Public health relevance of medicines developed under paediatric legislation in Europe and the USA: a systematic mapping study.

BACKGROUND: Legislation in the European Union (EU) and the USA promoting the development of paediatric medicines has contributed to new treatments for children. This study explores how such legislation responds to paediatric health needs in different country settings and globally, and whether it should be considered for wider implementation. METHODS: We searched EU and US regulatory databases for medicines with approved indications resulting from completed paediatric development between 2007 and 2018. Of 195 medicines identified, 187 could be systematically mapped to the burden of the target disease for six study countries (Australia, Brazil, Canada, Kenya, Russia, South Africa) and globally, using disability-adjusted life years (DALYs). All medicines were also screened for inclusion on the WHO Model List of Essential Medicines (EML) and the EML for children under 13 years (EMLc). RESULTS: The studied medicines were disproportionately focused on non-communicable diseases, which represented 68% of medicines and 21% of global paediatric DALYs. On the other hand, we found 28% of medicines for communicable, maternal, neonatal and nutritional disorders, representing 73% of global paediatric DALYs. Neonatal disorders and malaria were mapped with two medicines, tuberculosis and neglected tropical diseases with none. The gap between medicines and paediatric DALYs was greater in countries with lower income. Still, 34% of medicines are included in the EMLc and 48% in the EML. CONCLUSIONS: Paediatric policies in the EU and the USA are only partially responsive to paediatric health needs. To be considered for wider implementation, paediatric incentives and obligations should be more targeted towards paediatric health needs. International harmonisation of legislation and alignment with global research priorities could further strengthen its impact on child health and support ongoing efforts to improve access to medicines. Furthermore, efforts should be made to ensure global access to authorised paediatric medicines.

Knowledge, attitudes, and practices toward COVID-19 prevention in Yemen: a community-based cross-sectional study.

Background: Pandemics, especially in fragile war-torn countries like Yemen, challenge their already strained health systems. Community adherence to pandemic prevention measures is necessary to curb the severity and spread of emerging pandemics - which is influenced by factors, such as people's knowledge and attitudes toward the pandemic. No studies in Aden have been published on the communities' knowledge, attitudes, and practices (KAP) toward COVID-19 prevention to date. To understand adherence to pandemic prevention measures in contexts with fragile health systems, this study investigated KAP of Yemeni participants toward the COVID-19 pandemic. Methods: We conducted face-to-face semi-structured questionnaires among 400 eligible participants whom were identified for participation in this study through systematic household sampling from eight districts in Aden, Yemen. Eligible participants were Yemeni community members who were ≥ 18 years, living for more than 10 years in Yemen, and were willing to voluntarily participate in the study. The questionnaire included questions surrounding the participants' COVID-19 knowledge (e.g., awareness of spread and prevention), attitudes (e.g., willingness to accept the vaccine or other prevention measures), and prevention practices during the pandemic (e.g., mask wearing, social distancing, vaccine uptake). Total KAP scores were calculated. Univariate and bivariate statistical analyses were conducted using STATA 13 software. Results: From January to May 2021 we conducted 400 questionnaires with Yemeni community members. The average age was 41.5 ± 14.5 years (range 18-86 years). The results demonstrated that the participants in this study had an intermediate knowledge (53%) and fair attitude (58%) scores. However, participants reported very poor COVID-19 prevention practices- with only 11% demonstrating these practices. Only 25% (100/400) practiced social distancing, 25% (98/400) wore a mask, and only 6% (27/400) of participants accepted (at least one dose of) the COVID-19 vaccine. Factors associated with increased knowledge were being male, married, and surprisingly those having a primary and middle school education levels (p < 0.05). Also participants who were diagnosed with COVID-19 or had a family member diagnosed with COVID-19 (vs. those not diagnosed OR = 2.08, 95% CI 1.07-3.78, p < 0.05) were more likely to know that the vaccine protects against severe COVID-19 infection and were more likely to apply good practices such as accepting the vaccine (OR = 2.65, 95% CI 1.17-6.00, p < 0.05) compared to those who were not. Conclusion: These findings raise awareness for the need of community-oriented education programs for COVID-19 which considers associated factors to improve the level of public knowledge, attitudes, and practices.

