Mapping infectious disease hospital surge threats to lessons learnt in Singapore: a systems analysis and development of a framework to inform how to DECIDE on planning and response strategies

Outbreak preparedness and response strategies in ASEAN member states: a scoping review

Objectives

The 21st century has witnessed significant disease outbreaks with severe impact in Association of Southeast Asian Nations (ASEAN) countries, including SARS, H1N1, H5N1, and COVID-19. This review aimed to compile and analyze outbreak preparedness and response strategies, highlighting the success of coordinated multi-sectoral approaches and policy responses within the ASEAN region.

Methods

The protocol for this review was registered on the Open Science Framework and PROSPERO. A systematic analysis of publications from the 2002-2022 period was conducted following PRISMA guidelines on 4522 records retrieved from PubMed, CINAHL, Web of Science, and Scopus. The titles and abstracts were screened, and 229 articles were selected for full-text screening. Finally, 34 articles were included in this review.

Results

Four preparedness pillars were identified: governance and stewardship, disease detection, disease prevention, and health care management. The pillars were crucial in preparing for and responding to the COVID-19 pandemic. Coordinated responses among the ASEAN countries and local and international stakeholders were reported.

Conclusions

The findings emphasize that understanding the transmission dynamics of infectious diseases is paramount for effective disease prevention, surveillance, and timely response efforts to prevent the next pandemic. A well-coordinated multi-country and multi-agency policy response and understanding the different disease management models are crucial in addressing future outbreaks in the region. Future post-pandemic publications will shed more light on lessons learned and preparedness and response plans for future pandemics.

Operational priorities for engaging with India's private healthcare sector for the control of tuberculosis: a modelling study

OBJECTIVES

To estimate the potential impact of expanding services offered by the Joint Effort for Elimination of Tuberculosis (JEET), the largest private sector engagement initiative for tuberculosis (TB) in India.

DESIGN

We developed a mathematical model of TB transmission dynamics, coupled with a cost model.

SETTING

Ahmedabad and New Delhi, two cities with contrasting levels of JEET coverage.

PARTICIPANTS

Estimated patients with TB in Ahmedabad and New Delhi.

INTERVENTIONS

We investigated the epidemiological impact of expanding three different public-private support agency (PPSA) services: provider recruitment, uptake of cartridge-based nucleic acid amplification tests and uptake of adherence support mechanisms (specifically government supplied fixed-dose combination drugs), all compared with a continuation of current TB services.

RESULTS

Our results suggest that in Delhi, increasing the use of adherence support mechanisms among private providers should be prioritised, having the lowest incremental cost-per-case-averted between 2020 and 2035 of US$170 000 (US$110 000-US$310 000). Likewise in Ahmedabad, increasing provider recruitment should be prioritised, having the lowest incremental cost-per-case averted of US$18 000 (US$12 000-US$29 000).

CONCLUSION

Results illustrate how intervention priorities may vary in different settings across India, depending on local conditions, and the existing degree of uptake of PPSA services. Modelling can be a useful tool for identifying these priorities for any given setting.

Examining the extent, forms and factors influencing multiple job holding among medical doctors, professional nurses and rehabilitation therapists in two South African provinces: a cross-sectional study

OBJECTIVE

Multiple job holding (MJH), or working in more than one paid job simultaneously, is a common characteristic of health labour markets. The study examined the extent (prevalence), forms and factors influencing MJH among public sector medical doctors, professional nurses and rehabilitation therapists in two South African provinces.

DESIGN

A cross-sectional, analytical study.

SETTING

29 public sector hospitals in the Gauteng and Mpumalanga provinces of South Africa.

PARTICIPANTS

Full-time public sector medical doctors, professional nurses and rehabilitation therapists.

RESULTS

We obtained an overall response rate of 84.3%, with 486 medical doctors, 571 professional nurses and 340 rehabilitation therapists completing the survey. The mean age was 39.9±9.7 years for medical doctors, 43.7±10.4 years for professional nurses and 32.3±8.7 years for rehabilitation therapists. In the preceding 12 months, the prevalence of MJH was 33.7% (95% CI 25.8% to 42.6%) among medical doctors, 8.6% (95% CI 6.3% to 11.7%) among professional nurses and 38.7% (95% CI 31.5% to 46.5%) among rehabilitation therapists. Medical doctors worked a median of 20 (10-40) hours per month in their additional jobs, professional nurses worked 24 (12-34) hours per month and rehabilitation therapists worked 16 (8-28) hours per month. Private practice was the most prevalent form of MJH among medical doctors and rehabilitation therapists, compared with nursing agencies for professional nurses. MJH was significantly more likely among medical specialists (OR 4.3, p<0.001), married professional nurses (OR 2.4, p=0.022) and male rehabilitation therapists (OR 2.4, p=0.005).

CONCLUSION

The high prevalence of MJH could adversely affect the care of public sector patients. The study findings should inform the review and revision of existing MJH policies.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

Improving the diagnostic process for patients with possible bladder and kidney cancer: a mixed-methods study to identify potential missed diagnostic opportunities

BACKGROUND

Patients with bladder and kidney cancer may experience diagnostic delays.

AIM

To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs).

DESIGN AND SETTING

Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 and October 2019.

METHOD

Patients with possible bladder and kidney cancer were identified using eligibility criteria based on National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer. Primary care records were reviewed at recruitment and at 1 year for data on symptoms, tests, referrals, and diagnosis. Referral predictors were examined using logistic regression. Semi-structured interviews were undertaken with 15 patients to explore their experiences of the diagnostic process, and these were analysed thematically.

RESULTS

Participants (n = 940) were mostly female (n = 657, 69.9%), with a median age of 71 years (interquartile range 64-77 years). In total, 268 (28.5%) received a referral and 465 (48.5%) had a final diagnosis of urinary tract infection (UTI). There were 33 (3.5%) patients who were diagnosed with cancer, including prostate (n = 17), bladder (n = 7), and upper urothelial tract (n = 1) cancers. Among referred patients, those who had a final diagnosis of UTI had the longest time to referral (median 81.5 days). Only one-third of patients with recurrent UTIs were referred despite meeting NICE referral guidelines. Qualitative findings revealed barriers during the diagnostic process, including inadequate clinical examination, female patients given repeated antibiotics without clinical reviews, and suboptimal communication of test results to patients.

CONCLUSION

Older females with UTIs might be at increased risk of MDOs for cancer. Targeting barriers during the initial diagnostic assessment and follow-up might improve quality of diagnosis.

Impact of remuneration, extrinsic and intrinsic incentives on interprofessional primary care teams: protocol for a rapid scoping review

INTRODUCTION

Interprofessional teams and funding and payment provider arrangements are key attributes of high-performing primary care. Several Canadian jurisdictions have introduced team-based models with different payment models. Despite these investments, the evidence of impact is mixed. This has raised questions about whether team-based primary care models are being implemented to facilitate team collaboration and effectiveness. Thus, we present a protocol for a rapid scoping review to systematically map, synthesise and summarise the existing literature on the impact of provider remuneration mechanisms and extrinsic and intrinsic incentives in team-based primary care. This review will answer three research questions: (1) What is the impact of provider remuneration models on team, patient, provider and system outcomes in primary care?; (2) What extrinsic and intrinsic incentives have been used in interprofessional primary care teams?; and (3) What is the impact of extrinsic and intrinsic team-based incentives on team, patient, provider and system outcomes?

METHODS AND ANALYSIS

We will conduct a rapid scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. We will search electronic databases (Medline, Embase, CINAHL, PsycINFO, EconLit) and grey literature sources (Google Scholar, Google). This review will consider all empirical studies and full-text English-language articles published between 2000 and 2022. Reviewers will independently perform the literature search, data extraction and synthesis of included studies. The Mixed Methods Appraisal Tool will be used to appraise the quality of evidence. The literature will be synthesised, summarised and mapped to themes that answer the research question of this review.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings from this study will be written for publication in an open-access peer-review journal and presented at national and international conferences. Knowledge users are part of the research team and will assist with disseminating findings to the public, clinicians, funders and professional associations.

Realist synthesis of factors affecting retention of staff in UK adult mental health services

OBJECTIVES

The shortage of healthcare staff is a global problem. UK mental health services have, on average, a higher turnover of staff than the NHS. Factors affecting retention of this staff group need to be explored in more depth to understand what is working for whom, for what reasons and in what circumstances. This review aims to conduct a realist synthesis to explore evidence from published studies, together with stakeholder involvement to develop programme theories that hypothesise how and why retention occurs in the mental health workforce and identify additional evidence to explore and test these theories thereby highlighting any persistent gaps in understanding. This paper develops programme theories that hypothesise why retention occurs and in what context and tests these theories thereby highlighting any persistent gaps in understanding.

METHODS

Realist synthesis was used to develop programme theories for factors affecting retention of UK mental health staff. This involved: (1) stakeholder consultation and literature scoping to develop initial programme theories; (2) structured searches across six databases to identify 85 included relevant literature relating to the programme theories; and (3) analysis and synthesis to build and refine a final programme theory and logic model.

RESULTS

Phase I combined findings from 32 stakeholders and 24 publications to develop six initial programme theories. Phases II and III identified and synthesised evidence from 88 publications into three overarching programme theories stemming from organisational culture: interconnectedness of workload and quality of care, investment in staff support and development and involvement of staff and service users in policies and practice.

CONCLUSIONS

Organisational culture was found to have a key underpinning effect on retention of mental health staff. This can be modified but staff need to be well supported and feel involved to derive satisfaction from their roles. Manageable workloads and being able to deliver good quality care were also key.

Study of the medical service efficiency of county-level public general hospitals based on medical quality constraints: a cross-sectional study

OBJECTIVES

Since the new medical reform in 2009, county-level hospitals in China have achieved rapid development, but health resource waste and shortage issues still exist.

DESIGN

We applied the meta-frontier and slacks-based measurement-undesirable data envelopment analysis model to measure the medical service efficiency with or without medical quality constraints of the county-level public general hospitals (CPGHs). The assessment includes four inputs, three desirable outputs and one undesirable output. We conducted the assessment via Max-DEA V.8.19 software. Moreover, we analyse the factors affecting CPGHs' medical service efficiency based on the fractional response model.

