Mixed method evaluation of a learning from excellence programme for community health workers in Neno, Malawi

BACKGROUND

Community Health Workers (CHWs) play an essential role in linking communities to facility-based healthcare. However, CHW programmes have often been hampered by low levels of staff motivation, and new tools aimed at improving staff motivation and work environment are needed. One such intervention is the "Learning from Excellence" (LfE) programme. We aimed to assess feasibility, outputs, and impact of a co-designed LfE programme on CHW motivation, in Neno District.

METHODS

We conducted a convergent mixed-method evaluation of the LfE programme. Co-design of the programme and forms took place between October 2019 and January 2020. LfE forms submitted between September and November 2020 were analysed using descriptive statistics and memos summarising answers to the open-ended question. To investigate experiences with LfE we conducted in-depth semi-structured interviews with key stakeholders, CHWs, and site supervisors, which were analysed thematically. A pre-post intervention questionnaire was developed to assess the impact of the co-designed LfE intervention on CHW motivation and perceived supervision. Outcomes were triangulated into a logic model.

RESULTS

In total 555 LfE forms were submitted, with 34.4% of CHWs in Neno District submitting at least one LfE report. Four themes were identified in the interviews: LfE implementation processes, experience, consequences, and recommendations. A total of 50 CHWs participated in the questionnaire in January 2020 and 46 of them completed the questionnaire in December 2020. No statistically significant differences were identified between pre-and post-LfE measurements for both motivation (Site F: p = 0.86; Site G: p = 0.31) and perceived supervision (Site F: p = 0.95; Site G: p = 0.45). A logic model, explaining how the LfE programme could impact CHWs was developed.

CONCLUSIONS

Many CHWs participated in the LfE intervention between September 2020 and November 2020. LfE was welcomed by CHWs and stakeholders as it allowed them to appreciate excellent work in absence of other opportunities to do so. However, no statistically significant differences in CHW motivation and perceived supervision were identified. While the intervention was feasible in Neno District, we identified several barriers and facilitators for implementation. We developed a logic model to explain contextual factors, and mechanisms that could lead to LfE outcomes for CHWs in Neno District. The developed logic model can be used by those designing and implementing interventions like LfE for health workers.

Lived experience of recurrent miscarriage: women and their partners' experience of subsequent pregnancy and support within an NHS specialist clinic - a qualitative study

OBJECTIVE

This study aims to describe the lived experiences of couples with a history of recurrent miscarriage in subsequent pregnancies and their perception of clinic support and cytogenetic investigations.

DESIGN

A qualitative interview study with a phenomenological approach. Semistructured interviews were conducted using video conferencing software. Two researchers coded the transcripts and developed themes.

SETTING

A National Health Service (NHS) hospital in central England between May 2021 and July 2021, during the COVID-19 pandemic.

PARTICIPANTS

Patients attending a specialist recurrent miscarriage clinic and their partners. This clinic accepts referrals from all over the UK for couples who have suffered two or more miscarriages.

RESULTS

Seventeen participants were interviewed: 14 women and 3 male partners. Six main themes were identified from the data. Three related to the women's lived experience of recurrent miscarriage (emotions in pregnancy, confidence in their bodies, expectations and coping strategies) and three related to the clinical support offered by the NHS service (impact of early pregnancy scanning, effect of the COVID-19 pandemic and cytogenetic investigations).

CONCLUSIONS

Pregnancy following recurrent miscarriage is extremely difficult. Recurrent miscarriage specialist services can provide couples with support and access to early pregnancy scanning, which can make the first trimester of pregnancy manageable. Partners should not be excluded from the clinic as it can result in a feeling of disconnect. Cytogenetic testing of pregnancy tissue can offer couples with recurrent miscarriage closure after pregnancy loss and is a desired investigation.

Safety and upscaling of remote consulting for long-term conditions in primary health care in Nigeria and Tanzania (REaCH trials): stepped-wedge trials of training, mobile data allowance, and implementation

BACKGROUND

In-person health care poses risks to health workers and patients during pandemics. Remote consultations can mitigate these risks. The REaCH intervention comprised training and mobile data allowance provision for mobile phones to support remotely delivered primary care in Africa compared with no training and mobile data allowance. The aim of this study was to estimate the effects of REaCH among adults with non-communicable diseases on remote and face-to-face consultation rates, patient safety, and trustworthiness of consultations.

METHODS

In these two independent stepped-wedge cluster randomised controlled trials, we enrolled 20 primary care clusters in each of two settings (Oyo State, Nigeria, and Morogoro Region, Tanzania). Eligible clusters had 100 or more patients with diabetes, hypertension, and cardiovascular or pulmonary disease employing five health workers. Clusters were computer-randomised to one of ten (Nigeria) or one of seven (Tanzania) sequences to receive the REaCH intervention. Only outcome assessors were masked. Primary outcomes were consultation, prescription, and investigation rates, and trustworthiness collected monthly for 12 months (Nigeria) and 9 months (Tanzania) from open cohorts. Ten randomly sampled consulting patients per cluster-month completed patient reported outcome measures. This trial was registered with ISRCTN, ISRCTN17941313.

FINDINGS

Overall, 40 clusters comprising 8776 (Nigeria) and 3246 (Tanzania) patients' open cohort data were analysed (6377 [72·7%] of 8776 females in Nigeria, and 2235 [68·9%] of 3246 females in Tanzania). The mean age of the participants was 55·3 years (SD 13·9) in Nigeria and 59·2 years (14·2) in Tanzania. In Nigeria, no evidence of change in face-to-face consulting rate was observed (rate ratio [RR] 1·06, 95% CI 0·98 to 1·09; p=0·16); however, remote consultations increased four-fold (4·44, 1·34 to >10; p=0·01). In Tanzania, face-to-face (0·94, 0·61 to 1·67; p=0·99) and remote consulting rates (1·17, 0·56 to 5·57; p=0·39) were unchanged. There was no evidence of difference in prescribing rates (Nigeria: 1·05, 0·60 to 1·14; p=0·23; Tanzania: 0·92, 0·60 to 1·67; p=0·97), investigation rates (Nigeria: 1·06, 0·23 to 2·12; p=0·49; Tanzania: 1·15, 0·35 to 1·64; 0·58) or trustworthiness scores (Nigeria: mean difference 0·05, 95% CI -0·45 to 0·42; p=0·89; Tanzania: 0·07, -0·15 to 0·76; p=0·70).

INTERPRETATION

REaCH can be implemented and could improve intervention versus control health-care access. Remote consultations appear safe and trustworthy, supporting universal health coverage.

FUNDING

The UK Research and Innovation Collective Fund.

TRANSLATIONS

For the Swahili and Yoruba translations of the abstract see Supplementary Materials section.

