Transgender health in medical education.

Transforming our world the 2030 agenda for sustainable development is working towards a world that reflects equity, with universal respect for human dignity, pledging to leave no one behind. However, transgender and gender-diverse individuals experience significant health inequities, including negative health outcomes and multiple barriers to accessing care. In this article, we first highlight the health inequities that transgender and gender-diverse people face globally. We describe important aspects of transgender and gender-diverse health care, including the design and provision of health services, epidemiological considerations, transition-related care, changes in transition-related goals, cultural considerations, and political and legal issues. We then review the existing global literature on incorporating transgender health into medical curricula. We make a case for prioritizing improved education in medical schools on the specific health needs of transgender and gender-diverse people as part of addressing global health inequities in care. Our recommendations for comprehensive education on transgender health include cultural humility and anti-oppression training; involvement of transgender and gender-diverse community members; integration of transgender and gender-diverse health into curricula; practice-focused and in situ training; staff development in medical schools; and improving access to careers in medicine for transgender and gender-diverse people.

Transformer notre monde: le Programme de développement durable à l'horizon 2030 aspire à un monde où règne l'équité, le respect universel de la dignité humaine, et s'engage à ce que personne ne soit oublié. Pourtant, les individus transgenres et de genre variant subissent de profondes inégalités sur le plan sanitaire, qui affectent leur état de santé et compliquent grandement l'accès aux soins. Dans cet article, nous commençons par souligner les inégalités sanitaires auxquelles sont confrontés les individus transgenres et de genre variant à travers le monde. Nous évoquons d'importants aspects à prendre en compte pour les soins de santé aux personnes transgenres et de genre variant, parmi lesquels la conception et la fourniture de services de santé, les considérations d'ordre épidémiologique, les soins liés à la transition, l'évolution des objectifs liés à la transition, les facteurs culturels, ainsi que les enjeux politiques et juridiques. Nous examinons ensuite la littérature internationale consacrée à l'intégration de la santé transgenre dans les programmes d'enseignement médical. Nous soutenons que, dans le cadre de la lutte contre les inégalités sanitaires au niveau mondial, il faut privilégier une amélioration de l'enseignement dans les écoles de médecine afin de sensibiliser aux besoins spécifiques des individus transgenres et de genre variant en matière de santé. Nous avons formulé plusieurs recommandations en vue d'instaurer un enseignement qui tient compte de la santé des personnes transgenres: apprentissage anti-oppressif intégrant la notion d'humilité culturelle; implication de membres de la communauté transgenre et de genre variant; ajout de la santé transgenre et de genre variant dans les programmes de cours; formation centrée sur la pratique, dispensée sur le terrain; développement du personnel des écoles de médecine; et enfin, amélioration de l'accès aux carrières médicales pour les individus transgenres et de genre variant.

Transforming our world: the 2030 agenda for sustainable development (Transformar de nuestro mundo: la Agenda 2030 para el desarrollo sostenible) trabaja por un mundo que refleje la igualdad, con respeto universal por la dignidad humana, comprometiéndose a no dejar a nadie atrás. Sin embargo, las personas transgénero y con género diverso experimentan importantes desigualdades en materia de salud, incluidos resultados sanitarios negativos y múltiples obstáculos para acceder a la atención sanitaria. En este artículo, destacamos, en primer lugar, las desigualdades sanitarias a las que se enfrentan las personas transgénero y de género diverso en todo el mundo. Describimos aspectos importantes de la atención sanitaria a las personas transgénero y con género diverso, como el diseño y la prestación de servicios sanitarios, las consideraciones epidemiológicas, la atención relacionada con la transición, los cambios en los objetivos relacionados con la transición, las consideraciones culturales y las cuestiones políticas y jurídicas. A continuación, revisamos la documentación global existente sobre la incorporación de la salud transgénero en los planes de estudio de medicina. Defendemos la necesidad de dar prioridad a la mejora de la formación en las facultades de medicina sobre las necesidades sanitarias específicas de las personas transgénero y con género diverso como parte del tratamiento de las desigualdades sanitarias globales en la atención sanitaria. Nuestras recomendaciones para una educación integral sobre la salud de las personas transgénero incluyen la formación en humildad cultural y lucha contra la opresión; la participación de los miembros de la comunidad transgénero y con género diverso; la integración de la salud de las personas transgénero y con género diverso en los planes de estudio; la formación centrada en la práctica e in situ; el desarrollo del personal en las facultades de medicina; y la mejora del acceso a las carreras de medicina para las personas transgénero y con género diverso.

Tools and approaches to operationalize the commitment to equity, gender and human rights: towards leaving no one behind in the Sustainable Development Goals.

