Health Opportunities Research Articles

Impact of COVID-19 on the Pediatric Primary Care Model in Catalonia: Analysis of Changes in the Number and Type of Face-to-Face and Remote Visits.

The outbreak of COVID-19 has turned the care model of health systems around the world upside down. The health care crisis has led to opportunities for digital health to deliver quality care, and the system has been redirected toward telemedicine. In Catalonia, Spain, as of March 2020, the pattern of visits in primary care pediatric consultations changed, such that face-to-face visits decreased in favor of non-face-to-face visits. This study aimed to analyze variations in the types of pediatric visits in primary care centers in Catalonia before and after the onset of COVID-19. This was a descriptive observational study based on administrative data. The number and type of visits to primary care pediatric services in Catalonia between January 2019 and December 2022 were studied. A drop of more than 80% in face-to-face visits and an increase of up to 15 times in remote visits were observed as of March 2020 compared to the previous year. Subsequently, the face-to-face attendance rate began to recover, although it did not reach the same rate as before COVID-19. Non-face-to-face visits were maintained, representing more than 20% of the total after more than 2 years of the pandemic. COVID-19 has been the trigger for a transition in the types of visits to primary care pediatric services. The COVID-19 pandemic was a clear catalyst for the integration of telemedicine in Catalan pediatric health care. In this context, although face-to-face consultations have recovered in absolute numbers, after the pandemic period, the weight of telemedicine has increased.

Healthcare Public Relations – A Pilot Study in Romania

Communication is a critical component in the process of providing quality healthcare services and products. The role of public relations (PR), as a strategic, proactive, and responsible type of communication, is to establish and maintain a positive reputation and relationships with the public, based on trust and mutual understanding. Given the complex approach and process of this activity, when properly applied, PR can bring benefits to all stakeholders in the healthcare sector, contributing positively to its overall realities and outcomes. This paper presents the results of an exploratory pilot study aimed at identifying the coordinates of PR in the Romanian health sector by investigating perceptions on health public relations (HPR), its potential, challenges and opportunities, and stakeholders in healthcare. It is based on qualitative research, using interviews with a mixed group of professionals from the public and private sectors (doctors, medical service coordinators, medical professors, managers, and owners of entities that provide health services and products, and strategic communication professionals working for companies in healthcare). The results are discussed alongside relevant findings provided by previously published studies. In the final part of the article, the author proposes a PR model for entities in the medical area. It emphasizes that HPR should not only be used as a tactical tool or alternative to marketing efforts, nor only intended to manage an undesirable image or deliver damage control after an inconvenient situation or crisis. Instead, HPR services are at their true potential when a strategic approach is applied proactively, based on complex research and planning, designed to engage stakeholders and motivate them towards collaborative communication and sustained effort, based on partnership, for efficient and effective results in the health sector.

Exploring the Impact of Son Preference on the Well-being of Daughters in Tanzania: A Multifaceted Analysis

In Tanzania, entrenched cultural norms favoring male offspring significantly influence family dynamics and pose considerable challenges to the well-being of daughters. This phenomenon, known as son preference, manifests in biased resource allocation, limited educational opportunities, and distinct healthcare differentials. This study delves into the multifaceted consequences of son preference on Tanzanian daughters, particularly in the Arusha Region. The cultural roots of son preference in Tanzania can be traced to historical and societal norms, where male heirs are traditionally viewed as primary caretakers and providers for aging parents. This mindset leads to biased resource allocation, impacting daughters' access to essential resources such as education, healthcare, and nutrition. Educational disparities are particularly pronounced, limiting girls' prospects and perpetuating gender-based inequalities in the workforce. The study employs a mixed-method approach, combining qualitative and quantitative data collection and analysis. It adopts a descriptive survey design, conducted in all seven district councils of Arusha Region. Both probability and non-probability sampling techniques are applied to select respondents, encompassing young women, girls, and stakeholders from various organizations. Results indicate a prevalent acknowledgment of son preference, particularly in pastoralist and agro-pastoralist communities. The study reveals how son preference affects education, health, and economic opportunities for daughters. Educational disparities, early marriage, unequal access to health care, and limited economic prospects are identified consequences. To address these challenges, the study emphasizes the need for a comprehensive approach involving changes in societal attitudes, policies promoting gender equality, and initiatives to empower girls. By challenging ingrained cultural norms, fostering educational opportunities, and ensuring equal access to healthcare, Tanzania can work towards dismantling barriers hindering the potential of its daughters. The study contributes to the discourse on gender equality, advocating for interventions that ensure the holistic development and flourishing of Tanzanian daughters.

