Layered vulnerability and researchers' responsibilities: learning from research involving Kenyan adolescents living with perinatal HIV infection

BACKGROUND

Carefully planned research is critical to developing policies and interventions that counter physical, psychological and social challenges faced by young people living with HIV/AIDS, without increasing burdens. Such studies, however, must navigate a 'vulnerability paradox', since including potentially vulnerable groups also risks unintentionally worsening their situation. Through embedded social science research, linked to a cohort study involving Adolescents Living with HIV/AIDS (ALH) in Kenya, we develop an account of researchers' responsibilities towards young people, incorporating concepts of vulnerability, resilience, and agency as 'interacting layers'.

METHODS

Using a qualitative, iterative approach across three linked data collection phases including interviews, group discussions, observations and a participatory workshop, we explored stakeholders' perspectives on vulnerability and resilience of young people living with HIV/AIDS, in relation to home and community, school, health care and health research participation. A total of 62 policy, provider, research, and community-based stakeholders were involved, including 27 ALH participating in a longitudinal cohort study. Data analysis drew on a Framework Analysis approach; ethical analysis adapts Luna's layered account of vulnerability.

RESULTS

ALH experienced forms of vulnerability and resilience in their daily lives in which socioeconomic context, institutional policies, organisational systems and interpersonal relations were key, interrelated influences. Anticipated and experienced forms of stigma and discrimination in schools, health clinics and communities were linked to actions undermining ART adherence, worsening physical and mental health, and poor educational outcomes, indicating cascading forms of vulnerability, resulting in worsened vulnerabilities. Positive inputs within and across sectors could build resilience, improve outcomes, and support positive research experiences.

CONCLUSIONS

The most serious forms of vulnerability faced by ALH in the cohort study were related to structural, inter-sectoral influences, unrelated to study participation and underscored by constraints to their agency. Vulnerabilities, including cascading forms, were potentially responsive to policy-based and interpersonal actions. Stakeholder engagement supported cohort design and implementation, building privacy, stakeholder understanding, interpersonal relations and ancillary care policies. Structural forms of vulnerability underscore researchers' responsibilities to work within multi-sectoral partnerships to plan and implement studies involving ALH, share findings in a timely way and contribute to policies addressing known causes of vulnerabilities.

The challenges and potential solutions of achieving meaningful consent amongst research participants in northern Thailand: a qualitative study

BACKGROUND

Achieving meaningful consent can be challenging, particularly in contexts of diminished literacy, yet is a vital part of participant protection in global health research.

METHOD

We explored the challenges and potential solutions of achieving meaningful consent through a qualitative study in a predominantly hill tribe ethnic minority population in northern Thailand, a culturally distinctive population with low literacy. Semi-structured interviews were conducted with 37 respondents who had participated in scrub typhus clinical research, their family members, researchers and other key informants. A thematic analysis was conducted.

RESULTS

Our analysis identified four interrelated themes surrounding participants' ability to give consent: varying degrees of research understanding, limitations of using informal translators, issues impacting decisions to join research, and voluntariness of consent. Suggestions for achieving more meaningful consent included the use of formal translators and community engagement with research populations.

CONCLUSIONS

Participant's agency in decision making to join research should be supported, but research information needs to be communicated to potential participants in a way that they can understand. We found that improved understanding about the study and its potential benefits and harms goes beyond literacy or translation and requires attention to social and cultural factors.

Success of Liquid Tumor Biopsy in Men with Metastatic Prostate Cancer According to Self-Identified Race

PURPOSE/OBJECTIVE(S)

Liquid biopsy using cell-free DNA (cfDNA) is increasingly used to identify somatic prostate cancer (PrCa) alterations when tissue biopsy of a metastatic lesion is infeasible or impractical. High-risk somatic alterations identified by cfDNA have been recently shown to predict the benefit of metastasis-directed therapy with stereotactic body radiation therapy in PrCa. However, given the older age of PrCa patients, liquid biopsy is often contaminated with alterations related to clonal hematopoiesis of indeterminate potential (CHIP), generating uncertainty in the clinical utility of the results. Given the higher incidence and aggressiveness of metastatic PrCa in Black men, we sought to determine if the success of cfDNA testing varied by race in a large and diverse cohort of United States Veterans with metastatic PrCa, hypothesizing that race would not influence the success of cfDNA testing.

MATERIALS/METHODS

Veterans with metastatic PrCa underwent next-generation sequencing of cfDNA biopsy specimens through the VA National Precision Oncology Program from February 2019 to November 2022. Successful identification of PrCa with cfDNA testing was defined as the identification of an alteration in one or more PrCa-related related genes in the gene panel tested (AR, CDK12, SPOP, MED12, CCND1, BRAF, AKT1, TMPRSS2, ERG, ETV1, and ETV4). Univariate logistic regression was employed to explore the association between patient self-identified race, as well as other patient and disease-specific factors at the time of cfDNA biopsy, with the likelihood of yielding a successful cfDNA biopsy result.

RESULTS

A total of 2066 cfDNA tests from 1985 Veterans were related to a diagnosis of PrCa, passed quality control measures, and were linkable to patient-level demographics. Median age at testing was 74, median PSA at testing was 22.7, median PSA doubling time (PSADT) was 3.6 months, and median Gleason score was 8. 57% of Veterans self-identified as White, 33% as Black, and 10% as Other. Eight hundred fourteen (39%) tests were deemed successful by finding a PrCa related gene alteration. Among successful tests, the most frequently encountered alterations were AR alterations in 60.4% White men and 33.9% Black men (p = 0.72), followed by TMPRSS2 alterations in 70.3% White men and 22.0% Black men (p<0.001). Despite a lower rate of PrCa-specific alterations in Black men, on univariate analysis, Veteran self-identified race was not associated with successful cfDNA testing (OR 0.95, 95% CI 0.78-1.14, p = 0.6), whereas PSA in quintiles 2-4, PSADT <12 months, and unit increase in Gleason score were associated with successful cfDNA testing (p<0.01 for all).

