Despite universal health coverage and longstanding child-safety initiatives, socioeconomic and ethnic inequalities in childhood injury remain pronounced in Israel. Unintentional childhood injuries (UCI) function as a proxy for health inequity, reflecting structural gaps in preventive infrastructure and access to safe environments. This study examines two case studies that illustrate how differential public investment contributes to unequal injury risks: (1) public playgrounds availability, and (2) participation in school-based swimming lessons. Both are analyzed within a social-determinants-of-health framework, emphasizing the interaction of environment, education, and municipal capacity. Data on fatal childhood injuries in public spaces and drowning incidents were drawn from Beterem Safe Kids Israel's national media-based mortality database (2008-2025). Playground availability was assessed through triangulated sources, including OpenStreetMap, field validation, and Standards Institution of Israel records. Swimming-participation data were obtained from Ministry of Education responses to Freedom of Information requests for 2022-2023. Associations between infrastructure and training and child mortality were tested using Spearman's rank correlation. Across 62 municipalities with child populations above 10,000, a significant positive correlation was found between children per playground and UCI (Unintentional Child Injury) mortality in public spaces (ρ = 0.290, p < 0.05). Swimming participation displayed a inverse, though non-significant, relationship with drowning mortality (ρ = - 0.357, p = 0.08). Participation inequalities were substantial: only 25% of children from low-SES clusters (1-3) and 20.5% of Arab children participated in swimming instruction, compared with 60% in affluent and Jewish municipalities. Between 2021 and 2025, Arab children were more than twice as likely to die from drowning as Jewish children (rate ratio = 2.43, χ² = 14.83, p < 0.001). These findings point to a shared structural mechanism behind injury inequalities: persistent underinvestment and institutional barriers that restrict access to preventive infrastructure in low-income and minority municipalities. Although playgrounds and swimming lessons are distinct domains, both exemplify how inequitable distribution of safety-enhancing resources produces measurable health risks. Addressing these gaps requires coordinated policy reforms that integrate public health, education, and urban planning; establish equity-weighted funding for preventive infrastructure; and institutionalize monitoring of child-safety environments. Equitable investment in prevention is essential for reducing injury and advancing child health equity in Israel.
Labor and postpartum pain represent complex, multidimensional experiences shaped by physiological, psychological, and sociocultural factors. Effective pain management whether pharmacological (epidural analgesia) or non-pharmacological (acupuncture, massage) is integral to respectful maternity care and maternal well-being. Despite extensive clinical research, no comprehensive bibliometric analysis of the global scientific literature in this domain has been conducted. A bibliometric study was performed using data from the Web of Science Core Collection (2000–2025). The search strategy combined terms related to “labor or postpartum pain” and “analgesia, anesthesia, non-pharmacological interventions, or pain management.” Bibliometric indicators including co-authorship, co-citation, and keyword co-occurrence were analyzed using VOSviewer with fractional counting. Inclusion thresholds were: ≥5 documents and ≥50 citations per country, ≥30 occurrences per keyword, and ≥10 citations per cited source. Bibliometric indicators including co-authorship, co-citation, and keyword co-occurrence were analyzed using VOSviewer with fractional counting. Total link strength (sum of link strengths connecting a node to all others) served as the primary metric of collaborative influence and intellectual connectivity. Of the 80 countries identified, 36 were included in the visualization based on total link strength. The United States dominated in publications (n = 388), citations (5,412), and collaboration intensity (total link strength = 1,026), followed by the United Kingdom, Canada, and Australia. Thematic mapping revealed three core clusters: (1) psychological and physiological dimensions of pain, (2) pharmacological interventions (notably epidural analgesia), and (3) patient-centered, experiential care. High-impact journals spanned obstetrics (Obstetrics & Gynecology), anesthesiology (Anesthesia & Analgesia), and pain science (Pain). Low- and middle-income countries remained underrepresented despite bearing a disproportionate burden of maternal morbidity. This study maps the evolving, interdisciplinary landscape of labor and postpartum pain research and reveals persistent geographic, linguistic, and epistemic inequities. It underscores the need for equitable global research partnerships, inclusion of non-English literature, and context-sensitive, community-engaged approaches to ensure inclusive, respectful, and evidence-based pain management for all birthing individuals. Not applicable. Importantly, this article is based exclusively on a secondary analysis of publicly indexed scientific literature retrieved from the Web of Science main collection. This article does not involve any primary data collection, human subjects, animal experiments, or clinical interventions. Consequently, this study is exempt from ethical approval and no ethics committee approval was required or requested. The online version contains supplementary material available at 10.1186/s12939-026-02805-2. What is already known on this topic What this study adds How this study might affect research, practice or policy Labor and postpartum pain are recognized as multidimensional experiences influenced by physiological, psychological, and sociocultural factors. Numerous clinical studies and systematic reviews have evaluated pharmacological (epidural analgesia) and non-pharmacological (acupuncture, massage) interventions. Growing evidence highlights disparities in pain management by race, ethnicity, and geography. However, no comprehensive bibliometric analysis has mapped the global structure, thematic evolution, or collaborative networks in this field. This study reveals a highly centralized global research landscape dominated by high-income countries particularly the United States with marked underrepresentation of low- and middle-income countries despite their disproportionate maternal morbidity burden. It identifies three core thematic clusters: (1) psychological and physiological dimensions of pain, (2) pharmacological interventions, and (3) patient-centered care. The analysis documents a paradigm shift toward interdisciplinary, equity-informed models of pain management. The findings call for equitable global research partnerships, inclusion of non-English literature, and investment in context-sensitive, community-engaged pain research in underrepresented regions. For practice and policy, they reinforce the need to integrate psychosocial, cultural, and equity considerations into maternal pain management guidelines to ensure care is inclusive, respectful, and evidence-based for all birthing individuals.