Identification of candidate novel production variants on the Bos taurus chromosome X

Chromosome X is often excluded from bovine genetic studies due to complications caused by the sex specific nature of the chromosome. As chromosome X is the second largest cattle chromosome and makes up approximately 6% of the female genome, finding ways to include chromosome X in dairy genetic studies is important. Using female animals and treating chromosome X as an autosome, we performed X chromosome inclusive genome-wide association studies in the selective breeding environment of the New Zealand dairy industry, aiming to identify chromosome X variants associated with milk production traits. We report on the findings of these genome-wide association studies and their potential effect within the dairy industry. We identify missense mutations in the MOSPD1 and CCDC160 genes that are associated with decreased milk volume and protein production and increased fat production. Both of these mutations are exonic SNP that are more prevalent in the Jersey breed than in Holstein-Friesians. Of the 2 candidates proposed it is likely that only one is causal, though we have not been able to identify which is more likely.

Non-Animal Stabilized Hyaluronic Acid (NASHA) Gel Marker vs. Surgical Clips for Tumor Bed Delineation in Breast Cancer Using MR-Simulation

PURPOSE/OBJECTIVE(S)

Consistent delineation of the tumor bed (TB) after breast conserving surgery (BCS) is critical and remains a challenge with increasing prevalence of oncoplastic surgeries. Clips are generally used to help TB identification on CT-simulation but they are not well identified on MR-simulation. The aim of this study is to assess whether the use of NASHA gel with MR-simulation yields similar interobserver variability (inter-OV) compared to clips with CT-simulation.

MATERIALS/METHODS

This prospective single arm feasibility study included patients eligible for BCS. After lumpectomy, the surgeon placed both clips (>5) and NASHA gel drops as markers to define the TB. Patients underwent CT and MRI simulation scans. Five radiation oncologists and one radiologist delineated the TB aided by clips on CT, and gel on MRI. The observers also assessed the visibility and utility of the gel (scale from 1 to 10), as well as the cavity visualization score (CVS, scale from 1 to 5). The primary endpoint was the inter-OV of the delineated TB using the overlap difference of contours using clips and CT versus gel and MRI, with the conformity index measured according to the pair definition of the Dice Similarity Coefficient (DSC).

RESULTS

Of the 35 patients recruited, 30 were eligible for inter-OV analysis of TB delineation and 5 patients required further breast surgery for positive margins. One third of the eligible patients underwent an oncoplastic procedure. There were no significant differences between inter-OV of delineated TB using clips and CT versus gel and T2-weighted MRI with the mean DSC (0.60 vs 0.62, p = 0.364). The observers reported higher usefulness of gel in patients with an oncoplastic procedure than not (median US 8.2 vs 6.6, p = 0.024), and higher visibility of gel in patients who had their scans within 6 weeks than beyond post-op (median VS 8.1 vs 6.1, p = 0.013). When the CVS was higher (3-5), the median US of gel was lower (5.9 vs 7.8, p = 0.004), and the conformity index of clip and CT delineated TB was higher (median DSC 0.72 vs 0.53, p <0.001). Interestingly, a higher CVS did not lead to significantly higher conformity index of gel and T2-weighted MR delineated TB (mean DSC 0.67 vs 0.58, p = 0.073). NASHA gel injection added a median of 3 minutes to the operating theatre (OT) time and was rated as 'easy' in 89% of cases by surgeons. There were no immediate adverse events (AE) in OT, while 2 of 35 patients later experienced a grade 3 AE - hematoma which required evacuation in OT day 1 post-BCS, and infected seroma which required drainage and washout in OT 2 months post-BCS and axillary dissection. These reflect common risks with standard BCS and are not clearly attributed to gel injection alone.

CONCLUSION

Use of NASHA gel leads to similar inter-OV of BC TB delineation compared to >5 clips. NASHA gel is hence a reliable alternative to clips when MR-simulation is used.

Marginless 5-Fraction Robotic Radiosurgery for Unfavorable Nonfunctioning Pituitary Macroadenoma: 5-year Outcomes from a Single Institution Protocol

PURPOSE/OBJECTIVE(S)

Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established for single-session radiosurgery, but mature outcomes are lacking for multisession radiosurgery. We report our institution's 5-year efficacy and safety results for unfavorable nonfunctioning pituitary macroadenoma patients treated with marginless 5-fraction robotic radiosurgery.

MATERIALS/METHODS

Between 2010-2020, patients who completed marginless 5-fraction radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem or pituitary gland). Local control was calculated using the Kaplan-Meier Method.

RESULTS

Twenty predominately female patients (60%), age from 21-77 (median: 53 years) were included in this study. All underwent primary resection. Indications for radiosurgery included unresectable recurrence (85%) and residual disease progression (70%). Median tumor volume was 3.4 cm3 (range: 0.3-20.8 cm3) and 40% of the tumors were suprasellar. A mean dose of 28.8 Gy (range: 25 Gy-30 Gy), was delivered to a median isodose line of 80% (range: 75%-89%). The median optic chiasm maximum point dose was 21.8 Gy (range: 12.0-25.9 Gy). Toxicity was minimal with 12 patients (40%) developing acute short-lived headaches and 1 patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no radiation induced optic or pituitary dysfunction identified in this cohort. At a median follow up of 5 years local control was 95%. There was 1 in-field failure pathologically confirmed following surgery for pituitary tumor hemorrhage and 2 radiographically confirmed out-of-field failures in patients with large tumors (>20 cc).

CONCLUSION

The treatment of unfavorable nonfunctioning pituitary macroadenoma with marginless 5-fraction robotic radiosurgery provides excellent local control to date, with minimal toxicity. However, tumors with GTV's greater than 20 cc may require conventionally fractionated treatment with a margin to optimize local control.

Oral health in an urban slum, Nigeria: residents' perceptions, practices and care-seeking experiences

BACKGROUND/INTRODUCTION

One of the key recommendations for the new WHO global strategy for oral health is inclusion of disadvantaged populations and their engagement in policy dialogues such that their needs and views are addressed in policy decisions.

OBJECTIVES

This study explored oral health perceptions, practices and care-seeking experiences of slum residents in Ibadan, Nigeria.

METHOD

Focus group discussions (FGD) were conducted with family health-decision makers in an urban slum site. Oral health perceptions, practices, and care-seeking experiences were discussed. FGDs were recorded, transcribed, and translated. ATLAS.ti qualitative research software was deployed for analysis using thematic analysis.

RESULTS

Six FGD sessions, divided by gender and age, were conducted between September-October 2019, (N = total 58 participants, aged 25 to 59 years). Common dental ailments mentioned were dental pain, tooth sensitivity, bleeding gums, tooth decay, mouth odor, gum disease, and tooth fracture. Perceived causes of dental conditions included poor dental hygiene and habits, sugary diets, ignorance, and supernatural forces. Mouth cleaning was mostly done once daily using toothbrush and paste. Other cleaning tools were ground glass, wood ash, charcoal, "epa Ijebu" (a dentrifice), and "orin ata" (a type of chewing stick). Remedies for relieving dental pain included over-the-counter medicines, warm salted water, gin, tobacco (snuff/powdered), cow urine/dung, battery fluid, and various mixtures/ concoctions. Visits to the dentists were mentioned by a few but this was usually as last resort. Main barriers to accessing care from dental care facilities were unaffordability of service charges and fear of extreme treatment measures (extraction). Suggested measures to improve timely access to dental health care included reducing/subsidizing costs of treatments and medications, offering non-extraction treatment options, and oral health education programmes.