CONCLUSION

Successful cfDNA biopsy in metastatic PrCa is associated with PSA and PSADT, but not related to patient self-identified race. In appropriate clinical scenarios, patients who self-identify as Black or White are equally likely to have PrCa-specific alterations detected on cfDNA testing when evaluating metastatic PrCa patients for local and systemic therapies.

The hidden emotional labour behind ensuring the social value of research: Experiences of frontline health policy and systems researchers based in Kenya during COVID-19

Health policy and systems research (HPSR) is a multi-disciplinary, largely applied field of research aimed at understanding and strengthening the performance of health systems, often with an emphasis on power, policy and equity. The value of embedded and participatory HPSR specifically in facilitating the collection of rich data that is relevant to addressing real-world challenges is increasingly recognised. However, the potential contributions and challenges of HPSR in the context of shocks and crises are not well documented, with a particular gap in the literature being the experiences and coping strategies of the HPSR researchers who are embedded in health systems in resource constrained settings. In this paper, we draw on two sets of group discussions held among a group of approximately 15 HPSR researchers based in Nairobi, Kenya, who were conducting a range of embedded HPSR studies throughout the COVID-19 pandemic. The researchers, including many of the authors, were employed by the KEMRI-Wellcome Trust Research Programme (KWTRP), which is a long-standing multi-disciplinary partnership between the Kenya Medical Research Institute and the Wellcome Trust with a central goal of contributing to national and international health policy and practice. We share our findings in relation to three inter-related themes: 1) Ensuring the continued social value of our HPSR work in the face of changing priorities; 2) Responding to shifting ethical procedures and processes at institutional and national levels; and 3) Protecting our own and front-line colleagues' well-being, including clinical colleagues. Our experiences highlight that in navigating research work and responsibilities to colleagues, patients and participants through the pandemic, many embedded HPSR staff faced difficult emotional and ethical challenges, including heightened forms of moral distress, which may have been better prevented and supported. We draw on our findings and the wider literature to discuss considerations for funders and research leads with an eye to strengthening support for embedded HPSR staff, not only in crises such as the on-going COVID-19 pandemic, but also more generally.

Respecting relational agency in the context of vulnerability: What can research ethics learn from the social sciences?

Despite advances in theory, often driven by feminist ethicists, research ethics struggles in practice to adequately account for and respond to the agency and autonomy of people considered vulnerable in the research context. We argue that shifts within feminist research ethics scholarship to better characterise and respond to autonomy and agency can be bolstered by further grounding in discourses from the social sciences, in work that confirms the complex nature of human agency in contexts of structural and other sources of vulnerability. We discuss some of the core concepts and critiques emerging from the literature on women and children's agency in under-resourced settings, highlighting calls to move from individualistic to relational models of agency, and to recognise the ambiguous, value-laden, and heterogeneous nature of the concept. We then draw out what these conceptual shifts might mean for research ethics obligations and guidance, illustrating our analysis using a case vignette based on research ethics work conducted in South Africa. We conclude that if research practices are to be supportive of agency, it will be crucial to scrutinise the moral judgements which underpin accounts of agency, derive more situated definitions of and responses to agency, and enable people and participants to influence these based on their own experiences and self-perceptions.

Considering Risks to Researchers and Staff in Low-Resource Settings during Public Health Crises: A Proposed Conceptual Model

Human subjects research protections have historically focused on mitigating risk of harm and promoting benefits for research participants. In many low-resource settings (LRS), complex and often severe challenges in daily living, poverty, geopolitical uprisings, sociopolitical, economic, and climate crises increase the burdens of even minimal risk research. While there has been important work to explore the scope of ethical responsibilities of researchers and research teams to respond to these wider challenges and hidden burdens in global health research, less attention has been given to the ethical dilemmas and risk experienced by frontline researcher staff as they perform research-related activities in LRS. Risks such as job insecurity, moral distress, infection, or physical harm can be exacerbated during public health crises, as recently highlighted by the COVID-19 pandemic. We highlight the layers of risk research staff face in LRS and present a conceptual model to characterize drivers of this risk, with particular attention to public health crises. A framework by which funders, institutions, principal investigators, and/or research team leaders can systematically consider these additional layers of risk to researchers and frontline staff is an important and needed addition to routine research proposals and protocol review.

A community developed conceptual model for reducing long-term health problems in children with intellectual disability in India

Children with intellectual disability (ID) have a higher risk of long-term health problems in adulthood. India has the highest prevalence of ID of any country with 1.6 million under-five children living with the condition. Despite this, compared with other children, this neglected population is excluded from mainstream disease prevention and health promotion programmes. Our objective was to develop an evidence-based conceptual framework for a needs-based inclusive intervention to reduce the risk of communicable and non-communicable diseases among children with ID in India. From April through to July 2020 we undertook community engagement and involvement activities in ten States in India using a community-based participatory approach, guided by the bio-psycho-social model. We adapted the five steps recommended for the design and evaluation of a public participation process for the health sector. Seventy stakeholders from ten States contributed to the project: 44 parents and 26 professionals who work with people with ID. We mapped the outputs from two rounds of stakeholder consultations with evidence from systematic reviews to develop a conceptual framework that underpins an approach to develop a cross-sectoral family-centred needs-based inclusive intervention to improve health outcomes for children with ID. A working Theory of Change model delineates a pathway that reflected the priorities of the target population. We discussed the models during a third round of consultations to identify limitations, relevance of the concepts, structural and social barriers that could influence acceptability and adherence, success criteria, and integration with existing health system and service delivery. There are currently no health promotion programmes focusing on children with ID in India despite the population being at a higher risk of developing comorbid health problems. Therefore, an urgent next step is to test the conceptual model to determine acceptance and effectiveness within the context of socio-economic challenges faced by the children and their families in the country.

