Health Policy Changes Research Articles

Finite-time stability analysis and control of stochastic SIR epidemic model: A study of COVID-19

Finite-time stability analysis is a powerful tool for understanding the long-term behavior of epidemiological models and has been widely used to study the spread of infectious diseases such as COVID-19. In this paper, we present a finite-time stability analysis of a stochastic susceptible–infected–recovered (SIR) epidemic compartmental model with switching signals. The model includes a linear parameter variation (LPV) and switching system that represents the impact of external factors, such as changes in public health policies or seasonal variations, on the transmission rate of the disease. We use the Lyapunov stability theory to examine the long-term behavior of the model and determine conditions under which the disease is likely to die out or persist in the population. By taking advantage of the average dwell time method and Lyapunov functional (LF) method, and using novel inequality techniques the finite-time stability (FTS) criterion in linear matrix inequalities (LMIs) is developed. The finite-time stability of the resultant closed-loop system, with interval and linear parameter variation (LPV), is then guaranteed by state feedback controllers. By analyzing the modified SIR model with these interventions, we are able to examine the efficiency of different control measures and determine the most appropriate response to the COVID-19 pandemic and demonstrate the efficacy of the suggested strategy through simulation results.

Experiencing and treating ‘madness’ in the United States circa 1967–2022: Critical counter-histories

Over the past 55 years, in the United States, we have witnessed shifts and changes in mental health treatment practice and policy focused on ‘psychosis.’ Alarmingly, in this same period, neither in its social location nor its clinical outcomes, has psychosis, particularly multi-episode psychosis, shown much substantive improvement (Hansen et al., 2022; Huxley et al., 2021). Epidemiological studies of stigma have documented the worsening of perceived dangerousness and desired social distance (Pescosolido et al., 2010, 2019), while long-term trajectories include extraordinarily high rates of incarceration, homelessness, and unemployment (Lin et al., 2022; Ramsay et al., 2012; Wildeman and Wang, 2017). Disengagement from “services” viewed by users as unresponsive to the user's actual needs and values is thought to be part of the problem, although it is not clear that those who do engage do better (Hansen et al., 2022). Written from the first-person perspectives of current/former “users”—people who have experienced psychosis and “used” services—this paper leverages critical counter-history, conceptual analysis, and autoethnography to ask how and why treatment policies and practices continue to fail so many persons labelled with psychosis in the United States. Outcome, we argue, hangs on much more than clinical effort. We thus explain widespread “treatment failure” as a consequence of interpersonal misunderstanding and misrecognition as well as entrenched structural and institutional ableism, racism, and classism—factors to which clinical services and individualizing narratives alike consistently fail to adequately respond. On a more hopeful note, we trace histories of activist (user/survivor) resistance. This includes efforts that may appear fledgling or transient, but that have nevertheless sustained a distinctly different vision of what might be possible.

Abstract 45: How Did States Adapt Their Cancer Control Plan During the COVID-19 Pandemic?

Abstract Purpose: The COVID-19 pandemic upended the delivery of cancer services across the care continuum. In the United States, the federalist system of governance led to health policy changes by federal, state, and local jurisdictions. At the intersection of these levels of government are state cancer control plans. Funded by the federal government, state cancer control plans are developed by state health departments in collaboration with healthcare providers, public health agencies, and community organizations. By outlining specific strategies for addressing cancer in the state, these plans serve a critical role during a public health emergency. This policy analysis aims to understand how states updated their cancer control plan as a response to COVID-19. Methods: This qualitative policy analysis began by reviewing the cancer control plans of all 50 states and the District of Columbia. The inclusion criteria required that each plan be updated after March 2020 and included language related to “COVID”. These plans were then analyzed for COVID-19 related adaptations along three themes: 1) cancer care continuum, 2) service delivery, 2) population health and equity. Results: Among the 51 cancer plans analyzed, seven plans met the inclusion criteria (IL, IA, ME, NV, NC, UT, VT). Three states (IL, IA, ME) adapted their plans to increase cancer screenings, two plans to increase clinical trials (IA, ME), and one plan each targeted increased treatment (NC) and prevention activities (NV). Three states identified telehealth as a priority for service delivery (IL, NV, UT), but only two (IL, UT) identified telehealth equity as a barrier. Two states (IA, NC) prioritized addressing workforce shortage and disruptions caused by the pandemic. Health insurance loss and public health investments were also identified as service delivery concerns. Two states (IL, IA) acknowledged the role of social determinants of health exacerbating COVID-19 and cancer inequalities. Food insecurity (NV, UT) and job loss (ME, NV, UT) were also components of equity within these plans. Utah explicitly acknowledged the role of racism and gender as related to the disparate impact of COVID-19 on cancer care. Conclusion: This analysis highlighted how states adapted their cancer control plans in response to COVID-19 and may inform ongoing policy debate. Continued policy surveillance and evaluation could ensure that cancer patients receive timely, appropriate care during public health emergencies. Citation Format: Jason Semprini. How Did States Adapt Their Cancer Control Plan During the COVID-19 Pandemic? [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 45.

