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Background After retirement, elderly men and women allocate more time to housework activities, compared to working-age adults. Nonetheless, sleep constitutes the lengthiest time use activity among the elderly, but there has not been any study on the associations between time spent on housework activities, sleep duration and self-reported health among the older population. This study not only examined individual associations between self-reported health and both housework activities and sleep duration, but it also explored self-reported health by the interaction effect between housework activities and sleep duration separately for men and women. Methods Pooled data from the Multinational Time Use Study (MTUS) on 15,333 men and 20,907 women from Germany, Italy, Spain, UK, France, the Netherlands and the US were analysed. Multiple binary logistic regression models were used to examine the associations between three broad categories of housework activities ((1) cooking, cleaning and shopping, (2) gardening and maintenance; (3) childcare) and health. We further investigated the extent to which total housework hours and sleep duration were associated with self-reported health for men and women separately. Results We found a positive association between time devoted to housework activities, total housework and health status among elderly men and women. Compared to those who spent 1 to 3 h on total productive housework, elderly people who spent >3 to 6 h/day had higher odds of reporting good health (OR = 1.25; 95% CI = 1.14–1.37 among men and OR = 1.10; 95% CI = 1.01–1.20 among women). Both short (<7 h) and long (>8 h) sleep duration were negatively associated with health for both genders. However, the interactive associations between total productive housework, sleep duration, and self-reported health varied among men and women. Among women, long hours of housework combined with either short or long sleep was negatively associated with health. Conclusions Although time allocation to housework activities may be beneficial to the health among both genders, elderly women have higher odds of reporting poor health when more time is devoted total housework combined with either short or long sleep duration.

Paradoxically, despite their longer life expectancy, women report poorer health than men. Time devoted to differing social roles could be an explanation for the observed gender differences in health among the elderly. The objective of this study was to explain gender differences in self-reported health among the elderly by taking time use activities, socio-economic positions, family characteristics and cross-national differences into account. Data from the Multinational Time Use Study (MTUS) on 13,223 men and 18,192 women from Germany, Italy, Spain, UK and the US were analyzed. Multiple binary logistic regression models were used to examine the association between social factors and health for men and women separately. We further identified the relative contribution of different factors to total gender inequality in health using the Blinder-Oaxaca decomposition method. Whereas time allocated to paid work, housework and active leisure activities were positively associated with health, time devoted to passive leisure and personal activities were negatively associated with health among both men and women, but the magnitude of the association varied by gender and country. We found significant gender differences in health in Germany, Italy and Spain, but not in the other countries. The decomposition showed that differences in the time allocated to active leisure and level of educational attainment accounted for the largest health gap. Our study represents a first step in understanding cross-national differences in the association between health status and time devoted to role-related activities among elderly men and women. The results, therefore, demonstrate the need of using an integrated framework of social factors in analyzing and explaining the gender and cross-national differences in the health of the elderly population.

The large increase in numbers of refugees and asylum seekers in Germany and most of Europe has put the issue of migration itself, the integration of migrants, and also their health at the top of the political agenda. However, the dynamics of refugee health are not yet well understood. From a life-course perspective, migration experience is associated with various risks and changes, which might differ depending on the socioeconomic status (SES) of refugees in their home country. The aim of this paper was to analyze the relationship between pre-migration SES and self-reported health indicators after migration among Syrian refugees. Specifically, we wanted to find out how their SES affects the change in health satisfaction from pre- to post-migration. We used data from the 2016 refugee survey, which was part of the German Socio-Economic Panel (GSOEP). Although cross-sectional by design, this survey collected information referring to the current situation as a refugee in Germany as well as to their situation before migration. Using a sample of 2,209 adult Syrian refugees who had entered Germany between 2013 and 2016, we conducted a cross-sectional and a quasi-longitudinal (retrospective) analysis. The mean ± SD age was 35 ± 11 years, with 64% of the participants being male. Our results showed a positive association between pre-migration self-reported SES and several subjective health indicators (e.g., health satisfaction, self-reported health, mental health) in the cross-sectional analysis. However, the quasi-longitudinal analysis revealed that the socioeconomic gradient in health satisfaction before migration was strongly attenuated after migration (SES-by-time interaction: -0.48, 95% CI -0.61 to -0.35, p < 0.001; unstandardized regression coefficients, 5-point SES scale and 11-point health outcome scale). Similar results were produced after controlling for sociodemographic characteristics, experiences during the migration passage, and the current situation in Germany. A sex-stratified analysis showed that while there was some improvement in health satisfaction among men from the lowest SES over time, no improvement was found among women. A limitation of this study is that it considers only the first months or years after migration. Thus, we cannot preclude that the socioeconomic gradient regains importance in the longer run. Our findings suggest that the pre-migration socioeconomic gradient in health satisfaction is strongly attenuated in the first years after migration among Syrian refugees. Hence, a high SES before crisis and migration provides limited protection against the adverse health effects of migration passage.