Contribution of the veterinary profession to the Australian animal health surveillance system and opportunities for future contributions

Animal health surveillance is crucial for early detection of emergency animal diseases and effective responses. However, surveillance systems are complex and rely on the contributions of many animal health stakeholders. Veterinarians are key stakeholders in this system, given their role and skills in investigating, diagnosing, and reporting notifiable diseases. This study investigated the contribution of the veterinary workforce to the Australian animal health surveillance system and opportunities for future involvement. To achieve the aims of the study, an online cross-sectional survey among the veterinary profession was conducted. Descriptive statistics and regression analyses were used to provide an overview and investigate drivers of attitudes and practices of veterinarians in relation to animal health surveillance. A total of 311 usable responses were obtained, with 191 being from veterinarians who worked in private practice in the previous 12 months. Among private practitioners, 58.6% worked with companion animals, 34.0% were mixed practice veterinarians and 7.3% were equine veterinarians. Over half (56.6%) of all participants considered themselves active participants in the local animal disease management system. The level of confidence in understanding the reporting system and knowing and identifying signs of endemic and exotic diseases was moderate among those working in private practice, with companion animal veterinarians reporting the lowest levels of confidence (p < 0.05). Approximately 40% of veterinarians had taken samples for diagnosis for notifiable diseases in the last year, with just over 20% reporting a notifiable disease. Awareness of and participation in training and surveillance programs for animal diseases by veterinarians was low, with those working in private practice having lower levels of both awareness and participation for most programs. In relation to potential future contribution to the surveillance system, over half of participants reported being interested and available to undertake surveillance work on behalf of the government, with those in mixed practice reporting higher levels of interest (69.6%) compared to those in companion (49.5%) and equine practice (30.8%). However, key challenges identified were related to perceived conflict of interest, and tensions between client needs and government agenda, followed by profitability and suitability of the business. This study provides evidence of a significant existing contribution by the veterinary profession to the surveillance system, and the capacity and willingness to increase this contribution. However, there are gaps in awareness, confidence and participation, as well as financial and veterinary-client relationship challenges that should be considered in any future planning to strengthen the Australian surveillance system.

Finding flow in pandemic times: Leisure opportunities for optimal experience and positive mental health among Italian university students

The restrictions imposed during the COVID-19 pandemic disrupted citizens’ lives worldwide. In this emergency context, mental health levels and flow-promoting activities – with specific attention to leisure - were investigated among 1281 Italian university students attending courses in Health Sciences (HS) and Humanities, Social and Political Sciences (HuPS). They participated in an online survey including, among other instruments, the Mental Health Continuum-Short Form (MHC-SF), an open-ended question investigating flow activities, and demographic information. Most participants identified flow-promoting activities, primarily in the Productive and Leisure domains, but languishing students, as indicated by their scores on the MHC-SF, did it in a significantly lower percentage. Within Leisure, HuPS students reported Media/Reading and Hobbies, while HS students mentioned Sports in significantly higher percentages, suggesting a connection between flow activities and participants’ academic and professional goals. Findings also suggested that promoting flow among languishing students can help counterbalance their documented higher risk for psychopathology.

Standards of proficiency for registered nurses-To what end? A critical analysis of contemporary mental health nursing within the United Kingdom context.

