The politics of public health policy

Addressing Systemic Inequities: An Evaluation of the Resilience Catalysts in Public Health Program

CONTEXT

Resilience Catalysts (RC) in Public Health provides local health departments (LHDs) with a process and technical assistance (TA) to operationalize the Community Health Strategist (CHS) role, foster equity, and support community resilience through policy, practice, and program change across multiple sectors.

OBJECTIVES

This evaluation sought to (1) identify essential elements of the RC process and TA that help LHDs address the systemic drivers of adversity and inequity, and (2) expand understanding of RC's preliminary impact and inform implications for theory, practice, and funding in the post-COVID context.

DESIGN

The mixed-methods evaluation incorporated online surveys and semi-structured interviews. Key themes and takeaways were identified using framework analysis, constant comparison analysis, and descriptive statistics.

SETTING

The evaluation was conducted in 12 cities and counties across the United States, including California, Colorado, Florida, Iowa, Kentucky, Maryland, Massachusetts, New Jersey, North Carolina, Ohio, Tennessee, and Washington.

PARTICIPANTS

Survey participants consisted of 29 representatives of 11 RC sites. Interview participants included 33 individuals: 19 representatives of 9 RC sites and 14 individuals representing RC TA providers and funders.

MAIN OUTCOME MEASURES

The evaluation measured outcomes related to collaborative engagement, addressing inequity, systems change, knowledge change, ability to work within a local political and community context, sustainability, and scalability.

RESULTS

Evaluation results demonstrate outcomes related to community engagement, expansion of system-level thinking, advancing health and racial equity, clarity and understanding of RC process, building LHD and partners' capacity and skills needed to embody the CHS role.

CONCLUSIONS

The RC process prepared LHDs to operationalize the CHS role by providing the knowledge, skills, and capacities needed to understand root causes of adversity and inequity, address structural racism as a public health issue, and develop collaborative plans for addressing root causes.

Diabetes, Insulin & Politics: 28 Years of Stigma, Innovation, and Ableism

Nearly 3 decades after my type 1 diabetes diagnosis, I wrote this essay to document my journey. Through childhood and teen years where I experienced emotional abuse in clinic and felt the deepest of fears. Then in college, when I realized my voice mattered and I could elevate the voices of others with diabetes. During grad school, I began meeting with legislators and understanding how health policy works. I am now a health psychologist focused on improving health equity for people with diabetes and disabilities. Importantly, my research findings highlight how the U.S. medical system is not equipped to support people with diabetes. In this essay I also highlight key people in the diabetes and disability community who have served as lighthouses on my journey and continue to shine light across my path.

Systemic failures in nursing home care-A scoping study

Nursing homes (also referred to as residential aged care facilities, or long-term care facilities) cater for older people on a respite or long-term basis for those who are no longer able to live independently at home. Globally the sector struggles to meet societal expectations since it is torn between three competing agendas-meeting the needs of residents, meeting the demands of regulators, and meeting the financial imperatives of nursing home proprietors. Competing demands indicate that the system lacks a clear understanding of its purpose-without a clearly understood purpose any system will become dysfunctional overall and across all its levels of organisation. This scoping study aims to summarise and synthesise what is already known about the systemic function and failures in the nursing home system, and the impact this has on the wider health and aged care system.

METHOD

MEDLINE, EMBASE, PSYCHINFO, CINAHL and SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level.

RESULT

Thirty-eight articles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work.

CONCLUSIONS

The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system's purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any 'real' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. 'Systems thinking' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

Vaccine nationalism is not unethical from a political ethics perspective: Learning from the global COVID-19 vaccine distribution failure

During the COVID-19 pandemic, there was an apparent conflict between medical and political ethics regarding the ethical evaluation of vaccine nationalism - the "My Country First" vaccine allocation policy. Medical ethics sees this policy as selfish, leading to an unequal global vaccine allocation. Political ethics, however, argues that this policy is in the national interest and should not be labeled unethical. This conflict is one of the fundamental reasons why various medical ethics-based global vaccine allocation schemes, including the COVID-19 Vaccines Global Access Facility, have been difficult to implement. As long as the international community remains composed of different countries, vaccine nationalism will be difficult to eradicate. Therefore, international organizations, including World Health Organization, should focus on universal vaccine access rather than allocation based solely on medical ethics. Countries, especially low-income countries, must strengthen vaccine-related capacity-building to immunize their citizens as early as possible. Otherwise, they may still be at the bottom of the global vaccine allocation queue when the next globally challenging outbreak occurs. High-income countries should work to expand the distribution of vaccines, including donating vaccines to countries that lack them, helping other countries set up vaccine factories, and sharing vaccine production technology and intellectual property, which is the right choice from medical and political ethics perspectives.

Why does the COVAX facility fail to bridge the 'immunization gap'?

In April 2020, the World Health Organization launched a COVID-19 Vaccines Global Access (COVAX) Facility, a groundbreaking public health policy, to work "for global equitable access to COVID-19 vaccines". Although innovative, it fails to bridge the 'immunization gap' between high-income and low-income countries. The main reasons for this include: (1) failure to provide adequate incentives for self-financing countries to participate; (2) failure to design the vaccine allocation mechanism to reflect to national political considerations along with the perspective of medical ethics; (3) lack independent financing and power to enforce the policies globally. Constraints have limited the effectiveness of COVAX to date but transforming it into an information center to provide information on vaccine supply and demand, disseminate vaccine knowledge, and publish requests for help can accelerate progress.

The impact of public leadership on collaborative administration and public health delivery

BACKGROUND

This research depicts the linkage of public leadership on public health delivery (PHD) and collaborative administration. The research is also focused to examine the effect of public leadership on public health delivery through the intervening variable of collaborative administration by using both social information processing theory and collaboration theory.

METHODS

This research is based on quantitative method. Data was collected from 464 public hospital administration in the context of Pakistan. This study evaluated data using SPSS, AMOS, and PROCESS Macro.

RESULTS

Public leadership has a positive profound effect on public health delivery and collaborative administration, and that collaborative administration significantly promotes public health delivery. The outcomes also exposed that public leadership has substantial influence on public health delivery through intervening collaborative administration.

CONCLUSIONS

Whilst public leadership demonstrated positive outcomes on public health delivery and collaborative administration, there is a need for more rigor studies on collaborative governance leadership, collaborative ethics and collaborative norms in the public health service.

Global learning: A post-COVID-19 approach to advance health equity

The COVID-19 pandemic has accelerated acceptance of learning from other countries, especially for high-income countries to learn from low- and middle-income countries, a practice known as global learning. COVID-19's rapid disease transmission underscored how connected the globe is as well as revealed stark health inequities which facilitated looking outside of one's borders for solutions. The Global Learning for Health Equity (GL4HE) Network, supported by Robert Wood Johnson Foundation, held a 3-part webinar series in December 2021 to understand the current state of global learning and explore how global learning can advance health equity in the post-COVID-19 era. This paper reflects on these cutting-edge discussions about the current state of global learning, drawing upon the highlights, perspectives, and conclusions that emerged from these webinars. The paper also comments on best practices for global learning, including adapting for context, addressing biases, funding considerations, ensuring bidirectional partnerships, community engagement, and adopting a multidisciplinary approach.