This study aims to examine how infectious disease prevention mechanisms are constructed and operationalized within carceral settings in transitional states, using China as a representative case. It focuses on the discursive and structural strategies employed by stakeholders to navigate institutional challenges in epidemic control and to delineate responsibilities across health and justice sectors, while also considering the ethical implications of these strategies and upholding the dignity and rights of individuals affected. Guided by the epidemiological triangle model, the study adopts a dual-method qualitative design. First, it conducts a normative analysis of Chinese legal and administrative frameworks related to prison-based disease prevention. Second, it integrates empirical fieldwork based on 21 semi-structured interviews with correctional staff, health administrators, and incarcerated individuals across three provinces, supported by thematic and content analysis. Findings reveal that China's carceral health governance has undergone a three-stage transformation-from institutional neglect to legal formalization, and ultimately to preventive risk management. Stakeholders engage in discursive boundary work by aligning prison health efforts with national public health objectives, while structural boundary work manifests in spatial segregation, surveillance routines, and inter-agency protocols. Digital surveillance and health monitoring systems, as part of these structural strategies, have contributed to improving public health outcomes in carceral settings by enabling real-time data sharing and timely intervention. However, these systems also raise ethical concerns: individuals with drug use histories or criminal records often worry that such monitoring, linked to stigmatized or criminalized practices, may be used for punitive purposes or excessive control rather than solely for health protection. Despite advances, gaps remain in enforcement consistency, resource allocation, and the legal clarity of emergency mandates. Additionally, carceral settings have long been plagued by systemic issues such as overcrowding, inadequate basic health services, and the erosion of human dignity, which create favorable conditions for the rapid spread of infectious diseases-these structural deficiencies are key drivers of high disease transmission rates in such environments. The study highlights boundary work as a central mechanism for institutional adaptation in prison health governance. China's evolving approach offers scalable insights for other transitional states, emphasizing the need for integrated, context-aware strategies that reconcile biopolitical control with human rights considerations, and explicitly address ethical dilemmas arising from surveillance and other intervention measures. Effective prison health reform requires not only legal mandates but also infrastructural investment to address overcrowding and inadequate health services, intersectoral cooperation, sustained political commitment, and a fundamental commitment to restoring and upholding the human dignity of individuals in carceral settings. It also necessitates establishing safeguards to ensure that monitoring tools are used strictly for health purposes and do not become instruments of unfair control or discrimination.
Reducing health inequalities is a key element in the World Health Organization’s (WHO) sustainable development goals (SDG). While previous research has analyzed individual childhood malnutrition indicators and inequality by place of residence, there are no studies that have looked over time for rural vs. urban inequalities for all five-childhood malnutrition indicators for low- and middle-income countries (LMIC). The goal of the current study is to provide preliminary results to address this research gap by using a free software developed by WHO, the Health Equity Assessment Toolkit (HEAT). The 52 countries included in this study had at least two Demographics and Health Survey (DHS) datasets, between 1990 and 2021, available through the WHO HEAT. All five childhood malnutrition indicators (overweight, stunting, underweight, wasting, and severe wasting) were evaluated. An increase in inequality was considered to be an increase over time in the difference between the rural prevalence and the urban prevalence of a malnutrition indicator. Out of the 52 countries, 15 (29%) reduced inequality across all five malnutrition indicators, 13 (25%) reduced inequality for 4 indicators, 7 (13%) reduced inequality for 3 indicators, 7 (13%) reduced inequality for 2 indicators, 7 (13%) reduced inequality for one indicator, and 3 (6%) did not reduce inequality for any indicator. The overweight indicator had the most countries (42%) showing an increase in inequality, while the underweight indicator had the fewest countries (19%) showing an increase in inequality. Overall, most LMIC were showing progress towards reducing malnutrition inequality based on place of residence. Results show that malnutrition inequality is generally decreasing for LMIC, with the exception of the overweight indicator. To further understand what is driving the observed inequalities and inform policy changes, future analyses should evaluate possible drivers such as economic transitions, urbanization rates, or health policy changes. WHO HEAT software provides free and easy access to relevant survey data and provides summary statistics and plots that allow the user to understand the data and answer a variety of inequality-related research questions. The online version contains supplementary material available at 10.1186/s12939-026-02798-y.
