Health Delivery System Research Articles

A comparative analysis of the health services indicators distribution in public hospitals:guide for nursing transformation plan in Saudi Arabia

Healthcare in Saudi Arabia (SA) is a national system in which the government provides free universal coverage through public health services to meet the increasing demand for healthcare due to population growth. Saudi Vision 2030 is a national transformation program that translates into a system-wide transformation involving expanding healthcare services focusing on value-based healthcare. This translates into a system-wide transformation involving expanding healthcare services focusing on value-based healthcare. This contributes to a series of developments in the health delivery systems fields and nursing services. This study aims to explore the four selected indicators of health services and to provide a plan for nursing transformation in SA. The study employs the data of 4 selected indicators and data of the total population extracted from the statistical yearbooks of the last five years (2017- 2021). Descriptive statistics, normality distribution using the Shapiro-Wilk test, and Homogeneity of variance applying Levene’s test were employed. In the analysis of health distribution, the proportion between the total population as the independent factor and the total of health services as the dependent factor was conducted. The major total of the population was located in three main regions, with 66.3%. The spatial distribution of the selected health indicators was related to the population distribution in three main regions, with 43.7% of the hospitals, 51.6% of the hospital beds, 57.3% of the physicians, and 55.4% of the nurses. The abnormality of total population distribution with a p-value of 0.001 at the freedom degree of 13 was noticed. In addition, the analysis shows an abnormally distributed total of the selected health indicators with a p-value of 0.001-0.026 at a freedom degree of 13.

Community participation for reproductive, maternal, newborn and child health: insights from the design and implementation of the BornFyne-prenatal management system digital platform in Cameroon.

Across communities in low-middle income countries, digital health is currently revolutionizing the delivery of health services, particularly in the field of reproductive, maternal, newborn, and child health (RMNCH) services. While studies have shown the effectiveness of mHealth in delivering RMNCH services, there is little information about factors that enhance mHealth services utilization in low-cost settings including stakeholders' level of influence on the implementation of digital health intervention in sub-Saharan Africa. This paper seeks to describe important lessons on the levels of stakeholders' direct or indirect influence on the design and implementation of the BornFyne-PNMS digital health platform to support RMNCH services. A participatory research (PR) design approach was employed to explore stakeholders' perspectives of a new initiative, through direct engagement of local priorities and perspectives. The process of introducing the digital application called the BornFyne-PNMS for district health delivery system and the community, and integrating it within the district health delivery system was guided by research-to-action, consistent with the PR approach. To explore stakeholders' perspectives through a PR approach, we conducted a series of stakeholder meetings fashioned after focus group discussions. Issues around male involvement in the program, sensitization and equity concerns arose. Emergent challenges and proposed strategies for implementation from diverse stakeholders evidently enriched the design and implementation process of the project intervention. Stakeholder meetings informed the addition of variables on the mobile application that were otherwise initially omitted, which will further enhance the RMNCH electronic data collection for health information systems strengthening in Cameroon. This study charts a direction that is critical in digital health delivery of RMNCH in a rural and low-income community and describes the important iterative stakeholder input throughout the study. The strategy of stakeholders' involvement in the BornFyne PNMS implementation charts a direction for ownership and sustainability in the strengthening of Cameroon's health information system.

A "sludge audit" for health system colorectal cancer screening services.

"Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services. Mixed methods sludge audit. We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes. Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients. Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

Prevalence and appropriateness of in-person versus not-in-person ambulatory antibiotic prescribing in an integrated academic health system: A cohort study.

