Towards anti-racist policies and strategies to reduce poor health outcomes in racialised communities: introducing the O'Neill-Lancet Commission on Racism, Structural Discrimination, and Global Health

An emerging knowledge exchange framework: Leadership insight into a key capacity-building impact in a large urban, trauma-informed initiative supporting resiliency and promoting equity

BACKGROUND

Community capacity-building is the cornerstone of many public health initiatives, with increasing attention paid to community engagement, collective impact, and trauma-informed practices designed to support resiliency and promote health equity. Large-scale capacity-building projects proliferated during the global pandemic, highlighting the need for practical guidance and steps for efficiently responding to changing community needs and effectively communicating information across partnership and community members. The present qualitative longitudinal study provides a pragmatic framework for trauma-informed knowledge exchange across stakeholders in a large urban collective impact, capacity-building initiative designed to establish partnerships that engage community members, promote equity through tailored referrals and resource access, and address community needs and aspirations.

METHODS

Interviews were conducted with the leads of nine agencies funded to implement regionally responsive strategies addressing adverse childhood experience-driven health needs among their diverse subcommunities, while offsetting the impact of trauma, building capacities and improving resource access. We aimed to capture (1) the socioecological context of traumatic experiences and health barriers that propelled agencies to participate in a trauma-informed initiative; (2) agency leads' vision for community health; and (3) unfolding approaches to the initiatives' complex work, spanning pre-pandemic community needs and pandemic era challenges.

RESULTS

Agency leads' vision for healthy communities emerged from the strengths, adversity-driven challenges and health barriers of their communities; while focusing on relationship-building, trust-based engagement and equitable access to trauma-informed resources through knowledge exchange. Results support reflection-based learning practices that are characterized by a flexible mindset and action-oriented adaptability. Mechanisms that power multi-directional knowledge exchange included creative partnering; frameworks and trainings that address partnership and community needs; and actionable skill-building. Incorporating community members directly into the initiative's work exemplified the vision of an informed/resourced community, relationship-based engagement, use of adaptive practices and creative partnering. Lived experience staff provided a credibility bridge facilitating knowledge exchange between community and partnership members and creating power-sharing opportunities.

CONCLUSIONS

Engagement in public health initiatives is essential for community well-being and responsive public health initiatives. These data provide an emerging framework for thoughtful engagement and knowledge exchange among partnership and community members, while highlighting knowledge exchange as a key impact for outcome consideration.

Political determinants of digital health: beyond the rainbow

In 2021, the World Health Organization issued its first global strategy on digital technologies and health, calling on member states to develop their own national digital health strategies. However, the normative tools that guide the development of these strategies do not prompt member states to consider how broader political factors, such as law and policy, governance, and civic engagement, could shape health outcomes in the digital age. The digital gender divide, algorithmic biases linked to race, transnational private sector actors, and more must be thoroughly addressed in future digital health strategies. Experiences from the global HIV response have demonstrated that it is possible to do this, by mobilizing diverse government and non-governmental actors to systematically assess and act to strengthen the legal and political environment for health. This essay draws on the HIV response to critically engage with recent literature on the digital determinants of health, proposing an approach to analyzing broader political determinants of health, including commercial determinants of health, and other laws, policies, governance, and civic engagement relevant to digital health strategies. By rendering visible the role of politics, governance, and civic engagement in digital health, strategies can be tools to mobilize broad collaborations and advocacy that creates an enabling environment.

The Interaction Between Indigenous Identity and Rural Residency in Dementia Prevalence Among Ecuadorian Older Adults

BACKGROUND AND OBJECTIVES

While recognizing the acknowledged difference in dementia prevalence between Indigenous and non-Indigenous populations, most previous studies were conducted in the Global North. This study aims to examine the relationship between Indigenous ethnic identity and dementia status with a special focus on urban-rural differences among older adults in Ecuador.

RESEARCH DESIGN AND METHODS

Data came from Ecuador's Survey of Health, Welfare, and Aging, derived from a probability sample of households in Ecuador. The final sample comprised 4,984 adults aged 60 or older. Dementia status was assessed through 3 indicators: low scores on a cognitive assessment, the number of difficulties in instrumental activities of daily living, and self-reported dementia diagnosis. Logistic regression and multivariate decomposition analyses were utilized.

RESULTS

Indigenous participants, even after adjusting for sociodemographic and health-related factors, exhibited a higher likelihood of having dementia compared to their non-Indigenous counterparts. Among Indigenous participants, those residing in rural areas had a higher likelihood of having dementia status, while there was no significant urban-rural difference observed among non-Indigenous participants. Rural residency and covariates explain 91.0% of the observed difference in dementia prevalence between Indigenous and non-Indigenous older adults.

