the non-representative sample, self-report biases, and a cross-sectional design.

CONCLUSIONS

Findings highlight sex differences in the long-term consequences of CSA among underserved populations with BD, identifying CSA as a significant predictor of adult homelessness for females. Further research should explore bipolar symptomatology, sociocultural factors, and other potential mediators. Results underscore the need for integrated mental health and social services that are accessible across the lifespan, sex- and gender-sensitive, and trauma-informed.

COVID-19 Pandemic and the Developmental Health of Kindergarteners

Importance

Recent studies have associated the COVID-19 pandemic with negative developmental outcomes in children. However, research focused on young children remains limited, with few studies including multiple years of pre- and postpandemic onset data.

Objective

To examine the impact of the COVID-19 pandemic on US kindergarteners' developmental health.

Design, Setting, and Participants

This repeated cross-sectional panel study examined developmental health trends, as measured by the Early Development Instrument (EDI), among a convenience sample US kindergarteners from 2010 to 2023. EDI data were obtained from 390 school districts across 19 states. Data were analyzed from June December 2024.

Exposure

Kindergarteners' developmental health was compared between prepandemic (2018 to 2020) and postpandemic (2021 to 2023) onset cohorts.

Main Outcomes and Measures

Outcomes were EDI scores across time in 5 domains: (1) physical health and well-being, (2) social competence, (3) emotional maturity, (4) language and cognitive development, and (5) communication and general knowledge. The mean (95% CI) EDI scores were assessed.

Results

In this sample of of 475 740 US kindergarten students, 242 869 were male (51.1%), there were 53 841 African American or Black students (11.4%), 263 037 Hispanic or Latino/a students (55.5%), and 95 258 White students (20.1%), and the mean (SD) age was 6 (0.4) years (range, 4.0-8.0 years). Compared with the immediate prepandemic onset period, the rate of change in EDI scores was significantly lower following the pandemic onset in language and cognitive development (mean change, -0.45; 95% CI, -0.48 to -0.43), social competence (mean change, -0.03; 95% CI, -0.06 to -0.01), and communication and general knowledge (mean change, -0.18; 95% CI, -0.22 to -0.15). EDI scores were significantly higher in emotional maturity (mean change, 0.05; 95% CI, 0.03 to 0.07), and no significant changes were observed in the physical health and well-being domain (mean change, 0; 95% CI, -0.01 to 0.02).

Conclusions and Relevance

The COVID-19 pandemic was associated with varying developmental health outcomes in kindergarteners. Negative developmental trends existed immediately before the pandemic, with most persisting or slowing postpandemic onset. These results highlight troubling trends in kindergarteners' development, both before and during the pandemic, and more information is needed to understand why developmental outcomes are worsening over time.

The freedom to mentalize: The influence of socio-demographic indicators of empowerment on parental reflective functioning

Parental reflective functioning (PRF), a critical construct in the field of infant mental health, has been under investigated in non-WEIRD countries, where the majority of the world's infants are born. Studies from WEIRD contexts have demonstrated a relationship between socio-demographic and parental reflective functioning scores. This study used a mixed-methods concurrent exploratory research design to investigate relationships between socio-demographic factors and parental reflective functioning in a cohort of Black mothers living in Alexandra Township, South Africa. The study found relationships between parental reflective functioning and both abuse disclosure and father involvement in unexpected directions. Qualitative analysis of interview transcripts and intervention case notes highlighted the potential role of empowerment in the participants PRF scores. The findings highlight the central importance of considering the influence of power dynamics and social positioning when measuring parental reflective functioning for both research and clinical purposes.

Childhood Homelessness as an Adverse Childhood Experience (ACE): Adult Mental Health Outcomes

Adverse childhood experiences (ACEs) are experiences of abuse, neglect, and other household problems occurring before age 18 and contribute to the development of both physical and mental health concerns. People experiencing homelessness report disproportionately higher rates of ACEs and negative mental health concerns; however, little research has been conducted regarding the relationship between ACEs and mental health outcomes specifically for homeless populations. A dearth of research also exists regarding how childhood experiences of homelessness interact with ACEs and mental health outcomes. The present study examined the mental health outcomes for people experiencing homelessness, as well as how childhood experiences of homelessness may fit into the ACEs model using archival data. People experiencing homelessness (n = 100) completed the ACEs questionnaire, a demographics questionnaire, and a health appraisal questionnaire. Results found ACEs significantly predicted negative mental health outcomes for people experiencing homelessness. Childhood experiences of homelessness were predictive of negative mental health outcomes; however, this relationship became negligible when acting as a covariate with ACEs. This result suggests that the ACEs framework adequately explains the effects of traumatic events for children experiencing homelessness and the subsequent negative mental health outcomes.

Navigating the Maze of Social Media Disinformation on Psychiatric Illness and Charting Paths to Reliable Information for Mental Health Professionals : An Observational Analysis

BACKGROUND

Disinformation on social media can seriously affect mental health by spreading false information, increasing anxiety, stress, and confusion in vulnerable individuals as well as perpetuating stigma. This flood of misleading content can undermine trust in reliable sources and heighten feelings of isolation and helplessness among users.

OBJECTIVE

This study aimed to explore the phenomenon of disinformation about mental health on social media and provide recommendations to mental health professionals that would use social media platforms to create educational videos about mental health topics.

METHODS

A comprehensive analysis conducted on 1000 TikTok videos from over 16 countries, available in English, French, and Spanish, covering 26 mental health topics. The data collection was conducted using a framework on disinformation and social media. A multilayered perceptron algorithm was used to identify factors predicting disinformation. Recommendations to health professionals about the creation of informative mental health videos were designed as per the data collected.

RESULTS

Disinformation was predominantly found in videos about neurodevelopment, mental health, personality disorders, suicide, psychotic disorders, and treatment. A machine learning model identified weak predictors of disinformation, such as an initial perceived intent to disinform and content aimed at the general public rather than a specific audience. Other factors, including content presented by licensed professionals like a counseling resident, an ear-nose-throat surgeon, or a therapist, and country-specific variables from Ireland, Colombia, and the Philippines, as well as topics like adjustment disorder, addiction, eating disorders, and impulse control disorders, showed a weak negative association with disinformation. In terms of engagement, only the number of favorites was significantly associated with a reduction in disinformation. Five recommendations were made to enhance the quality of educational videos about mental health on social media platforms.

