A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England

OBJECTIVES

To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022).

METHODS

A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted.

FINDINGS

Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals.

CONCLUSIONS

Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.

A pandemic of metrics

The COVID-19 pandemic prompted critical attention to the performative power of metrics. We suggest that the existential capacities of metrics as a means of pandemic living warrant further consideration. We describe how the COVID-19 pandemic that came into existence as a public health and political event could only have occurred because of the anticipatory metrical practices that were used to transform SARS-COV-2 into a matter of global health concern. By exploring the affective potencies of COVID-19 metrics we show their abilities to engage the public in ways that cannot be contained; in detailing the narrative arcs created through metrics we show their opportunities, misdirections, and erasures. A pandemic way of life persists: a pandemic of metrics.

Is qualitative social research in global health fulfilling its potential?: a systematic evidence mapping of research on point-of-care testing in low- and middle-income contexts

BACKGROUND

Qualitative social research has made valuable contributions to understanding technology-based interventions in global health. However, we have little evidence of who is carrying out this research, where, how, for what purpose, or the overall scope of this body of work. To address these questions, we undertook a systematic evidence mapping of one area of technology-focused research in global health, related to the development, deployment and use of point-of-care tests (POCTs) for low-and middle-income countries (LMICs).

METHODS

We conducted an exhaustive search to identify papers reporting on primary qualitative studies that explore the development, deployment, and use of POCTs in LMICs and screened results to identify studies meeting the inclusion criteria. Data were extracted from included studies and descriptive analyses were conducted.

RESULTS

One hundred thirty-eight studies met our inclusion criteria, with numbers increasing year by year. Funding of studies was primarily credited to high income country (HIC)-based institutions (95%) and 64% of first authors were affiliated with HIC-based institutions. Study sites, in contrast, were concentrated in a small number of LMICs. Relatively few studies examined social phenomena related to POCTs that take place in HICs. Seventy-one percent of papers reported on studies conducted within the context of a trial or intervention. Eighty percent reported on studies considering POCTs for HIV and/or malaria. Studies overwhelmingly reported on POCT use (91%) within primary-level health facilities (60%) or in hospitals (30%) and explored the perspectives of the health workforce (70%).

CONCLUSIONS

A reflexive approach to the role, status, and contribution of qualitative and social science research is crucial to identifying the contributions it can make to the production of global health knowledge and understanding the roles technology can play in achieving global health goals. The body of qualitative social research on POCTs for LMICs is highly concentrated in scope, overwhelmingly focuses on testing in the context of a narrow number of donor-supported initiatives and is driven by HIC resources and expertise. To optimise the full potential of qualitative social research requires the promotion of open and just research ecosystems that broaden the scope of inquiry beyond established public health paradigms and build social science capacity in LMICs.

Acute fasciolosis in an alpaca: a case report

Background

The popularity of new world camelids, particularly alpacas, is growing rapidly in Ireland, presenting a clinical challenge to veterinary practitioners who may not have worked with these species previously. To the authors’ knowledge, the clinical course of a case of acute fasciolosis in an alpaca has not previously been reported, and fasciolosis has not been reported at all in alpacas in Ireland, making this case report a valuable addition to the current literature.

Case presentation

A three-year-old male castrated huacaya alpaca was admitted to UCD Veterinary Hospital with a two-day history of colic and tenesmus. He had been treated with albendazole, dexamethasone and potentiated amoxycillin by the referring veterinary practitioner with no response. On initial clinical exam, sensitivity to abdominal palpation was the only abnormality. However, the alpaca proceeded to show abnormal lying positions, tenesmus and reduced faecal output over the next 24 h. A general blood panel demonstrated moderate anaemia, marked hyperglobulinaemia and moderately increased hepatocellular and hepatobiliary enzyme activity. Abdominal radiography revealed enlargement of the first forestomach compartment without evidence of gastrointestinal obstruction or peritonitis. An abdominal ultrasound exam revealed an elongated, heterogenous mass in the caudoventral abdomen that appeared to be contiguous with the liver. FNA of this mass revealed that it was in fact a liver lobe with biliary stasis and inflammation. Faecal sedimentation demonstrated Fasciola hepatica eggs. In spite of treatment with triclabendazole and supportive treatment including blood transfusion, the alpaca’s condition continued to deteriorate and he was euthanised. On post-mortem exam, acute fasciolosis was diagnosed.

Conclusions

The clinical presentation and course of a case of acute fasciolosis in an individual alpaca is described, including the results of a range of diagnostic tests that were carried out. The final diagnosis is supported by a description of post-mortem findings. This information will serve as a resource for veterinary practitioners involved in the diagnosis and treatment of similar cases.

Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery.

METHODS

A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance.

RESULTS

The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = -2.22; CI, -2.77 to -1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65-0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = -0.98; CI, -1.37 to - 0.58; p < 0.0001).

CONCLUSION

Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes.

Opening up ‘fever’, closing down medicines

Rising concerns about antimicrobial resistance have sparked a renewed push to rationalise and ration the use of medicines. This article explores the case of the Integrated Management of Childhood Illness (IMCI) guideline, a periodically updated ‘global’ algorithm that shapes and normalises the centrality of medicines to care in low- and middle-income countries and, increasingly, the imperative to ration them. Using ‘classification work’ as analytic frame, we firstly consider the IMCI algorithm as a blueprint for global health that classifies illnesses, patients, and care in particular ways relative to available medicines. Zooming in on this blueprint, we then offer a classificatory reading of ‘fever’ over time, tracing ‘nonmalarial fever’ from being malaria’s residual ‘other’ category to becoming increasingly legible through attention to diagnostics and antibiotic (over)use. Our reading suggests that an apparent refinement of the ‘fever’ category may concurrently entail the closing down of medicine options. This raises the possibility that an increasingly high-tech but ‘empty’ form of pharmaceuticalised care is being incidentally worked into the infrastructure of weak health systems.

