The role of alcohol consumption in the lives of older Australian women: qualitative insights and an agenda for further research, policy and practice.

BACKGROUND: Alcohol consumption presents a threat to the health and wellbeing of women. The alcohol industry often pushes back at global efforts to prioritise the prevention of alcohol harms to women. Qualitative researchers have investigated how younger and midlife women conceptualise their alcohol consumption, but there is very limited research relating to older women (those 60 years and over). METHODS: Using data collected from an online qualitative survey, this paper explored the factors that influence how older Australian women drinkers (n = 144. 60-88 years) conceptualised the role of alcohol in their lives. The study used a 'Big Q' reflexive approach to thematic analysis, drawing upon sociological theories of risk and symbolic interactionism to construct four themes from the data. RESULTS: First, alcohol consumption was viewed by participants as an accepted and normalised social activity, that was part of Australian culture. Second, alcohol played a role for some participants as a way to cope with life changes (such as retirement), as well as managing stressful or challenging life circumstances (such as loneliness). Third, alcohol was part of the routines and rituals of everyday life for some women. For example, women discussed the consumption of wine with their evening meal as an important part of the structure of their day. Fourth, participants had clear personal expectancies about what it meant to be a 'responsible drinker'. They had clear narratives about personal control and moral obligation, which in some cases created a reduced perception of their own risk of alcohol-caused harm. CONCLUSIONS: This research provides a starting point for future public health research examining the factors that may shape older women's alcohol consumption beliefs and practices. Public health activities should consider the unique needs and potential vulnerabilities of older women drinkers, and how these may be potentially exploited by the alcohol industry.

Policy, system and service design influence on healthcare inequities for people with end-of-life chronic obstructive airways disease, their support people and health professionals.

BACKGROUND: People with end-of-life chronic obstructive pulmonary disease (COPD) experience debilitating physical limitations, with a high mortality rate. Our research has shown health system design and delivery leads to inequitable outcomes. Enabling people with end-of-life COPD, their support people, and health professionals to partner in setting the agenda for resource allocation may inform health service improvement. DESIGN: Qualitative methodology utilising focus groups including patients, family, friends, informal support people, health care workers and professionals. METHODS: The analysis, utilising critical theory and Actor-Network theory, positioned people with severe COPD, their support people and health professionals as experts in end-of-life care. Analyses triangulated these perspectives, and were reviewed by the research investigators and an expert reference group. RESULTS: Participants (n=74) in seven focus groups reported their experiences of inequity within the healthcare system. Equity was an overarching phenomenon identified by participants, with three specific themes being described: policy design, system design, and service design. CONCLUSION: Experiences of patients, their support people and health professionals as experts in end-of-life COPD care can inform health systems and health service design to address current inequities in funding and delivery of care for end-of-life COPD.

Analysis of social investment in health systems reform: a case study of results-based financing in Marondera District, Zimbabwe.

Introduction: suboptimal use of donor funds and poor health systems performance is rife across most developing countries; to address this, results-based financing (RBF) models were developed. However, it is imperative to explore the emic and context specific influence of results-based financing in health systems performance. This study therefore sought to explore the influence of results-based financing on health worker motivation and governance, temporal perspective, distributional principle, and policy coherence. Finally, the influence of results-based financing on interrelations across donors, technical partners, and health workers was explored. Methods: the study adopted a qualitative, exploratory, descriptive, phenomenological design using audio-recorded face-to-face semi-structured interviews to capture diverse perspectives from the remaining and available two health financing experts, two technical partner organization representatives, and six health workers who have been implementing results-based financing from 2011 to 2022 in the Marondera district of Zimbabwe. Data was transcribed and collectively analyzed using NVIVO software. Results: improved staff motivation, better governance, health system development, equity, and policy consistency were attributable to results-based financing, notwithstanding several challenges including understaffing, increased workload, procurement red tape, financial rigidity, and delays in subsidy payments, which eroded gains of better performance. Additionally, a lack of continuum of care due to user fees faced by the poor at higher levels of care, and limited engagement between donors and healthcare facility workers were also observed. Conclusion: reinforcing pinpointed positives is vital for sustaining realized health gains; however, urgent attention is required to address the challenges to safeguard the milestones achieved thus far.

