Social media opposition to the 2022/2023 UK nurse strikes

Previous research has established that the success of strikes, and social movements more broadly, depends on their ability to garner support from the public. However, there is scant published research investigating the response of the public to strike action by healthcare workers. In this study, we address this gap through a study of public responses to UK nursing strikes in 2022-2023, using a data set drawn from Twitter of more than 2300 publicly available tweets. We focus on negative tweets, investigating which societal discourses social media users draw on to oppose strike action by nurses. Using a combination of corpus-based approaches and discourse analysis, we identified five categories of opposition: (i) discourse discrediting nurses; (ii) discourse discrediting strikes by nurses; (iii) discourse on the National Health System; (iv) discourse about the fairness of strikers' demands and (v) discourse about potential harmful impact. Our findings show how social media users operationalise wider societal discourses about the nursing profession (e.g., associations with care, gender, vocation and sacrifice) as well as recent crises such as the Covid-19 pandemic to justify their opposition. The results also provide valuable insights into misconceptions about nursing, strike action and patient harm, which can inform strategies for public communication.

Efficacy of modified vacuum-assisted dressing versus conventional betadine dressing in wound healing of open fractures

Aim

This study aimed to compare the effectiveness of a customized vacuum-assisted dressing to traditional betadine dressings for wounds in open fractures.

Materials and methods

In this prospective comparative study, 30 patients from two groups-group A receiving V.A.C. while group B receiving traditional dressing-were given data from sixty participants with open fractures. Wound was evaluated on days 0, 3, 7, 11, and 15 of the study.

Results

In group A, there was a statistically significant decrease in the mean dimension of the wound overall (15.66 mm vs. 7.4 mm in group B), and it took an average of 9.83 days for healthy granulation tissue to emerge. In contrast to the 21 patients who had split skin grafting, five patients needed a flap as a final closure surgery. In group B, it took an average of 17 days for healthy granulation tissue to emerge. The authors used split skin grafting to close the wounds in 18 patients, and the wound was allowed to heal by secondary intention in 8 patients, while the flap was used in 4 patients.

Conclusion

On comparing the modified Vacuum-assisted dressing to the standard dressing, there was considerable wound contraction and accelerated healing. Therefore, the authors observed that vacuum-assisted dressing treatment is superior to traditional betadine dressing in open fractures.

The role of private healthcare sector actors in health service delivery and financing policy processes in low-and middle-income countries: a scoping review

The expansion of the private healthcare sector in some low-income and middle-income countries (LMICs) has raised key questions and debates regarding the governance of this sector, and the role of actors representing the sector in policy processes. Research on the role played by this sector, understood here as private hospitals, pharmacies and insurance companies, remains underdeveloped in the literature. In this paper, we present the results of a scoping review focused on synthesising scholarship on the role of private healthcare sector actors in health policy processes pertaining to health service delivery and financing in LMICs. We explore the role of organisations or groups-for example, individual companies, corporations or interest groups-representing healthcare sector actors, and use a conceptual framework of institutions, ideas, interests and networks to guide our analysis. The screening process resulted in 15 papers identified for data extraction. We found that the literature in this domain is highly interdisciplinary but nascent, with largely descriptive work and undertheorisation of policy process dynamics. Many studies described institutional mechanisms enabling private sector participation in decision-making in generic terms. Some studies reported competing institutional frameworks for particular policy areas (eg, commerce compared with health in the context of medical tourism). Private healthcare actors showed considerable heterogeneity in their organisation. Papers also referred to a range of strategies used by these actors. Finally, policy outcomes described in the cases were highly context specific and dependent on the interaction between institutions, interests, ideas and networks. Overall, our analysis suggests that the role of private healthcare actors in health policy processes in LMICs, particularly emerging industries such as hospitals, holds key insights that will be crucial to understanding and managing their role in expanding health service access.

SEVERITY OF MITRAL REGURGITATION AND ITS ASSOCIATION WITH LEFT VENTRICULAR DYSFUNCTION AND BRAIN-NATRIURETIC PEPTIDE LEVELS IN PATIENTS WITH ACUTE DECOMPENSATED HEART FAILURE

Acute decompensated heart failure (ADHF) is greatly influenced by levels of brain-natriuretic peptides (BNP) and thereby may have strong correlation with severity of mitral regurgitation (MR) and left ventricular ejection fraction (LVEF). The available data on its association is limited which sought us to investigate correlations between type of ADHF, BNP levels and severity of MR. A single-center, cross-sectional, observational study was conducted at Sri Ramachandra Institute of Higher Education and Research, Chennai, India. Adults aged >18 years, either gender, diagnosed as ADHF requiring hospital admission within 24 hours were incorporated into the research.Between June 2019 to June 2020, we included 79 patients of ADHF. The mean age was 64.9±11 years and 60.8% were males. The mean LVEF was 40.2±10.2%. The severity of MR was severe, moderate, and mild in 3.8%, 21.5% and 74.7% of patients, respectively. The proportion of patients with moderate to severe MR was significantly higher in ADHF patients with reduced EF compared to mid-range or preserved EF. The median levels of BNP significantly increased from 520.0 pg/ml in mild MR to 1020.0 pg/ml in moderate and 1410.0 pg/ml in severe MR. In patients with ADHF, MR is a common finding. The severity of MR is associated with greater reduction in ejection fraction. Determination of MR severity is essential in all ADHF cases. Further, stratification of patients using BNP levels may help in identifying those at higher risk of adverse outcomes in ADHF.

