Risk Management and Healthcare Policy

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.

BackgroundUnderstanding antimicrobial use and factors driving it in communities is essential to devise its stewardship and reduce emergence of antimicrobial resistance. ObjectivesTo study the intersectional influence of socioeconomic status, migration and place of treatment on antimicrobial use in a semi urban area in Tamil Nadu, India. MethodsWe conducted a cross-sectional survey among systematically sampled 525 adult men and women from three villages in a semi-urban area in Tiruvallur district. We collected data through structured interviews on incidence of infections in the past 3 months, treatment seeking behaviour, and audited the antimicrobial prescription or empty packs of medicines used. We analyzed the data using R statistical software and performed a multilevel analysis of individual heterogeneity and discriminatory accuracy to study intersectional effects. ResultsWe found that the incidence of infection syndrome was 37% with a majority of them being acute respiratory infections. 143 of them sought treatment, with 40% going to a private general practitioner. People belonging to middle class had a 3.7 times greater odds of going to private sector compared to lower class. Twenty eight (19.6%) of those who sought treatment received an antimicrobial prescription. Sixty percent of them belonged to Access group, 35.7% Watch and 3.6% Restrict group. There was a significant intersectional effect showing middle class- non migrant - private care seekers having 22% probability of antimicrobial use versus lower class - migrant - government care seekers having 16% probability. The variance partition coefficient was 2.6% showing a small by significant portion of the variance contributed by intersectional identities. ConclusionAntimicrobial use in the community is significantly shaped by the intersection of socioeconomic status, migrant status and place of seeking care for the infection. Regulation of private sector prescription patterns and improving access to health care for migrants are key policy interventions.

BackgroundChina has implemented policies to strengthen its pharmacist workforce since the 2009 healthcare reform, yet a comprehensive evaluation of their long-term systemic effects is lacking. ObjectiveTo systematically analyze the evolution of Chinas pharmacist workforce in healthcare institutions from 2007 to 2023 across four dimensions: quantity, quality, structure, and distribution, providing an empirical foundation for policy optimization. MethodsA retrospective analysis was conducted using longitudinal data from the China Health Statistics Yearbooks. Trends were delineated via descriptive statistics. Equity and spatial evolution were assessed using the Gini coefficient, Theil index decomposition, and spatial autocorrelation analyses (Global Morans I and hotspot analysis). ResultsFrom 2007 to 2023, the total number of pharmacists increased from 357,700 to 569,500 (average annual growth: 2.2%). This growth lagged behind physicians (4.6%) and nurses (7.4%),causing the pharmacist-to-physician ratio to decline from 1:5.15 to 1:8.39. The workforce showed trends of feminization (female proportion rose from 59.7% to 70.8%) and aging. While quality improved, 51.1% still held an associate degree or below, and only 6.6% held senior titles. Equity analysis revealed the provincial Gini coefficient improved from 0.145 to 0.093. Theil index decomposition confirmed intra-provincial disparities as the primary inequality driver. Spatial analysis showed a non-significant global Morans I by 2023 (0.154, P*>0.05), down from 0.254 (P<0.01) in 2007. Hotspot analysis confirmed this transition, revealing a contraction of high-confidence clusters and a trend toward balanced distribution. ConclusionsChina has made measurable progress in expanding pharmacist workforce size and improving inter-provincial equity since 2007. However, persistent structural challenges remain: relative workforce contraction compared to other health professions, an aging demographic, a shortage of senior talent, and significant intra-provincial inequity. Future policies must prioritize optimizing workforce structure and enhancing clinical service capabilities to catalyze a shift toward patient-centered pharmaceutical care. HighlightsO_LIFirst longitudinal study (2002-2023) tracking Chinas institutional pharmacist workforce post-healthcare reform, revealing a critical structural shortage. C_LIO_LIPharmacist growth rate (2.2% annually) severely lagged physicians (4.6%) and nurses (7.4%), causing the pharmacist-to-physician ratio to plummet from 1:5.15 to 1:8.39. C_LIO_LI69.2% of Chinas drug market (prescription drugs) is managed by only 569,500 institutional pharmacists--175,000 fewer than retail pharmacists, exposing a critical workload imbalance. C_LIO_LISpatial disparity paradox: Gini coefficient improved to 0.093 (high equity), yet Theil decomposition revealed intra-provincial (urban/rural) gaps as the primary driver of inequality. C_LIO_LIHigh-level talent deficit: Despite quality gains, only 6.6% hold senior titles and 6.1% have masters degrees--a bottleneck for advancing clinical pharmaceutical care. C_LI