Annual health examinations for older adults and patients with chronic diseases at community health service centers play a crucial role in early disease detection and complication prevention. Substantial evidence supports the use of internet-based technologies for improving intervention efficiency. This study aimed to systematically evaluate the effectiveness of an internet-based health examination model within primary care settings. We conducted a 6-year community demonstration trial at the Dashi Street Community Public Health Service Center in Panyu District, Guangzhou, China. The study focused on focus populations, defined as individuals aged over 65 years, or those aged 35 years and above with either hypertension or type 2 diabetes. Starting in 2021, an internet-based health examination model was introduced for these groups. The study utilized the Structure-Process-Outcome (SPO) framework for systematic evaluation and adopted a quasi-experimental design to assess model effectiveness. The internet-based model demonstrated superior performance in structural and process dimensions, facilitating expanded health examination coverage with reduced staffing needs. Outcome analyses included data from 47,380 participants over six years (2018–2023): 21,157 under the traditional model (2018–2020) and 26,223 under the internet-based model (2021–2023). Generalized estimating equation (GEE) analysis showed that the internet-based model achieved significantly higher participation rates than the traditional model among focus populations [OR = 1.148, 95% CI: 1.101–1.197, P < 0.001]. Interrupted time series (ITS) analysis revealed an immediate increase in participation numbers following implementation [β = 192.56, 95% CI: 68.17, 316.96, P = 0.004], with no significant change in trend [β = 1.28, 95% CI: -12.82, 15.37, P = 0.852]. The internet-based model was also more cost-effective, with a mean cost per participant of ¥395.95 compared to ¥1,213.74 for the traditional model. Incremental cost-effectiveness ratios (ICERs) indicated cost savings per additional percentage point in participation rate: ¥–130,685.51 for adults ≥ 65 years, ¥–78,974.64 for hypertensive patients, and ¥–98,100.68 for type 2 diabetes patients. Examination duration was significantly shorter across all age groups with the internet-based model (all P < 0.001). Satisfaction levels (χ²=98.169, P < 0.001) and willingness to reuse services (χ²=36.974, P < 0.001) were also significantly higher in the internet-based group. For community-based focus populations, the internet-based health examination model demonstrated superior effectiveness in expanding coverage rates and was highly cost-effective compared to the traditional model. The findings support its potential for broader adoption in community health service centers, though implementation should consider local infrastructure and population characteristics.
The population of migrant, refuge, and asylum-seeking children and adolescents across the globe has increased in recent decades. These minors often undergo adverse experiences that negatively impact their mental health and psychosocial well-being (MHPWB). In light of the transient nature and multiple stressors inherent in the transit stage, this scoping review was conducted to characterize the evidence on interventions aimed at promoting the MHPWB of minors during their migration journey. Following the PRISMA-ScR guidelines, we systematically searched the MEDLINE, Embase, Global Health, APA PsycInfo, and Web of Science databases, as well as the Google Scholar search engine, for studies published between January 2010 and September 2025 that included the evaluation of some aspect of interventions aimed at promoting MHPWB in minors during transit, regardless of the language and location where the study was conducted. Systematic reviews of the literature were excluded. The data most relevant to answering the research questions were presented in tables and accompanied by a narrative synthesis. Of the 1,835 unique documents identified, 28 met the inclusion criteria. Most of the interventions had been implemented in refugee camps and were aimed at school-age children and adolescents who had been forcibly displaced, mainly from the Middle East. Most of the interventions combined different approaches, such as psychoeducation and cognitive-behavioral therapy, and had a family or group approach. All interventions reported some degree of positive change on children's MHPWB. However, few studies considered at-risk subgroups, and no interventions targeted two of the main forcibly displaced populations at the time of the study, Venezuelans and South Sudanese. Our study effectively describes existing interventions aimed at promoting MHPWB for minors in transit and their effectiveness and/or implementation process, as well as identifies gaps in the current evidence and lessons learned that can help improve future interventions. INTRODUCCIóN: La población de niños y adolescentes migrantes, refugiados y solicitantes de asilo ha aumentado en las últimas décadas a nivel global. A menudo, estos menores experimentan experiencias adversas que impactan negativamente sobre su salud mental y bienestar psicosocial (SMBP). Considerando la naturaleza transitoria y los múltiples estresores inherentes a la etapa de tránsito, se realizó la presente revisión de alcance para caracterizar la evidencia sobre las intervenciones orientadas a promover la SMBP de menores durante el viaje migratorio. MéTODOS: Siguiendo las guías de PRISMA-ScR, buscamos de forma sistemática en las bases de datos MEDLINE, Embase, Global Health, APA PsycInfo y Web of Science, así como en el motor de búsqueda Google Scholar, estudios publicados entre enero de 2010 y septiembre de 2025 que incluyeran la evaluación de algún aspecto de las intervenciones destinadas a promover la SMBP de los menores durante el tránsito, independientemente del idioma y lugar donde se hubiera realizado el estudio. Se excluyeron revisiones sistemáticas de la literatura. Los datos más relevantes para responder a las preguntas de investigación fueron presentados en tablas y se acompañaron de una síntesis narrativa. RESULTADOS: De los 1835 documentos únicos identificados, 28 cumplieron con los requisitos de inclusión. La mayoría de las intervenciones habían sido implementadas en campos de refugiados y estaban dirigidas a menores en edad escolar y adolescentes desplazados forzados, principalmente originarios de Oriente Medio. La mayoría de las intervenciones combinaban diferentes abordajes, como la psicoeducación y la terapia cognitive-conductual, y tenían un abordaje familiar o grupal. Todas las intervenciones reportaron algún nivel de cambio positivo sobre la SMBP de los menores. Sin embargo, fueron pocos los estudios que consideraran a subgrupos en riesgo, así como no se identificaron intervenciones orientadas a dos de las principales poblaciones desplazadas forzosas en el período de estudio, la venezolana y sudsudanesa. CONCLUSIONES: Nuestro estudio logra de forma efectiva describir las intervenciones existentes destinadas a promover la SMBP de menores en tránsito y su efectividad y/o proceso de implementación, así como identificar brechas en la evidencia actual y aprendizajes que pueden ayudar a mejorar futuras intervenciones.