Associations, unions and everything in between: contextualising the role of representative health worker organisations in policy

Associations, unions and other organised groups representing health workers play a significant role in the development, adoption and implementation of health policy. These representative health worker organisations (RHWOs) are a key interface between employers, governments and their members (both actual and claimed), with varying degrees of influence and authority within and across countries. Existing research in global health often assumes-rather than investigates-the roles played by RHWOs in policy processes and lacks analytical specificity regarding the definitional characteristics of RHWOs. In this article, we seek to expand and complicate conceptualisations of RHWOs as key actors in global health by unpacking the heterogeneity of RHWOs and their roles in policy processes and by situating RHWOs in context. First, we define RHWOs, present a typology of RHWO dimensions and discuss perceived legitimacy of RHWOs as policy actors. Next, we unpack the roles of RHWOs in policy processes and distinguish RHWO roles in regulation from those of regulatory agencies. The final sections situate RHWOs in political and labour relations contexts, and in sociohistorical contexts, with attention to institutional frameworks, professional hierarchies and intersectional factors such as race, gender, sexuality, class, caste and religion. We conclude by outlining research gaps in the study of RHWOs and policy, and by encouraging global health researchers and practitioners to incorporate an expanded focus on these actors. Taking this approach will generate a wider range of strategies to better engage these organisations in policy processes and will ensure stronger health workforce policies globally.

Interest Groups and Health Facility Regulation - Future Directions for Health Policy and Systems Research Comment on "What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya's Health Facility Inspection Reforms"

In their paper, Tama and colleagues observe that one key challenge in a pilot, multi-component intervention to strengthen health facility regulation was the reaction from health facility owners and providers to regulatory processes. In this commentary, we propose that future research and action on health facility regulation in low- and middle-income countries (LMICs) contexts adopt an explicit focus on addressing the role of interests and interest groups in health systems 'hardware' and 'software.' Research on policy processes in LMICs consist of fewer investigations into the political economy of national or sub-national interest groups, such as physician associations or associations of health facility owners. A growing body of literature explores supply-side and demand-side interest groups, power relations within and between these stakeholders, and their advocacy approaches within LMIC health sector policy processes. We posit that such analyses will also help identify facilitators and challenges to implementation and scale-up of similar reforms to health facility regulation.

Coloniality, Elite Networks and Intersectionality: Key Concepts in Understanding Biomedical Power and Equity in Health Policy Processes Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process"

To understand the role of power in health policy processes in low- and middle-income country (LMIC) contexts, it is necessary to engage with global and local power structures and their historical contexts. In this commentary, we outline three dimensions that shape a dominant power in health policy processes-the biomedical power. We propose that understanding the linkages between medical power and colonialism; the close connection of public health, medicine and elite networks; and the intersectionalities that shape the powers of medical professionals can offer the means to examine the biomedical hegemony in health policy processes. Additionally we suggest that a more nuanced understanding of the interaction of local powers with global funding can offer some entry points to achieving more equitable and interdisciplinary health policy processes in LMICs.

Investigating the influence of institutions, politics, organizations, and governance on the COVID-19 response in British Columbia, Canada: a jurisdictional case study protocol

BACKGROUND

Research on public health responses to COVID-19 globally has largely focused on understanding the virus' epidemiology, identifying interventions to curb transmission, and assessing the impact of interventions on outcomes. Only recently have studies begun to situate their findings within the institutional, political, or organizational contexts of jurisdictions. Within British Columbia (BC), Canada, the COVID-19 response in early 2020 was deemed highly coordinated and effective overall; however, little is understood as to how these upstream factors influenced policy decisions.

METHODS

Using a conceptual framework we developed, we are conducting a multidisciplinary jurisdictional case study to explore the influence of institutional (I), political (P), organizational (O), and governance (G) factors on BC's COVID-19 public health response in 2020-2021. A document review (e.g. policy documents, media reports) is being used to (1) characterize relevant institutional and political factors in BC, (2) identify key policy decisions in BC's epidemic progression, (3) create an organizational map of BC's public health system structure, and (4) identify key informants for interviews. Quantitative data (e.g. COVID-19 case, hospitalization, death counts) from publicly accessible sources will be used to construct BC's epidemic curve. Key informant interviews (n = 15-20) will explore governance processes in the COVID-19 response and triangulate data from prior procedures. Qualitative data will be analysed using a hybrid deductive-inductive coding approach and framework analysis. By integrating all of the data streams, our aim is to explore decision-making processes, identify how IPOG factors influenced policy decisions, and underscore implications for decision-making in public health crises in the BC context and elsewhere. Knowledge users within the jurisdiction will be consulted to construct recommendations for future planning and preparedness.

DISCUSSION

As the COVID-19 pandemic evolves, governments have initiated retrospective examinations of their policies to identify lessons learned. Our conceptual framework articulates how interrelations between IPOG contextual factors might be applied to such analysis. Through this jurisdictional case study, we aim to contribute findings to strengthen governmental responses and improve preparedness for future health crises. This protocol can be adapted to and applied in other jurisdictions, across subnational jurisdictions, and internationally.

Perceptions of the Doctor-Patient Relationship Among Patients in a Private, Secondary-Level Hospital in Southern India

Introduction

An epidemic of non-communicable diseases (NCDs) in India is fueling a growing demand for primary care and hospitalization services. Difficulties in coordinating inpatient and outpatient care create significant barriers to providing high-quality medical care. In this paper, we describe patient experiences, perceptions, and expectations of doctor-patient relationships in a secondary-level private hospital in Karnataka, India.

Methods

We conducted a cross-sectional, mixed-method needs assessment with surveys and in-depth interviews at Dr. TMA Pai Hospital (TMAPH), a secondary-level, private sector hospital in Karnataka, India. Inclusion criteria included all adults over 18 years old hospitalized at TMAPH in the past year. Patients were consecutively recruited from August 2019-October 2019 and asked to rate aspects of their relationship with their primary care provider (PCP). Descriptive statistics and multivariable logistic regression were used to analyze predictors of the doctor-patient relationship. Patients were interviewed regarding their perceptions of care coordination and doctor-patient relationships. General Thematic Analysis was utilized to analyze qualitative data and develop themes. Quantitative and qualitative findings were then merged to interpret the various dimensions of doctor-patient relationships.