Ambulatory antibiotic stewardship generally aims to address the appropriateness of antibiotics prescribed at in-person visits. The prevalence and appropriateness of antibiotics prescribed outside of in-person visits is poorly studied. Retrospective cohort study of all ambulatory antibiotic prescribing in an integrated health delivery system in the United States. Antibiotic prescribers and patients receiving oral antibiotic prescriptions between January 2016 and December 2019. Proportion of antibiotics prescribed with in-person visits or not-in-person encounters (e.g., telephone, refills). Proportion of prescriptions in in 5 mutually exclusive appropriateness groups: 1) chronic antibiotic use; 2) antibiotic-appropriate; 3) potentially antibiotic-appropriate; 4) non-antibiotic-appropriate; and 5) not associated with a diagnosis. Over the 4-year study period, there were 714,057 antibiotic prescriptions ordered for 348,739 unique patients by 2,391 clinicians in 467 clinics. Patients had a mean age of 41 years old, were 61% female, and 78% White. Clinicians were 58% women; 78% physicians; and were 42% primary care, 39% medical specialists, and 12% surgical specialists. Overall, 81% of antibiotics were prescribed with in-person visits and 19% without in-person visits. The most common not-in-person encounter types were telephone (10%), orders only (5%), and refill encounters (3%). Of all antibiotic prescriptions, 16% were for chronic use, 15% were antibiotic-appropriate, 39% were potentially antibiotic-appropriate, 22% were non-antibiotic-appropriate, and 8% were not associated with a diagnosis. Antibiotics prescribed in not-in-person encounters were more likely to be chronic (20% versus 15%); less likely to be associated with appropriate or potentially appropriate diagnoses (30% versus 59%) or non-antibiotic-appropriate diagnoses (8% versus 25%); and more likely to be associated with no diagnosis (42% versus <1%). Ambulatory stewardship interventions that focus only on in-person visits may miss a large proportion of antibiotic prescribing, inappropriate prescribing, and antibiotics prescribed in the absence of any diagnosis.

Outcome of capacity building in mental health for well-being volunteers.

Volunteering is any activity in which time is given to assist another individual, group, or organization. It assists people who want to get involved in philanthropic programs that help volunteers develop awareness and lead healthier personal and social lives. Several volunteers have received specialized training in the fields in which they volunteer, such as health, mental health, education, or emergency rescue. Volunteers are rendering intervention in different areas in mental health. They are providing psychosocial support to the individuals, groups, community, promoting mental health through conducting various mental health awareness programs in the community. There is a growing concern about mental health in India due to the inaccessibility of services. The National Institute of Mental Health and Neuro Sciences (NIMHANS) being a premier institute for mental health, is devising innovative approaches to mental health care to reach the unreachable. One such initiative was to build the capacity of volunteers in the community who are interested in working for the cause of mental health. The objective of this study was to evaluate the outcome of the well-being volunteer program. This study used a descriptive cross-sectional research design, wherein all the 136 trained well-being volunteers (WBVs) were included as the study sample. The data was collected from the volunteers who attended the WBV program, which was initiated by NIMHANS Centre for Well-being (NCWB) and the Department of Psychiatric Social Work NIMHANS. A questionnaire on the outcome of the Well Being Volunteers program was developed for the study, and the Volunteer Motivation Inventory scale was used to collect the data from the WBVs. SPSS software was used to analyze the data. Ethical clearance was sought from the Institute Ethics Committee of NIMHANS. The WBV program enhanced volunteers' knowledge of mental health and benefited the volunteers in their personal and social life. They were also able to implement a satisfactory level of mental health-related volunteer activities in the community. Results of present study and the available literature suggest that engaging in voluntary services improves mental health knowledge. WBV program has provided opportunity to Volunteers to participate in mental health delivery system at different levels.

Patients’ perceptions of medication counseling and education provided by pharmacists

