Background:Evidence on the impact of adverse childhood experiences (ACEs) on multidimensional wellbeing, including health-related quality of life (HRQoL) and quality-adjusted life-years (QALYs), remains inadequate, particularly among young people. This study examines how ACEs and their interactions with sex, ethnicity, and socioeconomic status (SES) are associated with HRQoL and QALYs in United Kingdom (UK) adolescents.Methods:Baseline and follow-up data from the Determinants of Adolescent Social Well-being and Health (DASH) Study (N = 6648) and HeadStart Cornwall (HeadStart) (N = 4575) were used. ACE data were sourced from self-reports and official records and measured as binary and count variables. The Strengths and Difficulties Questionnaire (SDQ) was mapped to the Child Health Utility 9D (CHU9D) to calculate utility values for QALY estimation.Results: Over the 3- and 2-year follow-up periods, mean accumulated QALYs were 2.30 (standard error [SE]: 0.002) (DASH) and 1.45 (SE: 0.004) (HeadStart). The occurrence of any ACEs, self-reported and officially recorded, respectively, reduced QALYs by 0.064 (SE: 0.021) (DASH) and 0.060 (SE: 0.021) (HeadStart). These translate to losses of 23 (DASH) and 22 (HeadStart) days over the follow-up period. A greater count of ACEs was associated with stronger effects. Dose-dependent interactions were significant only for ACEs-ethnicity and ACEs-sex (≥2 ACEs), with White adolescents and females experiencing greater QALY losses as the number of ACEs increased.Conclusions:ACEs, whether self-reported or officially recorded, were associated with greater QALY losses, with the strength of association increasing as the number of ACEs increased. Furthermore, White and female adolescents exposed to a greater number of ACEs had the highest QALY losses. Further studies are needed to investigate the moderation of these associations and the mechanisms underlying the associations between ACEs and HRQoL/QALYs to inform targeted interventions.

BACKGROUND:Adolescence is a sensitive period when suicidal ideation can peak. Although traumatic life events are a well established risk factor for suicidal ideation, the role of cumulative ordinary life events across multiple dimensions, such as family, autonomy, and sexuality, remains underexplored. Crucially, no evidence is available on how multidimensional trajectories of cumulative exposure to such events relate to suicidal ideation throughout adolescence. We aimed to examine how cumulative and domain-specific trajectories of ordinary life events during adolescence relate to suicidal ideation. METHODS:In this multinational, prospective cohort study, we used longitudinal data from the IMAGEN cohort, gathered from eight centres in Germany, France, Ireland, and the UK between January, 2008, and January, 2010, to model trajectories of exposure to life events during adolescence, and to quantify the association between trajectory group and suicidal ideation. Participants were assessed at ages 14, 16, 19, and 23 years, and key inclusion criteria included having the capacity to provide informed assent or consent, and having parental completion of perinatal and developmental history. Exposure to 39 life events across seven dimensions (family, accidents, distress, autonomy, deviance, sexuality, and relocation) were assessed using the Life Events Questionnaire (LEQ), administered at each of the study timepoints. Childhood maltreatment was also assessed, using the Childhood Trauma Questionnaire, administered once at age 19 years. The primary outcome was the number of participants with suicidal ideation across trajectories, assessed via a dedicated item in the LEQ at the first three timepoints. We also compared self-harm and suicidal ideation responses from the Developmental and Well-Being Assessment at the first three timepoints. Latent trajectory analysis was used to identify classes of cumulative life event exposure across repeated assessments: high, mid-high, mid-low, and low. The association between trajectory group and suicidal ideation was quantified using logistic mixed model regressions, adjusting for childhood maltreatment and demographic covariates. No individuals with lived experience of suicidality or mental health conditions were involved in the design, conduct, or reporting of this research. FINDINGS:At baseline, 2161 adolescents, enrolled between January, 2008, and January, 2010, were included in the cohort (1106 [51·2%] female and 1055 [48·8%] male). Sample sizes at subsequent waves were 1581 at first follow-up (which took place between January, 2011, and January, 2012), 1474 at second follow-up (between January, 2013, and January, 2015), and 1331 at third follow-up (between January, 2016, and January, 2019). At each timepoint, the high trajectory group (1125 [52·1%] of 2161 participants) had the highest proportion of participants with suicidal ideation (90 [8·0%] of 1125 at pre-baseline, 127 [11·3%] of 1125 at age 14 years, 102 [13·4%] of 759 at age 16 years, and 78 [11·0%] of 709 at age 19 years). After controlling for demographics and childhood maltreatment, the high trajectory group had the highest predicted probability of suicidal ideation at each timepoint. Life events in the family dimension predicted adolescent suicidal ideation (marginal R2GLMM=0·078) more than those in all remaining dimensions combined (marginal R2GLMM=0·073). INTERPRETATION:We found that higher cumulative exposure to ordinary life events across multiple dimensions is associated with higher suicidal ideation in adolescence, with life events occurring within the family environment carrying the highest risk. These results point to the importance of evaluating different types of everyday life event exposure, not just childhood trauma or maltreatment, when assessing suicidal risk in adolescents. FUNDING:Abroad Advanced Study Fellowship, Chang Gung Medical Foundation, Taiwan; National Science and Technology Council, Taiwan; Medical Research Council, UK.

Introduction Indigenous adolescents experience unique biopsychosocial challenges compounded by cultural disruption, territorial displacement, and systematic marginalization. These factors contribute to elevated rates of psychological distress and suicide among Indigenous adolescent, necessitating culturally responsive mental health programmes that center youth voice and cultural values. Objective To develop and evaluate adolescent-led art-based vignettes as a culturally sensitive methodology for promoting mental health discussions among Kaingang Indigenous adolescents in the IMPACT study (Implementation of a multi-sectoral programme to improve Indigenous adolescent mental health in Brazil and Dominica) Method We conducted an exploratory qualitative study using participatory action research principles. Twenty-four Kaingang adolescents (ages 10-18) from two Indigenous schools participated in 12 workshops over six months. Participants created vignettes across multiple artistic formats (videos, drawings, songs) addressing school, family, and community contexts. Data collection included 10 group dynamics with adolescents, teachers, health professionals, and community leaders. Thematic analysis following Braun and Clarke’s framework was conducted with cultural validation from community members. Results Participants created 29 vignettes addressing key themes including cultural discrimination, substance use, environmental degradation, family dynamics, and spiritual practices. Protective factors identified included family support, sports participation, and community connections. Risk factors encompassed increased substance use, family conflict, discrimination, and environmental destruction. Vignettes effectively facilitated dialogue about sensitive topics including psychological distress, cultural identity, and belonging while creating safe spaces for collective reflection. Conclusion Adolescent-led vignette creation represents a promising, culturally grounded approach to Indigenous adolescent mental health promotion. This methodology successfully fostered meaningful dialogue, adolescent agency, and reflective engagement while honoring cultural values and community knowledge systems. Despite limitations in sample size, findings support expanding this participatory approach across diverse Indigenous contexts to strengthen intercultural mental health programmes.

BACKGROUND:There is increasing recognition of the challenge of representativeness in data, including economic, social, and ethnic diversity, in biological mental health research. This is a particular challenge in adolescence, where brain and body development are impacted by the environment. The first step in addressing this is understanding the scale of the challenge. As such, this scoping review aims to explore existing literature to identify and understand the needs, barriers, and facilitators in collecting biological data in adolescent mental health research. METHODS:A systematic search identified papers recruiting participants aged 11-18, collecting biological data, and focussing on mental health/related psychopathology. Screening was performed in duplicate, and data charting was iterative. RESULTS:The initial search identified 13,752 papers. After removal of duplicates and screening exclusions, 962 papers were included; 892 were explored for recruitment, retention, and engagement. Sample sizes <99 were most common (54.4%), and health settings (45%) were the most frequent recruitment source. As labels for 'barriers', 'facilitators', and 'needs' were rarely used, information on recruitment, retention, and engagement (e.g. strategies for stakeholder engagement) were explored as a proxy. Only 8.6% of papers reported engagement strategies; fewer evaluated their efficacy. Less than half (45.6%) reported retention data, with reasons for lost data mostly relating to the nature of the data collection. CONCLUSIONS:Papers do not adequately report the methods used to ensure sufficient collection of representative data. Limited reporting challenges whether or not facilitators are being implemented. Advancing the field requires detailed guidelines. We present recommendations that serve as a first step towards this development.

BACKGROUND:Climate change has severe health impacts, particularly for populations living in environmentally sensitive areas such as riversides, slopes, and forests. These challenges are exacerbated for Indigenous communities, who often face marginalisation and rely heavily on the land for their livelihoods. Despite their vulnerability, the perspectives of Indigenous populations on climate change and its impacts remain underexplored, creating a critical gap in the literature. This study explored the perceptions of Indigenous Brazilian university students on how climate change affects their daily lives and gathered their insights on potential adaptations to mitigate climate change-related impacts. METHODS:Using a participatory arts-based approach, participants captured photographs reflecting their lived experiences with climate change. Follow-up interviews provided a narrative framework for qualitative analysis, enabling participants to articulate the strengths and concerns of their communities while transcending cultural and linguistic barriers. RESULTS:The study revealed key themes, including (1) the fragility of ecosystems critical to Indigenous livelihoods, (2) the erosion of traditional knowledge systems due to environmental and social disruptions, and (3) the need for community-driven strategies to protect territories and preserve cultural identities. Participants highlighted the interconnectedness of their cultural values with environmental stewardship, emphasising the importance of maintaining these relationships as a form of resilience. CONCLUSION:This study underscores the importance of protecting Indigenous territories and respecting their cultural identities to safeguard their survival and traditions. The voices of Indigenous university students provided valuable insights into community-based adaptations and strategies for mitigating the impacts of climate change.

Sedentary lifestyle is a major risk factor for cardiovascular diseases (CVDs) which account for 8% of Kenya's non-communicable disease (NCD) burden. Prevalence of physical inactivity remains high globally. There is paucity of data on physical activity levels in rural Sub-Saharan Africa to inform effective interventions. This study sought to establish levels and factors associated with physical activity in a rural population in Kenya. This was a cross-sectional study in Vihiga, a predominantly rural County in Kenya. Participants were adults aged ≥18 years drawn from four community markets. Stratified sampling by ecological zones and rural/urban status was used to select the four markets and Sampling the Next Customer Exiting the Market method for the respondents. Researcher administered e-questionnaire adapted from International Physical Activity Questionnaire (IPAQ) was used to collect data. Physical activity was calculated as the sum of all Metabolic Equivalents (MET)-minutes/week. Multivariable binary logistic regression analysis was used to identify correlates of physical activity. Out of the total 375 (m: 49%; f: 51%) participants, 27% were physically inactive (m: 22%; f: 32%;) and 42% engaged in low level physical activity. Majority of the respondents (75.5%) engaged in transportation-related physical activity while 32% engaged in leisure physical activities. The odds of being physically inactive were 1.93 times higher for females, 2.62 higher for those aged ≥65 years, and 3.62 higher for those with high health literacy. 48% with high health literacy were in the early working age group (15-24 years). Majority (53%) received health information from healthcare workers, especially for the 60% physically inactive participants. This study highlights the need for targeted community interventions to address the observed physical inactivity especially among women and older adults in rural Kenya.

Peer-relationships are critically important for adolescent behavior, but how peer-friendship network composition and structure influence adolescent self-harm is less clear. The aim of this cross-sectional study was to explore the association between in-school peer-friendship networks, gender, and self-harm among inner-city adolescents. Participants were 2203 adolescents (mean age = 12.5 years, SD = 1.0; 53

BACKGROUND:Type 2 diabetes (T2D) is up to three times more common in people of Black African and Black Caribbean heritage living in the UK, compared to their White British counterparts. Structured education is the cornerstone of care but is less successful for people from minority ethnic groups. Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) was developed to support diabetes self-management in people of Black African and Caribbean heritage living with T2D in the UK. The intervention was designed using COM-B/behaviour change wheel methodology to specify the theory of change. In a process evaluation study, we explored how the selected behaviour change techniques (BCTs) supported behaviour change in the intervention. METHODS:Focus groups and interviews were conducted with participants who were randomised to receive the HEAL-D intervention in a feasibility trial. A topic guide directed discussions to explore experiences of HEAL-D, key learnings and impact, and behaviour change; the interviews gave the opportunity to probe further the focus group themes and areas requiring clarification. Sessions were audio-recorded and transcribed. Framework analysis was used to explore how the selected BCTs supported behaviour change in those attending HEAL-D. RESULTS:Thirty-six participants took part in one or both activities (44% Black African, 50% Black Caribbean, 6% Mixed race; 61% female, 83% first-generation; mean age 59.5 years, SD 10.02). Participants reported increased physical activity, reduced carbohydrate portion size and engagement in weight monitoring behaviour. BCTs to increase social opportunity (social comparison, social support) and overcome motivational barriers (credible sources and modelling) were effective in addressing cultural barriers relating to diet, stigma and health beliefs. BCTs to develop capability (demonstration, instruction, information on health consequences) were effective because of the cultural salience of the developed components. Less impactful BCTs were problem solving, graded tasks, goal setting, and feedback on outcomes. CONCLUSIONS:BCTs in the HEAL-D intervention were effective in supporting behaviour change, particularly those promoting social opportunity, as normative cultural habits and beliefs can conflict with diabetes self-management guidance. In addition, lifestyle interventions should include opportunity for experiential learning alongside culturally salient information provision. TRIAL REGISTRATION:number: NCT03531177, May 18th 2018.

Introduction Black and Asian women experience significantly higher rates of mortality and morbidity perinatally compared with white women and are more likely to lose their babies. These groups are also under-represented in clinical research, resulting in evidence that may not be generalisable. Tools have been developed to facilitate the inclusion of ethnic minority groups, but it is unknown to what extent representation and inclusion are considered in maternity trials.Aim To provide an overview of how ethnically diverse recruitment is considered and reported in maternity trials in the UK.Methods A scoping review was conducted, undertaking a systematic search to identify published trial protocols and their subsequent results papers, conducted within the UK, recruiting women during pregnancy or within 6 weeks postnatally between 2004 and 2024.Data was extracted from protocols on whether representation of participants was considered in the study design and if specific recruitment and retention strategies were planned for ethnic minority groups.Data extracted from results papers identified whether representation of participants was discussed and if recruitment strategies were discussed; these were compared against the protocol.Results A total of 96 published protocols met the inclusion criteria; 8 mentioned specific recruitment strategies and 5 mentioned specific retention strategies. Only two included both recruitment and retention strategies. The most common strategies included providing different types of language support and adapting interventions to be culturally appropriate. Strategies were not evaluated.67 results papers were available. Ethnicity was reported in 57 papers, with heterogeneity of categories between papers. Only 32 papers discussed representativeness of participants.Conclusion Few maternity trials report considerations on how they ensure they are recruiting and retaining ethnically representative participants. Minimal discussion is undertaken around the extent to which trial participants reflect the population to which findings will be applied.Further work is needed to support implementation and evaluation of inclusive research guidance. Failing to ensure those from ethnic minority groups are included in research can exacerbate inequalities.

This study aimed to explore longitudinal associations between bullying victimisation, coping, and self-harm among adolescents living in a diverse, densely-populated urban population in London, United Kingdom. Data on bullying victimisation, dispositional use of four coping strategies (active, avoidant, distraction, support seeking), and self-harm were drawn from REACH (Resilience, Ethnicity and AdolesCent mental Health), an accelerated cohort study of adolescent mental health in South London. Data was available for 3,060 adolescents aged 11–14 years (Mage = 12.4, 50.6

Young people in the MENA region face significant challenges due to socio-political instability, ongoing conflicts, and inequitable social and economic policies. These factors, combined with global threats like climate change and economic instability, hinder the potential of the region's 140 million young people aged 10–24. Addressing these compounded crises is crucial for the future of the region. It is essential to understand the contextual factors shaping young people's health outcomes through their own perspectives. Photovoice, a participatory research method, has shown promise in engaging young people in research. This scoping review aims to map the literature on photovoice studies that addressed health and its determinants among young people in the MENA region. It also seeks to highlight the challenges and strengths of employing the photovoice methodology in this context. The review included literature reporting photovoice projects that addressed young people's health and/or its social determinants, where participants took photos and engaged in discussions based on these images. Studies involving young people aged 10–24 years and focusing on photovoice in the MENA region were considered. Both peer-reviewed journal articles and grey literature with sufficient information addressing the review questions were included. The review followed the JBI Scoping Review Methodology and involved searches of seven English databases, two Arabic databases, and grey literature through Google search. Eleven studies/projects were included in the analysis. Most of the literature came from non-profit organizations, with few studies from peer-reviewed articles. The included studies focused on socio-economically disadvantaged, vulnerable, and marginalized young people, addressing topics such as environment, social integration, safety, and youth empowerment. The implementation of photovoice varied across studies, and there was limited participation of young people throughout the research process. The scoping review revealed a scarcity of literature on the use of photovoice among young people to address health inequalities and the factors influencing them in the MENA region. Given the public health value of photovoice as an action-oriented research approach that promotes meaningful participation from young people, further research is needed to leverage this methodology to tackle health inequalities effectively.

BACKGROUND:Healthy diet is an essential component of good health, yet many areas of the UK struggle with high burdens of diet-related diseases. Efforts to address diet-related diseases in the London Borough of Newham have had limited success so far, possibly due to the lack of engagement with Newham's distinct local context. Newham is ethnically diverse and within the 20% most deprived areas of England. To engage residents in public health action and encourage approaches that tackle the underlying causes of poor-quality diets, systems approaches were used to co-design healthy diet interventions with residents in Newham. The specific aims of the project described in this paper were to understand residents' perceptions of the determinants of unhealthy diets and identify their desired areas for action. METHODS:Twelve online Group Model Building workshops were conducted with 33 Newham residents from six Community Neighbourhoods. Participants reflected the ethnic and religious diversity of Newham's population. The first workshop explored residents' views of what is causing people to have unhealthy diets. Participants identified areas for action and brainstormed solutions to improve diets in the second workshop. RESULTS:Each workshop produced a neighbourhood-specific systems map of 'what's causing people in Newham to have unhealthy diets'. Residents identified multiple and connected political and economic, physical environment, social environment, and individual level causes of unhealthy diets. Suggested action included increasing food and nutrition education, addressing the unhealthy influence of social media, alleviating poverty and improving food business practices. CONCLUSIONS:Online Group Model Building activities represent a comprehensive yet low cost and low burden method for engaging communities in identifying areas for action to improve diets. The systems maps created in this project with Newham residents have been used to co-develop context-specific food interventions with Newham Council that focus on improving the food environment.

PROBLEM:Women from ethnic minority groups and those living in deprived areas are disproportionately at risks of adverse perinatal outcomes, including stillbirth, preterm birth, and poor-quality care. Despite growing policy attention, it remains unclear which interventions are most effective in addressing these inequalities. BACKGROUND:In the United Kingdom, a national inequalities strategy called NHS CORE20PLUS5 prioritises midwife continuity of care as a targeted intervention for women from Black, Asian and Minority Ethnic backgrounds and those living in the most deprived areas. An intersectional lens offers critical insight into overlapping systems of inequality. AIM:To explore whether a place-based midwifery continuity model can improve care experiences for women living in an ethnically diverse and socially deprived area of South London METHODS: A longitudinal qualitative study was conducted with fifteen women who received care through a community-based continuity model. Semi-structured interviews were carried out across three timepoints: third trimester, 0-3 months postpartum, and 9-12 months postpartum. Narrative analysis informed by intersectionality explored temporal experiences across settings. FINDINGS:Two narrative themes were identified: organisational power and interpersonal power. Organisational power reflected systemic constraints, institutional fragmentation, and women's marginalisation in standard maternity pathways which can contribute to inequity. In contrast, interpersonal power, particularly relationships with named midwives, enabled continuity, trust and engagement. CONCLUSION:This study shows how community-based continuity models can redistribute power and enhance relational care in ways that matter to women. Findings strengthen the evidence for continuity as a protective intervention and inform future policy and service design to address perinatal inequalities.

ABSTRACTBackgroundMental health problems are not distributed equally in society. Our understanding of when social inequalities in mental health emerge is limited. We sought to examine inequalities in trajectories of mental distress in diverse, representative cohorts of adolescents in inner-London.MethodsWe analysed longitudinal data from our cohort study of adolescent mental health, REACH (n=4663; 51% girls, 29% free school meals [FSM], 85% minoritised ethnic groups). We used latent growth curve models to estimate trajectories of mental distress (total, internalising, and externalising scores from the self-report Strengths and Difficulties Questionnaire) from age 11-16 years, overall and by gender, FSM, ethnic group, and their intersections.ResultsWe found strong evidence of differences in trajectories of mental distress by gender and FSM. Higher mean internalising scores in girls (vs. boys) were evident at age 11-12 and this inequality widened year-on-year (difference in mean intercepts: 0.74 [95% CI 0.52, 0.96]; slopes: 0.50 [0.39, 0.61]). Higher mean levels of distress among those receiving FSM (vs. not) were evident at age 11-12 years (e.g., difference in intercepts, general distress: 0.79 [0.19, 1.39]), and this difference, though modest, persisted through adolescence. By ethnic group and intersecting identities, the picture was more complex and mixed. Broadly, Black African youth generally reported better mental health trajectories vs. their peers; Black Caribbean and Mixed Black-and-White youth shared similar trajectories, differing somewhat from Black African; and by age 16, internalising distress was highest among lower-income White British girls.ConclusionsIn diverse inner-cities, adolescence is an important period in the emergence and persistence of some of the inequalities in mental health reported in adults; others are more nuanced.

Objective: Bullying has consistently been highlighted as a risk factor for youth self-harm. Less is known about associations by bullying sub-type (i.e., physical, verbal, relational, cyberbullying), among boys and girls in diverse urban populations. This study aimed to explore: (1) prevalence of bullying and lifetime self-harm; (2) cross-sectional associations between bullying and self-harm. Both aims investigated bullying sub-types and the role of sex. Method: Baseline data on bullying victimization and lifetime self-harm were drawn from REACH (Resilience, Ethnicity and AdolesCent Mental Health), an accelerated cohort study of adolescent mental health in London, United Kingdom. Data on baseline self-harm and sex were available for 3,060 adolescents aged 11-14 years (M-age=12.4, 50.6% girls, >80% ethnic minority groups) from 10 schools. Results: Prevalence of bullying in the past six months was 22.3% and lifetime self-harm was 16.9%. Both were more common in girls than boys (adjusted risk ratios: bullying, 1.13 [1.02,1.25]; self-harm, 1.45 [1.03,1.86]). By bullying sub-type, prevalence estimates ranged from 4.1% (cyberbullying) to 16.6% (physical bullying). Bullying was associated with self-harm (aRR 3.35 [2.89,3.82]) for both girls (aRR 3.61 [3.07,4.14]) and boys (aRR 2.96 [2.27,3.65]), independent of sex, age, free school meals and ethnic group. All sub-types were associated with self-harm (aRRs 3.16-4.34), for girls and boys. Conclusions: These baseline findings underline the importance of exploring nuances between bullying sub-types and self-harm, by sex or gender.

BACKGROUND:Improved screening uptake is essential for early breast cancer detection, women's health and reducing health disparities. However, minority ethnic and deprived communities often face lower breast cancer screening rates and limited access to culturally tailored educational materials. A recent review found limited culturally tailored materials for breast cancer education. AIM:To investigate the culturally appropriate interfaces and preferences of salon staff in educating their clients about breast cancer METHOD: We used a two-stage approach, following the Double Diamond framework; discover and define phases. Relevant breast cancer materials (i.e., based on cultural appropriateness, English language presentation, and alignment with the UK context) were assessed using the Suitability Assessment of Materials (SAM) toolkit. Interviews with ethnically diverse salon staff provided insights into their needs and preferences for client education materials. Thematic analysis was applied to interview transcripts. RESULTS:Cultural appropriateness was evident in 9/14 (64%) of the materials identified (e.g., targeting black ethnicities with positive representations). Of those, six of them demonstrated an overall SAM rating of 76% ("Superior"). Thematic analysis of interviews identified seven key themes, including the importance of engagement strategies, education and awareness for health promotion, salon staff's role, preferred training methods, supportive materials, inclusivity, representation, and participant satisfaction. CONCLUSION:This study highlights the SAM toolkit's role in selecting suitable educational materials for breast cancer prevention. The research offers prospects for improving breast cancer awareness in ethnically diverse communities and addressing healthcare access disparities, with salon hairdressers emerging as crucial advocates for health promotion.

Background The WHO identifies climate change as the most significant threat to global health systems. Indigenous peoples, whose lives are deeply intertwined with nature, are particularly vulnerable to the impacts of these changes.Objective This study aimed to understand the perspectives of Indigenous stakeholders and public services managers on the interconnectedness of climate change and Indigenous health.Design A qualitative study with 22 Indigenous stakeholders and public service managers on climate change and perceived impact on Indigenous health.Setting and participants Indigenous stakeholders and public service managers on climate change and perceived impact on Indigenous health from Brazil. Data was collected through interviews incorporating two vignette videos depicting environmental and health scenarios. Thematic content analysis was used to analyse the data.Results The analytical process yielded six subcategories that were further grouped into three overarching thematic macro-categories: environmental degradation and climate change in the context of Indigenous peoples; environment, vulnerability and impact on Indigenous mental health; and actions and public health policies for Indigenous peoples.Conclusion The perspectives of Indigenous stakeholders and public service managers on the interconnectedness of climate change and Indigenous health were deeply entrenched in their lived experiences of loss of their lands from deforestation and environmental degradation. They argued strongly for the strengthening of public health policies aimed at the Indigenous peoples, to face many challenges, especially suicide, and to have a voice in decision-making. A sensitive approach that values Indigenous peoples' connections with nature is fundamental to promote their health and well-being.

Introduction Epidemiological transition to NCDs is a challenge for fragile health systems in the Caribbean. The Congregations Taking Action against NCDs (CONTACT) Study intervention proposes that trained health advocates (HAs) from places of worship (PoWs), supervised by nurses at nearby primary healthcare centres (PHCs), could facilitate access to primary care among vulnerable communities. Drawing on participatory and systems thinking, we explored the capacity of local PHCs in three Caribbean countries to support this intervention. Methods Communities in Jamaica (rural, urban), Guyana (rural) and Dominica (Indigenous Kalinago Territory) were selected for CONTACT because of their differing socio-economic, cultural, religious and health system contexts. Through mixed-method concept mapping, we co-developed a list of perceived actionable priorities (possible intervention points ranked highly for feasibility and importance) with 48 policy actors, healthcare practitioners and civic society representatives. Guided in part by the concept mapping findings, we assessed the readiness of 12 purposefully selected PHCs for the intervention, using a staff questionnaire and an observation checklist to identify enablers and constrainers. Results Concept mapping illustrated stakeholder optimism for the intervention, but revealed perceptions of inadequate primary healthcare service capacity, resources and staff training to support implementation. Readiness assessments of PHCs identified potential enablers and constrainers that were consistent with concept mapping results. Staff support was evident. Constraints included under-staffing, which could hinder supervision of HAs; and inadequate essential NCD medicines, training in NCDs and financial and policy support for embedding community interventions. Despite a history of socio-political disadvantage, the most enabling context was found in the Kalinago Territory, where ongoing community engagement activities could support joint development of programmes between churches and PHCs. Conclusion Multi-sectoral stakeholder consultation and direct PHC assessments revealed viability of the proposed POW-PHC partnership for NCD prevention and control. However, structural and policy support will be key for implementing change.