Against the backdrop of cultural and political ideals, this article highlights both the significance of mental health nursing in meeting population needs and the regulatory barriers that may be impeding its ability to adequately do so. Specifically, we consider how ambiguous notions of 'proficiency' in nurse education-prescribed by the regulator-impact the development of future mental health nurses and their mental health nursing identity. A key tension in mental health practice is the ethical-legal challenges posed by sanctioned powers to restrict patients' freedom at the same time as the desire (and obligation) to promote patients' self-determined recovery. The genericism of the UK's Future Nurse Standards do little to prepare mental health nurses to navigate the tensions that ensue. This has consequences for nurses and patients alike, as both risk experiencing the distress and dissonance that attends giving or receiving poor care. We argue that more needs to be done to enable mental health nurses to define and articulate the nuances of the profession as part of becoming critical, thoughtfuland confident practitioners. Educators can contribute to this mission by aligning curriculum, pedagogyand assessment to create meaningful opportunities for mental health nursing students to engage with the complexities of mental health nursing practice. Without this, the credibility of the profession will continue to be questioned; its future uncertain.

Investigating the socio-ecological model factors influencing physical activity and health promotion among early adolescents in the southern parts of Ethiopia

Background: Currently the increased level of physical inactivity and lack of attention to health initiatives in educational settings is a hot issue in Ethiopia and worldwide. Therefore, the present study aimed to investigate socio-ecological model factors hindering the promotion of school physical activity programs among early adolescents in the Gamo Zone primary schools, in the southern part of Ethiopia. Methods: The study conducted a mixed-method design to explore the roles and perspectives of stakeholders, using semi-structured interviews. Then, Thematic analysis and IBM SPSS (ver. 26) were used to analyze the data. Participants: The study purposely involved 20 respondents, aged 40.60±7.90 SD with a work experience year of 14.5±7.714 SD from in and out of schools. Results: The study found that physical activity is crucial medicine to prevent non-communicable diseases, and enhance overall health opportunities, and academic performance in school-aged early adolescents. However, issues such as inadequate physical education curriculum, lack of qualified teachers, and lack of facilities hindered the implementation of physical activity programs in the Gamo zone primary schools. Recommendation: The study put forward that collaboration of stakeholders and the school community should be a key strategy to boost physical activity in school settings. Also, further research is needed on different research methods to examine obstacles to school health initiatives.

Focused ultrasound therapy in movement disorders: management roadmap toward optimal pathway organization.

MRI-guided focused ultrasound (MRgFUS) lesioning is an innovative, safe and effective treatment which provides an innovative development in the field of minimally invasive stereotactic neurosurgery. Based on the application of focused ultrasound energy under full MR planning and thermal imaging control, unilateral lesioning of the thalamus, subthalamic nucleus, and globus pallidus is indicated for the treatment of movement disorders, including essential tremor, Parkinson's disease, and dystonia. We started to apply this technique in February 2019 for the treatment of patients with movement disorders. The authors developed a diagnostic therapeutic care pathway, which is herewith proposed and applied as an explication of standard clinical practice in use. The project was the result of the application of different methods such as Health Technology Assessment (HTA), Strengths, Weaknesses, Opportunities and Threats analysis (SWOT) and Demin -Plan, Do, Check, Act (PDCA) cycle. The aim of this project was to standardize the MRgFUS diagnostic-therapeutic pathway (DTP), describe its application and the appropriateness of different phases (patient selection, intervention phase and follow-up). Here, we described in detail our experience in the DTP application from 2019 up to now in 610 patients with movement disorders.

