The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.

Social policies are important determinants of population health but may have varying effects on subgroups of people. Evaluating heterogeneous treatment effects (HTEs) of social policies is critical to determine how social policies will affect health inequities. Methods for evaluating HTEs are not standardized. Little is known about how often and by what methods HTEs are assessed in social policy and health research. A sample of 55 articles from 2019 on the health effects of social policies were evaluated for frequency of reporting HTEs; for what subgroupings HTEs were reported; frequency of a priori specification of intent to assess HTEs; and methods used for assessing HTEs. A total of 24 (44%) studies described some form of HTE assessment, including by age, gender, education, race/ethnicity, and/or geography. Among studies assessing HTEs, 63% specified HTE assessment a priori, and most (71%) used descriptive methods such as stratification; 21% used statistical tests (e.g., interaction terms in a regression); and no studies used data-driven algorithms. Although understanding HTEs could enhance policy and practice-based efforts to reduce inequities, it is not routine research practice. Increased evaluation of HTEs across relevant subgroups is needed.

Background: A growing number of studies indicate that exposure to social stress, such as perceived racial discrimination, may contribute to poor health, health behaviors, and health disparities. Increased physical activity (PA) may buffer the impact of social stress resulting from racial discrimination. However, to date, data on the relationship between racial discrimination and PA have been mixed. Part of the reason is that the effect of perceived racial discrimination on PA has primarily been examined in cross-sectional studies that captured retrospective measures of perceived racial discrimination associated with individuals’ current PA outcomes. The association between real-time perceived racial discrimination and PA among African Americans remains unclear. Objective: The purpose of this study is to examine the relationship among demographic, anthropometric and clinical, and psychological factors with lifetime racial discrimination and examine the within- and between-person associations between daily real-time racial discrimination and PA outcomes (total energy expenditure, sedentary time, and moderate-to-vigorous PA patterns) measured by ecological momentary assessment (EMA) and accelerometers in healthy African Americans. Methods: This pilot study used an intensive, observational, case-crossover design of African Americans (n=12) recruited from the community. After participants completed baseline surveys, they were asked to wear an accelerometer for 7 days to measure their PA levels. EMA was sent to participants 5 times per day for 7 days to assess daily real-time racial discrimination. Multilevel models were used to examine the within- and between-person associations of daily racial discrimination on PA. Results: More EMA-reported daily racial discrimination was associated with younger age (r=0.75; P=.02). Daily EMA-reported microaggression was associated with depressive symptoms (r=0.66; P=.05), past race-related events (r=0.82; P=.004), and lifetime discrimination (r=0.78; P=.01). In the within-person analyses, the day-level association of racial discrimination and sedentary time was significant (β=.30, SE 0.14; P=.03), indicating that on occasions when participants reported more racial discrimination than usual, more sedentary time was observed. Between-person associations of racial discrimination (β=−.30, SE 0.28; P=.29) or microaggression (β=−.34, SE 0.36; P=.34) with total energy expenditure were suggestive but inconclusive. Conclusions: Concurrent use of EMA and accelerometers is a feasible method to examine the relationship between racial discrimination and PA in real time. Examining daily processes at the within-person level has the potential to elucidate the mechanisms of which racial discrimination may have on health and health behaviors and to guide the development of personalized interventions for increasing PA in racial ethnic minorities. Future studies with a precision health approach, incorporating within- and between-person associations, are warranted to further elucidate the effects of racial discrimination and PA. International Registered Report Identifier (IRRID): RR2-10.1002/nur.22068