CONCLUSIONS

This study is the first to provide specific, data-driven recommendations to mental health providers globally, addressing the current state of disinformation on social media. Further research is needed to assess the implementation of these recommendations by health professionals, their impact on patient health, and the quality of mental health information on social networks.

CLINICALTRIAL

From safety to efficiency: How drivers of technology adoption changed during the COVID-19 pandemic in municipal home care

BACKGROUND

Home care underwent abrupt adaptations to handle the COVID-19 pandemic including an accelerated digitalization. While some research exists regarding the working conditions for home care personnel during the COVID-19 pandemic, few studies exist on the effect of everyday technology use in home care during the pandemic. The aim of this study was to investigate how digital technologies, introduced in Swedish municipal home care during the COVID-19 pandemic, were adopted and used by home care nurses and how well they fitted the context of use over time.

METHODS

An ethnographic approach was employed where qualitative data were gathered via semi-structured interviews and field observations. The data were subjected to thematic analysis. The Technology Acceptance Model (TAM) and the Task-Technology Fit (TTF) model were used as theoretical frameworks to identify and discuss factors associated with technology acceptance, use, and fit with the work.

RESULTS

Three new technologies were implemented: digital infection status lists, digital faxing, and digital meetings. Around these three technologies, two main themes related to the adoption and acceptance of technology were constructed: Ensuring safety and Striving for efficiency. Initially, the implementation of the technologies was solely driven by a need to ensure safety. However, benefits promoting efficiency were progressively discovered. After the pandemic, the perceived usefulness of the technologies was solely related to efficiency. Digital meetings continued to be in use also after the pandemic since they improved efficiency. Digital faxing continued to be in use despite being associated with usability problems, as the previous solution, the analogue fax, had been decommissioned. Thus, adoption was not only a matter of perceived usefulness but also a matter of other organizational factors and decisions.

CONCLUSIONS

Technology had a central role in home care during the pandemic as it was used to ensure safety. Contextual conditions changed over time, and with them motivations to use the new technologies. The dynamic nature that dictates technology use in practice is not captured well in the TAM and TTF theoretical frameworks. A more holistic discussion is needed where context, feedback, agency, and control at work are given greater consideration and space.

TRIAL REGISTRATION

Not applicable.

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.

Reducing Neonatal Mortality in Nepal's Remote Regions: A Narrative Review of Challenges, Disparities, and the Role of Helping Babies Breathe (HBB)

BACKGROUND

Nepal's diverse geography creates significant challenges for healthcare accessibility, particularly for neonatal care. Rural areas, especially in the mountainous regions, face severe healthcare gaps due to isolation, inadequate infrastructure, and a shortage of skilled staff. Strengthening healthcare in these underserved regions is essential to reducing neonatal mortality. Helping Babies Breathe (HBB) is a neonatal resuscitation training program designed to reduce neonatal mortality due to birth asphyxia in low-resource settings.

METHODS

A comprehensive literature search identified studies on neonatal mortality and interventions, particularly HBB, which were analyzed using a narrative synthesis approach. This review examines disparities in neonatal health outcomes, regional differences, and barriers to healthcare access.

FINDINGS

This review identifies key themes related to healthcare disparities, neonatal mortality, and birth outcomes in Nepal's remote regions. Geographical isolation, inadequate healthcare infrastructure, and cultural barriers contribute to persistently high neonatal mortality, particularly in mountainous areas such as Jumla and Dolpa, where rates exceed 60 per 1000 live births. HBB has shown a significant impact, reducing neonatal mortality by up to 60% when effectively implemented. However, infrastructural gaps, lack of emergency transport, and the uneven distribution of skilled birth attendants (SBAs) remain critical challenges. Addressing these disparities requires expanded training, increased availability of neonatal resuscitation equipment, and culturally sensitive healthcare strategies.

Outdoor recreation's association with mental health and well-being during the COVID-19 pandemic

Outdoor recreation provided a crucial way to maintain physical activity, reduce stress, and preserve a sense of normalcy during the COVID-19 pandemic. This study assessed the relationship between outdoor recreation and mental health in the context of COVID-19. Cross-sectional online survey data were collected in early 2021 from a sample (n = 503) representative of the U.S. adult population in age, gender, and race. We observed prevalent engagement in near-home outdoor activities, widespread reductions in outdoor engagement relative to the pre-COVID period, and significant age, financial, and racial differences in engagement patterns. Regression models suggested that reduced outdoor recreation was associated with higher levels of perceived stress and depressive symptoms, whereas more frequent outdoor activities predicted better well-being. The health implications of adaptive engagement versus cumulative exposure during times of significant disruptions are discussed, along with the need to address structural inequities in accessing outdoor recreation as a health behavior.

Communication Practices to Support Frontline Workers During Public Health Threats

BACKGROUND

Public health threats (PHTs) influence how and in what ways managers communicate with employees. Employee resources and information during uncertain times has been noted as a reoccurring gap, especially as it relates to personal protective equipment (PPE). This study explored general and PPE-specific communication practices with 22 healthcare and emergency medical service (EMS) managers to support workers, particularly in the context of preparedness and response.

METHODS

Data collection occurred in two phases that involved interviews and small group discussions to identify, examine, and better frame and execute communication practices. Qualitative analysis was informed by the 4i FACT framework and the social ecological model (SEM) to identify relevant communication practices and intervention points within health delivery settings.

RESULTS

Results elucidated perceived, effective leadership practices and interpersonal influences in the workplace. Tangible leadership communication practices were identified as important intervention points within the SEM, with a focus on proactive behaviors to procure necessary PPE and disseminate information. Participants emphasized one-on-one interactions with employees, and the use of trusted messengers to share health-related messages. They also highlighted the challenges of PPE shortages and the importance of access to resources across different job roles, organizations, and work settings.

CONCLUSIONS/APPLICATION TO PRACTICE

This study contributes insights into communication practices during a public health emergency, offering a nuanced understanding of managerial approaches, PPE-related communication, and the broader contextual factors influencing information dissemination. Further, the integration of frameworks like 4i FACT and SEM provides a structured perspective for future communication strategies, supporting tailored approaches across organizations.

