"Empathy for children is often missing": a mixed methods analysis of a German forum on COVID-19 pandemic measures.

BACKGROUND: The pandemic and its preventive measures disrupted daily routines and posed unforeseen obstacles for families. Users of public online forums chronicled these challenges by freely expressing their sentiments in unrestricted text-length formats. We explored a German COVID-19 forum to understand family perspectives and experiences of pandemic measures, particularly in terms of testing and vaccinating children. Our findings aim to inform future epidemic health policies. METHODS: We retrieved all 11,207 entries from a COVID-19 forum during its lifespan (June 2020 - December 2021), posted during the height of the pandemic. We classified the entries into topic clusters including general pandemic situation, testing, or vaccination using state-of-the-art text embeddings and clustering algorithms. The clusters were selected based on the research's aims and analysed qualitatively using a health policy triangle framework. RESULTS: Users generally appreciated pandemic public health safety measures for everyone's protection, yet voiced concerns about inconsistent policies and disproportional disadvantages for children compared to other societal groups, like the elderly. Non-compliers were overwhelmingly regarded with skepticism and critiqued. Users found COVID-19 (exit) strategies and information about the benefits of vaccination unclear. This created hurdles for parents and caregivers in navigating their children's school and social life. Users endorsed vaccinating children mainly for "normalising" children's lives rather than for their physical health benefits. Some users suggested prioritising teachers and early childhood educators on the vaccination eligibility list to speed up a return to "normality". CONCLUSIONS: During pandemics, governments should prioritize addressing the societal and mental health needs of children by implementing participatory and family-oriented public health measures for schools and kindergartens. Clear communication coupled with consistent design and implementation of safety measures and regulations, would be crucial for building trust in the general population and for ensuring compliance regarding testing and vaccination. Communicating the benefits and risks of vaccinating children is of paramount importance  for informed decision-making among parents. In future epidemics, computer-aided analysis of large online qualitative data would offer valuable insights into public sentiments and concerns, enabling proactive and adaptive epidemic responses.

Taking emic and etic to the family level: interlinking parents' and children's COVID-19 views and experiences in Germany.

BACKGROUND: COVID-19 impacted families globally, restricting movement, and changing daily routines and family dynamics. In order to explore and contrast children's and parents' experiences and perceptions of life during COVID-19, we used Pike's distinction of emic (an insider's view) and etic (an outsider's view) and adapted the concept to the family level to differentiate between children's and parents' own perspectives (emic) and their view of other family members (etic). METHODS: Our qualitative study is based on face-to-face in-depth individual interviews with parents (n = 13) and their children (n = 16) and included migrant families as a hitherto underrepresented group in COVID-19 research in Germany. Interviews were recorded, transcribed in NVivo and quality-checked. We employed thematic analysis to explore similarities and differences in perceptions and experiences of children and parents at the family level and across the entire data set. RESULTS: We identified the following major themes in parents' and children's experiences: managing role and relationship changes within the nuclear family, coping with social expectations and demands, and re-evaluations of life's priorities. Parents' etic views on children showed strong overlap with children's emic view in terms of physical movement restrictions, experiencing good and tense family times, and internalizing rules. For issues such as experiencing stigma, divorce or language acquisition, parents' views were not reflected in children's accounts. Children's testing experience, by contrast, was more nuanced than parents' perceptions of it. Children's etic views of parents, a perspective rarely found in qualitative research with children, overlapped with mothers' experiences of role strain. CONCLUSIONS: The consideration of parents' and children's emic and etic perspectives provided deeper insights into family members' experiences, navigation, and views of COVID-19 measures. Applying the emic/etic distinction to the family context enriches the sociology of childhood studies and enables a more nuanced understanding of diverging experiences within families and should thus be further explored within and beyond epidemics in order to guide future pandemic measures.

"The targets are driving the agenda and that probably needs to change": stakeholder perspectives on HIV partner notification in sub-Saharan Africa.

