Outcome prioritization and preferences among older adults with cancer starting chemotherapy in a randomized clinical trial.

INTRODUCTION: Older adults with cancer facing competing treatments must prioritize between various outcomes. This study assessed health outcome prioritization among older adults with cancer starting chemotherapy. METHODS: Secondary analysis of a randomized trial addressing vulnerabilities in older adults with cancer. Patients completed three validated outcome prioritization tools: 1) Health Outcomes Tool: prioritizes outcomes (survival, independence, symptoms) using a visual analog scale; 2) Now vs. Later Tool: rates the importance of quality of life at three times-today versus 1 or 5 years in the future; and 3) Attitude Scale: rates agreement with outcome-related statements. The authors measured the proportion of patients prioritizing various outcomes and evaluated their characteristics. RESULTS: A total of 219 patients (median [range] age 71 [65-88], 68% with metastatic disease) were included. On the Health Outcomes Tool, 60.7% prioritized survival over other outcomes. Having localized disease was associated with choosing survival as top priority. On the Now vs. Later Tool, 50% gave equal importance to current versus future quality of life. On the Attitude Scale, 53.4% disagreed with the statement "the most important thing to me is living as long as I can, no matter what my quality of life is"; and 82.2% agreed with the statement "it is more important to me to maintain my thinking ability than to live as long as possible". CONCLUSION: Although survival was the top priority for most participants, some older individuals with cancer prioritize other outcomes, such as cognition and function. Clinicians should elicit patient-defined priorities and include them in decision-making.

Exploring health equity integration among health service and delivery systems in Nova Scotia: perspectives of health system partners.

BACKGROUND: Achieving health equity is important to improve population health; however, health equity is not typically well defined, integrated, or measured within health service and delivery systems. To improve population health, it is necessary to understand barriers and facilitators to health equity integration within health service and delivery systems. This study aimed to explore health equity integration among health systems workers and identify key barriers and facilitators to implementing health equity strategies within the health service and delivery system in Nova Scotia, ahead of the release of a Health Equity Framework, focused on addressing inequities within publicly funded institutions. METHODS: Purposive sampling was used to recruit individuals working on health equity initiatives including those in high-level leadership positions within the Nova Scotia health system. Individual interviews and a joint interview session were conducted. Topics of discussion included current integration of health equity through existing strategies and perceptions within participant roles. The Consolidated Framework for Implementation Research (CFIR) was used to guide coding and analysis, with interviews transcribed and deductively analyzed in NVivo. Qualitative description was employed to describe study findings as barriers and facilitators to health equity integration. RESULTS: Eleven individual interviews and one joint interview (n = 5 participants) were conducted, a total of 16 participants. Half (n = 8) of the participants were High-level Leaders (i.e., manager or higher) within the health system. We found that existing strategies within the health system were inadequate to address inequities, and variation in the use of indicators of health equity was indicative of a lack of health equity integration. Applying the CFIR allowed us to identify barriers to and facilitators of health equity integration, with the power of legislation to implement a Health Equity Framework, alongside the value of partnerships and engagement both being seen as key facilitators to support health equity integration. Barriers to health equity integration included inadequate resources devoted to health equity work, a lack of diversity among senior system leaders and concerns that existing efforts to integrate health equity were siloed. CONCLUSION: Our findings suggest that health equity integration needs to be prioritized within the health service and delivery system within Nova Scotia and identifies possible strategies for implementation. Appropriate measures, resources and partnerships need to be put in place to support health equity integration following the introduction of the Health Equity Framework, which was viewed as a key driver for action. Greater diversity within health system leadership was also identified as an important strategy to support integration. Our findings have implications for other jurisdictions seeking to advance health equity across health service and delivery systems.

"I want to see them thrive!": exploring health service research priorities for young Aboriginal children growing up in Alice Springs - a qualitative study.