DISCUSSION AND IMPLICATIONS

Indigenous older adults who are living in rural areas are at particularly high risk of having dementia largely because they have presently recognized modifiable risk factors. These findings underscore the urgent need to prioritize provisions of appropriate and equitable service related to dementia for Indigenous people living in rural areas outside high-income countries.

TIDieR-WASH: A Guideline for Reporting Implementation of Water, Sanitation, and Hygiene Interventions

INTRODUCTION

Accurate information on context and implementation of public health interventions is necessary to replicate, adapt, and scale effective interventions and to interpret evaluations. Reporting the context and implementation of water, sanitation, and hygiene (WASH) interventions has been inconsistent and incomplete.

METHODS

To improve the reporting of WASH interventions, we developed the Template for Intervention Description and Replication for WASH (TIDieR-WASH) checklist and guide, by adapting and expanding the original TIDieR guide. We performed a scoping review of existing implementation reporting guidelines, and of current implementation reporting in WASH evaluations, to develop a list of candidate items to include in this checklist. We then used a 4-stages of review by international experts to reach consensus.

RESULTS

The resulting 14-item checklist comprises: a) name, b) theory of change, c) prior evidence, d) location and setting, e) context, f) suitability, g) implementers, h) recipients, i) targeting, j) activities, k) intervention dose, l) fidelity, m) costs, and n) materials. Definitions, explanations, examples, and instructions for use are reported in this article.

DISCUSSION

The checklist can be applied to all types of evaluations of WASH interventions, including direct service provision, behavior change, and systems strengthening interventions. We deliberately developed this guidance document to be accessible and relevant to practitioners and researchers. Adoption of this checklist will support transparent reporting of WASH implementation for research and practice. As with other sectors that have used TIDieR checklists, clear implementation reporting can assist with evidence synthesis, adaptation, and policy guidance. https://doi.org/10.1289/EHP14780.

Decolonising global health: why the new Pandemic Agreement should have included the principle of subsidiarity

The negotiations for the WHO Pandemic Agreement have brought attention to issues of racism and colonialism in global health. Although the agreement aims to promote global solidarity, it fails to address these deeply embedded problems. This Viewpoint argues that not including the principle of subsidiarity into Article 4 of the agreement as a pragmatic strategy was a missed opportunity to decolonise global health governance and promote global solidarity. Subsidiarity, as a structural principle, empowers local units to make decisions and address issues at their level, fostering collaboration, coordination, and cooperation. By integrating subsidiarity, the agreement could have ensured contextually appropriate responses, empowered local communities, and achieved justice in global health. This paper discusses the elements of subsidiarity-namely, agency and non-abandonment-and highlights the need to strike a balance between them. It also maps the principle of subsidiarity within the Pandemic Agreement, emphasising the importance of creating a practical framework for its implementation. By integrating subsidiarity into the agreement, a just and decolonialised approach to pandemic prevention and response could have been closer to being realised, promoting global solidarity and addressing health inequities.

Chronic respiratory disease in Indigenous peoples: a framework to address inequity and strengthen respiratory health and health care globally

Indigenous peoples around the world bear a disproportionate burden of chronic respiratory diseases, which are associated with increased risks of morbidity and mortality. Despite the imperative to address global inequity, research focused on strengthening respiratory health in Indigenous peoples is lacking, particularly in low-income and middle-income countries. Drivers of the increased rates and severity of chronic respiratory diseases in Indigenous peoples include a high prevalence of risk factors (eg, prematurity, low birthweight, poor nutrition, air pollution, high burden of infections, and poverty) and poor access to appropriate diagnosis and care, which might be linked to colonisation and historical and current systemic racism. Efforts to tackle this disproportionate burden of chronic respiratory diseases must include both global approaches to address contributing factors, including decolonisation of health care and research, and local approaches, co-designed with Indigenous people, to ensure the provision of culturally strengthened care with more equitable prioritisation of resources. Here, we review evidence on the burden of chronic respiratory diseases in Indigenous peoples globally, summarise factors that underlie health disparities between Indigenous and non-Indigenous people, propose a framework of approaches to improve the respiratory health of Indigenous peoples, and outline future directions for clinical care and research.

