Health Policy

Background: Postpartum Medicaid coverage and support are central maternal health policy issues, but county-level tools for identifying where postpartum Medicaid populations may face overlapping administrative, clinical, and contextual access barriers remain limited. Methods: We developed and internally validated a county-level Postpartum Medicaid Access Barrier Index for all 3,144 counties and county equivalents in the 50 states and District of Columbia. Public data sources included geocoded Medicaid office locations from Shafer et al. (2024), U.S. Census county boundaries, American Community Survey 2024 5-year county indicators, the National Center for Health Statistics 2023 Urban-Rural Classification Scheme for Counties, and county-level hospital-based obstetric care status from the University of Minnesota Rural Health Research Center. Medicaid office locations were spatially assigned to counties, then merged with ACS indicators, rurality, and obstetric care status by county FIPS. The theoretical score range was 0-11; the index assigned higher weights to two core infrastructure measures and lower weights to contextual indicators. Internal validation assessed component structure, known-groups validity, geographic clustering, weighting sensitivity, added value over simpler infrastructure screens, and separation across concern levels. Results: Across 3,144 counties, observed scores ranged from 0 to 10 on the theoretical 0-11 score, with a mean of 3.65 and median of 3. High or highest concern counties accounted for 665 counties (21.2%), including 56 counties (1.8%) in the highest concern group. Component correlations were low-to-moderate, with an average absolute phi of 0.176 and no pairwise component correlation at or above 0.50. Known-groups validity was strong: dual administrative and clinical gap counties scored 4.43 points higher than counties with neither gap (Cohen's d = 3.28, p < 0.001). Scores were geographically clustered (Moran's I = 0.375, permutation p = 0.005). A dual-gap-only screen captured 386 of 665 high/highest concern counties (58.0%) but missed 279 high/highest counties; a parsimonious rule requiring one infrastructure gap plus at least four contextual flags recovered 265 of these 279 missed counties (95.0%) with 100.0% precision. Discussion: The Postpartum Medicaid Access Barrier Index provides a transparent county-level screening tool for identifying places where administrative, clinical, and contextual barriers may overlap for postpartum Medicaid populations and should be externally validated against Medicaid enrollment, renewal, churn, coverage continuity, and postpartum care outcomes.

Background A small proportion of hospitalized patients generates a disproportionate share of inpatient admissions, bed-day utilization, and associated health expenditure globally. In Saudi Arabia, where Vision 2030 mandates measurable reductions in preventable hospitalizations and hospitals consume approximately 79% of public health expenditure, population-level evidence on inpatient frequent utilization is absent from the published literature. A key methodological limitation of existing studies is reliance on a single threshold that cannot distinguish acute high-frequency episodes from sustained multi-year hospital dependence. Methods A retrospective cross-sectional study analyzed electronic health records from three public hospitals in Jeddah - East Jeddah Hospital (EJH), King Abdul-Aziz Hospital (KAAH), and Thagher Hospital (TH) - for January 2022 to December 2024. Records from two clinical information systems (Oasis at KAAH and TH; Careware at EJH) were harmonized using an eight-stage data quality protocol applied to 258,391 raw encounters, yielding a final cohort of 82,160 unique patients and 100,685 valid inpatient visits. Three complementary definitions were applied: Frequent Utilizer (FU: >=3 admissions within any rolling 365-day window), Persistent Utilizer (PU: >=3 admissions with >=24 months between first and last), and Yearly Utilizer (YU: >=1 admission in each of 2022, 2023, and 2024). Analyses were conducted in JASP 0.95.4. Results FU prevalence was 2.96% (n=2,434), PU 0.60% (n=494), and YU 0.62% (n=507). Overlap analysis identified 177 compound utilizers (0.22%) satisfying all three criteria simultaneously, with a median of 7 admissions and 33.44 bed days - more than thirteen times the standard patient median. Compound utilizers had the youngest median age of any utilizer group (24 years), while Saudi nationality concentration rose progressively from 75.0% in standard patients to 87.6% in compound utilizers, and female predominance was highest in the persistence-defined groups (PU-only 62.9%, YU-only 63.6%). All three ANOVA models confirmed significant utilizer status x hospital interactions (all p<.001). Logistic regression confirmed age, Saudi nationality, and hospital as independent predictors across all definitions. A gender discrepancy - significant for males in FU Model 1 (OR=1.090, p=.039) but not Model 2 (p=.181) - was attributable to age confounding. Conclusions Approximately one in thirty-four inpatients meets the FU criterion in this Jeddah system, with significant between-hospital variation. The three-definition framework reveals clinically distinct utilization phenotypes invisible to any single threshold, including compound utilizers with extraordinary burden and unexpectedly young age, and persistent users entirely missed by annual-window definitions. Saudi nationality is the strongest and most consistent predictor across all definitions. Integrated clinical pathways connecting primary care and community services to hospital care, with shared accountability for quality across levels, are the recommended system response aligned with Vision 2030.