P11.49 An electrophysiological signature of glioma infiltration in the ex vivo human brain

BACKGROUND

Invading glioma cells affect the physiological function of the peritumoural cortex. This may manifest clinically as seizures. Here, we investigate the effect the invading glioma cells on the electrophysiological signalling of the peritumoral cortex using living human brain tissue donated by people having a craniotomy for glioma resection (REC approval, 18/SW/002).

MATERIAL AND METHODS

The brain tissue was cut into thin slices, which preserved the architecture of the glioma and the adjacent healthy brain. The brain slices were incubated in 5-aminolevulinic acid to make the glioma cells fluorescent. We observed 5-ALA induced fluorescence in both low-grade and high-grade gliomas. This enabled us to make electrophysiological recordings of brain activity across the boundary between glioma and brain.

RESULTS

We recorded from brain slices of 5 participants with glioblastoma and 4 participants with oligodendroglioma (WHO grade II - III). Spontaneous “seizure-like” discharges were recorded in brain slices from 5/8 participants (3 GBM, 2 oligodendroglioma) who reported seizures and from one participant (GBM) who had not had any clinical seizures. Further analysis of the electrical discharges revealed that they could be subdivided into two distinct types based on the major frequencies in the discharge.

CONCLUSION

We concluded that human brain slices from people with either a low-grade or a high-grade glioma can generate spontaneous seizure-like discharges. This electrophysiological signature will be compared to infiltration and grade of the glioma cells in the donated sample. The living human brain tissue preparation gives us a platform to study the mechanisms of tumour-associated seizures and how abnormal neural activity affects glioma growth.

Quick fix for care, productivity, hygiene and inequality: reframing the entrenched problem of antibiotic overuse

Antimicrobial resistance (AMR) is a major challenge of our time. A key global objective is to reduce antibiotic use (ABU), in order to reduce resistance caused by antimicrobial pressure. This is often set as a 'behaviour change' issue, locating intervention efforts in the knowledge and attitudes of individual prescribers and users of medicines. Such approaches have had limited impact and fall short of addressing wider drivers of antibiotic use. To address the magnitude of antibiotic overuse requires a wider lens to view our relationships with these medicines. This article draws on ethnographic research from East Africa to answer the question of what roles antibiotics play beyond their immediate curative effects. We carried out interviews, participant observation and documentary analysis over a decade in northeast Tanzania and eastern and central Uganda. Our findings suggest that antibiotics have become a 'quick fix' in our modern societies. They are a quick fix for care in fractured health systems; a quick fix for productivity at local and global scales, for humans, animals and crops; a quick fix for hygiene in settings of minimised resources; and a quick fix for inequality in landscapes scarred by political and economic violence. Conceptualising antibiotic use as a 'quick fix' infrastructure shifts attention to the structural dimensions of AMR and antimicrobial use (AMU) and raises our line of sight into the longer term, generating more systemic solutions that have greater chance of achieving equitable impact.

Development of a perceived exertion scale for dogs using selected physiologic parameters

OBJECTIVE

To develop a perceived exertion scale for dogs exercising on a treadmill and to assess intra- and inter-observer variability.

MATERIALS AND METHODS

Fifteen healthy client-owned dogs participated in paired exercise trials. Measurements of lactate, glucose, heart rate, temperature, respiratory rate and regional tissue oximetry were obtained before, during and after exercise. Perceived exertion scale scores were recorded during exercise and using video recordings to evaluate inter-observer variability. Correlations were evaluated using the Spearman's non-parametric method.

RESULTS

Thirteen dogs completed both trials. Dogs walked or trotted on the treadmill with an average perceived exertion score of 2 in both trials. Holter heart rate was positively correlated with perceived exertion scale scores from all observers for both trials. In trial 1, plasma glucose decreased in association with increase in perceived exertion and, in trial 2, cutaneous oximetry decreased, respiratory rate increased and temperature increased with increases on the perceived exertion scale. Inter-observer perceived exertion scale scores were positively correlated in both trials. There was no intra-observer variability between trials.

CLINICAL SIGNIFICANCE

The perceived exertion scale correlated with the measured physiologic parameters in dogs exercising at mild to moderate intensity. The perceived exertion scale was consistent and repeatable but larger study numbers and further validation are needed before it can be widely applied.

