Efficacy and immunogenicity of a single dose of human papillomavirus vaccine compared to multidose vaccination regimens or no vaccination: An updated systematic review of evidence from clinical trials.

Objectives: This study systematically reviewed the published literature from clinical trials on the efficacy and immunogenicity of single-dose HPV vaccination compared to multidose schedules or no HPV vaccination. Methods: Four databases were searched for relevant articles published from Jan-1999 to Feb-2023. Articles were assessed for eligibility for inclusion using pre-defined criteria. Relevant data were extracted from eligible articles and a descriptive quality assessment was performed for each study. A narrative data synthesis was conducted, examining HPV infection, other clinical outcomes and immunogenicity responses by dose schedule. Results: Fifteen articles reporting data from six studies (all in healthy young females) were included. One article was included from each of three studies that prospectively randomised participants to receive a single HPV vaccine dose versus one or more comparator schedule(s). The other 12 articles reported data from three studies that randomised participants to receive multidose HPV vaccine (or control vaccine) schedules; in those studies, some participants failed to complete their allocated schedule, and evaluations were conducted to compare participants who actually received one, two or three doses. Across all efficacy studies, the incidence or prevalence of HPV16/18 infection was very low among HPV-vaccinated participants, regardless of the number of doses received; with no evidence for a difference between dose groups. In immunogenicity studies, HPV16/18 antibody seropositivity rates were high among all HPV-vaccinated participants. Antibody levels were significantly lower with one dose compared to two or three doses, but levels with one dose were stable and sustained to 11 years post-vaccination. Conclusions: Results from this review support recent World Health Organization recommendations allowing either one- or two-dose HPV vaccination in healthy young females. Longer-term efficacy and immunogenicity data from ongoing studies are awaited. Randomised trials of single-dose HPV-vaccination are urgently needed in other populations, e.g. boys, older females and people with HIV.

The nexus between maternity care and bordering practices: A qualitative study of provider perspectives on maternal healthcare provision for Afghan women migrating through Serbia to Western Europe.

Serbia is a well-established transit country for Afghans travelling overland to seek protection in Western Europe, and Afghan women continue to experience pregnancy and birth during migration. This qualitative study aimed to explore the perspectives and experiences and of clinical and non-clinical perinatal care and support providers to Afghan women during migration through Serbia, using a critical border studies lens. Semi-structured interviews with 21 Serbia-based providers (conducted August 2021-October 2022 and analysed thematically) provided five inductive themes: (1) contours of life in Serbia for Afghan women; (2) providing maternity care and support to a highly mobile group; (3) enablers and barriers to accessing and using maternity care; (4) risks of onward migration; and (5) supporting women in a landscape of constant change. We identified ways in which regional geopolitics translated to bordering practices that interfered with maternity support provision to Afghan women in Serbia. We argue that non-exclusionary systems of care are needed to ensure women on the move receive adequate maternity support.

Dengue vector control in high-income, city settings: A scoping review of approaches and methods.

BACKGROUND: Dengue virus (DENV) is endemic to many parts of the world and has serious health and socioeconomic effects even in high-income countries, especially with rapid changes in the climate globally. We explored the literature on dengue vector control methods used in high-income, city settings and associations with dengue incidence, dengue prevalence, or mosquito vector densities. METHODS: Studies of any design or year were included if they reported effects on human DENV infection or Aedes vector indices of dengue-specific vector control interventions in high-income, city settings. RESULTS: Of 24 eligible sources, most reported research in the United States (n = 8) or Australia (n = 5). Biocontrol (n = 12) and chemical control (n = 13) were the most frequently discussed vector control methods. Only 6 sources reported data on the effectiveness of a given method in reducing human DENV incidence or prevalence, 2 described effects of larval and adult control on Aedes DENV positivity, 20 reported effectiveness in reducing vector density, using insecticide, larvicide, source reduction, auto-dissemination of pyriproxyfen and Wolbachia, and only 1 described effects on human-vector contact. CONCLUSIONS: As most studies reported reductions in vector densities, rather than any effects on human DENV incidence or prevalence, we can draw no clear conclusions on which interventions might be most effective in reducing dengue in high-income, city areas. More research is needed linking evidence on the effects of different DENV vector control methods with dengue incidence/prevalence or mosquito vector densities in high-income, city settings as this is likely to differ from low-income settings. This is a significant evidence gap as climate changes increase the global reach of DENV. The importance of community involvement was clear in several studies, although it is impossible to tease out the relative contributions of this from other control methods used.

