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

OBJECTIVE: Teen dating violence (TDV) is prevalent with lifelong adverse consequences, and strategies to reduce its burden are needed. Many U.S. states have enacted laws to address TDV in schools, but few studies have examined their effectiveness. This study aimed to assess whether state TDV laws were associated with changes in physical TDV victimization among high school students. METHODS: We used repeated cross-sectional data of high school students from the Youth Risk Behavior Survey across 41 states from 1999 to 2019. Using a difference-in-differences approach with an event study design, we compared changes in past-year physical TDV in states that enacted TDV laws (n = 21) compared to states with no required laws (n = 20). Analyses accounted for clustering at the state-level and state and year-fixed effects. We conducted sensitivity analyses to assess the robustness of our findings. RESULTS: In our sample of 1,240,211 students, the prevalence of past-year physical TDV was 9.2% across all state-years. In 1999, the prevalence of TDV at the state-level ranged from 7.5 to 13.0%; in 2019, the prevalence ranged from 3.7 to 10.5%. There was no significant association between TDV laws and past-year physical TDV. Six or more waves after enactment, we observed a non-significant 1.7% percentage point reduction in TDV in states with TDV laws (95% CI: -3.6 to 0.3 percentage points; p = 0.10). CONCLUSIONS: We found no significant association between enactment of TDV laws and physical TDV among high school students. Further research is needed to understand how TDV laws are implemented and components of TDV laws that may influence effectiveness.

Inclusion of people with disabilities in Chilean health policy: a policy analysis.

BACKGROUND: Around 18% of the population in Chile has disabilities. Evidence shows that this population has greater healthcare needs, yet they face barriers to accessing healthcare due to health system failures. This paper aims to assess the inclusion of people with disabilities in health policy documents and to explore the perceptions of key national stakeholders regarding the policy context, policy processes, and actors involved. METHODS: A policy content analysis was conducted of 12 health policy documents using the EquiFrame framework, adapted to assess disability inclusion. Documents were reviewed and rated on their quality of commitment against 21 core concepts of human rights in the framework. Key national stakeholders (n = 15) were interviewed, and data were thematically analysed under the Walt and Gilson Policy Analysis Triangle, using NVivo R1. RESULTS: Core human rights concepts of disability were mentioned at least once in nearly all health policy documents (92%). However, 50% had poor policy commitments for disability. Across policies, Prevention of health conditions was the main human rights concept reflected, while Privacy of information was the least referenced concept. Participants described a fragmented disability movement and health policy, related to a dominant biomedical model of disability. It appeared that disability was not prioritized in the health policy agenda, due to ineffective mainstreaming of disability by the Government and the limited influence and engagement of civil society in policy processes. Moreover, the limited existing policy framework on disability inclusion is not being implemented effectively. This implementation gap was attributed to lack of financing, leadership, and human resources, coupled with low monitoring of disability inclusion. CONCLUSIONS: Improvements are needed in both the development and implementation of disability-inclusive health policies in Chile, to support the achievement of the right to healthcare for people with disabilities and ensuring that the health system truly "leaves no one behind".

