Results and Strategies for a Diversity-Oriented Public Health Monitoring in Germany

Germany is a country of immigration; 27% of the population are people with a migration background (PMB). As other countries, Germany faces difficulties in adequately including hard-to-survey populations like PMB into national public health monitoring. The IMIRA project was initiated to develop strategies to adequately include PMB into public health monitoring and to represent diversity in public health reporting. Here, we aim to synthesize the lessons learned for diversity-oriented public health monitoring and reporting in Germany. We also aim to derive recommendations for further research on migration and health. We conducted two feasibility studies (interview and examination surveys) to improve the inclusion of PMB. Study materials were developed in focus groups with PMB. A systematic review investigated the usability of the concept of acculturation. A scoping review was conducted on discrimination as a health determinant. Furthermore, core indicators were defined for public health reporting on PMB. The translated questionnaires were well accepted among the different migrant groups. Home visits increased the participation of hard-to-survey populations. In examination surveys, multilingual explanation videos and video-interpretation services were effective. Instead of using the concept of acculturation, we derived several dimensions to capture the effects of migration status on health, which were more differentiated. We also developed an instrument to measure subjectively perceived discrimination. For future public health reporting, a set of 25 core indicators was defined to report on the health of PMB. A diversity-oriented public health monitoring should include the following: (1) multilingual, diversity-sensitive materials, and tools; (2) different modes of administration; (3) diversity-sensitive concepts; (4) increase the participation of PMB; and (5) continuous public health reporting, including constant reflection and development of concepts and methods.

Loneliness: An Immunometabolic Syndrome

Loneliness has been defined as an agonizing encounter, experienced when the need for human intimacy is not met adequately, or when a person’s social network does not match their preference, either in number or attributes. This definition helps us realize that the cause of loneliness is not merely being alone, but rather not being in the company we desire. With loneliness being introduced as a measurable, distinct psychological experience, it has been found to be associated with poor health behaviors, heightened stress response, and inadequate physiological repairing activity. With these three major pathways of pathogenesis, loneliness can do much harm; as it impacts both immune and metabolic regulation, altering the levels of inflammatory cytokines, growth factors, acute-phase reactants, chemokines, immunoglobulins, antibody response against viruses and vaccines, and immune cell activity; and affecting stress circuitry, glycemic control, lipid metabolism, body composition, metabolic syndrome, cardiovascular function, cognitive function and mental health, respectively. Taken together, there are too many immunologic and metabolic manifestations associated with the construct of loneliness, and with previous literature showcasing loneliness as a distinct psychological experience and a health determinant, we propose that loneliness, in and of itself, is not just a psychosocial phenomenon. It is also an all-encompassing complex of systemic alterations that occur with it, expanding it into a syndrome of events, linked through a shared network of immunometabolic pathology. This review aims to portray a detailed picture of loneliness as an “immunometabolic syndrome”, with its multifaceted pathology.

Rural Legal Deserts Are a Critical Health Determinant

We introduce “rural legal deserts,” or rural areas experiencing attorney shortages, as a meaningful health determinant. We demonstrate that the absence of rural attorneys has significant impacts on public health—impacts that are rapidly exacerbated by COVID-19. Our work builds on recent scholarship that underscores the public health relevance of attorneys in civil and criminal contexts. It recognizes attorneys as crucial to interprofessional health care teams and to establishing equitable health-related laws and policies. Attorney interventions transform institutional practices and help facilitate the stability necessary for health maintenance and recovery. Yet, critically, many rural residents cannot access legal supports. As more individuals experience unemployment, eviction, and insecure benefits amid the COVID-19 pandemic, there is a need for attorneys to address these social determinants of health as legal needs. Accordingly, the growing absence of attorneys in the rural United States proves particularly consequential—because of this pandemic context but also because of rural health disparities. We argue that unless a collaborative understanding of these interrelated phenomena is adopted, justice gaps will continue to compound rural health inequities.

Untangling complexity as a health determinant

As the healthcare system has modernized, it has also become rich with complexity. This complexity continues to foster the creation of wicked problems that at first consideration appear inherently insoluble. To compound matters, policy-makers and decision-makers continue to view the healthcare system in a reductionistic, linear manner. This paper advocates that all stakeholders within the system (policy-makers, providers, and patients) become comfortable with complexity as a determinant of health, and offers tools for productively working with complexity, instead of trying to solve it. These tools include complexity heuristics, adjusting to an emergent decision-making paradigm, and easing the anxiety associated with ambiguity and paradox by becoming antifragile. By adopting these methods, the health determinant of complexity within the Canadian healthcare system can be effectively handled. This will lead to sustainable and scalable interventions, strong patient-partners in care, and efficient use of monetary and human resources.