SETTING

A total of 77 sample CPGHs were selected from Shanxi province in China from 2013 to 2018.

RESULTS

The results of this study showed that the efficiency level of county-level public hospitals in Shanxi Province is relatively low overall (the mean value of efficiency is 0.61 without quality constraints and 0.63 under quality constraints). This showed that ignoring medical quality constraints will result in lower efficiency and lower health resource usage for high medical quality hospitals. The medical service efficiency of CPGHs differs greatly among different regions. Under the meta-frontier, the hospitals in the central region had the highest efficiency (efficiency score 0.70), followed by those in the south (efficiency score 0.63) and the hospitals in the north had the lowest efficiency (efficiency score 0.54). Factors that have larger impacts on the service efficiency of county public hospitals are the average length of hospital stay, per capita disposable income and financial subsidy income.

CONCLUSIONS

To improve CPGHs' medical service efficiency, the government should increase investment in the northern region, and hospitals should improve the management level and allocate human resources rationally.

Implementation and clinical utility of a Computer-Aided Risk Score for Mortality (CARM): a qualitative study

OBJECTIVES

The Computer-Aided Risk Score for Mortality (CARM) estimates the risk of in-hospital mortality following acute admission to the hospital by automatically amalgamating physiological measures, blood tests, gender, age and COVID-19 status. Our aims were to implement the score with a small group of practitioners and understand their first-hand experience of interacting with the score in situ.

DESIGN

Pilot implementation evaluation study involving qualitative interviews.

SETTING

This study was conducted in one of the two National Health Service hospital trusts in the North of England in which the score was developed.

PARTICIPANTS

Medical, older person and ICU/anaesthetic consultants and specialist grade registrars (n=116) and critical outreach nurses (n=7) were given access to CARM. Nine interviews were conducted in total, with eight doctors and one critical care outreach nurse.

INTERVENTIONS

Participants were given access to the CARM score, visible after login to the patients' electronic record, along with information about the development and intended use of the score.

RESULTS

Four themes and 14 subthemes emerged from reflexive thematic analysis: (1) current use (including support or challenge clinical judgement and decision making, communicating risk of mortality and professional curiosity); (2) barriers and facilitators to use (including litigation, resource needs, perception of the evidence base, strengths and limitations), (3) implementation support needs (including roll-out and integration, access, training and education); and (4) recommendations for development (including presentation and functionality and potential additional data). Barriers and facilitators to use, and recommendations for development featured highly across most interviews.

CONCLUSION

Our in situ evaluation of the pilot implementation of CARM demonstrated its scope in supporting clinical decision making and communicating risk of mortality between clinical colleagues and with service users. It suggested to us barriers to implementation of the score. Our findings may support those seeking to develop, implement or improve the adoption of risk scores.

Challenges and outcomes of implementing a national syphilis follow-up system for the elimination of congenital syphilis in Cambodia: a mixed-methods study

OBJECTIVES

We aimed to describe the challenges and outcomes of implementing a national syphilis follow-up system to improve syphilis management in maternal and child health (MCH) services in Cambodia.

DESIGN

Operational study; quantitative cohort data and cross sectional qualitative data.

SETTING

Public health facilities at national level and in four provinces with high syphilis prevalence in Cambodia.

PARTICIPANTS

Pregnant women screened for syphilis; MCH health care providers and managers.

METHODS

We conducted an operational research using syphilis screening and treatment data collected from a national follow-up system (cohort data) and reported in the health management information system (HMIS) between 2019 and 2020. We also conducted indepth interviews with 16 pregnant women and focus group discussions with 37 healthcare providers and managers. Descriptive statistics and thematic content analysis were used.

OUTCOME MEASURES

Syphilis testing and treatment results and perceptions regarding these services.

RESULTS

A total of 470 pregnant women who tested positive in rapid syphilis testing were recorded in the national syphilis follow-up system in 2019-2020. Of these, 71% (332 of 470) received a rapid plasma reagin (RPR) test and 95% (n=315) tested positive; 78% (246 of 315) received any syphilis treatment and only 28% (88 of 315) were treated adequately with benzathine penicillin G (BPG). Data from four provinces with high syphilis prevalence (more closely monitored) showed higher testing and treatment rates than at the national level. HMIS aggregated data reported a higher number of pregnant women screened and treated for syphilis than the follow-up system during the same period. Barriers to syphilis testing and treatment included late antenatal care, long distance to RPR testing and treatment, partners' lack of support to reach the health facility, BPG stockout and poor adherence to oral treatment in the absence of BPG. Providers and managers reported a lack of communication across services, insufficient skills to treat infants and absence of clear guidance regarding the revised follow-up system. Study findings contributed to changes in operating procedures nationwide to facilitate access to syphilis testing and adequate treatment and a systematic follow-up of pregnant women and exposed infants.

CONCLUSIONS

Study results contributed to informing improvements to syphilis management in MCH services in Cambodia.

Prevalence of completion of maternity continuum of care and its associated factors in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

The present study aimed to estimate the pooled prevalence of completion of the maternity continuum of care (CoC) and its associated factors in Ethiopia.

STUDY DESIGN

Systematic review and meta-analysis.

STUDY SETTING

Ethiopia.

STUDY PARTICIPANTS

A total of 6245 reproductive-age women were included.

PRIMARY OUTCOME

The pooled prevalence of completion of the maternity CoC.

SECONDARY OUTCOME

Factors associated with completion of the maternity CoC.

METHODS

We systematically searched international databases such as PubMed, Scopus, African Journals Online, Google Scholar and Web of Sciences to retrieve related articles. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were used for this study. Publication bias was assessed using the funnel plot and Egger's test. Evidence of heterogeneity was checked using Cochrane Q test and I2 statistics. Subgroup analysis was computed based on the study regions. Data were analysed using STATA V.14 statistical software. Weighted inverse variance random effect models were used to estimate the pooled prevalence of completion of the maternity CoC.

RESULTS

The pooled prevalence of completion of maternity continuum care in Ethiopia was 25.82% (95% CI: 16.69% to 34.94%). Urban residence(adjusted odds ratio (AOR)=2.77, 95% CI: 1.99 to 3.86), having secondary and above educational status (AOR=3.50, 95% CI: 2.50 to 50), prepregnancy contraceptive utilisation (AOR=3.25, 95% CI: 2.02 to 5.22), women's autonomy (AOR=3.81, 95% CI: 2.74 to 5.31), following mass media (AOR=2.51, 95% CI: 1.79 to 3.50), early initiation of antenatal care (ANC) (AOR=4.98, 95% CI: 3.28 to 7.57), planned pregnancy (AOR=2.93, 95% CI: 1.99 to 4.32), birth preparedness and complication readiness (AOR=1.80, 95% CI: 1.29 to 2.51) and distance from a health facility<30 min (AOR=3.29, 95% CI: 2.45 to 4.42) were factors associated with completion of maternity continuum care in Ethiopia.

CONCLUSION

The pooled prevalence of completion of maternity continuum care in Ethiopia was low. Therefore, policymakers and stakeholders should improve the completion of ANC, the rate of skilled birth attendants and postnatal follow-up. Enhancing the accessibility of health facilities, women's awareness and empowering women's decision-making are recommended.

PROSPERO REGISTRATION NUMBER

CRD42022312692.

Completion of the maternal continuum of care and its association with antenatal care attendance during previous pregnancy among women in rural areas of the Gurage Zone, Southwest Ethiopia: a community-based cross-sectional study

OBJECTIVE

The maternal continuum of care is a cost-effective intervention to prevent pregnancy and childbirth-related maternal and neonatal mortality and morbidity. This study aimed to investigate the prevalence of completion of the maternal continuum of care and its association with antenatal care (ANC) attendance during previous pregnancy among women in rural kebeles of Gurage Zone, Southwest Ethiopia.

DESIGN

A community-based cross-sectional study.

SETTING

The study took place in 12 rural kebeles of the Gurage Zone from 1 April 2022 to 12 May 2022.

PARTICIPANTS

Randomly selected 497 women who gave birth in the previous 12 months in rural kebeles of the Gurage Zone.

OUTCOME

The outcome of this study was the prevalence of completion of the maternal continuum of care.

RESULTS

Overall, the prevalence of completion of the maternal continuum of care was 15.5% (95% CI: 12.55% to 18.9%). After adjusting for potential confounders, having ANC attendance during a previous pregnancy (adjusted OR (AOR): 2.01; 95% CI: 1.07 to 3.76) was positively associated with the completion of the maternal continuum of care. In addition, having access to ambulance service as a means of transportation (AOR: 6.01; 95% CI: 3.16 to 11.39) and exposure to mass media (AOR: 2.43; 95% CI: 1.27 to 4.68) were positively associated with completion of the maternal continuum of care.

CONCLUSION

The prevalence of completion of the maternity continuum of care was unacceptably low in this study. This result indicates that the women did not receive the maximum possible health benefit from existing maternal healthcare services. The completion of the maternal continuum of care was affected by ANC attendance in a previous pregnancy. Therefore, interventions that can strengthen ANC are crucial in the maternal continuum of the care pathway.

Patient clusters and cost trajectories in the Swiss Atrial Fibrillation cohort

Objective

Evidence on long-term costs of atrial fibrillation (AF) and associated factors is scarce. As part of the Swiss-AF prospective cohort study, we aimed to characterise AF costs and their development over time, and to assess specific patient clusters and their cost trajectories.

Methods

Swiss-AF enrolled 2415 patients with variable duration of AF between 2014 and 2017. Patient clusters were identified using hierarchical cluster analysis of baseline characteristics. Ongoing yearly follow-ups include health insurance clinical and claims data. An algorithm was developed to adjudicate costs to AF and related complications.

Results

A subpopulation of 1024 Swiss-AF patients with available claims data was followed up for a median (IQR) of 3.24 (1.09) years. Average yearly AF-adjudicated costs amounted to SFr5679 (€5163), remaining stable across the observation period. AF-adjudicated costs consisted mainly of inpatient and outpatient AF treatment costs (SFr4078; €3707), followed by costs of bleeding (SFr696; €633) and heart failure (SFr494; €449). Hierarchical analysis identified three patient clusters: cardiovascular (CV; N=253 with claims), isolated-symptomatic (IS; N=586) and severely morbid without cardiovascular disease (SM; N=185). The CV cluster and SM cluster depicted similarly high costs across all cost outcomes; IS patients accrued the lowest costs.

