Correction: 'They eat it like sweets': A mixed methods study of antibiotic perceptions and their use among patients, prescribers and pharmacists in a district hospital in Kabul, Afghanistan

[This corrects the article DOI: 10.1371/journal.pone.0260096.].

How is the implementation of empirical research results documented in conflict-affected settings? Findings from a scoping review of peer-reviewed literature

Implementation science scholars argue that knowing 'what works' in public health is insufficient to change practices, without understanding 'how', 'where' and 'why' something works. In the peer reviewed literature on conflict-affected settings, challenges to produce research, make decisions informed by evidence, or deliver services are documented, but what about the understanding of 'how', 'where' and 'why' changes occur? We explored these questions through a scoping review of peer-reviewed literature based on core dimensions of the Extended Normalization Process Theory. We selected papers that provided data on how something might work (who is involved and how?), where (in what organizational arrangements or contexts?) and why (what was done?). We searched the Global Health, Medline, Embase databases. We screened 2054 abstracts and 128 full texts. We included 22 papers (of which 15 related to mental health interventions) and analysed them thematically. We had the results revised critically by co-authors experienced in operational research in conflict-affected settings. Using an implementation science lens, we found that: (a) implementing actors are often engaged after research is produced to discuss feasibility; (b) new interventions or delivery modalities need to be flexible; (c) disruptions affect how research findings can lead to sustained practices; (d) strong leadership and stable resources are crucial for frontline actors; (e) creating a safe learning space to discuss challenges is difficult; (f) feasibility in such settings needs to be balanced. Lastly, communities and frontline actors need to be engaged as early as possible in the research process. We used our findings to adapt the Extended Normalization Process Theory for operational research in settings affected by conflicts. Other theories used by researchers to document the implementation processes need to be studied further.

'They eat it like sweets': A mixed methods study of antibiotic perceptions and their use among patients, prescribers and pharmacists in a district hospital in Kabul, Afghanistan

BACKGROUND

Antibiotic resistance is a growing public health threat. In Afghanistan, high levels of indiscriminate antibiotic use exist, and healthcare programmes are not informed by understanding of local attitudes towards rational antibiotic use. Médecins Sans Frontières is an international non-governmental organization providing healthcare services to the Ahmad Shah Baba (ASB) District Hospital in Kabul, Afghanistan, since 2009. This mixed-methods study aimed to explore the perceptions and attitudes toward antibiotics among patients, prescribers, and pharmacists in the ASB District hospital outpatient department.

METHODS AND FINDINGS

Knowledge of antibiotics including their purpose and function, how and why they are used, and drivers for choice of antibiotic was examined at patient, prescriber, and provider-level. The first phase of the study, an exploratory qualitative component using an interpretative approach, was used to inform the second phase, a structured survey. Thirty-six interviews were conducted with 39 participants (21 patients or caretakers and 18 hospital health workers). Three hundred and fifty-one (351) patients and caretakers completed the second phase, the structured survey. This study found that poor knowledge of antibiotics and antibiotic resistance is a driving factor for inappropriate use of antibiotics. Participant perceptions of living in a polluted environment drove the high demand and perceived 'need' for antibiotics: patients, doctors and pharmacists alike consider dirty and dusty living conditions as causes of 'disease' in the body, requiring antibiotics to 'clean' and 'strengthen' it.

CONCLUSIONS

Findings highlight the need for strategies to improve awareness and knowledge of the general public, improve practice of doctors and pharmacists, regulate antibiotic dispensing in private pharmacies, and implement antibiotic stewardship in hospitals.

