Barreiras no acesso à Atenção Básica pela população LGBTQIA+: uma revisão integrativa / Barriers to access to Primary Care for the LGBTQIA+ population: an integrative review / Barreras de acceso a la Atención Primaria para la población LGBTQIA+: una revisión integradora

Introdução: A população LGBT constitui um grupo cujo acesso à saúde é historicamente limitado e ainda hoje é atravessado por questões complexas que envolvem desde a formação dos profissionais de saúde à própria estrutura organizacional do sistema assistencial. Apesar disso, a literatura científica acerca dos entraves que estes indivíduos enfrentam na Atenção Primária à Saúde (APS), porta de entrada e coordenadora do cuidado, é particularmente escassa. Objetivo: Caracterizar as barreiras envolvidas no acesso da população LGBTQIA+ à APS. Métodos: Trata-se de uma revisão integrativa de estudos científicos selecionados nas plataformas de busca PubMed e Portal Regional da Biblioteca Virtual em Saúde (BVS), sendo utilizados como descritores de busca os termos Minorias Sexuais e de Gênero, LGBTQIA+, APS e Acesso aos Serviços de Saúde. Foram incluídos artigos completos sem restrição de período nos idiomas inglês, português e espanhol. Foram excluídos textos do tipo: revisão bibliográfica; editorial; protocolos de estudo; opinião de especialistas e relato de experiência. Resultados: Foram selecionados 14 artigos, sendo seus conteúdos atribuídos a três eixos de discussão: barreiras físicas/organizacionais, barreiras sociais e barreiras relacionadas à educação/formação dos profissionais da saúde. Conclusões: É essencial expandir as discussões sociais acerca da temática de diversidade sexual e de gênero de modo a desconstruir os preconceitos instituídos; ademais, faz-se fundamental a revisão da estrutura física e organizacional ­ bem como da formação dos profissionais da saúde ­ para criar um ambiente assistencial inclusivo na atenção básica à população LGBTQIA+.

Introduction: The LGBT population is a group whose access to health care has historically been limited and is still crossed by complex issues ranging from the training of health professionals to the very organisational structure of the care system. Despite this, the scientific literature on the obstacles faced by these individuals in Primary Health Care, the gateway and coordinator of care, is particularly scarce. Objective: To characterize the barriers involved in the access of the LGBTQIA+ population to primary care. Methods: This is an integrative review of scientific studies selected from the PubMed and Virtual Health Library (VHL) Regional Portal search platforms, using as search descriptors the terms Sexual and Gender Minorities, LGBTQIA+, Primary Health Care, Health Services Accessibility. Complete articles were included without time restriction, in English, Portuguese and Spanish. Texts such as: literature reviews; editorials; study protocols; expert opinions and experience reports were excluded. Results: The review was composed by the selection of 14 studies, and their contents were assigned to three axes of discussion: physical/organizational barriers, social barriers, barriers related to education/training of health professionals. Conclusions: It is essential to expand the social discussions about the theme of sexual and gender diversity to deconstruct the established prejudices, moreover, it is essential to review the physical and organizational structure ­ as well as the training of health professionals ­ to create an inclusive care environment.

Introducción: La población LGTB es un colectivo cuyo acceso a la atención sanitaria ha estado históricamente limitado y sigue atravesado por complejas cuestiones que van desde la formación de los profesionales sanitarios hasta la propia estructura organizativa del sistema asistencial. A pesar de ello, la literatura científica sobre los obstáculos a los que se enfrentan estas personas en la Atención Primaria de Salud, puerta de entrada y coordinadora de la atención, es especialmente escasa. Objetivo: Caracterizar las barreras que supone el acceso de la población LGBT a la atención primaria. Métodos: Se trata de una revisión integradora de estudios científicos seleccionados de las plataformas de búsqueda PubMed y Portal Regional de la Biblioteca Virtual de Salud (BVS), utilizando como descriptores de búsqueda los términos Minorías Sexuales y de Género, LGBT, Atención Primaria de Salud, Accesibilidad a los Servicios de Salud. Se incluyeron artículos completos sin restriccíon de período, en inglés, portugués y español. Se excluyeron textos como revisiones bibliográficas, editoriales, protocolos de estudio, opiniones de expertos e informes de experiencias. Resultados: El corpus final de artículos se compuso de la selección de 14 artículos, y sus contenidos se asignaron a tres ejes de discusión: barreras físicas/organizativas, barreras sociales, barreras relacionadas con la educación/formación de los profesionales sanitarios. Conclusiones: Es esencial ampliar las discusiones sociales sobre el tema de la diversidad sexual y de género de manera que se deconstruyan los prejuicios institucionales, además, se hace fundamental la revisión de la estructura física y organizacional ­ así como la formación de los profesionales de la salud ­ para crear un ambiente asistencial inclusivo.

