No woman left behind: achieving cervical cancer elimination among women living with HIV.

Cervical cancer is the fourth most common malignancy in women of reproductive age globally. The burden of this disease is highest in low-income and middle-income countries, especially among women living with HIV. In 2018, WHO launched a global strategy to accelerate cervical cancer elimination through rapid scale-up of prophylactic vaccination, cervical screening, and treatment of precancers and cancers. This initiative was key in raising a call for action to address the stark global disparities in cervical cancer burden. However, achieving elimination of cervical cancer among women with HIV requires consideration of biological and social issues affecting this population. This Position Paper shows specific challenges and uncertainties on the way to cervical cancer elimination for women living with HIV and highlights the scarcity of evidence for the effect of interventions in this population. We argue that reaching equity of outcomes for women with HIV will require substantial advances in approaches to HPV vaccination and improved understanding of the long-term effectiveness of HPV vaccines in settings with high HIV burden cervical cancer, just as HIV, is affected by social and structural factors such as poverty, stigma, and gender discrimination, that place the elimination strategy at risk. Global efforts must, therefore, be galvanised to ensure women living with HIV have optimised interventions, given their substantial risk of this preventable malignancy.

The effects of cash transfers on adult and child mortality in low- and middle-income countries.

Poverty is an important social determinant of health that is associated with increased risk of death1-5. Cash transfer programmes provide non-contributory monetary transfers to individuals or households, with or without behavioural conditions such as children's school attendance6,7. Over recent decades, cash transfer programmes have emerged as central components of poverty reduction strategies of many governments in low- and middle-income countries6,7. The effects of these programmes on adult and child mortality rates remains an important gap in the literature, however, with existing evidence limited to a few specific conditional cash transfer programmes, primarily in Latin America8-14. Here we evaluated the effects of large-scale, government-led cash transfer programmes on all-cause adult and child mortality using individual-level longitudinal mortality datasets from many low- and middle-income countries. We found that cash transfer programmes were associated with significant reductions in mortality among children under five years of age and women. Secondary heterogeneity analyses suggested similar effects for conditional and unconditional programmes, and larger effects for programmes that covered a larger share of the population and provided larger transfer amounts, and in countries with lower health expenditures, lower baseline life expectancy, and higher perceived regulatory quality. Our findings support the use of anti-poverty programmes such as cash transfers, which many countries have introduced or expanded during the COVID-19 pandemic, to improve population health.

The Prevalence and Determinants of Child Hunger and Its Associations with Early Childhood Nutritional Status among Urban Poverty Households during COVID-19 Pandemic in Petaling District, Malaysia: An Exploratory Cross-Sectional Survey.

Child hunger was prevalent during the COVID-19 pandemic, but the extent, determinants, and impact on pre-school children aged 6 months to 7 years old from Malaysian urban poor households are still unknown. This exploratory cross-sectional study was performed between July 2020 and January 2021 at the Lembah Subang People Housing Project, Petaling. The households' food security status was assessed using the previously validated Radimer/Cornell questionnaire, and the children's anthropometric measurements were taken. Food diversity score was assessed using the World Health Organization Infant and Young Children Feeding (under-2 children) or Food and Agriculture Organization Women's Dietary Diversity (2-year-old-and-above children) systems. Overall, 106 households were recruited. The prevalence of child hunger is 58.4% (95% CI: 50.0, 67.4). Significant differences were found in breastfeeding and sugar-sweetened beverage consumption between under-2 and ≥2-year-old children. There were no significant differences between child hunger and other food-insecure groups in weight-for-age, height-for-age, and weight-for-height z-scores. Only a higher dietary diversity score was significantly protective against child hunger after adjusting for maternal age, paternal employment status, and the number of household children (ORadjusted: 0.637 (95% CI: 0.443, 0.916), p = 0.015)). Proactive strategies are warranted to reduce child hunger during the COVID-19 pandemic by improving childhood dietary diversity.

Barriers and facilitators to COVID-19 testing among staff and parents from San Diego schools.

