The WHO Regional Office for Europe conducted 9 country studies of migration of doctors and nurses. This paper identifies similarities and variations in migratory flows, factors that influence them, and related policy responses. The 9 countries include 4 that integrate the European Economic Area (EEA), Ireland, Malta, Norway, and Romania, and 5 non-EEA, Albania, Armenia, Georgia, Moldova, Tajikistan. Case writers used a common study template that covered international outflows and inflows, mobility push, and pull factors, and related policy interventions. Data sources include the WHO/Europe-OECD-Eurostat joint questionnaire and country databases. Emigration is motivated by low wages, dissatisfaction with working conditions, inadequate practice environment, excessive workloads and lack of opportunities for professional development. Flows for doctors and nurses vary in volume over time, and in countries of origin and destination. Pull factors include the free circulation of persons within the EEA for citizens of member states, easy access to work permits, common or easily learned language, and the presence of a diaspora in a destination country. Policies to improve retention include increasing the number of training places, making remuneration and working conditions more attractive and compulsory service. All countries have some health workforce development plan, but implementation is a challenge everywhere. Policies should be tailored to country labour market conditions, migration trends, and institutional capacity. Better understanding of migration flows will improve the effectiveness of policy responses.
BACKGROUND:In tuberculosis (TB) care, adherence is often assessed using a simple 80% threshold, which may overlook meaningful patterns. We analyzed adherence trajectories among individuals treated for rifampicin- or multidrug-resistant TB (RR/MDR-TB) in the endTB observational study to identify more informative patterns. METHODS:We applied a joint latent class mixed model to classify adherence trajectories and assess their relationship with treatment outcomes. Model performance was compared to common classification methods (eg 80% adherence threshold) using Kendall's τb and area under the receiver operating curve for predicting unsuccessful outcomes. RESULTS:Among 1787 individuals, we identified 4 adherence patterns: "consistently high" (72.5%), "high to low" (14.3%), "low to high" (7.3%), and "consistently low" (5.9%). Compared to the "consistently high" group, those in "high to low" (hazard ratio [HR] = 23.2; 95% confidence interval [CI]: 15.7-24.3) and "consistently low" (HR = 43.2; 95% CI: 26.2-71.5) groups had significantly higher risk of unsuccessful outcomes, while the "low to high" group did not (HR = 0.7; 95% CI: .1-3.8). Our trajectory model more accurately predicted outcomes than common classification methods (P < .01). CONCLUSIONS:Group-based trajectory modeling provides more nuanced insights into adherence patterns than conventional classification methods. Our findings demonstrate that patients with RR/MDR-TB who exhibited initial poor adherence followed by subsequent improvement achieved clinical outcomes comparable to those with consistently high adherence throughout treatment. This finding challenges the prevailing assumption that sustained high adherence is necessary for treatment success, suggesting that adherence patterns, rather than overall adherence rates, may be more predictive of clinical outcomes in the management of RR/MDR-TB.
BACKGROUND:Alcohol is a leading cause of global death and disability yet labelling requirements for alcohol products remain inconsistent across WHO Member States and comparatively weak in Canada, where Bill S-202 to mandate warnings is currently under review. In contrast, tobacco and cannabis are subject to more rigorous government mandated labelling requirements. This study compares federally-mandated labelling requirements for alcohol, tobacco, and cannabis across WHO regions to contextualize Canada's position within the global landscape and assess whether Canadian alcohol labelling requirements align with the documented health burden. METHODS:A systematic secondary data synthesis and document review of labelling regulations across all 194 WHO Member States was conducted in February 2023. Sources included WHO reports and regulatory databases on alcohol, tobacco, and cannabis labelling. Comparative analyses were undertaken across WHO regions. Labelling requirements were categorized by the presence and content of health warnings, including labelling design elements, and ingredient information, including allergens, calories, and additives, and content displays. RESULTS:While 32.5% of WHO Member States mandate alcohol health warnings, 84.5% WHO Member States mandate tobacco health warnings. Further, all jurisdictions with legal recreational cannabis require multiple labelling measures, including health warnings and ingredient information. In Canada, alcohol remains the only controlled substance without federally mandated warning labels. INTERPRETATION:Strengthening alcohol labelling requirements represents a policy strategy with high population reach to support informed decision-making and reduce substance-related harms. Establishing evidence-based minimum international standards for alcohol labelling could strengthen global regulatory coherence, while leadership from countries such as Canada may help catalyse progress internationally.
