Chiropractors in Multidisciplinary Teams: Enablers of Colocation Integration in GP-Led Primary Healthcare.

The aim of this study was to explore and document the enablers and barriers of chiropractic care colocation in general practice at a large-scale private primary care centre in Australia. This study focused on the perceptions of healthcare professionals regarding this integration. The research setting was a large integrated primary care centre located in an outer metro, low-socioeconomic area in the City of Moreton Bay, Queensland, Australia. Participant inclusion criteria included general medical practitioners, practice nurses, and medical managers who self-reported interactions with the physically collocated and integrated chiropractic practice. Data was collected from 22 participants using face-to-face, qualitative, semi-structured interviews with an average duration of 32 min. The data collected included perceptions of chiropractic treatment, enablers to patient referral pathways, and views of the integrated chiropractic care model. A reflexive thematic analysis was conducted on the data set. All participants reported that this was their first exposure to the colocation of a chiropractor within a general medical practice. Four key enablers of chiropractic care integration were identified: (1) the practitioner [chiropractor], (2) the organisation [general practice], (3) consumer flow, and (4) the environment [shared spaces and tenant ecosystem]. The chiropractic integration enhanced knowledge sharing and interprofessional trust among healthcare providers. The formal reporting of patient outcomes and understanding of the chiropractor's scope of practice further enabled referrals to the service. Shared administrative and business processes, including patient records, booking systems, and clinical meetings, facilitated relationship development between the chiropractor and referring health providers. Colocation as part of a larger primary care centre created proximity and convenience for health providers in terms of interprofessional communication, and for patients, in terms of access to chiropractic services. Existing governance structures supported communication, professional education, and shared values related to the delivery of patient-centred care. Identified barriers included limited public funding for chiropractic services resulting in reduced access for patients of low-socioeconomic status. Additionally, scepticism or negativity towards the discipline of chiropractic care was identified as an initial barrier to refer patients. In most cases, this view towards the chiropractor was overcome by regular patient reporting of positive treatment outcomes to their GP, the delivery of education sessions by the chiropractor for the health providers, and the development of interprofessional trust between the chiropractor and referring health providers. This study provides preliminary evidence and a conceptual framework of factors influencing the successful integration of chiropractic care within an Australian large primary care centre. The data collected indicated that integration of chiropractic care into a primary care centre serving a low-socioeconomic region can be achieved with a high degree of health provider satisfaction.

Building capacity for equitable healthcare workforce policy, learning from migrant healthcare workers: A qualitative study with Romanian physicians working in Germany during COVID-19.

BACKGROUND: Attention to the healthcare workforce has increased, yet comprehensive information on migrant healthcare workers is missing. This study focuses on migrant healthcare workers' experiences and mobility patterns in the middle of a global health crisis, aiming to explore the capacity for circular migration and support effective and equitable healthcare workforce policy. METHODS: Romanian physicians working in Germany during the COVID-19 pandemic served as an empirical case study. We applied a qualitative explorative approach; interviews (n = 21) were collected from mid of September to early November 2022 and content analysis was performed. RESULTS AND DISCUSSION: Migrant physicians showed strong resilience during the COVID-19 crisis and rarely complained. Commitment to high professional standards and career development were major pull factors towards Germany, while perceptions of limited career choices, nepotism and corruption in Romania caused strong push mechanisms. We identified two major mobility patterns that may support circular migration policies: well-integrated physicians with a wish to give something back to their home country, and mobile cosmopolitan physicians who flexibly balance career opportunities and personal/family interests. Health policy must establish systematic monitoring of the migrant healthcare workforce including actor-centred approaches, support integration in destination countries as well as health system development in sending countries, and invest in evidence-based circular migration policy.

The mental health needs of healthcare workers: When evidence does not guide policy. A comparative assessment of selected European countries.

BACKGROUND: The healthcare workforce (HCWF) globally is facing high stress levels and deteriorating mental health due to workplace, labour market and policy deficiencies that further exacerbate the existing crisis. However, comprehensive and effective action is missing. AIMS: We adopt a health system and governance perspective to address the mental health needs of healthcare workers (HCWs), considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support. MATERIAL AND METHODS: A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. We conducted a rapid assessment of HCWF developments in the European context (Germany, Portugal, Romania, Switzerland and the United Kingdom), drawing on secondary sources and country experts. RESULTS AND DISCUSSION: Awareness of mental health threats among HCWs increased, but policy discourse is driven by service delivery and labour market demands. The attention to HCWs' needs is stronger on the international level and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses. CONCLUSION: Adopting a health system approach is important but not sufficient. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms.