Cancer Care for Refugees in Türkiye: Challenges and Achievements

OBJECTIVES

In Türkiye, which hosts over 3.6 million Syrian refugees seeking safety and stability, reducing inequalities in access to adequate cancer care is pivotal and multifaceted. This study aims to critically discuss cancer care provided for refugees in Türkiye, focusing on the barriers they face, and the progress in addressing these challenges.

METHOD

This discussion paper employs an environmental scan approach. Literature searches in both English and Turkish were conducted using databases Web of Science, PubMed, TR Dizin, and MEDLINE, focusing on keywords such as "refugees," "cancer care," and "immigrants." Policy documents and regulations related to refugee health in Türkiye were also reviewed. The analysis incorporated information from official websites and online resources, including the Turkish Ministry of Health (MoH), Directorate General of Migration Management (DGMM), World Health Organization (WHO)United Nations High Commissioner for Refugees (UNHCR), United Nations Development Program (UNDP), and reports from the EU-funded SIHHAT Project. The Conceptual Framework for Health Service Use was utilized to structure the reporting and analysis of the literature, ensuring a comprehensive assessment of access to cancer care among refugees.

RESULTS

Findings reveal multiple factors influence refugees' access to cancer care in Türkiye. Predisposing factors, such as language barriers, limited health literacy, and cultural beliefs about cancer, impact refugees' willingness and ability to seek timely care. Enabling factors, including legal status, economic constraints, and availability of refugee-specific health services, significantly shape their access to diagnosis and treatment. Although policy reforms and community-based interventions aim to improve cancer care accessibility, need-based factors, such as delays in diagnosis and inadequate continuity of care, continue to hinder optimal healthcare utilization.

CONCLUSION

To ensure more inclusive cancer care, future strategies should focus on improving healthcare system navigation, strengthening financial and structural support, and enhancing the cultural competence of healthcare professionals. A comprehensive and sustainable approach is needed to bridge gaps and promote equitable cancer care access for all refugee populations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are crucial in improving cancer care for refugees by providing culturally sensitive education, enhancing communication between patients and healthcare providers, and advocating for health policies that address refugees' specific needs. Strengthening the role of nurses in multidisciplinary teams will further enhance the delivery of holistic and patient-centered cancer care for refugees.

Subject Modeling-Based Analysis of the Evolution and Intervention Strategies of Major Emerging Infectious Disease Events

Objective

Due to the popularity of the Internet and the extensive use of new media, after the occurrence of infectious diseases, the spread of social media information greatly affects the group's opinion and cognition and even the health behaviors they take, thus affecting the spread of infectious diseases. Therefore, this paper studies the event evolution from multiple dimensions.

Methods

To address this gap, we developed a three-layer model framework of major infectious disease event evolution based on subject modeling. This framework integrates three key factors-health transmission, perspective interaction, and risk perception-to analyze group perspective evolution, behavioral change, and virus transmission processes. The model's effectiveness was evaluated through simulation and sensitivity analysis. In addition, we conducted an empirical analysis by constructing a social media health transmission effect index system to identify the critical factors affecting health transmission.

Results

Simulation results reveal that among the three factors, health transmission has the most significant impact on the evolution of group perspectives during infectious disease events. Moreover, the dynamics of public viewpoint evolution influence individual decisions regarding the adoption of non-pharmacological interventions, which are shown to effectively reduce both the transmission rate of the virus and the peak number of infections.

Conclusion

The findings of this study enhance our understanding of the complex mechanisms and evolutionary pathways in infectious disease events. By integrating multiple dimensions of event evolution, the proposed model offers valuable insights for the design of effective countermeasures and strategies in emergency management and response to infectious disease outbreaks.

Care, dying, death, and loss in children's drawings from the Covid-19 pandemic in Sweden

Most studies gather data on children's Covid-19 experiences from proxy adults rather than from children. We explore depictions of end-of-life issues in drawings created by children in Sweden about their experiences during the Covid-19 pandemic, generated in response to an open invitation to schools, teachers, culture centers, etc. from a public archive of children's art. A transdisciplinary team inductively analyzed 172 drawings containing images of care, dying, death and loss, finding qualitatively different portrayals differentiated by focus on (re)actors versus victims in the pandemic. The virus was often drawn as an aggressive, active agent, while humans, including professionals, appeared reactive and at a loss. The largest group of victims were without identity, although some children depicted themselves as victims. These children illustrate Covid-19-related questions, concerns, and fears about the end of life, reflecting "epistemological uncertainty" resulting from the pandemic. This uncertainty should be addressed, for example by trustworthy support in making sense of surrounding world, and by pro-active death educational approaches for both children and the adults who are in contact with them.

State-level structural racism and adolescent mental health in the United States

We explored state-level indicators of structural racism on internalizing symptoms of depressive affect among US adolescents. We merged 16 indicators of state-level structural racism with 2015-19 Monitoring the Future surveys (n = 41 258) examining associations with loneliness, self-esteem, self-derogation, and depressive symptoms using regression analyses. Students racialized as Black in states with bans on food stamp eligibility and temporary assistance for drug felony conviction had 1.37 times the odds of high depressive symptoms (95% confidence interval [CI], 1.01-1.89) compared to students in states without bans. In contrast, students racialized as White living in states with more severe disenfranchisement of people convicted of felonies had lower odds of high self-derogation (odds ratio [OR], 0.89; 95% CI, 0.78-1.02) and high depressive symptoms (OR, 0.83; 95% CI, 0.70-0.99) compared to states with less severe disenfranchisement. These findings demonstrate the need to address the legacy of structural racism at the state level to reduce mental distress for US youth. This article is part of a Special Collection on Mental Health.