Issue of Data Imbalance on Low Birthweight Baby Outcomes Prediction and Associated Risk Factors Identification: Establishment of Benchmarking Key Machine Learning Models With Data Rebalancing Strategies.

Low birthweight (LBW) is a leading cause of neonatal mortality in the United States and a major causative factor of adverse health effects in newborns. Identifying high-risk patients early in prenatal care is crucial to preventing adverse outcomes. Previous studies have proposed various machine learning (ML) models for LBW prediction task, but they were limited by small and imbalanced data sets. Some authors attempted to address this through different data rebalancing methods. However, most of their reported performances did not reflect the models' actual performance in real-life scenarios. To date, few studies have successfully benchmarked the performance of ML models in maternal health; thus, it is critical to establish benchmarks to advance ML use to subsequently improve birth outcomes. This study aimed to establish several key benchmarking ML models to predict LBW and systematically apply different rebalancing optimization methods to a large-scale and extremely imbalanced all-payer hospital record data set that connects mother and baby data at a state level in the United States. We also performed feature importance analysis to identify the most contributing features in the LBW classification task, which can aid in targeted intervention. Our large data set consisted of 266,687 birth records across 6 years, and 8.63% (n=23,019) of records were labeled as LBW. To set up benchmarking ML models to predict LBW, we applied 7 classic ML models (ie, logistic regression, naive Bayes, random forest, extreme gradient boosting, adaptive boosting, multilayer perceptron, and sequential artificial neural network) while using 4 different data rebalancing methods: random undersampling, random oversampling, synthetic minority oversampling technique, and weight rebalancing. Owing to ethical considerations, in addition to ML evaluation metrics, we primarily used recall to evaluate model performance, indicating the number of correctly predicted LBW cases out of all actual LBW cases, as false negative health care outcomes could be fatal. We further analyzed feature importance to explore the degree to which each feature contributed to ML model prediction among our best-performing models. We found that extreme gradient boosting achieved the highest recall score-0.70-using the weight rebalancing method. Our results showed that various data rebalancing methods improved the prediction performance of the LBW group substantially. From the feature importance analysis, maternal race, age, payment source, sum of predelivery emergency department and inpatient hospitalizations, predelivery disease profile, and different social vulnerability index components were important risk factors associated with LBW. Our findings establish useful ML benchmarks to improve birth outcomes in the maternal health domain. They are informative to identify the minority class (ie, LBW) based on an extremely imbalanced data set, which may guide the development of personalized LBW early prevention, clinical interventions, and statewide maternal and infant health policy changes.

Building a Framework for a More Inclusive Healthcare System

Objective: With the explosion in the use of telehealth technologies, it is essential to address the challenges in global telehealth inequity in order to create a path to healthcare equality. To this end, this research paper focuses on investigating telehealth as it relates to the COVID-19 pandemic and its impact on healthcare inequality, telehealth inequity, and the continued vulnerabilities with increased demand in implementation. Study Design: A set of voluntary questions were e-mailed to active members of the IEEE-SA (Institute of Electrical and Electronics Engineers Standards Association) Transforming the Telehealth Paradigm: Sustainable Connectivity, Accessibility, Privacy, and Security for all. The interview answers were analyzed via deductive thematic analysis organized into higher themes and theme-specific codes. Setting: The country of residence varied among individuals who are the IEEE-SA Telehealth program members. These continents included: North America, South America, Africa, Asia, and Europe. Participants: Global healthcare leaders who are active members of the IEEE-SA Transforming the Telehealth Paradigm: Sustainable Connectivity, Accessibility, Privacy, and Security for all participated. The occupations of these individuals ranged from a variety of areas within the healthcare domain, such as physicians, scientists, and public health experts. Main outcome measure: Qualitative data obtained voluntarily from global healthcare leaders participating in the IEEE-SA Transforming the Telehealth Paradigm: Sustainable Connectivity, Accessibility, Privacy, and Security for all. Results: The major themes that emerged from the participants' responses included: telehealth infrastructure and access, digital literacy and user interface, government regulations, and telehealth legislation. Conclusions: Telehealth has the power to decrease healthcare disparities, thus getting closer to achieving health equity. However, there are three significant common global barriers to the implementation of telehealth: infrastructure, digital literacy, and government regulations. Because the results were based on interviewer responses, the conclusions acknowledged how the background of respondents, including career and education, influenced their experiences and, thus, the responses. Suggestions for change in reducing barriers to telehealth accessibility are detailed in this research. These suggestions were derived from respondents and focused on the global barriers to implementation. To reduce these barriers, changes in political health policy, patient health education, health provider telemedicine support, and in regulation for telemedicine are suggested. Limitations in our research project included a small sample size and the ensuing lack of representation from more geographical regions.