Integration of refugees in host countries is high on the political agenda, but the prospective influence of health at arrival on later integration outcomes remains unclear. This study describes the integration of Syrian refugees in Norway four years post-resettlement, exploring whether their health in early resettlement period serves as a predictor of subsequent integration. This prospective cohort study used data from the CHART/Integration for Health project, which examines the intertwined development of health and integration among Syrian quota refugees living in Norway four years after recruitment in Lebanon. Health status was assessed one-year post-arrival through self-reported chronic pain, non-communicable diseases (NCDs), anxiety/depression, and post-traumatic stress symptoms. Integration was measured four years after resettlement using the Immigration Policy Lab (IPL) Integration Index, with scores normalized from 0 to 1, where higher values indicate greater integration. Hierarchical linear regression was used to examine whether early post-resettlement health predicted overall and dimension-specific integration, adjusting for age, gender, and educational attainment. Four years after resettlement, Syrian refugees reported difficulties across several integration domains particularly social- and linguistic integration. Those reporting chronic pain were more likely to face challenges in economic integration (β = − 0.24, p < 0.05), while refugees with NCDs encountered greater difficulties in linguistic integration (β = − 0.17, p < 0.01). Additionally, symptoms of anxiety/depression one year after arrival were associated with later increased overall integration challenges, particularly navigating services (β = − 0.42, p < 0.01). However, poorer health did not uniformly predict disadvantage and was occasionally associated with fewer challenges in specific areas of integration. Poor health during the early post-resettlement period was mostly linked to greater challenges across multiple integration domains four years later. These findings underscore the importance of addressing refugees´ health needs shortly after arrival, within the broader context of integration. Ensuring timely and accessible healthcare at early resettlement staged, alongside comprehensive integration efforts, could promote better and more equitable integration outcomes for refugees. The online version contains supplementary material available at 10.1186/s12939-026-02837-8.
High-impact chronic pain (HICP) represents a severe subset of chronic pain characterized by substantial functional interference. Although chronic pain is known to be more prevalent in rural areas, the magnitude and determinants of urban-rural disparities in HICP among older adults in China remain inadequately understood. We conducted a community-based cross-sectional study among residents aged ≥ 60 years in Anning City, Yunnan Province, a region characterized by a distinct urban-rural composition. Chronic pain was identified via a structured questionnaire, and high-impact chronic pain (HICP) was assessed using the validated Chinese version of the PEG scale, operationally defined as a score ≥ 4 on any of the three domains(Pain intensity, Enjoyment of life, and General activity). Data on sociodemographic characteristics, lifestyle factors, comorbidities, and healthcare utilization were collected. Urban-rural comparisons were performed using Chi-square tests. To identify independent risk factors for HICP, we employed a two-stage binary logistic regression approach on the full analytical sample of chronic pain patients: univariate analyses were conducted first to examine crude associations, followed by multivariable logistic regression to estimate adjusted effects while controlling for potential confounders. Among 2,800 participants, the overall prevalence of chronic pain was 28.5%, with a significantly higher rate in rural areas (36.01%) than in urban areas (23.01%) (P < 0.001). Of those with chronic pain, 68.7% met the criteria for HICP, demonstrating a pronounced urban-rural disparity (81.92% rural vs. 53.49% urban, P < 0.001). In univariate logistic regression, rural residence exhibited the strongest crude association with HICP (odds ratio [OR] = 3.82, 95% confidence interval [CI]: 2.67-5.48). Additional factors significantly associated with increased odds included age ≥ 71 years (OR = 1.61, 95% CI: 1.14-2.28), occupation as a farmer (OR = 1.89, 95% CI: 1.31-2.71) or being unemployed (OR = 4.23, 95% CI: 1.98-9.02), and daily sedentary time ≥ 4 h (OR = 1.61, 95% CI: 1.14-2.28). In the fully adjusted multivariable model, rural residence remained the predominant independent risk factor for HICP (adjusted OR [aOR] = 3.56, 95% CI: 2.28-5.54). Advanced age (≥ 71 years) retained an independent association with elevated HICP risk (aOR = 1.48, 95% CI: 1.02-2.16). Notably, the significant crude effects of occupation and sedentary time were attenuated and no longer statistically significant after multivariable adjustment. Furthermore, good or very good self-reported sleep quality was independently associated with higher odds of HICP (aOR = 1.53, 95% CI: 1.04-2.25). Rural patients predominantly reported pain in weight-bearing joints and faced significant financial barriers to healthcare access. Profound urban-rural disparities exist in HICP among older adults in Southwest China, with rural residents exhibiting a markedly elevated risk of progressing to this most disabling form of chronic pain. These findings underscore the urgent need to integrate HICP screening into primary care and to develop tailored, community-based pain management strategies for rural aging populations.
