Multisectoral Action Research Articles

Health Communication Planning Implementation for the Healthy Living Community Movement Program based on Management by Objectives Theory in Banyumas Regency

GERMAS (Healthy Living Community Movement) is a program initiated by the Ministry of Health of the Republic of Indonesia to carry out comprehensive and holistic interventions to cultivate healthy living behavior in society. Regarding to this issue, several activities were launched in the forms of promotive, preventive, curative and rehabilitative efforts as a continuum of care or integrated sustainable care in line with the spirit of community empowerment and increasing multisectoral action. This study is to examine the implementation of Management by Objectives (MBO) Theory of Peter Drucker through the Community Health Center (Puskesmas) in GERMAS program. This research uses a descriptive-qualitative method with emphasis on triangulation of data collection techniques in the form of observation, interviews and literacy studies. In-depth observations and interviews were carried out with the Youth Posyandu team leader at the Puskesmas North Purwokerto 2, Banyumas District Nutrition Expert, Banyumas District pediatrician, and 15 Youth Posyandu cadres as an implementation of the use of data source triangulation. The other data were obtained from written documents such as Basic Health Research, Government Regulations from the Ministry of Health of the Republic of Indonesia, Technical Instructions for Organizing Youth Posyandu from the Ministry of Health, as well as the results of internal meetings at the Banyumas District Service regarding the implementation of Youth Posyandu. The results revealed that, (1) The stages of top management commitment have been clearly defined and stated in Presidential Instruction (Inpres) Number 1 of 2017. (2) The participation stage is marked by the setting of more concrete goals, namely preparing for a demographic bonus in the 2020-2035 range, Golden Indonesia 2045, and threats to the mental and physical health of teenagers. The release of the Technical Guidelines for the Implementation of Youth Posyandu in 2018 by the Ministry of Health constitutes an indicator of guidelines for program implementation. However, at present the implementation has not optimally conducted in various Puskesmas. This is caused by a lack of human resources, daily routine work that takes up a lot of time, and other programs already running also need attention. (3) The communication stage is marked by the implementation of the program for adolescents. The importance of raising awareness regarding the crucial importance of this program is not easy because teenagers consider that the age of 10-19 years is a healthy and productive age, so invitations to join Posyandu are less attractive.

Multi-sectoral collaborations in selected countries of the Eastern Mediterranean region: assessment, enablers and missed opportunities from the COVID-19 pandemic response

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has emphasized the importance of multi-sectoral collaboration to respond effectively to public health emergencies. This study aims to generate evidence on the extent to which multi-sectoral collaborations have been employed in the macro-level responses to the COVID-19 pandemic in nine selected countries of the Eastern Mediterranean region (EMR).MethodsThe study employed in-depth analytical research design and was conducted in two phases. In the first phase, data were collected using a comprehensive documentation review. In the second phase, key informant interviews were conducted to validate findings from the first phase and gain additional insights into key barriers and facilitators. We analysed the macro-level pandemic responses across the following seven components of the analytical framework for multi-sectoral collaborations: (1) context and trigger; (2) leadership, institutional mechanisms and processes; (3) actors; (4) administration, funding and evaluation; (5) degree of multi-sectoral engagement; (6) impact; and (7) enabling factors.ResultsGovernments in the EMR have responded differently to the pandemic, with variations in reaction speed and strictness of implementation. While inter-ministerial committees were identified as the primary mechanism through which multi-sectoral action was established and implemented in the selected countries, there was a lack of clarity on how they functioned, particularly regarding the closeness of the cooperation and the working methods. Coordination structures lacked a clear mandate, joint costed action plan, sufficient resources and regular reporting on commitments. Furthermore, there was no evidence of robust communication planning both internally, focused on promoting internal consensual decision-making and managing power dynamics, and externally, concerning communication with the public. Across the selected countries, there was strong representation of different ministries in the pandemic response. Conversely, the contribution of non-state actors, including non-governmental organizations, civil society organizations, the private sector, the media and citizens, was relatively modest. Their involvement was more ad hoc, fragmented and largely self-initiated, particularly within the selected middle- and low income- countries of the EMR. Moreover, none of the countries incorporated explicit accountability framework or included anti-corruption and counter-fraud measures as integral components of their multi-sectoral plans and coordination mechanisms. Key enablers for the adoption of multi-sectoral collaborations have been identified, paving the way for more efficient responses in the future.DiscussionMirroring global efforts, this study demonstrates that the selected countries in the EMR are making efforts to integrate multi-sectoral action into their pandemic responses. Nevertheless, persistent challenges and gaps remain, presenting untapped opportunities that governments can leverage to enhance the efficiency of future public health emergency responses.