CONCLUSION

The slum residents experience various forms of dental ailments mostly pain-related. The residents perceived formal dental clinics as unaffordable, thereby engaging in self-care remedies and harmful oral health practices before seeking professional help. Policymakers and decision-makers may leverage this empirical evidence for the people's education on early dental care and address challenges to affordable, available, and acceptable oral healthcare services among slum residents to improve access to care facilities.

The Prognostic Effect of Immune Cell Infiltration Depends on Molecular Subtype in Endometrioid Ovarian Carcinomas

PURPOSE

Endometrioid ovarian carcinoma (ENOC) is the second most-common type of ovarian carcinoma, comprising 10%-20% of cases. Recently, the study of ENOC has benefitted from comparisons to endometrial carcinomas including defining ENOC with four prognostic molecular subtypes. Each subtype suggests differential mechanisms of progression, although tumor-initiating events remain elusive. There is evidence that the ovarian microenvironment may be critical to early lesion establishment and progression. However, while immune infiltrates have been well studied in high-grade serous ovarian carcinoma, studies in ENOC are limited.

EXPERIMENTAL DESIGN

We report on 210 ENOC, with clinical follow-up and molecular subtype annotation. Using multiplex IHC and immunofluorescence, we examine the prevalence of T-cell lineage, B-cell lineage, macrophages, and populations with programmed cell death protein 1 or programmed death-ligand 1 across subtypes of ENOC.

RESULTS

Immune cell infiltrates in tumor epithelium and stroma showed higher densities in ENOC subtypes with known high mutation burden (POLEmut and MMRd). While molecular subtypes were prognostically significant, immune infiltrates were not (overall survival P > 0.2). Analysis by molecular subtype revealed that immune cell density was prognostically significant in only the no specific molecular profile (NSMP) subtype, where immune infiltrates lacking B cells (TILB minus) had inferior outcome (disease-specific survival: HR, 4.0; 95% confidence interval, 1.1-14.7; P < 0.05). Similar to endometrial carcinomas, molecular subtype stratification was generally superior to immune response in predicting outcomes.

CONCLUSIONS

Subtype stratification is critical for better understanding of ENOC, in particular the distribution and prognostic significance of immune cell infiltrates. The role of B cells in the immune response within NSMP tumors warrants further study.

Tooth adornment among siblings living in an urban slum in Nigeria: Health implications for a vulnerable population

Tooth jewelry boosts the appearance and confidence of wearers. However, its use may carry adverse health consequences. This paper creates awareness about a practice not previously reported in Nigeria, to prevent negative health consequences while appropriate measures are taken to quantify and describe the determinants and plan appropriate interventions.

Profiling the immune landscape in mucinous ovarian carcinoma

OBJECTIVE

Mucinous ovarian carcinoma (MOC) is a rare histotype of ovarian cancer, with low response rates to standard chemotherapy, and very poor survival for patients diagnosed at advanced stage. There is a limited understanding of the MOC immune landscape, and consequently whether immune checkpoint inhibitors could be considered for a subset of patients.

METHODS

We performed multicolor immunohistochemistry (IHC) and immunofluorescence (IF) on tissue microarrays in a cohort of 126 MOC patients. Cell densities were calculated in the epithelial and stromal components for tumor-associated macrophages (CD68+/PD-L1+, CD68+/PD-L1-), T cells (CD3+/CD8-, CD3+/CD8+), putative T-regulatory cells (Tregs, FOXP3+), B cells (CD20+/CD79A+), plasma cells (CD20-/CD79a+), and PD-L1+ and PD-1+ cells, and compared these values with clinical factors. Univariate and multivariable Cox Proportional Hazards assessed overall survival. Unsupervised k-means clustering identified patient subsets with common patterns of immune cell infiltration.

RESULTS

Mean densities of PD1+ cells, PD-L1- macrophages, CD4+ and CD8+ T cells, and FOXP3+ Tregs were higher in the stroma compared to the epithelium. Tumors from advanced (Stage III/IV) MOC had greater epithelial infiltration of PD-L1- macrophages, and fewer PD-L1+ macrophages compared with Stage I/II cancers (p = 0.004 and p = 0.014 respectively). Patients with high epithelial density of FOXP3+ cells, CD8+/FOXP3+ cells, or PD-L1- macrophages, had poorer survival, and high epithelial CD79a + plasma cells conferred better survival, all upon univariate analysis only. Clustering showed that most MOC (86%) had an immune depleted (cold) phenotype, with only a small proportion (11/76,14%) considered immune inflamed (hot) based on T cell and PD-L1 infiltrates.

CONCLUSION

In summary, MOCs are mostly immunogenically 'cold', suggesting they may have limited response to current immunotherapies.

A digital approach to asthma self-management in adults: Protocol for a pragmatic randomized controlled trial

Asthma self-management can improve symptom control, but adherence to established self-management behaviors is often poor. With adult asthma uncontrolled in over 60% of U.S. cases, there is a need for scalable, cost-effective tools to improve asthma outcomes. Here we describe a protocol for the Asthma Digital Study, a 24-month, decentralized, pragmatic, open-label, randomized controlled trial investigating the impact of a digital asthma self-management (DASM) program on asthma outcomes in adults. The program leverages consumer-grade devices with a smartphone app to provide "smart nudges," symptom logging, trigger tracking, and other features. Participants are recruited (target N = 900) from throughout the U.S., and randomized to a DASM or control arm (1:1). Co-primary outcomes at one year are a) asthma-associated costs for acute care and b) change from baseline in Asthma Control Test™ scores. Findings may inform decisions around adoption of digital tools for asthma self-management. Trial registration:clinicaltrials.gov identifier: NCT04609644. Registered: Oct 30, 2020.

Remote Consulting in Primary Health Care in Low- and Middle-Income Countries: Feasibility Study of an Online Training Program to Support Care Delivery During the COVID-19 Pandemic

Background

Despite acceleration of remote consulting throughout the COVID-19 pandemic, many health care professionals are practicing without training to offer teleconsultation to their patients. This is especially challenging in resource-poor countries, where the telephone has not previously been widely used for health care.

Objective

As the COVID-19 pandemic dawned, we designed a modular online training program for REmote Consulting in primary Health care (REaCH). To optimize upscaling of knowledge and skills, we employed a train-the-trainer approach, training health workers (tier 1) to cascade the training to others (tier 2) in their locality. We aimed to determine whether REaCH training was acceptable and feasible to health workers in rural Tanzania to support their health care delivery during the pandemic.

