Digital health technologies and inequalities: A scoping review of potential impacts and policy recommendations.

Digital health technologies hold promises for reducing health care costs, enhancing access to care, and addressing labor shortages. However, they risk exacerbating inequalities by disproportionately benefitting a subset of the population. Use of digital technologies accelerated during the Covid-19 pandemic. Our scoping review aimed to describe how inequalities related to their use were conceptually assessed during and after the pandemic and understand how digital strategies and policies might support digital equity. We used the PRISMA Extension for scoping reviews, identifying 2055 papers through an initial search of 3 databases in 2021 and complementary search in 2022, of which 41 were retained. Analysis was guided by the eHealth equity framework. Results showed that digital inequalities were reported in the U.S. and other high-income countries and were mainly assessed through differences in access and use according to individual sociodemographic characteristics. Health disparities related to technology use and the interaction between context and technology implementation were more rarely documented. Policy recommendations stressed the adoption of an equity lens in strategy development and multilayered and intersectoral collaboration to align interventions with the needs of specific subgroups. Finally, findings suggested that evaluations of health and wellbeing distribution related to the use of digital technologies should inform digital strategies and health policies.

Revisiting the Determination of the Degree of Deacetylation Using Potentiometric Titration: A New Equation for Modified Chitosan.

Chitosan is a biopolymer that can be subjected to a variety of chemical modifications to generate new materials. The properties of modified chitosan are affected by its degree of deacetylation (DDA), which corresponds to the percentage of D-glucosamine monomers in its polymeric structure. Potentiometric titration is amongst the simplest, most readily available, and most cost-effective methods of determining the DDA. However, this method often suffers from a lack of precision, especially for modified chitosan resins. This is in large part because the equation used to calculate the DDA does not consider the molecular weight of the chemically modified monomeric units. In this paper, we introduce a new equation that is especially suited for modified chitosan bearing three different types of monomers. To test this equation, we prepared naphthalene-chitosan resins and subjected them to potentiometric titration. Our results show that our new equation, which is truer to the real structure of the polymeric chains, gives higher DDA values than those of the routinely used equations. These results show that the traditional equations underestimate the DDA of modified chitosan resins.

Cocoa, livelihoods, and deforestation within the Tridom landscape in the Congo Basin: A spatial analysis.

In the context of emerging international trade regulations on deforestation-free commodities, the drivers of households' deforestation in conservation landscapes are of interest. The role of households' livelihood strategies including cocoa production, and the effects of human-elephant conflict are investigated. Using a unique dataset from a survey of 1035 households in the Tridom landscape in the Congo basin, the spatial autoregressive model shows that: (1) Households imitate the deforestation decisions of their neighbors; (2) A marginally higher income from cocoa production-based livelihood portfolios is associated with six to seven times higher deforestation compared to other livelihood strategies with a significant spillover effect on neighboring households' deforestation. The increase in income, mainly from cocoa production-based livelihoods in open-access systems can have a negative effect on forests. Households with a higher share of auto-consumption are associated with lower deforestation. If economic development brings better market access and lower auto-consumption shares, this is likely to positively influence deforestation. Without proper land use planning/zoning associated with incentives, promoting sustainable agriculture, such as complex cocoa agroforestry systems, may lead to forest degradation and deforestation.

Situations of anomie and the health workforce crisis: Policy implications of a socially sensitive and inclusive approach to human resources.

Health systems in most jurisdictions are facing an unprecedented workforce crisis, manifesting as labour shortages, high staff turnover, and increasing rates of absenteeism and burnout. These issues affect professional and occupational groups in both health and social care and individuals at early and later stages of their career. The intensity and pervasiveness of the crisis suggests that it is a multicausal phenomenon. Studies have focused on the relationship between working environments and worker satisfaction and well-being. However, these are of limited use in understanding the deeper mechanisms behind the large-scale workforce crisis. The subjective experience of work, while rooted in a particular work context, is also shaped by broader social and cultural phenomena that put social norms and individuals' ability to conform to them in tension. The concept of anomie, initially developed by Durkheim and redefined by Merton, focuses on the way social norms that guide conduct and aspirations lose influence and become incompatible with each other or unsuited to contemporary work contexts. Understanding the workforce crisis from the perspective of anomie enables the development and implementation of novel policies based on co-production strategies where concerned publics engage collaboratively in framing the problem and searching for solutions.