Prevalence of chronic conditions and multimorbidity among healthcare workers in Zimbabwe: Results from a screening intervention.

The burden of non-communicable diseases (NCDs) in southern Africa is expanding and is superimposed on high HIV prevalence. Healthcare workers are a scarce resource; yet are vital to health systems. There are very limited studies on the burden of chronic conditions among healthcare workers in Africa, and none exploring multimorbidity (≥2 chronic conditions). We describe the epidemiology of infectious (HIV) and non-communicable chronic conditions, and multimorbidity, among Zimbabwean healthcare workers. Healthcare workers (≥18 years) in eight Zimbabwean provinces were invited to a voluntary, cross-sectional health-check, including HIV, diabetes, hypertension and mental health screening. Statistical analyses described the prevalence and risk factors for multimorbidity (two or more of HIV, diabetes, hypertension or common mental disorder) and each condition. Missing data were handled using multiple imputation. Among 6598 healthcare workers (July 2020-July 2022) participating in the health-check, median age was 37 years (interquartile range 29-44), 79% were women and 10% knew they were living with HIV. Half had at least one chronic condition: 11% were living with HIV, 36% had elevated blood pressure, 12% had elevated HbA1c and 11% had symptoms of common mental disorder. The overall prevalence of multimorbidity was 15% (95% CI: 13-17%); 39% (95% CI: 36-43%) among people aged 50 and older. Whilst most HIV was diagnosed and treated, other chronic conditions were usually undiagnosed or uncontrolled. Limiting our definition of multimorbidity to two or more screened conditions sought to reduce bias due to access to diagnosis, however, may have led to a lower reported prevalence than that found using a wider definition. Half of healthcare workers screened were living with a chronic condition; one in seven had multimorbidity. Other than HIV, most conditions were undiagnosed or untreated. Multisectoral action to implement contextually relevant, chronic disease services in Africa is urgently needed. Specific attention on health workers is required to protect and retain this critical workforce.

On-site evaluation as external quality assessment of microbiology laboratories involved in sentinel laboratory-based antimicrobial resistance surveillance network in Burkina Faso

BackgroundThe laboratory-based surveillance of antimicrobial resistance (AMR) is a priority component of the multisectoral national action plan to combat AMR in Burkina Faso. This study aimed to assess the QMS of microbiology laboratories involved in the Sentinel laboratory-based antimicrobial resistance surveillance network in Burkina Faso.MethodsA cross-sectional study was conducted from September 1st to November 30th, 2022. The external quality assessment (EQA) method used was on-site evaluation using a checklist that was developed and validated by a technical committee of experts. Teams of two, including an antimicrobial susceptibility test (AST) specialist and a QMS specialist, were trained on this checklist to conduct the assessment. Satisfactory performance was defined as any on-site evaluation score 80% and above with the aim of developing action plans to address gaps.ResultsAll 18 laboratories were evaluated. The overall average performance score of the participating laboratories was 40%. The highest overall performance score was 58%, and the lowest overall performance score was 26%. The average overall scores were not significantly different between private and public laboratories (p value = 0.78). The only section of the checklist with the satisfactory performance concerned the “Analytical step of AST”, with 76.5% (13/17) of the sentinel laboratories having a score ≥ 80%.ConclusionThe performance of the QMS of the sentinel laboratories in Burkina Faso for AMR surveillance was unsatisfactory, and a corrective action plan was proposed to support these laboratories in improving their QMS over the next 3 years.

Monitoring progress on Antimicrobial Resistance (AMR) response in the World Health Organization African region: Insights from the Tracking AMR Country Self-Assessment Survey (TrACSS) 2021 results for the human health sector.