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 Innovation in pharmaceutical sectors operating under resource and institutional constraints may depend not only on knowledge and attitudes but also on the conditions that enable innovation-related activities to occur. This study examined the relationships among intellectual property (IP) literacy, innovation attitudes, innovation readiness, and reported innovation practice among pharmaceutical professionals in Syria. Methods A cross-sectional survey was conducted among 303 pharmaceutical professionals between March and April 2026. Four composite indices were constructed to assess IP literacy, innovation attitudes, innovation readiness, and innovation practice. Descriptive statistics, correlation analyses, group comparisons, and multivariable regression models were used to characterize patterns of association among study domains. The analysis was designed to identify empirical patterns rather than infer causal relationships. Results Innovation attitudes were comparatively high (73.56/100), whereas innovation readiness (17.00/100) and innovation practice (12.65/100) were substantially lower. IP literacy was positively associated with innovation readiness (r = 0.384, p < 0.001) and innovation practice (r = 0.205, p < 0.001). In contrast, innovation attitudes were not significantly associated with reported innovation practice (p = 0.332). Regression analyses indicated that the inclusion of innovation readiness improved model fit beyond specifications based on knowledge and attitudes alone ({Delta}R{superscript 2} = 0.058, p = 0.028). Significant differences in readiness and practice were observed across professional groups (p < 0.001), whereas knowledge and attitudes showed limited variation. Conclusions High levels of innovation-related knowledge and positive attitudes did not correspond to high levels of reported innovation practice in this setting. The findings suggest that innovation readiness may capture enabling conditions that are not reflected by knowledge or attitudinal measures alone. These results support the value of examining contextual and institutional factors when assessing innovation capacity in resource-constrained pharmaceutical systems. Given the substantial gap observed between innovation attitudes and innovation practice, educational strategies may represent one avenue for strengthening innovation readiness. In the Syrian context, strengthening innovation-oriented education and university-industry engagement may help cultivate innovation competencies and support the translation of research into practical applications.

Background: Antimicrobial resistance is the world's silent pandemic. The public knowledge, attitudes, and practices (KAP) about antibiotic usage are strongly related to the growing problem in Nepal. Methods: A cross-sectional descriptive survey was done to 263 respondents. Information on KAP regarding antibiotics, primary healthcare sources, and demography was collected through a questionnaire. To identify health literacy gaps and characteristics that contribute to improper antibiotic use, this study assessed these variables across an age group from 18 to 60 years. Descriptive statistics analysis was performed to analyze the data. Results: The majority of respondents were between the ages of 18 and 39 (85.1%), female (63.1%), and had at least a bachelor's degree (67.8%). Significant misunderstandings about antibiotics remained, even though 77.6% of respondents correctly recognized antibiotics as effective against bacteria; 44.1% incorrectly believed that antibiotics cure viral diseases, and 87.8% felt that antibiotics should be stopped right away if adverse effects develop. In practice, 52.9% acknowledged quitting antibiotics as soon as symptoms improved, despite 89.4% consulting doctors. Additionally, 43% of respondents said they have taken antibiotics without a prescription, frequently due to pharmacist recommendations (21.67%) and financial or geographical constraints. The main sources of information were doctors (11.07%) and pharmacist-doctor combinations (14.88%), yet 81.8% of respondents said they had never heard of the phrase antimicrobial resistance. Conclusion: There is a significant lack between theoretical understanding and practical application, despite the high levels of fundamental knowledge toward the prohibition of non-prescription sales. Self-medication and early withdrawal are still common inappropriate practices. It is crucial to implement focused teaching initiatives that highlight the differences between bacterial and viral diseases as well as the risks associated with leftover medicine. It is advised to use digital platforms for younger demographics and to strengthen the role of pharmacists in order to reduce AMR.