Results

A total of 150 patients (47.3% male) enrolled. Ten patients underwent qualitative interviews. The median patient age was 67 years (IQR 56-76). 112 (74.7%) of patients identified a PCP either at or outside of TMAPH. 89% had diabetes and/or hypertension. Compared to patients without a PCP, having a PCP led to a significantly higher adjusted odds of always spending optimal time with their doctors (aOR 2.7, 95% CI 1.1-6.8, p = 0.04), and always receiving clear instructions on managing their medical conditions (aOR 2.5, 95% CI 1.0-6.1, p = 0.04). The following themes were developed from patient interviews: (1) patients trusted and respected their PCP believing they were receiving high quality care; and (2) despite perceived fragmentation in care, patients spoke favorably of their relationships with their doctors.

Conclusions

Among a sample of recently hospitalized patients, those with a PCP reported more positive doctor-patient relationships, though rates of dissatisfaction with doctors were still high. Further research and strategies are required to optimize continuity of care and doctor-patient relationships across the entire continuum of outpatient and inpatient care.

Rare and Aggressive Primary Amelanotic Melanoma in Anorectal Region: A Case Series

Anorectal amelanotic melanoma is a rare and aggressive disease with high morbidity and mortality. A conclusive diagnosis of anorectal amelanotic melanoma poses a challenge to pathologists and clinicians due to the protean nature of this entity, be it in its initial clinical assessment appearing as non pigmented polypoidal growths usually mistaken for haemorrhoids or anorectal polyps. Histomorphologically, these entities get categorised in bewildering array of diagnoses like spindle cell carcinoma, Gastrointestinal Stromal Tumour (GIST), High grade sarcomas and even lymphoma. Thus Immunohistochemistry (IHC) remains a vital tool for conclusive diagnosis. The purpose of the present case series is to discuss in detail about the three patients all aged above 55 years and clinically assessed with anorectal polypoidal growths. All three cases on histopathological evaluation were diagnosed as spindle cell neoplasm with no discernible melanin pigments. The IHC performed on all three cases turned positive for S-100 and Human Melanoma Black 45 (HMB 45). This case series highlights the challenging and bewildering nature of presentation of anorectal amelanotic melanomas, by virtue of its rarity and hence justifies the need for it to be considered as a possible differential diagnosis.

Tuberous xanthoma with cardiac failure in a child

A 14-year-old girl presented with gradually progressive breathlessness for 3 weeks. On evaluation, it was found that she had left ventricular hypertrophy and nonprogressive R wave in ECG. An echocardiogram revealed aortic stenosis and severe left ventricular dysfunction.Computed Tomography (CT) imaging showed aortic annulus calcifications causing aortic stenosis. Over three years she had gradually developed asymptomatic cutaneous swellings over the small and large joints of the extremities suggestive of tuberous xanthomas. Skin biopsy revealed scattered foamy macrophages in the upper dermis and cholesterol clefts. Her lipid profile showed raised total cholesterol and low-density lipoprotein levels. With the above clinical, histological, and laboratory findings she was diagnosed as a case of familial homozygous hypercholesterolemia with tuberous xanthomas and cardiac failure. She was started on statins, ezetimibe, and other anti-failure measures. We present this case for its rarity. Early diagnosis of this condition based on skin findings, could have prevented cardiac failure by initiating early appropriate treatment.

Primary care physician involvement during hospitalisation: a qualitative analysis of perspectives from frequently hospitalised patients

OBJECTIVE

To explore frequently hospitalised patients' experiences and preferences related to primary care physician (PCP) involvement during hospitalisation across two care models.

DESIGN

Qualitative study embedded within a randomised controlled trial. Semistructured interviews were conducted with patients. Transcripts were analysed using qualitative template analysis.

SETTING

In the Comprehensive Care Programme (CCP) Study, in Illinois, USA, Medicare patients at increased risk of hospitalisation are randomly assigned to: (1) care by a CCP physician who serves as a PCP across both inpatient and outpatient settings or (2) care by a PCP as outpatient and by hospitalists as inpatients (standard care).

PARTICIPANTS

Twelve standard care and 12 CCP patients were interviewed.

RESULTS

Themes included: (1) Positive attitude towards PCP; (2) Longitudinal continuity with PCP valued; (3) Patient preference for PCP involvement in hospital care; (4) Potential for in-depth involvement of PCP during hospitalisation often unrealised (involvement rare in standard care; in CCP, frequent interaction with PCP fostered patient involvement in decision making); and (5) PCP collaboration with hospital-based providers frequently absent (no interaction for standard care patients; CCP patients emphasising PCP's role in interdisciplinary coordination).

CONCLUSION

Frequently hospitalised patients value PCP involvement in the hospital setting. CCP patients highlighted how an established relationship with their PCP improved interdisciplinary coordination and engagement with decision making. Inpatient-outpatient relational continuity may be an important component of programmes for frequently hospitalised patients. Opportunities for enhancing PCP involvement during hospitalisation should be considered.

Power analysis in health policy and systems research: a guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

Stakeholder perspectives on proposed policies to improve distribution and retention of doctors in rural areas of Uttar Pradesh, India

Background

In India, the distribution and retention of biomedical doctors in public sector facilities in rural areas is an obstacle to improving access to health services. The Government of Uttar Pradesh is developing a comprehensive, ten-year Human Resources for Health (HRH) strategy, which includes policies to address rural distribution and retention of government doctors in Uttar Pradesh (UP). We undertook a stakeholder analysis to understand stakeholder positions on particular policies within the strategy, and to examine how stakeholder power and interests would shape the development and implementation of these proposed policies. This paper focuses on the results of the stakeholder analysis pertaining to rural distribution and retention of doctors in the government sector in UP. Our objectives are to 1) analyze stakeholder power in influencing the adoption of policies; 2) compare and analyze stakeholder positions on specific policies, including their perspectives on the conditions for successful policy adoption and implementation; and 3) explore the challenges with developing and implementing a coordinated, ‘bundled’ approach to strengthening rural distribution and retention of doctors.