"Better dead than being mocked": an anthropological study on perceptions and attitudes towards unwanted pregnancy and abortion in the Democratic Republic of Congo

Unwanted pregnancy and unsafe abortion contribute significantly to the burden of maternal suffering, ill health and death in the Democratic Republic of Congo (DRC). This qualitative study examines the vulnerabilities of women and girls regarding unwanted pregnancy and abortion, to better understand their health-seeking behaviour and to identify barriers that hinder them from accessing care. Data were collected in three different areas in eastern DRC, using in-depth individual interviews, group interviews and focus group discussions. Respondents were purposively sampled. All interviews were audio recorded and transcribed verbatim. Transcriptions were screened for relevant information, manually coded and analysed using qualitative content analysis. Perceptions and attitudes towards unwanted pregnancy and abortion varied across the three study areas. In North Kivu, interviews predominantly reflected the view that abortions are morally reprehensible, which contrasts the widespread practice of abortion. In Ituri many perceive abortions as an appropriate solution for reducing maternal mortality. Legal constraints were cited as a barrier for health professionals to providing adequate medical care. In South Kivu, the general view was one of opposition to abortion, with some tolerance towards breastfeeding women. The main reasons women have abortions are related to stigma and shame, socio-demographics and finances, transactional sex and rape. Contrary to the prevailing critical narrative on abortion, this study highlights a significant need for safe abortion care services. The proverb "Better dead than being mocked" shows that women and girls prefer to risk dying through unsafe abortion, rather than staying pregnant and facing stigma for an unwanted pregnancy.

Dental implant procedures in immunosuppressed organ transplant patients: a systematic review

During the last decades, the number of immunosuppressed organ transplant patients has increased consistently. Nevertheless, immunosuppression has been discussed as a contraindication for dental implant procedures for many years. Hence, the purpose of this systematic review was to assess the survival rate and outcomes of dental implants after solid organ transplantation. An electronic and manual literature search was conducted up to March 2021. Publications describing dental implants placed in patients after organ transplantation were included without any limitations regarding study design or date of publication. Ten articles met the inclusion criteria, leading to a sample of 93 patients with 249 implants. Implant survival rates were 100% over a mean follow-up of 60 months. In every case, implant surgery was performed under antibiotic coverage. No major medication-related complications were reported. Despite the limited amount of evidence in the literature, implant procedures seem to be a safe treatment option in immunosuppressed organ transplant patients. The observance of appropriate treatment protocols including a strict maintenance programme seems to be crucial for the long-term success of such treatments. However, stringent data regarding various influencing factors such as the prevalence of peri-implantitis are still missing.

"They have been neglected for a long time": a qualitative study on the role and recognition of rural health motivators in the Shiselweni region, Eswatini

BACKGROUND

Community health workers (CHWs) are increasingly engaged to address human resource shortages and fill primary healthcare gaps. In Eswatini, a cadre of CHWs called Rural Health Motivators (RHM) was introduced in 1976 to respond to key public health challenges. However, the emergence of health needs, particularly HIV/TB, has been met with inadequate programme amendments, and the role of RHMs has become marginalised following the addition of other CHWs supported by non-governmental organisations. This study was implemented to understand the role of RHMs in decentralised HIV/TB activities. In this paper, we explore the findings in relation to the recognition of RHMs and the programme.

METHODS

This exploratory qualitative study utilised individual in-depth interviews, group and focus group discussions, participatory methods (utilising a game format) and observations. Participants were purposively selected and comprised RHM programme implementers, community stakeholders and local and non-governmental personnel. Data collection took place between August and September 2019. Interviews were conducted in English or siSwati and transcribed. SiSwati interviews were translated directly into English. All interviews were audio-recorded, manually coded and thematically analysed. Data was validated through methodical triangulation.

RESULTS

Suboptimal organisational structure and support, primarily insufficient training and supervision for activities were factors identified through interviews and observation activities. Significant confusion of the RHM role was observed, with community expectations beyond formally endorsed tasks. Community participants expressed dissatisfaction with receiving health information only, preferring physical assistance in the form of goods. Additionally, gender emerged as a significant influencing factor on the acceptability of health messages and the engagement of RHMs with community members. Expectations and structurally limiting factors shape the extent to which RHMs are recognised as integral to the health system, at all social and organisational levels.

CONCLUSIONS

Findings highlight the lack of recognition of RHMs and the programme at both community and national levels. This, along with historical neglect, has hindered the capacity of RHMs to successfully contribute to positive health outcomes for rural communities. Renewed attention and support mechanisms for this cadre are needed. Clarification of the RHM role in line with current health challenges and clearer role parameters is essential.