COVID-19 testing is an important risk mitigation strategy for COVID-19 prevention in school settings, where the virus continues to pose a public health challenge for in-person learning. Socially vulnerable school communities with the highest proportion of low-income, minority, and non-English speaking families have the least testing access despite shouldering a disproportionate burden of COVID-19 morbidity and mortality. Through the Safer at School Early Alert (SASEA) program, we investigated community perceptions of testing in San Diego County schools, with a focus on barriers and facilitators from the perspective of socially vulnerable parents and school staff. Using a mixed-methods approach, we administered a community survey and conducted focus group discussions (FGDs) with staff and parents from SASEA-affiliated schools and childcares. We recruited 299 survey respondents and 42 FGD participants. Protecting one's family (96.6%) and protecting one's community (96.6%) were marked as key motivators to testing uptake. School staff in particular reported that the reassurance of a negative status mitigated concerns about COVID-19 infection in schools. Participants expressed that COVID-19-related stigma, loss of income as a result of isolation/quarantine requirements, and lack of multilingual materials were the most significant barriers to testing. Our findings suggest that the testing barriers faced by school community members are predominantly structural. Testing uptake efforts must provide support and resources to manage the social and financial consequences of testing while continuously communicating its benefits. There is a clear need to continue to incorporate testing as a strategy to maintain school safety and facilitate access for vulnerable community members.

Impact of social and demographic factors on the spread of the SARS-CoV-2 epidemic in the town of Nice.

INTRODUCTION: Socio-demographic factors are known to influence epidemic dynamics. The town of Nice, France, displays major socio-economic inequalities, according to the National Institute of Statistics and Economic Studies (INSEE), 10% of the population is considered to live below the poverty threshold, i.e. 60% of the median standard of living. OBJECTIVE: To identify socio-economic factors related to the incidence of SARS-CoV-2 in Nice, France. METHODS: The study included residents of Nice with a first positive SARS-CoV-2 test (January 4-February 14, 2021). Laboratory data were provided by the National information system for Coronavirus Disease (COVID-19) screening (SIDEP) and socio-economic data were obtained from INSEE. Each case's address was allocated to a census block to which we assigned a social deprivation index (French Deprivation index, FDep) divided into 5 categories. For each category, we computed the incidence rate per age and per week and its mean weekly variation. A standardized incidence ratio (SIR) was calculated to investigate a potential excess of cases in the most deprived population category (FDep5), compared to the other categories. Pearson's correlation coefficient was computed and a Generalized Linear Model (GLM) applied to analyse the number of cases and socio-economic variables per census blocks. RESULTS: We included 10,078 cases. The highest incidence rate was observed in the most socially deprived category (4001/100,000 inhabitants vs 2782/100,000 inhabitants for the other categories of FDep). The number of observed cases in the most social deprivated category (FDep5: N = 2019) was significantly higher than in the others (N = 1384); SIR = 1.46 [95% CI:1.40-1.52; p < 0.001]. Socio-economic variables related to poor housing, harsh working conditions and low income were correlated with the new cases of SARS-CoV-2. CONCLUSION: Social deprivation was correlated with a higher incidence of SARS-CoV-2 during the 2021 epidemic in Nice. Local surveillance of epidemics provides complementary data to national and regional surveillance. Mapping socio-economic vulnerability indicators at the census block level and correlating these with incidence could prove highly useful to guide political decisions in public health.

"If I start panicking over having enough, then I start eating too much": Understanding the eating behaviors of SNAP recipients in larger bodies during COVID-19.

BACKGROUND/OBJECTIVE: Living in a food-insecure household may increase the risk for disordered eating. Though the Supplemental Nutrition Assistance Program (SNAP) was designed to reduce food insecurity, it may increase risk for disordered eating with the frequency in which benefits are distributed. Limited research has explored the lived experiences of managing eating behaviors while on SNAP, particularly among SNAP participants in larger bodies, and during COVID-19. Thus, the purpose of this study is to examine the experiences with eating behaviors among adults with a BMI ≥ 25 kg/m2, and who received SNAP benefits during the COVID-19 pandemic. METHODS: Eligible adults were recruited to participate in a semi-structured interview. Interviews were transcribed verbatim and analyzed using thematic analysis and content analysis. RESULTS: Participants (N = 16), had a mean (±SD) age of 43.4 ± 10.9 years, and overwhelmingly identified as female (86 %). One-third of the participants were Black. We identified 4 main themes: (1) not having enough money/benefits to cover needs; (2) navigating loss of control and emotional eating; (3) making sure the kids are alright; and (4) still feeling the pressure to manage weight. CONCLUSION: Managing eating behaviors while also navigating SNAP benefits is complex and may exacerbate risk of disordered eating.

State-level data on TANF policy changes during the COVID-19 pandemic.

