Migraine headache and other risk factors associated with glaucoma among the adult population living in Armenia: a case-control study

PURPOSE

This study aimed to assess the association between migraine headache and glaucoma among the adult population living in Armenia.

METHODS

This case-control study recruited 145 cases with glaucoma and 250 controls without glaucoma and other ocular disorders except refractive error from Optomed Canada Diagnostic Eye Center in Armenia. A structured questionnaire contained questions on socio-demographics, family history of glaucoma and stroke, ocular health, smoking, migraine, and obstructive sleep apnea. The Migraine Screening Questionnaire assessed possible migraine and the Berlin Questionnaire measured obstructive sleep apnea.

RESULTS

The mean ages of cases and controls were 63.3 (SD = 12.3) and 39.5 (SD = 13.5), respectively. Females comprised 62.8% of cases and 69.1% of controls. A total of 17.8% of cases and 19.0% of controls had possible migraine. In the adjusted analysis older age (OR 1.17; 95% CI 1.12; 1.23), average/lower than average socio-economic status (OR 5.27; 95% CI 1.30; 21.3), and family history of glaucoma (OR 4.25; 95% CI 1.51; 11.9) were associated with high-tension glaucoma.

CONCLUSION

Timely case detection of glaucoma among those with average/low socio-economic status and those with family history of glaucoma could prevent further progression of the disease. Further studies to explore the relationship between migraine headache and specific types of glaucoma may be worthwhile.

Prevalence of hepatitis B virus infection among general population of Armenia in 2021 and factors associated with it: a cross-sectional study

OBJECTIVES

This study sought to determine the prevalence and associated factors of hepatitis B virus (HBV) infection ever in life and chronic HBV infection in Armenia.

DESIGN

A population-based cross-sectional seroprevalence study combined with a phone survey of tested individuals.

SETTING

All administrative units of Armenia including 10 provinces and capital city Yerevan.

PARTICIPANTS

The study frame was the general adult population of Armenia aged ≥18 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The participants were tested for anti-HBV core antibodies (anti-HBc) and HBV surface antigen (HBsAg) using third-generation enzyme immunoassays. In case of HBsAg positivity, HBV DNA and hepatitis D virus (HDV) RNA PCR tests were performed. Risk factors of HBV infection ever in life (anti-HBc positivity) and chronic HBV infection (HBsAg positivity) were identified through fitting logistic regression models.

RESULTS

The seroprevalence study included 3838 individuals 18 years and older. Of them, 90.7% (3476 individuals) responded to the phone survey. The prevalence of anti-HBc positivity was 14.1% (95% CI 13.1% to 15.2%) and HBsAg positivity 0.8% (95% CI 0.5% to 1.1%). The viral load was over 10 000 IU/mL for 7.9% of HBsAg-positive individuals. None of the participants was positive for HDV. Risk factors for HBsAg positivity included less than secondary education (aOR=6.44; 95% CI 2.2 to 19.1), current smoking (aOR=2.56; 95% CI 1.2 to 5.6), and chronic liver disease (aOR=8.44; 95% CI 3.0 to 23.7). In addition to these, risk factors for anti-HBc positivity included age (aOR=1.04; 95% CI 1.04 to 1.05), imprisonment ever in life (aOR=2.53; 95% CI 1.41 to 4.56), and poor knowledge on infectious diseases (aOR=1.32; 95% CI 1.05 to 1.67), while living in Yerevan (vs provinces) was protective (aOR=0.74; 95% CI 0.59 to 0.93).

CONCLUSION

This study provided robust estimates of HBV markers among general population of Armenia. Its findings delineated the need to revise HBV testing and treatment strategies considering higher risk population groups, and improve population knowledge on HBV prevention.

Examining local smoke-free coalitions in Armenia and Georgia: context and outcomes of a matched-pairs community-randomised controlled trial

INTRODUCTION

Local coalitions can advance public health initiatives such as smoke-free air but have not been widely used or well-studied in low-income and middle-income countries.

METHODS

We conducted a matched-pairs community-randomised controlled trial in 28 communities in Armenia and Georgia (N=14/country) in which we helped establish local coalitions in 2019 and provided training and technical assistance for coalition activity promoting smoke-free policy development and enforcement (2019-2021). Surveys of ~1450 households (Fall 2018, May-June 2022) were conducted to evaluate coalition impact on smoke-free policy support, smoke-free home adoption, secondhand smoke exposure (SHSe), and coalition awareness and activity exposure, using multivariable mixed modelling.

RESULTS

Bivariate analyses indicated that, at follow-up versus baseline, both conditions reported greater smoke-free home rates (53.6% vs 38.5%) and fewer days of SHSe on average (~11 vs ~12 days), and that intervention versus control condition communities reported greater coalition awareness (24.3% vs 12.2%) and activity exposure (71.2% vs 64.5%). Multivariable modelling indicated that intervention (vs control) communities reported greater rates of complete smoke-free homes (adjusted Odds Ratio [aOR] 1.55, 95% confiedence interval [CI] 1.11 to 2.18, p=0.011) and coalition awareness (aOR 2.89, 95% CI 1.44 to 8.05, p=0.043) at follow-up. However, there were no intervention effects on policy support, SHSe or community-based activity exposure.

CONCLUSIONS

Findings must be considered alongside several sociopolitical factors during the study, including national smoke-free policies implementation (Georgia, 2018; Armenia, 2022), these countries' participation in an international tobacco legislation initiative, the COVID-19 pandemic and regional/local war). The intervention effect on smoke-free homes is critical, as smoke-free policy implementation provides opportunities to accelerate smoke-free home adoption via local coalitions.

TRIAL REGISTRATION NUMBER

NCT03447912.

Nationwide Rapid Assessment of Avoidable Blindness (RAAB) in Armenia

PURPOSE

This study aimed to estimate the prevalence and main causes of blindness and visual impairment in population aged 50 years and older in Armenia using Rapid Assessment of Avoidable Blindness (RAAB) methodology.

METHODS

The study team randomly selected 50 clusters (each consisting of 50 people) from all 11 regions of Armenia. Data on participants' demographics, presenting visual acuity, pinhole visual acuity, principal cause of presenting visual acuity, spectacle coverage, uncorrected refractive error (URE), and presbyopia were collected using the RAAB survey form. Four teams of trained eye care professionals completed data collection in 2019.

RESULTS

Overall, 2,258 people of 50 years and older participated in the study. The age- and gender- adjusted prevalence of bilateral blindness, severe and moderate visual impairment were 1.5% (95% CI: 1.0-2.1), 1.6% (95% CI: 1.0-2.2) and 6.6% (95% CI: 5.5-7.7), respectively.The main causes of blindness were cataract (43.9%) and glaucoma (17.1%). About 54.6% and 35.3% of participants had URE and uncorrected presbyopia, respectively. The prevalence of bilateral blindness and functional low vision increased with age and was the highest in participants 80 years and older.

CONCLUSION

The rate of bilateral blindness was comparable with findings from countries that share similar background and confirmed that untreated cataract was the main cause of blindness. Given that cataract blindness is avoidable, strategies should be developed aiming to further increase the volume and quality of cataract care in Armenia.