Percepções e ações da equipe multiprofissional em saúde sobre a medicina tradicional indígena / Perceptions and actions of the multi-professional health team on traditional indigenous medicine / Percepciones y acciones del equipo multidisciplinario de salud sobre la medicina tradicional indígena

Objetivo: compreender as percepções e as ações de uma equipe multiprofissional em saúde quanto à prática da medicina tradicional indígena em uma Casa de Atenção à Saúde Indígena. Método: estudo qualitativo descritivo, realizado em uma de Casa de Apoio à Saúde Indígena em um município do Pará, que incluiu oito profissionais de uma equipe multiprofissional. A coleta de dados foi realizada no ano de 2018 e estes foram examinados pelo método da análise de conteúdo. Resultados: inserção e prática do cristianismo; ritos e lideranças xamânicas; e postura da equipe de multidisciplinar foram as categorias elencadas, que apontam os entendimentos e atuações da equipe multiprofissional e da organização espacial da Casa de Saúde do município. Considerações finais: há novos costumes e valores entre as etnias, em virtude da aproximação de grupos religiosos, cujas ações foram registradas e apreendidas pela equipe de trabalhadores em saúde.

Objective: understanding the perceptions and actions of a multi-professional health team regarding the practice of traditional indigenous medicine in an Indigenous Health Care Center. Method: this is a descriptive qualitative study carried out in an Indigenous Health Support Center in a municipality in the state of Pará, which included eight professionals from a multi-professional team. Data was collected in 2018 and examined using the content analysis method. Results: insertion and practice of Christianity; shamanic rites and leadership; and the attitude of the multidisciplinary team were the categories listed, which point to the understandings and actions of the multi-professional team and the spatial organization of the Health Center in the municipality. Final considerations: there are new customs and values among ethnic groups, due to the approach of religious groups, whose actions were recorded and apprehended by the team of health workers.

Objetivo: comprender las percepciones y acciones de un equipo multidisciplinario de salud sobre la práctica de la medicina tradicional indígena en una Casa de Atención para la Salud Indígena. Método: estudio descriptivo cualitativo, realizado en una Casa de Apoyo a la Salud Indígena de un municipio de Pará, que incluyó ocho profesionales de un equipo multidisciplinario. La recolección de datos se realizó en 2018 y los datos fueron sometidos al método de análisis de contenido. Resultados: inserción y práctica del cristianismo; ritos y líderes chamánicos; y actitud del equipo multidisciplinario fueron las categorías enumeradas, que indican la percepción y las acciones del equipo multidisciplinario y la organización espacial de la Casa de Salud del municipio. Consideraciones finales: existen nuevas costumbres y valores entre las etnias, debido a la presencia de grupos religiosos, el equipo de los trabajadores de la salud registró y aprendió las acciones de los indígenas.

Second Look at Reported Racial-Ethnic Employment Differences in the Supported Employment Demonstration.