--Eleven tips for operational researchers working with health programmes: our experience based on implementing differentiated tuberculosis care in south India

Due to the workload and lack of a critical mass of trained operational researchers within their ranks, health systems and programmes may not be able to dedicate sufficient time to conducting operational research (OR). Hence, they may need the technical support of operational researchers from research/academic organisations. Additionally, there is a knowledge gap regarding implementing differentiated tuberculosis (TB) care in programme settings. In this 'how we did it' paper, we share our experience of implementing a differentiated TB care model along with an inbuilt OR component in Tamil Nadu, a southern state in India. This was a health system initiative through a collaboration of the State TB cell with the Indian Council of Medical Research institutes and the World Health Organisation country office in India. The learnings are in the form of eleven tips: four broad principles (OR on priority areas and make it a health system initiative, implement simple and holistic ideas, embed OR within routine programme settings, aim for long-term engagement), four related to strategic planning (big team of investigators, joint leadership, decentralised decision-making, working in advance) and three about implementation planning (conducting pilots, smart use of e-tools and operational research publications at frequent intervals). These may act as a guide for other Indian states, high TB burden countries that want to implement differentiated care, and for operational researchers in providing technical assistance for strengthening implementation and conducting OR in health systems and programmes (TB or other health programmes). Following these tips may increase the chances of i) an enriching engagement, ii) policy/practice change, and iii) sustainable implementation.

New Zealand Pae Ora Healthcare Reforms 2022: Viable by Design? A Qualitative Study Using the Viable System Model

BACKGROUND

The New Zealand (NZ) Pae Ora (Healthy Futures) health reforms came into effect in July 2022 with the establishment of Health New Zealand (HNZ) (Te Whatu Ora) and the Māori Health Authority (MHA) (Te Aka Whai Ora) - the organisations charged for healthcare provision and delivery. Given these changes represent major health system reform, we aimed to conduct an early evaluation of the design of the reforms to determine if they can deliver a viable and sustainable NZ health system going forward.

METHODS

The evaluation was informed by Beer's viable system model (VSM). A qualitative exploratory design with semi-structured interviews and documents analysis using thematic analysis was used. We conducted 28 interviews with senior healthcare managers and reviewed over 300 official documents and news analyses.

RESULTS

The VSM posits that for a system to be viable, all its five sub-systems (operations; co-ordination; operational control; development and governance) need to be strong. Our analysis suggests that the health reforms, despite their strengths, do not satisfy this requirement. The reforms do appreciate the complexity of the healthcare environment: multiple stakeholders, social inequalities, interdependencies. However, our analysis suggests a severe lack of detail regarding the implementation and operationalisation of the reforms. Furthermore, resourcing and coordination within the reformed system is also unclear.

CONCLUSION

The health system reforms may not lead to a viable future NZ health system. Poor communication of the reform implementation and operationalisation will likely result in system failure and inhibit the ability of frontline health organisations to deliver care.

Challenges for research uptake for health policymaking and practice in low- and middle-income countries: a scoping review

BACKGROUND

An estimated 85% of research resources are wasted worldwide, while there is growing demand for context-based evidence-informed health policymaking. In low- and middle-income countries (LMICs), research uptake for health policymaking and practice is even lower, while little is known about the barriers to the translation of health evidence to policy and local implementation. We aimed to compile the current evidence on barriers to uptake of research in health policy and practice in LMICs using scoping review.

METHODS

The scoping review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) and the Arksey and O'Malley framework. Both published evidence and grey literature on research uptake were systematically searched from major databases (PubMed, Cochrane Library, CINAHL (EBSCO), Global Health (Ovid)) and direct Google Scholar. Literature exploring barriers to uptake of research evidence in health policy and practice in LMICs were included and their key findings were synthesized using thematic areas to address the review question.

RESULTS

A total of 4291 publications were retrieved in the initial search, of which 142 were included meeting the eligibility criteria. Overall, research uptake for policymaking and practice in LMICs was very low. The challenges to research uptake were related to lack of understanding of the local contexts, low political priority, poor stakeholder engagement and partnership, resource and capacity constraints, low system response for accountability and lack of communication and dissemination platforms.

CONCLUSION

Important barriers to research uptake, mainly limited contextual understanding and low participation of key stakeholders and ownership, have been identified. Understanding the local research and policy context and participatory evidence production and dissemination may promote research uptake for policy and practice. Institutions that bridge the chasm between knowledge formation, evidence synthesis and translation may play critical role in the translation process.

A thematic content analysis of 2010-2015 state tobacco control legislation in the United States: Bill rationales and priority populations

Objective

Tobacco use causes numerous types of cancers, heart diseases, and chronic illnesses, and is responsible for nearly 1 in every 5 deaths in the United States (U.S.) annually. This study assessed whether tobacco control laws introduced in state legislatures between 2010 and 2015 provided a rationale for the proposed bill and/or specified priority population groups, and we then examined emerging themes in the text that did so.

Methods

Using LexisNexis® State Net®, we identified tobacco control bills introduced in all states and coded their bill rationales and population category. We then conducted qualitative thematic analysis on a sample of bills with rationales or specified populations.

Results

Of the 2815 tobacco control bills introduced in state legislatures in the analysis period, 422 (15.0%) included a bill rationale, and 1309 (46.5%) specified at least one priority population. Four overarching themes emerged: 1) Addressing tobacco-related health harms and financial costs incurred to society; 2) Protecting the public from tobacco-related harms as a government responsibility; 3) Providing services to priority populations; 4) Exempting or preempting some population groups and localities.

Conclusions

Rationalizing tobacco control legislation by focusing on both health and cost implications was a key feature of tobacco policy bill text we analyzed; given the history of this approach, it is likely to remain so in the future. Our study may serve as a benchmark for tracking current and future tobacco control legislation to examine whether there is a growth in prioritizing populations experiencing unjust burdens of tobacco use and related disease.

The Politics of School Reopening During COVID-19: A Multiple Case Study of Five Urban Districts in the 2020-21 School Year

Purpose: Nearly all schools in the United States closed in spring 2020, at the onset of the COVID-19 pandemic. We analyze traditional public and charter school reopenings for the 2020-21 school year in five urban districts. We provide a rich and theoretically grounded description of how and why educational leaders made reopening decisions in each of our case districts. Research Methods: We used data from a multiple-case study from March 2020 to July 2021. The research team conducted 56 interviews with school, district, and system-level leaders; triangulated with publicly available data; and also drew on interview data from a subsample of parents and guardians in each of our sites. We analyzed these data through qualitative coding and memo writing and conducted detailed single- and cross-case analyses. Findings: School system leaders in our case sites generally consulted public health authorities, accounted for state-level health and educational guidance, and engaged with and were responsive to the interests of different stakeholders. Districts' adherence to and strategic uses of public health guidance, as well as a combination of union-district relations and labor market dynamics, influenced reopening. Parents, city, and state lawmakers, and local institutional conditions also played a role, helping to explain differences across cases. Implications: In contrast to the "politics or science" framing that has dominated research and public discourse on school reopening, we show that local pandemic conditions and local political dynamics both mattered and in fact were interrelated. Our findings have some implications for how educational leaders might navigate future crises.

Local implementation of public health policies revealed by the COVID-19 crisis: the French case

BACKGROUND

Improving health system performance depends on the quality of health policy implementation at the local level. However, in general, the attention of researchers is mainly directed towards issues of health policy design and evaluation rather than implementation at the local level. The management of the COVID-19 crisis, especially in Europe, has particularly highlighted the complexity of implementing health policies, decided at the national or supranational level, at the local level.

METHODS

We conducted 23 semi-structured interviews with the main stakeholders in the management of the COVID-19 crisis in the second largest French region in order to identify the different actors and modes of coordination of the local implementation of health policies that this crisis management illustrates in a very visible way. Our methodology is complemented by a content analysis of the main guidelines and decisions related to this implementation.