Migrant healthcare workers during COVID-19: bringing an intersectional health system-related approach into pandemic protection. A German case study.

Introduction: Migrant healthcare workers played an important role during the COVID-19 pandemic, but data are lacking especially for high-resourced European healthcare systems. This study aims to research migrant healthcare workers through an intersectional health system-related approach, using Germany as a case study. Methods: An intersectional research framework was created and a rapid scoping study performed. Secondary analysis of selected items taken from two COVID-19 surveys was undertaken to compare perceptions of national and foreign-born healthcare workers, using descriptive statistics. Results: Available research is focused on worst-case pandemic scenarios of Brazil and the United Kingdom, highlighting racialised discrimination and higher risks of migrant healthcare workers. The German data did not reveal significant differences between national-born and foreign-born healthcare workers for items related to health status including SARS-CoV-2 infection and vaccination, and perception of infection risk, protective workplace measures, and government measures, but items related to social participation and work conditions with higher infection risk indicate a higher burden of migrant healthcare workers. Conclusions: COVID-19 pandemic policy must include migrant healthcare workers, but simply adding the migration status is not enough. We introduce an intersectional health systems-related approach to understand how pandemic policies create social inequalities and how the protection of migrant healthcare workers may be improved.

Defining medical deserts-an international consensus-building exercise.

BACKGROUND: Medical deserts represent a pressing public health and health systems challenge. The COVID-19 pandemic further exacerbated the gap between people and health services, yet a commonly agreed definition of medical deserts was lacking. This study aims to define medical deserts through a consensus-building exercise, explaining the phenomenon to its full extent, in a manner that can apply to countries and health systems across the globe. METHODS: We used a standard Delphi exercise for the consensus-building process. The first phase consisted of one round of individual online meetings with selected key informants; the second phase comprised two rounds of surveys when a consensus was reached in January 2023. The first phase-the in-depth individual meetings-was organized online. The dimensions to include in the definition of medical deserts were identified, ranked and selected based on their recurrence and importance. The second phase-the surveys-was organized online. Finally, external validation was obtained from stakeholders via email. RESULTS: The agreed definition highlight five major dimensions: 'Medical deserts are areas where population healthcare needs are unmet partially or totally due to lack of adequate access or improper quality of healthcare services caused by (i) insufficient human resources in health or (ii) facilities, (iii) long waiting times, (iv) disproportionate high costs of services or (v) other socio-cultural barriers'. CONCLUSIONS: The five dimensions of access to healthcare: (i) insufficient human resources in health or (ii) facilities, (iii) long waiting times, (iv) disproportionate high costs of services and (v) other socio-cultural barriers-ought to be addressed to mitigate medical deserts.

A five-year (2017-2021) time series evaluation of patient-reported informal healthcare payments in Romania.

Low wages of health professionals are widely recognized as one of the drivers of informal payments in Romania's healthcare system. In January 2018, the government increased wages by an average of 70% to 172% in the public healthcare sector. This study examined the trends in patient-reported informal healthcare payments, discussing the effect of a one-time wage increase in 2018 and the impact of the COVID-19 pandemic in 2020 and 2021. It draws on monthly survey data of patient-reported informal payments collected between January 2017 and December 2021. We analyzed three periods: before the wage rise ("low pay"), between the wage rise and the COVID-19 pandemic ("high pay"), and during the COVID-19 pandemic. We found that patient-reported informal payments decreased between the "low pay" and "high pay" period but with a sharper decline during the COVID-19 pandemic. The share of respondents willing to report informal payments increased during the "high pay" period, indicating a stronger willingness to voice dissatisfaction with health services and informal payments, but slowed down during the first lockdown in 2020. Informal payments were more frequently reported in larger hospitals and the poorest geographical areas. While the 2018 wage increase may have contributed to less prevalent informal payments, survey coverage and design must be improved to draw robust, system-level conclusions to inform tailored policy actions.