Business Opportunities and Drivers for Health and Spa Tourism: A Qualitative Research on Baile Felix Spa Resort, Romania

The tourism sector has witnessed continuous development over the last few decades, overcoming various challenges and crises. This resilience underscores the remarkable diversity of managerial and entrepreneurial initiatives capable of meeting the ever-growing and unpredictable global demand. Our objective is to explore the perceptions of factors and opportunities that encourage the launch and management of businesses in health and spa tourism utilizing a qualitative methodology. Our conclusions are based on the analysis of 32 hotel managers’ and small business owners’ interviews in a relevant tourist resort in Romania. This study reveals that all four types of identified opportunities and drivers influencing business creation and management in health and spa tourism (i.e., improving work quality and independence, professional and personal development, responses to opportunities, and upgrading existing services) are substantially influenced by gender, relevant work experience, and education. The novelty of our research lies in highlighting the influence of these drivers according to a specific context given by the size, management type, and ownership structure of tourism ventures, as well as the difference between large hotel managers and small business owners in terms of their perception and goals. We acknowledge that the limited number of interviewees and the spatially bound context of the research may have an effect on the relevance of the results. This study’s findings underscore the necessity for compromise and collaboration among diverse stakeholders in the tourism industry, particularly when developing long-term strategies for health and wellness destinations. This collaborative approach plays a critical role in promoting the well-being and prosperity of individuals, businesses, and the entire local community.

Combination Social Protection Programme as an HIV Prevention Mechanism: Experiences of Youths in Resource-Constrained Settings of Gauteng Province, South Africa

Regardless of the tremendous growth of combination social protection as a human immunodeficiency virus prevention mechanism in South Africa, little is known about the ways in which combination social protection improves prevention outcomes for youths. In this article, we report on the experiences of youths participating in the combination social protection. In the study, which was conducted among Black African youths in the City of Johannesburg township settings of Soweto, Alexandra, and Orange Farm, we adopted a qualitative approach. The aim of the study was to explore the experiences of youths participating in the combination social protection and their views on how the programme changed their risk behaviour and sexual practices. We used a purposively selected sample to identify participants for semi-structured qualitative interviews. In-depth individual interviews were conducted with thirty youths and focus group discussions with six non-governmental organisations practitioners and five Department of Social Development officials. The data were analysed by implementing Creswell and Creswell’s strategy of qualitative thematic analysis. The findings show that when youths are equipped with prevention informational resources, economic capabilities, and social assets, they are empowered with agency and purposefulness that may alter their intentions to engage in risky sexual behaviour. It is also revealed that, by providing space for youths to engage on issues of gender and differential access to health and economic opportunities, the programme advanced the empowerment of female youths. Thus, combination social protection could be part of the country’s comprehensive social work package for empowering youths in poor localities.

Health Business Sustainability in the Era of Globalization: a Reflection Analysis of Readiness and Challenges in Indonesia and the World

Every human being in any part of the world needs continuous health, both in normal conditions and in pandemic conditions. Health is one of the human capital that is indispensable in supporting economic development. This is because health is a prerequisite for increased productivity. Along with the development of today's era, the development of digitalization has grown rapidly. This has an impact on the sustainable health business at this time. This study aims to describe various health business challenges and opportunities that will be faced in the era of industrial globalization. This research uses a qualitative approach with a literature study method, which collects various information answering the formulation of research problems through various sources such as books and journals. The results of this study show that Globalization and climate change can be a significant influence on an economy, as happened in Indonesia and other countries. Globalization can affect policies set in the country specifically in other fields. The health industry makes all healthcare industry providers compete with each other to compete for competitive advantage amid potential health markets

Neighborhood-level sleep health and childhood opportunities.