Anaesthesia delivery systems in low and lower-middle-income Asian countries: A scoping review of capacity and effectiveness.

Literature on anaesthesia systems in low and lower middle-income countries is limited, focused on the Africa region, and provides minimal data on anaesthesia or associated disciplines within intensive care, pain management and emergency medicine. We thus conducted a scoping review of primary and secondary research literature on capacity and effectiveness of anaesthesia delivery in low and lower middle-income countries in the Asia region from 2000-2021, to clarify existing knowledge, important gaps, and possible subsequent steps. We applied Arksey and O'Malley's scoping literature review method to search five databases (i.e. EMBASE, CINAHL, Medline, Scopus, Web of Science), screen, extract, and synthesise data under three themes: (i) availability and type of anaesthesia workforce; (ii) anaesthesia system infrastructure, equipment, and supplies; and (iii) effectiveness of anaesthesia provision. We included 25 eligible sources of 603 identified. Only ten (40%) were published in the last 5 years and Asian lower-income countries were primarily represented in 15 multi-country sources. Fifteen (60%) sources used quantitative methods and provided limited information on data collection, e.g. sampling criteria or geographic areas included. No sources included countrywide data, despite anaesthesia delivery and resources differing significantly sub-nationally (e.g. central versus rural/remote, or insecure areas). Data on anaesthesiology delivery were limited, with findings including insufficiencies in workforce, supplies, training, and skills-building of anaesthesia personnel, along with the lack of consistent strategies for overcoming maldistribution of resources and improving anaesthesia delivery systems in the region. This review, a first attempt to synthesise existing data on anaesthesia delivery systems in low and lower-middle-income Asian countries, shows the anaesthesia literature is still limited. Findings highlight the urgent need for additional research and collaboration nationally and regionally to strengthen anaesthesia delivery and surgical facilities in resource-constrained settings.

Factors associated with initial AstraZeneca vaccine knowledge, attitudes, and uptake among hospital nurses: A cross-sectional study in Ghana's Upper East region.

The COVID-19 pandemic has caused over 171,657 confirmed cases and 1,462 deaths in Ghana, particularly among frontline health-workers involved in pandemic response. Prevention measures in Ghana include AstraZeneca 'Covishield' vaccination of health-workers, but research on factors affecting uptake of COVID-19 vaccines in Ghana were initially limited. Therefore, this study aimed to analyse knowledge, attitudes, and initial uptake of Covishield among nurses in the War Memorial Hospital in Navrongo, Upper East Region. We conducted a cross-sectional survey of 128 district hospital nurses using simple random sampling. We first calculated descriptive statistics and two composite variables summing either participant knowledge or attitude variables, with a threshold over 50% considered 'sufficient' or 'positive' respectively. We then analysed associations between demographic variables and Covishield knowledge, attitudes, or uptake using binomial logistic regression with a 95% confidence interval and p-value of <0.05 considered significant. All participants had heard of Covishield vaccine, with attitudes toward it generally positive (53%), and uptake high (72%). Reasons cited by the 28% unvaccinated included absence during vaccination, having already been infected with COVID-19, lack of trust in vaccine safety/efficacy, or pregnancy/breastfeeding. Education, residence, and family type were the only demographic factors significantly associated with nurses' knowledge about, attitudes towards, or uptake of COVID-19 vaccination. While 'positive' attitude was significantly associated with higher odds of being vaccinated (AOR 4.75; 95%CI 1.59-14.1), 'sufficient' knowledge was not (AOR 1.33; 95%CI 0.53-3.32). This is the first study in Ghana's resource-constrained Upper East region to examine health-worker perceptions of a novel vaccine and showed nurses' knowledge, attitudes, and uptake of COVID-19 vaccination were good overall. Further research is needed to determine how best to address hesitancy and understand findings that attitudes appeared more relevant than knowledge for uptake. Findings are relevant for local health authorities in improving vaccine availability and strengthening emergency risk communication and management of adverse events following immunisation.