French National Authority for Health assessment of metabolic surgery for type 2 diabetes remission-A meta-analysis in patients with class I to III obesity.

OBJECTIVE: Randomized controlled trials (RCTs) have demonstrated the superiority of metabolic surgery (MS) over medical therapy (MT) in patients with obesity and type 2 diabetes, leading, to a joint statement in 2016 proposing MS to patients with class I obesity and uncontrolled glycemia. Yet, these RCTs included few patients with class I obesity (body mass index 30-35 kg/m2) and even fewer patients with overweight. Our aim was to provide an updated systematic review (SR) with meta-analysis (MA) of RCTs reporting diabetes remission (DR) after MS in these patients. RESEARCH DESIGN AND METHODS: We included in the SR with MA only RCTs with at least 24-month follow-up found in Medline, Cochrane Library, Embase, and LiSSA between January 2008 and September 2022 comparing DR post-MT versus post-MS. We calculated relative risk (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel random-effects approach to examine differences in DR between patients allocated to MS versus MT. RESULTS: DR was significantly higher in MS versus MT after 36 months' follow-up in patients with obesity (RR = 6.65 [95 %CI 2.24;19.79]; I² = 27 %; 5 trials, 404 patients), but also specifically in patients with class I obesity (RR = 5.27 [1.31;21.23]; I² = 0 %; 4 trials, 80 patients). Furthermore, and in line with previous results, all additional MAs performed in patients with obesity in this work favor MS (specifically Roux-en-Y gastric bypass) over MT at 24, 36 (only) and 60 months of follow-up. CONCLUSIONS: Although the data available in patients with class I obesity and type 2 diabetes remains limited, MA shows higher rates of DR after MS compared with MT after 36 months' follow-up in these patients. Consequently, the French National Authority for Health French (HAS) recommends MS for these patients.

Implementation of the Acute Care for Elders Strategy to Improve the Quality of Care Transitions in Quebec and Ontario: a Retrospective Multiple Case Study.

Background: In 2016, two Canadian hospitals participated in a quality improvement (QI) program, the International Acute Care for Elders (ACE) Collaborative, and sought to adapt and implement a transition coach intervention (TCI). Both hospitals were challenged to provide optimal continuity of care for an increasing number of older adults. The two hospitals received initial funding, coaching, educational materials, and tools to adapt the TCI to their local contexts, but the QI project teams achieved different results. We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results. Methods: We conducted a retrospective multiple case study, including documentary analysis, 21 semi-structured individual interviews, and two focus groups. We performed thematic analysis using a hybrid inductive-deductive approach. Results: Both hospitals met initial organizational goals to varying degrees. Our qualitative analysis highlighted certain factors that were critical to the effective implementation and achievement of the QI project goals: the magnitude of changes and adaptations to the initial intervention; the organizational approaches to the QI project implementation, management, and monitoring; the organizational context; the change management strategies; the ongoing health system reform and organizational restructuring. Our study also identified other key factors for successful care transition QI projects: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance. Conclusion: Many of the lessons learned and strategies identified from our analysis will help clinicians, managers, and policymakers better address the issues and challenges of adapting evidence-based innovations in care transitions for older adults to local contexts.

A New and Rapid HPLC Method to Determine the Degree of Deacetylation of Glutaraldehyde-Cross-Linked Chitosan.

