Access Scheme Research Articles

Interest in Injectable and Oral PrEP for HIV Prevention Among Women and Men Who Inject Drugs.

People who inject drugs (PWID) are at increased risk for human immunodeficiency virus (HIV). Women who inject are a particularly vulnerable group. Preexposure prophylaxis (PrEP) is effective, but access and uptake has been limited. This study evaluated interest and concerns around oral and injectable PrEP among PWID based on gender. This cross-sectional analysis of survey data from 8 sites in the United States (n = 284) assessed attitudes and interest in PrEP. Demographics, HIV risk behaviors, and attitudes toward PrEP were described overall and by self-identified gender (female vs male). Participants completed the PrEP survey between 2019 and 2021. The mean (standard deviation) age was 44.6 (11.4) years, 29% female, and 66% White. Mean self-perceived HIV risk score (0-10) was 2.3 (standard deviation 2.0). Interest in injectable PrEP (49.5%) was significantly higher than interest in daily oral PrEP (20.1%) (P ≤ 0.001). The most cited concerns were medication side effects (53%) and medication interactions (39.2%). Perceived HIV risk and PrEP concerns were not significantly different between genders. There was high interest in injectable PrEP, particularly among females. The top concerns were medication side effects and medication interactions. These results suggest high acceptability of injectable PrEP among PWID. Future research could explore the advantages identified by female participants as well as implementation strategies for access and uptake among this vulnerable population.

Occupational injuries, mental workload and coping strategies among the nursing workforce in the Eastern Region of Ghana: a multi-centre study

BackgroundThe nursing profession plays a crucial role in the quality of healthcare services. While nurses face occupational injury challenges globally, mental workload, which is often overlooked, plays a significant role in these injuries. Understanding nurses’ coping strategies can help develop effective interventions. The study examined the influence of mental workload on occupational injuries and coping strategies among nurses.MethodsA multi-centre cross-sectional study was conducted in selected hospitals in the Eastern Region of Ghana. Using a stratified sampling technique, 317 nursing staff from 6 hospitals participated in the study. A researcher-developed occupational injury questionnaire, NASA Task Load Index and Brief COPE scale were used to measure occupational injury, mental workload and coping strategies among nurses. Descriptive statistics, Pearson moment-product correlations, and regression analysis were used to analyse the data at a statistical significance of 0.05.ResultsNeedle pricks, injuries from sharps, exposure to blood and other body fluids, and back pain and injury from patient handling tasks were shared among participants in the past year. The study also revealed a high level of mental workload among participants. A significant correlation was observed between mental workload and various occupational injuries. The participants adopted different coping strategies in dealing with the mental workload, with active coping and instrumental support being the most used coping strategies.ConclusionThe findings underscore the importance of addressing mental workload in nursing to reduce occupational injuries. To achieve this, nurses must be provided with appropriate coping strategies and support to minimise mental stress.ImplicationProviding accessible and effective coping strategies tailored to nurses’ needs can significantly improve their well-being and job performance. Healthcare administrators and policymakers should consider these results when designing interventions to support the nursing workforce.

Effect of the Duty‐Free and Quota‐Free Market Access Schemes for Least Developed Countries on Income Inequality and Poverty

Effect of the Duty‐Free and Quota‐Free Market Access Schemes for Least Developed Countries on Income Inequality and Poverty

Smart Communication E-Commerce Website

This paper considers the integration of digital platforms as a way of empowering rural artisans through the gap created between traditional craftsmanship and global markets. The system will include easy-to-use web and mobile interfaces, effective management tools for the products, and real-time analytics to facilitate the selling of products on the platforms. It will address limited market access, lack of technical knowledge, and poor inventory management to ensure the platform promotes economic growth and preserves cultural heritage. In this regard, the study outlines the importance of technology in the development of a rural area. It focuses on scalability, accessibility, and data-driven strategies as ways to promote artisans' participation in a competitive digital economy. Key Words: Rural artisans, digital platforms, traditional craftsmanship, market access, cultural heritage, inventory management, sales analytics, rural development, web and mobile interfaces, economic empowerment

Discovery of Methylated DNA Biomarkers for Potential Non-Endoscopic Detection of Barrett's Esophagus and Esophageal Adenocarcinoma.