Within-country inequalities in antenatal care (ANC) coverage are widely documented. With recent international guidelines recommending eight or more visits, we hypothesized that this increase could reveal wider inequalities in Brazil, consistent with the Inverse Equity Hypothesis, which postulates that new interventions initially widen socioeconomic gaps because privileged groups are the first to adopt them. We assess how the magnitude of inequality varies by increasing ANC visit thresholds. We analyzed data from the Brazilian Live Births Information System (SINASC) for 2,537,511 live births in 2023, calculating national coverage 1 + to 8 + ANC visits. Estimates were stratified by maternal schooling, self-reported race/skin color, age at birth, and geographic region. Measures of inequality included the Slope Index of Inequality (SII) and the mean absolute difference to the overall mean (MADM). National coverage for 1 + ANC visits was 99.4% and for 8 + visits, 67.4%. For maternal schooling, SII rose from 1.6% points (p.p.) for 1 + visit to 26.4 p.p. for 8 + visits. For 8 + visits, indigenous women showed the largest dropout rates and the lowest coverage (37.8%), whereas white women showed the opposite (74.7% coverage). The North region and adolescents also showed low coverage of 8 + ANC visits (50.8% and 55.4%, respectively). Increasing the number of recommended ANC visits exacerbates socioeconomic, racial, and regional inequities in Brazil, consistent with the inverse equity hypothesis. Higher coverage thresholds disclose wider inequities, thus further exposing the vulnerability of indigenous, with no formal schooling, adolescent women and residents of the North. Improved detection of such inequities is essential to guide policies that ensure high-quality ANC reaches all women and children, thereby eliminating current inequalities in maternal and newborn health outcomes. The online version contains supplementary material available at 10.1186/s12939-026-02811-4.
Existing quantitative studies of violence victimization in Brazil often examine individual demographic and socioeconomic risk factors, limiting insight into how identities can intersect to co-produce vulnerability or resilience. This study uses a nationally representative household survey to investigate how demographic, socioeconomic, and geographic factors intersect to shape the probability of experiencing psychological, physical, and sexual violence among Brazilian adults. Data from the 2019 Brazil National Health Survey was used to created indicators of 12-month experience of three types of interpersonal violence (psychological, physical, and sexual), a measure of any violence and one indicating 2 or more types. Previous literature guided the development of 356 clusters of intersectional identities based on demographic, socioeconomic and other factors. Analyses used the intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) approach based on multilevel analyses of all 356 intersectional strata in addition to individual-level factors. Among Brazilian adults, 18.3% (totaling 27,535,272) reported experiencing interpersonal violence and 3.7% experienced more than one type in the past 12 months. Psychological violence (17.4%) was most frequently reported, followed by physical (4.6%) and sexual (0.8%) violence. MAIHDA models revealed that prevalence and risk varied widely across intersectional strata, but that younger age (< 30), being single, living in an urban area, and living with a long-term illness or disability were consistently found in the strata with highest predicted probability of victimization across all types of violence. Being female, being Black, having a college-level education, and being in the lowest wealth tertile were also commonly found in the highest ranked strata across forms of violence victimization. The overall variance attributable to intersectional (as opposed to individual) effects was between 9.3% and 13.0% across different forms of violence, suggesting that risk of experiencing (or reporting) interpersonal violence in this study accumulates largely in additive rather than multiplicative ways. This study found that experiences of psychological, physical, and sexual interpersonal violence were patterned by intersecting social and economic inequalities, with higher risk among women, younger adults, Black or Brown individuals, those who are single, urban residents, and people living with long-term health problems. MAIHDA analyses revealed that risk accumulated across overlapping social positions—particularly among young, single, urban Black women with chronic conditions—highlighting the need for violence prevention strategies that address structural drivers of gender, racial, and socioeconomic inequality. Not applicable. The online version contains supplementary material available at 10.1186/s12939-026-02818-x.
People experiencing homelessness (PEH) face complex social and economic challenges that increase their risk of poor health. This study aimed to identify and synthesize key barriers to and facilitators of healthcare access from the perspective of PEH to inform more equitable and sustainable health strategies. A systematic scoping review was conducted in accordance with the guidelines of the Cochrane Collaboration and the Joanna Briggs Institute and was reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR). A PubMed, Embase and Web of Science search was conducted in January 2025 using terms related to homelessness, healthcare, and interventional and observational studies. A manual search of the reference lists of the included studies was also performed via conventional search engines. Two reviewers independently classified the relevance of the extracted studies according to predefined eligibility criteria. Any discrepancies were solved by a third reviewer. The final list of studies enabled extraction of barriers to and facilitators of access to healthcare, subsequently classified according to the socioecological model. A total of 79 studies (n = 51,110 PEH) published between 1989 and 2024, mostly from the United States of America (USA) (n = 48; 63.3%), were included. Interventions most frequently addressed general healthcare (n = 25; 31.6%), treatment of specific conditions (n = 23; 29.1%) and sexual and reproductive healthcare (n = 7; 8.9%). Common individual-level barriers included health related-beliefs and concerns (n = 43), cognitive and behavioral health challenges (n = 28), and substance use (n = 18), whereas increased health awareness (n = 13) facilitated healthcare utilization. At the interpersonal level, social stigma (n = 51) and negative provider attitudes (n = 31) were prominent barriers, whereas strong social networks (n = 34) supported engagement. Institutional-level barriers included bureaucracy (n = 21) and lack of service integration (n = 20); conversely, continuity of care (n = 8) and process simplification (n = 7) acted as facilitators. Community-level barriers involved limited-service availability (n = 22), direct (n = 34) and indirect costs (n = 19); facilitators were centered on structure of the health service (n = 16). At the policy level, limited resources and service offer (n = 7), as well as undocumented situations by PEH (n = 4) were key barriers; strategically located services (n = 7) facilitated healthcare utilization. Improving healthcare for PEH requires multilevel, person-centered strategies that address structural, interpersonal, and individual barriers while streamlining access through inclusive public policy. International Prospective Register of Systematic Reviews (PROSPERO): CRD42025635835. The online version contains supplementary material available at 10.1186/s12939-026-02840-z.
