bluuebunny/crossref_metadata_2025 huggingface dataset:
Strengthening Public Health Wales’ Global Health offer: refreshing our International Health Strategy
Authors: Clark E , Holt L , Malcolm A , Ezenwugo G , Green L , Dyakova M
Published: October 2023

Problem

Public health is inherently global. Public Health Wales (PHW) is the only public health institute with an International Health Strategy, published in 2017. Due to significant global and national contextual changes such as COVID-19, a refresh was required.

Description

The refresh, commenced in April 2022, aimed to evaluate the impact of the existing strategy, map global health work across PHW, and deliver an inspiring yet feasible update. Data were collected using a mixed methods approach: a scoping review of global health developments since 2017; wide consultation via online surveys for internal and external stakeholders; and key informant interviews. Qualitative data determined experiences, benefits, and priorities in international health work. Thematic analysis of findings, triangulation, and synthesis informed the strategy refresh. Emerging themes and priorities were presented across PHW for feedback.

Results

There are over 100 active international health projects/partnerships in PHW. Engagement findings identified their benefits including contributing to global challenges, sharing learning, and health system strengthening. Facilitators of global work included access to networks; practical support; and shared priorities. Participants emphasised the strategy's role in contributing to overarching organisational priorities; national aims such as the Well-being of Future Generations Act goals; and highlighted the strategic importance of international partnerships.

Lessons

The strategy strengthens PHW's global health offer. There is high recognition of the value of global work but still opportunity to reap benefits such as system leadership and staff development. Access to existing networks facilitated global health activities; strengthening this is a key vehicle to maximise bidirectional learning for policy and practice innovation. The methods and engagement findings may be transferable to other national Public Health Institutes planning a global health strategy.

Key messages

• International health activities are diverse, accessible, and integral to public health work; with wide-ranging benefits to staff, the organisation, and partners within and beyond Welsh borders.

• The organisational International Health Strategy will enable Public Health Wales to reach its overarching goals through recognition of and building on the benefits of international health work.
The NAVICARE Network for patient-oriented health services research - experiences and lessons learned
Authors: Schwengler S , Gödde K , Klein C , Rieckmann N , Holmberg C , Heintze C
Published: October 2023

Background

In 2017 NAVICARE was established as a Berlin/Brandenburg-based network for patient-oriented health services research. The overall aim is to reduce barriers for patients with age-associated diseases and multimorbidity in the fragmented German health care system. The networks structural goal was to develop a research environment in which scientifically developed regional health services interventions for better coordinated care are piloted.

Methods

During two funding periods, an overarching infrastructure was built in the network to connect and support participating researchers as well as external stakeholders from different disciplines, support education and coordinate the network's dissemination and events. In a critical reflection process between participating researchers, we collected experiences and lessons learned from work in the multidisciplinary research network.

Results

A shared coordinating infrastructure, including monthly meetings, to bring in different competencies, perspectives, methods and research questions has been described as beneficial. This includes expertise from participating researchers as well as connected external partners. Experienced challenges are high time effort of networking, bringing together different views as well as logistical-organizational barriers in building overarching and permanent structures.

Conclusions

Work in a research network can provide structural support by collating information and expertise to support better health services research and allowing the integration of different perspectives from internal as well as external partners involved in health care. An overarching coordinating infrastructure should provide an effective flow of information and connect all partners in a time efficient manner.

Key messages

• Multidisciplinary networking can support a patient-oriented health services research environment.

• However, for the regional network to be efficient a goal-oriented coordination and time-balanced communication is key.
Provision of COVID-19 treatments to non-hospitalised patients in Northern Ireland: an evaluation
Authors: Patterson L , McGuinness S , Bradley D T , Corrigan D
Published: October 2023

Background

The first UK interim clinical commissioning policy for the treatment of non-hospitalised patients with COVID-19 was published in December 2021. A service was established in Northern Ireland, with implementation and developments overseen by a multi-agency group. We investigated the reach, uptake and equity of the programme to understand performance and offer recommendations for improvement.

Description of the problem

Data were extracted for 16 December 2021 to 16 December 2022. The objectives were to: 1) describe referrals over time using weekly aggregate returns sourced from the commissioning agency for all of NI and; 2) for a subset of providers, to describe treatment acceptance and those treated by age group, sex, deprivation quintile and all-cause mortality using anonymised, linked administrative data. Treatment acceptance was analysed using logistic regression.

Results

Overall, 16,454 patients were referred of whom 9,536 (58%) were eligible for treatment. Of these, 5,849 (61.3%) accepted, 1,215 (12.7%) declined, 1,140 (12%) were already an inpatient and the remainder unknown (1,332; 14%). Using the subset, treatment acceptance was associated with increasing age (likelihood ratio test (LRT) P = 0.02) but not deprivation (LRT P = 0.83). Of those treated (3,645 people) the majority were aged 18-64 years (68%) and were female (59%). Just 8% lived in the ‘most deprived’ quintile, compared to 20% in all others. The 28-day all-cause mortality for those recommended treatment was <1%.

