Health System Barriers Research Articles

Barriers to uptake of cervical cancer screening services in low-and-middle-income countries: a systematic review

ObjectivesLow-and-middle-income countries (LMICs) bear a disproportionate burden of cervical cancer mortality. We aimed to identify what is currently known about barriers to cervical cancer screening among women in LMICs and propose remedial actions.DesignThis was a systematic review using Medical Subject Headings (MeSH) terms in Google Scholar, PubMed, Scopus, and Web of Science databases. We also contacted medical associations and universities for grey literature and checked reference lists of eligible articles for relevant literature published in English between 2010 and 2020. We summarized the findings using a descriptive narrative based on themes identified as levels of the social ecological model.SettingWe included studies conducted in LMICs published in English between 2010 and 2020.ParticipantsWe included studies that reported on barriers to cervical cancer screening among women 15 years and older, eligible for cervical cancer screening.ResultsSeventy-nine articles met the inclusion criteria. We identified individual, cultural/traditional and religious, societal, health system, and structural barriers to screening. Lack of knowledge and awareness of cervical cancer in general and of screening were the most frequent individual level barriers. Cultural/traditional and religious barriers included prohibition of screening and unsupportive partners and families, while social barriers were largely driven by community misconceptions. Health system barriers included policy and programmatic factors, and structural barriers were related to geography, education and cost. Underlying reasons for these barriers included limited information about cervical cancer and screening as a preventive strategy, poorly resourced health systems that lacked policies or implemented them poorly, generalised limited access to health services, and gender norms that deprioritize the health needs of women.ConclusionA wide range of barriers to screening were identified across most LMICs. Urgent implementation of clear policies supported by health system capacity for implementation, community wide advocacy and information dissemination, strengthening of policies that support women’s health and gender equality, and targeted further research are needed to effectively address the inequitable burden of cervical cancer in LMICs.

Abstract 13331: Low Statin Adherence Identified Across Diverse Populations in the All of Us Research Program

Introduction: Statins are a cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), the leading cause of death in the US. Despite conclusive evidence to the efficacy and safety of statins, low adherence remains a public health challenge. Although patient, clinician, and health system barriers to statin adherence have been documented, the effect of national policies targeting prescription access remains largely understudied. This study sought to assess the effect of the 2016 US Preventive Services Task Force (USPSTF) recommendation of statins on racial/ethnic disparities in treatment adherence. Methods: Utilizing records of the novel All of Us Research Program, a dataset of historically underrepresented groups in health research, we compared statin use in adult ASCVD non-Hispanic White (NHW) patients before (2014-2016) and after (2017-2020) the USPSTF recommendation with Black and Hispanic patients. Statin use was measured as percent days covered (PDC). Trends were compared using a regression model with demographics and an indicator variable for the change in recommendation as covariates. Regression coefficients and p-values were analyzed to assess the effect of the policy. Results: The study included 94,883 unique statin prescription records belonging to a patient cohort of which 52% were female, 21% Black and 12% Hispanic, with a mean age of 61.93 years. There was poor statin adherence across all racial/ethinic subgroups (PDC < 0.80). Following the policy, PDC increased 3.1% overall (p<0.01), 12 percentage points in Black patients and no change in Hispanics with respect to NHW. Conclusion: Our results provide preliminary evidence that the 2016 USPSTF changes increased statin adherence, yet there were differential effects among racial/ethnic subgroups. To address population adherence disparities, more research is needed to inform policy that will facilitate access for underserved populations in the United States.

Health Care Use and Barriers to Care for Chronic Inflammatory Diseases (CID) among First and Second Generation South Asian Immigrant Children and Parents in Ontario Canada.