We sought to develop a minimally-invasive, robust, accessible nonendoscopic strategy to diagnose Barrett's esophagus (BE), esophageal adenocarcinoma (EAC), and its immediate precursor lesion, high-grade dysplasia (HGD) based on methylated DNA biomarkers applied to a retrievable sponge-capsule device in a cohort representative of the BE population (i.e., mostly short-segment, non-dysplastic BE, NDBE). We identified 12 candidate methylation markers to distinguish normal vs. abnormal esophagus. These 12 markers were first assayed in 21-paired matched NDBE-normal esophageal tissues, then assessed in a case-control study of 234 esophageal samples collected using a sponge-capsule device. A classification algorithm was developed using Least Absolute Shrinkage and Selection Operator (LASSO) in a 199-patient training set and tested in an independent 35-patient test set. Twelve markers (A1BG, C9orf50, cg00720137, FLI1, GRAMD1B, HOXB13, IRF4, KCNQ3, NTNG1, SPX, TBC1D30, and USP44) were significantly hypermethylated (i.e., all P<0.05) in BE vs. matched normal esophageal biopsies. A discriminatory three-gene LASSO panel (USP44, TBCD1D30, NELL1), adjusted for age and sex, accurately distinguished HGD or EAC from normal control patients in both training (AUC=0.911, 95%CI=0.863-0.959) and test (AUC=0.969, 95%CI=0.911-1.00) sets. In normal vs. NDBE/LGD/HGD/EAC patients, this algorithm exhibited AUCs of 0.862 (95%CI=0.812-0.912) and 0.864 (95%CI=0.745-0.982) in training and test sets, respectively. In normal vs. NDBE patients, the algorithm yielded AUCs of 0.819 (95%CI=0.748-0.889) and 0.776 (95%CI=0.583-0.968) in training and test sets, respectively. This discriminatory biomarker panel algorithm exemplifies a practical nonendoscopic strategy to diagnose BE, HGD, and EAC using a minimally-invasive sponge-capsule device coupled with DNA methylation markers.

Curcumin mimics of potential chemoprevention with NQO1 induction properties

Chemoprevention is one of the accessible strategies for preventing, delaying or reversing cancer processing utilizing chemical intervention of carcinogenesis. NAD(P)H quinone oxidoreductase 1 (NQO1) is a xenobiotic metabolizing cytosolic enzyme/protein with important functional properties towards oxidation stress, supporting its ability in detoxification/chemoprotective role. A set of 3,5-diylidene-4-piperidones (as curcumin mimics) bearing alkyl sulfonyl group were synthesized with potential NQO1 induction properties. Compounds 5ab (R = 2-MeOC6H4, R’ = Me) and 5ac (R = 2-MeOC6H4, R’ = Et) are the most promising agents synthesized (% induction of NQO1 = 51.562, 45.793) relative to that of 4’-bromoflavone (4’-BF, reference standard) at 10 µM. LPS-induced iNOS production in RAW264.7 macrophages of the most promising agents discovered (5ab and 5ac) displayed concentration-dependent with comparable activities to the reference anti-inflammatory drug indomethacin. Molecular modeling studies (including QSAR, molecular docking and molecular dynamics) were accessed supporting the observed biological profiles.

Leg Ulcer and Venous Symptoms Related to Lower Extremity Arteriovenous Access for Hemodialysis: A Retrospective Review with Emphasis on Wound Complications.

Lower extremity arteriovenous (AV) access serves as a crucial alternative for hemodialysis when upper extremity options are no longer viable. While there are numerous reports on functional patency, limited information exists regarding complications related to venous insufficiency and postoperative quality of life. This study aims to assess the actual incidence of such complications and provide evidence-based insights for clinical decision-making. We retrospectively analyzed 121 end-stage renal disease patients who underwent lower extremity AV access at Maharaj Nakorn Chiang Mai Hospital from 2006 to 2023. Among them, 105 patients (86.8%) had lower extremity AV grafts, while 16 patients (13.2%) had lower extremity AVF. Primary and secondary patency rate were 69.4% and 81.8% at one year, respectively. The mortality probability was 50.4% with a mean follow-up of 58 months. Mortality predictors included age (P = .001), aspirin use (P = .022) and statin use (P = .005). Primary failure occurred in 8 patients (6.6%) and vascular graft infection is the primary cause. There were no occurrences of venous leg ulcers developed, suggesting that the risk of this complication may be lower than previously thought in the short to medium term. However, 13.3% of patients experienced leg swelling and 21.7% had hyperpigmentation. The mean revised venous clinical severity score was 1.22 and the average EQ-5D-5L quality of life score was 0.99. Our findings suggest that the risk of venous leg ulcers in patients with lower extremity AV access may be lower than previously thought, at least in the short to medium term. This should encourage surgeons to consider this technique when upper extremity options are exhausted, while maintaining vigilance for early signs of venous insufficiency. Continued research into the detrimental effects of the hyper-dynamic blood flow rate on AV access and preventive strategies will enhance the benefit of lower extremity AV access in the future.

