The cost-effectiveness of school-based interventions for chronic diseases: a systematic review.

BACKGROUND: Chronic diseases, or non-communicable diseases (NCD), are conditions of long duration and often influenced and contributed by complex interactions of several variables, including genetic, physiological, environmental, and behavioral factors. These conditions contribute to death, disability, and subsequent health care costs. Primary and secondary school settings provide an opportunity to deliver relatively low cost and effective interventions to improve public health outcomes. However, there lacks systematic evidence on the cost-effectiveness of these interventions. METHODS: We systematically searched four databases (PubMed/Medline, Cochrane, Embase, and Web of Science) for published studies on the cost-effectiveness of chronic-disease interventions in school settings. Studies were eligible for inclusion if they assessed interventions of any chronic or non-communicable disease, were conducted in a school setting, undertook a full cost-effectiveness analysis and were available in English, Spanish, or French. RESULTS: Our review identified 1029 articles during our initial search of the databases, and after screening, 33 studies were included in our final analysis. The most used effectiveness outcome measures were summary effectiveness units such as quality-adjusted life years (QALYs) (22 articles; 67%) or disability-adjusted life years (DALYs) (4 articles; 12%). The most common health condition for which an intervention targets is overweight and obesity. Almost all school-based interventions were found to be cost-effective (30 articles; 81%). CONCLUSION: Our review found evidence to support a number of cost-effective school-based interventions targeting NCDs focused on vaccination, routine physical activity, and supplement delivery interventions. Conversely, many classroom-based cognitive behavioral therapy for mental health and certain multi-component interventions for obesity were not found to be cost-effective.

A novel approach to estimate the impact of health workforce investments on health outcomes through increased coverage of HIV, TB and malaria services.

BACKGROUND: Globally, HIV, TB and malaria account for an estimated three million deaths annually. The Global Fund partnered with the World Health Organization to assist countries with health workforce planning in these areas through the development of an integrated health workforce investment impact tool. Our study illustrates the development of a user-friendly tool (with two MS Excel calculator subcomponents) that computes associations between human resources for health (HRH) investment inputs and reduced morbidity and mortality from HIV, TB, and malaria via increased coverage of effective treatment services. METHODS: We retrieved from the peer-reviewed literature quantitative estimates of the relation among HRH inputs and HRH employment and productivity. We converted these values to additional full-time-equivalent doctors, nurses and midwives (DNMs). We used log-linear regression to estimate the relation between DNMs and treatment service coverage outcomes for HIV, TB, and malaria. We then retrieved treatment effectiveness parameters from the literature to calculate lives saved due to expanded treatment coverage for HIV, TB, and malaria. After integrating these estimates into the tool, we piloted it in four countries. RESULTS: In most countries with a considerable burden of HIV, TB, and malaria, the health workforce investments include a mix of pre-service education, full remuneration of new hires, various forms of incentives and in-service training. These investments were associated with elevated HIV, TB and malaria treatment service coverage and additional lives saved. The country case studies we developed in addition, indicate the feasibility and utility of the tool for a variety of international and local actors interested in HRH planning. CONCLUSIONS: The modelled estimates developed for illustrative purposes and tested through country case studies suggest that HRH investments result in lives saved across HIV, TB, and malaria. Furthermore, findings show that attainment of high targets of specific treatment coverage indicators would require a substantially greater health workforce than what is currently available in most LMICs. The open access tool can assist with future HRH planning efforts, particularly in LMICs.

Effects of chronic workplace harassment on mental health and alcohol misuse: a long-term follow-up.

BACKGROUND: Research on the impacts of exposure to workplace harassment (WH) is largely cross-sectional, and existing prospective studies generally are between two and five years of follow-up, with the longest US study being 10 years. However, the effects of exposure to WH may persist longer, particularly if exposure has been chronic. This study fills this gap by examining effects of prior exposure to chronic sexual and generalized WH on psychological distress and alcohol misuse over an approximately 25 year study period. METHODS: Individuals originally recruited from a university-employed sample in the United States were surveyed at 8 time points from 1996-2007 and again in 2020-2021. A series of hybrid path analyses were tested on a sample of 2352 individuals, regressing recent outcomes on latent classes of harassment derived from earlier survey waves, controlling baseline outcomes and demographics. Model fit was assessed using a variety of fit statistics, and standardized regression coefficients were used to assess significance of individual pathways. RESULTS: Prior exposure to chronic sexual harassment had significant direct associations with psychological distress, alcohol misuse, and recent stressors at follow-up. Prior exposure to chronic generalized harassment had significant direct associations with lower income and alcohol misuse. Both forms of WH were significantly indirectly associated with psychological distress through recent stressors at follow-up. CONCLUSIONS: Exposure to chronic WH is associated with long-term effects on psychological distress and alcohol misuse in a sample representing a wide variety of job types and racial/ethnic identities. Enforcement of anti-sexual harassment law and policies and enactment of policies and laws to prevent generalized harassment/workplace bullying are imperative for the protection of worker health.

