Positive epidemiology, revisited: the case for centering human rights and economic justice.

In recent years, a growing body of research in positive epidemiology has sought to expand the traditional focus of epidemiologic research beyond risk factors for disease and towards a more holistic understanding of health that includes the study of positive assets that shape well-being more broadly. While this paradigm shift holds great promise for transforming people's lives for the better, it is also critiqued for showcasing decontextualized perspectives that could cause great harm to the public's health if translated uncritically into population-based interventions. In this commentary, we argue for orienting positive epidemiology within a human rights and economic justice framework to mitigate this threat, and we discuss two examples of previously proposed health assets (religious involvement and marriage) that demonstrate the urgent need for positive epidemiologic research to center health equity. Finally, to advance the field, we provide recommendations for how future research can address shortcomings of the extant literature by moving from individual-level to societal-level applications. In doing so, we believe that positive epidemiology can be transformed into a powerful force for health equity. This article is part of a Special Collection on Mental Health.

Digital health and health equity: How digital health can address healthcare disparities and improve access to quality care in Africa.

The healthcare industry is constantly evolving to bridge the inequality gap and provide precision care to its diverse population. One of these approaches is the integration of digital health tools into healthcare delivery. Significant milestones such as reduced maternal mortality, rising and rapidly proliferating health tech start-ups, and the use of drones and smart devices for remote health service delivery, among others, have been reported. However, limited access to family planning, migration of health professionals, climate change, gender inequity, increased urbanization, and poor integration of private health firms into healthcare delivery rubrics continue to impair the attainment of universal health coverage and health equity. Health policy development for an integrated health system without stigma, addressing inequalities of all forms, should be implemented. Telehealth promotion, increased access to infrastructure, international collaborations, and investment in health interventions should be continuously advocated to upscale the current health landscape and achieve health equity.

Aspiring toward equitable benefits from genomic advances to individuals of ancestrally diverse backgrounds.

Advancements in genomic technologies have shown remarkable promise for improving health trajectories. The Human Genome Project has catalyzed the integration of genomic tools into clinical practice, such as disease risk assessment, prenatal testing and reproductive genomics, cancer diagnostics and prognostication, and therapeutic decision making. Despite the promise of genomic technologies, their full potential remains untapped without including individuals of diverse ancestries and integrating social determinants of health (SDOHs). The NHGRI launched the 2020 Strategic Vision with ten bold predictions by 2030, including "individuals from ancestrally diverse backgrounds will benefit equitably from advances in human genomics." Meeting this goal requires a holistic approach that brings together genomic advancements with careful consideration to healthcare access as well as SDOHs to ensure that translation of genetics research is inclusive, affordable, and accessible and ultimately narrows rather than widens health disparities. With this prediction in mind, this review delves into the two paramount applications of genetic testing-reproductive genomics and precision oncology. When discussing these applications of genomic advancements, we evaluate current accessibility limitations, highlight challenges in achieving representativeness, and propose paths forward to realize the ultimate goal of their equitable applications.

Autonomous Artificial Intelligence Increases Access and Health Equity in Underserved Populations with Diabetes.

Diabetic eye disease (DED) is a leading cause of blindness in the world. Early detection and treatment of DED have been shown to be both sight-saving and cost-effective. As such, annual testing for DED is recommended for adults with diabetes and is a Healthcare Effectiveness Data and Information Set (HEDIS) measure. However, adherence to this guideline has historically been low, and access to this sight-saving intervention has particularly been limited for specific populations, such as Black or African American patients. In 2018, the US Food and Drug Agency (FDA) De Novo cleared autonomous artificial intelligence (AI) for diagnosing DED in a primary care setting. In 2020, Johns Hopkins Medicine (JHM), an integrated healthcare system with over 30 primary care sites, began deploying autonomous AI for DED testing in some of its primary care clinics. In this retrospective study, we aimed to determine whether autonomous AI implementation was associated with increased adherence to annual DED testing, and whether this was different for specific populations. JHM primary care sites were categorized as "non-AI" sites (sites with no autonomous AI deployment over the study period and where patients are referred to eyecare for DED testing) or "AI-switched" sites (sites that did not have autonomous AI testing in 2019 but did by 2021). We conducted a difference-in-difference analysis using a logistic regression model to compare change in adherence rates from 2019 to 2021 between non-AI and AI-switched sites. Our study included all adult patients with diabetes managed within our health system (17,674 patients for the 2019 cohort and 17,590 patients for the 2021 cohort) and has three major findings. First, after controlling for a wide range of potential confounders, our regression analysis demonstrated that the odds ratio of adherence at AI-switched sites was 36% higher than that of non-AI sites, suggesting that there was a higher increase in DED testing between 2019 and 2021 at AI-switched sites than at non-AI sites. Second, our data suggested autonomous AI improved access for historically disadvantaged populations. The adherence rate for Black/African Americans increased by 11.9% within AI-switched sites whereas it decreased by 1.2% within non-AI sites over the same time frame. Third, the data suggest that autonomous AI improved health equity by closing care gaps. For example, in 2019, a large adherence rate gap existed between Asian Americans and Black/African Americans (61.1% vs. 45.5%). This 15.6% gap shrank to 3.5% by 2021. In summary, our real-world deployment results in a large integrated healthcare system suggest that autonomous AI improves adherence to a HEDIS measure, patient access, and health equity for patients with diabetes - particularly in historically disadvantaged patient groups. While our findings are encouraging, they will need to be replicated and validated in a prospective manner across more diverse settings.