To better understand the specific influences of early life on the long-term health and well-being of local Aboriginal children in Alice Springs, high-quality local longitudinal data is required. The Central Australian Aboriginal Congress and the Murdoch Children's Research Institute are exploring the feasibility of establishing a cohort study to fill this gap. A nested qualitative study was conducted to identify priority issues that can be translated into research questions answerable through the proposed cohort study. Semi-structured interviews and focus group discussions (FGDs) were conducted with a range of key community stakeholders, parents and caregivers of young Aboriginal children from Alice Springs in the Northern Territory between 2020 and 2021. Two Aboriginal and two non-Aboriginal researchers conducted 27 interviews and 3 FGDs with 42 participants. Three broad themes were constructed through reflexive thematic analysis representing the areas of focus community stakeholders and parents want future research to prioritise: (1) social determinants of health (2) building positive connections, and (3) making sure kids grow up strong and healthy. Priority setting for future research should be driven by Aboriginal and Torres Strait Islander peoples in order to be of practical benefit to their community. This qualitative study found that housing, transport and positive connections through nurturing and engaged parents were some of the most important issues raised. Participants also wanted future research to focus on issues specific to children such as nutrition, hearing loss, language development and capacity to learn. These findings will guide future work led by local Aboriginal researchers to co-design the proposed cohort study.

Identifying health and healthcare priorities in rural areas: A concept mapping study informed by consumers, health professionals and researchers.

BACKGROUND: It is vital that health service delivery and health interventions address patients' needs or preferences, are relevant for practice and can be implemented. Involving those who will use or deliver healthcare in priority-setting can lead to health service delivery and research that is more meaningful and impactful. This is particularly crucial in rural communities, where limited resources and disparities in healthcare and health outcomes are often more pronounced. The aim of this study was to determine the health and healthcare priorities in rural communities using a region-wide community engagement approach. METHODS: This multi-methods study was conducted in five rural communities in the Grampians region, Western Victoria, Australia. It involved six concept mapping steps: (1) preparation, (2) generation (brainstorming statements and identifying rating criteria), (3) structuring statements (sorting and rating statements), (4) representation of statements, (5) interpretation of the concept map and (6) utilization. Community forums, surveys and stakeholder consultations with community members and health professionals were used in Step 2. An innovative online group concept mapping platform, involving consumers, health professionals and researchers was used in Step 3. RESULTS: Overall, 117 community members and 70 health professionals identified 400 health and healthcare issues. Six stakeholder consultation sessions (with 16 community members and 16 health professionals) identified three key values for prioritizing health issues: equal access for equal need, effectiveness and impact (number of people affected). Actionable priorities for healthcare delivery were largely related to access issues, such as the challenges navigating the healthcare system, particularly for people with mental health issues; the lack of sufficient general practitioners and other health providers; the high travel costs; and poor internet coverage often impacting technology-based interventions for people in rural areas. CONCLUSIONS: This study identified actionable health and healthcare priorities from the perspective of healthcare service users and providers in rural communities in Western Victoria. Issues related to access, such as the inequities in healthcare costs, the perceived lack of quality and availability of services, particularly in mental health and disability, were identified as priorities. These insights can guide future research, policy-making and resource allocation efforts to improve healthcare access, quality and equity in rural communities.

COVID-19 vaccination plans in Latin America and the Caribbean: a multi-country comparative analysis of prioritization strategies.

OBJECTIVES: This study aimed to synthesize and compare the prioritization strategies outlined in the national vaccination plans (NVPs) against Coronavirus Disease 2019 (COVID-19) developed by countries in the Latin America and Caribbean (LAC) region. STUDY DESIGN: We conducted a comparative policy analysis based on COVID-19 NVPs. METHODS: We conducted a search strategy in three stages to identify NVPs for COVID-19 across 41 countries/territories in the LAC region. Sources included official governmental repositories, complementary Google searches, and less formal documentation. We extracted key variables and conducted a comparative policy analysis based on the prioritization criteria and specific prioritization groups. RESULTS: The study identified 52 NVPs for COVID-19, corresponding to 27 (65.8 %) out of 41 countries/territories in the LAC region. Official national websites yielded documents for 12 countries. All NVPs included frontline healthcare personnel in the first prioritization phase/stage, whilst some included residents of long-term healthcare facilities, adults aged 60 years or more, and people with disabilities. The decision criteria for prioritization were declared in 14 countries/territories. Ethical considerations declared in five NVPs included human welfare, equality, solidarity, equity, and social justice as values. CONCLUSION: The early stages of vaccination rollout in LAC countries prioritized protection of the healthcare system and epidemiological risk for severe disease. Few countries included ethical considerations in their NVPs, and global inequities in vaccine access and distribution led to varied protections for vulnerable populations across LAC. This analysis highlights the need for improved emergency-response capacity, planning, and enhanced multilateral cooperation in the LAC region for future public health emergencies.

