State laws addressing teen dating violence in US high schools: A difference-in-differences study

OBJECTIVE

Teen dating violence (TDV) is prevalent with lifelong adverse consequences, and strategies to reduce its burden are needed. Many U.S. states have enacted laws to address TDV in schools, but few studies have examined their effectiveness. This study aimed to assess whether state TDV laws were associated with changes in physical TDV victimization among high school students.

METHODS

We used repeated cross-sectional data of high school students from the Youth Risk Behavior Survey across 41 states from 1999 to 2019. Using a difference-in-differences approach with an event study design, we compared changes in past-year physical TDV in states that enacted TDV laws (n = 21) compared to states with no required laws (n = 20). Analyses accounted for clustering at the state-level and state and year-fixed effects. We conducted sensitivity analyses to assess the robustness of our findings.

RESULTS

In our sample of 1,240,211 students, the prevalence of past-year physical TDV was 9.2% across all state-years. In 1999, the prevalence of TDV at the state-level ranged from 7.5 to 13.0%; in 2019, the prevalence ranged from 3.7 to 10.5%. There was no significant association between TDV laws and past-year physical TDV. Six or more waves after enactment, we observed a non-significant 1.7% percentage point reduction in TDV in states with TDV laws (95% CI: -3.6 to 0.3 percentage points; p = 0.10).

CONCLUSIONS

We found no significant association between enactment of TDV laws and physical TDV among high school students. Further research is needed to understand how TDV laws are implemented and components of TDV laws that may influence effectiveness.

How integration of refugees into national health systems became a global priority: a qualitative policy analysis

BACKGROUND

Despite a long history of political discourse around refugee integration, it wasn't until 2016 that this issue emerged as a global political priority. Limited research has examined the evolution of policies of global actors around health service provision to refugees and how refugee integration into health systems came onto the global agenda. This study seeks to fill this gap.

METHODS

Drawing on a document review of 20 peer-reviewed articles, 46 global policies and reports, and 18 semi-structured interviews with actors representing various bilateral, multilateral and non-governmental organizations involved with refugee health policy and funding, we analyze factors that have shaped the global policy priority of integration. We use the Shiffman and Smith Policy Framework on determinants of political priority to organize our findings.

RESULTS

Several important factors generated global priority for refugee integration into national health systems. Employing the above-mentioned framework, actor power increased due to network expansion through collaborations between humanitarian and development actors. Ideas took hold through the framing of integration as a human rights and responsibility sharing. While political context was influenced through several global movements, it was ultimately the influx of Syrian refugees into Europe and the increasing securitization of the refugee crisis that led to key policies, and critically, global funding to support integration within refugee hosting nations. Finally, issue characteristics, namely the magnitude of the global refugee crisis, its protractedness and the increasing urbanicity of refugee inflows, led integration to emerge as a manageable solution.

CONCLUSION

The past decade has seen a substantial reframing of refugee integration, along with increased financing sources and increased collaboration, explains this shift towards their integration into health systems. However, despite the emergence of integration as a global political priority, the extent to which efforts around integration have translated into action at the national level remains uncertain.

Prospective policy analysis-a critical interpretive synthesis review

Most policy analysis methods and approaches are applied retrospectively. As a result, there have been calls for more documentation of the political-economy factors central to health care reforms in real-time. We sought to highlight the methods and previous applications of prospective policy analysis (PPA) in the literature to document purposeful use of PPA and reflect on opportunities and drawbacks. We used a critical interpretive synthesis (CIS) approach as our initial scoping revealed that PPA is inconsistently defined in the literature. While we found several examples of PPA, all were researcher-led, most were published recently and few described mechanisms for engagement in the policy process. In addition, methods used were often summarily described and reported on relatively short prospective time horizons. Most of the studies stemmed from high-income countries and, across our sample, did not always clearly outline the rationale for a PPA and how this analysis was conceptualized. That only about one-fifth of the articles explicitly defined PPA underscores the fact that researchers and practitioners conducting PPA should better document their intent and reflect on key elements essential for PPA. Despite a wide recognition that policy processes are dynamic and ideally require multifaceted and longitudinal examination, the PPA approach is not currently frequently documented in the literature. However, the few articles reported in this paper might overestimate gaps in PPA applications. More likely, researchers are embedded in policy processes prospectively but do not necessarily write their articles from that perspective, and analyses led by non-academics might not make their way into the published literature. Future research should feature examples of testing and refining the proposed framework, as well as designing and reporting on PPA. Even when policy-maker engagement might not be feasible, real-time policy monitoring might have value in and of itself.

Punitive legal responses to prenatal drug use in the United States: A survey of state policies and systematic review of their public health impacts

BACKGROUND

Punitive legal responses to prenatal drug use may be associated with unintended adverse health consequences. However, in a rapidly shifting policy climate, current information has not been summarized. We conducted a survey of U.S. state policies that utilize criminal or civil legal system penalties to address prenatal drug use. We then systematically identified empirical studies evaluating these policies and summarized their potential public health impacts.

METHODS

Using existing databases and original statutory research, we surveyed current U.S. state-level prenatal drug use policies authorizing explicit criminalization, involuntary commitment, civil child abuse substantiation, and parental rights termination. Next, we systematically identified quantitative associations between these policies and health outcomes, restricting to U.S.-based peer-reviewed research, published January 2000-December 2022. Results described study characteristics and synthesized the evidence on health-related harms and benefits associated with punitive policies. Validity threats were described narratively.

RESULTS

By 2022, two states had adopted policies explicitly authorizing criminal prosecution, and five states allowed pregnancy-specific and drug use-related involuntary civil commitment. Prenatal drug use was grounds for substantiating civil child abuse and terminating parental rights in 22 and five states, respectively. Of the 16 review-identified articles, most evaluated associations between punitive policies generally (k = 12), or civil child abuse policies specifically (k = 2), and multiple outcomes, including drug treatment utilization (k = 6), maltreatment reporting and foster care entry (k = 5), neonatal drug withdrawal syndrome (NDWS, k = 4) and other pregnancy and birth-related outcomes (k = 3). Most included studies reported null associations or suggested increases in adverse outcome following punitive policy adoption.

CONCLUSIONS

Nearly half of U.S. states have adopted policies that respond to prenatal drug use with legal system penalties. While additional research is needed to clarify whether such approaches engender overt health harms, current evidence indicates that punitive policies are not associated with public health benefits, and therefore constitute ineffective policy.

School bullying prevention and intervention strategies in the United Arab Emirates: a scoping review

INTRODUCTION

Schools in the United Arab Emirates (UAE) witnessed an increase of 7% in bullying prevalence since 2005. This review aimed to map antibullying interventions in the UAE.

METHODS

A systematic search was performed in five electronic databases (EMBASE, PubMed, PsycINFO, Scopus and Eric) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review. Studies addressing antibullying interventions and grey literature in the UAE from 2010 to 2021 were included. Interventions were mapped using distribution across key sectors, public health practice levels, and organisation types.

RESULTS

Of the 2122 identified papers, only 2 were included. Both articles were published in 2019 and used qualitative methods. From the search of governmental and non-governmental websites, 22 multilevel interventions were included and presented on the three levels of public health practice across the different sectors and target stakeholders. Eight interventions were at the federal level, and six were by private stakeholders. The government funded 59% of all interventions. Four interventions addressed cyberbullying, and three used multisectoral collaboration.

CONCLUSIONS

Although the UAE is building capacity for bullying prevention, we found limited knowledge of antibullying prevention efforts. Further studies are needed to assess current interventions, strategies and policies.

Comparison of the number of pedestrian and cyclist injuries captured in police data compared with health service utilisation data in Toronto, Canada 2016-2021

INTRODUCTION

Pedestrian and cyclist injuries represent a preventable burden to Canadians. Police-reported collision data include information on where such collisions occur but under-report the number of collisions. The primary objective of this study was to compare the number of police-reported collisions with emergency department (ED) visits and hospitalisations in Toronto, Canada.

METHODS

Police-reported collisions were provided by Toronto Police Services (TPS). Data included the location of the collision, approximate victim age and whether the pedestrian or cyclist was killed or seriously injured. Health services data included ED visits in the National Ambulatory Care Reporting System and hospitalisations from the Discharge Abstract Database using ICD-10 codes for pedestrian and cycling injuries. Data were compared from 2016 to 2021.

RESULTS

Injuries reported in the health service data were higher than those reported in the TPS for cyclists and pedestrians. The discrepancy was the largest for cyclists treated in the ED, with TPS capturing 7.9% of all cycling injuries. Cyclist injuries not involving a motor vehicle have increased since the start of the pandemic (from 3629 in 2019 to 5459 in 2020 for ED visits and from 251 in 2019 to 430 for hospital admissions).