Knowing antmicrobial resistance in practice: a multi-country qualitative study with human and animal healthcare professionals

Background: Antimicrobial resistance (AMR) is a growing global problem. Raising awareness is central to global and national action plans to address AMR in human and livestock sectors. Evidence on the best ways to reduce antibiotic use, and the impact of awareness raising activities is mixed. This paucity of evidence is acute in Low-Middle-Income Country (LMIC) settings, where healthcare professionals who prescribe and dispense antimicrobial medicines are often assumed to have limited awareness of AMR and limited knowledge of the optimum use of antimicrobials. Objectives: This research aimed to explore AMR awareness among human and animal healthcare professionals and the contextual issues influencing the relationship between awareness and practices of antimicrobial prescribing and dispensing across different LMIC settings. Methods: Qualitative interviews and field observations were undertaken in seven study sites in Ethiopia, India, Nigeria, the Philippines, Sierra Leone and Vietnam. Data included transcripts from interviews with 244 purposively sampled healthcare professionals, analysed for cross-cutting themes. Results: AMR awareness was high among human and animal healthcare professionals. This awareness of AMR did not translate into reduced prescribing and dispensing; rather, it linked to the ready use of next-line antibiotics. Contextual factors that influenced prescribing and dispensing included antibiotic accessibility and affordability; lack of local antibiotic sensitivity information; concerns over hygiene and sanitation; and interaction with medical representatives. Conclusions: The high awareness of AMR in our study populations did not translate into reduced antibiotic prescribing. Contextual factors such as improved infrastructure, information and regulation seem essential for reducing reliance on antibiotics.

The Anatomical Society's core anatomy syllabus for undergraduate nursing

The Anatomical Society has developed a series of learning outcomes in consultation with nursing educators delivering anatomical content to undergraduate (preregistration) nursing students. A Delphi panel methodology was adopted to select experts within the field that would recommend core anatomical content in undergraduate nursing programmes throughout the UK. Using the Anatomical Society's Core Gross Anatomy Syllabus for Medical Students as a foundation, a modified Delphi technique was used to develop discipline-specific outcomes to nursing graduates. The Delphi panel consisted of 48 individuals (n = 48) with a minimum of 3 years' experience teaching anatomy to nursing students, representing a broad spectrum of UK Higher Education Institutions. The output from this study was 64 nursing specific learning outcomes in anatomy that are applicable to all undergraduate (preregistration) programmes in the UK. The new core anatomy syllabus for Undergraduate Nursing offers a basic anatomical framework upon which nurse educators, clinical mentors and nursing students can underpin their clinical practice and knowledge. The learning outcomes presented may be used to develop anatomy teaching within an integrated nursing curriculum.

Strategies for developing sustainable health research capacity in low and middle-income countries: a prospective, qualitative study investigating the barriers and enablers to locally led clinical trial conduct in Ethiopia, Cameroon and Sri Lanka

OBJECTIVES

In 2013, the WHO stated that unless low-income and middle-income countries (LMICs) become producers of research, health goals would be hard to achieve. Among the capacities required to build a local evidence base, ability to conduct clinical trials is important. There is no evidence-based guidance for the best ways to develop locally led trial capacity. This research aims to identify the barriers and enablers to locally led clinical trial conduct in LMICs and determine strategies for their sustainable development.

DESIGN

Prospective, multiple case study design consisting of interviews (n=34), focus group discussions (n=13) and process mapping exercises (n=10).

SETTING

Case studies took place in Ethiopia (2011), Cameroon (2012) and Sri Lanka (2013).

PARTICIPANTS

Local health researchers with previous experiences of clinical trials or stakeholders with an interest in trials were purposively selected through registration searches and snowball sampling (n=100).

PRIMARY AND SECONDARY OUTCOME MEASURES

Discussion notes and transcripts were analysed using thematic coding analysis. Key themes and mechanisms were identified.

RESULTS

Institutions and individuals were variably successful at conducting trials, but there were strong commonalities in the barriers and enablers across all levels and functions of the research systems. Transferable mechanisms were summarised into the necessary conditions for trial undertaking, which included: awareness of research, motivation, knowledge and technical skills, leadership capabilities, forming collaborations, inclusive trial operations, policy relevance and uptake and macro and institutional strengthening.

CONCLUSIONS

Barriers and enablers to locally led trial undertaking exist at all levels and functions of LMIC research systems. Establishing the necessary conditions to facilitate this research will require multiple, coordinated interventions that seek to resolve them in a systemic manner. The strategies presented in the discussion provide an evidence-based framework for a self-sustaining capacity development approach. This represents an important contribution to the literature that will be relevant for research funders, users and producers.

Health research capacity development in low and middle income countries: reality or rhetoric? A systematic meta-narrative review of the qualitative literature

OBJECTIVES

Locally led health research in low and middle income countries (LMICs) is critical for overcoming global health challenges. Yet, despite over 25 years of international efforts, health research capacity in LMICs remains insufficient and development attempts continue to be fragmented. The aim of this systematic review is to identify and critically examine the main approaches and trends in health research capacity development and consolidate key thinking to identify a more coherent approach.

METHODS

This review includes academic and grey literature published between January 2000 and July 2013. Using a predetermined search strategy, we systematically searched PubMed, hand-searched Google Scholar and checked reference lists. This process yielded 1668 papers. 240 papers were selected based on a priori criteria. A modified version of meta-narrative synthesis was used to analyse the papers.

RESULTS

3 key narratives were identified: the effect of power relations on capacity development; demand for stronger links between research, policy and practice and the importance of a systems approach. Capacity development was delivered through 4 main modalities: vertical research projects, centres of excellence, North-South partnerships and networks; all were controversial, and each had their strengths and weaknesses. A plurality of development strategies was employed to address specific barriers to health research. However, lack of empirical research and monitoring and evaluation meant that their effectiveness was unclear and learning was weak.

CONCLUSIONS

There has been steady progress in LMIC health research capacity, but major barriers to research persist and more empirical evidence on development strategies is required. Despite an evolution in development thinking, international actors continue to use outdated development models that are recognised as ineffective. To realise newer development thinking, research capacity outcomes need to be equally valued as research outputs. While some development actors are now adopting this dedicated capacity development approach, they are in the minority.