Indigenous Identity and Household Food Insecurity are Associated with Poor Health Outcomes in Canada.

Purpose: To examine whether Indigenous identity and food insecurity combined were associated with self-reported poor health.Methods: Data from the 2015-2016 Canadian Community Health Survey and multiple logistic regression were employed to evaluate the association between Indigenous identity, household food insecurity, and health outcomes, adjusted for individual and household covariates. The Alexander Research Committee in Alexander First Nation (Treaty 6) reviewed the manuscript and commented on the interpretation of study findings.Results: Data were from 59082 adults (3756 Indigenous). The prevalence of household food insecurity was 26.3% for Indigenous adults and 9.8% for non-Indigenous adults (weighted to the Canadian population). Food-secure Indigenous adults, food-insecure non-Indigenous adults, and food-insecure Indigenous adults had significantly (p < 0.001) greater odds of poor health outcomes than food-secure non-Indigenous adults (referent group). Food-insecure Indigenous adults had 1.96 [95% CI:1.53,2.52], 3.73 [95% CI: 2.95,4.72], 3.00 [95% CI:2.37,3.79], and 3.94 [95% CI:3.02,5.14] greater odds of a chronic health condition, a chronic mental health disorder, poor general health, and poor mental health, respectively, compared to food-secure non-Indigenous adults.Conclusions: Health policy decisions and programs should focus on food security initiatives for all Canadians, including addressing the unique challenges of Indigenous communities, irrespective of their food security status.

Health Care Workers Online YouTube Content Compared to AUA Prevention of Recurrent Urinary Tract Infections in Women Guidelines: An Integrative Review of Quality and Comprehensiveness Analysis.

INTRODUCTION: We document the quality, veracity, and comprehensiveness of recurrent UTI information on YouTube to increase health care workers' (HCWs') awareness of UTI-related content online, and to identify deficits in understanding, clarify misconceptions, and reduce stigmatization risk. METHODS: High-traffic topic search terms were curated by Google Trends to extract 200 videos, of which 45 met inclusion criteria. Five independent reviewers used a standardized questionnaire based on the AUA recurrent UTI guidelines to assess the definition of UTI, marketing content, prophylaxis/prevention strategies, and antibiotic use/stewardship. RESULTS: Incongruent or incomplete guideline UTI definitions were found in 78% (35/45) of videos (K = 0.40), despite 80% (36/45) being authored by HCWs. Forty-two percent (19/45) promoted nonguideline-based hygiene practices; 25% (11/45) advocated front-to-back wiping (K = 0.71). Descriptors identified within the videos included the mention of women with UTI as unclean. Only 55% (25/45) discussed increasing fluid intake (K = 0.59), while 33% (15/45) discussed the use of cranberry supplementation (K = 0.81). CONCLUSIONS: Discussion of hygiene practices which lack a specific guideline statement is particularly evident. Descriptors that characterize women with UTI as "unclean" may create a health equity concern for women experiencing UTIs. These findings should alert HCWs to the scope and emphasis in online education that patients may view to self-educate; both the errors and the issues of equity are problematic. Educational materials on UTI should be based on evidence-based guidelines, such as those by the AUA.

