Food safety in vulnerable populations: A perspective on the challenges and solutions.

Vulnerable populations are a particular group that are not capable of fending for themselves due to a number of limitations. Among many things, of particular concern is the food safety challenges faced by these individuals and the high risk of susceptibility to foodborne diseases. In this paper, an attempt is made to point out the various challenges faced by vulnerable populations that make them more susceptible to foodborne illness than other healthy adults. Also, the paper highlights possible improvement pathways through which these people can have access to safe and nutritious food, and the current interventional steps taken to address the food safety risk associated with food handling activities of food meant for vulnerable groups.

Measuring Spatial Access of Vulnerable Population to HIV Testing Facilities in the Baton Rouge Metropolitan Statistical Area, Louisiana.

Ensuring adequate and equitable access to affordable HIV testing is a crucial step toward ending the HIV epidemic (EHE). Using the high-burden Baton Rouge Metropolitan Statistical Area (MSA) as an example, we measure spatial access to HIV testing facilities for vulnerable populations and assess whether their access would improve if eliminating a considerable barrier-costs. Locations and status (free, low-cost, and full cost) of HIV testing facilities are searched on the Internet and confirmed through a field survey. Vulnerable populations include the uninsured and people living with HIV (PLWH), disaggregated from county-level HIV prevalence data. Spatial access is computed by a normalized urban-rural two-step floating catchment area (NUR2SFCA) method. Our survey confirms that only 11% and 37% of the 103 Internet-searched HIV testing facilities are indeed free and low-cost. Making more facilities cheaper or free increases the average access of PLWH, the uninsured, and the entire population but their geographic patterns vary. Free testing facilities, clustered in Baton Rouge city, are highly accessible to 82.6%, 69.4%, and 70.2% of three population groups living in East and West Baton Rouge Parish. In comparison, making all low-cost facilities free increases access in most outlying parishes but at the cost of reducing access in East Baton Rouge Parish, leaving west Livingston, north Iberville, and east Pointe Coupee Parish with the poorest access. Making all full-cost facilities cheaper or free exhibits a similar pattern. The study has important policy implications for where and how to improve access to HIV testing for vulnerable populations.

RESUMEN: Medimos el acceso espacial a las instalaciones de pruebas de VIH para poblaciones vulnerables y evaluamos si su acceso mejoraría si se eliminaran las barreras de costos, utilizando como ejemplo el área estadística metropolitana de Baton Rouge, que tiene una alta carga. Nuestra encuesta confirma que el 11% y el 37% de los 103 centros de pruebas de VIH buscados en Internet son efectivamente gratuitos y de bajo costo. Hacer que más instalaciones sean más baratas o gratuitas aumenta el acceso promedio de las PLWH, las personas sin seguro y toda la población, pero sus patrones geográficos varían. Las instalaciones de pruebas gratuitas, agrupadas en la ciudad de Baton Rouge, son muy accesibles para el 82,6%, el 69,4% y el 70,2% de los tres grupos de población del este y oeste de Baton Rouge. En comparación, hacer que las instalaciones de bajo costo sean gratuitas aumenta el acceso en las parroquias periféricas, pero a costa de reducir el acceso en East Baton Rouge. Hacer que las instalaciones de costo total sean más baratas o gratuitas muestra un patrón similar. El estudio tiene importantes implicaciones políticas para mejorar el acceso a las pruebas del VIH para las poblaciones vulnerables.

Assessing chronic gestational exposure to environmental chemicals in pregnant women: Advancing the co-PBK model.

