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Inappropriate antibiotic use contributes significantly to the global challenge of antimicrobial resistance. While government-initiated population-level interventions are fundamental in addressing this issue, their full potential remains to be explored. This systematic review aims to assess the effectiveness of such interventions in reducing inappropriate antibiotic use among antibiotic providers and users in healthcare and community settings. We will conduct a systematic literature search across multiple databases and grey literature sources. We will include studies which evaluate the effectiveness of population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings in both high-income and low- and middle-income countries. This includes government-initiated measures targeting antibiotic use through education, restriction, incentivization, coercion, training, persuasion, context modification, behavior modeling, or barrier reduction. Two reviewers will independently perform screening to select eligible studies, followed by data extraction. The outcomes of interest are various measures of antibiotic prescription and consumption, such as Defined Daily Dose (DDD) or number of prescriptions per year. We anticipate including a broad range of study designs and outcome measures. Therefore, we will narratively synthesize results using the categories of the population-level policy interventions of the Behavior Change Wheel Framework. We will organize outcome data by economic contexts, target populations, and implementation settings. This review will strengthen the evidence base for the use of population-level interventions to address inappropriate antibiotic use. Drawing lessons from global experiences, the findings will provide valuable guidance to health policymakers, public health authorities, and researchers on tailoring interventions to specific economic contexts, populations, and settings, thereby enhancing their capacity to drive substantial improvement in appropriate antibiotic use.

Inappropriate antibiotic use contributes significantly to the global challenge of antimicrobial resistance. While government-initiated population-level interventions are fundamental in addressing this issue, their full potential remains to be explored. This systematic review aims to assess the effectiveness of such interventions in reducing inappropriate antibiotic use among antibiotic providers and users in healthcare and community settings. We will conduct a systematic literature search across multiple databases and grey literature sources. We will include studies which evaluate the effectiveness of population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings in both high-income and low- and middle-income countries. This includes government-initiated measures targeting antibiotic use through education, restriction, incentivization, coercion, training, persuasion, context modification, behavior modeling, or barrier reduction. Two reviewers will independently perform screening to select eligible studies, followed by data extraction. The outcomes of interest are various measures of antibiotic prescription and consumption, such as Defined Daily Dose (DDD) or number of prescriptions per year. We anticipate including a broad range of study designs and outcome measures. Therefore, we will narratively synthesize results using the categories of the population-level policy interventions of the Behavior Change Wheel Framework. We will organize outcome data by economic contexts, target populations, and implementation settings. This review will strengthen the evidence base for the use of population-level interventions to address inappropriate antibiotic use. Drawing lessons from global experiences, the findings will provide valuable guidance to health policymakers, public health authorities, and researchers on tailoring interventions to specific economic contexts, populations, and settings, thereby enhancing their capacity to drive substantial improvement in appropriate antibiotic use.

Substance use is disproportionately high among people who are homeless or vulnerably housed. We performed a systematic overview of reviews examining the effects of selected harm reduction and pharmacological interventions on the health and social well-being of people who use substances, with a focus on homeless populations. We searched MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute EBP, Cochrane Database of Systematic Reviews and DARE for systematic reviews from inception to August 2019. We conducted a grey literature search and hand searched reference lists. We selected reviews that synthesized evidence on supervised consumption facilities, managed alcohol programs and pharmacological interventions for opioid use disorders. We abstracted data specific to homeless or vulnerably housed populations. We assessed certainty of the evidence using the GRADE approach. Our search identified 483 citations and 30 systematic reviews met all inclusion criteria, capturing the results from 442 primary studies. This included three reviews on supervised consumption facilities, 24 on pharmacological interventions, and three on managed alcohol programs. Supervised consumption facilities decreased lethal overdoses and other high risk behaviours without any significant harm, and improved access to care. Pharmaceutical interventions reduced mortality, morbidity, and substance use, but the impact on retention in treatment, mental illness and access to care was variable. Managed alcohol programs reduced or stabilized alcohol consumption. Few studies on managed alcohol programs reported deaths. Substance use is a common chronic condition impacting homeless populations. Supervised consumption facilities reduce overdose and improve access to care, while pharmacological interventions may play a role in reducing harms and addressing other morbidity. High quality evidence on managed alcohol programs is limited.