Impact of public health policy and mobility change on transmission potential of severe acute respiratory syndrome coronavirus 2 in Rhode Island, March 2020 – November 2021

ABSTRACT To study the SARS-CoV-2 transmission potential in Rhode Island (RI) and its association with policy changes and mobility changes, the time-varying reproduction number, Rt, was estimated. The daily incident case counts (16 March 2020, through 30 November 2021) were bootstrapped within a 15-day sliding window and multiplied by Poisson-distributed multipliers (λ = 4, sensitivity analysis: 11) to generate 1000 estimated infection counts, to which EpiEstim was applied to generate Rt time series. The median Rt percentage change when policies changed was estimated. The time lag correlations were assessed between the 7-day moving average of the relative changes in Google mobility data in the first 90 days, and Rt and estimated infection count, respectively. There were three major pandemic waves in RI in 2020–2021: spring 2020, winter 2020–2021 and fall-winter 2021. The median Rt fluctuated within the range of 0.5–2 from April 2020 to November 2021. Mask mandate (18 April 2020) was associated with a decrease in Rt (−25.99%, 95% CrI: −37.42%, −14.30%). Termination of mask mandates on 6 July 2021 was associated with an increase in Rt (36.74%, 95% CrI: 27.20%, 49.13%). Positive correlations were found between changes in grocery and pharmacy, Rt retail and recreation, transit, and workplace visits, for both Rt and estimated infection count, respectively. Negative correlations were found between changes in residential area visits for both Rt and estimated infection count, respectively. Public health policies enacted in RI were associated with changes in the pandemic trajectory. This ecological study provides further evidence of how non-pharmaceutical interventions and vaccination slowed COVID-19 transmission in RI.

Increases in IUD Provision at Alabama Department of Public Health Clinics From 2016 to 2019.

The Alabama Department of Public Health (ADPH) began allocating Title X funding to intrauterine device (IUD) provision at family planning clinics in 2019, instated more training opportunities, and expanded nurse practitioner scope of practice to include IUD placements. We assessed IUD provision and protocols at ADPH Title X clinics in 2016 and 2019 before and after ADPH policy changes. Generalized binomial regression models assessed differences between years. The proportion of ADPH clinics reporting offering any IUD on-site increased by 61.6 percentage points ( P < .001), stockpiling IUDs on-site increased by 85.9 percentage points ( P < .001), IUD placement/removal training increased by 71.4 percentage points ( P < .001), and same-visit IUD placement trainings increased by 64.1 percentage points ( P < .001). Advanced practice nurses were significantly more likely to place IUDs in 2019 compared with 2016 ( P < .001). These findings highlight the positive impact of policy changes related to Title X funding allocation and scope of practice on provision of a full range of contraceptive methods. These changes in policies and practices at the state and local levels within ADPH have expanded the availability of the full range of contraceptive options across the state of Alabama. This expanded access to contraceptive options is especially important given the rapid changes in reproductive health policies occurring in Alabama and across the United States.

Impact of a free care policy on routine health service volumes during a protracted Ebola virus disease outbreak in the Democratic Republic of Congo

BackgroundIn response to the DRC's 10th Ebola Virus Disease (EVD) outbreak, the government subsidized routine health services in select health zones with the goal of maintaining routine service volumes. We assess the impact of the initial and revised Free Care Policies (FCP) on total clinic visits, uncomplicated malaria, simple pneumonia, fourth antenatal care clinic visits, and measles vaccinations, testing the hypothesis that routine services would not significantly decrease during the FCP. Methods and findingsWe used data from the DRC's national health information system spanning January 2017 to November 2020. Intervention facilities were those that were initially and secondarily enrolled in the FCP, which occurred in August 2018 and November 2018, respectively. Comparison facilities were limited to the North Kivu Province and were from health zones that recorded at least one case of Ebola. A controlled interrupted time series analysis was conducted. The FCP appeared to have a positive effect in increasing overall clinic attendance rates, uncomplicated malaria case rates, and simple pneumonia case rates in those health zones where the policy was enacted relative to comparison sites. The longer-term effects of the FCP were mostly non-significant or, if significant, relatively modest in nature. Rates for measles vaccinations and fourth ANC clinic visits appeared to be unaffected or minimally affected, respectively, by the implementation of the FCP and relative to comparison sites. We did not observe the decrease in measles vaccinations that has been observed elsewhere. The study is limited in that we were unable to account for health facility bypassing and service volumes at private health facilities. ConclusionsOur findings provide evidence that FCPs can be used to maintain routine service provision during outbreaks. Additionally, the study design demonstrates that routinely reported health information from the DRC are sensitive enough to detect changes in health policy.

