Expanding a Behavioral View on Digital Health Access: Drivers and Strategies to Promote Equity.

The potential and threat of digital tools to achieve health equity has been highlighted for over a decade, but the success of achieving equitable access to health technologies remains challenging. Our paper addresses renewed concerns regarding equity in digital health access that were deepened during the COVID-19 pandemic. Our viewpoint is that (1) digital health tools have the potential to improve health equity if equitable access is achieved, and (2) improving access and equity in digital health can be strengthened by considering behavioral science-based strategies embedded in all phases of tool development. Using behavioral, equity, and access frameworks allowed for a unique and comprehensive exploration of current drivers of digital health inequities. This paper aims to present a compilation of strategies that can potentially have an actionable impact on digital health equity. Multilevel factors drive unequal access, so strategies require action from tool developers, individual delivery agents, organizations, and systems to effect change. Strategies were shaped with a behavioral medicine focus as the field has a unique role in improving digital health access; arguably, all digital tools require the user (individual, provider, and health system) to change behavior by engaging with the technology to generate impact. This paper presents a model that emphasizes using multilevel strategies across design, delivery, dissemination, and sustainment stages to advance digital health access and foster health equity.

What Should Clinicians in Organizations Without Established MLP Programs Do When Their Patients Need Lawyers to Meet Their Health Needs?

Undocumented people in the United States face innumerable legal and structural barriers to health and health care services, including for kidney failure. Their experiences vary across states and regions due to wide variation in insurance coverage and unreliable access to health-promoting resources, including medical-legal partnerships. This commentary on a case canvasses key policy about structural and legal determinants of health for undocumented persons.

Why MLP Legal Care Should Be Financed as Health Care.

Medical-legal partnership (MLP) integrates the unique expertise of lawyers into collaborative clinical environments. MLP teams meet the needs of individual patients while also detecting structural problems at the root of health inequities and advancing solutions at the institutional, community, and system levels. Yet MLPs today operate in limited settings and survive on scant budgets. Expanding their impact requires secure funding. Financing MLPs as health care can do the following: (1) help address inequity at the point of care; (2) enable expert diagnosis and treatment of nonmedical drivers of health; (3) enhance team-based practice in health care organizations; (4) offer another way for clinicians to participate in advocacy; and (5) bolster a broader movement to increase access to justice.

How Is Access to Legal Resources and Advocacy Foundational to Health Justice?

Health justice as a movement incorporates research about how to more effectively leverage law, policy, and institutions to dismantle inequitable power distributions and accompanying patterns of marginalization that are root causes of health inequity. Legal advocacy is key to health justice because it addresses patients' health-harming legal needs in housing, public benefits, employment, education, immigration, domestic violence, and other areas of law. In medical-legal partnerships, lawyers and clinicians are uniquely positioned to jointly identify and remove legal barriers to patients' health, advocate for structural reform, and build community power.

Poverty and Its Impact on Surgical Care.

In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.

Children's surgery and the emergency, critical, and operative care resolution: immediate actions to eliminate disparities in surgical anesthesia and perioperative care for all children.

1.7 billion children lack access to surgical care worldwide. The emergency, critical, and operative care (ECO) resolution represents a call to action to reinvigorate the efforts to address these disparities. We review the ECO resolution and highlight the avenues that may be utilized in advocating for children's surgical care.

Role of men in women's health service utilisation in northern Nigeria: a qualitative study of women, men and provider perspectives.

BACKGROUND: The 2018 Nigeria Demographic and Health Survey shows poor maternal health in northern Nigeria. Contraceptive use remains low and maternal mortality high. Studies show that cultural norms related to men's decision-making role in the family significantly contribute to this phenomenon. OBJECTIVES: The assessment was designed to identify barriers to service delivery and utilisation of maternal-health and family-planning services in three northern Nigerian states, focusing on aspects of service delivery affected by husband involvement. DESIGN: Qualitative design included 16 focus group discussions and 12 in-depth interviews with facility clients, and 16 in-depth interviews with healthcare providers, in each of the three states. SETTING: Primary healthcare facilities in three northern Nigeria states: Bauchi, Kebbi and Sokoto. PARTICIPANTS: Women who came to the facility for family-planning services (n=233 in 24 focus groups); women who came for antenatal care (n=97 in 12 focus groups); men married to women who either received antenatal care or delivered in a facility (n=96 in 12 focus groups); mothers of newborns who delivered in a facility (n=36) and healthcare providers (n=48). RESULTS: We found gender barriers to contraceptive use and to obtaining maternal healthcare, with some women requiring their husband's permission to use services, even in emergencies. Several supply-side barriers exacerbate the situation. Many healthcare providers would not provide women with a family-planning method without their husbands' presence or approval; some male providers would not admit a woman to deliver in a facility if her husband objected to her being treated by a man and there was no female provider present and some facilities do not have the infrastructure to accommodate men. CONCLUSION: Despite years of programming, barriers to women's family-planning and maternal-health service utilisation persist. State governments in northern Nigeria should invest in additional provider training, improving infrastructure and hiring more female healthcare providers.