IMPLICATIONS

While police-reported data are important, it under-reports the burden. There have been increases in cyclist collisions not involving motor vehicles and decreases in pedestrian injuries since the start of the pandemic. The results suggest that using police data alone when planning for road safety is inadequate, and that linkage with other health service data is essential.

Assessing Growth of BACB Certificants (1999-2019)

Geographic distribution patterns of board certified behavior analysts may be useful in analyzing the growth of the field. First, we present an international snapshot of Behavior Analyst Certification Board (BACB) certificants, then analyze relative growth rates between countries from 1999 to 2019. This is followed by an in depth review of certificant distribution patterns in the United States and Canada, as well as the ratios of experienced behavior analysts to new certificants. These data highlight regions with a potential deficit of qualified supervisors. There are factors that influence different dispersal patterns, and without drilling deeper into the data we may be unable to effectively identify or influence them in order meet the specific needs of a geographic region.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-023-00370-5.

State Level Policies on First Responder Mental Health in the U.S.: A Scoping Review

A growing body of evidence demonstrates potential adverse mental health outcomes associated with exposure to occupational trauma among first responders. In response, policymakers nationwide are eager to work on these issues as evidenced by the number of states covering or considering laws for mental health conditions for first responders. Yet, little information exists to facilitate understanding of the impact of mental health-related policies in the United States on this important population. This study aims to identify and synthesize relevant state-level policies and related research on first responder mental health in the United States. Using a scoping review framework, authors searched the empirical and policy literature. State level policies were identified and grouped into two categories: (1) Workers' Compensation-related policies and (2) non-Workers' Compensation (WC) related policies. While benefits levels and other specifics vary greatly by state, 28 states cover certain first responder mental health claims under WC statutes. In addition, at the time of this study, 28 states have policies governing first responder mental health outside of WC. Policies include requiring mental health assessments, provisions for counseling and critical incident management, requiring education and training, providing funding to localities for program development, bolstering peer support initiatives and confidentiality measures, and establishing statewide offices of responder wellness, among others. Authors found a dearth of outcomes research on the impact of state level policies on first responder mental health. Consequently, more research is needed to learn about the direct impact of legislation and establish best practice guidelines for implementing state policy on first responder mental health. By conducting systematic evaluations, researchers can lay the foundation for an evidence-based approach to develop more integrated systems that effectively deliver and finance mental health care for first responders who experience work-related trauma. Such evaluations are crucial for building an understanding of the impact of policies and facilitating improvements in the support provided to first responders in managing mental health challenges arising from their work.

Policy implementation deviation of government purchase of old age care services in Jiangsu, China: based on empirical and policy analysis

BACKGROUND

Government purchase of social forces to participate in old age care services can release the burden of social care. Current research on performance evaluation in this field mainly focussed on the establishment of appropriate evaluation indices. However, discussion on the policy implementation deviation is scarce. This study aimed to evaluate the performance of China's local government purchase of old age care services, analyse the characteristics of related policies and explore their deviation.

METHODS

The persons who participated in the Training of the Trainer (ToT) organized by the Red Cross Society were enrolled. The policy documents were obtained from the official websites. The K-means cluster was used to determine the project performance grades. We compared the project performance grades between service objects and undertakers with different characteristics utilizing the non-parametric test. Based on the framework of 'Collaborative Participation - Project Performance Objective', we analysed the content of relevant policy aiding by NVivo 12.

RESULTS

Data of project performance were collected from 306 participants. The standardized mean score of the efficiency dimension was the lowest (0.70 ± 0.24). The projects were divided into four grades: poor (17.0%), average (27.5%), good (12.4%) and excellent (43.1%). There were statistically significant differences in project performance grades only between advanced ageing groups (Z = 2.429, P = 0.015). As well, the policy also mentioned that the services focus should be tilted towards the oldest old. The purchasers mainly involved the Ministry of Civil Affairs and Health management departments in the policy. Respite services were less mentioned in the responsibilities of the undertakers. The requirement for efficiency and effectiveness was mentioned in less than half of the policy documents.

CONCLUSION

Policy attention is needed for the responsibilities and functions of the intermediate purchasing force, as well as more precise directions and responsibilities of undertakers. The purchasers and undertakers should improve management abilities and capacity of old age care services and focus on associated factors to achieve the best marginal benefit. In addition, the embedded performance evaluation needs to be updated periodically to bridge the deviation between policy implementation and policy formulation.

Impact of direct payments and non-financial support on smallholder income from environmentally friendly agriculture in Tohoku region, Japan

In the face of climate-related challenges in agriculture, Japan's 'Direct Payment for Environmentally Friendly Farming' policy stands as a proactive effort to incentivize sustainable practices among smallholder farmers. This study evaluates the policy's impact on smallholder farmers' net farm income within the Tohoku Region, employing a propensity score matching (PSM) methodology to analyze survey data encompassing household-specific attributes and engagement with the policy. Our results indicate that participation in the direct payment scheme enhances farmer income, averting an estimated reduction of 125 thousand JPY per annum. While direct payments demonstrated a positive effect on smallholder income, our findings surprisingly revealed that skill training, a key non-financial support, had a negligible impact on household earnings. The findings highlight the policy's efficacy in promoting practices that decrease reliance on chemical inputs and increase organic farming, thereby contributing to carbon emissions mitigation. Notably, our analysis suggests that subsidies directed towards integrating renewable energy on farms may have a less immediate financial impact compared to other forms of support. This research underscores the complex interplay between agricultural subsidies, environmental sustainability, and farmer income, revealing that direct financial incentives are pivotal in fostering climate-conscious agricultural practices among smallholders.

Recreational cannabis legalization and pediatric exposures in Massachusetts, United States

INTRODUCTION

In Massachusetts, US, medical cannabis legalisation was associated with increased paediatric cannabis exposure cases, including emergency department (ED) visits and hospitalizations. The impact of recreational cannabis legalisation (RCL) on paediatric exposures in Massachusetts has yet to be studied.

METHODS

To compare the incidences before and after RCL in Massachusetts, US, we queried the data on paediatric cannabis exposure cases in 2016-2021 from the Centre for Healthcare and Analysis and Injury Surveillance Programme at the Massachusetts Department of Public Health. The pre-and post-legalisation phases comprised the periods between 2016-2018 and 2019-2021, respectively. Cannabis-related exposure cases included ED visits and hospitalizations among children and young adolescents of 0-19 years old.

RESULTS

During the 6-year period (2016-2021), 2357 ED visits and 538 hospitalizations related to cannabis exposure among children and teenagers (0-19 years) were reported in Massachusetts. The incidence of ED visits for all age groups increased from 18.5 per 100 000 population before RCL to 31.0 per 100 000 population (incidence rate ratio (IRR), 1.6; 95% CI, 1.5 to 1.8). Children in the age groups of 0-5 and 6-12 years experienced the highest increase in cannabis-related ED visits. Additionally, the incidence of hospitalisation due to cannabis intoxication substantially increased following RCL (IRR, 2.2; 95% CI, 1.8 to 2.7), a 126% increase.

CONCLUSIONS

Cannabis-related ED visits and hospitalizations among children and teenagers increased after recreational cannabis became legal in Massachusetts, US. Further efforts are warranted to prevent the unintentional impact of RCL, especially considering substantial increases in cannabis exposure cases among young children.

Advanced child tax credit payments and national child abuse hotline contacts, 2019-2022

BACKGROUND

Children in households experiencing poverty are disproportionately exposed to maltreatment. Income support policies have been associated with reductions in child abuse and neglect. The advance child tax credit (CTC) payments may reduce child maltreatment by improving the economic security of some families. No national studies have examined the association between advance CTC payments and child abuse and neglect. This study examines the association between the advance CTC payments and child abuse and neglect-related contacts to the Childhelp National Child Abuse Hotline.

METHODS

A time series study of contacts to the Childhelp National Child Abuse Hotline between January 2019 and December 2022 was used to examine the association between the payments and hotline contacts. An interrupted time series (ITS) exploiting the variation in the advance CTC payments was estimated using fixed effects.

RESULTS

The CTC advance payments were associated with an immediate 13.8% (95% CI -17.5% to -10.0%) decrease in contacts to the hotline in the ITS model. Following the expiration of the advance CTC payments, there was a significant and gradual 0.1% (95% CI +0.0% to +0.2%) daily increase in contacts. Sensitivity analyses found significant reductions in contacts following each payment, however, the reductions were associated with the last three of the six total payments.

CONCLUSION

These findings suggest the advance CTC payments may reduce child abuse and neglect-related hotline contacts and continue to build the evidence base for associations between income-support policies and reductions in child abuse and neglect.