Vale Jude Byrne

March marks the second anniversary of the passing of globally esteemed drug reform advocate Jude Byrne. Internationally, as well as in her home country of Australia, Jude was a courageous advocate for the marginalised. Identifying unapologetically as a person who injects drugs for over 40 years, Jude's living experience drove her human rights perspectives on drug use, law and health. While spearheading political change, Jude inspired generations of people who use drugs, advocates, policy makers, treatment providers and researchers. Jude's passion for human rights and equity shone in her early work with women who use drugs in the 1980s through to her advocacy with politicians, senior bureaucrats and researchers at national and international levels. As a person who used drugs, her profound understanding of the social and political repercussions of marginalisation and stigma laid the foundation for innovative health programs, educational initiatives and policy change. To name a few, Jude coordinated the first peer-based drug user organisation in Canberra, helped to establish the Australian Injecting and Illicit Drug Users League as the national body advocating for people who use drugs in the early 1990s, became the first peer representative on a Prime Minister's Advisory Committee on drug policy and was key to the creation of the International Network of People Who Use Drugs. Jude lived through the heights of the HIV/AIDS and hepatitis C epidemics in Australia and was at the forefront of public health initiatives wherever she could get her foot in the door and even where she could not! Whether it was a high-level committee on national HIV prevention or a small, locally led health initiative to encourage hepatitis C testing, Jude provided advocacy and leadership. Her unique character—both formidable and compassionate—meant that people from all walks of life respected her point of view. Still, it would be remiss to ignore the stigma and discrimination she faced every step of the way. Jude's death underscores the importance of ongoing capacity building for, and investment in, the drug user movement. The type of skills and experience that Jude brought to the field was not built overnight. Such expertise is based on decades of persistence—courageous persistence in the face of intolerance and prejudice. It is often only when we lose a champion that we realise how hard they have had to work and fight to be the voice of their community. It should not have to be so difficult to build and maintain a strong peer-led drug user movement in Australia (and globally). Jude did not just point at the gaps and lament their existence, she committed to the engagement of people who use drugs, as she understood that this is the crucial aspect of driving change. Reflecting on Jude's life, we are struck by the big and small efforts she led to build genuine capacity and facilitate meaningful engagement. But it remains a fact that many harm reduction initiatives around the world are developed and run by peer organisations without appropriate political support and funding. Unremitting peers who fight to ensure that as many people as possible have access to life-saving and life-enhancing harm reduction services. Too often, they are doing it while waiting for broader society to catch up. Jude's passing begs us to honour her legacy by doubling down on our collective responsibility to lift up drug user representatives and to ensure that future leaders do not have to fight the same battles. In honour of Jude's immense contribution to the field, Drug and Alcohol Review is preparing a special section. As a transdisciplinary group of peers, advocates, clinicians and researchers committed to peer leadership in harm reduction, we have commissioned and are editing a series of papers for the section, which will reflect key areas influenced by Jude's life and work. Vale Jude, rest in power—we miss you.

Research on Adolescent Physical Health Policy Change – Based on Discontinuous Equilibrium Theory

Based on the punctuated equilibrium theory, this paper explains the internal mechanism of the policy change of adolescents' physical health. The study found that the youth physical health policy presents an evolution from equilibrium to intermittent to long-term equilibrium. When the policy landscape is relatively stable, the policy will undergo gradual fine-tuning. When the policy landscape cannot adapt to the external environment, the policy will change. . The study not only verified the applicability of the punctuated equilibrium theory for adolescent physical health policies, but also made a Chinese revision of the punctuated equilibrium theory, and provided enlightenment for the decision-making practice of adolescent physical health.

Abstract PR006: Screening under-served populations by mobile low dose computerized tomography (LDCT) scans results in stage shift with potential cures: Time for a change in health policy?