RESULTS

The analysis of these data allows us to identify three levels of implementation of health policies at the local level (administrative, organizational and operational). Interviews also reveal the existence of different types of coordination specific to each of these levels of local implementation of health policies. These results then make it possible to identify important managerial avenues for promoting global coordination of these three levels of implementation.

CONCLUSIONS

Although research on health services emphasizes the existence of several levels of local implementation of health policies, it offers little in the way of definition or characterization of these levels. The identification in this study of the three levels of local implementation of health policies and their specific forms of coordination contribute to a more precise characterization of this implementation in order to promote, in practice, its global coordination.

Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework

BACKGROUND

There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries.

METHODS

We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework.

RESULTS

The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility.

CONCLUSIONS

This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

The Future of Public Health: Ensuring An Adequate Infrastructure

Policy Points The US public heath infrastructure is in disrepair and building a sustainable system is the central challenge for the nation. Doing so in a highly patrician environment is the mission for the next ten years.

Priming COVID-19's consequences can increase support for investments in public health

Can messaging that emphasizes the costs of COVID-19 increase popular support for more proactive public health policies? People who experience disasters often become more supportive of policies to address their underlying causes, and the pandemic may have similar spillover effects for public opinion. To test this idea, the study implements a survey experiment in Italy, Germany, and the United States in which half of the respondents were randomly assigned to a prime about the impact of the pandemic prior to answering questions about their support for public health policies. The results show that respondents who received the prime became more favorable toward increased government spending on domestic and foreign public health programs alike. These treatment effects were consistent across countries, across two different surveys in the United States conducted at different points in time, and across partisan subgroups. However, the treatment did not consistently increase support for more active and intrusive government policies to address specific public health challenges like smoking or HIV/AIDS. The results suggest that public health advocates may benefit from messaging that connects COVID-19 to the need for public health funding beyond the context of the pandemic.

When policy meets reality: the new 18-hour on-call shift policy and the Israeli anesthesia workforce crisis

BACKGROUND

The Israeli physician workforce faces multiple challenges. These include planned policies reducing physician on-call from 26 to 18 h and, from 2026, allowing only graduates of Ministry of Health approved foreign medical schools to take the Israeli licensing examination and an ongoing physician shortage (2019: Israel had 3.19 physicians/1000 persons vs. OECD average of 3.49 physicians/1000 persons). This study examines the potential impact of these planned policies on the Israeli anesthesiology workforce.

METHODS

Surveys conducted among 34 public and private Israeli hospital anesthesiology department chairs collected data on their department's number of weekday on-call anesthesiologists and current shortage of anesthesiologists. A subsequent survey collected data on each anesthesiologist in the workforce, including the country where they studied medicine.

RESULTS

Each weekday night there were 114 on-call anesthesiologists; 72 residents and 42 attendings. Using productive work coefficients, this translates to 104 resident and 51 attending anesthesiologists. Furthermore, 21 departments had existing anesthesia workforce shortages totaling 110 anesthesiologists. There were 873 anesthesiologists from non-OECD countries whose medical schools are not accredited by the World Federation for Medical Education, of whom 332 were residents (61.9% of residents). Only 20.1% of anesthesiology residents were Israeli medical school graduates.

CONCLUSIONS

Descriptive survey data assessed the immediate and long-term consequences for the healthcare system and anesthesiology workforce of two new Health Ministry policies. Implementing the 18-h policy will immediately remove from the daytime workforce 155 anesthesiologists and who will be unavailable to staff elective surgery operating rooms. This will compound the current national shortage of 110 anesthesiologists. It is unclear how to replace this shortfall since there are no surplus Israeli physicians and very few Israeli graduates choose anesthesiology as a specialty. This situation will be exacerbated after 2026 when graduates of certain foreign medical schools will be unable to enter the medical workforce, further reducing the pool of potential anesthesiology residents. Both policies were promulgated without adequate operational and budgetary planning or fiscal or workforce resources; implementation of the 18-h on-call policy has already been postponed. Therefore, new or updated policies must be accompanied by specific operational plans, budgetary allocations and funds for additional workforce.

Academic Framing as a Cause of Eco-Anxiety

Eco-anxiety, a highly mediatized emotion that is complex to characterize [...].

Patient perspectives of pandemic-related disruptions in gastrointestinal care: developing communication strategies

Objective

Normal elective outpatient care has been impacted during the COVID-19 pandemic, due to limitations imposed by healthcare systems. Clear communication is necessary to address patient concerns as resumption of elective care gains pace.

Methods

Thirty patients who had diagnostic gastrointestinal (GI) testing within our motility lab during the initial viral surge in our state spring 2020 underwent semi-structured interviews. Codes were derived from transcripts using the constant comparative method.

Results

Framework analysis revealed several patient themes, including (1) patient specific factors such as age and comorbidity; (2) pandemic-related evolution including case surges; and (3) healthcare related function - or dysfunction - that directly influenced patient perceptions of disrupted gastrointestinal care. These themes provide areas in which to focus communication using the shared decision making model to achieve resumption of delayed care.

Conclusions

When communicating with patients, it is difficult to predict patient preferences and as much flexibility as possible should be offered. Concrete steps of (1) identification of patient barriers; (2) intervening upon then, and (3) having concrete plans to influence care will need to guide such communication.

Innovation

Our patients' perspectives during the first viral surge can guide new communication strategies should healthcare delivery be compromised in the future.

Relationship of political ideology of US federal and state elected officials and key COVID pandemic outcomes following vaccine rollout to adults: April 2021–March 2022

Background

Scant research, including in the United States, has quantified relationships between the political ideologies of elected representatives and COVID-19 outcomes among their constituents.

Methods

We analyzed observational cross-sectional data on COVID-19 mortality rates (age-standardized) and stress on hospital intensive care unit (ICU) capacity for all 435 US Congressional Districts (CDs) in a period of adult vaccine availability (April 2021–March 2022). Political metrics comprised: (1) ideological scores based on each US Representative's and Senator's concurrent overall voting record and their specific COVID-19 votes, and (2) state trifectas (Governor, State House, and State Senate under the same political party control). Analyses controlled for CD social metrics, population density, vaccination rates, the prevalence of diabetes and obesity, and voter political lean.

Findings

During the study period, the higher the exposure to conservatism across several political metrics, the higher the COVID-19 age-standardized mortality rates, even after taking into account the CD's social characteristics; similar patterns occurred for stress on hospital ICU capacity for Republican trifectas and US Senator political ideology scores. For example, in models mutually adjusting for CD political and social metrics and vaccination rates, Republican trifecta and conservative voter political lean independently remained significantly associated with an 11%–26% higher COVID-19 mortality rate.

Interpretation

Associations between the political ideologies of US federal elected officials and state concentrations of political party power with population health warrant greater consideration in public health analyses and monitoring dashboards.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

BACKGROUND

Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA.

METHODS

We conducted a scoping review using Arksey and O'Malley (2005) to understand the drivers of health reforms in SSA.

RESULTS

We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion.

CONCLUSION

Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.

A Comparative Analysis on the Social Determinants of COVID-19 Vaccination Coverage in Fragile and Conflict Affected Settings and Non-fragile and Conflict Affected Settings

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has coerced various resources of all the countries. While the high-income nations redirected financial and human resources to understand specific determinants of vaccination coverage, fragile and conflict-affected setting (FCS) nations were waiting for global bodies to cater to their ever-growing need for vaccines and other lifesaving drugs. This study aimed to determine various factors influencing vaccine coverage in the FCS context.

