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Lebanese and Syrian refugee parents' experiences of accessing mental health care for their children in Lebanon: Findings from a qualitative study.
Get PDFGlobally, more than 250 million children and adolescents experience mental health (MH) disorders. The estimated 43 million children forcibly displaced at the end of 2022, most commonly displaced to neighbouring low-and-middle-income countries where health and social protection systems are under-resourced, are at especially high risk of developing MH problems. In such settings, host community and refugee parents must often navigate complex pathways to attain the care their children need. Lebanon has experienced multiple crises and now hosts over 1 million refugees from Syria. We explore Lebanese and Syrian refugee parents' experiences of seeking MH care for their children in Lebanon. This study is part of a larger study qualitatively assessing how Syrian refugee and host populations pay for and access MH services. As part of this study, we conducted a narrative enquiry comprising 10 interviews with purposively selected Lebanese and Syrian parents of children with mental health problems, living in the Greater Beirut and Mount Lebanon area. Data were analysed collaboratively and inductively. Parents reported that the decision to seek MH services for their children commonly followed an acute event, encouragement by family members, or advice from health and child protection organisations. Many described how, even though stigma associated with MH is decreasing in Lebanon, it persists among some communities and creates significant barriers to accessing care, with parents often concealing their care seeking activities. Parents followed a range of pathways to access care, often encountering financial and accessibility barriers. The economic and COVID-19 crises in Lebanon have exacerbated their problems, affecting Lebanese and Syrian families alike. However, Syrian parents needed more support for their children's basic and educational needs, vital aspects of maintaining their MH and wellbeing. All parents stressed how important it was for MH services to provide comprehensive family support, preserving parents' dignity, and building trust with both parents and children. They also recommended integrating life skills, recreational activities, and assistance with basic needs into MH services and preferred counselling and psychotherapy over medication. We conclude that Lebanese and Syrian parents in Lebanon face multiple challenges obtaining care for children with MH concerns, a situation exacerbated by the many crises facing Lebanon. Lebanon's health financing system needs urgent reform to improve MH services to host-community and refugee populations, while governmental and humanitarian stakeholders must seek to deliver cross-sectoral holistic services to children and their families, avoiding the siloed approach that focuses only on children's MH in isolation from family and social environments
Ocular morbidity, visual impairment and its association with social factors in children attending primary healthcare services for any health-related problem in Pavagada, India - A health facility-based cross-sectional study.
Get PDFBACKGROUND: Primary eye healthcare in India has potential for improvement; enhancing it can play a role in universal health coverage, integrated people-centered eye care, and reducing the burden on overloaded secondary/tertiary facilities. PURPOSE: To assess the unmet need for primary eye care services in Pavagada taluk, Karnataka, India, by estimating ocular morbidity, blindness, and visual impairment among children <18 years, attending primary health centers for any health-related issue, and to examine their association with social factors. SETTING AND DESIGN: Health facility-based cross-sectional study in primary health centers in Pavagada. METHODS: Trained ophthalmic technicians used E charts, red reflex testing, and external examination to screen. Patients with vision <6/9, abnormal red reflex, or external examination were referred to the base hospital. STATISTICAL METHODS: The data was analyzed using STATA17. RESULTS: Of 965 patients screened (mean [SD] age 6.87 [4.97] years), 125 were referred to the base hospital; seventy-two (57.5%) reported. The unmet need was 54% (39/72). Only 9/39 (23%) had major ocular morbidity necessitating secondary/tertiary care. Ocular morbidity was 8.60%, with uncorrected refractive errors predominant (6.84%). Visual impairment rates were lower among children of mothers with 8-12 years of education (13.64%), housewives (7%), upper-middle-class (0%), compared to those with no formal education (25%), non-agricultural laborers (29%), middle (22%), lower-middle class (17%), respectively. CONCLUSION: Pavagada taluk has a significant unmet need for primary eye care services. Addressing this requires improving infrastructure, manpower, and training at existing health centers to provide primary eye care services and alleviate the burden on secondary/tertiary care facilities
How the care workforce navigates the digital 'skills gap': problems and opportunities from policy to practice.