INTRODUCCIóN: Alrededor del 18% de la población de Chile tiene discapacidad. Los datos demuestran que esta población tiene mayores necesidades de salud, pero se enfrenta a barreras para acceder a la salud debido a las deficiencias del sistema sanitario. El objetivo de este estudio es evaluar la inclusión de las personas con discapacidad en las políticas sanitarias y explorar las percepciones de actores nacionales en relación al contexto político, los procesos políticos y los actores implicados. MéTODOS: Se realizó un análisis de contenido de 12 políticas sanitarias utilizando el marco EquiFrame, adaptado para discapacidad. Se calificó la calidad de compromiso de las políticas con respecto a 21 conceptos de derechos humanos del EquiFrame. Se entrevistó a 15 actores nacionales, y los datos se analizaron temáticamente según el Triángulo de Políticas de Walt y Gilson, utilizando NVivo R1. RESULTADOS: Los conceptos de derechos humanos en materia de discapacidad se mencionaron al menos una vez en casi todas las políticas sanitarias (92%). Sin embargo, en el 50% de los casos los compromisos políticos en materia de discapacidad eran escasos. En todas las políticas, la Prevención de los problemas de salud fue el principal concepto de derechos humanos reflejado, mientras que la Privacidad de la información fue el concepto menos mencionado. Los participantes describieron un movimiento de la discapacidad y una política sanitaria fragmentados, relacionados con un modelo biomédico dominante de la discapacidad. Pareciera que la discapacidad no es prioritaria en la agenda política sanitaria, debido a su ineficaz integración por parte del Gobierno y a la limitada participación de la sociedad civil en los procesos políticos. Además, el limitado marco político existente sobre salud inclusiva no se está implementando eficazmente. Esta deficiencia en la implementación se atribuyó a la falta de financiamiento, liderazgo y recursos humanos, junto con el escaso monitoreo de la discapacidad. CONCLUSIONES: Se requieren mejoras tanto en el desarrollo como en la implementación de políticas de salud inclusivas de la discapacidad en Chile, para apoyar el alcance del derecho a la salud de las personas con discapacidad y asegurar que el sistema de salud realmente "no deje a nadie atrás".

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

INTRODUCTION: Pedestrian and cyclist injuries represent a preventable burden to Canadians. Police-reported collision data include information on where such collisions occur but under-report the number of collisions. The primary objective of this study was to compare the number of police-reported collisions with emergency department (ED) visits and hospitalisations in Toronto, Canada. METHODS: Police-reported collisions were provided by Toronto Police Services (TPS). Data included the location of the collision, approximate victim age and whether the pedestrian or cyclist was killed or seriously injured. Health services data included ED visits in the National Ambulatory Care Reporting System and hospitalisations from the Discharge Abstract Database using ICD-10 codes for pedestrian and cycling injuries. Data were compared from 2016 to 2021. RESULTS: Injuries reported in the health service data were higher than those reported in the TPS for cyclists and pedestrians. The discrepancy was the largest for cyclists treated in the ED, with TPS capturing 7.9% of all cycling injuries. Cyclist injuries not involving a motor vehicle have increased since the start of the pandemic (from 3629 in 2019 to 5459 in 2020 for ED visits and from 251 in 2019 to 430 for hospital admissions). IMPLICATIONS: While police-reported data are important, it under-reports the burden. There have been increases in cyclist collisions not involving motor vehicles and decreases in pedestrian injuries since the start of the pandemic. The results suggest that using police data alone when planning for road safety is inadequate, and that linkage with other health service data is essential.

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

BACKGROUND: Children in households experiencing poverty are disproportionately exposed to maltreatment. Income support policies have been associated with reductions in child abuse and neglect. The advance child tax credit (CTC) payments may reduce child maltreatment by improving the economic security of some families. No national studies have examined the association between advance CTC payments and child abuse and neglect. This study examines the association between the advance CTC payments and child abuse and neglect-related contacts to the Childhelp National Child Abuse Hotline. METHODS: A time series study of contacts to the Childhelp National Child Abuse Hotline between January 2019 and December 2022 was used to examine the association between the payments and hotline contacts. An interrupted time series (ITS) exploiting the variation in the advance CTC payments was estimated using fixed effects. RESULTS: The CTC advance payments were associated with an immediate 13.8% (95% CI -17.5% to -10.0%) decrease in contacts to the hotline in the ITS model. Following the expiration of the advance CTC payments, there was a significant and gradual 0.1% (95% CI +0.0% to +0.2%) daily increase in contacts. Sensitivity analyses found significant reductions in contacts following each payment, however, the reductions were associated with the last three of the six total payments. CONCLUSION: These findings suggest the advance CTC payments may reduce child abuse and neglect-related hotline contacts and continue to build the evidence base for associations between income-support policies and reductions in child abuse and neglect.