Conclusion

Our results highlight three well-defined patient clusters with specific costs that could be used for stratification in both clinical and economic studies. Patient characteristics associated with adjudicated costs as well as cost trajectories may enable an early understanding of the magnitude of upcoming AF-related healthcare costs.

Effect of social prescribing link workers on health outcomes and costs for adults in primary care and community settings: a systematic review

OBJECTIVES

To establish the evidence base for the effects on health outcomes and costs of social prescribing link workers (non-health or social care professionals who connect people to community resources) for people in community settings focusing on people experiencing multimorbidity and social deprivation.

DESIGN

Systematic review and narrative synthesis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

DATA SOURCES

Cochrane Database, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, EU Clinical Trials Register, CINAHL, Embase, Global Health, PubMed/MEDLINE, PsycInfo, LILACS, Web of Science and grey literature were searched up to 31 July 2021. A forward citation search was completed on 9 June 2022.

ELIGIBILITY CRITERIA

Controlled trials meeting the Cochrane Effectiveness of Practice and Organisation of Care (EPOC) guidance on eligible study designs assessing the effect of social prescribing link workers for adults in community settings on any outcomes. No language restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data, evaluated study quality using the Cochrane EPOC risk of bias tool and judged certainty of the evidence. Results were synthesised narratively.

RESULTS

Eight studies (n=6500 participants), with five randomised controlled trials at low risk of bias and three controlled before-after studies at high risk of bias, were included. Four included participants experiencing multimorbidity and social deprivation. Four (n=2186) reported no impact on health-related quality of life (HRQoL). Four (n=1924) reported mental health outcomes with three reporting no impact. Two US studies found improved ratings of high-quality care and reduced hospitalisations for people with multimorbidity experiencing deprivation. No cost-effectiveness analyses were identified. The certainty of the evidence was low or very low.

CONCLUSIONS

There is an absence of evidence for social prescribing link workers. Policymakers should note this and support evaluation of current programmes before mainstreaming.

PROSPERO REGISTRATION NUMBER

CRD42019134737.

Quantifying antibiotic use in typhoid fever in India: a cross-sectional analysis of private sector medical audit data, 2013-2015

OBJECTIVES

To estimate the antibiotic prescription rates for typhoid in India.

DESIGN

Cross-sectional study.

SETTING

Private sector primary care clinicians in India.

PARTICIPANTS

The data came from prescriptions of a panel of 4600 private sector primary care clinicians selected through a multistage stratified random sampling accounting for the region, specialty type and patient turnover. The data had 671 million prescriptions for antibiotics extracted from the IQVIA database for the years 2013, 2014 and 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Mean annual antibiotic prescription rates; sex-specific and age-specific prescription rates; distribution of antibiotic class.

RESULTS

There were 8.98 million antibiotic prescriptions per year for typhoid, accounting for 714 prescriptions per 100 000 population. Children 10-19 years of age represented 18.6% of the total burden in the country in absolute numbers, 20-29 year age group had the highest age-specific rate, and males had a higher average rate (844/100 000) compared with females (627/100 000). Ten different antibiotics accounted for 72.4% of all prescriptions. Cefixime-ofloxacin combination was the preferred drug of choice for typhoid across all regions except the south. Combination antibiotics are the preferred choice of prescribers for adult patients, while cephalosporins are the preferred choice for children and young age. Quinolones were prescribed as monotherapy in 23.0% of cases.

CONCLUSIONS

Nationally representative private sector antibiotic prescription data during 2013-2015 indicate a higher disease burden of typhoid in India than previously estimated. The total prescription rate shows a declining trend. Young adult patients account for close to one-third of the cases and children less than 10 years account for more than a million cases annually.

Healthcare Workers' Resilience Toolkit for Disaster Management and Climate Change Adaptation

Climate change has been recognised as a multiplier of risk factors affecting public health. Disruptions caused by natural disasters and other climate-driven impacts are placing increasing demands on healthcare systems. These, in turn, impact the wellness and performance of healthcare workers (HCWs) and hinder the accessibility, functionality and safety of healthcare systems. This study explored factors influencing HCWs' disaster management capabilities with the aim of improving their resilience and adaptive capacity in the face of climate change. In-depth, semi-structured interviews were conducted with thirteen HCWs who dealt with disasters within two hospitals in Queensland, Australia. Analysis of the results identified two significant themes, HCWs' disaster education and HCWs' wellness and needs. The latter comprised five subthemes: HCWs' fear and vulnerability, doubts and uncertainty, competing priorities, resilience and adaptation, and needs assessment. This study developed an 'HCWs Resilience Toolkit', which encourages mindfulness amongst leaders, managers and policymakers about supporting four priority HCWs' needs: 'Wellness', 'Education', 'Resources' and 'Communication'. The authors focused on the 'Education' component to detail recommended training for each of the pre-disaster, mid-disaster and post-disaster phases. The authors conclude the significance of the toolkit, which provides a timely contribution to the healthcare sector amidst ongoing adversity.

Qualitative study exploring the well-being experiences of paediatric critical care consultants working in the UK during the COVID-19 pandemic

OBJECTIVES

The aim of this study was to examine the well-being experiences of consultants working in paediatric critical care (PCC) settings in the UK during the COVID-19 pandemic.

DESIGN

Qualitative design using individual interviews and thematic analysis.

SETTING

PCC.

PARTICIPANTS

Eleven medical consultants working in PCC in a range of PCC settings/transport teams in the UK from nine units participated. Participants ranged in years of experience as a consultant from four to 23 years.

METHODS

A set of open semistructured questions were used to elicit information about participants' experiences of workplace well-being. Interviews were audiorecorded and transcribed.

FINDINGS

Thematic analysis identified six themes and data saturation was reached. These were as follows: (1) positive and negative impact of working during COVID-19, (2) job satisfaction and public scrutiny in the unique environment of PCC, (3) supporting the workforce through modified shift work, (4) perceptions of support and recognition offered from the hospital management, (5) successful coping strategies are personal and adaptive, and (6) importance of civility and good teamwork CONCLUSION: Findings show that consultants' well-being is challenged in a number of ways and that the solutions to the problem of burn-out are multifaceted. Action is required from individual consultants, clinical teams, hospital management and national regulatory bodies. Our work corroborates the recent General Medical Council report highlighting doctors' core needs for well-being: autonomy, belonging, competence. Burn-out is a long-term problem, requiring sustainable solutions. Future research needs to develop and evaluate the effectiveness of evidence-based interventions to improve consultants' well-being. Trials of effectiveness need to present evidence that will persuade hospital management to invest in their consultants' well-being within the economic context of reduced budgets and limited PCC workforce.

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study

OBJECTIVES

Multifactorial interventions, which involve assessing an individual's risk of falling and providing treatment or onward referral, require coordination across settings. Using a mixed-methods design, we aimed to develop a process map to examine onward referral pathways following falls risk assessment in primary care.

SETTING

Primary care fall risk assessment clinics in the South of Ireland.

PARTICIPANTS

Focus groups using participatory mapping techniques with primary care staff (public health nurses (PHNs), physiotherapists (PT),and occupational therapists (OT)) were conducted to plot the processes and onward referral pathways at each clinic (n=5).

METHODS

Focus groups were analysed in NVivo V.12 using inductive thematic analysis. Routine administrative data from January to March 2018 included details of client referrals, assessments and demographics sourced from referral and assessment forms. Data were analysed in Stata V.12 to estimate the number, origin and focus of onward referrals and whether older adults received follow-up interventions. Quantitative and qualitative data were analysed separately and integrated to produce a map of the service.

RESULTS

Nine staff participated in three focus groups and one interview (PHN n=2; OT n=4; PT n=3). 85 assessments were completed at five clinics (female n=69, 81.2%, average age 77). The average number of risk factors was 5.4 out of a maximum of 10. Following assessment, clients received an average of three onward referrals. Only one-third of referrals (n=135/201, 33%) had data available on intervention receipt. Primary care staff identified variations in how formally onward referrals were managed and barriers, including a lack of client information, inappropriate referral and a lack of data management support.

CONCLUSION

Challenges to onward referral manifest early in an integrated care pathway, such as clients with multiple risk factors sent for initial assessment and the lack of an integrated IT system to share information across settings.

Factors affecting vaccination demand in Indonesia: a secondary analysis and multimethods national assessment

OBJECTIVES

Vaccine hesitancy remains a major barrier to immunisation coverage worldwide. We explored influence of hesitancy on coverage and factors contributing to vaccine uptake during a national measles-rubella (MR) campaign in Indonesia.

DESIGN

Secondary analyses of qualitative and quantitative data sets from existing cross-sectional studies conducted during and around the campaign.

METHODS

Quantitative data used in this assessment included daily coverage reports generated by health workers, district risk profiles that indicate precampaign immunisation programme performance, and reports of campaign cessation due to vaccine hesitancy. We used t-test and χ² tests for associations. The qualitative assessment employed three parallel national and regional studies. Deductive thematic analysis examined factors for acceptance among caregivers, health providers and programme managers.

RESULTS

Coverage data were reported from 6462 health facilities across 395 districts from 1 August to 31 December 2018. The average district coverage was 73%, with wide variation between districts (2%-100%). One-third of districts fell below 70% coverage thresholds. Sixty-two of 395 (16%) districts paused the campaign due to hesitancy. Coverage among districts that never paused campaign activities due to hesitancy was significantly higher than rates for districts ever-pausing the campaign (81% vs 42%; p<0.001). Precampaign adequacy of district immunisation programmes did not explain coverage gaps (p=0.210). Qualitative analysis identified acceptance enablers including using digital health monitoring and feedback systems, increasing caregiver knowledge and awareness, making immunisation social norm, effective cross-sectoral collaboration, conducive service environment and positive experiences for mothers and children. Barriers included misinformation diffusion on social media, halal-haram issues, lack of healthcare provider knowledge, negative family influences and traditions, previous poor experiences and misinformation on adverse events.

