Community-level Strategies Research Articles

Adaptation to Flooding in St. Augustine, USA

While sea level rise is usually considered as a problem that will be faced in the future, the cumulative effect of decades of slowly rising water levels have meant that many low-lying communities around the planet are already experiencing an increased frequency in tidal flooding. This includes many communities in the United States, such as the city of St. Augustine, in Florida, which has also been devastated by several hurricanes in the early 21st century. The process of how communities will adapt or relocate is notably complicated, and in the present work the authors outline an improved framework that can help to explain the process which individuals undergo as a consequence of individual stressors caused by climate change. Particularly, the feelings of individuals has so far not been studied in detail, and the authors thus conducted a qualitative analysis of the adaptation response by interviewing 20 individuals in two different neighborhoods of St. Augustine, focusing on how “eco-anxiety” might influence them. The results suggest that adaptation countermeasures have been implemented at the city, and sometimes individual level, though community-level strategies have so far been lagging. While short-term adaptation strategies to flooding might be adequate even if individuals are not aware -or deny- long-term climate change, it is unclear whether long-term adaptation by such retroactive approaches might lead to maladaptation practices.

Community-Level Strategies for Addressing Disparities in Healthy People 2030 Leading Health Indicators.

The Healthy People 2030 Leading Health Indicators (LHIs) offer a select set of measurable objectives to help community-based organizations focus their efforts to improve health equity and reduce health disparities across the lifespan within the populations they serve. Disparities are observed across LHIs, including infant mortality, maternal mortality, and food insecurity, and reducing these disparities is a key strategy for improving health and well-being for all. This study was designed to answer the following research questions: (1) What programs and initiatives are organizations implementing to address the LHIs of focus - infant mortality, maternal mortality, and food insecurity? (2) How do organizations determine which programs and initiatives they will implement? NORC conducted 9 qualitative interviews with Healthy People 2030 Champions, organizations dedicated to furthering Healthy People goals and objectives, who are working to address disparities within infant mortality, maternal mortality, and food insecurity through a variety of strategies, interventions, and programs. Wraparound services, doula programs, and education and advocacy emerged as common strategies for addressing disparities in maternal and infant mortality. Organizations that are working to reduce household food insecurity and hunger implemented food pharmacies and support participant enrollment in federal food assistance programs. Interviewees shared strategies for determining programs to implement and continued program improvement including assessing community needs, leveraging partnerships, and measuring program success. Healthy People Champion organizations are using several multidimensional strategies to address infant mortality, maternal mortality, and food insecurity in their communities. These strategies, and the community-based organizations that implement them, are critical for addressing disparities in priority health outcomes among the people who have the greatest need. These findings offer insights into how local communities are tackling national priorities and underscore opportunities for more rigorous evaluation to demonstrate progress toward addressing disparities in the LHIs.

Health literacy of pregnant women in Hungary

Abstract Health literacy determines our state of health and through this our quality of life. The health behavior of women of reproductive age should be treated with priority, since the lifestyle of pregnant women shows a correlation with the occurrence of premature birth and intrauterine development, and also between fetal development and the occurrence of chronic diseases in adulthood. The aim of our research is to explore the factors influencing the health behavior of pregnant women, to analyze regional differences, and to identify the causes of regional differences and inequalities. During a prospective, cross-sectional study, the health behavior of pregnant women living in Hungary was assessed using a questionnaire. In the course of our research, we examined health literacy using two measuring instruments, the Chew questionnaire and The Newest Vital Sign test. A total of 2,000 questionnaires were distributed of which 1,655 evaluable questionnaires were returned, the willingness to answer was 75%. The most people considered their own health to be good or very good (59.7%). 59.5% of the respondents changed their health behavior because of their pregnancy, mainly for the sake of the health of the fetus. 18.1% of pregnant women most likely have insufficient, 15.0% probably limited and 48.1% most likely have adequate functional health literacy. Age, education, place of residence and financial situation of pregnant women show a significant correlation with health literacy. Our results confirmed that sociodemographic factors, especially age and education, significantly influence the health literacy, perceived health status and health behavior of pregnant women. The two health literacy questionnaires we use can be combined well with each other and complement each other. The results greatly contribute to the development of health literacy, and thus to the development of individual and community-level strategies for improving health behavior in the field of pregnant women’s care. Key messages • Health literacy of pregnant women in Hungary. • Health literacy in health promotion.