Vulnerable populations, such as pregnant women and their fetuses, confront potential health risks due to exposure to environmental toxic compounds. Computational methods have been popular in assessing chemical exposure to populations, contrasting with traditional cohort studies for human biomonitoring. This study proposes a screening-level approach based on physiologically based kinetic (PBK) modeling to evaluate the steady-state exposure of pregnant women to environmental chemicals throughout pregnancy. To exemplify the modeling application, naphthalene was chosen. Simulation results indicated that maternal fat exhibited significant bioaccumulation potential, with the log-transformed BTF of naphthalene at 0.51 mg kg-1 per mg d-1 in the steady state. The placenta was primarily exposed to 0.83 mg/d naphthalene for a 75.2 kg pregnant woman, considering all exposure routes. In the fetal structure, single-organ fetal PBK modeling estimated a naphthalene exposure of 123.64 mg/d to the entire fetus, while multiple-organ fetal PBK modeling further revealed the bioaccumulation highest in fat tissue. The liver identified as the vital organ for metabolism, kBioT,LiverM was demonstrated with the highest sensitivity among rate constants in the maternal body. Furthermore, the first-order kinetic rate constants related to the placenta and blood were found to impact the distribution process of naphthalene in the fetus, influencing gestational exposure. In conclusion, urgent attention is needed to develop a computational biomonitoring tool for assessing toxic chemical exposure in vulnerable populations.

A systematic review of animal feeding operations including concentrated animal feeding operations (CAFOs) for exposure, health outcomes, and environmental justice.

BACKGROUND: Despite growing literature on animal feeding operations (AFOs) including concentrated animal feeding operations (CAFOs), research on disproportionate exposure and associated health burden is relatively limited and shows inconclusive findings. OBJECTIVE: We systematically reviewed previous literature on AFOs/CAFOs, focusing on exposure assessment, associated health outcomes, and variables related to environmental justice (EJ) and potentially vulnerable populations. METHODS: We conducted a systematic search of databases (MEDLINE/PubMed and Web of Science) and performed citation screening. Screening of titles, abstracts, and full-text articles and data extraction were performed independently by pairs of reviewers. We summarized information for each study (i.e., study location, study period, study population, study type, study design, statistical methods, and adjusted variables (if health association was examined), and main findings), AFO/CAFO characteristics and exposure assessment (i.e., animal type, data source, measure of exposure, and exposure assessment), health outcomes or symptoms (if health association was examined), and information related to EJ and potentially vulnerable populations (in relation to exposure and/or health associations, vulnerable populations considered, related variables, and main findings in relation to EJ and vulnerable populations). RESULTS: After initial screening of 10,963 papers, we identified 76 eligible studies. This review found that a relatively small number of studies (20 studies) investigated EJ and vulnerability issues related to AFOs/CAFOs exposure and/or associated health outcomes (e.g., respiratory diseases/symptoms, infections). We found differences in findings across studies, populations, the metrics used for AFO/CAFO exposure assessment, and variables related to EJ and vulnerability. The most commonly used metric for AFO/CAFO exposure assessment was presence of or proximity to facilities or animals. The most investigated variables related to disparities were race/ethnicity and socioeconomic status. CONCLUSION: Findings from this review provide suggestive evidence that disparities exist with some subpopulations having higher exposure and/or health response in relation to AFO/CAFO exposure, although results varied across studies.

A retrospective cohort analysis of treatment outcomes of patients with tuberculosis who used substances in Tel Aviv, Israel.

AIMS: To outline the demographic, clinical, laboratory characteristics, and treatment outcomes of tuberculosis (TB) patients who used substances. METHODS: This retrospective cohort study compared 50 TB patients who used substances with a matched random sample of 100 TB patients who did not use substances between 2007 and 2017. Treatment failure was defined as a sputum smear or culture that tested positive after 5 months of treatment, loss to follow-up, unevaluated patients, or death. RESULTS: TB patients who used substances were typically younger, experienced homelessness, smokers, and had fewer chronic diseases than those who did not use substances. They also were hospitalized for longer periods, their treatment durations were longer, had higher rates of multidrug resistant strains, increased rates of treatment failure, and higher mortality. Individuals whose treatment failed predominantly originated from the former Soviet Union, experienced homelessness, and had chronic diseases compared with those whose treatment was successful. In the multivariate analysis, homelessness [odds ratios (OR) = 6.7], chronic diseases (OR = 12.4), and substance use (OR = 4.0) were predictors of treatment failures. CONCLUSIONS: TB patients who used substances were more likely to have treatment failure. Targeted interventions, including early diagnosis and enhanced support during treatment, are essential to achieve treatment success in this vulnerable population, in addition to TB-alcohol/drug collaborative activities.