"When a story gets a face ": Visual elicitation of Serbian perspectives on Afghan refugee women's maternity experiences in Serbia.

Serbia is a country through which many Afghans pass, en route to the European Union. Pregnancy and birth continues for Afghan women while journeying. This study aims to examine the understanding and attitudes of Serbian health professionals and members of women's civil society organisations (CS0) about the perinatal experiences of Afghan women in Serbia, using a webcomic to elicit responses. A total of 38 respondents completed the questionnaire, including health professionals (n = 10), women's CSO members (n = 6), and others (n = 10). The majority had little awareness of the experiences of Afghan women around the childbearing time and for most respondents, viewing the webcomic raised their awareness. Qualitative questionnaire data were analysed thematically, and four inductive themes developed: (1) maternal health provision as inadequate; (2) Afghan women face difficulties in Serbia; (3) solidarity with Afghan women; and (4) the webcomic raises awareness. Webcomics, as a visual modality, may play a valuable role in increasing empathy and awareness of refugee women's perinatal experiences among citizens.

The role of global health partnerships in vaccine equity: A scoping review.

The emergence of global health partnerships (GHPs) towards the end of the twentieth century reflected concerns about slow progress in access to essential medicines, including vaccines. These partnerships bring together governments, private philanthropic foundations, NGOs, and international agencies. Those in the vaccine field seek to incentivise the development and manufacture of new vaccines, raise funds to pay for them and develop and support systems to deliver them to those in need. These activities became more critical during the COVID-19 pandemic, with the COVAX Facility Initiative promoting global vaccine equity. This review identifies lessons from previous experiences with GHPs. Findings contribute to understanding the emergence of GHPs, the mechanisms they leverage to support global access to vaccines, and the inherent challenges associated with their implementation. Using Arksey and O'Malley's method, we conducted a scoping review to identify and synthesise relevant articles. We analysed data thematically to identify barriers and opportunities for success. We included 68 eligible articles of 3,215 screened. Most (65 [95%]) were discussion or review articles describing partnerships or programmes they supported, and three (5%) were commentaries. Emerging themes included policy responses (e.g., immunisation mandates), different forms of partnerships arising in vaccine innovation (e.g., product development partnerships, public-private partnerships for access), and influence on global governance decision-making processes (e.g., the rising influence of foundations, diminishing authority of WHO, lack of accountability and transparency, creation of disease silos). If global health partnerships are to maximise their contributions, they should: (1) increase transparency, especially regarding their impacts; (2) address the need for health systems strengthening; and (3) address disincentives for cooperative vaccine research and development partnerships and encourage expansion of manufacturing capacity in low and middle-income countries.

'COVID-19 is just another way to die ': a qualitative longitudinal study of frontline COVID-19 response governance across Syria.