Landscape analyses of gaps in reproductive, maternal, newborn, child, and adolescent health policies and guidelines to catalyse policy implementation improvement in Uganda

BACKGROUND

Despite many improvements in maternal, newborn, sexual, and reproductive health (RMNCAH) in sub-Saharan Africa, the overall progress remains inadequate and uneven. Some of the reasons for this include fragmented healthcare systems, gaps in evidence-based policy, inadequate investment and funding for health, and weaknesses in policy dissemination and implementation. Current stakeholder views on RMNCAH policy formulation and policy implementation in Uganda has not been exhaustively studied to help inform adjustments in policy formulation approaches and implementation strategies. The objective was to conduct a situation analysis to identify gaps in RMNCAH policies and guidelines formulation, dissemination, and implementation in Uganda to be able to recommend strategies to address these gaps, and catalyse policy formulation and implementation.

METHODS

This was an exploratory qualitative study conducted among RMNCAH stakeholders at central level and four district local governments in Uganda. Data were collected through review of RMNCAH policies and guideline documents using a document review guide, two guided small-group discussions (SGDs) with central government stakeholders and partners, four SGDs with district health teams (DHTs), eight key informant interviews (KIIs), and four focus group discussions (FGDs) with women 20-35 years of age. The interviews and group discussions were conducted using pretested interview guides, audio-recorded and transcribed verbatim. The transcripts were analysed by thematic analysis using open code software.

RESULTS

It was established that the policy and guideline documents addressing most of RMNCAH components existed. However, the indicators have not improved adequately to meet the international targets. The main policy implementation gaps reported revolved around policy leadership and coordination such as weaknesses in district and facility leadership and management, insufficient monitoring and evaluation, inadequate community engagement in policy formulation and implementation, inadequate policy and guidelines dissemination, limited multisectoral approach, and insufficient resource allocation to implement the policies and guidelines.

CONCLUSION

Policies and guidelines covering all RMNCAH components are in place, but implementing and translating these into improved indicators has been the major challenge. A strategic framework should be developed to test interventions to address these gaps to catalyse policy implementation in selected districts and later be rolled out to cover the whole country to cause wholesome policy impact.

Quality of post-abortion care services in the greater Accra region: connecting the perspectives of service providers and experiences of clients

BACKGROUND

Access to quality abortion services will not only help to reach SDG Target 3.1 and Goal 3 of Agenda 2063 but will also enhance maternal health in sub-Saharan Africa. Post-abortion care was thus introduced as a key component in managing complications from abortion. However, not much is known about the quality of post-abortion care services and practices. The main objective of this study was to examine the connecting experiences of clients and service providers perspectives on the quality of post-abortion care services.

METHODS

An in-depth interview technique was used to collect data from 18 purposively selected post-abortion care clients and 13 post-abortion care service providers from selected health facilities in urban Accra. Data were analysed using NVivo 12 software using a quantitative thematic analysis technique.

RESULTS

We noted that the providers' perspectives and clients' experiences or narratives about PAC quality converged around interpersonal and technical quality. Apart from the consensus on what quality meant and what clients received, there were subtle divergences or variations in quality perspectives. Specifically, while the clients considered quality communication to be concerned with behaviour and mannerisms, service providers perceived it as patient-centred. Also, while clients considered quality treatment to be the immediate outcome of treatment, service providers perceived it as one with no adverse event. We also found that the quality of PAC services at health facilities could be improved by making consumables readily available and the provision of separate treatment rooms.

CONCLUSION

Although PAC services are generally considered high quality in the Greater Accra region, there is still room for improvement. The private health facility owners, the Ministry of Health and the Ghana Health Services could take pragmatic steps to enhance synchronisation of notions of quality PAC services through sensitisation and education based on existing PAC protocol requirements.

Strategies for Effective Public Health Communication in a Complex Information Environment

Development and amplification of effective, culturally resonant, trustworthy, and evidence-based public health communication are urgently needed. Research evidence, theory, and practical experience from within and beyond the interdisciplinary field of health communication are well-positioned to help public health authorities, researchers, and advocates navigate the complex societal challenges that influence health and well-being in global contexts. This review offers a broad overview of the field, considers what constitutes "effectiveness" versus "effects" in public health communication, and describes core concepts of public health communication as a process rather than a product. We review domains and dominant foci of public health communication research, articulate challenges for health communication to advance health and social equity and address mis-/disinformation, and offer practical guidance on message development, audience segmentation, multilevel intervention, and evaluation of communication programs. We conclude by identifying important questions for future public health communication research, interventions, and funding.

A mixed-methods investigation of COVID-19 pandemic-specific stress in college students

OBJECTIVE

To identify pandemic-specific stressors among college students and compare patterns of stressors in samples obtained during early and chronic phases of the pandemic.

METHOD

Different undergraduate student samples from a Southeastern university completed an online survey in Spring 2020 (early pandemic; N = 673) and Fall 2020 (chronic pandemic; N = 439). This repeated cross-sectional survey study used a mixed methods triangulation design to validate and expand on quantitative findings using qualitative data.

RESULTS

Quantitative and qualitative analyses revealed 13 pandemic stressor domains, with academics and lifestyle adjustment among the most stressful in both samples, and more stressful in the chronic pandemic sample. Non-freshmen, female, and first-generation college students were at greater risk for pandemic stress.

CONCLUSIONS

As college students continue to experience stressors related to COVID-19 and encounter future crises, colleges and universities must adapt to meet their unique needs specific to the context.

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.

Access to clinical genetic services: An evaluation of patient referral characteristics and identifying barriers in Michigan

The utilization of genetics in medical care has enhanced the utility of precision medicine and hence increased the need for clinical genetic services. These services have reduced the costs and expanded the availability of genetic testing, but their use is limited in certain populations. This study explores the access to clinical genetic services for Michigan patients referred to a genetics clinic on the western side of the state. Factors included the travel distance (miles), wait time for appointment (days from the referral date to the date of first appointment), population demographics, and cultural characteristics. A retrospective record review of all aged patients (n = 568) referred to a genetics clinic in 2018 demonstrated that all patients were insured (100%), of which majority were white-non-Hispanic (90.7%), more than half were < 10 years of age at referral (53.3%), and most of them kept their first appointment (93.5%). Our analysis showed that the wait time was associated with referral non-compliance, p < 0.01. Adjusting for all variables, for each additional day in wait time, patients had 1% increased risk of not seeking clinical genetic services (OR = 1.01, 90% CI [1.01, 1.02]). Policies to encourage genetic service utilization and improve equitable access to precision health are needed. An opportunity exists for strategies that broaden and add diverse populations to those receiving genetic services.