Cancer in Victorian prisoners: a description of cancer diagnoses, demographics, risk factors and barriers to optimal care.

BACKGROUND: The Victorian prison population is growing and ageing. Little has been documented about this group's cancer incidence, presentation or treatment. AIMS: To conduct a retrospective review of Victorian prisoners with cancer, including assessment of change over 15 years and adequacy of treatment delivery. METHODS: Detailed demographic, cancer and treatment data were collected for all prisoners with malignancy treated at St Vincent's Hospital Melbourne from 2002 to 2017. Detailed analysis of adherence to Optimal Care Guidelines was undertaken for a subset. Descriptive statistics were used. RESULTS: We identified 200 cancers in 191 prisoners. The population was predominantly male (185 of 191, 93%), with a median age of 54 years. Rates of cigarette smoking (118 of 191, 59%), mental illness (92 of 191, 46%) and intravenous drug use (59 of 191, 29.5%) were high. Exposure-related cancers predominated (nonmelanoma skin cancer, lung cancer and hepatoma). Most were symptomatic (154 of 191, 77%) and almost one-third had incurable disease at diagnosis (64 of 191, 32%). The number of prisoners with cancer increased over time (2002-2006 [T1], n = 31 vs 2012-2016 [T3], n = 101), as did the median age (45 years in T1 vs 55 years in T3) and rates of mental illness (10 of 31 [32%] in T1 vs 55 of 101 [54%] in T3). Delayed treatment initiation occurred in eight of 12 (66%) assessable patients, largely because of nonattendance. CONCLUSIONS: Victorian prisoners with cancer are at risk of poor outcomes because of late presentation, delayed treatment initiation and medical comorbidities. Tailored interventions are urgently required to improve the provision of timely, comprehensive cancer care to this vulnerable and growing population.

Differential impacts of health systems and sociocultural environment on vulnerable populations during the COVID-19 pandemic: lessons from four Asia-Pacific countries.

BACKGROUND: This study aims to evaluate healthcare systems and pandemic responses in relation to marginalized and vulnerable groups, identify populations requiring urgent care, and assess the differential impacts on their health during the pandemic. METHODS: Data were collected by the Asia-Pacific Observatory on Health Systems and Policies (APO)-National University of Singapore and APO-International Health Policy Program consortium members: Korea, Indonesia, Philippines, and Singapore. Data were collected through a combination of semi-structured interviews, policy document reviews, and analysis of secondary data. RESULTS: Our findings reveal that the pandemic exacerbated existing health disparities, particularly affecting older adults, women, and children. Additionally, the study identified LGBTI individuals, healthcare workers, slum dwellers, and migrant workers as groups that faced particularly severe challenges during the pandemic. LGBTI individuals encountered heightened discrimination and limited access to health services tailored to their needs. Healthcare workers suffered from immense stress and risk due to prolonged exposure to the virus and critical working conditions. Slum dwellers struggled with healthcare access and social distancing due to high population density and inadequate sanitation. Migrant workers were particularly hard hit by high risks of virus transmission and stringent, often discriminatory, isolation measures that compounded their vulnerability. The study highlights the variation in the extent and nature of vulnerabilities, which were influenced by each country's specific social environment and healthcare infrastructure. It was observed that public health interventions often lacked the specificity required to effectively address the needs of all vulnerable groups, suggesting a gap in policy and implementation. CONCLUSIONS: The study underscores that vulnerabilities vary greatly depending on the social environment and context of each country, affecting the degree and types of vulnerable groups. It is critical that measures to ensure universal health coverage and equal accessibility to healthcare are specifically designed to address the needs of the most vulnerable. Despite commonalities among groups across different societies, these interventions must be adapted to reflect the unique characteristics of each group within their specific social contexts to effectively mitigate the impact of health disparities.