BACKGROUND: Voluntary assisted partner notification (VAPN) in HIV contact tracing is a globally recommended strategy to identify persons who have been exposed to HIV and link them to HIV testing and follow-up. However, there is little understanding about how VAPN is experienced by stakeholders in sub-Saharan African (SSA) contexts. We conducted a multi-level and multi-national qualitative analysis evaluating stakeholder perspectives surrounding VAPN implementation to inform the development of future VAPN policies. METHOD: We conducted in-depth interviews (IDIs) with VAPN stakeholders at global (n = 5), national (n = 6), and community level (n = 4) across a total of seven SSA countries. Eligible participants were ≥ 18 years old and had experience developing, implementing, or overseeing VAPN policies in SSA. We sought to understand stakeholder's perspectives on policy development, implementation, and perceived outcomes (barriers and facilitators). Interviews were audio recorded, transcribed, and analyzed thematically using a combination of inductive and deductive approaches. RESULTS: Between December 2019 and October 2020 we conducted 15 IDIs. While participants agreed that VAPN resulted in a high yield of people newly diagnosed with HIV; they noted numerous barriers surrounding VAPN implementation across global, national, and community levels, the majority of which were identified at community level. Barriers at global and national level included high target setting, contradictory laws, and limited independent research disenfranchising the experiences of implementing partners. The barriers identified at community level included client-level challenges (e.g., access to healthcare facilities and fear of adverse events); healthcare worker challenges (e.g., high workloads); limited data infrastructure; and cultural/gender norms that hindered women from engaging in HIV testing and VAPN services. In response to these barriers, participants shared implementation facilitators to sustain ethical implementation of VAPN services (e.g., contact tracing methods) and increase its yield (e.g., HIV self-testing integrated with VAPN services). CONCLUSION: Overall, stakeholders perceived VAPN implementation to encounter barriers across all implementation levels (global to community). Future VAPN policies should be designed around the barriers and facilitators identified by SSA stakeholders to maximize the implementation of (ethical) HIV VAPN services and increase its impact in sub-Saharan African settings.

"Deadly", "fierce", "shameful": notions of antiretroviral therapy, stigma and masculinities intersecting men's life-course in Blantyre, Malawi.

BACKGROUND: Stigma and masculinity represent persistent barriers in delivering successful HIV interventions to men. Our study examined community perceptions of HIV and anti-retroviral therapy (ART) and their implications for men on ART across the life course in Blantyre, Malawi. METHODS: Our qualitative study is based on 72 face-to-face semi-structured interviews. Participants were selected purposively and included men on ART (with suppressed and unsuppressed viral loads), adult male community members irrespective of HIV status and other HIV stakeholders such as health personnel and program implementers. Interviews were conducted in Chichewa and English, transcribed verbatim and analyzed thematically in NVivo 12. We applied the socio-ecological model as our theoretical framework as well as a "life-course" perspective. RESULTS: Our findings highlight lingering negative perceptions towards ART in general and towards PLHIV irrespective of viral load suppression. With intersecting notions of masculinity and stigma, men's descriptions of anticipated stigma in their relationships and when visiting health facilities dominated. Stigma was experienced at the personal, interpersonal, facility and community level. Yet, men living with HIV were perceived differently throughout the life-course, with young sexually active men seen as the most stigmatized group and older men seen as drawing resilience from a greater range of masculine norms. Some men of all ages displayed "transformative" masculinities independent of stigma and community expectations. CONCLUSIONS: We propose the "life-course" as a useful concept for studies on masculinity, HIV and stigma. Considering gendered constructions of "respectable" midlife-older age vis-à-vis younger age, and how they influence stigma as well as uptake and adherence to ART might lead to more targeted services for men that build on "transformative masculinities".

From Doxastic to Epistemic: A Typology and Critique of Qualitative Interview Styles.

Qualitative interview styles have been guided by precedent within academic disciplines. The nature of information sought, and the role of interviewer and interviewee are key determinants across styles, which range from doxastic (focused on understanding interviewees' experiences or behaviors) to epistemic (focused on co-constructing knowledge). In this article, we position common interview styles along a doxastic-epistemic continuum, and according to the role of the interviewee (from respondent to equal partner). Through our typology and critique of interview styles, we enhance epistemic interviewing by introducing "deliberative interviews," which are more debate oriented and closer to equality in the interviewee and interviewer relationship than existing interview styles. Deliberative interviews require a comprehensive, pre-interview briefing on the subject matter followed by interactive deliberation wherein complex issues are debated across viewpoints in an effort to devise solutions. The effectiveness of this interview style in generating new knowledge warrants empirical testing across academic disciplines.

'You Can Get That Person on ART but You Can't Give Them Back Their Social System': A Qualitative Analysis of Voluntary Assisted Partner Notification for HIV for Marginalised and Vulnerable Populations.