'We Should Not Be Quiet but We Should Talk': Qualitative Accounts of Community-Based Communication of HIV Pre-Exposure Prophylaxis.

Community leaders play an important role in the acceptance of public health services, but little is known about their willingness to facilitate HIV pre-exposure prophylaxis (PrEP) roll-out in Eswatini. We conducted in-depth interviews (n = 25) with purposefully selected male and female community leaders in Eswatini. We analysed our data inductively using a thematic analysis approach. Community leaders feel they are important communicators of culturally appropriate PrEP messaging. Our participants described a complex social space within their communities influenced by religion, tradition, values, and HIV stigma. Community leaders use their position to provide leverage for unique, effective, and easily accessible messages and platforms to reach the community in a manner that ensures trust, relatability, familiarity, and shared faith. Community leaders feel that they are trusted and see trust manifesting in the conversations they are able to engage in, and have a reach that extends beyond formal health services. Existing PrEP programming should embed community leader participation in PrEP programming and engage the trust, knowledge, and potential of community leaders to support PrEP uptake and acceptance.

Knowledge, Implementation, and Gaps of Gender-Based Violence Management Guidelines among Health Care Workers.

(1) Background: Gender-based violence (GBV) is widespread globally and has a myriad of adverse effects but is vastly under-reported. Health care workers are among the first responders in GBV. The objective of this study was to assess the knowledge of health workers with regard to GBV and related management guidelines and implementation. (2) Methods: The study employed a descriptive, sequential mix-method study, beginning with the quantitative part, followed by the qualitative component. Qualitative analysis was conducted using a content framework approach. (3) Results: More than two-thirds (71.79%) of health workers were found to be generally knowledgeable about gender-based violence; however, only 36.9% had good knowledge about gender-based violence management guidelines for gender-based violence and the mean value for all the items was less than 3 which indicates poor knowledge of the management guideline. Additionally, only 36.8% found the gender-based violence management guidelines useful and practical in clinical care for gender-based violence cases. (4) Conclusions: The finding of this study revealed that knowledge of gender-based violence management guideline was not adequate among health workers and rarely used during management of GBV cases. This calls for continuous training and specific refresher courses, including on-site practical sessions, professionals' mentorship, and supervision.

Exploring the Role of Infodemics in People's Incompliance with Preventive Measures during the COVID-19 in Conflict Settings (Mixed Method Study).

The evolving availability of health information on social media, regardless of its credibility, raises several questions about its impact on our health decisions and social behaviors, especially during health crises and in conflict settings where compliance with preventive measures and health guidelines is already a challenge due to socioeconomic factors. For these reasons, we assessed compliance with preventive measures and investigated the role of infodemic in people's non-compliance with COVID-19 containment measures in Yemen. To this purpose and to triangulate our data collection, we executed a mixed method approach in which raw aggregated data were taken and analyzed from multiple sources (COVID-19 Government Response Tracker and Google COVID-19 Community Mobility Reports), then complemented and verified with In-depth interviews. Our results showed that the population in Yemen had relatively complied with the governmental containment measures at the beginning of the pandemic. However, containment measures were not supported by daily COVID-19 reports due to low transparency, which, together with misinformation and lack of access to reliable sources, has caused the population not to believe in COVID-19 and even practice social pressure on those who showed some compliance with the WHO guidelines. Those results indicate the importance of adopting an infodemic management approach in response to future outbreaks, particularly in conflict settings.

Effects of the COVID-19 pandemic on general health and malaria control in Ghana: a qualitative study with mothers and health care professionals.