Methods

We utilized three forms of data collection for this study – document review, in-depth interviews and focus group discussions. We conducted 17 interviews and three focus group discussions with key stakeholders between September and November 2019.

Results

We found that the adoption of a coordinated policy approach for rural retention and distribution of doctors is negatively impacted by governance challenges and fragmentation within and beyond the health sector. Respondents also noted that the opposition to certain policies by health worker associations created challenges for comprehensive policy development. Finally, respondents believed that even in the event of policy adoption, implementation remained severely hampered by several factors, including weak mechanisms of accountability and perceived corruption at local, district and state level.

Conclusion

Building on the findings of this analysis, we propose several strategies for addressing the challenges in improving access to government doctors in rural areas of UP, including additional policies that address key concerns raised by stakeholders, and improved mechanisms for coordination, accountability and transparency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06765-x.

The impact of colonial-era policies on health workforce regulation in India: lessons for contemporary reform

BACKGROUND

Regulation is a critical function in the governance of health workforces. In many countries, regulatory councils for health professionals guide the development and implementation of health workforce policy, but struggle to perform their responsibilities, particularly in low- and middle-income countries (LMICs). Few studies have analyzed the influence of colonialism on modern-day regulatory policy for health workforces in LMICs. Drawing on the example of regulatory policy from India, the goals of this paper is to uncover and highlight the colonial legacies of persistent challenges in medical education and practice within the country, and provide lessons for regulatory policy in India and other LMICs.

MAIN BODY

Drawing on peer-reviewed and gray literature, this paper explores the colonial origins of the regulation of medical education and practice in India. We describe three major aspects: (1) Evolution of the structure of the apex regulatory council for doctors-the Medical Council of India (MCI); (2) Reciprocity of medical qualifications between the MCI and the General Medical Council (GMC) in the UK following independence from Britain; (3) Regulatory imbalances between doctors and other cadres, and between biomedicine and Indian systems of medicine.

CONCLUSIONS

Challenges in medical education and professional regulation remain a major obstacle to improve the availability, retention and quality of health workers in India and many other LMICs. We conclude that the colonial origins of regulatory policy in India provide critical insight into contemporary debates regarding reform. From a policy perspective, we need to carefully interrogate why our existing policies are framed in particular ways, and consider whether that framing continues to suit our needs in the twenty-first century.

A Draconian Law: Examining the Navigation of Coalition Politics and Policy Reform by Health Provider Associations in Karnataka, India

A comprehensive picture of provider coalitions in health policy making remains incomplete because of the lack of empirically driven insights from low- and middle-income countries. The authors examined the politics of provider coalitions in the health sector in Karnataka, India, by investigating policy processes between 2016 and 2018 for developing amendments to the Karnataka Private Medical Establishments Act. Through this case, they explore how provider associations function, coalesce, and compete and the implications of their actions on policy outcomes. They conducted in-depth interviews, document analysis, and nonparticipant observations of two conferences organized by associations. They found that provider associations played a major role in drafting the amendments and negotiating competing interests within and between doctors and hospital associations. Despite the fragmentation, the associations came together to reinterpret the intentions of the amendments as being against the interests of the profession, culminating in a statewide protest and strike. Despite this show of strength, provider associations only secured modest modifications. This case demonstrates the complex and unpredictable influence of provider associations in health policy processes in India. The authors' analysis highlights the importance of further empirical study on the influence of professional and trade associations across a range of health policy cases in low- and middle-income countries.

Governance Roles and Capacities of Ministries of Health: A Multidimensional Framework

The lack of capacity for governance of Ministries of Health (MoHs) is frequently advanced as an explanation for health systems failures in low- and middle-income countries (LMICs). But do we understand what governance capacities MoHs should have? Existing frameworks have not fully captured the dynamic and contextually determined role of MoHs, and there are few frameworks that specifically define capacities for governance. We propose a multidimensional framework of capacities for governance by MoHs that encompasses both the "hard" (de jure , explicit and functional) and "soft" (de facto , tacit, and relational) dimensions of governance, and reflects the diversification of their mandates in the context of the Sustainable Development Goals (SDGs). Four case studies illustrate different aspects of the framework. We hope that the framework will have multiple potential benefits including benchmarking MoH governance capacities, identifying and helping analyze capacity gaps, and guiding strategies to strengthen capacity.

Visualizing the drivers of an effective health workforce: a detailed, interactive logic model

BACKGROUND

A strong health workforce is a key building block of a well-functioning health system. To achieve health systems goals, policymakers need information on what works to improve and sustain health workforce performance. Most frameworks on health workforce planning and policymaking are high-level and conceptual, and do not provide a structure for synthesizing the growing body of empirical literature on the effectiveness of strategies to strengthen human resources for health (HRH). Our aim is to create a detailed, interactive logic model to map HRH evidence and inform policy development and decision-making.

METHODS

We reviewed existing conceptual frameworks and models on health workforce planning and policymaking. We included frameworks that were: (1) visual, (2) comprehensive (not concentrated on specific outcomes or strategies), and (3) designed to support decision-making. We compared and synthesized the frameworks to develop a detailed logic model and interactive evidence visualization tool.

RESULTS

Ten frameworks met our inclusion criteria. The resulting logic model, available at hrhvisualizer.org , allows for visualization of high-level linkages as well as a detailed understanding of the factors that affect health workforce outcomes. HRH data and governance systems interact with the context to affect how human resource policies are formulated and implemented. These policies affect HRH processes and strategies that influence health workforce outcomes and contribute to the overarching health systems goals of clinical quality, responsiveness, efficiency, and coverage. Unlike existing conceptual frameworks, this logic model has been operationalized in a highly visual, interactive platform that can be used to map the research informing policies and illuminating their underlying mechanisms.

CONCLUSIONS

The interactive logic model presented in this paper will allow for comprehensive mapping of literature around effective strategies to strengthen HRH. It can aid researchers in communicating with policymakers about the evidence behind policy questions, thus supporting the translation of evidence to policy.