Lessons

This was a rapidly established service which has treated 5,849 people. Acceptance of treatment increased with age but was not affected by deprivation. However, a higher percentage of those treated were from least deprived areas. Recommendations include monitoring equitability of access and a greater focus on those eligible for treatment but who decline, both highlighting the importance of engaging and empowering service users to make an informed choice around COVID-19 treatment.

Key messages

• Almost 6,000 people in the community have received a COVID-19 treatment since the inception of the service in Northern Ireland.

• Equitability of access should continue to be monitored.
Bridging public health and primary care in an Italian Urban Area. Lessons learnt from pandemic
Authors: Frisicale E M , Barbara A , Borghini A , Carini E , Grossi A , Tanese A , Goletti M , Parente P
Published: October 2023

COVID-19 pandemic represented a disruptive event for all sectors, especially the healthcare one. It revealed weakness of healthcare systems, often organised in silos, and called for a great coordination among several stakeholders. Different healthcare organizational solutions were implemented in order to address this extraordinary situation. This study investigates the impact of an organizational innovation, District Operation Centres (DOCs), of a Local Health Authority (LHA) in Rome aimed at responding overall to primary care and public health (PH) needs during the first phases of pandemic. In the DOCs health districts professionals supported general physicians (GPs) and family paediatricians (FPs), acting as a bridge with the PH Department, in order to better manage COVID-19 patients and close contacts. To understand the utility and the areas of support to GPs and FPs a survey (21 open questions or on a Likert scale), realised according the Delphi method, was admnistered to them. The sample was calculated using Epi Info, randomization was performed through Excel. A descriptive analysis of the sample and of the answers was carried out. When appropriate, statistical tests were used to understand differences among districts. 215 doctors were interviewed between Dec 2020 and Jan 2021. More than 50% declared to have found DOCs useful, above all for guiding to legislation and to activate medical equipes to deliver swabs at home. The support was evaluated not good regarding COVID-19 cases/contacts and cluster(s) management. Further needs as support in frail patients’ management, involvement of specialists, delivery of telemedicine, more involvement of GPs/FPs in district activities were identified. DOCs were an attempt to support GPs/FPs in improving care to COVID-19 patients/contacts. To provide this new service in the pandemic emergency denotes great leadership in the LHA to yield collaboration among several stakeholeders and vision about patient-centered healthcare.

Key messages

• Although several limits like need of more integration, DOCs represent an experience aimed at overcoming duality between primary care and public health systems and the fragmentation of the system.

• DOCs could be considered an organizational innovation to make the system more resilient and patient-centered.
Complex social factors in pregnancy - a Scottish health needs assessment
Authors: Harpur A , Goodfellow A , Garbe F , Wilson S
Published: October 2023

Issue

Health inequalities begin prior to conception. In the UK, babies born to women living in the most deprived areas are twice as likely to be stillborn compared to babies from the least deprived areas. Maternity services have a vital role in tackling health inequalities during the antenatal period but are not always equipped to optimally achieve this.

Description

A health needs assessment (HNA) of pregnant women experiencing complex social factors (CSFs) was undertaken in NHS Lothian. The objectives were to describe the epidemiology of CSF in pregnancy, identify the needs arising from these, map the services available, and understand the experiences of staff and pregnant women. The HNA reviewed data from >42,000 maternity records between 2016-2020, engaged with midwives through focus groups and questionnaires, and undertook focus groups with women who had recently used antenatal services.

Results

Between 2016-2020, socio-economic deprivation was the most common CSF at booking (17%), followed by domestic abuse (4%), living in temporary accommodation (4%) and teenage pregnancy (4%). Other CSFs included problem substance use, difficulty reading/speaking English and involvement in the justice system. Midwives highlighted that CSFs could affect anyone at anytime, were often multiple and overlapping, and required additional time and partnership working to support. Whilst excellent models of care existed, there was geographical inequity in the quantity and quality of support available. Conversations with women emphasised the importance of continuity of care and described how a single point of contact through a trusted practitioner helped them access the range of services required.

Lessons

The HNA made 15 recommendations on how maternity services could better support CSFs. These related to developing better data systems to understand CSFs, increasing staff support, designing flexible care models, and strengthening multi-agency working.

Key messages

• The HNA has raised awareness of the range of CSFs encountered by pregnant women and their links to short- and long-term health inequalities for women and their babies.

• The HNA is being used by maternity services to improve CSF support by using routine health data, allocating resources in a way that is proportionate to need and strengthening multi-agency working.
Perceived and functional parental health literacy and vaccine hesitancy among Cypriot parents
Authors: Menikou J , Middleton N , Papastavrou E , Nicolaou C
Published: October 2023

Background

Assessing the association of perceived health literacy (PHL) and functional health literacy (FHL) with childhood vaccination hesitancy (VH) among parents is important in the context of developing targeted responses given that VH is of increasing public health concern.