OBJECTIVE: COVID-19 mitigation measures prompted many states to revise the administration of their welfare programs. States adopted policies that varied across the U.S. to respond to the difficulties in fulfilling program requirements, as well as increased financial need. This dataset captures the changes made to Temporary Assistance for Needy Families (TANF) programs during the COVID-19 pandemic, from March 2020 through December 2020. The authors created this dataset as part of a larger study that examined the health effects of TANF policy changes during the COVID-19 pandemic. DATA DESCRIPTION: TANF is the main cash assistance program for low-income families in the U.S., but benefits are often conditional on work requirements and can be revoked if an individual is deemed noncompliant. Structural factors during the COVID-19 pandemic made meeting these criteria more difficult, so some states relaxed their rules and increased their benefits. This dataset captures 24 types of policies that state TANF programs enacted, which of the states enacted each of them, when the policies went into effect, and when applicable, when the policies ended. These data can be used to study the effects of TANF policy changes on various health and programmatic outcomes.

Effectiveness of a multicomponent intervention to face the COVID-19 pandemic in Rio de Janeiro's favelas: difference-in-differences analysis.

INTRODUCTION: Few community-based interventions addressing the transmission control and clinical management of COVID-19 cases have been reported, especially in poor urban communities from low-income and middle-income countries. Here, we analyse the impact of a multicomponent intervention that combines community engagement, mobile surveillance, massive testing and telehealth on COVID-19 cases detection and mortality rates in a large vulnerable community (Complexo da Maré) in Rio de Janeiro, Brazil. METHODS: We performed a difference-in-differences (DID) analysis to estimate the impact of the multicomponent intervention in Maré, before (March-August 2020) and after the intervention (September 2020 to April 2021), compared with equivalent local vulnerable communities. We applied a negative binomial regression model to estimate the intervention effect in weekly cases and mortality rates in Maré. RESULTS: Before the intervention, Maré presented lower rates of reported COVID-19 cases compared with the control group (1373 vs 1579 cases/100 000 population), comparable mortality rates (309 vs 287 deaths/100 000 population) and higher case fatality rates (13.7% vs 12.2%). After the intervention, Maré displayed a 154% (95% CI 138.6% to 170.4%) relative increase in reported case rates. Relative changes in reported death rates were -60% (95% CI -69.0% to -47.9%) in Maré and -28% (95% CI -42.0% to -9.8%) in the control group. The case fatality rate was reduced by 77% (95% CI -93.1% to -21.1%) in Maré and 52% (95% CI -81.8% to -29.4%) in the control group. The DID showed a reduction of 46% (95% CI 17% to 65%) of weekly reported deaths and an increased 23% (95% CI 5% to 44%) of reported cases in Maré after intervention onset. CONCLUSION: An integrated intervention combining communication, surveillance and telehealth, with a strong community engagement component, could reduce COVID-19 mortality and increase case detection in a large vulnerable community in Rio de Janeiro. These findings show that investment in community-based interventions may reduce mortality and improve pandemic control in poor communities from low-income and middle-income countries.

Mitigating the impacts of the COVID-19 pandemic on vulnerable populations: Lessons for improving health and social equity.

The COVID-19 pandemic had an inequitable and disproportionate impact on vulnerable populations, reversing decades of progress toward healthy populations and poverty alleviation. This study examines various programmatic tools and policy measures used by governments to support vulnerable populations during the pandemic. A comparative case study of 15 countries representing all World Health Organization's regions offers a comprehensive picture of countries with varying income statuses, health system arrangements and COVID-19 public health measures. Through a systematic desk review and key informant interviews, we report a spectrum of mitigation strategies deployed in these countries to address five major types of vulnerabilities (health, economic, social, institutional and communicative). We found a multitude of strategies that supported vulnerable populations such as migrant workers, sex workers, prisoners, older persons and school-going children. Prioritising vulnerable populations during the early phase of COVID-19 vaccination campaigns, direct financial subsidies and food assistance programmes were the most common measures reported. Additionally, framing public health information and implementing culturally sensitive health promotion interventions helped bridge the communication barriers in certain instances. However, these measures remain insufficient to protect vulnerable populations comprehensively. Our findings point to the need to expand fiscal space for health, enlarge healthcare coverage, incorporate equity principles in all policies, leverage technology, multi-stakeholder co-production of policies and tailored community engagement mechanisms.

Developing a peer-led intervention to promote COVID-19 testing in low-income housing settings.