BACKGROUND: COVID-19 has severely impacted health systems and the management of non-COVID-19 diseases, including malaria, globally. The pandemic has hit sub-Saharan Africa less than expected; even considering large underreporting, the direct COVID-19 burden was minor compared to the Global North. However, the indirect effects of the pandemic, e.g. on socio-economic inequality and health care systems, may have been more disruptive. Following a quantitative analysis from northern Ghana, which showed significant reductions in overall outpatient department visits and malaria cases during the first year of COVID-19, this qualitative study aims to provide further explanations to those quantitative findings. METHODS: In the Northern Region of Ghana, 72 participants, consisting of 18 health care professionals (HCPs) and 54 mothers of children under the age of five, were recruited in urban and rural districts. Data were collected using focus group discussions with mothers and through key informant interviews with HCPs. RESULTS: Three main themes occurred. The first theme-general effects of the pandemic-includes impacts on finances, food security, health service provision as well as education and hygiene. Many women lost their jobs, which increased their dependance on males, children had to drop out of school, and families had to cope with food shortages and were considering migration. HCPs had problems reaching the communities, suffered stigmatisation and were often barely protected against the virus. The second theme-effects on health-seeking-includes fear of infection, lack of COVID-19 testing capacities, and reduced access to clinics and treatment. The third theme-effects on malaria-includes disruptions of malaria preventive measures. Clinical discrimination between malaria and COVID-19 symptoms was difficult and HCPs observed increases in severe malaria cases in health facilities due to late reporting. CONCLUSION: The COVID-19 pandemic has had large collateral impacts on mothers, children and HCPs. In addition to overall negative effects on families and communities, access to and quality of health services was severely impaired, including serious implications on malaria. This crisis has highlighted weaknesses of health care systems globally, including the malaria situation; a holistic analysis of the direct and indirect effects of this pandemic and an adapted strengthening of health care systems is essential to be prepared for the future.

Does EU and US paediatric legislation improve the authorization availability of medicines for children in other countries?

AIM: For over 15 years, the pharmaceutical industry has been engaged in developing medicines for children to comply with the European Union (EU) and the United States (US) regulatory requirements. We assessed the authorization availability of these medicines in countries without paediatric regulatory obligations. Special attention was given to the authorization availability of paediatric formulations. METHODS: Medicines for children were sampled from the US Food and Drug Administration and European Medicines Agency websites. We carried out systematic content analysis of product information and compared paediatric labelling in Australia, Brazil, Canada, Russia and South Africa with the EU or the US. The authorization availability of paediatric formulations in originator and generic medicines was reviewed. In Kenya, the authorization availability of sampled medicines and paediatric formulations was investigated. RESULTS: A total of 161 medicines authorized in the EU or the US were sampled. Whilst at least one paediatric indication was found in 70% of the medicines, the EU and US level of authorization was on average 38% in Australia, Brazil, Canada, Russia and South Africa. Paediatric formulations were authorized on average for 40% of originator and 36% of generic medicines. Kenya had the lowest authorization availability of medicines (40%) and formulations (26%). CONCLUSIONS: The authorization availability of novel medicines for children is lower in countries without paediatric regulatory obligations. Paediatric formulations often do not reach other countries if left unregulated, and their generic uptake is low. To increase authorization availability, submission of paediatric development results should become obligatory in each jurisdiction. Policy initiatives to stimulate the introduction of developed formulations should be encouraged.

Clinical and Epidemiological Presentation of COVID-19 among Children in Conflict Setting.

Background: This study aims to describe the observable symptoms of children with COVID-19 infection and analyze access to real-time polymerase chain reaction (RT-PCR) testing among children seeking care in Yemen. Method: In the period of March 2020−February 2022, data were obtained from 495 children suspected to have been infected with COVID-19 (from a larger register of 5634 patients) from the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden, Yemen. Results: Overall, 21.4% of the children with confirmed COVID-19 infection were asymptomatic. Fever (71.4%) and cough (67.1%) were the most frequently reported symptoms among children, and children were less likely to have fever (p < 0.001), sore throat (p < 0.001) and cough (p < 0.001) compared to adults. A lower frequency of COVID-19-associated symptoms was reported among children with positive RT-PCR tests compared to children with negative tests. A lower rate of testing was conducted among children (25%) compared to adults (61%). Fewer tests were carried out among children <5 years (11%) compared to other age groups (p < 0.001), for children from other nationalities (4%) compared to Yemeni children (p < 0.001) and for girls (21%) compared to boys (30%) (p < 0.031). Conclusion: Understanding and addressing the cause of these disparities and improving guidelines for COVID-19 screening among children will improve access to care and control of the COVID-19 pandemic.