Progress and challenges in implementing non-communicable disease policies in Sudan

Non-communicable diseases (NCD) pose a substantial global public health challenge, representing the leading cause of morbidity and mortality worldwide. This study investigates the progress and challenges in implementing NCD policies in Sudan. Document analysis following the ready your materials, extract data, analyse data and distil your findings (READ) approach, was utilized to review published literature and reports. Data from the NCD Progress Monitor showed that the percentage of NCD-related mortality had increased from 32% in 2015 to 54% in 2022. Sudan's progress in implementing NCD policies has been slow and challenging; eight of the 19 NCD target indicators had never been fully achieved, and only five targets were fully achieved in the year 2022. However, these figures may be underestimated due to the lack of robust NCD information systems. Like many countries, Sudan faces challenges in implementing NCD policies, particularly those targeting healthy diets, medications and data management systems. This may be linked to the prolonged history of conflict, shortage of trained health personnel, limited resources and lack of robust NCD surveillance systems in the country. The ongoing devastating war and destruction of the healthcare system infrastructure in Sudan further intensified these challenges. Prioritizing NCD policies and programmes during the anticipated post-conflict health system reforms is crucial for enhancing NCD prevention and outcomes in Sudan.

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.

Government, governance, and place-based approaches: lessons from and for public policy

BACKGROUND

Place-based approaches are increasingly applied to address the determinants of health, many of which are complex problems, to ultimately improve population health outcomes. Through public policy, government actions can affect the effectiveness of place-based approaches by influencing the conceptualisation, development, implementation, governance, and/or evaluation of place-based approaches. Despite the important role of public policy, there has been limited examination of public policy related to place-based approaches. We add to the limited knowledge base by analysing Australian national public policy, to explore: (1) the definitions, conceptualisations, and characteristics of place-based approaches in public policy; (2) the government's perception and communication of its role in place-based approaches; and (3) the extent to which government policy reflects the necessary conditions for successful place-based governance developed by Marsh and colleagues, namely localised context, embedded learning, and reciprocal accountability.

METHODS

This research was underpinned by the Theory of Systems Change and methodologically informed by the READ approach to document analysis. Ritchie and Spencer's framework method was utilised to analyse the data.

RESULTS

We identified and reviewed 67 policy documents. In terms of conceptualisation, common characteristics of place-based approaches related to collaboration, including community in decision-making, responsiveness to community needs, and suitability of place-based approaches to address complex problems and socio-economic determinants of health. Three roles of government were identified: funder, partner, and creator of a supportive policy environment. From the three criteria for successful place-based governance, localised context was the most dominant across the documents and reciprocal accountability the least.

CONCLUSIONS

Based on our findings, we drew key implications for public policy and research. There was a disproportionate emphasis on the bottom-up approach across the documents, which presents the risk of diminishing government interest in place-based approaches, potentially burdening communities experiencing disadvantage beyond their capacities. Governments engaged in place-based approaches should work towards a more balanced hybrid approach to place-based approaches that maintain the central functions of government while allowing for successful place-based governance. This could be achieved by promoting consistency in conceptualisations of 'place-based', employing an active role in trust building, advancing the creation of a supportive policy environment, and embedding 'learning' across place-based approaches.

More than meets the eye: a critical discourse analysis of a Swedish health system reform

BACKGROUND

In line with international trends acknowledging the importance of Primary Health Care (PHC) for improving population health and reducing health inequalities, the Swedish health system is undergoing a restructuring towards the coordinated development of a modern, equitable, accessible, and effective system, with PHC principles and functions at its core. Since discursive analyses of documents underpinning PHC reforms are scarce in Sweden and beyond, the aim of this study was to explore how the reorientation towards good quality and local health care has been represented in official government reports.

METHODS

Based on a policy-as-discourse analysis, four Swedish Government Official Reports underpinning the good quality and local health care reform were interrogated following four questions of Bacchi's "What's the Problem Represented to be?" (WPR) approach. By applying the first WPR question, concrete proposals guiding the reorientation were identified, analyzed and thematized into candidate problem representations. These problem representations were then analyzed in relation to previous empirical and conceptual research considering WPR questions two and three, which resulted in the development of three problem representations. Potential silences that the problem representations might produce were then identified by applying WPR question four.

RESULTS

The three problem representations connected the Swedish health system "problem" to a narrow mission, a siloed structure, and a front-line service disconnected, especially from the needs and preferences of individual patients. By representing the problem along these lines, the analysis also illustrated how the policy reorientation towards good quality and local health care risk silencing important PHC aspects such as health promotion, equitable access, and human resources.

CONCLUSION

The results from this study indicate that as discursively framed within concrete proposals, government official reports in Sweden represent the health system problem in particular ways and with these problem representations overlooking several aspects that are central to a health system characterized by PHC principles and functions. In the continued reorientation towards good quality and local health care, these silences might need to be acknowledged.

A critical analysis of national plans for climate adaptation for health in South America

Climate adaptation measures are critical for protecting human health. National Adaptation Plans (NAPs), Nationally Determined Contributions (NDCs), and National Communications (NCs) play a crucial role in helping countries identify, analyze, and address their vulnerabilities to climate change impacts, while also assessing available resources and capacities. This study aimed to assess the comprehensiveness of South American countries' NAPs, NDCs, and NCs in addressing the effects of climate change on health. A total of 38 NAPs, NDCs, and NCs of 12 South American countries were analysed. Ad hoc scores were developed to assess baseline information, adaptation proposals, identification of involved institutions, funding needs and allocation, measurable progress indicators, and coherence. Overall, all South American countries have NDCs and NCs, and seven have NAPs. In most countries, the intersectoral health analysis revealed a lack of linkage to health issues related to that sector. Additionally, most planning documents lack detailed information to guide policymakers in taking practical actions; areas with low scores include allocation of funds, involvement of health-related institutions, and measurable indicators. While South American countries acknowledge the health impacts of climate change in their plans, enhancing public health protection requires maximizing climate policy benefits and including health-related issues across all relevant sectors.

Funding

This study was not funded. However, three co-authors received funding for some of their time: AV and KC were supported by the Wellcome Trust (209734/Z/17/Z); RCN was funded by K01AI139284 (NIH-NIAID). Funding for the publication was provided by Universidad Peruana Cayetano Heredia.

Nutrition policy reforms to address the double burden of malnutrition in Zambia: a prospective policy analysis

The evolution of nutrition patterns in Zambia has resulted in the coexistence of undernutrition and overnutrition in the same population, the double burden of malnutrition. While Zambia has strong policies addressing undernutrition and stunting, these do not adequately address food environment drivers of the double burden of malnutrition and the adolescent age group and hence the need for nutrition policy reforms. We conducted a theory-based qualitative prospective policy analysis involving in-depth interviews with nutrition policy stakeholders and policy document review to examine the feasibility of introducing nutrition policy options that address the double burden of malnutrition among adolescents to identify barriers and facilitators to such policy reforms. Using the multiple streams theory, we categorized the barriers and facilitators to prospective policy reforms into those related to the problem, policy solutions and politics stream. The use of a life-course approach in nutrition programming could facilitate policy reforms, as adolescence is one of the critical invention points in a person's lifecycle. Another key facilitator of policy reform was the availability of institutional infrastructure that could be leveraged to deliver adolescent-focused policies. However, the lack of evidence on the burden and long-term impacts of adolescent nutrition problems, the food industry's strong influence over governments' policy agenda setting and the lack of public awareness to demand better nutrition were perceived as critical barriers to policy reforms. In addition, the use of the individual responsibility framing for nutrition problems was dominant among stakeholders. As a result, stakeholders did not perceive legislative nutrition policy options that effectively address food environment drivers of the double burden of malnutrition to be feasible for the Zambian context. Policy entrepreneurs are required to broker policy reforms that will get legislative policy options on the government's agenda as they can help raise public support and re-engineer the framing of nutrition problems and their solutions in Zambia.

Unlocking policy synergies, challenges and contradictions influencing implementation of the Comprehensive Sexuality Education Framework in Zambia: a policy analysis

BACKGROUND

Comprehensive sexuality education (CSE) has recently become salient, but adolescent sexual reproductive health and rights (ASRHR) challenges are still a global health problem. Studying policies which have implications for CSE implementation is a crucial but neglected issue, especially in low and middle-income countries (LMICs) like Zambia. We analyzed policy synergies, challenges and contradictions influencing implementation of CSE framework in Zambia.

METHODS

We conducted a document review and qualitative interviews with key stakeholders from Non-Governmental Organizations, as well as health and education ministries at the National and all (10) provincial headquarters. Our methods allowed us to capture valuable insights into the synergies, challenges and contradictions that exist in promoting CSE framework in Zambia.