Challenges and possible improvements for healthcare teams at outreach clinics in Nepal - a qualitative study.

BACKGROUND: All Nepalese citizens have the right to high-quality healthcare services free of charge. To achieve this, healthcare services for the rural population in Nepal need to be improved in terms of personnel, medicines, and medical equipment. OBJECTIVES: To explore challenges and possible improvements healthcare personnel experience when travelling to rural parts of Nepal to provide healthcare. METHOD: Data was collected from various health professionals using focus group discussions at Dhulikhel Hospital in Nepal. The data were transcribed and analysed using Systematic text condensation. RESULTS: Twenty-two professional healthcare personnel participated in five group discussions. Four categories emerged from the collected material: Finding ORC services being underutilised, Wanting to fulfil tasks and do a good job, Facing inadequate resources, and Seeing the need for improved organisation and cooperation. There was consensus that rural clinics are important to maintaining health for the rural population of Nepal. However, there was frustration that the rural population was not benefitting from all available healthcare services due to underutilisation. CONCLUSION: Rural healthcare clinics are not utilised appropriately, according to healthcare workers at the rural outreach clinics. Potential ways of overcoming the perceived challenges of underutilising available healthcare services include financial and human resources. The rural population´s health awareness needs to be increased, and the work environment for rural healthcare workers needs to be improved. These issues need to be prioritised by the government and policymakers.

Main findings: Outreach clinics in Nepal are perceived as underutilised by health providers.Added knowledge: Increased awareness among rural people on when to seek healthcare, improved work conditions for health providers and collaboration with other health facilities may strengthen the utilisation of offered care.Global health impact for policy and action: Updated policies reflecting these Nepalese suggestions on strengthening rural healthcare may be useful and benefit other rural populations in similar settings.

Data linkage studies of primary care utilisation after release from prison: a scoping review.

BACKGROUND: Primary care plays a central role in most, if not all, health care systems including the care of vulnerable populations such as people who have been incarcerated. Studies linking incarceration records to health care data can improve understanding about health care access following release from prison. This review maps evidence from data-linkage studies about primary care use after prison release. METHODS: The framework by Arksey and O'Malley and guidance by the Joanna Briggs Institute (JBI) were used in this review. This scoping review followed methods published in a study protocol. Searches were performed (January 2012-March 2023) in MEDLINE, EMBASE and Web of Science Core Collection using key-terms relating to two areas: (i) people who have been incarcerated and (ii) primary care. Using eligibility criteria, two authors independently screened publication titles and abstracts (step 1), and subsequently, screened full text publications (step 2). Discrepancies were resolved with a third author. Two authors independently charted data from included publications. Findings were mapped by methodology, key findings and gaps in research. RESULTS: The database searches generated 1,050 publications which were screened by title and abstract. Following this, publications were fully screened (n = 63 reviewer 1 and n = 87 reviewer 2), leading to the inclusion of 17 publications. Among the included studies, primary care use after prison release was variable. Early contact with primary care services after prison release (e.g. first month) was positively associated with an increased health service use, but an investigation found that a large proportion of individuals did not access primary care during the first month. The quality of care was found to be largely inadequate (measured continuity of care) for moderate multimorbidity. There were lower levels of colorectal and breast cancer screening among people released from custody. The review identified studies of enhanced primary care programmes for individuals following release from prison, with studies reporting a reduction in reincarceration and criminal justice system costs. CONCLUSIONS: This review has suggested mixed evidence regarding primary care use after prison release and has highlighted challenges and areas of suboptimal care. Further research has been discussed in relation to the scoping review findings.