Objectives: Pharmacists can increase patients’ knowledge and understanding of their medications and assist them to make appropriate decisions. However, clients’ perception is a rate determining step to their accepting such Pharmacists roles. In this study we evaluated clients’ perceptions on pharmacists provided medication counseling and education. Materials and Methods: A descriptive cross-sectional survey was conducted using a 27 item, three sectioned questionnaire among 405 respondents &gt; 16years old for 10 weeks in secondary Health facility in Lagos state. Nigeria. Using Statistical Package for Social Sciences (SPSS) version 22, descriptive analysis (frequency), reliability (Cronbach alpha), correlation (spearman’s rho), association (chi-square) were conducted with P value&lt; 0.05. Three (3) was used as a logical mid-point and a positive perception was assumed if an overall mean of above 3 was obtained. Results: Majority of the respondents were female 267 (65.9%), 47.4% fall within the age range of 20-39 years, and the highest proportion of respondents (44%) have secondary school educational qualification. About half of the respondents strongly disagreed that pharmacists are responsible for providing information on disease condition and minor ailments 181(44.7%) and strongly agreed that pharmacists always indicate medication use in writing, 278 (68.6%), there was correlation between this and pharmacists usually re-emphasized information in writing using spearman’s rho (p=0.000). Most respondents strongly disagreed that pharmacy is only a business and of no benefit to patients 314 (78.9%) and 270 (66.7%) agreed that pharmacists should be an integral part of the health delivery system. Overall mean ± SD was 4.11 ± 0.841, while mean ± SD on patients’ knowledge of pharmacists’ roles and their opinion on usefulness of pharmacists counseling and education were 4.26 ± 0.839 and 3.95 ± 0.840 respectively. Overall value of 0.66 was obtained for reliability test using Cronbach’s’ alpha. There is significant association between the patients’ age and their perception on need to go back to physician for clarification on medication use after pharmacists counseling (P=0.000), also between respondents’ gender and their perception that counseling received from pharmacists has benefits to them. (P=0.007). CONCLUSION: Generally, respondents have positive perceptions on pharmacist provided medication counseling and education. Our study results showed that pharmacists are seen as important professionals in providing medication related information.

Towards a better understanding of mental health care delivery systems: From stories to system components

ABSTRACT The growing demand for better quality of care, together with an increasing awareness of limited resources, is bringing attention to the need for design in healthcare. In mental health, considered the largest single cause of disability in the UK, the need is great. Existing services often fail to meet current levels of demand and do not consistently deliver good quality care for all service users. The design of better delivery systems has the potential to improve service user experience and care outcomes. This paper reports how through the interactive and participatory method of storytelling, the key components of a mental health delivery system were identified. We explain each of the ten components and discuss their implications for system understanding and service design. A model of a mental health delivery system has also been proposed.

Mental health among first-generation college students: Findings from the national Healthy Minds Study, 2018-2021.

A mounting body of evidence reveals that college mental health outcomes are worsening over time. That said, little is known about the mental health needs of the nearly eight million first-generation students in U.S. postsecondary education. The present study uses population-level data from the national Healthy Minds Study to compare prevalence of mental health symptoms and use of services for first-generation and continuing-generation students from 2018-2021. The sample includes 192,202 students at 277 campuses, with 17.3% being first-generation. Findings reveal a high prevalence of mental health symptoms among both first-generation and continuing-generation students. Controlling for symptoms, FG students had significantly lower rates of mental health service use. Just 32.8% of first-generation students with symptoms received therapy in the past year, relative to 42.8% among continuing-generation students, and this disparity widened during the COVID-19 pandemic. Findings have important implications for the design and implementation of higher education policies, mental health delivery systems, college persistence and retention initiatives, and public health efforts in school settings.

The cost of implementing measles campaign in Nigeria: comparing the stand-alone and the integrated strategy

BackgroundEffective integration, one of the seven strategic priorities of the Immunization Agenda 2030, can contribute to increasing vaccination coverage and efficiency. The objective of the study is to measure and compare input costs of “non-selective” measles vaccination campaign as a stand-alone strategy and when integrated with another vaccination campaign.MethodsWe conducted a cost-minimization study using a matched design and data from five states of Nigeria. We carried-out our analysis in 3 states that integrated measles vaccination with Meningitis A and the 2 states that implemented a stand-alone measles campaign. The operational costs (e.g., costs of personnel, training, supervision etc.) were extracted from the budgeted costs, the financial and technical reports. We further used the results of the coverage surveys to demonstrate that the strategies have similar health outputs.ResultsThe analysis of the impact on campaign budget (currency year: 2019) estimated that savings were up to 420,000 United States Dollar (USD) with the integrated strategies; Over 200 USD per 1,000 children in the target population for measles vaccination (0.2 USD per children) was saved in the studied states. The savings on the coverage survey components were accrued by lower costs in the integration of trainings, and through reduced field work and quality assurance measures costs.ConclusionsIntegration translated to greater value in improving access and efficiency, as through sharing of costs, more life-saving interventions are made accessible to the communities. Important considerations for integration are resource needs, micro-planning adjustments, and health systems delivery platforms.