The Rehabilitation Landscape in a Low-to-Middle-Income Country: Stakeholder Perspectives and Policy Implications-A Qualitative Study.

The need for rehabilitation is increasing on a global level due to a rise in non-communicable diseases, aging and medical advances, and in South Africa (SA), due to the quadruple burden of disease. More information is required regarding rehabilitation scope and practices in SA to optimize the provision of rehabilitation interventions in the context of the transforming health care sector in SA, a low-to-middle-income country (LMIC). The purpose of this study is to explore the perspectives of South African rehabilitation stakeholders on the landscape of rehabilitation in SA. A descriptive qualitative study, with an interpretive approach, was used to explore stakeholder perspectives on rehabilitation practices in the public health care sector of SA. Semi-structured interviews were conducted with 12 rehabilitation stakeholders. Data were analyzed using a combination of deductive and inductive processes to generate themes and categories. We identified 5 main themes, with subsequent categories and sub-categories. The themes include a composite definition of rehabilitation, core elements of rehabilitation provision, challenges affecting rehabilitation practices, the importance of policy implementation, and the progress of rehabilitation in SA. Despite a common understanding of rehabilitation practices in SA amongst stakeholders, many persistent challenges hamper the delivery of effective rehabilitation services. We recommend that further research explore the rehabilitation needs of end-users, together with collaborative research for priority setting on the translation of policy to practice ensuring equitable and quality rehabilitation service delivery.

Medicare Part D Protected-Class Policy Is Associated With Lower Drug Rebates.

Medicare Part D does not allow plans to exclude drugs in six protected classes from their formularies, which may limit plans' ability to negotiate rebates and lead to higher spending. We estimated the association between protected-class status, US-level estimated rebates, and formulary coverage during the period 2011-19. We found that protected classes indeed had significantly lower exclusion rates in Medicare Part D during this period relative to nonprotected classes, and this difference was larger than the corresponding difference in commercial plans. US-level average rebates grew 22.5 percentage points less in protected than in nonprotected classes during 2011-19, a period when formulary exclusions increased. Relative to nonprotected classes, US-level average rebates in protected classes were especially low among drugs with high Medicare market share. These results suggest that Medicare Part D protected-class policy may reduce rebates.

Ethnicity and access to water, sanitation, and hygiene in Bangladesh: a study using MICS data and policy reviews.

INTRODUCTION: Safe drinking water, sanitation, and hygiene (WASH) are crucial to human health. Reducing inequalities and ensuring universal access to WASH are essential to achieving the agenda of sustainable development. We aimed to measure access to WASH among ethnic minority populations in Bangladesh and understand the situation and factors affecting WASH practices among them. Additionally, we reviewed policy related to WASH to highlight the inequality faced by ethnic minority populations. METHODOLOGY: We utilized data from the multiple indicator cluster survey-2019. We used the chi-square test for bivariate analysis and multilevel mixed-effect logistic regression analyses to identify the effect of ethnicity on WASH in Bangladesh after controlling selected covariates. Furthermore, we systematically reviewed Bangladesh's WASH-related policies and programs. FINDINGS: While 98.5% of Bengalis had access to basic drinking water services, the percentage is 60.6% for the ethnic minority population. For improved sanitation facilities not shared with others, the difference between Bengali and ethnic populations was 22.3% (64.6% vs. 42.3%). On the other hand, 75% of the Bengali population had a handwashing facility with water and soap, and 50% of the ethnic population had them. Ethnicity appeared to be a statistically significant predictor of every component of WASH. Compared to Bengali, the ethnic population had 87%, 45%, 31%, and 45% less access to water (aOR = 0.13, p ≤ 0.001), sanitation (aOR = 0.55, p ≤ 0.001), and handwashing (aOR = 0.69, p ≤ 0.05), and WASH facilities aOR = 0.55, p ≤ 0.001), respectively. Among the policies of Bangladesh, only one identified action for WASH rights of ethnic minorities. CONCLUSION: The government should identify the issues of WASH among ethnic minorities and represent them adequately in policies to achieve the aim of 'leaving none behind' of sustainable development goals.