INTRODUCTION: Governance of COVID-19 responses has been challenging for all countries. Syria has been particularly challenged due to protracted multiparty conflict and debilitated health systems fragmented across different areas of control. To improve response governance, better understanding of frontline response policy implementation across the country is needed. This study thus explored perspectives of COVID-19 response governance among frontline healthcare providers over time and across major areas of control. METHODS: We used a qualitative longitudinal study design, conducting five rounds of remote semistructured interviews in Arabic (ie, approximately eight interviews each in March 2020, July 2020, September 2020, December 2020 and September 2021) with 14 purposively sampled public and private healthcare providers in the three main areas of control (ie, opposition-controlled area, Autonomous Administration-controlled area and al-Assad government-controlled area (GCA)). We conducted integrative thematic analysis in Arabic within and across geography and time. RESULTS: Almost all participants across all areas and rounds expressed distrust of local health authorities and dissatisfaction with COVID-19 response governance. This was most apparent in initial rounds and in GCA. Response planning was identified as insufficient, non-participatory and non-transparent. Limited infrastructure and resources were the main challenges across time, though anticipated rapid virus spread and health systems' collapse did not occur and participant optimism increased over time. Public adherence to prevention measures varied-initially weak due to general scepticism, increasing after first cases were confirmed and then fluctuating with case numbers and challenges of insecurity and misinformation. Perceptions of COVID-19 vaccination varied, with low uptake and hesitancy attributed to misinformation, disinformation and disinterest. Suggested improvements to COVID-19 response governance focused on strengthening health systems' capacity and coordination. CONCLUSION: This is a unique longitudinal study of COVID-19 responses. Addressing transparency and misinformation should be a first step to improving public engagement and trust and thus response governance for health emergencies in Syria.

Anaesthesia provision challenges in public hospitals of Pakistan's Punjab province: a qualitative study of expert perspectives.

OBJECTIVES: Anaesthesia delivery in Pakistan remains limited to conventional intraoperative procedures, with research showing ongoing challenges in quality and resourcing. We aimed to identify systemic challenges in the delivery of the WHO-World Federation of Societies of Anaesthesiologists' (WHO-WFSA) 'highly recommended' standards of quality anaesthesia services for surgical support in Pakistan's Punjab province. STUDY DESIGN AND SETTING: This single-method qualitative study included 22 semistructured interviews with purposively selected anaesthesia system experts in Punjab province, including heads of teaching hospital anaesthesia departments, healthcare commission (HCC) representatives and health department officials. We analysed data thematically, using deductive and inductive coding. PARTICIPANTS: 10 participants worked as anaesthesia department heads of teaching hospitals across Punjab, 5 worked for the HCC and 7 worked for the health department. All were selected purposively and had at least 5 years of experience working as head of department or serving in legislative departments. RESULTS: We identified three themes experienced as major challenges within the specialty, namely anaesthetist recruitment and retention, quality of care and in-service training, and discrepancies between specialities. Findings indicated that workforce shortages and maldistribution, insufficient in-service training and standards, inadequate equipment maintenance and lack of anaesthesia representation in decision-making compromised anaesthesia provision quality and safety. CONCLUSIONS: Improving anaesthesia provision in Punjab would require increasing physician and non-physician anaesthetist numbers and rotation to peripheral postings, strengthening training quality and ensuring availability of WFSA-specified essential equipment and supplies. To achieve essential anaesthesia provision standards, policy interventions are needed to, for example, balance anaesthesiologist and surgeon/obstetrician-gynaecologist numbers, require that anaesthesiology postgraduates work a few years in-country (eg, scholarship bonds), ensure in-service training attendance for skills updates and implement quality assurance standards for equipment and supplies.

'What we lacked was the courage to take decisions that differed from the rest of the world': expert perspectives on the role of evidence in COVID-19 policymaking in Iraq.

