Multisectoral Policy Research Articles

Strengthening the governance of food systems for nutrition in Africa: a political economy analysis of food policy in South Africa and Ghana.

To examine underlying political economy factors that enable or impede the integration of nutrition considerations into food system governance. Comparative political economy analysis of data collected through (1) value chain analyses of selected healthy and unhealthy commodities and (2) food system policy analyses, using a theoretical framework focused on power, politics, interests and ideas. Ghana and South Africa. Value chain actors relevant to healthy and unhealthy foods (Ghana n 121; South Africa n 72) and policy stakeholders from government (Health, Agriculture, Trade and Industry, Finance), academia, civil society, development partners, Civil Society Organization (CSO) and private sector (Ghana n 28; South Africa n 48). Nutrition was a stated policy priority in both countries; however, policy responsibility was located within the health sector, with limited integration of nutrition into food system sectors (including Agriculture, Trade and Industry). Contributing factors included a conceptions of policy responsibilities for nutrition and food systems, dominant ideas and narratives regarding the economic role of the food industry and the purpose of food system policy, the influence of large food industry actors, and limited institutional structures for cross-sectoral engagement and coordination. Integrating nutrition into multi-sectoral food policy to achieve multiple food system policy goals will require strategic action across jurisdictions and regional levels. Opportunities included increasing investment in healthy traditional foods, strengthening urban/rural linkages and informal food systems, and strengthening institutional structures for policy coherence and coordination related to nutrition.

Assessing antimicrobial consumption in public and private sectors within the Costa Rican health system: current status and future directions

BackgroundAntimicrobial resistance is a significant global health threat. Therefore, robust surveillance systems for antimicrobial consumption (AMC) are essential to develop public health strategies. However, Latin American countries, including Costa Rica, face challenges in regularly reporting AMC data. This study aims to estimate and analyse the overall AMC in Costa Rica for 2019.MethodsThis study is a national-level, retrospective, observational, and descriptive analysis of AMC in Costa Rica from 1 January to 31 December 2019. The study followed the World Health Organization (WHO) guidelines for the Surveillance of National AMC. The Anatomical Therapeutic Chemical (ATC) / Defined Daily Doses (DDD) system was used to analyse types of antimicrobials and DDD per 1000 inhabitants per day (DID). Antimicrobial dispensation data from the Costa Rican Social Security Fund (CCSS) represented the public sector, while the private sector data was sourced from IQVIA. The analysis included data from both inpatient and outpatient sectors.ResultsA total AMC of 14.32 DID, of which 12.75 DID was within the public sector and 4.12 DID was within the private sector. Penicillins had the highest consumption nationally and in the public sector, while macrolides and lincosamides predominate in the private sector. According to the WHO-AWaRe (Access-Watch-Reserve) classification, antibiotics predominantly consumed nationally (74.7%) and in the public (83.0%) sectors are categorized under Access, whereas the private (61.0%) sector predominates the Watch category.ConclusionThis study illustrates the importance of enhancing AMC surveillance by integrating data from both the public and private sectors. The findings indicate an excessive use of “Watch” antimicrobials in the private sector. To address this issue, all sectors and regulatory authorities must play an active and supportive role, in the development of effective, multisectoral policies. The methodology employed in this study is applicable to other Latin American countries, and therefore should be utilized for future analysis AMC in this region.

7.H. Round table: Advancing societal goals through health systems: Insights from the Renewed HSPA Framework