Assessing young Kenyan women's willingness to engage in a peer-delivered HIV self-testing and referral model for PrEP initiation: A qualitative formative research study.

Background: Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but uptake remains low, especially among adolescent girls and young women (AGYW) in Kenya. A model in which trained AGYW using PrEP deliver HIV self-tests to their close friends and refer them to PrEP may help increase PrEP uptake in this population. To understand AGYW's potential willingness to engage in such a model, we conducted a qualitative formative study in Kenya. Method: We conducted semi-structured in-depth interviews (IDIs) with AGYW (16 to 24 years) in Kiambu County who were determined at risk of HIV acquisition. We purposively recruited "PrEP-naïve" (no prior PrEP use) and "PrEP-experienced" AGYW who used PrEP for at least 1 month within the previous year. We solicited perspectives on initiating/engaging in conversations about HIV risk and PrEP, distributing/receiving HIV self-test kits, and referring/following through on a referral to clinic-based HIV services. We analyzed verbatim transcripts using rapid qualitative analysis and a combination of inductive and deductive approaches, with the latter informed by the Integrated Behavior Model (IBM). Results: From August to December 2020, we conducted 30 IDIs: 15 with PrEP-experienced and 15 with PrEP-naïve AGYW. Participants' median age was 20 [interquartile range (IQR): 20-22]. Overall, most participants anticipated that they would be willing to engage in this model. PrEP-experienced AGYW emphasized the salience of their concerns about friends' HIV risk behaviors, with several noting that they are already in the habit of discussing PrEP with friends. Many additionally expressed positive attitudes toward the proposed target behaviors, perceived these to be normative among AGYW, and expressed confidence in their ability to carry out the behaviors with proper support. Although few participants had HIVST experience, nearly all anticipated they would be able to use an HIV self-test kit correctly if provided instruction. Conclusion: The Kenyan AGYW who participated in this study generally anticipated that they would be willing to engage in a formal peer PrEP referral model enhanced with peer-delivered HIV self-tests. Future research is needed to pilot test this model to determine its acceptability, feasibility, and effect on HIVST and PrEP uptake within this population.

Increasing health system synergies in low-income settings: Lessons learned from a qualitative case study of Rwanda.

Building synergies is seen as an effective strategy to address and decrease existing fragmentation in health systems of low-and middle-income countries (LMICs). To that end, different programmes, such as the Sector Wide Approach, have been adopted to increase health system synergies. Despite these efforts, fragmentation remains an enduring problem, hampering health system performance in LMICs. This study is part of the Lancet Commission on synergies between Universal Health Coverage, Health Security, and Health Promotion; we aimed to document synergising strategies adopted by Rwanda. Data for this paper came from a qualitative study including in-depth interviews of 15 key informants and a document review. A thematic analysis embracing deductive and inductive approaches was used to analyse the data. We found that Rwanda adopted three main strategies to increase health system synergies: (1) alignment of health programmes with national health policies and strategies, (2) increased coordination across national health institutions, and (3) effective monitoring and evaluation frameworks. Achieving synergies in a low-resource country is challenging but not impossible. To meet the target of global health agendas such as the Sustainable Development Goals and the prevention of future global pandemics, efforts to increase health system synergies in LMICs need to be strengthened.

Mental Wellbeing and Social Resilience of Eritrean Refugees Living in Germany.