Language barriers in healthcare continue to pose major challenges to equitable, high-quality care, particularly in mental health settings where communication is central to diagnosis, therapeutic alliance, and treatment planning. Translation technologies, including machine translation applications, offer potential solutions, but their real-world usability in mental health care remains underexplored. This cross-country qualitative study examined the experiences, attitudes, needs, and suggestions regarding the use of translation technologies to overcome language barriers in mental health care. Semi-structured interviews were conducted with 175 participants, including healthcare providers, interpreters, service users, supporters, and stakeholders (e.g., policymakers, community organisation representatives), across five countries: Germany, South Africa, Romania, the Netherlands, and China. The data were analysed thematically using a hybrid deductive-inductive approach, with Bronfenbrenner’s ecological systems model applied as a sensitising framework. Six overarching themes emerged: (1) perceived effectiveness and limitations of translation tools, (2) cultural, linguistic, and social fit, (3) human aspects of communication and care, (4) ethical and attitudinal dimensions, (5) implementation and improvement pathways, and (6) access barriers. Participants often found the translation tools to be helpful for basic communication but inadequate for complex or emotional interactions central to mental health care. Key concerns included translation accuracy limitations, cultural inappropriateness, reduced empathy and trust, data protection issues, and poor workflow integration. Infrastructure constraints, institutional barriers, and lack of formal guidance hindered effective implementation. Participants emphasised the importance of hybrid models combining technology with human interpreters, tailored training, and clear policy frameworks to address these challenges. Translation technologies can help bridge language gaps in mental healthcare, particularly in urgent or resource-constrained settings. However, their effective use remains highly context-dependent and constrained by technical, ethical, relational, and infrastructural challenges. Adequate and equitable implementation requires system-level investment, participatory design, and safeguards that protect both the emotional and cultural dimensions of communication, among others. Translation tools should be seen as supplementary, not substitutive, in delivering safe and person-centred mental healthcare. Not applicable. The online version contains supplementary material available at 10.1186/s12939-026-02821-2.
Evidence on how poverty and social determinants influence adverse maternal and perinatal outcomes in the UK is limited. While ethnicity and area-level deprivation are well described, fewer studies examine the cumulative impact of poverty-related factors such as low income, employment insecurity, housing, and access to social support. We analysed 67,308 pregnancies from the eLIXIR cohort using linked NHS records. Social determinants were defined using the WHO framework as structural (ethnicity, migration status, area deprivation) and intermediary (housing, employment, financial hardship, social support, barriers to care). The primary outcome was a composite adverse perinatal outcome. Binary logistic regression models with random intercepts accounted for repeated pregnancies, and adjusted risk ratios (aRRs) were estimated controlling for key sociodemographic and clinical factors. Structural poverty-related social determinants of health were associated with increased risk of adverse perinatal outcomes, including Black (aRR 1.50, 95% CI 1.42-1.59), Asian (aRR 1.49, 95% CI 1.39-1.59), and other minoritised ethnic backgrounds (aRR 1.50, 95% CI 1.42-1.59), residence in the most deprived areas (aRR 1.10, 95% CI 1.01-1.20), non-UK birth (aRR 1.20, 95% CI 1.15-1.25), and recent migration (aRR 1.32, 95% CI 1.14-1.53). Intermediary poverty-related social determinants of health were independently associated with increased risk beyond ethnicity and deprivation, including lack of social support (aRR 1.21, 95% CI 1.02-1.42), unemployment (aRR 1.16, 95% CI 1.10-1.23), financial hardship (aRR 1.17, 95% CI 1.01-1.35), living in social housing (aRR 1.16, 95% CI 1.09-1.24), transfer of care between hospitals (aRR 1.27, 95% CI 1.18-1.37), missed appointments (aRR 1.19, 95% CI 1.04-1.37), and unscheduled maternity care use (aRR 1.21, 95% CI 1.14-1.29). Women exposed to multiple overlapping poverty-related social determinants of health had a substantially higher likelihood of adverse perinatal outcomes (aRR 1.23, 95% CI 1.12-1.35). Structural and intermediary social determinants related to poverty have a substantial and cumulative impact on maternal and perinatal outcomes, independent of individual clinical risk. Addressing these inequities requires integrated, cross-sector strategies that extend beyond healthcare to the wider social conditions influencing maternal and child health. Not applicable.
Historically, neglected tropical diseases (NTDs) have received far less global attention than the ‘big three’ diseases of global health (HIV, TB, and malaria), reinforcing health inequities experienced by those affected. Policy advocacy has been a necessary part of the work of NTD specialists, including researchers. One commonly used tool to support planned change is Theory of Change (ToC), employed by organisations such as the World Health Organization, non-governmental organisations, and research funders, who often require ToC diagrams at proposal stage. However, ToC practices can produce models of social change that are not particularly human-like, projecting an imaginary of change that is linear, predictable, unidirectional, mechanical, and largely detached from emotion, lived experience, or individual commitment. This paper offers an alternative perspective on how change often happens, informed by an anthropological case study of NTD policy change in practice. We do not argue that conventional ToC models ignore context or uncertainty altogether. Rather, our findings show that, in practice, especially in proposal-stage diagrams, ToC models often focus heavily on linear pathways and planned mechanisms, while treating assumptions and context as background notes rather than as active forces that can change how policy develops. Insights are drawn from a three-year anthropological research project examining how policy change related to NTDs unfolds in practice, focusing on the experiences of researchers and public health practitioners advocating internationally for three politically neglected NTDs: scabies, mycetoma, and podoconiosis. Methods include in-depth interviews, document analysis, and ethnographic observation. Narrative ethnographic analysis reveals that policy change in practice is often multidirectional, contingent, and shaped by happenstance. Individual biographies, emotional connections, and sustained personal commitment, observed ethnographically, operate as integral elements of policy change rather than as contextual add-ons, alongside more formal mechanisms. Dramatic events, such as the outbreak of the 2023 Sudan civil war, should not be understood as unusual disruptions of an otherwise stable Theory of Change, but as reminders of the limits of very rigid or mechanical models in capturing real-world unpredictability. Drawing on African ontological philosophy and rhizome theory, this paper proposes a plural and relational perspective on the reality of change. It subsequently argues for a reimagined Theory of Change and suggests practical ways of working with ToC that treat happenstance, serendipity, emotion, and human relationships as constitutive elements of change rather than residual factors. Such an approach may illuminate opportunities for influence that more linear models overlook and offer a more relatable and supportive way of thinking for those engaged in policy advocacy, contributing to more equitable global health responses.