Objective Communities are important settings for health promotion and prevention. The community readiness assessment offers a structured approach to assess resources and opportunities to tackle a health problem within a community. The assessment relies on semi-structured interviews with key informants from the communities. A number of 4–6 key informant interviews are recommended in the literature. However, it is unclear whether this is sufficient to obtain a valid representation of the respective community. This study analysed whether increasing the number of key informants from 4–6 to 12–15 alters the results of the community readiness assessment. Results A total of 55 community readiness interviews were carried out in 4 communities. Overall, the community readiness scores showed little variation after having interviewed 10 key informants in a community. However, even after completing 10 interviews in a community, key informants were still able to identify up to 6 new information items regarding community efforts for physical activity promotion among the elderly, contact and communication channel for informing or approaching the target group, or barriers to participation.

Digital interventions offer a solution to address the high demand for mental health promotion, especially when facing physical contact restrictions or lacking accessibility. Engagement with digital interventions is critical for their effectiveness; however, retaining users' engagement throughout the intervention is challenging. It remains unclear what strategies facilitate engagement with digital interventions that target mental health promotion. Our aim is to conduct a scoping review to investigate user engagement strategies and methods to evaluate engagement with digital interventions that target mental health promotion in adults. This scoping review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews. The search was conducted in 7 electronic databases from inception to April 2020. The inclusion criteria for studies were as follows: adult (aged ≥18 years) users of digital interventions for mental health promotion from the general population; any digital intervention for mental health promotion; and user engagement strategies described in the intervention design. We extracted the following data items: study characteristics, digital intervention (type and engagement strategy), evaluation of engagement strategy (method and result specifying whether the strategy was effective at facilitating engagement), and features of engagement (extent of use and subjective experience of users). A total of 2766 studies were identified, of which 16 (0.58%) met the inclusion criteria. The 16 studies included randomized controlled trials (6/16, 37%), studies analyzing process data (5/16, 31%), observational studies (3/16, 19%), and qualitative studies (2/16, 13%). The digital interventions for mental health promotion were either web based (12/16, 75%) or mobile app based (4/16, 25%). The engagement strategies included personalized feedback about intervention content or users' mental health status; guidance regarding content and progress through e-coaching; social forums, and interactivity with peers; content gamification; reminders; and flexibility and ease of use. These engagement strategies were deemed effective based on qualitative user feedback or responses on questionnaires or tools (4/16, 25%), usability data (5/16, 31%), or both (7/16, 44%). Most studies identified personalized support in the form of e-coaching, peer support through a social platform, personalized feedback, or joint videoconference sessions as an engaging feature. Personalized support during the intervention, access to social support, and personalized feedback seem to promote engagement with digital interventions for mental health promotion. These findings need to be interpreted with caution because the included studies were heterogeneous, had small sample sizes, and typically did not address engagement as the primary outcome. Despite the importance of user engagement for the effectiveness of digital interventions, this field has not yet received much attention. Further research is needed on the effectiveness of different strategies required to facilitate user engagement in digital interventions for mental health promotion.