CONCLUSION

Barriers to vaccine uptake contributed to coverage gaps during national MR campaign in Indonesia. A range of supply-related and demand-related strategies were identified to address hesitancy contributors. Advancing a portfolio of tailored multilevel interventions will be critical to enhance vaccine acceptance.

Developing an evidence-informed model of long-term life care at home for older adults with medical, functional and/or social care needs in Ontario, Canada: a mixed methods study protocol

INTRODUCTION

The COVID-19 pandemic exacerbated existing challenges within the Canadian healthcare system and reinforced the need for long-term care (LTC) reform to prioritise building an integrated continuum of services to meet the needs of older adults. Almost all Canadians want to live, age and receive care at home, yet funding for home and community-based care and support services is limited and integration with primary care and specialised geriatric services is sparse. Optimisation of existing home and community care services would equip the healthcare system to proactively meet the needs of older Canadians and enhance capacity within the hospital and residential care sectors to facilitate access and reduce wait times for those whose needs are best served in these settings. The aim of this study is to design a model of long-term 'life care' at home (LTlifeC model) to sustainably meet the needs of a greater number of community-dwelling older adults.

METHODS AND ANALYSIS

An explanatory sequential mixed methods design will be applied across three phases. In the quantitative phase, secondary data analysis will be applied to historical Ontario Home Care data to develop unique groupings of patient needs according to known predictors of residential LTC home admission, and to define unique patient vignettes using dominant care needs. In the qualitative phase, a modified eDelphi process and focus groups will engage community-based clinicians, older adults and family caregivers in the development of needs-based home care packages. The third phase involves triangulation to determine initial model feasibility.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the University of Waterloo Research Ethics Board (ORE #42182). Results of this study will be disseminated through peer-reviewed publications and local, national and international conferences. Other forms of knowledge mobilisation will include webinars, policy briefs and lay summaries to elicit support for implementation and pilot testing phases.

Investigating Organizational Learning and Adaptations for Improved Disaster Response Towards "Resilient Hospitals:" An Integrative Literature Review

Background:

For hospitals, learning from disaster response efforts and adapting organizational practices can improve resilience in dealing with future disruptions. However, amidst global disruptions by climate change, the coronavirus disease 2019 (COVID-19) pandemic, and other disasters, hospitals’ ability to cope continues to be highly variable. Hence, there are increasing calls to improve hospitals’ capabilities to grow and adapt towards enhanced resilience.

Aim:

This study aims two-fold: (1) to characterize the current state of knowledge about how hospitals are gaining knowledge from their responses to disasters, and (2) to explore how this knowledge can be applied to inform organizational practices for hospital resilience.

Method:

This study used Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) guidelines for data collection and framework for data analysis, Covidence software, and Medical Subject Headings (MeSH) terms and keywords relevant to “hospitals,” “learn,” “disaster response,” and “resilience.” The quality appraisal used an adapted version of the Mixed Methods Assessment Tool (MMAT).

Results:

After applying inclusion and exclusion criteria and quality appraisal, out of the 420 articles retrieved, 22 articles remained for thematic and content analysis. The thematic analysis included the hospital’s functional (operational) and physical (structural and non-structural) sections. The content analysis followed nine learning areas (Governance and Leadership, Planning and Risk Assessment, Surveillance and Monitoring, Communication and Network Engagement, Staff Practices and Safety, Equipment and Resources, Facilities and Infrastructure, Novelty and Innovation, and Learning and Evaluation).

On applying the Deming cycle, only four studies described a completed learning cycle wherein hospitals adapted their organizational structures using the prior experience and evaluation gained in responding to disaster(s).

Conclusions:

There is a gap between hospitals’ organizational learning and institutionalized practice. The conceptualized Hybrid Resilience Learning Framework (HRLF) aims to guide the hospitals’ decision makers in evaluating organizational resilience and knowledge.

In the face of disasters, both the stressful factors and the coping strategies that affect the health care workers (HCWs) should be substantially considered.

Towards a cervical cancer-free future: women's healthcare decision making and cervical cancer screening uptake in sub-Saharan Africa

OBJECTIVE

We investigated the association between women's healthcare decision making and cervical cancer screening uptake in sub-Saharan Africa.

DESIGN

Secondary data from the Demographic and Health Surveys of six countries in sub-Saharan Africa were used. We employed multilevel binary logistic regression modelling.

SETTING

Sub-Saharan Africa.

PARTICIPANTS

Women aged 15-49 years in Benin (n=5282), Côte d'Ivoire (n=1925), Cameroon (n=7558), Kenya (n=6696), Namibia (n=1990) and Zimbabwe (n=5006).

PRIMARY OUTCOME MEASURES

Cervical cancer screening uptake.

RESULTS

The overall prevalence of cervical cancer screening across the six sub-Saharan African countries was 13.4%. Compared with women whose healthcare decisions were made solely by husbands/partners/someone else, the likelihood of cervical cancer screening uptake was significantly higher among women who took healthcare decisions in consultation with their husbands/partners (aOR=1.38; 95% CI 1.19 to 1.59), but highest among those who made healthcare decisions alone (aOR=1.66; 95% CI 1.44 to 1.91). Women aged between 40 and 45 years (aOR=5.18; 95% CI 3.15 to 8.52), those with higher education (aOR=2.13; 95% CI 1.57 to 2.88), those who had ever heard of cervical cancer (aOR=32.74; 95% CI 20.02 to 53.55), read newspaper or magazine at least once a week (aOR=2.11; 95% CI 1.83 to 2.44), listened to the radio at least once a week (aOR=1.35; 95% CI1.18 to 1.52) and those in households with richest wealth index (aOR=1.55; 95% CI 1.20 to 2.00) had significantly higher odds of screening for cervical cancer compared to their counterparts.

CONCLUSION

Women who are able to make autonomous healthcare decisions and those who practice shared decision making are more likely to uptake cervical cancer screening. Therefore, policy interventions should focus on empowering women to be able to take autonomous healthcare decisions or shared decision making while targeting subpopulations (ie, multiparous and rural-dwelling women, as well as those in other religious affiliations aside from Christianity) that are less likely to uptake cervical cancer screening. Also, the radio and print media could be leveraged in raising awareness about cervical cancer screening to accelerate cervical cancer screening uptake in sub-Saharan Africa.

Effectiveness and active ingredients of social prescribing interventions targeting mental health: a systematic review

OBJECTIVE

This study aims to establish the effectiveness and active ingredients of UK-based social prescribing interventions targeting mental health and well-being outcomes.

DESIGN

Systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysies guidelines and a published protocol.

DATA SOURCES

Nine databases were systematically searched up to March 2022.

ELIGIBILITY CRITERIA

Social prescribing interventions in the UK involving adults aged ≥18 years, which reported on mental health outcomes.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data on study characteristics; outcomes; referral pathways; treatment fidelity strategies; person-centredness; intervention development processes and theory-linked behaviour change techniques (BCTs). Data were narratively synthesised.

RESULTS

52 074 records were retrieved by the search, 13 interventions reported across 17 studies were included in this review (N=5036 participants at post-intervention). Fifteen studies were uncontrolled before-and-after designs, one a randomised controlled trial and one a matched groups design. The most frequently reported referral pathway was the link worker model (n=12), followed by direct referrals from community services (n=3). Participants were predominantly working age adults, and were referred for anxiety, depression, social isolation and loneliness. 16 out of 17 studies reported statistically significant improvements in outcomes (mental health, mental well-being, general health, or quality of life). Strategies to enhance treatment fidelity were suboptimal across studies. Only two studies used a specific theoretical framework. A few studies reported engaging service users in codesign (n=2) or usability and/or feasibility testing (n=4). Overall, 22 BCTs were coded across 13 interventions. The most frequently coded BCTs were social support-unspecified (n=11), credible source (n=7) and social support-practical (n=6).

CONCLUSIONS

Robust conclusions on the effectiveness of social prescribing for mental health-related outcomes cannot be made. Future research would benefit from comprehensive intervention developmental processes, with reference to appropriate theory, alongside long-term follow-up outcome assessment, using treatment fidelity strategies and a focus on principle of person-centred care.

PROSPERO REGISTRATION NUMBER

CRD42020167887.

Interventions to improve media coverage of medical research: a codesigned feasibility and acceptability study with Australian journalists

OBJECTIVES

Although the media can influence public perceptions and utilisation of healthcare, journalists generally receive no routine training in interpreting and reporting on medical research. Given growing evidence about the problems of medical overuse, the need for quality media reporting has become a greater priority. This study aimed to codesign and assess the feasibility of a multicomponent training intervention for journalists in Australia.

DESIGN

A small pragmatic feasibility study using a pre- and postdesign.

SETTING

90 min online workshop.

PARTICIPANTS

Eight journalists currently working in Australia, recruited through the study's journalist advisor and existing contacts of the researchers.

INTERVENTION

The training intervention covered a range of topics, including study designs, conflicts of interest, misleading medical statistics, population screening and overdiagnosis. The intervention also provided tools to help journalists with reporting, including a Tip Sheet and list of expert contacts in health and medicine. Preworkshop and postworkshop questionnaires were administered via Qualtrics.

MEASURES

Acceptability and feasibility of the intervention, and journalists' knowledge of overdiagnosis and common issues with health stories. Quantitative results were analysed descriptively using SPSS. Qualitative data were thematically analysed.

RESULTS

All participants completed preworkshop and postworkshop questionnaires, and 6 completed the 6-week follow-up (75% retention). Feasibility findings suggest the intervention is acceptable and relevant to journalists, with participants indicating the workshop increased confidence with reporting on medical research. We observed increases in knowledge preworkshop to postworkshop for all knowledge measures on overdiagnosis and common issues with media coverage of medicine. Analysis of free-text responses identified several areas for improvement, such as including more examples to aid understanding of the counterintuitive topic of overdiagnosis and more time for discussion.

CONCLUSIONS

Piloting suggested the multicomponent training intervention is acceptable to journalists and provided important feedback and insights to inform a future trial of the intervention's impact on media coverage of medicine.