Bureaucracies and power: Examining the Medical Council of India and the development of emergency medicine in India

In many countries, professional councils are mandated to oversee the training and conduct of health professionals, including doctors, nurses, pharmacists and allied health workers. The proper functioning of these councils is critical to overall health system performance. Yet, professional councils are sometimes criticized, particularly in the context of low- and middle-income countries, for their misuse of power and overtly bureaucratic nature. The objective of this paper is to understand how professional councils use their bureaucratic power to shape health policy and systems, drawing upon the recent development of emergency medicine in the context of the former Medical Council of India. We undertook a qualitative case study, conducting 87 interviews, observing 6 meetings and conferences, and reviewing approximately 96 documents, and used the Framework method to analyze our data. The passive exercise of bureaucratic power by the Council resulted in three challenges - 1) Opaque policy processes for recognizing new medical specialties; 2) Insular, non-transparent training policy formulation; 3) Unaccountable enforcement for regulating new courses. The Council did not have the requisite technical expertise to manage certain policy processes, and further, did not adequately utilize external expertise. In this time period, the Council applied its bureaucratic power in a manner that negatively impacted emergency medicine training programs and the development of emergency medicine, with implications for availability and quality of emergency care in India. The successor to the Council, the National Medical Commission, should consider new approaches to exercising bureaucratic power in order to meet its objectives of strengthening medical education in India and ensuring access to high-quality services. Future studies should also explore the utilization of bureaucratic power in the health sectors of low- and middle-income countries in order to provider a deeper understanding of institutional barriers to improvements in health.

Strengthening medical specialisation policy in low-income and middle-income countries

The availability of medical specialists has accelerated in low-income and middle-income countries (LMICs), driven by factors including epidemiological and demographic shifts, doctors' preferences for postgraduate training, income growth and medical tourism. Yet, despite some policy efforts to increase access to specialists in rural health facilities and improve referral systems, many policy questions are still underaddressed or unaddressed in LMIC health sectors, including in the context of universal health coverage. Engaging with issues of specialisation may appear to be of secondary importance, compared with arguably more pressing concerns regarding primary care and the social determinants of health. However, we believe this to be a false choice. Policy at the intersection of essential health services and medical specialties is central to issues of access and equity, and failure to formulate policy in this regard may have adverse ramifications for the entire system. In this article, we describe three critical policy questions on medical specialties and health systems with the aim of provoking further analysis, discussion and policy formulation: (1) What types, and how many specialists to train? (2) How to link specialists' production and deployment to health systems strengthening and population health? (3) How to develop and strengthen institutions to steer specialisation policy? We posit that further analysis, discussion and policy formulation addressing these questions presents an important opportunity to explicitly determine and strengthen the linkages between specialists, health systems and health equity.

The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi, India

Introduction

Ambulance-based emergency medical systems (EMS) are expensive and remain rare in low- and middle-income countries, where trauma victims are usually transported to hospital by passing vehicles. Recent developments in transportation network technologies could potentially disrupt this status quo by allowing coordinated emergency response from layperson networks. We sought to understand the barriers to bystander assistance for trauma victims in Delhi, India, and implications for a layperson-EMS.

Methods

We used qualitative methods to analyse data from 50 interviews with frontline stakeholders (including taxi drivers, medical professionals, legal experts and police), one stakeholder consultation and a review of documents.

Results

Respondents noted that most trauma victims in Delhi are rapidly brought to hospital by bystanders, taxis and police. While ambulances are common, they are primarily used for interfacility transfers. Entrenched medico-legal practices result in substantial police presence at the hospital, which is a major source of harassment of good Samaritans and interferes with patient care. Trauma victims are often turned away by for-profit hospitals due to their inability to pay, leading to delays in treatment. Recent policy efforts to circumscribe the role of police and force for-profit hospitals to stabilise patients appear to have been unsuccessful.

Conclusions

Existing healthcare and medico-legal practices in India create large systemic impediments to improving trauma outcomes. Until India’s ongoing health and transport sector reforms succeed in ensuring that for-profit hospitals reliably provide care, good Samaritans and layperson-EMS providers should take victims with uncertain financial means to public facilities. To avoid difficulties with police, providers of a layperson-EMS would likely need official police sanction and carry visible symbols of their authority to provide emergency transport. Delhi already has several key components of an EMS (including dispatcher coordinated police response, large ambulance fleet) that could be integrated and expanded into a complete system of emergency care.

A framework for medical power in two case studies of health policymaking in India and Niger

Medical professionals influence health policymaking but the power they exercise is not well understood in low- and middle-income countries. We explore medical power in national health policymaking for child survival in Niger (late 1990s-2012) and emergency medicine specialisation in India (early 1990s-2015). Both case studies used document review, in-depth interviews and non-participant observation; combined analysis traced policy processes and established theoretical categories around power to build a conceptual framework of medical power in health policymaking. Medical doctors, mainly specialists, utilised their power to shape policy differently in each case. In Niger, a small, connected group of paediatricians pursued a policy of task-shifting after a powerful non-medical actor, the country's president, shifted the debate by enacting broad health systems improvements. In India, a more fragmented group of specialists prioritised tertiary-level healthcare policies likely to benefit only a small subset of the population. Compared to high-income settings, medical power in these cases was channelled and expressed with greater variability in the profession's ability to organise and influence policymaking. Taken together, both cases provide evidence that a concentration of medical power in health policymaking can result in the medicalisation of public health issues.

The Making of a New Medical Specialty: A Policy Analysis of the Development of Emergency Medicine in India

Background: Medical specialization is an understudied, yet growing aspect of health systems in low- and middleincome countries (LMICs). In India, medical specialization is incrementally, yet significantly, modifying service delivery, workforce distribution, and financing. However, scarce evidence exists in India and other LMICs regarding how medical specialties evolve and are regulated, and how these processes might impact the health system. The trajectory of emergency medicine appears to encapsulate broader trends in medical specialization in India – international exchange and engagement, the formation of professional associations, and a lengthy regulatory process with the Medical Council of India. Using an analysis of political priority setting, our objective was to explore the emergence and recognition of emergency medicine as a medical specialty in India, from the early 1990s to 2015.