METHODS

World Bank's classification of FCS states was the primary source for country classification. The study utilized data from various other open sources. The study models cross-country inequities in COVID-19 vaccine coverage and we have employed multi-variate log-linear regressions to understand the relationship between COVID-19 vaccine coverage and cross-country macro-level determinants. The analysis was conducted on two samples, non-FCS Countries and the FCS countries.

RESULTS

Socio-economic determinants such as gross domestic product (GDP) per capita, socioeconomic resilience; health system determinants such as density of human resources, government spending on health expenditure; and political determinants such as effective government, more power to regional governments, political stability and absence of violence play a pivotal role in vaccine coverage. We also found that FCS countries with a higher share of people strongly believing in the vaccine effectiveness have a positive association with COVID-19 vaccine coverage.

CONCLUSION

The study confirmed that political factors, government effectiveness and political stability are also important determinants of vaccine coverage. The result further draws attention to few policy implications such as promoting future research to explore the linkages between the perceived equality before the law and individual liberty and its effect on vaccination coverage in the FCS.

An evaluation of North Carolina science advice on COVID-19 pandemic response

This qualitative case study contributes to the international research project EScAPE (Evaluating Scientific Advice in a Pandemic Emergency) and aims to understand how state leaders mobilized science advice in pandemic response during 2020 and into the early months of 2021. North Carolina, a state in the southeastern United States, mobilized much of its pandemic science advice through the state's Department of Health and Human Services. A fluid relationship between advisors and the governor-credited as a crucial component of a science driven, balanced pandemic response-created an opaque hub of advising and power. I analyze three advisory processes apparent during early stages of pandemic response noting strengths in mutual respect and trust between advisors and policymakers, data transparency, and commitment to equitable vaccine distribution. The interpersonal dynamics that provided these "good" science advice outcomes are a result of the individuals involved but the dynamic is not guaranteed in government over time. Also, while North Carolina provided data transparency it is unclear how data trends connected to decisions. There is a general lack of transparency around the breadth and content of advice. Transparency of advisory mechanisms is important to maintain public trust in government. Deep partisanship in the United States and distrust between leaders of opposing parties underscores the need for states to develop strong institutions for science advise to policymakers in an emergency. This article closes with several recommendations.

Creating Political Will for Action on Health Equity: Practical Lessons for Public Health Policy Actors

BACKGROUND

Despite growing evidence on the social determinants of health and health equity, political action has not been commensurate. Little is known about how political will operates to enact pro-equity policies or not. This paper examines how political will for pro-health equity policies is created through analysis of public policy in multiple sectors.

METHODS

Eight case studies were undertaken of Australian policies where action was either taken or proposed on health equity or where the policy seemed contrary to such action. Telephone or face-to-face interviews were conducted with 192 state and non-state participants. Analysis of the cases was done through thematic analysis and triangulated with document analysis.

RESULTS

Our case studies covered: trade agreements, primary healthcare (PHC), work conditions, digital access, urban planning, social welfare and Indigenous health. The extent of political will for pro-equity policies depended on the strength of path dependency, electoral concerns, political philosophy, the strength of economic and biomedical framings, whether elite interests were threatened and the success or otherwise of civil society lobbying.

CONCLUSION

Public health policy actors may create political will through: determining how path dependency that exacerbates health inequities can be broken, working with sympathetic political forces committed to fairness; framing policy options in a way that makes them more likely to be adopted, outlining factors to consider in challenging the interests of elites, and considering the extent to which civil society will work in favour of equitable policies. A shift in norms is required to stress equity and the right to health.

What drives variations in public health and social services expenditures? the association between political fragmentation and local expenditure patterns

The US spends two times more than the OECD average in health expenditure but has a much smaller portion of public health spending to total health expenditure than other OECD countries. While it has been suggested that public health and social services spending is crucial to promoting health outcomes, less is known about what drives variations in public health expenditure across regions. This study aims to examine whether political fragmentation in local governance is associated with variations in public health and social services expenditures. Using the US Census of Governments, we constructed a panel dataset of political fragmentation and local government spending patterns (1997-2012) for 792 US counties (population > 60,882, top 25%) and employed Least Squares Dummy Variable (LSDV) and Generalized Estimating Equations (GEE) models. We found that per capita public health spending tended to be smaller in areas where the degree of political fragmentation was higher (Coef:  - 0.034; p < 0.01), particularly when general-purpose governments were more fragmented (Coef:  - 0.087; p < 0.001). The proportion of public health spending also decreased when local governments were more fragmented (Coef:  - 0.012; p < 0.001). Social services expenditures and their proportions to total government expenditure fell with an increase in the degree of political fragmentation. Our findings suggest that fragmented governance settings, in which localities are more likely to face competition with others, may lead to a reduction in public spending essential for population health and that political fragmentation can also have a deterrent effect on broader categories of health-related social services spending.

Improving Policy for the Prevention of Falls Among Community-Dwelling Older People-A Scoping Review and Quality Assessment of International National and State Level Public Policies

Objectives: Effective public policy to prevent falls among independent community-dwelling older adults is needed to address this global public health issue. This paper aimed to identify gaps and opportunities for improvement of future policies to increase their likelihood of success. Methods: A systematic scoping review was conducted to identify policies published between 2005-2020. Policy quality was assessed using a novel framework and content criteria adapted from the World Health Organization's guideline for Developing policies to prevent injuries and violence and the New Zealand Government's Policy Quality Framework. Results: A total of 107 articles were identified from 14 countries. Content evaluation of 25 policies revealed that only 54% of policies met the WHO criteria, and only 59% of policies met the NZ criteria. Areas for improvement included quantified objectives, prioritised interventions, budget, ministerial approval, and monitoring and evaluation. Conclusion: The findings suggest deficiencies in a substantial number of policies may contribute to a disconnect between policy intent and implementation. A clear and evidence-based model falls prevention policy is warranted to enhance future government efforts to reduce the global burden of falls.

A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic

The coronavirus disease (COVID-19) pandemic has highlighted the link between individual behavior and public health, along with the importance of evidence-based efforts to promote prosocial individual behavior. Insights from behavioral science can inform the design of effective behavior change techniques, or nudges, to influence individual behavior. The MINDSPACE framework organizes 9 behavioral science principles that can be used to guide policy design: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments, and Ego. Using MINDSPACE as an organizing framework, this article provides a review of the literature on nudges to influence prosocial behaviors relevant during a pandemic: handwashing, avoidance of social gatherings, self-isolation and social distancing, and sharing public health messages. Additionally, empirical evidence on the use of nudges during the first several months of the COVID-19 pandemic in 2020 is summarized. Recommendations regarding the use of nudges to achieve public health policy goals during pandemics are provided. Organizational leaders, policymakers, and practitioners can use nudges to promote public health when mandates are not politically feasible or enforceable.

Lessons learnt from implementing the Good Governance for Medicines Programme in Zimbabwe

WHO launched the Good Governance for Medicines (GGM) programme in 2004 with the aim of fighting the problem of corruption in the pharmaceutical sector. Zimbabwe adopted the GGM programme in 2015 and developed its own implementation framework (GGM-IF) in 2017 based on the WHO global guidelines and recommendations. Zimbabwe’s GGM-IF emerged from; (1) home-based expertise, (2) extensive local consultations and (3) effective incorporation into existing institutions. The GGM-IF committed to implementing a focused programme over a 5-year period from 2017 to 2022 with the expressed goal of improving transparency and accountability in the pharmaceutical sector as a key enabler to improve access to medicines. Midway through its projected lifespan, some notable achievements materialised attributed to key success drivers, including mutual collaboration with the Ministry of Health and Child Care’s existing Global Fund supported Quality Assurance Programme. Key challenges faced include limited funding for the programme, a shifting policy environment driven by a political transition and reorientation of priorities in the wake of the COVID-19 pandemic. This manuscript articulates 3-year operationalisation of Zimbabwe’s GGM-IF highlighting the success drivers, implementation challenges and lessons learnt.