Lung Cancer Survival Trends in the Veterans Health Administration.

INTRODUCTION: Lung cancer survival is improving in the United States. We investigated whether there was a similar trend within the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States. MATERIALS AND METHODS: Data from the Veterans Affairs Central Cancer Registry were analyzed for temporal survival trends using Kaplan-Meier estimates and linear regression. RESULTS: A total number of 54,922 Veterans were identified with lung cancer diagnosed from 2010 to 2017. Histologies were classified as non-small-cell lung cancer (NSCLC) (64.2%), small cell lung cancer (SCLC) (12.9%), and 'other' (22.9%). The proportion with stage I increased from 18.1% to 30.4%, while stage IV decreased from 38.9% to 34.6% (both P < .001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, P < .001), stage II (35.5% to 48.4%, P < .001), stage III (18.7% to 29.4%, P < .001), and stage IV (3.4% to 7.8%, P < .001). For NSCLC, the median OS increased from 12 to 21 months (P < .001), and the 3-year OS increased from 24.1% to 38.3% (P < .001). For SCLC, the median OS remained unchanged (8 to 9 months, P = .10), while the 3-year OS increased from 9.1% to 12.3% (P = .014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (P = .81), and those with SCLC had higher OS (P = .003). CONCLUSION: Lung cancer survival is improving within the VHA. Compared to White Veterans, Black Veterans had similar or higher survival rates. The observed racial equity in outcomes within a geographically and socioeconomically diverse population warrants further investigation to better understand and replicate this achievement in other healthcare systems.

Midwives' experience of telehealth and remote care: a systematic mixed methods review.

INTRODUCTION: Increasing the midwifery workforce has been identified as an evidence-based approach to decrease maternal mortality and reproductive health disparities worldwide. Concurrently, the profession of midwifery, as with all healthcare professions, has undergone a significant shift in practice with acceleration of telehealth use to expand access. We conducted a systematic literature review to identify and synthesize the existing evidence regarding how midwives experience, perceive and accept providing sexual and reproductive healthcare services at a distance with telehealth. METHODS: Five databases were searched, PubMed, CINHAL, PsychInfo, Embase and the Web of Science, using search terms related to 'midwives', 'telehealth' and 'experience'. Peer-reviewed studies with quantitative, qualitative or mixed methods designs published in English were retrieved and screened. Studies meeting the inclusion criteria were subjected to full-text data extraction and appraisal of quality. Using a convergent approach, the findings were synthesized into major themes and subthemes. RESULTS: After applying the inclusion/exclusion criteria, 10 articles on midwives' experience of telehealth were reviewed. The major themes that emerged were summarized as integrating telehealth into clinical practice; balancing increased connectivity; challenges with building relationships via telehealth; centring some patients while distancing others; and experiences of telehealth by age and professional experience. CONCLUSIONS: Most current studies suggest that midwives' experience of telehealth is deeply intertwined with midwives' experience of the response to COVID-19 pandemic in general. More research is needed to understand how sustained use of telehealth or newer hybrid models of telehealth and in-person care are perceived by midwives.

Incorporating social vulnerability in infectious disease mathematical modelling: a scoping review.

BACKGROUND: Highlighted by the rise of COVID-19, climate change, and conflict, socially vulnerable populations are least resilient to disaster. In infectious disease management, mathematical models are a commonly used tool. Researchers should include social vulnerability in models to strengthen their utility in reflecting real-world dynamics. We conducted a scoping review to evaluate how researchers have incorporated social vulnerability into infectious disease mathematical models. METHODS: The methodology followed the Joanna Briggs Institute and updated Arksey and O'Malley frameworks, verified by the PRISMA-ScR checklist. PubMed, Clarivate Web of Science, Scopus, EBSCO Africa Wide Information, and Cochrane Library were systematically searched for peer-reviewed published articles. Screening and extracting data were done by two independent researchers. RESULTS: Of 4075 results, 89 articles were identified. Two-thirds of articles used a compartmental model (n = 58, 65.2%), with a quarter using agent-based models (n = 24, 27.0%). Overall, routine indicators, namely age and sex, were among the most frequently used measures (n = 42, 12.3%; n = 22, 6.4%, respectively). Only one measure related to culture and social behaviour (0.3%). For compartmental models, researchers commonly constructed distinct models for each level of a social vulnerability measure and included new parameters or influenced standard parameters in model equations (n = 30, 51.7%). For all agent-based models, characteristics were assigned to hosts (n = 24, 100.0%), with most models including age, contact behaviour, and/or sex (n = 18, 75.0%; n = 14, 53.3%; n = 10, 41.7%, respectively). CONCLUSIONS: Given the importance of equitable and effective infectious disease management, there is potential to further the field. Our findings demonstrate that social vulnerability is not considered holistically. There is a focus on incorporating routine demographic indicators but important cultural and social behaviours that impact health outcomes are excluded. It is crucial to develop models that foreground social vulnerability to not only design more equitable interventions, but also to develop more effective infectious disease control and elimination strategies. Furthermore, this study revealed the lack of transparency around data sources, inconsistent reporting, lack of collaboration with local experts, and limited studies focused on modelling cultural indicators. These challenges are priorities for future research.