'She is like my mother': Community-based care of drug-resistant tuberculosis in rural Eswatini

Patients with drug-resistant tuberculosis (DR-TB) have received community-based care in Eswatini since 2009. Trained and compensated community treatment supporters (CTSs) provide directly observed therapy (DOT), injectables and psychological support. We examined the acceptability of this model of care among DR-TB patients, including the perspective of family members of DR-TB patients and their CTSs in relation to the patient's experience of care and quality of life. This qualitative research was conducted in rural Eswatini in February 2018. DR-TB patients, CTSs and family members participated in in-depth interviews, paired interviews, focus group discussions and PhotoVoice. Data were thematically analysed and coded, and themes were extracted. Methodological triangulation enhanced the interpretation. All patients and CTSs and most family members considered community-based DR-TB care to be supportive. Positive aspects were emotional support, trust and dedicated individual care, including enabling practical, financial and social factors. Concerns were related to social and economic problems within the family and fears about infection risks for the family and the CTSs. Community-based DR-TB care was acceptable to patients, family members and CTSs. To reduce family members' fears of TB infection, information and sensitisation within the family and constant follow-up appear crucial.

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study

Background

Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients.

Methods

To explore how the nurse-led community ART programme (NCAP) is perceived, we interviewed eighteen purposively selected patients receiving ART through NCAP and the four nurses providing the community-based health care. Information obtained from them was complemented with observations by the study team. Interviews were recorded and transcribed. Data was analysed using manual coding and thematic analysis.

Results

Through the NCAP, patients were able to save money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations (although this required care providers to set clear boundaries and stick to schedule).

Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. Considerations for community-led healthcare programmes include the provision of transportation for care providers; the physical structure of community sites (in regard to private spaces); the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles.

Conclusions

The patients interviewed in this study preferred the NCAP approach to the facility-based model of care because it saved them money on transport, reduced waiting-times, and allowed for a more thorough consultation, while continuing to provide quality HIV care. However, when considering a community-level DMOC approach, certain factors – including staff transportation and workload – must be taken into consideration and purposefully planned.

Intraligamentary anaesthesia as a possible anaesthetic option in oral implantology: a retrospective analysis

This investigation was conducted to analyse the usefulness of intraligamentary anaesthesia (ILA) as an alternative anaesthetic procedure in oral implantology. Forty consecutive patients with single-tooth gaps in the posterior mandible were included in the analysis. Implant insertion was performed after ILA of the gap-delimiting teeth (two injections distal to the mesial tooth, two injections mesial to the distal tooth). Implant surgery was performed successfully under ILA of the gap-delimiting teeth in 39 cases. Injection pain correlated significantly with lower periodontal probing depths (<3mm) of the delimiting teeth (P=0.003). The total amount of anaesthetic solution and the pain during surgery were significantly higher if a root canal-treated tooth was present in the area of surgery (P=0.010 and P=0.020, respectively). Overall, the mean pain score during treatment was low at 0.76±0.51 on a numerical rating scale from 0 to 10. At the control visit, no major complication was encountered. All implants were successfully restored with single crowns after a healing period of 2 months. Taking into consideration the limitations of the study, ILA seems to fulfil all conditions to be defined as an alternative, minimally invasive anaesthetic technique for the insertion of single-gap implants.

Human papillomavirus prevalence in a Mid-European oral squamous cell cancer population: A cohort study

OBJECTIVES

Human papillomavirus infection has been investigated intensively regarding oropharyngeal carcinoma. However, there is still lack of knowledge about the impact of oral HPV infections concerning oral squamous cell carcinoma. This study investigates the prevalence of oral HPV infection in such patients, identifying possible differences between HPV+ and HPV- patients.

SUBJECTS AND METHODS

One hundred and six consequent patients were investigated. After completion of a study questionnaire regarding risk factors, a brush smear sample was taken in each subject to identify the individual oral HPV status (overall/low risk/high risk).

RESULTS

About 35.8% of the patients were tested positive for HPV in the oral cavity (14% low risk, 28.3% high risk). Patients with oral HPV infection and high-risk HPV infection were significantly younger (p < 0.001) and had a higher alcohol consumption (p = 0.0075 resp. p = 0.0022). A high number of different sexual partners were significantly correlated with any type of HPV infection. At last, patients with high-risk oral HPV infection had experienced more tooth extractions during their lifetime.