Recreational cannabis legalization and pediatric exposures in Massachusetts, United States.

INTRODUCTION: In Massachusetts, US, medical cannabis legalisation was associated with increased paediatric cannabis exposure cases, including emergency department (ED) visits and hospitalizations. The impact of recreational cannabis legalisation (RCL) on paediatric exposures in Massachusetts has yet to be studied. METHODS: To compare the incidences before and after RCL in Massachusetts, US, we queried the data on paediatric cannabis exposure cases in 2016-2021 from the Centre for Healthcare and Analysis and Injury Surveillance Programme at the Massachusetts Department of Public Health. The pre-and post-legalisation phases comprised the periods between 2016-2018 and 2019-2021, respectively. Cannabis-related exposure cases included ED visits and hospitalizations among children and young adolescents of 0-19 years old. RESULTS: During the 6-year period (2016-2021), 2357 ED visits and 538 hospitalizations related to cannabis exposure among children and teenagers (0-19 years) were reported in Massachusetts. The incidence of ED visits for all age groups increased from 18.5 per 100 000 population before RCL to 31.0 per 100 000 population (incidence rate ratio (IRR), 1.6; 95% CI, 1.5 to 1.8). Children in the age groups of 0-5 and 6-12 years experienced the highest increase in cannabis-related ED visits. Additionally, the incidence of hospitalisation due to cannabis intoxication substantially increased following RCL (IRR, 2.2; 95% CI, 1.8 to 2.7), a 126% increase. CONCLUSIONS: Cannabis-related ED visits and hospitalizations among children and teenagers increased after recreational cannabis became legal in Massachusetts, US. Further efforts are warranted to prevent the unintentional impact of RCL, especially considering substantial increases in cannabis exposure cases among young children.

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

INTRODUCTION: Schools in the United Arab Emirates (UAE) witnessed an increase of 7% in bullying prevalence since 2005. This review aimed to map antibullying interventions in the UAE. METHODS: A systematic search was performed in five electronic databases (EMBASE, PubMed, PsycINFO, Scopus and Eric) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review. Studies addressing antibullying interventions and grey literature in the UAE from 2010 to 2021 were included. Interventions were mapped using distribution across key sectors, public health practice levels, and organisation types. RESULTS: Of the 2122 identified papers, only 2 were included. Both articles were published in 2019 and used qualitative methods. From the search of governmental and non-governmental websites, 22 multilevel interventions were included and presented on the three levels of public health practice across the different sectors and target stakeholders. Eight interventions were at the federal level, and six were by private stakeholders. The government funded 59% of all interventions. Four interventions addressed cyberbullying, and three used multisectoral collaboration. CONCLUSIONS: Although the UAE is building capacity for bullying prevention, we found limited knowledge of antibullying prevention efforts. Further studies are needed to assess current interventions, strategies and policies.

Community and multisector partner engagement in US Vision Zero plan development.

BACKGROUND: Vision Zero aims to eliminate serious and fatal road injuries using a Safe System approach. Safe System principles establish that safety is a shared responsibility; this involves both multisector partners and community engagement. This descriptive study explored multisector partners and community engagement in the development of municipal Vision Zero plans. METHODS: We reviewed all first edition Vision Zero plans published by US municipalities from 2014 to 2022. Using a structured coding tool, we abstracted partner involvement and community engagement strategies used in the development of Vision Zero plans. RESULTS: We identified, reviewed and abstracted 64 plans. The average number of partner groups per plan was 11.5 (12.0 for municipalities with a population ≥150 000; 10.1 for municipalities <150 000) and was higher for later plans (11.9 for plans published 2019-2022; 10.0 for plans published 2014-2018). Common partner groups engaged in the plan were law enforcement (85.9% of plans), local transportation planning (78.3%), mayor/city council/city manager (78.1%), engineering/public works (78.1%) and schools (73.4%). Community engagement strategies were reported in 71.9% of the plans and were more frequent among municipalities with a population ≥150 000 (76.1%) compared with a population <150 000 (61.1%), and in those with more recent plans (82.1%) versus earlier ones (56.0%). The most common community engagement strategies were public meetings, online surveys and map mark-ups. CONCLUSIONS: These findings highlight the extent to which Vision Zero plans were aligned with core Safe System tenets regarding diverse partner involvement and community engagement. Plan developers should consider the translation of Safe System principles in Vision Zero plan development.