INTRODUCTION: Iraq reported its first COVID-19 case on 24 February 2020 and formed a national committee and advisory committees to support its response. While global experts have suggested that the COVID-19 pandemic provided an exceptional opportunity for advancing evidence-informed policymaking (EIPM), no research has examined this in Iraq. Therefore, this study aimed to examine evidence use in COVID-19 policymaking in Iraq. METHODS: This qualitative study employed semi-structured interviews with 20 Iraqi policymakers and researchers. Data were analysed thematically in Arabic using inductive coding. FINDINGS: Participants described COVID-19 policy in Iraq as based on research conducted in other countries, with poor access and quality of routine data and lack of national research priorities and academic freedom as barriers to national research production. Most researchers influenced policy individually, with universities and other research bodies not seen as contributing to policy development. Public non-compliance could be traced to mistrust in both political and healthcare systems and became particularly problematic during the pandemic. Proposed strategies to increase national research production included dedicated funding, establishing communication and collaboration for research priority setting, and protection of academic freedom. CONCLUSION: Sociopolitical and economic realities in Iraq were unsupportive of national or subnational evidence generation even before the COVID-19 pandemic, and government relied on international evidence and policy transfer rather than contextually informed EIPM. Strengthening evidence-informed infectious disease policymaking and policy transfer would thus require governmental focus on improving the quality and relevance of Iraqi research, engagement between researchers and policymakers, and processes of evidence use and policy transfer.

Enhancement of scoping review methodology to reflect Aboriginal and Torres Strait Islander ways of knowing, being and doing.

OBJECTIVE: This paper argues for the enhancement of scoping review methods to incorporate Indigenous ways of knowing, being, and doing for more effective understandings of evidence of importance to Indigenous populations. METHODS: Scoping review methodology typically aims to understand existing evidence and support translation of evidence into practice. Levac and colleagues (2010) scoping review methodology stages: 1) Identify the research question; 2) Identify relevant studies; 3) Study selection; 4) Charting the data; 5) Collating, summarising, and reporting results; and 6) Consultation were considered from the perspective of Indigenous knowledges and adapted accordingly. RESULTS: An enhanced method better aligns with Indigenous methodologies which are based on relationality, collaboration, partnership, reciprocity, and benefit. Consultation was redefined in this enhancement as partnership and integrated throughout scoping review stages, which are underpinned by key methodological principles. CONCLUSIONS: Enhancement of scoping review stages with Indigenous ways of knowing, being, and doing has the potential to strengthen the utility of scoping review methods to better meet the needs of and ensure relevance for Indigenous populations. IMPLICATIONS FOR PUBLIC HEALTH: These enhancements can increase the potential for knowledge translation and implementation of culturally relevant evidence-based approaches into practice for Indigenous populations and for other populations who experience health inequities.

Exploring self-determined solutions to service and system challenges to promote social and emotional wellbeing in Aboriginal and Torres Strait Islander people: a qualitative study.

Introduction: Many Aboriginal and Torres Strait Islander people living on Kaurna Country in northern Adelaide experience adverse health and social circumstances. The Taingiwilta Pirku Kawantila study sought to understand challenges facing Aboriginal and Torres Strait Islander communities and identify solutions for the health and social service system to promote social and emotional wellbeing. Methods: This qualitative study applied Indigenous methodologies undertaken with Aboriginal and Torres Strait Islander governance and leadership. A respected local Aboriginal person engaged with Aboriginal and Torres Strait Islander community members and service providers through semi-structured interviews and yarning circles that explored community needs and challenges, service gaps, access barriers, success stories, proposed strategies to address service and system challenges, and principles and values for service design. A content analysis identified the breadth of challenges in addition to describing key targets to empower and connect communities and optimize health and social services to strengthen individual and collective social and emotional wellbeing. Results: Eighty-three participants contributed to interviews and yarning circles including 17 Aboriginal community members, 38 Aboriginal and Torres Strait Islander service providers, and 28 non-Indigenous service providers. They expressed the need for codesigned, strengths-based, accessible and flexible services delivered by Aboriginal and Torres Strait Islander workers with lived experience employed in organisations with Aboriginal and Torres Strait Islander leadership and governance. Community hubs and cultural events in addition to one-stop-shop service centres and pre-crisis mental health, drug and alcohol and homelessness services were among many strategies identified. Conclusion: Holistic approaches to the promotion of social and emotional wellbeing are critical. Aboriginal and Torres Strait Islander people are calling for places in the community to connect and practice culture. They seek culturally safe systems that enable equitable access to and navigation of health and social services. Aboriginal and Torres Strait Islander workforce leading engagement with clients is seen to safeguard against judgement and discrimination, rebuild community trust in the service system and promote streamlined access to crucial services.