Antimicrobial resistance (AMR) is a major 21st century global health challenge. The WHO African Region Member States committed to develop and implement multisectoral national action plans (NAPs) that address AMR, in line with the Global Action Plan on AMR (GAP). The aim of this paper is to present the progress of AMR response in the WHO African Region based on the annual Tracking AMR Country Self-Assessment Survey (TrACSS), with a focus on human health indicators. This was a secondary data analysis of responses from forty-one countries that participated in the 2021 TrACSS. Of the 41 countries that responded to the 2021 TrACSS, 35(85%) have developed NAPs. Fifteen 15(37%) of countries have functional AMR multisector working groups. 55% (21/41) of countries are collating data nationally on AMR surveillance. Forty nine percent of countries conducted small-scale AMR awareness campaigns and 53% (21/41) covered AMR in some pre- and in-service training for human health workers. While 83% of countries reported having laws and regulations on the prescription and sale of antimicrobials, only 32% (13/41) have national systems for monitoring antimicrobial use. Twenty-three (58%, 23/41) reported having Infection Prevention and Control (IPC) programs at select health facilities. Countries have developed and are implementing AMR NAPs. Gaps still exist across key indicators monitored through TrACSS. Effective AMR response requires established functional multisectoral governance mechanisms in the One Health approach; political commitment, sustainable funding, and clear monitoring and reporting is critical.

Using the settings approach to health promotion in hospital and health services to support collaboration, engagement, and partnership in integrated care systems.

Introduction: Hospitals and health services within integrated care systems can implement the 2020 Standards for Health Promoting Hospitals and Health Services to promote the mutual values reflected in the nine pillars of integrated care, such as shared vision and multisectoral action, improving population health, people-centered care, community participation, staff health, leadership, and quality improvement. After the impact of the COVID-19 pandemic, a shift towards these shared values is needed to better address burnout and a decreasing workforce.
 Intervention: The International Network of Health Promoting Hospitals & Health Services’ (HPH) 600 members from 33 countries work towards supporting the integration of health promotion into the organizational structure and culture of organizations to create health promoting settings. To operationalize this vision and guide decision makers in transforming their institutions into settings that support collaboration, engagement, and partnership, the 2020 Standards for Health Promoting Hospitals and Health Services and complimentary Self-Assessment tools were conceived. 
 Five overarching standards, 18 substandards, and 86 standard statements resulted from a methodological consolidation of existing HPH standards (addressing equity, mental health, the environment, health literacy, patient-centered care, groups such as the elderly, children, and adolescents) and from two Delphi consultation rounds with HPH subject experts. The standards reflect over 30 years of knowledge and international experience in health promotion implementation across various areas of policy, practice, and evidence within the International HPH Network. Complementary self-assessment tools, developed with input from 14 countries, can be used to identify key members of multidisciplinary steering teams, to compare data and monitor progress, and develop targeted quality improvement plans based on data collected. Currently, the Standards are available in 11 languages on the HPH website.
 Outcomes: Hospitals and health services who adopt a comprehensive health promotion approach are agile, better able to respond to challenges and are receptive to change. During Delphi consultation rounds to define the standards, high ratings of relevance were given to population health needs, organizational commitment, and environmental health amongst countries contributing to the design of the Standards. The standards, therefore, strongly focus on organizational collaboration; engagement of patients, family, staff, and the community; and building alliances and partnerships between stakeholders along a patients’ care pathway. Organizations adopting this holistic approach are efficient, leading to better health outcomes, satisfaction for all involved, and lower costs, which are shared aims of integrated care. Health promoting settings are supportive of integrated care and can be implemented as a first step in a system-wide transformation. 

MULTISECTOR COLLABORATION DRIVES THE DEVELOPMENT OF THE FOURTH HEALTHY BRAIN INITIATIVE ROAD MAP

Abstract Partnerships and collaboration across sectors played a critical role in the development of the fourth edition of the Healthy Brain Initiative Road Map (Road Map). The public health community, leaders in related fields, and people living with dementia contributed to the development and review. The Alzheimer’s Association and CDC invited 20 national leaders from public health, aging, academia, health care and health systems to guide the development of the fourth HBI Road Map as a part of the Leadership Committee. Their contributions included reviewing data, setting the overall direction of the review and leading five workgroups, composed of 68 subject-matter experts, who recommended actions on Risk Reduction of Cognitive Decline; Timely Detection, Diagnosis and Management of Cognitive Impairment; Dementia Caregiving; Health Equity; and Community Linkages. Health departments offered input through facilitated listening sessions and an open input period. Their feedback emphasized the importance increased information on health equity and partnerships in the Road Map. The Leadership Committee also advised continued partner engagement through the review process. This translated to review by the Alzheimer’s Association, CDC subject matter experts, external health equity experts, the Leadership Committee, workgroup members, the Healthy Brain Initiative Collaborative, the Alzheimer’s Association Early Stage Advisory Group and ultimately CDC leadership. This presentation will explore important themes that emerged throughout this process that shaped the design and evolution of the HBI Road Map series to its most recent iteration, as a guiding document with health equity and multi-sector collaboration action at its core.