Tackling “half” of the non-communicable disease burden in Bangladesh: a diagonal service delivery model with a life-course approach

In the context of increasing morbidity and mortality due to non-communicable diseases (NCDs) globally and particularly in low-resource countries, it has become important to explore newer health systems delivery models. In low-and middle-income countries (LMICs) women traditionally challenged with multiple barriers in accessing health services, are at even greater disadvantage compared to men. In Bangladesh, women constitute almost half of the country’s population and are disproportionately affected by NCDs like other LMICs. The country’s reproductive, maternal, newborn, child and adolescent health (RMNCAH) services are well established and designed to reach women in their households through community health workers (CHWs). This paper discusses how NCDs screening and control measures could be integrated into the existing RMNCAH pathway and proposes a conceptual model for such diagonal service delivery integration. The paper also describes multiple RMNCAH service delivery touchpoints that could be utilized for screening and treating women for NCD risk factors, across their life-course.

Evaluation of potential socioeconomic and racial/ethnic disparities in all-cause mortality in adolescent and young adult patients with cancer.

6501 Background: Adolescent Young Adult (AYA) cancer patients, aged 15-39, have historically been understudied. For older adults, socioeconomic (SES) and racial/ethnic disparities in mortality have been demonstrated, but less is known about survival disparities for AYA patients. Most existing studies do not account for the influence of insurance status and access to care. To address this gap, we evaluated the association of SES and race/ethnicity with overall mortality for AYA cancer patients who were members of an integrated health delivery system with relatively equal access to care. Methods: Patients diagnosed with cancer at age 15-39 years old in Kaiser Permanente Southern California between 2010-2018 were included. The fourteen most common AYA cancer types within our cohort were included (excluding thyroid cancer due to low mortality rate). The Neighborhood Deprivation Index (NDI) was used as a marker of SES. Patients were placed into NDI quartiles (Q1: least deprived-Q4: most deprived). Mortality rate per 1,000 patient years was calculated for each racial/ethnic group and NDI quartile. Multivariable cox model was used to estimate hazard ratios (HRs) for all-cause mortality. Models included race/ethnicity and NDI subgroup simultaneously, adjusting for sex, age and stage at diagnosis, and cancer type. Results: A total of 6,380 patients (59% female, median age: 33) were followed for a maximum of ten years. Racial/ethnic distribution was 45% Hispanic, 36% non-Hispanic White, 10% non-Hispanic Asian/Pacific Islander, 7% non-Hispanic Black, 2% Other/Unknown. Overall mortality was 21.8 deaths per 1,000 person years. Crude mortality rates were higher among Non-White racial/ethnic groups (Asian/Pacific Islander: 26.7, Black: 26.2, Hispanic: 25.6, Other/Unknown: 30.3) compared to White patients (16.4). In the adjusted model, Hispanic (HR=1.32, 95% confidence interval [CI] 1.03-1.50, p=0.004) and Black (HR=1.35, 95% CI 1.00-1.83, p=0.05) patients experienced significantly higher risk of all-cause mortality compared to White patients. No mortality differences were observed between Asian/Pacific Islander and White patients. Patients from more deprived neighborhoods had higher mortality risk (Q1: 19.9, Q2: 19.8, Q3: 24.1, Q4: 27.4). In the adjusted model, there was no significant difference in all-cause mortality between Q1 and Q2-Q4 [Q2 (HR=0.88, 95% CI 0.71-1.10), Q3 (HR=0.94, 95% CI 0.75-1.17), Q4 (HR=0.96, 95% CI 0.76-1.22)]. Conclusions: Our study suggests that for insured AYA cancer patients with similar access to care, Hispanic and Black patients have increased risk of all-cause mortality as compared to White patients, while no significant SES survival disparities were observed. These findings warrant further investigation, awareness, and intervention to address inequities in cancer care among vulnerable populations.