Methods

A cross-sectional study was conducted with a convenience sample of parents of children, aged 6 months to 15 years old, presenting in pediatric primary care centers across 3 Cypriot cities. Participants responded to the HLS-EU-Q47 and the NVS (Newest Vital Sign), a self-rated and performance-based tool of health literacy (HL), respectively. They also completed a questionnaire tapping on attitudes and practices regarding childhood vaccinations. Parents were classified according to the overall and domain-specific PHL and FHL, and associations with VH were explored.

Results

Amongst 207 parents (82.6% female, 86.0% tertiary education), higher PHL was associated with certain positive attitudes and practices related to childhood vaccination e.g. childhood vaccination according to health science, whereas higher FHL appeared to be associated with certain negative attitudes and practices e.g. more concerns about side effects of vaccines. Lack of accurate information was the only reported vaccination barrier associated with lower PHL (34.28, SD = 7.54 versus 36.51, SD = 7.20 p = 0.04), whereas no vaccination barrier was associated with FHL. No significant associations between PHL and VH were observed. In contrast, higher FHL was associated with VH (p = 0.01) with parents categorized as ‘refusers’ (3.67, SD = 2.64) or ‘hesitant acceptors’ (3.15, SD = 2.74) having higher FHL than parents categorized as ‘delayers’ (2.95, SD = 2.63) or ‘non-hesitant acceptors’ (2.99, SD = 2.42).

Conclusions

Assessing both PHL and FHL led to a more comprehensive understanding on the influence of parental HL towards childhood vaccination which can guide the design and implementation of interventions to address VH among parents.

Key messages

• While parental HL is associated with childhood VH, a mixed pattern emerged depending on whether HL was operationalized using a perceived or functional measure.

• While health education at clinical and population level are needed to counteract parental VH, the association of parental HL with childhood vaccination attitudes and practices is not straightforward.
Effect of smoking on long-term immunity after hepatitis B vaccine in infancy. A 20-year cohort study
Authors: Fonzo M , Amoruso I , Serpentino M , Miccolis L , Baldovin T , Bertoncello C , Trevisan A
Published: October 2023

The immune response to hepatitis B vaccination has been shown to be associated with a number of different factors, including age, sex, BMI, comorbidities and modifiable determinants, including smoking. However, while there is a strong evidence suggesting that smokers are at higher risk of not responding to the vaccine, the effect of smoking on long-term antibody persistence is not fully understood. Therefore, we aimed to evaluate the effect of smoking habit on long-term immunity (∼20 years) after primary vaccination. Individuals were recruited on the occasion of the occupational health surveillance medical examination at the University of Padova, Italy. Participants had to have received a standard 3-dose schedule in infancy (2-12 months of age) with no subsequent booster dose, and be 18-24 years of age at the enrolment. Information was collected on age, sex, body mass index (BMI), age at first dose and interval between doses. Antibody titres <10IU/l were considered non-protective according to international standards. Given the young age of the participants, current and former smokers were considered together. A single-step logistic regression was performed to assess the effect of smoking on a non-protective antibody titre, adjusting for all variables considered. A total of 2,133 individuals were included, of whom 62.6% were female. The mean age of the participants was 20.28±0.92 years. The risk of a non-protective antibody titre was significantly higher in smokers compared to non-smokers (AOR: 1,287; 95%CI: 1,002-1,652). Smokers have a + 29% risk of having antibody levels below the recommended threshold when assessing long-term immunity, although it should be noted that a titre <10IU/l does not automatically mean lack of protection. Smoking habit not only negatively affects the short-term response to the vaccine in adults, but also the long-term immunity when vaccinated in infancy, making the need for additional immunity enhancement in this subpopulation reasonable.

Key messages

• Smoking has a negative effect on long-term immunity (about 20 years) after hepatitis B vaccination in infancy, not just on short-term responsiveness in adults.

• Smokers have a + 29% higher risk of having a non-protective antibody titre, raising the question of the need for additional immunity enhancement in this subpopulation.
Guidelines for Physical Activity, Sedentary Behavior, and Sleep in Colombian Youth during COVID-19
Authors: Valencia Rivero K , Muñoz Pinzón D , Caviativa Castro Y , Jaramillo Guzmán V , Álvarez Salazar C , Perea Rodríguez R , Sánchez Güette L , Valero Inerarity A , Hernández Garay A , Cruz Quiroga L
Published: October 2023

