'Forgotten as first line providers': The experiences of midwives during the COVID-19 pandemic in British Columbia, Canada.

OBJECTIVE: To explore midwives' experiences working on the frontlines of the COVID-19 pandemic in British Columbia, Canada. DESIGN: Qualitative study involving three semi-structured focus groups and four in-depth interviews with midwives. SETTING: The COVID-19 pandemic in British Columbia, Canada from 2020-2021. PARTICIPANTS: 13 midwives working during the first year of the COVID-19 pandemic in British Columbia. FINDINGS: Qualitative analysis surfaced four key themes. First, midwives faced a substantial lack of support during the pandemic. Second, insufficient support was compounded by a lack of recognition. Third, participants felt a strong duty to continue providing high-quality care despite COVID-19 related restrictions and challenges. Lastly, lack of support, increased workloads, and moral distress exacerbated burnout among midwives and raised concerns around the sustainability of their profession. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Lack of effective support for midwives during the initial months of the COVID-19 pandemic exacerbated staffing shortages that existed prior to the pandemic, creating detrimental gaps in essential care for pregnant people, especially with increasing demands for homebirths. Measures to support midwives should combat inequities in the healthcare system, mitigating the risks of disease exposure, burnout, and professional and financial impacts that may have long-lasting implications on the profession. Given the crucial role of midwives in women- and people-centred care and advocacy, protecting midwives and the communities they serve should be prioritized and integrated into pandemic preparedness and response planning to preserve women's health and rights around the world.

Women healthcare workers' experiences during COVID-19 and other crises: A scoping review.

BACKGROUND: Throughout the COVID-19 pandemic, as measures have been taken to both prevent the spread of COVID-19 and provide care to those who fall ill, healthcare workers have faced added risks to their health and wellbeing. These risks are disproportionately felt by women healthcare workers, yet health policies do not always take a gendered approach. OBJECTIVES: The objective of this review was to identify the gendered effects of crises on women healthcare workers' health and wellbeing, as well as to provide guidance for decision-makers on health systems policies and programs that could better support women healthcare workers. METHODS: A scoping review of published academic literature was conducted. PubMed, EMBASE, and CINAHL were searched using combinations of relevant medical subject headings and keywords. Data was extracted using a thematic coding framework. Seventy-six articles met the inclusion criteria. RESULTS: During disease outbreaks women healthcare workers were found to experience: a higher risk of exposure and infection; barriers to accessing personal protective equipment; increased workloads; decreased leadership and decision-making opportunities; increased caregiving responsibilities in the home when schools and childcare supports were restricted; and higher rates of mental ill-health, including depression, anxiety, and post-traumatic stress disorder. There was a lack of attention paid to gender and the health workforce during times of crisis prior to COVID-19, and there is a substantial gap in research around the experiences of women healthcare workers in low- and middle-income countries during times of crises. CONCLUSION: COVID-19 provides an opportunity to develop gender-responsive crisis preparedness plans within the health sector. Without consideration of gender, crises will continue to exacerbate existing gender disparities, resulting in disproportionate negative impacts on women healthcare workers. The findings point to several important recommendations to better support women healthcare workers, including: workplace mental health support, economic assistance to counteract widening pay gaps, strategies to support their personal caregiving duties, and interventions that support and advance women's careers and increase their representation in leadership roles.

Supporting community health workers in fragile settings from a gender perspective: a qualitative study.

OBJECTIVE: To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences. SETTING: Two districts in three fragile countries. Sierra Leone-Kenema and Bonthe districts; Liberia-two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)-Aru and Bunia districts in Ituri Province. PARTICIPANTS AND METHODS: Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only). RESULTS: While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families. CONCLUSIONS: Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre.

Health systems resilience in fragile and shock-prone settings through the prism of gender equity and justice: implications for research, policy and practice.