Acceptability of a task sharing and shifting model between family physicians and physiotherapists in French multidisciplinary primary healthcare centres: a cross-sectional survey

OBJECTIVES

The rising prevalence of musculoskeletal disorders increases pressure on primary care services. In France, patients with musculoskeletal disorders are referred to physiotherapist (PT) by family physician (FP). To improve access to musculoskeletal care, a new model of task sharing and shifting is implemented between FPs and PTs for patients with acute low back pain. This new model enables French PTs to expand their usual scope of practice by receiving patients as first-contact practitioner, diagnosing low back pain, prescribing sick leave and analgesic medication. The aim of this study is to investigate the acceptability of FPs and PTs regarding this new model.

DESIGN

A cross-sectional survey design was used. Acceptability was measured using a questionnaire on the perception of the model and the perception of PTs' skills to manage low back pain. Descriptive analyses were performed to compare results among participants.

SETTING

French FPs and PTs working in multidisciplinary primary healthcare centres were invited to complete an online survey.

PARTICIPANTS

A total of 174 respondents completed the survey (81 FPs and 85 PTs).

RESULTS

A majority of participants had a positive perception of the task sharing and shifting model. A majority of the participants were mostly or totally favourable towards the implementation of the model (FPs: n=46, 82% and PTs: n=40, 82%). The perceived level of competencies of PTs to manage acute low back pain was high. The confidence level of FPs was higher than that of PTs regarding PTs' ability to adequately diagnose low back pain, refer patient to physiotherapy and prescribe sick leave or analgesic medication.

CONCLUSION

Based on this limited sample of participants, there appears to be good acceptability of the task sharing and shifting model for acute low back pain. Additional studies are needed to better determine the factors affecting the acceptability of such a model.

Benefits and limitations of business process model notation in modelling patient healthcare trajectory: a scoping review protocol

INTRODUCTION

The adoption of business process model notation (BPMN) in modelling healthcare trajectory can enhance the efficiency and efficacy of healthcare organisations, improve patient outcomes while restraining costs. Existing systematic reviews have been inconclusive regarding the effectiveness of BPMN in modelling healthcare trajectory. The aims of this scoping review are to map and aggregate existing evidence on the benefits and limitations associated with BPMN in healthcare trajectory, highlighting areas of improvement on BPMN and its extensions in healthcare. We will assess BPMN's ability to model key dimensions or concepts of the healthcare process and to meet the needs of stakeholders. The review will highlight the advantages of this approach to support clinical activities and decision-making processes associated with the healthcare trajectory, proposing a conceptual framework for improving the use of BPMN in healthcare.

METHODS AND ANALYSIS

This study will be performed in accordance with the methodological framework suggested by Arksey and O'Malley. A wide range of electronic databases and grey literature sources will be systematically searched using predefined keywords. The review will include any study design focusing on the application of the BPMN approach for optimising healthcare trajectories, published in either English or French from 1 January 2004 to 9 December 2021. Two reviewers will independently screen titles, abstracts and full-text articles and select articles meeting the inclusion criteria. A customised data extraction form will be used to extract data. The results will be presented using descriptive statistics and thematic analysis on qualitative data.

ETHICS AND DISSEMINATION

Research ethics approval is not required. Review findings will be used to advance understanding about BPMN, its extensions and application in healthcare trajectory optimisation. The review will develop recommendations on tailoring BPMN strategies for optimising care pathways and decision-making processes. Findings will be disseminated in peer-reviewed journals, conferences and discussions with relevant organisations and stakeholders.

Exploring how and why social prescribing evaluations work: a realist review

OBJECTIVE

The evidence base for social prescribing is inconclusive, and evaluations have been criticised for lacking rigour. This realist review sought to understand how and why social prescribing evaluations work or do not work. Findings from this review will contribute to the development of an evidence-based evaluation framework and reporting standards for social prescribing.

DESIGN

A realist review.

DATA SOURCES

ASSIA, CINAHL, Embase, Medline, PsycINFO, PubMed, Scopus Online, Social Care Online, Web of Science and grey literature.

ELIGIBILITY CRITERIA

Documents reporting on social prescribing evaluations using any methods, published between 1998 and 2020 were included. Documents not reporting findings or lacking detail on methods for data collection and outcomes were excluded.

ANALYSIS

Included documents were segregated into subcases based on methodology. Data relating to context, mechanisms and outcomes and the programme theory were extracted and context-mechanism-outcome configurations were developed. Meta-inferences were drawn from all subcases to refine the programme theory.

RESULTS

83 documents contributed to analysis. Generally, studies lacked in-depth descriptions of the methods and evaluation processes employed. A cyclical process of social prescribing evaluation was identified, involving preparation, conducting the study and interpretation. The analysis found that coproduction, alignment, research agency, sequential mixed-methods design and integration of findings all contributed to the development of an acceptable, high-quality social prescribing evaluation design. Context-mechanism-outcome configurations relating to these themes are reported.

CONCLUSIONS

To develop the social prescribing evidence base and address gaps in our knowledge about the impact of social prescribing and how it works, evaluations must be high quality and acceptable to stakeholders. Development of an evaluation framework and reporting standards drawing on the findings of this realist review will support this aim.

PROSPERO REGISTRATION NUMBER

CRD42020183065.

Models of care for low back pain patients in primary healthcare: a scoping review protocol

INTRODUCTION

Low back pain (LBP) is the most prevalent musculoskeletal condition worldwide and it is responsible for high healthcare costs and resources consumption. It represents a challenge for primary care services that struggle to implement evidence-based practice. Models of care (MoCs) are arising as effective solutions to overcome this problem, leading to better health outcomes. Although there is growing evidence regarding MoCs for the management of LBP patients, an analysis of the existing body of evidence has not yet been carried out. Therefore, this scoping review aims to identify and map the current evidence about the implementation of MoCs for LBP in primary healthcare. Findings from this study will inform policy makers, health professionals and researchers about their characteristics and outcomes, guiding future research and best practice models.

METHODS AND ANALYSIS

This protocol will follow the Joanna Briggs Institute methodological guidelines for scoping reviews. Studies that implemented an MoC for LBP patients in primary healthcare will be included. Searches will be conducted on PubMed, EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science, grey literature databases and relevant organisations websites. This review will consider records from 2000, written in English, Portuguese or Spanish. Two researchers will independently screen all citations and full-text articles and abstract data. Data extracted will include the identification of the MoC, key elements of the intervention, organisational components, context-specific factors and patient-related, system-related and implementation-related outcomes.

ETHICS AND DISSEMINATION

As a secondary analysis, this study does not require ethical approval. It will provide a comprehensive understanding on existing MoCs for LBP, outcomes and context-related challenges that may influence implementation in primary healthcare, which is meaningful knowledge to inform future research in this field. Findings will be disseminated through research papers in peer-reviewed journals, presentations at relevant conferences and documentation for professional organisations and stakeholders.

Worker and manager perceptions of the utility of work-related mental health literacy programmes delivered by community organisations: a qualitative study based on the theory of planned behaviour

OBJECTIVES

Reluctance to seek help is a leading contributor to escalating mental injury rates in Australian workplaces. We explored the benefit of using community organisations to deliver mental health literacy programmes to overcome workplace barriers to help-seeking behaviours.

DESIGN

This study used a qualitative application of the theory of planned behaviour to examine underlying beliefs that may influence worker's intentions to participate in mental health literacy programmes delivered by community organisations and manager support for them.

SETTING

This study took place within three large white-collar organisations in the Australian state of Victoria.

PARTICIPANTS

Eighteen workers and 11 managers (n=29) were interviewed to explore perspectives of the benefits of such an approach.

RESULTS

Community organisations have six attributes that make them suitable as an alternative mental health literacy programme provider including empathy, safety, relatability, trustworthiness, social support and inclusivity. Behavioural beliefs included accessibility, understanding and objectivity. The lack of suitability and legitimacy due to poor governance and leadership was disadvantages. Normative beliefs were that family and friends would most likely approve, while line managers and colleagues were viewed as most likely to disapprove. Control beliefs indicated that endorsements from relevant bodies were facilitators of participation. Distance/time constraints and the lack of skills, training and lived experiences of coordinators/facilitators were seen as barriers.

CONCLUSIONS

Identifying workers' beliefs and perceptions of community organisations has significant implication for the development of effective community-based strategies to improve worker mental health literacy and help seeking. Organisations with formal governance structures, allied with government, peak bodies and work-related mental health organisations would be most suitable. Approaches should focus on lived experience and be delivered by qualified facilitators. Promoting supervisor and colleague support could improve participation. Models to guide cross-sector collaborations to equip community organisations to deliver work-related mental health literacy programmes need to be explored.

Equity impact of participatory learning and action community mobilisation and mHealth interventions to prevent and control type 2 diabetes and intermediate hyperglycaemia in rural Bangladesh: analysis of a cluster randomised controlled trial

Background

A cluster randomised trial of mHealth and participatory learning and action (PLA) community mobilisation interventions showed that PLA significantly reduced the prevalence of intermediate hyperglycaemia and type 2 diabetes mellitus (T2DM) and the incidence of T2DM among adults in rural Bangladesh; mHealth improved knowledge but showed no effect on glycaemic outcomes. We explore the equity of intervention reach and impact.

Methods

Intervention reach and primary outcomes of intermediate hyperglycaemia and T2DM were assessed through interview surveys and blood fasting glucose and 2-hour oral glucose tolerance tests among population-based samples of adults aged ≥30 years. Age-stratified, gender-stratified and wealth-stratified intervention effects were estimated using random effects logistic regression.

Results

PLA participants were similar to non-participants, though female participants were younger and more likely to be married than female non-participants. Differences including age, education, wealth and marital status were observed between individuals exposed and those not exposed to the mHealth intervention.

PLA reduced the prevalence of T2DM and intermediate hyperglycaemia in all age, gender and wealth strata. Reductions in 2-year incidence of T2DM of at least 51% (0.49, 95% CI 0.26 to 0.92) were observed in all strata except among the oldest and least poor groups. mHealth impact on glycaemic outcomes was observed only among the youngest group, where a 47% reduction in the 2-year incidence of T2DM was observed (0.53, 95% CI 0.28 to 1.00).

Conclusion

Large impacts of PLA across all strata indicate a highly effective and equitable intervention. mHealth may be more suitable for targeting higher risk, younger populations.

Trial registration number

ISRCTN41083256.