The Canadian 24-Hour movement guidelines integrate physical activity, sedentary behaviour and sleep habits for children and adolescents. This study aims to assess the compliance of these guidelines in Colombia, as an instrument to design strategies of health promotion in this population. A cross-sectional study in 619 scholars aged 7-17 in Caribbean Colombian region was performed to measure aerobic activity, muscular force and flexibility during 7 days through the ActivityGram questionnaire of the Cooper Institute. The data was gathered in May, 2021, through phone interviewing, and parents and participants signed an informed consent form. The screen time was measured (in hours/day), as well as the times sitting and sleeping, to perform a regression analysis and determine the Pearson coefficient characterizing the correlation between the total time in physical activity and the time in aerobic exercise. A 73.5% of the sample do not comply with the Canadian physical activity guidelines. The mean sleeping time per day is 7.9±1.2 h, being 8.1±1.2 h for 7-13 scholars and 7.5±1.3 h for 14-17 adolescents (p = 0.003). Sedentary behaviour exceeds 2 h per day, being 4.7±1.3 h sitting and 3.2±1.9 h screen time. Aerobic exercise was the most influential in the total time of physical activity (r = 0.82, p = 0.0001). The sample was composed of 51.5% males, and the mean age was 11.5±3.2 years. In this sample, 80.5% were socioeconomically vulnerable, and 55.7% were involved in remote learning activities. The COVID-19 health emergency increased the non-compliance of the physical activity guidelines and the sedentary behaviour in childhood and adolescence. It is mandatory to design health promotion strategies to encourage active life styles during these stages, as they lay the foundations of healthy habits in the future, and this is a shared responsibility between educational institutions, families and policy-making institutions

Key messages

• The ActivityGram test assesses physical activity in children and adolescents.

• Analysis of physical activity and sedentary habits help to design health promotion policies in young people.
The Fundamentals of Advocacy: Designing an online learning course for health and social care staff
Authors: Duggan C , Taaffe C , Walshe C , Weir L , Rourke N O
Published: October 2023

Background

The Health Information and Quality Authority (HIQA) develops national standards for health and social care services and tools to assist with implementation. In 2023, HIQA developed resources to help health and social care staff support advocacy in their work. This followed a recommendation of the COVID-19 Nursing Homes Expert Panel Report (2020). As this project is founded in human rights-based practice and in lessons learned from COVID-19, it is relevant across health and social care.

Objectives

We wanted to know: 1. the barriers to advocacy in health and social care services; 2. how best to address this.

We found knowledge and understanding of advocacy to be a significant barrier, and therefore developed an online course. The course was informed by focus groups with health and social care staff, service-users and inspectors, and by user-testing. The objectives are that learners understand:

• what advocacy is

• the role of health and social care staff in advocacy

• how to support people to have their will and preference met

• the boundaries of their role as advocates, including any conflicts of interest

• how to raise awareness of independent advocacy services, and when to support people to access these services.

The course includes case studies, interviews and self-assessment. We are measuring impact through surveys, interviews and focus groups.

Results

Through stakeholder engagement and a review of evidence we identified knowledge and understanding as a significant barrier to advocacy. Since the course was launched in April 2023, 90% of participants report that, based on the course, they will make changes to the way that they work. A selection of these participants will be interviewed after six months to measure impact.

Conclusions

Our research identified a need to improve knowledge and understanding of advocacy among health and social care staff. The course evaluations to date have shown that the course has achieved this.

Key messages

• There is a need to improve knowledge of advocacy among health and social care staff. HIQA has developed an online learning course to address this, informed by extensive stakeholder engagement.

• Advocacy is about supporting and empowering people to communicate their will and preference, secure their human rights, or represent their interests.
Exploring methods and tools for estimating and measuring medical staff shortages
Authors: Parzonka K , Ndayishimiye C , Domagała A
Published: October 2023

Background

Healthcare systems face major challenges due to shortages in the healthcare workforce (HWF). In order to effectively plan for the future, it is critical to forecast the HWF needs. This study aimed to identify, map, and synthesize the tools, methods, and procedures for measuring medical staff deficits in Europe.

Methods

The study was performed in accordance with the Arksey and O'Malley scoping review methodology. The authors searched 4 scientific databases: Medline via PubMed, EMBASE, Web of Science, Cochrane Library, as well as manually, by searching for relevant reports. The results were analyzed using both qualitative and quantitative methods. The final searches were conducted until October 2022.

Results

The study included 38 publications published between 2002 and 2022. Among included publications, 25 were empirical studies, 6 theoretical papers, 5 reports, 1 a literature review, and 1 a guidebook. The majority of the publications estimated or measured shortages of physicians (14/38) and nurses and midwives (7/38), or the HWF generally (10/38). A variety of methods was used, including projections, estimations, predictions, simulation models, and surveys, which utilized tools such as special computer software or customized indicators, such as the Workload Indicators of Staffing Need method. HWF shortages were estimated at both national and regional levels, often based on demand, supply, and/or need.

Conclusions

While these methods and tools provide valuable insights, they may not always be suitable for the needs of a country or a medical facility. The problem of shortages in the health service is growing and its effects are already being felt, while data on the extent of medical staff shortages are usually outdated and underestimated, which highlights the need for further development, testing and implementation of validated methods.