Mental health and social resilience play a significant role in refugees' adaptation during the resettlement process in the host country. Maintaining good mental wellbeing helps the refugees to respond to stressful experiences with healthy life choices. This study aimed to explore the mental wellbeing and social resilience of Eritrean refugees living in Germany and to identify social conditions and enablers to foster adaptation. This study employs a qualitative approach with a semi-structured, in-depth interview data collection method. Informants were identified among mostly young adult refugees living in Heidelberg, Germany, with a migration history of 3-6 years. In total, 15 informants were recruited through snowball sampling. Data were sorted and analyzed using the five pillars of the Adaptation and Development after Persecution and Trauma (ADAPT) model. The findings suggest that Eritrean refugees experienced psychological distress after resettlement in Germany; however, with time, their mental health improved. The study revealed conditions that were experienced as hindrances, as well as ones that were considered to be resources of positive mental wellbeing and social resilience for resettled refugees. Resettlement challenges described by the participants were the language barrier, discrimination, unemployment, insecure residence status, loss of family and friends, conflict within the diaspora community, and isolation. The main sources of mental wellbeing and social resilience include the feeling of being welcomed by local communities, access to social services, adopting new relationships, and educational opportunities. These experiences encouraged refugees to have a favorable view of their lives and futures and were also found to facilitate better integration and adaptation. Understanding refugee mental wellbeing and social resilience requires a multidimensional perspective. Eritrean refugees living in Germany have experienced and are still experiencing resettlement challenges, such as, for example, loss of family and friends, negative perception of the German system, loss of past achievements, or unemployment. However, they have developed adaptive and resilience mechanisms, as well, such as seeing an opportunity for a better life, adopting new roles, and accepting Germany as a "second home". In addressing those issues reported by the refugees as hindrances, these could be turned into sources of mental wellbeing and resilience.

Impact of the COVID-19 pandemic on malaria cases in health facilities in northern Ghana: a retrospective analysis of routine surveillance data.

BACKGROUND: The COVID-19 pandemic and its collateral damage severely impact health systems globally and risk to worsen the malaria situation in endemic countries. Malaria is a leading cause of morbidity and mortality in Ghana. This study aims to describe the potential effects of the COVID-19 pandemic on malaria cases observed in health facilities in the Northern Region of Ghana. METHODS: Monthly routine data from the District Health Information Management System II (DHIMS2) of the Northern Region of Ghana were analysed. Overall outpatient department visits (OPD) and malaria case rates from the years 2015-2019 were compared to the corresponding data of the year 2020. RESULTS: Compared to the corresponding periods of the years 2015-2019, overall visits and malaria cases in paediatric and adult OPDs in northern Ghana decreased in March and April 2020, when major movement and social restrictions were implemented in response to the pandemic. Cases slightly rebounded afterwards in 2020, but stayed below the average of the previous years. Malaria data from inpatient departments showed a similar but more pronounced trend when compared to OPDs. In pregnant women, however, malaria cases in OPDs increased after the first COVID-19 wave. CONCLUSIONS: The findings from this study show that the COVID-19 pandemic affects the malaria burden in health facilities of northern Ghana, with declines in inpatient and outpatient rates except for pregnant women. They may have experienced reduced access to insecticide-treated nets and intermittent preventive malaria treatment in pregnancy, resulting in subsequent higher malaria morbidity. Further data, particularly from community-based studies and ideally complemented by qualitative research, are needed to fully determine the impact of the pandemic on the malaria situation in Africa.

Adherence to appointments for gestational diabetes testing and experiences with two-hour postprandial glucose test: a mixed-methods study in Ghana.

BACKGROUND: Failure to attend scheduled appointments is a common problem in healthcare. In obstetrics, diagnostic and treatment protocols for gestational diabetes mellitus (GDM) require client booking, test preparations, management and follow-up reviews. We identified the socio-demographic, obstetric and medical drivers influencing adherence to appointments for GDM testing and experiences of pregnant women's regarding performing oral glucose tolerance test (OGTT). METHODS: A convergent parallel mixed-methods study comprising a cross-sectional survey and an explorative qualitative descriptive design were used. We recruited 817 women in their first trimester of pregnancy from the antenatal clinics of primary, secondary and tertiary health facilities in Ghana. After obtaining their demographic and health history, we scheduled them for 2-h OGTT between 24 and 28 gestational weeks and estimated the odds of returning for the test. In the qualitative phase, we called 166 participants to ascertain why they failed to report. Also, we had in-depth and focused group discussions with 60 postpartum women who performed the OGTT to explore their experiences with the test. RESULTS: Out of 817 pregnant women scheduled, 490 (59.97%) reported of which 54.59, 54.33 and 53.24% completed fasting plasma glucose, 1-h and 2-h OGTT, respectively. Maternal age above 35 years (OR: 3.56, 95% CI:1.49-8.47), secondary education (OR: 3.21, 95% CI: 1.19-8.69), formal sector employment (OR: 2.02, 95% CI: 1.16-3.51) and having same-sex children (OR: 4.37, 95% CI: 1.98-9.66) increased odds of appointment adherence whereas healthcare in a tertiary hospital (OR:0.46, 95% CI:0.22-0.96), rural residence (OR: 0.53, 95% CI: 0.34-0.85) and being overweight (OR: 0.45, 95% CI: 0.25-0.78) decreased the likelihood. Experiences were thematized into feelings about test procedure, acceptability of test, skillfulness of the health workers and information on the test. Despite the apprehension and discomforts associated with the test, the desire to know one's disease status was the chief motivation. Empathy, reassurance and receiving ample information on the test procedures eased anxiety and improved test compliance. CONCLUSIONS: Although 40% of participants scheduled did not return, the test was generally acceptable. Socio-cultural underpinnings influenced the health-seeking behaviors, meaning that health worker interactions on test procedures need to be sensitive to the woman's situation.