A mixed-methods evaluation of the indoor and outdoor smoking ban in dining venues in Armenia: Early successes and challenges

INTRODUCTION

Since March 2022, Armenia introduced a comprehensive smoking ban on all types of tobacco products in indoor and outdoor areas of hospitality venues. We aimed to rapidly appraise the implementation of the ban in the dining areas of the capital Yerevan and explore any differences in compliance and enforcement patterns between indoor and outdoor areas of the venues.

METHODS

We used a mixed-methods approach through quantitative air quality monitoring, qualitative observations, and in-depth interviews (IDIs). We visited one venue in each remote district of the city and more venues from the central districts that have a much higher density of dining areas. Overall, we made 24 measurements of PM2.5 particles, 24 unobtrusive observations in the 19 visited venues, and 11 IDIs with six visitors and five workers. We used Stata13 for the analysis of numerical data and completed direct deductive content analysis of the textual data.

RESULTS

Active tobacco use was observed in 12 out of 24 venues (50.0%) with more cases of smoking in outdoor areas (10 out of 12; 83.3%). No warning by workers or no reports to the police were observed. We detected elevated levels of PM2.5 particles in indoor and outdoor areas. The IDIs revealed predominantly negative attitudes towards the outdoor ban and the lack of awareness of and readiness to engage in the enforcement measures. The lack of enforcement by the owners and the respective bodies was mentioned as a contributor to continued violations of the ban. The change in the dynamic and the characteristics of the visitors, cleaner air, and less unpleasant work were mentioned as important positive aftermaths of the ban.

CONCLUSIONS

The Government of Armenia should enhance the monitoring and enforcement activities and organize tailored awareness-raising campaigns to inform the general public and the hospitality industry of the health and social implications of the ban.

Associations Between Pro/Anti-Tobacco Media and Messaging Exposure and Knowledge and Support of Smoke-Free Policy Among Adults in Armenia and Georgia

CONTEXT

Despite high smoking rates, Armenia and Georgia recently adopted smoke-free policies (2022 and 2018).

OBJECTIVE

We examined associations between exposure to pro-tobacco media (news opposing smoke-free policies; cigarette, e-cigarette, heated tobacco product [HTP] advertisements) and anti-tobacco media (media, community-based action) and (1) knowledge that the policies applied to alternative tobacco products (ATPs), and (2) support for the policies applying to ATPs and various settings.

DESIGN

We analyzed 2022 survey data.

SETTING

Data were from 28 communities in Armenia and Georgia.

PARTICIPANTS

The sample comprised 1468 adults (31.6% past-month smokers).

METHODS

We conducted multivariable regressions, controlling for country and sociodemographics.

RESULTS

Participants were knowledgeable that the policy applied to ATPs (79.2%) and supportive of them applying to ATPs and various settings (means = 3.43 and 3.00; 1-4 = strongly support). Greater exposure to anti-tobacco media/community-based action correlated with more likely knowing that the policies applied to ATPs and greater support of the policies applying to various settings; HTP advertisement exposure correlated with less support of the policies applying to various settings. Less exposure to news opposing smoke-free policies and greater exposure to media supporting such policies correlated with greater support of the policies applying to ATPs.

CONCLUSIONS

Media and community-based action may promote smoke-free policy knowledge and support. HTP advertisements may uniquely undermine smoke-free policies.

Health-Related Quality of Life after Cataract Surgery in Armenia: A Cross-Sectional Survey

Cataract surgery helps to enhance visual function and improve the quality of life of cataract patients. The present study assessed visual outcomes and explored health-related quality of life (HRQoL) and factors associated with it following cataract surgery in Armenia. An interviewer-administered survey along with the ophthalmologic examination was conducted among 248 patients. It explored socio-demographic characteristics, use of eye care services, smoking status, comorbidities, and receiving and giving social support. A Short Form Health Survey (SF-36) was used to measure HRQoL. Simple and multivariable linear regression was used for the analysis. About 72.8% of examined eyes had good visual outcomes, while 17.7% had borderline outcomes. Poor visual outcomes were detected in 9.5% of the eyes. The mean composite SF-36 score for physical health was 50.8, while the mean composite score for mental health was 49.9. Gender, socioeconomic status, having a non-communicable disease, and receiving and giving tangible social support were significantly associated with SF-36 physical component in the adjusted analysis, while the variables which demonstrated significant association with the mental component included socioeconomic status, having a non-communicable disease, and giving tangible support. The visual outcome after cataract surgery in Armenian patients is below WHO-recommended standards. The quality of ophthalmological surgical care should be monitored to maximize the visual outcome in Armenian patients, with a focus on women, patients with poor socioeconomic status, and those with non-communicable diseases.

Cataract Blindness in Armenia: The Results of Nationwide Rapid Assessment of Avoidable Blindness (RAAB)

PURPOSE

This study assessed the prevalence of cataract blindness, cataract surgical coverage (CSC), effective CSC, visual outcome after cataract surgery, and barriers to cataract surgery in a population aged 50 years and older in Armenia using Rapid Assessment of Avoidable Blindness (RAAB) methodology.

METHODS

The study sample included 2258 individuals aged 50 years and older who were randomly selected from 11 provinces of Armenia in 2019 following the RAAB methodology. The study team randomly selected 50 clusters, 50 people in each. The RAAB survey form was used to collect information on cataract blindness, visual outcome after cataract surgery, and barriers to cataract surgery.

RESULTS

The mean age of the participants was 65.3 (SD = 9.9) ranging from 50 to 99. The majority of participants were women (65.6%). Age- and sex-adjusted prevalence of blindness due to all causes was 1.5%; of which 36.4% was bilaterally blind due to cataract. The CSC and effective CSC at a cataract surgical threshold of <6/12 were 55.1% and 24.4%, respectively. Good outcome was reported in 43.7% of eyes after cataract surgery, borderline in 37.2% of eyes, and poor outcome in 19.1%. The main barriers to cataract surgery included "cost," "need not felt," or "fear."

CONCLUSION

The prevalence of cataract blindness in our study was higher compared to high-income regions and lower than estimates from South/Southeast Asia. This study suggests the urgent need to update the National Strategic Plan to prevent blindness in Armenia with a focus on improving the quality and coverage of cataract surgery.

Factors associated with health-related quality of life among people with visual impairments living in nursing homes in Armenia: a cross-sectional study

PURPOSE

The study aimed to examine the effect of visual impairment (VI), eye diseases, and other risk factors on health-related quality of life (HRQoL) in nursing home residents in Armenia.

METHODS

This cross-sectional study administered an interviewer-administered structured questionnaire to collect information about socio-demographics, chronic diseases, HRQoL, smoking, receiving and giving instrumental/emotional social support, and sleeping disorders among 313 nursing home residents. An ophthalmic examination of the participants was conducted.

RESULTS

The mean age was 72.5 years, ranging from 45.5 to 91.4. Women constituted 50% of the sample. The prevalence of normal vision by presenting visual acuity with available correction was 55.3%, while VI and blindness were present in 40.8% and 3.9%, respectively. Uncorrected refractive error (URE) was found in 20% of participants. The mean HRQoL score was 51.3, ranging from 7.9 to 95.0. In the adjusted analysis, having at least one chronic non-communicable disease, sleeping disorders, eye diseases, URE, VI, blindness, and giving instrumental social support were associated with HRQoL.

CONCLUSIONS

Regular eye care services could improve the eye health and HRQoL of nursing home residents. Interventions addressing vision loss and chronic non-communicable diseases could enhance the functioning and overall well-being of the target population.