Exploring female medical students' knowledge, attitudes, practices, and perceptions related to breast cancer screening: a scoping review.

Early detection measures for breast cancer, such as breast self-exams, clinical breast exams, and mammography, have considerable benefits in effectively reducing breast cancer-related mortality. As the incidence of breast cancer is steadily increasing, it is crucial to raise awareness on early detection. This scoping review assessed the current knowledge, attitudes, practices, and perceptions of breast cancer screening among female medical students. We used the six phases of Arksey and O'Malley's framework from the Joanna Briggs Institute Manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) template. Our analysis included 43 articles from Google Scholar and PubMed search engines, focusing on female medical students. Our results showed that most female medical students had a satisfactory level of knowledge about the most common signs, symptoms, and early detection methods of breast cancer. Generally, their attitude and perceptions were positive regarding breast cancer-related preventive measures. However, the level of practice was reduced. Further efforts are necessary to promote and improve the practice of breast self-examination, clinical breast exams, and mammography among female medical students. Potential interventions could include modifications to the medical curriculum and social media campaigns to enhance engagement and adoption of these practices.

Going Remote: Evaluating a Global Health Practicum Program During COVID-19 Travel Restrictions.

Background: Short-term experiences in global health (STEGHs) are an important part of global health degree programs. Due to the COVID-19 pandemic, travel was not possible for students planning to participate in the Johns Hopkins Center for Global Health's Global Health Established Field Placement (GHEFP) program in 2020. Working with willing faculty mentors, in-country collaborators, and students, the Center allowed students to complete their practicums remotely so that students could gain practicum experience despite not being able to travel, and faculty and collaborators could receive the planned support on their projects. Objectives: This evaluation aims to describe the experience of pivoting the GHEFP program from an in-person, in-country program to a remote practicum. Methods: We analyzed program evaluation data from 30 students, 20 faculty members, and 10 in-country collaborators. Surveys for each group consisted of multiple choice, scale rating, and open-ended questions. The quantitative data was analyzed using Microsoft Excel to calculate survey response frequencies. The open-ended responses were analyzed for emergent themes. Findings: The remote GHEFP experience enabled students to gain practice working on global health projects from a distance, but it came with challenges related to preparation, communication, shifting scopes of work, and contextualization. All participants would have preferred an in-person experience if given a choice, but most agreed that a remote practicum was better than not participating at all. Conclusions: The remote program served its purpose during the height of the pandemic. Given the hybrid nature of global health today, many aspects of the remote practicum experience are helpful for global health training. Future iterations of remote STEGHs should initially be designed for remote work to ensure meaningful scopes for students that are helpful to faculty mentors and collaborators. Hybrid models may also be useful. Mutually beneficial twinning relationships should also be incorporated into remote and in-person STEGHs to foster a more equitable global health training environment.

Strategies for the Psychological Support of the Healthcare Workforce during the COVID-19 Pandemic: The ERNST Study.

The COVID-19 pandemic led to the implementation of interventions to provide emotional and psychological support to healthcare workers in many countries. This ecological study aims to describe the strategies implemented in different countries to support healthcare professionals during the outbreak. Data were collected through an online survey about the measures to address the impact of the pandemic on the mental health of healthcare workers. Healthcare professionals, researchers, and academics were invited to respond to the survey. Fifty-six professionals from 35 countries contributed data to this study. Ten countries (28.6%) reported that they did not launch any national interventions. Both developed and developing countries launched similar initiatives. There was no relationship between the existence of any type of initiative in a country with the incidence, lethality, and mortality rates of the country due to COVID-19, and per capita income in 2020. The 24 h hotline for psychological support was the most frequent intervention. Tools for self-rescue by using apps or websites were extensively used, too. Other common interventions were the development of action protocols, availability of regular and updated information, implantation of distance learning systems, early detection of infection programs for professionals, economic reinforcements, hiring of staff reinforcement, and modification of leave and vacation dates.

Romanian patients' access to clubfoot treatment services.