OBJECTIVE: The Supported Employment Demonstration (SED) trial, which studied the effects of individual placement and support (IPS) among individuals initially denied Social Security Administration disability benefits for mental illness, reported racial-ethnic differences in IPS' effect on employment. Because of high rates of attrition in the SED, this finding warranted further study. The current reanalysis used a subsample with a directly observed measure of competitive employment and less attrition to try to corroborate the reported racial-ethnic differences. METHODS: The authors compared self-reported employment (collected via telephone interviews) with observed employment (reported monthly by multidisciplinary teams) among a representative subsample (N=614) of the SED, stratified by race and ethnicity. RESULTS: The observed competitive employment outcomes showed no significant racial-ethnic differences among those assigned to participate in IPS. CONCLUSIONS: Congruent with previous research, reanalysis based on more complete data and more rigorous outcome measurements implied an absence of racial-ethnic differences in IPS' effect on observed employment outcomes.

Perception, Practice and Cost Burden of Medical Tourism Among Physicians in Public Tertiary Health Facilities in Oyo State, South-West, Nigeria.

BACKGROUND: Physicians are key to the clinical decision-making of their clients. Their perception and practice of medical tourism could influence their clients' uptake of the same. This study assessed the perceptions about medical tourism among physicians practising in public tertiary health facilities in Oyo state. We then assessed its practice and cost burden among physicians who had ever engaged in medical tourism. METHODOLOGY: This cross-sectional study conducted in 2019 involved 360 physicians working in two public tertiary health facilities in Oyo State, selected via a two-stage simple random sampling technique. Quantitative data was collected using a semi-structured pre-tested self-administered tool. Data collected was analysed using STATA 17.0 with statistical significance inferred at p<0.05. FINDINGS: The physicians' mean score on knowledge of medical tourism was 4.0±0.8 of 5 marks obtainable. Organ transplant was the most commonly known reason for engaging in medical tourism. Destination country hospital facilities and equipment ranked highest and cost considerations ranked least of perceived factors promoting it. Twenty-four (6.7%) of the physicians studied ever engaged in medical tourism, while 258 (71.7%) intend to if the need arose. The most popular destination country was India. The mean direct cost of engaging in medical tourism was $3,351±$4,357. The mean indirect cost was $2,389±$774, while the mean total cost was $5,739.6±$4,841.8. The majority of the 24 physicians (83.3%) who engaged in medical tourism suffered catastrophic health spending from it. CONCLUSION: High burden of medical tourism on the physicians. Funds spent on medical tourism by them could be used to strengthen the delivery of health services, such as ensuring children are fully immunised.

CONTEXTE: Les médecins jouent un rôle clé dans la prise de décision clinique de leurs patients. Leur perception et leur pratique du tourisme médical pourraient influencer l'adoption de cette pratique par leurs patients. Cette étude a évalué les perceptions concernant le tourisme médical parmi les médecins exerçant dans des établissements de santé tertiaires publics de l'État d'Oyo. Nous avons ensuite évalué sa pratique et son coût parmi les médecins ayant déjà eu recours au tourisme médical. MÉTHODOLOGIE: Cette étude transversale menée en 2019 a impliqué 360 médecins travaillant dans deux établissements de santé tertiaires publics de l'État d'Oyo, sélectionnés par une technique d'échantillonnage aléatoire simple en deux étapes. Des données quantitatives ont été recueillies à l'aide d'un outil semi-structuré pré-testé et auto-administré. Les données collectées ont été analysées à l'aide de STATA 17.0, avec une signification statistique déduite à p<0,05. RÉSULTATS: Le score moyen des médecins en termes de connaissance du tourisme médical était de 4,0±0,8 sur 5 points possibles. La greffe d'organes était la raison la plus souvent citée pour recourir au tourisme médical. Les infrastructures et équipements hospitaliers du pays de destination étaient les facteurs les plus influents, tandis que les considérations de coût étaient les moins perçues. Vingt-quatre (6,7 %) des médecins étudiés avaient déjà eu recours au tourisme médical, tandis que 258 (71,7 %) avaient l'intention de le faire en cas de besoin. Le pays de destination le plus populaire était l'Inde. Le coût direct moyen du recours au tourisme médical était de 3 351 $±4 357 $. Le coût indirect moyen était de 2 389 $±774 $, tandis que le coût total moyen était de 5 739,6 $±4 841,8$. La majorité des 24 médecins (83,3 %) ayant eu recours au tourisme médical ont subi des dépenses de santé catastrophiques à cause de cela. CONCLUSION: Le fardeau du tourisme médical sur les médecins est élevé. Les fonds dépensés pour le tourisme médical pourraient être utilisés pour renforcer la prestation des services de santé, comme assurer que les enfants soient entièrement vaccinés. MOTS CLÉS: Tourisme médical, Connaissance, Pratique, Fardeau des coûts, Services de santé, Dépenses de santé catastrophiques, Facteurs déterminants du tourisme médical, Touristes médicaux.