Deconvolution of cancer cell states by the XDec-SM method

Proper characterization of cancer cell states within the tumor microenvironment is a key to accurately identifying matching experimental models and the development of precision therapies. To reconstruct this information from bulk RNA-seq profiles, we developed the XDec Simplex Mapping (XDec-SM) reference-optional deconvolution method that maps tumors and the states of constituent cells onto a biologically interpretable low-dimensional space. The method identifies gene sets informative for deconvolution from relevant single-cell profiling data when such profiles are available. When applied to breast tumors in The Cancer Genome Atlas (TCGA), XDec-SM infers the identity of constituent cell types and their proportions. XDec-SM also infers cancer cells states within individual tumors that associate with DNA methylation patterns, driver somatic mutations, pathway activation and metabolic coupling between stromal and breast cancer cells. By projecting tumors, cancer cell lines, and PDX models onto the same map, we identify in vitro and in vivo models with matching cancer cell states. Map position is also predictive of therapy response, thus opening the prospects for precision therapy informed by experiments in model systems matched to tumors in vivo by cancer cell state.

Abstract P2-23-01: Patient-derived xenografts allow deconvolution of single agent and combination chemotherapy responses in triple-negative breast cancer

Background: Triple-negative breast cancer (TNBC) patients frequently receive combination chemotherapy treatment, but a direct comparison of response to carboplatin, docetaxel, and their combination in 50 TNBC patient-derived xenografts (PDXs) showed that combination treatment was largely ineffective at generating enhanced responses over the best single agent. This suggests de-escalation of chemotherapy may be possible if molecular mechanisms and biomarkers underlying response to individual treatments can be identified. To this end, we performed multi-omics profiling for the 50 TNBC PDXs. Methods: Orthotopic TNBC PDXs were treated with four weekly cycles of docetaxel, carboplatin, or the combination. Changes in tumor volume after 4 weeks of treatment were assessed quantitatively and by modified RECIST criteria. Genomic, transcriptomic, and mass-spectrometry-based proteomic profiling were performed on baseline tumors prior to treatments to identify associations with chemotherapy response at the gene and pathway level. ProMS was used to integrate both RNA and protein data to select a 5 RNA feature combination for optimized prediction of carboplatin response in a logistic regression model. Publicly available neoadjuvant chemotherapy clinical datasets with transcriptomic data and response information used for validation/testing included TNBC samples from: GSE18864, I-SPY2 (GSE194040), and BrighTNess (GSE164458). Results: Proteogenomic profiles revealed distinct genes associated with response to each agent and their combination, respectively, suggesting distinct molecular mechanisms underlying response to each treatment. A substantial number of genes associated with single agent and combination treatment were validated in multiple independent patient cohorts receiving platinum and taxane containing neoadjuvant therapy, confirming clinical relevance of our PDX panel. For the same treatment, different types of molecular data identified distinct sets of associated genes, providing highly complementary information. At the pathway level, RNA and protein data converged to metabolic and E2F/G2M related pathways which were upregulated in PDXs resistant or responsive to all treatment types, respectively, while variable levels of MYC-related proliferation pathways were observed across all treatments suggesting pathways that are common across and unique to different treatments. Several individual genes found to be higher in PDXs with better response to either single-agent had discriminatory power in external clinical TNBC datasets treated with similar neoadjuvant chemotherapy regimens. In addition, a logistic regression-based carboplatin response prediction model trained to select a group of 5 RNA markers (TKT, MAGI2, ATF6B, MCM7, LRP6) using both RNA and protein data performed the best in predicting response to cisplatin in a clinical TNBC dataset vs predicting response to other datasets with taxane and platinum + taxane combination containing chemotherapy regimens, demonstrating specificity of the prediction model. These results suggest potential individual biomarkers or biomarker combinations to select TNBC tumors that may respond to either single agent carboplatin, docetaxel, or their combination. PDXs refractory to all treatment arms had higher levels of proteostasis-related pathways including proteasome degradation and the unfolded protein response (UPR) related to endoplasmic reticulum stress and altered levels of chromatin regulation. Subsequent pharmacological targeting of the UPR pathway and targeting HDACs enhanced chemotherapy response. Conclusion: Proteogenomic characterization identifies molecular mechanisms and putative biomarkers for stratifying TNBC tumors for single or combination chemotherapy treatments, suggests targeted therapies to augment chemotherapy response, and provides a valuable resource for researchers and clinicians.

Citation Format: Jonathan T. Lei, Chen Huang, Ramakrishnan R. Srinivasan, Suhas Vasaikar, Lacey E. Dobrolecki, Alaina N. Lewis, Na Zhao, Jin Cao, Susan G. Hilsenbeck, C. Kent Osborne, Mothaffar Rimawi, Matthew J. Ellis, Varduhi Petrosyan, Alexander B. Saltzman, Anna Malovannaya, John D. Landua, Bo Wen, Antrix Jain, Gerburg M. Wulf, Shunqiang Li, Daniel C. Kraushaar, Tao Wang, Xi Chen, Gloria V. Echeverria, Meenakshi Anurag, Bing Zhang, Michael T. Lewis. Patient-derived xenografts allow deconvolution of single agent and combination chemotherapy responses in triple-negative breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-23-01.

Prevalence and risk factors of hepatitis C virus infection in Armenia, 2021

Background

Liver damage caused by hepatitis C virus (HCV) is common, especially in low- and middle-income countries. Chronic HCV infection is among the leading causes of chronic liver disease, cirrhosis and hepatocellular carcinoma. Data on prevalence and risk factors of HCV infection are important for planning effective interventions to fight the virus. This study investigated the prevalence of HCV, its genotypes and factors associated with chronic HCV infection in Armenia.

Methods

The study included 3838 individuals 18 years and older selected via stratified two-stage cluster sampling from all regions of Armenia. Anti-HCV antibodies were detected using a third generation immunoassay. Those testing positive were further tested by Polymerase Chain Reaction and genotyping. Shortly after testing, the participants underwent a telephone survey. Logistic regression model was fitted to identify factors associated with chronic HCV infection.

Results

The participants mean age was 49.5 years, 70.0% were female. The prevalence of HCV antibodies weighted by age and sex was 1.9% (95% CI 1.5, 2.3), and chronic HCV infection - 0.7% (95% CI 0.4, 0.9), with genotype 3 being the most common (41.7%), followed by genotypes 2 (37.5%) and 1 (20.8%). The prevalence of both antibodies and chronic infection were higher among 50-69 years old (3.4% and 1.3%, respectively). In weighted analysis, the risk factors for chronic HCV infection included male sex (95% CI 1.23, 11.59), having tattoos (95% CI 1.10, 7.80), and reporting liver disease (95% CI 1.24, 14.61). Being employed was protective (95% CI 0.14, 0.93).

Conclusions

This study was the first attempt to measure the prevalence of HCV infection among the general population of Armenia, creating prerequisites for estimating the HCV-related disease burden and developing strategies to cope with it. The identified risk factors demonstrate that there is still room for strengthening safety measures to prevent the transmission of HCV in Armenia.

Key messages

• The prevalence of HCV antibodies is 1.9% among adult population of Armenia, increasing with age. Over one-third of seropositive cases have chronic infection caused by HCV genotypes 3, 2 or 1.

• Having tattoos is associated with higher risk of being infected with HCV, demonstrating the need for strengthening safety measures during similar procedures to prevent viral transmission.