Effects of COVID-19 on sexual and reproductive health services access in the Asia-Pacific region: a qualitative study of expert and policymaker perspectives.

The COVID-19 pandemic has strained health systems globally, with governments imposing strict distancing and movement restrictions. Little is known about the effects of the COVID-19 pandemic on sexual and reproductive health (SRH). This study examined perceived effects of COVID-19 on SRH service provision and use in the Asia-Pacific region. We conducted a qualitative study using semi-structured interviews with 28 purposively sampled SRH experts in 12 Asia-Pacific countries (e.g. United Nations, international and national non-governmental organisations, ministries of health, academia) between November 2020 and January 2021. We analysed data using the six-stage thematic analysis approach proposed by Braun and Clarke (2019). Interviewees reported that COVID-19 mitigation measures, such as transport restrictions and those that decreased the availability of personal protective equipment (PPE), reduced SRH service provision and use in most countries. SRH needs related to service barriers and gender-based violence increased. Systemic challenges included fragmented COVID-19 response plans and insufficient communication and collaboration, particularly between public and private sectors. SRH service-delivery challenges included COVID-19 response prioritisation, e.g. SRH staff task-shifting to COVID-19 screening and contact tracing, and lack of necessary supplies and equipment. Innovative SRH delivery responses included door-to-door antenatal care and family planning provision in the Philippines, online platforms for SRH education and outreach in Viet Nam, and increasing SRH service engagement through social media in Myanmar and Indonesia. To ensure continuation of SRH services during health emergencies, governments should earmark human and financial resources and prioritise frontline health-worker safety; work with communities and the private sector; and develop effective risk communications.

Circulating epigenomic biomarkers correspond with kidney disease susceptibility in high-risk populations with type 2 diabetes mellitus.

AIMS: To investigate epigenomic indices of diabetic kidney disease (DKD) susceptibility among high-risk populations with type 2 diabetes mellitus. METHODS: KDIGO (Kidney Disease: Improving Global Outcomes) clinical guidelines were used to classify people living with or without DKD. Differential gene methylation of DKD was then assessed in a discovery Aboriginal Diabetes Study cohort (PROPHECY, 89 people) and an external independent study from Thailand (THEPTARIN, 128 people). Corresponding mRNA levels were also measured and linked to levels of albuminuria and eGFR. RESULTS: Increased DKD risk was associated with reduced methylation and elevated gene expression in the PROPHECY discovery cohort of Aboriginal Australians and these findings were externally validated in the THEPTARIN diabetes registry of Thai people living with type 2 diabetes mellitus. CONCLUSIONS: Novel epigenomic scores can improve diagnostic performance over clinical modelling using albuminuria and GFR alone and can distinguish DKD susceptibility.

Experiences of Egypt as a destination and transit country for Syrian refugee healthcare workers: a qualitative study.