Transition from hospital to home care for preterm babies: A qualitative study of the experiences of caregivers in Uganda

Improving care for preterm babies could significantly increase child survival in low-and middle income countries. However, attention has mainly focused on facility-based care with little emphasis on transition from hospital to home after discharge. Our aim was to understand the experiences of the transition process among caregivers of preterm infants in Uganda in order to improve support systems. A qualitative study among caregivers of preterm infants in Iganga and Jinja districts in eastern Uganda was conducted in June 2019 through February 2020, involving seven focus group discussions and five in-depth interviews. We used thematic-content analysis to identify emergent themes related to the transition process. We included 56 caregivers, mainly mothers and fathers, from a range of socio-demographic backgrounds. Four themes emerged: caregivers' experiences through the transition process from preparation in the hospital to providing care at home; appropriate communication; unmet information needs; and managing community expectations and perceptions. In addition, caregivers' views on 'peer-support' was explored. Caregivers' experiences, and their confidence and ability to provide care were related to preparation in the hospital after birth and until discharge, the information they received and the manner in which healthcare providers communicated. Healthcare workers were a trusted source of information while in the hospital, but there was no continuity of care after discharge which increased their fears and worries about the survival of their infant. They often felt confused, anxious and discouraged by the negative perceptions and expectations from the community. Fathers felt left-out as there was very little communication between them and the healthcare providers. Peer-support could enable a smooth transition from hospital to home care. Interventions to advance preterm care beyond the health facility through a well-supported transition from facility to home care are urgently required to improve health and survival of preterm infants in Uganda and other similar settings.

Vulnerability and agency in research participants' daily lives and the research encounter: A qualitative case study of participants taking part in scrub typhus research in northern Thailand

BACKGROUND

Researchers have a responsibility to protect all participants, especially vulnerable participants, from harm. Vulnerability is increasingly understood to be context specific, yet limited guidance is available regarding the vulnerability and agency of research participants in different cultural settings. This study aims to explore research participants' daily vulnerability and agency, and how these interact with participants' research experiences in their own words. Researchers' views and responses were also explored.

METHODS

A qualitative study was conducted around two scrub typhus research studies in northern Thailand. A thematic analysis was carried out on 42 semi-structured interviews with research participants, their families, researchers and key informants.

RESULTS

The majority of the research participants belonged to a hill tribe ethnic minority group. Common challenges were related to Thai language barriers, travel difficulties, uncertain legal status, unstable employment, lack of education and healthcare. We did not identify new vulnerabilities but we found that the extent of these vulnerabilities might be underestimated or even hidden from researchers in some cases. Despite these challenges people demonstrated agency in their daily lives and were often motivated and supported in this by family members. The majority of perceived research benefits were related to healthcare and gaining knowledge, while attending follow-up visits could be a burden for some.

CONCLUSIONS

Our approach to research in culturally and socioeconomically diverse settings should be more responsive to participants' specific vulnerabilities and abilities evidenced in their daily life, rather than attributing vulnerability on the basis of membership of pre-defined 'vulnerable groups'. Researchers need to be aware and responsive towards the challenges participants face locally in order to minimise the burdens of research participation whilst allowing participants to benefit from research.

Culturally responsive research ethics: How the socio-ethical norms of Arr-nar/Kreng-jai inform research participation at the Thai-Myanmar border

Despite advances, international research ethics guidelines still tend to consist of high-level ethical principles reflecting residual influence from North American and European traditions of ethics. Local ethics committees and community advisory boards can offer more culturally-sensitive approaches to training but most institutions lack substantive practical ethics guidance to engage rich moral understandings in day-to-day research practice in diverse cultural contexts. To address this gap, we conducted an international series of qualitative research ethics case studies, linked prospectively to active research programs in diverse settings. Here, we share findings from two case studies with a research team working on malaria and hepatitis B prevention with pregnant women in clinics serving migrants along the Thai-Myanmar border. In this sociocultural ethical analysis, we consider how core ethical requirements of voluntary participation, provision of fair benefits, and understandings of research risks and burdens are shaped, enriched, and in some instances challenged, by deep-seated and widespread Burmese, Karen and Thai cultural norms known as Arr-nar (in Burmese and Karen) or Kreng-jai (in Thai), encompassing multiple meanings including consideration for others and graciousness. We offer a model illustrating how one might map ethically significant sociocultural influences across the research practice pathway and close with lessons for developing a more culturally responsive research ethics practice in other international settings.

A simple setup for in situ alkali metal electronic spin polarimetry

Faraday rotation is considered a gold standard measurement of the electronic spin polarization of an alkali metal vapor produced under optical pumping. However, during the production of large volumes of hyperpolarized xenon gas, transmission monitoring measurements, otherwise known as field cycling measurements, are generally employed to measure the spin polarization of alkali metal atoms in situ as this method is easier to implement than Faraday rotation on standard polarizer setups. Here, we present a simple, low-cost experimental setup to perform Faraday rotation measurements of the electronic spin polarization of alkali metal atoms that can be easily implemented on standard polarizer setups. We then compare Rb polarization measurements obtained with the Faraday rotation method to those obtained with the transmission monitoring method. To our knowledge, a direct comparison of these methods has never been made. Overall, we found good agreement between the two methods, but at low Rb density and high laser power, we found evidence of nonlinear magneto-optical effects that may prevent Faraday rotation from being used under these conditions.