Cost-related medication nonadherence in adults with COPD in the United States 2013-2020.

BACKGROUND: Cost-related medication nonadherence (CRN) is associated with poor prognosis among patients with chronic obstructive pulmonary disease (COPD), a population that requires long-term treatment for secondary prevention. In this study, we aimed to estimate the prevalence and sociodemographic characteristics of CRN in individuals with COPD in the US. METHODS: In a nationally representative survey of US adults in the National Health Interview Survey (2013-2020), we identified individuals aged ≥18 years with a self-reported history of COPD. Cross-sectional study. RESULTS: Of the 15,928 surveyed individuals, a weighted 18.56% (2.39 million) reported experiencing CRN, including 12.50% (1.61 million) missing doses, 13.30% (1.72 million) taking lower than prescribed doses, and 15.74% (2.03 million) delaying filling prescriptions to save costs. Factors including age < 65 years, female sex, low family income, lack of health insurance, and multimorbidity were associated with CRN. CONCLUSIONS: In the US, one in six adults with COPD reported CRN. The influencing factors of CRN are multifaceted and necessitating more rigorous research. Targeted interventions based on the identified influencing factors in this study are recommended to enhance medication adherence among COPD patients.

Adolescent experiences during perinatal care in the COVID-19 pandemic: synthesis of qualitative studies.

OBJECTIVES: To understand how the perinatal care experiences among adolescents were impacted during the early years of the COVID-19 pandemic. STUDY DESIGN: Integrative review. METHODS: We performed a search in the literature focusing on qualitative studies regarding the perceptions of pregnant adolescents during the pandemic (2020-2023). We described the most frequent thematic axes observed in the included studies, and we synthesized the results. RESULTS: The selection involved 69 articles, resulting in 9 studies from 7 countries (Indonesia, Kenya, the United Kingdom, South Africa, the United States, Malawi, and India). The studies highlight six main thematic axes: 1. Economic impact: the pandemic adversely influenced personal and family conditions, leading to early marriages and violence and exacerbating pre-existing economic inequalities. 2. Mental health: increased anxiety, depression, isolation, and fear among pregnant adolescents, with a focus on concerns related to contamination and perinatal uncertainties. 3. Compromised perinatal care: restrictions during prenatal and delivery care and lack of emotional and professional support lead to negative impacts on care for pregnant adolescents. 4. Breakdown of family Support network: school closures, family losses, and increased domestic violence affected family dynamics, influencing the occurrence of early pregnancies. 5. Impact on sexual education: school closures hindered access to contraceptives, contributing to unplanned pregnancies. 6. Vaccine hesitancy: misinformation led to hesitancy among pregnant women, highlighting the need for better communication to increase confidence in vaccination. CONCLUSIONS: The review emphasizes the wide geographic variety of the studies and highlights the interconnection between economic, social, and mental health factors. The pandemic intensified preexisting challenges, underscoring the importance of comprehensive support for pregnant adolescents, including emotional and psychological support. The COVID-19 pandemic exacerbated social and economic inequalities, negatively impacting the perinatal experiences of pregnant adolescents. The emphasis is on the need for comprehensive support, considering psychosocial factors, highlights the importance of more inclusive and sensitive health policies addressing the specific needs of this group during public health crises. The identified thematic axes, spanning economic, mental health, perinatal care, family support networks, sexual education, and vaccine hesitancy, illuminate the intricate challenges faced by adolescents during the pandemic. The identification of these axes provided a comprehensive analysis of the diverse consequences experienced by adolescents during the COVID-19 pandemic. It also allows the proposition of tailored interventions to mitigate the adverse effects on adolescent well-being and inform public health strategies for future pandemics or crises.