Introduction Shadowing, as an educational method based on active observation, can foster a realistic understanding of professional roles and enhance the communication skills of medical students. This study aimed to design, implement, and evaluate a shadowing program for basic sciences medical students. Methods This development study was conducted based on the ADDIE model in five phases. The study population consisted of 799 medical students in semesters 2 to 5. The stages included Analysis (determining needs through literature review and expert panels), Design (specifying learning environments and evaluation methods), Development (preparing guides and educational tools), Implementation (within the Medical Ethics course), and Evaluation (using questionnaires and reflection forms). Findings This study aimed to design and evaluate an educational shadowing program based on the ADDIE model. In the Analysis phase, the profiles of 799 students and learning objectives were determined. In the Design phase, a structured program for four types of shadowing was designed. In the Development phase, all guides and educational tools were prepared. In the Implementation phase, the program was carried out with complete coverage and adherence to ethical considerations. Finally, the program evaluation showed that "Motivation to become a good physician" (3.75-3.95) and "Enhancing empathy" (3.50-3.94) received the highest scores, while "Increasing understanding of the basic science-clinical connection" (2.53-2.89) and "Willingness to attend on holidays" (1.87-2.31) received the lowest scores. Conclusion The findings indicate that implementing the shadowing program is an effective method for strengthening the professional attitudes and academic motivation of medical students. However, the program did not significantly improve students perception of the basic science-clinical connection, indicating a need for curricular refinement. The continuation and extension of this program to other levels and fields of medical sciences are recommended.

ObjectiveTo quantify waiting time in days for scheduled outpatient specialist consultations and to compare waiting time between standardized and non-standardized access pathways in Ecuadorian public hospitals. MethodsWe analyzed hospital-based survey data from Ecuadorian public hospitals, restricted to adults attending a scheduled outpatient specialist consultation (n = 4,436). Emergency care, unscheduled urgent visits, procedures, and follow-up visits were excluded by design. Access pathway was classified from participants self-report as standardized (institutional or system-based) or non-standardized (informal or non-system-based). Waiting time, defined as the number of days between obtaining the appointment and attending the consultation, was compared using the Mann-Whitney U test. Sociodemographic correlates of non-standardized access were examined using adjusted logistic regression, and adjusted median differences were estimated using quantile regression ({tau} = 0.50). Analyses were stratified into direct-access specialties and referral-required specialties. ResultsNon-standardized access was associated with shorter waiting times than standardized access. In adjusted median regression, non-standardized access was associated with a 3.2-day shorter median waiting time (95% CI -4.6 to -1.8). The difference was larger in direct-access specialties (-15.0 days, 95% CI -15.0 to -6.0) than in referral-required specialties (-5.0 days, 95% CI -5.0 to 0.0). ConclusionAmong patients who attended a scheduled outpatient specialist consultation in Ecuadorian public hospitals, non-standardized access was associated with shorter waiting times, particularly in direct-access specialties. These findings suggest that, within routine outpatient care, parallel access pathways may shape timeliness and warrant greater transparency in appointment allocation and referral coordination.

BackgroundBefore obtaining professional medical care, many people in peri-urban and rural Pakistan contact herbalists, spiritual healers, and unlicensed caregivers. This study examined the social, economic, and cultural factors influencing the use of informal care by analysing the health-seeking behaviours of individuals in the Faisalabad District. MethodsAn exploratory mixed-methods study was conducted in Makkuana and the surrounding villages of Faisalabad District, Punjab. The quantitative component involved a cross-sectional survey of 69 adults using a structured questionnaire adapted from the I-CAM-Q. The qualitative component comprised twelve in-depth interviews and two focus group discussions. Descriptive statistics and chi-square analysis were used for quantitative data. Thematic analysis, guided by the Health Belief Model and Andersens Behavioural Model, was applied to qualitative data. ResultsThe mean age of participants was 40.4 years; 62.3% were female, and 79.7% had monthly household incomes below PKR 60,000. Of the 69 participants, 68 (98.6%) sought care from an informal provider first, most commonly an unqualified practitioner (50.7%), herbal practitioner (29.0%), or homeopath (17.4%). Trust was the leading reason for provider choice (43.5%), followed by proximity (24.6%) and low cost (15.9%). Complications were reported by 21.7% of participants, and 39.1% later required formal care for the same illness. Eight qualitative themes emerged: structural and economic barriers to formal care; proximity and convenience as determinants of informal care; trust, familiarity, and social networks; cultural and religious normalisation of traditional practices; poor doctor-patient communication in formal settings; perceived safety and naturalness of alternative remedies; awareness deficits about provider qualifications; and treatment-related harm and delayed escalation to formal care. ConclusionInformal health care seeking is nearly universal in this community, driven by intersecting economic, structural, cultural, and interpersonal factors. Enhancing primary care affordability, accessibility, and the quality of provider-patient communication together with culturally sensitive health literacy programs, is essential to redirect care seeking toward qualified providers.