RESULTS

The study highlighted the synergies between policies that create opportunities for implementation of CSE through the policy window for adoption of sexual reproductive health and rights (SRHR) that opened around the 1990s in Zambia, promotion of inclusive development via education, adoption of an integrated approach in dealing with SRHR problems, and criminalization of gender-based violence (GBV). This analysis also identified the policy challenges and contradictions including restricted delivery of education on contraception in schools; defining childhood: dual legal controversies and implications for children, grey zones on the minimum age to access SRHR services; inadequate disability inclusiveness in SRHR legal frameworks; policy silences/contentious topics: LGBTQI + rights, abortion, and grey zones on the minimum age to access SRHR services.

CONCLUSION

While many policies support the implementation of CSE in schools, the existence of policy silences and challenges are among the barriers affecting CSE implementation. Thus, policy reformulation is required to address policy silences and challenges to enhance effective promotion and integration of the CSE framework.

Evaluating the effects of minimum unit pricing in Scotland on the prevalence of harmful drinking: a controlled interrupted time series analysis

OBJECTIVES

In May 2018, the Scottish Government introduced a minimum unit price (MUP) for alcohol of £0.50 (1 UK unit = 8 g ethanol) to reduce alcohol consumption, particularly among people drinking at harmful levels. This study aimed to evaluate MUP's impact on the prevalence of harmful drinking among adults in Scotland.

STUDY DESIGN

This was a controlled interrupted monthly time series analysis of repeat cross-sectional data collected via 1-week drinking diaries from adult drinkers in Scotland (N = 38,674) and Northern England (N = 71,687) between January 2009 and February 2020.

METHODS

The primary outcome was the proportion of drinkers consuming at harmful levels (>50 [men] or >35 [women] units in diary week). The secondary outcomes included the proportion of drinkers consuming at hazardous (≥14-50 [men] or ≥14-35 [women] units) and moderate (<14 units) levels and measures of beverage preferences and drinking patterns. Analyses also examined the prevalence of harmful drinking in key subgroups.

RESULTS

There was no significant change in the proportion of drinkers consuming at harmful levels (β = +0.6 percentage points; 95% confidence interval [CI] = -1.1, +2.3) or moderate levels (β = +1.4 percentage points; 95% confidence interval = -1.1, +3.8) after the introduction of MUP. The proportion consuming at hazardous levels fell significantly by 3.5 percentage points (95% CI = -5.4, -1.7). There were no significant changes in other secondary outcomes or in the subgroup analyses after correction for multiple testing.

CONCLUSIONS

Introducing MUP in Scotland was not associated with reductions in the proportion of drinkers consuming at harmful levels but did reduce the prevalence of hazardous drinking. This adds to previous evidence that MUP reduced overall alcohol consumption in Scotland and consumption among those drinking above moderate levels.

Policy analysis of the protection of Iranian households against catastrophic health expenditures: a qualitative analysis

BACKGROUND

Despite the adoption of various policies and strategies in recent decades, the Iranian health system has not succeeded in protecting households against catastrophic health expenditures (CHE) and impoverishment. Accordingly, this qualitative study aimed to critically analyze current policies for reducing CHE.

METHODS

This qualitative study was conducted as a retrospective policy analysis based on a document review and semi-structured interviews with key informants between July to October 2022. Two theoretical frameworks were used, including the Analysis of Determinants of Policy Impact (ADEPT) model and Walt and Gilson's "Policy Triangle framework." The country's related documents were searched through databases. In total, 35 participants were interviewed. Interviews and documents were analyzed using directed content analysis in MAXQDA v12 software. Interobserver reliability, peer check, and member check were done to confirm the trustworthiness of the data.

RESULTS

Twelve main themes and 42 sub-themes emerged from the data. The findings revealed that policy accessibility, policy background, and a clear statement of goals influenced the policy process. However, resources, monitoring and evaluation, opportunities, and obligations negatively affected the implementation process. In addition, a policy analysis based on the policy triangle framework demonstrated that the main factors affecting the policy on reducing CHE in Iran were "conflicts of interest," "contextual factors," "monitoring and evaluation," and "intersectoral relationship" factors.

CONCLUSION

The present study reflected the multifaceted nature of the barriers to reducing CHE in Iran. The implementation of the policy on reducing CHE requires the political will to improve intersectoral collaboration, strengthen the stewardship role of the Ministry of Health, design monitoring and evaluation mechanisms, and prevent personal and organizational conflicts of interest.

Indonesia free from pasung: a policy analysis

BACKGROUND

Many people with mental illnesses remain isolated, chained, and inside cages, called Pasung in Indonesia. Despite numerous policies introduced to eradicate Pasung, Indonesia has made slow progress in decreasing this practice. This policy analysis examined existing policies, plans and initiatives in Indonesia targeted at eradicating Pasung. Policy gaps and contextual constraints are identified in order to propose stronger policy solutions.

METHODS

Eighteen policy documents were examined, including government news releases and organisational archives. A content analysis was undertaken of national-level policies that address Pasung within the context of the health system, social system and human rights since the establishment of Indonesia. This was followed by a case study analysis of policy and program responses particularly in West Java Province.

FINDINGS

While policy to address Pasung exists at a national level, implementation at national and local levels is complicated. Pasung policy has generated a sense of awareness but the different directions and ambiguous messaging across all stakeholders, including policy actors, has created a lack of clarity about institutions' roles and responsibilities in the implementation process, as well as accountability for outcomes. This situation is exacerbated by an incomplete decentralisation of healthcare policymaking and service delivery, particularly at the primary level. It is possible that policymakers have overlooked international obligations and lessons learned from successful policymaking in comparable regional countries, resulting in disparities in target-setting, implementation mechanisms, and evaluation.

CONCLUSION

While the public has become more informed of the need to eradicate Pasung, ongoing communication with the various clusters of policy actors on the aforementioned issues will be critical. Addressing the various segments of the policy actors and their challenges in response to policy will be critical as part of building the evidence base to establish a feasible and effective policy to combat Pasung in Indonesia.

Hospital admissions for paracetamol poisoning declined following codeine re-scheduling in Australia

BACKGROUND

Codeine was restricted to prescription only in Australia in 2018. This intervention aimed to reduce harms from codeine dependance and use, including toxicity from co-formulated paracetamol. We aimed to quantify the impact of this intervention on paracetamol poisoning hospital admissions in a national hospital admissions database.

METHODS

We analyzed the number of paracetamol overdoses resulting in hospital admissions from the Australian Institute of Health and Welfare National Hospital Morbidity Database, January 2011 to June 2020. We used interrupted time series analysis to quantify the effect of codeine re-scheduling on the monthly number of paracetamol poisoning-related hospital admissions in Australia. We compared paracetamol poisonings with no opioid combinations, and poisonings with probable paracetamol-codeine combinations.

RESULTS

There was an immediate and sustained decrease (level shift) in the number of paracetamol poisoning-related hospital admissions following codeine re-scheduling (RR=0.85; 95% CI 0.80-0.89). This reduction was due to the decrease in poisonings with likely paracetamol-codeine combinations (RR=0.62; 95% CI 0.57-0.67) while there was no change in other paracetamol poisonings (RR=0.91; 95% CI 0.96-1.01).

CONCLUSION

Codeine re-scheduling in Australia appears to have reduced paracetamol poisoning-related hospital admissions.

Development of an inexact simulation-evaluation model for the joint analysis of water pricing and groundwater allocation policies

A critical step in water management policy development is the analysis of its socio-economic and environmental implications. However, few methods could proactively and reliably predict and assess the impacts of policies while handling the inherent uncertainty. To fill such a gap, an inexact simulation-evaluation method was developed for analyzing the impacts of multiple water management policies under uncertainty. The interval positive mathematical programming (IPMP) method was proposed as the simulation tool by coupling interval programming with positive mathematical programming (PMP). The evaluation tool was developed by combining the interval TOPSIS method and the interval maximum deviation method. This simulation-evaluation method can directly communicate a policy's simulation outcomes into the evaluation process while addressing the uncertainties in both simulation and evaluation. The proposed method can also reproduce the actual situation with a calibration process, which enables accurate and smooth responses to policy changes. This approach was used for agricultural water management in arid north-west China. Seventy-five policy alternatives generated from three groundwater allocation limits and twenty-five differential water pricing levels were investigated. The impacts of these alternatives on farmer income, farmer employment, water consumption, planting areas, and fertilizer use were simulated using IPMP. Twenty-four non-inferior alternatives were selected and further evaluated with multi-dimensional criteria. The final results showed that, the water price for grain crops with traditional irrigation methods should rise by 60%, those for cash crops with drip irrigation should decrease by 60%, and the groundwater quota should be reduced by 20%. Compared with traditional models, IPMP can increase simulation accuracy by reproducing observed situations, enhance robustness by reflecting input uncertainty, and improve flexibility in decision-making by providing interval solutions. The inexact simulation-evaluation model can also be widely used to analyze other policies.