Preparedness, impacts, and responses of public health emergencies towards health security: qualitative synthesis of evidence

BackgroundNatural and human-made public health emergencies (PHEs), such as armed conflicts, floods, and disease outbreaks, influence health systems including interruption of delivery and utilization of health services, and increased health service needs. However, the intensity and types of impacts of these PHEs vary across countries due to several associated factors. This scoping review aimed to synthesise available evidence on PHEs, their preparedness, impacts, and responses.MethodsWe conducted a scoping review of published evidence. Studies were identified using search terms related to two concepts: health security and primary health care. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines to select studies. We adapted the review framework of Arksey and O’Malley. Data were analyzed using a thematic analysis approach and explained under three stages of PHEs: preparedness, impacts, and responses.ResultsA total of 64 studies were included in this review. Health systems of many low- and middle-income countries had inadequate preparedness to absorb the shocks of PHEs, limited surveillance, and monitoring of risks. Health systems have been overburdened with interrupted health services, increased need for health services, poor health resilience, and health inequities. Strategies of response to the impact of PHEs included integrated services such as public health and primary care, communication and partnership across sectors, use of digital tools, multisectoral coordination and actions, system approach to responses, multidisciplinary providers, and planning for resilient health systems.ConclusionsPublic health emergencies have high impacts in countries with weak health systems, inadequate preparedness, and inadequate surveillance mechanisms. Better health system preparedness is required to absorb the impact, respond to the consequences, and adapt for future PHEs. Some potential response strategies could be ensuring need-based health services, monitoring and surveillance of post-emergency outbreaks, and multisectoral actions to engage sectors to address the collateral impacts of PHEs. Mitigation strategies for future PHEs could include risk assessment, disaster preparedness, and setting digital alarm systems for monitoring and surveillance.

The need for multisectoral actions for dengue control in Peru: A One Health approach

Sr. Editor, La infección por el virus del dengue se ha convertido en la primera emergencia sanitaria en varios países de América Latina, especialmente en Perú, donde al primer semestre del 2023 hubo más 206 mil casos y 357 muertes. Pero, ¿cuál es la mejor perspectiva para analizar el problema del dengue en el Perú?

Conceptual definition for drowning prevention: a Delphi study

BackgroundExpanding support for drowning prevention is evidenced by interlinked Resolutions at the United Nations (2021) and World Health Assembly (2023). While progress has accelerated, a universally agreed definition for drowning...

“She gives it to her child who doesn’t even talk”: a qualitative exploration of alcohol and drug use among primary school-age children in Uganda

BackgroundThere is little research on alcohol and other drugs (AOD) use by school-age children in low-resource settings like Uganda. Including the voices of children in research can inform prevention and early intervention efforts for those at risk of AOD use. The aim of this study was to understand the perspectives of children aged 6 to 13 years regarding AOD in Uganda.MethodsThis qualitative study was conducted in Mbale district, Uganda from February to March 2020. Eight focus group discussions (FGDs) were conducted with 56 primary school-age children, stratified by age (6–9 and 10–13 years), sex (male and female), and school status (in school and out of school). All FGDs were conducted in either Lumasaaba or Luganda. The FGDs were audio-recorded, transcribed verbatim, and translated into English. Data were coded, and overarching themes were identified using thematic framework analysis.ResultsTwo themes identified were (1) Children’s perceptions and experiences with AODs. The participants understood alcohol by its consistency, colour, odour, and by brand/logo. They described the types and quantities of AOD consumed by school-age children, brewing processes for homemade alcoholic drinks, and short and long-term consequences of the use of alcohol. (2) Contributing factors to childhood drinking included: Stress relief for children who experienced multiple adversities (orphaned, poverty-stricken, and hailing from broken homes), fitting in with friends, influence from families, and media exposure that made alcohol look cool. Children would start drinking at an early age) or were given alcohol by their parents, sometimes before they could start talking. In the community, alcohol and other drugs were cheap and available and children could drink from anywhere, including in the classroom.ConclusionsChildren eligible for primary education in Uganda can easily access and use AOD. Several factors were identified as contributing to alcohol and other drug use among children, including availability and accessibility, advertising, lack of parental awareness and supervision, peer influence, adverse childhood experiences, socioeconomic factors, and cultural norms. There is a need for multi-sectoral action for awareness of childhood AOD use and deliberate consideration of children in the planning, design, and implementation of research, policies, and programs for prevention and early intervention.