Emergency department visits as a potential opportunity to promote primary care attachment and modify utilization patterns - results of a pilot study in Berlin, Germany.

BACKGROUND: Utilization by low acuity patients contributes to emergency department (ED) crowding. Both knowledge deficits about adequate care levels and access barriers in primary care are important promoters of such presentations. Concurrently, not having a general practitioner (GP) increases the likelihood of low-acuity ED utilization. This pilot study thus investigated feasibility, acceptance, and potential effects of an ED-delivered intervention for low-acuity patients with no regular primary care provider, consisting of an educational leaflet on acute care options and an optional GP appointment scheduling service. METHODS: Low-acuity ED consulters not attached to a GP were given an information leaflet about alternative care offers for acute health problems and offered optional personal appointment scheduling at a local GP practice. Patients were surveyed on demographics, medical characteristics, health care utilization, valuation of the intervention, and reasons for not being attached to a GP and visiting the ED. A follow-up survey was conducted after twelve months. Trends in health and health care utilization were evaluated. RESULTS: Between December 2020 and April 2022, n = 160 patients were enrolled, n = 114 were followed up. The study population was characterized by young age (mean 30.6 years) and predominantly good general health. Besides good health, personal mobility was a central reason for not being attached to a GP, but general preference for specialists and bad experiences with primary care were also mentioned. Most frequently stated motives for the ED consultation were subjective distress and anxiety, a belief in the superiority of the hospital, and access problems in primary care. The interventional offers were favorably valued, 52.5% (n = 84) accepted the GP appointment scheduling service offer. At follow-up, GP utilization had significantly increased, while there were no significant changes regarding utilization of other providers, including ED. An additional practice survey showed a 63.0% take-up rate for the appointment service. CONCLUSIONS: With this pilot study, we were able to show that a personalized appointment scheduling service seems to be a promising approach to promote GP attachment and increase primary care utilization in patients without a regular GP in a highly urbanized setting. Further larger-scale studies are needed to investigate potential quantitative effects on ED visits. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00023480); date 2020/11/27.

2022 insights on hospital bed distribution in Saudi Arabia: evaluating needs to achieve global standards.

BACKGROUND: Equitable geographical distribution of health resources, such as hospital beds, is fundamental in ensuring public accessibility to healthcare services. This study examines the distribution of hospital beds across Saudi Arabia's 20 health regions. METHODS: A secondary data analysis was conducted using the 2022 Saudi Ministry of Health Statistical Yearbook. The study focused on calculating the hospital beds-per-1,000-people ratio across Saudi Arabia's 20 health regions. The analysis involved comparing regional bed distributions using the Gini index and Lorenz curve to assess the distribution of hospital beds. RESULTS: The national average beds-per-1,000-people ratio was 2.43, serving a population of approximately 32.2 million. The calculated mean Gini index for bed distribution was 0.15, which indicates a relatively equitable distribution. Further analysis revealed some regional disparities, with health regions like Makkah and Jeddah displaying critically low bed-to-population ratios. In contrast, others like Al-Jouf and the Northern region reported higher ratios. The study also identified the need for an additional 17,062 beds to meet international standards of 2.9 beds per 1,000 people. CONCLUSIONS: The findings revealed a national average beds-per-1,000-people ratio of 2.43, with some regional disparities. The study highlights the critical need for targeted healthcare planning and policy interventions to address the uneven distribution of hospital beds across Saudi Arabia. TRIAL REGISTRATION: Not applicable.

Challenges and coping strategies for providing maternal health care services among health care professionals in rural health facilities in Wolaita Zone, Southern Ethiopia: a qualitative study.