Analysis and evolution of health policies in Iran through policy triangle framework during the last thirty years: a systematic review of the historical period from 1994 to 2021

Background

Health policy analysis as a multi-disciplinary approach to public policy illustrates the need for interventions that highlight and address important policy issues, improve the policy formulation and implementation process and lead to better health outcomes. Various theories and frameworks have been contributed as the foundation for the analysis of policy in various studies. This study aimed to analyze health policies during the historical period of the almost last 30 years in Iran using policy triangle framework.

Method

To conduct the systematic review international databases (PubMed / Medline, Scopus, Web of Sciences, CINAHL, PsycINFO, Embase, the Cochran Library) and Iranian databases from January 1994 to January 2021 using relevant keywords. A thematic qualitative analysis approach was used for the synthesis and analysis of data. The Critical Appraisal Skills Programme for Qualitative Studies Checklist (CASP) was conducted.

Results

Out of 731 articles, 25 articles were selected and analyzed. Studies used health policy triangle framework to analyze policies in the Iranian health sector has been published since 2014. All the included studies were retrospective. The main focus of most of studies for the analysis was on the context and process of polices as the elements of the policy triangle.

Conclusion

The main focus of health policy analysis studies in Iran over the last thirty years was on the context and process of polices. Although range of actors within and outside the Iran government influence health policies but in many policy processes the power and the role of all actors or players involved in the policy are not recognized carefully. Also, Iran's health sector suffers from lack of a proper framework for evaluating various implemented policies.

Naloxone expansion is not associated with increases in adolescent heroin use and injection drug use: Evidence from 44 US states

BACKGROUND

Naloxone distribution is central to ongoing efforts to address the opioid overdose crisis. Some critics contend that naloxone expansion may inadvertently promote high-risk substance use behaviors among adolescents, but this question has not been directly investigated.

METHODS

We examined relationships between naloxone access laws and pharmacy naloxone distribution with lifetime heroin and injection drug use (IDU), 2007-2019. Models generating adjusted odds ratios (aOR) and 95% confidence intervals (CI) included year and state fixed effects, controlled for demographics and sources of variation in opioid environments (e.g., fentanyl penetration), as well as additional policies expected to impact substance use (e.g., prescription drug monitoring). Exploratory and sensitivity analyses further examined naloxone law provisions (e.g., third-party prescribing) and applied e-value testing to assess vulnerability to unmeasured confounding.

RESULTS

Adoption of any naloxone law was not associated with changes in adolescent lifetime heroin or IDU. For pharmacy dispensing, we observed a small decrease in heroin use (aOR: 0.95 [CI: 0.92, 0.99]) and a small increase in IDU (aOR: 1.07 [CI: 1.02, 1.11]). Exploratory analyses of law provisions suggested that third-party prescribing (aOR: 0.80, [CI: 0.66, 0.96]) and non-patient-specific dispensing models (aOR: 0.78, [CI: 0.61, 0.99]) were associated with decreased heroin use but not decreased IDU. Small e-values associated with the pharmacy dispensing and provision estimates indicate that unmeasured confounding may explain observed findings.

CONCLUSION

Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages.

How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study

BACKGROUND

Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000.

METHODS

Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020.

RESULTS

The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers.

CONCLUSION

Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.

The role of consumer choice in out-of-pocket spending on health

BACKGROUND

Analyses of out-of-pocket healthcare spending often suffer from an inability to distinguish necessary from optional spending in the data without making further assumptions. We propose a two-dimensional rating of the spending categories often available in household budget survey data where we consider the requirement to pay for necessary healthcare as one dimension and the incentive to pay extra for additional services, higher quality options or more convenience as a second dimension to assess the distortionary potential of higher spending for additional healthcare or higher quality options.

METHODS

We use three waves of a large German Household Budget Survey and decompose the Kakwani-index of total out-of-pocket healthcare spending into contributions of the eleven spending categories available in our data, across which user charge regulations vary considerably. We compute and decompose Kakwani-indexes for the different spending categories to compare the degrees of regressiveness across them.

RESULTS

The results suggest that categories with higher incentives for additional spending exhibit smaller contributions to the overall regressive effect of total out-of-pocket spending than categories where spending is presumably mostly on necessary and effective care.

CONCLUSIONS

Assessing the consumer choice potential of different spending categories is important because extra spending among the better-off may outweigh necessary spending in aggregate expenditure data, and may also hint at potential inequalities in the quality of provided healthcare.

Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?

BACKGROUND

Despite political promise to reduce out-of-pocket (OOP) expenditure on healthcare through the National Health Insurance Program (NHIP) of Nepal, its implementation is challenging with low enrolment and high drop-out rates. Program performance can often be linked with political economy considerations and interests of stakeholders. This study aimed to develop an in-depth understanding of organizational and systemic challenges in implementing NHIP.

METHODS

We conducted a structured narrative review of available literature on the NHIP in Nepal. We analysed data using a political economy analysis for health financing reform framework. The findings were explained under six broad categories: interest groups, bureaucracy, budgets, leadership, beneficiary and external actors. In addition, we triangulated and further presented the literature review findings using expert opinions (views expressed in public forums).

RESULTS

Nepal has formulated acts, rules, regulations, and policies to implement NHIP. Under this program, the Health Insurance Board (HIB) is the purchaser of health services, and health facilities under the Ministry of Health and Population (MoHP) are the providers. The NHIP has been rolled out in all 77 districts. Several challenges have hindered the performance of NHIP at the policy and implementation levels. Challenges under interest groups included inadequate or delayed reimbursement and drop-out of hospitals in implementing the programme. Bureaucracy-related challenges were hegemony of provider over the purchaser, and inadequate staff (delay in the approval of organogram of HIB). There was inadequate monitoring of premium collection, and claim reimbursement was higher than collected premium. Challenges under leadership included high political commitments but weak translation into action, consideration of health insurance as poor return on investment, and intention of leaders to privatize the NHIP. Beneficiaries experienced compromised quality of care or lack of services when needed, high drop-out rates and low interest in renewal of premiums. External actors provided technical assistance in policy design but limited support in implementation.

CONCLUSIONS

Despite enabling a policy environment, the NHIP faced many challenges in implementation. There is an urgent need for institutional arrangements (e.g. digitalization of claims and reimbursement, endorsement of organogram of HIB and recruitment of staff), increased coverage of financial protection and service (increased benefit package and introduction of cost-sharing/co-payment model), legislative reforms (e.g. legal provision for cost-sharing mechanism, integration of fragmented schemes, tripartite agreement to reimburse claims and accreditation of health facilities to ensure quality healthcare), and leveraging technical support from the external actors. High levels of commitment and accountability among political leaders and bureaucrats are required to strengthen financial sustainability and implementation.

Mental health outcome measures in the Australian context: what is the problem represented to be?

BACKGROUND

There is growing interest in the use of routine outcome measures (ROM) in mental health services worldwide. Australia has been at the forefront of introducing ROM in public mental health services, with the aim of improving services and consumer outcomes.

METHODS

An in-depth policy and document analysis was conducted using Carol Bacchi's 'What is the problem represented to be?' approach to critically analyse the use of ROM. This approach was used to identify and analyse the problem representations relating to the need for, and the choice of, outcome measures in Australian public mental health services, and the potential consequences of policy and practice. Data included in the analysis were seven policy documents, four reports on the introduction of outcome measures in Australia, the Australian Mental Health Outcomes and Classifications Network website, and the content of the outcome measures themselves.

RESULTS

Two dominant representations of the 'problem' were identified: 1) the 'problem' of mental health service quality and accountability, relating to the need for mental health outcome measures; and 2) the 'problem' of addressing deficits in biopsychosocial functioning of mental health consumers, which relates to the choice of outcome measures. Framing the 'problem' of mental health outcomes in these ways locates the problem within individual health providers, services, and consumers, ignoring the broader socioeconomic conditions underpinning mental health and effective service provision.

CONCLUSIONS

This critical analysis of the introduction and use of ROM in public mental health services in Australia highlights the need to consider the role of the social determinants of mental health, mental health service funding, and recovery-oriented care in ensuring services are meeting consumer needs and expectations. Broader governmental engagement is central to genuine change and opportunities.