Although immigrants are disproportionately impacted by growing chronic inflammatory disease (CIDs) rates, yet suffer barriers to access health care, little attention has been given to their primary healthcare or specialist healthcare access as it relates to complex, chronic diseases in Canada, a country with universal health care. This study aims to investigate CID health care use and barriers to care among first- and second-generation immigrant South Asian children and parents in the Greater Toronto Area, Ontario. Drawing on analysis of 24 in depth interviews with children and parents (14 children, 10 parents), the results reveal that although CIDs disproportionately affects South Asian immigrants, they encounter health system, geographic, interpersonal, and knowledge barriers to access requisite care. These barriers exist despite participants having a GP, and are compounded further by limited familial systems, culturally insensitive care, and structural inequities that in some instances make parents choose between health access or other basic needs. Although all participants recognized the importance of specialized care, only 11 participants regularly accessed specialized care, creating new schisms in CID management. The findings suggest that a multisectoral approach that address individual and structural level socio-structural drivers of health inequities are needed to create more equitable healthcare access.

Improving routine childhood immunisation outcomes in low-income and middle-income countries: an evidence gap map

ObjectiveTo support evidence-informed decision-making, we created an evidence gap map to characterise the evidence base on the effectiveness of interventions in improving routine childhood immunisation outcomes in low-income and middle-income...

Outcomes of a community-based antiretroviral therapy programme for key populations living with HIV in Benue State, Nigeria: protocol for a realist evaluation

IntroductionKey populations (KP) living with HIV are underserved and often face social and health system barriers to HIV care. To optimise access to quality HIV services among KP, the WHO...

Health System Barriers for HPV-vaccine uptake in females with a Turkish or Moroccan Migration background in the Netherlands

Abstract Background HPV vaccine uptake in female adolescents with a Turkish or Moroccan migration background in the Netherlands is lower as compared to the national average. This study aimed to study health system barriers for HPV vaccine uptake in these groups. Methods Semi-structured interviews with Turkish/Moroccan (2nd and 3rd degree migrants) female adolescents (12-18 years old), their parents and grandparents were conducted. In addition a focus group discussion with healthcare providers with particular experience with HPV immunization and the target groups was organized. Data was collected between November 2021-April 2022. Results 22 interviews were conducted among twenty-three individual participants. Sixteen participants with a Turkish migration background were recruited and seven participants were having a Moroccan migration background. In thirteen cases young women in the families did not receive an HPV vaccination. Health system barriers identified were: language barriers in the information provided, focus on HPV being a sexually transmitted disease in information campaigns, lack of knowledge and awareness on HPV among participants and healthcare providers and inability to reach the target groups with tailored immunization programs. Similar health system barriers were mentioned by the healthcare providers, but also included a lack of trust in the government and healthcare institutions, insufficient coordination and collaboration between different healthcare providers. National immunization programs with mass campaign vaccination is mentioned as a barrier to reach families with a Turkish/Moroccan migration background. Conclusions Various health system barriers were addressed to be related to HPV vaccine uptake in females with a Turkish/Moroccan migration background in the Netherlands. Despite similarities concerning health system barriers among community members and healthcare providers, different health system barriers were also mentioned.

Health system barriers to HPV vaccination in marginalized Roma communities in Slovakia

Abstract Background People from marginalized Roma communities often experience poverty, limited access to education, employment, housing, and health care (HC). The aim of the study was to explore the perceptions of people from marginalized Roma communities and health professionals regarding health system (HS) barriers to HPV vaccination. Methods A qualitative study was conducted in the Kosice region as a part of the RIVER-EU project. Semi-structured interviews with marginalized Roma parents (N = 18), children (N = 15), and health professionals (N = 18) were audio-recorded and thematic analysis of the transcripts was performed in MAXQDA. Findings Four main themes were identified regarding HS barriers: 1. Lack of information (lack of culturally and linguistically appropriate information, lack of information provision from HC providers, unreliable and conflicting information on the internet), 2. Restricted access to HC providers (lack of capacities, work overload, long wait in the waiting room, distance, traffic connection), 3. Financial and organizational barriers (limited coverage of vaccination expenses from health insurance, picking up prescribed vaccines in a pharmacy by parents, parental consent), 4. Attitudes and behaviours of HC providers (neglect of care, double standard, inappropriate behaviour and communication, prejudices, racism). Conclusions The reasoning and perception of several barriers to HPV vaccination differ among groups of respondents. Nevertheless, HPV is not viewed as a priority by both - marginalized Roma and health professionals. HS fails to reach marginalized Roma with appropriate information about HPV and HPV vaccination. Moreover, the lack of capacities and motivation of HC providers to address these topics lead to a lack of awareness. Organization and health insurance coverage of vaccination pose additional barriers to HPV vaccination.