Glaucoma, "the silent thief of sight": patients' perspectives and health seeking behaviour in Bauchi, northern Nigeria

BACKGROUND

In Nigeria, glaucoma has a high prevalence and is the second cause of blindness among adults after cataract. People with glaucoma frequently present very late with advanced disease, and acceptance of and adherence to treatment is low. The purpose of the study was to explore how patients' understand and respond to glaucoma in order develop an intervention to improve adherence to treatment.

METHOD

Hospital based qualitative study. Six focus group discussions were held with patients with advanced disease and who had either undergone glaucoma surgery, were receiving medical treatment, or had neither surgery nor medical treatment. Two traditional healers who treat eye conditions were interviewed. Audio files were transcribed, translated into English and recurring themes coded and categorized as the impact of vision loss, and understandings of the disease and its management.

RESULTS

Visual loss impacted significantly on the lives of people with glaucoma in many ways. Many heard the term "glaucoma" for the first time during the study. Local terms to describe the symptoms included Hawan jinin ido ("hypertension of the eye"). Patients sought treatment in pharmacies, or with traditional healers who had different interpretations of glaucoma and its treatment to biomedical understandings. Cost and forgetfulness were the main reasons for low adherence to treatment while fear was a reason for not accepting surgery. Lack of money and negative staff attitudes were reasons for low follow up.

CONCLUSION

Halting the progression of glaucoma is possible with treatment but the condition will remain a "silent thief of sight" in West Africa unless awareness, uptake of services and adherence to treatment improve. Understanding how glaucoma is locally conceptualised, lived with and responded to by patients is essential to aid the design of interventions to prevent glaucoma blindness in Africa. Findings have been used to adapt a motivational interviewing intervention, which is being evaluated in a clinical trial.

Bringing the state into the clinic? Incorporating the rapid diagnostic test for malaria into routine practice in Tanzanian primary healthcare facilities

The roles that rapid, point-of-care tests will play in healthcare in low-income settings are likely to expand over the coming years. Yet, very little is known about how they are incorporated into practice, and what it means to use and rely upon them. This paper focuses on the rapid diagnostic test for malaria (mRDT), examining its introduction into low-level public health facilities in Tanzania within an intervention to improve the targeting of costly malaria medication. We interviewed 26 health workers to explore how a participatory training programme, mobile phone messages, posters and leaflets shaped the use and interpretation of the test. Drawing on notions of biopolitics, this paper examines how technologies of the self and mechanisms of surveillance bolstered the role mRDT in clinical decision-making. It shows how the significance of the test interacted with local knowledge, the availability of other medication, and local understandings of good clinical practice. Our findings suggest that in a context in which care is reduced to the provision of medicines, strict adherence to mRDT results may be underpinned by increasing the use of other pharmaceuticals or may leave health workers with patients for whom they are unable to provide care.

A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria

BACKGROUND

Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking. The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria (mRDTs) in registered drug shops in Uganda, with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy (ACT) in patients seeking treatment for fever in drug shops.

METHODS

A cluster-randomized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district, central Uganda. Ten clusters were randomly allocated to the intervention (diagnostic confirmation of malaria by mRDT followed by ACT) and ten clusters to the control arm (presumptive treatment of fevers with ACT). Treatment decisions by providers were validated by microscopy on a reference blood slide collected at the time of consultation. The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as: malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate, and patients with no malaria parasites not given ACT.

FINDINGS

A total of 15,517 eligible patients (8672 intervention and 6845 control) received treatment for fever between January-December 2011. The proportion of febrile patients who received appropriate ACT treatment was 72·9% versus 33·7% in the control arm; a difference of 36·1% (95% CI: 21·3 - 50·9), p<0·001. The majority of patients with fever in the intervention arm accepted to purchase an mRDT (97·8%), of whom 58·5% tested mRDT-positive. Drug shop vendors adhered to the mRDT results, reducing over-treatment of malaria by 72·6% (95% CI: 46·7- 98·4), p<0·001) compared to drug shop vendors using presumptive diagnosis (control arm).

CONCLUSION

Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01194557.

'It puts life in us and we feel big': shifts in the local health care system during the introduction of rapid diagnostic tests for malaria into drug shops in Uganda

This paper is an analysis of the social interaction between drug sellers, their clients and local health care workers within a medical trial that introduced rapid diagnostic tests for malaria into private sector drug shops in Mukono District, Uganda. It locates the introduction of a new technology to test blood and a system of referral within the context of local concerns about the choice and evaluation of treatment; and the socially legitimated statuses, roles and hierarchies within the local health care system. Based on the multi-layered interpretation of 21 focus group discussions, we describe three key aspects of the trial central to local interpretation: openly testing blood, supervisory visits to drug shops and a new referral form. Each had the potential to shift drug shop vendors from outsider to insider of the formal health service. The responses of the different groups of participants reflect their situation within the health care system. The clients and patients welcomed the local availability of new diagnostic technology and the apparent involvement of the government in securing good quality health services for them from providers with often uncertain credentials. The drug shop vendors welcomed the authorization to openly test blood, enabling the demonstration of a new skill and newfound legitimacy as a health worker rather than simple drug seller. Formal sector health workers were less enthusiastic about the trial, raising concerns about professional hierarchies and the maintenance of a boundary around the formal health service to ensure the exclusion of those they considered untrained, unprofessional and untrustworthy personnel.

Post-operative 3-dimensional contrast-enhanced ultrasound (CEUS) versus Tc99m-DTPA in the detection of post-surgical perfusion defects in kidney transplants - preliminary findings

PURPOSE

2800 renal transplants are carried out annually in the UK and it is standard practice to perform a Tc-DTPA renogram examination after surgery to check perfusion. This provides some functional information but suffers from low spatial resolution, is lengthy, immobile and costly and uses ionizing radiation. We surmised that contrast-enhanced ultrasound (CEUS) would provide an accurate alternative with increased speed, resolution (temporal and spatial), cost efficiency and safety.

MATERIALS AND METHODS

97 renal transplant patients underwent both Tc-DTPA and CEUS after surgery to assess the perfusion of the graft. Tc-DTPA was performed in the nuclear medicine department with at least 10 minutes of continuous screening and a standard dose of 150 mBq Tc-DTPA. CEUS consisted of I. V. 2.4 ml Sonovue contrast agent, 60 seconds continuous capture and a 3 D acquisition of the organ. 3 D CEUS was assessed using QLab analysis software.

RESULTS

Tc-DTPA detected 9 perfusion defects of varying size. CEUS detected all these defects plus 14 further defects (0.2 - 17 % of total renal volume) not detected on DTPA. These results demonstrate a statistically significant divergence (p < 0.0001). Retrospective clinical correlation showed ligated polar arteries in 8 of these 14 cases.

CONCLUSION

CEUS will detect perfusion defects seen with Tc-DTPA and due to increased spatial and temporal resolution and multiple scanning angles, will detect further perfusion defects not seen on Tc-DTPA. 3 D CEUS is useful in the quantification of perfusion defects. CEUS is an accurate examination for detecting renal transplant perfusion defects and will detect significantly more defects than DTPA.

Designing and implementing interventions to change clinicians' practice in the management of uncomplicated malaria: lessons from Cameroon

Background

Effective case management of uncomplicated malaria is a fundamental pillar of malaria control. Little is known about the various steps in designing interventions to accompany the roll out of rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). This study documents the process of designing and implementing interventions to change clinicians’ practice in the management of uncomplicated malaria.

Methods

A literature review combined with formative quantitative and qualitative research were carried out to determine patterns of malaria diagnosis and treatment and to understand how malaria and its treatment are enacted by clinicians. These findings were used, alongside a comprehensive review of previous interventions, to identify possible strategies for changing the behaviour of clinicians when diagnosing and treating uncomplicated malaria. These strategies were discussed with ministry of health representatives and other stakeholders. Two intervention packages - a basic and an enhanced training were outlined, together with logic model to show how each was hypothesized to increase testing for malaria, improve adherence to test results and increase appropriate use of ACT. The basic training targeted clinicians’ knowledge of malaria diagnosis, rapid diagnostic testing and malaria treatment. The enhanced training included additional modules on adapting to change, professionalism and communicating effectively. Modules were delivered using small-group work, card games, drama and role play. Interventions were piloted, adapted and trainers were trained before final implementation.

Results

Ninety-six clinicians from 37 health facilities in Bamenda and Yaounde sites attended either 1-day basic or 3-day enhanced training. The trained clinicians then trained 632 of their peers at their health facilities. Evaluation of the training revealed that 68% of participants receiving the basic and 92% of those receiving the enhanced training strongly agreed that it is not appropriate to prescribe anti-malarials to a patient if they have a negative RDT result.

Conclusion

Formative research was an important first step, and it was valuable to engage stakeholders early in the process. A logic model and literature reviews were useful to identify key elements and mechanisms for behaviour change intervention. An iterative process with feedback loops allowed appropriate development and implementation of the intervention.

Trial registration

ClinicalTrials.gov: NCT01350752.

Understanding the investigators: a qualitative study investigating the barriers and enablers to the implementation of local investigator-initiated clinical trials in Ethiopia

OBJECTIVES

Clinical trials provide 'gold standard' evidence for policy, but insufficient locally relevant trials are conducted in low-income and middle-income countries. Local investigator-initiated trials could generate highly relevant data for national governments, but information is lacking on how to facilitate them. We aimed to identify barriers and enablers to investigator-initiated trials in Ethiopia to inform and direct capacity strengthening initiatives.

DESIGN

Exploratory, qualitative study comprising of in-depth interviews (n=7) and focus group discussions (n=3).

SETTING

Fieldwork took place in Ethiopia during March 2011.

PARTICIPANTS

Local health researchers with previous experiences of clinical trials or stakeholders with an interest in trials were recruited through snowball sampling (n=20).

OUTCOME MEASURES

Detailed discussion notes were analysed using thematic coding analysis and key themes were identified.

RESULTS

All participants perceived investigator-initiated trials as important for generating local evidence. System and organisational barriers included: limited funding allocation, weak regulatory and administrative systems, few learning opportunities, limited human and material capacity and poor incentives for conducting research. Operational hurdles were symptomatic of these barriers. Lack of awareness, confidence and motivation to undertake trials were important individual barriers. Training, knowledge sharing and experience exchange were key enablers to trial conduct and collaboration was unanimously regarded as important for improving capacity.

CONCLUSIONS

Barriers to trial conduct were found at individual, operational, organisational and system levels. These findings indicate that to increase locally led trial conduct in Ethiopia, system wide changes are needed to create a more receptive and enabling research environment. Crucially, the creation of research networks between potential trial groups could provide much needed practical collaborative support through sharing of financial and project management burdens, knowledge and resources. These findings could have important implications for capacity-strengthening initiatives but further research is needed before the results can be generalised more widely.

Malaria "diagnosis" and diagnostics in Afghanistan

In many malaria-endemic areas, including Afghanistan, overdiagnosis of malaria is common. Even when using parasite-based diagnostic tests prior to treatment, clinicians commonly prescribe antimalarial treatment following negative test results. This practice neglects alternative causes of fever, uses drugs unnecessarily, and might contribute to antimalarial drug resistance. We undertook a qualitative study among health workers using different malaria diagnostic methods in Afghanistan to explore perceptions of malaria diagnosis. Health workers valued diagnostic tests for their ability to confirm clinical suspicions of malaria via a positive result, but a negative result was commonly interpreted as an absence of diagnosis, legitimizing clinical diagnosis of malaria and prescription of antimalarial drugs. Prescribing decisions reflected uncertainty around tests and diagnosis, and were influenced by social- and health-system factors. Study findings emphasize the need for nuanced and context-specific guidance to change prescriber behavior and improve treatment of malarial and nonmalarial febrile illnesses.

"We learn from them, they learn from us": global health experiences and host perceptions of visiting health care professionals

PURPOSE

It is increasingly common for health care professionals from developed countries to travel to developing regions of the world to learn or teach. This project aimed to describe the perceptions held by health care professionals in a developing region toward those who visit their communities to learn or teach.

METHOD

Semistructured interviews were conducted in July, 2011, with nine health care professionals from the University of Namibia School of Medicine. Questions revolved around participants' perceptions of benefits, harms, and ethical impressions of a health care professional visiting from a developed country. Interviews were tape-recorded, transcribed, and analyzed qualitatively using an inductive, iterative approach.

RESULTS

The interview analysis identified three main narratives that shaped participant perceptions of visits: (1) culture, context, and concern, (2) expectations, intentions, and miscommunications, and (3) partnership and the desire to share and gain knowledge.

CONCLUSIONS

Participants' comments supported actively seeking out information regarding cultural and environmental context before visiting, completing a needs assessment to ensure that activities are needed and relevant, attempting to formulate long-term sustainable relationships, and traveling with the appropriate attitude. These themes provide valuable insight into how international educational collaborations can be created in order to be mutually beneficial.

Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study

OBJECTIVE

To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan.

DESIGN

Prospective observational study.

SETTING

22 clinics in two Afghan provinces, one in the north (adjoining Tajikistan) and one in the east (adjoining Pakistan); areas with seasonal transmission of Plasmodium vivax and Plasmodium falciparum.

PARTICIPANTS

2357 patients of all ages enrolled if clinicians suspected malaria.

INTERVENTIONS

Established (>5 years) microscopy (12 clinics in east Afghanistan), newly established microscopy (five clinics in north Afghanistan), and no laboratory (five clinics in north Afghanistan). All clinics used the national malaria treatment guidelines.

MAIN OUTCOME MEASURES

Proportion of patients positive and negative for malaria who received a malaria drug; sensitivity and specificity of clinic based diagnosis; prescriber's response to the result of the clinic slide; and proportion of patients positive and negative for malaria who were prescribed antibiotics. Outcomes were measured against a double read reference blood slide.

RESULTS

In health centres using clinical diagnosis, although 413 of 414 patients were negative by the reference slide, 412 (99%) received a malaria drug and 47 (11%) received an antibiotic. In clinics using new microscopy, 37% (75/202) of patients who were negative by the reference slide received a malaria drug and 60% (103/202) received an antibiotic. In clinics using established microscopy, 50.8% (645/1269) of patients who were negative by the reference slide received a malaria drug and 27.0% (342/1269) received an antibiotic. Among the patients who tested positive for malaria, 94% (443/472) correctly received a malaria drug but only 1 of 6 cases of falciparum malaria was detected and appropriately treated. The specificity of established and new microscopy was 72.9% and 79.9%, respectively. In response to negative clinic slide results, malaria drugs were prescribed to 270/905 (28.8%) and 32/154 (21%) and antibiotics to 347/930 (37.3%) and 99/154 (64%) patients in established and new microscopy arms, respectively. Nurses were less likely to misprescribe than doctors.

CONCLUSIONS

Despite a much lower incidence of malaria in Afghanistan than in Africa, fever was substantially misdiagnosed as malaria in this south Asian setting. Inaccuracy was attributable to false positive laboratory diagnoses of malaria and the clinicians' disregard of negative slide results. Rare but potentially fatal cases of falciparum malaria were not detected, emphasising the potential role of rapid diagnostic tests. Microscopy increased the proportion of patients treated with antibiotics producing a trade-off between overtreatment with malaria drugs and probable overtreatment with antibiotics.

A cost-effectiveness analysis of provider interventions to improve health worker practice in providing treatment for uncomplicated malaria in Cameroon: a study protocol for a randomized controlled trial

BACKGROUND

Governments and donors all over Africa are searching for sustainable, affordable and cost-effective ways to improve the quality of malaria case management. Widespread deficiencies have been reported in the prescribing and counselling practices of health care providers treating febrile patients in both public and private health facilities. Cameroon is no exception with low levels of adherence to national guidelines, the frequent selection of non-recommended antimalarials and the use of incorrect dosages. This study evaluates the effectiveness and cost-effectiveness of introducing two different provider training packages, alongside rapid diagnostic tests (RDTs), designed to equip providers with the knowledge and practical skills needed to effectively diagnose and treat febrile patients. The overall aim is to target antimalarial treatment better and to facilitate optimal use of malaria treatment guidelines.