Abstract The purpose of this workshop, entitled ‘Advancing societal goals through health systems: Insights from the renewed HSPA framework,’ is to take a deeper look at the intricate relationships between health systems and broader societal objectives. We will dissect the contributions of health systems to societal well-being, a concept that stretches beyond mere economic growth to include social cohesion, environmental sustainability, and economic development. The session will examine the renewed global Health System Performance Assessment Framework, which serves as a tool for policymakers to better understand how health systems fit together and explains how they perform. This framework allows for a clearer interpretation of health data and provides a pathway to pinpoint health system issues and design that are most likely to enhance performance and resilience. The workshop will delve into the three dimensions of societal well-being-social cohesion, economic development, and environmental sustainability-nested within the HSPA framework. We will explore the health system’s role in advancing these dimensions, such as fostering community bonds, supporting economic growth through a healthy workforce, and contributing to the sustainable management of environmental resources. Integrating health system performance into societal goals is a practical obligation to create a resilient, cohesive, and economically robust society. This workshop will engage stakeholders in a discourse to translate this integration into multisectoral and actionable policies, aligning health system goals with societal aspirations for a sustainable future. This workshop will focus on: How health system assessments can capture contributions to societal goals, underpinning sustainable economic and environmental practices. Real-world case studies showcasing health systems’ role in fostering societal well-being and advancing public health policies. Interactive discussions will shed light on how health systems can be pivotal in achieving the Sustainable Development Goals, particularly in the face of modern challenges such as climate change, demographic shifts, and economic pressures. Key messages • Health systems play a pivotal role in advancing societal well-being beyond traditional health outcomes. • The renewed HSPA framework is a robust tool for policymakers to align health system performance with broader societal goals. Speakers/Panelists Scott Greer University of Michigan, European Observatory on Health Systems and Policies, Ann Arbor, USA Andrea Schmidt Austrian Public Health Institute, Vienna, Austria

Implementing a pilot primary care program: Armenia’s steps toward universal health coverage

Abstract Problem Armenia has struggled to transform its ineffective primary healthcare (PHC) system into one that can address the non-communicable disease burden, which causes 93% of mortality. To address this issue, Armenia aims to establish universal health coverage and invest in high-quality primary care. Description In 2023, the Armenian Ministry of Health signed a multisectoral policy to implement a pilot primary care program to trial a multitude of reforms related to diabetes (DM) and hypertension (HTN). Pilot interventions include pathways for screening/diagnosis, provider training, free medications and diagnostics, and new provider financial incentives. The key question to be answered is if these pilot interventions cause DM and HTN health outcomes to improve. Beginning in 2024, the program is being piloted in a primary care clinic in Dsegh. Results As a result of the 2023 Ministerial policy, multisectoral stakeholders designed and implemented this pilot program. Baseline focus groups found that the pilot addresses the financial barriers that community members noted lead to delays in seeking care and that providers perceive the pilot to be beneficial to their patients. Although final results are not yet available, the pilot has already positively changed features in the national EMR and brought together stakeholders in a way never done before. Lessons The pilot’s innovation comes from it being the first time that hypertension and cholesterol medications are provided by the government for free, provider bonuses are based on outcome indicators, indicator targets are set this high, a point-of-care A1c machine is utilized, and a robust monitoring and evaluation (M&E) plan is implemented, all of which are currently shaping discussions on national policy. For countries similarly working on strengthening primary care, it is recommended to pilot specific reforms and establish mechanisms through M&E systems that allow pilots to inform evidence-based decision making. Key messages • To move towards universal health coverage, pilot programs designed with multi-sectoral stakeholders are needed to trial suggested healthcare reforms. • It is essential to invest in monitoring and evaluations systems to generate the data necessary to develop evidence-based policies.

Revolutionising multi-sectoral nutrition policy: Insights from the Ethiopian National Information Platform for Nutrition (NiPN) approach.

Revolutionising multi-sectoral nutrition policy: Insights from the Ethiopian National Information Platform for Nutrition (NiPN) approach.

Public Health Challenges and Responses to the Growing Ageing Populations

ABSTRACTBackgroundHuman populations are rapidly ageing worldwide due to declining birth rates and rising life expectancies. This profound demographic shift presents complex public health challenges. Synthesizing evidence on key public health issues impacting ageing populations and policy strategies is required to address these needs.MethodsThe study employs narrative literature review based on the PubMed database. Data have been extracted on public health challenges to ageing populations and its recommended policy solutions.ResultsThe key public health challenges identified include rising chronic disease burden, risks for preventable multi‐morbidities and co‐morbidities, disability and dependencies, mental health issues, caregiving gaps, long‐term care system deficiencies, health inequities, healthcare access barriers, end‐of‐life care needs, financial instability, ageism/elder abuse, adverse built environments, climate/disaster threats, and social isolation. Evidence‐based policy responses span interventions in healthcare, social services, urban planning, emergency preparedness, economics, technology, anti‐ageism advocacy and so on.ConclusionsProactively addressing the array of public health challenges faced by rapidly growing ageing populations globally requires implementing collaborative, multisectoral policy solutions focused on promoting healthy, equitable, and socially engaged ageing. Healthcare systems, communities, and policies must be optimized to meet the needs of elderly people and tap into their strengths.