Methods: We used a qualitative case study methodology, drawing on the Shiffman and Smith framework. We conducted 87 in-depth interviews, reviewing 122 documents, and observing six meetings and conferences. We used a modified version of the ‘Framework’ approach in our analysis.

Results: Momentum around emergency medicine as a viable solution to weak systems of emergency care in India gained traction in the 1990s. Public and private sector stakeholders, often working through transnational professional medical associations, actively pursued recognition from Medical Council of India. Despite fragmentation within the network, stakeholders shared similar beliefs regarding the need for specialty recognition, and were ultimately achieved this objective. However, fragmentation in the network made coalescing around a broader policy agenda for emergency medicine challenging, eventually contributing to an uncertain long-term pathway. Finally, due to the complexities of the regulatory system, stakeholders promoted multiple forms of training programs, expanding the workforce of emergency physicians, but with limited coordination and standardization.

Conclusion: The ideational centrality of postgraduate medical education, a challenging national governance system, and fragmentation within the transnational stakeholder network characterized the development of emergency medicine in India. As medical specialization continues to shape and influence health systems globally, research on the evolution of new medical specialties in LMICs can enhance our understanding of the connections between specialization, health systems, and equity.

Socialization, legitimation and the transfer of biomedical knowledge to low- and middle-income countries: analyzing the case of emergency medicine in India

BACKGROUND

Medical specialization is a key feature of biomedicine, and is a growing, but weakly understood aspect of health systems in many low- and middle-income countries (LMICs), including India. Emergency medicine is an example of a medical specialty that has been promoted in India by several high-income country stakeholders, including the Indian diaspora, through transnational and institutional partnerships. Despite the rapid evolution of emergency medicine in comparison to other specialties, this specialty has seen fragmentation in the stakeholder network and divergent training and policy objectives. Few empirical studies have examined the influence of stakeholders from high-income countries broadly, or of diasporas specifically, in transferring knowledge of medical specialization to LMICs. Using the concepts of socialization and legitimation, our goal is to examine the transfer of medical knowledge from high-income countries to LMICs through domestic, diasporic and foreign stakeholders, and the perceived impact of this knowledge on shaping health priorities in India.

METHODS

This analysis was conducted as part of a broader study on the development of emergency medicine in India. We designed a qualitative case study focused on the early 1990s until 2015, analyzing data from in-depth interviewing (n = 87), document review (n = 248), and non-participant observation of conferences and meetings (n = 6).

RESULTS

From the early 1990s, domestic stakeholders with exposure to emergency medicine in high-income countries began to establish Emergency Departments and initiate specialist training in the field. Their efforts were amplified by the active legitimation of emergency medicine by diasporic and foreign stakeholders, who formed transnational partnerships with domestic stakeholders and organized conferences, training programs and other activities to promote the field in India. However, despite a broad commitment to expanding specialist training, the network of domestic, diasporic and foreign stakeholders was highly fragmented, resulting in myriad unstandardized postgraduate training programs and duplicative policy agendas. Further, the focus in this time period was largely on training specialists, resulting in more emphasis on a medicalized, tertiary-level form of care.

CONCLUSIONS

This analysis reveals the complexities of the roles and dynamics of domestic, diasporic and foreign stakeholders in the evolution of emergency medicine in India. More research and critical analyses are required to explore the transfer of medical knowledge, such as other medical specialties, models of clinical care, and medical technologies, from high-income countries to India.

Regulating recognition and training for new medical specialties in India: the case of emergency medicine

Regulation is essential to health systems and is central to advancing equity-oriented policy objectives in health. Regulating new medical specialties is an emerging, yet underexplored, aspect of health sector governance in low- and middle-income countries (LMICs), such as India. Limited research exists regarding how regulatory institutions in India decide what specialties should be formally recognized and how training programmes for these specialties should be organized. Understanding these regulatory functions provides a lens into how policymakers envision the role of these specialties in the broader health system and how they view the linkages between medical education, health system needs and equity. Drawing upon the recent development of emergency medicine in India, the goal of this study was to understand how recognition and training for new medical specialties are regulated in India. Building on previous frameworks, we examined the institutions, functions, enforcement, mechanisms and institutional relationships that make up the regulatory architecture, and situated our analysis in historical context. Two data sources were iteratively utilized: document review (n = 93) and in-depth interviews (n = 87). Our analysis reveals a plurality of institutions involved in regulating recognition and training for new medical specialties in India, characterized by a lack of coordination, limited collaboration and weak accountability. We also found an absence of clear responsibility for the systematic, planned development of specialties, particularly in terms of health system in strengthening and achieving health equity. As medical specialization continues to shape health systems in LMICs, further streamlining and coordination in the regulatory system will enable policymakers, researchers, practitioners and civil society to proactively plan for how these specialties can better integrate with health systems, and to advance their contribution to improving health outcomes.

10 best resources on power in health policy and systems in low- and middle-income countries

Power is a critical concept to understand and transform health policy and systems. Power manifests implicitly or explicitly at multiple levels-local, national and global-and is present at each actor interface, therefore shaping all actions, processes and outcomes. Analysing and engaging with power has important potential for improving our understanding of the underlying causes of inequity, and our ability to promote transparency, accountability and fairness. However, the study and analysis of the role of power in health policy and systems, particularly in the context of low- and middle-income countries, has been lacking. In order to facilitate greater engagement with the concept of power among researchers and practitioners in the health systems and policy realm, we share a broad overview of the concept of power, and list 10 excellent resources on power in health policy and systems in low- and middle-income countries, covering exemplary frameworks, commentaries and empirical work. We undertook a two-stage process to identify these resources. First, we conducted a collaborative exercise involving crowdsourcing and participatory validation, resulting in 24 proposed articles. Second, we conducted a structured literature review in four phases, resulting in 38 articles reviewed. We present the 10 selected resources in the following categories to bring out key facets of the literature on power and health policy and systems-(1) Resources that provide an overarching conceptual exploration into how power shapes health policy and systems, and how to investigate it; and (2) examples of strong empirical work on power and health policy and systems research representing various levels of analyses, geographic regions and conceptual understandings of power. We conclude with a brief discussion of key gaps in the literature, and suggestions for additional methodological approaches to study power.