METHODS/DESIGN

A 3-arm stratified, cluster randomized trial will be conducted to assess whether introducing RDTs with provider training (basic or enhanced) is more cost-effective than current practice without RDTs, and whether there is a difference in the cost effectiveness of the provider training interventions. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit public and mission health facilities. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider knowledge. Costs will be estimated from a societal and provider perspective using standard economic evaluation methodologies.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00981877.

Quality assurance of qualitative research: a review of the discourse

Background

Increasing demand for qualitative research within global health has emerged alongside increasing demand for demonstration of quality of research, in line with the evidence-based model of medicine. In quantitative health sciences research, in particular clinical trials, there exist clear and widely-recognised guidelines for conducting quality assurance of research. However, no comparable guidelines exist for qualitative research and although there are long-standing debates on what constitutes 'quality' in qualitative research, the concept of 'quality assurance' has not been explored widely. In acknowledgement of this gap, we sought to review discourses around quality assurance of qualitative research, as a first step towards developing guidance.

Methods

A range of databases, journals and grey literature sources were searched, and papers were included if they explicitly addressed quality assurance within a qualitative paradigm. A meta-narrative approach was used to review and synthesise the literature.

Results

Among the 37 papers included in the review, two dominant narratives were interpreted from the literature, reflecting contrasting approaches to quality assurance. The first focuses on demonstrating quality within research outputs; the second focuses on principles for quality practice throughout the research process. The second narrative appears to offer an approach to quality assurance that befits the values of qualitative research, emphasising the need to consider quality throughout the research process.

Conclusions

The paper identifies the strengths of the approaches represented in each narrative and recommend these are brought together in the development of a flexible framework to help qualitative researchers to define, apply and demonstrate principles of quality in their research.

The feasibility of introducing rapid diagnostic tests for malaria in drug shops in Uganda

Background

National malaria control programmes and international agencies are keen to scale-up the use of effective rapid diagnostic tests (RDTs) for malaria. The high proportion of the Ugandan population seeking care at drug shops makes these outlets attractive as providers of malaria RDTs. However, there is no precedent for blood testing at drug shops and little is known about how such tests might be perceived and used. Understanding use of drug shops by communities in Uganda is essential to inform the design of interventions to introduce RDTs.

Methods

We conducted a qualitative study, with 10 community focus group discussions, and 18 in-depth interviews with drug shop attendants, health workers and district health officials. The formative study was carried out in Mukono district, central Uganda an area of high malaria endemicity from May-July 2009.

Results

Drug shops were perceived by the community as important in treating malaria and there was awareness among most drug sellers and the community that not all febrile illnesses were malaria. The idea of introducing RDTs for malaria diagnosis in drug shops was attractive to most respondents. It was anticipated that RDTs would improve access to effective treatment of malaria, offset high costs associated with poor treatment, and avoid irrational drug use. However, communities did express fear that drug shops would overprice RDTs, raising the overall treatment cost for malaria. Other fears included poor adherence to the RDT result, reuse of RDTs leading to infections and fear that RDTs would be used to test for human immune deficiency virus (HIV). All drug shops visited had no record on patient data and referral of cases to health units was noted to be poor.

Conclusion

These results not only provide useful lessons for implementing the intervention study but have wide implications for scaling up malaria treatment in drug shops.

Enhanced relapse prevention for bipolar disorder by community mental health teams: cluster feasibility randomised trial

BACKGROUND

Relapse prevention for bipolar disorder increases time to relapse but is not available in routine practice.

AIMS

To determine the feasibility and effectiveness of training community mental health teams (CMHTs) to deliver enhanced relapse prevention.

METHOD

In a cluster randomised controlled trial, CMHT workers were allocated to receive 12 h training in enhanced relapse prevention to offer to people with bipolar disorder or to continue giving treatment as usual. The primary outcome was time to relapse and the secondary outcome was functioning.

RESULTS

Twenty-three CMHTs and 96 service users took part. Compared with treatment as usual, enhanced relapse prevention increased median time to the next bipolar episode by 8.5 weeks (hazard ratio 0.79, 95% CI 0.45-1.38). Social and occupational functioning improved with the intervention (regression coefficient 0.68, 95% CI 0.05-1.32). The clustering effect was negligible but imprecise (intracluster correlation coefficient 0.0001, 95% CI 0.0000-0.5142).

CONCLUSIONS

Training care coordinators to offer enhanced relapse prevention for bipolar disorder may be a feasible effective treatment. Large-scale cluster trials are needed.

Sub-optimal hand sanitiser usage in a hospital entrance during an influenza pandemic, New Zealand, August 2009

The hand hygiene behaviours of the public in response to the current H1N1 influenza pandemic 2009 (or other pandemics) have not previously been described. An observational study was undertaken to examine hand hygiene behaviours by people passing a hand sanitiser station in the foyer of a public hospital in New Zealand in August 2009. Of the 2,941 subjects observed, 449 (18.0%, 95% confidence interval: 16.6, 19.6) used the hand sanitiser. This is a far from optimal result in response to the health promotion initiatives in the setting of a pandemic. These findings suggest the need for more effective health promotion of hand hygiene and also provide baseline measurements for future evaluation of hygiene practices.