Public health priorities for the Gulf states.

The newly established Gulf Center for Disease Prevention and Control (Gulf CDC) has to identify priorities to tackle in the first 2 years of operation. A rapid situational assessment involving a selected sample of national stakeholders, an objective study of the strengths and gaps in the national public health programmes and a study estimating the burden of the main disease/risk factors were carried out. The findings of an objective ranking survey, followed by consensus discussion in an in-person meeting for senior Gulf states' experts, were combined with the evidence available from the previous three studies to result in a short list of the most pressing priority topics for the Gulf CDC to tackle. Both communicable (lead priorities: antimicrobial resistance and immunisation) and non-communicable diseases (leads: cardiovascular disease, then cancer, diabetes, and mental health) are the consensus priorities. Also, the risks associated with non-communicable diseases (high BMI, blood sugar, high blood pressure) and unhealthy lifestyle (poor diet, low physical activity and tobacco use) were also highlighted as top priorities to tackle.

Global health impact, priority and time.

This paper addresses normative issues that arise in relation to indicators and measures of health impact. With inspiration from Nicole Hassoun's recent proposal, the paper argues and illustrates that those interested in measuring global health impact face questions about how to prioritize among those with ill-health, how to weigh benefits to those who cannot lead minimally good lives against benefits to the better off, and how to think about whether someone is badly off.

COVID-19-related global health governance and population health priorities for health equity in G20 countries: a scoping review.

Since the declaration of the COVID-19 pandemic, the promotion of health equity including the health of various population sub-groups has been compromised, human rights jeopardised, and social inequities further exacerbated. Citizens worldwide, including in the Group of 20 (G20) countries, were affected by both global health governance (GHG) processes and decisions and public health measures taken by governments to respond to COVID-19. While it is critical to swiftly respond to COVID-19, little is known about how and to what extent the GHG is affecting population health priorities for health equity in global economies such as the G20 countries. This scoping review synthesised and identified knowledge gaps on how the COVID-19-related GHG is affecting population health priorities for policy, programme, and research in G20 countries. We followed the five-stage scoping review methodology promoted by Arksey and O'Malley and the PRISMA Extension for Scoping Reviews guidelines. We searched four bibliographic databases for references conducted in G20 countries and regions and published in English and French, between January 2020 and April 2023. Out of 4,625 references and after two phases of screening, 14 studies met the inclusion criteria. G20 countries included in the review were Australia, Brazil, Canada, China, France, India, Italy, Japan, Russia, South Africa, the United Kingdom, the United States of America, and the European Union. We found insufficient collaboration and coordination and misalignment among governance actors at multiple levels. In most cases, equity considerations were not prioritised while unequal consequences of COVID-19 public health measures on population groups were widely reported. COVID-19-related population health priorities mainly focused on upstream and midstream determinants of health. Our scoping review showed the stark inequities of COVID-19 public health outcomes, coupled with a prevalent lack of coherent collaboration and coordination among governance actors. Moreover, governance as an object of empirical study is still emerging when examining its intersection with global health and population health policy, programme, and research. An urgent shift is required to effectively act upon structural health determinants that include transformative and comprehensive policies for prevention, equity, resilience, and sustainable health.

Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework.

BACKGROUND: There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries. METHODS: We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework. RESULTS: The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility. CONCLUSIONS: This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

How health care professionals handle limited resources in primary care - an interview study.