Developing the National Knowledge Platform in India: a policy and institutional analysis

BACKGROUND

The importance of strong engagement between researchers and decision-makers in the improvement of health systems is increasingly being recognised in low- and middle-income countries (LMICs). In 2013, in India, the Ministry of Health and Family Welfare began exploring the formation of a National Knowledge Platform (NKP) for guiding and supporting public health and health systems research in the country. The development of the NKP represents an important opportunity to enhance the linkage between policy-makers and researchers from the health policy and systems research field in India. However, the development process also reflects the highly complex reality of policy-making in the Indian health sector. Our objective is to provide insight into the policy-making process for establishing a health sector knowledge platform in India, and in doing so, to analyse the enabling contextual factors, the interests and actions of stakeholders, and the varying institutional arrangements explored in the development of the NKP.

METHODS

We used a qualitative case study methodology, conducting 16 in-depth interviews and reviewing 42 documents. We utilised General Thematic Analysis to analyse our data. Our research team combined perspectives from both outsiders (independent researchers with no prior or current involvement with the policy) and insiders (researchers involved in the policy-making process).

RESULTS

We found that enabling contextual factors, and a combination of government and non-governmental stakeholders with core interests in public health and health systems, were able to gain considerable momentum in moving the idea for the NKP forward. However, complex evidence-to-policy processes in the Indian health sector resulted in complications in determining the right institutional arrangement for the platform. Establishing the appropriate balance between legitimacy and independence, as well as frequent changes in institutional leadership, were found to be additional issues that stakeholders contended with in building the NKP.

CONCLUSION

As interest in platforms linking health sector policy-makers and researchers grows in LMICs, our findings may allow stakeholders to learn from the Indian experience thus far, and to anticipate some of the facilitators and barriers that could potentially arise in establishing such mechanisms.

Synergies, strengths and challenges: findings on community capability from a systematic health systems research literature review

Background

Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs).

Methods

We searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” We identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability.

Results

When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed.

Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality.

Conclusions

Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment. Our simpler framework to define community capability may help researchers better recognize, support and assess it.

Translational Pharmacokinetic/Pharmacodynamic Modeling of Tumor Growth Inhibition Supports Dose-Range Selection of the Anti-PD-1 Antibody Pembrolizumab

Pembrolizumab, a humanized monoclonal antibody against programmed death 1 (PD‐1), has a manageable safety profile and robust clinical activity against advanced malignancies. The lowest effective dose for evaluation in further dose‐ranging studies was identified by developing a translational model from preclinical mouse experiments. A compartmental pharmacokinetic model was combined with a published physiologically based tissue compartment, linked to receptor occupancy as the driver of observed tumor growth inhibition. Human simulations were performed using clinical pharmacokinetic data, literature values, and in vitro parameters for drug distribution and binding. Biological and mathematical uncertainties were included in simulations to generate expectations for dose response. The results demonstrated a minimal increase in efficacy for doses higher than 2 mg/kg. The findings of the translational model were successfully applied to select 2 mg/kg as the lowest dose for dose‐ranging evaluations.

Social Media and Library Marketing: Experiences of KN Raj Library

Marketing is essential for attracting potential customers and retaining existing customers. Libraries and information centres are also increasingly entering into the foray of library marketing and public relations using all available means. The various Web 2.0 and social media tools are very convenient for the libraries to market their resources and services. The paper explains various popular social media tools and argues for their extensive use in libraries for marketing and publicity. How these social media tools can be effectively put to use in libraries for marketing its resources and services are explained by illustrating services in the KN Raj Library of Centre for Development Studies, Thiruvananthapuram.DOI: 10.14429/djlit.36.3.9810

Comparative analysis of three prehospital emergency medical services organizations in India and Pakistan

OBJECTIVES

Strengthened emergency medical services (EMS) are urgently required in South Asia to reduce needless death and disability. Several EMS models have been introduced in India and Pakistan, and research on these models can facilitate improvements to EMS in the region. Our objective was to conduct a cross-case comparative analysis of three EMS organizations in India and Pakistan - GVK EMRI, Aman Foundation and Rescue 1122 - in order to draw out similarities and differences in their models.

STUDY DESIGN

Case study methodology was used to systematically explore the organizational models of GVK EMRI (Karnataka, India), Aman Foundation (Karachi, Pakistan), and Rescue 1122 (Punjab, Pakistan).

METHODS

Qualitative methods - interviews, document review and non-participant observation - were utilized, and using a process of constant comparison, data were analysed across cases according to the WHO health system 'building blocks'.

RESULTS

Emergent themes under each health system 'building block' of service delivery, health workforce, medical products and technology, health information systems, leadership and governance, and financing were described. Cross-cutting issues not applicable to any single building block were further identified.

CONCLUSIONS

This cross-case comparison, the first of its kind in low- and middle-income countries, highlights key innovations and lessons, and areas of further research across EMS organizations in India, Pakistan and other resource-poor settings.

Community Participation in Health Systems Research: A Systematic Review Assessing the State of Research, the Nature of Interventions Involved and the Features of Engagement with Communities

BACKGROUND

Community participation is a major principle of people centered health systems, with considerable research highlighting its intrinsic value and strategic importance. Existing reviews largely focus on the effectiveness of community participation with less attention to how community participation is supported in health systems intervention research.