Background: Transition timing to post-acute rehabilitation after ischemic stroke is heavily influenced by non-clinical factors, introducing potential systemic disparities in care access. We evaluated the association between insurance payor status and acute hospital length of stay (LOS) prior to inpatient rehabilitation discharge among critically ill stroke patients. Methods: Using the MIMIC-IV database, we identified ICU-admitted adults with ischemic stroke discharged to inpatient rehabilitation (n=1,285). The primary outcome was hospital LOS prior to rehab transfer. Multivariable log-transformed linear regression evaluated the association with insurance payor (Medicare, private, other/unknown; reference: Medicaid), adjusting for demographics, diagnostic-code counts (medical complexity), and ICU LOS (acute illness severity). Results: Median hospital LOS before rehab discharge was longest for Medicaid patients (13.2 days) compared with private insurance (11.0 days) and Medicare (9.5 days). In the adjusted model, Medicare insurance was associated with a significantly shorter transition time to inpatient rehabilitation, corresponding to a 13.5% shorter acute hospital stay (adjusted LOS ratio 0.87; 95% CI: 0.79-0.96; p=0.005) relative to Medicaid. Private insurance demonstrated a descriptive trend toward shorter LOS that did not achieve statistical significance (adjusted LOS ratio 0.93; 95% CI: 0.84-1.02; p=0.122). Other and unknown payor categories showed no significant differences. Conclusions: Insurance payor status serves as an independent predictor of acute care transition timing for stroke patients requiring inpatient rehabilitation. The prolonged acute stays observed among Medicaid beneficiaries suggest significant non-clinical, administrative bottlenecks in post-acute placement, underscoring the critical need for standardized, streamlined insurance approval pathways to ensure equitable neurological recovery.

Ethnic minority and migrant populations experienced disproportionately severe COVID-19 outcomes across Europe, yet the mechanisms underlying these disparities, particularly inequities in healthcare access, remain insufficiently understood at the patient level. This qualitative study examines healthcare-seeking behaviours and access to care among ethnically diverse patients hospitalised with COVID-19 in Amsterdam between 2020 and 2022, and the contextual factors shaping their pathways to care. Twenty adults of Turkish, Moroccan, Surinamese, Ghanaian, and Dutch ethnic backgrounds, all hospitalised with COVID-19, were interviewed using a semi-structured retrospective approach to reconstruct individual care pathways from symptom onset to hospitalisation. Data were analysed thematically, guided by the Candidacy Framework and the Health Belief Model. Pandemic-induced structural disruptions, including healthcare system strain, capacity shortages, absent care protocols, and fragmented referral pathways, constituted the primary barriers to care across all ethnic groups. Participants with longer hospital stays tended to be older, less educated, and with more comorbidities, yet reported fewer barriers once hospitalised, as disease severity triggered prioritisation. Those with shorter stays or emergency department visits without admission encountered greater difficulties, including repeated discharge despite worsening symptoms. Language barriers and prior negative experiences with healthcare services compounded access challenges for some participants with migrant backgrounds, though pandemic phase and disease severity were the dominant determinants across the sample. Inequities in access to care were driven primarily by pandemic-induced structural factors rather than ethnic background. Pre-existing vulnerabilities among migrant groups, including reduced institutional trust and language barriers, intensified these structural barriers for some. These findings are directly relevant for equity-sensitive pandemic preparedness: crisis response frameworks must explicitly address structural accessibility alongside targeted support for groups facing compounding disadvantage.