Impact of natural disasters on HIV risk behaviors, seroprevalence, and virological supression in a hyperendemic fishing village in Uganda.

Understanding the impact of natural disasters on the HIV epidemic in populations with high HIV burden is critical for the effective delivery of HIV control efforts. We assessed HIV risk behaviors, seroprevalence, and viral suppression in a high HIV prevalence Lake Victoria fishing community before and after COVID-19 emergence and lockdown and a severe lake flooding event, both of which occurred in 2020. We used data from the largest Lake Victoria fishing community in the Rakai Community Cohort Study, an open population-based HIV surveillance cohort in south-central Uganda. The data were collected both prior to (September-December 2018) and after (October-December 2021) COVID-19 emergence and a severe flooding event. Households impacted by flooding were identified via drone data and through consulting village community health workers. The entire study population was subject to extensive COVID-19-related lockdowns in the first half of 2020. Differences in HIV-related outcomes before and after COVID, and between residents of flooded and non-flooded households, were assessed using a difference-in-differences statistical modeling approach. A total of 1,226 people participated in the pre- and post-COVID surveys, of whom 506 (41%) were affected by flooding. HIV seroprevalence in the initial period was 37% in flooded and 36.8% in non-flooded households. After the COVID-19 pandemic and lockdown, we observed a decline in HIV-associated risk behaviors: transactional sex declined from 29.4% to 24.8% (p = 0.011), and inconsistent condom use with non-marital partners declined from 41.6% to 37% (p = 0.021). ART coverage increased from 91.6% to 97.2% (p<0.001). There was 17% decline in transactional sex (aPR = 0.83, 95% CI: 0.75-0.92) and 28% decline in the overall HIV risk score (aPR = 0.83, 95% CI: 0.75-0.92) among HIV-seronegative participants. We observed no statistically significant differences in changes of HIV risk behavior, seroprevalence, or viral suppression outcomes when comparing those affected by floods to those not affected by floods, in the periods before and after COVID-19, based on difference-in-differences analyses. Despite a high background burden of HIV, the COVID-19 pandemic, and severe flooding, we observed no adverse impact on HIV risk behaviors, seroprevalence, or virologic outcomes. This may be attributed to innovative HIV programming during the period and/or population resilience. Understanding exactly what HIV programs and personal or community-level strategies worked to maintain good public health outcomes despite extreme environmental and pandemic conditions may help improve HIV epidemic control during future natural disaster events.

Clinicians’ perspectives on strategies for suicide prevention in Pakistan: a qualitative inquiry

Suicide is a public health concern and represents one of the increasing causes of mortality worldwide. In Pakistan, the severity of suicide is worsened by the lack of a national prevention program and adequate mental health facilities. This study, through 16 in-depth interviews with clinicians, aimed to identify prevention strategies. Two main categories emerged: community-level strategies (eg raising awareness, psychoeducation, restricting access to lethal means) and clinician-level strategies (eg training programs, safety plans, fundraising, tele-counseling). Effective prevention requires comprehensive policies to overcome existing barriers.

Partnering With Immigrant Patients and Families to Move Beyond Cultural Competence: A Role for Clinicians and Health Care Organizations