Transition and change: opportunities and challenges of CHW programme reform for community health systems and vertical disease programmes in Liberia.

BACKGROUND: Globally, community health worker (CHW) programmes are critical to addressing health worker shortages and have been recognised as critical pillars within the drive towards universal health coverage (UHC). In 2016, the Liberian Ministry of Health launched the National Community Health Services Policy 2016-2021, which included significant CHW programme reform to address ongoing health workforce capacity gaps in the country. However, little consideration was given to the impact of such reforms on ongoing health interventions that rely heavily on the use of CHW cadres. Our study explores how CHW programme reform in Liberia influenced performance of CHWs involved in the delivery of Neglected Tropical Disease (NTD) programmes to elucidate how health systems reform can impact the delivery of routine health interventions and vice versa. METHODS: We used a qualitative case study approach conducted between March 2017 and August 2018. Our instrumental case study approach uses qualitative methods, including document review of five CHW and NTD program-related policy documents; 25 key informant interviews with facility, county, and national level decision-makers; and 42 life and job histories with CHWs in Liberia. Data were analysed using a thematic framework approach, guided by Kok et al. framework of CHW performance. Data were coded in QRS NVIVO 11 Pro. RESULTS: Our findings show that CHW programme reform provides opportunities and challenges for supporting enhanced CHW performance. In relation to health system hardware, we found that CHW programme reform provides better opportunities for: formal recognition of CHWs; strengthening capacity for effective healthcare delivery at the community level through improved and formalised training; a more formal supervision structure; and provision of monthly incentives of 70 US dollars. Efficiency gaps in routine intervention delivery can be mitigated through the strengthening of these hardware components. Conversely, supervision deficits in routine CHW functioning can be supported through health interventions. In relation to systems software, we emphasise the ongoing importance of community engagement in CHW selection that is responsive to gendered power hierarchies and accompanied by gendered transformative approaches to improving literacy. CONCLUSIONS: This study shows how CHW programme reform provides opportunities and challenges for health system strengthening that can both positively and negatively impact the functioning of routine health interventions. By working together, CHW programmes and routine health interventions have the opportunity to leverage mutually beneficial support for CHWs, which can enhance overall systems functioning by enhancing CHW performance.

State-Level Childhood Lead Poisoning Prevention Policies and Practices in the United States: 2022-2023.

OBJECTIVES: The purpose of this analysis is to better understand laws and practices guiding prevention activities in childhood lead poisoning prevention programs funded by the Centers for Disease Control and Prevention (CDC). METHODS: In 2022, CDC surveyed 62 funded programs using the Awardee Lead Profile Assessment. Information was collected about childhood lead poisoning-related laws and guidance, surveillance and prevention strategies, and program services including at what blood lead levels (BLLs) various activities are performed. Separately, CDC reviewed state health department websites to obtain information on which states implemented CDC's updated blood lead reference value. RESULTS: Awardee Lead Profile Assessment results are only reported for 47 states, the District of Columbia, and Puerto Rico. Almost all programs (96%) have laws requiring reporting of BLLs, and 51% require BLLs be reported electronically to jurisdictional health departments. Most programs (80%) prioritize areas and populations that are high risk for lead poisoning prevention activities. Approximately half of the programs (51%) have a lead elimination plan or goal. Thirty-nine percent of the programs have already implemented policies, laws, or regulations to achieve lead elimination, and 74% are in the Northeast and Midwest regions of the country. As of March 2023, 71% of the programs have implemented CDC's updated blood lead reference value, and most (65%) did so via guidance for health care providers and laboratories for what BLL should initiate case management and other services for lead-exposed children. CONCLUSIONS: Almost all programs have mandatory BLL reporting laws, and about two-thirds of the programs updated their BLLs that trigger public health action.

Changing direction for health in Africa.

Current developments augurs well for sexual and reproductive health in Africa. With the African Union joining the G20 group, it is expected that its regional health priorities will be given special consideration. Social protection and empowerment of youth and women were prominent at the recent Summit of the Future. The impending change in leadership at the African regional office of the World Health Organization brings great expectations for sound policy formulation and surveillance for detecting outbreaks of epidemics. At the United Nations, Africa will benefit from reform of the Security Council besides intensified activities pertaining to the Sustainable Development Goals.