2.M. Workshop: Empowering examples of high vaccination in minorities: learning from three underserved communities

Abstract Childhood vaccine uptake in most minority or ethnic communities in Europe is typically substantially and unacceptably lower compared to the general population. Ethnic, religious, or cultural minorities are more likely to encounter health system barriers to accessing health care services which are a major contributor to comparatively low vaccine uptake among these disadvantaged communities. Despite these challenges, some minority communities manage to achieve high uptake for childhood immunization sometimes higher than the general population in their respective countries. We have called these populations “empowering examples”. As part of RIVER-EU (Reducing Inequalities in Vaccine uptake in the European region - Engaging Underserved communities) an EU funded project aiming to improve access to vaccine services for children and youth, reducing inequality and improving vaccine uptake of HPV and MMR vaccination in underserved communities in Europe, we collected evidence on health system barriers and enablers to vaccination among underserved communities, including three empowering examples of underserved minority communities that achieve high vaccine uptake: the Somali community in Finland, the Arab community in Israel, and the Bangladeshi community in the United Kingdom. Understanding enablers to vaccination in these populations will help generate knowledge that will be translated to other populations in order to facilitate similar enablers, thus improving vaccine uptake. The main objective of this workshop is to share and discuss the preliminary findings related to health system enablers from these three “empowering examples.” The workshop will be structured in 3 presentations of 12 minutes each. Each empowering example will present preliminary findings from interviews and focus group sessions conducted with each minority community. Presentations will be followed by a moderated questions and answers session that will help the audience understand what factors have contributed high vaccine uptake in these populations and how they can be applied to others. Participants will be invited to share experiences from their own countries. Key messages • Accessibility, trust in the health care system, and perceived vaccine safety, were found to be powerful health system enablers to HPV and MMR vaccination among three underserved populations studied. • Normalizing vaccination as “just something you do” seems to be a common approach among the highly vaccinated minorities.

3.M. Workshop: Health system barriers to vaccination in underserved communities: a tale of four countries

Abstract The literature highlights low vaccination coverage among most minority or ethnic pediatric communities in EU, including migrants. In addition to being less likely to get a vaccine, such communities may be vulnerable to developing certain infectious diseases. It is particularly important in the context of the current humanitarian crisis connected with Russia's aggression towards Ukraine. Identification of potential barriers to vaccination and system gaps is crucial to further ensure that underserved pediatric communities benefit from the same level of protection as the general population in terms of disease prevention and control, including those diseases which can be prevented by routine vaccinations. The proposed workshop moderated by well-known experts of the subject (Bernardette Kumar and Maria Ganczak) will be based on the results from qualitative data collected as a part of the 5-year RIVER-EU (Reducing Inequalities in Vaccine uptake in the European region - Engaging Underserved communities) project which tackles health system barriers among selected underserved communities living in four countries: Ukrainian migrants in Poland, females with a Turkish and Moroccan migration background in the Netherlands, marginalized Roma communities in Slovakia and migrants/refugees in Greece. This interactive workshop will provide short (5 minutes per country) comparisons of the health system barriers to vaccination against MMR (measles, mumps, rubella) and Human Papillomavirus (HPV) in children living in different underserved communities, and contrast barriers to vaccination experienced by the community members with barriers perceived by the health care professionals. International comparisons of in-depth information collected during qualitative studies (interviews and focus groups) will help to provide an increased understanding of the health system determinants of low vaccine uptake in their specific multi-factorial contexts that will vary in terms of geography, size, wealth, health sector structures, culture and vaccination law. Such qualitative research is particularly valuable regarding its potential for producing comprehensive and refinement analyses adjusted for understanding the voices of underserved communities. The session will go beyond describing those. Based on the presentations the participants will be divided into 4 groups to discuss (15 minutes) the Key Barriers; Key Facilitators to vaccination; Main lessons Learnt; Ways forward for the future to increase vaccine uptake among underserved pediatric communities to reduce the burden of vaccine preventable diseases. These 4 groups of workshop participants will be led by experts from the MEMH and IDC sections. Then, concluding remarks will be presented by each group (5 minutes per group). The final resume delivered by session chairs will end the workshop. Key messages • The health system barriers to child vaccination among underserved communities vary among European countries, and the optimal way to adequately address them is likely to be context specific. • The RIVER-EU project gives an opportunity to discuss lessons already learnt around the different components of the vaccination process and to pinpoint ways forward for the future to reduce the VPD.