Australian women's experiences and perceptions of interconception care: a qualitative descriptive study.

BACKGROUND: Interconception, the time between pregnancies, is an opportunity to improve the health outcomes of women, infants and subsequent pregnancies. Interconception care involves the assessment of previous pregnancy outcomes, management of maternal risk factors, advice regarding optimal pregnancy spacing, and postpartum contraception provision. However, there is no consistent provision of interconception care, and limited understanding of consumer perspectives. This study aims to describe Australian women's perceptions and experiences of interconception care. METHODS: A qualitative descriptive semi-structured interview study was undertaken in July 2022 with women of reproductive age who had given birth to at least one child with intention to have another child. Reflexive thematic analysis was conducted and the standards for reporting qualitative research informed the writing of this study. RESULTS: From 15 participants, analysis identified two major themes: (1) women's lack of engagement with interconception care services; and (2) difficulties accessing interconception care. All participants were unfamiliar with interconception terminology, but most perceived it as a distinct care need, largely accessed in primary healthcare settings. Participants wanted further support to be initiated by healthcare professionals about issues such as breastfeeding, postpartum care and lifestyle risk reduction. Interconception care availability and content was perceived as inconsistent, ineffective and provided opportunistically. Participants outlined the need for improved consumer and healthcare professional interconception care awareness, education, and woman-centred continuity of care. CONCLUSIONS: Interconception care awareness is needed by women and healthcare professionals to better meet the needs of women during this life stage.

Navigating Uncertainty: Adapting Guidance for Mental Health During the COVID-19 Public Health Emergency & the Crucial Role of Bi-directional Feedback.

In response to the COVID-19 public health emergency, state and local mental health authorities rapidly developed and disseminated guidance to community mental health agencies. While tailored communication is effective to reach target audiences under usual circumstances, strategies to facilitate the implementation of guidance amidst a rapidly evolving public health emergency are not well understood. This project sought to understand factors informing decision-making about adaptations to guidance, and strategies used to disseminate and facilitate guidance implementation among system-level community partners in OnTrackNY Coordinated Specialty Care (CSC) programs for early psychosis. Semi-structured interviews were conducted with New York State Office of Mental Health (NYS OMH) state and local mental health authorities including state leaders (n = 3) and NYS OMH field office directors (n = 4), OnTrackNY program directors (n = 4), and leadership and trainers of an intermediary organization, OnTrack Central (n = 12). Interviews were analyzed using content analysis. Code reports relevant to guidance decision-making and dissemination were reviewed to identify emerging themes. For state and local mental health authorities, decision-making was influenced by changing COVID-19 risk levels, need for alignment between federal and local guidance, and balancing support for workforce capacity and mental health service continuity. For OnTrackNY program directors, decision-making was influenced by internal infrastructure and processes (e.g., program autonomy), availability of resources (e.g., technology), and perspective on managing risk and uncertainty (e.g., COVID-19, regulatory waiver expiration). For OnTrack Central, decision-making focused on balancing CSC model fidelity with OnTrackNY team capacity and resources. Dissemination of guidance consisted of mass and targeted strategies. Information flow was bidirectional such that top-down dissemination of guidance (e.g., from state mental health authorities to providers) was informed and refined with bottom-up feedback (e.g., from providers to state leadership) through surveys and professional forums (e.g., COVID-19 town halls, provider learning collaboratives). Unlike a planned approach to disseminate new policies, public health emergencies create variable landscapes that may warrant a deeper understanding of how guidance may be adapted to fit rapidly evolving community partner needs. Findings may inform efforts to identify processes that contribute to adaptation and dissemination of guidance for mental health during future public health emergencies.

