Smoke-free home restrictions in Armenia and Georgia: motives, barriers and secondhand smoke reduction behaviors.

BACKGROUND: Promoting smoke-free homes (SFHs) in Armenia and Georgia is timely given high smoking and secondhand smoke exposure (SHSe) rates and recent national smoke-free policy implementation. This study examined theoretical predictors (e.g. motives, barriers) of SFH status, and among those without SFHs, past 3-month SFH attempts and intent to establish SFHs in the next 3 months. METHODS: Multilevel logistic regression analyzed these outcomes using 2022 survey data from 1467 adults (31.6% past-month smokers) in Armenia (n = 762) and Georgia (n = 705). Correlates of interest included SHSe reduction behaviors and SFH motives and barriers; models controlled for country, community, age, sex, smoking status and other smokers in the home. RESULTS: In this sample, 53.6% had SFHs (Armenia: 39.2%; Georgia: 69.2%). Among those without SFHs, one-fourth had partial restrictions, no smokers in the home and/or recent SFH attempts; 35.5% intended to establish SFHs; and ∼70% of multiunit housing residents supported smoke-free buildings. We documented common SHSe reduction behaviors (opening windows, limiting smoking areas), SFH motives (prevent smell, protect children/nonsmokers) and barriers (smokers' resistance). Correlates of SFHs were being from Georgia, other smokers in the home, fewer SHSe reduction behaviors, greater motives and fewer barriers. Among participants without SFHs, correlates of recent SFH attempts were other smokers in the home, greater SHSe reduction behaviors and SFH motives, and fewer barriers; correlates of SFH intentions were being female, greater SHSe reduction behaviors, greater motives, and fewer barriers. CONCLUSIONS: SFH interventions should address motives, barriers and misperceptions regarding SHSe reduction behaviors. Moreover, smoke-free multiunit housing could have a great population impact.

Comparison of Conditional and Marginal Models in Assessing a Child Nutrition Intervention in Armenia.

INTRODUCTION: Child malnutrition is a major issue in conflict zones. Evidence-based interventions and their thorough evaluation could help to eliminate malnutrition. We aimed to assess the causal effect of a community-based multidisciplinary nutrition program for children in a chronic conflict zone near the northeastern border of Armenia on two main outcomes: stunting and anemia. We further compared the interpretations and public health relevance of the obtained effect estimates. METHODS: In 2016, the study measured hemoglobin and anthropometric measures and collected data from the children's caregivers. We used propensity score matching analyses, inverse probability weighting, and overlap weighting methods to examine the average treatment effects among treated population (ATT), and among population with overlapping weights (ATO). RESULTS: The ATT for stunting among children who participated in the intervention program estimated by propensity score matching analyses (PSM-ATT) was (1.95; 95%CI 1.15-3.28). Nevertheless, children who took part in the program had a lower risk of anemia (0.28; 95%CI 0.19-0.42). The ATT, estimated by inverse probability weighting (IPTW-ATT), was slightly lower for stunting (1.82; 95%CI 1.16-2.86) while similar for anemia (0.33; 95%CI 0.23-0.46) compared to PSM-ATT. Compared to the IPTW-ATT and PSM-ATT the ATO was lower for stunting (1.75; 95%CI 1.14-2.68) and similar for anemia (0.31; 95%CI 0.22-0.43). DISCUSSION: Marginal models could be used in similar quasi-experimental settings to identify the causal effect of interventions in specific populations of interest. Nonetheless, these methods do not eliminate threats to internal validity. Thorough study design and accurate data collection are necessary to improve the efficiency of marginal models.

Pediatric Locally Advanced Synovial Sarcoma: What Would Be the Best Treatment Option?

KEY POINTS • Synovial sarcomas are often mistreated with unplanned tumor resection. • Attention from specialists early in the course of SS can minimize the risk of recurrence, metastases, and the necessity for resurgery, all of which are increased with unplanned tumor resection. • Chemotherapy alone does not provide sufficient local control of the tumor. • Resurgery, in conjunction with radiotherapy and chemotherapy, is the best choice of management for this patient.

Development and Evaluation of a Tele-Education Program for Neonatal ICU Nurses in Armenia.