This commentary examines the serious implications of the United States’ (US) decision to withdraw funding from the World Health Organization (WHO) and the United Nations (UN) system for maternal and child health and nutrition in Latin America and the Caribbean (LAC). The region has made significant progress in reducing maternal and infant mortality through coordinated efforts led by WHO, PAHO, and other UN agencies, as an example, infant mortality decrease in LAC by 67% between 1990 and 2015. However, many countries, particularly low-income countries and small island nations, remain highly dependent on international funding and technical support for essential services, such as maintaining immunization coverage and reducing maternal and infant mortality. Importantly, the impacts on the health of LAC due to the US departure from WHO can be devastating, by contributing to the weakening of epidemiological surveillance, the reduction of the capacity to respond to disasters and other public health emergencies, and affecting services for vulnerable populations, such as women and children. The US, historically the largest WHO donor (22% of its budget), has supported essential programs such as vaccination, neonatal care, nutrition, and health services for migrant populations. This major disruption in funds is especially concerning for vulnerable communities, and will likely increase the risk of disease resurgence. It will also weaken regional preparedness for future pandemics. This commentary calls for urgent action from LAC governments to safeguard public health. Recommended strategies include diversifying funding through earmarked taxes, social impact bonds, and public-private partnerships, and increasing domestic health investment. Allocating at least 2% of GDP to maternal and child health could help mitigate the impact of global policy shifts and reduce internal inequities, ensuring continued progress in the region.
Women of refugee background in high-income countries experience disproportionately poorer maternity care experiences and maternal health outcomes compared to non-refugee women. Their maternity care needs remain under-recognised and under-researched. This qualitative systematic review aimed to synthesise evidence on (1) what women of refugee background need from maternity care in high-income countries, and (2) the barriers and enablers experienced by health, social, and community-based maternity care professionals providing maternity care to this population. Following the JBI methodology for systematic reviews, five databases were searched for peer-reviewed qualitative studies published in English between 2013 and 2025. Eligible studies were screened, data were extracted and appraised critically for methodological quality. Findings were synthesised using meta-aggregation and the overall confidence in synthesised findings were assessed using the JBI ConQual approach. The EQUIP framework was applied to the findings to ensure health equity considerations were captured. Fifty-six studies met the inclusion criteria. Three synthesised findings were generated: (1) Structural and systemic factors shape the provision of and access to equity-oriented maternity care; (2) Key components to equity-oriented maternity care are: trauma-informed care, culturally responsive care, woman and family-centred care, and continuity of care and carer; and (3) women’s settlement experiences influence their transition to new healthcare systems. Addressing the persistent health inequities faced by women of refugee background in high-income countries requires systemic reform, sustainable workforce investments and specialised training for care providers. Further research on the co-design of equity-oriented care interventions is also needed to ensure maternity services are responsive to the needs of this population. The online version contains supplementary material available at 10.1186/s12939-026-02848-5.
Multimorbidity-the co-occurrence of two or more chronic health conditions-has become a major public health challenge in ageing societies. However, most research continues to frame it as a clinical or epidemiological issue, overlooking the role of social determinants and healthcare system dynamics. This study investigates the patterns, experiences, and structural implications of multimorbidity in southern Spain, aiming to uncover how health inequalities shape disease profiles and care experiences in one of the most deprived regions of the country. We employed a mixed-methods sequential explanatory design. The quantitative phase was based on a cross-sectional telephone survey of 1,592 individuals aged 50 and over with multimorbidity. Latent Class Analysis (LCA) was used to identify multimorbidity patterns based on 33 chronic conditions. Associations with sociodemographic factors and healthcare utilisation were analysed using chi-square tests. The qualitative phase consisted of 18 semi-structured interviews with healthcare professionals and patients, analysed thematically to explore lived experiences, care trajectories, and institutional barriers. Five multimorbidity patterns were identified: unspecific, cardiometabolic, musculoskeletal, musculoskeletal-mental, and complex multimorbidity. These patterns showed clear social stratification: complex and musculoskeletal-mental profiles were more prevalent among low-income individuals, women, and residents in deprived areas. Healthcare utilisation also varied across patterns, with higher service use in more complex profiles. Qualitative findings revealed that multimorbidity was experienced as a cycle of physical decline, emotional vulnerability, and systemic neglect. Patients faced difficulties in treatment adherence, experienced long waiting times, and often relied on informal caregiving, predominantly by women. Healthcare professionals highlighted systemic fragmentation, lack of coordination, and the inadequacy of clinical guidelines for complex cases. Multimorbidity in this context is not merely a clinical challenge but a socially embedded condition shaped by structural inequality and institutional failures. Health systems must move beyond single-disease logic and adopt integrated, equity-oriented models of care that consider the syndemic nature of multimorbidity. This study highlights the need to incorporate social determinants into chronic care strategies and to prioritise the lived experiences of patients and caregivers in future health policy and planning.