Methods

We developed and pretested the REaCH training program in July 2020 and created 8 key modules. The program was then taught remotely via Moodle and WhatsApp (Meta Platforms) to 12 tier 1 trainees and cascaded to 63 tier 2 trainees working in Tanzania’s rural Ulanga District (August-September 2020). We evaluated the program using a survey (informed by Kirkpatrick's model of evaluation) to capture trainee satisfaction with REaCH, the knowledge gained, and perceived behavior change; qualitative interviews to explore training experiences and views of remote consulting; and documentary analysis of emails, WhatsApp texts, and training reports generated through the program. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed thematically. Findings were triangulated and integrated during interpretation.

Results

Of the 12 tier 1 trainees enrolled in the program, all completed the training; however, 2 (17%) encountered internet difficulties and failed to complete the evaluation. In addition, 1 (8%) opted out of the cascading process. Of the 63 tier 2 trainees, 61 (97%) completed the cascaded training. Of the 10 (83%) tier 1 trainees who completed the survey, 9 (90%) would recommend the program to others, reported receiving relevant skills and applying their learning to their daily work, demonstrating satisfaction, learning, and perceived behavior change. In qualitative interviews, tier 1 and 2 trainees identified several barriers to implementation of remote consulting, including lacking digital infrastructure, few resources, inflexible billing and record-keeping systems, and limited community awareness. The costs of data or airtime emerged as the greatest immediate barrier to supporting both the upscaling of REaCH training and subsequently the delivery of safe and trustworthy remote health care.

Conclusions

The REaCH training program is feasible, acceptable, and effective in changing trainees’ behavior. However, government and organizational support is required to facilitate the expansion of the program and remote consulting in Tanzania and other low-resource settings.

Systematic review of educational interventions to improve the menstrual health of young adolescent girls

OBJECTIVES

To systematically review interventions that include an element of menstrual education delivered to young adolescent girls.

DESIGN

This was a systematic review and meta-analysis. Selected articles were quality assessed using the Mixed Methods Appraisal Tool quality appraisal checklist. A meta-analysis was conducted on a subset of articles, and the effect size of the intervention was calculated using Cohen's d. A logic model was constructed to frame the effect of menstrual education interventions on menstrual health.

SETTING

Papers reporting on interventions in high-income and low-income and middle-income countries were sought.

INFORMATION SOURCES

Seven electronic databases were searched for English-language entries that were published between January 2014 and May 2020.

PARTICIPANTS

The interventions were aimed at younger adolescent girls aged 10-14 years old.

INTERVENTIONS

The interventions were designed to improve the menstrual health of the recipients, by addressing one or more elements of menstrual knowledge, attitude or practices (KAP).

ELIGIBILITY CRITERIA

Interventions that had not been evaluated were excluded.

PRIMARY AND SECONDARY OUTCOMES

The most common type of output was a difference in knowledge or skill score ascertained from a pre and post test. Some studies measured additional outcomes, such as attitude or confidence.

RESULTS

Twenty-four eligible studies were identified. The number of participants varied from 1 to 2564. All studies reported improvements in menstrual KAP. The meta-analysis indicates that larger effect sizes were attained by those that encouraged discussion than those that distributed pamphlets.

CONCLUSIONS

Education interventions are effective in increasing the menstrual knowledge of young adolescent girls and skills training improves competency to manage menstruation more hygienically and comfortably. Interactive interventions are more motivating than didactic or written. Sharing concerns gives girls confidence and helps them to gain agency on the path to menstrual health.

TRIAL REGISTRATION NUMBER

For this review, a protocol was not prepared or registered.

Factors associated with accessing and utilisation of healthcare and provision of health services for residents of slums in low and middle-income countries: a scoping review of recent literature

OBJECTIVE

To identify factors associated with accessing and utilisation of healthcare and provision of health services in slums.

DESIGN

A scoping review incorporating a conceptual framework for configuring reported factors.

DATA SOURCES

MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from their inception to December 2021 using slum-related terms.

ELIGIBILITY CRITERIA

Empirical studies of all designs reporting relevant factors in slums in low and middle-income countries.

DATA EXTRACTION AND SYNTHESIS

Studies were categorised and data were charted according to a preliminary conceptual framework refined by emerging findings. Results were tabulated and narratively summarised.

RESULTS

Of the 15 469 records retrieved from all years, 4368 records dated between 2016 and 2021 were screened by two independent reviewers and 111 studies were included. The majority (63 studies, 57%) were conducted in Asia, predominantly in India. In total, 104 studies examined healthcare access and utilisation from slum residents' perspective while only 10 studies explored provision of health services from providers/planners' perspective (three studies included both). A multitude of factors are associated with accessing, using and providing healthcare in slums, including recent migration to slums; knowledge, perception and past experience of illness, healthcare needs and health services; financial constraint and competing priorities between health and making a living; lacking social support; unfavourable physical environment and locality; sociocultural expectations and stigma; lack of official recognition; and existing problems in the health system.

CONCLUSION

The scoping review identified a significant body of recent literature reporting factors associated with accessing, utilisation and provision of healthcare services in slums. We classified the diverse factors under seven broad categories. The findings can inform a holistic approach to improving health services in slums by tackling barriers at different levels, taking into account local context and geospatial features of individual slums. SYSTEMATIC REVIEW REGISTRATION NUMBER: https://osf.io/694t2.

A contextual exploration of healthcare service use in urban slums in Nigeria

Introduction

Many urban residents in low- and middle-income countries live in unfavorable conditions with few healthcare facilities, calling to question the long-held view of urban advantage in health, healthcare access and utilization. We explore the patterns of healthcare utilization in these deprived neighborhoods by studying three such settlements in Nigeria.

Methods

The study was conducted in three slums in Southwestern Nigeria, categorized as migrant, indigenous or cosmopolitan, based on their characteristics. Using observational data of those who needed healthcare and used in-patient or out-patient services in the 12 months preceding the survey, frequencies, percentages and odds-ratios were used to show the study participants’ environmental and population characteristics, relative to their patterns of healthcare use.

Results

A total of 1,634 residents from the three slums participated, distributed as 763 (migrant), 459 (indigenous) and 412 (cosmopolitan). Residents from the migrant (OR = 0.70, 95%CI: 0.51 to 0.97) and indigenous (OR = 0.65, 95%CI: 0.45 to 0.93) slums were less likely to have used formal healthcare facilities than those from the cosmopolitan slum. Slum residents were more likely to use formal healthcare facilities for maternal and perinatal conditions, and generalized pains, than for communicable (OR = 0.50, 95%CI: 0.34 to 0.72) and non-communicable diseases (OR = 0.61, 95%CI: 0.41 to 0.91). The unemployed had higher odds (OR = 1.45, 95%CI: 1.08 to 1.93) of using formal healthcare facilities than those currently employed.