Key messages

• Improvement of tools for measuring HWF shortages should be an integral part of HWF planning.

• Validated methods and tools are needed to measure, estimate, and prepare forecasts of HWF shortages.
The cost of psychological distress among healthcare workers during the COVID-19 pandemic
Authors: Lee B , Ling M , Boyd L , Chatterton M L , Sheen J
Published: October 2023

Background

Since it began, the COVID-19 pandemic has placed significant stress on healthcare workers (HCW) and have left them experiencing higher levels of psychological distress. These mental health impacts can persist long term, leading to lower workforce wellbeing and higher costs to organisations if unaddressed. This study aimed to identify those most at risks, modifiable factors, and the organisational cost of psychological distress among Australian frontline HCWs

Methods

In January 2023, 210 HCWs working in Australian hospitals completed an online measure of psychological distress (Kessler-six item: K6) and the Coronavirus Health and Impact Survey. Data was analysed using adjusted multivariate regressions and relative weight analysis to determine key predictors. To estimate organisational cost, K6 items regarding days out of role and days working at reduced capacity were used in combination with salary rates from public enterprise agreements.

Results

Severe psychological distress was present in 9.5% of participants. Risk factors include younger age (p < 0.05, R2=2.5%), poor pre covid mental health (p < 0.001, R2=15.4%), and outdoors time (p < 0.001, R2=5.1%). Protective factors include positive relationship changes (p < 0.05, R2=2.8%) and better supervisor support (p < 0.01, R2=4.7%). Among the sample, 32.2% had at least one day out of role and 52.0% had at least one day working at reduced capacity, which combined costs organisations on average between $859 to $1461 AUD per person per month. Days out of role and working at reduced capacity were both predicted by K6 scores (p < 0.001), pre covid mental health (p < 0.001), physical health (p < 0.01), supervisor support (p < 0.01), and relationships stress (p < 0.05).

Conclusions

Psychological distress continues to remain prevalent among frontline HCWs, highlighting the need for ongoing and targeted supports to mitigate long term mental health issues and the high organisational cost associated with it.

Key messages

• The COVID-19 continues to place significant psychological burden on HCWs and findings demonstrate that this has led to high costs to organisations.

• Findings highlight risk and protective factors for psychological distress that can be targeted to reduce both psychological distress and the high organisational cost associated with it.
How do medical students visit psychologists in Hungary?
Authors: Umami A , Zsiros V , Maróti-Nagy Á , Máté Zs , Molnár R , Paulik E
Published: October 2023

Background

Mental health problems are more common among medical students than other student groups, and although medical students as future physicians will be responsible to give advice people for seeking healthcare, they frequently avoid seeking advice for their own mental health problems. The aim of this study was to investigate the factors influencing medical students’ decisions to seek psychologist comparing international (IN) and Hungarian (HU) students.

Methods

A self-administered questionnaire based cross-sectional study included 688 medical students (IN: 326; HU: 362) at the University of Szeged in 2021. Multivariable logistic regression models were used to examine the correlations between the variables influencing students’ visits to psychologists.

Results

In the sample, 50.9% of students (IN: 49.7%; HU: 51.9%) had poor mental health, 17.2% of them (IN: 14.1%; HU: 19.9%) visited psychologists. Both IN and HU students were more likely to visit a psychologist when they reported poor mental health (IN: OR = 3.08, 95% CI 1.47-6.45; HU: OR = 2.45, 95% CI 1.31-4.60). IN female students had significantly higher odds of visiting a psychologist than male students (OR = 2.21, 95% CI 1.11-4.41), and HU students were more likely to visit a psychologist when they were in the clinical years compared to the preclinical years (OR = 1.74, 95% CI 1.00-3.01).

Conclusions

Although healthcare-seeking behaviour is influenced by many factors, this study showed that the main reasons were the students’ mental health problems. Another point is that visiting psychologist was more typical during clinical years among Hungarian students what should encourage medical schools to improve students’ oriented mental health services.

Key messages

• Minimizing dangerous behaviour and providing medical students with proper mental health care.

• Students have to get help during their final years to formal their career aims and reduce their stress level.
Behind the ‘creative destruction’ of human diets: an analysis of the structure and dynamics of the ultra-processed food manufacturing industry and implications for public health
Authors: Williams O , Baker P , Sacks G
Published: October 2023

Background

The role of ultra-processed food (UPF) manufacturers in driving unhealthy diets is coming under increasing scrutiny. While many of the strategies used by UPF corporations to push for and maintain high levels of UPF consumption are well documented, there has been limited analysis of how the UPF industry has evolved over time. This study aimed to examine trends in the structure and dynamics of the UPF manufacturing industry as part of efforts to understand and address the political economic drivers of the global UPF dietary transition.