The Impact of Introducing Midwives and also Mentoring on the Quality of Sexual, Reproductive, Maternal, Newborn, and Adolescent Health Services in Low- and Middle-Income Countries: An Integrative Review Protocol.

Midwives have the potential to significantly contribute to health-delivery systems by providing sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) care. However, scant research finds barriers to understanding what midwives need to realize their full potential. There are gaps in the definition of a midwife and an understanding of effective means to support the implementation of midwifery care. Mentorship has been found to support systems and healthcare providers to improve care availability and quality. We describe the methodology of an integrative review that aims to generate evidence of the impact of introducing midwives and also on-site facility mentoring to better understand facilitators and barriers to implementation of the quality and availability of SRMNAH services in low- and middle-income countries (LMICs). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be used to carry out the integrative review. Four electronic bibliographic databases, PubMed MEDLINE, EMBASE, Scopus, and CINAHL, will be used to identify eligible studies. All types of qualitative or quantitative studies will be considered. Eligible studies will be screened according to Population, Intervention, Comparison, and Outcome (PICO) inclusion criteria, and data will be extracted against a predetermined format. The aspects of health system strengthening in providing improved SRMNCH care will be examined in this review to generate evidence on how midwives and mentorship can improve routine care and health outcomes using the World Health Organization's Six Building Blocks approach. The quality of the articles will be thematically analyzed in four areas: coherence and integrity, appropriateness for answering the question, relevance and focus, and overall assessment using the Gough weight-of-evidence framework. The literature review will consider assessing both upstream health systems regulators and downstream effectors for implementing midwifery interventions. Within this building block framework, this research will report on the outcomes and experiences of introducing midwives and the effectiveness of mentoring midwives and other staff in midwives' roles in improving care quality and health outcomes.

Assessment of Services Available in Public Health Facilities among High Priority Districts of Jharkhand under Reproductive Maternal Newborn Child Health + Adolescence

Background: The reproductive maternal newborn child health + adolescence (RMNCH + A) strategy is based on the provision of comprehensive care through the five pillars, or thematic areas, of reproductive, maternal, neonatal, child, and adolescent health, and is guided by central tenets of equity, universal care, entitlement, and accountability. This study aims to assess the services available in public health facilities among the selected high-priority districts (HPDs) of Jharkhand under RMNCH + A and also to compare the services available in public health facilities among different HPDs of Jharkhand under RMNCH + A. Materials and Methods: The proposed study was an observational study done by the Department of PSM/Community Medicine, Rajendra Institute of Medical Sciences, Ranchi, with a total duration of the study (24 months) (April 2015–March 2017). Supportive supervision (SS) was conducted in the HPDs selected as Palamu, Latehar, Lohardaga, Gumla, and Simdega of Jharkhand state. The Government of India SS checklist was used during the field visits as data collection tool. After visit, compiled report was prepared as observations. Results: The observations of the visits were done under three broad headings of health-care utilization, health system, and service delivery in a comparative manner for all the five HPDs. It was found that outpatient department numbers and deliveries of pregnant women were maximum at district hospitals. Some logistics such as comprehensive abortion care needs to be ensured at the health facilities. Immunization services were available in almost all the selected facilities. Supply of few drugs such as albendazole, salbutamol, and zinc needed to be ensured so that it can be served to the poor and deprived population of the selected districts. Conclusion: It was concluded from the study that under various public health facilities are available at different health centers of the state which are being utilized by the beneficiaries in huge numbers. Some facilities still need to be strengthened and some logistics availability needs to be ensured.