Regional sleep differences may reflect other important indicators of health and well-being. Examining sleep health at the regional level can help inform policies to improve population health. We examined the relationship between neighborhood-level adult sleep health (modeled in this study via adult sleep duration) and other health metrics and multiple indicators of child-relevant opportunity. Data were obtained from the "500 Cities" data collected by the CDC, including the proportion of the adult population in each tract that report obtaining at least 7 h of sleep. The Child Opportunity Index (COI) provides indices for "education," "health and environment," and "social and economic" domains, as well as a global score. When data were merged, 27,130 census tracts were included. Linear regression analyses examined COI associated with the proportion of the adult population obtaining 7 h of sleep. Adult sleep duration was associated with global COI, such that for each additional percent of the population that obtains ≥ 7 h of sleep, COI increases by 3.6 points (95%CI[3.57, 3.64]). Each component of COI was separately related to adult sleep duration. All associations were attenuated but significant in adjusted analyses. In stepwise analyses, sleep health via adult sleep duration emerged as the strongest correlate of global COI, accounting for 57.2% of the variance (p < 0.0001). Similarly, when stepwise analyses examined each component of COI as dependent variable, sleep health consistently emerged as the most substantial correlate (all p < 0.0001). Community levels of sufficient sleep are associated with greater childhood opportunities, which itself is robustly associated with a wide range of health and economic outcomes. Future work can examine whether this association can develop into scalable interventions.

Behavioural responses to the COVID-19 pandemic and their implications for Sustainable Development Goals in Hong Kong

ABSTRACT This paper examines the nexus between behaviours, the Sustainable Development Goals (SDG), and the behavioural changes induced by the COVID-19 pandemic in Hong Kong. Through an extensive review of 208 written sources spanning March 2020 to July 2021, the study analyses how the pandemic has affected the progress and relevance of the SDG targets in the city. Using UN-provided SDG indicators, the study evaluates the written accounts of behavioural change and establishes the linkages between them and the SDGs. Saaty’s Analytical Hierarchy Process was applied to rank 75 SDG sub-targets according to their importance and urgency in Hong Kong’s pandemic context. Notably, four SDGs stand out among the top 15: SDG3 (Good Health and Well-being), SDG8 (Decent Work and Economic Growth), SDG1 (No Poverty), and SDG10 (Reduced Inequalities), reflecting the significant challenges and opportunities for public health, the economy, vulnerable communities, and environmental sustainability in Hong Kong. The paper provides a comprehensive framework for developing post-pandemic strategies to address the city’s SDG targets. It also offers valuable insights into health, consumption, social and environmental engagement, quality of life, and institutions and organisations for policymakers and stakeholders involved in Hong Kong’s pandemic recovery and sustainable development efforts.

Determinants of body weight changes during Ramadan fasting in India amid COVID-19: A cross-sectional study.

Ramadan intermittent fasting (RIF) presents unique challenges and opportunities for public health and clinical practice, especially in populations with a high prevalence of non-communicable diseases. This study aims to investigate the impact of RIF on weight change among Indian Muslims and explore the associated demographic, dietary, and behavioral factors. A cross-sectional survey was conducted with a sample of Indian Muslim adults who observed RIF. Participants were asked to report their demographic information, family and personal health history, and dietary and lifestyle behaviors before and during Ramadan month. The primary outcome was body weight change, with secondary outcomes including changes in dietary patterns, physical activity, and other health-related lifestyle behaviors. The study found that during Ramadan, nearly half of the participants (48.5%) self-reported a retained initial weight, while a significant fraction (30.9%) self-reported a modest weight reduction between 0.5 to 2.5 kg at the end of Ramadan. Additionally, self-reported eating practices demonstrated moderately altered by about half (48.4%) of the study participants, with 32.2% reporting minor changes and 8.2% indicating substantial changes. An urban residence was associated with a higher likelihood of weight gain, where urban residents showed 3 times the odds of increased weight compared to rural inhabitants. Employment status emerged as a significant determinant for weight fluctuation, influencing both weight gain and loss. During Ramadan, there was a significant rise in snacking frequency, increasing from 21.7% to 32.6% in comparison with pre-Ramadan. The consumption of large quantities of food more frequently grew from 14.9% to 36%, and the incidence of eating despite not being hungry went up from 17.4% to 33.2%. The study demonstrates that RIF is associated with variable changes in body weight among adult Indian Muslims, influenced by urbanization, employment status, and dietary changes. The findings suggest that clinicians should provide tailored advice about body weight regulation during Ramadan and consider integrating community-based health initiatives within religious settings to improve health outcomes.