Differences in the cost and environmental impact between the current diet in Brazil and healthy and sustainable diets: a modeling study

BackgroundWhile healthy and sustainable diets benefit human and planetary health, their monetary cost has a direct impact on consumer food choices. This study aimed to identify the cost and environmental impact of the current Brazilian diet (CBD) and compare it with healthy and sustainable diets.MethodsData from the Brazilian Household Budget Survey 2017/18 and the Footprints of Foods and Culinary Preparations Consumed in Brazil database were used for a modeling study comparing the cost of healthy and sustainable diets (based on the Brazilian Dietary Guidelines (BDG) diet and the EAT-Lancet diet) versus the CBD. The DIETCOST program generated multiple food baskets for each scenario (Montecarlo simulations). Nutritional quality, cost, and environmental impact measures (carbon footprint (CF) and water footprint (WF)) were estimated for all diets and compared by ANOVA. Simple linear regressions used standardized environmental impacts measures to estimate differentials in costs and environmental impacts among diets scenarios.ResultsWe observed significant differences in costs/1000 kcal. The BDG diet was cheaper (BRL$4.9 (95%IC:4.8;4.9) ≈ USD$1.5) than the CBD (BRL$5.6 (95%IC:5.6;5.7) ≈ USD$1.8) and the EAT-Lancet diet (BRL$6.1 (95%IC:6.0;6.1) ≈ USD$1.9). Ultra-processed foods (UPF) and red meat contributed the most to the CBD cost/1000 kcal, while fruits and vegetables made the lowest contribution to CBD. Red meat, sugary drinks, and UPF were the main contributors to the environmental impacts of the CBD. The environmental impact/1000 kcal of the CBD was nearly double (CF:3.1 kg(95%IC: 3.0;3.1); WF:2,705 L 95%IC:2,671;2,739)) the cost of the BDG diet (CF:1.4 kg (95%IC:1.4;1.4); WF:1,542 L (95%IC:1,524;1,561)) and EAT-Lancet diet (CF:1.1 kg (95%IC:1.0;1.1); WF:1,448 L (95%IC:1,428;1,469)). A one standard deviation increase in standardized CF corresponded to an increase of BRL$0.48 in the cost of the CBD, similar to standardized WF (BRL$0.56). A similar relationship between the environmental impact and the cost of the BDG (CF: BRL$0.20; WF: BRL$0.33) and EAT-Lancet (CF: BRL$0.04; WF: BRL$0.18) was found, but with a less pronounced effect.ConclusionsThe BDG diet was cost-effective, while the EAT-Lancet diet was slightly pricier than the CBD. The CBD presented almost double the CF and WF compared to the BDG and EAT-Lancet diets. The lower cost in each diet was associated with lower environmental impact, particularly for the BDG and EAT-Lancet diets. Multisectoral public policies must be applied to guide individuals and societies towards healthier and more sustainable eating patterns.

Stakeholders’ Participation in the Creative Economic Development of Cirebon City

This study aims to examine the participation level of stakeholders, identify the dominant stakeholders, and investigate the factors inhibiting stakeholders’ participation in the planning, implementation, and evaluation of creative economic development in Cirebon City. “Creative City” is politically and legally stipulated as the city vision in the regional mid-term development plan 2018-2023 of Cirebon City. As the creative economy is centered around the production, exchanges, and consumption of goods and services from human creativity, Cirebon City is, therefore, a significant case study to investigate how the local government implements participatory processes in developing a creative city.Using qualitative methods, data were collected through a semi-guided interview of 190 respondents from five stakeholders: academics, businesses, communities, government institutions, and media organizations. It was followed by a focus group discussion of 12 key respondents selected purposively from the five stakeholders. With primary and secondary data sources, qualitative data was analyzed through the process of data reduction, data display, and conclusion drawing/verification.This study concluded that stakeholders' participation in all stages of creative economic development in Cirebon was still minimal. The businesses in culinary subsectors as the most dominant stakeholders in the participation processes. The lack of socialization from the municipal government and the limited collaboration amongst the stakeholders were identified as the inhibiting factors of inclusive participation in creative city development. The government needs to accelerate creative economic development through multisectoral policies, including improvement of business knowledge and skills of the local business actors, goods and services’ quality upgrading and assurance, certification and legal assistance, as well as promotion and market expansion

Social value framing of physical activity in European Member State policies: a content analysis.