Conclusion

The cosmopolitan slum, situated in a major financial center and national economic hub, had a higher proportion of formal healthcare facility usage than the migrant and indigenous slums where about half of families were classified as poor. The urban advantage premise and Anderson behavioral model remain a practical explanatory framework, although they may not explain healthcare use in all possible slum types in Africa. A context-within-context approach is important for addressing healthcare utilization challenges in slums in sub-Saharan Africa.

Prevalence and determinants of oral health conditions and treatment needs among slum and non-slum urban residents: Evidence from Nigeria

Oral diseases constitute a neglected epidemic in Low and Middle-Income Countries (LMICs). An understanding of its distribution and severity in different settings can aid the planning of preventive and therapeutic services. This study assessed the oral health conditions, risk factors, and treatment needs among adult residents in the slum and compared findings with non-slum urban residents in Ibadan, Nigeria. The Multistage sampling was used to select adult (≥18-years) residents from a slum and a non-slum urban sites. Information sought from participants included dietary habits, oral hygiene practices, and the use of dental services. Oral examinations were performed in line with WHO guidelines. Associations were examined using logistic regression. Mediation analysis was undertaken using generalized structural equation modeling. The sample comprised 678 slum and 679 non-slum residents. Median age in slum vs non-slum was 45 (IQR:32-50) versus 38 (IQR:29-50) years. Male: female ratio was 1:2 in both sites. Prevalence of oral diseases (slum vs non-slum sites): dental caries (27% vs 23%), gingival bleeding (75% vs 53%) and periodontal pocket (23% vs 16%). The odds of having dental caries were 21% higher for the slum dwellers compared to non-slum residents (OR = 1.21, 95% CI:0.94 to 1.56); and 50% higher for periodontal pocket (OR = 1.50, 95%CI: 1.13 to 1.98), after adjusting for age and sex. There was little evidence that tooth cleaning frequency mediated the relationship between place of residence and caries (OR = 0.95, 95%CI: 0.87 to 1.03 [indirect effect], 38% mediated) or periodontal pocket (OR = 0.95, 95%CI: 0.86 to 1.04, 15% mediated). Thirty-five percent and 27% of residents in the slum and non-slum sites respectively required the "prompt and urgent" levels of treatment need. Oral diseases prevalence in both settings are high and the prevalence was generally higher in the slum with correspondingly higher levels of prompt and urgent treatment needs. Participants may benefit from targeted therapeutic and health promotion intervention services.

A review of guidelines for evaluating a minor modification to a validated assay

Any modification to a validated assay must be evaluated in terms of the impact on the assay's performance characteristics and whether the assay remains fit for the intended purpose. The comparison is referred to as a 'method comparison', 'method comparability', 'method change', or 'comparative validation'. This review presents recommendations and examples of studies found in the current literature as a means of assessing minor modifications. In addition, the authors discuss common statistical approaches used for these comparisons.

Outcomes, mechanisms and contextual factors of positive psychology interventions for health workers: a systematic review of global evidence

BACKGROUND

Interventions using positive psychology (PP), which build on positive qualities of healthcare personnel and institutions, could potentially enhance organisational performance in healthcare. The aim of this systematic review was to identify if PP interventions have an impact on organisational performance of healthcare personnel, and if so, how this impact can be achieved. We developed a logic model to explain the impact of PP interventions on organisational performance.

METHODS

We searched Web of Science, Medline, Psychinfo, Embase, Scopus and CINAHL (from inception until March 2019) and references of included articles to identify studies that evaluated the impact of a PP intervention for health personnel. Study quality was assessed using the SQUIRE checklist for quality improvement studies. Data were extracted about study details, setting, participants, intervention, method of evaluation and results. Outcomes, mechanisms and contexts were coded in nVivo. Data synthesis was guided by Lewis' theory of the impact of PP interventions on organisational performance and Kneale et al.'s method for logic model development. Collected data were integrated into a logic model explaining initial inputs, processes, and intermediate outcomes of PP interventions that lead to improved organisational performance in healthcare settings.

RESULTS

We retrieved 4638 articles and identified five through references of included articles of which 29 studies (31 articles) met our inclusion criteria. Most articles were of low quality (n = 19) and outcome measures varied widely. We identified 54 different outcomes of PP interventions, including 'improved well-being' and 'improved interaction and support'. Forty-nine mechanisms were identified including 'recognising and reframing negative interpretations'. Twenty four contextual factors were identified of which seven acted as barriers. 'Managerial support' was a facilitator mentioned in eight studies. All identified outcomes, mechanisms and contextual factors were integrated into a logic model explaining how interventions using PP can impact organisational performance in healthcare.

CONCLUSION

Few identified outcomes were statistically significant, however, trends in both quantitative and qualitative outcomes show that PP interventions can increase well-being and interaction and support and thus improve organisational performance in healthcare. The developed logic model can be used in the implementation and evaluation of interventions using PP for health personnel.

Coronary collaterals provide more than half of normal perfusion in patients with coronary artery disease - quantification by myocardial perfusion SPECT during elective balloon occlusion

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

The coronary collateral circulation is a preformed network of anastomotic connections acting as a "natural bypass" mechanism. Whilst the prevalence of collaterals varies between species, approximately 25% of patients have angiographically visible robust collaterals at the time of ST elevation myocardial infarction. While the presence of collaterals is associated with improved outcomes, the magnitude of myocardial perfusion which can be provided by the collateral circulation remains uncertain.

PURPOSE

The aim was to quantify collateral myocardial perfusion during experimental coronary balloon occlusion in patients with CAD.

METHODS

The study was approved by the local investigational review board, and all patients provided informed consent. Patients without prior infarction, bypass surgery, or angiographically visible collaterals undergoing elective percutaneous transluminal coronary angioplasty (PTCA) to a single epicardial vessel, underwent two scans with 99mTc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT). All subjects underwent at least three minutes of angiographically verified complete balloon occlusion, at which time an intravenous injection of the radiotracer was administered, followed by SPECT imaging. A second radiotracer injection followed by SPECT imaging was performed 24 hours after PTCA.

RESULTS

The study included 21 patients (median [interquartile range] age 70 [56-74] years, 52% male). The degree of diameter stenosis of treated vessels ranged from 60-99%, with successful PTCA performed with a mean 5-minute balloon occlusion time, resulting in ≤20% residual stenosis in all cases. The vessels undergoing PTCA were 6 in the LAD, 5 in the LCx, and 10 in the RCA. For the cohort, the size of the perfusion defect was 16 [8-30]% of the LV and the collateral perfusion at rest within the perfusion defect was 64 [58-68]% of normal perfusion within that region. Collateral perfusion was negatively correlated with perfusion defect size (R2 = 0.85, p &lt; 0.001), but did not differ by sex (p = 0.27) or age (p = 0.58). CONCLUSIONS: This is the first study to describe the magnitude of microvascular collateral perfusion in CAD. On average, despite coronary occlusion and an absence of angiographically visible collateral vessels, collaterals provide approximately 60% of the perfusion that reaches the jeopardized myocardium during coronary occlusion. This magnitude of collateral perfusion is much higher than previously speculated. A previous study using microspheres in dogs found that collateral perfusion in the setting of an occluded vessel was 6% of normal. By comparison, the current study found ten times greater collateral perfusion in patients with CAD.