8.M. Pro/con workshop: Moving towards primary health care-oriented health systems: Insights from the PHC Primer

Abstract Primary health care (PHC) has been the focus of intense global attention over the past few years. It has been acknowledged as having a key role in achieving Universal Health Coverage, in advancing health equity and in enabling health system resilience. PHC as a whole-of-society approach translates the fundamental human right to health, the central role of people in co-creating their health and the responsibility of governments to enable the maintenance and restoration of health for all. The PHC approach aims to maximize the level and distribution of health and well-being through the three PHC components as endorsed in the Astana Declaration: (a) primary care and essential public health functions as the core of integrated health services; (b) multisectoral policy and action; and (c) empowered people and communities. A ‘PHC-oriented health system’ is composed of ‘models of care’ and core ‘health system levers’ that support UHC and access to services that are acceptable and affordable to the population and enhance equity. This session will present the comprehensive PHC approach that is enshrined in the understanding that fragmented approaches focusing on single diseases do not deliver on the goal of improving health for all. It will outline different models of care (MoC) that are reoriented around the values of PHC, namely solidarity, community empowerment and equity and show how different MoC components can operationalise the PHC principles. This session will further outline how countries implement the PHC approach across the WHO European region and highlight their trajectories. In particular, it will demonstrate Slovenia's experience in its transition towards comprehensive, integrated, people-centred PHC. More specifically, the session aims to: • summarize the evidence-informed contemporary theoretical and political rationale for PHC to guide its implementation in the 21st century, • cultivate a common understanding of the concept, with a focus on developments in the global and public health arena in the last 20 years, • provide a grounding in a thorough conceptual and practical comprehension of the possibilities and challenges of PHC to advance its implementation. This workshop presents results from a global publication on primary health care, the PHC Primer, that is jointly produced by the World Health Organization and the European Observatory on Health Systems and Policies. The PHC Primer collects latest evidence on primary health care and current approaches and developments adopted by countries to transform health systems towards more person-centred, holistic systems. Key messages • The development of strong PHC-oriented health systems requires a multi-pronged approach and policies in all operational levers. • PHC oriented model of care should extend beyond integrated health services to facilitate engagement with communities and multisectoral action. Speakers/Panelists Luke Allen LSHTM, London, UK Erica Barbazza University of Amsterdam, Amsterdam, Netherlands Toni Dedeu WHO European Centre for Primary Health Care, Almaty, Kazakhstan Pia Vracko NIJZ, Ljubljana, Slovenia

One Health good practices across the European Region: the co-production of a Compendium

Abstract Issue/problem The international and scientific community has been calling for many years to strengthen prevention and preparedness to threats at the human-animal-environment interface by integrating a systemic approach, such One Health (OH). Furthermore, the COVID-19 pandemic highlighted the importance of OH to enhance health security. However, at the national level, governments are delaying the integration of OH in their public health systems or in national health plans. Description of the problem The WHO Regional Office for Europe is supporting the elaboration of a Compendium of operationalized and/or implemented OH practices within the Region, highlighting enabling factors and lessons learnt to promote OH adoption, in line with the One Health Joint Plan of Action 2022-2026 (OH JPA) of the Quadripartite Organizations. The Compendium is part of the efforts of the WHO European Region 2024-2030 strategy and it responds to the recommendations of the 2021 Pan-European Commission on Health and Sustainable Development. Results OH practices within the European Region are identified through a rapid review and are validated with stakeholder interviews to select those concretely supporting OH operationalization and implementation. The practices are described according to the following characteristics: country, sector, OH JPA action track, OH principles, disciplines and stakeholders involved. Specific additional attributes, like innovation, sustainability, efficacy, replicability and advancement of the Sustainable Development Goals (SDGs), are supporting the process of inclusion in the Compendium. Lessons Lessons learned from the practices provide a framework for action to scale up OH within the Region and globally. Collective action for OH operationalization and implementation in preventing, preparing for, detecting, and managing health threats at national and local level is advanced, supporting the achievement of key SDGs, with an up-to-date vision according to the OH JPA. Key messages • OH good practices within the European Region are collected in a Compendium to promote and guide OH approaches integration in national plans and to enhance health security in the Region and globally. • The Compendium supports multisectoral and multistakeholder actions for OH operationalization and implementation, with an up-to-date vision supporting the OH JPA and the achievement of key SDGs.