Background: Unintended pregnancies can introduce stress and shift life trajectories. Social support may buffer these effects, yet its influence during an unintended pregnancy and into the early parenthood period is not clear. This study aimed to understand the types and gaps of social support experienced throughout this period. Methods: This study utilized interview data under the RISE UP study in The Hague, the Netherlands. 13 mothers and 8 partners who experienced an unintended pregnancy participated in semi structured interviews between 2024 and 2025. Interviews were thematically analyzed using House's social support framework. Results: Different types of support were highlighted across the entire timeline from pregnancy to early parenthood, underlining its dynamic nature. Emotional and instrumental support stood out the most throughout. A key form of emotional support was knowing that support is available, even if not needed immediately. Conclusions: Perceived support during unintended pregnancy is shaped more by contextual factors than by pregnancy intention. While emotional and instrumental support are valued throughout, their form differs by the family's unique circumstances, emphasizing the need for tailored support across the perinatal and postpartum periods.

Background Personal choice in health behaviours raises difficult questions: when individuals freely decline effective preventive interventions, who should bear the resulting costs? This tension is acute in insurance systems where resources are pooled, yet all health systems pursuing Universal Health Coverage must navigate the boundary between collective solidarity and individual accountability. During the COVID-19 pandemic, vaccines were freely available to members of South African private medical schemes, creating conditions in which non-vaccination could plausibly be examined as a matter of personal choice rather than constrained access. This study applied a luck egalitarian framework to assess whether non-vaccination reflected personal choice or constrained circumstance, and to quantify resulting excess costs. Methods A contextual review assessed barriers to vaccination. Using de-identified claims data for approximately 550,000 individuals (March 2020 to December 2022), logistic regression estimated each person's predicted probability of vaccination based on demographic and clinical factors, with observed and predicted rates compared across strata to infer choice versus circumstance. A zero-inflated negative binomial model estimated predicted expenditure among vaccinated members, applied to the full population to simulate universal vaccination. Excess costs were calculated across predicted probability strata. Results Predicted and observed vaccination rates were closely aligned, suggesting that residual non-vaccination in higher-probability groups reflected personal choice rather than constrained circumstance. Observed costs exceeded predicted costs by 22% under universal vaccination, concentrated among older adults and those with comorbidities. Among those with a 60 to 70% predicted probability of vaccination, observed costs exceeded predicted costs by 127.6%. In contrast, among younger, low-risk members, predicted costs slightly exceeded observed expenditure, as vaccination costs were not offset by reduced hospitalisation. Conclusion Risk pooling depends on solidarity, yet non-vaccination due to personal choice shifts costs in ways that challenge fairness in community-rated insurance. These findings highlight the need for transparent deliberation about when personal responsibility should inform equitable health financing design.

Introduction: Primary care clinicians (PCC) commonly make decisions in the context of time delay and uncertainty. Delay discounting (DD) and probability discounting (PD) are cognitive biases related to delay and uncertainty that are minimally explored in PCC. We assessed DD and PD in PCC and evaluated their association with low-value care (LVC) decision-making. Methods: We administered a survey to PCC in a Southeastern U.S health system and within the American Academy of Family Physicians networks. The survey comprised standardized psychometric assessments of DD and PD and four LVC clinical vignettes. Outcomes included DD and PD discounting rates for two monetary rewards ($100 and $10,000) and ratings of LVC likelihood (0-100). We used regression analysis with model selection to evaluate the relationship between variables. Results: 225 PCC (89% physicians, 11% advanced practice providers) participated. Heterogeneity in DD and PD rates was observed. For the $10,000 reward, ln k(DD)= -6.80, IQR:-7.60--6.10) and ln h(PD)= 1.75, IQR:1.75-2.36). The reward amount impacted DD and PD in opposing directions (i.e., lower DD/higher PD rates for $10,000 vs. $100). LVC likelihood was highest for low-value antibiotics and lowest for low-value cervical cancer screening (median 20, IQR:10-40 and 0, IQR:0-10, respectively). Model selection revealed demographic associations with LVC likelihood, but no association with DD or PD. Conclusions: Consistent with effects previously reported in non-clinicians, PCC exhibited a range of DD and PD, which ranged by reward magnitude. Neither DD nor PD predicted vignette-based LVC likelihood. Further research should investigate actual clinical practice patterns and other LVC scenarios.