Inequality in the distribution of resources and health care in the poverty quintiles: Evidence from Peruvian comprehensive health insurance 2018-2019

&lt;b&gt;Introduction: &lt;/b&gt;In many regions of the world, healthcare is inequitable and limited, affecting poor populations who need greater health opportunities. Given that Peru’s comprehensive health insurance (SIS) seeks to enhance its coverage for the entire population, it is important to know if its coverage benefits the poorest populations.&lt;br /&gt; &lt;b&gt;Objectives: &lt;/b&gt;To determine the allocation of SIS resources and care to the poorest quintile during 2018 and 2019 in Peru.&lt;br /&gt; &lt;b&gt;Methods:&lt;/b&gt; We conducted a secondary analysis of data from five Peruvian technical institutions. In 39,8207 Peruvian households, we analyzed the per capita budget assigned to the population affiliated with SIS in microregions of quintile 1 and quintile 2 (poor), and quintile 4 and quintile 5 (non-poor), health coverage, and the level of poverty considering the human development index (HDI) and the regional competitiveness index (RCI).&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt; The poorest regions are inversely correlated with HDI and RCI and have an average service of 25.0% affiliates. In poor areas, the allocated budget was lower (approximately $303,000 to $2.2 million), but the proportion of members requiring care was higher (&amp;gt;70.0%). The budget allocated to health was unfair (p&amp;lt;0.05) between poor areas (maximum resources from $96.28 to $108.14) and non-poor areas (maximum resources from $150.00 to $172.43). Low budget allocations and low household per capita income contributed to poverty in quintile 1 and quintile 2 (p&amp;lt;0.01).&lt;br /&gt; &lt;b&gt;Conclusions:&lt;/b&gt; the poorest regions have greater inequity and the majority of affiliates do not use or do not have access to SIS services, but they have a greater need for health care. In addition, poor regions have a high amount of population without SIS coverage, and low allocated budgets, which affects competitiveness and regional development.

Preconception health risks by presence and type of disability among U.S. women

BackgroundPoor preconception health may contribute to adverse perinatal outcomes among women with disabilities. While prior research has found higher prevalence of preconception health risks among women with versus without disabilities, existing U.S. studies have not assessed how preconception health risks may differ by disability type. Understanding such differences is relevant for informing and targeting efforts to improve health opportunities and optimize pregnancy outcomes. ObjectiveThis cross-sectional study examined preconception health in relation to disability type among reproductive-age women in the United States. MethodsWe analyzed 2016–2019 data from the Behavioral Risk Factor Surveillance System to estimate the prevalence of 19 preconception health risk among non-pregnant women 18–44 years of age. We used modified Poisson regression to compare women with different types of disability to non-disabled women. Disability categories included: 1) hearing difficulty only; 2) vision difficulty only; 3) physical/mobility difficulty only; 4) cognitive difficulty only; 5) multiple or complex disabilities (including limitations in self-care or independent living activities). Multivariable analyses adjusted for other sociodemographic characteristics such as age and marital status. ResultsWomen with each disability type experienced a higher prevalence of indicators associated with poor preconception health compared to women with no disabilities. The number and extent of health risks varied substantially by disability type. Women with cognitive disabilities and women with multiple or complex disabilities experienced the greatest risk. ConclusionsAddressing the specific preconception health risks experienced by women with different types of disabilities may help reduce adverse perinatal outcomes for disabled women and their infants.

Applying Team Science to Collaborative Digital Health Research: Learnings from the Wearable Clinic.

Collaboration across disciplinary boundaries is vital to address the complex challenges and opportunities in Digital Health. We present findings and experiences of applying the principles of Team Science to a digital health research project called 'The Wearable Clinic'. Challenges faced were a lack of shared understanding of key terminology and concepts, and differences in publication cultures between disciplines. We also encountered more profound discrepancies, relating to definitions of "success" in a research project. We recommend that collaborative digital health research projects select a formal Team Science methodology from the outset.