Commercial Influence on Political Declarations: The Crucial Distinction Between Consultation and Negotiation and the Need for Transparency in Lobbying Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases".

Suzuki and colleagues' rare and elaborate analysis of the political processes behind the 2018 United Nations (UN) non-communicable diseases (NCD) Declaration discloses various pathways towards influencing global public health policies. Their study should be a wake-up call for further scientific political scrutiny and analysis, including clearly distinguishing between consultations such as UN multi-stakeholder hearings preceding high-level meetings and the actual negotiating and decision making process. While stakeholder positions at interactive hearings are documented and published and thus made transparent, the negotiating process among member states is not publicly known. The extent to which intergovernmental negotiations are influenced at country or regional levels by commercial interests through direct and indirect lobbying outside of public consultations should be given more attention. Lobby registers should be implemented more stringently and legislative footprints required and applied not only to legally binding but also to internationally important documents such as political declarations.

Addressing Policy Coherence Between Health in All Policies Approach and the Sustainable Development Goals Implementation: Insights From Kenya.

BACKGROUND: Addressing health in the Sustainable Development Goals (SDGs) calls for intersectoral strategies that mutually enhance both health promotion and sustainable development. Health in All Policies (HiAP) approach aims to address this as well as promote ownership among key stakeholders. Kenya was at the forefront of adopting the SDGs and has committed to the HiAP approach in its Health Policy document for the period 2014-2030. This study aims to assess how the adoption of the HiAP approach can leverage on SDGs implementation in Kenya. METHODS: This is an exploratory case study using qualitative data and some descriptive quantitative data. The Organisation for Economic Co-operation and Development's (OECD's) eight building blocks for policy coherence on sustainable development was our guiding framework. Qualitative data was derived from a review of relevant peer-reviewed and grey literature, as well as 40 key informant interviews and analyzed in NVIVO. Quantitative data was accessed from the United Nations SDG indicator database and exported to Excel. RESULTS: Kenya has expressed a strong political commitment to achieving the SDGs and has now adopted HiAP. The study showed that Kenya can leverage on local level implementation and long-term planning horizons that it currently has in place to address the SDGs as it rolls out the HiAP approach. The SDGs could be mapped out against the sectors outlined in the Adelaide statement on HiAP. It is also possible to map out how various ministries could coordinate to effectively address HiAP and SDGs concurrently. Funding for HiAP was not addressed in the OECD framework. CONCLUSION: Kenya can advance a HiAP approach by leveraging the ongoing SDGs implementation. This will be made possible by facilitating coordinated intersectoral action both at national and local level. Funding for HiAP is crucial for its propagation, especially in low- and middle-income countries (LMICs) and can be considered in the budgetary allocations for SDGs.

Barriers to screening, diagnosis and management of hyperglycaemia in pregnancy in Africa: a systematic review.