Persons experiencing homelessness and vulnerable housing or those with lived experience of homelessness have worse health outcomes than individuals who are stably housed. Structural violence can dramatically affect their acceptance of interventions. We carried out a systematic review to understand the factors that influence the acceptability of social and health interventions among persons with lived experience of homelessness. We searched through eight bibliographic databases and selected grey literature sources for articles that were published between 1994 and 2019. We selected primary studies that reported on the experiences of homeless populations interacting with practitioners and service providers working in permanent supportive housing, case management, interventions for substance use, income assistance, and women- and youth-specific interventions. Each study was independently assessed for its methodological quality. We used a framework analysis to identify key findings and used the GRADE-CERQual approach to assess confidence in the key findings. Our search identified 11,017 citations of which 35 primary studies met our inclusion criteria. Our synthesis highlighted that individuals were marginalized, dehumanized and excluded by their lived homelessness experience. As a result, trust and personal safety were highly valued within human interactions. Lived experience of homelessness influenced attitudes toward health and social service professionals and sometimes led to reluctance to accept interventions. Physical and structural violence intersected with low self-esteem, depression and homeless-related stigma. Positive self-identity facilitated links to long-term and integrated services, peer support, and patient-centred engagement. Individuals with lived experience of homelessness face considerable marginalization, dehumanization and structural violence. Practitioners and social service providers should consider anti-oppressive approaches and provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care. Accepting and respecting others as they are, without judgment, may help practitioners navigate barriers to inclusiveness, equitability, and effectiveness for primary care that targets this marginalized population.

Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management. Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Background Youth often experience unique pathways into homelessness, such as family conflict, child abuse and neglect. Most research has focused on adult homeless populations, yet youth have specific needs that require adapted interventions. This review aims to synthesize evidence on interventions for youth and assess their impacts on health, social, and equity outcomes. Methods We systematically searched Medline, Embase, PsycINFO, and other databases from inception until February 9, 2018 for systematic reviews and randomized controlled trials on youth interventions conducted in high income countries. We screened title and abstract and full text for inclusion, and data extraction were completed in duplicate, following the PRISMA-E (equity) review approach. Results Our search identified 11,936 records. Four systematic reviews and 18 articles on randomized controlled trials met the inclusion criteria. Many studies reported on interventions including individual and family therapies, skill-building, case management, and structural interventions. Cognitive behavioural therapy led to improvements in depression and substance use, and studies of three family-based therapies reported decreases in substance use. Housing first, a structural intervention, led to improvements in housing stability. Many interventions showed inconsistent results compared to services as usual or other interventions, but often led to improvements over time in both the intervention and comparison group. The equity analysis showed that equity variables were inconsistently measured, but there was data to suggest differential outcomes based upon gender and ethnicity. Conclusions This review identified a variety of interventions for youth experiencing homelessness. Promising interventions include cognitive behavioural therapy for addressing depression, family-based therapy for substance use outcomes, and housing programs for housing stability. Youth pathways are often unique and thus prevention and treatment may benefit from a tailored and flexible approach.

Pregnant and postpartum women face major psychological stressors that put them at higher risk of developing common mental disorders, such as depression and anxiety. Yet, their limited access to and uptake of traditional mental health care is inequitable, especially during the COVID-19 pandemic. Mobile interventions emerged as a potential solution to this discontinued healthcare access, but more knowledge is needed about their effectiveness and impact on health equity. This equity-focused systematic review examined the effectiveness and equity impact of mobile interventions targeting common mental disorders among pregnant and postpartum women. We systematically searched MEDLINE, EMBASE, PsychINFO and 3 other databases, from date of database inception and until January 2021, for experimental studies on mobile interventions targeting pregnant and postpartum women. We used pooled and narrative synthesis methods to analyze effectiveness and equity data, critically appraised the methodological rigour of included studies using Cochrane tools, and assessed the certainty of evidence using the GRADE approach. Our search identified 6148 records, of which 18 randomized and non-randomized controlled trials were included. Mobile interventions had a clinically important impact on reducing the occurrence of depression (OR = 0.51 [95% CI 0.41 to 0.64]; absolute risk reduction RD: 7.14% [95% CI 4.92 to 9.36]; p<0.001) and preventing its severity perinatally (MD = -3.07; 95% CI -4.68 to -1.46; p<0.001). Mobile cognitive behavioural therapy (CBT) was effective in managing postpartum depression (MD = -6.87; 95% CI -7.92 to -5.82; p<0.001), whereas other support-based interventions had no added benefit. Results on anxiety outcomes and utilization of care were limited. Our equity-focused analyses showed that ethnicity, age, education, and being primiparous were characteristics of influence to the effectiveness of mobile interventions. As the COVID-19 pandemic has increased the need for virtual mental health care, mobile interventions show promise in preventing and managing common mental disorders among pregnant and postpartum women. Such interventions carry the potential to address health inequity but more rigorous research that examines patients' intersecting social identities is needed.