Assessing Policy Impacts on Chronic Disease Risk Reduction: The Science and Art of Policy Measurement and Rating Systems

Public policies have been instrumental in influencing population health, and the desire to study their impact led to the development of the fields of policy surveillance and legal epidemiology. The standardized practice of creating policy measurement systems allows researchers to track and evaluate policy impacts across jurisdictions and over time. Policy measures may take many forms, including dichotomous measures, ordinal ratings, composite measures, or scale measures. The policy measures are determined largely based on the research question but should also consider factors impacting policy implementation and equity. Many sources of evidence, including expert input, national standards, scientific evidence, and existing policies, can be used in the development of policy measurement and rating systems. Any system must be tested, reliable, and clearly documented to create a robust and rigorous dataset. This article reviews key considerations for the development of policy measurement and rating systems for use in public health research.

Longitudinal analysis of Covid-19 infection trends and in-hospital mortality across six pandemic waves in Tunisia

BACKGROUND

The global impact of the COVID-19 pandemic was remarkably diverse, unfolding with multiple waves that have touched countries and continents in distinctive ways, leading to varying rates of mortality. The objectives of this study were to examine the characteristics and in-hospital fatality rates of COVID-19 patients hospitalized in the Monastir governorate over two years, with an overall analysis and a wave-specific breakdown throughout the pandemic's progression.

METHODS

We carried out a two-year longitudinal study, enrolling all COVID-19-infected patients admitted to both public and private health facilities in the governorate of Monastir from March 2020 to March 2022. The study covered six complete infection waves. Patients were followed from their first day of admission to their outcome in hospital. The data were collected using a questionnaire manually completed by well-trained residents. The data were globally analyzed across all hospitalized patients and then compared based on the different waves.

RESULTS

Overall, 5176 were hospitalized. The cumulative in-hospital case fatality rate (CFR) over the study period was 21.4%. After the first wave (W1), the in-hospital CFR followed a gradual increase, reaching its peak at 27.5% during W4 (alpha variant). Later, it decreased to 21.8% during W5 (delta variant), and further declined to 19.5% during W6, associated with the Omicron variant (overall p < 0.001). W5 exhibited the highest proportions of infections, hospitalizations, and in-hospital deaths. W6 featured a low hospitalization rate of 2.8% and a decline in severe cases. Nevertheless, there was a significant surge in hospitalizations among both the pediatric (≤ 18 years) and geriatric (≥ 75 years) populations, with a pronounced impact on the elderly with chronic conditions. This surge resulted in an increase in fatalities among the elderly. The length of stay (LoS) decreased throughout the course of the pandemic, declining from 13 days [10;14] in W1 to 4 days [2;9] in W6 with almost half of them had a LoS less than seven days (55.6%).

CONCLUSION

This study underscores the critical interplay of variant-specific disease severity, patient demographics, and evolving healthcare responses in managing COVID-19's impact on hospital outcomes.

Perceived Barriers to Hypertension Control: A Cross-Sectional Study Among Healthcare Providers in the Ashanti Region of Ghana

Background and Aims

Uncontrolled hypertension (HPT) is a major public health challenge in Ghana. This study investigated the impact of government health system, and healthcare provider-level barriers on hypertension management in the Ashanti region.

Methods

A cross-sectional survey of 210 healthcare providers at Komfo Anokye Teaching Hospital was conducted using a pre-tested questionnaire. Descriptive and inferential statistical analyses were employed to examine the associations between barriers and hypertension management.

Results

Government and health system-level barriers were significantly associated with healthcare providers' perceived effectiveness in managing hypertension and policy effectiveness. Similarly, healthcare provider-level barriers were linked to perceived effectiveness and policy impact. However, multivariable analysis revealed that the effects of these barriers on hypertension management were attenuated.

Conclusion

While government, health system, and healthcare provider barriers influence hypertension management in Ghana, their impact is less pronounced than anticipated. This finding is encouraging for achieving the national hypertension control target. However, further research is needed to identify factors mitigating the effects of these barriers to inform effective interventions.

Multiple Disadvantage and Social Networks: Toward an Integrated Theory of Health Care Use During Reentry From Criminal Justice Settings

Research consistently finds the disproportionate negative health impact of the criminal justice system on racial and ethnic minorities. Yet less is known about the underlying mechanisms of health care utilization during community reintegration. We contribute to the literature theoretically by integrating two perspectives: network theory of social capital and multiple disadvantage hypothesis and providing a more nuanced explanation of health service use during reentry. We identify incarceration history as a unique disadvantaged status that precludes people from accessing social networks and social capital. We further elaborate on the phenomenon of racialized reentry and illustrate how multiple disadvantaged statuses are linked to social networks and health care.

A potential environmental paradox in India: Associations between air pollution precautions and sedentary behaviour among children and youth

The negative impact of ambient air pollution on movement behaviours in the global south is a significant concern. Yet, evidence about this complex relationship is limited. This study assessed how precautions taken to prevent ambient air pollution exposure are associated with sedentary behaviour among children and youth in India. Participants aged 5-17 years (N = 986) from 41 schools in 28 urban and rural areas across India completed online surveys to provide information on movement behaviours, including precautions taken to avoid exposure to air pollution, perception of built environment, and sedentary behaviour. Multivariate gamma regression models were developed, adjusting for sociodemographic variables with sedentary behaviour as the primary criterion variable. Apart from an overall sample model, six segregated models were built to understand age, gender, and geographical variations. Children and youth who reported taking precautions to prevent ambient air pollution exposure were associated with significantly higher daily minutes of sedentary behaviour in both the overall sample (β = 0.085, 95 % CI = 0.001, 0.169) and the 13 to 17 age group (β = 0.110, 95 % CI = 0.007, 0.227). However, being able to access outdoor physical activity facilities before or after school was associated with lower sedentary behaviour in the following models: overall, rural, 5 to 12 and 13 to 17 age groups, and boys and girls. To our knowledge, this is the first study to depict a potential paradoxical relationship between precautions taken to avoid exposure to ambient air pollution and higher sedentary behaviour among children and youth in India i.e., a health-preserving behaviour is perpetuating another chronic disease risk factor.