Migrant-sensitive healthcare in Europe: advancing health equity through accessibility, acceptability, quality, and trust

The advancement of migrant-sensitive health care in Europe has been a topic of many initiatives and academics debates for over 20 years in Europe, yet with rather limited progress in terms of comprehensive and sustainable implementation. We argue that a human rights-based approach with clearly defined duties and responsibilities of governments, relevant public and private institutions as well as professionals is needed, in line with a sound understanding and thoughtful implementation and further development of concepts and standards for providing migrant sensitive care as an essential component of Universal Health Coverage. We suggest drawing particular attention to the interrelated features of accessibility, acceptability, quality, and trust to inform policies and practice. Innovative approaches with substantial involvement of social and cultural sciences are needed for adapting clinical care and health services to the growing social and cultural diversity of European societies.

Challenges and Opportunities for Paving the Road to Global Health Equity Through Implementation Science

Implementation science focuses on enhancing the widespread uptake of evidence-based interventions into routine practice to improve population health. However, optimizing implementation science to promote health equity in domestic and global resource-limited settings requires considering historical and sociopolitical processes (e.g., colonization, structural racism) and centering in local sociocultural and indigenous cultures and values. This review weaves together principles of decolonization and antiracism to inform critical and reflexive perspectives on partnerships that incorporate a focus on implementation science, with the goal of making progress toward global health equity. From an implementation science perspective, wesynthesize examples of public health evidence-based interventions, strategies, and outcomes applied in global settings that are promising for health equity, alongside a critical examination of partnerships, context, and frameworks operationalized in these studies. We conclude with key future directions to optimize the application of implementation science with a justice orientation to promote global health equity.

Making cities mental health friendly for adolescents and young adults

Urban life shapes the mental health of city dwellers, and although cities provide access to health, education and economic gain, urban environments are often detrimental to mental health1,2. Increasing urbanization over the next three decades will be accompanied by a growing population of children and adolescents living in cities3. Shaping the aspects of urban life that influence youth mental health could have an enormous impact on adolescent well-being and adult trajectories4. We invited a multidisciplinary, global group of researchers, practitioners, advocates and young people to complete sequential surveys to identify and prioritize the characteristics of a mental health-friendly city for young people. Here we show a set of ranked characteristic statements, grouped by personal, interpersonal, community, organizational, policy and environmental domains of intervention. Life skills for personal development, valuing and accepting young people's ideas and choices, providing safe public space for social connection, employment and job security, centring youth input in urban planning and design, and addressing adverse social determinants were priorities by domain. We report the adversities that COVID-19 generated and link relevant actions to these data. Our findings highlight the need for intersectoral, multilevel intervention and for inclusive, equitable, participatory design of cities that support youth mental health.

Anti-racist interventions to reduce ethnic disparities in healthcare in the UK: an umbrella review and findings from healthcare, education and criminal justice

OBJECTIVES

To assess the evidence for anti-racist interventions which aim to reduce ethnic disparities in healthcare, with a focus on implementation in the UK healthcare system.

DESIGN

Umbrella review.

DATA SOURCES

Embase, Medline, Social Policy and Practice, Social Care Online and Web of Science were searched for publications from the year 2000 up to November 2023.

ELIGIBILITY CRITERIA

Only systematic and scoping reviews of anti-racist interventions reported in English were included. Reviews were excluded if no interventions were reported, no comparator interventions were reported or the study was primarily descriptive.

DATA EXTRACTION AND SYNTHESIS

A narrative synthesis approach was used to integrate and categorise the evidence on anti-racist interventions for healthcare. Quality appraisal (including risk of bias) was assessed using the AMSTAR-2 tool.

RESULTS

A total of 29 reviews are included in the final review. 26 are from the healthcare sector and three are from education and criminal justice. The most promising interventions targeting individuals include group-based health education and providing culturally tailored interventions. On a community level, participation in all aspects of care pathway development that empowers ethnic minority communities may provide an effective approach to reducing ethnic health disparities. Interventions to improve quality of care for conditions with disproportionately worse outcomes in ethnic minority communities show promise. At a policy level, structural interventions including minimum wage policies and integrating non-medical interventions such as housing support in clinical care has some evidence for improving outcomes in ethnic minority communities.

CONCLUSIONS

Many of the included studies were low or critically low quality due to methodological or reporting limitations. For programme delivery, different types of pathway integration, and providing a more person-centred approach with fewer steps for patients to navigate can contribute to reducing disparities. For organisations, there is an overemphasis on individual behaviour change and recommendations should include a shift in focus and resources to policies and practices that seek to dismantle institutional and systemic racism through a multilevel approach.

Introduction to the special issue on brain health

None.