Chitosan is a linear biopolymer composed of D-glucosamine and N-acetylglucosamine units. The percentage of D-glucosamine in the polymeric chain can vary from one sample to another and is expressed as the degree of deacetylation (DDA). Since this parameter has an impact on many properties, its determination is often critical, and potentiometric titration is a common analytical technique to measure the DDA. Cross-linking with glutaraldehyde is one of the most explored modifications of chitosan; however, the determination of the DDA for the resulting reticulated chitosan resins can be challenging. In this paper, we report a new, rapid, and efficient method to determine the DDA of glutaraldehyde-cross-linked chitosan resins via HPLC. This method relies on the use of 2,4-dinitrophenylhydrazine (DNPH) as a derivatizing agent to measure the level of reticulation of the polymer (LR) after the reticulation step. In this study, we prepare three calibration curves (with an R2 value over 0.92) for three series of reticulated polymers covering a large range of reticulation levels to demonstrate that a correlation can be established between the LR established via HPLC and the DDA obtained via titration. The polymers are derived from three different chitosan starting materials. These standard calibration curves are now used on a routine basis in our lab, and the HPLC method has allowed us to change our DDA analysis time from 20 h to 5 min.

Equilibrium in the governance of cross-sectoral policies: how does it translate into practice?

BACKGROUND: There is growing interest from health researchers in the governance of Health in All Policies (HiAP). Furthermore, the COVID-19 pandemic has re-ignited managers' interest in HiAP governance and in health prevention activities that involve actors from outside health ministries. Since the dynamics of these multi-actor, multi-sectoral policies are complex, the use of systems theory is a promising avenue toward understanding and improving HiAP governance. We focus on the concept of equilibrium within systems theory, especially as it points to the need to strike a balance between actors that goes beyond synergies or mimicry-a balance that is essential to HiAP governance. METHOD: We mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in Quebec, Canada. RESULTS: In total, we identified 12 equilibrium-related elements relevant to HiAP governance and related to knowledge, actors, learning, mindsets, sustainability, principles, coordination, funding and roles. The equilibria were both operational and conceptual in nature. CONCLUSIONS: We conclude that policy makers and policy implementers could benefit from mobilizing these 12 equilibrium-related elements to enhance HiAP governance. Evaluators of HiAP may also want to consider and integrate them into their governance assessments.

Employee-Driven Innovation in Health Organizations: Insights From a Scoping Review.

BACKGROUND: Employee-driven innovation (EDI) occurs when frontline actors in health organizations use their firsthand experience to spur new ideas to transform care. Despite its increasing prevalence in health organizations, the organizational conditions under which EDI is operationalized have received little scholarly attention. METHODS: This scoping review identifies gaps and assembles existing knowledge on four questions: What is EDI in health organizations and which frontline actors are involved? What are the characteristics of the EDI process? What contextual factors enable or impede EDI? And what benefits does EDI bring to health organizations? We searched seven databases with keywords related to EDI in health organizations. After screening 1580 studies by title and abstract, we undertook full-text review of 453 articles, retaining 60 for analysis. We performed a descriptive and an inductive thematic analysis guided by the four questions. RESULTS: Findings reveal an heterogeneous literature. Most articles are descriptive (n = 41). Few studies are conceptual and empirical (n = 15) and four are conference papers. EDI was often described as a participatory, learning innovation process involving frontline clinical and non-clinical staff and managers. Majority EDI were top-down, often driven by the organization's focus on participatory improvement and innovation and research-based initiatives. Five categories of methods is used in top-down EDI, two thirds of which includes a learning, a team and/or a digital component. Hybrid EDI often involves a team-based component. Bottom-up EDI emerged spontaneously from the work of frontline actors. Enablers, barriers, and benefits of EDI are seen at macro, organizational, team and individual levels; some benefits spread to other health organizations and health systems. CONCLUSION: This scoping review provides a comprehensive understanding of the organizational conditions under which EDI is operationalized. It offers insights for researchers, health organizations, and policy-makers about how and why frontline actors' involvement is crucial for the transformation of care.

Web-based comparative study of some national experiences of health care quality management.

Since the publication of study results on adverse events to health care in OECD countries, the importance of the national quality improvement strategies has been recognised. To examine how these strategies have been shaped in different jurisdictions, we carried out this study. We conducted a web-based comparative study of international practices. We first defined seven key health care and services quality management functions. We then drew on the experience of authors to make a reasoned selection of 13 countries or states across the world. We determined the distance that separates each of these functions from a country's Ministry of Health (MoH); and examined whether these functions are concentrated in a single organisation or dispersed across several organisations. Afterwards, we correlated our results with the quality level of these countries based on the OECD's health care indicators. Overall, Netherlands, Québec (Canada), Korea, Germany, England (UK), and the United States had at least 50% of their quality management functions controlled by self-regulated organisations. The Market Concentration Index ranged from 937 for the United States to 6800 for Russia. Graphical representation has shown us two health system models. Our results also clearly showed that countries had a better quality of care most often when they belong to model 1 of our taxonomy. These findings will help countries design and implement large-scale health care and services quality strategies for better and safer health care and services.