Protective role of health insurance coverage in reducing under-five mortality in Ethiopia: Gompertz inverse-Gaussian shared frailty modelling

OBJECTIVE

To determine the association between health insurance coverage and under-five mortality in Ethiopia using data from the 2016 Ethiopia Demographic and Health Survey (EDHS).

METHODS

The current study used a total of 10 641 under-five children from the 2016 EDHS. To identify the predictors, the Gompertz inverse-Gaussian shared frailty model was fitted. The theta value, Akaike Information Criteria and Bayesian Information Criteria were applied for model evaluation, and variables with p values less than 0.2 were included in the multivariable analysis. The strength and statistical significance of the associations were demonstrated by reporting the adjusted HR (AHR) with a 95% CI in the multivariable Gompertz inverse-Gaussian shared frailty model.

RESULTS

According to the study's findings, 96.46% of the children were born to mothers not covered by health insurance. The study found that health insurance coverage was significantly associated with a lower risk of under-five mortality (not covered: AHR=0.13; 95% CI 0.02, 0.95). Other factors that showed significant associations with under-five mortality include place of residency, family size, twin status, place of delivery and preceding birth interval.

CONCLUSION

The findings indicate that health insurance coverage in Ethiopia is significantly associated with a lower risk of mortality among children under five. However, coverage remains low among mothers of these children, highlighting an urgent need for policies and interventions aimed at expanding health insurance coverage and addressing key determinants of child health to reduce under-five mortality and improve child survival outcomes. Addressing gaps in health insurance and other contributing factors is vital for creating effective strategies to lower under-five mortality rates.

Workload, job, and family satisfaction in dual-earning parents with adolescents: the mediating role of work-to-family conflict

Introduction

The study examined the direct and indirect effects of parents' workload, work-to-family conflict (WtoFC), job satisfaction, and family satisfaction among dual-earning parents and their adolescent children.

Methods

A total of 516 dual-earning parents and one adolescent child were enlisted for the study using non-probabilistic sampling. Mothers and fathers completed assessments about workload, WtoFC, and the Overall Job Satisfaction Scale, while all three family members responded to the Satisfaction with Family Life Scale.

Results

The data were analyzed using the mediation Actor-Partner Interdependence Model and structural equation modeling. The findings revealed a negative association between mothers' workload and family satisfaction. Moreover, both parents' workloads reduce adolescents' family satisfaction. Both parents' workload was positively associated with their WtoFC. Additionally, WtoFC was found to significantly mediate across intraindividual and interindividual domains, linking workload and job satisfaction in parents and workload and family satisfaction for parents and their adolescent children.

Discussion

These empirical insights underscore the critical need to mitigate workload and WtoFC to enhance parental job satisfaction and family satisfaction of all family members. The study's practical implications provide the audience with actionable insights that can be applied to workplace practices, empowering them to make informed decisions.

Households willingness to join and pay for community-based health insurance: implications for designing community-based health insurance based on economic Status in Ethiopia

BACKGROUND

Despite the encouraging results achieved by community-based health insurance in Ethiopia, the program faces significant challenges. Among these challenges is the current practice where premium contributions to Community Based Health Insurance are either a flat rate or based solely on family size, rather than considering households' socio-economic status The overall aim of this study was to assess households' willingness to join and pay for Community Based Health Insurance in reference to socio-economic status to design sliding scale-based Community Based Health Insurance contributions in Ethiopia.

METHODS

A community based cross-sectional study was conducted in districts from two different contexts: urban areas and agrarian areas in two major regions in Ethiopia, namely Oromia, and Amhara. A double-bounded dichotomous contingent valuation method was used to determine households' willingness to pay. Descriptive statistics were used to summarize the data. A chi-square test was used to assess background factors associated with willingness to join and pay for Community Based Health Insurance, and tobit regression analyses were conducted to identify factors that determine the amount of willingness to pay for Community Based Health Insurance. The statistical significance of all results was interpreted using an adjusted two-sided Type I error rate of 0.05.

RESULT

A total of 786 households participated in this study. Overall, 532 (67.7%) study households have ever participated in the Community Based Health Insurance scheme. The reason for never participating was unaffordability of payment (30.3%), and they stated that the service was unsatisfactory (21.7%). Generally, 647 (82.3%) of the households were willing to join Community Based Health Insurance or renew their scheme membership in the future, with higher willingness among rural and urban residents and households with food insecurity (p < 0.05. The average amount households were willing to pay was 538.2 Ethiopian Birr with mode (570.0 Ethiopian Birr). In contrast with the existing premium contribution policy, the vast majority of households preferred premium contributions that considered households' economic status (81.2%). Increased household size, better household food security, and being rural residents, increased satisfaction with the scheme; and rural households' economic status significantly predicted the value of money households are willing to contribute to Community Based Health Insurance (p < 0.05).

CONCLUSION

This study revealed a strong willingness among community members to participate in or renew their membership in the Community Based Health Insurance scheme, with a clear preference for a socio-economic-based sliding scale approach over current flat rate or family size-dependent premium systems. This preference highlights the potential for transforming towards more equitable citizen contributions. Policymakers should therefore consider household economic status, alongside factors like household food security and family size, in determining Community Based Health Insurance membership fees. Furthermore, enhancing the quality of healthcare services is essential to boosting Community Based Health Insurance member satisfaction and ensuring the program's long-term sustainability. This comprehensive approach not only improves health outcomes but also strengthens community trust and support for the Community Based Health Insurance initiative.

State of multi-morbidity among adults in Cape Verde: findings from the 2020 WHO STEPS non-communicable disease survey

BACKGROUND

This study investigates the prevalence and factors associated with multi-morbidity in Cape Verde, where healthcare systems are traditionally focused on single diseases.

METHODS

Multi-morbidity was defined as having two or more conditions (i.e. hypertension, diabetes, and overweight/obesity). We analyzed the data of 1781 adults aged 18-69 who participated in the 2020 WHO STEPS survey. Cross-tabulations and logistic regression analyses were performed.