The number of clubfoot new cases in Romania is on the rise. According to orthopedic research, the Ponseti method is the elective treatment for clubfeet. This paper aims to provide an overview of the current facilitators and barriers in accessing clubfoot treatment services in Romania and to assess the impact of care-related factors on patients' well-being. Our research shows that nationally, few orthopedic surgeons are using the Ponseti method and most of them are concentrated only in Cluj-Napoca. Moreover, gynecologists, neonatologists, and family physicians were not informed about the initial diagnosis and the current treatment of clubfoot. Primary medical care was significantly postponed in some cases. Moreover, no clubfoot organizations were mentioned by the parents included in the study, and psychological support was provided neither for the parents nor for the children. Based on the results of our study, we conclude that more efforts need to be done for the diagnosis and treatment of children with clubfeet. These include actions which are focused on raising awareness around this abnormality and more well-developed treatment guidelines.

Predictors of planned caesarean section births in a sample of Romanian women.

OBJECTIVES: Romania has one of the highest incidences of births by caesarean section (CS) in the European Union (EU). The present study aims to identify the possible predictors of planned caesarean section (PCS) in a convenience sample of Romanian women. METHODS: This is a secondary analysis of the cross-sectional data collected as part of the EU-level Babies Born Better online survey from 1908 Romanian women who gave birth between 2013 and 2018. Univariable and multivariable logistic regression models were performed to identify the potential individual and health system-level predictors of PCS. RESULTS: PCS was reported by 36.7% (n = 657) of the women. In the multivariable regression model, older maternal age (aOR: 1.10, 95% CI: 1.07-1.14) and presence of medical or non-medical problems during pregnancy (adjusted odds ratio [aOR]: 1.67, 95% CI: 1.31-2.12) were significantly associated with PCS. Conversely, birth at a very high level of competence hospital was inversely associated with PCS (aOR: 0.48, 95% CI: 0.30-0.76). CONCLUSIONS: Our findings indicate that PCS may be associated with both individual and health system-level variables. Our results are significant because they could be used to inform decision-making processes aimed at lowering PCS incidence.

Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems.

This article is dedicated to the WHO International Year of Health and Care Workers in 2021 in recognition of their commitment during the COVID-19 pandemic. The study aims to strengthen health workforce preparedness, protection and ultimately resilience during a pandemic. We argue for a health system approach and introduce a tool for rapid comparative assessment based on integrated multi-level governance. We draw on secondary sources and expert information, including material from Denmark, Germany, Portugal and Romania. The results reveal similar developments across countries: action has been taken to improve physical protection, digitalization and prioritization of healthcare worker vaccination, whereas social and mental health support programmes were weak or missing. Developments were more diverse in relation to occupational and organizational preparedness: some ad-hoc transformations of work routines and tasks were observed in all countries, yet skill-mix innovation and collaboration were strongest in Demark and weak in Portugal and Romania. Major governance gaps exist in relation to education and health integration, surveillance, social and mental health support programmes, gendered issues of health workforce capacity and integration of migrant healthcare workers (HCW). There is a need to step up efforts and make health systems more accountable to the needs of HCW during global public health emergencies.

Normative data for optical coherence tomography in children: a systematic review.

The purpose of this study is to systematically review the reported data of normal optical coherence tomography (OCT) results in the paediatric population. A systematic literature search was performed using the PubMed, Embase, and Web of Science databases, using the keywords "optical coherence tomography"; "normative data" or "healthy eyes"; "children" or "paediatric population". Studies with at least 50 participants were included, irrespective of the OCT equipment employed. We excluded the OCT angiography studies or the studies investigating the choroidal thickness. Seventy-four studies were included in the final analysis and information on study design, number of participants, demographic characteristics, type of OCT equipment, OCT parameters and results was collected. Due to the high variability of OCT instruments and parameters used, a meta-analysis was not feasible. We report the normative values for the peripapillary retinal nerve fibre layer thickness and the macular retinal thickness for each ETDRS quadrant, as provided by the studies included in the present analysis. We also report the influence of ethnicity, age, gender, eye laterality, ISNT rule, spherical equivalent, and axial length on OCT results.

The economic burden of stroke: a systematic review of cost of illness studies.

Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.

The geriatric workforce in Romania: the need to improve data and management.