Operationalizing Anti-Racism Accountability with Equitable Admissions in Nursing Education Accreditation.

For decades, health professional organizations have recommended increased diversity in the workforce and education. To address persistent inequities in health care, the racial composition of the nursing workforce needs be congruent with the U.S. population. Without first addressing structural inequity in nursing education programs, the nursing profession cannot begin to address structural racism in health care. The lack of nursing student diversity is reflective of barriers in program admissions. This article is a call to nursing accreditation bodies to operationalize anti-racism to improve U.S. nursing workforce diversity by introducing accountability structures that require evidence-based holistic admission review and analysis of admission data to ensure that student cohorts are diverse across nursing programs, thereby ensuring a future workforce that reflects the diversity of the U.S. population.

Perceptions and beliefs of community gatekeepers about genomic risk information in African cleft research.

BACKGROUND: A fundamental ethical issue in African genomics research is how socio-cultural factors impact perspectives, acceptance, and utility of genomic information, especially in stigmatizing conditions like orofacial clefts (OFCs). Previous research has shown that gatekeepers (e.g., religious, political, family or community leaders) wield considerable influence on the decision-making capabilities of their members, including health issues. Thus, their perspectives can inform the design of engagement strategies and increase exposure to the benefits of genomics testing/research. This is especially important for Africans underrepresented in genomic research. Our study aims to investigate the perspectives of gatekeepers concerning genomic risk information (GRI) in the presence of OFCs in a sub-Saharan African cohort. METHODS: Twenty-five focus group discussions (FGDs) consisting of 214 gatekeepers (religious, community, ethnic leaders, and traditional birth attendants) in Lagos, Nigeria, explored the opinions of participants on genomic risk information (GRI), OFC experience, and the possibility of involvement in collaborative decision-making in Lagos, Nigeria. Transcripts generated from audio recordings were coded and analyzed in NVivo using thematic analysis. RESULTS: Three main themes-knowledge, beliefs, and willingness to act-emerged from exploring the perspective of gatekeepers about GRI in this group. We observed mixed opinions regarding the acceptance of GRI. Many participants believed their role is to guide and support members when they receive results; this is based on the level of trust their members have in them. However, participants felt they would need to be trained by medical experts to do this. Also, religious and cultural beliefs were crucial to determining participants' understanding of OFCs and the acceptance and utilization of GRI. CONCLUSIONS: Incorporating cultural sensitivity into public engagement could help develop appropriate strategies to manage conflicting ideologies surrounding genomic information in African communities. This will allow for more widespread access to the advances in genomics research in underrepresented populations. We also recommend a synergistic relationship between community health specialists/scientists, and community leaders, including spiritual providers to better understand and utilize GRI.

Identifying key factors for successful formulation and implementation of healthcare policies on non-communicable diseases: a multinational analysis.