Little is known about Voluntary Assisted Partner Notification (VAPN) in groups in sub-Saharan Africa that experience marginalisation, and whether its use is suitable for referral to HIV care pathways. We conducted semi-structured in-depth interviews with purposively selected medical and health professionals (N = 15) regarding their perspectives and experiences with VAPN policy and its implementation. Data were analysed following a Reflexive Thematic Analysis approach. Respondents highlighted the flexibility in VAPN policy implementation and described adjustments made by health workers. Women were seen as vulnerable and lacked access to support against gender-based violence. Men who have sex with men could face exclusion from important social networks. Age-appropriate VAPN assistance was also considered unavailable for sexually active children. Embedding understandings of identity, belonging, and safety into VAPN could address individual priorities and needs. Community support networks, tailored care for children, and family-orientated approaches to HIV notification may overcome issues relating to vulnerability and marginalisation.

A qualitative analysis of voluntary assisted partner notificationLittle is known about Voluntary Assisted Partner Notification (VAPN) in groups in sub-Saharan Africa that experience marginalisation. We conducted semi-structured in-depth interviews with purposively selected medical and health professionals (N = 15) regarding their perspectives and experiences with VAPN policy and implementation. Data were analysed following a Reflexive Thematic Analysis approach. Respondents highlighted flexibility in VAPN policy implementation and described adjustments made by health workers. Women were seen as vulnerable and lacked access to support against gender-based violence. Men who have sex with men could face exclusion from important social networks. Age-appropriate VAPN assistance was also considered unavailable for sexually active children. Embedding understandings of identity, belonging, and safety into VAPN could address individual priorities and needs. Community support networks, tailored care for children, and family-orientated approaches to HIV notification may overcome issues relating to vulnerability and marginalisation.

"We have been so patient because we know where we are coming from" Exploring the acceptability and feasibility of a mobile electronic medical record system designed for community-based antiretroviral therapy in Lilongwe, Malawi.

Background: Mobile health (mHealth) is reshaping healthcare delivery, especially in HIV management. The World Health Organization advocates for mHealth to provide healthcare workers (HCWs) with real-time data, enhancing patient care. However, in Malawi's Lighthouse Trust antiretroviral therapy (ART) clinic, the nurse-led community-based ART (NCAP) program faces hurdles with data management due to lack of access to electronic medical records systems (EMRS) in the community setting. EMRS is not typically available in differentiated service delivery settings where reliable power and internet are often unavailable. We used human-centered design (HCD) processes to create a mobile EMRS prototype, the Community-based ART Retention and Suppression (CARES) app. We explore progress to simplify workflow for HCWs and improve client care. Methods: To evaluate the CARES app's feasibility and acceptability among NCAP HCWs, we conducted in-depth interviews among 15 NCAP HCWs. We used a rapid qualitative analysis approach guided by the extended Technology Acceptance Model. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results: As a likely result of HCD, HCWs demonstrated high expectations for the CARES app to improve healthcare delivery and data management. However, challenges such as app performance, data integration, and system navigation were significant barriers to acceptance or feasibility. Despite challenges, HCWs remained optimistic about the potential for CARES to enhance NCAP clinical decision-making and data flow. HCWs emphasized the need for continuous training and stakeholder engagement, improved infrastructure, data security protections, and establishing the CARES app and EMRS integration to facilitate CARES' longterm success at scale. Conclusion: The study's findings underscore the importance of HCD for mHealth buy-in. As HCWs were invested in CARES success, they remained optimistic that the app could enhance NCAP services if user experience and app performance improved. Incorporation of HCW feedback would help deliver beyond the promise of CARES.

"I couldn't see my friends; the internet was bad, and I hardly went out" - insights into children's and adolescents' experiences of COVID-19 in Germany.

PURPOSE: We explored children's experiences of COVID-19 in terms of proximity and distance to significant others. METHODS: Our qualitative study with children in Germany (6-15 years of age) explored their views and experiences of COVID-19 times via drawings and face-to-face semi-structured interviews (n = 13). We analysed data thematically and used the socio-ecological model as the theoretical underpinning. Case studies contextualized how children dealt with the COVID-19 precautions. RESULTS: Salient motives in children's drawings were school scenarios showing distance-keeping and mask-wearing as an expression of interpersonal distance; in the home-schooling context, loneliness was highlighted. Drawings also illustrated the impact of COVID-19 in terms of separation, illness and death. A dynamic perception of proximity and distance emerged from drawings and interviews. COVID-19 barred children from spending "real" time together with close friends. Bridging physical distance virtually was easier for adolescents than for children. CONCLUSION: To bolster children's mental and social resilience in future epidemics, participants' plea for maintaining social and physical interactions with significant others and for keeping schools open should be heeded by policy-makers. Our study also highlights the benefits of conducting direct research with children and using non-verbal methods of data collection.