Primary motivations for and experiences with paediatric minimally invasive tissue sampling (MITS) participation in Malawi: a qualitative study

OBJECTIVE

To understand family member consent decision-making influences and experiences in Malawi in order to inform future minimally invasive tissue sampling (MITS) studies.

DESIGN

Qualitative study.

SETTING

Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, which serves as the central referral hospital for southern Malawi and where MITS participants were recruited from.

PARTICIPANTS

Families of paediatric MITS participants.

METHODS

We conducted in-depth interviews with 16 families 6 weeks after the death of paediatric MITS participants. Data were analysed using a combination of thematic content and theoretical framework approaches to explain the findings.

RESULTS

Improved cause of death (CoD) ascertainment was the principal motivator for participation to protect remaining or future children. Community burial norms, religious doctrine and relationships with healthcare workers (HCWs) were not reported influencers among family members who consented to the procedure. Primary consenters varied, with single mothers more likely to consent independently or with only female family members present. Clear understanding of MITS procedures appeared limited 6 weeks postprocedure, but research was described as voluntary and preconsent information satisfactory for decision-making. Most families intended to share about MITS only with those involved in the consent process, for fear of rumours or judgement by extended family members and the wider community.

CONCLUSION

Among those who consented to MITS, decision-making was informed by individual and household experiences and beliefs, but not by religious affiliation or experiences with HCWs. While understanding of the MITS procedure was limited at the time of interview, families found informed consent information sufficient for decision-making. Future MITS studies should continue to explore information presentation best practices to facilitate informed consent during the immediate grieving period.

A79 AIMING TO PROVIDE EARLIER CARE WHILE REDUCING SPECIALTY CLINIC WAIT TIMES: DEVELOPING A RELIABLE PROCESS OF ASSESSING THE ELIGIBILITY OF GASTROENTEROLOGY REFERRALS FOR PRIMARY CARE PATHWAYS

Background

Gastrointestinal (GI) diseases are common and are a source of substantial morbidity, mortality, and cost, accounting for the largest share of medical referrals from primary care physicians (PCPs) in Canada. Long wait times and increasing numbers of referrals for GI consultation have thus become a significant issue, and while awaiting consultation many patients experience impaired quality of life. Primary care clinical pathways are structured care plans outlining detailed steps for treating patients with specific GI conditions, supporting the translation of clinical guidelines into local protocols and clinical practice.

Aims

To identify the proportion of referrals sent from PCPs to the Queen’s Gastroenterology division that meet the eligibility criteria for a clinical care pathway.

Methods

A review was conducted to identify the proportion of non-urgent referrals in triage sent from PCPs to the Queen’s Gastroenterology division that met the criteria for a clinical care pathway from July 2019 to May 2020. The reason for referral from PCP to gastroenterology was recorded. Individual patient characteristics included in each referral letter were assessed, including age, sex, GI symptoms or signs, relevant clinical features (i.e. time course of symptoms, frequency of bowel movements), relevant laboratory parameters (i.e. CBC, LFTs, electrolytes) or any investigations ordered to evaluate the cause of the patient’s symptoms or signs by the PCP. Four reviewers assessed an initial sample of 200 referral letters and classified each patient’s eligibility for a primary care pathway (GERD, diarrhea, IBS, dyspepsia, or ineligible). After every 100 referrals, discrepancies were reviewed, and a consensus was reached for each case. Data from 100 subsequent referral letters were collected by two independent reviewers, and the inter-rater reliability was calculated. Following a high level of agreement, the final 70 referrals were assessed by two reviewers.

Results

Out of 370 referrals sent from PCPs to the Queen’s Gastroenterology division from July 2019 to December 2019, a total of 170 (46%) met the eligibility criteria for a clinical care pathway. From the eligible referrals, the proportion of patients in each pathway were as follows: 35% GERD, 12% diarrhea, 34% IBS and 19% dyspepsia. The inter-rater reliability for the first 100 referrals assessed by two independent reviewers was 94% (κ = 0.873).

Conclusions

These findings demonstrate that a significant proportion of the patient population referred from PCPs to Queen’s Gastroenterology would be eligible for a primary care pathway. Future steps include implementing these pathways to determine their effectiveness in reducing wait times and empowering PCPs to care for patients who do not require specialist referral.

Funding Agencies

None

Model for developing context-sensitive responses to vulnerability in research: managing ethical dilemmas faced by frontline research staff in Kenya

Health research in low-resource settings often involves individuals and populations defined as 'vulnerable'. There is growing attention in the literature to the ethical dilemmas that frontline research staff face while conducting such research. However, there is little documented as to how research staff might support one another in identifying and handling these dilemmas in different contexts. Over the course of conducting empirical ethics research embedded in the Childhood Acute Illness & Nutrition Network, we developed an approach to examine and respond to the ethical issues and dilemmas faced by the study teams, particularly frontline staff. In this paper we describe the specific tools and approach we developed, which centred on regular cross-team ethics reflection sessions, and share lessons learnt. We suggest that all studies involving potentially vulnerable participants should incorporate activities and processes to support frontline staff in identifying, reflecting on and responding to ethical dilemmas, throughout studies. We outline the resources needed to do this and share piloted tools for further adaptation and evaluation. Such initiatives should complement and feed into-and certainly not in any way replace or substitute for-strong institutional ethics review, safeguarding and health and safety policies and processes, as well broader staff training and career support initiatives.