Abstract Background: More than 60% of under-served patients with lung cancer first present with advanced/metastatic disease. Randomized trials have shown that LDCT of chest reduces lung cancer mortality but under-served populations have been excluded from these studies because of financial, geographic, insurance and access problems. We have tested the first mobile LDCT units and demonstrated improved access. We report a shift to earlier stage at diagnosis and potential cures in a large under-served population that includes African American, Hispanic/LatinX and Native American subjects. Methods: We developed two coaches fitted with portable 32 slice low-dose CT scanners to screen uninsured and under-served heavy smokers for lung cancer in an IRB-approved program ("The Oncologist", 2019). All films were reviewed by a central panel (using LUNG RADS protocol). Medicare patients were excluded because their insurance covers LDCT lung screening (but it should be noted that the elderly population is at increased risk for lung cancer, leading to a negative case selection bias). Results: We initially screened 1200 uninsured/under-insured subjects, mean age 61 years (range 55-64), with average pack year history of 47.8 (range 30- &amp;gt;150); 61% male; 18% Black, 3% Hispanic/LatinX, &amp;lt;1% Native American; 78% rural. We found 97 pts with LUNG RADS 4 (very high risk) lesions, 30 lung cancers (2.5%), including 18 at stage I-III treated with curative intent (60%); &amp;gt;50% had intercurrent cardiovascular disease and COPD seen on LDCT. We have additionally screened 574 cases, including 51 Native Americans (in a structured assessment of one tribe). Of the Native Americans, 5 had LUNG RADS 3-4 (high risk) lesions, but no cancers have been identified to date. For the total series of 1774 subjects with age-related negative case selection bias, 42 lung cancers have been identified (2.4%), 26 of which were treated with curative intent (62%) via surgery, radiation, or chemo-radiation. Only one patient of 18 treated with curative intent in the first series of 30 lung cancers has relapsed to date (median follow up 3 years, with 5 without evidence of disease beyond 3.5 years). These data confirm a shift to detection of early-stage lung cancer in this large under-served population, with an apparent potential for cure. Conclusion: Mobile LDCT yields a higher screening rate for under-served patients than prior hallmark trials, with a consequent shift to early-stage detection of lung cancer, with sustained treatment-induced complete remissions beyond 4 years. This approach could be applied to improve national lung cancer survival in the under-served. Citation Format: Derek Raghavan, Darcy Doege, Mellisa Wheeler, Kia Dungan, John Doty III, Glenn Hickman, Kathryn Mileham, Daniel Carrizosa. Screening under-served populations by mobile low dose computerized tomography (LDCT) scans results in stage shift with potential cures: Time for a change in health policy? [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr PR006.

Comparing Neuro-COVID-19 between Waves Requires Clear Cohort Selection.

We read with interest the article by Sureshbabu et al. on a retrospective, single-center, observational study comparing first- and second-wave neurological manifestations of COVID-19.[1] A detailed questionnaire on co-morbidities, admission details, and clinical characteristics was applied to 1700 COVID-19 patients in the first and 1500 COVID-19 patients in the second wave.[1] The most common neurological manifestations of the second wave were headache, fatigue myalgia, dysgeusia, dysosmia, dizziness, encephalopathy, and stroke.[1] Dizziness, myalgia, headache, meningoencephalitis, occurred more commonly in the second wave than in the first wave. Cerebrovascular disease occurred less frequently in the second wave than in the first wave.[1] The mortality of COVID-19 patients with neurological involvement was higher in the second compared to the first wave.[1] The study is appealing but raises concerns that should be discussed. A limitation of the study is its retrospective design. The quality of the data depends heavily on the care and accuracy with which the data were collected and documented. Missing data can no longer be added. Confirmed diagnoses can no longer be corrected. Another limitation relates to the demarcation between first and second wave. There is no mention of how the end of the first wave and the beginning of the second wave was defined. It is therefore conceivable that an overlap occurred and some patients actually belong to the other group or vice versa. Another limitation of the study is that the waves were defined by a time criterion and not be the presence of a specific viral mutant. Different mutants of a virus variant with different pathogenicity and therefore different tropism for the central and peripheral nervous system can circulate during a single wave. Therefore, neither patients of the first nor the second wave represent a homogenous cohort and can therefore only be compared to a limited extent. Another limitation is that it remains unclear how the authors ruled out that neurological manifestations were not a manifestation of the infection but were actually side effects of the treatment the enrolled patients received to treat COVID-19. In particular, neuropathy and myopathy have been reported as side effects of commonly administered anti-COVID-19 drugs, such as colchicine, tocilizumab, prednisolone, or remdesivir.[2] Surprisingly, according to Table 1, the number of imaging examinations is very small. It is therefore conceivable that a number of cerebrovascular abnormalities may actually have been missed. Quite a few patients had to be transferred to the intensive care unit (ICU) (n = 127).[1] Because a stay in the ICU can be complicated by critical illness neuropathy/myopathy,[3] we should know how the authors ruled out that neuropathy or myopathy was actually a critical illness neuropathy/myopathy, but not due to the infection. Another limitation is that the cerebro-spinal fluid (CSF) was obviously not examined in any of the patients.[1] We should therefore know how meningo-encephalitis was diagnosed in the five meningo-encephalitis patients listed in Table 2. Was the diagnosis established just based on the imaging or the clinical picture? It is not comprehensible why a distinction was made between “visual impairment,” “smell and taste disorder,” and “altered sensorium.”[1] We should know which specific sense was altered in the 40 patients with altered sensorium. One second wave patient was diagnosed with cerebral vasculitis.[1] We should know what subtype of vasculitis was diagnosed and how. Has this particular patient had an intracranial artery biopsy or was the diagnosis suspected based on imaging criteria? An unaccounted explanation for the difference between wave one and wave two patients is the variable availability of medical resources over time. With progression of the pandemic, there may have been significant changes in health policy, the pathogenicity of virus variants, and the availability of hospital or ICU beds. Overall, the interesting study has some limitations and inconsistencies that call the results and their interpretation into question. Addressing these limitations could further strengthen and reinforce the statement of the study. Ethics approval Only secondary data were used. Availability of data All data are available from the corresponding author. Author contribution JF: design, literature search, discussion, first draft, critical comments, final approval. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Policy transfer and health policymaking process: The case of social health insurance in Ghana