Strengthening nutrition policy and service delivery: Lessons learned from a six-country assessment of Alive and Thrive's technical assistance.

Alive & Thrive (A&T) provides strategic technical assistance (TA) to develop effective policies; improve maternal, infant, and young child nutrition (MIYCN) programme design and implementation and enhance system capacity to sustain quality MIYCN service delivery at scale. A qualitative assessment was conducted using document review and stakeholder interviews (n = 79) to describe a selection of A&T's TA in six countries and systematically assess the contextual and TA process-related factors that influenced the results achieved and document the lessons learned about MIYCN TA design and implementation. To facilitate the selection of different types of TA, we classified TA into two levels of stakeholder engagement and intensity. Under the Technical Advisor TA category, we assessed A&T's support to strengthen national policy formulation, monitoring, and implementation of the International Code of Marketing of Breast-milk Substitutes. For Capacity Development TA, we assessed A&T support to scale-up maternal nutrition services and to increase strategic use of data. Factors important for TA provision included identifying and engaging with the right people, using evidence to support advocacy and decision-making, using multiple ways to strengthen capacity, developing packages of tools to support programme scale-up, and reinforcing feedback mechanisms to improve service provision and data quality. Challenges included shifts in the political context, poorly functioning health systems, and limited resources to replicate or sustain the progress made. Continued investment in evidence-based and practical TA that strengthens the institutionalization of nutrition across all stakeholders-including government, medical associations, civil society and development partners-is essential. Future TA must support governments to strengthen system capacity for nutrition, including financial and human resource gaps that hamper full scale-up.

An updated model of rural hospital financial distress.

PURPOSE: To create a model that predicts future financial distress among rural hospitals. METHODS: The sample included 14,116 yearly observations of 2311 rural hospitals recorded between 2013 and 2019. We randomly separated all sampled hospitals into a training set and test set at the start of our analysis. We used hospital financial performance, government reimbursement, organizational traits, and market characteristics to predict a given hospital's risk of experiencing one of three financial distress outcomes-negative cash flow margin, negative equity, or closure. FINDINGS: The model's area under the receiver operating characteristic curve (AUC) equaled 0.87 within the test set, indicating good predictive ability. We classified 30.55% of the observations in our sample as lowest risk of experiencing financial distress over the next 2 years. In comparison, we classified 32.52% of observations as mid-lowest risk of distress, 26.40% of observations as mid-highest risk, and 10.52% of observations as highest risk. Among test set observations classified as lowest-risk, 5.78% experienced negative cash flow margin within 2 years, 1.50% experienced negative equity within 2 years, and zero observations experienced closure within 2 years. Within the highest-risk group, 61.57% of observations experienced negative cash flow margin, 43.02% experienced negative equity, and 3.33% experienced closure. CONCLUSIONS: Given the ongoing challenges and consequences of rural hospital unprofitability, there is a clear need for accurate assessments of financial distress risk. The financial distress model can be used by researchers, policymakers, and rural health advocates as a screening tool to identify at-risk rural hospitals for closer monitoring.

Evaluating a volunteer 'Health Champions' intervention supporting people with severe mental illness to manage their physical health: feasibility hybrid randomised controlled trial.