Reducing inequality in health-service coverage is central to universal health coverage, but the evidence base on how to design successful equity-oriented policies is inadequate to inform decision makers and tends to rely on case studies. Further, conventional measures of inequality capture a single timepoint, one service at a time; this obscures how inequity evolves as coverage increases. We reframe equity as a trajectory and ask how it evolves as total coverage rises, comparing systematically across countries and health areas. Using 132 Demographic and Health Surveys from 22 low- and middle-income countries (1990-2023), we estimated coverage at the subnational (admin1) level by wealth quintile for six representative maternal and child health indicators. For each country-indicator pair, we fit a natural cubic spline of the wealthiest-poorest gap against total regional coverage, extracted features describing each curve, and grouped them using hierarchical clustering. This yielded three archetypes: large rollout gaps (mean peak ~58%), modest but persistent inequality (~30%), and minimal inequality that sometimes reversed to favor the poor (~17%). Most trajectories traced an inverted U pattern, widening early, then closing only near 100% regional coverage. How a service is delivered, more than where, drove its path: institutional delivery was the most inequitable (15 of 20 countries with large gaps), whereas one-touch and campaign-delivered services such as bed nets and vaccines rarely produced large gaps and were sometimes pro-poor. Despite this, some countries achieved equity across nearly all services, indicating that proactive governance may be able to overcome structural challenges to achieve equitable outcomes. For policy, these archetypes let programs anticipate which groups will be left behind and when, replace assumed scenarios with empirical ones in impact models, and target investment early to ensure that new services achieve more equitable coverage.

Effective management of biomedical equipment prevents breakdowns, extends equipment lifespan, ensures perioperative safety and cost-efficiency. There are major challenges in managing biomedical equipment, particularly in low- and middle-income countries. This study aimed to assess the availability, functionality, and adherence to maintenance practices of biomedical equipment in operating rooms (ORs) and post-anaesthesia care units (PACUs) across Rwanda. A cross-sectional observational study was conducted at one Level 2 district hospital in each of Rwanda's five provinces (n=5 sites). Data were collected using three main tools: 1) a medical equipment checklist, 2) a checklist for hospital biomedical management, and 3) direct inspections of selected biomedical equipment. All tools underwent pretesting and face validation with support from biomedical experts prior to data collection in May 2024. Key measures, including the availability and functionality of biomedical equipment, and adherence to maintenance and management practices, were summarised using descriptive statistics. The five hospitals had a total of 16 ORs, 4 PACUs, and 226 pieces of equipment. The overall availability of biomedical equipment was 45%, and the functionality of the available equipment was 96%. The mean adherence rate to national management practices was 66%. The Rwandan government, non-governmental organisations, and hospitals were identified as direct funders of the equipment, accounting for 42%, 12%, and 4%, respectively. However, 42% of the equipment surveyed could not be linked to any of the above sources of acquisition. Among non-functional equipment, 75% was due to a lack of spare parts, while 25% was due to a lack of skills to maintain the equipment. In summary, we found low availability of perioperative biomedical equipment across Rwanda, although the available equipment was highly functional. Adherence to national management practice guidelines was relatively low, threatening the sustainability of functional equipment. We recommend that the government and hospital administrators implement robust, regular auditing systems to ensure proper management of biomedical equipment.

Background Personal choice, the opportunity to select an action from available options, free from external constraint, significantly affects health, risks, and treatment needs. Unhealthy lifestyles contribute substantially to global disease burden, pressuring health systems and reigniting debate about individual responsibility for health. The COVID-19 pandemic brought these debates into sharp focus. In South Africa's private health sector, vaccine hesitancy persisted where vaccines were freely available, raising questions about fairness when avoidable costs are imposed on others within pooled insurance. This paper develops and applies a structured framework to assess the case for applying personal responsibility(policies linking contributions, coverage, or costs to factors under individual control) using COVID-19 vaccination in a South African insured population. Methods We employed a multi-part approach drawing on administrative claims and vaccination data from approximately 550,000 insured members (March 2020 to December 2022). We examined vaccination on hospitalisation, utilisation, and expenditure; evaluated fairness from utilitarian (cost-effectiveness and cost-utility) and luck egalitarian (choice vs cost distribution) perspectives; assessed the practical feasibility of responsibility-based mechanisms; and integrated findings through a decision framework. Results Vaccination was associated with >90% lower hospitalisation risk, shorter stays, and 35 to 55% lower costs. Cost-utility analysis showed vaccination dominated non-vaccination (more QALYs at lower cost). Predictive modelling indicated non-vaccination in higher-risk groups reflected personal choice rather than constrained circumstance. Observed costs exceeded modelled costs (if all vaccinated) by 22%, concentrated among older adults and those with comorbidities. Practical assessment identified a hierarchy from low-risk vaccination rewards to higher-risk surcharges and benefit restrictions. Conclusion Vaccination was impactful and cost-effective; non-vaccination in higher-risk groups reflected personal choice. Responsibility-sensitive approaches may be justified where choice is demonstrable, impacts clear, and mechanisms proportionate, fair, and feasible. Incentive-based mechanisms offer lower-risk starting points than punitive designs. The framework offers policymakers a tool to weigh accountability, fairness, and solidarity in health-financing policy. Key Words COVID-19 vaccination; personal responsibility; luck egalitarianism; health insurance; South Africa; priority-setting