A Lightweight Transformer-Based Collision Detection and Load Estimation Scheme for Massive Random Access in 6G Satellite-Ground Integrated Vehicular Networks

A Lightweight Transformer-Based Collision Detection and Load Estimation Scheme for Massive Random Access in 6G Satellite-Ground Integrated Vehicular Networks

A low‐complexity block EP‐based detector for iterative detection and decoding in unsourced random access

AbstractHere, a multi‐user signal iterative detection and decoding scheme named LBEP based on block expectation propagation (BEP) is proposed for LDPC‐coded two‐phase unsourced random access (URA) scheme. In the iterative process, the approximation of matrix inversion is used to facilitate expectation propagation (EP). In addition, this idea is also applied to the double EP (DEP) scheme. The simulation results show that, in the two‐phase URA scheme, the performance of the proposed LBEP scheme is similar to the BEP scheme for LDPC codes, but the complexity of the receiver is greatly reduced.

The 30-year evolution of oral cholera vaccines: A case study of a collaborative network alternative innovation model.

Cholera outbreaks have been rapidly increasing around the world. While long-term cholera prevention and control measures rely on improvements in water, sanitation, and hygiene, oral cholera vaccines (OCVs) are used for prevention and control in the short-to-medium term. OCVs lack the market incentives available in other more profitable disease areas. The development of OCVs was made possible through an alternative innovation model, which sustained innovation across multiple generations of the product for more than three decades. To examine how this alternative innovation model worked, we conducted 18 semi-structured interviews with key stakeholders related to the development of several OCVs, including "Dukoral", "Shanchol", and "Euvichol-Plus", as well as additional cholera vaccines currently under development. Interview data was analyzed thematically according to the resources used by organizations (including funding, knowledge, relationships, and manufacturing), and the practices they implemented during each stage of the R&D process (including knowledge management and intellectual property strategies, approaches to transparency, and global access strategies). Next, we created participatory network maps to illustrate the structure of the relationships between stakeholders and how these evolved over time. We found that a core group of stakeholders were able to influence policies to promote the use of OCVs, and successfully develop, finance, and obtain WHO Prequalification for safe, effective, and affordable OCVs for global procurement and distribution. The evolution of OCVs demonstrates how a collaborative network innovation model can successfully develop new pharmaceutical products that are affordable and well-suited for use in context. This model could be applied to other areas of pharmaceutical innovation, such as pandemic preparedness, for more equitable outcomes for global public health.

Assessment of complications and success rates of Percutaneous nephrolithotomy: single tract vs. multi tract approaches.

The objective of this study was to assess the success and complication rates of single-tract access vs. multi-tract percutaneous nephrolithotomy (PNL). The medical records of consecutive patients who underwent PNL for staghorn, partial staghorn, and complex kidney stones between 2014 and 2022 were retrospectively reviewed. The demographic data, stone volumes, fluoroscopy and operation durations, changes in hemoglobin levels, numbers of blood transfusions, stone-free rates, perioperative complications, duration of nephrostomy removal, and length of hospital stay parameters were noted. The complications and complexity of PNL were graded using the modified Clavien and Guy's stone scores, respectively. Single and multi-tract subgroups were determined based on PNL access strategy and the subgroups were analyzed. The study involved 208 patients, with 158 in the single-tract group and 50 in the multi-tract group. The groups were comparable in age, ASA scores, and comorbidities (p > 0.05). The characteristics of the stones, such as their location, size, and density, did not show any significant differences between the groups (p > 0.05), except for Guy's stone score, which was higher in the multi-tract group (p = 0.028). The multi-tract group also had significantly longer fluoroscopy and operation times (p < 0.001). There was no statistically significant difference in stone-free rates between the two groups (76.0% vs. 78.0%, p = 0.766). Although the drop in hemoglobin levels was more significant in the multi-tract group (p = 0.027), transfusion rates did not differ significantly between the two groups (p = 0.334). Complication rates were higher in the multi-tract group, but this difference was not statistically significant (p = 0.896). This study demonstrated that multi-tract PNL can achieve high stone-free rates with a modest increase in the occurrence of acceptable complications when performed by an experienced surgeon.