Background Studies of the relationship between diverse populations, healthcare access and health outcomes have been dominated by approaches focusing on ethno-national groups or specific healthcare sectors. Healthcare bricolage conceptualises the processes by which individuals use multiple resources to address health concerns. It is relevant in superdiverse neighbourhoods with complex populations. This paper is original in its application of mixed methods to examine the extent to which, and the reasons why, individuals engage in healthcare bricolage. Methods The study utilized a parallel sequential methodology. Eight superdiverse neighbourhoods were selected, two in each of Bremen, Birmingham, Lisbon and Uppsala. Ethnographic research scoping the nature of each healthcare ecosystem was followed by 160 interviews (20 each neighbourhood) with a maximum variation sample of residents undertaken October 2015 to December 2016. Interviewees were asked to recall a health concern and describe actions taken to attempt resolution. Data was coded with a MAXQDA codebook checked for inter-coder reliability. Interview findings enabled identification of five types of bricolage, the nature of healthcare resources utilised and the factors which influenced residents’ tactics. Results were used to design a household survey using new questions and validated epidemiological instruments implemented January to October 2017. Respondents were identified using random address files and interviewed in person or by telephone. Multinomal logistic regressions were used to estimate the effect of changing the values of determinants on the probability of observing an outcome. Results Age, gender, level of education, migration background and extent of functional limitation were associated with bricolage tactics. Individuals demonstrating high levels of agency were more likely than those with low levels to engage in bricolage. Residents with high levels of trust in physicians were less likely to bricolage than those with lower levels of trust. Levels of health literacy showed no significant effects. Conclusions The nature and severity of health concern, trust in physicians and agency shaped residents’ bricolage tactics. The concept of bricolage enabled us to make visible the actions and resources utilised around public healthcare systems that would otherwise remain outwith healthcare access research. Actions were frequently undertaken via networks offering insights into healthcare-seeking behaviour.

Background Health literacy comprises the ability to identify, obtain, interpret and act upon health information. Low health literacy is a major risk factor for hospitalizations, use of emergency care and premature mortality among others. Known risk factors for low health literacy such as lower educational attainment, migration history and chronic illnesses overlap with those for long-term unemployment – in itself a risk factor for low health literacy. These factors are difficult to address in interventions to support health literacy. Therefore, the objective of this review is to identify potentially modifiable predictors of HL in populations potentially affected by long-term unemployment. Methods A rapid review (PROSPERO registration number: 290873) was carried out in Pubmed and SCOPUS including quantitative studies on potentially modifiable predictors of health literacy in working-age populations following PRISMA guidelines for systematic reviews. Where possible, reported effect sizes were transformed into r, and random-effects meta-analyses were conducted where appropriate to pool effect sizes for the association between modifiable predictors and health literacy. Results In total, 4765 titles and abstracts were screened, 114 articles were assessed in full-text screening, and 54 were included in the review. Forty-one effect sizes were considered for 9 different meta-analyses. Higher language proficiency, higher frequency of internet use, using the internet as a source of health information more often, being more physically active, more oral health behaviours, watching more health-related TV and a good health status were significantly associated with higher health literacy. Significant heterogeneity suggests between-study differences. Conclusions Improving language proficiency and/or providing information in multiple and simplified languages, together with reliable and accessible health information on the internet and in linear media are potentially promising targets to improve health literacy levels in working-age populations.

Background As crises escalate worldwide, there is an increasing demand for innovative solutions to enhance humanitarian outcomes. Within this landscape, digital health tools have emerged as promising solutions to tackle certain health challenges. The integration of digital health tools within the international humanitarian system provides an opportunity to reflect upon the system’s paternalistic tendencies, driven largely by Global North organisations, that perpetuate existing inequities in the Global South, where the majority of crises occur. The Participation Revolution , a fundamental pillar of the Localisation Agenda , seeks to address these inequities by advocating for greater participation from crisis-affected people in response efforts. Despite being widely accepted as a best practice; a gap remains between the rhetoric and practice of participation in humanitarian response efforts. This study explores the extent and nature of participatory action within contemporary humanitarian digital health projects, highlighting participatory barriers and tensions and offering potential solutions to bridge the participation gap to enhance transformative change in humanitarian response efforts. Methods Sixteen qualitative interviews were conducted with humanitarian health practitioners and experts to retrospectively explored participatory practices within their digital health projects. The interviews were structured and analysed according to the Localisation Performance Measurement Framework’s participation indicators and thematically, following the Framework Method. The study was guided by the COREQ checklist for quality reporting. Results Varied participatory formats, including focus groups and interviews, demonstrated modest progress towards participation indicators. However, the extent of influence and power held by crisis-affected people during participation remained limited in terms of breadth and depth. Participatory barriers emerged under four key themes: project processes, health evidence, technology infrastructure and the crisis context. Lessons for leveraging participatory digital health humanitarian interventions were conducting thorough pre-project assessments and maintaining engagement with crisis-affected populations throughout and after humanitarian action. Conclusion The emerging barriers were instrumental in shaping the limited participatory reality and have implications: Failing to engage crisis-affected people risks perpetuating inequalities and causing harm. To advance the Participation Revolution for humanitarian digital health response efforts, the major participatory barriers should be addressed to improve humanitarian efficiency and digital health efficacy and uphold the rights of crisis-affected people.