Grandparent caregiving in Cambodian skip-generation households: Roles and impact on child nutrition

This study aims to understand nutrition-related roles, responsibilities and ethical issues of grandparents caring for their grandchildren in skip-generation households in rural Cambodia. Over the past decade, Cambodia has experienced a rise in economic migration of working age populations. This has resulted in increasing numbers of 'skip-generation' households, in which grandparents and grandchildren co-reside without parents, reflecting potential household vulnerability. This qualitative study involved in-depth interviews and focus group discussions with Cambodian grandparents who were primary caregivers to grandchildren for six months or longer. A total of 39 grandparents were recruited at two sites in north-west Cambodia. Interviews and focus group discussions were conducted in Khmer and were recorded, transcribed and translated into English. Data were analysed using thematic analysis. Grandparents in this study looked after an average of three children, aged between two months and 18 years old. Overall, 40% were sole caregivers. Analysis showed that grandparents, particularly grandmothers, played a central role in their grandchildren's health and nutrition. Although grandchildren's health and nutrition were a major priority to grandparents, they reported facing significant challenges to safeguard their grandchildren's and their own nutritional needs. As a result, grandparents frequently faced difficult ethical trade-offs and prioritised their grandchildren's health and nutrition over their own. This study highlights that in order to improve child nutrition, policies and interventions need to be designed in ways that support and enable grandparent caregivers to meet their grandchildren's health and nutritional needs without neglecting their own.

Vulnerability, Agency, and the Research Encounter: Family Members' Experiences and Perceptions of Participating in an Observational Clinical Study in Kenya

Pediatric clinical research in low-resourced countries involves individuals defined as "vulnerable" in research ethics guidance. Insights from research participants can strengthen the design and oversight of studies. We share family members' perspectives and experiences of an observational clinical study conducted in one Kenyan hospital as part of an integrated empirical ethics study. Employing qualitative methods, we explored how research encounters featured in family members' care-seeking journeys. Our data reveals that children's vulnerability is intricately interwoven with that of their families, and that research processes and procedures can inadvertently add to hidden burdens for families. In research, the potential for layered and intersecting situational and structural vulnerability should be considered, and participants' agency in constrained research contexts actively recognized and protected.

Hypothetical acceptability of hospital-based post-mortem pediatric minimally invasive tissue sampling in Malawi: The role of complex social relationships

BACKGROUND

Child mortality rates remain unacceptably high in low-resource settings. Cause of death (CoD) is often unknown. Minimally invasive tissue sampling (MITS)-using biopsy needles to obtain post-mortem samples-for histopathological and microbiologic investigation is increasingly being promoted to improve child and adult CoD attribution. "MITS in Malawi" is a sub-study of the Childhood Acute Illness & Nutrition (CHAIN) Network, which aims to identify biological and socioeconomic mortality risk factors among young children hospitalized for acute illness or undernutrition. MITS in Malawi employs standard MITS and a novel post-mortem endoscopic intestinal sampling approach to better understand CoD among children with acute illness and/or malnutrition who die during hospitalization.

AIM

To understand factors that may impact MITS acceptability and inform introduction of the procedure to ascertain CoD among children with acute illness or malnutrition who die during hospitalization in Malawi.

METHODS

We conducted eight focus group discussions with key hospital staff and community members (religious leaders and parents of children under 5) to explore attitudes towards MITS and inform consent processes prior to commencing the MITS in Malawi study. We used thematic content analysis drawing on a conceptual framework developed from emergent themes and MITS acceptability literature.

RESULTS

Feelings of power over decision-making within the hospital and household, trust in health systems, and open and respectful health worker communication with parents were important dimensions of MITS acceptability. Other facilitating factors included the potential for MITS to add CoD information to aid sense-making of death and contribute to medical knowledge and new interventions. Potential barriers to acceptability included fears of organ and blood harvesting, disfigurement to the body, and disruption to transportation and burial plans.

CONCLUSION

Social relationships and power dynamics within healthcare systems and households are a critical component of MITS acceptability, especially given the sensitivity of death and autopsy.

Research ethics in context: understanding the vulnerabilities, agency and resourcefulness of research participants living along the Thai-Myanmar border

BACKGROUND

Research ethics guidelines set a high bar for conducting research with vulnerable populations, often resulting in their exclusion from beneficial research. Our study aims to better characterise participants' vulnerabilities, agency, resourcefulness and sources of support.

METHODS

We undertook qualitative research around two clinical studies involving migrant women living along the Thai-Myanmar border. We conducted 32 in-depth interviews and 10 focus group discussions with research participants, families, researchers and key informants.

RESULTS

We found that being 'undocumented' is at the core of many structural vulnerabilities, reflecting political, economic, social and health needs. Although migrant women lead challenging lives, they have a support network that includes family, employers, community leaders, non-governmental organisations and research networks. Migrant women choose to participate in research to access quality healthcare, gain knowledge and obtain extra money. However, research has the potential to exacerbate existing vulnerabilities, such as the burdens of cross-border travel, foregoing work and being more visible as migrants.

CONCLUSIONS

Our study confirms that research is important to provide evidence-based care and was viewed by participants as offering many benefits, but it also has hidden burdens. Migrant women exercised agency and resourcefulness when navigating challenges in their lives and research participation.

Managing ancillary care in resource-constrained settings: Dilemmas faced by frontline HIV prevention researchers in a rural area in South Africa

BACKGROUND

We describe the findings from a research ethics case study, linked with a team evaluating a package of intervention services to prevent HIV infection in adolescent girls and young women (AGYW) living in a rural and poor setting of KwaZulu-Natal, South Africa.

METHODS

We conducted qualitative interviews (n=77) with members of the linked research team evaluating the intervention programme, programme implementing staff, AGYW enrolled in the intervention programme, caregivers, ethics committee members, Public Engagement officers, community advisory board members and community stakeholders. Data were analysed iteratively using thematic framework analysis. Themes were determined by the study aims combined with an inductive development of codes emerging from the data.