Les développements actuels sont de bon augure pour la santé sexuelle et reproductive en Afrique. Avec l'adhésion de l'Union africaine au groupe du G20, on s'attend à ce que ses priorités régionales en matière de santé fassent l'objet d'une attention particulière. La protection sociale et l'autonomisation des jeunes et des femmes étaient au centre du récent Sommet du futur. Le changement imminent à la tête du bureau régional africain de l'Organisation mondiale de la santé suscite de grands espoirs en matière de formulation de politiques et de surveillance judicieuses pour détecter les flambées d'épidémies. Aux Nations Unies, l'Afrique bénéficiera de la réforme du Conseil de sécurité ainsi que de l'intensification des activités liées aux objectifs de développement durable.

Working in a relational way is everything: Perceptions of power and value in a drug policy-making network.

BACKGROUND: The development of drug policies has been a major focus for policy-makers across North America in light of the ongoing public health emergency caused by the overdose crisis. In this context, the current study examined stakeholders' experiences and perceptions of power and value in a drug policy-making process in a North American city using qualitative, questionnaire, and social network data. METHODS: We interviewed 18 people who participated in the development of a drug policy proposal between October 2021 and March 2022. They represented different groups and organizations, including government (n = 3), people who use drugs-led advocacy organizations (n = 5), other drug policy advocacy organizations (n = 5), research (n = 3) and police (n = 2). Most of them identified as men (n = 8) and white (n = 16), and their ages ranged between 30 and 80 years old (median = 50). Social network analysis questionnaires and semi-structured qualitative interviews were administered via Zoom. Social network data were analysed using igraph in R, and qualitative data were analysed using thematic analysis. The analyses explored perceptions of value and power within a drug policy-making network. RESULTS: The policy-making network showed that connections could be found across participants from different groups, with government officials being the most central. Qualitative data showed that inclusion in the network and centrality did not necessarily translate into feeling powerful or valued. Many participants were dissatisfied with the process despite having structurally advantageous positions or self-reporting moderately high quantitative value scores. Participants who viewed themselves as more valued acknowledged many process shortcomings, but they also saw it as more balanced or fair than those who felt undervalued. CONCLUSIONS: While participation can make stakeholders and communities feel valued and empowered, our findings highlight that inclusion, position and diversity of connections in a drug policy-making network do not, in and of itself, guarantee these outcomes. Instead, policy-makers must provide transparent terms of reference guidelines and include highly skilled facilitators in policy discussions. This is particularly important in policy processes that involve historical power imbalances in the context of a pressing public health emergency.

LGBTQIA+ inclusion in the global health policy agenda: A critical discourse analysis of the Lancet Commission report archive.

CONTEXT: LGBTQIA+ people worldwide experience discrimination, violence, and stigma that lead to poor health outcomes. Policy plays a crucial role in ensuring health equity and safety for LGBTQIA+ communities. Given Lancet Commissions' substantial impact on health policy across domains, we aimed to determine how LGBTQIA+ communities and their care needs are incorporated throughout Lancet Commission reports and recommendations. METHODS: Using critical discourse analysis, we analyzed 102 Commissions for inclusion of and reference to LGBTQIA+ communities using 36 key terms. Three levels of analysis were conducted: 1) micro-level (overview of terminology use); 2) meso-level (visibility and placement of LGBTQIA+ references); and 3) macro-level (outlining characterizations and framing of references with consideration of broader social discourses). FINDINGS: 36 of 102 (35%) Commissions referenced LGBTQIA+ communities with 801 mentions in total. There were minimal (9/36) references made in the "Executive Summary," "Recommendations," and/or "Key Messages" sections of reports. LGBTQIA+ communities were most frequently discussed in reports related to HIV/AIDS and sexual and reproductive health. Few Commissions related to public health, or chronic conditions (9/60) referenced LGBTQIA+ communities. Some reports made non-specific or unexplained references; many discussed the LGBTQIA+ population without specific reference to sub-groups. LGBTQIA+ communities were often listed alongside other marginalized groups without rationale or a description of shared needs or experiences. We identified framings (legal, vulnerability, risk) and characterizations (as victims, as blameworthy, as a problem) of LGBTQIA+ communities that contribute to problematizing discourse. CONCLUSIONS: LGBTQIA+ people were rarely included in the Commissions, resulting in an inadvertent marginalization of their health needs. Policy initiatives must consider LGBTQIA+ groups from a strengths-based rather than problematizing perspective, integrating evidence-based approaches alongside community-based stakeholder engagement to mitigate inequities and promote inclusive care and policymaking.