Fragile and shock-prone settings (FASP) present a critical development challenge, eroding efforts to build healthy, sustainable and equitable societies. Power relations and inequities experienced by people because of social markers, e.g., gender, age, education, ethnicity, and race, intersect leading to poverty and associated health challenges. Concurrent to the growing body of literature exploring the impact of these intersecting axes of inequity in FASP settings, there is a need to identify actions promoting gender, equity, and justice (GEJ). Gender norms that emphasise toxic masculinity, patriarchy, societal control over women and lack of justice are unfortunately common throughout the world and are exacerbated in FASP settings. It is critical that health policies in FASP settings consider GEJ and include strategies that promote progressive changes in power relationships. ReBUILD for Resilience (ReBUILD) focuses on health systems resilience in FASP settings and is underpinned by a conceptual framework that is grounded in a broader view of health systems as complex adaptive systems. The framework identifies links between different capacities and enables identification of feedback loops which can drive or inhibit the emergence and implementation of resilient approaches. We applied the framework to four different country case studies (Lebanon, Myanmar, Nepal and Sierra Leone) to illustrate how it can be inclusive of GEJ concerns, to inform future research and support context responsive recommendations to build equitable and inclusive health systems in FASP settings.

How to prevent and address safeguarding concerns in global health research programmes: practice, process and positionality in marginalised spaces.

Safeguarding is rapidly rising up the international development agenda, yet literature on safeguarding in related research is limited. This paper shares processes and practice relating to safeguarding within an international research consortium (the ARISE hub, known as ARISE). ARISE aims to enhance accountability and improve the health and well-being of marginalised people living and working in informal urban spaces in low-income and middle-income countries (Bangladesh, India, Kenya and Sierra Leone). Our manuscript is divided into three key sections. We start by discussing the importance of safeguarding in global health research and consider how thinking about vulnerability as a relational concept (shaped by unequal power relations and structural violence) can help locate fluid and context specific safeguarding risks within broader social systems. We then discuss the different steps undertaken in ARISE to develop a shared approach to safeguarding: sharing institutional guidelines and practice; facilitating a participatory process to agree a working definition of safeguarding and joint understandings of vulnerabilities, risks and mitigation strategies and share experiences; developing action plans for safeguarding. This is followed by reflection on our key learnings including how safeguarding, ethics and health and safety concerns overlap; the challenges of referral and support for safeguarding concerns within frequently underserved informal urban spaces; and the importance of reflective practice and critical thinking about power, judgement and positionality and the ownership of the global narrative surrounding safeguarding. We finish by situating our learning within debates on decolonising science and argue for the importance of an iterative, ongoing learning journey that is critical, reflective and inclusive of vulnerable people.

Publisher Correction: Human mid-trimester amniotic fluid (stem) cells lack expression of the pluripotency marker OCT4A.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Local ownership of health policy and systems research in low-income and middle-income countries: a missing element in the uptake debate.

Health policy and systems researchers (HPSRs) in low-income and middle-income countries (LMICs) aim to influence health systems planning, costing, policy and implementation. Yet, there is still much that we do not know about the types of health systems evidence that are most compelling and impactful to policymakers and community groups, the factors that facilitate the research to decision-making process and the real-world challenges faced when translating research findings into practice in different contexts. Drawing on an analysis of HPSR from LMICs presented at the Fifth Global Symposium on Health Systems Research (HSR 2018), we argue that while there is a recognition in policy studies more broadly about the role of co-production, collective ownership and the value of localised HPSR in the evidence-to-policy discussion, 'ownership' of research at country level is a research uptake catalyst that needs to be further emphasised, particularly in the HPSR context. We consider embedded research, participatory or community-initiated research and emergent/responsive research processes, all of which are 'owned' by policymakers, healthcare practitioners/managers or community members. We embrace the view that ownership of HPSR by people directly affected by health problems connects research and decision-making in a tangible way, creating pathways to impact.

Modelling mitochondrial dysfunction in Alzheimer's disease using human induced pluripotent stem cells.