INTRODUCTION: Health care systems around the world are struggling with limited resources, in relation to the prevailing health care need. An accessible primary care is an important part of the solution for how to provide affordable care for the population and reduce pressure on the overall health care system such as unnecessary hospital stays and associated costs. As primary care constitutes an important first line of healthcare, the task of prioritising and deciding what to do and for whom lies in practice, primarily with the primary care professionals. Thus, the decisions and behaviour of primary care professionals have a central role in achieving good and equal health in the population. The aim of this study is to explore how primary health care professionals handle situations with limited resources and enhance our knowledge of priorities in practice.  METHODS: Semi-structured interviews with 14 health care professionals (7 nurses, 7 physicians) working in Swedish primary care were interviewed. Data were analysed inductively with content analysis. FINDINGS: Three main categories were found: Influx of patients; Structural conditions; and Actions. Each category illustrates an important aspect for what primary care professionals do to achieve good and equal care. The influx of patients concerned what the professionals handled in terms of patients' healthcare needs and patient behaviour. Structural conditions consisted of policies and goals set for primary care, competence availability, technical systems, and organisational culture. To handle situations due to limited resources, professionals performed different actions: matching health care needs with professionals' competency, defining care needs to suit booking systems appointments, giving care at the inappropriate health care level, rearranging workhours, and passing on the decision making. CONCLUSION: Priorities in primary care are not, "one fits all" solution. Our study shows that priorities in primary care comprise of ongoing daily processes that are adapted to the situation, context of patient influx, and structural conditions. Healthcare professional's actions for how influx of patients' is handled in relation to limited resources, are created, and shaped within this context which also sets the boundaries for their actions.

Underlying motivations hampering Flemish primary care physicians from overcoming the barriers in osteoporosis care: an EMR-facilitated clinical reasoning study.

BACKGROUND: Over half of the European population aged minimum 65 years presents with at least two chronic diseases. Attention towards these diseases exhibits disparities, with limited primary care physician (PCP) attention for osteoporosis. This was confirmed in a previous integrated osteoporosis care (IOC) project in which notable difficulties to enlist PCPs arose. Consequently, this study was initiated in Flemish PCPs for in-depth analysis of underlying mechanisms hampering PCPs to fully commit to osteoporosis care. METHODS: A qualitative Electronic Medical Record (EMR)-facilitated clinical reasoning study was conducted. A semi-structured interview guide was employed to guide PCPs from reflections on their own patients to broader views regarding osteoporosis care. An inductive thematic analysis was performed using NVivo 12. RESULTS: Thirteen PCPs were interviewed. They stated that osteoporosis patients often had complex (medical) profiles. PCPs emphasised the ongoing necessity for prioritisation within this context. This leads to a competition for PCP attention during consultations at three levels: i. between acute versus preventive care; ii. between primary fracture prevention and other preventive services and iii. between secondary fracture prevention and other preventive services; spanning eight areas of competition: disease significance, perceived impact, PCP awareness, the patient agenda, PCP competence, PCP support, perceived patient burden, and efficiency of care provision. Applicability of these areas of competition differed between levels. CONCLUSION: The intricate context in which PCPs operate, creates a competition for PCP attention leading to a lack of attention for fracture prevention. To preserve efforts in fracture prevention, areas of competition should be systematically addressed. TRIAL REGISTRATION: Approval for the study has been provided by the Ghent University Hospital Ethics Committee (BC-09797).

Priority setting to support a public health research agenda: a modified Delphi study with public health stakeholders in Germany.