Punitive state policies targeting alcohol use during pregnancy and alcohol consumption among pregnant women.

This study aimed to determine whether punitive state alcohol policies targeting pregnant women who drink alcohol are associated with decreased alcohol consumption among pregnant women over time. This study used data from the Pregnancy Risk Assessment Monitoring System (15 states) between 1990 and 2015. A difference-in-difference (DiD) approach was employed to determine whether passage of state laws changed alcohol consumption rates among pregnant women, while controlling for state and time fixed effects. The study specifically examined punitive state alcohol policies that clarify the admissibility of evidence in child welfare proceedings related to prenatal alcohol exposure, focusing on allegations of child abuse, child neglect, child deprivation, or child dependence, as well as proceedings seeking termination of parental rights. Punitive state alcohol policies were not significantly associated with decreased rates of alcohol consumption among pregnant women (+ 1.54%, 95% CI, -1.47-4.55), within 3 years of implementation. State alcohol policies that adopted a punitive stance toward pregnant women who drink alcohol did not result in the reduction of drinking during pregnancy. Given that punitive policies may not effectively reduce alcohol consumption during pregnancy, our findings highlight the need for reevaluation and potential reform to better address maternal/child health outcomes.

Long COVID and Health Inequalities: What's Next for Research and Policy Advocacy?

INTRODUCTION: Organised by the 'Qualitative Long Covid Network', a workshop for qualitative Long COVID (LC) researchers, LC charity representatives and people with LC took place in June 2023, where research on the intersectional inequalities affecting LC prevalence, recognition and care was shared and discussed. METHODS: Five key themes were drawn up from presentations, discussions and reflections during the workshop, which are presented in this study. RESULTS: The following five themes are discussed: the unfairness of LC, difficulties in accessing care, mistrust of the healthcare system, a lack of understanding of LC and experiences of stigma and discrimination. Factors that widen or narrow inequalities related to LC were identified. CONCLUSION: A call to action is proposed to investigate and address inequalities through a robust LC research agenda that speaks with conviction to policy and decision-makers. We argue that there needs to be a strong investment in research and evidence-based policy and practice to mitigate the worst effects of the condition and address the inequalities in experience, treatment and support, which are experienced more often and more acutely by some of society's most vulnerable and disadvantaged individuals. PATIENT AND PUBLIC (PPI) CONTRIBUTION: Projects included in this article had PPI ongoing activity to inform their research. A member of the CONVALESCENCE PPI group presented at the QLC Network 'Long Covid and Health Inequalities' workshop, as did members of Long COVID Kids, Long COVID Support and Long COVID SOS charities. They were all invited to be co-authors of this article.

Cooperators or competitors? The interactions between WHO and the World Bank in global health governance.

Interactions between International Organisations (IOs) within a regime complex often manifest themselves through competition and cooperation. Current research has examined the factors that promote inter-organisational competition and cooperation, yet the precise timing of when such competition or cooperation commences remains unclear. This paper focuses on two pivotal IOs in global health governance, the World Health Organization (WHO) and the World Bank, to explore the timing and onset of competition and cooperation within a regime complex, as well as the driving factors in the evolution of their inter-organisational relationships. By looking into the interactions between the WHO and the World Bank in norm-setting and resource mobilising, the paper sheds light on how their relationships have transitioned from competitors to cooperators. It systematically presents the mechanisms and processes of policy transformation in inter-organisational interactions. As a new agenda arises, IOs within a regime complex often compete for dominance, with ideational differences driving them to propose and implement distinct governance strategies. They will compete for resources and mainstream of their strategy. The negative spillover effects of competitive policies consequently undermine the effectiveness of IOs' policy, thereby undercut their legitimacy. To surmount these challenges, the international community should promote inter-institutional coordination in global governance.