Pottie et al discuss the clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. Homelessness encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it. Clinical assessment and care of homeless and vulnerably housed populations should include tailoring approaches to a person's gender, age, Indigenous heritage, ethnicity and history of trauma; and advocacy for comprehensive primary health care. As initial steps in the care of homeless and vulnerably housed populations, permanent supportive housing is strongly recommended, and income assistance is also recommended. Case-management interventions, with access to psychiatric support, are recommended as an initial step to support primary care and to address existing mental health, substance use and other morbidities.

Home-based records (HBRs) may improve the health of pregnant women, new mothers and their children, and support health care systems. We assessed the effectiveness of HBRs on maternal, newborn and child health reporting, care seeking and self-care practice, mortality, morbidity and women's empowerment in low-, middle- and high-income countries. We conducted a systematic search in MEDLINE, EMBASE, CENTRAL, Health Systems Evidence, CINAHL, HTA database, NHS EED, and DARE from 1950 to 2017. We also searched the WHO, CDC, ECDC, JICA and UNAIDS. We included randomised controlled trials, prospective controlled trials, and cost-effectiveness studies. We used the Cochrane Risk of Bias tool to appraise studies. We extracted and analyzed data for outcomes including maternal, newborn and child health, and women's empowerment. We synthesized and presented data using GRADE Evidence Profiles. We included 14 studies out of 16,419 identified articles. HBRs improved antenatal care and reduced likelihood of pregnancy complications; improved patient-provider communication and enhanced women's feelings of control and empowerment; and improved rates of vaccination among children (OR: 2·39, 95% CI: 1.45-3·92) and mothers (OR 1·98 95% CI:1·29-3·04). A three-year follow-up shows that HBRs reduced risk of cognitive delay in children (p = 0.007). HBRs used during the life cycle of women and children in Indonesia showed benefits for continuity of care. There were no significant effects on healthy pregnancy behaviors such as smoking and consumption of alcohol during pregnancy. There were no statistically significant effects on newborn health outcomes. We did not identify any formal studies on cost or economic evaluation. HBRs show modest but important health effects for women and children. These effects with minimal-to-no harms, multiplied across a population, could play an important role in reducing health inequities in maternal, newborn, and child health.

Mothers, caregivers, and healthcare providers in 163 countries have used paper and electronic home-based records (HBRs) to facilitate primary care visit. These standardized records have the potential to empower women, improve the quality of care for mothers and children and reduce health inequities. This review examines experiences of women, caregivers and providers with home-based records for maternal and child health and seeks to explore the feasibility, acceptability, affordability and equity of these interventions. We systematically searched MEDLINE, MEDLINE In-Process, MEDLINE Ahead of Print, Embase, CINAHL, ERIC, and PsycINFO for articles that were published between January 1992 and December 2017. We used the CASP checklist to assess study quality, a framework analysis to support synthesis, and GRADE-CERQual to assess the confidence in the key findings. Of 7,904 citations, 19 studies met our inclusion criteria. In these studies, mothers, caregivers and children shared HBR experiences in relation to maternal and child health which facilitated the monitoring of immunisations and child growth and development. Participants' reports of HBRs acting as a point of commonality between patient and provider offer an explanation for their perceptions of improved communication and patient-centered care, and enhanced engagement and empowerment during pregnancy and childcare. Healthcare providers and nurses reported that the home-based record increased their feeling of connection with their patients. Although there were concerns around electronic records and confidentiality, there were no specific concerns reported for paper records. Mothers and other caregivers see home based records as having a pivotal role in facilitating primary care visits and enhancing healthcare for their families. The records' potential could be limited by users concerns over confidentiality of electronic home-based records, or shortcomings in their design. Health systems should seize the opportunity HBRs provide in empowering women, especially in the contexts of lower literacy levels and weak health care delivery systems.