Effects of Self-Care Education on Self-Neglect Among Older Adults

Introduction: Self-neglect, a form of abuse, significantly impacts the physical, mental, and social health of older adults, leading to a diminished quality of life and, in severe cases, death. For older adults experiencing self-neglect, attention to self-care is crucial for preventing or managing health issues. This study aimed to investigate the effect of self-care education on self-neglect among older adults. Methods: This quasi-experimental study was conducted in 2021 with 100 eligible individuals selected from older adults receiving services at comprehensive health service centers in Qazvin, Iran. Participants were chosen using a non-randomized method and were divided into two groups: the self-care education group and the control group. The intervention comprised six outdoor sessions lasting 45-60 minutes each, held twice weekly at a health center. These sessions addressed five dimensions of self-care for older adults, which were validated by experts. Participants in the control group received only routine care. Post-tests were administered six weeks later. Results: Before the intervention, the mean self-neglect scores were 1.345 ± 0.89 in the control group and 1.453 ± 0.43 in the self-care education group (p = 0.034). After the intervention, mean scores improved significantly to -0.760 ± 0.43 in the self-care education group and -7.056 ± 2.31 in the control group (p = 0.001). Conclusion: Self-care education addressing various dimensions—physical, psychological-emotional, social, and spiritual—can serve as an effective, accessible, and cost-effective strategy for preventing and reducing self-neglect among older adults in care centers and hospitals. Future studies should consider larger populations and diverse cultural contexts to develop comprehensive clinical guidelines for preventing self-neglect

Cost-effectiveness of caplacizumab in immune thrombotic thrombocytopenic purpura in the United States.

Immune thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening thrombotic microangiopathy. Caplacizumab is the only treatment approved by the European Medicines Agency and the US Food and Drug Administration for iTTP, to be given in combination with plasma exchange therapy (PEX) and immunosuppression (IS). The National Institute for Health and Care Excellence's independent appraisal committee assessed the cost-effectiveness of caplacizumab and concluded that the addition of caplacizumab to PEX+IS is cost-effective under a patient access scheme in the United Kingdom. To assess the cost-effectiveness of caplacizumab in iTTP from the US payer perspective. The National Institute for Health and Care Excellence's model was adapted to the US setting using US costs and discount rates. In contrast to previous cost-effectiveness analyses that accounted only for acute outcomes, our model consisted of a 3-month decision tree for an acute iTTP episode, followed by a Markov model to project long-term costs and outcomes (time horizon: up to 55 years; 3-monthly cycles). Patients taking caplacizumab with PEX+IS experienced an incremental gain of 2.96 life years (LYs) and 1.75 quality-adjusted LYs relative to PEX+IS alone, at an increased lifetime cost of $256,000. The incremental cost-effectiveness ratio was $86,400 per LY and $146,300 per quality-adjusted LY gained. Considering willingness-to-pay thresholds of $150,000 to $200,000, the addition of caplacizumab to PEX+IS may be cost-effective compared with PEX+IS alone for the treatment of iTTP in a US setting.

Retrospective review of the development and implementation of a bedside tunneled dialysis catheter program.