PURPOSE: Neonatal mortality currently accounts for more than 60% of all infant mortality in Armenia. The majority of health professionals in Neonatal Intensive Care Units (NICU) however, have had no specialized training in neonatology. Local and global agencies have emphasized the need for improvement in the education and skills of NICU health professionals. The objective of this study was to design, implement, and evaluate an innovative tele-education program for NICU nurses in Armenia. DESIGN AND METHODS: Seven online tele-education courses were designed on various neonatal nursing topics using Final Cut Pro and translated professionally to Armenian. The videos were uploaded to YouTube. All NICU nurses employed in two hospitals (n = 35) in Yerevan, Armenia, completed a diagnostic pretest, course viewing, a posttest, and a satisfaction survey for each topic. A difference in knowledge was defined as the number of correct test answers obtained before and after the course. Participant satisfaction was measured using a Likert scale. RESULTS: The combined average for completed pre-tests for all courses was 45% and 71% for post-tests, which was statistically significant for each course (p < 0.05). A majority of the nurses either agreed or strongly agreed with all of the satisfaction parameters of the course. CONCLUSIONS: These results support a tele-education model for effectively providing continuing education to NICU nurses in Armenia. A similar platform could be used to establish nationwide certification programs for neonatal nurses. PRACTICE IMPLICATIONS: Tele-education technology can be used effectively by nursing educators working in global health as part of international learning collaboratives.

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.

Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia.

OBJECTIVES: The aim of the study was to assess the efficacy and acceptability of a regimen using mifepristone and buccal misoprostol with unlimited dosing for second trimester abortion in Armenia. METHODS: Women seeking to terminate 13-22 week pregnancies were enrolled in the study. Participants swallowed 200 mg mifepristone in the clinic and were instructed to return to the hospital for induction 24-48 h later. During induction, women were given 400 µg buccal misoprostol every 3 h until the fetus and placenta were expelled. The abortion was considered a success if complete uterine evacuation was achieved without oxytocin or surgery. RESULTS: A total of 120 women with a median gestational age of 18 weeks participated in the study. All women began misoprostol induction around 24 h after taking mifepristone. Complete uterine evacuation was achieved in 119 (99.2%) women. The median induction-to-abortion interval was 10.3 h (range 4-17.4) with a mean of 9.5 ± 2.5 h. A median of four misoprostol doses (range 2-6) with a mean of 4 ± 1 misoprostol doses were administered. The induction-to-abortion interval, number of misoprostol doses, pain score and analgesia use increased as gestational age advanced. Acceptability of the method was high among both patients and providers. CONCLUSION: The medical abortion regimen of 200 mg mifepristone followed 24 h later by induction with 400 µg buccal misoprostol administered every 3 h, with no limit on the number of doses used for the termination of pregnancies of 13-22 weeks' gestation is an effective and acceptable option for women.

Child and Adolescent Health in Armenia: Experiences and Learned Lessons.

The health of children and adolescents of Armenia has been affected by various socioeconomic, environmental, educational, and behavioral factors, demonstrating trends typical for both developed and developing countries. Key issues to be addressed by Armenian pediatricians are child mortality, malnutrition, and growth failure in the early years and overweight in later years. The case of Armenia illustrates how countries in transition are currently tackling both "old" problems (mortality and malnutrition) and "new" emerging morbidities (chronic diseases and adolescent health problems) based on social and health determinants, but the financing of the health system is far from satisfactory. Lessons of Armenia indicate the need for more cooperation between general practitioners and pediatricians at a primary care level. In addition, a better balance between inpatient and outpatient care could be achieved, which is not yet the case. Nevertheless, the overall performance of the Armenian child health care system can be considered satisfactory when bearing in mind the limitation of resources. Among the successful factors are those inherited from the Soviet period health system, including key institutions such as rural health posts and health centers, city polyclinics, and hospitals. These institutions mostly meet the needs of Armenian children and families today.

Performance assessment through pre- and post-training evaluation of continuing medical education courses in prevention and management of cardio-vascular diseases in primary health care facilities of Armenia.

To assess the difference of pre- and post-training performance evaluation of continuing medical education (CME) courses in cardio-vascular diseases (CVD) management among physicians at primary health care facilities of Armenian regions we conducted an evaluation survey. 212 medical records were surveyed on assessment of performance before and after the training courses through a self-employed structured questionnaire. Analysis of survey revealed statistically significant differences (p < 0.05) in a number of variables: threefold increased recording of lipids and body mass index (p = 0.001); moderate increased recording of comorbidities and aspirin prescription (p < 0.012); eightfold increased recording of dyslipidemia management plan, twofold increased recording for CVD management plan and fivefold increased recording for CVD absolute risk (p = 0.000). Missing records of electrocardiography and urine/creatinine analyses decreased statistically significantly (p < 0.05). Statistically significant decrease was observed in prescription of thiazides and angiotensin receptor blockers/angiotensin converting enzyme inhibitors (p < 0.005), while prescription of statins and statins with diet for dyslipidemia management showed increased recording (p < 0.05). Similarly, we observed increased records for counseling of rehabilitation physical activity (p = 0.006). In this survey most differences in pre- and post-evaluation of performance assessment may be explained by improved and interactive training modes, more advanced methods of demonstration of modeling. Current findings may serve a basis for future planning of CME courses for physicians of remote areas facing challenges in upgrading their knowledge, as well as expand the experience of performance assessment along with evaluation of knowledge scores.

Effects of armed conflict on maternal and infant health: a mixed-methods study of Armenia and the 2020 Nagorno-Karabakh war.

INTRODUCTION: Armed conflict worldwide and across history has harmed the health of populations directly and indirectly, including generations beyond those immediately exposed to violence. The 2020 war between Armenia and Azerbaijan over Nagorno-Karabakh, inhabited by an ethnically Armenian population, provides an example of how conflict harmed health during COVID-19. We hypothesised that crises exposure would correspond to decreased healthcare utilisation rates and worse health outcomes for the maternal and infant population in Armenia, compounded during the pandemic. METHODS: Following a mixed-methods approach, we used ecological data from 1980 to 2020 to evaluate health trends in conflict, measured as battle-related deaths (BRDs), COVID-19 cases, and maternal and infant health indicators during periods of conflict and peace in Armenia. We also interviewed 10 key informants about unmet needs, maternal health-seeking behaviours and priorities during the war, collecting recommendations to mitigate the effects of future crisis on maternal and infant health. We followed a deductive coding approach to analyse transcripts and harvest themes. RESULTS: BRDs totalled more in the 2020 war compared with the previous Nagorno-Karabakh conflicts. Periods of active conflict between 1988-2020 were associated with increased rates of sick newborn mortality, neonatal mortality and pre-eclampsia or eclampsia. Weekly average COVID-19 cases increased sevenfold during the 2020 Nagorno-Karabakh war. Key informants expressed concerns about the effects of stress and grief on maternal health and pregnancy outcomes and recommended investing in healthcare system reform. Participants also stressed the synergistic effects of the war and COVID-19, noting healthcare capacity concerns and the importance of a strong primary care system. CONCLUSIONS: Maternal and infant health measures showed adverse trends during the 2020 Nagorno-Karabakh war, potentially amplified by the concurrent COVID-19 pandemic. To mitigate effects of future crises on population health in Armenia, informants recommended investments in healthcare system reform focused on primary care and health promotion.

A first aid training course for primary health care providers in Nagorno Karabagh: assessing knowledge retention.

INTRODUCTION: Conflict in the South Caucasus' Nagorno Karabagh region has damaged health facilities and disrupted the delivery of services and supplies as well as led to depletion of human and fixed capital and weakened the de facto government's ability to provide training for health care providers. PROBLEM: In response to documented medical training deficits, the American University of Armenia organized a first aid training course (FATC) for primary health care providers within the scope of the USAID-funded Humanitarian Assistance Project in Nagorno Karabagh. This paper reports the follow-up assessments conducted to inform policy makers regarding FATC knowledge and skill retention and the potential need for periodic refresher training. METHODS: Follow-up assessments were conducted six months and 18 months following the FATC to assess the retention of knowledge, attitudes, and self-reported practices. Eighty-four providers participated in the first follow-up and 210 in the second. The assessment tool contained items addressing the use and quality of the first aid skills, trainee's evaluation of the course, and randomly selected test questions to assess knowledge retention. RESULTS: At both follow-up points, the participants' assessment of the course was positive. More than 85% of the trainees self-assessed their skills as "excellent" or "good" and noted that skills were frequently practiced. Scores of approximately 58% on knowledge tests at both the first and second follow-ups indicated no knowledge decay between the first and second survey waves, but substantial decline from the immediate post-test assessment in the classroom. CONCLUSION: The trainees assessed the FATC as effective, and the skills covered as important and well utilized. Knowledge retention was modest, but stable. Refresher courses are necessary to reverse the decay of technical knowledge and to ensure proper application in the field.