The delivery of culturally competent health care is recognized as critical to providing quality, equitable care for marginalized groups. This includes immigrant patients and families who experience significant barriers to health care and poor health outcomes. However, operationalization of cultural competence challenges health care delivery. Complementary concepts have also emerged such as cultural humility, cultural safety, and structural competence, recognizing the need for multi-level approaches involving patients, families, clinicians, health care organizations, the larger community, and policymakers. In this review, we define cultural competency and related frameworks and their applicability to immigrant patients and families. The evolution in terminology reflects an increasingly more comprehensive approach to understanding culture as multidimensional and shaped by social and structural factors. We then highlight strategies at each level, focusing on clinicians and organizations to leverage loci of control most directly within clinicians’ reach. Community-level strategies include community engagement (ie, vis-à-vis community health workers or community advisory boards) for clinical and research practice. Organization-level strategies include “immigrant-friendly,” or “immigration-informed” policies aimed at reducing immigration-related stressors, like limiting cooperation with immigration enforcement agencies or developing medical-legal partnerships to assist with patients’ legal needs. Lastly, policy-level strategies seek to change local and federal policies to address needs beyond health care (eg, education, housing, other social services), taking a “Health in All” policies approach that articulates health considerations into policymaking across sectors. Finally, we conclude with suggestions for future directions that center the experiences of immigrants, with the ultimate goal of sustainably meeting the complex needs of immigrant patients and families.

Transformational narrative changes as a community-level approach to the prevention of adverse childhood experiences and substance use.

There is increasing scientific evidence linking substance use, childhood adversity, and social determinants of health. However, little research has considered the evaluation of community-level strategies to reduce substance use by increasing awareness and implementation of evidence-based strategies for preventing adverse childhood experiences (ACEs). This article lays out the conceptual framework for a $2.9 million demonstration project designed to raise awareness of the impact of ACEs on substance use, including primary prevention strategies. Communities used transformational narrative change-with an emphasis on the voices of those most impacted by ACEs and substance use-to highlight the importance of addressing social determinants of health along with primary prevention strategies. The conceptual background highlighted in this article informed media, public health, and local efforts in the three accompanying articles and invited commentary. These findings may help inform future efforts to promote community-level strategies and strengthen the evidence-base for transformational narrative change efforts.

An International Classification of Functioning, Disability and Health Model-Based Analysis of Suicidal Ideation among 9920 Community-Dwelling Korean Older Adults.

Many complex factors contribute to suicide in older adults. The suicidal ideation that precedes suicide is an especially direct predictor of suicide. This study aimed to identify the effects between variables affecting suicidal ideation among older adults using the International Classification of Functioning, Disability and Health (ICF) model and understand the causal relationships to systematize complex factors. This study used data from 9920 community-dwelling older adults who completed a national survey in 2020 to classify predictors of suicidal ideation (e.g., depression, subjective health status, sociodemographic factors, health factors, social support, instrumental activities of daily living (IADL), and social participation) by using the ICF model. To determine the causal relationship between variables, this study examined significance based on the critical ratio (C.R.) and squared multiple correlation (SMC) by using a path model. Gender, education level, economic level, age, IADL, relationship satisfaction with a child, depression, and the number of chronic diseases significantly affected suicidal ideation, while age, employment status, participation in social groups, formal and informal support, satisfaction with a friend/neighbor relationship, and subjective health status did not significantly influence it. Moreover, depression mediated the relationship between each of these variables and suicidal ideation. It was found that depression was the most direct and mediating factor in suicidal ideation among many factors affecting the suicidal ideation of community-dwelling older adults. Additional studies should be conducted to develop community-level strategies based on these factors and understand causal relationships.

Community infant safe sleep and breastfeeding promotion and population level-outcomes: A mixed methods study

ProblemIn the U.S., sudden unexpected infant deaths due to accidental suffocation and strangulation in bed are increasing. Though breastfeeding is a protective factor against sudden unexpected infant death, motivations to breastfeed often couple with unsafe infant sleep practices. Racial/ethnic disparities are present in sudden unexpected infant death, accidental suffocation and strangulation in bed, and breastfeeding. BackgroundPromoting infant safe sleep and breastfeeding through community-level initiatives could address disparities in related outcomes. AimInvestigate the relationship between community-level strategies and associated state-level outcomes for infant safe sleep and breastfeeding. MethodsWe employed an intervention mixed methods framework and exploratory sequential design. The qualitative component entailed a hermeneutical phenomenological framework to analyze key informant interview data from seven U.S. community-level providers participating in a practice improvement initiative. The quantitative component entailed descriptively analyzing infant safe sleep and breastfeeding indicators from the 2019 Pregnancy Risk Assessment Monitoring System and Ohio Pregnancy Assessment Survey. Qualitative and quantitative data were linked through embedded integration. FindingsWe identified two mixed insights: gaps in promotion and outcomes, and persistent disparities between infant safe sleep and breastfeeding promotion and outcomes. DiscussionOur findings indicate conversational approaches could improve infant safe sleep and breastfeeding promotion, outcomes, and relative disparities. We find that community collaboration is needed to address organizational capacity limitations in promoting infant safe sleep and breastfeeding. ConclusionCommunity-level organizations and providers should consider tailoring program offerings and care delivery to include conversational approaches and community collaboration to promote infant safe sleep and breastfeeding and decrease relative disparities in outcomes.