Get PDFINTRODUCTION: Care systems and services across the globe are under pressure, with challenges related to the recruitment and retention of the care workforce identified as a particular issue. In England, digital technologies are presented in policy discourse and strategy as a potential way to navigate these complexities by delivering faster, cheaper and better care. The workforce, meanwhile, tends to be defined as requiring better digital skills to enable the full potential of digital technologies to be realised. METHODS: We carried out qualitative case study research of seven social care provider organisations, involving interviews with a total of 62 people from a range of roles across the care workforce and observations of work-based practices. Drawing on this data, we explore in-depth the workforce's experiences of and perspectives on using new technologies, and the requisite skills. RESULTS: The results show how the issue of maximising the adoption of technologies is (1) affected less by a deficit in worker skills, and more by the type of digital technologies in use, the job role of the worker, and the type of care provider, (2) can be facilitated by a supportive learning environment, and (3) can be impeded by issues in the functionality of systems and devices. DISCUSSION: We show a disconnect between the assumptions made in policy discourse and the practicalities and variations in how workers adapt, apply, and develop skills. We also explore the importance of peer support, albeit hindered by time constraints and sometimes overly relying on individual workers. In addition, the paper highlights the importance of understanding how new technology adoption can be stymied by the design of the technology itself, rather than the result of the workforce's lack of digital skills per se. An unintended consequence of defining the problem as a skills mismatch and the solution as skilling the workforce is that the abilities of the workforce to creatively and flexibly manage the short-comings of digital devices and systems are overlooked and under-utilised - reflecting a wider failure to acknowledge and compensate care workers' skills
Syphilis Exposure During Pregnancy and Childhood Hospital Admissions in Brazil.
Get PDFIMPORTANCE: While the short-term impacts of congenital syphilis are well documented, the long-term outcomes and effects on children exposed to syphilis during pregnancy but without congenital infection detected at birth remain unclear. OBJECTIVE: To compare the rates of all-cause hospitalization in children younger than 5 years between those exposed to syphilis during pregnancy (with and without congenital syphilis) and those unexposed to syphilis during pregnancy. DESIGN, SETTING, AND PARTICIPANTS: Population-based study using linked data from the Center of Data and Knowledge Integration for Health Birth Cohort, including singleton live births between January 1, 2011, and December 31, 2015. Children were followed up until age 5 years, death, or December 31, 2018, whichever occurred first. Data were made available in 2020 and analyzed between March and September 2024. EXPOSURES: In this study, syphilis during pregnancy was categorized into 3 groups: (1) maternal syphilis, (2) congenital syphilis, and (3) no exposure, for those without syphilis records. MAIN OUTCOMES AND MEASURES: Primary outcomes were: (1) general and age-stratified first hospital admission rates, (2) length of stay for the first hospital admission, and (3) International Classification of Diseases and Related Health Problems, Tenth Revision diagnoses of the first hospitalization. Secondary outcomes included: (1) recurrent hospital admissions and (2) mortality. RESULTS: The study included 8 286 867 singleton births, with 30 039 exposed to maternal syphilis (15 482 [51.5%] male, 7642 [25.4%] Asian, 2442 [8.1%] Black, and 16 930 [56.4%] Pardo [denotes individuals who are White and Indigenous, White and Black, Black and Indigenous, or Black and another race]) and 36 443 with congenital syphilis (18 286 [50.2%] male, 6977 [19.1%] Asian, 3769 [10.3%] Black, 16 930 [56.4%] Pardo). Exposed births were more prevalent in Black, single, and less educated women. Compared with children with no exposure, those with congenital syphilis had an increased risk of first hospitalization (hazard ratio [HR], 6.19; 95% CI, 6.11-6.28), as did those exposed to maternal syphilis (HR, 1.90; 95% CI, 1.86-1.94). The highest risk of first hospitalization was observed in the first month of life, among those with congenital syphilis (HR, 11.53; 95% CI, 11.36-11.70). Although the risk decreased with age, children exposed to syphilis continued to have higher hospitalization rates than the nonexposed group until the age of 36 months. Live-born children exposed to syphilis during pregnancy also had more and longer hospital admissions. Those with congenital syphilis had a lower prevalence of respiratory and digestive diagnoses than those with maternal syphilis and the nonexposed group. CONCLUSIONS AND RELEVANCE: In this cohort study, we observed that those children exposed to syphilis during pregnancy, even without congenital syphilis detected at birth, had a higher risk of hospital admission and were hospitalized for longer periods. These findings underscore the need for close monitoring of exposed children and emphasize the importance of preventing syphilis in women of childbearing age
Time to direct-acting antiviral initiation and liver-related events in people with HIV and hepatitis C virus.