Methods

We used multiple methods to examine the structure and market dynamics of the UPF industry, according to an adopted structure-conduct-performance model. Quantitative methods were used to analyse diverse metrics (e.g., industry size, market concentration, profitability). Data were sourced from several business and market research databases, with periods of analysis based on available data. We conducted a narrative literature review to supplement findings from the quantitative analysis, including on corporate strategy.

Results

Our findings show that, since the late-1800s, the global UPF manufacturing industry has been instrumental in transforming food systems around the world to the extent that many are now heavily geared towards the consumption and production of UPFs. A key explanatory factor behind this trend is that a group of major UPF corporations have developed an extensive and highly profitable network of large, concentrated UPF markets. Our study also suggests that, since the 1980s, the same corporations have been increasingly prioritising the financial interests of their shareholders above other concerns.

Conclusions

Reversing the UPF dietary transition will likely require substantial changes to the structural and regulatory conditions under which food systems around the world operate, such that population and planetary health are actively promoted and incentivised.

Speakers/Panelists

Samuele Tonello

Eurohealthnet, Brussels, Belgium
The social gradient in adolescent mental health problems and the role of physical activity
Authors: Dahlstrand J , Friberg P , Petzold M , Chen Y
Published: October 2023

Background

In Sweden, the share of 13 and 15-year-old students reporting ≥ 2 psychosomatic symptoms (PSS) more than once a week doubled between 1985/1986 and 2017/2018, during which there were increases in both income inequalities and adolescents with insufficient physical activity (PA). PA during non-school time has been shown to be negatively associated with stress and PSS among adolescents. We aimed to explore whether there is a socioeconomic status (SES)-related gradient in adolescent mental health problems, and if so, whether non-school sedentary time (SED) and PA mediate this social gradient.

Methods

We used data from STARS, a prospective and observational cohort study of 2283 7th grade students in Västra Götaland, Sweden. A total of 1235 participants (mean age 13.6±0.394 years, 59% females) returned with valid accelerometer data (≥ 10 hours per day for ≥ 4 days), answered questionnaires regarding stress and PSS, and had parents’ earned income registry data. Ordinary least square for linear regressions and bootstrapping for mediation analysis were used with 95% CI, repeated for males and females separately.

Results

We found that higher income was associated (α = 5%) with less stress (-0.1108, p ≤ 0.001 and PSS (-0.1315, p ≤ 0.001). For stress, we found that non-school PA partly mediated this association. This was true for light PA (LPA) (-0.0040, [-0.0093-0.0003]), moderate to vigorous PA (MVPA) (-0.0077, [-0.0152-0.0023]) and vigorous PA (VPA) (-0.0090, [-0.0166, -0.0031]). When separated by sex, mediation via PA was found only in females. For PSS, mediation effect was found for MVPA (-0.0071, [-0.0137, -0.0018]) and VPA (-0.0103, [-0.0182, -0.0039]), but not when separated by sex.

Conclusions

There is a social gradient in both stress and psychosomatic symptoms among adolescents, mediated by physical activity although to a relatively small part. This shows the relevance to inform policy on the need to enable extracurricular sports activities for adolescents.

Key messages

• Physical activity partly explains the social gradient in adolescent mental health.

• Supporting extracurricular sports activities may help to reduce the social gradient in adolescent mental health.
Shared decision-making in a medicalized birth environment: mixed-methods exploratory study, Cyprus
Authors: Middleton N , Koliandri I , Hadjigeorgiou E , Christodoulides V , Nicolaou C , Kouta C , Karanikola M , Orphanides I , Kolokotroni O ,   Baby Buddy Forward team
Published: October 2023

Background

Maternity care practices are not always supportive of participation in decision-making; a fundamental pillar of the WHO Respectful Maternity Care framework. With the highest caesarean section (C/S) rate in the EU (>60%), high episiotomy rates (70.9%) etc, the medicalised birth environment in Cyprus raises questions about Informed Choice.

Methods

Following focus groups (N = 12) with pregnant women and new mums (N = 62), an online survey was shared via the Baby Buddy Cyprus webapp. Women responded to the Maternal Autonomy in Decision-Making (MADM) scale along a battery of scales, including perceived efficacy in patient-provider interaction (PEPPI) and Kim Alliance Scale (KAS).

Results

Based on MADM classification, 54.3% of 387 participants (64% primiparas, 42% C/S, 80% private sector) were classified as having high autonomy, while one in five were classified as low or very low. There were lower scores among primiparous women (p = 0.02) and higher among those receiving care in the private sector (p < 0.001). Perceived efficacy in interaction was related to educational attainment (p-value for trend=0.02). In regression models, KAS (b coeff= 1.25 95%CI 1.06, .1.45; p < 0.001) and PEPPI (b coeff = 0.38 95%CI 0.24, 0.52; p < 0.001) were independently associated with MADM after adjusting for socio-demographic and pregnancy characteristics. Consistently, having a “confident voice” in an ‘unsupportive system’ where the ‘art of communication’ is often left to the women themselves emerged as themes from the qualitative study.