Since the introduction of the user fee system of healthcare financing in 1969 and its subsequent modifications, the burden of healthcare expenditure on residents of Ghana created health inequality. This system encouraged the poor and vulnerable to have limited access to essential drugs and services. Policy entrepreneurs contributed to raising awareness about the poor and vulnerable people in Ghana not having access to health due to the user fee system as a public policy problem. This awareness began to spread among political leaders, the masses, and professional groups, warranting the attention of policymakers. As significant public dissatisfaction and agitation against the user fee policy continued, the media continued to hold the government responsible for initiating the policy. The democratization process and election period between 1998 and 2000 provided a window of opportunity that led to the idea of health policy change. In 2003, Ghana established the National Social Health Insurance, a form of Social Health Insurance. This study examines the process of establishing the social health insurance scheme through policy transfer framework. First, the paper examines Ghana’s health policy after independence, the National Health Service, and the User Fee Policy that was implemented in 1985. Second, the paper accessed the policy transfer framework and applied it to the transfer of social health insurance. Third, the paper explains the radical change from the user fee policy to the social health insurance model. This essay uses time series analysis and comparative analysis to assess the impact of the social health insurance on the under-five mortality ratio, maternal mortality ratio and out-of-pocket expenditure. The assessment results show that the social health insurance scheme has a positive impact on under-five mortality, maternal mortality and out-of-pocket payment compared to Nigeria without social health insurance for the poor and other vulnerable groups. The paper concludes that policy transfer alone cannot be a single variable to explain radical health policy change, but when combined with other complementary perspectives, an empirically grounded account of policy change can be developed.

Determining the Longitudinal Serologic Response to COVID-19 Vaccination in the Chronic Kidney Disease Population: A Clinical Research Protocol.

People living with chronic kidney disease (CKD) have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic, including higher rates of infection, hospitalization, and death. Data on responsiveness to COVID-19 vaccination strategies and immunogenicity are limited, yet required to inform vaccination strategies in this at-risk population. The objective of this study is to characterize the longitudinal serologic response to COVID-19 vaccination. This is a prospective observational cohort study. Participating outpatient kidney programs within Ontario and British Columbia. Up to 2500 participants with CKD G3b-5D receiving COVID-19 vaccination, including participants receiving dialysis and kidney transplant recipients (CKD G1T-5T). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG antibodies (anti-spike, anti-receptor binding domain, anti-nucleocapsid) will be detected by ELISA (enzyme-linked immunosorbent assay) from serum or dried blood spot testing. In a subset of participants, neutralizing antibodies against novel variants of concern will be evaluated. Peripheral blood mononuclear cells will be collected for exploratory immune profiling of SARS-CoV-2 specific cellular immunity. Participants will be recruited prior to or following any COVID-19 vaccine dose and have blood sampled for serological testing at multiple timepoints: 1, 3, 6, 9, and 12 months post vaccination. When possible, samples will be collected prior to a dose or booster. Participants will remain in the study for at least 1 year following their last COVID-19 vaccine dose. The adaptive design of this study allows for planned modification based on emerging evidence or rapid changes in public health policy surrounding vaccination. Limitations include incomplete earlier timepoints for blood collection due to rapid vaccination of the population. This large multicenter serologic study of participants living with kidney disease will generate data on the kinetics of SARS-CoV-2 immune response to vaccination across the spectrum of CKD, providing insights into the amplitude and duration of immunity conferred by COVID-19 vaccination and allowing for characterization of factors associated with immune response. The results of this study may be used to inform immunization guidelines and public health recommendations for the 4 million Canadians living with CKD.