Elder abuse is a significant public health issue, particularly among those from ethnic minorities who often face unique cultural and social challenges that may exacerbate their vulnerability. However, research on elder abuse in this population remains limited. This study aimed to explore the prevalence of vulnerability to abuse among older ethnic minorities in China and to develop a risk assessment model to inform the development of prevention strategies in this population. From February to September 2024, a cross-sectional study was employed to survey 314 older adults from ethnic minorities in Chenzhou, Yongzhou, and Jishou, in Hunan Province of China. The questionnaire included the Vulnerability to Abuse Screening Scale (VASS), the UCLA Loneliness Scale-8 (ULS-8), and the Patient Health Questionnaire-9 (PHQ-9). Statistical analyses were performed using the chi-square test and logistic regression. The overall prevalence of self-reported elder abuse risk among older ethnic minorities in China was 58.92%, with the main types being psychological abuse (34.08%), physical abuse (29.94%), neglect (28.34%), and financial exploitation (13.06%). Loneliness and depressive symptoms were identified as risk factors for elder abuse vulnerability (odds ratio [OR] = 1.098 and 1.101, respectively), whereas living in rural areas and receiving community support were identified as protective factors (OR = 0.565 and 0.520, respectively). The risk assessment model was developed as follows: logit(p) = - 1.154 - 0.571×living in rural areas - 0.653× community support services + 0.094×loneliness + 0.096×depressive symptoms. The area under the receiver operating characteristic (ROC) curve of the model was 0.744, with a sensitivity of 0.568 and specificity of 0.860. The Hosmer-Lemeshow goodness-of-fit test showed a P value of 0.383. The prevalence of self-reported elder abuse risk among older ethnic minorities in China is relatively high and is associated with living in rural areas, receiving community support services, loneliness, and depressive symptoms. The prediction model developed in this study has satisfactory discriminative efficacy and holds certain social application value. These findings inform policymakers and service providers to promote community support services, integrate mental health interventions, and improve older adults' rights protection networks in ethnic minorities to reduce the vulnerability to abuse. Not applicable.
Trust and mistrust shape how people engage with health organizations, influencing cooperation, compliance, and institutional legitimacy. While trust supports collective action, mistrust can reflect rational responses to inequity or institutional failure. Yet evidence on how these constructs are defined, measured, and addressed remains fragmented. This review synthesizes two decades of research to clarify definitions, determinants, measurement tools, and interventions related to trust and mistrust in health organizations. PRISMA guidelines were followed and the protocol was registered at PROSPERO registry for systematic reviews. We searched PubMed, Scopus, Web of Science and PsycINFO from inception to October 2025 for studies on trust or mistrust directed at health organizations. Eligible studies examined conceptualisations, determinants, instruments, and interventions. Two reviewers independently screened, extracted data, and appraised study quality (KMET, JBI). We included 149 studies from 52 countries (2003–2025); 71.8% came from high-income settings, and 92.6% were empirical, predominantly cross-sectional (55.7%). Trust was defined in 91.3% of studies; mistrust was conceptualized as a distinct construct shaped by structural, historical, and social inequities, rather than simply the absence of trust. Determinants clustered at individual, organizational, and systemic levels. Across quantitative studies, organizational characteristics constituted approximately two-thirds of all statistically tested predictors of trust, particularly transparent communication (42.3%), competence and service quality (38.3%), and perceived fairness (18.1%). Individual factors were key drivers of mistrust, while systemic factors were shaped by governance quality, corruption, and broader issues of equity. Only 29.5% of studies used validated instruments (14 distinct scales), mostly developed and applied in U.S. settings, with limited cross-cultural validation. Thirty-seven intervention studies (24.8%) evaluated strategies across five domains; community engagement and governance reforms showed the most consistent improvements in trust-related indicators, but evidence was largely short-term and rarely linked to behavioural or system-level outcomes. Trust functions as both a determinant and an indicator of equitable health-system performance. Progress requires validated, culturally adaptable measures and interventions that address the structural and historical roots of mistrust, especially among marginalized groups. Sustained investment in transparent governance, participatory communication, fair service delivery, and responsible digital infrastructures is essential to building trusted and resilient health organizations. Prospero Protocol number CRD420251155996. The online version contains supplementary material available at 10.1186/s12939-026-02819-w.
Responses to health misinformation increasingly emphasize the importance of community engagement, yet the role of participation and power sharing remains under-theorized and inconsistently described in the peer-reviewed literature. Drawing on findings from the systematic review Overcoming Health Misinformation in Marginalized Groups, which examined 32 studies evaluating approaches to tackling health misinformation, we reflect on how the depth and quality of community participation shape trust, engagement, and intervention success. We argue that sustained partnership, shared decision-making, and local ownership enhance message credibility and reach by embedding health information within trusted social contexts. We propose strengthening equity-focused responses through structured reporting tools that center power, trust, and co-production as practical design principles rather than implementation add-ons. Making participation visible is critical if community engagement is to move beyond rhetoric and contribute meaningfully to addressing health misinformation in contexts of low institutional trust.