Evaluating the safety and patient impacts of an artificial intelligence command centre in acute hospital care: a mixed-methods protocol

INTRODUCTION

This paper presents a mixed-methods study protocol that will be used to evaluate a recent implementation of a real-time, centralised hospital command centre in the UK. The command centre represents a complex intervention within a complex adaptive system. It could support better operational decision-making and facilitate identification and mitigation of threats to patient safety. There is, however, limited research on the impact of such complex health information technology on patient safety, reliability and operational efficiency of healthcare delivery and this study aims to help address that gap.

METHODS AND ANALYSIS

We will conduct a longitudinal mixed-method evaluation that will be informed by public-and-patient involvement and engagement. Interviews and ethnographic observations will inform iterations with quantitative analysis that will sensitise further qualitative work. Quantitative work will take an iterative approach to identify relevant outcome measures from both the literature and pragmatically from datasets of routinely collected electronic health records.

ETHICS AND DISSEMINATION

This protocol has been approved by the University of Leeds Engineering and Physical Sciences Research Ethics Committee (#MEEC 20-016) and the National Health Service Health Research Authority (IRAS No.: 285933). Our results will be communicated through peer-reviewed publications in international journals and conferences. We will provide ongoing feedback as part of our engagement work with local trust stakeholders.

"Well, I Signed Up to Be a Soldier; I Have Been Trained and Equipped Well": Exploring Healthcare Workers' Experiences during COVID-19 Organizational Changes in Singapore, from the First Wave to the Path towards Endemicity

(1) Background: As COVID-19 transmission continues despite vaccination programs, healthcare workers (HCWs) face an ongoing pandemic response. We explore the effects of this on (1) Heartware, by which we refer to morale and commitment of HCWs; and identify how to improve (2) Hardware, or ways of enabling operational safety and functioning. (2) Methods: Qualitative e-diary entries were shared by HCWs during the early phases of the outbreak in Singapore from June to August 2020. Data were collected via an online survey of n = 3616 HCWs of all cadres. Nine institutions—restructured hospitals (n = 5), affiliated primary partners (n = 2) and hospices (n = 2)—participated. Applied thematic analysis was undertaken and organized according to Heartware and Hardware. Major themes are in italics (3) Results: n = 663 (18%) HCWs submitted a qualitative entry. Dominant themes undermining (1) Heartware consisted of burnout from being overworked and emotional exhaustion and at times feeling a lack of appreciation or support at work. The most common themes overriding morale breakers were a stoic acceptance to fight, adjust and hold the line, coupled with motivation from engaging leadership and supportive colleagues. The biggest barrier in (2) Hardware analysis related to sub-optimal segregation strategies within wards and designing better protocols for case detection, triage, and admissions criteria. Overall, the most cited enabler was the timely and well-planned provision of Personal Protective Equipment (PPE) for front-liners, though scope for scale-up was called for by those not considered frontline. Analysis maps internal organizational functioning to wider external public and policy-related narratives. (4) Conclusions: COVID-19 surges are becoming endemic rather than exceptional events. System elasticity needs to build on known pillars coupling improving safety and care delivery with improving HCW morale. Accordingly, a model capturing such facets of Adaptive Pandemic Response derived from our data analyses is described. HCW burnout must be urgently addressed, and health systems moved away from reactive “wartime” response configurations.

Qualitative inquiry into barriers and facilitators to transforming primary care for lesbian, gay, bisexual and transgender people in US federally qualified health centres

OBJECTIVES

Health systems must rapidly move knowledge into practice to address disparities impacting sexual and gender minority (SGM) patients. This qualitative study explores barriers and facilitators that arose during an initiative to improve care for SGM patients in federally qualified health centres (FQHCs) from the perspectives of FQHC staff.

DESIGN

Cross-sectional qualitative content analysis, using a general inductive approach, of secondary data from transcripts of intervention events offered to FQHC staff and semistructured interviews with staff and FQHC leadership during the intervention.

SETTING

10 FQHCs from nine states in the USA.

PARTICIPANTS

FQHC quality improvement (QI) and clinical care staff, and leaders at each FQHC.

INTERVENTIONS

The transforming care for lesbian, gay, bisexual and transgender people QI initiative combined two evidence-based programmes, Learning Collaborative (LC) and Project Extension for Community Healthcare Outcomes (ECHO), to assist primary care health centres in developing capacity to identify SGM patients, monitor their health and care, and improve disparities.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was identification of barriers and facilitators to implementing initiatives to improve care for SGM patients. The secondary outcome was clarification of how intervention participants used Project ECHO sessions versus LC meetings to obtain information that influenced implementation of the initiative at their FQHC.

RESULTS

Barriers and facilitators mapped to two major themes: 'Clinical' (patients' health, wellness, and available treatment) and Health Systems and Institutional Culture (FQHC operations, and customs and social institutions within the FQHCs and in the external environment). Common 'Clinical' inquiries were for assistance with behavioural health, pre-exposure prophylaxis and transgender hormone therapy. Prevalent facilitators included workflow change and staff training, while adapting electronic health records for data collection, decision support and data extraction was the most prevalent barrier.

CONCLUSIONS

Project ECHO and LC provided complimentary forums to explore clinical and operational changes needed to improve care for SGM at FQHCs.

Model of delivery of cancer care in South Africa's Eastern Cape and Mpumalanga provinces: a situational analysis protocol

INTRODUCTION

Cancer contributes to a significant proportion of morbidity and mortality globally. Low-income and middle-income countries such as South Africa tend to be characterised by poor and inequitable access to cancer services. Cancer resources are more likely to be found in urban areas, tertiary centres and quaternary hospitals. However, little is known about the linkages to care, continuity of care and packages of cancer care in rural South African settings. This study describes cancer service delivery for South Africa's Eastern Cape and Mpumalanga provinces.

METHODS AND ANALYSIS

A mixed-methods qualitative and quantitative research methods of three substudies which include semistructured interviews with patients, focus group discussions with health providers and a quantitative record review that will be carried out at both Rob Ferreira hospital, Witbank hospital and Nelson Mandela Academic hospital in Mpumalanga and Eastern Cape province, respectively. Instruments assess demographic characteristics, explore packages of cancer care, explore challenges experienced by health professionals, and maps out the referral pathway of patients with a cancer diagnosis in the study sites. Numerical, quantitative data will be explored for normality using the Shapiro-Wilk test and reported using either the mean, SD and range or the median and IQR depending on the normality of the distribution. Qualitative data will be analysed using the phenomenological approach.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Human Research Ethics Committee of Walter Sisulu University (040/2020) and the University of the Witwatersrand (M210211), South Africa. To the research team's knowledge, this is the first study presenting the model of cancer delivery in South Africa's Eastern Cape and Mpumalanga province. This will thus provide better understanding of cancer service delivery systems, packages of cancer care from primary care to quaternary care.

Exploration of Factors Influencing Nurses’ Preparedness and Response to the COVID-19 Outbreak

Introduction and Objective

Nurses as the core of the health care workforce affect an organization's preparedness and response. This study explores the factors and unique determinants influencing nurses’ preparedness and response to the coronavirus disease 2019 (COVID-19) outbreak in Singapore.

Methods

This qualitative phenomenological study utilized purposive sampling and in-depth interviews with 10 registered nurses and two enrolled nurses who had worked or were still working in an infectious disease (ID) hospital during the COVID-19 outbreak at the point of recruitment. The data were collected from September 2020 to December 2020.

Results

(1) Before the outbreak: Factors such as knowledge, skills, and experiences that enhanced nurses’ adaptability and response through training and exposure prior to the outbreak influenced preparedness. In addition, the importance of nurses’ knowing their purpose and the role of their institute during the outbreak also influenced preparedness. (2) The COVID-19 phase: Factors such as the novelty of the disease, communication, load and demand, and coping mechanisms affected participants’ working response to the outbreak. (3) Learning and looking forth: Lessons learnt to enhance preparedness and response to future outbreaks, and positive sentiments as part of the nation's effort to combat the disease.

Conclusion

Ground nurses should be actively involved in outbreak planning to gain a better view of their responsibilities and unpredictable events that may occur. A transparent and bidirectional communication among management and nurses is crucial amidst rapid changes in an outbreak to strike a balance between the needs of nurses and leadership and to enhance nurses’ resilience throughout this challenging journey.

Impact of COVID-19 on emergency department attendance in an Australia hospital: a parallel convergent mixed methods study

OBJECTIVES

The COVID-19 pandemic has changed the way people are accessing healthcare. The aim of this study was to examine the impact of COVID-19 on emergency department (ED) attendance for frequent attenders and to explore potential reasons for changes in attendance.

DESIGN

This convergent parallel mixed methods study comprised two parts.

SETTING

An interrupted time-series analysis evaluated changes in ED presentation rates; interviews investigated reasons for changes for frequent ED users in a culturally and linguistically diverse setting.

PARTICIPANTS

A total of 4868 patients were included in the time series. A subgroup of 200 patients were interviewed, mean age 66 years (range 23-99).

RESULTS

Interrupted time-series analysis from 4868 eligible participants showed an instantaneous decrease in weekly ED presentations by 36% (p<0.001), with reduction between 45% and 67% across emergency triage categories. 32% did not know they could leave home to seek care with differences seen in English versus non-English speakers (p<0.001). 35% reported postponing medical care. There was a high fear about the health system becoming overloaded (mean 4.2 (±2) on 6-point scale). Four key themes emerged influencing health-seeking behaviour: fear and/or avoidance of hospital care; use of telehealth for remote assessment; no fear or avoidance of hospital care; not leaving the house for any reason.

CONCLUSIONS

This study demonstrated reduced ED use by a vulnerable population of previously frequent attenders. COVID-19 has resulted in some fear and avoidance of hospitals, but has also offered new opportunity for alternative care through telehealth.

Predictors of health insurance enrolment and wealth-related inequality in Nepal: evidence from Multiple Indicator Cluster Survey (MICS) 2019

OBJECTIVES

We analysed predictors of health insurance enrolment in Nepal, measured wealth-related inequality and decomposed inequality into its contributing factors.

DESIGN

Cross-sectional study.

SETTING

We used nationally representative data based on Nepal Multiple Indicator Cluster Survey 2019. Out of 10 958 households included in this study, 6.95% households were enroled in at least one health insurance scheme.