RESULTS

The findings show that the burden of providing ancillary care fell primarily on the shoulders of frontline researchers and programme staff. Dilemmas around responding to gender-based violence illustrated the limits of 'referral to services' as a solution for meeting ancillary care obligations in contexts with barriers to basic health and social services.

CONCLUSION

Our findings show important gaps in meeting ancillary care needs. Participants' needs required social and economic support which frontline researchers and implementing partners were not able to meet, causing moral distress.

Optimizing G6PD testing for Plasmodium vivax case management and beyond: why sex, counseling, and community engagement matter

Safe access to the most effective treatment options for  Plasmodium vivax malaria are limited by the absence of accurate point-of-care testing to detect glucose-6-phosphate dehydrogenase (G6PD) deficiency, the most common human genetic disorder. G6PD-deficient patients are at risk of life-threatening hemolysis when exposed to 8-aminoquinolines, the only class of drugs efficacious against  P. vivax hypnozoites. Until recently, only qualitative tests were available in most settings. These can identify patients with severe G6PD deficiency (mostly male) but not patients with intermediate G6PD deficiency (always female). This has led to and reinforced a gap in awareness in clinical practice of the risks and implications of G6PD deficiency in females—who, unlike males, can have a heterozygous genotype for G6PD. Increasing recognition of the need for radical cure of   P. vivax, first for patients’ health and then for malaria elimination, is driving the development of new point-of-care tests for G6PD deficiency and their accessibility to populations in low-resource settings. The availability of user-friendly, affordable, and accurate quantitative point-of-care diagnostics for the precise classification of the three G6PD phenotypes can reduce sex-linked disparities by ensuring safe and effective malaria treatment, providing opportunities to develop supportive counseling to enhance understanding of genetic test results, and improving the detection of all G6PD deficiency phenotypes in newborns and their family members.

Vulnerability and agency across treatment-seeking journeys for acutely ill children: how family members navigate complex healthcare before, during and after hospitalisation in a rural Kenyan setting

BACKGROUND

Child mortality rates during hospitalisation for acute illness and after discharge are unacceptably high in many under-resourced settings. Childhood vulnerability to recurrent illness, and death, is linked to their families' situations and ability to make choices and act (their agency). We examined vulnerability and agency across treatment-seeking journeys for acutely ill children and considered the implications for policy and practice.

METHOD

A qualitative sub-study was embedded within the prospective CHAIN Network cohort study, which is investigating mechanisms of inpatient and post-hospital discharge mortality among acutely ill young children across a spectrum of nutritional status. Primary data were collected from household members of 20 purposively selected cohort children over 18 months through formal interviews (total n = 74), complemented by informal discussions and observations. Data were analysed using narrative and thematic approaches.

RESULTS

Treatment-seeking pathways were often long and complex, particularly for children diagnosed as severely malnourished. Family members' stories reveal that children's carers, usually mothers, navigate diverse challenges related to intersecting vulnerabilities at individual, household and facility levels. Specific challenges include the costs of treatment-seeking, confusing and conflicting messaging on appropriate care and nutrition, and poor continuity of care. Strong power inequities were observed between family members and health staff, with many mothers feeling blamed for their child's condition. Caregivers' agency, as demonstrated in decision-making and actions, often drew on the social support of others but was significantly constrained by their situation and broader structural drivers.

CONCLUSION

To support children's care and recovery, health systems must be more responsive to the needs of families facing multiple and interacting vulnerabilities. Reducing incurred treatment costs, improving interpersonal quality of care, and strengthening continuity of care across facilities is essential. Promising interventions need to be co-designed with community representatives and health providers and carefully tested for unintended negative consequences and potential for sustainable scale-up.

Nb3Sn multicell cavity coating system at Jefferson Lab

Superconducting radio frequency niobium cavities are the building blocks of modern accelerators for scientific applications. Lower surface resistance, higher fields, and high operating temperatures advance the reach of the future accelerators for scientific discovery as well as potentially enabling cost-effective industrial solutions. We describe the design and performance of an Nb₃Sn coating system that converts the inner surface of niobium cavities to an Nb₃Sn film. The niobium surface, heated by radiation from the niobium retort, is exposed to Sn and SnCl₂ vapor during the heat cycle, which results in about 2 μm Nb₃Sn film on the niobium surface. Film composition and structure as well as radio frequency properties with 1-cell R&D cavities and 5-cell practical accelerator cavities are presented.

Optimizing G6PD testing for Plasmodium vivax case management: why sex, counseling, and community engagement matter

Safe access to the most effective treatment options for Plasmodium vivax malaria are limited by the absence of accurate point-of-care testing to detect glucose-6-phosphate dehydrogenase (G6PD) deficiency, the most common human genetic disorder. G6PD-deficient patients are at risk of life-threatening hemolysis when exposed to 8-aminoquinolines, the only class of drugs efficacious against P. vivax hypnozoites. Until recently, only qualitative tests were available in most settings. These accurately identify patients with severe G6PD deficiency (mostly male) but not patients with intermediate G6PD deficiency (always female). This has led to and reinforced a gap in awareness in clinical practice of the risks and implications of G6PD deficiency in females—who, unlike males, can have a heterozygous genotype for G6PD. Increasing recognition of the need for radical cure of P. vivax, first for patients’ health and then for malaria elimination, is driving the development of new point-of-care tests for G6PD deficiency and their accessibility to populations in low-resource settings. The availability of simple, affordable, and accurate point-of-care diagnostics for the precise classification of the three G6PD phenotypes can reduce sex-linked disparities by ensuring safe and effective malaria treatment, providing opportunities to develop supportive counseling to enhance understanding of genetic test results, and improving the detection of all G6PD deficiency phenotypes in newborns and their family members.