RESULTS

Overall, 17.9% of adults (95% confidence interval: 15.5-20.6) lived with multi-morbidity. Hypertension was more prevalent in men (37.2%), while diabetes and overweight/obesity were higher in women, at 5% and 57.4%, respectively. Rural residents had a higher prevalence of hypertension (30.6%), but urban areas showed greater rates of diabetes (4.4%) and overweight/obesity (50.7%). Women had 28% lower odds of multi-morbidity. Individuals aged 60 years and older showed higher odds of multi-morbidity. Participants with tertiary education and current smokers had significantly lower odds of multi-morbidity, while married individuals and urban residents exhibited higher odds.

CONCLUSION

Older age, being married, and living in urban areas were associated with higher odds of multi-morbidity, while higher education and being a woman exhibited protective effects. These results underscore the need for a comprehensive approach in Cape Verde's healthcare system to address the growing burden of multi-morbidity.

Experience of the COVID-19 Pandemic in the Care of Patients with Predominantly Antibody Deficiencies (PADs)-A Qualitative Study with Perspectives from Both Patients and Nurses

Background/Objectives: One of the risk groups during the COVID-19 pandemic was people with predominantly antibody deficiencies (PADs) that have a compromised immune system. In the absence of evidence and clinical experience, there were challenges for patients in their daily life and for staff in counseling during this time. Therefore, the aim of this study was to explore the experiences of PAD patients and nurses during the COVID-19 pandemic. Methods: Focus group interviews with patients (n = 12) and nurses (n = 12) were performed separately, which were then analyzed using content analysis. Results: The daily life of PAD patients was affected during the pandemic, with concerns about becoming seriously ill. Social isolation and adherence to recommendations by the majority of the Swedish population resulted in patients feeling infectiously healthier during this period. The rapid transition of specialist care to telemedicine care encounters was an important measure taken to address patients' concerns and questions according to both patients and nurses. In addition, patients expressed a need for a coordinated care plan to facilitate access to integrated care. Conclusions: The high level of trust for authorities in Sweden was related to the high compliance with the recommendations, which reduced the spread of the infection. The role of specialized care is an important support for PAD patients, which was particularly evident during the pandemic. Information transfer to a specific risk group, such as people with PADs, is important and can usefully be coordinated by their specialist clinic. Telemedicine meetings are an important complement for people with PADs and need to be further elaborated. Also, there is a need to clarify how to better coordinate primary and specialized care.

Factors influencing the demand for individual voluntary private health insurance in Iran

BACKGROUND

Financial risk protection is one of the main goals of healthcare systems worldwide and prepayment system plays an important role to achieve it. There are some prepayment schemes, and Individual voluntary private health insurance (IVPHI) as a way can be affected by some variables.

OBJECTIVE

This study aimed to investigates the factors affecting the purchase and selection of IVPHI coverage in Iran.

METHODS

This study used secondary data from a private insurance company in Iran, collected in 2023. Data were retrospectively gathered via an online questionnaire covering demographics, health status, and lifestyle factors used to assess risk for voluntary health insurance plans. Individuals with high-risk profiles were referred to the company's physician for a clinical examination, after which they were categorized into high-risk or low-risk groups. The insurer then decided whether to approve the purchase of individual supplementary health insurance (ISHI). After data extraction and cleaning, a multivariate logistic regression model was used to identify determinants of voluntary health insurance purchase.

RESULTS

Most ISHI sales occurred in low-deprivation provinces (71%), with women (64%) and those aged 26-49 (70%) more likely to purchase. Higher coverage (Plan 4) was preferred across all age groups. Key factors influencing ISHI purchase included health status, basic insurance, and region, with moderate deprivation areas showing higher demand for higher coverage plans.

CONCLUSION

The findings emphasize regional, demographic, and health status disparities in ISHI purchases. Policymakers should focus on improving access to higher coverage plans, especially in more deprived areas, to ensure equitable insurance distribution.

Nanopore sequencing of MiniHap biomarkers for forensic DNA mixture deconvolution: A proof-of-principle study

Mixture deconvolution remains one of the major challenges in the field of forensic science. Currently, genetic markers are used and studied in the field of forensic genetics, including short tandem repeat (STR), insertion/deletion polymorphism (InDel), single nucleotide polymorphism (SNP), InDel closely linked to STR (DIP-STR), SNP closely linked to STR (SNP-STR), InDel closely linked to SNP (DIP-SNP) and microhaplotype (MH), all of which have been studied for DNA mixture analysis and have their own advantages and disadvantages. Mini-haplotype (MiniHap), as a novel haplotype genetic marker, contains 5 or more SNPs. A previous study has substantiated its significant high polymorphic characteristics, and it is expected to have potential applications in individual identification, paternity testing, ancestry inference, and mixture deconvolution. In this study, we first screened 22 MiniHaps with high polymorphism potential and constructed a panel based on the QNome nanopore sequencing device. Subsequently, we tested 100 unrelated Chinese Han individuals to evaluate the sequencing performance, allele (haplotype) frequencies, effective number of alleles (Ae) and forensic parameters of the 22 MiniHaps markers included in this novel assay. Next, a series of mixture simulations (two- or three-person mixtures with mixing ratios of 1:1-1:99 or 1:1:1-1:8:1) based on three standard materials (9947 A, 9948 and 2800 M) were detected by this MiniHap panel to explore its potential for DNA mixture deconvolution. The average Ae value was 10.9574, and 52.38 % of MiniHap loci had Ae values greater than 12.0000. The mean values of genetic diversity (GD) and power of discrimination (PD) were 0.8717 and 0.9457, respectively. Notably, most MiniHaps (85.71 %) had PD values exceeding 0.9000. The combined match probability (CMP) and combined power of exclusion (CPE) of this MiniHap panel were 4.4505 × 10-31 and 0.999999999999999996653, respectively. Moreover, the results of mixture analysis demonstrated that this MiniHap panel allowed detecting the components of minor contributor (s) even in imbalanced mixture samples, with detection limits of 1:39 and 1:8:1 for two- and three-person mixtures, respectively. In summary, MiniHap markers have remarkable application potential in mixture deconvolution, and it is necessary to conduct in-depth research on MiniHap markers for mixture analysis in the future.