Alzheimer's disease (AD) is the most common form of dementia. To date, only five pharmacological agents have been approved by the Food and Drug Administration for clinical use in AD, all of which target the symptoms of the disease rather than the cause. Increasing our understanding of the underlying pathophysiology of AD will facilitate the development of new therapeutic strategies. Over the years, the major hypotheses of AD etiology have focused on deposition of amyloid beta and mitochondrial dysfunction. In this review we highlight the potential of experimental model systems based on human induced pluripotent stem cells (iPSCs) to provide novel insights into the cellular pathophysiology underlying neurodegeneration in AD. Whilst Down syndrome and familial AD iPSC models faithfully reproduce features of AD such as accumulation of Aß and tau, oxidative stress and mitochondrial dysfunction, sporadic AD is much more difficult to model in this way due to its complex etiology. Nevertheless, iPSC-based modelling of AD has provided invaluable insights into the underlying pathophysiology of the disease, and has a huge potential for use as a platform for drug discovery.

Human mid-trimester amniotic fluid (stem) cells lack expression of the pluripotency marker OCT4A.

Expression of OCT4A is one of the hallmarks of pluripotency, defined as a stem cell's ability to differentiate into all the lineages of the three germ layers. Despite being defined as non-tumorigenic cells with high translational potential, human mid-trimester amniotic fluid stem cells (hAFSCs) are often described as sharing features with embryonic stem cells, including the expression of OCT4A, which could hinder their clinical potential. To clarify the OCT4A status of hAFSCs, we first undertook a systematic review of the literature. We then performed extensive gene and protein expression analyses to discover that neither frozen, nor fresh hAFSCs cultivated in multipotent stem cell culture conditions expressed OCT4A, and that the OCT4A positive results from the literature are likely to be attributed to the expression of pseudogenes or other OCT4 variants. To address this issue, we provide a robust protocol for the assessment of OCT4A in other stem cells.

Gendered health systems: evidence from low- and middle-income countries.

BACKGROUND: Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. METHODS: The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. RESULTS: Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. CONCLUSION: The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

How do gender relations affect the working lives of close to community health service providers? Empirical research, a review and conceptual framework.

Close-to-community (CTC) providers have been identified as a key cadre to progress universal health coverage and address inequities in health service provision due to their embedded position within communities. CTC providers both work within, and are subject to, the gender norms at community level but may also have the potential to alter them. This paper synthesises current evidence on gender and CTC providers and the services they deliver. This study uses a two-stage exploratory approach drawing upon qualitative research from the six countries (Bangladesh, Indonesia, Ethiopia, Kenya, Malawi, Mozambique) that were part of the REACHOUT consortium. This research took place from 2013 to 2014. This was followed by systematic review that took place from January-September 2017, using critical interpretive synthesis methodology. This review included 58 papers from the literature. The resulting findings from both stages informed the development of a conceptual framework. We present the holistic conceptual framework to show how gender roles and relations shape CTC provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, influence of family and intra-household dynamics are of importance. Important at the health systems level, are career progression and remuneration. We present suggestions for how the role of a CTC provider can, with the right support, be an empowering experience. Key priorities for policymakers to promote gender equity in this cadre include: safety and well-being, remuneration, and career progression opportunities. Gender roles and relations shape CTC provider experiences across multiple levels of the health system. To strengthen the equity and efficiency of CTC programmes gender dynamics should be considered by policymakers and implementers during both the conceptualisation and implementation of CTC programmes.

NF-κB Activity Initiates Human ESC-Derived Neural Progenitor Cell Differentiation by Inducing a Metabolic Maturation Program.

Human neural development begins at embryonic day 19 and marks the beginning of organogenesis. Neural stem cells in the neural tube undergo profound functional, morphological, and metabolic changes during neural specification, coordinated by a combination of exogenous and endogenous cues. The temporal cell signaling activities that mediate this process, during development and in the postnatal brain, are incompletely understood. We have applied gene expression studies and transcription factor-activated reporter lentiviruses during in vitro neural specification of human pluripotent stem cells. We show that nuclear factor κB orchestrates a multi-faceted metabolic program necessary for the maturation of neural progenitor cells during neurogenesis.