Cultural Repertoires and Situated Selections as an Alternative Framework to Hegemonic Masculinities: Findings From Eswatini.

Since the 1980s studies on men have frequently utilized Connell's framework of hegemonic masculinities. We critically appraise this framework in the context of a population-based HIV pre-exposure prophylaxis study in Eswatini. Our findings highlight that men confidently show variation in their behavior and choices, which manifest across different men and within the same men acting in particular situations and over the life course. This led us to interrogate the hegemonic masculinities framework on the following grounds: Men's choices and behavior do not seem to fit the model of aspiring to a hegemonic ideal; the delineation of masculine traits as hegemonic or subordinate remain vague in terms of "responsibility," "fidelity," and "consideration for others"; the binary gender concept underpinning hegemonic masculinities seems outdated. Building on the work of Hirsch and Kachtan, we propose cultural repertoires as an alternative framework which also bridges the gender divide.

Exploring computer-aided health decision-making on cervical cancer interventions through deliberative interviews in Ethiopia.

Cervical cancer is a significant disease burden in Ethiopia. Mathematical models and computer simulations on disease dynamics can support effective resource allocation. The objectives of this work are (i) to explore the perspectives of health decision-makers on computer-aided predictions supporting cervical cancer interventions, (ii) to identify their information needs from these predictions, and (iii) their willingness to apply the results in their work. We conducted deliberative interviews with 15 health decision-makers and advisors in Ethiopia in autumn 2019. We analyze the data using a five steps framework approach drawing on thematic analysis and find that Ethiopian health decision-makers are willing to use computer-aided predictions in their decisions. Data on HPV prevalence and the cervical cancer burden are scarce but valued highly and decision-makers are particularly interested in the identification of local HPV hotspots. Data-driven mathematical models and computer simulations may increasingly influence health decision-making in Ethiopia.

Commercial Influence on Political Declarations: The Crucial Distinction Between Consultation and Negotiation and the Need for Transparency in Lobbying Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases".

Suzuki and colleagues' rare and elaborate analysis of the political processes behind the 2018 United Nations (UN) non-communicable diseases (NCD) Declaration discloses various pathways towards influencing global public health policies. Their study should be a wake-up call for further scientific political scrutiny and analysis, including clearly distinguishing between consultations such as UN multi-stakeholder hearings preceding high-level meetings and the actual negotiating and decision making process. While stakeholder positions at interactive hearings are documented and published and thus made transparent, the negotiating process among member states is not publicly known. The extent to which intergovernmental negotiations are influenced at country or regional levels by commercial interests through direct and indirect lobbying outside of public consultations should be given more attention. Lobby registers should be implemented more stringently and legislative footprints required and applied not only to legally binding but also to internationally important documents such as political declarations.

Real-life Evaluation of an Interactive Versus Noninteractive e-Learning Module on Chronic Obstructive Pulmonary Disease for Medical Licentiate Students in Zambia: Web-Based, Mixed Methods Randomized Controlled Trial.

BACKGROUND: e-Learning for health professionals in many low- and middle-income countries (LMICs) is still in its infancy, but with the advent of COVID-19, a significant expansion of digital learning has occurred. Asynchronous e-learning can be grouped into interactive (user-influenceable content) and noninteractive (static material) e-learning. Studies conducted in high-income countries suggest that interactive e-learning is more effective than noninteractive e-learning in increasing learner satisfaction and knowledge; however, there is a gap in our understanding of whether this also holds true in LMICs. OBJECTIVE: This study aims to validate the hypothesis above in a resource-constrained and real-life setting to understand e-learning quality and delivery by comparing interactive and noninteractive e-learning user satisfaction, usability, and knowledge gain in a new medical university in Zambia. METHODS: We conducted a web-based, mixed methods randomized controlled trial at the Levy Mwanawasa Medical University (LMMU) in Lusaka, Zambia, between April and July 2021. We recruited medical licentiate students (second, third, and fourth study years) via email. Participants were randomized to undergo asynchronous e-learning with an interactive or noninteractive module for chronic obstructive pulmonary disease and informally blinded to their group allocation. The interactive module included interactive interfaces, quizzes, and a virtual patient, whereas the noninteractive module consisted of PowerPoint slides. Both modules covered the same content scope. The primary outcome was learner satisfaction. The secondary outcomes were usability, short- and long-term knowledge gain, and barriers to e-learning. The mixed methods study followed an explanatory sequential design in which rating conferences delivered further insights into quantitative findings, which were evaluated through web-based questionnaires. RESULTS: Initially, 94 participants were enrolled in the study, of whom 41 (44%; 18 intervention participants and 23 control participants) remained in the study and were analyzed. There were no significant differences in satisfaction (intervention: median 33.5, first quartile 31.3, second quartile 35; control: median 33, first quartile 30, second quartile 37.5; P=.66), usability, or knowledge gain between the intervention and control groups. Challenges in accessing both e-learning modules led to many dropouts. Qualitative data suggested that the content of the interactive module was more challenging to access because of technical difficulties and individual factors (eg, limited experience with interactive e-learning). CONCLUSIONS: We did not observe an increase in user satisfaction with interactive e-learning. However, this finding may not be generalizable to other low-resource settings because the post hoc power was low, and the e-learning system at LMMU has not yet reached its full potential. Consequently, technical and individual barriers to accessing e-learning may have affected the results, mainly because the interactive module was considered more difficult to access and use. Nevertheless, qualitative data showed high motivation and interest in e-learning. Future studies should minimize technical barriers to e-learning to further evaluate interactive e-learning in LMICs.