Predictors of seropositivity against SARS-COV-2: a population-based seroepidemiological study

Background

Data on parameters of actual exposure to SARS-CoV-2 is limited, and specific population groups might be at a higher risk of infection. In line with the growing need for large-scale investigations to determine the presence of antibodies against SARS-CoV-2 among different population groups, we conducted a nationwide assessment in Armenia.

Methods

We performed a cross-sectional seroepidemiological study among the adult population in Armenia, in May-September 2021. A multi-stage cluster random sampling was performed to recruit the participants across the capital city and regions. The study had two main components: blood sampling, which took place in primary care facilities and a phone survey on socio-demographic characteristics, comorbidities, and previous history of COVID-19.

Results

The number of participants included in both blood sampling and phone survey was 3483. The nationwide prevalence of SARS-CoV 2 antibodies weighted by age and gender was 66.4% with significantly higher prevalence in urban compared to rural areas (67.3% vs 59.3%, p &lt; 0.001). Only 22.7% (n = 772) of the total sample reported a previous history of PCR confirmed COVID-19, among whom antibodies were detected in 94.2% (n = 727). In the final adjusted model, the seropositivity was associated with being female (OR = 1.60, 95% CI: 1.32; 1.92), employed (OR = 1.41, 95% CI: 1.17; 1.69), and having previous PCR confirmed COVID-19 (OR = 10.6, 95% CI: 7.39; 15.21).

Conclusions

Over 66% of the population were seropositive for antibodies against SARS-CoV 2; and over ⅕ of the sample reported a previous PCR diagnosis. Factors associated with increased odds of seropositivity included gender, employment status, and place of residence. Targeted interventions are recommended to minimize the risk of infection among those groups, including vaccination and infection prevention and control measures.

Key messages

• The prevalence of SARS-CoV 2 antibodies is about three times higher than the rate of infection based on PCR confirmed prevalence of COVID-19.

• Women, people living in urban areas, and those employed are at a higher risk for exposure to SARS-CoV 2.

Implementation of “COVID-19 case investigation and contact tracing” training program in Armenia

Background

Comprehensive contact tracing and case identification (CICT) is key to preventing the SARS-COV-2 transmission. During the COVID-19 waves in Armenia, the effectiveness of CICT practices was suboptimal due to weak capacity of evidence-based CICT. The American University of Armenia and the University of California, Los Angeles offered a continuous education program for the public health workforce in Armenia which is relevant for any country aiming to improve its CICT capacities.

Objectives

We developed and implemented a fully remote yet synchronous ‘COVID-19 case investigation and contact tracing” training program through didactic lectures, demonstrations of CICT interviews, small-group skill labs, and opinion polls. It covered the basic principles of public health and epidemiology, the main methods of CICT in relation to COVID-19, and health coaching techniques. We evaluated the knowledge improvement through a pre-experimental evaluation design at baseline and follow-up. The training sessions were held from November 2020 to June 2021. The participants received 10 CME credits upon completion of the training course.

Results

The online modality allowed to reach professionals across the country, though affected the participation in the evaluation surveys. Overall, 93 professionals participated in the training program, yet only 57 returned completed surveys. The paired analysis showed an increase in the mean knowledge scores (0-24) at baseline and follow-up (14.5 vs 15.82 (p = 0.0083). A more notable increase was detected on questions that measured knowledge of health coaching techniques (0-6) (2.76 vs 3.44 (p = 0.0052)).

Conclusions

New knowledge and skills penetrated into daily CICT practices across Armenia. This was a good example of a quick mobilization of local and international expertise to assist the national efforts in responding to a public health emergency by utilizing evidence-based approaches and lessons learned from the past infectious diseases’ outbreaks.

Key messages

• Our training program strengthened the human resource capacities of Armenia’s existing public health system and assisted Armenia’s COVID-19 response efforts.

• The model of our training program can be effectively adapted and extrapolated for various countries and settings which aim to improve response capacities to other threats of public health importance.

The impact of smoking on immunological response to SARS-COV 2: a nationwide seroepidemiological study

Background

Smoking influences cellular and humoral immune responses and affects the immune system by increasing inflammation and decreasing activity against infections. The current study investigates the association between smoking and immunological response to SARS-CoV-2 in the Armenian population.

Methods

We performed a nationwide cross-sectional seroepidemiological study among the adult population (≥18 years old) in Armenia. We used a multi-stage cluster random sampling to recruit participants from the capital city and all regions of Armenia. We invited selected participants to primary healthcare facilities to provide blood samples for antibody testing followed by a phone survey on demographic characteristics, smoking status, and other variables. Logistic regression analysis was used to test the relationship between smoking and having SARS-CoV-2 antibodies adjusted for other covariates.

Results

3483 people participated in the study (71% women). The total sample included 16.8% current smokers (n = 571), 8.6% past smokers (n = 294) and 76.4% never smokers (n = 2538). The prevalence of SARS CoV-2 antibodies among current smokers was statistically significantly lower as compared with never smokers (46.9% vs 73.4%, p-value&lt;0.001). In the multivariable logistic regression model, the odds of having SARS CoV-2 antibodies among the current smokers was 70% lower (OR 0.30, 95%CI: 0.22; 0.40) compared to never smokers, when adjusted for demographic factors and the time of PCR diagnosis of COVID-19. No statistically significant difference was found between past smokers and having SARS CoV-2 antibodies.

Conclusions

In addition to being a risk factor for various chronic diseases, smoking weakens immune response to infectious diseases, including COVID-19, worsening the outcomes. The significantly lower level of antibody prevalence among smokers with previous PCR confirmed COVID 19 implies a poorer immune response to the infection and not a lower risk of getting the infection.

Key messages

• Smoking weakens immune response and contributes to a higher burden of infectious diseases, such as COVID-19.

• Lower level of antibody prevalence among smokers indicates a poorer immune response to the infection rather than a lower risk of getting the infection.

XDec-CHI reveals immunosuppressive interactions in pancreatic ductal adenocarcinoma

Most cancers harbor a diverse collection of cell types including a typically heterogeneous cancer cell fraction. To reconstruct cell-intrinsic and heterotypic interactions driving tumor progression, we combine the XDec deconvolution method with cell-type-specific gene expression correlation analysis into the XDec-CHI method. XDec-CHI identifies intra- and inter-cellular pathways using correlation and places them in the context of specific tumor subtypes, as defined by the state of constituent cancer cells. We make the method web-accessible for analysis of publicly accessible pancreatic ductal adenocarcinoma, breast, head and neck, glioblastoma, and glioma tumors. We apply the method to TCGA and ICGC datasets to identify immune-suppressive interactions within PDAC tumors that are relevant for immunotherapies targeting PD-L1. Subtype-specific interactions derived from correlative analyses validated in co-culture experiments suggest PDAC subtypes have distinct therapeutic weaknesses, with Basal-like and MSLN-high Classical B tumors most likely to respond to therapies targeting PD-L1.

•

XDec-CHI deconvolutes cell-type-specific gene interactions from bulk RNAseq data

•

Subtypes of PDAC upregulate PD-L1 using distinct intra- and inter-cellular pathways

•

Distinct PD-L1 pathways suggest subtype-specific therapy targets and responses

•

XDec-CHI software and pre-computed datasets for several solid cancers is provided

699 Accounting for Fixation Shrinkage in Temporal Artery Biopsy

Aim

Ascertain the length shrinkage of Temporal Artery Biopsy (TAB) following fixation to inform current practice and ensure samples taken are in keeping with the British Society of Rheumatology Recommendations.

The British Society of Rheumatology (2020) recommends a sample size of at least 1cm post fixation to be of diagnostic value for Giant Cell Arteritis (GCA). Formalin has been shown to cause 20–30% volume shrinkage of histopathological specimens. Shrinkage relating to length, specifically with TABs was shown to be approximately 8% based on a sample size of 13 patients.

Method

A consecutive sample of patients undergoing TAB between January-December 2021 were analysed. Those with measurements documented in the op note were compared to the post fixation measurement documented in the histopathology report. Statistical analysis included demographic data as well p values calculated for the differences in length.

Results

Forty Seven patients were treated for TAB, M:F (1:1.26), Mean Age=73.06 (47–94). Mean pre-fixation length = 26.84mm (SD-8.38), Mean post-fixation length = 20.27mm (SD-8.72). Overall shrinkage was calculated at 25% with a p value of 0.0046, confirming a significant difference between the two sample groups.

Conclusion

This sample demonstrates there to be a clear difference between the two measurements, with a significant percentage shrinkage. Appreciation of shrinkage is vital in obtaining a suitable sample to ensure diagnostic value and appropriate patient care. Further evaluation, both prospective and retrospective is underway with the results pending.

Tobacco-related risk perceptions, social influences and public smoke-free policies in relation to smoke-free home restrictions: findings from a baseline cross-sectional survey of Armenian and Georgian adults in a community randomised trial

OBJECTIVES

Given high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions.

DESIGN

Cross-sectional survey study design.

SETTING

28 communities in Armenia and Georgia surveyed in 2018.

PARTICIPANTS

1456 adults ages 18-64 in Armenia (n=705) and Georgia (n=751).

MEASUREMENTS

We used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively.

RESULTS

Participants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p<0.001), lower SHS risk perception (OR=0.43, p<0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p<0.001), without children (OR=5.88, p<0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026).

CONCLUSIONS

Private settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours.

TRIAL REGISTRATION NUMBER

NCT03447912.

Knowledge, Attitude, And Practice Towards Antibiotic Resistance Among General Practitioners in Polyclinics in Yerevan, Armenia

Aim: The objectives of the study were measuring knowledge, attitude, and practice scores among general practitioners on antibiotic resistance; exploring associations between antibiotics prescribing practice score among general practitioners and their knowledge and attitude scores after adjusting for other factors; and identifying barriers for rational antibiotics prescription by general practitioners. Methods: A cross-sectional study design was used. A self-administered survey was conducted among general practitioners employed in private and public polyclinics in Yerevan, Armenia. All general practitioners, working in Yerevan polyclinics and fluent in the Armenian language, were eligible for the study. The study was conducted in primary healthcare facilities of Yerevan, Armenia. All polyclinics (n=18) serving 30,000 or more populations were included in the study. All general practitioners available in selected polyclinics at the time of the survey were invited to take part in the survey, to target 20 general practitioners from each polyclinic. Results: Overall, 291 general practitioners participated in the study. Knowledge, attitude, and practice mean percent scores were 58.3%, 67.5%, and 63.0%, respectively. In the adjusted analysis, the practice percent score was significantly associated with the attitude percent score, though the relationship between the practice and knowledge scores was insignificant. The main barriers reported by general practitioners: lack of rapid diagnostic tests, high costs of laboratory tests, high costs of some antibiotics, and lack of guidelines. Conclusion: Identified low knowledge, attitude, and practice mean percent scores suggest a need for improvements in these areas. Availability of rapid and inexpensive diagnostic tests, enforcement of prescriptions could potentially prevent the development of antibiotic resistance. Keywords: drug resistance, general practitioners, polyclinics, prescribing

Correction: CTD: An information-theoretic algorithm to interpret sets of metabolomic and transcriptomic perturbations in the context of graphical models

[This corrects the article DOI: 10.1371/journal.pcbi.1008550.].

Knowledge, attitude and practice towards antibiotic resistance among general practitioners in Armenia

Background

Antibiotic resistance is an important public health issue. This study sought to measure general practitioners' (GPs) knowledge, attitude, and practice on antibiotic resistance; explore the adjusted associations between their antibiotics prescribing practice score and knowledge and attitude scores, and identify barriers for rational prescription of antibiotics by GPs.

Methods

A cross-sectional self-administered survey was conducted among GPs. Multivariable linear regression was applied to analyze the data.

Results

Overall, 291 GPs participated in the study. Knowledge, attitude, and practice mean percent scores were 58.3%, 67.5%, and 63.0%, respectively. In the adjusted analysis, the practice percent score was significantly associated with the attitude percent score (β = 0.58; 95% CI: 0.41, 0.75; p &lt; 0.001), though the relation between the practice and knowledge scores was insignificant. The main barriers reported by GPs: lack of rapid diagnostic tests, high costs of laboratory tests, high costs of some antibiotics, and lack of guidelines.

Conclusions

Identified low knowledge, attitude, and practice mean percent scores suggest a need for improvements in these areas. Availability of rapid and inexpensive diagnostic tests, enforcement of prescriptions could potentially prevent the development of antibiotic resistance.

Key messages

Availability of rapid and inexpensive diagnostic tests, enforcement of prescriptions, and regulation of antibiotics’ prices could help to improve antibiotics prescribing practices of GPs. Low knowledge, attitude and practice levels regarding antibiotic resistance among GPs in polyclinics suggests a need for improvement in these areas.

Abstract 2992: Proteogenomic characterization of triple-negative breast cancer patient-derived xenografts reveals molecular correlates of differential chemotherapy response and potential therapeutic targets to overcome resistance

Background: Chemotherapy is essential for the management of patients with triple-negative breast cancer (TNBC). Identification of biomarkers that may indicate treatment efficacy will be critical to improve patient stratification prior to treatment. To elucidate molecular determinants underlying chemotherapy response, we conducted a proteogenomic study using TNBC patient-derived xenografts (PDXs) treated with chemotherapy.

Approach: 50 TNBC PDXs were treated with either docetaxel or carboplatin. Changes in tumor volume after 4 weeks from baseline were evaluated. Genomic, transcriptomic, and mass-spectrometry-based proteomic profiling were performed on baseline tumors prior to treatment to identify associations with chemotherapy response. Fisher's exact tests were used to test for significant enrichment of mutation and copy number events (p&lt;0.05). Gene Set Enrichment Analysis was performed for pathway analyses.

Results: At the DNA level, genomic aberrations in BRCA2 and BCL2 were enriched in carboplatin-responsive PDXs, while ARID1B aberrations were enriched in docetaxel-responsive PDXs. Gene-drug response correlations supported by both mRNA and protein-based measurements, but not mRNA or protein alone, for both carboplatin and docetaxel treatment in PDXs were associated with prognosis from basal and claudin-low human breast tumors in receipt of any chemotherapy from the METABRIC dataset. These data suggest that the combination of mRNA and protein data increased power to identify genes related to clinical outcome in TNBC. Some of the top genes overexpressed at both mRNA and protein levels in chemoresistant PDXs are targets of approved drugs, many of which have not been evaluated for their ability to augment response to taxane- or platinum-based chemotherapies. These genes are being investigated as therapeutic targets as well as markers of chemotherapy response. At the pathway level, both RNA and protein data associated models resistant to both agents with enhanced oxidative phosphorylation and translation regulation. Protein data further associated resistant models with elevated cytoplasmic ribosomal proteins. In contrast, both RNA and protein data associated tumors sensitive to both agents with genes involved in the E2F-Rb axis and cell cycle progression. Moreover, DNA mismatch repair and mRNA processing pathways were uniquely associated with carboplatin and docetaxel sensitivity, respectively, while amino acid metabolism and MAPK signaling pathways were uniquely associated with carboplatin and docetaxel resistance, respectively.

Conclusion: Taken together, proteogenomic analysis of PDX tumors identifies diverse genes and pathways associated with chemotherapy response and further suggests potential therapeutic opportunities in TNBC.

Citation Format: Jonathan T. Lei, Chen Huang, Ramakrishnan R. Srinivasan, Suhas Vasaikar, Lacey E. Dobrolecki, Alaina N. Lewis, Christina Sallas, Susan G. Hilsenbeck, C Kent Osborne, Mothaffar F. Rimawi, Matthew J. Ellis, Varduhi Petrosyan, Alexander B. Saltzman, Anna Malovannaya, Gerburg Wulf, Daniel C. Kraushaar, Tao Wang, Gloria V. Echeverria, Bing Zhang, Michael T. Lewis. Proteogenomic characterization of triple-negative breast cancer patient-derived xenografts reveals molecular correlates of differential chemotherapy response and potential therapeutic targets to overcome resistance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2992.

CTD: An information-theoretic algorithm to interpret sets of metabolomic and transcriptomic perturbations in the context of graphical models

We consider the following general family of algorithmic problems that arises in transcriptomics, metabolomics and other fields: given a weighted graph G and a subset of its nodes S, find subsets of S that show significant connectedness within G. A specific solution to this problem may be defined by devising a scoring function, the Maximum Clique problem being a classic example, where S includes all nodes in G and where the score is defined by the size of the largest subset of S fully connected within G. Major practical obstacles for the plethora of algorithms addressing this type of problem include computational efficiency and, particularly for more complex scores which take edge weights into account, the computational cost of permutation testing, a statistical procedure required to obtain a bound on the p-value for a connectedness score. To address these problems, we developed CTD, "Connect the Dots", a fast algorithm based on data compression that detects highly connected subsets within S. CTD provides information-theoretic upper bounds on p-values when S contains a small fraction of nodes in G without requiring computationally costly permutation testing. We apply the CTD algorithm to interpret multi-metabolite perturbations due to inborn errors of metabolism and multi-transcript perturbations associated with breast cancer in the context of disease-specific Gaussian Markov Random Field networks learned directly from respective molecular profiling data.

Addressing cancer prevention and control in Armenia: tobacco control and mHealth as key strategies

This paper focuses on the particular challenges in cancer prevention and control (CPC) in low- and middle-income countries (LMICs). In particular, this paper extrapolates challenges and opportunities in Armenia, which has the 2nd highest rate of cancer-related deaths in the world, the 11th highest smoking prevalence among men globally, and an evolving health system infrastructure for non-communicable disease (NCD) prevention and control, including CPC. Despite significant progress in enhancing research capacity in Armenia over the past decade, additional efforts are needed, particularly in CPC-related research. Key opportunities are to advance tobacco control and utilization of mHealth. Public health training programs remain insufficient in the area of CPC, and in-country research expertise regarding CPC and related areas (e.g., tobacco control, mHealth, policy) is limited, particularly given the need to address the diverse and complex determinants of onset, prevention, and management of cancer. Moreover, critical gaps in research dissemination and knowledge translation from evidence to policy and practice continue to exist. Thus, public health infrastructure must be enhanced, in-country CPC leaders across various relevant disciplines must be further developed and supported, and medical and public health training must more fully integrate CPC and research dissemination and translation to inform policy and practice.

Smoking cessation knowledge, attitude and practices among tuberculosis physicians: A qualitative study

INTRODUCTION

Smoking cessation interventions within tuberculosis (TB) care are feasible, effective and efficient for increasing smoking cessation rates. We aimed to assess TB physicians’ smoking cessation knowledge, attitude, and practices (KAP).

METHODS

We conducted a qualitative study with 21 TB physicians and utilized directed deductive content analysis with predefined knowledge, attitude, and practice categories. Physicians’ practice was analyzed using the ABC approach (Ask, Brief advice, and Cessation support).

RESULTS

Physicians acknowledged the importance of quitting for improved treatment outcomes and decreased risk of TB relapse. Physicians revealed presumed drug interactions, possible side effects of pharmacotherapy, and reluctance to take additional medications as challenges of smoking cessation interventions. Physicians asked about smoking behavior and provided a brief quitting advice to TB patients; however, implementation of cessation support was limited due to poor knowledge of evidence-based cessation methods and the absence of formal tobacco dependence treatment algorithms within TB care.

CONCLUSIONS

TB physicians’ KAP on smoking cessation was limited. Interventions targeting physicians’ knowledge and skills, and formalization of tobacco dependence treatment within TB care, are core for improving their smoking cessation practices in Armenia.

Prevalence and determinants of uncorrected refractive error among a socially vulnerable older adult population living in Armenia

OBJECTIVE

This study estimated the prevalence of uncorrected refractive error (URE) and its determinants in a socially vulnerable older population living in Armenia.

STUDY DESIGN

The study design used in the stidy is a cross-sectional study.

METHODS

A total of 485 people responded to a survey on sociodemographic characteristics, spectacle use, and ophthalmic services' use. All participants underwent a comprehensive ophthalmic examination including assessment of presenting and best-corrected visual acuity, measuring intraocular pressure and dilated eye fundus examination. Patients who had presenting visual acuity (<6/12) but improved ≥ one line with/without available spectacles after refraction in the better eye were considered to have URE. Descriptive statistics described the sample and estimated the prevalence of the URE in the population. Logistic regression models were used to evaluate its determinants.

RESULTS

The mean age of participants was 74.5 (7.27) years, ranging from 51 to 94 years. Women constituted the majority of participants (86%). The prevalence of URE in the better eye was 26%. In bivariate analysis, those who were older and who had less than 10 years of education had higher odds of URE than younger and more educated respondents. In multivariable analysis, only education remained associated with URE (OR = 3.71; 95% CI: 1.10-12.5). The rate of normal vision (≥6/12) improved from 58.9% to 81.5%, whereas the rate of visual impairment (<6/12) decreased from 41.1% to 18.5% after best correction in the better eye.

CONCLUSION

The prevalence of URE was high in this study population. The findings warrant the need for eye screening and provision of affordable spectacle correction to the target population in Armenia.

Do primary healthcare providers have the competency of providing adolescent-friendly health services?

Background

Investment in adolescents' health is one of the most rewarding efforts for meeting the Sustainable Development Goals. The national standard on state assured free-of-charge services defines the minimum requirements of adolescent-friendly healthcare services (AFHS) in primary healthcare facilities (PHCFs); however, services for adolescents are highly inconsistent in terms of quality and coordination. We aimed to assess the PHC providers' (PHPs) capacity to provide AFHS in PHC facilities in Armenia.