CONCLUSION

Oral HPV infections may influence the course of disease of oral squamous cell carcinoma as HPV+ patients are about 10 years younger. It seems that high alcohol consumption facilitates high-risk HPV infection. It may be presumed that both alcohol consumption and high-risk oral HPV infection act synergistically, explaining earlier cancer onset.

The correlation between the quality of oral hygiene and oral HPV infection in adults: a prospective cross-sectional study

OBJECTIVES

Various risk factors for oral human papillomavirus (HPV) infections have been described, including tobacco smoking and sexual behavior. However, less is known about the influence of oral health on such infections. The present study aimed to determine a possible association between the quality of oral hygiene and the presence of oral HPV.

METHODS

In a prospective analysis, the approximal plaque index (API), the gingival bleeding index (GBI), and the lifetime number of extracted teeth was determined in 187 patients. Additionally, the presence of oral low-risk and/or high-risk HPV was investigated by brush smear testing in all participants.

RESULTS

Seventy-four patients had an API < 20%, 84 participants showed an API of 20-40%, and in 29 cases, an API > 40% was recorded. Ninety-six patients presented a GBI < 20%, 75 had a GBI of 20-40%, and 16 showed a GBI > 40%. One hundred four patients had experienced one to three extractions, and 36 had lost more than three teeth. Thirty-nine participants had a positive oral HPV testing (27 high-risk HPV, 26 low-risk HPV, 14 low- and high-risk HPV). A higher API respectively GBI and a greater number of extracted teeth were significantly correlated with the presence of high-risk HPV. The presence of low-risk HPV was significantly higher in patients with API > 40% and GBI > 40% (OR 7.89). Similar results were found regarding the number of extracted teeth.

CONCLUSION

The present analysis confirms a relationship between the quality of oral hygiene, determined by objective markers. Thus, improvement of oral health may reduce the incidence of oral HPV infection.

CLINICAL SIGNIFICANCE

The present article investigates the relationship between oral hygiene and the presence of oral HPV. As a significant correlation between these two factors could be recorded, improvement of oral hygiene may reduce actively the incidence of oral HPV. Thereby, good oral hygiene may contribute oral cancer prevention.

Long-term influence of mandibular advancement on the volume of the posterior airway in skeletal Class II-patients: a retrospective analysis

In the past, maxillomandibular advancement has resulted in considerable improvement in the volume of the posterior airway space. The objective of the present study was to find out how mandibular advancement without maxillary involvement would affect the posterior airway space in patients with mandibular retrognathism. Cone-beam computed tomographic (CT) scans were done for 20 patients before, and six months after, mandibular advancement. Cephalometric analysis at both time points included 2-dimensional and 3-dimensional assessment of the upper airway. Eight men and 12 women presented a preoperative mean (SD) Wits value of 7.4 (1.54) mm, with an airway area of 7.11 (1.88) cm² and a volume of 14.92 (4.46) cm³. Six months postoperatively they showed a Wits value of 2.7 (0.41) mm, an airway area of 11.33 (3.49) cm², and a volume of 25.7 (6.10) cm³. There was a mean (range) enlargement of 59 (22-82) % of the area and 73 (29-108) % of the volume. A preoperative Wits value of 8mm or more correlated significantly with a larger increase of the posterior airway space (p=0.002). At the same time, an improvement in the Wits value of 4.5mm or more correlated significantly with an increase in volume (p=0.016). The effect of mandibular advancement on the posterior airway space was significant, and the volumetric effect seems to be even more relevant than the two-dimensional changes.

"My Favourite Day Is Sunday": Community Perceptions of (Drug-Resistant) Tuberculosis and Ambulatory Tuberculosis Care in Kara Suu District, Osh Province, Kyrgyzstan

OBJECTIVES

Kyrgyzstan is one of the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries listed by the WHO. In 2012, Médecins Sans Frontières (MSF) started a drug-resistant tuberculosis (DR-TB) project in Kara Suu District. A qualitative study was undertaken to understand the perception of TB and DR-TB in order to improve the effectiveness and acceptance of the MSF intervention and to support advocacy strategies for an ambulatory model of care.