The inappropriate use of antimicrobials enhances antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) is a coordinated effort of prescribers, pharmacists, and nurses. Still, local data regarding AMS-related knowledge, attitudes, and practices (KAP) are scarce in many low and middle-income countries. We evaluated KAP regarding AMS among the healthcare providers at Komfo Anokye Teaching Hospital (KATH), Ghana, and found the related factors. A cross-sectional survey in the form of a descriptive survey was conducted among medical doctors, pharmacists, and nurses at KATH. Knowledge, attitude, and practice were evaluated using a structured questionnaire. The scores were converted into percentages and classified as good (>=60%) or poor (<60%). Chi-square tests were used to test associations, and logistic regression to predict good KAP (p<0.05). A total of 349 healthcare professionals participated, which comprised: 91 medical doctors (26.1%), 101 pharmacists (28.9%), and 157 nurses (45.0%). The majority of the respondents had formal AMS/AMR training (69.6%), and 37.0% had updated training the previous year. Only 18.6% demonstrated good AMS-related knowledge, although attitudes were largely positive (95.7% good) and reported practices were mostly appropriate (77.4% good). In multivariable models, greater years of practice (5-9 years: adjusted odds ratio [AOR] 2.32; >=15 years: AOR 2.77) and formal training (AOR 2.94) were associated with good knowledge. Formal training was also associated with good attitudes (AOR 5.19). Compared with medical doctors, nurses had lower odds of good practice (AOR 0.29), while pharmacists had higher odds (AOR 1.41). Participants with 10-14 years of experience had higher odds of good practice (AOR 3.18). This study revealed that marked knowledge deficits exist, despite favourable attitudes and generally good self-reported AMS practices. Role-tailored, competency-based AMS training with regular updates and reinforcement through practical stewardship tools is needed to translate positive attitudes into evidence-based prescribing and administration behaviours.

Background: Standardized evaluation of agentic artificial intelligence (AI) for medication management is lacking. Given the potential lethality of medication errors endorsed or missed by AI, performance evaluation constructs are essential. The purpose of this evaluation was to develop a standardized grading framework for performance evaluation of medication management tasks. Methods: A mixed-methods approach was undertaken that included literature evaluation for standards and best practices of comprehensive medication management (CMM), panel discussions, and iterative application to set of cases. The goal was to develop a grading framework that effectively evaluated domains like safety, factuality, and clinical relevance that can be employed for a broad range of medication domains (i.e., electrolyte replacement, antibiotic selection). Inter-rater reliability with intraclass Krippendorffs Alpha was the primary outcome. Results: A total of 5 panelists developed the CMM Evaluation Framework, which includes 4 dimensions: safety, factuality, completeness, and preference. These dimensions are applied to three CMM skills: collecting patient data, analyzing information, and designing regimens. Each dimension is rated from 1-5. An additional dimension evaluated the presence of hallucinations and errors with high harm scores (i.e., absolute failure criteria regardless of an overall score). The Krippendorffs Alpha was highest in the medication therapy problem and medication therapy format categories, for 50 pneumonia cases, run in triplicate (150 total). Conclusions: This framework is informed by national standards for CMM and the healthcare professionals dedicated to the provision of this service. These domains allow for the possibilities of practice variation via the preference domain while also having strong guardrails against the commission of medication errors. Further analyses beyond pilot testing are necessary.