Abstract Figure. Collateral perfusion during occlusion.

Mobile consulting as an option for delivering healthcare services in low-resource settings in low- and middle-income countries: A mixed-methods study

OBJECTIVE

Remote or mobile consulting is being promoted to strengthen health systems, deliver universal health coverage and facilitate safe clinical communication during coronavirus disease 2019 and beyond. We explored whether mobile consulting is a viable option for communities with minimal resources in low- and middle-income countries.

METHODS

We reviewed evidence published since 2018 about mobile consulting in low- and middle-income countries and undertook a scoping study (pre-coronavirus disease) in two rural settings (Pakistan and Tanzania) and five urban slums (Kenya, Nigeria and Bangladesh), using policy/document review, secondary analysis of survey data (from the urban sites) and thematic analysis of interviews/workshops with community members, healthcare workers, digital/telecommunications experts, mobile consulting providers, and local and national decision-makers. Project advisory groups guided the study in each country.

RESULTS

We reviewed four empirical studies and seven reviews, analysed data from 5322 urban slum households and engaged with 424 stakeholders in rural and urban sites. Regulatory frameworks are available in each country. Mobile consulting services are operating through provider platforms (n = 5-17) and, at the community level, some direct experience of mobile consulting with healthcare workers using their own phones was reported - for emergencies, advice and care follow-up. Stakeholder willingness was high, provided challenges are addressed in technology, infrastructure, data security, confidentiality, acceptability and health system integration. Mobile consulting can reduce affordability barriers and facilitate care-seeking practices.

CONCLUSIONS

There are indications of readiness for mobile consulting in communities with minimal resources. However, wider system strengthening is needed to bolster referrals, specialist services, laboratories and supply chains to fully realise the continuity of care and responsiveness that mobile consulting services offer, particularly during/beyond coronavirus disease 2019.

Robust impurity detection and tracking for tokamaks

A robust impurity detection and tracking code, able to generate large sets of dust tracks from tokamak camera footage, is presented. This machine learning-based code is tested with cameras from the Joint European Torus, Doublet-III-D, and Magnum-PSI and is able to generate dust tracks with a 65-100% classification accuracy. Moreover, the number dust particles detected from a single camera shot can be up to the order of 1000. Several areas of improvement for the code are highlighted, such as generating more significant training data sets and accounting for selection biases. Although the code is tested with dust in single two-dimensional camera views, it could easily be applied to multiple-camera stereoscopic reconstruction or nondust impurities.

Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: results of pre-COVID and COVID-19 lockdown stakeholder engagements

INTRODUCTION

With COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider access to healthcare before and during COVID-19 with those working and living in slum communities.

METHODS

In seven slums in Bangladesh, Kenya, Nigeria and Pakistan, we explored stakeholder perspectives and experiences of healthcare access for non-COVID-19 conditions in two periods: pre-COVID-19 and during COVID-19 lockdowns.

RESULTS

Between March 2018 and May 2020, we engaged with 860 community leaders, residents, health workers and local authority representatives. Perceived common illnesses in all sites included respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension. Pre-COVID, stakeholders described various preventive, diagnostic and treatment services, including well-used antenatal and immunisation programmes and some screening for hypertension, tuberculosis, HIV and vectorborne disease. In all sites, pharmacists and patent medicine vendors were key providers of treatment and advice for minor illnesses. Mental health services and those addressing gender-based violence were perceived to be limited or unavailable. With COVID-19, a reduction in access to healthcare services was reported in all sites, including preventive services. Cost of healthcare increased while household income reduced. Residents had difficulty reaching healthcare facilities. Fear of being diagnosed with COVID-19 discouraged healthcare seeking. Alleviators included provision of healthcare by phone, pharmacists/drug vendors extending credit and residents receiving philanthropic or government support; these were inconsistent and inadequate.

CONCLUSION

Slum residents' ability to seek healthcare for non-COVID-19 conditions has been reduced during lockdowns. To encourage healthcare seeking, clear communication is needed about what is available and whether infection control is in place. Policymakers need to ensure that costs do not escalate and unfairly disadvantage slum communities. Remote consulting to reduce face-to-face contact and provision of mental health and gender-based violence services should be considered.

'Our culture prohibits some things': qualitative inquiry into how sociocultural context influences the scale-up of community-based injectable contraceptives in Nigeria

OBJECTIVES

To explore how sociocultural factors may support or impede the adoption of community-based distribution of injectable contraceptives in Nigeria.

DESIGN

A qualitative study based on inductive thematic analysis was conducted through in-depth interviews and focus group discussions.

SETTING

Most participants lived in Gombe State, North-East Nigeria. Other participants were from Ibadan (South-West) and Abuja (Federal Capital Territory).

PARTICIPANTS

Through seven key informant interviews, 15 in-depth interviews and 10 focus group discussions, 102 participants were involved in the study.

METHODS

This study conducted in 2016 was part of a larger study on scale-up of community-based distribution of injectable contraceptives. Qualitative data were collected from traditional and religious leaders, health workers and community members. The data were audio recorded, transcribed and analysed using a thematic framework method.

RESULTS

Sociocultural challenges to scale-up included patriarchy and men's fear of losing control over their spouses, traditional and religious beliefs about fertility, and myths about contraceptives and family planning. As a result of deep-rooted beliefs that children are 'divine blessings' and that procreation should not be regulated, participants described a subtle resistance to uptake of injectable contraceptives. Since Gombe is largely a patriarchal society, male involvement emerged as important to the success of meaningful innovation uptake. Community leaders largely described their participation in the scale-up process as active, although they also identified the scope for further involvement and recognition.

CONCLUSION

Scale-up is more than setting up health sector implementing structures, training health workers and getting innovation supplies, but also requires preparedness which includes paying attention to complex contextual issues. Policy implementers should also see scale-up as a learning process and be willing to move at the speed of the community.

Mobile consulting (mConsulting) and its potential for providing access to quality healthcare for populations living in low-resource settings of low- and middle-income countries

Objective

The poorest populations of the world lack access to quality healthcare. We defined the key components of consulting via mobile technology (mConsulting), explored whether mConsulting can fill gaps in access to quality healthcare for poor and spatially marginalised populations (specifically rural and slum populations) of low- and middle-income countries, and considered the implications of its take-up.