Projected impact of population aging on non-communicable disease burden and costs in the Kingdom of Saudi Arabia, 2020-2030.

BACKGROUND: The number of people aged greater than 65 years per 100 people aged 20-64 years is expected to almost double in The Kingdom of Saudi Arabia (KSA) between 2020 and 2030. We therefore aimed to quantify the growing non-communicable disease (NCD) burden in KSA between 2020 and 2030, and the impact this will have on the national health budget. METHODS: Ten priority NCDs were selected: ischemic heart disease, stroke, type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, dementia, depression, osteoarthritis, colorectal cancer, and breast cancer. Age- and sex-specific prevalence was projected for each priority NCD between 2020 and 2030. Treatment coverage rates were applied to the projected prevalence estimates to calculate the number of patients incurring treatment costs for each condition. For each priority NCD, the average cost-of-illness was estimated based on published literature. The impact of changes to our base-case model in terms of assumed disease prevalence, treatment coverage, and costs of care, coming into effect from 2023 onwards, were explored. RESULTS: The prevalence estimates for colorectal cancer and stroke were estimated to almost double between 2020 and 2030 (97% and 88% increase, respectively). The only priority NCD prevalence projected to increase by less than 60% between 2020 and 2030 was for depression (22% increase). It is estimated that the total cost of managing priority NCDs in KSA will increase from USD 19.8 billion in 2020 to USD 32.4 billion in 2030 (an increase of USD 12.6 billion or 63%). The largest USD value increases were projected for osteoarthritis (USD 4.3 billion), diabetes (USD 2.4 billion), and dementia (USD 1.9 billion). In scenario analyses, our 2030 projection for the total cost of managing priority NCDs varied between USD 29.2 billion - USD 35.7 billion. CONCLUSIONS: Managing the growing NCD burden in KSA's aging population will require substantial healthcare spending increases over the coming years.

Behavioural economic interventions to reduce health care appointment non-attendance: a systematic review and meta-analysis.

BACKGROUND: Appointment non-attendance - often referred to as "missed appointments", "patient no-show", or "did not attend (DNA)" - causes volatility in health systems around the world. Of the different approaches that can be adopted to reduce patient non-attendance, behavioural economics-oriented mechanisms (i.e., psychological, cognitive, emotional, and social factors that may impact individual decisions) are reasoned to be better suited in such contexts - where the need is to persuade, nudge, and/ or incentivize patients to honour their scheduled appointment. The aim of this systematic literature review is to identify and summarize the published evidence on the use and effectiveness of behavioural economic interventions to reduce no-shows for health care appointments. METHODS: We systematically searched four databases (PubMed/Medline, Embase, Scopus, and Web of Science) for published and grey literature on behavioural economic strategies to reduce no-shows for health care appointments. Eligible studies met four criteria for inclusion; they were (1) available in English, Spanish, or French, (2) assessed behavioural economics interventions, (3) objectively measured a behavioural outcome (as opposed to attitudes or preferences), and (4) used a randomized and controlled or quasi-experimental study design. RESULTS: Our initial search of the five databases identified 1,225 articles. After screening studies for inclusion criteria and assessing risk of bias, 61 studies were included in our final analysis. Data was extracted using a predefined 19-item extraction matrix. All studies assessed ambulatory or outpatient care services, although a variety of hospital departments or appointment types. The most common behaviour change intervention assessed was the use of reminders (n = 56). Results were mixed regarding the most effective methods of delivering reminders. There is significant evidence supporting the effectiveness of reminders (either by SMS, telephone, or mail) across various settings. However, there is a lack of evidence regarding alternative interventions and efforts to address other heuristics, leaving a majority of behavioural economic approaches unused and unassessed. CONCLUSION: The studies in our review reflect a lack of diversity in intervention approaches but point to the effectiveness of reminder systems in reducing no-show rates across a variety of medical departments. We recommend future studies to test alternative behavioural economic interventions that have not been used, tested, and/or published before.