Employment Quality as a Health Determinant: Empirical Evidence for the Waged and Self-Employed

In this study, the authors investigate the health associations of different employment arrangements in the contemporary European labor market. In doing so, a new approach based on the concept of “employment quality” is introduced. Employment quality refers to the multiple dimensions characterizing the employment situation of wage- and self-employed (European Working Conditions Survey 2015 – N = 31,929). Latent class cluster analyses were applied to construct an overarching typology of employment quality for the waged and self-employed. Using logistic regression analyses, strong associations were found with mental well-being and self-reported general health, pointing at a disadvantaged situation for the most precarious employment arrangements. The study shows that employment quality should be taken seriously as a health determinant both among waged workers and the self-employed. Our (novel) holistic approach offers an alternative to current analyses of the health associates of labor market segmentation that were criticized for being overly simplistic and amounting to inconclusive findings.

Systematic Review and Meta-Analysis of Sex-Specific COVID-19 Clinical Outcomes

To successfully mitigate the extraordinary devastation caused by the Coronavirus disease 2019 (COVID-19) pandemic, it is crucial to identify important risk factors for this disease. One such neglected health determinant is the sex of the patient. This is an essential clinical characteristic, as it can factor into a patient's clinical management and preventative measures. Some clinical studies have shown disparities in the proportion between males and females that have more severe clinical outcomes or, subsequently, die from this disease. However, this association has not been unequivocally established. Thus, the purpose of this investigation was to examine the association between male sex and COVID-19 severity. We systematically reviewed the literature, identified non-randomized studies that matched predetermined selection criteria, and performed a meta-analysis to evaluate the proportion of males among four disease severity categories. Appropriate assessment strategies were implemented to assess and minimize potential biases. The results of this meta-analysis indicated that males constituted a significantly higher proportion of those who had adverse clinical outcomes and died from COVID-19. As the coronavirus spread from the East to the West, male sex remained a consistent risk factor. Our results support the establishment of the male sex as an important risk factor for this disease. Early identification and appropriate medical care for males with lab-confirmed COVID-19 may substantially change the course of clinical prognosis, resulting in greater numbers of lives saved.

DOES LEADERSHIP STYLE INFLUENCE HEALTH STATUS OF LEADERS, AND IS IT A NEW DETERMINANT OF HEALTH?

Introduction: The discourse of health and leadership has not empirically established whether leadership styles (transactional, transformational, and laissez-faire) is a health determinant. Objective: This study seeks to examine whether selected demographic characteristics and leadership styles are factors of self-reported general health status. Methods and materials: A standardized questionnaire was developed to evaluate whether or not leadership styles are correlated with health status and if this should be included as a new health determinant. This was administered between August and September 2019. The population for this research was leaders who serve in Seventh-day Adventist Churches in Central Jamaica. Statistical significance was determined a p-value less than or equal to five percentage points (≤ 0.05)– two-tailed test. Multivariate analyzing (logistic binary regression) was used to model factors influencing the good health status of the sampled respondents, and exploratory factor was used to determine the suitability of the indexations such as leadership styles and self-reported health status. Results: Three variables emerged as statistically significant predictors of self-reported good health status of leaders (transformational leadership: OR=19.241, 95%CI: 3.225-114.8, R2=47.6%; Transactional leadership: OR=0.143, 95%CI: 0.31-0.664; and age of respondents: OR=0.954, 95%CI: 0.911-0.999). Based on the Nagelkerke R Square, 48% of the variance in good health is explained by age, transactional and transformational leadership styles. Conclusion: Leadership style is a potential determinant of health (social determinant) that offers further explanation of people’s well-being (health) that cannot be discounted any longer. Keywords: Health determinants, transactional leadership, transformational leadership, laisses-faire leadership

An ethnographic exploration of factors that drive policing of street-based female sex workers in a U.S. setting - identifying opportunities for intervention.

Background: Building on a broader sociological discourse around policing approaches towards vulnerable populations, increasing public health and human rights evidence points to policing practices as a key health determinant, particularly among street-based sex workers. Despite the importance of policing as a structural health determinant, few studies have sought to understand the factors that underlie and shape harmful policing practices towards sex workers. This study therefore aimed to explore the drivers for policing attitudes and practices towards street-based cisgender female sex workers.Methods: Drawing on ethnographic methods, 280 hours of observations with police patrol and 10 stakeholder interviews with senior police leadership in Baltimore City, USA were carried out to better understand the drivers for policing strategies towards cisgender female sex workers. Analysis was data- and theory-driven, drawing on the concepts of police culture and complementary criminological and sociological literature that aided exploration of the influence of the ecological and structural environment on policing practices.Results: Ecological factors at the structural (e.g., criminalization), organizational (e.g., violent crime control), community and individual level (e.g., stigmatizing attitudes) emerged as key to shaping individual police practices and attitudes towards cisgender female sex workers in this setting. Findings indicate senior police support for increased alignment with public health and human rights goals. However, the study highlights that interventions need to move beyond individual officer training and address the broader structural and organizational setting in which harmful police practices towards sex work operate. Conclusions: A more in-depth understanding of the circumstances that drive law enforcement approaches to street-based sex work is critical to the collaborative design of interventions with police in different settings. In considering public health-police partnerships to address the rights and health of sex worker populations in the U.S. and elsewhere, this study supports existing calls for decriminalization of sex work, supported by institutional and policy reforms, neighborhood-level dialogues that shift the cultural landscape around sex work within both the police and larger community, and innovative individual-level police trainings.