BACKGROUND: People with severe mental illness (SMI) have worse physical health than the general population. There is evidence that support from volunteers can help the mental health of people with SMI, but little evidence regarding the support they can give for physical health. AIMS: To evaluate the feasibility of an intervention where volunteer 'Health Champions' support people with SMI in managing their physical health. METHOD: A feasibility hybrid randomised controlled trial conducted in mental health teams with people with SMI. Volunteers delivered the Health Champions intervention. We collected data on the feasibility of delivering the intervention, and clinical and cost-effectiveness. Participants were randomised by a statistician independent of the research team, to either having a Health Champion or treatment as usual. Blinding was not done. RESULTS: We recruited 48 participants: 27 to the intervention group and 21 to the control group. Data were analysed for 34 participants. No changes were found in clinical effectiveness for either group. Implementation outcomes measures showed high acceptability, feasibility and appropriateness, but with low response rates. No adverse events were identified in either group. Interviews with participants found they identified changes they had made to their physical health. The cost of implementing the intervention was £312 per participant. CONCLUSIONS: The Health Champion intervention was feasible to implement, but the implementation of the study measures was problematic. Participants found the intervention acceptable, feasible and appropriate, and it led them to make changes in their physical health. A larger trial is recommended, with tailored implementation outcome measures.

Artificial Intelligence in Identifying Patients With Undiagnosed Nonalcoholic Steatohepatitis.

Background: Although increasing in prevalence, nonalcoholic steatohepatitis (NASH) is often undiagnosed in clinical practice. Objective: This study identified patients in the Veterans Affairs (VA) health system who likely had undiagnosed NASH using a machine learning algorithm. Methods: From a VA data set of 25 million adult enrollees, the study population was divided into NASH-positive, non-NASH, and at-risk cohorts. We performed a claims data analysis using a machine learning algorithm. To build our model, the study population was randomly divided into an 80% training subset and a 20% testing subset and tested and trained using a cross-validation technique. In addition to the baseline model, a gradient-boosted classification tree, naïve Bayes, and random forest model were created and compared using receiver operator characteristics, area under the curve, and accuracy. The best performing model was retrained on the full 80% training subset and applied to the 20% testing subset to calculate the performance metrics. Results: In total, 4 223 443 patients met the study inclusion criteria, of whom 4903 were positive for NASH and 35 528 were non-NASH patients. The remainder was in the at-risk patient cohort, of which 514 997 patients (12%) were identified as likely to have NASH. Age, obesity, and abnormal liver function tests were the top determinants in assigning NASH probability. Conclusions: Utilization of machine learning to predict NASH allows for wider recognition, timely intervention, and targeted treatments to improve or mitigate disease progression and could be used as an initial screening tool.

Marketing mental health services: a mixed-methods analysis of racially and ethnically diverse college students' engagement with and perspectives on U.S. university mental health clinics' websites.

BACKGROUND: The United States (U.S.) faces a significant mental health crisis, with around 52.9 million adults experiencing mental health disorders, with young adults (18-25 years old), such as college students, having the highest prevalence and lowest service utilization rates. While efforts to expand mental health services through "push" strategies are in place (e.g., training therapists in evidence-based therapies), limited initial engagement suggests a need for "pull strategies" and targeted marketing that make services attractive to college students and increase demand. This mixed-methods study identifies U.S. university mental health clinic websites and website characteristics that are attractive and engaging to college students interested in seeking mental health services (i.e., students were considering or actively looking for mental health support). METHODS: Eleven U.S. university websites were chosen (10 randomly and one from the university where students were attending) from a pool of 44 Psychological Clinical Science Accreditation System training clinics websites. Fifty-seven college students (Mage = 20.95, SD = 2.97; 81% female; 68% racial/ethnic minority) were videorecorded engaging with two U.S. university mental health clinic websites, completed self-report engagement measures, and gave detailed feedback about websites through semi-structured interviews. RESULTS: Likert scale scores revealed moderate engagement with all websites (e.g., they were interesting and helpful). Qualitative results indicated that websites that provided important and easily understood information about key features of services (e.g., types, evidence-base, and cost), therapist backgrounds, psychoeducation, used lay language, and had an appealing website layout (e.g., color, font, images, organization, and interactive components) generated greater consumer interest and trust in their mental health services. CONCLUSIONS: This study emphasizes the importance of using marketing strategies to enhance college students' engagement through mental health service websites. Salient features, psychoeducation, and effective promotional strategies (e.g., how information is presented) were identified as crucial for website engagement and subsequent mental health service uptake. Using marketing strategies, such as tailoring language to consumer literacy levels, describing the evidence-base of services, and improving website design may address college students' needs and enhance initial mental health service engagement.