PRIMARY OUTCOME

measures health insurance (of any type) enrolment.

RESULTS

Households were more likely to have health insurance membership when household head have higher secondary education or above compared with households without formal education (adjusted OR 1.87; 95% CI: 1.32 to 2.64)). Households with mass media exposure were nearly three times more likely to get enroled into the schemes compared with their counterparts (adjusted OR 2.96; 95% CI 2.03 to 4.31). Hindus had greater odds of being enroled (adjusted OR 1.82; 95% CI 1.20 to 2.77) compared with non-Hindus. Dalits were less likely to get enroled compared with Brahmin, Chhetri and Madhesi (adjusted OR 0.66; 95% CI 0.47 to 0.94). Households from province 2, Bagmati and Sudurpaschim were less likely to have membership compared with households from province 1. Households from Richer and Richest wealth quintiles were more than two times more likely to have health insurance membership compared with households from the poorest wealth quintile. A positive concentration index 0.25 (95% CI 0.21 to 0.30; p<0.001) indicated disproportionately higher health insurance enrolment among wealthy households.

CONCLUSIONS

Education of household head, exposure to mass media, religious and ethnic background, geographical location (province) and wealth status were key predictors of health insurance enrolment in Nepal. There was a significant wealth-related inequality in health insurance affiliation. The study recommends regular monitoring of inequality in health insurance enrolment across demographic and socioeconomic groups to ensure progress towards Universal Health Coverage.

Assessment of drug use pattern using WHO core drug use indicators in selected general hospitals: a cross-sectional study in Tigray region, Ethiopia

OBJECTIVE

Inappropriate use of medicine is a global challenge with greater impact on developing countries. Assessment of drug use pattern is used to identify gaps in medicine utilisation to implement strategies for promoting rational drug use. This study aimed to assess drug use pattern using the WHO drug use indicators in selected general hospitals in Tigray region, Ethiopia.

DESIGN

A cross-sectional study was conducted using WHO drug use indicators in two public hospitals located in Tigray.

SETTING

Prescriptions recorded from 1 January 2017 to 1 June 2019 were randomly selected, and participants who visited the public hospitals from 1 March 2019 to 30 August 2019 and hospital pharmacies were interviewed.

PARTICIPANTS

100 patients who visited both outpatient clinics and hospital pharmacy departments of the public hospitals.

RESULTS

The average number of medicines per prescription was 1.69 (±0.81). Prescriptions containing antibiotics and injectables were 58.2% and 15.9%, respectively. The percentages of medicines prescribed with a generic name from essential medicines list of Ethiopia were 97.5% (974) and 88.1% (970) in Mekelle Hospital and Quiha Hospital, respectively. The patients spent an average of 6.6(±3.5) min with their general practitioners, while only 22.8 (±21.7) s with their pharmacists. Of the patients interviewed, 56.9% knew their dosing regimen and 32.7% of them had their medication labelled.

CONCLUSION

The finding of the present study revealed deviation of drug use pattern from the WHO optimal levels suggesting the hospitals had limitations in appropriate utilisation of medicines. Understanding the factors attributed to the observed gaps and implementing corrective measures are required to conform with the recommended standards of appropriate drug utilisation.

Protocol for implementation of the 'AusPROM' recommendations for elective surgery patients: a mixed-methods cohort study

INTRODUCTION

Incorporating patient-reported outcome measures (PROMs) into usual care in hospitals can improve safety and quality. Gaps exist in electronic PROM (ePROM) implementation recommendations, including for elective surgery. The aims are to: (1) understand barriers and enablers to ePROM implementation in hospitals and develop Australian ePROM implementation recommendations (AusPROM); (2) test the feasibility and acceptability of the Quality of Recovery 15 item short-form (QoR-15) PROM for elective surgery patients applying the AusPROM and (3) establish if the QoR-15 PROM has concurrent validity with the EQ-5D-5L.

METHODS AND ANALYSIS

Phase I will identify staff barriers and facilitators for the implementation of the AusPROM recommendations using a Delphi technique. Phase II will determine QoR-15 acceptability for elective surgery patients across four pilot hospitals, using the AusPROM recommendations. For phase II, in addition to a consumer focus group, patients will complete brief acceptability surveys, incorporating the QoR-15, in the week prior to surgery, in the week following surgery and 4 weeks postsurgery. The primary endpoint will be 4 weeks postsurgery. Phase III will be the national implementation of the AusPROM (29 hospitals) and the concurrent validity of the QoR-15 and generic EQ-5D-5L. This protocol adopts the Guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trials Protocols guidelines.

ETHICS AND DISSEMINATION

The results will be disseminated via public forums, conferences and peer-reviewed journals. Ethics approval: La Trobe University (HEC20479).

TRIAL REGISTRATION NUMBER

ACTRN12621000298819 (Phase I and II) and ACTRN12621000969864 (Phase III).

Prevalence of and risk factors for diabetes mellitus in the school-attending adolescent population of the United Arab Emirates: a large cross-sectional study

OBJECTIVES

The prevalence of diabetes has reportedly increased among adolescents in low-income and middle-income countries of the Middle East and may be linked to social, demographic and economic contextual factors. This study aimed: (1) to estimate the prevalence of self-reported diagnosis of diabetes in the adolescent population of the United Arab Emirates (UAE); (2) to assess differences in the prevalence based on gender and (3) to identify other characteristics of those with diabetes including parental marital status, smoking/illegal drug use, quality of life and nationality.

DESIGN

A secondary data analysis was performed on data from the National Study of Population Health in the UAE, conducted between 2007 and 2009.

SETTING

Large cross-sectional population-based survey study.

PARTICIPANTS

Survey was administered to a stratified random sample of 151 public and private schools from the UAE, across 7 emirates. 6365 school-attending adolescents (12-22 years; mean=16 years) participated.

OUTCOMES

Multivariable logistic regression analysis was used to examine the relationships between diabetes diagnosis and characteristics of participants after adjusting for confounding from other predictors.

RESULTS

The overall prevalence of self-reported diabetes was 0.9% (95% CI 0.7% to 1.2%) and was higher in males 1.5% (95% CI 1.0% to 2.1%) than females 0.5% (95% CI 0.3% to 0.8%), (p<0.001). Children of parents who were not currently married had more than twice the odds of self-reporting diabetes (p=0.031) compared with those with married parents. Adolescents who reported ever smoking/using illegal drugs had more than three times the odds of diabetes (p<0.001).

CONCLUSION

We found a positive association between certain characteristics of adolescents and their diabetes status, including male gender, parental marital status and smoking/illegal drug use. The high prevalence of smoking/illegal drug use among those reporting a diagnosis of diabetes suggests the need for behavioural and mental health interventions for adolescents with diabetes, as well as strong parental support and involvement.

Main Factors Affecting the Readiness and Responsiveness of Healthcare Systems during Epidemic Crises: A Scoping Review on Cases of SARS, MERS, and COVID-19

Background:

Given the significance of the preparedness and responsiveness of healthcare systems in relation to epidemics, this study aimed to determine their influencing factors during epidemic crises with a view to utilizing the findings in the battle against the coronavirus disease 2019 (COVID-19) outbreak.

Methods:

This scoping study was conducted in 2020 via the Arksey and O’Malley approach. A systematic search was conducted on five online databases from January 2000 to June 15, 2020. Initially, 1926 English articles were retrieved based on their abstracts. After the screening process, 60 articles were considered for the final analysis. Data were charted by applying Microsoft Office Excel 2013 and were synthesized via thematic analysis.

Results:

Five main factors have affected the responsiveness and preparedness of countries during the epidemics of severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19: community-related interventions, managerial interventions, socioeconomic factors, the readiness of hospitals and health centers, and environmental factors. These themes are associated with 38 related sub-themes. The thematic framework shows that interactions between these five determinantes can affect the preparedness and responsiveness of healthcare systems during pandemics/epidemics.

Conclusion:

According to the results, healthcare systems need to pay attention to their internal capacities, managerial interventions, and health centers to overcome the current pandemic. They should also consider such external factors as socioeconomic and environmental determinants that can affect their potential preparedness against pandemic/epidemic crises. Community-related interventions such as improvement of the community health literacy, teamwork, and social responsibility can enhance the readiness of healthcare systems against the COVID-19 outbreak.

Essential Emergency and Critical Care: a consensus among global clinical experts

BACKGROUND

Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19.

METHODS

In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements.

RESULTS

The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19.

CONCLUSION

The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.

Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D)

INTRODUCTION

Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work.

METHODS AND ANALYSIS

The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations.

TRIAL REGISTRATION NUMBER

researchregistry5041.

Protocol for DexEnceph: a randomised controlled trial of dexamethasone therapy in adults with herpes simplex virus encephalitis

INTRODUCTION

Herpes simplex virus (HSV) encephalitis is a rare severe form of brain inflammation that commonly leaves survivors and their families with devastating long-term consequences. The virus particularly targets the temporal lobe of the brain causing debilitating problems in memory, especially verbal memory. It is postulated that immunomodulation with the corticosteroid, dexamethasone, could improve outcomes by reducing brain swelling. However, there are concerns (so far not observed) that such immunosuppression might facilitate increased viral replication with resultant worsening of disease. A previous trail closed early because of slow recruitment.

METHOD

DexEnceph is a pragmatic multicentre, randomised, controlled, open-label, observer-blind trial to determine whether adults with HSV encephalitis who receive dexamethasone alongside standard antiviral treatment with aciclovir for have improved clinical outcomes compared with those who receive standard treatment alone. Overall, 90 patients with HSV encephalitis are being recruited from a target of 45 recruiting sites; patients are randomised 1:1 to the dexamethasone or control arms of the study. The primary outcome measured is verbal memory as assessed by the Weschler Memory Scale fourth edition Auditory Memory Index at 26 weeks after randomisation. Secondary outcomes are measured up to 72 weeks include additional neuropsychological, clinical and functional outcomes as well as comparison of neuroimaging findings. Patient safety monitoring occurs throughout and includes the detection of HSV DNA in cerebrospinal fluid 2 weeks after randomisation, which is indicative of ongoing viral replication. Innovative methods are being used to ensure recrutiment targets are met for this rare disease.