The decision to place a subcutaneously tunneled catheter is an infection prevention strategy for long term venous access allowing the proceduralist to access a vein and relocate the catheter exit site to a region on the body where care and maintenance can be safely performed. Subcutaneously tunneled centrally inserted dialysis catheter (ST-CIDC) placement is commonly performed in patients with renal disease and is traditionally performed with fluoroscopy in the interventional radiology suite or the operating theater. However, today's interventional radiologists and surgeons perform advanced invasive procedures that can be time-consuming resulting in delays in the scheduling of elective tunneled catheter placements. In this retrospective case series, we present data from a quality improvement initiative aimed at integrating available evidence for bedside tunneled dialysis catheter placement with electrocardiograph (ECG) tip positioning, to expedite care, improve patient safety outcomes, and reduce healthcare costs associated with the procedure. Most patients in the study had end-stage renal disease (59%) or acute kidney injury (37%) and were receiving placement for the first time (91%). The right jugular vein was cannulated in 84% of the placements and rates of post-insertion complications were <1%, regardless of the vessel cannulated. Performing bedside tunneled dialysis catheter placement resulted in a cost savings of $385,938.76 over a 2-year period. The placement of ultrasound guided tunneled dialysis catheters at the bedside following a pre-procedural evaluation of the right jugular, brachiocephalic, and femoral veins is a safe option resulting in expedited patient care, decreased resource utilization, and significant cost savings. Non-bedside techniques performed in interventional radiology, or the operating room should remain a consideration for patients requiring left sided venous access, signs of central stenosis, a history of multiple tunneled catheters, or patients requiring moderate sedation outside of the ICU.

Predicting severe multivessel coronary artery disease to guide access strategy in patients undergoing invasive coronary angiography.

Given radial artery conduits are increasingly utilized for coronary artery bypass grafting (CABG), avoiding transradial access (TRA) for invasive coronary angiography (ICA) may benefit patients who ultimately undergo CABG. We sought to predict the likelihood of severe multivessel disease (MVD) before ICA to guide this decision. This was a single-center study of 1485 patients with stable symptoms who underwent ICA. A model to predict severe MVD was developed. Relative importance analyses were performed to identify clinical characteristics most associated with the presence or absence of severe MVD. When predicting severe MVD, the model had a sensitivity of 70.3% and specificity of 71.8% (area under the curve = 0.7105). With a prevalence of 12.5% in our cohort, the model had a strong negative predictive value of 94.4%. Relative importance analyses showed factors most associated with the presence of severe MVD were a history of abnormal noninvasive tests, typical chest pain, aspirin use, insulin-dependent diabetes, increasing age, and a family history of coronary artery disease. Conversely, the absence of severe MVD was most associated with female sex, undergoing ICA as workup for either noncardiac or valve surgery, lung disease, atypical chest pain, and increased BMI. Clinical information available before ICA can risk stratify the likelihood of severe MVD and therefore aid in identifying patients that may need CABG and could stand to benefit from TRA avoidance. The potential benefits of maximizing radial artery conduit availability by avoiding TRA must be balanced against the risks of alternative access on an individual patient basis.

A study protocol for the policy intervention design and development of the implementation strategies for direct access to physiotherapists in primary care: a sequential mixed-method study using implementation mapping and a Delphi survey

BackgroundIn many Asian jurisdictions, patients are required to obtain referrals from registered doctors before consulting physiotherapists. In contrast, countries such as the United States, the United Kingdom, and Australia have a direct access model for physiotherapists designed across different healthcare settings and under prescribed conditions. While research has demonstrated the benefits of direct access, issues remain on the appropriate policy design for direct access in the context of patient safety and organizational challenges in the implementation. Recently the policy to allow direct access in primary care context is being considered in Hong Kong. This study aims to examine the intervention design options for the policy of direct access to physiotherapists and identify corresponding implementation strategies, to inform the appropriate intervention design for direct access to physiotherapists and the implementation strategies.MethodsWe adopt a systematic process for developing the design of the policy and the implementation strategies using an Implementation Mapping approach informed by Consolidated Framework for Implementation Research (CFIR). We will conduct literature reviews to understand the different aspects of policy intervention design and employ qualitative in-depth interviews and focus group discussions to understand key stakeholders’ perspectives related to the direct access model. The identified barriers and facilitators associated with policy implementation of an acceptable intervention design will inform the development of an effective implementation strategy tailored to the implementation context. Our approach will involve mapping the research evidence and the subsequent findings from the stakeholders’ deliberations into the CFIR domains and referencing the Expert Recommendations for Implementing Change (ERIC) to develop the acceptable intervention characteristics and the corresponding implementation strategies. These insights will be further validated in a Delphi Expert Survey, for a consensus-based approach.DiscussionThis study employs a sequential mixed-method approach to explore the intervention characteristics for an acceptable intervention design in the policy formulation and the corresponding implementation strategy for direct access to physiotherapists. Integrating research insights into actionable policy recommendations and refining these recommendations in a Delphi Survey will inform the appropriate policy intervention design and implementation strategy for direct access to physiotherapy services.