Increasing support for the prevention of adverse childhood experiences and substance use: Implementation of narrative change strategies in local health departments.

Adverse childhood experiences (ACEs) are potentially traumatic but preventable experiences that occur before the ages of 18, including child abuse, witnessing violence, and parental substance use. ACEs have been linked with increased risk for substance use, along with a variety of other negative health outcomes. However, there is limited evidence of community-level strategies that link ACEs and substance to increase awareness of prevention efforts. This article reports on a $2.9 million program to promote health equity and inform narratives for the prevention of ACEs and substance use within three Midwestern communities. Program partners sought to create new transformational narratives that linked ACEs and substance use, while underscoring the importance of addressing social determinants of health (SDOH) that lead to disparities in ACEs and substance use. A mixed-methods evaluation design included document review, in-depth interviews with program staff (N = 8) and community liaisons (N = 2), and site reports from program staff (N = 8) and their community partners (N = 17). Analyses showed that successful implementation efforts had early leadership buy-in and support, set clear and manageable expectations at the outset of implementation, and developed strong relationships with organizations that engage in health equity work. Training and technical assistance were critical to helping community partners build trust, recognize each other's perspectives, broaden and reframe their world view, and better understand narrative efforts for the primary prevention of ACEs and substance use.

Shorter sleep duration and lesser sleep efficiency are associated with poorer memory functions among non-demented, middle-aged, and older rural Indians.

Sleep is known to be involved in cognitive processes, such as memory encoding and consolidation, and poor sleep is a potential risk factor for dementia. This study aims to investigate the effect of sleep quality on memory functions among middle-aged and older adults from a rural Indian population. Participants were non-demented, rural Indians (≥45 years) from an ongoing, prospective, aging cohort study, namely Srinivaspura Aging, NeuroSenescence, and COGnition (SANSCOG) study. Cross-sectional (baseline) data on seven sleep dimensions was obtained using the Pittsburgh Sleep Quality Index (PSQI). Memory functions were assessed using immediate recall, delayed recall, name-face association, and semantic association from a culturally validated, computerized, neurocognitive test battery. Linear regression models, unadjusted and adjusted for cognitive status, age, sex, and depression were used to analyze the association between each sleep dimension and the memory tests. A total of 1195 participants, with a mean age of 57.10 years, were included. Out of the seven sleep dimensions of the PSQI, only two dimensions, namely sleep duration and sleep efficiency, were significantly associated with memory functions. In the fully adjusted model, shorter sleep duration was significantly associated with poorer performance in delayed recall, and lesser sleep efficiency was significantly associated with poorer delayed recall and semantic association performance. Specific sleep characteristics appear to influence memory functions in aging Indians well before the onset of dementia. In the backdrop of the non-availability of a definitive treatment for dementia, promptly identifying and addressing these problems could be an effective, community-level strategy for preventing dementia.