Mapping patients' experiences from initial change in health to cancer diagnosis: a qualitative exploration of patient and system factors mediating this process

Delays in the diagnosis of cancer are common, and they are attributed to both patient and healthcare system factors. Minimizing such delays and improving early detection rates is a key goal of the new cancer reform strategy in England, in light of recent data showing that survival rates in the UK are low. The aim of this study was to explore the pathway from initial persistent change in health to diagnosis of cancer in a sample of patients from seven diagnostic groups in the UK and the factors mediating this process. Qualitative interviews with patients diagnosed with cancer were carried out. Seventy-five cancer patients discussed their pre-diagnosis experience as part of a broader exploration of their symptom experience for a larger study. Data were analysed by using content analysis and chart events. A broader range of mediating factors affecting and extending the patient pathway to diagnosis were reported in relation to lung, gastrointestinal and head and neck cancers and lymphoma, compared with breast, gynaecological and brain cancer patients. Many of the mediating factors were patient-related (e.g. misattribution of symptoms to common ailments, underestimation of the seriousness of the symptoms, self-medication or monitoring of symptoms, etc.). Primary care practitioner-factors were also prominent, including the exploration of firstly more common possibilities for treating the presenting symptoms without follow-up of persisting symptoms. Public health education about common cancer signs and symptoms, educational approaches in primary care to improve early diagnoses of cancer and updated guidelines for referral of suspected cancers should be enhanced before we can see any improvements in survival rates from cancer in the UK.

Deployment of ACT antimalarials for treatment of malaria: challenges and opportunities

Following a long period when the effectiveness of existing mono-therapies for antimalarials was steadily declining with no clear alternative, most malaria-endemic countries in Africa and Asia have adopted artemisinin combination therapy (ACT) as antimalarial drug policy. Several ACT drugs exist and others are in the pipeline. If properly targeted, they have the potential to reduce mortality from malaria substantially. The major challenge now is to get the drugs to the right people. Current evidence suggests that most of those who need the drugs do not get them. Simultaneously, a high proportion of those who are given antimalarials do not in fact have malaria. Financial and other barriers mean that, in many settings, the majority of those with malaria, particularly the poorest, do not access formal healthcare, so the provision of free antimalarials via this route has only limited impact. The higher cost of ACT creates a market for fake drugs. Addressing these problems is now a priority. This review outlines current evidence, possible solutions and research priorities.

Pharmacovigilance of antimalarial treatment in Uganda: community perceptions and suggestions for reporting adverse events

OBJECTIVES

The deployment of new antimalarials in Africa provides an important opportunity to develop systems for pharmacovigilance. To inform strategies for reporting adverse events in Uganda, we investigated local perceptions and experiences with antimalarial treatment, and evaluated existing and potential systems for pharmacovigilance.

METHODS

Focus group discussions (FGD) were conducted with community members and health workers from urban and rural Uganda exploring knowledge of fever/malaria, perceptions and expectations of treatment, understanding of adverse effects, and experiences with adverse events. Sessions were recorded, transcribed into English, and analysed using a coding scheme developed from pre-defined topics together with themes emerging from the data.

RESULTS

Between April and July 2006, we conducted 25 FGDs; 16 with community members and nine with health workers. All respondents had extensive experience with malaria and its treatment. Community members commonly recognized adverse effects of antimalarial therapy. However, events were uncommonly reported, and certain events were often interpreted as signs of successful treatment. Community members often felt that the costs of reporting or seeking additional care outweighed the potential benefits. Health workers were unfamiliar with formal pathways for reporting, and were deterred by the additional work of reporting and fear of incrimination. Respondents provided suggestions for incentives and methods of reporting, emphasizing that pharmacovigilance should ideally encompass the public and private sector, and the community.

CONCLUSIONS

To be successful, pharmacovigilance relying on voluntary reporting will require active participation of patients and health workers. Addressing the costs and benefits of reporting, and providing sensitization, training and feedback will be important.

Perceptions of mothers and hospital staff of paediatric care in 13 public hospitals in northern Tanzania

User and provider perceptions of quality of care are likely to affect both use and provision of services. However, little is known about how health workers and mothers perceive the delivery of care in hospital paediatric wards in Africa. Paediatric staff and mothers of paediatric inpatients were interviewed to explore their opinions and experience of the admission process and conditions on the ward. Overcrowding, unsanitary conditions and lack of food were major concerns for mothers on the ward, who were deterred from seeking treatment earlier due to fears that hospital admission posed a significant risk of exposure to infection. While most staff were seen as being sympathetic and supportive to mothers, a minority were reported to be judgemental and authoritarian. Health workers identified lack of trained staff, overwork and low pay as major concerns. Staff shortages, lack of effective training and equipment are established problems but our findings also highlight a need for wards to become more parent-friendly, particularly with regard to food, hygiene and space. Training programmes focused on professional conduct and awareness of the problems that mothers face in seeking and receiving care may result in a more supportive and cooperative attitude between staff and mothers.

Isospin symmetry of odd-odd mirror nuclei: identification of excited states in N=Z-2 48Mn

Excited states have been observed in the N=Z-2 odd-odd nucleus 48Mn for the first time. Through comparison with the structure of 48V, a first high-spin study of an odd-odd mirror pair has been achieved. Differences between the T=1 analogue states in this pair have been interpreted in terms of Coulomb effects, with the aid of shell-model calculations in the full pf valence space. Unlike other mirror pairs, the energy differences have been interpreted almost entirely as due to a monopole effect associated with smooth changes in radius (or deformation) as a function of angular momentum. In addition, the large energy shift between analogue negative-parity states is interpreted in terms of the electromagnetic spin-orbit interaction in nuclei.