BACKGROUND: Refugee healthcare workers (HCWs) can make important contributions in host countries, particularly in the wake of the ongoing COVID-19 pandemic, which has exacerbated existing shortages of frontline HCWs. However, refugee HCWs often face challenges entering the labour markets of such countries even where needs exist. Syria's decade-long conflict has forced thousands of HCWs from their homes; however, data on this population are limited, impeding the formation of policies that can support them. This study explores the experiences of Syrian refugee HCWs in Egypt. METHODS: Key informants (KIs) were selected using purposive and snowball sampling method and semi-structured interviews were conducted in person in Cairo and remotely from the UK during July 2019. Interviews were conducted in Arabic and analysed using a combined deductive and inductive thematic analysis framework after transcription into English. RESULTS: Fifteen KI interviews were analysed. The main emerging themes from the qualitative interviews are those relating to 1. Education, training, and licensing 2. Politics and bureaucracy 3. Societal factors 4. Economic factors. Political changes in Egypt altered opportunities for Syrian HCWs over time; however, refugee HCWs broadly reported acceptance among Egyptian patients and colleagues. Bureaucratic factors which impede the ability of Syrian refugee HCWs to obtain a full license to practice and leave to remain and the absence of clearly defined policies were reported as barriers. Economic factors including the risk of economic exploitation e.g. in the informal sector and financial insecurity were noted to have a negative psychosocial impact. CONCLUSIONS: This is the first qualitative research study which explores the experiences of Syrian refugee HCWs in Egypt. It adds to the sparse literature on the topic of Syrian refugee HCWs but provides evidence for further discussions on how to support refugee HCWs in Egypt and in other host countries in the region. Though interviews were conducted before the COVID-19 pandemic, the pandemic itself lends urgency to the discussion around refugee HCWs on an international level.

"My young life, finished already?": a qualitative study of embedded social stressors and their effects on mental health of low-wage male migrant workers in Singapore.

BACKGROUND: Increasing evidence shows low-wage migrant workers experience a high prevalence of mental health disorders and adverse health outcomes. Significant disparities in health services usage among migrant workers create added vulnerability to health complications. However, much remains unclear about how vulnerabilities are constructed in migrant worker populations. Additionally, no studies in Singapore have attempted to critically examine the degree to which social environment and structures affect the health and wellbeing of migrant workers. Therefore, this study aimed to critically situate the socio-structural factors creating conditions of vulnerability among migrant workers using a social stress perspective. METHODS: We conducted semi-structured individual and group interviews with migrant workers focused on individual life experiences, community experiences (individual and collective social capital), health (mental and physical health concerns) and stress response behaviours. We used a grounded theory approach to identify sources of stress and stress responses and uncover pathways to social vulnerabilities. RESULTS: Findings from 21 individual and 2 group interviews revealed that migrant workers were embedded in a cycle of chronic stress driven by structural factors that were mutually reinforced by stressors arising from their social environment. Socio-structural stressors enacted as poor living, working and social conditions resulted in their negative quality-of-life appraisal. Stressors arising from being "foreign" resulted in anticipated stigma, concealment, and healthcare avoidance. These factors synergistically created a persistent mental health burden for migrant workers. CONCLUSIONS: Findings highlight the need to address the mental health burden placed on migrant workers and create avenues for migrant workers to seek psychosocial support to manage their stressors.

Policy versus practice: Syrian refugee doctors in Egypt.

The COVID-19 pandemic has renewed interest in streamlining processes which allow refugee doctors and other healthcare workers to make up for the shortfall in healthcare delivery, which many countries are facing increasingly. The protracted conflict in Syria is the biggest driver of forced displacement internationally with refugees, including healthcare workers seeking safety in host countries, however many face challenges to entering the workforce in a timely manner. The majority are in countries surrounding Syria (Lebanon, Jordan and Turkey) however the restrictive labour policies in these countries, particularly for healthcare workers have forced many to look further afield to Europe or the Gulf. Egypt's context is interesting in this regard, as it hosts a smaller number of registered Syrian refugees and was initially welcoming of Syrian medical students and doctors. However, recent socio-political changes have led to restrictions in training and work, leading doctors who initially considering staying in Egypt to increasingly consider it a transit country rather than a destination country. Here, we explore the processes by which Syrian doctors in Egypt can work and how documented policies may differ to practice. We do this through a document review and from the first-hand experiences of the authors.

"In general people aren't excited about the vaccine ": Frontline perspectives on COVID-19 vaccine hesitancy across Syria.