BACKGROUND: Research priority setting (RPS) studies are necessary to close the significant gap between the scientific evidence produced and the evidence stakeholders need. Their findings can make resource allocation in research more efficient. However, no general framework for conducting an RPS study among public health stakeholders exists. RPS studies in public health are rare and no such study has been previously conducted and published in Germany. Therefore, we aimed to investigate which research topics in public health are prioritised by relevant stakeholders in Germany. METHODS: Our RPS study consisted of a scoping stage and a Delphi stage each split into two rounds. Firstly, we invited members of the German Public Health Association to gather expert insights during two initial workshops. Next, we defined the relevant stakeholder groups and recruited respondents. Thereafter, we collected research topics and assessment criteria with the respondents in the first Delphi round and aggregated the responses through content analysis. Finally, we asked the respondents to rate the research topics with the assessment criteria in the second Delphi round. RESULTS: In total, 94 out of the 140 invited public health organisations nominated 230 respondents for the Delphi study of whom almost 90% participated in both Delphi rounds. We compiled a comprehensive list of 76 research topics that were rated and ranked by several assessment criteria. We split the research topics into two types, substantive research topics and methodological-theoretical research topics respectively, to ensure the comparability among the research topics. In both types of research topics-substantive research topics and methodological-theoretical research topics-the respective top five ranked research topics hardly differed between public health researchers and public health practitioners. However, clear differences exist in the priority ranking of many (non-top priority) research topics between the stakeholder groups. CONCLUSIONS: This research demonstrates that it is possible, with limited resources, to prioritise research topics for public health at the national level involving a wide range of pertinent stakeholders. The results can be used by research funding institutions to initiate calls for research projects with an increased relevance for health and/or scientific progress.

Partnering to implement the Global Initiative for Childhood Cancer in the Americas: prioritizing systems strengthening.

Working with PAHO/WHO to prioritize childhood cancer in the context of systems strengthening is central to St. Jude Children's Research Hospital (SJCRH)'s role as WHO Collaborating Centre for Childhood Cancer. This manuscript focuses on how SJCRH and PAHO/WHO have partnered to apply C5 (Country Collaboration for Childhood Cancer Control) to define and implement priority actions regionally, strengthening Ministry programs for childhood cancer, while implementing the Global Initiative for Childhood Cancer since 2018. Using C5, a tool developed by SJCRH, PAHO/WHO and SJCRH co-hosted regional/national workshops engaging authorities, clinicians and other stakeholders across 10 countries to map health systems needs and prioritize strategic activities (spanning Central America, Dominican Republic, Haiti, Brazil and Uruguay). SJCRH provided English/Spanish/Portuguese C5 versions/templates for analysis/prioritization exercises, and worked with PAHO/WHO and country teams to implement C5, analyze findings, and develop outputs. In an eight-country regional workshop, countries defined priorities within national/regional initiatives and ranked their value and political will, incorporating country-specific surveys and stakeholder dialogues. Each country prioritized one strategic activity for 2022-2023, exchanged insights via storytelling, and disseminated and applied results to inform country-specific and regional action plans. National workshops analyses have been incorporated into cancer control planning activities and collaborative work regionally. Implementation success factors include engaging actors beyond the clinic, enabling flexibility, and focusing on co-design with stakeholders. Joint implementation of C5 catalyzed prioritization and accelerated strategic activities to improve policies, capacity, and quality of care for children in the Americas, supporting Ministries to integrate childhood cancer interventions as part of systems strengthening.