METHODS

This paper reports findings from 63 interviews with patients, caregivers, health care providers and members of communities. Data was analysed using a qualitative content analysis. Validation was ensured by triangulation and a 'thick' description of the research context, and by presenting deviant cases.

RESULTS

Findings show that the general population interprets TB as the 'lungs having a cold' or as a 'family disease' rather than as an infectious illness. From their perspective, individuals facing poor living conditions are more likely to get TB than wealthier people. Vulnerable groups such as drug and alcohol users, homeless persons, ethnic minorities and young women face barriers in accessing health care. As also reported in other publications, TB is highly stigmatised and possible side effects of the long treatment course are seen as unbearable; therefore, people only turn to public health care quite late. Most patients prefer ambulatory treatment because of the much needed emotional support from their social environment, which positively impacts treatment concordance. Health care providers favour inpatient treatment only for a better monitoring of side effects. Health staff increasingly acknowledges the central role they play in supporting DR-TB patients, and the importance of assuming a more empathic attitude.

CONCLUSIONS

Health promotion activities should aim at improving knowledge on TB and DR-TB, reducing stigma, and fostering the inclusion of vulnerable populations. Health seeking delays and adherence problems will be countered by further implementation of shortened treatment regimens. An ambulatory model of care is proposed when convenient for the patient; hospitalisation is favoured only when seen as more appropriate for the respective individual.

The impact of sexual behavior on oral HPV infections in young unvaccinated adults

OBJECTIVE

Different authors hypothesized an important impact of sexual behavior on the prevalence of oral human papillomavirus (HPV) infections. In order to investigate this relationship more in detail and in contrast to most other studies, the present work focused on the population group with the highest risk for sexually transmitted infections: young and sexual active adults.

MATERIALS AND METHODS

Three hundred and ten men and women aged 18-30 years could be recruited. After the completion of a risk-factor survey, brush smear samples for oral HPV detection were taken in every participant.

RESULTS

In 18.1 %, oral HPV could be detected. Overall, smoking (p = 0.0074) and a high number of different sexual partners (vaginal: p = 0.0001; oral: p < 0.0001) were significantly correlated with a positive HPV testing. In case of high risk HPV infections, besides tobacco and sexual behavior, alcohol consumption showed a significant association with a positive testing (p = 0.0212).

CONCLUSIONS

Overall, the prevalence of oral HPV seems to be higher in young, sexual active adults compared to other population groups. Tobacco and alcohol may facilitate an oral HPV infection. Sexual behavior, especially oral sex practices, seems to play a crucial role in the transmission of oral HPV.

CLINICAL RELEVANCE

The presented data, especially the association of oral high risk HPV positivity and promiscuity, may lead to improvements in the existing oral HPV prevention strategies like a HPV vaccination for both genders.

Odontogenic deep neck space infection as life-threatening condition in pregnancy

Odontogenic deep neck space infections represent a severe disease with possible life-threatening complications. Despite knowledge of these infectious diseases, treatment remains a challenge for every maxillofacial surgeon. Therapy of severe neck infections is even more crucial during pregnancy because of the possible life-threatening situation for both the mother and the foetus. The possible compromise of oral health during pregnancy is well known, however severe odontogenic infections are rarely considered in the literature. The following case report describes the dramatic course of a deep neck space infection in a pregnant patient, commencing with typical symptoms of localized odontogenic infection and ending in a critical, life-threatening condition for the patient and a lethal condition for the foetus. The case represents the first description of intrauterine, foetal death caused by a deep neck space infection. Implications for dental and medical treatment during pregnancy, especially regarding odontogenic infections, are presented and discussed with findings in the international literature.