Subtle industry interference in public health: the case of the alcohol industry

Abstract Upstream drivers of alcohol consumption forcing people to consume alcohol frequently and excessively and experience alcohol-related harms are in fact all industry-related factors: easy physical access to alcohol, cheap alcohol beverage pricing, and heavy alcohol advertising and promotion. Unequivocal evidence exists on how these visible industry tactics effectively allow the infiltration of alcohol products into the market, targeting specific subgroups (women, youth), increase total per capita consumption and subsequently alcohol-related morbidity and mortality. This presentation will highlight using country cases and various examples the more subtle mechanisms in which the industry has successfully been interfering with nations’ progress in alcohol policy (e.g., NoLo beverages, interfering with WHO definitions, using SDGs to foster partnerships). Using the whole-of-government whole-of-society approaches, the presentation will also present evidence-based multi-sectoral actions (their facilitators and barriers) for more effective national alcohol policy. Given that alcohol is no ordinary commodity, the presentation will end with implications for policy to counterbalance global alcohol industry interference and support national actions.

Identifying strategic priorities for advancing global drowning prevention: a Delphi method

IntroductionThe burden of drowning is gaining prominence on the global agenda. Two United Nations system resolutions in 3 years reflect rising political support, but priorities remain undefined, and the issue...

Determinants of the unmet needs for information, education and communication on sexual health among single youths in Burundi.

The prevalence of HIV/AIDS among young people aged 15-24 in urban areas is at least 12 times higher among girls than boys in Burundi, while it is twice as high in Rwanda. The gap between the two countries could be narrowed if Burundi's single young people were provided with sufficient information about their sexual health through appropriate channels. The aim of this study was to examine the social and individual "determinants" of unmet needs for sexual health information, education and communication (IEC) among unmarried young boys and girls aged 15-24 in Burundi, using data from the 2016 Demographic and Health Survey (DHS). Data were analyzed at the bivariate level using cross-tabulations and chi-squared tests, and at the multivariate level using binary logistic regression methods. According to the results of the study, the 'determinants' of the phenomenon studied are, for both sexes, the size of the household, the age of the youths, their level of education, their knowledge of where to take the HIV/AIDS test and their region of residence; only in the case of boys do we find, in addition, the age of the head of the household, his level of education and the adolescents' exposure to the media; similarly, only in the case of girls do we find their economic activity and their perception of HIV/AIDS. Multisectoral IEC actions on sexual health for young people should therefore be strengthened in Burundi.

Using a systems thinking approach to explore the complex relationships between schizophrenia and premature mortality.

People with schizophrenia have a higher risk of mortality compared to the general population, which has not improved over time. The majority of premature deaths are due to comorbid physical diseases, driven by interrelated factors operating at the individual level, through health systems and influenced by social determinants of health. A holistic understanding of this problem and the causal pathways linking these factors together is lacking. This study aims to understand why the mortality gap between people with schizophrenia and the general population is not improving by developing a causal loop diagram (CLD), a systems thinking approach which enables empirical research and theoretical knowledge to be combined into a visual representation of causal relationships and feedback loops. The CLD was constructed using published literature, including both quantitative and qualitative studies, to identify key variables and relationships, and refined through consultation with experts in the topic area. A total of 21 variables and 68 connections were included in the CLD, with 23 distinct feedback loops identified. Stigma and social support had the most connections, while unemployment was involved in the greatest number of feedback loops. Most feedback mechanisms served to reinforce behavioural risk factors, inadequate healthcare and social disadvantage. The CLD has created a holistic and dynamic understanding of the causal pathways driving the mortality gap between people with schizophrenia and the general population, providing insights into why it has persisted over time. One of the key findings was the critical role of social determinants in shaping health outcomes, highlighting the need for person-centred models of care and multisectoral government action.

Multisectoral actions in primary health care: A realist synthesis of scoping review.