PO-01-091 VEIN OF MARSHALL ETHANOL ABLATION AND LATERAL MITRAL ISTHMUS LINE TO IMPROVE EFFICACY OF PERSISTENT AF ABLATION

The optimal approach to ablation of persistent AF has not been well-established, and current strategies are only modestly successful. To assess the efficacy of additional vein of Marshall (VOM) ethanol ablation and lateral mitral isthmus ablation in addition to standard persistent AF ablation strategies using a stepwise approach. Sixty -Five consecutive patients undergoing ablation for persistent AF were included. . All patients underwent PVI with RF ,left atrial roof ablation with confirmed roof line block, and cavotricuspid isthmus ablation were performed. VOM ethanol ablation with concomitant lateral mitral annular ablation ( from the LA endocardium and Coronary sinus as needed) to achieve block were attempted in all patients. Patients underwent follow-up ambulatory monitoring and in -office and telephonic follow-up in a closed health delivery system for at least 12 months f/u from procedure. A total of 38 of 65 patients had successful Vom ethanol injection. .35 of these patients achieved successful mitral annular block. 27 patients did not receive therapy due to venous collateralization (29)%, inability to cannulate, vessel (29%) VOM not identified (19%) and target vessel dissection or extravasation (23%.) With an average follow up of 12 months, patients with successful VOM ethanol ablation and lateral mitral line had an 82% clinical arrhythmia- free survival. In patients with unsuccessful VOM attempt, the arrhythmia free survival was 58%. All patients were off antiarrhythmic drugs, and had only one procedure. One patient with successful VOM ethanol ablation was readmitted with pericarditis without effusion managed with colchicine. The addition of VOM ethanol ablation and lateral mitral isthmus ablation is associated with an improved arrhythmia-free survival in persistent AF ablation.

Enablers and barriers to effective HIV self-testing in the private sector among sexually active youths in Nigeria: A qualitative study using journey map methodology.

HIV is a public health burden in Nigeria. HIV self-testing is one of the approaches to testing, which is the first of the 95:95:95 cascade of a coherent response to the epidemic. The ability to self-test HIV is influenced by various factors that can either serve as enablers or barriers. Exploring these enablers and barriers to the uptake of HIVST will help achieve optimal HIV self-testing and provide a deeper understanding of the HIVST kits users' journey. The purpose of the study was to identify enablers and barriers to the uptake of HIV self-testing among sexually active youth in Nigeria using journey map methodology. We conducted a qualitative exploratory study between January 2021 to October 2021 to understand the journey map for taking up and using HIVST in the private health delivery systems which include the pharmacies and PPMVs. 80 youths in Lagos, Anambra and Kano states were interviewed using IDIs and in-person FGDs. Their responses were audio-recorded, transcribed and analyzed using a qualitative software package (Nvivo software). A journey map for taking up and effectively using HIVST using the private sector among sexually active youths using key enablers and barriers at the attract, purchase, use, confirmation, linkage, and reporting stage was developed. The major enablers among participants were privacy and confidentiality, bundling purchases with other health products, easy-to-use instructions, and past experience with other self-testing kits. The major barriers were fear of discrimination, big packaging, high price, lack of confidence from user error and fear of status disclosure. Sexually active young people's perspectives enhance our understanding of the barriers and enablers of using HIVST through the private sector. Optimizing the enablers such as improved confidentiality that may be seen in e-pharmacy, reducing barriers and factoring sexually young people's perspectives will enhance the market and the uptake of HIVST towards ensuring sustainability and accelerating progress towards the 95-95-95 targets.

Health service behaviors of migrants: A conceptual framework.

Universal health coverage is vital to the World Health Organization's (WHO's) efforts to ensure access to health as a human right. However, it has been reported that migrants, including both international immigrants and internal migrants, underuse health services. Establishing a conceptual framework to facilitate research on the health service behaviors (HSB) of migrants is particularly important. Many theoretical frameworks explaining the general population's HSB have been published; however, most theoretical frameworks on migrants' HSB only focus on international immigrants without the inclusion of internal migrants. Of note, internal migrants are much more abundant than immigrants, and this group faces similar barriers to HSB as immigrants do. Based on theoretical frameworks of immigrants' HSB and Anderson's behavior model, the author proposes a new conceptual framework of migrants' HSB that includes both immigrants and internal migrants. The new conceptual framework divides the determinants into macro-structural or contextual factors, health delivery system characteristics, and characteristics of the population at risk and describes subgroup-specific factors. The author added some variables and reclassified variables in some dimensions, including characteristics of health delivery systems and access to healthcare. The characteristics of health delivery systems comprise the volume, organization, quality, and cost of the health delivery system, while the characteristics of access to healthcare include time accessibility, geographic accessibility, and information accessibility. The outcomes of HSB have been expanded, and relationships between them have been reported. The mediating effects of some variables have also been described. This conceptual framework can facilitate a deep and comprehensive understanding of the HSB determination process for migrants, including internal migrants.