Conclusions

Participation in decision-making among pregnant women in Cyprus is problematic. Given that reduction of C/S, most classified as elective by maternal request, was identified as national Public Health priority, further research is necessary. Continuous professional training along with population-level interventions to promote self-agency may be needed, especially since childbirth rights were further compromised during the COVID-19 pandemic.

Key messages

• Against physician dominance in communication, birthing women in Cyprus do not rate participation in decision-making favourably.

• Further research is needed around Informed Choice, including educational and population-level interventions targeted at healthcare providers as well as women.
The mental health of children and adolescents at Matosinhos: characteristics and obstacles to care
Authors: Barbabela R , Duarte G , Leão T
Published: October 2023

Background

Mental health disorders are a public health issue. Most mental disorders begin during childhood and adolescence. Epidemiological studies regarding the diagnosis, prevalence, and access to treatment by children and adolescents are scarce, especially in Portugal. This research protocol aims to characterize the referral process and waiting times for these consultations at a Portuguese Local Health Unit between 2017 and 2022 (covering about 180,000 people); and to identify barriers to adequate health care for children and adolescents from the perspective of healthcare professionals from the hospital and primary care units.

Methods

We used a mixed methods study. Qualitative data allowed interpretation and reflection of quantitative data, with validation and integration of results. We conducted a descriptive analysis of the variables obtained through the local Health Information System and semi-structured interviews with a sample of healthcare professionals involved in mental health care for children and adolescents at the hospital and primary care unit levels.

Results

Preliminary results show a break in the number of consultations in 2018, due to the lack of professionals, and a yearly increase after COVID-19. Follow-up appointments and evaluation processes have long waiting times since there is a focus on ensuring shorter waiting times for the first consultation, and there is a shortage of professionals in mental health teams. The staff identified the need to integrate schools into care - referral and evaluation - and to promote community-based programs that train skills in children, adolescents, and caregivers.

Conclusions

Health indicators allow the assessment of epidemiological data and access to care, yet it is fundamental to listen to the professionals in the field to identify barriers, needs, and possible actions that more effectively promote mental health in this population.

Key messages

• Mental health disorders in children and adolescents are a significant public health issue in Portugal, yet there are scarce epidemiological studies on diagnosis, prevalence, and access to treatment.

• There is a need to address the shortage of mental health professionals and integrate schools and community-based programs into mental health care to improve access and promote mental health.
Designing and planning natural experimental evaluations with good practice recommendations
Authors: Craig P
Published: October 2023

Background

There have been significant developments in methods, infrastructure, and data availability for natural experimental evaluations. The rise in the use of natural experimental approaches means it is important that researchers, public health practitioners, funders, and users of intervention research understand the phases involved when designing and planning a natural experimental evaluation and are aware of good practice considerations.

Methods

Guidance was developed from three international workshops and an online consultation with researchers, journal editors and end users of natural experimental evaluations. The project team comprised researchers with expertise in natural experimental evaluations. The project included an oversight group and an advisory group of independent experts.

Results

The design and planning of an evaluation involves understanding the definition of a natural experiment, being aware of opportunities for a natural experimental evaluation and the relevance of a systems perspective and mixed methods approaches. The practicalities of planning an evaluation involve assessing the evaluability and feasibility of the evaluation and identifying and involving stakeholders throughout the process. Good practice considerations include understanding the evaluation design and planning processes, engaging stakeholders, and recognising the respective strengths of different analytical approaches. Recommendations for policymakers, public health practitioners and commissioners of evaluations include recognising and using high quality evaluations and incorporating evaluation plans into the implementation of new policies and programmes.

Conclusions

Understanding the processes involved in designing and planning a natural experimental evaluation are important to successfully conducting and evaluating natural experiment interventions.
Addressing inequality: a school-based intervention to improve pupils’ well-being and social inclusion
Authors: Myhr A , Ekmann L
Published: October 2023

Issue

Educational achievement, health, and well-being among children varies greatly. Early interventions in primary education are among the most effective policy tools to reduce such gaps. A coherent and cross sectoral school approach, as well as a specialized school leadership, can promote social equality among pupils.

Description of the problem

A lower secondary school in Mid-Norway discovered problems related to social exclusion and well-being among the pupils. Between 2020 and 2023 the school engaged its employees, pupils, parents, and broader local community in a common dialogue and learning process about diversity and mental health. In order to understand whether and how this intervention impact on a) pupils’ well-being, sense of inclusion and social cohesion, and b) attitudes and behavior among pupils, parents, school employees and the community members, interviews with principal and pupils were conducted, as well as surveys among pupils, school employees, parents, and local community members.

Results

The pupils experienced that the school environment became more inclusive, positive, and supportive. They reported less bullying, bad language and social exclusion, and improved cohesion and wellbeing at school. The problems turned out to be embedded in both the school and broader local community context. A large share of the pupils, school employees, parents, and local community members reported that they had changed towards more inclusive attitudes and behavior, and that they had become more socially included in the local community.