Embryonic Stem Cell-Derived Mesenchymal Stem Cells (MSCs) Have a Superior Neuroprotective Capacity Over Fetal MSCs in the Hypoxic-Ischemic Mouse Brain.

Human mesenchymal stem cells (MSCs) have huge potential for regenerative medicine. In particular, the use of pluripotent stem cell-derived mesenchymal stem cells (PSC-MSCs) overcomes the hurdle of replicative senescence associated with the in vitro expansion of primary cells and has increased therapeutic benefits in comparison to the use of various adult sources of MSCs in a wide range of animal disease models. On the other hand, fetal MSCs exhibit faster growth kinetics and possess longer telomeres and a wider differentiation potential than adult MSCs. Here, for the first time, we compare the therapeutic potential of PSC-MSCs (ES-MSCs from embryonic stem cells) to fetal MSCs (AF-MSCs from the amniotic fluid), demonstrating that ES-MSCs have a superior neuroprotective potential over AF-MSCs in the mouse brain following hypoxia-ischemia. Further, we demonstrate that nuclear factor (NF)-κB-stimulated interleukin (IL)-13 production contributes to an increased in vitro anti-inflammatory potential of ES-MSC-conditioned medium (CM) over AF-MSC-CM, thus suggesting a potential mechanism for this observation. Moreover, we show that induced pluripotent stem cell-derived MSCs (iMSCs) exhibit many similarities to ES-MSCs, including enhanced NF-κB signaling and IL-13 production in comparison to AF-MSCs. Future studies should assess whether iMSCs also exhibit similar neuroprotective potential to ES-MSCs, thus presenting a potential strategy to overcome the ethical issues associated with the use of embryonic stem cells and providing a potential source of cells for autologous use against neonatal hypoxic-ischemic encephalopathy in humans. Stem Cells Translational Medicine 2018;7:439-449.

Neuroprotection of the hypoxic-ischemic mouse brain by human CD117+CD90+CD105+ amniotic fluid stem cells.

Human amniotic fluid contains two morphologically-distinct sub-populations of stem cells with regenerative potential, spindle-shaped (SS-hAFSCs) and round-shaped human amniotic fluid stem cells (RS-hAFSCs). However, it is unclear whether morphological differences correlate with functionality, and this lack of knowledge limits their translational applications. Here, we show that SS-hAFSCs and RS-hAFSCs differ in their neuro-protective ability, demonstrating that a single contralateral injection of SS-hAFSCs into hypoxic-ischemic P7 mice conferred a 47% reduction in hippocampal tissue loss and 43-45% reduction in TUNEL-positive cells in the hippocampus and striatum 48 hours after the insult, decreased microglial activation and TGFß1 levels, and prevented demyelination. On the other hand, RS-hAFSCs failed to show such neuro-protective effects. It is possible that SS-hAFSCs exert their neuroprotection via endoglin-dependent inhibition of TGFß1 signaling in target cells. These findings identify a sub-population of CD117+CD90+CD105+ stem cells as a promising source for the neuro-protection of the developing brain.

The importance of gender analysis in research for health systems strengthening.

This editorial discusses a collection of papers examining gender across a range of health policy and systems contexts, from access to services, governance, health financing, and human resources for health. The papers interrogate differing health issues and core health systems functions using a gender lens. Together they produce new knowledge on the multiple impacts of gender on health experiences and demonstrate the importance of gender analyses and gender sensitive interventions for promoting well-being and health systems strengthening. The findings from these papers collectively show how gender intersects with other axes of inequity within specific contexts to shape experiences of health and health seeking within households, communities and health systems; illustrate how gender power relations affect access to important resources; and demonstrate that gender norms, poverty and patriarchy interplay to limit women's choices and chances both within household interactions and within the health sector. Health systems researchers have a responsibility to promote the incorporation of gender analyses into their studies in order to inform more strategic, effective and equitable health systems interventions, programmes, and policies. Responding to gender inequitable systems, institutions, and services in this sector requires an 'all hands-on deck' approach. We cannot claim to take a 'people-centred approach' to health systems if the status quo continues.