Cognitively healthy Indians with higher Framingham Cardiovascular Risk Scores have higher WMH burden with lesser grey matter, white matter and hippocampal volumes

AbstractBackgroundIncreasing evidence indicates the important role of cardiovascular risk factors in dementia risk, particularly in Indians. It is known that cardiovascular risk factors tend to cluster together, and a widely used multivariable risk scoring is the Framingham Cardiovascular Risk Score (FRS). However, very little is known about the association between FRS and structural brain MRI parameters in cognitively healthy Indians.MethodBaseline clinical and brain MRI data of 487 cognitively healthy Indians (Clinical Dementia Rating score of ‘0’), who are part of two ongoing, large, aging cohort studies in India – Srinivaspura Aging, Neuro Senescence and COGnition study (SANSCOG) study (n = 200) and Tata Longitudinal Study of Aging (TLSA, n = 289) were utilized. FRS was calculated using clinical and blood biochemistry data, whereas brain MRI scans were performed on 3T MRI scanners. White matter hyperintensity (WMH) lesion segmentation was performed using Lesion Segmentation Toolbox (LST) and brain volumes (total grey matter, total white matter, 3rd ventricle, right and left hippocampus) were derived using FreeSurfer software and normalized according to total intracranial volumes of the respective subjects. Linear regression analysis was performed with FRS as independent variable and various structural MRI parameters as dependent variables. A p value of &lt;0.05 was considered significant.ResultUrban subjects with higher FRS had significantly higher WMH volume (β = 0.00011, p&lt;0.001, R2 = 0.130), lower grey matter (β = ‐0.00285, p&lt;0.001, R2 = 0.206), white matter (β = ‐0.00180, p&lt;0.001, R2 = 0.106), right hippocampal (β = ‐0.00004, p&lt;0.001, R2 = 0.180), left hippocampal (β = ‐0.00003, p&lt;0.001, R2 = 0.156) volumes and higher 3rd ventricle volumes (β = 0.00003, p&lt;0.001, R2 = 0.150). Rural subjects higher FRS had lower grey matter (β = ‐0.00166, p&lt;0.001, R2 = 0.118, white matter (β = ‐0.0011, p&lt;0.001, R2 = 0.060), right hippocampal (β = ‐0.00002, p&lt;0.001, R2 = 0.087), left hippocampal (β = ‐0.00002, p&lt;0.001, R2 = 0.084) volumes and higher 3rd ventricle volumes (β = 0.00004, p&lt;0.001, R2 = 0.264) but no significant association was seen with WMH volume.ConclusionThese findings indicate that cardiovascular risk is associated with structural brain changes in cognitively healthy Indians. Since cardiovascular risk can be reduced through cost‐effective community level strategies, such as lifestyle‐based interventions, promptly addressing this risk in Indians could be an important part of dementia prevention strategies.

Microbial community ecosystem network model for chemical energy transport

Microorganisms thriving in low-energy ecosystems have evolved diverse strategies to sustain life, including individual-level energy conservation, optimizing energy utilization through interspecies competition, and mutually beneficial interspecies syntrophy. This study introduces a novel community-level strategy to enhance energy efficiency. We employed an oxidation-reduction (redox) reaction network model to capture the intricate metabolic interactions within microbial communities. Our findings highlight the importance of microbial functional diversity in facilitating metabolic handoffs, leading to an improved energy utilization efficiency. Moreover, the mutualistic division of labor and the resulting complexity of redox pathways actively facilitate material cycling, thereby enhancing energy exploitation. These findings provide new insights into the potential of self-organized ecological interactions to develop efficient energy utilization strategies, with significant implications for the functioning and evolution of microbial ecosystems.

Predictors of depressive symptoms among people with type 2 diabetes mellitus in Indonesia: a cross-sectional study

Working conditions and quality of work life reflect a person’s overall quality of life and well study to date has investigated the factors contributing to depressive symptoms in people with type 2 DM in Indonesia. This study aimed to investigate the predictors of depressive symptoms among people with type 2 DM in Indonesia. This was a cross‐sectional study using secondary data from the Indonesian family life survey 5 (IFLS-5). A total of 774 respondents with type 2 DM were selected for this study. The dependent variable was depressive symptoms while the independent variables were demographics, economic status, smoking, duration of diabetes, chronic conditions, self-rated health, and physical function. The center for epidemiologic studies depression scale was used to measure depressive symptoms. The data were analyzed with multivariate logistic regression. The results showed that 70.70% of respondents had depressive symptoms. The risk of experiencing depressive symptoms decreased with age ≥ 50 years (AOR= 0.40; 95%CI 0.25 to 0.64; p&lt;0.001) and good self-rated health (AOR= 0.54; 95%CI= 0.35 to 0.81; p= 0.003). Otherwise, the risk of experiencing depressive symptoms increased with a higher level of education (AOR= 1.78; 95%CI= 1.02 to 3.12; p= 0.042) and with chronic conditions (AOR= 1.64; 95%CI= 1.07 to 2.51; p= 0.023). Depressive symptoms were significantly associated with personal health conditions including older age, level of education, self-rated health and chronic conditions. Individual and community level strategies that can improve personal health conditions can be further studied to address depressive symptoms in type 2 DM patients.