Universities provide a key opportunity to deliver social prescribing, a care pathway that aims to connect people with non-medical forms of support within the community to address their social, emotional, and practical needs. However, it is unclear whether students in the UK are aware of social prescribing and whether it would be an acceptable form of support. We surveyed 775 university students across the UK who completed a questionnaire measuring awareness and perceptions of social prescribing. We described awareness and attitudes and used logistic regression to explore how they differed according to individual characteristics. We found an awareness-attitude paradox. Only 25% of students were aware of social prescribing, but attitudes were overwhelmingly positive once explained: 97% thought it could support mental health and wellbeing; 95% believed universities should offer it; and 89% would accept social prescribing if offered by a healthcare professional. Students who were older, postgraduates, and had English as their first language were among those with higher odds of being aware of social prescribing, but positive attitudes were more evenly reported across the sample. Our findings indicate that implementation efforts should prioritise awareness-raising and clear referral pathways, rather than increasing students' willingness to engage with social prescribing.

Perimenopausal women, often in the prime of their careers, make up a significant proportion of the workforce. Previous studies have revealed the significant symptoms burden associated with perimenopause, yet its workplace and economic consequences remain poorly understood. We examined work impairment by symptom severity and across reproductive stages in a cross-sectional survey of U.S. women aged 35-59 (n=945), using the Work Productivity and Activity Impairment questionnaire and Menopause Rating Scale. We then estimated associated productivity losses using a human capital approach. Perimenopausal women were equally likely to remain in the labour force as premenopausal women (76.6% vs. 78.0%) but reported substantially higher work impairment (22.5% vs. 12.7%). Work impairment rose from 3.4% among women with minimal symptoms to 33.4% among those with severe symptoms and was driven predominantly by presenteeism rather than absenteeism. Somatic and psychological symptoms showed the strongest associations with work impairment, whereas urogenital symptoms were not significantly associated. The observed work impairment translated into an estimated annual productivity loss of approximately $6,061 per woman in perimenopause and a societal burden of $56.7 billion in the United States. These findings suggest that perimenopause is a substantial but under-recognised workplace health challenge, requiring better recognition and tailored, symptom-matched, workforce support. Keywords: perimenopause, symptom burden, work impairment, productivity loss.

Health workforce performance is central to service quality, yet little empirical work has examined how performance management systems operate for physiotherapists in rehabilitation services in low- and middle-income settings. This cross-sectional study assessed the current state, perceived effectiveness, and process gaps of performance management systems among physiotherapists working in public rehabilitation centers in Dhaka, Bangladesh. A pretested semi-structured questionnaire was administered to 105 physiotherapists between September and October 2025. Descriptive statistics were used to summarize participant characteristics and performance management indicators. Wilson 95% confidence intervals were estimated for key proportions. A nine-item exploratory performance management system maturity score was constructed from process indicators. Fisher exact tests with Cramer's V were used to examine associations with perceived system effectiveness, and exploratory logistic regression estimated odds ratios for effective or moderately effective performance management. The mean age of respondents was 31.6 years, 56 of 105 were male, and 85 of 105 had graduate or postgraduate qualifications. Formal performance management systems were reported by 102 of 105 respondents (97.1%, 95% CI 91.9-99.0). Standardized appraisal timing and method, assessment form use, performance planning, and formal evaluation systems were each reported by about 60-70% of participants. Reward-performance linkage was perceived as motivating by 97 of 105 respondents (92.4%, 95% CI 85.7-96.1). Overall, 81 of 105 respondents (77.1%, 95% CI 68.2-84.1) rated the system as effective or moderately effective. Training recipient category was associated with perceived effectiveness (Fisher exact p=0.0035; Cramer's V=0.363), as was perceived appropriateness of the process (p=0.0323; Cramer's V=0.258). The maturity score was not independently associated with perceived effectiveness in exploratory regression. Public rehabilitation centers in Dhaka appear to have formal performance management systems, but the systems are only moderately developed. Strengthening training coverage, transparent evaluation criteria, routine feedback, and formal system review may improve staff confidence in performance management processes.