Objectives: Non-communicable diseases (NCDs) are a major public health concern that accounts for 74% of global deaths each year. The increasing burden of NCDs exhausts public health resources and threatens the achievement of the 2030 agenda for sustainable development. The purpose of this study is to thematically analyze the contributory factors in the health policy process and reforms to strengthen the prevention of NCDs across borders, as well as the milestones achieved through the process of policy-making, change, and implementation. Method: This study informs and draws on the findings of contributory factors in the health policy process for preventing NCDs across borders: United States, England, Sweden, Bangladesh, Singapore, South Korea, and Thailand. Ten experts from the seven countries were recruited purposively for a semi-structured interview (e-Interview) on the NCD policy-making process in their countries, either through health ministries or the authors' network. This descriptive qualitative study design is guided by the "Three I's" framework of public policy (institutions, ideas, and interests). In addition to the information obtained from the interviewee, data were also sourced from relevant documents and homepages suggested by the interviewee, as well as health homepages of the countries. Result: The following themes were generated: (1) environmental policies and social determinants, (2) multistakeholder involvement, (3) interministerial collaboration, (4) independent evidence and review institution, (5) integrated health data, and (6) primary care system. There was a shift from individual-targeted policies to environmental policies and social determinants. Notably, national campaigns were developed through non-governmental organizations (NGOs) for the primary prevention of NCDs. Conclusion: The shift from behavioral modification and treatment to social determinants is important. NCDs are broad and require a multisector and multilevel approach. Establishing an organization or hierarchical body to overlook NCDs could result in increased awareness, focus, and surveillance and enhance the policy process.

Examining differences in time to appointment and no-show rates between rural telehealth users and non-users.

Background: Telehealth has undergone widespread implementation since 2020 and is considered an invaluable tool to improve access to healthcare, particularly in rural areas. However, telehealth's applicability may be limited for certain populations including those who live in rural, medically underserved communities. While broadband access is a recognized barrier, other important factors including age and education influence a person's ability or preference to engage with telehealth via video telehealth or a patient portal. It remains unclear the degree to which these digital technologies lead to disparities in access to care. Purpose: The purpose of this analysis is to determine if access to healthcare differs for telehealth users compared with non-users. Methods: Using electronic health record data, we evaluated differences in "time to appointment" and "no-show rates" between telehealth users and non-users within an integrated healthcare network between August 2021 and January 2022. We limited analysis to patient visits in endocrinology or outpatient behavioral health departments. We analyzed new patients and established patients separately. Results: Telehealth visits were associated with shorter time to appointment for new and established patients in endocrinology and established patients in behavioral health, as well as with lower no-show rates for established patients in both departments. Conclusions: The findings suggest that those who are unwilling or unable to engage with telehealth may have more difficulty accessing timely care.

Integrative Health Equity: Definition, Principles, Strategies, and Reflections.

In this viewpoint, we define integrative health equity as optimal health for all through a whole-person approach that explicitly recognizes cultural, social, and structural determinants of health. We describe seven guiding principles, along with organizational goals, strategies, and reflections to advance integrative health equity.

A review of dairy food intake for improving health among black infants, toddlers, and young children in the US.

Adequate nutrition is paramount for proper growth and musculoskeletal, neurocognitive, and immunological development in infants, toddlers, and young children. Among breastfeeding mother-child dyads, this critical window of development, is impacted by both maternal and offspring dietary patterns. For mothers, their dietary patterns impact not only their own health and well-being, but also the nutrition of their breast milk - which is recommended as the sole source of food for the first 6 months of their infant's life, and as a complementary source of nutrition until at least 2 years of age. For infants and toddlers, the breast milk, formulas, and first foods they consume can have both short-term and long-term effects on their health and well-being - with important impacts on their taste perception, microbiome composition, and immune function. According to dietary intake data in the US, infants and young children meet a greater number of nutrient requirements than older children and adults, yet numerous disparities among socially disadvantaged racial/ethnic groups still provide significant challenges to achieving adequate nutrition during these early life stages. For example, Black children are at greater risk for disparities in breastfeeding, age-inappropriate complementary feeding patterns, nutrient inadequacies, food insecurity, and obesity relative to most other racial/ethnic groups in the US. For infants who do not receive adequate breast milk, which includes a disproportionate number of Black infants, dairy-based infant formulas are considered the next best option for meeting nutritional needs. Fermented dairy foods (e.g., yogurt, cheese) can serve as ideal first foods for complementary feeding, and cow's milk is recommended for introduction during the transitional feeding period to help meet the nutrient demands during this phase of rapid growth and development. Low dairy intake may put children at risk for multiple nutrient inadequacies and health disparities - some of which may have lifelong consequences on physical and mental health. A burgeoning body of research shows that in addition to breast milk, cow's milk and other dairy foods may play critical roles in supporting physical growth, neurodevelopment, immune function, and a healthy gut microbiome in early life. However, most of this research so far has been conducted in White populations and can only be extrapolated to Black infants, toddlers, and young children. Therefore, to better understand and support the health and development of this population, greater research and education efforts on the role of milk and dairy products are urgently needed. This review presents the current evidence on health disparities faced by Black children in the US from birth to four years of age, and the role that dairy foods can play in supporting the normal growth and development of this vulnerable population.