Engagement in physical activity (PA) benefits physical and mental health as well as many other areas of society. In Europe however, 1/3 adults do not meet minimum PA recommendations. Social value, and its quantification through social return on investment (SROI) evidence, may be a useful framing to enhance PA promotion. This study aimed to assess the current use of social value framing of PA in European Union (EU) policies. Content analysis of 45 EU member state policies which contain reference to PA was conducted to evaluate the presence of five social value domains and SROI evidence. Data was analysed using manual inductive coding, supported by DeepL translation and NVivo tools. Social value framing was present to a certain extent in existing policies, with improved health being the most commonly referenced benefit of PA, followed by reference to social and community and then environmental benefits. Acknowledgement of the positive impacts of PA on wellbeing and education was the least present. Reference to SROI evidence was also limited. Generally, policies lacked holistic recognition of the social value of PA. Policies from the health sector were particularly limited in recognising the wider benefits of PA, whilst those from the environmental sector acknowledged the widest range of co-benefits. Adopting social value framing could be a useful approach for enhancing PA promotion. Whilst it is present to a certain extent in existing policy, this could be increased in terms of comprehensiveness to increase issue salience and multisectoral policy action.

Multisectoral approaches for sustainable food and nutrition security actions in Ethiopia

Ethiopia has demonstrated a commitment to tackling the high burden of Food and Nutrition Security (FNS) challenges by developing and implementing various policies, strategies, and programs. Despite the efforts, the current FNS situation is of significant public health concern observed by various nutrition indices. The narrative review aimed to appraise multisectoral policy, strategic and programmatic initiatives aimed at addressing FNS challenges and identify entry points for enhancing coherent and integrated FNS approaches. The review involved broad literature research using Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. A total of 1,086 articles and grey literature were identified. Out of this, 47 full-text articles and documents met the selection criteria and were included in this review. Evidence was synthesized in themes to characterize the successes and challenges of key FNS policies, strategies, and programs and identify potential areas of improvement to enhance multisectoral actions and address FNS challenges. Overall, Ethiopia has made considerable progress in enhancing FNS through the implementation of a range of FNS policies, strategies, and programs such as the National Nutrition Program (NNP), Productive Safety Net Program (PSNP), and Agricultural Growth Program (AGP) among others. These efforts have resulted in notable achievements, such as the reduction of the prevalence of undernourishment from 47.0% in 2000 to 24.9% in 2020 and the reduction of stunting among children under five years from 57.4% to 35.2% over the same period. Nonetheless, the pace of progress has been hindered by various contextual and programmatic challenges such as climatic shocks, poverty, high inflation, political instability, limited access to production resources, inadequate coverage of FNS interventions, inadequate financing, and inadequate multisectoral coherence and integration. A comprehensive and integrated multisectoral FNS approach focusing on enhancing commitment, planning, coordination, financing, capacity building, and accountability across sectors and levels is imperative. Strengthening coherence across various sectors, alongside the operationalization of robust multisectoral monitoring and evaluation systems highlighted in the National Food and Nutrition Strategy, constitutes the most suitable entry points for ensuring sustainable advancement in mitigating the prevailing FNS challenges in Ethiopia. Key words: Food and nutrition security, policy and program, multisectoral approaches, Integration, Ethiopia

Policies for expanding family planning coverage: lessons from five successful countries.

Enhancing the design of family planning interventions is crucial for promoting gender equality and improving maternal and child health outcomes. We identified, critically appraised, and synthesized policies and strategies from five selected countries that successfully increased family planning coverage. We conducted a policy analysis through a scoping review and document search, focusing on documents published from 1950 to 2023 that examined or assessed policies aimed at enhancing family planning coverage in Brazil, Ecuador, Egypt, Ethiopia, and Rwanda. A search was conducted through PubMed, SCOPUS, and Web of Science. Government documents and conference proceedings were also critically analyzed. National health surveys were analyzed to estimate time trends in demand for family planning satisfied by modern methods (mDFPS) at the national level and by wealth. Changes in the method mix were also assessed. The findings of the studies were presented in a narrative synthesis. We selected 231 studies, in which 196 policies were identified. All countries started to endorse family planning in the 1960s, with the number of identified policies ranging between 21 in Ecuador and 52 in Ethiopia. Most of the policies exclusively targeted women and were related to supplying contraceptives and enhancing the quality of the services. Little focus was found on monitoring and evaluation of the policies implemented. Among the five selected countries, a multitude of actions were happening simultaneously, each with its own vigor and enthusiasm. Our findings highlight that these five countries were successful in increasing family planning coverage by implementing broader multi-sectoral policies and considering the diverse needs of the population, as well as the specific contextual factors at play. Successful policies require a nuanced consideration of how these policies align with each culture's framework, recognizing that both sociocultural norms and the impact of past public policies shape the current state of family planning.