COVID-19 vaccine hesitancy is a new phenomenon in Syria, about which relatively little is known. We aimed to explore this, drawing from 37 semi-structured interviews with frontline health-workers and service-users across Syria's major military areas-of-control. We found COVID-19 vaccine hesitancy was common and increasing among service-users and less common, but still present, among health-workers in all areas. Interrelated reasons included pragmatic fears of novel vaccine risks, unreliable information, and conflict-related hesitancies as a form of resistance or reasserting some perceived control, particularly outside Al-Assad government-controlled areas. Vaccine hesitancy has thus become a socio-political issue, requiring macro-level responses, across Syria.

Socio-political and organizational influences on national infectious disease surveillance for refugees: A qualitative case study in Lebanon.

Infectious disease surveillance provides actionable information on displaced populations and helps identify outbreaks. Though not a signatory to the 1951 Refugee Convention, Lebanon has experienced large refugee influxes (e.g. Palestinians in 1948, Syrians in 2011), yet information on socio-political and organizational influences shaping surveillance targeting refugees is limited. We thus aimed to examine how Lebanese socio-politics affected infectious disease surveillance for refugees in Lebanon. We conducted a qualitative multimethod single case study of government engagement with refugee infectious disease surveillance (2011-2018) drawing from document analysis, semi-structured observations, and semi-structured key informant interviews at four surveillance sites in Lebanon. We analysed data thematically, using deductive and inductive coding. National politics delayed government and thus its epidemiological surveillance program's (ESU) engagement with refugee disease surveillance, largely due to Lebanon not being a 1951 Refugee Convention signatory and internal policy disagreements. Thus, it was initially difficult for the ESU to lead surveillance activities, though it later became more active. The ESU was limited by unclear reporting mechanisms and resources and its reliance on aggregated surveillance data prevented provision of data-informed responses. Though the ESU led surveillance nationally, and we identified positive provincial level collaborations due to individual efforts, some partners still conducted parallel surveillance. We found no systematic approach to infectious disease surveillance for refugees. The ESU could improve surveillance for refugees by collaborative strategic planning with partners for preparedness, surveillance, reporting, and sustainable resource allocation during refugee crises. Further suggestions include collecting disaggregated data, and piloting potentially more efficient syndromic surveillance, based on symptom clusters, for refugee populations.

Health system evaluation in conflict-affected countries: a scoping review of approaches and methods.

INTRODUCTION: Strengthening health systems in conflict-affected settings has become increasingly professionalised. However, evaluation remains challenging and often insufficiently documented in the literature. Many, particularly small-scale health system evaluations, are conducted by government bodies or non-governmental organisations (NGO) with limited capacity to publish their experiences. It is essential to identify the existing literature and main findings as a baseline for future efforts to evaluate the capacity and resilience of conflict-affected health systems. We thus aimed to synthesise the scope of methodological approaches and methods used in the peer-reviewed literature on health system evaluation in conflict-affected settings. METHODS: We conducted a scoping review using Arksey and O'Malley's method and synthesised findings using the WHO health system 'building blocks' framework. RESULTS: We included 58 eligible sources of 2,355 screened, which included examination of health systems or components in 26 conflict-affected countries, primarily South Sudan and Afghanistan (7 sources each), Democratic Republic of the Congo (6), and Palestine (5). Most sources (86%) were led by foreign academic institutes and international donors and focused on health services delivery (78%), with qualitative designs predominating (53%). Theoretical or conceptual grounding was extremely limited and study designs were not generally complex, as many sources (43%) were NGO project evaluations for international donors and relied on simple and lower-cost methods. Sources were also limited in terms of geography (e.g., limited coverage of the Americas region), by component (e.g., preferences for specific components such as service delivery), gendered (e.g., limited participation of women), and colonised (e.g., limited authorship and research leadership from affected countries). CONCLUSION: The evaluation literature in conflict-affected settings remains limited in scope and content, favouring simplified study designs and methods, and including those components and projects implemented or funded internationally. Many identified challenges and limitations (e.g., limited innovation/contextualisation, poor engagement with local actors, gender and language biases) could be mitigated with more rigorous and systematic evaluation approaches.