Health system barriers to vaccination among Ukrainian economic migrants in Poland

Abstract Background Before Russia's aggression, Ukrainians were the largest migrant group in Poland. However, data on health system barriers to vaccination in this vulnerable group were not collected. The study aimed to explore barriers to child MMR/HPV vaccination and related access to Polish healthcare services. Methods Between December 2021-January 2022, a qualitative study of Ukrainian migrants (UM) living in Poland, recruited through a snowball sampling method, was conducted as a part of RIVER-EU project. 8 focus groups were held with 49 UM aged 16-44 years, followed by interviews with 12 health care providers (HCP). Results UM and HCP experienced communication barriers despite language similarities. HCP reported that since a UM is not willing to register at a GP practice he cannot be reached by the Polish vaccination system. UM experienced challenges in navigating the system and accessing credible information in Ukrainian, no official local health authority vaccination material existed either. UM complained that there are no translated versions of vaccination materials accessible at the PHC facilities and they are not adequately informed about the possible side effects of vaccines; HCP reported the lack of time provided by the system for health promotion. UM were not familiar and rather hesitant regarding self-paid vaccines, such as HPV vaccine. In Poland and Ukraine this topic is not targeted at school curriculum neither by information campaigns. UM reported that HPV vaccine is not of interest for them due to the high cost, however they might consider it for their daughters, if the cost was fully refunded. Conclusions The study identified main health system barriers to child vaccination regarding economic UM in Poland, seen from the perspective of migrants and HCP and pinpointed issues for improvement. This can serve as a starting point to confront vaccination related challenges in the context of Ukrainian refugee crisis Poland is currently dealing with.

Health system barriers to HPV and MMR vaccination in recent migrants/refugees in Greece

Abstract Background Migrants have lower vaccination rates compared to the general population and report multiple barriers in accessing related services. We explored practices and perceptions regarding MMR & HPV vaccinations in migrant children & adolescents from third countries to inform the development of tailored interventions to increase vaccination coverage. Third country nationals for the RIVER-EU project are migrants arriving to the EU from countries beyond Europe (the Middle East, Asia & Africa) escaping civil conflict, war, and poverty. Methods A qualitative study was conducted in the wider Athens area as part of the RIVER-EU project. Four Focus Groups and 23 semi-structured interviews were conducted with health care professionals, children and parents with a migrant background. Data were analysed using thematic content analysis. Findings: Identified barriers relate to the lack of standard operational procedures at system level that would define a schedule of vaccinations for migrants. Migrant vaccinations are subject to availability of vaccines (MMR as opposed to HPV) and potential threat of outbreaks (MMR vs HPV). There is no consistent, unified recording system of vaccinations while at system level there is a lack of trained cultural mediators. Targeted health promotion campaigns are rare while the few related activities that do exist are not systematically evaluated. Conclusions MMR vaccination is more frequent compared to HPV which is not prioritised by the target group or health professionals. Nevertheless, the target group is open to learning more about HPV while the important role of mothers concerning vaccinations emerged as crucial. Health professionals focus more on MMR due to the availability of the vaccine and the threat of outbreaks. The vaccination system has flaws and inconsistencies with a lack of vaccination related data. There is urgent need for culturally appropriate vaccination and appropriately evaluated vaccination campaigns.