Can increased support to foster care families reduce the number of moves for children in out‐of‐home care? Evidence from Norway

AbstractNorwegian youth in out‐of‐home care move three times as frequently as their peers. Such placement instability is linked to negative outcomes in terms of social attachment, well‐being, educational achievements, health, and future opportunities. Norway implemented a new child welfare service reform in 2022 that increased the municipalities responsibilities for out‐of‐home care. The “incentive package” and “Barneløftet” were measures implemented to prepare the municipalities for these changes. This study evaluates how the implemented measures affect the number of moves within out‐of‐home care in Trøndelag county. An event‐study design with difference‐in‐difference estimates was used to study the effect of the measures. The data are Norwegian registers that include most children in out‐of‐home care from 2013 to 2021. The findings of this study indicate that increased support for foster care homes significantly reduces the number of moves. Increased placement stability is associated with an increased sense of belonging, thus facilitating positive development.

Synergistic interplay of UV radiation and urban particulate matter induces impairment of autophagy and alters cellular fate in senescence-prone human dermal fibroblasts.

Skin aging is a complex process influenced by intrinsic factors and environmental stressors, including ultraviolet (UV) radiation and air pollution, among others. In this study, we investigated the effects of UVA and UVB radiation, combined with urban particulate matter (UPM), on human dermal fibroblasts (HDF). We show here that treatment of HDF with a subcytotoxic dose of UVA/UVB results in a series of events leading to mitochondrial dysfunction, increased ROS levels, and DNA damage. These effects are known to trigger either cellular senescence or cell death, depending on the cells' ability to clear damage by activating autophagy. Whereas UPM treatment in isolation did not affect proliferation or survival of HDF, of note, simultaneous UPM treatment of UV-irradiated cells selectively inhibited autophagic flux, thereby changing cell fate of a fraction of the cell population from senescence to apoptotic cell death. Our findings highlight the synergistic effects of UV radiation and UPM on skin aging, emphasizing the need to consider these factors in assessing the impact of environmental stressors on human health and opening opportunities for developing comprehensive approaches to protect and preserve skin integrity in the face of growing environmental challenges.

A Hybrid Pragmatic and Factorial Cluster Randomized Controlled Trial for an Anti-racist, Multilevel Intervention to Improve Mental Health Equity in High Schools

Systemic racism is pervasive in US society and disproportionately limits opportunities for education, work, and health for historically marginalized and minoritized racial and ethnic groups, making it an urgent issue of social justice. Because systemic racism is a social determinant of health prevalent across multiple social and institutional structures, it requires multilevel intervention approaches using effective designs and analytic methods to measure and evaluate outcomes. Racism is a fundamental cause of poor health outcomes, including mental health outcomes; thus, mental health services and programs that address racism and discrimination are key to promoting positive mental health of racial and ethnic minority youth. While multilevel interventions are well-suited for improving outcomes like youth mental health disparities, their evaluation poses unique methodological challenges, requiring specialized design and analytic approaches. There has been limited methodological guidance provided to researchers on how to test multilevel interventions using approaches that balance methodological rigor, practicality, and acceptability across stakeholder groups, especially within communities most affected by systemic racism. This paper addresses this gap by providing an example of how to rigorously evaluate a hypothetical, theoretically based, multilevel intervention promoting mental health equity in three US school systems using an anti-racist approach intervening at the macro- (i.e., school system), meso- (i.e., school), and micro- (i.e., family and student) levels to improve mental health in adolescents. We describe the design, sample size considerations, and analytic methods to comprehensively evaluate its effectiveness while exploring the extent to which the components interact synergistically to improve outcomes. The methodological approach proposed can be adapted to other multilevel interventions that include strategies addressing macro-, meso-, and micro-levels of influence.