Emergency care in post-conflict settings: a systematic literature review.

BACKGROUND: Emergency care systems (ECS) organize and provide access to life-saving care both during transport and at health facilities. Not enough is known about ECS in uncertain contexts such as post-conflict settings. This review aims to systematically identify and summarize the published evidence on the delivery of emergency care in post-conflict settings and to guide health sector planning. METHODS: We searched five databases (PubMed MEDLINE, Web of Science, Embase, Scopus, and Cochrane) in September 2021 to identify relevant articles on ECS in post-conflict settings. Included studies (1) described a context that is post-conflict, conflict-affected, or was impacted by war or crisis; (2) examined the delivery of an emergency care system function; (3) were available in English, Spanish, or French; and (4) were published between 1 and 2000 and 9 September 2021. Data were extracted and mapped using the essential system functions identified in the World Health Organization (WHO) ECS Framework to capture findings on essential emergency care functions at the scene of injury or illness, during transport, and through to the emergency unit and early inpatient care. RESULTS: We identified studies that describe the unique burden of disease and challenges in delivering to the populations in these states, pointing to particular gaps in prehospital care delivery (both during scene response and during transport). Common barriers include poor infrastructure, lingering social distrust, scarce formal emergency care training, and lack of resources and supplies. CONCLUSION: To our knowledge, this is the first study to systematically identify the evidence on ECS in fragile and conflict-affected settings. Aligning ECS with existing global health priorities would ensure access to these critical life-saving interventions, yet there is concern over the lack of investments in frontline emergency care. An understanding of the state of ECS in post-conflict settings is emerging, although current evidence related to best practices and interventions is extremely limited. Careful attention should be paid to addressing the common barriers and context-relevant priorities in ECS, such as strengthening prehospital care delivery, triage, and referral systems and training the health workforce in emergency care principles.

The psychological impact of deprivation in regions affected by conflict: a multilevel analysis of a cross-sectional survey in the occupied Palestinian territory.

BACKGROUND: Deprivation is an important determinant of poor health. Locality can be key in understanding variation in deprivation across a population. This study aimed to analyse how different forms of deprivation affect mental health among Palestinians, and how they account for locality effects in the occupied Palestinian territory. METHODS: We used multilevel modelling to analyse data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which had a sample size of 7827 adults representing the same number of households. The main outcome is a General Health Questionnaire (GHQ) score, in which a higher score signifies worse mental health. Deprivation variables include subjective deprivation, material deprivation, food deprivation, and political deprivation (which was measured by use of the human insecurity scale). For the analysis, we included data on experience of different stressors (economic, political, health-related, and weather-related stress) reported at the household level in the 6 months preceding the survey, and we controlled for demographic characteristics, including age, gender, education, wealth, and region. We also conducted a two-level random effects multilevel regression, with locality as a proxy for neighbourhood. FINDINGS: The model indicates significant variance at the locality (neighbourhood) level. There is a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Education beyond secondary school level and wealth have a significant inverse association with poor mental health. Individuals who indicated that they felt somewhat or very deprived have significantly higher GHQ scores than individuals who indicated that they did not feel deprived (ß=1·73 and 4·33 for those who felt deprived and who did not feel deprived, respectively, p<0·0001). Food consumption was inversely associated with GHQ score (ß=-0·01, p<0·0001) and food insecurity was positively associated with GHQ score (ß=0·19, p<0·0001). Political deprivation, and health-related, political, and economic stressors were significantly positively associated with GHQ scores (ß=0·043, 0·23, 0·35, and 0·19 respectively, p<0·0001). Age (ß=0·079, p<0·0001) and being a woman were positively associated with GHQ score (ß=0·26, p=0·0040), whereas education beyond secondary school level was inversely associated with GHQ score (ß=-0·54, p<0·0001). INTERPRETATION: The findings that the mental health of Palestinians is associated with various forms of deprivation and stressors, provide further evidence that political and social factors are determinants of health. Correlated factors include both subjective and objective measures, and suggest that although material conditions are important, people's subjective experiences are also important. Feeling deprived is an important correlate of mental health. The community effect suggests that services (or lack thereof), checkpoints and blockades, political situations, and other factors that vary across localities, may influence mental health issues at the neighbourhood level. FUNDING: This project is part of the study "Re-conceptualising health in wars and conflicts: a new focus on deprivation and suffering" funded by the Middle East Centre at the London School of Economics and Political Science.