School health-care team members' reflections of their promotion of sexual and reproductive health and rights (SRHR): Important but neglected.

OBJECTIVE: Young people are prioritized regarding the promotion and safeguarding of sexual and reproductive health and rights - SRHR. In Sweden, the school is seen as an important arena with members of the school health-care or SHC team as vital actors in this work. This study explored SRHR-related work in SHC teams in Sweden. METHODS: Within an explorative qualitative design, structured interviews were conducted with 33 nurses, counsellors, SHC unit managers and headmasters. Reflexive thematic analysis was applied, and two main themes found. RESULTS: SHC team members see SRHR as an urgent topic, but address it only 'when necessary', not systematically - and they experience a shortage of guidance and cooperation regarding SRHR-related work. Even in a country with agreement on the importance of SRHR for all and on providing holistic comprehensive sex education in schools, young people are left to chance - i.e., to the SRHR competence in the professionals they meet. CONCLUSION: SHC team members in Sweden see SRHR as an urgent topic but do not address it systematically. Moreover, they experience a shortage of guidance for their work. To avoid any professional stress of conscience and for equitable school health care regarding SRHR to be realized, research-informed policy needs to underline systematic, comparable and proactive practice.

"We have to work for wholeness no matter what": Family and culture promoting wellness, resilience, and transcendence.

Sociocultural, mental, behavioral, and physical factors are interrelated associates of chronic health conditions-such as diabetes, obesity, and cardiovascular disease-all of which are disproportionally high and drive much of the mortality and morbidity for Indigenous peoples. Indigenous worldviews conceptualize health holistically, with inseparability across social, spiritual, cultural, familial, mental, behavioral, physical, and social dimensions of wellness. Food, family, and culture are fundamental to Indigenous wellness. The purpose of this article is to use the Framework of Historical Oppression, Resilience, and Transcendence (FHORT) conceptualization of relational wellness to honor urban and rural U.S. Indigenous perspectives that highlight the intersections of family, culture, physical health, spiritual, and mental health to promote resilience and wellness. This research focused on interconnections between wellness, culture, health, and family. Thirty-one critical ethnographic interviews used a life-history approach with methodology following an Indigenous toolkit for ethical and culturally sensitive research strategies, such as building upon cultural strengths, engaging in long-term, relational commitments with communities, incorporating storytelling and oral history traditions, centering Indigenous methodologies and preferences, working with cultural insiders, and prioritizing the perspectives of Indigenous peoples. Emergent themes included: (a) roots of Indigenous wellness: cultural values promoting balance and connection; (b) practicing resilience: family transmission of health information; and (c) wholistic mental wellness and resilience, with the subtheme culture and wellness. Interventions can be developed in collaboration with tribes for optimum efficacy and cultural relevancy and can approach wellness holistically in culturally relevant ways that center foodways, culture, family, and spirituality.

INdigenous Systems and Policies Improved and Reimagined for Ear and hearing care (INSPIRE): a multi-method study protocol.

INTRODUCTION: Otitis media (middle ear disease) severity and chronicity among Aboriginal and Torres Strait Islander people, as well as gaps in socioeconomic outcomes related to hearing loss, indicates a breakdown in the current ear and hearing care system. The ear and hearing care system spans multiple sectors due to long-term impacts of otitis media and hearing loss in health, education and employment, necessitating a multi-disciplinary cross-sectorial approach to ear and hearing care. Public policies shape the current ear and hearing care system and here it is argued that a critical public policy analysis across different sectors is needed, with strong Aboriginal and Torres Strait Islander leadership and guidance. The current study aims to establish consensus-based ear and hearing care policy solutions for Aboriginal and Torres Strait Islander people in Australia. METHODS AND ANALYSIS: This multi-method study will be guided by a Brains Trust with strong Aboriginal and Torres Strait Islander leadership. Public policies in hearing health, social services, and education will be scoped to identify policy gaps, using the World Health Organization framework. Qualitative data will be collected through a culturally specific process of yarning circles to identify policy challenges and/or limitations in enabling accessible ear and hearing care programs/services for Aboriginal and Torres Strait Islander people, using dimensions of Morestin's public policy appraisal tool as an interview guide for stakeholders. Themes from the yarning circles will be used to inform an expert Delphi process to establish consensus-based policy solutions for optimising the ear and hearing care system for Aboriginal and Torres Strait Islander people. ETHICS AND DISSEMINATION: This study has approval from the Australian Institute of Aboriginal and Torres Strait Islander Studies Ethics Committee. Study findings will be disseminated to community through Brains Trust members and study participants, as well as through publications in peer-reviewed journals and research forum presentations.