Impact of neighborhood deprivation on disability free survival in patients with aggressive B cell non-Hodgkin lymphoma.

7564 Background: Advancements in treatment over the last decade have greatly improved survival in B cell non-Hodgkin’s lymphoma (NHL), yet not all patients (pts) benefit the same. Non-Hispanic Black (NHB), uninsured and lower socioeconomic status pts continue to suffer worse survival. However, the impact of neighborhood deprivation on disability has not been explored. We aimed to assess the association between neighborhood deprivation and disability free survival (DFS) in NHL pts. Methods: 258 aggressive NHL pts treated between 2005-2020 were included. Pts without documented follow up were excluded. Race/ethnicity was categorized as non-Hispanic white (NHW), Hispanic, NHB and other. Primary outcomes included progression free survival (PFS), overall survival (OS) and DFS. DFS was defined as time to needing any rehabilitative, home-health or skilled nursing services immediately following induction therapy, indicating disability and lack of functional independence. Neighborhood deprivation was assigned using the national Area Deprivation Index (ADI), a validated measure classifying neighborhood adversity. Pts were categorized into high (67-99), intermediate (34-66) or low (1-33) ADI scores, with least disadvantaged designated by lower scores. Kaplan-Meier analyses were used to compare PFS, OS and DFS. Results: Demographic data is shown in the table; 45% were female, 65% were NHW, 10% were NHB, 8% were Hispanic and 10% were other. Median age at diagnosis was 57 years. There was no difference in PFS or OS between racial/ethnic groups (p=0.91 and p=0.23 respectively). Payor source influenced both PFS and OS (p&lt;0.001 and p&lt;0.001 respectively), with self-pay associated with worse PFS and OS. Neighborhood deprivation based on ADI did not influence PFS (p=0.33) or OS (p=0.76). High ADI score was associated with worse DFS compared to lower ADI scores (p=0.03). ADI score differed significantly based on race/ethnicity (p&lt;0.0001), with more NHB pts residing in areas of high ADI scores (40% vs 5% NHW vs 10% Hispanic). There was no association between ADI score and a pt’s ECOG performance status, IPI score or albumin at diagnosis (p=0.87, p=0.78 and p=0.59 respectively). Conclusions: NHL pts with higher neighborhood adversity experience more disability after treatment despite similar survival. Further work is needed to better understand how neighborhood factors are contributing to disability before community-level strategies for improvement can be developed. [Table: see text]

Food security definition, measures and advocacy priorities in high-income countries: a Delphi consensus study.

To establish an international consensus on the definition of food security, measures and advocacy priorities in high-income countries. A two-round online Delphi survey with closing in March 2020 and December 2021. Consensus was set a priori at 75 %. Qualitative data were synthesised and priorities were ranked. High-income countries. Household food security experts in academia, government and non-government organisations who had published in the last 5 years. Up to thirty-two participants from fourteen high-income countries responded to the Delphi with a 25 % response rate in Round 1 and a 38 % response rate in Round 2. Consensus was reached on the technical food security definition and its dimensions. Consensus was not reached on a definition suitable for the general public. All participants agreed that food security monitoring systems provide valuable data for in-country decision-making. Favoured interventions were those that focused on upstream social policy influencing income. Respondents agreed that both national and local community level strategies were required to ameliorate food insecurity, reinforcing the complexity of the problem. This study furthers the conceptual understanding of the commonly used definition of food security and its constituent dimensions. Strong advocacy is needed to ensure food security monitoring, policy and mitigation strategies are implemented. The consensus on the importance of prioritising actions that address the underlying determinants of household food security by experts in the field from across wealthy nations provides evidence to focus advocacy efforts and generate public debate.