Background: The Housing Collaborative project at Eastern Virginia Medical School has developed a method of adapting public health guidance from public housing communities, which face tremendous health challenges in cardiometabolic health, cancer, and other major health conditions. In this paper, we describe how academic and community partners in the Housing Collaborative came together to do this work with a focus on COVID-19 testing in the context of the emerging pandemic. Methods: The academic team used virtual community engagement methods to interact with the Housing Collaborative Community Advisory Board (HCCAB) and a separate cohort of research participants (N = 102) recruited into a study of distrust in COVID-19 guidance. We conducted a series of 44 focus group interviews with participants on related topics. Results from these interviews were discussed with the HCCAB. We used the collaborative intervention planning framework to inform adaptation of public health guidance on COVID-19 testing delivered in low-income housing settings by including all relevant perspectives. Results: Participants reported several important barriers to COVID-19 testing related to distrust in the tests and those administering them. Distrust in housing authorities and how they might misuse positive test results seemed to further undermine decision making about COVID-19 testing. Pain associated with testing was also a concern. To address these concerns, a peer-led testing intervention was proposed by the Housing Collaborative. A second round of focus group interviews was then conducted, in which participants reported their approval of the proposed intervention. Conclusion: Although the COVID-19 pandemic was not our initial focus, we were able to identify a number of barriers to COVID-19 testing in low-income housing settings that can be addressed with adapted public health guidance. We struck a balance between community input and scientific rigor and obtained high quality, honest feedback to inform evidence-based recommendations to guide decisions about health.

Period poverty and mental health in a representative sample of young women in Barcelona, Spain.

BACKGROUND: The intersection between poverty and mental health is clear. Period poverty, understood as the lack of access to menstrual products, has been gaining attention especially among low and middle-income countries as an overlooked aspect of gendered poverty. Less is known about the incidence of period poverty in high-income countries and its association with mental health. The purpose of this study is to examine this association in a representative sample of young women living in an urban setting in southern Europe. METHODS: This is a cross-sectional study. Data were obtained from a representative survey of individuals aged 15 to 34 in the city of Barcelona (Spain), with a sample group of 647 young women. Subjects were selected through a systematic stratified random sampling method. A proportional quota sampling was used. The information was registered using CAPI data collection method. Period poverty was measured by a combination of three questions about the lack of access or misuse of menstrual products for economic reasons. The GHQ-12 was used to measure the risk of poor mental health. The analysis was carried out using multivariable logistic regression. RESULTS: From our sample, 15.3% of young women reported having experienced period poverty. Higher odds of poor mental health were estimated for women facing period poverty (AOR = 1.85 p < 0.05). This effect is statistically significant after controlling by their income status and level of deprivation. Young women living in poorer households have a higher probability of poor mental health than those living in high-income households (AOR = 0.47 p < 0.05). Finally, material deprivation was associated to an increased risk of poor mental health among young women reporting period poverty (AOR = 2.59 p < 0.01). CONCLUSION: We found that a considerable number of young women living in an urban setting in a high-income country cannot afford menstrual products, and this may have an impact on their mental wellbeing. The relationship between period poverty and respondents' mental health is significant when controlling for factors known to confer an increased risk of poor mental health. If confirmed by further research, the public health burden of poor mental health in young women could be reduced by policy-level interventions to improve access to menstrual products.

Poverty related diseases amongst Malaysia's low-income community: a review.

Poverty, as proven by several studies, is a driving force behind poor health and hygiene practices. This review attempts to outline common communicable and non-communicable diseases that disproportionately affect Malaysia's 2.91 million low-income households. The current study also looks into the government's housing and healthcare programmes for this demographic to improve their health and well-being. The initial examination yielded incredibly little research on this marginalised community, with event reporting typically generalised to the Malaysian community as a whole rather than analysing disease incidences based on household income, which would better reflect povertydriven diseases. As a result, there is an acute need for more accurate information on the epidemiology of diseases among the poor in order to address this public health issue and provide conclusions that can drive policy designs.

Telehealth Usage Among Low-Income Racial and Ethnic Minority Populations During the COVID-19 Pandemic: Retrospective Observational Study.