Organisational perspectives on Public Health delivery in Ireland: Lessons learned from COVID-19

Abstract Background The COVID-19 pandemic has placed healthcare systems worldwide under unprecedented pressure, with the Irish Public Health system no different. To strengthen delivery of Essential Public Health Functions (EPHFs) and increase future pandemic preparedness, Public Health leaders are now focused on identifying learnings from the pandemic. Within Ireland, given their experience, organisations situated within the Public Health system may be in a unique position to provide valuable information around the delivery of EPHFs, both prior to and in light of the COVID-19 pandemic, and how this can be improved in the future. Methods An online survey was distributed by the Department of Health, from 2 March 2022 to 25 March 2022, amongst organisations situated within the Public Health domain in Ireland. The survey consisted of six open-ended questions around the delivery of EPHFs prior to and in light of the pandemic, success stories that could provide scalable solutions to EPHF delivery and current health system barriers, key areas in the public health system that require strengthening, and barriers to achieving these actions. Thematic analysis to identify key themes was conducted on survey responses. Results Twenty-eight organisational responses were received. Themes around the workforce were apparent throughout, with staff training, staff diversity and staff morale, identified as areas for strengthening EPHF delivery. Themes around ICT, data collection and research were frequently identified with a lack of adequate ICT identified as a key lesson from the pandemic, while the Public Health ICT strategy was identified as key to strengthening future EPHF delivery. Conclusions In general, themes around the workforce; leadership, management and governance and ICT, data collection and research were reoccurring across organisational responses and therefore may be key areas for consideration when strengthening delivery of the EPHFs in Ireland. Speakers/Panelist Louise Hendricks Department of Health, Ireland Sohel Saikat WHO, Geneva, Switzerland

Assessment of needs-based usefulness of interventions to address system barriers to HPV vaccination

Abstract Background Adolescents of underserved communities face multiple health system barriers to access HPV vaccination. The Horizon 2020 project RIVER-EU will implement interventions to address these barriers in the migrant community in Greece, the Turkish and Moroccan communities in the Netherlands, the Ukrainian community in Poland and the Roma community in Slovakia. The objective of this study was to identify promising evidence-based interventions that potentially meet the specific contextual needs of the target groups, as a basis for assessing their transferability. Methods Based on the PIET-T models of transferability, we developed a methodology to assess the needs-based usefulness of an intervention for a target context. Criteria of intervention usefulness addressed specific aspects of the health issue, population, intervention content, outcomes, up-to-datedness, applicability, quality and usefulness of the evidence-base. Guided by methodological workshops, country members with their local advisory boards performed a rating of 32 interventions identified from a systematic literature search. Results Through independent assessment in each country, 5 of 32 interventions were selected as useful, with overlap: 2 interventions were selected by all countries, and 1 by 2 countries. In all countries, trained community members to support HPV vaccination were seen as promising. In Greece and the Netherlands, an educational programme in schools was included. Further, the Netherlands chose an intervention addressing providers’ HPV vaccine communication, and Slovakia a multilevel intervention. Discussion The feedback of the country members on the assessment emphasised the structured way to face complexity of understanding the potential usefulness of an intervention from the perspective of the target country. Critical discussions on the interventions enabled to specify needs for further clarification, for adaptations, and alternatives to consider for transferability analyses. Key messages

Cannabis use for pain relief in the context of health service barriers: Accounts of street-involved Nigerian women suffering chronic pain.

This study explored cannabis use for pain relief among socially marginalised Nigerian women in the context of barriers to pain management. The study was designed as a qualitative exploratory study of pain experience and management. Sixteen in-depth, individual interviews were conducted with street-involved women who use drugs and had chronic pain. Transcripts were coded and analysed thematically. Pain was experienced as a pervasive feature of everyday life that disrupted daily routines, affected economic activities, strained social relationships and had adverse effects on health and wellbeing. Participants sought treatment in health facilities, but faced social and health system barriers to service utilisation including financial cost of services, dismissal of symptoms by providers, stigma due to physical appearance, substance use and lack of social support. These barriers encouraged disengagement from services and reliance on cannabis (along with heroin and diverted prescription opioids) for pain management. Cannabis use relieved pain and improved daily functioning, enabling participants to undertake economic activities. However, using cannabis to enhance the effects of opioids and heavy and long-term use owing to pain chronicity and disability generated concerns about harms. Findings show the therapeutic benefits of cannabis in the face of barriers to pain management. This support calls to explore the potentials of cannabis for pain management for socially marginalised populations and to develop medical guidelines to reduce the risk of adverse health consequences. Therapeutic cannabis, provided based on medical guidance, could improve pain management for socially marginalised populations.