Racial/ethnic disparities in sleep health among adolescents in South Korea: The role of substance use behaviours.

AIM: To examine the relationship between racial/ethnic disparities and substance use behaviours (alcohol and tobacco use) and their impact on the sleep health of South Korean adolescents. DESIGN: Secondary analysis of cross-sectional study data from the 2021 Korea Youth Risk Behaviour Web-based Survey dataset. METHODS: Given that Korean society has historically linked its racial/ethnic identity to a shared bloodline, we categorized 2644 adolescents from the Korea Youth Risk Behaviour Web-based Survey based on their racial/ethnic status, determined by their parents' birthplaces. Using multiple linear regression, we investigated whether the impact of racial/ethnic disparities on sleep health (sleep duration, debt, and timing) varies depending on substance use behaviours (alcohol and tobacco use) after controlling for age, sex, household economic status, depressed mood, suicidal ideation, perceived excessive stress, and anxiety level. RESULTS: Despite no statistical differences in sleep health and the prevalence of substance use between racial/ethnic groups, racial/ethnic minority adolescents experienced greater sleep debt than racial/ethnic majority adolescents when consuming alcohol. Moreover, racial/ethnic minority adolescents were more likely to report psychosocial distress and had lower parental education level. CONCLUSION: Racial/ethnic minority adolescents were more vulnerable to the detrimental effects of alcohol use on sleep health compared to racial/ethnic majority adolescents. This heightened vulnerability may be attributed to the more pronounced psychosocial challenges and the lower socioeconomic status of parents in the racial/ethnic minority group. IMPACT: Racial/ethnic disparities are concerning in South Korea, particularly since the negative effects of substance use on sleep health are intensified among racial/ethnic minority adolescents. Nurses and other healthcare providers should recognize the importance of addressing the social disadvantages linked to racial/ethnic disparities. Beyond just advocating for the cessation of substance use, it is crucial to address these underlying issues to reduce sleep disparities among South Korean adolescents. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Assessing Telemental Health Uptake and Associated Health Care Resource Implications among Mississippi Medicaid Enrollees with Major Depression.

Objective: Investigate the association between Telemental Health (TMH) uptake and sociodemographic characteristics, and how TMH uptake relates to health care resource utilization and Medicaid expenditures among Mississippi Medicaid enrollees with major depression. Methods: A retrospective cohort study was conducted (2019-2020), comparing those who utilized TMH and those who did not. Results: Among the 21,239 identified enrollees, 806 (3.79%) utilized TMH. The TMH cohort was more likely to be of older age, non-Hispanic White, comprehensive managed care organization enrollees, rural residents, and from areas with a higher area deprivation index, and have higher Charlson comorbidity index scores. The TMH cohort also exhibited higher mental health-related and all-cause outpatient and emergency department utilization, along with higher Medicaid expenditures. Conclusion: As the first study investigating telehealth utilization among Mississippi Medicaid enrollees, this study highlights sociodemographic disparities in telehealth adoption. Addressing barriers hindering telehealth adoption among vulnerable populations and ensuring the availability of quality data are vital for future research.

Telemental Health Services Usage and Association with Health Care Utilization and Expenditures Among Vulnerable Medicare Beneficiaries in 2019: A Comparative Study Using Propensity Score Matching.