20 years of gender mainstreaming in health: lessons and reflections for the neglected tropical diseases community.

Neglected tropical diseases (NTDs) affect the poorest of the poor. NTD programmes can and should rise to the challenge of playing a part in promoting more gender equitable societies. Gender equity shapes poverty and the experience of disease in multiple ways; yet to date, there has been little attention paid to gender equity in NTD control efforts. Drawing on a synthesis of relevant literature, the tacit knowledge and experience of the authors, and discussions at a meeting on women, girls and NTDs, this analysis paper distills five key lessons from over 20 years of gender mainstreaming in health. The paper links this learning to NTDs and Mass Drug Administration (MDA). Our first lesson is that tailored gender frameworks support gender analysis within research and programming. We present a gender review framework focusing on different MDA strategies. Second, gender interplays with other axes of inequality, such as disability and geographical location; hence, intersectionality is important for inclusive and responsive NTD programmes. Third, gender, power and positionality shape who is chosen as community drug distributors (CDDs). How CDDs interact with communities and how this interface role is valued and practised needs to be better understood. Fourth, we need to unpack the gender and power dynamics at household level to assess how this impacts MDA coverage and interactions with CDDs. Finally, we need to collect and use sex disaggregated data to support the development of more equitable and sustainable NTD programmes.

Bioluminescence Monitoring of Promoter Activity In Vitro and In Vivo.

The application of luciferase reporter genes to provide quantitative outputs for the activation of promoters is a well-established technique in molecular biology. Luciferase catalyzes an enzymatic reaction, which in the presence of the substrate luciferin produces photons of light relative to its molar concentration. The luciferase transgene can be genetically inserted at the first intron of a target gene to act as a surrogate for the gene's endogenous expression in cells and transgenic mice. Alternatively, promoter sequences can be excised and/or amplified from genomic sources or constructed de novo and cloned upstream of luciferase in an expression cassette transfected into cells. More recently, the development of synthetic promoters where the essential components of an RNA polymerase binding site and transcriptional start site are fused with various upstream regulatory sequences are being applied to drive reporter gene expression. We have developed a high-throughput cloning strategy to develop lentiviral luciferase reporters driven by transcription factor activated synthetic promoters. Lentiviruses integrate their payload cassette into the host cell genome, thereby facilitating the study of gene expression not only in the transduced cells but also within all subsequent daughter cells. In this manuscript we describe the design, vector construction, lentiviral transduction, and luciferase quantitation of transcription factor activated reporters (TFARs) in vitro and in vivo.

TGFß-induced osteogenic potential of human amniotic fluid stem cells via CD73-generated adenosine production.

The human amniotic fluid stem cell (hAFSC) population consists of two morphologically distinct subtypes, spindle-shaped and round-shaped cells (SS-hAFSCs and RS-hAFSCs). Whilst SS-hAFSCs are routinely expanded in mesenchymal-type (MT) conditions, we previously showed that they acquire broader differentiation potential when cultured under embryonic-type (ET) conditions. However, the effects of culture conditions on RS-hAFSCs have not been determined. Here, we show that culturing RS-hAFSCs under ET conditions confers faster proliferation and enhances the efficiency of osteogenic differentiation of the cells. We show that this occurs via TGFß-induced activation of CD73 and the associated increase in the generation of extracellular adenosine. Our data demonstrate that culture conditions are decisive for the expansion of hAFSCs and that TGFß present in ET conditions causes the phenotype of RS-hAFSCs to revert to an earlier state of stemness. Cultivating RS-hAFSCs in ET conditions with TGFß may therefore increase their therapeutic potential for clinical applications.