A qualitative assessment of facility readiness and barriers to the facility-based management of childhood severe acute malnutrition in the public healthcare settings in Bangladesh.

To assess facility readiness and identify barriers to the facility-based management of childhood severe acute malnutrition (SAM) in public healthcare settings. Qualitative methods were applied to assess readiness and identify different perspectives on barriers to the facility-based management of children with SAM. Data collection was done using in-depth interviews, key informant interviews, exit interviews and pre-tested observation tools. Two tertiary care and four district hospitals in Rangpur and Sylhet Divisions of Bangladesh. Healthcare professionals and caregivers of children with SAM. Anthropometric tools, glucometer, medicines, F-75, F-100 and national guidelines for facility-based management of childhood SAM were found unavailable in some of the hospitals. Sitting and sleeping arrangements for the caregivers were absent in all of the chosen facilities. We identified a combination of health system and contextual barriers that inhibited the facility-based management of SAM. The health system barriers include inadequate manpower, rapid turnover of staff, increased workload, lack of training and lack of adherence to management protocol. The major facility barriers were insufficient space and unavailability of required equipment, medicines and foods for hospitalised children with SAM. The reluctance of caregivers to complete the treatment regimen, their insufficient knowledge regarding proper feeding, increased number of attendants and poverty of parents were the principal contextual barriers. The study findings provide insights on barriers that are curbing the facility-based management of SAM and emphasise policy efforts to develop feasible interventions to reduce the barriers and ensure the preparedness of the facilities for effective service delivery.

"We're Lucky to Have Doctors at All"; A Qualitative Exploration of Australian Farmers' Barriers and Facilitators to Health-Related Help-Seeking.

This study aimed to explore barriers and facilitators that impact on farmers’ help-seeking behaviours for health and mental health concerns. Fifteen semi-structured interviews were conducted with farmers (12 male; age 51.7 ± 12.6 years) from three rural regions in South Australia. Interviews explored demographic and farm-related characteristics, perceptions of individual (and where relevant family) health and mental health concerns and experiences, and perceived barriers of health support-seeking. Thematic analysis was used to identify key themes. Four key themes were identified relating to help-seeking; personal attitudes and beliefs, farm-related barriers, health system barriers and the provision of support from family and friends. Dominant personal attitudes included valuing independence, strength and privacy. Farm related barriers included the ‘farm comes first’ and the fact that ‘farm work is never done’. Health system barriers included issues relating to availability of choice and access, professionals (lack of) understanding of farm life, and time and financial costs of accessing care. Provision of support from family and friends involved informal help and advice, including facilitating access to professional support. Multiple attitudinal, structural, and farm-related issues affect farmers’ help-seeking. Professionals who understand farm work practices and routines are valued by farmers and this is likely to facilitate access to care. Workforce development programs and community programs that involve farmers’ perspectives as consumers and co-designers, using evidence-based strategies, may assist in strengthening these relationships.

244.10: Health System Barriers and Facilitators to Living Donor Kidney Transplantation: A Tale of Two States With the Highest and Lowest Rates

Purpose: Current efforts to increase living donor kidney transplantation (LDKT) entails identifying patient-level barriers and little is known about barriers that exist at the level of the health systems. The provision of transplantation in Canada is at the provincial level and there is wide variability in LDKT performance across different provinces. We aimed to learn and compare health systems with the best and the worst performance in LDKT, and to identify health system-level barriers to LDKT. Methods: This study took the form of a comparative case study analysis. Case study research is an in-depth and non-interventional examination of a single case over time using retrospective and contemporary data. Data collection entailed semi-structured interviews, document review, and participant observation. Data were analyzed thematically to generate themes surrounding the attributes and processes of a health system that facilitate the delivery of LDKT to patients, and those that create barriers. Results: In the best-performing province of Canada, five themes emerged as facilitators to the delivery of LDKT to patients. The relationship between two provincial organizations (a regional transplant and a regional nephrology order) was identified as key to enabling the mandate and processes for LDKT. On the other hand, in the worst-performing province, similar themes emerged as barriers to LDKT. Barriers were identified at the levels of organizational coordination, professional knowledge, resources, geography, and governance. Particularly, inconsistent coordination between regional clinics and transplant centers and poor role definition was seen to hinder and delay care processes. Conclusion: By comparing two health systems with variable rates of LDKT, we have identified several real-world health system-level barriers to the delivery of LDKT to patients. Many of these barriers are modifiable and have implications for practitioners, policymakers, administrators, and patients. This work is supported by a Gift of Life Institute Clinical Faculty Development Research Grant from the American Society of Transplantation and a Health Research Grant, Kidney Foundation of Canada.