Methods

We utilised realist methodology. First, we undertook a scoping review of mobile health literature and searched for examples of mConsulting. Second, we formed our programme theories and identified potential benefits and hazards for deployment of mConsulting for poor and spatially marginalised populations. Finally, we tested our programme theories against existing frameworks and identified published evidence on how and why these benefits/hazards are likely to accrue.

Results

We identified the components of mConsulting, including their characteristics and range. We discuss the implications of mConsulting for poor and spatially marginalised populations in terms of competent care, user experience, cost, workforce, technology, and the wider health system.

Conclusions

For the many dimensions of mConsulting, how it is structured and deployed will make a difference to the benefits and hazards of its use. There is a lack of evidence of the impact of mConsulting in populations that are poor and spatially marginalised, as most research on mConsulting has been undertaken where quality healthcare exists. We suggest that mConsulting could improve access to quality healthcare for these populations and, with attention to how it is deployed, potential hazards for the populations and wider health system could be mitigated.

Health system readiness for innovation scale-up: the experience of community-based distribution of injectable contraceptives in Nigeria

BACKGROUND

Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. However, there is limited understanding of health system factors that may facilitate or impede the successful scale-up of this innovation beyond the pilot site. Thus, this study assessed the health system readiness to deliver CBDIC in Nigeria and how this may influence the scale-up process.

METHODS

This study was conducted in two Local Government Areas in Gombe State in September 2016. Seven key informant interviews were held with purposively sampled senior officials of the ministries of health at the federal and state levels as well as NGO program managers. Also, 10 in-depth interviews were carried out with health workers. All transcripts were analyzed using the thematic framework analysis approach.

RESULT

The availability of a policy framework that supports task-shifting and task-sharing, as well as application of evidence from the pilot programme and capacity building programmes for health workers provided a favourable environment for scale-up. Health system challenges for the scale-up process included insufficient community health workers, resistance to the task-shifting policy from professional health groups (who should support the CHEWs), limited funding and poor logistics management which affected commodity distribution and availability. However, there were also a number of health worker innovations which kept the scale-up going. Health workers sometimes used personal resources to make up for logistics failures and poor funding. They often modify the process in order to adapt to the realities on the ground.

CONCLUSION

This study shows health system weaknesses that may undermine scale-up of CBDIC. The study also highlights what happens when scale-up is narrowly focused on the intervention without considering system context, capacity and readiness. However, agency and discretionary decision-making among frontline health workers facilitated the process of scaling up, although the sustainability of this is questionable. Benefits observed during the pilot may not be realised on a larger scale if health system challenges are not addressed.

Can institutional entrepreneurship strengthen clinical governance and quality improvement: a case study of a district-based clinical specialist team in South Africa

We present an interpretive qualitative account of micro-level activities and processes of clinical governance by recently introduced district-based clinical specialist teams (DCSTs) in South Africa. We do this to explore whether and how they are functioning as institutional entrepreneurs (IE) at the local service delivery level. In one health district, between 2013 and 2015, we carried out 59 in-depth interviews with district, sub-district and facility managers, nurses, DCST members and external actors. We also ran one focus group discussion with the DCST and analysed key policies, activities and perceptions of the innovation using an institutional entrepreneurship conceptual lens. Findings show that the DCST is located in a constrained context. Yet, by revealing and bridging gaps in the health system, team members have been able to take on certain IE characteristics, functioning-more or less-as announcers of reforms, articulating a strategic vision and direction for the system, advocating for change, mobilizing resources. In addition, they have helped to reorganize services and shape care practices by re-framing issues and exerting power to influence organizational change. The DCST innovation provides an opportunity to promote institutional entrepreneurship in our context because it influences change and is applicable to other health systems. Yet there are nuanced differences between individual members and the team, and these need better understanding to maximize this contribution to change in this context and other health systems.

Characterisation and outcome of idiopathic pyogranulomatous lymphadenitis in 64 English springer spaniel dogs

OBJECTIVES

To describe the history, clinicopathological abnormalities, diagnostic imaging findings, lymph node cytological/histological appearance, treatment and outcome of English springer spaniels diagnosed with idiopathic pyogranulomatous lymphadenitis.

MATERIALS AND METHODS

In this retrospective UK-based multicentre study, 64 dogs were recruited from 10 referral centres, 32 first-opinion practices and three histopathology/cytology laboratories, between 2010 and 2016.

RESULTS

The median age at presentation was 6 years (range: 0.17 to 11.75). Neutered females were frequently affected. Pyrexia (83.8%), peripheral lymphadenomegaly (78.4%), dermatological lesions (72.9%), lethargy (67.6%), hyporexia (54%), diarrhoea (29.7%), coughing (24.3%), epistaxis, sneezing or nasal discharge (21.6%), ocular signs (21.6%) and vomiting (16.2%) were reported in dogs for which the history and physical examination records were available. Popliteal (45.3%), superficial cervical (35.9%) and submandibular (37.5%) lymphadenomegaly were frequently reported. Haematology and serum biochemistry revealed non-specific changes. When undertaken, testing for infectious diseases was negative in all cases. Lymph node cytology, histopathology or both demonstrated mixed inflammatory (27%), pyogranulomatous (24%), neutrophilic (20%) or granulomatous (11%) lymphadenitis. Treatment details were available for 38 dogs, with 34 receiving prednisolone for a median duration of 15 weeks (range: 1 to 28 weeks). A good to excellent clinical response was reported in all but one case. Ten dogs relapsed after discontinuing prednisolone.

CLINICAL SIGNIFICANCE

Idiopathic pyogranulomatous lymphadenitis should be considered as a differential diagnosis for lymphadenopathy and pyrexia in English springer spaniels. The characteristics of the disease, absence of identifiable infectious aetiology and response to glucocorticoid therapy suggest an immune-mediated aetiology.

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa

BACKGROUND

In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others.

METHODS

A multiple case study design comprising three cases was conducted. Data collection in 2012 - early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts.

RESULTS

Managers valued the national Minister of Health's role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved.

CONCLUSION

Those driving reform processes from 'the top' must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion.

Patients' perspectives of acceptability of ART, TB and maternal health services in a subdistrict of Johannesburg, South Africa

Background

The field of acceptability of health services is emerging and growing in coherence. But there are gaps, including relatively little integration of elements of acceptability. This study attempted to analyse collectively three elements of acceptability namely: patient-provider, patient-service organisation and patient-community interactions.

Methods

Mixed methods were used to analyse secondary data collected as part of the Researching Equity in Access to Health Care (REACH) study of access to tuberculosis (TB) treatment, antiretroviral therapy (ART) and maternal health (MH) services in South Africa’s public health sector.

Results

Provider acceptability was consistently high across all the three tracer services at 97.6% (ART), 96.6% (TB) and 96.4% (MH). Service acceptability was high only for TB tracer (70.1%). Community acceptability was high for both TB (83.6%) and MH (96.8%) tracers.