The challenges associated with the prevention of smuggling and counterfeiting health goods in Iran.

BACKGROUND: Smuggling health goods given the importance and critical nature of health services should be undeniably addressed and controlled by all countries. This issue is especially more widespread in developing countries with more damaging consequences. This paper therefore aims to identify and analyze the challenges of preventing smuggling of health goods in Iran. METHOD: Within this qualitative study, we conducted face-to-face, semi-structured interviews with 30 purposefully recruited key informants and stakeholders in the detection, prevention, and combating of health goods smuggling. Each interview was analyzed thematically, using an inductive approach to generate codes, then categorized and presented in the form of main themes and sub-themes. Maxqda 11 assisted in coding, analysis, and data management. RESULTS: Three main themes emerged representing the challenges of prevention of smuggling in Iran in the areas of anti-smuggling policy development, including categories of inefficient policy and plan, and failure to reach agenda; policy implementation; categorized into actors, resources and instruments, and implementation guarantee; and finally monitoring and evaluation; including, procedures and practices, and the role of surveyors. CONCLUSION: Prevention of smuggling health goods proves to be a highly complex, challenging, and multi-faceted practice. Therefore, strengthening policy-making, regulatory frameworks, and facilitation functions about smuggling, counterfeiting, and corruption should be promoted in parallel.

Addressing loneliness and social isolation in 52 countries: a scoping review of National policies.

BACKGROUND: Even prior to the advent of the COVID-19 pandemic, there was ample evidence that loneliness and social isolation negatively impacted physical and mental health, employability, and are a financial burden on the state. In response, there has been significant policy-level attention on tackling loneliness. The objective of this scoping review was to conduct a loneliness policy landscape analysis across 52 countries of the UN European country groups. Our policy analysis sought to highlight commonalities and differences between the different national approaches to manage loneliness, with the goal to provide actionable recommendations for the consideration of policymakers wishing to develop, expand or review existing loneliness policies. METHODS: We searched governmental websites using the Google search engine for publicly available documents related to loneliness and social isolation. Seventy-eight documents were identified in total, from which 23 documents were retained. Exclusion of documents was based on predetermined criteria. A structured content analysis approach was used to capture key information from the policy documents. Contextual data were captured in a configuration matrix to highlight common and unique themes. RESULTS: We could show that most policies describe loneliness as a phenomenon that was addressed to varying degrees in different domains such as social, health, geographical, economic and political. Limited evidence was found regarding funding for suggested interventions. We synthesised actionable recommendations for the consideration of policy makers focusing on the use of language, prioritisation of interventions, revisiting previous campaigns, sharing best practice across borders, setting out a vision, evaluating interventions, and the need for the rapid and sustainable scalability of interventions. CONCLUSIONS: Our study provides the first overview of the national loneliness policy landscape, highlighting the increasing prioritisation of loneliness and social isolation as a major public health and societal issue. Our findings suggest that policymakers can sustain this momentum and strengthen their strategies by incorporating rigorous, evidence-based intervention evaluations and fostering international collaborations for knowledge sharing. We believe that policymakers can more effectively address loneliness by directing funds to develop and implement interventions that impact the individual, the community and society.

European policies for public health in border regions: no European mindset as yet.