Methods

A qualitative cross-sectional study through in-depth interviews and focus-group discussions was conducted in two biggest cities of Armenia. Overall, six focus group discussions and 16 in-depth interviews were conducted with adolescents (18 and 19 years old), PHPs, managers of PHCFs, and experts in adolescent health. Eight PHC facilities were chosen for conducting observations. The WHO Global standards for quality health-care services for adolescents guided the deductive content analysis.

Results

PHPs' capacity to provide AFHS in assessed PHCFs was not satisfactory. PHPs did not know the specific age range of adolescence and the content of AFHS in the national standard. PHPs perceived friendliness of services as welcoming and good attitude. Facility managers and most PHPs did not participate in professional education activities to advance their expertise in adolescent health. Experts concluded that services provided to adolescents were not “friendly” and PHPs did not have appropriate competencies. However, PHPs' had the opposite opinion - they were confident in their knowledge and skills to work with adolescents. Adolescents complained that PHPs did not provide explanations for provided services and lacked appropriate communication skills.

Conclusions

The PHCFs have formal grounds to provide AFHS, however lack of appropriate competencies among PHPs and managers of PHCs hinder advancement of AFHS.

Key messages

Qualitative findings suggest that visited PHCFs fail to appropriately implement AFHS as guided by the national standard. Provision of AFHS can be promoted in PHCFs through strengthening PHPs' competencies via continuous professional development activities.

An assessment of the Armenian national midwifery curriculum as per international standards

Background

Literature suggests increasing evidence that incompetent midwifery education results in poor quality of care. The study compared and evaluated the level of compliance of the Armenian national criterion on midwifery with the global competency standards and developed recommendations for improvement.

Methods

The study team conducted a document review using a standardized checklist, which was adapted from the International Confederation of Midwives (ICM) core assessment tools. The document review explored if the main knowledge and skills/ability related elements of each ICM competency were separately covered by different modules of the national criterion using a scoring system with categories: not met, partially met, fully met and unspecified.

Results

Although the national criterion did not have specifically defined competencies, most of the elements required by the ICM were present as specific learning outcomes under different modules of the criterion. Midwifery program curriculum was described as intensive with unnecessarily heavy workload. Additionally, the document review reviled that most of the learning outcome defined in modules of the national criterion focused more on theoretical knowledge rather than practical skills and abilities. Overall, the ICM required competency in provision of care during pregnancy was the most comprehensively covered one in the national criterion, while the competency in facilitation of abortion related care was the lowest covered. National criterion did not highlight the importance of topics such as women's rights and health, principles of epidemiology, statistical methods of research, cultural, local and ethical beliefs.

Conclusions

The systematic comparison of the national criterion with internationally recognized essential competencies demonstrates significant gaps. The study team recommends revisions to the national criterion to make it competency based.

Key messages

Midwifery education criteria in Armenia did not reflect internationally accepted midwifery competency’s fundamental philosophy and values. Given the shortcomings of the current national midwifery education criterion, a comprehensive revision of the competencies of midwives in Armenia should be considered.

Patient-centered approaches applied in inpatient and outpatient TB services in Armenia

Background

Healthcare system performance indicators are common instruments measuring and facilitating quality improvement. The End-TB strategy urges provision of integrated patient-centered (PC) care for all forms of tuberculosis (TB). This study aimed to assess and compare quality of inpatient and outpatient TB services using international standards on specific PC indicators to identify potential targets for improvement.

Methods

Joint Commission International (JCI) accreditation standards, adapted to local needs and context, were used as a basic instrument for qualitative and quantitative data collection. We utilized Patient and Family Right (PFR) and Patient and Family Education (PFE) 15 standards with 49 measurable elements as PC indicators for the nationwide assessment of TB services. A scoring system and a scaling approach were used to convert all-source-data and present the overall performance of services.

Results

We reviewed and analyzed data from 10 legal documents, 34 medical records and 155 interviews and focus group discussions with TB healthcare providers, patients and family members from inpatient and outpatient TB services to define the degree of compliance of their practices and treatment experiences to JCI standards. Outpatient TB services met the PFR and PFE standards at the 51%-level receiving a grading of partially performed and requiring improvements. The inpatient services met the PFR and PFE standards at 39%- and 26%-level respectively, receiving a grading of minimally performed for the JCI standards, showing statistically significantly less patient centeredness compared to the outpatient services (p = 0.007, CI 0.234; 0.4234), and requiring major improvements.

Conclusions

Strengthening interventions towards patient-centeredness are essential in both inpatient and outpatient services, but Armenia needs to put more emphasis on inpatient care to bridge the gap between the existing and recommended practices.

Barriers to reproductive health services utilization among adolescents

Background

Adolescents' access to quality reproductive health services is crucial for their psychosocial and physical wellbeing. Yet, adolescents encounter various barriers while utilizing reproductive health services, globally. Adolescent-friendly health services (AFHS) is an evidence-based intervention to meet the reproductive health needs inclusively of all adolescents. The study aimed to explore adolescents' experiences while seeking reproductive health services in primary healthcare facilities (PHCF) in Armenia.

Methods

We conducted a qualitative cross-sectional study using in-depth interviews, focus group discussions and observations of PHCFs. The study participants included adolescents (aged 18-19 years) (n = 17), PHC providers (PHP) (n = 29), managers of PHCFs (n = 7) and experts in the field of adolescent health (n = 5) from the two largest cities in Armenia. The Global standards for quality healthcare services for adolescents guided the instrument development process and deductive content analysis.

Results

Barriers to the utilization of reproductive health services by adolescents at PHCFs were related to various personal, cultural, and social factors. PHPs and experts blamed adolescents' insufficient knowledge of reproductive health and related services for being a major barrier. However, adolescents' reported a different set of important barriers to reproductive health services: PHPs' judgmental attitude, lack of efforts to protect privacy and confidentiality (due to lack of PHP competencies to provide AFHS and inadequate PHCF infrastructure), negative public opinion and lack of community support.

Conclusions

The study findings shed light on different perspectives related to various challenges adolescents come across in PHCFs. Addressing identified barriers have the potential of positively influencing adolescents' experiences while utilizing reproductive health services in PHCFs.

Key messages

Adolescents’ insufficient knowledge, PHPs’ judgmental attitude, lack of privacy and confidentiality, and negative public opinion are among the main barriers to the reproductive health services. Further enforcement of adolescent-friendly health services in primary healthcare facilities is needed to ensure accessibility of quality reproductive health services for all adolescents.

Health equity and COVID-19: global perspectives

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

People-centred care versus clinic-based DOT for continuation phase TB treatment in Armenia: a cluster randomized trial

Background

WHO’s directly observed therapy (DOT) strategy for tuberculosis (TB) treatment depends upon a well–organized healthcare system. This study sought to evaluate the effectiveness of self-administered drug intake supported by a family member versus in-clinic DOT.

Methods

This open–label, nationally-representative stratified cluster randomized controlled non–inferiority trial with two parallel equal arms involved drug–susceptible pulmonary TB patients in the continuation treatment phase. We randomly assigned outpatient–TB–centres (52 clusters) to intervention and control arms. The intervention included an educational/counseling session to enhance treatment adherence; weekly visits to outpatient–TB–centres to receive medication, and daily SMS medication reminders and phone calls to track adherence and record side effects. Controls followed clinical DOT at Outpatient–TB–centres. Both groups participated in baseline and 4–5 months follow–up surveys. The trial’s non–inferiority comparisons include: treatment success as the clinical (primary) outcome and medication adherence (self–reported), knowledge, depressive symptoms, stigma, quality of life, and social support as non–clinical (secondary) outcomes.