Effect of Different Fat Sources and Vitamin E Isoforms/Levels on Carcass Characteristics and Meat Quality of Pigs Grown to 150 Kg

ObjectivesThe objective was to evaluate the effect of supplementing α- and γ-tocopherol vitamin E isoforms with corn oil and tallow on carcass characteristics and meat quality of pigs grown to heavier weights (>150 kg).Materials and MethodsIndividually fed pigs (n = 72; 36 barrows, 36 gilts; 28.55 ± 1.16 kg) were randomly assigned to 12 dietary treatments in a 2 × 6 factorial arrangement. Fat treatments were tallow and corn oil (5?). The vitamin E treatments included four levels of α-tocopheryl-acetate (ATA; 11, 40, 100, and 200 ppm) and two levels of mixed tocopherols (primarily γ-tocopherol; 40 and 100 ppm). Pigs were humanely slaughtered at approximately 150 kg. 45 min pH was taken at the 10th rib. After 24 h chill (4°C), carcass measurements were taken (carcass length, backfat depth at first rib, last rib, 10th rib and last lumbar, loin muscle area, and 24 h pH at the 10th rib). In addition, wholesale weights from the Boston butt (IMPS #406), shoulder picnic (IMPS #405), loin (IMPS #412), and belly (IMPS #408) and spareribs were recorded. Furthermore, bellies were divided into eight sections and the average depth was taken at each section and the vertical and lateral belly flex was measured. Drip loss was determined by suspending a 1.3cm chop at 4°C for 48 h and purge loss was determined from approximately 2kg vacuum packaged loin muscle sections at 0, 7, 14, and 30d. Objective (Hunter Lab Colorimeter XE Plus) and subjective (NPPC color, marbling and firmness scores) measurements were taken at the 10th rib. Data analysis were performed in SAS by least squares analysis of variance using the generalized linear model as a randomized complete block design. The individual pig served as the experimental unit and results were reported as least square means.ResultsThere were no differences in dressing percentage, 24 h pH, backfat depth, loin muscle area, primal cuts, purge loss, and drip loss between the two vitamin E isoforms. Fat treatments did not affect dressing percentage, 45 min and 24 h pH, backfat depth, loin muscle area, primal cuts, purge loss, drip loss as well as objective and subjective color. Although not significant (P = 0.07), pork from the γ-tocopherol pigs had a lower pH than the ATA treatment. The γ-tocopherol supplementation tended to have a lighter subjective color (P = 0.06) as well as increased L*, decreased a*, and increased the hue angle calculations at 7d shelf-life. The belly depth was greater (P = 0.01) along with higher lateral (P < 0.01) and a lower vertical (P < 0.01) flex for pigs fed tallow.ConclusionIn conclusion, feeding tallow to heavy weight pigs (150 kg) could improve belly firmness. Also, α-tocopherol did not improve shelf-life stability and γ-tocopherol could negatively affect subject and objective pork loin color.

"If I have a cancer, it is not my fault I am a refugee": A qualitative study with expert stakeholders on cancer care management for Syrian refugees in Jordan

BACKGROUND

Noncommunicable diseases including cancer are widespread amongst the 5.6 million Syrian refugees currently hosted in the Middle East. Given its prevalence as the third leading cause of death in Syria, cancer is likely to be an important health burden among Syrian refugees. Against this background, our aim was to describe the clinical, ethical and policy decision-making experiences of health actors working within the current refugee cancer care system; the impact of refugee cancer care health policies on health care providers and policy makers in this context; and provide suggestions for the way delivery of care should be optimised in a sustained emergency situation.

METHODS

From April-July 2016, we conducted in-depth interviews with 12 purposively sampled health officials and health care workers from the Jordanian Ministry of Health, multilateral donors and international non-governmental organisations. Data were analysed using a framework analysis approach to identify systemic, practical and ethical challenges to optimising care for refugees, through author agreement on issues emerging from the data and those linked more directly to areas of questioning.

RESULTS

As has been previously reported, central challenges for policy makers and health providers were the lack of quality cancer prevalence data to inform programming and care delivery for this refugee population, and insufficient health resource allocation to support services. In addition, limited access to international funding for the host country, the absence of long-term funding schemes, and barriers to coordination between institutions and frontline clinicians were seen as key barriers. In this context where economic priorities inevitably drive decision-making on public health policy and individual care provision, frontline healthcare workers and policy makers experienced significant moral distress where duties of care and humanitarian values were often impossible to uphold.

CONCLUSIONS

Our findings confirm and expand understanding of the challenges involved in resource allocation decisions for cancer care in refugee populations, and highlight these for the particular situation of long term Syrian refugees in Jordan. The insights offered by frontline clinicians and policy makers in this context reveal the unintended personal and moral impact of resource allocation decisions. With many countries facing similar challenges in the provision of cancer care for refugees, the lessons learned from Jordan suggest key areas for policy revision and international investment in developing cancer care policies for refugees internationally.