Multisectoral actions (MSAs) on health are key to implementation of primary health care (PHC) and achieving the targets of the Sustainable Development Goal 3. However, there is limited understanding and interpretation of how MSAs on health articulate and mediate health outcomes. This realist review explored how MSAs influence on implementing PHC towards universal health coverage (UHC) in the context of multilevel health systems. We reviewed published evidence that reported the MSAs, PHC and UHC. The keywords used in the search strategy were built on these three key concepts. We employed Pawson and Tilley's realist review approach to synthesize data following Realist and Meta-narrative Evidence Syntheses: Evolving Standards publication standards for realist synthesis. We explained findings using a multilevel lens: MSAs at the strategic level (macro-level), coordination and partnerships at the operational level (meso-level) and MSAs employing to modify behaviours and provide services at the local level (micro-level). A total of 40 studies were included in the final review. The analysis identified six themes of MSAs contributing to the implementation of PHC towards UHC. At the macro-level, themes included influence on the policy rules and regulations for governance, and health in all policies for collaborative decision makings. The meso-level themes were spillover effects of the non-health sector, and the role of community health organizations on health. Finally, the micro-level themes were community engagement for health services/activities of health promotion and addressing individuals' social determinants of health. Multisectoral actions enable policy and actions of other sectors in health involving multiple stakeholders and processes. Multisectoral actions at the macro-level provide strategic policy directions; and operationalise non-health sector policies to mitigate their spillover effects on health at the meso-level. At micro-level, MSAs support service provision and utilisation, and lifestyle and behaviour modification of people leading to equity and universality of health outcomes. Proper functional institutional mechanisms are warranted at all levels of health systems to implement MSAs on health.

A qualitative analysis of the nurturing care environment of families participating in Brazil's Criança Feliz early childhood program.

Investing in early childhood programs such as Brazil's Criança Feliz Program (PCF) to support low-income families in providing a nurturing care environment is critical to ensure that children reach their full developmental potential. We aimed to analyze the influence of the PCF on the nurturing care environment provided by families enrolled in the program in the Federal District, Brazil. A qualitative case study was conducted based on in-depth interviews with a purposive sampling of 22 caregivers enrolled in the PCF for at least six months. Eighteen subthemes emerged from the thematic analysis following the five components of the Nurturing Care Framework (i.e., good health, adequate nutrition, responsive care, early learning, and security and safety). Caregivers recognized the benefits of the PCF on children's mental health (good health) and reported challenges in providing adequate nutrition due to food insecurity (adequate nutrition). A bond between the home visitor and families was identified as critical to promote responsive parenting practices (responsive care). Caregivers appreciated the early stimulation activities provided during PCF home visits (opportunities for early learning). Access to social welfare programs, such as conditional cash transfer and food assistance, were facilitated through PCF multisectoral actions (safety and security). On the other hand, families reported not receiving support from PCF for issues such as breastfeeding, maternal mental health, and disciplinary practices. In summary, PCF enhanced the components of the nurturing care environment provided by families. However, their vulnerabilities and contextual implementation barriers may prevent families from fully benefiting from PCF activities.

Integrated person- and people-centred primary care for diabetes in low- and middle-income countries: The nurses' perspective on patient needs.

The aim of this study was to identify what nurses working in primary care settings perceive as necessary to support the life needs of people with type 2 diabetes. Articulate these needs with the needs expressed by people with diabetes in a previous study. Finally, illustrate the potential of the used method. A highly structured qualitative group method for brainstorming and idea sharing was used to generate a participant-owned concept map that can support and evaluate practice change. Data were collected between April and May 2022 in two public primary healthcare centres in Sacaba, Bolivia, with 33 professional nurses, technical nurses, nurse trainees and one physician. The concept mapping process by Trochim was used to generate, share and structure ideas, maximizing equality of input. The nurses identified 73 unique needs that were structured in 11 conceptual clusters related to four different stakeholders or domains: organization of care and health policy, strengthening knowledge, skills and attitudes of healthcare providers, empower people living with diabetes and their family, and community-level health promotion and diabetes education. The needs and domains identified by nurses and people with type 2 diabetes are very similar and inform a multisectoral and transdisciplinary action plan to jointly monitor and evaluate progress towards people-centred care for people with diabetes. This study demonstrates nurses' important contribution to analysing and designing people-centred care in their community. They identify and act upon social determinants of health related to schools, safety and legislation. Besides global relevance, results inform the municipal health plan and an ongoing research project on cardiometabolic health. Data from prior patient consultations were included in the study design, and study results inform the municipal health plan.