Food insecurity in the context of conflict: analysis of survey data in the occupied Palestinian territory.

BACKGROUND: Conflict impacts food security and decreases household dietary diversity. However, few studies have explored the routes by which prolonged conflict and social stressors affect food insecurity experience and food diversity. This study examines the influence of political, economic, and agricultural stressors on food insecurity and food diversity, and evaluates variations in food insecurity and food diversity with location of residence for households in the occupied Palestinian territory. METHODS: A secondary data analysis with structural equation modelling was carried out on data from the Socio-Economic & Food Security Survey 2014 of the Palestinian Central Bureau of Statistics. The survey was completed by a representative sample of the Palestinian population in the occupied Palestinian territory at governorate and locality levels, and consisted of 4215 households in the West Bank and 2916 households in the Gaza Strip. The primary outcomes were food diversity (measured with a food consumption score) and food insecurity (assessed with a composite experience-based measure of food security). We used structural equation models to examine the relationships between location of residence (in the West Bank, living in Area C versus not Area C; in the Gaza Strip, proximity of residence to the buffer zone), the number of political stressors, economic stressors, and agricultural stressors (eg, restricted access to land), and the primary outcomes. We controlled for demographic characteristics, including education, governorate, and wealth. FINDINGS: In the West Bank, there was no statistically significant direct association between living in Area C and food insecurity. Living in Area C is associated with a higher number of agricultural stressors than not Area C (p=0·032), and a higher number of agricultural stressors is in turn associated with lower food diversity (p=0·0080) and higher food insecurity (p=0·040). In the Gaza Strip, proximity to the buffer zone is directly associated with higher food insecurity (p=0.041) and lower food diversity (p=0·019) and a higher number of political stressors (p=0·057). A higher number of political stressors is associated with a higher number of economic stressors (p=0·026) and higher food insecurity (p=0·034). INTERPRETATION: The findings suggest that political, economic, and agricultural factors contribute to food insecurity and food diversity, and that their interactions are complex. Conflict and occupation affect food availability through both direct and indirect channels. In the Gaza Strip, living in close proximity to the buffer zone is associated with lower food diversity and higher food insecurity. In the West Bank, although residing in Area C may not directly increase food insecurity, the hardship generated by the conditions in Area C contributes to higher food insecurity. FUNDING: The Emirates Foundation.

Relationship between symptoms, barriers to care and healthcare utilisation among children under five in rural Mali.

OBJECTIVES: To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high-mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation. METHODS: Using baseline household survey data from a cluster-randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio-demographic factors, symptoms and utilisation outcomes in mixed-effect logistic regressions. RESULTS: Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one-quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider. CONCLUSIONS: Even distances as short as 2-5 km significantly reduced children's likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers.

A needs-based methodology to project physicians and nurses to 2030: the case of the Kingdom of Saudi Arabia.

BACKGROUND: The Kingdom of Saudi Arabia (KSA), as part of its 2030 National Transformation Program, set a goal of transforming the healthcare sector to increase access to, and improve the quality and efficiency of, health services. To assist with the workforce planning component, we projected the needed number of physicians and nurses into 2030. We developed a new needs-based methodology since previous global benchmarks of health worker concentration may not apply to the KSA. METHODS: We constructed an epidemiologic "needs-based" model that takes into account the health needs of the KSA population, cost-effective treatment service delivery models, and worker productivity. This model relied heavily on up-to-date epidemiologic and workforce surveys in the KSA. We used demographic population projections to estimate the number of nurses and physicians needed to provide this core set of services into 2030. We also assessed several alternative scenarios and policy decisions related to scaling, task-shifting, and enhanced public health campaigns. RESULTS: When projected to 2030, the baseline needs-based estimate is approximately 75,000 workers (5788 physicians and 69,399 nurses). This workforce equates to 2.05 physicians and nurses per 1000 population. Alternative models based on different scenarios and policy decisions indicate that the actual needs for physicians and nurses may range from 1.64 to 3.05 per 1000 population in 2030. CONCLUSIONS: Based on our projections, the KSA will not face a needs-based health worker shortage in 2030. However, alternative model projections raise important policy and planning issues regarding various strategies the KSA may pursue in improving quality and efficiency of the existing workforce. More broadly, where country-level data are available, our needs-based strategy can serve as a useful step-by-step workforce planning tool to complement more economic demand-based workforce projections.