Addressing the gender-knowledge gap in glucose-6-phosphate dehydrogenase deficiency: challenges and opportunities

Glucose-6-phosphate dehyrdgoenase (G6PD) deficiency is a common X-linked genetic trait, with an associated enzyme phenotype, whereby males are either G6PD deficient or normal, but females exhibit a broader range of G6PD deficiencies, ranging from severe deficiency to normal. Heterozygous females typically have intermediate G6PD activity. G6PD deficiency has implications for the safe treatment for Plasmodium vivax malaria. Individuals with this deficiency are at greater risk of serious adverse events following treatment with the only curative class of anti-malarials, 8-aminoquinolines, such as primaquine. Quantitative diagnostic tests for G6PD deficiency are complex and require sophisticated laboratories. The commonly used qualitative tests, do not discriminate intermediate G6PD activities. This has resulted in poor understanding of the epidemiology of G6PD activity in females and its corresponding treatment ramifications. New simple-to-use quantitative tests, and a momentum to eliminate malaria, create an opportunity to address this knowledge gap. While this will require additional resources for clinical studies, adequate operational research, and appropriate pharmacovigilance, the health benefits from this investment go beyond the immediate intervention for which the G6PD status is first diagnosed.

Research on Medical Practices: Why Patients Consider Participating and the Investigational Misconception

Understanding how patients decide whether to enroll in research can help improve educational materials, protocols, and recruitment rates. However, little is known about patients' willingness to participate in research on medical practices (ROMP), or studies comparing interventions within usual care. We assessed willingness to consider participating in ROMP by surveying 1095 adults in the United States, of whom 834 answered at least one open-ended question about their reasons for being willing or unwilling to consider participating in two scenarios involving ROMP. Most respondents were willing to consider participating in the research scenarios. The most commonly cited reasons for being willing to consider participating included benefit to others and oneself; the top reasons for being unwilling to consider participating included belief that the research was unsafe and an unfavorable view of experimentation. Responses also revealed misconceptions about ROMP among both those who were willing and unwilling to consider participating. Because these misconceptions may present an obstacle to recruiting participants in ROMP, there may be a need for educational initiatives to clarify the nature of these types of studies.

Role of the Ocean's AMOC in setting the Uptake Efficiency of Transient Tracers

The central role played by the ocean's Atlantic Meridional Overturning Circulation (AMOC) in the uptake and sequestration of transient tracers is studied in a series of experiments with the GISS and MIT ocean circulation models. Forced by observed atmospheric timeseries of CFC-11, both models exhibit realistic distributions in the ocean, with similar surface biases but different response over time. To better understand what controls uptake, we ran idealized forcing experiments in which the AMOC strength varied over a wide range, bracketing the observations. We found that differences in the strength and vertical scale of the AMOC largely accounted for the different rates of CFC-11 uptake and vertical distribution thereof. A 2-box model enables us to quantify, and relate uptake efficiency of passive tracers to AMOC strength and how uptake efficiency decreases in time. We also discuss the relationship between passive tracer and heat uptake efficiency, of which the latter controls the transient climate response to anthropogenic forcing in the North Atlantic. We find that heat uptake efficiency is substantially less (by about a factor of five) than that for a passive tracer.

Interactive nature of climate change and aerosol forcing

The effect of changing cloud cover on climate, based on cloud-aerosol interactions, is one of the major unknowns for climate forcing and climate sensitivity. It has two components: (1) the impact of aerosols on clouds and climate due to in situ interactions (i.e., rapid response) and (2) the effect of aerosols on the cloud feedback that arises as climate changes-climate feedback response. We examine both effects utilizing the NASA Goddard Institute for Space Studies ModelE2 to assess the indirect effect, with both mass-based and microphysical aerosol schemes, in transient twentieth century simulations. We separate the rapid response and climate feedback effects by making simulations with a coupled version of the model as well as one with no sea surface temperature or sea ice response ("atmosphere-only" simulations). We show that the indirect effect of aerosols on temperature is altered by the climate feedbacks following the ocean response, and this change differs depending upon which aerosol model is employed. Overall, the effective radiative forcing (ERF) for the "direct effect" of aerosol-radiation interaction (ERFari) ranges between -0.2 and -0.6 W m^-2 for atmosphere-only experiments, while the total effective radiative forcing, including[C0]the indirect effect (ERFari+aci) varies between about -0.4 and -1.1 W m^-2 for atmosphere-only simulations; both ranges are in agreement with those given in Intergovernmental Panel on Climate Change (2013). Including the full feedback of the climate system lowers these ranges to -0.2 to -0.5 W m^-2 for ERFari and -0.3 to -0.74 W m^-2 for ERFari+aci. With both aerosol schemes, the climate change feedbacks have reduced the global average indirect radiative effect of atmospheric aerosols relative to what the emission changes would have produced, at least partially due to its effect on tropical upper tropospheric clouds.

Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use

AbstractReducing barriers associated with maternal health service use, household water treatment, and improved hygiene is important for maternal and neonatal health outcomes. We surveyed a sample of 201 pregnant women who participated in a clinic-based intervention in Kenya to increase maternal health service use and improve household hygiene and nutrition through the distribution of water treatment products, soap, protein-fortified flour, and clean delivery kits. From multivariable logistic regression analyses, the adjusted odds of ≥ 4 antenatal care (ANC4+) visits (odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.9-4.5), health facility delivery (OR = 5.3, 95% CI = 3.4-8.3), and any postnatal care visit (OR = 2.8, 95% CI = 1.9-4.2) were higher at follow-up than at baseline, adjusting for demographic factors. Women who completed primary school had higher odds of ANC4+ visits (OR = 1.8, 95% CI = 1.1-2.9) and health facility delivery (OR = 4.2, 95% CI = 2.5-7.1) than women with less education. For women who lived ≤ 2.5 km from the health facility, the estimated odds of health facility delivery (OR = 2.4, 95% CI = 1.5-4.1) and postnatal care visit (OR = 1.6, 95% CI = 1.0-2.6) were higher than for those who lived > 2.5 km away. Compared with baseline, a higher percentage of survey participants at follow-up were able to demonstrate proper handwashing (P = 0.001); water treatment behavior did not change. This evaluation suggested that hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women.