Caregivers increasingly act as proxies, managing patients digital accounts and making complex end-of-life decisions. Greater dyadic engagement in advance care planning (ACP) improves patient and caregiver outcomes, yet empirical evidence linking formal digital proxy roles to ACP engagement remains limited. The study aims to quantify patterns of ACP engagement, digital proxy roles, and how these caregivers behaviors are associated among caregivers in Singapore. We conducted a cross-sectional survey among an online panel of nationally representative adults in Singapore to identify caregivers and assessed their lifetime engagement in formal proxy roles across legal, financial, and medical digital domains, along with ACP proxy behaviors. Formal digital proxies had institutional or joint access to digital financial accounts (for financial digital proxies) or digital patient health/caregiver accounts (for medical digital proxies). ACP engagement was measured using 13 proxy-related behaviors, such as discussing end-of-life care preferences. Multivariable regressions were performed. In total, we identified 276 caregivers, who assisted with instrumental activities daily living to another adult from 311 completed responses. Among caregivers (age 41.0{+/-}13.8, 46.2% female), 28.9% were legal proxies and 40.2% were formal digital proxies (31.5% financial; 29.0% medical). Overall engagement was modest (mean 3.97{+/-}4.54) despite most reported completing at least one behavior. Compared to non-proxies, medical (AME=3.722, 95%CI: 2.143-5.301) and financial digital proxies (AME=1.515, 95%CI: 0.121-2.910) reported significantly higher ACP engagement while legal proxy status did not. High-stakes discussions on life-sustaining treatment and health-state preferences showed low engagement. Formal digital proxy roles are positively associated with ACP engagement and may provide a strategic entry point for interventions. Persistent deficits in high-stakes ACP highlight limited readiness for complex end-of-life decisions and the need for targeted decision-support tools.

Purpose: Human papillomavirus (HPV) infection and HPV-associated diseases impact health-related quality of life (HRQOL). We aimed to measure HRQOL in women with HPV-positive test results, cervical intraepithelial neoplasia (CIN), or cervical cancer in Latin America. Methods: We enrolled women aged 18 to 75 years from Bolivia, Colombia, Honduras, Peru, and Uruguay. We used the EQ-5D-5L instrument to calculate EQ-5D index scores with country-specific sets of health preferences when available. We calculated medians and interquartile ranges (IQR) of EQ-5D index and conducted an exploratory analysis comparing HRQOL loss by diagnosis and country with a gamma regression. Results: We present results from 1,073 participants. Median age was 43 years (IQR: 34-52). The EQ-5D index scores by diagnosis were as follows: HPV-positive test alone 0.906 (standard deviation [SD]: 0.129), CIN1: 0.891 (SD: 0.136), CIN2: 0.892 (SE: 0.124), CIN3: 0.870 (SD: 0.138), and cervical cancer: 0.737 (SD: 0.268). HRQOL was associated with age, diagnosis, and country; there was a significant decreasing trend in HRQOL with worsening health state. Women with cervical cancer had a 3.19-fold higher HRQOL loss than women with an HPV-positive test alone or CIN1. We also found significant differences in HRQOL loss across countries, after adjustment for diagnosis and sociodemographic factors. Conclusion: HRQOL decreased with diagnosis severity, with significant differences between countries. To conduct cost-effectiveness modeling on HPV preventive interventions, obtaining accurate HRQOL estimates is essential. This process should consider the diverse local health preferences influenced by sociodemographic and cultural factors, as well as the population's beliefs and experiences regarding health.