Conclusion

Through mixed methods, this paper provides a nuanced view of acceptability of health services.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Implementation of district-based clinical specialist teams in South Africa: Analysing a new role in a transforming system

BACKGROUND

Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role.

METHODS

Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts.

RESULTS

We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors' expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery.

CONCLUSION

Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme

BACKGROUND

Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC.

METHODS

Using a cross-sectional survey across four of South Africa's nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status.

RESULTS

A quarter of respondents remained uninsured, even higher among 20-29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits.

CONCLUSIONS

By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country's financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.

Identification of rare HIV-1 Group N, HBV AE, and HTLV-3 strains in rural South Cameroon

Surveillance of emerging viral variants is critical to ensuring that blood screening and diagnostic tests detect all infections regardless of strain or geographic location. In this study, we conducted serological and molecular surveillance to monitor the prevalence and diversity of HIV, HBV, and HTLV in South Cameroon. The prevalence of HIV was 8.53%, HBV was 10.45%, and HTLV was 1.04% amongst study participants. Molecular characterization of 555 HIV-1 specimens identified incredible diversity, including 7 subtypes, 12 CRFs, 6 unclassified, 24 Group O and 2 Group N infections. Amongst 401 HBV sequences were found a rare HBV AE recombinant and two emerging sub-genotype A strains. In addition to HTLV-1 and HTLV-2 strains, sequencing confirmed the fifth known HTLV-3 infection to date. Continued HIV/HBV/HTLV surveillance and vigilance for newly emerging strains in South Cameroon will be essential to ensure diagnostic tests and research stay a step ahead of these rapidly evolving viruses.

Microleakage of Lithium Disilicate Crown Margins Finished on Direct Restorative Materials

OBJECTIVE

For some esthetic clinical situations, it is necessary to finish crown margins on direct restorative materials to preserve tissue integrity, bonding integrity, and biological width. The purpose of this research was to investigate microleakage at the interface between bonded lithium disilicate crowns and various direct restorative materials in a class III and class V position.

METHODS AND MATERIALS

Class III or class V restorations were prepared on one side of extracted incisors with either Tetric EvoCeram, Tetric Evoceram Bulk, Fuji II LC, or Tetric Evoflow. The teeth were prepared for and received a lithium disilicate crown. After load fatiguing, the specimens were thermo-cycled with a fuchsin dye and sectioned. The depth and area of dye penetration were measured with a dimensional grid in micrometers using stereomicroscopy and reported as mean dye depth and area (μm) ± SD. The comparison of multiple categorical independent variables with ratio scale dependent variables was evaluated with an analysis of variance and Tukey's post hoc analysis.

RESULTS

A statistically significant higher dye penetration was noted for all treatment groups compared with the positive control (side opposite the restoration after sagittal sectioning was used as positive control) regardless of material or placement area (p<0.05). In comparing treatment groups, the Tetric EvoFlow experienced a statistically higher dye penetration than did the other treatment groups regardless of material or placement area (p<0.05). There was no statistically significant difference between the Tetric EvoCeram, Tetric Evoceram Bulk, and Fuji II LC materials regardless of placement area (p>0.05).

CONCLUSIONS

Within the limitations of this study, it can be concluded that flowable composite materials as finish lines that interact with resin cements could lead to exacerbated interfacial degradation. Finishing lithium disilicate all-ceramic crowns on flowable resin composite materials in the esthetic zone should be used with caution. If necessary, finishing lithium disilicate all-ceramic crowns on nanofilled resin composite or resin-modified glass ionomer materials seems to provide the least dye penetration depth and area.

Discourses of Order and Their Disruption: The Texts of the South African Truth & Reconciliation Commission

This paper asserts that selected texts of the South African Truth and Reconciliation Commission possess a powerful political potential in their ability to challenge and refute historical relations of racialised power in South Africa. The prospective political efficacy of these texts is seen as residing in their critical ability to subvert and challenge the predominant understandings, discourses and representations of Apartheid, or the ‘old’, South Africa. Three overlapping routes of enquiry are explored in this regard. Firstly, the political efficacy of such texts is seen as arising from their role in terms of the recovery of previously repressed histories. This recovery enlarges the archive of South Africa's past and contributes to the constitution of a new body of knowledge, from which credible standpoints of resistance and opposition may be articulated. A second explanation highlights the fact these texts are able to exert a form of discursive critique upon the predominant practices and representations of both former and reigning social orders. This level of critique enables us, in Foucautt's (1981) terms to restore to political discourses their nature as contextual and discontinuous practices of construction as opposed to naturally-occurring, seamlessly-unified, purely significatory instances of language. The last account engages more directly with the radical and transgressive nature of these texts, with their affective and ultimately symptomatic qualities. It is here suggested that these texts have earned their extraordinary visceral charge, their special power and horror, for many South Africans, precisely because they have exposed and stretched to the limit the boundaries of the past discursive order, of what had been known, what was understood and what could be represented in the Apartheid State.

Bacterial Cholangitis, Cholecystitis, or both in Dogs

Background

Bacterial cholangitis and cholecystitis are rarely reported, poorly characterized diseases in the dog.

Objectives

To characterize the clinical features of these conditions.

Animals

Twenty‐seven client‐owned dogs with bacterial cholangitis, cholecystitis, or both.

Methods

Multicenter, retrospective cases series of dogs with bacterial cholangitis, cholecystitis, or both, presenting January 2000 to June 2011 to 4 Veterinary Schools in Ireland/United Kingdom. Interrogation of hospital databases identified all cases with the inclusion criteria; histopathologically confirmed cholangitis or cholecystitis and bile culture/cytology results supporting a bacterial etiology.

Results

Twenty‐seven dogs met the inclusion criteria with approximately 460 hepatitis cases documented over the same study period. Typical clinical pathology findings were increases in liver enzyme activities (25/26), hyperbilirubinemia (20/26), and an inflammatory leukogram (21/24). Ultrasound findings, although nonspecific, aided decision‐making in 25/26 cases. The most frequent hepatobiliary bacterial isolates were Escherichia coli (n = 17; 16 cases), Enterococcus spp. (n = 8; 6 cases), and Clostridium spp. (n = 5; 5 cases). Antimicrobial resistance was an important feature of aerobic isolates; 10/16 E. coli isolates resistant to 3 or more antimicrobial classes. Biliary tract rupture complicated nearly one third of cases, associated with significant mortality (4/8). Discharged dogs had a guarded to fair prognosis; 17/18 alive at 2 months, although 5/10 re‐evaluated had persistent liver enzyme elevation 2–12 months later.

Conclusion and Clinical Significance

Bacterial cholangitis and cholecystitis occur more frequently than suggested by current literature and should be considered in dogs presenting with jaundice and fever, abdominal pain, or an inflammatory leukogram or with ultrasonographic evidence of gallbladder abnormalities.