Prioritizing public health? Factors affecting the issuance of stay-at-home orders in response to COVID-19 in Africa

COVID-19 has sickened and killed millions of people globally. Conventional non-pharmaceutical interventions, particularly stay-at-home orders (SAHOs), though effective for limiting the spread of disease have significantly disrupted social and economic systems. The effects also have been dramatic in Africa, where many states are already vulnerable due to their developmental status. This study is designed to test hypotheses derived from the public health policymaking literature regarding the roles played by medical and political factors as well as social, economic, and external factors in African countries' issuance of SAHOs in response to the early stages of the COVID-19 pandemic. Using event history analysis, this study analyzed these five common factors related to public health policy to determine their impact on African states' varying decisions regarding the issuance of SAHOs. The results of this analysis suggest that medical factors significantly influenced decisions as did factors external to the states, while the role of political factors was limited. Social and economic factors played no discernible role. Overall, this study suggests how African leaders prioritized competing factors in the early stages of a public health crisis.

Use of research evidence varied in efforts to expand specific pharmacist autonomous prescriptive authority: an evaluation and recommendations to increase research utilization

BACKGROUND

An expanding body of literature shows that pharmacists' interventions improve health outcomes and are cost-saving. However, diverse state regulations of pharmacists' scope of practice create a discrepancy between what pharmacists are trained to do and what they legally can do. This study investigated how stakeholders utilized research evidence when developing expanded scope of practice policies in their respective states.

METHODS

Using autonomous pharmacist prescriptive authority as a surrogate for general pharmacist scope of practice, a general policy document analysis was performed to understand the scope of practice landscape for pharmacists across the United States. Next, semi-structured interviews with policy-makers and pharmacy advocates were conducted to explore how the identified states in the policy document analysis utilized evidence during the policy-making process. Investigators analysed findings from the transcribed interviews through application of the SPIRIT Action Framework. Resulting codes were summarized across themes, and recommendations to researchers about increasing utilization of research evidence were crafted.

RESULTS

Sixteen states with 27 autonomous pharmacist prescriptive authority policies were identified. Public health need and safety considerations motivated evidence engagement, while key considerations dictating utilization of research included perceptions of research, access to resources and experts, and the successful implementation of similar policy. Research evidence helped to advocate for and set terms for pharmacist prescribing. Barriers to research utilization include stakeholder opposition to pharmacist prescribing, inability to interpret research, and a lack of relevant evidence. Recommendations for researchers include investigating specific metrics to evaluate scope of practice policy, developing relationships between policy-makers and researchers, and leveraging pharmacy practice stakeholders.

CONCLUSIONS

Overall, alignment of researcher goals and legislative priorities, coupled with timely communication, may help to increase research evidence engagement in pharmacist scope of practice policy. By addressing these factors regarding research engagement identified in this study, researchers can increase evidence-based scope of practice, which can help to improve patient outcomes, contain costs, and provide pharmacists with the legal infrastructure to practise at the top of their license.

Understanding Antimicrobial Resistance from the Perspective of Public Policy: A Multinational Knowledge, Attitude, and Perception Survey to Determine Global Awareness

Minimizing the effect of antimicrobial resistance (AMR) requires an adequate policy response that relies on good governance and coordination. This study aims to have a better comprehension of how AMR is understood and perceived by policy-makers and stakeholders in a multinational context. A digital survey was designed to capture the knowledge, attitudes, and perceptions (KAP) towards AMR, and it was distributed to politicians, policy advisors, and stakeholders. A total of 351 individuals from 15 different countries participated, 80% from high-income countries (HICs) and 20% from low- and middle-income countries (LMICs). The Netherlands, Spain, and Myanmar were the top 3 represented countries. Participants had sufficient knowledge regarding AMR and reported the importance of political willingness to tackle AMR. Overall, LMIC participants demonstrated better knowledge of AMR but showed poor perception and attitude towards antimicrobial use compared to HIC participants. In addition, level of education and field of expertise were significantly associated with knowledge, perception, and practices regardless of demographic characteristics. Inter-regional differences in KAP regarding AMR exist among politicians, policy advisors, and relevant stakeholders. This study captures multinational policy-maker and stakeholder mapping that can be used to propose further policy implementation on various governance levels.

When Covid-19 first struck: Analysis of the influence of structural characteristics of countries - technocracy is strengthened by open democracy

Context

The Covid-19 pandemic hit the developed world differentially due to accidental factors, and countries had to respond rapidly within existing resources, structures, and processes to manage totally new health challenges. This study aimed to identify which pre-existing structural factors facilitated better outcomes despite different starting points, as understanding of the relative impact of structural aspects should facilitate achieving optimal forward progress.

Methods

Desk study, based on selecting and collecting a range of measures for 48 representative characteristics of 42 countries’ demography, society, health system, and policy-making profiles, matched to three pandemic time points. Different analytic approaches were employed including correlation, multiple regression, and cluster analysis in order to seek triangulation.

Findings

Population structure (except country size), and volume and nature of health resources, had only minor links to Covid impact. Depth of social inequality, poverty, population age structure, and strength of preventive health measures unexpectedly had no moderating effect. Strongest measured influences were population current enrolment in tertiary education, and country leaders’ strength of seeking scientific evidence. The representativeness, and by interpretation the empathy, of government leadership also had positive effects.

Conclusion

Strength of therapeutic health system, and indeed of preventive health services, surprisingly had little correlation with impact of the pandemic in the first nine months measured in death- or case-rates. However, specific political system features, including proportional representation electoral systems, and absence of a strong single party majority, were consistent features of the most successful national responses, as was being of a small or moderate population size, and with tertiary education facilitated. It can be interpreted that the way a country was lead, and whether leadership sought evidence and shared the reasoning behind resultant policies, had notable effects. This has significant implications within health system development and in promoting the population’s health.

Intended and unintended consequences of the implementation of minimum unit pricing of alcohol in Scotland: a natural experiment

Background

Scotland was the first country to implement minimum unit pricing for alcohol nationally. Minimum unit pricing aims to reduce alcohol-related harms and to narrow health inequalities. Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. This study comprised three components.

Objectives

This study comprised three components assessing alcohol consumption and alcohol-related attendances in emergency departments, investigating potential unintended effects of minimum unit pricing on alcohol source and drug use, and exploring changes in public attitudes, experiences and norms towards minimum unit pricing and alcohol use.

Design

We conducted a natural experiment study using repeated cross-sectional surveys comparing Scotland (intervention) and North England (control) areas. This involved comparing changes in Scotland following the introduction of minimum unit pricing with changes seen in the north of England over the same period. Difference-in-difference analyses compared intervention and control areas. Focus groups with young people and heavy drinkers, and interviews with professional stakeholders before and after minimum unit pricing implementation in Scotland allowed exploration of attitudes, experiences and behaviours, stakeholder perceptions and potential mechanisms of effect.

Setting

Four emergency departments in Scotland and North England (component 1), six sexual health clinics in Scotland and North England (component 2), and focus groups and interviews in Scotland (component 3).

Participants

Research nurses interviewed 23,455 adults in emergency departments, and 15,218 participants self-completed questionnaires in sexual health clinics. We interviewed 30 stakeholders and 105 individuals participated in focus groups.