Background: Telemental health (TMH) offers a promising approach to managing major depressive disorder (MDD). The objective of our work was to evaluate TMH usage among a vulnerable population of MDD Medicare beneficiaries and its association with health care utilization and expenditures. Methods: This cohort study analyzed 2019 Mississippi Medicare fee-for-service data for adult beneficiaries with MDD. Subjects were matched by the use of TMH following 1:1 propensity score matching. Comparisons between TMH and non-TMH cohorts were made on health care utilization and expenditure outcomes, adjusting for provider types postmatching. Results: Among 7,673 identified beneficiaries, 551 used TMH and 7,122 did not. Prematching, TMH cohort showed greater proportions of dual beneficiaries, rural residents, subjects with income below $40,000, those with disability entitlement, and higher Charlson comorbidity index scores, compared to the non-TMH cohort (all p < 0.001). Moreover, the TMH cohort had fewer outpatient visits, but more inpatient admissions, emergency department (ED) visits, and higher medical, pharmacy, and total expenditures (all p < 0.001). Postmatching, TMH was associated with a 25% reduction in outpatient visits (p < 0.001) and a 20% reduction in pharmacy expenditures (p = 0.01), with no significant effect on inpatient admissions, ED visits, medical expenditures, or total expenditures. Conclusions: These results underscore the potential of TMH in enhancing accessible health care services for vulnerable populations and affordable services for Medicare. Our results provide a robust baseline for future policy discussions concerning TMH. Future studies should consider identifying barriers to TMH use among vulnerable populations and ensuring equitable and high-quality patient care.

Feasibility of Remote Blood Pressure Monitoring for Detection and Management of Maternal Hypertension in a predominantly Black, Rural and Medicaid Population in Mississippi.

Background: Remote patient monitoring (RPM) has potential in hypertension management, but limited studies have focused on maternal hypertension, especially among vulnerable populations. The objective of this study was to integrate RPM into perinatal care for pregnant patients at elevated risk of hypertensive disorders to show feasibility, acceptability, and safety. Methods: A prospective pilot cohort study was conducted at the University of Mississippi Medical Center 2021-2023. Participants' blood pressure readings were remotely captured and monitored until 8-week postpartum, with timely assessment and intervention. Results: Out of 98 enrollees, 77 utilized RPM, and no maternal or neonatal deaths occurred within 60-day postpartum. High program satisfaction was reported at discharge. Conclusion: This study demonstrates the feasibility and acceptability of RPM for perinatal care in a vulnerable population. Positive outcomes were observed, including high patient satisfaction and no maternal or neonatal deaths. Further research should address patient engagement barriers and develop tailored protocols for improved clinical outcomes.

Barriers in Cleft Service Access in Sub-Saharan Africa: A Thematic Analysis of Practical Needs of Rural Families.

OBJECTIVE: To explore the experiences and perceptions of barriers of parents and family members of patients with cleft lip and palate in accessing cleft services in remote northwest Nigeria. DESIGN: Face-to-face semi-structured audio recorded interviews were used to obtained qualitative textual data. Thematic analysis using interpretative descriptive techniques was employed to understand the participants' lived experiences with barriers and accessibility to cleft services. SETTING: Participants were from Sokoto, Kebbi and Zamfara states in remote northwest, Nigeria. PARTICIPANTS: Consisted of 22 caregivers (17 parents and 5 extended family members) were purposively sampled between 2017 and 2020. MAIN OUTCOME MEASURES: Barriers experienced while accessing cleft services were identified during thematic analysis. RESULT: Over three quarter of the respondents had patients with both cleft lip and palate and without any previous family history (n = 20). About two-thirds of the participants (n = 15) were females. Most of the interviews were conducted before the surgeries (n = 15). FIVE THEMES EMERGED: lack of information, financial difficulty, misrepresentation from health workers, multiple transportation and previous disappointment. CONCLUSIONS: Areas of poor awareness, misinformation from primary health care workers, financial hurdles, multiple transportation logistics and others were identified. Aggressive broadcasting of information through radio, timely treatment and collaboration with influential religious leaders were emphasized. Support, grants and subsidies from government and voluntary agencies are encouraged to mitigate the huge out of pocket cost of cleft care in the region.

Occupational exposure to chemical substances and health outcomes among hospital environmental services workers: A scoping review of international studies.