Assistência à saúde bucal na população LGBTQIA+

ABSTRACT This study analyzes oral health care for the LGBTQIA+ population in view of the lack of information on oral health in this population and the recent changes in the National Oral Health Policy (PNSB), that have weakened progress and enabled setbacks in this area. A descriptive cross-sectional study was carried out, using a semi-structured questionnaire that was self-applied online. A total of 359 people answered, 329 (91.9%) were eligible. Of these, 38% gays, 23.4% lesbians, and 13.4% transgenders. Most were between 18 and 39 years old (73.3%) and Black (51.4%). The percentage of people receiving care was high in the five years prior to the survey (92.9%), as well as in the last six months (44.7%); it was lower in the transgender population (88.7% and 18.2% respectively). Only 18.8% of this population had been treated in the public health system, and this was higher among transgender people (45.5%) and Black people (25.4%). The self-perception of oral health for the majority was good or very good (53.2%); but bad or very bad (45.5%) for transgender. Most reported preferring to be assisted by an LGBT professional (69.0%). The transgender and Black population were the most vulnerable to assistance, indicating that race, gender, and sexuality directly influence access to health care, so an intersectional approach is essential for the organization of the service.

Prioridades de políticas de salud. Encuentro SESPAS en la XXXIII Escuela de Salud Pública de Menorca

ObjectiveIn September 2022, the Sociedad Española de Salud Pública y Administración Sanitaria (SESPAS) brought together a panel of experts with the aim of defining and prioritizing health policy proposals, from the perspective of the Spanish State as a whole, to adapt the National Health System (NHS) to current risks and to contemporary/present-day society. MethodExpert meeting structured using a mix of procedures adapted from brainstorming, nominal group and Rand consensus method techniques. Relevance and feasibility of proposals identified were assessed individually by each panelist. Proposals were then ordered thematically and ranked according to the median and quartile deviation of relevance scores. ResultsPanelists identified and prioritized several proposals in different areas: governance and funding of the NHS, reform of the portfolio of services and benefits and of the NHS human resources, public health and health policy, actions against inequality and poverty, and healthcare delivery reform, including socio-sanitary, primary and end-of-life care. ConclusionsThe results of the meeting show the urgent need to address in-depth changes in many state-wide health policies, including a major reconfiguration of governance, public health, and health care structures. They also point out potential areas of improvement, constituting a tentative guide of prioritized issues to be addressed.

The Epistemology and Ethics of Analysing Lived Experience Data: A Pragmatic Foucauldian-Informed Approach to Coproducing Student Mental Health Initiatives in the Neoliberal University

Analysis of lived experience data is increasingly advocated as an enabling strategy to inform ethical and effective policy and practice, particularly in the university mental health field. However, where Michel Foucault’s work is often drawn on to frame subjectivity of lived experience in the neoliberal university, this brings forth epistemological, methodological, and ethical tensions in using student voice to inform changes in mental health policy and practice. In Foucauldian terms, a double bind emerges wherein the power of student voice to destabilise existing forms of mental health knowledge and to reimagine the distress-inducing power structures within the neoliberal university are recuperated to (re)produce the same neoliberal structures and subjectivities. Drawing on data from 10 student focus groups, this study explores the epistemic, methodological, and ethical questions attached to analysis of student lived experience data in the context of a Foucauldian-informed understanding of the neoliberal university. It is argued that in pragmatist terms, whilst student voice must be contextualised within the socio-material and socio-psychological context of the neoliberal system to ensure beneficial consequences for student experience, a Foucauldian approach to interpreting lived experience data can also re-empower the subject with the freedom to resist and disrupt the reproduction of mentally unhealthy structures within the neoliberal system as part of a whole university approach.