Impact of a link worker social prescribing intervention on non-elective admitted patient care costs: A quasi-experimental study

Healthcare systems in many countries are enthusiastically adopting link worker social prescribing interventions that aim to tackle the social determinants of health by linking patients to voluntary and community sector activities and sources of support to address their social needs and improve condition management. Social prescribing interventions aim to improve health and reduce healthcare spending. However, despite the diversion of healthcare budgets to fund social prescribing, we still lack robust evidence for its effectiveness. In this study we evaluate whether participation in a social prescribing intervention reduced non-elective admitted patient care use and costs for 8283 patients aged between 40 and 74 years, with a diagnosis of type 2 diabetes and living in an area of high socioeconomic deprivation in north-east England. Patients were followed for a total of 6 years: 2 years pre-intervention and 4 years post intervention. Exploiting a natural experiment, we used a two-part difference-in-differences regression model to estimate costs conditional on healthcare use. We also estimated intervention effects across several intervention and control groups and sample subgroups. Participation in the intervention resulted in reductions of up to -£77.57 [95% CI: -152.30, -2.84] (for high engagement patients) per patient, per year, in non-elective care costs. Reductions were greater for patients with higher levels of engagement with the intervention. Sub-group analyses showed greater cost reductions for non-White patients, older patients, and patients without additional co-morbidities. Our findings suggest that engagement with a link worker social prescribing intervention may reduce non-elective healthcare spending, perhaps through enabling better condition management that results in fewer avoidable health crises.

Main actors in the new population policy with a growing trend in Iran: a stakeholder analysis

The total fertility rate in Iran has declined to below replacement level recently, and a new approach has been taken to tackle this issue. Thus, this study aimed to identify the involved stakeholders and their characteristics in the new population policy change in Iran. We employed a qualitative approach using the purposive sampling of key informants and the identification of relevant documents. The main stakeholders were divided into seven key groups: religious, political, governmental, professional, international sectors, media, and nongovernmental organizations. In addition, there was no centralized, clear, and comprehensive mechanism to guide the activities of stakeholders to coordinate and bring the total fertility rate to the replacement level in Iran. Despite the importance of the new population policy in Iran, in recent years, we still experience dispersion and inconsistency among various actors in this area. It is imperative to go through a consensus and coalition at macro-level authorities alongside evidenced-based population policymaking.

Policy Analysis on Power Seat Elevation Systems

In the early 2000s the Centers for Medicare and Medicaid Services determined that power seat elevation systems did not meet the definition of durable medical equipment, and therefore are non-covered items. Yet, power seat elevation systems are covered by other funding sources, and many power wheelchair users utilize these systems regularly when performing tasks such as transferring, reaching, and looking at objects in environments designed for ambulatory people. Adjusting for height when performing these tasks may reduce the onset of pain and comorbidities. To improve access to power seat elevation systems, a clinical team of 4 Clinician Task Force members investigated applicable literature, compiled evidence, and evaluated existing policies to explain the medical nature of power seat elevation systems as a part of a greater interprofessional effort. This manuscript aims to analyze Medicare's policy decision that power seat elevation systems are not primarily medical in nature using Bardach's 8-step framework. As a special communication, this will inform health care professionals of the medical nature of power seat elevation systems and the evidence-based conditions under which power wheelchair users may need power seat elevation systems, as well as empower clinicians to engage in policy directives to affect greater change.

Addressing challenges of an ageing population by rationally forecasting travel behaviours of the elderly: a case study in China

This research aims to investigate the difference of the travel behaviours of the elderly in different urban areas. On the basis of the results of cluster analysis, the nested logit (NL) model is adopted to investigate the travel decision of the elderly in central urban areas and non-central urban areas. Moreover, it is used to forecast the change of their travel behaviours by implementing the policies of age-friendly society. The results show that the elderly in central urban areas are inclined to decide travel modes in advanced of determining trip chains, while the trip chains are first determined in non-central urban areas. For the central urban areas, the policies mainly affect the choice of travel modes of the elderly, rather than the choice of trip chains. However, for the non-central urban area, the policies simultaneously influence the choice of travel mode and trip chains of the elderly. Based on the results of the forecast, some measures are proposed in this study to meet different travel requirements of the elderly in central urban areas and non-central urban areas.

Stakeholders analysis of COVID-19 management and control: a case of Iran

Background

The COVID-19 pandemic is a multi-faceted phenomenon with many political, economic and social consequences. Success in managing and controlling this pandemic depends on the coordinated efforts of many organizations and institutions. Therefore, this study aimed to identify and analyze the actors and stakeholders related to managing and controlling this pandemic in Iran.

Methods

This mix-method stakeholder analysis was conducted in 2021 nationwide as retrospectively. The purposive sampling method was applied when inviting eligible participants to participate in the study. Our study was conducted in two phases. In the qualitative phase, data were collected using a semi-structured interview. An interview guide was developed based on the WHO stakeholder analysis framework. In the quantitative phase, we used a questionnaire developed based on the study framework. Each question was scored on a 5-point Likert scale, with a score greater than 4 was considered as high, 3–4 was considered as moderate, and 1–3 was considered as low. Data were analyzed using framework analysis, WHO stakeholders’ analysis framework and MENDELOW matrix. MAXQDA qualitative data analysis software Version 11 and Policy Maker software (Version. 4) were used for data analysis.

Results

A total of 48 stakeholders were identified. Ministry of Health (MoH), National Headquarters for Coronavirus Control (NHCC) had the highest participation level, high supportive position, and knowledge of the subject. The Parliament of Iran (PoI), Islamic Revolutionary Guard Corps (IRGC), and Islamic Republic of Iran Broadcasting (IRIB) had the highest power/influence during the Covid-19 epidemic. Only two stakeholders (6.06%) had high participation, and 18.18% had moderate participation. All stakeholders except for the NHCC and the MoH lacked appropriate knowledge of the subject. Furthermore, only three stakeholders (9.09%) had high power/influence.

Conclusion

Given the multidimensional nature of Covid-19, most institutions and organizations were involved in managing this pandemic. Stakeholders with high power/authority and resources had a low/moderate participation level and a moderate supportive position. Moreover, organizations with a high supportive position and participation had low power/authority and resources to cope with COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14219-0.

Migrants in Swedish sexual and reproductive health and rights related policies: a critical discourse analysis

BACKGROUND

Previous research has shown that migrants in Sweden are disadvantaged in terms of sexual and reproductive health and rights (SRHR). SRHR policies might play a crucial role in shaping migrants' SRHR outcomes. The purpose of the study was to critically examine: a) how migrants were represented in the discourses embedded within Swedish SRHR-related policies, and b) how migrants' SRHR-related issues were framed and addressed within these discourses.

METHODS

Critical discourse analysis (CDA) was used to analyze a total of 54 policy documents. Following Jäger's approach to CDA, discourse strands and entanglements between different discourse strands were examined.

RESULTS

Our findings consisted of three discourse strands: 1) "Emphasizing vulnerability", 2) "Constructing otherness", and 3) "Prioritizing the structural level or the individual level?". Migrants' representation in Swedish SRHR-related policies is often associated with the concept of vulnerability, a concept that can hold negative connotations such as reinforcing social control, stigma, and disempowerment. Alongside the discourse of vulnerability, the discourse of otherness appears when framing migrants' SRHR in relation to what is defined as honor-related violence and oppression. Furthermore, migrant SRHR issues are occasionally conceptualized as structural issues, as suggested by the human rights-based approach embraced by Swedish SRHR-related policies. Relevant structural factors, namely migration laws and regulations, are omitted when addressing, for example, human trafficking and HIV/AIDS.

CONCLUSIONS

We conclude that the dominant discourses favor depictions of migrants as vulnerable and as the Other. Moreover, despite the prevailing human rights-based discourse, structural factors are not always considered when framing and addressing migrants' SRHR issues. This paper calls for a critical analysis of the concept of vulnerability in relation to migrants' SRHR. It also highlights the importance of avoiding othering and paying attention to the structural factors when addressing migrants' SRHR.

Strengthening implementation of diet-related non-communicable disease prevention strategies in Fiji: a qualitative policy landscape analysis

Background

Noncommunicable diseases (NCDs) are the leading cause of death globally, and the World Health Organization (WHO) has recommended a comprehensive policy package for their prevention and control. However, implementing robust, best-practice policies remains a global challenge. In Fiji, despite political commitment to reducing the health and economic costs of NCDs, prevalence of diabetes and cardiovascular disease remain the highest in the region. The objective of this study was to describe the political and policy context for preventing diet-related NCDs in Fiji and policy alignment with WHO recommendations and global targets. We used a case study methodology and conducted (1) semi-structured key informant interviews with stakeholders relevant to diet-related NCD policy in Fiji (n = 18), (2) documentary policy analysis using policy theoretical frameworks (n = 11), (3) documentary stakeholder analysis (n = 7), and (4) corporate political activity analysis of Fiji’s food and beverage industry (n = 12). Data were sourced through publicly available documents on government websites, internet searches and via in-country colleagues and analysed thematically.