BackgroundIn Ukraine, historical challenges of vaccination behavior and uptake, rooted in complex social and structural factors, have long hindered efforts to reach the 95% childhood vaccination coverage for herd immunity. These difficulties were further exacerbated by the Russian Federation's full-scale invasion in February 2022. Internally displaced people (IDPs) encountered additional barriers in host regions already under considerable strain, and vulnerable regions of Ukraine continued to experience suboptimal routine vaccination coverage and growing misinformation. Empirical research exploring vaccine behavior and uptake using qualitative methods in Ukraine is limited.MethodsThis study employed a qualitative design comprised of 12 online focus group discussions with parents and caregivers, including IDPs, of children under 7 years old between July and August 2024. Regions selected included the Zakarpattia oblast and the frontline areas of Kharkivska, Odeska, and Dnipropetrovska. The analysis was guided by the Capability, Opportunity, and Motivation model of behavior change (COM-B) to identify vaccination behaviors at the individual and community level.ResultsParticipants' capability factors demonstrated moderate knowledge of vaccines, with most of this knowledge held by mothers or female caregivers. The psychological and financial impact of the war has dramatically affected their livelihoods. Strong motivating factors included the need to protect their children from disease. A small number firmly believed the vaccine caused harm and did not vaccinate their child. State-provided free vaccines with origins outside of Europe motivated some participants to pay out of pocket. Factors affecting physical opportunities to vaccination included infrastructure damage, supply issues, and a lack of access to healthcare providers (especially for IDPs), mainly due to the war. Factors influenced by social opportunities included perceived vaccine experiences within family circles and online community groups, and the spread of vaccine rumors and misinformation. Participants heavily relied on family doctors for vaccine-related information, but many reported challenges with information-seeking and access.ConclusionUkraine faces heightened risks of vaccine-preventable disease outbreaks due to war-related disruptions, limiting vaccination opportunities despite strong parental motivation. Improving access to services, increasing vaccine availability, providing tailored public health education, and conducting further research are needed to strengthen routine immunization among children.
Background:Tajikistan has accomplished reductions in maternal, newborn, and child mortality over the past decades through targeted policies and interventions. Challenges remain in providing quality healthcare due to limited resources, geographic barriers, and inadequate infrastructure. We aimed to evaluate the impact of a quality improvement (QI) initiative implemented in ten district hospitals from 2021 to 2024 to improve maternal, newborn, and childcare to accelerate progress towards achieving the Sustainable Development Goals. Methods:A baseline assessment was conducted in 2021, with an endline assessment in 2023, using updated WHO quality assessment tools. A multidisciplinary team of national and international experts evaluated hospital performance across three domains: support systems, clinical management, and organisation of care. Data was collected through observations, interviews, and medical record reviews. Project interventions included working with hospital-level Quality Improvement committees, capacity building in effective perinatal care, and the use of the WHO Pocketbook of Hospital Care for Children. Regular supportive supervision and half-yearly collaborative quality improvement meetings were held among the ten hospitals. We graphically displayed, analysed, and summed the assessment scores. Results:We observed notable improvements in the quality of hospital care, with most facilities progressing from substandard to better-performing categories. Seven out of ten hospitals demonstrated advancements in their maternity and neonatal units, with improvements in clinical management and hospital support systems, including access to drugs and equipment. Challenges remained in paediatric care, with only two of ten hospitals showing improvements in infrastructure and laboratory services, and none improving drug availability. Improvements in infection prevention and control were minimal; however, four in ten hospitals managed to improve their practices despite challenges with resource availability, infrastructure, and current protocols. Conclusions:Comprehensive QI interventions can raise standards of care in resource-limited settings like Tajikistan. Despite measurable progress, systemic barriers persist, with weak infrastructure, unstable workforce, and limited infection prevention and control, requiring targeted investment and political commitment. Sustained success depends on equitable resource allocation, robust monitoring systems, and the promotion of a non-punitive, systems-oriented culture. Scaling up this initiative nationwide is critical to achieving long-term improvements in health.