Using policy codesign to achieve multi-sector alignment in adolescent behavioral health: a study protocol

BackgroundPolicymaking is quickly gaining focus in the field of implementation science as a potential opportunity for aligning cross-sector systems and introducing incentives to promote population health, including substance use disorders (SUD) and their prevention in adolescents. Policymakers are seen as holding the necessary levers for realigning service infrastructure to more rapidly and effectively address adolescent behavioral health across the continuum of need (prevention through crisis care, mental health, and SUD) and in multiple locations (schools, primary care, community settings). The difficulty of aligning policy intent, policy design, and successful policy implementation is a well-known challenge in the broader public policy and public administration literature that also affects local behavioral health policymaking. This study will examine a blended approach of coproduction and codesign (i.e., Policy Codesign), iteratively developed over multiple years to address problems in policy formation that often lead to poor implementation outcomes. The current study evaluates this scalable approach using reproducible measures to grow the knowledge base in this field of study.MethodsThis is a single-arm, longitudinal, staggered implementation study to examine the acceptability and short-term impacts of Policy Codesign in resolving critical challenges in behavioral health policy formation. The aims are to (1) examine the acceptability, feasibility, and reach of Policy Codesign within two geographically distinct counties in Washington state, USA; (2) examine the impact of Policy Codesign on multisector policy development within these counties using social network analysis; and (3) assess the perceived replicability of Policy Codesign among leaders and other staff of policy-oriented state behavioral health intermediary organizations across the USA.DiscussionThis study will assess the feasibility of a specific approach to collaborative policy development, Policy Codesign, in two diverse regions. Results will inform a subsequent multi-state study measuring the impact and effectiveness of this approach for achieving multi-sector and evidence informed policy development in adolescent SUD prevention and treatment.

Holistic Approach in Strengthening of Primary Health Care Service

Holistic Approach in Strengthening of Primary Health Care Service

Food security and nutrition in refugee camps in the European Union: Development of a framework of analysis linking causes and effects

AbstractThe literature on food security and nutrition -FSN among refugees found high rates of food insecurity- FI among refugees in both, low- and middle-income - LMIC countries and high-income countries- HIC. Despite high rates of FI among refugees in HIC, little is known about FSN status of refugees and asylum-seekers living in refugee camps in the European Union- EU. This paper addresses this knowledge gap by reviewing issues related to the Food Security and Nutrition-FSN of refugees in the EU and worldwide and provides three main contributions to the existing knowledge. Firstly, it identifies the main drivers of FSN in a refugee context and offer a causal framework describing the main causes and effects of FNI in refugee camps. The immediate causes of FNI are poor Shelter and Settlement, Water, Sanitation and Hygiene and Healthcare. Moreover, secondary causes of FNI are the lack of adaptation to a new environment; Lack of culturally adapted food; Inadequate FSN interventions; Poor livelihood strategies. Secondly, it demonstrates that FNI exists in European refugee camps underscoring that EU member states have been unable to deliver sustainable solutions towards the realization of FSN in the E.U. Finally, the paper calls for a multisectoral and non-discriminatory European common policy targeting refugees’ FSN.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence.

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at thesubnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

Is addressing violence against women prioritised in health policies? Findings from a WHO policies database.