Evaluation of an interprofessional primary healthcare team as a new model of primary care in Quebec: a protocol for a type 2 effectiveness-implementation hybrid study.

INTRODUCTION: One family medicine group (FMG) in Quebec has commenced a 5-year pilot project, which is herein referred to as the Archimède model, to implement a patient-centred model based on interprofessional care and the optimal use of healthcare providers' practice scopes. A research project will be conducted to: (1) assess this model's effect on the FMG's operational performance, and its users' resource utilisation at the public health system level; (2) investigate its optimisation with respect to professional roles, interprofessional teamwork and patient-centredness and (3) document users' experience with the model. The aim of this article is to describe the protocol that will be used for this research. METHODS AND ANALYSIS: A hybrid implementation approach (type 2 model) will be used. We will collect both quantitative and qualitative data. Regarding the quantitative dimension, and because this is a single-unit intervention study, we will use either or both synthetic control methods and one-sample generalised linear models for analyses at the FMG level. To evaluate the broader impact of Archimède on the public health system, we will use mixed-effects models and propensity score matching methods. Regarding the qualitative research dimension, using an interpretative descriptive approach, we will document users' experience and identify the factors that optimise professional scopes of practice, collaborative practices and patient-centredness. We will conduct individual in-depth semistructured interviews with healthcare providers, administrative staff, stakeholders involved in the Archimède model implementation and patients. ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee of the Sectoral Research in Population Health and Primary Care of the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (#2019-1503). The results of the investigation will be presented to the stakeholders involved in the advisory committees and at several scientific conferences. Manuscripts will be submitted to peer-reviewed journals.

Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation.

BACKGROUND: The health workforce is central to healthcare systems and population health, but marginal in comparative health policy. This study aims to highlight the crucial relevance of the health workforce and contribute comparative evidence to help improve the protection of healthcare workers and prevention of inequalities during a major public health crisis. METHODS: Our integrated governance framework considers system, sector, organizational and socio-cultural dimensions of health workforce policy. The COVID-19 pandemic serves as the policy field and Brazil, Canada, Italy, and Germany as illustrative cases. We draw on secondary sources (literature, document analysis, public statistics, reports) and country expert information with a focus on the first COVID-19 waves until the summer of 2021. RESULTS: Our comparative investigation illustrates the benefits of a multi-level governance approach beyond health system typologies. In the selected countries, we found similar problems and governance gaps concerning increased workplace stress, lack of mental health support, and gender and racial inequalities. Health policy across countries failed to adequately respond to the needs of HCWs, thus exacerbating inequalities during a major global health crisis. CONCLUSIONS: Comparative health workforce policy research may contribute new knowledge to improve health system resilience and population health during a crisis.

How can entrepreneurs experience inform responsible health innovation policies? A longitudinal case study in Canada and Brazil.

AIM: To foster equity and make health systems economically and environmentally more sustainable, Responsible Innovation in Health (RIH) calls for policy changes advocated by mission-oriented innovation policies. These policies focus, however, on instruments to foster the supply of innovations and neglect health policies that affect their uptake. Our study's aim is to inform policies that can support RIH by gaining insights into RIH-oriented entrepreneurs' experience with the policies that influence both the supply of, and the demand for their innovations. METHODS: We recruited 16 for-profit and not-for-profit organisations engaged in the production of RIH in Brazil and Canada in a longitudinal multiple case study. Our dataset includes three rounds of interviews (n = 48), self-reported data, and fieldnotes. We performed qualitative thematic analyses to identify across-cases patterns. FINDINGS: RIH-oriented entrepreneurs interact with supply side policies that support technology-led solutions because of their economic potential but that are misaligned with societal challenge-led solutions. They navigate demand side policies where market approval and physician incentives largely condition the uptake of technology-led solutions and where emerging policies bring some support to societal challenge-led solutions. Academic intermediaries that bridge supply and demand side policies may facilitate RIH, but our findings point to an overall lack of policy directionality that limits RIH. CONCLUSION: As mission-oriented innovation policies aim to steer innovation towards the tackling of societal challenges, they call for a major shift in the public sector's role. A comprehensive mission-oriented policy approach to RIH requires policy instruments that can align, orchestrate, and reconcile health priorities with a renewed understanding of innovation-led economic development.