OBJECTIVE

To explore the extent, nature and quality of community participation in health systems intervention research in low- and middle-income countries.

METHODOLOGY

We searched for peer-reviewed, English language literature published between January 2000 and May 2012 through four electronic databases. Search terms combined the concepts of community, capability/participation, health systems research and low- and middle-income countries. The initial search yielded 3,092 articles, of which 260 articles with more than nominal community participation were identified and included. We further excluded 104 articles due to lower levels of community participation across the research cycle and poor description of the process of community participation. Out of the remaining 160 articles with rich community participation, we further examined 64 articles focused on service delivery and governance within health systems research.

RESULTS

Most articles were led by authors in high income countries and many did not consistently list critical aspects of study quality. Articles were most likely to describe community participation in health promotion interventions (78%, 202/260), even though they were less participatory than other health systems areas. Community involvement in governance and supply chain management was less common (12%, 30/260 and 9%, 24/260 respectively), but more participatory. Articles cut across all health conditions and varied by scale and duration, with those that were implemented at national scale or over more than five years being mainstreamed by government. Most articles detailed improvements in service availability, accessibility and acceptability, with fewer efforts focused on quality, and few designs able to measure impact on health outcomes. With regards to participation, most articles supported community's in implementing interventions (95%, n = 247/260), in contrast to involving communities in identifying and defining problems (18%, n = 46/260). Many articles did not discuss who in communities participated, with just over a half of the articles disaggregating any information by sex. Articles were largely under theorized, and only five mentioned power or control. Majority of the articles (57/64) described community participation processes as being collaborative with fewer describing either community mobilization or community empowerment. Intrinsic individual motivations, community-level trust, strong external linkages, and supportive institutional processes facilitated community participation, while lack of training, interest and information, along with weak financial sustainability were challenges. Supportive contextual factors included decentralization reforms and engagement with social movements.

CONCLUSION

Despite positive examples, community participation in health systems interventions was variable, with few being truly community directed. Future research should more thoroughly engage with community participation theory, recognize the power relations inherent in community participation, and be more realistic as to how much communities can participate and cognizant of who decides that.

Lysosomal membrane protein composition, acidic pH and sterol content are regulated via a light-dependent pathway in metazoan cells

In metazoans, lysosomes are characterized by a unique tubular morphology, acidic pH, and specific membrane protein (LAMP) and lipid (cholesterol) composition as well as a soluble protein (hydrolases) composition. Here we show that perturbation to the eye-color gene, light, results in impaired lysosomal acidification, sterol accumulation, altered endosomal morphology as well as compromised lysosomal degradation. We find that Drosophila homologue of Vps41, Light, regulates the fusion of a specific subset of biosynthetic carriers containing characteristic endolysosomal membrane proteins, LAMP1, V0-ATPase and the cholesterol transport protein, NPC1, with the endolysosomal system, and is then required for the morphological progression of the multivesicular endosome. Inhibition of Light results in accumulation of biosynthetic transport intermediates that contain these membrane cargoes, whereas under similar conditions, endosomal delivery of soluble hydrolases, previously shown to be mediated by Dor, the Drosophila homologue of Vps18, is not affected. Unlike Dor, Light is recruited to endosomes in a PI3P-sensitive fashion wherein it facilitates fusion of these biosynthetic cargoes with the endosomes. Depletion of the mammalian counterpart of Light, hVps41, in a human cell line also inhibits delivery of hLAMP to endosomes, suggesting an evolutionarily conserved pathway in metazoa.

Where there is no anesthetist--increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors

OBJECTIVE

The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs' experience of the program, and identified factors leading to post-training performance.

METHODS

The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n=14). Data on facility preparedness and monthly case load were also collected.

RESULTS

Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.

CONCLUSION

Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program.

Provision of anaesthesia services for emergency obstetric care through task shifting in South Asia

Anaesthesia is required for certain procedures in emergency obstetric care, such as caesarean section and the repair of ruptured uterus. Task shifting for provision of anaesthesia has been implemented in public sector rural hospitals of South Asia in recent years because of significant shortages of anaesthetists, but there has been limited research on this issue. This paper reviews the literature on this topic and documents existing programmes for task shifting anaesthesia services to mid-level providers in South Asia to increase access to emergency obstetric care and reduce maternal mortality. We found that task shifting of anaesthesia services has been effective in expanding coverage and access to care in South Asia, but most programmes have not been implemented systematically as part of an overall human resources strategy. A comprehensive approach, to maximise the benefits of these programmes, calls for countries to appoint a director at national or state level who is responsible for the availability of anaesthesia services in rural areas; legal protections, licensing by a competent authority and registration to perform anaesthesia services, including prescription of anaesthesia drugs; supportive managerial arrangements, competency-based training, monitoring and evaluation; performance rewards, career structure and job clarity; adequate equipment and supplies; support from specialist anaesthetists and quality assurance for safety.

Bisexual desire and familism: Latino/a bisexual young men and women in New York City

Families are of critical importance for Latino communities in the USA. Familism - or the cultural value that weighs on interdependence between nuclear and extended family members for support, emotional connectedness, familial honour, loyalty and solidarity - has been demonstrated to reduce sexual health risks among heterosexual youth, yet this relationship has not been examined among Latino bisexual teenagers. In this study, we examined how familism shapes sexual-decision making regarding behaviour and expressions of bisexuality among Latino youth. To accomplish this, we conducted 25 in-depth interviews and ethnographic observations among bisexual male and female youth (15-19 years of age) for nine months in New York City. We carried out a recurrent theme analysis together with the selection of case studies to illustrate key themes regarding familism and Latino teenage bisexuality. Findings suggest that bisexual Latino youth valued closeness to their families by maintaining family ties and seeking their emotional and material support. The negative consequence for those who wanted to keep their bisexuality private is the constant surveillance of the family network. Familism is a complex construct that has a strong potential for providing insights into sexual health practices of bisexual Latino youth.