BACKGROUND: Many factors can decrease job productivity and cause physical and psychological complications for health care professionals providing maternal care. Information on challenges and coping strategies among healthcare professionals providing maternal healthcare services in rural communities is crucial. However, there needs to be more studies, especially qualitative research, to explore challenges and coping strategies for providing maternal health care services in Ethiopia among health care professionals, particularly in the Wolaita zone. OBJECTIVE: To explore the challenges and coping strategies of professionals providing maternal health care in rural health facilities in Wolaita Zone, Southern Ethiopia, in 2023. METHOD: A phenomenological qualitative study design was applied from May 20 to June 20, 2023. The study was conducted in rural areas of the Wolaita Zone, southern Ethiopia. Healthcare professionals from rural areas were selected using purposive sampling, and in-depth interviews were conducted. A qualitative thematic analysis was employed to analyze the data. Field notes were read, recordings were listened to, and each participant's interview was written word for word and analyzed using ATLAS.ti 7 software. RESULT: Five main themes emerged from the data analysis. These themes included inadequate funding from the government, societal barriers to health and access to health care, professionals' personal life struggles, infrastructure related challenges and health system responsiveness, and coping strategies. Reporting to responsible bodies, teaching mothers about maternal health care services, and helping poor mothers from their pockets were listed among their coping strategies. CONCLUSION: Healthcare professionals have a crucial role in supporting women in delivering babies safely. This study revealed that they are working under challenging conditions. So, if women's lives matter, then this situation requires a call to action.

Evaluating barriers to reaching women with public health information in remote communities in Mali.

Telecommunications offers an alternative or supplement to community-based interventions as a means of extending healthcare services and improving health outcomes in remote settings but can fail to reach target communities and achieve the desired impact if barriers to access are not overcome. We conducted seven focus group discussions and 26 interviews with community health workers, community leaders, and female members of the public who declared that they had or had not previously accessed free audio health messages provided via a mobile platform in two rural communities of Mali, Koulikoro and Bougouni. A content analysis showed that participants accessed and trusted health information from a range of sources, including radio, telephone and television, as well as town criers, local relays and community health centres. Barriers to access faced by women included economic factors, lack of network or electricity, and social factors such as illiteracy, cultural restrictions and being unaware of mobile communication. Through analysis and interpretation of the participants' responses, we have made recommendations for future campaigns for the dissemination of health-related information for women in remote settings.

Restrictive migration policies and their impact on HIV prevention, care and treatment services.

Migration policies have a significant impact on population health, particularly for individuals living with human immunodeficiency virus (HIV). These policies not only determine who is allowed to enter a country but also influence which immigrants can access services provided by the government. Some countries continue to impose restrictions on HIV-positive individuals, justifying these measures as necessary to protect public health and mitigate healthcare and economic concerns. However, these restrictions lack a valid public health rationale. Due to social, economic and political constraints, restrictive migration laws hinder access to HIV prevention, care and treatment services for immigrants living with HIV. Immigrants face numerous challenges in accessing medication, adhering to treatment regimens and benefitting from HIV preventive efforts. This situation increases the risk of HIV infection and adverse health outcomes due to limited access to preventive programmes, social stigma and engagement in risky behaviours. Additionally, these restrictive migration rules negatively affect immigrants' mental health. To improve the health of both immigrants and host communities, inclusive and evidence-based migration policies that address healthcare through public health and human rights lenses are required.

Provider perspectives on adolescent access to contraception in South Africa.

BACKGROUND:  Poor access to contraception influences adolescent health outcomes and may lead to sexual and reproductive health challenges. Unmet sexual and reproductive health should contribute to unplanned adolescent pregnancies, sexually transmitted infections, and other conditions. Therefore, it is crucial to enable adolescents to access appropriate contraceptive methods easily. AIM:  This study explored factors influencing adolescents' access to contraceptive methods from the perspective of primary healthcare providers in South Africa. SETTING:  This study was conducted in two health districts of the Western Cape province in South Africa: the City of Cape Town Metropolitan Municipality and the West Coast district. METHODS:  Using a qualitative research design, in-depth semi-structured interviews were conducted with 24 healthcare providers who work in primary healthcare clinics. Subsequently, the interviews were transcribed and verified for errors. Braun and Clarke's thematic analysis model guided the data analysis using ATLAS.ti software (version 22). The study adhered to the consolidated criteria for reporting qualitative studies checklist for qualitative research. RESULTS:  Four themes emerged through the data analysis: (1) personal influences, (2) community-level influences, (3) health system influences, and (4) policy-level influences. Representative quotations were used to illustrate the themes and sub-themes. CONCLUSION:  Adolescence is shaped by various influences that affect adolescents' ability to access contraception. These factors include their awareness of contraception, social environment, provider biases and school policies. Understanding these influences is crucial for addressing unintended pregnancies and promoting sexual and reproductive health among this age group.Contribution: This study highlights strategies that facilitate and hinder adolescents' access to contraception.