BACKGROUND: The sudden emergence of COVID-19 in 2020 demonstrated that Europe was not prepared for a public health crisis like this pandemic. In the European Union, matters of health have remained primarily under the jurisdiction of individual Member States. However, certain events, such as the Kohll-Decker ruling on free mobility of health services and the COVID-19 pandemic, compelled the EU to address health matters in border regions. This study examines how EU policies address public health in border regions. To that end, we have drawn from border studies, a field that provides insight into the fluidity and complexity of borders in everyday life. Besides that we used constructivist policy studies as a lens for the analysis of EU policy documents. METHODS: A policy discourse analysis was conducted to explore how European policy addresses the development of a transnational, European public health in border regions. Key European policy documents published between 2002 and 2027 were analysed to understand how policies are constructed and problems are framed. The analysis was guided by research questions and the theoretical approach. RESULTS: The analysis reveals that, while having limited competences in the field of health care, the EU is slowly developing a rationale and a knowledge base to increase its competences in health care. It also shows that in the field of public health, the EU argues for addressing health determinants and promoting healthy lifestyles, though it does not address health promotion in border regions. The EU's authority in public health in border regions revolves primarily around addressing physical, biological and chemical threats rather than social health problems. CONCLUSION: Though the EU has carefully developed a transnational perspective on health care, the EU has not developed any authority with respect to transnational public health. Though public health and health promotion in border regions have been confronted with specific challenges, neither specific Member States nor the EU have a transnational collaborative perspective that does justice to the characteristics of border regions. When it comes to public health in border regions, there is no European mindset as yet.

Halting and re-issuing of the Zambia community health strategy (2017-2021): a retrospective analysis of the policy process and implications for community health systems.

BACKGROUND: Over the years, low-and middle-income countries have adopted several policy initiatives to strengthen community health systems as means to attain Universal Health Coverage (UHC). In this regard, Zambia passed a Community Health Strategy in 2017 that was later halted in 2019. This paper explores the processes that led to the halting and re-issuing of this strategy with the view of drawing lessons to inform the development of such strategies in Zambia and other similar settings. METHODS: We employed a qualitative case study comprising 20 semi-structured interviews with key stakeholders who had participated in either the development, halting, or re-issuing of the two strategies, respectively. These stakeholders represented the Ministry of Health, cooperating partners and other non-government organizations. Inductive thematic analysis approach was used for analysis. RESULTS: The major reasons for halting and re-issuing the community health strategy included the need to realign it with the national development framework such as the 7th National Development Plan, lack of policy ownership, political influence, and the need to streamline the coordination of community health interventions. The policy process inadequately addressed the key tenets of community health systems such as complexity, adaptation, resilience and engagement of community actors resulting in shortcomings in the policy content. Furthermore, the short implementation period, lack of dedicated staff, and inadequate engagement of stakeholders from other sectors threatened the sustainability of the re-issued strategy. CONCLUSION: This study underscores the complexity of community health systems and highlights the challenges these complexities pose to health policymaking efforts. Countries that embark on health policymaking for community health systems must reflect on issues such as persistent fragmentation, which threaten the policy development process. It is crucial to ensure that these complexities are considered within similar policy engagement processes.

Tanzania's and Germany's Digital Health Strategies and Their Consistency With the World Health Organization's Global Strategy on Digital Health 2020-2025: Comparative Policy Analysis.