Consent Requirements for Testing Health Policies: An Intercontinental Comparison of Expert Opinions.

Individual informed consent is a central requirement for clinical research on human subjects, yet whether and how consent requirements should apply to health policy experiments (HPEs) remains unclear. HPEs test and evaluate public health policies prior to implementation. We interviewed 58 health experts in Tanzania, Bangladesh and Germany on informed consent requirements for HPEs. Health experts across all countries favored a strong evidence base, prior information to the affected populations, and individual consent for 'risky' HPEs. Differences pertained to individual risk perception, how and when consent by group representatives should be obtained and whether HPEs could be treated as health policies. The study adds to representative consent options for HPEs, yet shows that more research is needed in this field - particularly in the present Covid-19 pandemic which has highlighted the need for HPEs nationally and globally.

"Thought provoking", "interactive", and "more like a peer talk": Testing the deliberative interview style in Germany.

Proponents of the newly-developed "deliberative interview" argue that examining complex issues requires more dynamic and engaging interview exchanges. Unlike traditional qualitative interviews, deliberative interviewing champions opinion sharing, active debates and similar speaking times by both sides throughout the interview. Drawing on 20 interviews with health experts in Germany, we examined the process and outcome of deliberative versus conventional interviews on the topic of informed consent. The deliberative interview expedited clarity on the issue, led to more nuanced discussion and generated more knowledge overall, but was challenging because it broke the mold for traditional interviewing. Alignment in terms of gender, age, personality and professional background facilitated rapport, regardless of interview style. To manage expectations, we recommend a thorough, perhaps video-based explanation of the deliberative style prior to the interview. Deliberative interviews can bolster knowledge generation for complex issues and can be applied in public health and beyond.

"It's hard for us men to go to the clinic. We naturally have a fear of hospitals." Men's risk perceptions, experiences and program preferences for PrEP: A mixed methods study in Eswatini.

Few studies on HIV Pre-Exposure Prophylaxis (PrEP) have focused on men who have sex with women. We present findings from a mixed-methods study in Eswatini, the country with the highest HIV prevalence in the world (27%). Our findings are based on risk assessments, in-depth interviews and focus-group discussions which describe men's motivations for taking up or declining PrEP. Quantitatively, men self-reported starting PrEP because they had multiple or sero-discordant partners or did not know the partner's HIV-status. Men's self-perception of risk was echoed in the qualitative data, which revealed that the hope of facilitated sexual performance or relations, a preference for pills over condoms and the desire to protect themselves and others also played a role for men to initiate PrEP. Trust and mistrust and being able or unable to speak about PrEP with partner(s) were further considerations for initiating or declining PrEP. Once on PrEP, men's sexual behavior varied in terms of number of partners and condom use. Men viewed daily pill-taking as an obstacle to starting PrEP. Side-effects were a major reason for men to discontinue PrEP. Men also worried that taking anti-retroviral drugs daily might leave them mistaken for a person living with HIV, and viewed clinic-based PrEP education and initiation processes as a further obstacle. Given that men comprise only 29% of all PrEP users in Eswatini, barriers to men's uptake of PrEP will need to be addressed, in terms of more male-friendly services as well as trialing community-based PrEP education and service delivery.

Where is the 'global' in the European Union's Health Research and Innovation Agenda?

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021-2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries.