Abstract Background Sex and gender both affect health outcomes, often in complex ways that intertwine biological and social influences. While researchers have criticized the conflation of sex and gender in quantitative studies, it remains a challenge to analytically disentangle them. We investigated an approach to conceptualize sex and gender as interrelated constructs embedded within a specific social context and estimate their direct effects on health outcomes simultaneously. Methods To analyze migraine and stroke incidence from 2011 until 2022, we used longitudinal data from the representative German Socio-Economic Panel (SOEP) within a causal framework. We applied a directed acyclic graph (DAG) to formalize hypothesized effects of sex and gender. Gender was modeled as an unobserved latent variable, influenced by sex assigned at birth and indicated by a set of gender-related variables. We codified the causal model as a structural equation model (SEM), enabling the joint estimation of the latent gender construct and the direct effects of both sex and gender on the health outcomes. We tested prior hypotheses in the SEM and explored additional relationships using causal discovery techniques. Results Migraine incidence was 3.1 times higher among participants of female sex (6.2% vs. 2.0%). Sex had the strongest effect on reporting a new migraine diagnosis (β = 0.044, 95% CI [0.033, 0.056], p < .001), while gender showed no direct effect. Stroke incidence was lower among female respondents (1.2% vs. 1.7%), with sex showing a statistically significant negative effect, indicating that slightly fewer female persons reported a new stroke diagnosis (β = -0.010, 95% CI [-0.017, -0.004], p < .01). In contrast, gender showed a small, but significant positive effect (β = 0.006, 95% CI [0.002, 0.009], p < .01), suggesting that gender-related characteristics that were more frequently reported by female individuals had an effect on stroke incidence. Conclusions Both sex and gender differentially affected stroke, whereas only sex showed a direct effect on migraine. We demonstrated that biological and social dimensions of sex and gender can be systematically addressed within the same model including gender as an unobserved latent variable, while remaining attentive to contextual complexity.

In Germany, abortion is criminalised but permitted without punishment through a specific mandatory counselling process. Navigating this highly regulated pathway may be particularly challenging for recently arrived migrants such as asylum-seekers, who often face specific vulnerabilities. The study analyses the barriers to access to abortion for recent migrants in Germany, to identify barriers for recent migrants with unwanted pregnancies by analysing qualitative data from 17 interviews with counsellors providing mandatory counselling, client advocates, and healthcare providers in the federal states of Berlin and Brandenburg. We employed a thematic analysis approach using MaxQDA.We identified two kinds of barriers for migrant access to abortion care in Germany. The first includes barriers that arise from the current legal frameworks for abortion and for migration, specifically related to mandatory counselling for abortion-seekers in Germany, and housing in collective large-scale accommodation facilities for asylum-seekers. The second relates to health system capacity and includes barriers that directly result from the limited and unequal availability of information and services in the languages spoken by clients. Interviews revealed a clear difference between Brandenburg, where abortion services are limited and predominantly provided by white German-speakers, and Berlin, where there is a more diverse network of healthcare providers, client advocates and support persons, relatively better access to care for migrants and language needs are more systemically addressed.Our findings of the disproportionate barriers experienced by migrants and asylum-seekers under the current abortion pathway further underscore the importance of the recommendation for decriminalisation of abortion in the first trimester, and of the diversification of healthcare providers. This would ensure better access to abortion care for migrants and asylum-seekers, themselves often a vulnerable group at higher risk for an unwanted pregnancy.

Introduction During the coronavirus disease-19 (COVID-19) lockdowns, children repeatedly experienced social isolation. Dealing with the resulting post-pandemic health implications remains a challenge. The role of group recreational activities is crucial in promoting children's health; however the implementation can encounter challenges, especially when infections such as COVID-19 are surging.Objectives In this prospective observational study, we aimed to investigate whether safe cohorts can be created through appropriate test strategies to facilitate music trips during the COVID-19 waves. The primary outcome was the occurrence of positive cases during the journey. Secondarily, a survey was conducted to evaluate the physical and mental health status of participants before and after the first journey.Methods Two school music trips were conducted. The first trip (T1) took place from 4 January 2022 to 9 January 2022, and the second trip (T2) from 3 January 2023 to 8 January 2023. For T1, central laboratory SARS-CoV-2 polymerase chain reaction (PCR) pool tests were performed before departure. For T2, prior point-of-care (PoC) PCR pool tests were conducted to validate the findings. A hygiene protocol was mandatory for T1 and recommended for T2.Results Before T1, 95 volunteers underwent PCR laboratory pool testing, which revealed one positive COVID-19 case. During the travel, one student had a positive antigen test. Questionnaires for the mental health status were collected before T1 from 95 participants and again as a follow-up after T1 from 79 participants. There was a significant decrease in cold symptoms among students (p = 0.002). Following this, the perceived risk of infection significantly increased in the students' group (p = 0.019). Additionally, anxiety symptoms [as measured using generalized anxiety disorder (GAD)-7 score] and the fear of getting infected marginally increased in students. All T1 participants indicated that they would be willing to attend a similar trip again. In the initial T2 pool testing, 88 participants took part. Two participants tested positive for SARS-CoV-2, with one solely showing signs of a subsiding infection and the other being highly infectious, which led to the exclusion of the highly infectious participant from the travel. During the trip and the follow-up period, no further cases were reported.Conclusion Both testing concepts effectively identified positive "SARS-CoV-2 cases in advance and prevented transmissions, enabling safe school music trips during the winter. The use of PoC-PCR may be superior in terms of time efficiency and flexibility. Despite the increase in the perceived fear of infection among children, the overall experience of the journey was positive.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the 'Save PDF' action button.

Health-related quality of life (HRQoL) in the context of COVID-19 is not fully understood. We assessed HRQoL using Patient-Reported Outcomes Measurement Information System® measures among 559 former COVID-19 patients and 298 non-infected individuals. HRQoL was captured once up to 2 years after the initial test. Additionally, we described associations of characteristics with impaired HRQoL. Overall, HRQoL scores were inferior among former patients. A meaningful group difference of at least three T-score points was discernible until 12 months after testing for fatigue (3.1), sleep disturbance (3.5), and dyspnoea (3.7). Cognitive function demonstrated such difference even at >18 months post-infection (3.3). Following dichotomization, pronounced differences in impaired HRQoL were observed in physical (19.2% of former patients, 7.3% of non-infected) and cognitive function (37.6% of former patients, 16.5% of non-infected). Domains most commonly affected among former patients were depression (34.9%), fatigue (37.4%), and cognitive function. Factors that associated with HRQoL impairments among former patients included age (OR ≤2.1), lower education (OR ≤5.3), and COVID-19-related hospitalization (OR ≤4.7), among others. These data underline the need for continued attention of the scientific community to further investigate potential long-term health limitations after COVID-19 to ultimately establish adequate screening and management options for those affected.

Access to abortion is recognised as a key component of the right to healthcare. Yet, to this day, abortion in Germany without medical or criminal indication is illegal and treated under the penal code, although not punished if taking place in the first 12 gestational weeks and following a formalised process including mandatory counselling. Our study aimed to critically examine the pathway to abortion necessitated by the current criminalising legal framework in Germany. We conducted a qualitative study between November 2023 and July 2024, using 17 interviews to capture views of abortion-related service providers on barriers and enablers to abortion in Berlin and Brandenburg, applying a thematic analysis approach using MaxQDA. Our findings point to multiple individual barriers to abortion along the pathway, whose complexity itself presents a structural barrier. Even providers were sometimes insecure about how parts of the process worked and what they were or were not allowed to do. We identified a 9-step series of actions which most individuals seeking abortion must undergo to end an unwanted pregnancy, involving multiple health service visits and the repeated need to communicate their personal situation to different authorities. Our study illustrates that the pathway to abortion in Germany produces a state-induced barrier to a fundamental reproductive health service, and in this respect can be viewed as a form of structural violence against pregnant individuals in a critically decisive situation. Our findings support existing recommendations to decriminalise abortion, which would align Germany´s abortion policy with its international commitments and with international best practices as outlined by WHO.

IntroductionLong-term health consequences after mild COVID-19 are not well described. Our aim was to estimate their prevalence and describe the time course of signs and symptoms for a period of up to 24 months after SARS-CoV-2 infection.MethodsWe conducted a cohort study matched for age, sex, and test week among individuals who had attended the public COVID-19 test center at Charité—Universitätsmedizin Berlin, Germany. In early 2022, 576 former COVID-19 patients (>95% non-hospitalized) and 302 uninfected individuals responded to a questionnaire on retrospective monthly symptoms since the test date up to 24 months ago.ResultsSymptoms compatible with long COVID were present in 42.9% (247/576) of former COVID-19 patients, compared with 21.2% (64/302) in the uninfected group. In former patients, unadjusted odds ratios (OR) were highest for disturbed taste/smell (OR 9.1 [95% CI: 4.0–21.1]), memory difficulties (OR 5.1 [95% CI: 2.9–8.9]), and shortness of breath at rest (OR 4.5 [95% CI: 1.9–10.6]). In most former COVID-19 patients, symptoms occurred in one coherent period and resolved after a median of 6.5 months, while taste/smell disturbance and neurological/cognitive symptoms showed longer times until recovery. Factors associated with long COVID-compatible symptoms included hospitalization, symptomatic COVID-19 infection, low household income and female sex.ConclusionPost-infection symptoms in mild COVID-19 patients mostly persist for about half a year, but sometimes longer. Among uninfected individuals who never experienced COVID-19, 21.2% also reported long COVID-compatible symptoms. The current long COVID definition might require revision to prevent misclassification and over-reporting, and to improve diagnosis and prevalence estimates.

Despite existing evidence supporting birth companionship of choice as a simple, low-cost measure to improve quality of care in childbirth, it is inconsistently practiced in many regions. In Sierra Leone, one of the least safe countries for women to deliver a baby, Princess Christian Maternity Hospital (PCMH) began encouraging companionship of choice for women during childbirth in March 2022. However, little is known about the perspectives of healthcare workers or the perinatal experiences of women and their companions. Our objective was to describe the experiences and perceptions surrounding birth companionship of choice among healthcare workers, women, and their companions. We conducted a qualitative assessment at PCMH in August 2022 through eleven focus group discussions and thirteen in-depth interviews with healthcare workers, women, and their companions. Discussions and interviews were recorded, transcribed, and thematically coded for analysis. Women described various means of support from their birth companion and cited trust and the ability to provide expertise as key criteria when choosing a companion. Healthcare workers emphasized that, despite initial hesitation, companionship has been advantageous. However, there were still many challenges for healthcare workers when companions were present in the labor ward, such as maintaining patient privacy. Companions revealed that they were learning about facility-based delivery through companionship and sharing their positive experiences with their community. With a few exceptions, both companions and women reported overall satisfaction with their treatment in the labor ward. Findings suggest that birth companionship of choice is a key component of a positive birth experience, improving perceived quality of care and potentially increasing the number of women giving birth in facilities. It also presents many advantages and challenges for healthcare workers. The presence of a birth companion inside the labor ward increases appreciation for facility-based care and potentially alleviates mistrust between the healthcare system and the community.

Background:Although mobile health (mHealth) interventions have shown promise in improving health outcomes, most of them rarely translate to scale. Prevailing mHealth studies are largely small-sized, short-term and donor-funded pilot studies with limited evidence on their effectiveness. To facilitate scale-up, several frameworks have been proposed to enhance the generic implementation of health interventions. However, there is a lack of a specific focus on the implementation and integration of mHealth interventions in routine care in low-resource settings. Our scoping review aimed to synthesize and develop a framework that could guide the implementation and integration of mHealth interventions. Methods:We searched the PubMed, Google Scholar, and ScienceDirect databases for published theories, models, and frameworks related to the implementation and integration of clinical interventions from 1st January 2000 to 31st December 2023. The data processing was guided by a scoping review methodology proposed by Arksey and O'Malley. Studies were included if they were i) peer-reviewed and published between 2000 and 2023, ii) explicitly described a framework for clinical intervention implementation and integration, or iii) available in full text and published in English. We integrated different domains and constructs from the reviewed frameworks to develop a new framework for implementing and integrating mHealth interventions. Results:We identified eight eligible papers with eight frameworks composed of 102 implementation domains. None of the identified frameworks were specific to the integration of mHealth interventions in low-resource settings. Two constructs (skill impartation and intervention awareness) related to the training domain, four constructs (technical and logistical support, identifying committed staff, supervision, and redesigning) from the restructuring domain, two constructs (monetary incentives and nonmonetary incentives) from the incentivize domain, two constructs (organizational mandates and government mandates) from the mandate domain and two constructs (collaboration and routine workflows) from the integrate domain. Therefore, a new framework that outlines five main domains-train, restructure, incentivize, mandate, and integrate (TRIMI)-in relation to the integration and implementation of mHealth interventions in low-resource settings emerged. Conclusion:The TRIMI framework presents a realistic and realizable solution for the implementation and integration deficits of mHealth interventions in low-resource settings.

Background Spread of SARS-CoV-2 in Sub-Saharan African countries has been poorly investigated, especially in the later pandemic stages. We aimed to assess the post-Omicron situation in Sierra Leone in November/December 2022 considering SARS-CoV-2 serostatus, vaccinations, and behavioral factors. Methods In a cross-sectional study conducted in a maternity hospital in Freetown, Sierra Leone, both patients and staff provided dried blood spot samples for analysis of anti-S and anti-N IgG prevalence using Anti-SARS-CoV-2-ELISA. Additionally, we collected sociodemographic and infection-related information through questionnaires. Outcome parameters included seropositivity, infection-related seroprevalence, and self-reported vaccination status. We used logistic regression to identify associations with prior infection and with vaccination status. Results Out of 791 participants (389 patients, 402 staff), 670 (84.7 %) displayed a positive SARS-CoV-2 serostatus resulting from either infection or vaccination. Among a sub-sample of 514 participants within which determination of prior natural infection was possible, 441individuals (85.8 %) were affected. Prior infection was associated with female sex and tertiary education level. Overall, 60.3 % reported having been vaccinated. Staff as opposed to patients, and individuals with higher socioeconomic status were more likely to report vaccination. Individuals who assessed their risk of COVID-19 as either higher or lower compared to a medium-level risk were more likely to have contracted the virus and less likely to have received vaccination. Conclusion Our findings suggest that since the Omicron wave in 2022, the Sierra Leonean population has almost universally been exposed to SARS-CoV-2. While this is encouraging in the light of relatively low excess mortality in the country, future investigations on the long-term effect of high viral exposure on epidemic resilience and public health impact will be crucial.

SARS-CoV-2 serology may be helpful to retrospectively understand infection dynamics in specific settings including kindergartens. We assessed SARS-CoV-2 seroprevalence in individuals connected to kindergartens in Berlin, Germany in September 2021. Children, staff, and household members from 12 randomly selected kindergartens were interviewed on COVID-19 history and sociodemographic parameters. Blood samples were collected on filter paper. SARS-CoV-2 anti-S and anti-N antibodies were assessed using Roche Elecsys. We assessed seroprevalence and the proportion of so far unrecognized SARS-CoV-2 infections. We included 277 participants, comprising 48 (17.3%) kindergarten children, 37 (13.4%) staff, and 192 (69.3%) household members. SARS-CoV-2 antibodies were present in 65.0%, and 52.7% of all participants were vaccinated. Evidence of previous infection was observed in 16.7% of kindergarten children, 16.2% of staff, and 10.4% of household members. Undiagnosed infections were observed in 12.5%, 5.4%, and 3.6%, respectively. Preceding infections were associated with facemask neglect. In conclusion, two-thirds of our cohort were SARS-CoV-2 seroreactive in September 2021, largely as a result of vaccination in adults. Kindergarten children showed the highest proportion of non-vaccine-induced seropositivity and an increased proportion of previously unrecognized SARS-CoV-2 infection. Silent infections in pre-school children need to be considered when interpreting SARS-CoV-2 infections in the kindergarten context.

In the earlier phases of the COVID-19 pandemic, studies in Germany and elsewhere found an overall reduction in health-related quality of life (HRQoL) among students. However, there is little evidence on later pandemic stages as well as socioeconomic influencing factors. We aimed to 1) describe HRQoL in a Berlin student cohort at two time points in mid-2021, and to 2) analyze the effects of household income and education. We assessed HRQoL of students from 24 randomly selected primary and secondary schools in Berlin, Germany with the KIDSCREEN-10 index in June and September 2021. To adjust for non-response bias, inverse probability weighting was applied. The potential effects of both household income and education (lower vs. higher) were estimated in generalized linear mixed models, based on prior assumptions presented in directed acyclic graphs. Our cohort comprised 660 students aged 7-19 years. In June 2021, 11.3% reported low HRQoL, whereas in September 2021, this increased to 13.7%, with adolescent girls more frequently reporting low HRQoL than boys and younger children at both time points (20% and 29%). While there was no statistically significant total effect of lower household income on HRQoL, a negative effect of lower household education was statistically significant ( β = -2.15, SE = 0.95, 95% CI = -4.01 to -0.29, p = 0.024). In summary, students’ HRQoL in mid-2021 was better than that documented in other studies conducted at pandemic onset. Female adolescents reported low HRQoL more often, and lower household education significantly reduced children's HRQoL. Support strategies for psychosocial wellbeing should consider socioeconomically disadvantaged children as important target groups.

We implemented and assessed a comprehensive, antenatal care (ANC)-embedded strategy to prevent HIV seroconversions during pregnancy in Uganda. HIV-negative first-time ANC clients were administered an HIV risk assessment tool and received individual risk counseling. Those attending ANC without partners obtained formal partner invitation letters. After three months, repeat HIV testing was carried out; non-attending women were reminded via phone. We analyzed uptake and acceptance, HIV incidence rate, and risk behavior engagement. Among 1081 participants, 116 (10.7%) reported risk behavior engagement at first visit; 148 (13.7%) were accompanied by partners. At the repeat visit (n = 848), 42 (5%, p < 0.001) reported risk behavior engagement; 248 (29.4%, p < 0.001) women came with partners. Seroconversion occurred in two women. Increased odds for risk behavior engagement were found in rural clients (aOR 3.96; 95% CI 1.53-10.26), women with positive or unknown partner HIV-status (2.86; 1.18-6.91), and women whose partners abused alcohol (2.68; 1.15-6.26). Overall, the assessed HIV prevention strategy for pregnant women seemed highly feasible and effective. Risk behavior during pregnancy was reduced by half and partner participation rates in ANC doubled. The observed HIV incidence rate was almost four times lower compared to a pre-intervention cohort in the same study setting.

Background During the COVID-19 pandemic, children and adolescents worldwide have disproportionally been affected in their psychological health and wellbeing. We conducted a cohort study among German school children, aiming at assessing levels of general anxiety disorder (GAD) and identifying associated factors in the second pandemic year. Methods A cohort of 660 students from 24 Berlin schools was recruited to fill in questionnaires including the GAD-7 tool on anxiety symptoms at three time points between June and September 2021. To adjust for non-random attrition, we applied inverse probability weighting. We describe reported GAD levels stratified by time point, sex, and school type and report odds ratios from univariate logistic regression. Results In total, 551 participants (83%) filled in at least one questionnaire at any time point. At the first time point in June 2021, 25% of the children and adolescents reported anxiety symptoms with a GAD-7 score ≥ 5, decreasing to 16% in August 2021 directly after the summer holidays and rising again to 26% in September 2021. The majority of reported anxiety levels belonged to the least severe category. Being female, attending secondary school, coming from a household with lower education or with lower income level, and being vaccinated against COVID-19 were significantly linked with reporting anxiety symptoms. Preceding COVID-19 infection and anxiety were negatively associated. Conclusion Overall, anxiety in school children was lower in mid-2021 than in the first pandemic year, but still double compared to pre-pandemic data. Reporting of anxiety symptoms during the second pandemic year was especially high in females and in secondary school students. Policy makers should pay additional attention to the mental health status of school children, even as the pandemic situation might stabilize.

Background During the ongoing COVID-19 pandemic, school-related leisure activities were either completely prohibited or only feasible to a limited extent. Especially group musical activities carry a high risk of transmission. Up until now, the question of whether they can be safely re-implemented, has hardly been systematically examined. Therefore, we aimed at investigating the feasibility of school music trips with a hygiene and testing concept in times of high SARS-CoV-2 incidence rates and the Omicron wave. Methods We accompanied a one-week school music trip (January 2022). 81 students and 14 teachers of three big bands, mainly from two schools in Berlin, took part. Polymerase chain reaction (PCR) pool tests and a questionnaire before departure as well as a follow-up survey after return were performed. During the trip, a hygiene concept (including daily antigen tests) was applied. Primary endpoint was the occurrence of positive SARS-CoV-2 tests during the study period. The health status before and afterwards as well as the individually perceived fear and risk of a getting a SARS-CoV-2 infection were defined as secondary endpoints. An evaluation of the music trip experience was likewise done. Results 95 PCR pool tests and 95 survey responses were evaluated from outward journey. 79 follow-up questionnaires were sent in. One positive SARS-CoV-2 pool was detected, containing one positive participant who was excluded from the journey. One student turned positive in antigen-testing (day four), was isolated and sent home after PCR confirmation testing. In both cases, the Omicron variant was detected. After return, a reduction of physical symptoms was visible among students, especially regarding cold signs (p = 0.002, McNemar test). The perceived risk of infection increased in the children’s group afterwards (p = 0.019, Wilcoxon rank test). All participants indicated that they want to attend such a music trip again. Conclusion School music trips under pandemic conditions are feasible with a hygiene concept and a safe cohort, regardless of the high incidence rates during the Omicron wave. Although we found an increase in perceived risk of infection among students, this did not negatively affect the perception of the trip experience.

Abstract Background Maternal health remains a major issue of concern in Sierra Leone. In the main referral maternity institution, Princess Christian Maternity Hospital (PCMH), up to 25% of maternal deaths occur during or shortly after transit from another health facility. There is an urgent need to improve referral systems between peripheral health units (PHUs) and PCMH. Our aim was to pilot and evaluate an eHealth tool facilitating referral of obstetric emergency cases through effective teleconsultation between PHUs and PCMH. Methods A web application was designed to capture unclear or complicated delivery cases at PHUs and request respective telemedical counselling from the referral institution PCMH. The eHealth tool was piloted at 10 PHUs in Western area urban and rural in August 2021. Necessary devices were provided and delivery staff was trained to use the app. In December 2021, we conducted focus group discussion with 3-6 delivery staff at five PHUs and at PCMH to evaluate utilization and outcomes of the tool. Results All participants perceived the eHealth tool as an improvement of referral procedures. Response time from PCMH after a request for counselling from a PHU was mostly <30 minutes. The main perceived advantage of the tool was the systematic documentation of obstetric complications and procedures. This relieved staff from fear of wrong treatment accusations, and recorded communication with PCMH made processes and responsibilities transparent. Another important benefit was PCMH staff being already prepared to receive a specific emergency case after use of the app, thus reducing the ‘third delay’ within the referral facility. As a major obstacle to smooth referral despite the eHealth tool, a lacking ambulance system was mentioned as a critical gap. Conclusions Exceedingly positive user experiences with this simple tool seem to make an expansion to more PHUs worthwhile. Benefits of using the app in more remote districts in Sierra Leone should be further investigated. Key messages • Delivery staff in Sierra Leone was capable of using a web app for telemedical counselling in a useful and effective manner. • The eHealth tool was perceived as very helpful in systematically and transparently documenting emergency delivery cases and treatment procedures.

While SARS-CoV-2 infection activity in German kindergartens during the first year of the pandemic appeared to be overall low, outbreaks did occur. We retrospectively investigated an outbreak in November and December 2020 in a Berlin kindergarten participating in the Berlin Corona School and Kindergarten Study (BECOSS). Interviews were conducted with affected families regarding symptomatology, contact persons and possible sources of infection, as well as relevant information on the conditions on-site and infection prevention measures. A chronology of the outbreak was elaborated, and based on data on contacts and symptoms, we mapped the most likely chains of infection. Overall, 24 individuals, including ten educators, seven children, and seven household members, were infected with SARS-CoV-2 in a four-week time interval. Courses of infection ranged from asymptomatic to severe, with children less affected by symptoms. Viral spread within the facility seemed to occur mainly through kindergarten staff, while children primarily transmitted infections within their families. Interviewees reported that hygiene measures were not always adhered to inside the facility. To prevent outbreaks in kindergartens, especially in the light of current and newly emerging viral variants of concern, strict compliance to hygiene rules, staff vaccinations against SARS-CoV-2, and immediate reaction to suspected cases by quarantining and frequent testing seem reasonable measures.