Violence against women (VAW) affects almost 1 in 3 women and can lead to short and long-term adverse health outcomes. The health sector is an important entry point to respond to VAW. Globally, countries have committed to eliminating VAW through the SDGs and WHO Member States have endorsed a Global Plan of Action on Violence, which asks countries to provide comprehensive health services to VAW survivors. To track progress and establish a baseline for the Global Plan of Action on Violence, WHO developed a VAW Policies Database to assess how countries are addressing VAW in health and multisectoral policies. This paper presents findings from 15 select indicators related to the existence of VAW-related policies and the inclusion of health services for survivors in policies in line with WHO recommendations. Results show that while 80% of countries have multisectoral VAW policies in place, only 34% have national health policies that include VAW response and/or prevention as a strategic priority, and 48% have clinical guidelines for the health sector response. Policies were analysed to identify inclusion of WHO-recommended VAW health services: 75% of countries' policies mention provision of first-line support; while 50% or fewer of countries mention clinical enquiry to identify intimate partner violence, post-rape care services, or mental health assessment, referral and treatment. The high-income countries group had the lowest proportion of countries that specified each of the above-mentioned health services in policies. Findings show that more efforts are needed to raise the awareness of ministries of health about the public health impact of VAW and the importance of including VAW in health policies. Where policies exist, many are not aligned with WHO-recommendations. Policy dialogues should be conducted with governments on how to better align their VAW policies with internationally-agreed, evidence-based standards, and to implement them through programmes and services.

Classifying climate vulnerability and inequalities in India, Mexico, and Nigeria: a latent class analysis approach

The climate crisis exacerbates social, economic, and health disparities. This study employs innovative methods to identify distinct groups affected by recent climate events. A mobile phone-based survey was conducted in April 2022 with individuals residing in multiple climate-affected states across three countries: India (n = 1020), Mexico (n = 1020), and Nigeria (n = 1021). Latent class analysis and classification and regression tree analysis were used to identify the groups most exposed to climate events, the effects and responses taken, and then to identify the characteristics associated with group membership. Effects included housing damage or lost work, while responses included actions such as borrowing money or dropping out of school. Findings revealed four distinct groups: Group 1 reported low exposure, no effects, or responses (49% of respondents in India, 43% in Mexico, and 27% in Nigeria); Group 2 experienced multiple hazards with moderate effects and some responses; Group 3 was characterized by drought exposure with more effects and responses taken; Group 4 was affected by heavy flooding and rainfall with varied effects. Notably, India had the largest proportion of respondents in Group 3 (17%), in Mexico over a quarter (29%) were in group 4, while over half of Nigerian respondents were in Group 2 (52%). Characteristics associated with membership in each group varied by country. Overall, men from rural areas with lower incomes and reliant on agriculture experienced the highest levels of exposure and vulnerability, while urban women from higher-income households were the least affected. This study underscores the importance of considering the intersectionality of risk and vulnerability when formulating policies and programs to address the impacts of climate change. Results emphasize the need for multi-sectoral policies that target the needs of different groups, to reduce inequalities and tailor to the context-specific needs of the most vulnerable people and households.

Abstract WMP60: Comparison of Demographic and Clinical Characteristics and the CDC Social Vulnerability Index Among Medicare Beneficiaries Hospitalized With Acute Ischemic Stroke, April 2020 - December 2021

Introduction: Extensive evidence shows that social inequities create health disparities. However, limited information exists on how demographic and clinical factors are associated with social inequities among older patients hospitalized with acute ischemic stroke (AIS) during COVID-19. Methods: We analyzed data on Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with AIS from April 1, 2020, to December 31, 2021. All patients were followed until March 31, 2023. We used US Centers for Disease Control and Prevention’s 2020 Social Vulnerability Index (SVI) and compared demographic and clinical features by SVI tertiles (low 0-0.33, moderate 0.34-0.66, high 0.67-1.0). Results: Among 249299 Medicare FFS beneficiaries with AIS, there were 57814 (23.2%) with low, 88565 (35.5%) moderate, and 102920 (41.3%) high SVI. Demographic and clinical features differed significantly across SVI tertiles. Compared to AIS patients living in low SVI communities, patients living in high SVI areas were significantly younger (median age 79.0 vs 79.9 years), more likely to be non-Hispanic Black (15.4% vs 4.3%), had more severe stroke at admission per National Institutes of Health Stroke Scale (NIHSS) score (9.4% NIHSS ≥20 vs 8.4%), more history of COVID-19 (7.7% vs 6.3%), higher proportion of death at the end of follow-up (40.4% vs 38.2%), and more comorbidities. Conclusion: Medicare patients with AIS hospitalizations live in communities with higher SVI. These data identified racial disparities and more severe outcomes among AIS patients living in areas with higher social vulnerabilities, signaling a need for multisectoral interventions and policies that impact AIS outcomes.