Facing severe under-funding and significant workforce maldistribution, the health system in Romania is challenged to provide adequate care for the ageing population. The aim of this article is to connect health labour market data of the geriatrics workforce in Romania with individual perceptions of front-line workers in geriatrics in order to better understand the 'human' factors of effective health workforce development. Comprehensive health workforce data are not available; we therefore used a rapid scoping review and interviews to combine quantitative and qualitative data sources, such as the 'Healthcare Facility Activity Report', policy documents and available reports. They show that despite a consistent increase in the overall number of geriatricians, their majority is based in Bucharest, the capital city. The initial review points to possible geriatrician burnout, caused in part by high workload. The geriatrics workforce in Romania is poorly developed. Significant efforts are still needed to create policies addressing inflows and outflows, training, maldistribution and inefficiencies related to their practice. Addressing burnout by improving teamwork and collaboration is vital for maintaining and improving the workforce morale and motivation. Two major policy recommendations emerged: an urgent need for better health workforce data in Romania and development of more effective workforce management.

Migrant carers in Europe in times of COVID-19: a call to action for European health workforce governance and a public health approach.

The present study explores the situation of migrant carers in long-term care (LTC) in European Union Member States and the disruptions caused by the COVID-19 pandemic from a public health perspective. The aim is to bring LTC migrant carers into health workforce research and highlight a need for trans-sectoral and European heath workforce governance. We apply an exploratory approach based on secondary sources, document analysis and expert information. A framework comprising four major dimensions was developed for data collection and analysis: LTC system, LTC health labour market, LTC labour migration policies and specific LTC migrant carer policies during the COVID-19 crisis March to May 2020. Material from Austria, Italy, Germany, Poland and Romania was included in the study. Results suggest that undersupply of carers coupled with cash benefits and a culture of family responsibility may result in high inflows of migrant carers, who are channelled in low-level positions or the informal care sector. COVID-19 made the fragile labour market arrangements of migrant carers visible, which may create new health risks for both the individual carer and the population. Two important policy recommendations are emerging: to include LTC migrant carers more systematically in public health and health workforce research and to develop European health workforce governance which connects health system needs, health labour markets and the individual migrant carers.

A call for action to establish a research agenda for building a future health workforce in Europe.

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains insufficiently understood. There is a compelling argument to be made for a comprehensive research agenda to address the questions. With a focus on Europe and taking a health systems approach, we introduce an agenda linked to the 'Health Workforce Research' section of the European Public Health Association. Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. This article highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policy-makers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. This requires dedicated research funding, new academic education programmes, comparative methodology and knowledge transfer and leadership that can help countries to build a people-centred health workforce.

Implementing the Code of Practice on International Recruitment in Romania - exploring the current state of implementation and what Romania is doing to retain its domestic health workforce.

BACKGROUND: The Romanian health system is struggling to retain its health workers, who are currently facing strong incentives for migration to Western European health systems. Retention issues, coupled with high levels of migration, complicate Romania's efforts in providing basic health services for rural, underserved, and marginalized populations, as well as in achieving equitable health access for all. The WHO Global Code of Practice on International Recruitment of Health Personnel (the Code) aims to promote ethical international recruitment and health systems strengthening. We explore Romania's implementation of the Code's principles and recommendations. METHODS: We analysed peer-reviewed and grey literature, in English and Romanian, and sought secondary data from the websites of Romania's largest medical universities. The analysis was guided by the following themes and recommendations in the Code: health personnel development and health systems sustainability, international cooperation, data gathering, information exchange, and implementation and monitoring of the Code. RESULTS: Romania's implementation of the Code was observed to be limited. Gaps were identified with regards to several aspects of the Romanian health system, including the lack of support to health personnel training, recruitment, and retention in order to increase the appeal for health providers to practice in Romania and in underserved areas. In terms of international cooperation, the Code recommends various policy instruments to guide recruitment, including bilateral agreements. However, we could not determine which of these instruments were used as a result of the Code and whether or not they were effective. We identified little evidence of initiatives for health workers' professional and personal support. Insufficient data and few information exchange platforms exist on health workforce issues, hindering active sharing of data on migration with European Union and WHO audiences. We could not identify any evidence of monitoring of the Code's implementation to date. CONCLUSIONS: In the absence of major system reforms, health workers will continue to migrate to urban areas and abroad. Romanian policymakers should address more of the Code's recommendations by developing a national policy for human resources for health, a central database to aid health workforce planning and management, stronger platforms for information exchange and civil society engagement, and updated and transparent bilateral agreements.