Background The prevalence of chronic heart failure is increasing in Singapore and is associated with frequent hospitalisations, high costs, and impaired quality of life. Patient empowerment interventions for chronic diseases, which are structured approaches that enable patients to actively engage in and influence their care, have demonstrated promising effects on health-related outcomes. In chronic heart failure, however, many interventions focus on selected aspects of empowerment, and there remains limited synthesis of which approaches are most acceptable, preferred, and effective as comprehensive intervention packages. This protocol describes the methods for a study to identify an empowerment-based intervention for adults with chronic heart failure that is both contextually suitable and cost-effective in Singapore. Methods We will use a staged, sequential design comprising three objectives. Objective one is to conduct a systematic review (PROSPERO registration number CRD420251249957) and meta-analysis to synthesise international evidence of the effectiveness of empowerment-based interventions for adults with chronic heart failure. Objective two is to complete a mixed-methods study, including semi-structured interviews with chronic heart failure patients, as well as their caregivers, to identify empowerment-related needs, barriers and facilitators in local chronic heart failure care. This will be followed by a discrete choice experiment to elicit patients preferences for features of an empowerment-based intervention. Objective three is to conduct a cost-effectiveness analysis of the proposed intervention from the perspective of the Singapore health system. Discussion This series of studies integrates international evidence with local stakeholder perspectives and patient preferences to inform a feasible, patient-centred empowerment intervention for chronic heart failure in Singapore. The findings will inform intervention design and provide policy-relevant evidence on costs, health outcomes, and implementation decisions for empowerment-based chronic heart failure care in Singapore.

Maternal and newborn mortality in The Gambia remains high despite expanded coverage of essential interventions, and progress towards SDG targets 3.1 and 3.2 has stalled. The National Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy (2017 to 2026) ends in 2026, and a successor plan is in development. We aimed to identify and rank nationally defined maternal and newborn health (MNH) research priorities in The Gambia to inform the successor RMNCAH plan and align research investment with national health system needs. We conducted a national, stakeholder-led MNH research prioritisation exercise in October 2023 using an adapted Child Health and Nutrition Research Initiative (CHNRI) method. Forty-six participants, including Ministry of Health policymakers and programme managers, clinicians, midwives, researchers, and development partners, took part in a two-day workshop. A starting set of 46 questions from the 2019 African Academy of Sciences (AAS) continental MNH prioritisation exercise and four questions from The Gambia's National Health Research Agenda was expanded through facilitated discussion to a final list of 61 questions, organised by MNH grand challenge area and CHNRI research domain. Participants independently scored each question against four weighted criteria, and national rankings were compared descriptively with AAS continental and West African subregional rankings. The priority list was dominated by delivery-focused research (49 of 61 questions, 80 percent), concentrated in better care during pregnancy and better postnatal care. The five highest-ranked priorities addressed management of obstetric emergencies before referral, retention and equitable distribution of the MNH workforce, neonatal resuscitation at peripheral facilities, maternal recognition of danger signs, and kangaroo mother care. Pre-transfer emergency obstetric management was the top national priority but was not prominent in AAS continental or West African subregional rankings. This first national MNH research priority-setting exercise in The Gambia identifies a coherent set of implementation and health systems research priorities and surfaces context-specific questions, particularly pre-transfer emergency management, that were under-emphasised in continental rankings. The agenda provides an evidence base for the successor RMNCAH plan and for partner alignment in The Gambia and comparable high-burden settings.

Background: Postpartum recovery is a public health concern. The Obstetric Quality of Recovery-10 (ObsQoR-10) is a brief patient-reported outcome measure designed to assess early recovery after childbirth. Its validation is currently limited to the first three days postpartum. This study aimed to evaluate the psychometric properties of the ObsQoR-10 across the first 30 days postpartum. Methods:We conducted a cross-sectional psychometric evaluation of the ObsQoR-10 using baseline data from a national Swiss multilingual cohort (French, German, Italian, and English). Women were recruited within the first week postpartum and completed the ObsQoR-10 and the EuroQol 5-Dimensions 5-Levels (EQ-5D-5L) at a single time point within 30 days postpartum. Clinical data were extracted from medical records. Analyses were performed across three postpartum windows (0-2, 3-7, and 8-30 days). Structural validity, measurement invariance, reliability, and construct validity (convergent and known-groups) were assessed. Results:A total of 1935 women were included. Structural validity supported a stable four-factor structure with excellent model fit (CFI 0.995-0.997; RMSEA 0.055-0.059), and bifactor analysis supported essential unidimensionality. Measurement invariance was confirmed at metric and scalar levels across postpartum windows. Reliability was good (Cronbach's alpha 0.83-0.86). Convergent validity was supported by moderate correlations with the EQ-5D-5L (;0.51 to 0.30), decreasing over time. Known-groups validity was demonstrated by significantly lower scores in women with poorer health status, postpartum haemorrhage, and operative or caesarean birth (all p <0.001). Conclusions:The ObsQoR-10 demonstrates consistent, valid, and reliable psychometric properties for assessing postpartum recovery across the first 30 days.