La colaboración con la OPS/OMS para priorizar el cáncer infantil en el contexto del fortalecimiento de los sistemas es fundamental para la labor del St. Jude Children's Research Hospital (SJCRH) como centro colaborador de la OMS contra el cáncer infantil. Este artículo se centra en la alianza entre el SJCRH y la OPS/OMS en la aplicación de la herramienta C5 (colaboración nacional para el control del cáncer infantil) para definir y ejecutar medidas prioritarias a nivel regional, fortalecer los programas contra el cáncer infantil del ministerio y poner en marcha la Iniciativa Mundial contra el Cáncer Infantil desde el 2018. Con C5, una herramienta elaborada por el SJCRH, la OPS/OMS y este hospital organizaron conjuntamente talleres regionales y nacionales con autoridades, personal médico y otras partes interesadas en diez países para determinar cuáles son las necesidades de los sistemas de salud y priorizar las actividades estratégicas (en América Central, República Dominicana, Haití, Brasil y Uruguay). El SJCRH proporcionó versiones y plantillas de C5 en inglés, español y portugués para actividades de análisis y priorización y trabajó con la OPS/OMS y los equipos de país para ejecutar la herramienta C5, analizar los resultados y elaborar productos. En un taller regional de ocho países, se definieron las prioridades en las iniciativas regionales y nacionales, se clasificó su valor y la voluntad política y se incorporaron encuestas específicas para cada país y diálogos con las partes interesadas. Cada país priorizó una actividad estratégica para el período 2022-2023, intercambió ideas por medio de narrativas, y difundió y aplicó los resultados para fundamentar planes de acción tanto regionales como específicos para el país. Los análisis de los talleres nacionales se han incorporado a las actividades de planificación del control del cáncer y al trabajo colaborativo a nivel regional. Entre los factores de éxito de la ejecución se encuentra involucrar a los agentes más allá de lo clínico, permitir que haya flexibilidad y centrarse en un diseño elaborado en colaboración con las partes interesadas. La ejecución conjunta de la herramienta C5 catalizó la priorización y aceleró las actividades estratégicas para mejorar las políticas, la capacidad y la calidad de la atención infantil en la Región de las Américas y brindó apoyo a los ministerios para integrar las intervenciones contra el cáncer infantil en el fortalecimiento de los sistemas.

A colaboração com a OPAS/OMS para priorizar o câncer infantil no contexto do fortalecimento dos sistemas é fundamental para o papel do St. Jude Children's Research Hospital (SJCRH) como Centro Colaborador da OMS para o Câncer Infantil. Este artigo mostra como o SJCRH e a OPAS/OMS se associaram para aplicar a ferramenta C5 (Colaboração Nacional para Controle do Câncer Infantil), com o propósito de definir e implementar ações prioritárias regionalmente, fortalecendo programas ministeriais para o câncer na infância, durante a implementação da Iniciativa Global para o Câncer Infantil desde 2018. Com auxílio da C5, uma ferramenta desenvolvida pelo SJCRH, a OPAS/OMS e o SJCRH organizaram conjuntamente oficinas regionais/nacionais com a participação de autoridades, profissionais de saúde e outras partes interessadas em 10 países, com a finalidade de mapear as necessidades dos sistemas de saúde e priorizar atividades estratégicas (abrangendo América Central, República Dominicana, Haiti, Brasil e Uruguai). O SJCRH forneceu versões/modelos da C5 em inglês, espanhol e português para exercícios de análise/priorização e colaborou com a OPAS/OMS e as equipes dos países para implementar a C5, analisar resultados e desenvolver produtos. Em uma oficina regional com oito países, foram definidas as prioridades das iniciativas nacionais/regionais e classificados seu valor e vontade política, incorporando levantamentos nacionais e diálogos entre as partes interessadas. Cada país priorizou uma atividade estratégica para 2022-2023, trocou conhecimentos por meio da narração de histórias e disseminou e aplicou os resultados para informar planos de ação nacionais e regionais. As análises das oficinas nacionais foram incorporadas às atividades de planejamento para controle do câncer e ao trabalho conjunto no âmbito regional. Entre os fatores de êxito da implementação estão o engajamento de agentes de fora do segmento da saúde, a oferta de flexibilidade e a ênfase no planejamento conjunto com as partes interessadas. A implementação conjunta da C5 catalisou a priorização e acelerou atividades estratégicas para aprimorar as políticas, a capacidade e a qualidade da atenção às crianças nas Américas, apoiando os ministérios na integração das intervenções contra o câncer infantil como parte do fortalecimento dos sistemas.

Crafting Community-Based Participatory Research Stroke Interventions.