Therapeutic vapes for smoking cessation and nicotine dependence.

The Australian Government has enacted laws restricting the supply of electronic cigarettes (vapes) to people requiring them for smoking cessation or the treatment of nicotine dependence, under the care of a medical practitioner, nurse practitioner or pharmacist. Currently no vapes are included on the Australian Register of Therapeutic Goods, meaning that the prescription and supply of therapeutic vapes must be through the Special Access Scheme or Authorised Prescriber pathways. Clinical guidelines state that therapeutic vapes may be considered for supporting people who have been unable to quit smoking using first-line therapies (a combination of behavioural support and registered nicotine replacement therapies or oral smoking cessation medicines). Clinical review should occur 1 week after vape initiation, with additional follow-up according to an individualised management plan, to monitor progress, review adverse effects (e.g. cough, irritated throat, headache or nausea), encourage the use of behavioural smoking cessation supports, and discourage dual use of vapes and conventional cigarettes. An attempt to wean or stop vaping after 12 weeks is recommended, with a possible transition to registered smoking cessation medicines if required (in addition to ongoing behavioural support). The maximum recommended duration of vape use is 12 months.

Non-orthogonal multiple access scheme based on color-coded four-dimensional constellation pairing mapping

This paper proposes a short-range optical access method based on four-dimensional non-orthogonal multiple access (4D-NOMA), utilizing 4D constellation pairing mapping and two-dimensional inverse discrete Fresnel transform (2D-IDFnT) technology, achieving high compatibility with OFDM systems. An innovative color-coded 4D constellation pair mapping scheme was designed, introducing two types of four-dimensional spatial structures with 32 constellation points. By extending the three-dimensional constellation to four dimensions through color coding, the constellation figure of merit (CFM) increased by 22.2%. A 43.29 Gb/s 4D-NOMA transmission over a seven-core optical fiber was successfully demonstrated, verifying the feasibility and superiority of the proposed solution. Compared to conventional low-dimensional constellations, 4D-NOMA exhibits significant improvements in bit error rate and signal transmission sensitivity. Under the HD-FEC threshold, it provides approximately 0.9 dB and 1.3 dB sensitivity gains over traditional three-dimensional and two-dimensional constellations, respectively. This study indicates that the four-dimensional constellation structure and the 4D-NOMA scheme hold great potential for future short-range optical access systems.

Elucidating the Mechanism of Electrooxidative Allene Dioxygenation: Dual Role of Tetramethylpiperidine N-Oxyl (TEMPO).

The cumulated π system of a nonsymmetric allene contains three distinct unsaturated carbons that imbue it with unique reactivity toward radicals as compared to its alkene and alkyne counterparts. Despite the synthetic potential of these versatile building blocks, electrochemical transformations of allenes have been historically underexplored. Myriad strategies for easy access to allenes, coupled with the resurgence of interest in sustainable oxidative transformations of hydrocarbons, prompted our efforts to conduct an in-depth investigation of a rare example of an electrochemical TEMPO-mediated allene dioxygenation. The resultant vinyl-TEMPO motif is readily postfunctionalized to install a heteroatom at each allene carbon. Mechanistic investigations, including cyclic voltammetry (CV) studies, computations, and monitoring by operando NMR (ReactNMR) were performed to lay the groundwork for future electrochemical allene functionalizations that deliver unique synthetic building blocks.

Critical Examination of Healthcare Access Strategies and Their Implications on Public Health

Healthcare accessibility is one of the main determinants of health in the population and the world. The three A’s, access, cost, and availability of health facilities, play a significant role in how quality health care is being delivered and, in the effort, to prevent diseases and improve the health standards of the communities. Analyzing healthcare access models, this paper discusses best practices as well as problems that have been observed in different world regions. Major factors are assessed, including UHC, selective health policies, PPL, and the implementation of technologies for describing and increasing access to health care services. The research also focuses on a particular aspect of healthcare availability: the number of accessible healthcare facilities available to people and the extent to which they can address the population’s health needs in terms of existing disparities, economic burden, and response to emerging public health issues. This paper analyzes global case studies that reveal emerging challenges and suggest solutions to strengthen healthcare access for diverse populations.