Management of frontal sinus fractures--treatment decision based on metric dislocation extent

The treatment of frontal sinus fractures is still a matter of research in neurosurgical and craniofacial surgery. The present study aimed to determine new criteria regarding surgical or observational treatment, especially concerning the fracture dislocation. Clinical information on 164 consecutive patients with fractures of the frontal sinus, treated at the Department of Craniomaxillofacial Surgery of the Medical University of Innsbruck from 2006 to 2010, have been evaluated. 23 female (14%) and 141 male (86%) patients suffered mainly from traffic (31.7%) and sports accidents (28.0%), followed by work accidents (20.1%), violence (3.7%) and accidents at home (3.1%). 51.8% presented an isolated fracture of the anterior wall, 47.6% both anterior and posterior wall fracture, 0.6% an isolated posterior wall fracture. Injury of the nasofrontal duct was found in 29.2%, CSF liquorrhoea in 15.9%. In total, 44.5% of the patients underwent surgical therapy, 55.5% were treated conservatively by observation. Treatment decision depended significantly on concomitant injuries of the nasofrontal duct and the presence of rhinoliquorrhoea as well as on the fracture dislocation. A new classification of frontal sinus fractures depending on their maximum dislocation is proposed. In addition, a treatment algorithm considering displacement, liquorrhoea and injury of the nasofrontal duct is presented.

Impact of a prior medical degree on students' dental school performance in Innsbruck, Austria

The purpose of this study was to identify the performance differences between two groups of Austrian dental students (one with a prior medical degree and one without a medical degree) during their dental school training and final dental licensure examination. A specific aim was to determine if having a medical degree is a predictive factor for dental students' scores on the Austrian Dental Admission Test (Austrian DAT), performance in the dental clinic, and scores on final exam. The study consisted of a retrospective analysis of 122 students (thirty-nine with a medical degree and eighty-three without a medical degree) who were enrolled in the Dental Clinic at Innsbruck Medical University, Innsbruck, Austria, between 2001 and 2006. Three performance categories were considered: Austrian DAT results, clinical performance after the first clinical year in dental school, and performance on the final dental licensure examination. Information on students' age, gender, and previous medical degree was collected from official records. Analyses with student's t-test and Pearson's chi-square test revealed that the students with a medical degree had significantly higher Austrian DAT total test scores, grade point averages after the first clinical year, and scores on the final exam. Additionally, those students had significantly better performance on the final exam in prosthodontics and oral and maxillofacial surgery. The linear regression analysis showed that a medical degree had an independent effect on average scores on the final exam, age, and Austrian DAT test scores, while gender showed no statistically significant effect. Overall, the study found that dental students with a prior medical degree had significantly higher Austrian DAT total test scores and performed significantly better in the first clinical year and on the final exam than those without a prior medical degree.

Clinical performance of porcelain laminate veneers for up to 20 years

PURPOSE

The aim of this clinical retrospective study was to evaluate the clinical quality, success rate, and estimated survival rate of anterior veneers made of silicate glass-ceramic in a long-term analysis of up to 20 years.

MATERIALS AND METHODS

Anterior teeth in the maxillae and mandibles of 84 patients (38 men, 46 women) were restored with 318 porcelain veneer restorations between 1987 and 2009 at the Medical University Innsbruck, Innsbruck, Austria. Clinical examination was performed during patients' regularly scheduled maintenance appointments. Esthetic match, porcelain surface, marginal discoloration, and integrity were evaluated following modified California Dental Association/Ryge criteria. Veneer failures and reasons for failure were recorded. The study population included 42 (50.0%) patients diagnosed with bruxism and 23 (27.38%) smokers. The success rate was determined using Kaplan-Meier survival analysis.

RESULTS

The mean observation time was 118 ± 63 months. Twenty-nine failures (absolute: 82.76%, relative: 17.24%) were recorded. The main reason for failure was fracture of the ceramic (44.83%). The estimated survival rate was 94.4% after 5 years, 93.5% at 10 years, and 82.93% at 20 years. Nonvital teeth showed a significantly higher failure risk (P = .0012). There was a 7.7-times greater risk of failure associated with existing parafunction (bruxism, P = .0004). Marginal discoloration was significantly greater in smokers (P ⋜ .01).

CONCLUSION

Porcelain laminate veneers offer a predictable and successful restoration with an estimated survival probability of 93.5% over 10 years. Significantly increased failure rates were associated with bruxism and nonvital teeth, and marginal discoloration was worse in patients who smoked.