Projecting health labor market dynamics for a health system in transition: planning for a resilient health workforce in Saudi Arabia.

BACKGROUND: Health workforce planning is critical for health systems to safeguard the ability to afford, train, recruit, and retain the appropriate number and mix of health workers. This balance is especially important when macroeconomic structures are also reforming. The Kingdom of Saudi Arabia is moving toward greater diversification, privatization, and resiliency; health sectorreform is a key pillar of this transition. METHODS: We used the Ministry of Health Yearbook data on the number of workers and health expenditures from 2007 to 2018 and projected health labor market supply and demand of workers through 2030, evaluated the potential shortages and surpluses, and simulated different policy scenarios to identify relevant interventions. We further focused on projections for health workers who are Saudi nationals and health worker demand within the public sector (versus the private sector) to inform national objectives of reducing dependency on foreign workers and better deploying public sector resources. RESULTS: We projected the overall health labor market to demand 9.07 physicians and nurses per 1,000 population (356,514) in 2030; the public sector will account for approximately 67% of this overall demand. Compared to a projected supply of 10.16 physicians and nurses per 1,000 population (399,354), we estimated an overall modest surplus of about 42,840 physicians and nurses in 2030. However, only about 17% of these workers are estimated to be Saudi nationals, for whom there will be a demand shortage of 287,895 workers. Among policy scenarios considered, increasing work hours had the largest effect on reducing shortages of Saudi workers, followed by bridge programs for training more nurses. Government resources can also be redirected to supporting more Saudi nurses while still ensuring adequate numbers of physicians to meet service delivery goals in 2030. CONCLUSION: Despite projected overall balance in the labor market for health workers in 2030, without policy interventions, severe gaps in the Saudi workforce will persist and limit progress toward health system resiliency in Saudi Arabia. Both supply- and demand-side policy interventions should be considered, prioritizing those that increase productivity among Saudi health workers, enhance training for nurses, and strategically redeploy financial resources toward employing these workers.

The costs of delivering emergency care at regional referral hospitals in Uganda: a micro-costing study.

BACKGROUND: Uganda experiences a high morbidity and mortality burden due to conditions amenable to emergency care, yet few public hospitals have dedicated emergency units. As a result, little is known about the costs and effects of delivering lifesaving emergency care, hindering health systems planning, budgeting and prioritization exercises. To determine healthcare costs of emergency care services at public facilities in Uganda, we estimate the median cost of care for five sentinel conditions and 13 interventions. METHODS: A direct, activity-based costing was carried out at five regional referral hospitals over a four-week period from September to October 2019. Hospital costs were determined using bottom-up micro-costing methodology from a provider perspective. Resource use was enumerated via observation and unit costs were derived from National Medical Stores lists. Cost per condition per patient and measures of central tendency for conditions and interventions were calculated. Kruskal-Wallis H-tests and Nemyeni post-hoc tests were conducted to determine significant differences between costs of the conditions. RESULTS: Eight hundred seventy-two patient cases were captured with an overall median cost of care of $15.53 USD ($14.44 to $19.22). The median cost per condition was highest for post-partum haemorrhage at $17.25 ($15.02 to $21.36), followed by road traffic injuries at $15.96 ($14.51 to $20.30), asthma at $15.90 ($14.76 to $19.30), pneumonia at $15.55 ($14.65 to $20.12), and paediatric diarrhoea at $14.61 ($13.74 to $15.57). The median cost per intervention was highest for fracture reduction and splinting at $27.77 ($22.00 to $31.50). Cost values differ between sentinel conditions (p < 0.05) with treatments for paediatric diarrhoea having the lowest median cost of all conditions (p < 0.05). CONCLUSION: This study is the first to describe the direct costs of emergency care in hospitals in Uganda by observing the delivery of clinical services, using robust activity-based costing and time motion methodology. We find that emergency care interventions for key drivers of morbidity and mortality can be delivered at considerably lower costs than many priority health interventions. Further research assessing acute care delivery would be useful in planning wider health care delivery systems development.

The effect of sugar and processed food imports on the prevalence of overweight and obesity in 172 countries.