Health information acquisition and lifestyle choices among cancer survivors in China: Examining the roles of patient-centered communication, patient trust, and system trust

Guided by the health information model and pathway model of health communication, this study investigates the relationship between different health information acquisition (seeking/scanning) and healthy lifestyle behaviors in a nationally representative, cross-sectional sample of cancer survivors (N = 567) in China. A moderated mediation model was employed to explore the mediating roles of patient-centered communication (PCC) and patient trust in physicians in the relationship between health information acquisition and healthy lifestyle behaviors. The study also examined the moderating role of system trust. Results indicate that health information seeking and scanning positively correlate with healthy lifestyle behaviors (i.e. fruit and vegetable consumption) via PCC and patient trust. Moreover, system trust positively moderates the relationship between health information seeking and PCC. These findings contribute to health communication and psychology literature and highlight the importance of patient-centered care in managing self-health, especially within the Chinese healthcare context.

National and subnational epidemiology and correlates of high alcohol use attributable burden in Iran from 1990 to 2021

High alcohol use remains a public health challenge worldwide, with deaths and disability-adjusted life-years (DALYs) attributable to it showing a decreasing trend globally. Despite this global progress, Iran continues to face challenges in reducing high alcohol use-related health issues. This study aimed to report the national and subnational burden of diseases and injuries attributable to high alcohol use in Iran over 1990-2021 by age, sex, socio-demographic index (SDI), and underlying cause. Data on death and DALY numbers, as well as age-standardized rates of conditions attributable to high alcohol use, were extracted from the Global Burden of Disease 2021 study. High alcohol use was defined as drinking above the theoretical minimum risk exposure level, which is the amount that minimizes overall risk. In 2021, the age-standardized DALY and death rates attributable to high alcohol use were 105.7 and 2.1 per 100,000, respectively. The age-standardized DALY rates increased by 24.9% over 1990-2021. Males had higher rates than females. The burden was highest in the 95 + age group. Substance use disorders were the leading condition associated with just high alcohol use. Sistan and Baluchistan had the greatest burden in 2021. SDI was generally positively associated with the alcohol-attributable burden. The burden of alcohol-attributable conditions in Iran has increased over the past 32 years. Targeted prevention and harm reduction strategies are recommended to address this rising burden.

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.

The effect of COVID-19 on health insurance and mental health

BackgroundThe outbreak of the novel coronavirus SARS-CoV-2, first discovered in Wuhan, Hubei province of the People's Republic of China, has spread to virtually every country which caused a global pandemic. The pandemic in the United States may have caused disruption of health coverage for millions of people. Researchers have found that the pandemic has affected health insurance coverage for millions in the United States. However, there is a gap in the literature that assesses the mental health status of those affected with health insurance by the covid-19 pandemic.ObjectiveOur hypothesis postulates that those who had employer-based insurance were negatively affected and those who had public insurance were positively affected. Furthermore, we hypothesized that those who lost their health insurance experienced adverse mental health effects and conditions such as anxiety, depression, and stress. The aim of this study is to examine the effect of Covid-19 pandemic on health insurance behavior and mental health.MethodsWe conducted a cross-sectional method to determine whether the covid-19 pandemic influenced health insurance behavior. An online questionnaire was administered to 500 adults residing in the United States through an online platform, Prolific, that helps researchers recruit participants for online research. Enrollment was on a first-come, first-served basis. Participants completed the questionnaire on March 27, 2023. The survey administered assessed the participants mental health status with their experience of healthcare during the pandemic. Two regression analysis were conducted to understand the pandemic's effect on participants health. Our dependent variable was the answers to the participants health from the pandemic using a summative scale. The independent variable was whether participants had health insurance. And if so, the type of health insurance.ResultsThe results showed that loss of employer health insurance has a significant effect on mental health. Furthermore, certain demographics were more likely to experience adverse health from the pandemic.ConclusionFurther studies should be explored to understand the health disparities from the pandemic.

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.

Status and associated factors of health insurance enrollment among women in Nepal

The Government of Nepal (GoN) introduced a Health Insurance Program (HIP) in 2016 aiming to ensure quality healthcare for all Nepalese citizens without financial hardship. However, the HIP has not attracted as many people as expected. It shows low enrollment and high dropout rates. Studies on this issue are scarce, particularly regarding women. To identify the factors associated with women enrollment in health insurance (HI), this study utilized a cross‐sectional design, analyzing secondary data (n = 14,845) from the Nepal Demographic and Health Survey 2022. Chi‐square test and logistic regression were used to identify associations with women participation in the HIP. Women enrollment in HI was positively and significantly associated with province, age, ethnicity, educational level, religion, place of residence, ecological region, wealth index, women's autonomy in household decisions, household head status, and current employment (p < 0.01). Socioeconomic and demographic factors of the respondents, such as being over 35 years old (aOR = 1.98; 95% confidence interval [CI]: 1.65–2.39), having a secondary or higher education (aOR = 2.96; 95% CI: 2.43–3.64), being currently employed in a paid job (aOR = 1.31; 95% CI: 1.17–1.47), and belonging to the richest wealth status (aOR = 5.64; 95% CI: 4.33–7.34), were more likely to be enrolled in the HIP compared to their respective reference groups. In conclusion, being of privileged socioeconomic status, belonging to a specific ethnic group, having a higher educational level, being employed, and living in the Mountain region are all associated with women enrollment in HIP. Policymakers may consider these findings when planning and implementing future interventions.

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.

Genomics insights of candidiasis: mechanisms of pathogenicity and drug resistance

Candidiasis, a prevalent class of human infections caused by fungi belonging to the Candida genus, is garnering increasing attention due to its pathogenicity and the emergence of drug resistance. The advancement of genomics technologies has offered powerful tools for investigating the pathogenic mechanisms and drug resistance characteristics of Candida. This comprehensive review provides an overview of the applications of genomics in candidiasis research, encompassing genome sequencing, comparative genomics, and functional genomics, along with the pathogenic features and core virulence factors of Candida. Moreover, this review highlights the role of genomic variations in the emergence of drug resistance, further elucidating the evolutionary and adaptive mechanisms of Candida. In conclusion, the review underscores the current state of research and prospective avenues for exploration of candidiasis, providing a theoretical basis for clinical treatments and public health strategies.

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.

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.