Background Forced displacement is a crucial determinant of poor health. With 31 people displaced every minute worldwide, this is an important global issue. Addressing this, the Participation Revolution workstream from the World Humanitarian Summit’s Localisation commitments has gained traction in attempting to improve the effectiveness of humanitarian aid. Simultaneously, digital health initiatives have become increasingly ubiquitous tools in crises to deliver humanitarian assistance and address health burdens. Objective This scoping review explores how the localisation agenda’s commitment to participation has been adopted within digital health interventions used by displaced people in low-and-middle-income countries. Methods This review adopted the Arksey and O’Malley approach and searched five academic databases and three online literature repositories with a Population , Concept and Context inclusion criteria. Data were synthesised and analysed through a critical power lens from the perspective of displaced people in low-and-middle-income-countries. Results 27 papers demonstrated that a heterogeneous group of health issues were addressed through various digital health initiatives, principally through the use of mobile phones. The focus of the literature lay largely within technical connectivity and feasibility assessments, leaving a gap in understanding potential health implications. The varied conceptualisation of the localisation phenomenon has implications for the future of participatory humanitarian action: Authorship of reviewed literature primarily descended from high-income countries exposing global power dynamics leading the narrative. However, power was not a central theme in the literature: Whilst authors acknowledged the benefit of local involvement, participatory activities were largely limited to informing content adaptations and functional modifications within pre-determined projects and objectives. Conclusion With over 100 million people displaced globally, effective initiatives that meaningfully address health needs without perpetuating harmful inequalities are an essential contribution to the humanitarian arena. The gap in health outcomes evidence, the limited constructions of health, and the varying and nuanced digital divide factors are all indicators of unequal power in the digital health sphere. More needs to be done to address these gaps meaningfully, and more meaningful participation could be a crucial undertaking to achieve this. Registration  The study protocol was registered before the study (10.17605/OSF.IO/9D25R) at https://osf.io/9d25r .

Digital health literacy is a key factor in enabling users to navigate in an increasingly digitalized health care system. Low levels of digital health literacy are associated with higher age, low education, and income, as well as low functional health literacy. Around 6.2 million adults living in Germany have low reading and writing skills. Due to their low literacy, this group is often underrepresented in research studies and therefore little is known about their digital health literacy and use of digital health tools. The objectives of this study were to assess digital health literacy in adults with low reading and writing skills and to explore which digital health tools they use in daily life. An interviewer-administered survey and focus groups were conducted with adult residents of Bremen, Germany, who were aged 18-64 years and had low reading and writing skills. In addition, a stakeholder workshop was held to derive recommendations on how digital health literacy could be improved. The survey questionnaire included 21 items addressing the use of digital health technologies and digital health literacy (eHealth Literacy Scale). Focus group participants completed several tasks on web-based health information and then discussed their experiences. Survey data were analyzed using descriptive statistics and linear regression. Qualitative content analysis was applied to analyze the focus group data and the written documentation of the stakeholder workshop. Survey participants (n=96) were on average 43 (SD 10.7) years old, 72% (69/96) were female, and 92% (88/96) were not born in Germany. Participants reported mainly using information-related digital health technologies such as health apps (40/96, 42%), health websites (30/96, 31%), or activity trackers (27/96, 28%). The mean digital health literacy score was 22 (SD 8) points, with 35% (34/96) of participants classified as having a low digital health literacy (score between 8-19/40 points). Digital health technology use was associated with higher digital health literacy. For participants in the 5 focus groups (total n=39; mean age 43, SD 12.6 years; n=34, 87% female), limited technical skills and language problems were the most important challenges. Furthermore, focus group participants reported that they favor videos when searching for web-based health information and prefer to seek support from family members or local organizations for health issues. Stakeholders (n=15) recommended that health websites should be available in multiple languages, contain simple and easy-to-read language, and use images, symbols, and videos. While adults with low reading and writing skills use digital health technologies, many find it challenging to search for health information on the internet due to lacking technical skills and language problems. To ensure that adults with low reading and writing skills are not further left behind, future research should focus on developing tailored interventions to promote digital health literacy.