Intervention

Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers.

Results

The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented. The odds ratio for illicit drug consumption following minimum unit pricing was 1.04 (95% confidence interval 0.88 to 1.24; p = 0.612). Concerns about harms, including crime and the use of other sources of alcohol, were generally not realised. Stakeholders and the public generally did not perceive price increases or changed consumption. A lack of understanding of the policy may have caused concerns about harms to dependent drinkers among participants from more deprived areas.

Limitations

The short interval between policy announcement and implementation left limited time for pre-intervention data collection.

Conclusions

Within the emergency departments, there was no evidence of a beneficial impact of minimum unit pricing. Implementation appeared to have been successful and there was no evidence of substitution from alcohol consumption to other drugs. Drinkers and stakeholders largely reported not noticing any change in price or consumption. The lack of effect observed in these settings in the short term, and the problem-free implementation, suggests that the price per unit set (£0.50) was acceptable, but may be too low. Our evaluation, which itself contains multiple components, is part of a wider programme co-ordinated by Public Health Scotland and the results should be understood in this wider context.

Future work

Repeated evaluation of similar policies in different contexts with varying prices would enable a fuller picture of the relationship between price and impacts.

Trial registration

Current Controlled Trials ISRCTN16039407.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

Educating the Next Generation of Global Neurosurgeons: Competencies, Skills, and Resources for Medical Students Interested in Global Neurosurgery

BACKGROUND

Global neurosurgery operates at the intersection of neurosurgery and public health. Although most global neurosurgery initiatives have targeted neurosurgeons and trainees, medical students represent the future of global neurosurgery.

METHODS

A narrative review of the literature regarding research methodology, education, economics, health policy, health advocacy, relevant to global neurosurgery was conducted.

RESULTS

We summarize pearls that all medical students interested in global neurosurgery should know.

DISCUSSION

To become effective agents of change within global neurosurgery, medical students must master competencies of motivation, organization, collaborativeness, dependability, flexibility, resilience, creative problem-solving, ethical thinking, cultural humility, and global awareness and gain knowledge and skills regarding research, education, policy making, and advocacy. Discussions with neurosurgeons and trainees, neurosurgery interest groups, conferences, university global neurosurgery initiatives, and student organizations represent opportunities for learning and becoming involved in global neurosurgery.

Public Opinion and Expectations: Development of Public Health Education in China After COVID-19 Pandemic

Background: Policymakers must promote the development of public health education and human resources. As a feature of the political environment, public opinion is essential for policy-making, but virtually the attitudes of Chinese citizens toward human resources development in public health is unknown. Methods: This study conducted a crosssectional survey from February 4, 2021 to February 26, 2021 in China. We adopted a convenient sampling strategy to recruit participators. Participants filled out the questions, which assess the attitudes of the expanding public health professionals. A logistic regression analysis was given to identify the predictors associated with the attitudes of the subjects. Results: There were 2,361 residents who have finished our questionnaire. Chinese residents who lived in urban (OR = 1.293, 95% CI = 1.051-1.591), "themselves or relatives and friends have participated in relevant epidemic prevention work" (OR = 1.553, 95% CI = 1.160-2.079), "themselves or family members engaged in medical-related work" (OR = 1.468, 95% CI = 1.048-2.056), and those who "were aware of public health before the outbreak of COVID-19" (OR = 1.428, 95% CI = 1.125-1.812) were more likely to support the promotion of public health education and training. Conclusions: The present study found that 74.50% of Chinese citizens supported the promotion of public health education and training in China, in which economic status, personal perception, and comprehension are the crucial factors that influence public opinion. COVID-19 has aroused the attention of Chinese residents to public health education, with only 22.11% of residents being aware of public health before the outbreak of COVID-19. The COVID-19 pandemic has profound implications for human society. Literally, this impact will feed back into future public health policies based on public opinion. This innovative perspective will also help us better understand the potential social impact of COVID-19 on human resources and development for health in the modern world.

Improving Decision-Making for Population Health in Nonhealth Sectors in Urban Environments: the Example of the Transportation Sector in Three Megacities-the 3-D Commission

Noncommunicable diseases (NCDs) represent a significant global public health burden. As more countries experience both epidemiologic transition and increasing urbanization, it is clear that we need approaches to mitigate the growing burden of NCDs. Large and growing urban environments play an important role in shaping risk factors that influence NCDs, pointing to the ineluctable need to engage sectors beyond the health sector in these settings if we are to improve health. By way of one example, the transportation sector plays a critical role in building and sustaining health outcomes in urban environments in general and in megacities in particular. We conducted a qualitative comparative case study design. We compared Bus Rapid Transit (BRT) policies in 3 megacities-Lagos (Africa), Bogotá (South America), and Beijing (Asia). We examined the extent to which data on the social determinants of health, equity considerations, and multisectoral approaches were incorporated into local politics and the decision-making processes surrounding BRT. We found that all three megacities paid inadequate attention to health in their agenda-setting, despite having considerable healthy transportation policies in principle. BRT system policies have the opportunity to improve lifestyle choices for NCDs through a focus on safe, affordable, and effective forms of transportation. There are opportunities to improve decision-making for health by involving more available data for health, building on existing infrastructures, building stronger political leadership and commitments, and establishing formal frameworks to improve multisectoral collaborations within megacities. Future research will benefit from addressing the political and bureaucratic processes of using health data when designing public transportation services, the political and social obstacles involved, and the cross-national lessons that can be learned from other megacities.

Parental perspectives towards sugar-sweetened beverages and polices: a qualitative study

PURPOSE

This qualitative study aimed to understand parental perception of (1) sugar-sweetened beverages (SSB) and implications of SSB on health; (2) their role in shaping their children's consumption of SSB; (3) the influences on SSB consumption of their children; and (4) potential government policies targeted at controlling SSB consumption.

METHODS

English-speaking parents of pre-schoolers aged 2-6 years were recruited. Semi-structured interviews based on the knowledge, attitude, practice framework were conducted, and transcripts were subjected to thematic analysis based on inductive approaches. Recruitment continued until data saturation was reached.

RESULTS

Twenty parents participated in the study and themes addressing the objectives identified. (1) There were misconceptions regarding the healthfulness of certain non-packaged SSB such as traditional remedies and juices. Some were unaware about the association between SSB and dental caries. (2) The need to reduce and restrict sugar consumption for overall and oral health reasons was well-recognised, but the extent of control varied. (3) Multiple stakeholders including pre-schools, grandparents and domestic helpers were involved in shaping children's diet. Children's sugar intake was also influenced by environmental factors, such as the ubiquitously available SSB, targeted marketing and high cost of healthy alternatives. (4) Participants were less accepting towards SSB taxation than the ban of SSB sales.

CONCLUSION

Despite the awareness of the types of SSBs and the general/oral health implications of sugar consumption, misconceptions exist. Although most parents possessed the knowledge and attitude, this did not translate into the practice of reducing sugar consumption in their children. There was no SSB reduction policy that had overwhelming acceptability.

Analysis for policy to overcome barriers to reducing the prevalence of vitamin a deficiency among children (15-23 months) in Iran

BACKGROUND

About 30% of children < 5 years old are estimated to experience vitamin A deficiency worldwide. Globally, vitamin A deficiency can be reduced by five major interventions: supplementation, dietary modification, fortification, promotion of both public health, and breastfeeding. This prospective policy analysis (Prospective policy analysis focuses on the future outcomes of a proposed policy. Adapted from Patton, CV, and Sawicki DS. Basic Methods of Policy Analysis and Planning, Prentice-Hall, Inc. New Jersey,1993). (Patton A, Carl V, and David S. Basic methods of policy analysis and planning, prentice-hall, 3th ed. 2012) aimed to identify evidence-based policy options to minimize prevalence (VAD) among 15-23 months-children in Iran.