What is the best strategy for iron deficiency anemia prevention and control in Iran? a policy analysis study protocol.

BACKGROUND: The present study is a type of exploratory qualitative studies and applied research. The approach of this study is a prospective policy analysis in which we will formulate appropriate policy options to prevent and control iron deficiency anemia in Iran. METHODS AND MATERIALS: Current study is a multi-method research with an analysis for policy approach containing three phases. First, through a literature review study, policies, programs and interventions of different countries to control and prevent anemia caused by iron deficiency will be identified. Then, in the qualitative phase of the study, the challenges, barriers, facilitators of the policies and programs implemented and ongoing in Iran will be examined. The content and policy-making process, as well as the context and role of stakeholders and actors will be analyzed using the framework of the policy triangle and analysis of the policy process using the Kingdon's multiple streams model. Then, the proposed initial policy options will be developed. In the next phase, an expert panel contain experts, authorities and policymakers will be formed and the proposed options will be reviewed and categorized. In order to prioritize policy options and evaluate their feasibility in Iran, the Delphi technique and the policy options analysis framework of the Centers for Disease Control and Prevention (CDC) will be used. At the end, policy options will be selected based on the highest score and will be presented as appropriate policy options. CONCLUSION: Prospective policy analysis allows the selection of potentially practical and effective policy options to control iron deficiency anemia. The findings of current study will be presented as reports and research articles for policy makers.

Neocolonialism and science diplomacy: personal reflections from the Middle East on mental health policy and practice.

Neocolonialism has led to an imbalance in the production of knowledge and a clunky imposition of frameworks and models of practice that do not meet the needs of local communities. In contrast they can serve the central function of colonialism by draining valuable resources. Inequity of science diplomacy has diluted local voices and given precedence to colonialist knowledge and models of practice. It is argued that clinical, training and research excellence applies to those activities that meet and fulfil the clinical, training and research needs of the community in which they are embedded. Through personal reflection on contrasting Middle Eastern settings (Palestine and the UAE), the call is for the source of knowledge production and the driver for innovation to be daily clinical experiences listening to families in the community. This will result in policy and practices that are meaningful and impactful as illustrated by way of three examples: (1) a narrative approach to exploring suicide (2) an "all-hands-on-deck" clinical pathway for Autism assessments which transformed the lives of children and families with little additional resource, but with a fundamental shift in approach from "top down" to "bottom up" one as part of an organization-wide "Patient First" approach and (3) a rights-based, collective approach to developing mental health strategy. These examples are linked in terms of taking a shared "listening approach" but are applied to different levels moving from personal individual narratives to community clinical service to national strategy.

Assessment of Smoking Behaviour of Adolescents in Two Districts of Nepal and Implications of the MPOWER Policy Measures: A Mixed Method Study.

INTRODUCTION: Tobacco use is the single most preventable cause of death and disease worldwide. This study aimed to assess the smoking behaviour of adolescents in two districts of Nepal and examine the implications of the MPOWER policy on their smoking behaviour. METHODS: An explanatory, mixed-method study was conducted in two districts of Nepal. Qualitative in-depth interviews were conducted among nine participants aged 35-50, representatives of the Ministry of Health, academic institutions, and managers of organisations working in tobacco control, using snowball sampling method. A total of 306 students of age 13-15 years, from six government schools were recruited through simple random sampling method using an adapted version of the Global Youth Tobacco Survey (GYTS). Findings of the qualitative and quantitative study were explained for concurrence and relevance to present overall study findings. Ethical approval was received from the Nepal Health Research Council and Mahidol University. RESULTS: Findings from the survey reported that a total of 25 (8.10%) of respondents were smokers, from which 13 (4.20%) were current smokers and 12 (3.90%) were ever smokers. Socio-economic status played a crucial role in the smoking behaviour. Although the survey among adolescents indicated an awareness of the policies, there was a lack of cessation services, which was concurrent with the qualitative findings. The interviews recommended improvements in the implementation of policy ban on public smoking, taxation, and availability of cessation services. CONCLUSIONS: The MPOWER policies are not regulated strictly, especially in areas of the ban on public smoking, regulating the selling of cigarettes to adolescents <18 years, and availability of cessation services.