Review of Israel's action and response during the COVID-19 pandemic and tabletop exercise for the evaluation of readiness and resilience-lessons learned 2020-2021.

Reevaluating response plans is essential to ensuring consistent readiness and resilience to the COVID-19 pandemic. The "During Action Review" and Tabletop (DART) methodology provides a retrospective and prospective assessment to inform the adaptive response. Israel introduced COVID-19 vaccinations in December 2020 and was the first country to implement booster vaccination to address waning immunity and surges caused by new variants. We assessed Israel's readiness and resilience related to COVID-19 response while capturing the pre-vaccination and vaccination periods. A DART analysis was conducted between December 2020 and August 2021 among experts involved in the management of the COVID-19 pandemic in Israel. During the retrospective stage, a role-based questionnaire and discussions were undertaken in a participant-led review of the response, focusing on epidemiology and surveillance, risk communication, and vaccines. The prospective stage included tabletop exercises to evaluate short to long-term simulated scenarios. Participants emphasized the pivotal role of Israel globally by sharing experiences with the pandemic, and vaccination. Perceived strengths included multi-sectoral collaboration between the Ministry of Health, healthcare providers, academia, military, and others, stretching capacities, expanding laboratory workload, and establishing/maintaining surveillance. The vaccine prioritization plan and strong infrastructure, including computerized databases, enabled real-life assessment of vaccine uptake and impact. Challenges included the need to change case definitions early on and insufficient staffing. Quarantine of patients and contacts was particularly challenging among underprivileged communities. Risk communication approaches need to focus more on creating norms in behavior. Trust issues and limited cooperation were noted, especially among ethnic and religious minorities. To ensure readiness and resiliency, participants recommended establishing a nationally deployed system for bringing in and acting upon feedback from the field, especially concerning risk communication and vaccines. Our study appraised strengths and weaknesses of the COVID-19 pandemic response in Israel and led to concrete recommendations for adjusting responses and future similar events. An efficient response comprised multi-sectoral collaboration, policy design, infrastructure, care delivery, and mitigation measures, including vaccines, while risk communication, trust issues, and limited cooperation with minority groups were perceived as areas for action and intervention.

Too hot to thrive: a qualitative inquiry of community perspectives on the effect of high ambient temperature on postpartum women and neonates in Kilifi, Kenya

ObjectiveTo understand community perspectives on the effects of high ambient temperature on the health and wellbeing of neonates, and impacts on post-partum women and infant care in Kilifi.DesignQualitative study using key informant interviews, in-depth interviews and focus group discussions with pregnant and postpartum women (n = 22), mothers-in-law (n = 19), male spouses (n = 20), community health volunteers (CHVs) (n = 22) and stakeholders from health and government ministries (n = 16).SettingsWe conducted our research in Kilifi County in Kenya’s Coast Province. The area is largely rural and during summer, air temperatures can reach 37˚C and rarely go below 23˚C.Data analysisData were analyzed in NVivo 12, using both inductive and deductive approaches.ResultsHigh ambient temperature is perceived by community members to have direct and indirect health pathways in pregnancy and postpartum periods, including on the neonates. The direct impacts include injuries on the neonate’s skin and in the mouth, leading to discomfort and affecting breastfeeding and sleeping. Participants described babies as “having no peace”. Heat effects were perceived to be amplified by indoor air pollution and heat from indoor cooking fires. Community members believed that exclusive breastfeeding was not practical in conditions of extreme heat because it lowered breast milk production, which was, in turn, linked to a low scarcity of food and time spend by mothers away from their neonates performing household chores. Kangaroo Mother Care (KMC) was also negatively affected. Participants reported that postpartum women took longer to heal in the heat, were exhausted most of the time and tended not to attend postnatal care.ConclusionsHigh ambient temperatures affect postpartum women and their neonates through direct and indirect pathways. Discomfort makes it difficult for the mother to care for the baby. Multi-sectoral policies and programs are required to mitigate the negative impacts of high ambient temperatures on maternal and neonatal health in rural Kilifi and similar settings.