To explore the safety of combined use of lidocaine/prilocaine aerosol and condoms of different materials, this study conducted compatibility tests between them. By observing changes in various physical properties of condom materials after exposure to the aerosol, the compatibility of different polymer materials with the aerosol was analyzed.The results showed that within 15 minutes of exposure to the aerosol, there was no significant difference in all physical properties of natural rubber latex condoms compared with the blank control group (P>0.05), indicating they can be used together. In contrast, obvious changes in physical properties of polyurethane condoms occurred within 5 minutes of exposure (P<0.05), and their performances failed to meet industrial application standards, so combined use is strictly prohibited.This study clarifies the compatibility differences between two mainstream condom materials and lidocaine/prilocaine aerosol, providing experimental evidence and theoretical references for rational matching in clinical and daily use as well as avoiding potential safety risks.

BackgroundVascular access is essential in treating patients undergoing prolonged endovenous therapy such as chemotherapy, antibiotics, and parenteral nutrition. Since the 1990s, when PICCs (peripherally inserted central catheters) appeared, vascular access options have expanded significantly, revolutionizing the treatment landscape for all types of patients. ObjectiveTo analyze and describe the profile of the use of PICCs in a Brazilian quaternary hospital over 10 years with data collected by the infusion therapy team. Evaluating the number of PICCs implanted over the years, patients epidemiology and clinical characteristics, insertion details, associated complications, and the reason for removal. MethodsA retrospective cohort study that employs a quantitative, non-experimental approach to classify and statistically analyze past events associated with 21,652 PICCs implanted from January 2012 to December 2021 in a quaternary hospital at Sao Paulo - Brazil. All the catheters were implanted, and the data was collected by a team of nurses specializing in infusion therapy. We analyzed the number of catheters implanted over the years, insertion characteristics, patients epidemiology and clinical data, possible associated complications, and the reason for removal. Statistical analyses were conducted using R software (version 4.4.1) and SPSS (version 29) for Windows (IBM Corp, Armonk, NY). ResultsDuring the specified period, 21,652 catheters were analyzed. The patients gender distribution was nearly balanced (48.2% versus 51.8%), and the average age was 66 years. Cardiovascular and metabolic issues were the most common comorbidities, and between 2020 and 2021, 29.3% of the sample tested positive for COVID-19. The most common location of hospitalization and implantation was the ward (31.6% - 44.2%), and the most used type of catheter was the Power Picc (83.9%). The estimated complication incidence density is 2.94 complications per 1,000 catheter-days. Almost all the PICCs (98,2%) were adequately located at the cavo-atrial junction after the first attempt, 82.2% of catheters were removed in the end of therapy, and the median duration of catheter use was 12 days. ConclusionPICCs are widely employed for drug infusion, with their use growing progressively due to specialized teams greater availability and training. The high efficiency of these devices with a relatively low risk of complications already observed in previous studies was reinforced by the findings of this study of more than 20,000 catheters.

Introduction Indigenous peoples in Canada face persistent health inequities rooted in colonialism, systemic racism, discrimination and social exclusion, all of which operate with particular intensity within healthcare institutions. Despite a growing qualitative literature documenting the discrimination and stigmatisation of Indigenous people by healthcare professionals, no validated instrument existed in the Canadian context to measure the stigmatizing attitudes and behaviors of clinicians toward this population. Aim This study aimed to co-develop and validate an instrument using clinical case vignettes designed to capture the affective, cognitive, and behavioral dimensions of stigmatization of indigenous peoples. Method Following Boateng et al.'s three-phase scale development approach, a multidisciplinary team including Indigenous patient partners, researchers, clinicians, and measurement experts generated 244 items across three paired clinical vignettes addressing type 2 diabetes, chronic back pain, and depressive disorder. Each vignette was developed in two versions, one featuring an Indigenous patient (test) and one featuring a non-Indigenous patient (control), distinguished solely by name and origin. Content validity was assessed by an expert committee using a Content Validity Index. The instrument was subsequently administered to a sample of nurses and physicians from two canadian health institutions using a twelve-arm randomization design. Analyses were carried to assess the internal structure of the instrument, convergent and concurrent validity as well as internal consistency. Results Our results show that the instrument developed has good psychometric qualities, particularly in terms of internal consistency, concurrent validity and factor structure, which reflects the theoretical structure assumed. Concurrent validity of the tool with the M-PATAS scale demonstrated weak to moderate significant correlations. Developed through a participatory process centering Indigenous expertise and lived experience, this instrument constitutes a significant methodological advance in the study of racialized stigmatization in Canadian healthcare.