BACKGROUND: Studies find that economic, political, and social globalization - as well as trade liberalization specifically - influence the prevalence of overweight and obesity in countries through increasing the availability and affordability of unhealthful food. However, what are the mechanisms that connect globalization, trade liberalization, and rising average body mass index (BMI)? We suggest that the various sub-components of globalization interact, leading individuals in countries that experience higher levels of globalization to prefer, import, and consume more imported sugar and processed food products than individuals in countries that experience lower levels of globalization. METHOD: This study codes the amount of sugar and processed food imports in 172 countries from 1995 to 2010 using the United Nations Comtrade dataset. We employ country-specific fixed effects (FE) models, with robust standard errors, to examine the relationship between sugar and processed foods imports, globalization, and average BMI. To highlight further the relationship between the sugar and processed food import and average BMI, we employ a synthetic control method to calculate a counterfactual average BMI in Fiji. CONCLUSION: We find that sugar and processed food imports are part of the explanation to increasing average BMI in countries; after controlling for globalization and general imports and exports, sugar and processed food imports have a statistically and substantively significant effect in increasing average BMI. In the case of Fiji, the increased prevalence of obesity is associated with trade agreements and increased imports of sugar and processed food. The counterfactual estimates suggest that sugar and processed food imports are associated with a 0.5 increase in average BMI in Fiji.

Understanding patients' preferences for surgical management of urethral stricture disease.

OBJECTIVES: To understand how prioritization of treatment attributes and treatment choice varies by patient characteristics, we sought to specifically determine how demographic variables affect patient treatment preference. PATIENTS AND METHODS: Male patients with urethral stricture disease participated in a choice-based conjoint (CBC) analysis exercise evaluating six treatment attributes associated with internal urethrotomy and urethroplasty. Demographic and past symptom data were collected. Stratified analysis of demographic variables, including age, education, income, was conducted using a mixed effect logistic regression model to evaluate the coefficient size and confidence intervals between the treatments attribute preferences of each strata. RESULTS: 169 patients completed the CBC exercise and were included in our analysis. Overall success of the procedure is the most important treatment attribute to patients and this persists across strata. Older patients (≥65) express preferences for better success rates and fewer future procedures, whereas younger patients prefer a less invasive approach and are more willing to accept additional procedures if needed. Patients with lower levels of education preferred open reconstruction and had a stronger preference against multiple future procedures, whereas those with higher levels of education preferred endoscopic treatment and had a less strong preference against multiple future procedures. Low-income individuals express statistically significant stronger negative preferences against high copay costs compared to high-income individuals. CONCLUSION: These results can help to inform physicians' counseling about surgical management of urethral stricture disease to better align patient preferences with treatment selection and encourage shared decision making.

Evidence on the impact of community health workers in the prevention, identification, and management of undernutrition amongst children under the age of five in conflict-affected or fragile settings: a systematic literature review.

BACKGROUND: Malnutrition, specifically undernutrition, is a significant global challenge that contributes to nearly half of deaths in children under the age of five. The burden of undernutrition is disproportionately borne by conflict-affected, fragile settings (CAFS); children living in a conflict zone being more than twice as likely to suffer from malnourishment. Community health worker (CHW) models have been employed in CAFS to improve healthcare coverage and identify and treat illnesses. However, there lacks systematic evidence on the impact of CHW models in preventing, identifying, and managing child undernutrition in CAFS. We conducted this review to systematically evaluate evidence of CHW models in preventing, identifying, and managing undernutrition in children under the age of five in CAFS. METHODOLOGY: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. The search strategy was developed using the Population-Intervention-Comparisons-Outcomes-Setting framework as a guide. Searches were performed using Ovid online database search platform, searching the databases of Ovid MEDLINE(R), COCHRANE, Embase Classic, Embase, Econlit, Global Health, SCOPUS, and Social Policy and Practice. Peer-reviewed publications were eligible for inclusion if they evaluated an intervention using a CHW model that aims to prevent, identify, or manage some form of undernutrition in children under five in a CAFS. RESULTS: We identified 25 studies-spanning 10 countries-that were included in the systematic review. CHW models were implemented alongside a variety of interventions, including behaviour change communication, supplementary foods, nutrition counselling, and integrated community health programmes. Key barriers in implementing successful CHW models include disruption of programmes due to active conflict, states of emergency, militancy, or political unrest; weak links between the community-based interventions and public health system; weak health system capacity that impeded referral and follow-ups; and cost of care and care-seeking. Key facilitators include CHWs' connection to the community, close proximity of programmes to the community, supervision, and investment in high quality training and tools. CONCLUSIONS: The findings suggest that CHW models may be effective, cost-effective, acceptable, feasible, and scalable in the prevention, identification, and management child undernutrition in CAFS. The study findings also confirmed a need for greater evidence in the field. These findings may inform policymaking, programme implementation, and design to strengthen best practices for CHW models addressing child undernutrition in CAFS.