How do South African policies address provision of contraception among adolescents?

BACKGROUND:  The South African government has pioneered several policy documents that emphasise the importance of sexual and reproductive health (SRH). AIM:  We examined how national policies address access and provision of contraception to adolescents in South Africa. SETTING:  South African national policies. METHODS:  We systematically searched various academic databases such as EbscoHost, Science Direct, Google Scholar, PubMed and Scopus, and other relevant sources to obtain 854 policy documents. Using a set of explicit inclusion criteria, we screened and selected 11 South African policies for analysis. Next, we analysed three international policies and frameworks to extract the key elements from them. Thereafter, we used these key elements to develop an analytical framework for conducting the analysis of the South African national policies. RESULTS:  We found that South Africa's SRH policies largely address the provision of contraception by following international guidelines. These policies recognise the value of providing contraception to adolescent girls. However, we also found gaps in some policies, which could impede how they are translated into practice. These include recognising that adolescent boys can play a role in contraception; adolescents have varying SRH needs and are a key stakeholder not only for policy development but also for monitoring and accountability. CONCLUSION:  With a specific focus on South Africa's contraception services in the public sector, these findings are relevant to policymakers, providers and users of contraceptives.Contribution: This review proposes recommendations that will assist with strengthening health policy development and thus improve primary health care services related to contraception for adolescents.

Migration and primary healthcare in sub-Saharan Africa: A scoping review.

BACKGROUND:  Migration in Africa is increasing and driven by a variety of inter-related socio-economic, conflict and climate-related causes. Primary healthcare (PHC) migration on PHC service will be in the forefront of responding to the associated health issues. AIM:  This study aimed to review the literature on the effect of migration on PHC service delivery in Africa and the challenges facing migrants in accessing PHC. METHOD:  A systematic approach (Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews) was applied across six databases and grey literature from African universities (2010 to 2021). Data were extracted and analysed quantitatively and qualitatively. RESULTS:  A total of 3628 studies were identified and 50 were included. Most studies were descriptive or used mixed methods. Publications came from 25 countries, with 52% of studies from South Africa, Uganda and Kenya. Most migrants originated from Zimbabwe, the Democratic Republic of Congo and Somalia. Population health management for migrant communities was challenging. Migration impacted PHC services through an increase in infectious diseases, mental health disorders, reproductive health issues and malnutrition. Primary healthcare services were poorly prepared for handling displaced populations in disaster situations. Access to PHC services was compromised by factors related to migrants, health services and healthcare workers. CONCLUSION:  Several countries in Africa need to better prepare their PHC services and providers to handle the increasing number of migrants in the African context.Contribution: The review points to the need for a focus on policy, reducing barriers to access and upskilling primary care providers to handle diversity and complexity.

Childhood visual impairment causes and barriers to accessing eye care: A suggested approach for Africa.

BACKGROUND:  Childhood vision impairment (VI) has a significantly harmful effect on both health and social outcomes. AIM:  To assess the causes of childhood VI, to determine obstacles to accessing eye care services and to develop a strategy for the childhood eye care system in African nations. METHOD:  This systematic review was conducted by searching several online databases, including; Scopus, PubMed, ProQuest, Web of Science, Google Scholar, Ebsco and Medline. They focussed on articles available between 2003 and 2023. These studies were conducted to evaluate the causes of childhood VI and to assess obstacles to accessing eye care services in African countries. RESULTS:  The main causes of childhood VI in African nations can be avoided with timely diagnosis and an appropriate management strategy. The leading obstacles to accessing childhood eye care services were a lack of availability, accessibility and affordability. In addition to these barriers, we found that there are concerns with quality of services, primary health care system, geographic barriers, incorrect health beliefs, inappropriate parental perception, a lack of knowledge, attitudes and inadequate practices related to paediatric eye care. CONCLUSION:  The main causes of childhood VI were uncorrected refractive error (RE), amblyopia, cataract and corneal opacities that can be avoided with timely diagnosis and an appropriate management strategy. While the main obstacles to accessing childhood eye care services were a lack of availability, accessibility, affordability and healthcare system.Contribution: The recommended strategy for childhood eye-care services includes models for delivery and training.