Results

Per–protocol analysis showed that the intervention (n = 187) and control (n = 198) arms achieved successful treatment outcome of 92.0 and 92.9%, respectively, indicating that the treatment success in the intervention group was non–inferior to DOT. Knowledge, depression, stigma, quality of life, and social support also showed non–inferiority, demonstrating substantial improvement over time for knowledge (change in the intervention = 1.05: 95%CL (0.49, 1.60); change in the control = 1.09: 95%CL (0.56, 1.64)), depression score (change in the intervention = − 3.56: 95%CL (− 4.99, − 2.13); change in the control = − 1.88: 95% CL (− 3.26, − 0.49)) and quality of life (change in the intervention = 5.01: 95%CL (− 0.64, 10.66); change in the control = 7.29: 95%CL (1.77, 12.81)). The intervention resulted in improved treatment adherence.

Conclusions

This socially empowering alternative strategy might be a preferable alternative to DOT available to patients in Armenia and in other countries. Further research evaluating cost effectiveness of the intervention and generalizability of the results is warranted.

Trial registration

Clinicaltrials.gov: NCT02082340, March 10, 2014.

Quality of Inpatient Tuberculosis Health Care in High-Burden Resource-Limited Settings: Protocol for a Comprehensive Mixed Methods Assessment Study

Background

The quality of care for tuberculosis (TB) is deficient in high-burden countries and urgently needs improvement. However, comprehensively identifying the required improvements is challenging. Providing high-quality TB care is an important step toward improving patients’ quality of life and decreasing TB morbidity and mortality. Effective tools for assessing the quality of TB services using international standards and guidelines can identify existing gaps in services and inform improvements to ensure high-quality inpatient TB services.

Objective

This study aimed to develop evaluation instruments for defining the quality of provision of TB services.

Methods

To assess quality of services in the largest TB hospital in Armenia, we developed instruments based on the Joint Commission International Accreditation Standards for Hospitals, International Standards for TB Care, TB Laboratories Bio-Safety Standards, and the World Health Organization framework for conducting TB program reviews. A mixed methods approach was utilized, triangulating quantitative (checklists) and qualitative (in-depth interviews) results. A scoring system and strengths, weaknesses, opportunities, and treats analysis was applied to detail results for each of the 122 standards assessed. A scaling approach was used to present overall performances of inpatient services for eight patient-centered functions and five organization management functions.

Results

Overall, 40 in-depth interviews and 91 checklists (21 observations, 16 policy papers, 20 staff qualification documents, and 34 medical records) were developed, utilized, and analyzed to explore practices of health care professionals, assess inpatient treatment experience of patients and their family members, evaluate facility environmental conditions, and define the degree of compliance to standards.

Conclusions

The effective comprehensive evaluation instruments and methods developed in this study for quality of inpatient TB services support the implementation of similar effective assessments in other countries. It may also become a platform to develop similar approaches for assessing ambulatory TB services in resource-limited countries.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13903

An Evaluation of Midwifery Education System in Armenia

Background

Competencies, knowledge and skills of health care professionals largely depend upon their education. Well-educated and competent midwives can improve women’s and infants’ health related outcomes. The current study evaluated the compliance of the current midwifery education system in Armenia with the global International Confederation of Midwives (ICM) standards.

Methods

The research team used a qualitative cross-sectional study design with deductive content analysis. Through purposeful sampling we recruited five nursing colleges providing midwifery education in Armenia; two in the capital city and three in different regions. The study population included midwifery students, faculty and administrative representatives of the selected colleges (n = 56). During fall 2018, we conducted observations of midwifery education textbooks and equipment and in-depth interviews and focus group discussions with participants.

Results

Despite widely used interactive teaching methodology and more than 60% of teaching time allocated for practical learning, students graduated from the program without obtaining essential competencies. Lack of teaching resources, especially in the regional colleges, and lack of quality clinical learning opportunities in hospitals were barriers for students to develop essential practical skills.

Conclusions

The study recommends the governmental bodies to ensure provision of equity-based distribution of finances and tangible resources between the capital city and regional nursing colleges. The practical component of midwifery education programs need substantial enhancement.

Key messages

The lack of teaching resources and access to hospital sites were barriers to obtaining essential competencies for midwifery students. In order to develop a sufficient professional skillset, midwifery education programs should arrange comprehensive and structured practical experience for students.

Learning to assist smokers through encounters with standardized patients: An innovative training for physicians in an Eastern European country

Objectives

A lack of physician training is a major obstacle for effective tobacco dependence treatment. This study assessed the feasibility of an active learning training program and its effects on smoking cessation counselling skills of medical residents in Armenia, an Eastern European country with high smoking prevalence.

Study design

The study used a pre-post assessment of smoking cessation counselling activities and a course evaluation survey to assess the feasibility of the intervention in a different environment.

Methods

We adapted an active learning training model developed in Switzerland. Residents were trained in Yerevan, Armenia, using video-taped counselling sessions, role plays, standardized patients (actors), group discussions and immediate feedback. The training evaluation was done using a semi-structured anonymous questionnaire. The study assessed the physicians’ self-reported smoking cessation counselling activities before and 6 months after the training. A non-parametric Mann-Whitney test was used to assess pre-post differences in physicians’ counselling skills measured on ordinal scale.

Results

Of the 37 residents trained, 75% were female, 89% aged 20–29 years and 83% were never-smokers. Twenty-eight trainees (76%) returned the course evaluation survey and 32 (86%) answered a questionnaire on skills self-assessment at 6 months follow-up. The majority agreed the course was successful in achieving its learning objectives (64%-96%) and increased their confidence in assisting their patients to quit (74%). After 6 months, the physicians were more likely than at baseline to adhere to evidence-based counselling strategies, including assessing the smoking status and dependence and matching the advice to the patient motivation. The training did not, however, improve the prescription of tobacco dependence medications.

Conclusions

Six months after the training, several self-reported smoking cessation counselling activities had significantly improved compared to baseline. This training model is acceptable for medical residents in Yerevan, Armenia and offers a promising approach in addressing the lack of physician counselling skills in similar settings and populations.

Diabetes mellitus and treatment outcomes of pulmonary tuberculosis: a cohort study

OBJECTIVES

This study aimed to investigate the impact of diabetes on the treatment outcomes among pulmonary TB patients in Yerevan, Armenia.

METHODS

We utilized a cohort study design that included TB patients with diabetes and TB patients without diabetes. The data collection was conducted in the National Tuberculosis Control Center, eight tuberculosis outpatient centers and the 'Prisoners' Hospital' in Yerevan, Armenia. Data were collected from an existing national TB database and patients medical records. Multivariable logistic regressions were conducted to construct the final model and test the associations.

RESULTS

The final sample included 621 patients 5.8% of whom had diabetes. The odds of having treatment failure was 8.99 times higher among TB patients with diabetes (95% confidence interval 2.51-32.23) compared to TB patients without diabetes after adjusting for weight and sputum smear status.

CONCLUSIONS

Diabetes comorbidity had a negative effect on TB treatment outcomes. Countries with a high burden of both TB and diabetes need to develop mechanisms for active screening for diabetes among patients with TB and address their treatment needs carefully.

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study

Background

Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.

Methods

This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.

Results

The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government’s reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers’ concern.

Conclusion

The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.