BACKGROUND: In recent years, the fast-paced adoption of digital health (DH) technologies has transformed health care delivery. However, this rapid evolution has also led to challenges such as uncoordinated development and information silos, impeding effective health care integration. Recognizing these challenges, nations have developed digital health strategies (DHSs), aligning with their national health priorities and guidance from global frameworks. The World Health Organization (WHO)'s Global Strategy on Digital Health 2020-2025 (GSDH) guides national DHSs. OBJECTIVE: This study analyzes the DHSs of Tanzania and Germany as case studies and assesses their alignment with the GSDH and identifies strengths, shortcomings, and areas for improvement. METHODS: A comparative policy analysis was conducted, focusing on the DHSs of Tanzania and Germany as case studies, selected for their contrasting health care systems and cooperative history. The analysis involved a three-step process: (1) assessing consistency with the GSDH, (2) comparing similarities and differences, and (3) evaluating the incorporation of emergent technologies. Primary data sources included national eHealth policy documents and related legislation. RESULTS: Both Germany's and Tanzania's DHSs align significantly with the WHO's GSDH, incorporating most of its 35 elements, but each missing 5 distinct elements. Specifically, Tanzania's DHS lacks in areas such as knowledge management and capacity building for leaders, while Germany's strategy falls short in engaging health care service providers and beneficiaries in development phases and promoting health equity. Both countries, however, excel in other aspects like collaboration, knowledge transfer, and advancing national DHSs, reflecting their commitment to enhancing DH infrastructures. The high ratings of both countries on the Global Digital Health Monitor underscore their substantial progress in DH, although challenges persist in adopting the rapidly advancing technologies and in the need for more inclusive and comprehensive strategies. CONCLUSIONS: This study reveals that both Tanzania and Germany have made significant strides in aligning their DHSs with the WHO's GSDH. However, the rapid evolution of technologies like artificial intelligence and machine learning presents challenges in keeping strategies up-to-date. This study recommends the development of more comprehensive, inclusive strategies and regular revisions to align with emerging technologies and needs. The research underscores the importance of context-specific adaptations in DHSs and highlights the need for broader, strategic guidelines to direct the future development of the DH ecosystem. The WHO's GSDH serves as a crucial blueprint for national DHSs. This comparative analysis demonstrates the value and challenges of aligning national strategies with global guidelines. Both Tanzania and Germany offer valuable insights into developing and implementing effective DHSs, highlighting the importance of continuous adaptation and context-specific considerations. Future policy assessments require in-depth knowledge of the country's health care needs and structure, supplemented by stakeholder input for a comprehensive evaluation.

Achilles' heel: elderly COVID-19 vaccination policy in China.

BACKGROUND: Despite high overall COVID-19 vaccine coverage, the continuously low elderly vaccination rate in mainland China remains a dangerous threat as the country shifts away from its zero-Covid policy. This retrospective study uses the Multiple Streams Framework to examine how macro-level factors may explain poor elderly vaccination outcomes. METHODS: We performed a thematic analysis of qualitative data obtained from 95 official press conferences from October 20, 2020, to February 27, 2023, vaccination-related policy documents, and media coverage, using both inductive and deductive coding approaches. RESULTS: Our findings suggest that in the problem stream, elderly vaccination was not a "focusing event" during the initial vaccine rollout, resulting in delayed outreach to this population. Additionally, ideologically driven complacency and discrepancies in top-down implementation undermined elderly vaccination in the political stream. In the policy stream, precautious and ambiguous statements, inconsistent policy content, radical shifting media messages, and less age-friendly digital technologies also affected elderly vaccination. CONCLUSIONS: The poor convergence of the three streams led the elderly to be the Achilles' heel of China's COVID-19 containment strategy. Future studies should focus on priority identification, adoption of enforcement measures, and timely and effective policy dissemination. The empirical lessons from China can inform and optimize elderly vaccination policy design and implementation in the post-pandemic era.

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

BACKGROUND: Government purchase of social forces to participate in old age care services can release the burden of social care. Current research on performance evaluation in this field mainly focussed on the establishment of appropriate evaluation indices. However, discussion on the policy implementation deviation is scarce. This study aimed to evaluate the performance of China's local government purchase of old age care services, analyse the characteristics of related policies and explore their deviation. METHODS: The persons who participated in the Training of the Trainer (ToT) organized by the Red Cross Society were enrolled. The policy documents were obtained from the official websites. The K-means cluster was used to determine the project performance grades. We compared the project performance grades between service objects and undertakers with different characteristics utilizing the non-parametric test. Based on the framework of 'Collaborative Participation - Project Performance Objective', we analysed the content of relevant policy aiding by NVivo 12. RESULTS: Data of project performance were collected from 306 participants. The standardized mean score of the efficiency dimension was the lowest (0.70 ± 0.24). The projects were divided into four grades: poor (17.0%), average (27.5%), good (12.4%) and excellent (43.1%). There were statistically significant differences in project performance grades only between advanced ageing groups (Z = 2.429, P = 0.015). As well, the policy also mentioned that the services focus should be tilted towards the oldest old. The purchasers mainly involved the Ministry of Civil Affairs and Health management departments in the policy. Respite services were less mentioned in the responsibilities of the undertakers. The requirement for efficiency and effectiveness was mentioned in less than half of the policy documents. CONCLUSION: Policy attention is needed for the responsibilities and functions of the intermediate purchasing force, as well as more precise directions and responsibilities of undertakers. The purchasers and undertakers should improve management abilities and capacity of old age care services and focus on associated factors to achieve the best marginal benefit. In addition, the embedded performance evaluation needs to be updated periodically to bridge the deviation between policy implementation and policy formulation.