The objective of this article is to present specific resources developed by the World Health Organization on equity, gender and human rights in order to support Member States in operationalizing their commitment to leave no one behind in the health Sustainable Development Goals (SDGs), and other health-related goals and targets. The resources cover: (i) health inequality monitoring; (ii) barrier analysis using mixed methods; (iii) human rights monitoring; (iv) leaving no one behind in national and subnational health sector planning; and (v) equity, gender and human rights in national health programme reviews. Examples of the application of the tools in a range of country contexts are provided for each resource.

Ethical issues in the development and implementation of nutrition-related public health policies and interventions: A scoping review.

BACKGROUND: The limited integration of ethics in nutrition-related public health policies and interventions is one major concern for those who have the task of implementing them. Ethical challenges that are overlooked during the development of such interventions could raise serious ethical issues during their implementation and even after. As a result, these decision makers need technical support and ethical guidance for adaptation of interventions to local (cultural, social, economic, etc.) contexts. AIM: The goal of this scoping review is to delineate and "map" the range of ethical issues in nutrition-related public health interventions, as well as the range of the various fields in which they may arise. METHODS: A scoping review of empirical research and conceptual literature was conducted following the framework of Arksey and O'Malley. Searches using PubMed with Medical Subject Headings (MeSH) categories and Advanced Search Builder as well as in the Global Health Library were performed. The final sample consists of 169 publications. RESULTS: The ethics of public health prevention or treatment of obesity and non-communicable diseases is the most explicitly and frequently discussed subject. In comparison, ethical issues raised by public health interventions in the fields of undernutrition, breastfeeding, vitamin/mineral supplementation and food fortification, food security, food sustainability and food safety are addressed in a lower proportion of the sample. The results illustrate the various natures, types, and scopes of existing public health nutrition-related interventions, and the various ethical issues that may be raised by these interventions, in addition to the numerous and different contexts in which they may be implemented. DISCUSSION: The ethical issues faced in the development and implementation of nutrition-related public health interventions are varied and cannot be equated with, nor generalized about, when dealing with specific activities in this field. More importantly, these ethical issues cannot be managed without a careful consideration for the complexity of contexts in which nutrition-related interventions are expected to be implemented. These interventions engage a variety of actors with diverse perspectives and interests. We discuss these challenges and also comment on the importance of considering ethical impacts in the monitoring and evaluation of such interventions. CONCLUSION: General ethical frameworks or recommendations-although useful-cannot be expected to provide policy makers, implementators and other public health personnel with sufficient practical ethical guidance as they cannot consider and anticipate the particularities of all specific nutrition-related public health interventions and the complexity of the contexts in which they are implemented. Further research is needed in order to develop more targeted ethical frameworks.

Interventions promoting healthy eating as a tool for reducing social inequalities in diet in low- and middle-income countries: a systematic review.

INTRODUCTION: Diet is a major risk factor for non-communicable diseases (NCDs) and is also strongly patterned by socioeconomic factors. Whether interventions promoting healthy eating reduce social inequalities in diet in low- and middle-income countries (LMICs) remains uncertain. This paper aims to summarize current evidence on interventions promoting healthy eating in LMICs, and to establish whether they reduce social inequalities in diet. METHODS: Systematic review of cross-sectional or quasi-experimental studies (pre- and post-assessment of interventions) in Pubmed, Scielo and Google Scholar databases, including adults in LMICs, assessing at least one outcome of healthy eating and showing results stratified by socioeconomic status. RESULTS: Seven intervention studies including healthy eating promotion, conducted in seven LMICs (Brazil, Chile, Colombia, Iran, Panama, Trinidad and Tobago, and Tunisia), met our inclusion criteria. To promote healthy eating, all interventions used nutrition education and three of them combined nutrition education with improved acces to foods or social support. Interventions targeted mostly women and varied widely regarding communication tools and duration of the nutrition education sessions. Most interventions used printed material, media use or face-to-face training and lasted from 6 weeks to 5 years. Four interventions targeted disadvantaged populations, and three targeted the entire population. In three out of four interventions targeting disadvantaged populations, healthy eating outcomes were improved suggesting they were likely to reduce social inequalities in diet. All interventions directed to the entire population showed improved healthy eating outcomes in all social strata, and were considered as having no impact on social inequalities in diet. CONCLUSION: In LMICs, agentic interventions promoting healthy eating reduced social inequalities in diet when specifically targeting disadvantaged populations. Further research should assess the impact on social inequalities in diet of a combination of agentic and structural approaches in interventions promoting healthy eating.

Large-scale fortification of condiments and seasonings as a public health strategy: equity considerations for implementation.