No full textOBJECTIVE: People with HIV-hepatitis C virus (HCV) co-infection need antiretroviral treatment (ART) to suppress HIV and direct-acting antivirals (DAAs) to cure HCV. ART is typically prioritized, but delays in DAA initiation may increase the risk of liver-related events and HCV transmission to others. DESIGN: Target trial emulation with observational data collected in routine clinical practice from a collaboration of cohorts from Europe and North America. METHODS: We included DAA-naive adults with HIV-HCV co-infection who achieved HIV virologic suppression (HIV RNA 6 months) DAA initiation and the 36-month risk of liver-related events (liver decompensation or hepatocellular carcinoma). RESULTS: Of 862 eligible individuals (median age 46 years; interquartile range 36-56), 14% were women, and 52% had a history of injection drug use. The 6-month and 36-month probabilities of not initiating DAA were 58% [95% confidence interval (CI): 55-61] and 24% (21-27), respectively. The 36-month risk of liver-related events was 1.1% (0.4-2.0) for early initiation and 1.7% (0.7-2.5) for delayed initiation; risk difference -0.5% (-1.2 to 0.4). CONCLUSION: Almost one-quarter of people with HIV-HCV co-infection on ART had not initiated DAA 3 years after HIV virologic suppression. Because the 3-year risk of liver-related events was low, estimates of the impact of delayed DAA initiation were imprecise
PrEP Uptake and Utilisation Among Adolescent Girls and Young Women in Sub-Saharan Africa: A Scoping Review.
Get PDFAdolescent girls and young women (AGYW) in sub-Saharan Africa (SSA) are disproportionately affected by HIV. Despite the effectiveness of oral pre-exposure prophylaxis (PrEP) in preventing HIV, uptake and effective utilisation among AGYW remain suboptimal. This scoping review maps research on PrEP delivery outside clinical trials to AGYW in SSA. Quantitative and qualitative data were extracted from 58 studies on the facilitators and barriers to PrEP uptake and utilisation (including initiation, persistence, and adherence), and recommendations for effective PrEP delivery from AGYW and PrEP providers. Only studies on oral PrEP met the inclusion criteria. Facilitators of effective PrEP utilisation included social support with strong familial and peer networks positively influencing PrEP adherence and persistence. Healthcare provider interactions were pivotal in promoting PrEP uptake through dissemination of accurate information and ongoing support. Studies reported consistent barriers to PrEP uptake and utilisation including anticipated or experienced stigma, pill burden, and side effects. Addressing identified barriers and leveraging facilitators can enhance future effectiveness for PrEP delivery. There is a lack of strategies to support AGYW in long-term persistence and engagement with PrEP services. Our findings emphasise the urgent need for people-centred and localised, context-specific strategies to improve PrEP delivery among AGYW in SSA. Effective PrEP delivery strategies should include differentiated service delivery models, innovative approaches such as digital health, and integration with existing services such as antenatal care for pregnant and breastfeeding AGYW. More data is needed for PrEP delivery among AGYW across the region, including other PrEP modalities as they roll out
Theoretical foundations and mechanisms of health systems responsiveness: a realist synthesis.
Get PDFHealth systems responsiveness is a key health systems goal, operationalised as an outcome measured across domains such as dignity and confidentiality. It also reflects values and inputs towards improved health. In this realist synthesis, we critically reviewed underpinning theories, examined mechanisms, and propose a theoretical model of health systems responsiveness. Four theories enhance the understanding of responsiveness: Complex Adaptive Systems, Human Agency, Health Equity, Justice and Social Accountability, and Cultural Capital. It is a social construct reflecting what people expect from the system within social and cultural contexts; and what systems actors (providers, managers) expect from people in the context of standards of care and available resources. Responsiveness is shaped by the societal context of care and the health systems context. Domains of responsiveness are inter-related and comprise values, processes and resources. Our proposed theory highlights the importance of favourable social and organisational contexts in triggering sense of agency, literacy and empowerment that contribute to enhanced people's capacity to engage with health systems and health system's capacity to respond to people's expectations. We hope it offers a useful heuristic to inform efforts in improving health systems responsiveness
Unravelling the conundrums of social autopsy for maternal mortality in low- and middle-income countries.