Environmental services (EVS) workers are essential to preventing the spread of disease in hospitals. However, their exposure to hazardous chemicals and drugs is understudied. This scoping review will synthesize literature on hazardous chemical exposures and adverse health outcomes among EVS workers to identify research gaps and trends for further investigation. The scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure complete and accurate reporting. The scoping review included 25 studies on occupational exposure to chemicals among EVS workers in hospitals. Most studies focused on exposure to cleaning products, which led to dermal, respiratory, and ocular symptoms, oxidative stress, and inflammation. While personal protective equipment (PPE), training, education, and policies have the potential to enhance safety, further research is required to examine the long-term impacts of exposure and the cost-effectiveness of interventions. Future studies should utilize longitudinal approaches and self-reported data collection methods, such as diaries and interviews, to comprehensively assess exposure risks and develop effective interventions and policies. Future research is needed to understand the potential health risks faced by EVS workers from exposure to chemicals in hospitals. Longitudinal studies with objective exposure assessments and larger sample sizes should be conducted. Policies and interventions must be developed and implemented to improve safe work practices and reduce negative health outcomes.

[Health and climate change-what is the potential of real-world data?] / Gesundheit und Klimawandel ­ welche Potenziale haben versorgungsnahe Daten?

This article addresses the question of how climate change may affect health and to what extent real-world data can contribute to research in this topic area. Climate change is altering the environmental and living conditions of humankind, and has thus also become a relevant health problem. The increase in extreme weather events, changes in exposure to UV and air pollution, and the climate-associated spread of allergens or novel pathogens are significantly changing the spectrum of diseases and the need for medical care in the population. However, in Germany, only few findings on the consequences for the healthcare system and on particularly affected population groups exist so far. Real-world data (primary data, register data, and administrative data) in combination with environmental exposure data and other relevant data (e.g., socio-economic data) have the potential to significantly advance research on the health consequences of climate change. This paper identifies changes in environmental and living conditions and associated health risks. It describes the databases that are generally available for analysing health effects of climate change. A concrete example is used to show how individual health data (in this case claims data of the statutory health insurance), environmental exposure data and other data can be successfully combined. Finally, the article offers a comprehensive overview of open research questions that can be answered with real-world data.

[Sexual health and vulnerable populations, some background information]. / Santé sexuelle et populations vulnérabilisées, quelques éléments de cadrage.

Taking an interest in the sexual health of vulnerable populations also means taking into account the notion of risky behavior. The aim here is to support and promote these behaviors and reduce the risks that may arise. Faced with such challenges, the public authorities have put this issue on the agenda by developing strategic and operational tools to achieve the objectives defined for 2030.

Why are they "unreached"? Macro and Meso determinants of health care access in hard to reach areas of Odisha, India.

BACKGROUND: Reaching hard to reach populations is key to reduce health inequities. Despite targeted interventions, status of crucial public health indicators like neonatal and maternal mortality is still far from optimal. Complex interplay of social determinants can influence both communities and health care workers to effectively access each other. We argue that culturally sensitive and contextually relevant healthcare provision has potential to increase health care utilization by the vulnerable communities living in remote areas. METHODS: The study is an exploratory case study using rapid ethnographic techniques to understand the interplay of social determinants in hard to reach areas of Odisha state, India. We used in-depth interviews, focus group discussion, participatory action research and key informant interviews as tools for data collection. The analysis of data has been guided by thematic analysis approach. RESULTS: We found that there are further layers within the designated hard to reach areas and those can be designated as-i) extremely remote ii) remote and iii) reachable areas. Degree of geographic difficulties and cultural dynamics are deciding the 'perceived' isolation and interaction with health care providers in hard to reach areas. This ultimately leads to impacting the utilization of the facilities. At extremely remote areas, felt health needs are mainly fulfilled by traditional healers and ethno-medical practices. In reachable areas, people are more prone to seek care from the public health facilities because of easy accessibility and outreach. Being in middle people in remote areas, diversify health care seeking depending upon social (e.g. patient's gender) economic (e.g. avoid catastrophic expenditure) and health system (timely availability of health human resources, language barriers) factors. CONCLUSION: Our research highlights the need to value and appreciate different worldviews, beliefs and practices, and their understanding of and engagement with the pluralistic health care system around them. Other than pursuing the 'mainstreaming' of a standardized health system model across hard to reach areas, strategies need to be adaptive as per local factors. To handle that existing policies need revision with a focus on culturally sensitive and contextual care provision.