S-36-5: TEAM-BASED CARE TO DIAGNOSE, TREAT AND CONTROL HYPERTENSION: FINDINGS FROM RESOLVE TO SAVE LIVES (RTSL)

In order to achieve population-wide control of hypertension, team-based care is essential, especially in low- and middle-income countries (LMIC) where there are insufficient numbers of physicians to diagnose hypertension and prescribe medications. RTSL is a global initiative to dramatically improve hypertension control from 14% to 50% worldwide. One key aspect of our approach to team-based care is generating evidence useful in transforming health care delivery. Types of evidence can broadly be classified as follows: (1) literature synthesis to understand evidence on the types and effects of team-based care for hypertension, and (2) empirical studies of health system changes designed to scale up and improve hypertension care. The empirical studies are typically community-based and involve community health workers (CHWs) who are given greater responsibility beyond basic administrative and clinical tasks. Below are a sample of RTSL studies. Our first study involved understanding the global gap between physician capacity and patient need. We documented that most low- and lower middle income countries did not have the physician capacity to provide 3 annual visit for patients with hypertension (figure). Our principal conclusion is that health system and policy changes are needed, including task-sharing. In a second study, we conducted a meta-analysis and documented that team-based care significantly lowers blood pressure in LMIC, with the extent of blood pressure reduction related to the clinical training of team members. In a third study, we conducted surveys to understand current level of task sharing and barriers to task sharing; few countries allowed non-physicians to conduct advanced clinical tasks, e.g. diagnosing hypertension, initiating treatment, and titrating medications. In a fourth study, MUTU conducted in Nepal, we tested a health system change in which CHWs, under the supervision of a physician, initiated and titrated treatment with amlodipine (MUTU results will be presented at ISH on Oct 16). Currently, we are designing a study in which CHWs, supervised remotely via telemedicine, initiate and titrate medication in persons with untreated hypertension in rural Bangladesh. Other studies involve developing and evaluating training materials for non-physician health care workers and modelling the effects of task shifting on the number of persons treated for hypertension in India, along with associated costs. While these studies are being conducted, many RTSL countries have already implemented health system initiatives that involve team-based care for hypertension. These initiatives studies and RTSL studies hold great promise as a means to improve hypertension control rates in LMIC.

The strategy of venue creation: Explaining health policy change in Greece

How do policy entrepreneurs affect policy change in environments of institutional instability? The literature has predominantly explored policy entrepreneur strategizing in contexts with established institutional settings. In this paper, we argue that under conditions of institutional fluidity and a weak and politicized public administration, venue creation is the more frequently encountered and the more likely successful strategy. We define venue creation as the entrepreneurial strategy of setting-up institutional arrangements of finite duration, predominantly in the form of committees, delegated exclusively with designing reforms. We test our hypothesis in the Greek health policy sector. We explore two policy instances: the unsuccessful attempt at a public health reform in 1992 and the successful introduction of radical policy change for public health in 2003. We employ a process tracing approach spanning thirty years, processing primary data (elite interviews and documents) applying the Multiple Streams Framework (MSF). We find that under conditions of institutional fluidity and administrative weakness, policy entrepreneurs failed in their pursuit of change using venue shopping in 1992 but succeeded through venue creation in 2003, confirming our hypothesis. We conclude with insights for contingent policy entrepreneurship success, the MSF and patterns of policymaking in Greece.

A Comprehensive Review of Optimal Approaches to Co-Design in Health with First Nations Australians

Australia's social, structural, and political context, together with the continuing impact of colonisation, perpetuates health care and outcome disparities for First Nations Australians. A new approach led by First Nations Australians is required to address these disparities. Co-design is emerging as a valued method for First Nations Australian communities to drive change in health policy and practice to better meet their needs and priorities. However, it is critical that co-design processes and outcomes are culturally safe and effective. Aims: This project aimed to identify the current evidence around optimal approaches to co-design in health with First Nations Australians. First Nations Australian co-led team conducted a comprehensive review to identify peer-reviewed and grey literature reporting the application of co-design in health-related areas by and with First Nations Australians. A First Nations Co-Design Working Group (FNCDWG) was established to guide this work and team.A Collaborative Yarning Methodology (CYM) was used to conduct a thematic analysis of the included literature. After full-text screening, 99 studies were included. Thematic analysis elicited the following six key themes, which included 28 practical sub-themes, relevant to co-design in health with First Nations Australians: First Nations Australians leadership; Culturally grounded approach; Respect; Benefit to First Nations communities; Inclusive partnerships; and Evidence-based decision making. The findings of this review provide a valuable snapshot of the existing evidence to be used as a starting point to guide appropriate and effective applications of co-design in health with First Nations Australians.