Background: Shared decision-making (SDM) is a key component in patient-centered care for people consulting health care due to chronic musculoskeletal pain, including subacromial pain syndrome (SAPS). Limited research has explored how patients, relatives, and healthcare professionals perceive the content and delivery of SDM for managing SAPS in primary care. Thus, this study aims to explore stakeholder perspectives on the content, delivery, and contextual requirements for a context-specific SDM intervention for SAPS, and to identify shared challenges and co-develop ideas to inform intervention development. Methods: We conducted three separate future workshops (patients/relatives, physiotherapists/chiropractors, and general practitioners), each consisting of structured critique, fantasy, and implementation phases. A rapid preliminary analysis of workshop data was followed by semi-structured stakeholder interviews to validate, challenge, or elaborate the findings. All data were analysed thematically using an iterative, reflexive approach. Results: Twenty-eight participants took part across three workshops: patients/relatives (n = 10), physiotherapists/chiropractors (n = 12), and general practitioners (n = 6). Six additional stakeholders provided inputs via subsequent interviews (three physiotherapists, one patient, one relative and one GP). Thematic analysis identified 20 themes and 59 sub-themes, which were refined into two overarching categories: (1) shared barriers to SDM in SAPS care, including diagnostic uncertainty, fragmented clinical care pathways, time constraints, and decision fatigue; and (2) stakeholder visions for future SDM interventions, emphasising continuity, tailored communication tools, and supportive digital ecosystems. Conclusion: Based on stakeholder input, SDM in SAPS care may consider integrating dynamic, integrated systems that account for diagnostic ambiguity, contextual constraints, and varying patient capacities. These findings provide an actionable foundation for co-developing and piloting a context specific SDM intervention for primary care.

Background: Evaluating outbreak detection models is a key component of syndromic surveillance. However, balancing timeliness, predictive performance, and local surveillance constraints remains a major challenge. We developed and assessed whether stacking ensemble approaches, which integrate multiple outbreak detection methods, can improve the timeliness and predictive performance of influenza-like illness (ILI) surge detection. Methods: We developed a two-stage stacking ensemble framework to detect early warning of ILI surges in city-level Primary Health Care encounter time series from Brazil (2022 to 2025). Epidemic thresholds were defined using the Moving Epidemic Method (MEM). In the first stage, multiple outbreak detection models (ODMs) generated warnings of unusual ILI activity. In the second, these warnings were then used as inputs to three supervised meta-classifiers: Logistic Regression, Extreme Gradient Boosting (XGB), and a Multi-layer Perceptron (MLP). For comparison, a Majority Voting (MV) aggregation is also examined. Timeliness, sensitivity, specificity, positive and negative predictive values are evaluated to measure each model's ability to anticipate epidemic periods of varying intensity in 2025. Robustness was further assessed using simulated outbreak scenarios with varying magnitudes and durations. Findings: We identified 5,765 ILI surge onsets across 5,365 Brazilian municipalities in 2025. Compared with individual ODMs and MV, stacking ensemble meta-classifiers anticipated up to 33% of surge onsets three weeks in advance (an average improvement of 15 percentage points) while reducing missed detections to <10%. They achieved sensitivity >90%, while maintaining balanced specificity >80%, PPV >65%, and NPV >99%. Improvements were greatest for very high-intensity surges, with missed detections reduced by more than half compared with individual ODMs. In simulated outbreak scenarios, the MLP and XGB classifiers remained robust despite being trained on fewer than half of all simulated surge events, consistently outperforming individual detection methods and simpler integration approaches. Interpretation: We provide a practical framework for integrating complementary ODMs into a single, robust early warning decision. By improving both timeliness and predictive performance without requiring additional surveillance data or resources, this approach offers a scalable methodological upgrade for syndromic surveillance systems and supports more reliable public health decision-making. Funding: The Rockefeller Foundation (award 2023 PPI 007 to MB-N); Brazilian National Research Council - CNPq (408775/2024-6); MB-N, PIPR, RFSA are CNPq fellows.