The impact of the COVID-19 pandemic on conflict and health system-related violent events in Libya: An interrupted time series analysis.

As a response to the COVID-19 pandemic, the United Nations Security Council passed resolution S/RES2532 (2020), requesting the cessation of hostilities. Despite ceasefire initiatives, evidence suggests that both conflict and violent events remained unabated-and, in some cases, escalated during the first months of the pandemic. This study uses interrupted time series analyses to examine the impact of the pandemic on violent and non-violent political events-including health system-related violence-in Libya, which has been experiencing a protracted conflict since 2014. We find a reduction of approximately 21 battles (p < 0.001) only during the first month of the pandemic. However, overall, throughout the pandemic, there was an increase of roughly one battle per month (p < 0.001). The violence that affected healthcare workers decreased during the first year of the pandemic (p < 0.001); but by the second year the reduction in healthcare worker-related violence had dissipated. While the pandemic seems to have mitigated the level of violence experience by healthcare workers, the overall pattern of violence is a troubling one, particularly since they were observed while there is an international agreement for a ceasefire in place and a specific peace agreement occurring in Libya. The pattern suggests that policy to protect healthcare workers may need to be enhanced even more during crisis settings.

Patient Preferences for Out-of-Hospital Cardiac Arrest Care in South Africa: A Discrete Choice Experiment.

OBJECTIVE: This study examined the trade-offs low-resource setting community members were willing to make in regard to out-of-hospital cardiac arrest care using a discrete choice experiment survey. METHODS: We administered a discrete choice experiment survey to a sample of community members 18 years or older across South Africa between April and May 2022. Participants were presented with 18 paired choice tasks comprised of 5 attributes (distance to closest adequate facility, provider of care, response time, chances of survival, and transport cost) and a range of 3 to 5 levels. We used mixed logit models to evaluate respondents' preferences for selected attributes. RESULTS: Analyses were based on 2228 responses and 40 104 choice tasks. Patients valued care with the shortest response time, delivered by the highest qualified individuals, which placed them within the shortest distance of an adequate facility, gave them the highest chance of survival, and costed the least. In addition, patients preferred care delivered by their family members over care delivered by the lay public. The highest mean willingness-to-pay for increased survival is 11 699 South African rand (ZAR), followed by distance to health facility (8108 ZAR), and response time (5678 ZAR), and the lowest for increasing specialization of provider (1287 ZAR). CONCLUSIONS: In low-resource settings, it may align with patients' preference to include targeted resuscitation training for family members of individuals with high-risk for cardiac arrest as a part of out-of-hospital cardiac arrest intervention strategies.

Lingering Effects of COVID-19 Stressors on Mental Health and Alcohol Use in Middle Aged to Older Adults.

Background: Older adults have faced not only health threats but grave mental health challenges since the emergence of the Coronavirus disease 2019 (COVID-19) pandemic. Using factor analysis, this study is the first to identify the underlying dimensions of COVID-19-related stressors, then examine the relationship between these factors and mental health and alcohol use/misuse longitudinally in a middle aged to older adult sample in the United States. Methods: As part of a long-term follow-up study, 921 survey participants completed measures of COVID-related stressors, psychological distress, and alcohol use/misuse in a 2020 survey. An exploratory factor analysis was conducted to examine the dimensionality of COVID-related stress. Regression models were utilized to examine relationships between the extracted factors and depression, anxiety, and alcohol-related outcomes measured approximately one year later, in 2021. Results: Four dimensions of COVID-19 stressors were extracted, including 1) jobs, finances and loss of routine; 2) practical difficulties; 3) social worries and challenges; and 4) supply shortages. Practical difficulties were associated with higher depression at follow-up, while jobs, finances and loss of routine were associated with past 12 month frequency of intoxication at follow-up. Conclusions: Challenges from the pandemic may have longer-term implications for mental health in older adults past the acute phase of the pandemic. It is important to allocate sufficient attention and resources to the prevention of late life depression and mental health as policymakers and health professionals continue to deal with the pandemic and future variants of the virus.