BackgroundUnderstanding of context-specific retention strategies for doctors will guide targeted interventions and policy framework for strengthening the district health system in South Africa. Several strategies have been examined, some more impactful than others, with resilience playing a role in retention of staff, but data is lacking in the Eastern Cape Province, South Africa. AimTo assess factors influencing the retention and resilience of doctors at district hospitals in the Eastern Cape. SettingDistrict hospitals in Amathole and Buffalo City health district municipalities in the Eastern Cape. MethodsIn this cross-sectional survey, participants rated retention strategies as well as a validated resilience scale (the CD-RISC 25). ResultsA total of 74 doctors were surveyed; mostly [&le;]34 years (66%), Black Africans (69%), and [&le;]5 years of professional experience (59%). The majority had worked in their current facilities for [&le;]5 years (76%). Significant proportion of young (78%), single (59%), and Grade 1 medical officers (86%) intend to leave their current facilities. Improving hospital accommodation was significantly associated with the intention to stay longer at the rural district hospitals. While not statistically significant, factors affecting professional development and growth scored higher while those related to financial remuneration scored lowest. There were no associations between resilience and intention to stay. ConclusionEarly career doctors prioritise career growth and development, while more experienced doctors rated improved living condition as the main determinants of retention in the rural health facilities. Future studies should recruit representative sample of doctors from the various municipalities and across provinces in the country. ContributionImproving hospital accommodation and enhancing career growth and development may increase retention of doctors in the rural district hospitals.

Essential medicines are one of the cornerstones of financial protection and health equity. The REMEDIAR Program is an initiative of the Argentine Ministry of Health aimed at ensuring free access to essential medicines for the uninsured at the point of care in primary healthcare centers (PHC). This study analyzes the financing, procurement, and distribution of this program over two decades (2002 to 2024). It evaluates how the program's capacity to navigate economic and political challenges ensured an uninterrupted supply of essential drugs at the primary healthcare level in a federal country where health services are devolved to provinces. We adopted a mixed-methods approach to examine the duality between international concessional loans and domestic treasury funding. Findings reveal that while international financing enhanced predictability and efficiency, reducing procurement timelines from 458 to 235 days, it also constrained domestic planning through external conditionalities. Conversely, while national centralized procurement achieved superior price efficiency and lower dispersion, it faced rigidities in adapting to local needs. Territorial distribution analysis confirms that REMEDIAR reduced access barriers for vulnerable households without formal insurance. However, the program entered a stabilization phase, failing to consolidate robust coordination with subnational policies, becoming entrenched in its own operational logic. The study concludes that program effectiveness depends not only on resource volume but on management quality. To guarantee long-term sustainability, transition to national financing requires profound institutional redesign. This must integrate operational capacities with federal coordination and domestic regulations, ensuring that the primary healthcare supply chain remains resilient to macroeconomic volatility and political shifts, aligned with sub-national strategies.