Endometrial Cancer - Long-Term Survival in Certified Cancer Centers and Non-Certified Hospitals: Comparative Analysis Based on a Large German Retrospective Cohort Study (WiZen).

Introduction Endometrial cancer is the most common malignant tumor of the female genital organs. In Germany, treatment is provided in both cancer centers certified by the German Cancer Society (Deutsche Krebsgesellschaft, DKG) and in non-certified hospitals. This study investigated whether treatment in DKG-certified centers leads to improved overall survival of patients with endometrial cancer. Materials and Methods Data from 11 legally independent German statutory health insurance (SHI) funds of the AOK were analyzed as well as data from four clinical cancer registries (CCR), resulting in inclusion of 30 102 AOK patients and 8190 registry patients with a diagnosis (incidental cases) of ICD-10-GM code C54 (malignant neoplasm of corpus uteri). For comparative survival analyses, multivariable Cox regressions and Kaplan-Meier analyses were used. Results The Kaplan-Meier estimator for 5-year overall survival was 66.7% for patients from certified centers and 65.0% for patients from non-certified hospitals (using SHI data; CCR data: 63.4% vs. 60.7%). Cox regression adjusted for relevant confounders showed a hazard ratio (HR) of 0.93 (SHI data; 95% CI 0.86 - 1.00; p = 0.050) and 0.935 (CCR data; 95% CI 0.827 - 1.057; p = 0.281) for all-cause mortality. In a subgroup analysis (CCR), patients with International Union against Cancer Control (UICC) stage I had a significant survival benefit if treated in a certified center (HR 0.783; 95% CI 0.620 - 0.987; p = 0.038). Conclusion The study presented herein shows that patients with endometrial cancer treated in a certified cancer center tend to have better survival rates. This should be considered when selecting the treating hospital.

Depressive and Anxiety Symptoms Were More Common for Transgender Individuals Whose Gender-Affirming Surgeries Were Cancelled or Delayed Due to COVID-19: A Global Cross-Sectional Study.

Gender-affirming surgeries, which have well-established mental health benefits, were cancelled and delayed for transgender people worldwide during the COVID-19 crisis. Of 253 scheduled gender-affirming surgeries among transgender adults across 35 countries in late 2020, 27% (n=69) reported that the COVID-19 crisis limited their access to gender-affirming surgery (i.e., cancelled, postponed indefinitely, or rescheduled). In adjusted models, respondents with reduced access to surgeries were somewhat more likely to screen positive for depressive or anxiety symptoms, whereas those who maintained access were more likely to report higher levels of happiness. Our findings illustrate the transgender-specific harms of the COVID-19 crisis on gender-affirming surgeries and mental health.

Meeting Men Where they are: Motivators and Barriers to Accessing Health Services through a Men's Mobile Wellness Clinic, October 2019 to March 2020, Blantyre, Malawi.

BACKGROUND: In Malawi approximately, 88.3% people living with HIV are aware of their HIV status. Significant gaps are among men aged 15-34 years; only 72% know their HIV status. To reach men, Jhpiego, in collaboration with the Ministry of Health (MOH), implemented the Men's Mobile Wellness Clinic (MMWC) at workplace settings in Blantyre, Malawi between October 2019 and March 2020. METHODS: We conducted a descriptive qualitative study to understand motivators and barriers to MMWC service uptake by employees and employers. Primary data was drawn from in-depth telephone interviews from four study populations: employers who accepted or declined to host the MMWC at their worksite, and employees who accessed or did not access the services. We performed a thematic analysis using Nvivo 12 software to identify patterns and themes across the dataset. FINDINGS: Main reasons given for using the service among male employees were a desire to know their health status, availability of free health services at the workplace, and good quality services offered by MMWC staff, and support from their supervisor. Men who did not access services stated reasons such as work-clinic scheduling conflicts, lack of adequate promotion of the service, and miscommunication on the criteria about who should attend the MMWC. Employers who accepted to host the MMWC stated convenience and employee's rights to know their health status. Those who declined either stated that employees did not want the services or COVID-19 preventive measures by the MOH between October 2019 and March 2020 restricted participation. CONCLUSION: This study underscores the potential utility of MMWC services including HIV testing among men. The desire to know their health status, availability of free MMWC services at the workplace, good quality services offered by MMWC staff, and the endorsement of MMWC by supervisors were main motivators to access the MMWC services. Sensitizing supervisors and employees about the benefits of the MMWC services, strengthening demand creation, and clarifying eligibility are important to facilitate MMWC uptake among men in Malawi.