BACKGROUND: Despite considerable efforts to encourage telehealth use during the COVID-19 pandemic, we witnessed a potential widening of health inequities that may continue to plague the US health care system unless we mitigate modifiable risk factors. OBJECTIVE: This study aimed to examine the hypothesis that there are systemic differences in telehealth usage among people who live at or below 200% of the federal poverty level. Factors that we consider are age, gender, race, ethnicity, education, employment status, household size, and income. METHODS: A retrospective observational study was performed using the COVID-19 Research Database to analyze factors contributing to telehealth inequities. The study period ranged from March 2020 to April 2021. The Office Ally database provided US claims data from 100 million unique patients and 3.4 billion claims. The Analytics IQ PeopleCore Consumer database is nationally representative of 242.5 million US adults aged 19 years and older. We analyzed medical claims to investigate the influence of demographic and socioeconomic factors on telehealth usage among the low-income racial and ethnic minority populations. We conducted a multiple logistic regression analysis to determine the odds of patients in diverse groups using telehealth during the study period. RESULTS: Among 2,850,831 unique patients, nearly 60% of them were female, 75% of them had a high school education or less, 49% of them were unemployed, and 62% of them identified as non-Hispanic White. Our results suggest that 9.84% of the patients had ≥1 telehealth claims during the study period. Asian (odds ratio [OR] 1.569, 95% CI 1.528-1.611, P<.001) and Hispanic (OR 1.612, 95% CI 1.596-1.628, P<.001) patients were more likely to use telehealth than non-Hispanic White and -Black patients. Patients who were employed full-time were 15% (OR 1.148, 95% CI 1.133-1.164, P<.001) more likely to use telehealth than unemployed patients. Patients who identified as male were 12% (OR 0.875, 95% CI 0.867-0.883, P<.001) less likely to use telehealth than those who identified as female. Patients with high school education or less were 5% (OR 0.953, 95% CI 0.944-0.962, P<.001) less likely to use telehealth than those with a bachelor's degree or higher. Patients in the 18-44-year age group were 32% (OR 1.324, 95% CI 1.304-1.345, P<.001) more likely to use telehealth than those in the ≥65-year age group. CONCLUSIONS: Factors that impact telehealth usage include age, gender, race, education, employment status, and income. While low-income racial and ethnic minority communities are at greater risk for health inequities among this group, Hispanic communities are more likely to use telehealth, and non-Hispanic Black patients continue to demonstrate telehealth inequity. Gender, age, and household income contribute to health inequities across gradients of poverty. Strategies to improve health use should consider characteristics of subgroups, as people do not experience poverty equally.

Catastrophic "costs": A hindrance to eliminate tuberculosis.

Globally, one quarter of the population is infected with TB; and only a small proportion of those infected will become sick. Tuberculosis along with poverty disproportionately affects the households causing a financial burden and catastrophic costs (if the total costs incurred by a household's exceeds 20% of its annual income), which could be direct or indirect and procuring detrimental effects on the effective strategic plans. Out of all diseases, India accounts for 18% of the catastrophic health expenditure including tuberculosis. Therefore, an utmost need for a national cost survey either separately or combined with other health surveys should be held for the comprehension of the baseline burden of Tuberculosis in the affected households, to identify the predictors of catastrophic costs, and simultaneously, intensive research and appropriate innovations are needed to assess the effectiveness of the measures undertaken for the reduction of the proportionate patients who overlook catastrophic costs.

Association of socio-economic deprivation with COVID-19 incidence and fatality during the first wave of the pandemic in Italy: lessons learned from a local register-based study.

BACKGROUND: COVID-19 has been characterised by its global and rapid spread, with high infection, hospitalisation, and mortality rates worldwide. However, the course of the pandemic showed differences in chronology and intensity in different geographical areas and countries, probably due to a multitude of factors. Among these, socio-economic deprivation has been supposed to play a substantial role, although available evidence is not fully in agreement. Our study aimed to assess incidence and fatality rates of COVID-19 across the levels of socio-economic deprivation during the first epidemic wave (March-May 2020) in the Italian Province of Foggia, Apulia Region. METHODS: Based on the data of the regional active surveillance platform, we performed a retrospective epidemiological study among all COVID-19 confirmed cases that occurred in the Apulian District of Foggia, Italy, from March 1st to May 5th, 2020. Geocoded addresses were linked to the individual Census Tract (CT) of residence. Effects of socio-economic condition were calculated by means of the Socio-Economic and Health-related Deprivation Index (SEHDI) on COVID-19 incidence and fatality. RESULTS: Of the 1054 confirmed COVID-19 cases, 537 (50.9%) were men, 682 (64.7%) were 0-64 years old, and 338 (32.1%) had pre-existing comorbidities. COVID-19 incidence was higher in the less deprived areas (p < 0.05), independently on age. The level of socio-economic deprivation did not show a significant impact on the vital status, while a higher fatality was observed in male cases (p < 0.001), cases > 65 years (p < 0.001), cases having a connection with a nursing home (p < 0.05) or having at least 1 comorbidity (p < 0.001). On the other hand, a significant protection for healthcare workers was apparent (p < 0.001). CONCLUSIONS: Our findings show that deprivation alone does not affect COVID-19 incidence and fatality burden, suggesting that the burden of disease is driven by a complexity of factors not yet fully understood. Better knowledge is needed to identify subgroups at higher risk and implement effective preventive strategies.