Incentivizing Drug Development in Serious Mental Illness

Serious mental illness (SMI) imposes a significant burden on individuals and society. Individuals living with SMI have worse expected health, education, and career outcomes during their lifetime. Although treatments exist, pharmaceutical innovation in this area has lagged many other disease areas, despite an important need for new treatments. This report describes barriers that have hindered innovation and the development of new drugs for SMI, including science and research, regulatory, and health system barriers. To address these barriers, this report presents policies that may incentivize investment in this area.

The anti-inflammatory effects of a Mediterranean diet: a review.

Chronic noncommunicable diseases remain the leading cause of morbidity and mortality worldwide and the majority are preventable with a healthy diet and lifestyle, but controversy remains as to the best approach. Greater adherence to a traditional Mediterranean diet has consistently been associated with lower morbidity and mortality from cardiovascular disease, diabetes and many cancers, and lower all-cause mortality. Despite the well known benefits on chronic disease risk there remains some scepticism as to the effects of this dietary pattern across populations outside the Mediterranean and the mechanisms of action of this traditional plant-based dietary pattern.This narrative review aims to summarize the latest evidence on the health protective effects of a traditional Mediterranean diet on chronic noncommunicable diseases, specifically focussing on the anti-inflammatory effects of this highly published dietary pattern. Recent high-quality evidence now supports a Mediterranean diet in secondary prevention of cardiovascular disease with impacts on atherosclerosis progression, likely through reduction of systemic inflammation and irrespective of changes in cholesterol or weight. The Mediterranean diet has a low Dietary Inflammatory Index illustrating its anti-inflammatory potential. This dietary pattern beneficially modulates the gut microbiota and immune system, including emerging evidence for efficacy against severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019). Emerging evidence shows clinicians are not routinely recommending a Mediterranean diet despite well known evidence due to barriers such as lack of training, patient materials and concerns about potential patient adherence. The physiological mechanisms of action of this healthy diet pattern are becoming better understood to be multisystem and involving the gut. Larger controlled trials investigating mechanistic effects in broader non-Mediterranean populations are warranted. Although reflected in therapeutic guidelines for chronic disease management worldwide there are individual, clinical practice and health system barriers to its implementation that need a multisectoral approach to address.

Scoping the needs, roles and implementation of bilingual community navigators in general practice settings.

This research aimed to explore the needs, potential roles and implementation of Bilingual Community Navigators (BCNs) in providing navigation support for patients in general practice settings in Australia. A total of 19 participants (general practitioners, practice managers, practice nurses and receptionists) from five general practices in Sydney where most of the patients spoke a language other than English were interviewed about their views on needs, potential roles and implementation of BCNs in general practice settings. Data were collected between August 2019 and July 2020. The interview transcripts were inductively analysed for themes. Themes emerged across four broad categories: patients' barriers to access health and social care services; potential roles of BCNs; recruitment, training, and employment of BCNs and considerations and anticipated barriers to BCNs' role. Many barriers both at the patient and at the service provider levels in accessing healthcare and social care services were consistent with the Levesque et al. access framework including lack of understanding of the health system, language and cultural barriers, hesitancy to approach general practice and problems navigating services. Participants believed that BCNs would be able to help overcome these barriers through health education, support in booking appointments, arranging transport, providing language and cultural support and improving communication with the health services. Conditions for effective implementation of BCNs in practice included proper training of the navigators to ensure patient confidentiality and addressing organisational/system barriers such as lack of a funding mechanism, a clear role definition of BCNs and acceptance of BCNs by patients. BCNs potential role in facilitating access to appropriate care by culturally and linguistically diverse (CALD) patients in general practice warrants further evaluation in the context of the Australian healthcare system.