Stroke exerts a tremendous burden on individuals, families, communities, and health systems globally. Even more troublesome are the striking disparities faced across diverse populations. These disparities are further exacerbated by the COVID-19 pandemic. Despite efforts to advance stroke research, substantial gaps remain in understanding factors that contribute to stroke disparities, including the Social Determinants of Health. Strategically designed studies and tailored interventions are needed to bridge the inequities high-risk populations face and to meet their specific needs. Community-based participatory research offers an approach to equitably partner with community members to understand and work collaboratively to address community-specific health priorities. In this focused update, we highlight the main processes of community-based participatory research studies and share exemplars from our team's work in stroke research and from the literature. As we continue to face an increasing prevalence of stroke, compounded by the COVID-19 pandemic and ongoing implications of the Social Determinants of Health, partnering with communities to address community-driven health priorities can inform interventions targeted to overcome the disparities faced by certain populations.

International perspectives on the development, application, and evaluation of a multicancer early detection strategy.

The development and implementation of a multicancer early detection (MCED) test that is effective and affordable has the potential to change cancer care systems around the world. However, careful consideration is needed within the context of different health care settings (both low- and middle-income countries and high-income countries) to roll out an MCED test and promote equity in access.

My Goals Are Not Their Goals: Barriers and Facilitators to Delivery of Patient-Centered Care for Patients with Multimorbidity.

BACKGROUND: Patient-centered care reflecting patient preferences and needs is integral to high-quality care. Individualized care is important for psychosocially complex or high-risk patients with multiple chronic conditions (i.e., multimorbidity), given greater potential risks of interventions and reduced benefits. These patients are increasingly prevalent in primary care. Few studies have examined provision of patient-centered care from the clinician perspective, particularly from primary care physicians serving in integrated, patient-centered medical home settings within the US Veterans Health Administration. OBJECTIVE: We sought to clarify facilitators and barriers perceived by primary care physicians in the Veterans Health Administration to delivering patient-centered care for high-risk or complex patients with multimorbidity. DESIGN: We conducted semi-structured telephone interviews from April to July 2020 among physicians across 20 clinical sites. Findings were analyzed with deductive content analysis based on conceptual models of patient-centeredness and hierarchical factors affecting care delivery. PARTICIPANTS: Of 23 physicians interviewed, most were female (n = 14/23, 61%), serving in hospital-affiliated outpatient clinics (n = 14/23, 61%). Participants had a mean of 21 (SD = 11.3) years of experience. KEY RESULTS: Facilitators included the following: effective physician-patient communication to individualize care, prioritize among multiple needs, and elicit goals to improve patient engagement; access to care, enabled by interdisciplinary teams, and dictating personalized care planning; effortful but worthwhile care coordination and continuity; meeting complex needs through effective teamwork; and integrating medical and non-medical care aspects in recognition of patients' psychosocial contexts. Barriers included the following: intra- and interpersonal (e.g., perceived patient reluctance to engage in care); organizational (e.g., limited encounter time); and community or policy impediments (e.g., state decisional capacity laws) to patient-centered care. CONCLUSIONS: Physicians perceived individual physician-patient interactions were the greatest facilitators or barriers to patient-centered care. Efforts to increase primary care patient-centeredness for complex or high-risk patients with multimorbidity could focus on targeting physician-patient communication and reducing interpersonal conflict.

Framing the detection of incipient tuberculosis infection: A qualitative study of political prioritisation.

OBJECTIVE: Incipient Tuberculosis (ITB) refers to Mycobacterium tuberculosis infection that is likely to progress to active disease in the absence of treatment, but without clinical signs, symptoms, radiographic or microbiological evidence of disease. Biomarker-based tests to diagnose incipient TB hold promise for better prediction and, through TB preventive therapy, prevention of disease. This study explored current and future framing and prioritisation of ITB. METHODS: Twenty-two interviews across eight countries were conducted. A modified Shiffman & Smith Framework, containing four categories-Ideas, Issue Characteristics, Actor Power, and Political Contexts-was used to analyse the current landscape and potential for prioritisation of diagnosis and treatment of ITB. RESULTS: Latent TB policy implementation has been slow due to technical, logistical and financial challenges, and because it has been framed in a manner non-conducive to gaining political priority. Framing ITB testing as 'early detection' rather than 'prediction', and its management as 'treatment' rather than 'preventive therapy', may help raise its importance in policies, and its acceptance among actors. CONCLUSION: Consensus surrounding the framing of ITB will be crucial for the successful adoption of ITB diagnostics and treatment. When designing ITB tools and policies, it will be important to address challenges that pertain to latent TB policies.