METHODS

Thirty-eight semi-structured face-to-face interviews were held with experts at high, middle, and low managerial levels in Iran's health system, as well as at Schools of Nutrition Sciences and dietetics, using purposive and snowball sampling. All interviews were recorded by a digital voice recorder and then transcribed, codified, and eventually analyzed using a mixed approach (inductive-deductive) by MAXQDA software version 10.

RESULTS

Most policies related to VAD reduction in this age group are supplementation, expansion of education, and awareness. Three main factors affecting VAD reduction policies emerged from the analysis: basic factors (governance, infrastructure, and organization), underlying factors (social factors, economy), and immediate factors (services). Due to its cross-sectoral nature, evaluating the results of the implementation of this policy requires strong and coherent inter-sectoral cooperation. The existing primary healthcare network (PHC) is a crucial means for successful implementation of policies to address VAD in Iran.

CONCLUSIONS

In addition to supplementation and assistance in this age group, other policies should be also planned to reduce VAD in various regions. In addition to the Ministry of Health & Medical Education (MoHME), other actors need to be involved, we advocate, throughout the entire policymaking process of policy-making to reduce VAD in Iran.

Implementation research approaches to promoting universal health coverage in Africa: a scoping review

BACKGROUND

Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of initiatives promoting the uptake of implementation research in Africa, its role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). Hence, this scoping review aimed to identify and characterise the use of implementation research initiatives for assessing UHC-related interventions or programmes in Africa.

METHODS

The review protocol was developed based on the methodological framework proposed by Arksey and O'Malley, as enhanced by the Joanna Briggs Institute. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). MEDLINE, Scopus and the Cochrane Library were searched. The search also included a hand search of relevant grey literature and reference lists. Literature sources involving the application of implementation research in the context of UHC in Africa were eligible for inclusion.

RESULTS

The database search yielded 2153 records. We identified 12 additional records from hand search of reference lists. After the removal of duplicates, we had 2051 unique records, of which 26 studies were included in the review. Implementation research was used within ten distinct UHC-related contexts, including HIV; maternal and child health; voluntary male medical circumcision; healthcare financing; immunisation; healthcare data quality; malaria diagnosis; primary healthcare quality improvement; surgery and typhoid fever control. The consolidated framework for implementation research (CFIR) was the most frequently used framework. Qualitative and mixed-methods study designs were the commonest methods used. Implementation research was mostly used to guide post-implementation evaluation of health programmes and the contextualisation of findings to improve future implementation outcomes. The most commonly reported contextual facilitators were political support, funding, sustained collaboration and effective programme leadership. Reported barriers included inadequate human and other resources; lack of incentives; perception of implementation as additional work burden; and socio-cultural barriers.

CONCLUSIONS

This review demonstrates that implementation research can be used to achieve UHC-related outcomes in Africa. It has identified important facilitators and barriers to the use of implementation research for promoting UHC in the region.

Politicisation, depoliticisation, and repoliticisation of health care controversies: Vaccination and mental health care reform in the Czech Republic

This article analyses the politicisation of public health debates by focusing on vaccination and mental health care in the Czech Republic. The mainstream understanding of politicisation commonly refers to politics-as-sphere, linked with the political instrumentalisation of health care controversies as part of electoral campaigning and power struggles. In our analysis, we conceive politicisation more broadly, as politics-as-activity, which encompasses the role of civic engagement and the involvement of patients in these processes. We thus view politicisation as a process which encompasses a plurality of political actors and, in addition to politicians, includes patients, users, carers, citizens, and experts. Our analysis draws on extensive empirical evidence, consisting of observations, semi-structured interviews, and a review of available documents. The study took place in the Czech Republic from 2017 to 2019. We conclude that politicisation takes place alongside four dimensions: (1) contingency, (2) agency, (3) a plurality of opinions and approaches, and (4) visibility. We further argue that the contingent nature of biomedical controversies is articulated in three different, possibly interconnected layers. Thus, the politicisation of the two Czech analysed cases refers to (a) uncertainties and problematic aspects of biomedical objects of controversy; to (b) social rights, economic needs, and legal aspects as well as social representations of illness and vaccinations in the public debate; and to (c) the political processes which determine the previous two layers of politicisation, labelled as meta-politicisation. Last but not least, we stress the dynamic and non-linear nature of politicisation processes, the varieties of connections between the third sector and expertise, and the necessity to analyse the politicisation of public health controversies hand in hand with its connection to depoliticisation and repoliticisation.

Evidence and politics of patient experience in Ontario: The perspective of healthcare providers and administrators

BACKGROUND

Patient experience has a direct impact on patients' engagement in healthcare, their commitment to treatment plans, and their relationship with their healthcare providers, all of which can impact their health outcomes. The complexity of the healthcare system, the increasing health needs of the population, and the priority and knowledge differences among healthcare stakeholders impact how they conceptualize and seek to achieve the ideal patient experience and the weights that they give to different elements of this experience.

AIMS

This study sought to understand the perspectives of healthcare providers and administrators in Ontario regarding the factors affecting the patient experience.

MATERIALS & METHODS

Qualitative data were collected between April 2018 and May 2019. Twenty-one semi-structured interviews were conducted. Interviewees included physicians, nurses, optometrists, dietitians, quality managers, and policymakers. Thematic analysis was used to analyse the data, utilizing and extending a previously developed patient experience framework.

RESULTS

Several themes emerged in the data, and they represent two perspectives on patient experience: the biomedical perspective, which prioritizes health outcomes and gives high weights to healthcare experience factors that can be controlled by healthcare providers, while ignoring other factors, and the sociopolitical perspective, which recognizes the impacts of healthcare politics and the social context of health on patient experience in Ontario.

CONCLUSION

The study is timely in light of the current changes in the Ontario healthcare system and the healthcare reform started by the new government, as it sheds light on the possible negative impact of healthcare policy and politics on patient experience.

Promoting healthy and sustainable diets: barriers and enablers for successful policy activities in Australia

Consumption of healthy and sustainable diets (HSD) provides opportunities to co-benefit human health and adapt to and mitigate climate change. Despite robust evidence and policy recommendations from authoritative groups to reorientate the food system to favour consumption of HSD there has been limited policy action. This study investigated potential barriers and enablers for successful HSD policies in Australia. A review of HSD policy recommendations and of current Australian policies was undertaken. Results from the reviews informed a Delphi study, which investigated Australian stakeholder opinions on the effectiveness of HSD policy recommendations and barriers and enablers to creating successful HSD policies. Nine participants completed two Delphi iterations. A lack of consensus was reached on the effectiveness of policy recommendations. Consensus was reached on the effect of five barriers and three enablers. Key barriers were: the complex nature of the food system, competing interests of stakeholders, pressure from industry, government silos and lack of political will. Key enablers were: building relationships with key stakeholders across multiple disciplines and sectors, understanding the policy making process and developing a clear and coherent solution. Most of the identified barriers fall under the broad category of lack of political will. Interrelationships between barriers are likely worsening the impact of inadequate political will. There is a need to act on the identified barriers and enablers to secure the HSD policies that are required. Interactions between barriers may present an opportunity to address them simultaneously.