Fortification of staple foods with vitamins and minerals is an effective approach to increase micronutrient intake and improve nutritional status. The specific use of condiments and seasonings as vehicles in large-scale fortification programs is a relatively new public health strategy. This paper underscores equity considerations for the implementation of large-scale fortification of condiments and seasonings as a public health strategy by examining nonexhaustive examples of programmatic experiences and pilot projects in various settings. An overview of conceptual elements in implementation research and equity is presented, followed by an examination of equity considerations for five implementation strategies: (1) enhancing the capabilities of the public sector, (2) improving the performance of implementing agencies, (3) strengthening the capabilities and performance of frontline workers, (3) empowering communities and individuals, and (4) supporting multiple stakeholders engaged in improving health. Finally, specific considerations related to intersectoral action are considered. Large-scale fortification of condiments and seasonings cannot be a standalone strategy and needs to be implemented with concurrent and coordinated public health strategies, which should be informed by a health equity lens.

[Considerations on the development of nutrition-related guidelines by the World Health Organization and their implementation]. / Consideraciones sobre la elaboración de las directrices de nutrición de la Organización Mundial de la Salud y su implementación.

The World Health Organization (WHO) follows a complex and rigorous process to develop global guidelines. With regard to nutrition-related guidelines, the joint participation of national authorities from Member States and their partners, including those of the social economy, is key to strengthening the process of evidence-informed guideline development and the subsequent implementation as part of national public health strategies. WHO puts forward a series of tools that can assist national authorities on health and social development in the elaboration of evidence-informed policies, considering their pertinence, relevance and implementability. This adoption and adaptation process must consider equity in order to avoid widening existing inequities. WHO global nutrition guidelines contribute to the effective implementation of nutrition interventions in Member States. Two experiences of implementation, one in Panama and one in Peru, exemplify this process. The paper ends by suggesting a deeper understanding and utilization of implementation research during programmes to identify what factors ensure effective interventions, appropriate scale up strategies and greater health equity.

Consideraciones sobre la elaboración de las directrices de nutrición de la Organización Mundial de la Salud y su implementación / Considerations on the development of nutrition-related guidelines by the World Health Organization and their implementation

La Organización Mundial de la Salud (OMS) sigue un proceso complejo y riguroso para la elaboración de directrices mundiales. En el caso de las directrices relacionadas con nutrición, la participación conjunta de las autoridades de los Estados Miembros de la OMS y sus aliados, incluidos aquellos de la economía social y solidaria, es clave para fortalecer el proceso de elaboración de directrices informadas por las pruebas científicas y su posterior implementación, como parte de las estrategias nacionales de salud pública. Para las autoridades en materia de salud y desarrollo social, la OMS desarrolla una serie de herramientas para la formulación de políticas informadas por las pruebas científicas, considerando su pertinencia, relevancia e implementabilidad. Este proceso de adopción y adaptación debe considerar aspectos de equidad, para evitar la ampliación de brechas en salud. Las directrices mundiales de la OMS contribuyen a que las intervenciones en nutrición en sus Estados Miembros sean implementadas de manera adecuada. Dos experiencias de implementación de intervenciones en nutrición, una en Panamá y otra en Perú, ejemplifican este proceso. El artículo concluye sugiriendo profundizar en el conocimiento y aplicación de la investigación de la implementación de programas para identificar los factores que permiten a una intervención ser efectiva, tener una mejor estrategia de escalabilidad y contribuir a la equidad en salud.

The World Health Organization (WHO) follows a complex and rigorous process to develop global guidelines. With regard to nutrition-related guidelines, the joint participation of national authorities from Member States and their partners, including those of the social economy, is key to strengthening the process of evidence-informed guideline development and the subsequent implementation as part of national public health strategies. WHO puts forward a series of tools that can assist national authorities on health and social development in the elaboration of evidenceinformed policies, considering their pertinence, relevance and implementability. This adoption and adaptation process must consider equity in order to avoid widening existing inequities. WHO global nutrition guidelines contribute to the effective implementation of nutrition interventions in Member States. Two experiences of implementation, one in Panama and one in Peru, exemplify this process. The paper ends by suggesting a deeper understanding and utilization of implementation research during programmes to identify what factors ensure effective interventions, appropriate scale up strategies and greater health equity.

Equity in access to fortified maize flour and corn meal.

Mass fortification of maize flour and corn meal with a single or multiple micronutrients is a public health intervention that aims to improve vitamin and mineral intake, micronutrient nutritional status, health, and development of the general population. Micronutrient malnutrition is unevenly distributed among population groups and is importantly determined by social factors, such as living conditions, socioeconomic position, gender, cultural norms, health systems, and the socioeconomic and political context in which people access food. Efforts trying to make fortified foods accessible to the population groups that most need them require acknowledgment of the role of these determinants. Using a perspective of social determinants of health, this article presents a conceptual framework to approach equity in access to fortified maize flour and corn meal, and provides nonexhaustive examples that illustrate the different levels included in the framework. Key monitoring areas and issues to consider in order to expand and guarantee a more equitable access to maize flour and corn meal are described.