BackgroundPatient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly used to integrate patient perspectives into healthcare delivery, yet their routine implementation in general internal medicine (GIM) remains limited. This study evaluated participation rates and the acceptability, appropriateness, and feasibility of collecting PROMs and PREMs among GIM patients and study nurses across five Swiss university hospitals. MethodsWe conducted a sequential mixed-methods study embedded in a larger multicenter trial involving inpatients with two or more chronic conditions, hospitalized for acute illness and study nurses from GIM divisions. Inpatients completed three generic PROMs (paper or digital) at day 3, discharge, and 10 and 30 days post-discharge: the ESAS-r (Edmonton Symptom Assessment System revised), the EQ-5D-5L (European Quality of Life 5 Dimensions 5 Level), and the Distress Thermometer. A customized PREM assessing perceived quality of care was collected at discharge only. Patients and study nurses rated acceptability, appropriateness, and feasibility using Weiners implementation outcome measures. Study nurses recommendations for clinical integration were explored subsequentially in a focus group. Quantitative data were analyzed using descriptive analyses, while qualitative data were analyzed thematically. ResultsAmong 1,773 eligible GIM inpatients, 59% (median age 72 years, IQR 63-81) agreed to participate in PROM and PREM collection. Overall, patients rated all the PROMs as highly acceptable, appropriate, and feasible. Study nurses rated the ESAS-r and the EQ-5D-5L accordingly but expressed a moderate rating for the Distress Thermometer and the PREM primarily for their ease of use. Focus group findings emphasized staff training, digital integration into electronic medical records, reduced questionnaire burden, and hierarchical support as key implementation facilitators. ConclusionOur study demonstrates that PROM and PREM collection in Swiss University Hospital Settings was considered acceptable, appropriate, and feasible by patients and study nurses in a multicentric GIM inpatient setting. Routine implementation warrants specific strategies. SUMMARY TABLEO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIPROMs and PREMs are widely used in many medical specialties to incorporate patient perspectives and evaluate the quality and value of care. C_LIO_LIRoutine use of patient-reported measures in acutely ill GIM inpatients living with multimorbidity remains limited. C_LIO_LIImplementation often faces barriers related to workload, workflows, and digital infrastructure. C_LI What this study addsO_LITwo-thirds of acutely ill GIM inpatients in Swiss University Hospitals living with multimorbidity are willing to participate in PROM and PREM collection. C_LI How this study might affect research, practice or policyO_LIStaff training, digitalization, and hierarchical support are key facilitators, and embedding tools into electronic medical records with fewer measures may improve adoption in GIM. C_LI

BackgroundHealthcare workers are at increased risk of post-traumatic stress disorder (PTSD) due to prolonged exposure to high-stress clinical environments. Although the Health Belief Model (HBM) has been widely used to explain health behaviors, its application to psychological outcomes such as PTSD remains limited. The role of cognitive-emotional processes, particularly experiential avoidance, in linking health beliefs to trauma symptoms is not well understood. MethodsThis study adopted a quantitative cross-sectional design to collect data from 475 healthcare workers in Ekiti State, Nigeria. Participants completed standardized measures assessing Health Belief Model constructs, experiential avoidance, and PTSD symptoms. Data were analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM), with bootstrapping used to test direct, indirect (mediation), and moderation effects. Cluster analysis was also conducted using SPSS to validate differences in PTSD symptom severity across psychological constructs and demographic variables. ResultsExperiential avoidance significantly predicted PTSD symptoms ({beta} = 0.395, 95% CI [0.231, 0.565]). HBM constructs were negatively associated with experiential avoidance ({beta} = - 0.198, 95% CI [-0.270, -0.108]) and PTSD symptoms ({beta} = -0.119, 95% CI [-0.216, -0.006]). Mediation analysis indicated that experiential avoidance partially mediated the relationship between HBM constructs and PTSD ({beta} = -0.078, 95% CI [-0.132, -0.037]), with a total effect of - 0.197. Age moderated the relationship between HBM and experiential avoidance ({beta} = -0.114, 95% CI [-0.207, -0.025]) as well as the indirect pathway to PTSD. Sex significantly predicted PTSD symptoms ({beta} = 0.358, 95% CI [0.214, 0.501]). Cluster analysis showed that experiential avoidance and perceived barriers significantly differentiated high and low PTSD symptom groups. ConclusionThe findings support a conditional cognitive-emotional model in which Health Belief Model constructs influence PTSD symptoms both directly and indirectly through experiential avoidance. Demographic factors shape the strength of these relationships, while perceived barriers and experiential avoidance emerge as key determinants of trauma-related distress among healthcare workers.