Results

Opportunities to strengthen and scale-up NCD policies in Fiji in line with WHO recommendations included (1) strengthening multisectoral policy engagement, (2) ensuring a nutrition- and health-in-all policy approach, (3) using a whole-of-society approach to tighten political action across sectors, and (4) identifying and countering food industry influence.

Conclusion

Diet-related NCD policy in Fiji will be strengthened with clearly defined partner roles, responsibilities and accountability mechanisms, clear budget allocation and strong institutional governance structures that can support and counter industry influence. Such initiatives will be needed to reduce the NCD burden in Fiji.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00859-9.

State-level Medicaid 1915(c) home and community-based services waiver support for caregivers

BACKGROUND

Informal caregivers encounter emotional distress, worsening personal health, and financial strain. The Medicaid 1915(c) Home and Community-Based Services (HCBS) waiver programs provide an array of services including support for caregivers.

PURPOSE

This policy analysis examined Medicaid waiver services offered to persons 65 and older among the 50 states and District of Columbia (DC).

METHODS

Data were obtained from Medicaid waiver applications for adults age 65 and older available at Medicaid.gov. Data elements included number of waiver programs and services for supporting caregivers. Descriptive statistics were applied.

FINDINGS

Forty-three states including DC (84%) offered a Medicaid waiver for older adults; seven states (14%) offer two waiver programs; eight states (16%) had no Medicaid waiver. Payment to a relative or legal guardian caregiver was the most common service offered in 39 (76%) states. Other services included in-home respite care and adult day health care (35 states; 67%), out-of-home respite care (32 states; 63%), skilled nursing (28 states; 55%), paid spousal caregivers (18 states; 35%), caregiver training (15 states; 29%), and adult day care for socialization (7 states, 14%).

DISCUSSION

This study identifies wide variability in caregiver support across state-based Medicaid waivers. Future research should evaluate effectiveness of the waiver programs in supporting caregivers and inform evidence-based policy advocacy for supporting caregivers.

Understanding the policy dynamics of COVID-19 vaccination in Ghana through the lens of a policy analytical framework

Background

Ghana became the first African country to take delivery of the first wave of the AstraZeneca/Oxford vaccine from the COVAX facility. But why has this promising start of the vaccination rollout not translated into an accelerated full vaccination of the population? To answer this question, we drew on the tenets of a policy analytical framework and analysed the diverse interpretations, issue characteristics, actor power dynamics and political context of the COVID-19 vaccination process in Ghana.

Methods

We conducted a rapid online review of media reports, journal articles and other documents on debates and discussions of issues related to framing of the vaccination rollout, social constructions generated around vaccines, stakeholder power dynamics and political contentions linked to the vaccination rollout. These were complemented by desk reviews of parliamentary reports.

Results

The COVID-19 vaccination was mainly framed along the lines of public health, gender-centredness and universal health coverage. Vaccine acquisition and procurement were riddled with politics between the ruling government and the largest main opposition party. While the latter persistently blamed the former for engaging in political rhetoric rather than a tactical response to vaccine supply issues, the former attributed vaccine shortages to vaccine nationalism that crowded out fair distribution. The government’s efforts to increase vaccination coverage to target levels were stifled when a deal with a private supplier to procure 3.4 million doses of the Sputnik V vaccine collapsed due to procurement breaches. Amidst the vaccine scarcity, the government developed a working proposal to produce vaccines locally which attracted considerable interest among pharmaceutical manufacturers, political constituents and donor partners. Regarding issue characteristics of the vaccination, hesitancy for vaccination linked to misperceptions of vaccine safety provoked politically led vaccination campaigns to induce vaccine acceptance.

Conclusions

Scaling up vaccination requires political unity, cohesive frames, management of stakeholder interests and influence, and tackling contextual factors promoting vaccination hesitancy.

Maternity protection for female non-standard workers in South Africa: the case of domestic workers

BACKGROUND

Many women work in positions of non-standard employment, with limited legal and social protection. Access to comprehensive maternity protection for all working women could ensure that all women and children can access health and social protection. This study aimed to describe the maternity protection benefits available to women in positions of non-standard employment in South Africa, using domestic workers as a case study.

METHODS

A qualitative descriptive study design was used. National policy documents containing provisions on maternity protection were identified and analysed. Interviews were conducted with purposively selected key informants. Data extracted from published policy documents and information obtained from interviews were triangulated. A thematic analysis approach was used for evaluation of policy content and analysis of the interviews.

RESULTS

Twenty-nine policy and legislative documents were identified that contain provisions on maternity protection relevant to non-standard workers. These documents together with three key informant interviews and two media releases are used to describe availability and accessibility of maternity protection benefits for non-standard workers in South Africa, using domestic workers as a case study. Maternity protection is available in South Africa for some non-standard workers. However, the components of maternity protection are dispersed through many policy documents and there is weak alignment within government on maternity protection. Implementation, monitoring, and enforcement of existing maternity protection policy is inadequate. It is difficult for non-standard workers to access maternity protection benefits, particularly cash payments. Some non-standard workers have unique challenges in accessing maternity protection, for example domestic workers whose place of work is a private household and therefore difficult to monitor.

CONCLUSION

The heterogeneity of non-standard employment makes it challenging for many women to access maternity protection. There are policy amendments that could be made and improvements to policy implementation that would enhance non-standard workers' access to maternity protection. Potential long-term benefits to women and children's health and development could come from making comprehensive maternity protection available and accessible to all women.

Lesson from the continuing 21st century motor vehicle success

In 1999, the Centers for Disease Control and Prevention proclaimed the reduction in motor vehicle fatalities to be one of the great public health achievements of the 20th century. That motor vehicle success story has had enormous intellectual impact on the injury prevention field, providing many guiding lessons. Can we learn any lessons from what has happened to motor vehicle safety in the 21st century? A key lesson may come from the fact that the great injury achievement of reducing the motor vehicle death rate did not stop in 2000-it continued. We believe that is largely due to the 20th century creation of the conditions that promote continuous declines in injury. By contrast, in the firearms area, these conditions do not exist, and rates of death have not fallen, but have increased. As the idea of continuous quality improvement has become a staple in medicine, we should similarly have a focus on how to continuously reduce injuries. An important lesson from the 21st century motor vehicle success story for the injury prevention field is that we should put more strategic emphasis on creating the conditions that will lead to continuous reductions in injuries. But first we need a much better understanding of what those conditions are.

What factors drive state firearm law adoption? An application of exponential-family random graph models

Guns are a ubiquitous feature of contemporary US culture, driven, at least partly, by firearms' constitutional enshrinement. However, the majority of laws intended to restrict or expand firearm access and use are formulated and passed in the states, leading to 50 different firearm-related legal environments. To date, little is known about why some states pass more restrictive or permissive firearm laws than others. In this article, we identify patterns of firearm law adoption across states, by framing the problem as a bipartite network (states connected to laws and laws connected to states) that is the result of a complex, and interconnected system of unobserved forces. We employ Exponential-family Random Graph Models (ERGMs), a class of statistical network models that allow for the dispensing of the assumptions of statistical independence, to identify factors that increase or decrease the likelihood of states adopting permissive or restrictive firearms laws over the period 1979 to 2020. Results show that more progressive state governments are associated with a higher chance of enacting restrictive firearm laws, and a lower chance of enacting permissive ones. Conservative state governments are associated with the analogous reversed association. States are more likely to adopt laws if bordering states have also adopted that law. For both restrictive and permissive laws the presence of a law in a neighboring state increased the conditional likelihood of a state having that law, that is laws diffuse across state borders. High levels of homicides are associated with a state having adopted more permissive, but not more restrictive, firearm laws. In summary, these results point to a complex interplay of state internal and external factors that seem to drive different patterns of firearm law adoption Based on these results, future work using related classes of models that take into account the time evolution of the network structure may provide a means to predict the likelihood of future law adoption.

The impact of social determinants of health on early childhood development: a qualitative context analysis in Iran

BACKGROUND

Social determinants have a significant impact on children's development and their abilities and capacities, especially in early childhood. They can bring about inequity in living conditions of children and, as a result, lead to differences in various dimensions of development including the social, psychological, cognitive and emotional aspects. We aimed to identify and analyze the social determinants of Early Childhood Development (ECD) in Iran and provide policy implications to improve this social context.