Lessons

The intervention promoted a culture of inquiry within the school context, where active and critical engagement generated personal meaning and mutual understanding. The school became a ‘community active school', linking pupils, parents, school employees and the extended local community in meaningful dialogue and activities, promoting social inclusion and wellbeing in a powerful way.

Key messages

• A culture of inquiry in the school context can address and promote public health issues among pupils.

• A ‘community active’ school can be a powerful means to promote social inclusion and well-being in school as well as within the broader local community context.
Prenatal and postnatal care in a frozen conflict zone: results from a household survey
Authors: Musheghyan L , Sargsyan Z , Agopian A , Aprahamian D , Lazaryan Z , Dorian A
Published: October 2023

Introduction

Maternal and child health are crucial for the well-being of a society. Armed conflicts negatively affect health systems including maternal and child health services. We explored access and utilization of prenatal and postnatal care services in Nagorno-Karabakh: a frozen conflict zone.

Methods

We applied cluster sampling to draw a sample of 1023 households in Nagorno-Karabakh in 2022. Interviewer-administered surveys were conducted among women of reproductive age (18-49) from the selected households. The instrument captured key reproductive health, and maternal and child health indicators, for the youngest 0-5 y.o. child.

Results

Out of 1023 women, 299 (29.5%) had at least one 0-5 y.o. child: 54.5% males and 45.5% females. Almost all the respondents received prenatal care (97.7%), the majority of them (95%) starting in the first trimester with frequency of more than 4 visits (90.7%). The visits included blood pressure measurement (99.3%), urine test (99.7%), blood test (99.7%), checking baby's heartbeat (99.3%), ultrasound (98.3%), nutrition education (82.9%) and breastfeeding counseling (79.8%), and asking about vaginal bleeding episodes (58.2%). Less than half of the respondents reported folic acid (49.5%) and iron (46.5%) supplementation during the pregnancy. While in the healthcare facility, mostly doctors checked mothers’ and babies’ health, 78.6% and 90.3%, respectively. Once discharged, less than 50% of the mothers and more than 80% of the babies received follow-up health checks.

Conclusions

Despite operating in a frozen-conflict zone, the health system of Nagorno-Karabakh was able to provide prenatal care in line with global evidence-based recommendations. Our findings indicate some gaps in breastfeeding counseling, folic-acid supplementation, and utilization of postnatal services. Capacity-building and community-based educational programs have the potential to improve overall prenatal and postnatal care and build sustainable health systems.

Key messages

• This unique study showed that despite operating in a frozen-conflict zone, the health system of Nagorno-Karabakh was able to provide prenatal care in line with global evidence-based recommendations.

• Capacity building, as well as patient-provider and community-based educational programs have the potential to improve overall prenatal and postnatal care in Nagorno-Karabakh.
Factors that influence the uptake and delivery of HPV vaccines in migrants: a systematic review
Authors: Mansour R , Razai M , Hargreaves S
Published: October 2023

Background

Migrants are known to be an under-immunised group for many routine vaccinations. We did a global systematic review to explore and assess factors that influence uptake of vaccines for human papillomavirus (HPV) infection, using the WHO-endorsed Behavioural and Social Driver of Vaccination Framework (BeSD).

Methods

Using PRISMA guidelines, 3,075 records were found from 7 databases (2006-2023), with no exclusions based on country or language. After title/abstract screening and full-text review, data were extracted for thematic analysis using BeSD (4 domains for vaccine behavioural change) and qualitative synthesis.

Results

We included 104 studies from 16 countries: two thirds from the US, 25% from Europe, and only 2% from LMICs. The majority focused on vaccine eligibility and/or parents; 10% looked at providers’ views; 2% involved wider stakeholders, and most research focused on females. Migrant sub-groups reported diverse views and experiences about HPV vaccines. Many examined vaccine initiation and identified low awareness/knowledge of HPV/HPV vaccine. “What people think/feel” domain: barriers such as concerns on vaccine safety, cultural belief, lack of information, vaccine unnecessary; mixed view on vaccine benefit. “Social process”: doctor recommendation and information via providers/peers was influential but depended on framing and migrant characteristics. “Motivation” domain was understudied. “Practical issues” that impact uptake included cost, mobility, accessibility, and language.

Conclusions

Culturally sensitive education to address misconception and enhance importance of HPV vaccines were considered important, alaongside practical efforts to address mobility (mHealth), proactive vaccine behaviour and strong provider recommendation. A comprehensive strategy along the BeSD pathway, using a multipronged approach, would be valuable, and may be further enhanced by exploring wider macro-level factors.

Key messages

• Special efforts will be needed to engage mobile groups in HPV vaccination, with further research needed in LMICs.

• Culturally sensitive education to address misconception and enhance importance of HPV vaccines were considered important.