Gestational diabetes mellitus (GDM) complicates pregnancies in Africa. Addressing the burden is contingent on early detection and management practices. This review aimed at identifying the barriers to diagnosing and managing GDM in Africa. We searched PUBMED, Web of Science, WHOLIS, Google Scholar, CINAHL and PsycINFO databases in May 2020 for studies that reported barriers to diagnosis and management of hyperglycaemia in pregnancy. We used a mixed method quality appraisal tool to assess the quality and risk of bias of the included studies. We adopted an integrated and narrative synthesis approach in the analysis and reporting. Of 548 articles identified, 14 met the eligibility criteria. Health system-related barriers to GDM management were the shortage of healthcare providers, relevant logistics, inadequate knowledge and skills, as well as limited opportunities for in-service training. Patient-related barriers were insufficient knowledge about GDM, limited support from families and health providers and acceptability of the diagnostic tests. Societal level barriers were concomitant use of consulting traditional healers, customs and taboos on food and body image perception. It was concluded that constraints to GDM detection and management are multidimensional. Targeted interventions must address these barriers from broader, systemic and social perspectives.

From disgusting and complicated to simple and brilliant: Implementation perspectives and lessons learned from users and rejectors of mail-in SARS-CoV-2 gargle tests.

Background: Despite the important role of testing as a measure against the COVID-19 pandemic, user perspectives on SARS-CoV-2 tests remain scarce, inhibiting an improvement of testing approaches. As the world enters the third year of the pandemic, more nuanced perspectives of testing, and opportunities to expand testing in a feasible and affordable manner merit consideration. Methods: Conducted amid the second pandemic wave (late 2020-early 2021) during and after a multi-arm trial evaluating SARS-CoV-2 surveillance strategies in the federal state Baden-Württemberg, Germany, this qualitative sub-study aimed to gain a deeper understanding of how test users and test rejectors perceived mail-in SARS-CoV-2 gargle tests. We conducted 67 semi-structured in-depth interviews (mean duration: 60 min) via telephone or video call. Interviews were audio-recorded, transcribed verbatim and analyzed inductively using thematic analysis. The Consolidated Framework for Implementation Research guided the findings' presentation. Results: Respondents generally described gargle sampling as simple and comfortable. However, individual perceptions of the testing method and its feasibility varied widely from disgusting and complicated to simple and brilliant. Self-sampling was appreciated for lowering infection risks during testing, but also considered more complex. Gargle-sampling increased participants' self-efficacy to sample correctly. Communication (first contact, quantity and content of information, reminders, support system) and trust (in the study, its institutional affiliation and test method) decisively influenced the intervention's acceptability. Conclusion: User-driven insights on how to streamline testing include: consider communication, first impressions of tests and information as key for successful mail-in testing; pay attention to the role of mutual trust between those taking and administering tests; implement gargle self-sampling as a pleasant alternative to swab testing; offer multiple test methods to increase test up-take.

Eritrean Refugees' and Asylum-Seekers' Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study.

Oral health concerns in Eritrean refugees have been an overlooked subject. This qualitative study explored the access of Eritrean refugees and asylum-seekers (ERNRAS) to oral health care services in Heidelberg, Germany, as well as their perceptions and attitudes towards oral health care. It involved 25 participants. We employed online semi-structured interviews (n = 15) and focus group discussions (n = 2). The data was recorded, transcribed, and analysed, using thematic analysis. The study found out that most of the participants have a relatively realistic perception and understanding of oral health. However, they have poor dental care practices, whilst a few have certain misconceptions of the conventional oral hygiene tools. Along with the majority's concerns regarding psychosocial attributes of poor oral health, some participants are routinely consuming Berbere (a traditional spice-blended pepper) to prevent bad breath. Structural or supply-side barriers to oral healthcare services included: communication hurdles; difficulty in identifying and navigating the German health system; gaps in transculturally, professionally, and communicationally competent oral health professionals; cost of dental treatment; entitlement issues (asylum-seekers); and appointment mechanisms. Individual or demand-side barriers comprised: lack of self-sufficiency; issue related to dental care beliefs, trust, and expectation from dentists; negligence and lack of adherence to dental treatment follow-up; and fear or apprehension of dental treatment. To address the oral health burdens of ERNRAS, it is advised to consider oral health education, language-specific, inclusive, and culturally and professionally appropriate healthcare services.