METHODS

In a qualitative study, data were collected through semi-structured interviews with 40 experts from October 2017 to June 2018. Based on Leichter's (1979) framework and using the deductive approach, two independent researchers conducted the data analysis. We used MAXQDA.11 software for data management.

RESULTS

We identified challenges related to ECD context in the form of 8 themes and 22 subthemes in 4 analytical categories relevant to the social determinants of ECD including: Structural factors (economic factors: 6 subthemes, political factors: 2 subthemes), Socio-cultural factors (the socio-cultural setting of society: 6 subthemes, the socio-cultural setting of family: 4 subthemes), Environmental or International factors (the role of international organizations: 1 subtheme, political sanctions: 1 subtheme), and Situational factors (genetic factors: 1 subtheme, the phenomenon of air pollution: 1 subtheme). We could identify 24 policy recommendations to improve the existing ECD context from the interviews and literature.

CONCLUSION

With regard to the challenges related to the social determinants of ECD, such as increasing social harms, decreasing social capital, lack of public awareness, increasing socio-economic inequities, economic instability, which can lead to the abuse and neglect of children or unfair differences in their growth and development, the following policy-making options are proposed: focusing on equity from early years in policies and programs, creating integration between policies and programs from different sectors, prioritizing children in the welfare umbrella, empowering families, raising community awareness, and expanding services and support for families, specially the deprived families subject to special subsidies.

Using Bayesian Belief Networks to Investigate Farmer Behavior and Policy Interventions for Improved Nitrogen Management

Increasing farmers' adoption of sustainable nitrogen management practices is crucial for improving water quality. Yet, research to date provides ambiguous results about the most important farmer-level drivers of adoption, leaving high levels of uncertainty as to how to design policy interventions that are effective in motivating adoption. Among others, farmers' engagement in outreach or educational events is considered a promising leverage point for policy measures. This paper applies a Bayesian belief network (BBN) approach to explore the importance of drivers thought to influence adoption, run policy experiments to test the efficacy of different engagement-related interventions on increasing adoption rates, and evaluate heterogeneity of the effect of the interventions across different practices and different types of farms. The underlying data comes from a survey carried out in 2018 among farmers in the Central Valley in California. The analyses identify farm characteristics and income consistently as the most important drivers of adoption across management practices. The effect of policy measures strongly differs according to the nitrogen management practice. Innovative farmers respond better to engagement-related policy measures than more traditional farmers. Farmers with small farms show more potential for increasing engagement through policy measures than farmers with larger farms. Bayesian belief networks, in contrast to linear analysis methods, always account for the complex structure of the farm system with interdependencies among the drivers and allow for explicit predictions in new situations and various kinds of heterogeneity analyses. A methodological development is made by introducing a new validation measure for BBNs used for prediction.

Formulation of Water Sustainability Index for India as a performance gauge for realizing the United Nations Sustainable Development Goal 6

Anthropogenic activities targeting economic progress have triggered changes in the Earth system processes causing depletion of resources and degradation of ecosystems. Water is a critical natural resource which has been severely impacted through groundwater depletion, surface water contamination and ocean acidification resulting in repercussions on human health and biodiversity losses. Likewise, India, a mega biodiversity nation has been critically affected by degradation and drawdown of water resources with far-reaching consequences on environmental vitality and socio-economic development. In order to prevent extreme water scarcity in the near future, the country needs to promote sustainable utilisation of water resources by adhering to the targets of Goal 6 of the United Nations Sustainable Development Goals (UN-SDGs). The present work, therefore, has focussed on the development of a Water Sustainability Index (WSI) for India that would help attaining the targets of SDG 6. A total of 12 indicators categorized under biophysical and social development dimensions and synonymous with the targets of SDG 6 have been used for the formulation of WSI and thereby understanding how much water resources are used annually in a sustainable manner. The study also highlights the interrelationship between the diverse social development and health indicators (SDG 3) of Indian community. The research has the potential to provide guidance for efficient use of water resources in India. Acting as a yardstick and guiding star, the sustainability metric will help the nation to monitor whether it is on the right track and navigate its journey towards achieving water sustainability. It also calls for cautious course correction and restructuring of current Indian policy and operational instruments for effective green governance and sustainable water management.

Agricultural work-related fatalities and injuries in Punjab (India)

OBJECTIVE

Analysis of data on monetary compensation and estimating the rate of injuries related to agricultural activities in the state of Punjab.

METHODS

The primary data were collected from 22 districts of Punjab state for 2012-2015 through Punjab State Agricultural Marketing Board, Mohali. Data were analysed for the nature of health hazards, type of injuries, possible causes and factors of injuries and their gender.

RESULTS

During the four consecutive years (2012-2015) an overall 5888 hazards cases related to agricultural activities were reported from the state, out of which 1993 (33.85%) were fatal and 3895 (66.15%) were non-fatal injuries. Among the fatal cases, the leading causes reported were due to electric motors (34.47%), poisoning through snake bites (21.48%), poisoning through pesticide applications with sprayers (19.62%) and crushed under/falling from the tractors and related equipment (13.50%). The annual fatality rate of the state of Punjab was estimated as 14.14 per 100 000 agricultural workers, while the overall injury incidence rate was observed as 39.57 per 100 000 agricultural workers.

CONCLUSIONS

Majority of agricultural work-related health hazards in Punjab were mainly due to negligence, lack of knowledge/experience, restlessness/sleeplessness, inadequate safety measures, over speed and wrong practices employed by the operator. There is a need for better ergonomic controls, work environments and practices for the prevention of injuries and health hazards related to agricultural activities.

Mature Australian VET markets: a data-driven case study of public policy implementation

Australian vocational education and training (VET) policy makers have persistently proposed more user choice when reforming the national training system. Increasing alternatives by encouraging multiple providers to trade in regulated contestable markets remains the cornerstone of governments' policies. However, despite policy intentions, students' options are declining. Longitudinal quantitative jurisdiction-level statistics identify well-established trends of a reduced variety of providers, a smaller range of qualifications on offer and decreased public funding. These outcomes are occurring notwithstanding the continuous supportive policy environment for intensified competition and amplified choice. Rather than portray reduced choice as policy failure, this research makes novel use of large nationally consistent regulatory and enrolment data sets to provide evidence of successful public policy implementation that is approaching the end of the market life cycle. The results invite an exploration of issues that arise when VET markets are considered to be mature rather than unrealised aspirations. Choices provided in these fully-fledged markets that balance public and private provision are still necessary, but no longer sufficient, to meet national skills needs. It is argued that policy success is not permanent and should be revisited in light of contemporary economic alternatives to guide future VET policy making.

Public Policy Research-Born in the USA, at Home in the World?

Public policy emerged as an academic subfield in the United States after the second World War. The theoretical foundations of the discipline are essentially based on analyses of Anglo-Saxon policies and politics and were originally aimed at providing knowledge for the policy process of pluralistic democracies. Given the increasing transfer of the subject and related approaches to other countries, it is necessary to clarify how suitable theories, goals, and methods of policy research are applied in other contexts. What needs to be considered when transferring theories of the policy process, and what can be learned from existing applications of the various approaches in different settings? The compilation of contributions on selected theoretical public policy lenses and their transfer to other countries and regions provides a nuanced answer to these questions.

Policy analysis of socio-cultural determinants of salt, sugar and fat consumption in Iran

Background

Noncommunicable diseases (NCDs) are the first reason for death worldwide, in which poor diet is the leading risk factor. It is estimated that 20% of all death is related to food. The Unhealthy diet includes many foods with excessive salt, sugar and fat. This paper reports a national study on the socio-cultural determinants affecting salt, sugar and fat consumption in Iran.

Methods

This is a qualitative study. We conducted semi-structured interviews with 30 various purposefully identified key stakeholders to collect data from December 2018 until August 2019 in Iran.

Results

We identified socio-cultural determents of salt, fat and sugar consumption as follows: Inadequate structure of traditional medicine and people’s desire for traditional foods, low health literacy, the global trend of nutritional transition and its impact on Iranian society, The progressive decline of people’s trust in NGOs, and Inappropriate media management. Worse still, the global trend of nutritional transition and people’s tendency towards fast foods, unhealthy diet and junk foods, partially due to establishing children’s taste mainly with salty, high-fat and sweet foods, has jeopardized their desire to eat healthily during adulthood.

Conclusion

Reducing salt, fat and sugar consumption is problematic in Iran, mainly due to multi-dimensional socio-cultural determinants. In line with sustainable development goal (SDG) 3.4 to reduce 30% of premature death due to NCDs and related risk factors by 2030 in Iran, various stakeholders from multiple sectors need to initiate coherent series of interventions to alter people’s approach to select food so that they may reduce the consumption of foods with excessive salt, fat and sugar.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00518-7.