The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage.

BACKGROUND: Patients referred to specialised mental health care are usually triaged based on referral information provided by general practitioners. However, knowledge about this system's ability to ensure timely access to and equity in specialised mental health care is limited. We aimed to investigate to the degree to which patient triage, based on referral letter information, corresponds to triage based on a hospital specialist's consultation with the patient, and whether the degree of correspondence is affected by the quality of the referral letter. METHODS: We gathered information from three specialised mental health centres in Norway regarding patients that were referred and offered health care (N = 264). Data consisted of triage decisions for each patient (i.e., the hospital specialist's assessment of maximum acceptable waiting time), which were determined on the basis of a) referral information and b) meeting the patient. Referral letter quality was evaluated using the Quality of Referral information-Mental Health checklist. The reliability of priority setting and the impact of referral letter quality on this measure were investigated using descriptive analyses, binary logistic regression and Nadaraya-Watson kernel regression. RESULTS: In 143 (54%) cases, the triage decision based on referral information corresponded with the decision based on patient consultation. In 70 (27%) cases, the urgency of need for treatment was underestimated when based on referral information compared with that based on information from patient consultation. Referral letter quality could not explain the differences between the two triage decisions. However, when a cut-off value of 7 on the Quality of Referral information-Mental Health scale was used, low-quality letters were found more frequently among patients whose urgency of need was underestimated, compared with those whose need was overestimated. CONCLUSIONS: Deciding the urgency of patient need for specialised mental health care based on referral information is a reliable system in many situations. However, the possibility of under- and overestimation is present, implying risks to patient safety and inappropriate use of resources. Improving the content of referral letters does not appear to reduce this risk when the letters are of acceptable quality. TRIAL REGISTRATION: NCT01374035 .

On the person in personal health responsibility.

In this paper, we start by comparing the two agents, Ann and Bob, who are involved in two car crashes. Whereas Ann crashes her car through no fault of her own, Bob crashes as a result of reckless driving. Unlike Ann, Bob is held criminally responsible, and the insurance company refuses to cover the car's damages. Nonetheless, Ann and Bob both receive emergency hospital treatment that a third party covers, regardless of any assessment of personal responsibility. What warrants such apparent exceptionalism with respect to personal responsibility in the healthcare context? We turn our attention to an understudied aspect of the debate on personal health responsibility, namely, the conceptualisation of the person in need of emergency hospital treatment. Drawing on the research of Joshua Knobe and Shaun Nichols, we propose that a context-dependent conceptualisation of the person may help explain a reluctance to ascribe responsibility to the individual for negative health outcomes.

Regulatory reliance pathways during health emergencies: enabling timely authorizations for COVID-19 vaccines in Latin America.

Objectives: To map the timing and nature of regulatory reliance pathways used to authorize COVID-19 vaccines in Latin America. Methods: An observational study was conducted assessing the characteristics of all COVID-19 vaccine authorizations in Latin America. For every authorization it was determined whether reliance was used in the authorization process. Subgroups of reference national regulatory authorities (NRAs) and non-reference NRAs were compared. Results: 56 authorizations of 10 different COVID-19 vaccines were identified in 18 countries, of which 25 (44.6%) used reliance and 12 (21.4%) did not. For the remaining 19 (33.0%) it was not possible to determine whether reliance was used. Reference agencies used reliance less often (40% of authorizations with a known pathway) compared to non-reference agencies (100%). The median review time was just 15 days and does not meaningfully differ between reliance and non-reliance authorizations. Conclusions: This study demonstrated that for these vaccines, despite reliance pathways being associated with numerous rapid authorizations, independent authorization review times were not considerably longer than reliance reviews; reliance pathways were not a prerequisite for rapid authorization. Nevertheless, reliance pathways provided rapid authorizations in response to the COVID-19 emergency.