A Scoping Review of Populist Radical Right Parties' Influence on Welfare Policy and its Implications for Population Health in Europe

BACKGROUND

In light of worrying public health developments such as declining life expectancy gains and increasing health inequalities, there is a heightened interest in the relationship between politics and health. This scoping review explores the possible welfare policy consequences of populist radical right (PRR) parties in Europe and the implications for population health. The aim is to map the available empirical evidence regarding the influence of PRR parties on welfare policy reforms and to understand how this relationship is mediated by political system characteristics in different countries.

METHODS AND ANALYSIS

A scoping review of peer-reviewed empirical literature addressing the relationship between PRR parties, political systems and welfare policy in Europe was performed using the methodology by the Joanna Briggs Institute. Data was charted on main study characteristics, concepts and relevant results, after which a qualitative content analysis was performed. The data was categorised according to the political system characteristics: constitution, political economy, interest representation and partisanship. Five expert interviews were conducted for validation purposes. Early evidence from 15 peer-reviewed articles suggests that exclusionary welfare chauvinistic positions of PRR parties are likely to have negative effects on the access to welfare provisions and health of vulnerable population groups. Differences in implementation of welfare chauvinistic policy reforms are partly explained by mediation of the constitutional order (judicial institutions at national and European Union [EU] level), political economy (healthcare system funding and European single market) and partisanship (vote-seeking strategies by PRR and mainstream parties). No clear evidence was found regarding the influence of interest representation on welfare chauvinistic policies.

DISCUSSION

While early evidence suggests that the welfare chauvinistic ideology of PRR parties is harmful for public health, the possible mediating role of political system characteristics on PRR welfare policy influence offers risk and protective factors explaining why the PRR ideology plays out differently across Europe.

Study protocol for the COvid-19 Toolbox for All IslaNd (CONTAIN) project: A cross-border analysis in Ireland to disentangle psychological, behavioural, media and governmental responses to COVID-19

COVID-19 represents a serious challenge to governments and healthcare systems. In addition to testing/contact tracing, behavioural and social responses such as handwashing and social distancing or cocooning are effective tools for mitigating the spread of the disease. Psychological (e.g., risk perceptions, self-efficacy) and contextual factors (government, public health messaging, etc.) are likely to drive these behaviours. Collated real-time information of these indicators strengthens local, national and international public health advice and messaging. Further, understanding how well public health and government messages and measures are understood, communicated via (social) media and adhered to is vital. There are two governments and public health jurisdictions on the island of Ireland, the Republic of Ireland (ROI) and Northern Ireland (NI). This represents an opportunity to explore implications of differing measures and messaging across these two jurisdictions as they relate to COVID-19 on two similar populations. The expert research team are drawn from a range of disciplines in the two countries. This project has four nested studies: Assessment of key behavioural, social and psychological factors through a large, prospective representative telephone survey of individuals aged over-18 on a weekly basis over eight weeks (n=3072); and conduct qualitative focus groups over the same period.Interrogation of social media messaging and formal media responses in both jurisdictions to investigate the spread of (mis)information.Modelling data from Studies 1 and 2, plotting the psychosocial/behavioural and media messaging information with international, ROI and NI incidence and mortality data. Conducting an assessment of health policy transfer in an attempt to incorporate the most significant public health and political insights from each jurisdiction. The CONTAIN project will develop an evidence-based toolbox for targeting public health messaging and political leadership and will be created for use for the anticipated second wave of COVID-19, and subsequently for future epidemics/pandemics.

Protocol for a scoping review of implementation research approaches to universal health coverage in Africa

INTRODUCTION

Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of institutions and initiatives promoting the uptake of implementation research in Africa, their role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). This review aims to extensively identify and characterise the nature, facilitators and barriers to the use of implementation research for assessing or evaluating UHC-related interventions or programmes in Africa.

METHODS AND ANALYSIS

This scoping review will be developed based on the methodological framework proposed by Arksey and O'Malley and enhanced by the Joanna Briggs Institute. It will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A comprehensive search of the following electronic databases will be conducted: Medline (via PubMed), Scopus and the Cochrane Library. Relevant grey literature and reference lists will also be searched. All publications describing the application of implementation research in the context of UHC will be considered for inclusion. Findings will be narratively synthesised and analysed using a predefined conceptual framework. Where applicable, quantitative evidence will be aggregated using summary statistics. There will be consultation of stakeholders, including UHC-oriented health professionals, programme managers, implementation researchers and policy-makers; to provide methodological, conceptual and practical insights.

ETHICS AND DISSEMINATION

The data used in this review will be sourced from publicly available literature; hence, this study will not require ethical approval. Findings and recommendations will be disseminated to reach a diverse audience, including UHC advocates, implementation researchers and key health system stakeholders within the African region. Additionally, findings will be disseminated through an open-access publication in a relevant peer-reviewed journal.

Study protocol for the COvid-19 Toolbox for All IslaNd (CONTAIN) project: A cross-border analysis in Ireland to disentangle psychological, behavioural, media and governmental responses to COVID-19

COVID-19 represents a serious challenge to governments and healthcare systems. In addition to testing/contact tracing, behavioural and social responses such as handwashing and social distancing or cocooning are effective tools for mitigating the spread of the disease. Psychological (e.g., risk perceptions, self-efficacy) and contextual factors (government, public health messaging, etc.) are likely to drive these behaviours. Collated real-time information of these indicators strengthens local, national and international public health advice and messaging. Further, understanding how well public health and government messages and measures are understood, communicated via (social) media and adhered to is vital. There are two governments and public health jurisdictions on the island of Ireland, the Republic of Ireland (ROI) and Northern Ireland (NI). This represents an opportunity to explore implications of differing measures and messaging across these two jurisdictions as they relate to COVID-19 on two similar populations. The expert research team are drawn from a range of disciplines in the two countries.

This project has four nested studies:

Assessment of key behavioural, social and psychological factors through a large, prospective representative telephone survey of individuals aged over-18 on a weekly basis over eight weeks (n=3072); and conduct qualitative focus groups over the same period.

Interrogation of social media messaging and formal media responses in both jurisdictions to investigate the spread of (mis)information.

Modelling data from Studies 1 and 2, plotting the psychosocial/behavioural and media messaging information with international, ROI and NI incidence and mortality data. 

Conducting an assessment of health policy transfer in an attempt to incorporate the most significant public health and political insights from each jurisdiction.

The CONTAIN project will develop an evidence-based toolbox for targeting public health messaging and political leadership and will be created for use for the anticipated second wave of COVID-19, and subsequently for future epidemics/pandemics.

Integration of community health workers into the health system in Tanzania: Examining the process and contextual factors

Integration of community health workers (CHWs) into the health systems has become a global concern. Recently, the Government of Tanzania through the then Ministry of Health and Social Welfare initiated different strategies that aimed at integrating CHWs into the health system. This paper discusses the process and factors that influence the integration of CHWs into the health system in Tanzania. The study employed qualitative case study design using in-depth interviews (n = 37). In addition, various documents including health policies, Community-based Health Policy, community health workers guideline and Community health workers training curriculum were reviewed. Data were analysed by using thematic analysis. The findings indicated that potential CHWs were selected based on the National Council for Technical Education standards that required an applicant to have four (4) passes in the ordinary level examination. None of the CHWs who had undergone training had been employed by the government. This differed from what was prescribed in the CHWs guidelines. Integration of CHWs into health system in Tanzania has not been optimal because of inadequate preparations in terms of stakeholders engagement, infrastructure, legal and policy frameworks, technical expertise and financial resources. Effective integration of CHWs into the health system requires working with different actors to communicate objectives, achieve ownership of the stakeholders, manage conflict and cooperation, and sustain changes.