The COVID-19 pandemic exposed critical vulnerabilities in globally concentrated biomedical supply chains and accelerated interest in nearshoring and hemispheric health-security strategies. The Dominican Republic, already the third-largest medical device exporter in Latin America, occupies a strategically significant but institutionally constrained position within this realignment. This study evaluates stakeholder perceptions of the principal opportunities and barriers affecting biomedical ecosystem development in the Dominican Republic, with particular attention to governance, workforce capacity, and value-chain upgrading pathways. Methods. A concurrent mixed-methods design was employed, integrating a cross-sectional electronic survey of 142 purposively sampled domain experts (administered September-December 2025) with a qualitative executive consultation with senior government and industry leaders. Survey analyses combined descriptive statistics, one-sample t-tests against the scale neutral midpoint, chi-square goodness-of-fit tests, Friedman non-parametric ranking, Spearman rank correlations, and exploratory linear and logistic multivariable regression. Qualitative responses were analyzed using a framework approach grounded in the Triple Helix model of innovation systems. Results. Perceived government support was significantly below neutral (mean = 2.67, SD = 1.12; p = 0.034). Workforce shortages (83.3%) and weak academia-industry collaboration (71.4%) were the most frequently endorsed barriers ({chi}2(5) = 18.7, p = 0.002). Regulatory modernization (88.1%) and workforce development (85.7%) ranked as the highest-priority policy levers (Friedman p = 0.005). Clinical trials and contract research organization services were the dominant sub-sector priority (76.2%, binomial p < 0.001). In multivariable analysis, perceived government support, talent availability, and confidence in IP protection jointly explained 46% of the variance in sector competitiveness (R2 = 0.46, p < 0.001). Strong majority support existed for a formal public-private biomedical coordination authority (73.8%, p < 0.001).Conclusion. Institutional credibility and advanced human capital--rather than geography or market access--are the perceived binding constraints on the Dominican Republics biomedical trajectory. Regulatory modernization, targeted workforce investment, and the establishment of a national biomedical coordination authority represent the highest-leverage interventions for positioning the country as a hemispheric hub for biomedical manufacturing, clinical research, and health security.

IntroductionEmpirical evidence linking specific national structural policies to the provision of key HIV services in low- and middle-income settings remains scarce. This study addresses the research gap by quantifying the within-country relationships between six national structural policy indicators and the presence of the HIV prevention service component targeted at sex workers in Southeast Asia. MethodsWe constructed a balanced panel dataset covering eight Southeast Asian countries from 2018 to 2025 from the UNAIDS Global AIDS Monitoring (GAM) framework. We used Fixed-Effects (FE) and Random-Effects (RE) models to analyse the relationships, with the FE model selected as the more statistically appropriate estimator. We enhanced robustness by using clustered standard errors and one-period lagged explanatory variables. ResultsThe primary finding from the FE model indicated a statistically significant and positive contemporaneous association between the existence of legal or administrative barriers to social protection (barriers_spi,t) and the presence of HIV prevention services for sex workers ({beta} = 0.8531; p< 0.001). However, the robustness check revealed a statistically significant negative association between the two when using the lagged barrier variable (barriers_spi,t-1), suggesting a decline in HIV prevention service availability over time ({beta} = -0.3540; p < 0.05). We did not find any other policy variables coefficient to be statistically significant in the FE models. ConclusionsWhile the immediate recognition (contemporaneous effect) of structural barriers to access social protection may occur alongside prioritised HIV prevention service provision, the sustained presence of these impediments acts as a long-term constraint that undermines the effectiveness and sustainability of targeted HIV programmes. National HIV programmes must urgently prioritise the removal of structural barriers to ensure long-term service stability for key populations. Key MessagesO_LIWhat is already known on this topic: The global HIV response requires addressing structural determinants, such as legal barriers to social protection, to achieve epidemic control. However, there is a lack of robust empirical evidence linking the adoption of specific national structural policies to the actual availability of essential HIV services for key populations in low- and middle-income settings. C_LIO_LIWhat this study adds: This study provides the first evidence using FE panel data that the existence of national policy barriers to social protection is initially associated with a higher likelihood of having an HIV prevention service component for sex workers. The study also demonstrates that this positive association is short-lived, with the sustained presence of the barrier negatively impacting HIV prevention service availability for sex workers in the subsequent year. C_LIO_LIHow this study might affect research, practice or policy: Policymakers should recognise that simply identifying and reporting structural barriers, while perhaps coinciding with initial HIV prevention service investment, is insufficient for sustained policy intervention effectiveness. Policy should focus not just on the adoption of targeted programmes but on the urgent removal of structural barriers to ensure the long-term sustainability and success of prevention services for key populations. C_LI