Critical illness among patients experiencing homelessness: a retrospective cohort study.

PURPOSE: To understand the epidemiology and healthcare use of critically ill patients experiencing homelessness compared to critically ill patients with stable housing. METHODS: This retrospective population-based cohort study included adults admitted to any ICU in Alberta, Canada, for a 3-year period. Administrative and clinical data from the hospital, ICU and emergency department were used to examine healthcare resource use (processes of care, ICU and hospital length of stay, hospital readmission and emergency room visits). Regression was used to quantify differences in healthcare use by housing status. RESULTS: 2.3% (n = 1086) of patients admitted to the ICU were experiencing homelessness; these patients were younger, more commonly admitted for medical reasons and had fewer comorbidities compared to those with stable housing. Processes of care in the ICU were mostly similar, but healthcare use after ICU was different; patients experiencing homelessness who survived their index hospitalization were more than twice as likely to have a visit to the emergency department (OR = 2.3 times, 95% CI 2.0-2.6, < 0.001) or be readmitted to hospital (OR = 2.1, 95% CI 1.8-2.4, p < 0.001) within 30 days, and stayed 10.1 days longer in hospital (95% CI 8.6-11.6, p < 0.001), compared with those who have stable housing. CONCLUSIONS: Patients experiencing homelessness have different characteristics at ICU admission and have similar processes of care in ICU, but their subsequent use of healthcare resources was higher than patients with stable housing. These findings can inform strategies to prepare patients experiencing homelessness for discharge from the ICU to reduce healthcare resource use after critical illness.

Impaired health-related quality of life in the HCV cure era: who is concerned? (ANRS CO22 HEPATHER French cohort).

PURPOSE: Hepatitis C virus (HCV) cure after treatment with direct-acting antivirals (DAAs) can improve health-related quality of life (HRQoL). However, specific groups with chronic HCV may still exhibit worse post-cure HRQoL because of persisting severe liver fibrosis or social vulnerability factors (e.g. unhealthy alcohol use, living in poverty). We assessed the effect of such factors on longitudinal measures of HRQoL in chronic HCV patients. METHODS: ANRS CO22 HEPATHER is a prospective cohort of chronic HCV patients receiving DAAs, which included notably patients with social vulnerability factors, a population usually under-represented in clinical trials. Multivariable mixed-effects linear regression models helped identify factors associated with longitudinal measures of HRQoL (PROQOL-HCV scores). RESULTS: At enrolment, 52.4% of the 2740 participants were men, median age was 56 years [interquartile range 50-64], and 21.5% had severe liver fibrosis (FIB-4 > 3.25). Twenty-eight per cent reported current or past unhealthy alcohol use [> 2(3) alcohol units per day for women (men)], and 28.1% were living in poverty (standard of living under 1015€/month per household consumption unit). At first PROQOL-HCV completion, 54.0% of patients were HCV-cured. After multivariable adjustment, people with current or past unhealthy alcohol use, individuals living in poverty, those with severe liver fibrosis, and women had worse HRQoL in the dimensions explored. Conversely, HCV cure was associated with better HRQoL. CONCLUSIONS: Specific socially vulnerable groups of patients with chronic HCV infection still experience impaired HRQoL, independently of HCV cure. Patient-centred interventions, including social support and referral for comorbidities, should be prioritized for them. Trial registration with ClinicalTrials.gov NCT01953458.