Get PDFAny meaningful effort to tackle maternal mortality in low- and middle-income countries (LMICs) needs to be founded on a robust understanding of its causes. In LMICs, verbal autopsies are used to determine the clinical causes of death through interviews with the deceased person’s next-of-kin or caregivers. In addition, social autopsies have been conducted to allow capture of the story behind the death, enabling a comprehensive understanding of the socio-cultural, behavioural, and health system factors that contributed to the death [1,2]. However, researchers implementing social autopsies in LMICs are faced with some conun�drums. In this opinion, we discuss three key conundrums and propose a way forward for the fiel
Stressors faced by forcibly displaced Ukrainians in England within 6 months of arrival: A qualitative study.
Get PDFStressors faced by Ukrainians forcibly displaced by the 2022 Russian invasion is a relatively unexplored area. The aim of this paper is to explore stressors shaping the mental well-being of forcibly displaced Ukrainians in England. Semi-structured qualitative interviews were conducted with 15 forcibly displaced Ukrainians (within 6 months of arrival) and 6 stakeholders, focusing on life experiences in England and barriers accessing critical services. We drew on the Four Core Stressors Framework to conduct reflexive thematic analysis, focusing on the following sources of stress: trauma, acculturation and resettlement. Key stressors centered on barriers in accessing housing and employment, compounded by the language barrier, family separation and ongoing war-related trauma. These stressors were perceived to contribute to feelings of fear, uncertainty, sorrow, numbness, disorientation, confusion, helplessness, and anxiety. Greater support in accessing housing, employment and language instruction would address key stressors, which may bolster mental health. Findings may be relevant to policymakers structuring the support system for forcibly displaced persons in other high-income settings
Investigating the Role of Cytomegalovirus as a Cause of Stillbirths and Child Deaths in Low- and Middle-Income Countries Through Postmortem Minimally Invasive Tissue Sampling.
Get PDFBACKGROUND: There is paucity of information on the role of cytomegalovirus (CMV) infection as a cause of stillbirths or childhood deaths in low- and middle-income countries (LMICs). We investigated attribution of CMV disease in the causal pathway to stillbirths and deaths in children <5 years of age in 7 LMICs participating in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. METHODS: We analyzed stillbirths and decedents enrolled between December 2016 and July 2023. Deaths were investigated using postmortem minimally invasive tissue sampling with histopathology and molecular diagnostic investigations of tissues and body fluids, along with review of clinical records. Multidisciplinary expert panels reviewed findings and reported on the causal pathway to death. RESULTS: CMV was detected in 19.5% (1140/5841) of all evaluated deaths, including 5.0% (111/2204), 6.2% (139/2229), 41.2% (107/260), 68.1% (323/474), and 68.2% (460/674) of stillbirths, neonates (deaths <28 days postnatal), early infants (28 to <90 days), late infants (90 to <365 days), and children (12 to <60 months), respectively. CMV disease was attributed in the causal pathway to death in 0.9% (20/2204) of stillbirths, 0.8% (17/2229) of neonates, 13.1% (34/260) of early infants, 9.7% (46/474) of late infants, and 3.3% (22/674) of children. Decedents with CMV disease, compared with those without CMV disease in the causal pathway, were more likely to have severe microcephaly (38.2% vs 21.1%; adjusted odds ratio [aOR], 2.2 [95% confidence interval {CI}, 1.3-3.6]) and to have human immunodeficiency virus (HIV) (36.9% vs 6.2%; aOR, 10.9 [95% CI, 6.5-18.5]). CONCLUSIONS: CMV disease is an important contributor to deaths during infancy and childhood and is often associated with severe microcephaly and HIV infection. Improving management of CMV in children with HIV and a vaccine to prevent CMV are needed interventions