Fibroids and unexplained infertility treatment with epigallocatechin gallate: a natural compound in green tea (FRIEND) - protocol for a randomised placebo-controlled US multicentre clinical trial of EGCG to improve fertility in women with uterine fibroids.

INTRODUCTION: Uterine fibroids affect 30%-77% of reproductive-age women and are a significant cause of infertility. Surgical myomectomies can restore fertility, but they often have limited and temporary benefits, with postoperative complications such as adhesions negatively impacting fertility. Existing medical therapies, such as oral contraceptives, gonadotropin hormone-releasing hormone (GnRH) analogues and GnRH antagonists, can manage fibroid symptoms but are not fertility friendly. This study addresses the pressing need for non-hormonal, non-surgical treatment options for women with fibroids desiring pregnancy. Previous preclinical and clinical studies have shown that epigallocatechin gallate (EGCG) effectively reduces uterine fibroid size. We hypothesise that EGCG from green tea extract will shrink fibroids, enhance endometrial quality and increase pregnancy likelihood. To investigate this hypothesis, we initiated a National Institute of Child Health and Human Development Confirm-funded trial to assess EGCG's efficacy in treating women with fibroids and unexplained infertility. METHODS AND ANALYSIS: This multicentre, prospective, interventional, randomised, double-blinded clinical trial aims to enrol 200 participants with fibroids and unexplained infertility undergoing intrauterine insemination (IUI). Participants will be randomly assigned in a 3:1 ratio to two groups: green tea extract (1650 mg daily) or a matched placebo, combined with clomiphene citrate-induced ovarian stimulation and timed IUI for up to four cycles. EGCG constitutes approximately 45% of the green tea extract. The primary outcome is the cumulative live birth rate, with secondary outcomes including conception rate, time to conception, miscarriage rate, change in fibroid volume and symptom severity scores and health-related quality of life questionnaire scores. ETHICS AND DISSEMINATION: The FRIEND trial received approval from the Food and Drug adminstration (FDA) (investigational new drug number 150951), the central Institutional Review Board (IRB) at Johns Hopkins University and FRIEND-collaborative site local IRBs. The data will be disseminated at major conferences, published in peer-reviewed journals and support a large-scale clinical trial. TRIAL REGISTRATION NUMBER: NCT05364008.

Bridging the digital health divide-patient experiences with mobile integrated health and facilitated telehealth by community-level indicators of health disparity.

OBJECTIVE: Evaluate the impact of community tele-paramedicine (CTP) on patient experience and satisfaction relative to community-level indicators of health disparity. MATERIALS AND METHODS: This mixed-methods study evaluates patient-reported satisfaction and experience with CTP, a facilitated telehealth program combining in-home paramedic visits with video visits by emergency physicians. Anonymous post-CTP visit survey responses and themes derived from directed content analysis of in-depth interviews from participants of a randomized clinical trial of mobile integrated health and telehealth were stratified into high, moderate, and low health disparity Community Health Districts (CHD) according to the 2018 New York City (NYC) Community Health Survey. RESULTS: Among 232 CTP patients, 55% resided in high or moderate disparity CHDs but accounted for 66% of visits between April 2019 and October 2021. CHDs with the highest proportion of CTP visits were more adversely impacted by social determinants of health relative to the NYC average. Satisfaction surveys were completed in 37% of 2078 CTP visits between February 2021 and March 2023 demonstrating high patient satisfaction that did not vary by community-level health disparity. Qualitative interviews conducted with 19 patients identified differing perspectives on the value of CTP: patients in high-disparity CHDs expressed themes aligned with improved health literacy, self-efficacy, and a more engaged health system, whereas those from low-disparity CHDs focused on convenience and uniquely identified redundancies in at-home services. CONCLUSIONS: This mixed-methods analysis suggests CTP bridges the digital health divide by facilitating telehealth in communities negatively impacted by health disparities.