Background: Chatbots have the potential to increase people’s access to quality health care. However, the implementation of chatbot technology in the health care system is unclear due to the scarce analysis of publications on the adoption of chatbot in health and medical settings. Objective: This paper presents a protocol of a bibliometric analysis aimed at offering the public insights into the current state and emerging trends in research related to the use of chatbot technology for promoting health. Methods: In this bibliometric analysis, we will select published papers from the databases of CINAHL, IEEE Xplore, PubMed, Scopus, and Web of Science that pertain to chatbot technology and its applications in health care. Our search strategy includes keywords such as “chatbot,” “virtual agent,” “virtual assistant,” “conversational agent,” “conversational AI,” “interactive agent,” “health,” and “healthcare.” Five researchers who are AI engineers and clinicians will independently review the titles and abstracts of selected papers to determine their eligibility for a full-text review. The corresponding author (ZN) will serve as a mediator to address any discrepancies and disputes among the 5 reviewers. Our analysis will encompass various publication patterns of chatbot research, including the number of annual publications, their geographic or institutional distribution, and the number of annual grants supporting chatbot research, and further summarize the methodologies used in the development of health-related chatbots, along with their features and applications in health care settings. Software tool VOSViewer (version 1.6.19; Leiden University) will be used to construct and visualize bibliometric networks. Results: The preparation for the bibliometric analysis began on December 3, 2021, when the research team started the process of familiarizing themselves with the software tools that may be used in this analysis, VOSViewer and CiteSpace, during which they consulted 3 librarians at the Yale University regarding search terms and tentative results. Tentative searches on the aforementioned databases yielded a total of 2340 papers. The official search phase started on July 27, 2023. Our goal is to complete the screening of papers and the analysis by February 15, 2024. Conclusions: Artificial intelligence chatbots, such as ChatGPT (OpenAI Inc), have sparked numerous discussions within the health care industry regarding their impact on human health. Chatbot technology holds substantial promise for advancing health care systems worldwide. However, developing a sophisticated chatbot capable of precise interaction with health care consumers, delivering personalized care, and providing accurate health-related information and knowledge remain considerable challenges. This bibliometric analysis seeks to fill the knowledge gap in the existing literature on health-related chatbots, entailing their applications, the software used in their development, and their preferred functionalities among users. International Registered Report Identifier (IRRID): PRR1-10.2196/54349

Hepatitis C (HCV) is a global pandemic. The World Health Organization has developed a strategic plan for HCV elimination that focuses on low- and middle-income countries (LMICs) and high-risk populations, including people who inject drugs (PWID). While direct-acting antiviral (DAA) therapies are highly effective at eliminating HCV infections and have few side effects, medical professionals and policymakers remain concerned about the risk of reinfection among PWID. This study is a systematic review of research measuring the rate of HCV reinfection among PWID in LMICs and identifies additional areas for further research. A systematic search strategy was used to identify studies documenting HCV reinfection after sustained virologic response in PWID in LMICs. We refined results to include studies where at least 50% of participants had DAA treatment for primary HCV infection. Pooled reinfection rate was calculated across all studies. Seven studies met eligibility criteria. Most studies were conducted in six upper middle-income countries (Mexico, Romania, Russia, Taiwan, Georgi, and Brazil) and one lower middle-income country (Bangladesh) with a total of 7665 participants. No study included information from PWID in low-income countries. Sample sizes ranged from 200 to 3004 individuals, with demographic data missing for most participants. Four studies used deep gene sequencing, and reflex genotyping procedures to differentiate reinfection (infection by a different HCV genotype/subtype) from virologic relapse (infection by the same strain). The follow-up time of people cured from primary chronic HCV infection ranged from 12 weeks to 6.6 years. The pooled reinfection rate of all seven studies was 2.8 (range: 0.02 to 10.5) cases per 100 person-years (PY). In the five studies that differentiated relapse from reinfection, the incidence of reinfection was 1.0 per 100 PY. To date, research on reinfection rates among PWID in LMICs remains limited. Research focused on PWID in low-income countries is particularly needed to inform clinical decision making and evidence-based programs. While rates of reinfection among PWID who complete DAA treatment in upper and lower middle-income countries were similar or lower than rates observed in PWID in high-income countries, the rates were highly variable and factors may influence the accuracy of these measurements. This systematic review identifies several areas for continued research. Policies concerning access to HCV testing and treatment should be comprehensive and not place restrictions on PWID in these settings.

People who inject drugs (PWID) face disparities in human immunodeficiency virus (HIV) treatment outcomes and may be less likely to achieve durable viral suppression. We characterized transitions into and out of viral suppression from 1997 to 2017 in a long-standing community-based cohort study of PWID, the AIDS Link to Intravenous Experience (ALIVE) Study, analyzing HIV-positive participants who had made a study visit in or after 1997. We defined the probabilities of transitioning between 4 states: 1) suppressed, 2) detectable, 3) lost to follow-up, and 4) deceased. We used multinomial logistic regression analysis to examine factors associated with transition probabilities, with a focus on transitions from suppression to other states. Among 1,061 participants, the median age was 44 years, 32% were female, 93% were African-American, 59% had recently injected drugs, and 28% were virologically suppressed at baseline. Significant improvements in durable viral suppression were observed over time; however, death rates remained relatively stable. In adjusted analysis, injection drug use and homelessness were associated with increased virological rebound in earlier time periods, while only age and race were associated with virological rebound in 2012–2017. Opioid use was associated with an increased risk of death following suppression in 2012–2017. Despite significant improvements in durable viral suppression, subgroups of PWID may need additional efforts to maintain viral suppression and prevent premature mortality.