From challenges to opportunities: Digital transformation in hospital-at-home care.

BACKGROUND: Digital transformation is an ongoing sosio-technological process that can create opportunities in the health sector. However, the current landscape of digital transformation in hospital-at-home care is unknown. AIM: To describe healthcare providers' perspectives of digital transformation in hospital-at-home care. METHODS: A total of 25 semi-structured interviews were conducted in September-October 2023 in all Finnish wellbeing services counties (n = 21), the city of Helsinki (n = 1), and private health care providers (n = 3). Snowball sampling was used (N = 46). The data underwent an inductive content analysis. RESULT: The analysis revealed four main and 17 generic categories of challenges and opportunities of digital transformation in hospital-at-home care. These challenges and opportunities were related to 1) Health information exchange in and across hospital-at-home care; 2) Management of hospital-at-home care; 3) Logistics in hospital-at-home care planning and delivery; and 4) Digital health interventions in hospital-at-home care delivery. CONCLUSIONS: The challenges and opportunities of digital transformation in the hospital-at-home care is intricately linked to the efficiency of health information exchange, management, logistics, and digital health interventions. Addressing the key areas of improvement in health information exchange can lead to more streamlined patient care processes and improved communication between healthcare professionals and patients. Digital transformation in management and logistics can improve overall efficiency within healthcare systems. Digital health interventions may promote equitable and universal access to high-quality healthcare. Continued focus on health care information infrastructure, in particular interoperability of electronic health records and optimization of information flow, will be essential to realize the full potential of digitalization.

Precision emergency medicine in health care delivery and access: Framework development and research priorities.

BACKGROUND: The integration of precision emergency medicine (EM) into our conceptualization of the health care system affords the opportunity to improve health care access, delivery, and outcomes for patients. As part of the Society for Academic Emergency Medicine (SAEM) Consensus Conference, we conducted a rapid literature review to characterize the current state of knowledge pertaining to the intersection of precision EM (defined as the use of big data and technology to deliver acute care for individual patients and their communities) with health care delivery and access. We then used our findings to develop a proposed conceptual model and research agenda. METHODS: We completed a rapid review of the existing literature on the utilization of big data and technology to ensure and enhance access to acute/unscheduled care for individual patients and their communities. Literature searches were conducted using Ovid MEDLINE, Embase.com, Cochrane CENTRAL via Ovid, and ClinicalTrials.gov in January 2023. Using the identified articles, we determined core domains, developed a framework to guide the conceptualization of precision EM in health care delivery and access, and used these to identify a research agenda. RESULTS: Of the 815 studies identified for initial screening, 60 underwent full-text review by our technical expert panel and 21 were included in the evaluation. Core domains identified included expedited/personalized prehospital care, delivery to the right level of care, personalized ED care, alternatives to ED care/post-ED care, prediction tools for system readiness, and creation of equitable systems of care. A research agenda with four priority research questions was defined following identification of the core domains. CONCLUSIONS: Precision EM includes consideration of the health care delivery system as a mechanism for improving access to emergency care using data-driven strategies. This provides a unique opportunity to use data and technology to advance systems of care while also centering patients, communities, and equity in these advances.