Participatory policy analysis in health policy and systems research: reflections from a study in Nepal.

BACKGROUND: Participatory policy analysis (PPA) as a method in health policy and system research remains underexplored. Using our experiences of conducting PPA workshops in Nepal to explore the impact of the country's move to federalism on its health system, we reflect on the method's strengths and challenges. We provide an account of the study context, the design and implementation of the workshops, and our reflections on the approach's strengths and challenges. Findings on the impact of federalism on the health system are beyond the scope of this manuscript. MAIN BODY: We conducted PPA workshops with a wide range of health system stakeholders (political, administrative and service-level workforce) at the local and provincial levels in Nepal. The workshops consisted of three activities: river of life, brainstorming and prioritization, and problem-tree analysis. Our experiences show that PPA workshops can be a valuable approach to explore health policy and system issues - especially in a context of widespread systemic change which impacts all stakeholders within the health system. Effective engagement of stakeholders and activities that encourage both individual- and system-level reflections and discussions not only help in generating rich qualitative data, but can also address gaps in participants' understanding of practical, technical and political aspects of the health system, aid policy dissemination of research findings, and assist in identifying short- and long-term practice and policy issues that need to be addressed for better health system performance and outcomes. Conducting PPA workshops is, however, challenging for a number of reasons, including the influence of gatekeepers and power dynamics between stakeholders/participants. The role and skills of researchers/facilitators in navigating such challenges are vital for success. Although the long-term impact of such workshops needs further research, our study shows the usefulness of PPA workshops for researchers, for participants and for the wider health system. CONCLUSIONS: PPA workshops can effectively generate and synthesize health policy and system evidence through collaborative engagement of health system stakeholders with varied roles. When designed with careful consideration for context and stakeholders' needs, it has great potential as a method in health policy and systems research.

Associations between Adolescent Marijuana Use, Driving after Marijuana Use and Recreational Retail Sale in Colorado, USA.

OBJECTIVE: We investigated associations between the retail distribution of recreational marijuana in Colorado and (i) past 30-day marijuana use and (ii) driving after marijuana use (DAMU) among a representative sample of public high school students using four waves of data from a state surveillance system. METHODS: Past 30-day marijuana use was assessed among all sampled students (n = 85,336). DAMU was assessed among students 15 years or older who indicated driving (n = 47,518). Modified Poisson regression with robust variance estimates was used to estimate prevalence ratios (PR) comparing the pre-distribution (2013) and post-distribution (2015, 2017, 2019) periods for marijuana-related behaviors. Frequency of behavioral engagement was assessed using a multinomial approach. RESULTS: An estimated 20.3% of students engaged in past 30-day marijuana use and 10.5% of student drivers engaged in DAMU. Retail distribution of recreational marijuana was not significantly associated with the prevalence of any marijuana use or DAMU. However, it was associated with 1.16 (95% CI: 1.04-1.29) times the prevalence of using marijuana one or two times in the last 30 days, 1.27 (1.03, 1.55) times the prevalence of DAMU one time, and 0.82 (0.69, 0.98) times the prevalence of DAMU six or more times. No significant associations were observed for the remaining frequency categories. CONCLUSIONS: Approximately 1 in 10 students who drive reported DAMU. Varying prevalence in the frequency of past 30-day marijuana use and DAMU was observed following the retail distribution of recreational marijuana in Colorado. Care should be taken to properly educate adolescent drivers regarding the dangers of DAMU.