DISCUSSION

DexEnceph aims to be the first completed randomised controlled trial of corticosteroid therapy in HSV encephalitis. The results will provide evidence for future practice in managing adults with the condition and has the potential to improve outcomes .

ETHICS AND DISSEMINATION

The trial has ethical approval from the UK National Research Ethics Committee (Liverpool Central, REF: 15/NW/0545, 10 August 2015). Protocol V.2.1, July 2019. The results will be published and presented as soon as possible on completion.

TRIAL REGISTRATION NUMBERS

ISRCTN11774734, EUDRACT 2015-001609-16.

Segmentation and shielding of the most vulnerable members of the population as elements of an exit strategy from COVID-19 lockdown

This study demonstrates that an adoption of a segmenting and shielding strategy could increase the scope to partially exit COVID-19 lockdown while limiting the risk of an overwhelming second wave of infection. We illustrate this using a mathematical model that segments the vulnerable population and their closest contacts, the 'shielders'. Effects of extending the duration of lockdown and faster or slower transition to post-lockdown conditions and, most importantly, the trade-off between increased protection of the vulnerable segment and fewer restrictions on the general population are explored. Our study shows that the most important determinants of outcome are: (i) post-lockdown transmission rates within the general and between the general and vulnerable segments; (ii) fractions of the population in the vulnerable and shielder segments; (iii) adherence to protective measures; and (iv) build-up of population immunity. Additionally, we found that effective measures in the shielder segment, e.g. intensive routine screening, allow further relaxations in the general population. We find that the outcome of any future policy is strongly influenced by the contact matrix between segments and the relationships between physical distancing measures and transmission rates. This strategy has potential applications for any infectious disease for which there are defined proportions of the population who cannot be treated or who are at risk of severe outcomes. This article is part of the theme issue 'Modelling that shaped the early COVID-19 pandemic response in the UK'.

Risk of 30-day hospital readmission associated with medical conditions and drug regimens of polymedicated, older inpatients discharged home: a registry-based cohort study

OBJECTIVES

The present study analysed 4 years of a hospital register (2015-2018) to determine the risk of 30-day hospital readmission associated with the medical conditions and drug regimens of polymedicated, older inpatients discharged home.

DESIGN

Registry-based cohort study.

SETTING

Valais Hospital-a public general hospital centre in the French-speaking part of Switzerland.

PARTICIPANTS

We explored the electronic records of 20 422 inpatient stays by polymedicated, home-dwelling older adults held in the hospital's patient register. We identified 13 802 hospital readmissions involving 8878 separate patients over 64 years old.

OUTCOME MEASURES

Sociodemographic characteristics, medical conditions and drug regimen data associated with risk of readmission within 30 days of discharge.

RESULTS

The overall 30-day hospital readmission rate was 7.8%. Adjusted multivariate analyses revealed increased risk of hospital readmission for patients with longer hospital length of stay (OR=1.014 per additional day; 95% CI 1.006 to 1.021), impaired mobility (OR=1.218; 95% CI 1.039 to 1.427), multimorbidity (OR=1.419 per additional International Classification of Diseases, 10th Revision condition; 95% CI 1.282 to 1.572), tumorous disease (OR=2.538; 95% CI 2.089 to 3.082), polypharmacy (OR=1.043 per additional drug prescribed; 95% CI 1.028 to 1.058), and certain specific drugs, including antiemetics and antinauseants (OR=3.216 per additional drug unit taken; 95% CI 1.842 to 5.617), antihypertensives (OR=1.771; 95% CI 1.287 to 2.438), drugs for functional gastrointestinal disorders (OR=1.424; 95% CI 1.166 to 1.739), systemic hormonal preparations (OR=1.207; 95% CI 1.052 to 1.385) and vitamins (OR=1.201; 95% CI 1.049 to 1.374), as well as concurrent use of beta-blocking agents and drugs for acid-related disorders (OR=1.367; 95% CI 1.046 to 1.788).

CONCLUSIONS

Thirty-day hospital readmission risk was associated with longer hospital length of stay, health disorders, polypharmacy and drug regimens. The drug regimen patterns increasing the risk of hospital readmission were very heterogeneous. Further research is needed to explore hospital readmissions caused solely by specific drugs and drug-drug interactions.

Values, preferences and burden of treatment for the initiation of GLP-1 receptor agonists and SGLT-2 inhibitors in adult patients with type 2 diabetes: a systematic review

OBJECTIVES

Assess values, preferences and burden of treatment that patients with type 2 diabetes consider when initiating glucagon-like peptide-1 receptor agonists (GLP-1 RA) or sodium-glucose cotransporter-2 inhibitors (SGLT-2i) compared with other glucose-lowering options.

METHODS

Paired reviewers independently included studies reporting quantitative or qualitative methods to assess values, preferences and burden of treatment reported by patients with type 2 diabetes regarding the initiation of GLP-1 RA or SGLT-2i over other alternatives. A systematic search in MEDLINE, Scopus, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials from inception until May 2020 was performed by an experienced librarian. Risk of bias was assessed with a specifically designed tool for values and preferences studies.

RESULTS

17 studies (7296 patients) proved eligible. Studies fulfilling criteria for SGLT-2i were not identified. Five studies (2662 patients) evaluated preferences for GLP-1 RA compared with other glucose-lowering medications. 12 studies (4634 patients) evaluated preferences between, at least, two kinds of GLP-1 RA or their injection devices based on the following attributes: efficacy, dose, application frequency, device characteristics. Among studies comparing GLP-1 RA to other glucose-lowering medications, some preferences were observed for dypeptil peptidase-4 inhibitors compared with once daily liraglutide. Comparing different attributes of GLP-1 RA drugs and devices, cardiovascular risk reduction, glucose lowering potential, once weekly and simple administered regimens were the most preferred.

CONCLUSIONS

As no evidence for preferences on SGLT-2i was available, only preferences for GLP-1 RA were assessed; however, evidence is still limited for the latter. Studies comparing preferences for GLP1-RA to other glucose-lowering alternatives only included twice daily or once daily injection regimens of GLP-1 RA drugs. According to our findings, once weekly alternatives are widely preferred than the formers. The extent to which patients with type 2 diabetes value reduced adverse cardiovascular and kidney outcomes, weighed benefits against harms and burden of treatment is limited and with very low certainty.

PROSPERO REGISTRATION NUMBER

CRD42020159284.

What factors are associated with pre-pregnancy nutritional status? Baseline analysis of the KITE cohort: a prospective study in northern Ethiopia

OBJECTIVE

To assess a broad range of factors associated with pre-pregnancy nutritional status, a key step towards improving maternal and child health outcomes, in Ethiopia.

DESIGN

A baseline data analysis of a population-based prospective study.

SETTING

Kilite-Awlaelo Health and Demographic Surveillance Site, eastern zone of Tigray regional state, northern Ethiopia.

PARTICIPANTS

We used weight measurements of all 17 500 women of reproductive age living in the surveillance site between August 2017 and October 2017 as a baseline. Subsequently, 991 women who became pregnant were included consecutively at an average of 14.8 weeks (SD: 1.9 weeks) of gestation between February 2018 and September 2018. Eligible women were married, aged 18 years or older, with a pre-pregnancy weight measurement performed, and a gestational age ≤20 weeks at inclusion.

OUTCOME MEASURES

The outcome measure was pre-pregnancy nutritional status assessed by body mass index (BMI) and mid-upper arm circumference (MUAC). Undernutrition was defined as BMI of <18.5 kg/m2 and/or MUAC of <21.0 cm. BMI was calculated using weight measured before pregnancy, and MUAC was measured at inclusion. Linear and spline regressions were used to identify factors associated with pre-pregnancy nutritional status as a continuous and Poisson regression with pre-pregnancy undernutrition as a dichotomous variable.

RESULTS

The mean pre-pregnancy BMI and MUAC were 19.7 kg/m2 (SD: 2.0 kg/m2) and 22.6 cm (SD: 1.9 cm), respectively. Overall, the prevalence of pre-pregnancy undernutrition was 36.2% based on BMI and/or MUAC. Lower age, not being from a model household, lower values of women empowerment score, food insecurity, lower dietary diversity, regular fasting and low agrobiodiversity showed significant associations with lower BMI and/or MUAC.

CONCLUSION

The prevalence of pre-pregnancy undernutrition in our study population was very high. The pre-pregnancy nutritional status could be improved by advancing community awareness on dietary practice and gender equality, empowering females, raising agricultural productivity and strengthening health extension. Such changes require the coordinated efforts of concerned governmental bodies and religious leaders in the Ethiopian setting.

Measurement and prevalence of sexual harassment in low- and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

We synthesise evidence on sexual harassment from studies in low-income and middle-income countries (LMICs) to estimate its prevalence and conduct a meta-analysis of the association between sexual harassment and depressive symptoms.

METHODS

We searched eight databases. We included peer-reviewed studies published in English from 1990 until April 2020 if they measured sexual harassment prevalence in LMICs, included female or male participants aged 14 and over and conceptualised sexual harassment as an independent or dependant variable. We appraised the quality of evidence, used a narrative syntheses approach to synthesise data and conducted a random effects meta-analysis.

RESULTS

From 49 included studies, 38 focused on workplaces and educational institutions and 11 on public places. Many studies used an unclear definition of sexual harassment and did not deploy a validated measurement tool. Studies either used a direct question or a series of behavioural questions to elicit information on acts considered offensive or defined as sexual harassment. Prevalence was higher in educational institutions than in workplaces although there was high heterogeneity in prevalence estimates across studies with no international comparability. This posed a challenge for calculating an overall estimate or measuring a range. Our meta-analysis showed some evidence of an association between sexual harassment and depressive symptoms (OR: 1.75; 95% CI: 1.11 to 2.76; p=0.016) although there were only three studies with a high risk of bias.

CONCLUSION

To our knowledge, this is the first systematic review to assess measurement approaches and estimate the prevalence of sexual harassment across settings in LMICs. We also contribute a pooled estimate of the association between sexual harassment and depressive symptoms in LMICs. There is limited definitional clarity, and rigorously designed prevalence studies that use validated measures for sexual harassment in LMICs. Improved measurement will enable us to obtain more accurate prevalence estimates across different settings to design effective interventions and policies.