A community developed conceptual model for reducing long-term health problems in children with intellectual disability in India.

Children with intellectual disability (ID) have a higher risk of long-term health problems in adulthood. India has the highest prevalence of ID of any country with 1.6 million under-five children living with the condition. Despite this, compared with other children, this neglected population is excluded from mainstream disease prevention and health promotion programmes. Our objective was to develop an evidence-based conceptual framework for a needs-based inclusive intervention to reduce the risk of communicable and non-communicable diseases among children with ID in India. From April through to July 2020 we undertook community engagement and involvement activities in ten States in India using a community-based participatory approach, guided by the bio-psycho-social model. We adapted the five steps recommended for the design and evaluation of a public participation process for the health sector. Seventy stakeholders from ten States contributed to the project: 44 parents and 26 professionals who work with people with ID. We mapped the outputs from two rounds of stakeholder consultations with evidence from systematic reviews to develop a conceptual framework that underpins an approach to develop a cross-sectoral family-centred needs-based inclusive intervention to improve health outcomes for children with ID. A working Theory of Change model delineates a pathway that reflected the priorities of the target population. We discussed the models during a third round of consultations to identify limitations, relevance of the concepts, structural and social barriers that could influence acceptability and adherence, success criteria, and integration with existing health system and service delivery. There are currently no health promotion programmes focusing on children with ID in India despite the population being at a higher risk of developing comorbid health problems. Therefore, an urgent next step is to test the conceptual model to determine acceptance and effectiveness within the context of socio-economic challenges faced by the children and their families in the country.

Gender in public health research: Reflections on design and process across four research projects in low-and middle-income countries.

A growing body of work clearly documents the gendered inequalities in health. The COVID-19 pandemic further exposed these deep inequities: men appear to be more vulnerable to poorer outcomes, but most of the global health workforce is female who are at increased risk of exposure to hospital infection. However, researchers often fail to adequately embed gender as part of the public health research. This paper reports findings from a synthesis exercise that identified some of the challenges of integrating gender in the design and processes of research studies in four projects conducted in six low- and middle-income countries. Through a collective retrospective meta-synthesis process with researchers from each project, we identified two main themes; (i) we deep dive on two of the structural pillars of conducting public health research (design and process) and (ii) we describe some of the underlying opportunities and resistances to the integration of a gender perspective in these research projects. In conclusion, we suggest that public health funding bodies require researchers to integrate gender in public health research from early on as part of the design and to conduct gendered analysis, as part of the overall drive towards more equitable health systems delivery.

Application of big data in ophthalmology.

The advents of information technologies have led to the creation of ever-larger datasets. Also known as big data, these large datasets are characterized by its volume, variety, velocity, veracity, and value. More importantly, big data has the potential to expand traditional research capabilities, inform clinical practice based on real-world data, and improve the health system and service delivery. This review first identified the different sources of big data in ophthalmology, including electronic medical records, data registries, research consortia, administrative databases, and biobanks. Then, we provided an in-depth look at how big data analytics have been applied in ophthalmology for disease surveillance, and evaluation on disease associations, detection, management, and prognostication. Finally, we discussed the challenges involved in big data analytics, such as data suitability and quality, data security, and analytical methodologies.

Human Services and Behavioral Health Integration: A Model for Whole-Person Medicaid Managed Care.

A comprehensive, whole-person approach to individuals' health care can be achieved by aligning, integrating, and coordinating health services with other human services. HealthChoices, Pennsylvania's managed Medicaid program, delegates responsibility for Medicaid-funded behavioral health service management to individual counties or multicounty collaboratives. County administrators' programmatic and fiscal oversight of Medicaid-funded services allows them to create synergies between behavioral health and other human service delivery systems and to set priorities on the basis of local needs. This model supports access to community-based care, integration of general medical and behavioral health services, and programs that address social determinants of health.