Societal- and community-level strategies to improve social connectedness among older adults.

OPINION article Front. Public Health, 04 May 2023Sec. Aging and Public Health Volume 11 - 2023 | https://doi.org/10.3389/fpubh.2023.1176895

Issues, challenges and opportunities in accessing primary health services in tribal-rural setting in India: a decadal view

Even after 75 years of independence, the country's most underprivileged tribal population is still far from getting health benefits. Tribals in India have poor health and present a bleak picture in terms of social development metrics, especially health. From this perspective, this paper is intended to identify the problems and existing challenges faced by tribal communities in accessing health care from primary health care settings. Exploring the observations based on reviewed scholarly articles published between 2012 and 2022 from databases like PubMed and Google Scholar and in addition to several government reports and articles. These articles were selected and subsequently analyzed to extract specific outcomes. By applying the principle of the 'five A' approach, the analysis revealed a significant shortfall in the service delivery of health wellness centers. It was implicit that despite the introduction of affirmative policies by the government, gaps still existed in the healthcare system at grass root level. Major gaps are lack of human resources, staff stereotyping indigenous population, and inadequate infrastructure; and high health costs due to out of pocket expenditure and informal payments were evident. The paper recommended both individual and community-level strategies to overcome the barriers of rural health services. More decentralized planning and cultural competency training are immediate measures for the inclusion of tribal-rural people in healthcare services. Further, we proposed developing a "Mangal Health Team' which will coordinate between Health and wellness centre and villagers.

Defining the role of pharmacists in addressing the social determinants of health.

As one of the overreaching goals of Healthy People 2030, addressing the social determinants of health (SDOH) to reduce health disparities is a nationwide concern, with objectives informed by interdisciplinary teams of experts. However, there remains much discussion regarding the roles of healthcare providers in addressing SDOH. While current guidance suggests that all members of the healthcare team must be empowered to address SDOH, current guidance explicitly references physicians, nurses, social workers and staff, and do not specifically include pharmacists. While pharmacists are taught about the impact of SDOH in pharmacy curricula, actionable strategies for pharmacists to address SDOH in practice have not been clearly outlined. Pharmacists have multifaceted interactions with patients and may be influential in meeting individual patient needs, identifying social risk factors, and addressing upstream causes of health disparities. This paper proposes a framework for the role of pharmacists in addressing the SDOH through strategies at the patient, practice, and community levels. The concepts presented in this paper are meant to serve as a launch point for discussion and to promote the inclusion of pharmacists in the conversations around sustainable efforts to achieve health equity. This framework is not intended to limit the scope of pharmacists in addressing SDOH - on the contrary, it is our hope that this outline may be used to expand the education of future healthcare professionals regarding their role in addressing the social determinants of health.

Actor-network analysis of community-based organisations in health pandemics: evidence from the COVID-19 response in Freetown, Sierra Leone.

Freetown, Sierra Leone, is confronted with health risks that are compounded by rapid unplanned urbanisation and weak capacities of local government institutions. Addressing them implies a shared responsibility between government and non‐state actors. In low‐income areas, the role of community‐based organisations (CBOs) in combating health disasters is well‐recognised. Yet, empirical evidence on how they have utilised their networks and coordinated community‐level strategies in responding to the COVID‐19 pandemic is scant. This paper, based on a qualitative study in two informal settlements in Freetown, employs actor‐network theory to understand how CBOs problematise COVID‐19 as a health risk, interact with other entities, and the subsequent tensions that arise. The findings show that community vulnerabilities and past experiences of health disasters informed CBOs' perception of COVID‐19 as a communal emergency. In response, they coordinated sensitisation and mobilisation programmes by relying on a network of actors to support COVID‐19 risk reduction strategies. Nonetheless, misunderstandings among them caused friction.