How Community-Based Health and Social Care Professionals Support Unpaid Caregivers: Experiences From One Health Authority in Ontario, Canada.

In Ontario, Canada, rising rates of caregiver distress have been the 'canary in the coal mine' for a health system out of balance with the needs of an ageing population. Community-based health and social care professionals are well placed to play an important role in the caregiver support process; however, a gap has remained in the understanding of if and how caregiver support strategies are operationalized or experienced by community service providers (CSPs). The goal of this study was to describe how CSPs interpreted policy and how those interpretations may enable their work in supporting unpaid caregivers. Using a qualitative constructionist design, we interviewed 24 participants and reviewed 92 publicly available documents. Braun and Clarke's method of thematic analysis was used for analysis strategy. Four overarching themes were identified: (1) community care as a priority, (2) sidewalk accountability, (3) creative care planning through partnerships, and (4) challenges to care delivery. We found that the importance of caregivers to the health system was reflected in organizational policy and strategy. There is an opportunity to improve health outcome for caregivers and the population alike through strong leadership and a clear shared vision. Our findings also suggested that social capital was a significant factor in enabling providers in their work, leveraging long-standing relationships, and accumulated local knowledge to implement highly creative care plans.

Policy analysis for informing climate adaptation, environmental resilience, and irrigation demands in the Rio Grande Basin.

Water policymakers internationally face the challenge of adapting to climate, supporting environmental resource needs, and meeting irrigation demands for food security in the world's arid and semi-arid regions. Much recent work has assessed the economic performance of environmental river flows to support endangered species habitat protection. However, little published work to date has systematically formulated and applied methods to identify the economic performance of various policy measures that adapt to climate, support endangered species, and meet irrigation demands for water. This work's original contribution with international relevance is to address those gaps by identifying the economic performance of various water shortage sharing methods for handling climate water stress while supporting protection of critical habitat to protect the endangered Southwestern willow flycatcher (Empidonax traillii extimus) along with Willow tree (Salix bonplandiana) habitat in the middle part of the Rio Grande Basin in North America, a region facing a number of conflicts between commercial uses of water and protection of key ecological assets. It develops a hydroeconomic optimization model containing information on crop water use and endangered species requirements in that region to identify the economic performance of three climate adaptation policy scenarios for handling water shortages while respecting endangered species habitat protection requirements. Results show how water shortages as well as policy responses for handing those shortages affect the economic value of water in agriculture for food security both with and without critical habitat to support the endangered flycatcher. This work's international relevance comes from its capacity to inform policy debates on the costs of protecting endangered species habitat under various climate scenarios and climate policy adaptation measures. Findings provide a general framework to address existing gaps in understanding and measuring the economic performance of measures to promote environmental resilience.

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

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

Waste management in primary healthcare centers in Saudi Arabia: a policy analysis.

Medical waste poses high risks to healthcare workers, patients, the environment, and public health. Governments have adopted measures and enacted policies to ensure proper medical waste management. Through a retrospective policy analysis, we analyzed the waste management policy for primary healthcare centers in Saudi Arabia. By adopting Walt and Gilson's health policy analysis framework, we conducted a thematic analysis of documents to analyze the policy context, process, actors, and content. Contextual factors including accreditation, the Saudi Vision-2030 and the healthcare transformation plan contributed to the development of the policy. The policy was adapted from a regional policy that was enacted about 15 years ago. The policy content overlooked components relevant to the specific context of primary healthcare centers. Lack of training and cooperation among stakeholders challenged successful implementation and thus compliance with the policy. Respective stakeholders must take further actions to ensure implementation fidelity and sustainability of the policy.