Health reforms and policy capacity: the Canadian experience.

Recent work on health system strengthening suggests that a combination of leadership and policy capacity is essential to achieve transformation and improvement. Policy capacity and leadership are mutually constitutive but difficult to assemble in a coherent and consistent way. Our paper relies on the nested model of policy capacity to empirically explore how health reformers in seven Canadian provinces address the question of policy capacity. More specifically, we look at emerging representations of policy capacity within the context of health reforms between 1990 and 2020. Based on the exploration of the scientific and grey literature (legislation, annual reports of Ministries, agencies and organizations, meeting minutes, press, etc.) and interviews with key informants (n = 54), we identify how policy capacity is considered and framed within health reforms A series of core dilemmas emerge from attempts by each province to develop policy capacity for and through health reforms.

Determination of the degree of quaternization of N,N,N-trimethylchitosan by CP-MAS 13C NMR.

Chitosan is used in several fields such as medicine, environment and advanced functional materials. The N-alkylation of chitosan into N,N,N-trimethylchitosan (TMC) allows to improve some properties. The current quantification methods of the degree of quaternization (DQ) like titration and 1H NMR spectroscopy require the solubilization of TMC. In this study, a solid-state 13C NMR quantification method was developed for insoluble TMCs. For this purpose, four TMC derivatives acting as reference were synthesized and their degrees of quaternization, N,N-dimethylation (DD) and acetylation (DA) were determined in solution by 1H NMR. CP-MAS 13C NMR spectra of those derivatives were deconvolved with Lorentz functions. Several ratios of the 13C NMR peak areas were correlated with the degrees of substitution obtained in 1H NMR. The best quantification method of DQ involved the correlation of the carbon signal of methyl groups. The method was also applied for the determination of the DD and DA of TMCs.

Climate Change Vulnerability Assessment in Mangrove-Dependent Communities of Manoka Island, Littoral Region of Cameroon.

This study was conducted on Manoka Island (Littoral Region of Cameroon) with the aim of analyzing climate change vulnerability and local adaptation strategies based on the local community's perceptions and biophysical evidence. We used household surveys, focus group discussions, field observation, GIS, and remote sensing to collect data on variables of exposure, sensitivity, and adaptive capacity. Historical changes in rainfall and temperature, mangrove cover, and the occurrence of extreme climatic events were used as indicators of exposure. Property losses and income structure were used as indicators of sensitivity, while human, natural, social, financial, and physical assets represented adaptive capacity. 89 households were interviewed in the nine settlements of the island. Results show that Manoka Island is experiencing irregular rainfall patterns (with average annual values deviating from the mean by -1.9 to +1.8 mm) and increasing temperature (with annual values deviating from the mean by -1.2 to +3.12). The dynamics of the coastline between 1975 and 2017 using EPR show average setbacks of more than ±3 m/year, with erosion levels varying depending on the period and location. The number of households perceiving extreme climatic events like seasonal variability, flood, and rain storm was higher. From respondents' perception, housing and health are the sectors most affected by climate change. The reported high dependence of households on fishing for income, their overall low livelihood diversification, and their poor access to climate information reported by 65% of respondents portray their poor adaptive capacity. Local response initiatives are ineffective and include among others constructing buildings on stilts and using car wheels to counter the advancement of seawater inland. The study concludes that households on Manoka Island are vulnerable to the impacts of climate change. Income diversification, mangrove reforestation, the development of sustainable supply chains for wood fuel, and sustainable fish smoking devices are the main pathways for adaptation planning in this area.