The Implementation of the WHO Mental Health Gap Intervention Guide (mhGAP-IG) in Ukraine, Armenia, Georgia and Kyrgyz Republic.

Despite the increasing burden of mental disorders, a lot of people worldwide suffer a gap in receiving necessary care in these countries. To close this gap, the WHO has developed mhGAP training modules aimed at scaling up mental health and substance use disorders services, especially in low- and middle-income countries. This article presents the experience of implementing the Mental Health Gap Action Programme (mhGAP) in Ukraine, Armenia, Georgia, and Kyrgyz Republic. Data were gathered from an electronic questionnaire administered to representatives from higher educational institutions where the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) was implemented in existing curricula for medical students, interns, and residents in family medicine and neurology, practicing physicians, and master's program in mental health students. More than 700 students went through the programs that provided the feedback. Evaluations of program effectiveness mainly involved standard discipline tests or pre- and post-tests proposed in the mhGAP trainer manual. This finding suggested that mhGAP-IG can be successfully adapted and implemented both on undergraduate and on postgraduate education levels and among medical and nonmedical specialists. Future evaluations need to more definitively assess the clinical effectiveness of mhGAP-IG implementation.

Can a brief training intervention on schizophrenia and depression improve knowledge, attitudes and practices of primary healthcare workers? The experience in Armenia.

BACKGROUND: Although the World Health Organization has called for mental health services to be integrated into primary care, mental health remains in most countries, and especially in low- and middle-income countries, one of the most neglected topics in the training curriculum of frontline health workers. As a result, primary healthcare professionals leave medical and nursing schools with insufficient knowledge, and often with negative attitudes towards mental disorders. AIM: We investigated the effect of a brief training intervention on schizophrenia and depression conducted among general practitioners and nurses in Armenia. METHODS: Training interventions were one-day, face-to-face, interactive workshops, including didactic presentations and discussions of case studies. We used a quasi-experimental design of the before/after type, to compare data on knowledge, attitudes and practices collected before and after the training sessions. RESULTS: Mean scores for knowledge, attitudes and practices increased significantly (p < 0.001) among both nurses and GPs for both schizophrenia (111 GPs and 167 nurses) and depression (459 GPs and 197 nurses). CONCLUSIONS: Our experience suggests that a brief training intervention can result in significant improvements in knowledge, attitudes and practices among primary healthcare workers and could help improve mental health services.

Using allocative efficiency analysis to inform health benefits package design for progressing towards Universal Health Coverage: Proof-of-concept studies in countries seeking decision support.

BACKGROUND: Countries are increasingly defining health benefits packages (HBPs) as a way of progressing towards Universal Health Coverage (UHC). Resources for health are commonly constrained, so it is imperative to allocate funds as efficiently as possible. We conducted allocative efficiency analyses using the Health Interventions Prioritization tool (HIPtool) to estimate the cost and impact of potential HBPs in three countries. These analyses explore the usefulness of allocative efficiency analysis and HIPtool in particular, in contributing to priority setting discussions. METHODS AND FINDINGS: HIPtool is an open-access and open-source allocative efficiency modelling tool. It is preloaded with publicly available data, including data on the 218 cost-effective interventions comprising the Essential UHC package identified in the 3rd Edition of Disease Control Priorities, and global burden of disease data from the Institute for Health Metrics and Evaluation. For these analyses, the data were adapted to the health systems of Armenia, Côte d'Ivoire and Zimbabwe. Local data replaced global data where possible. Optimized resource allocations were then estimated using the optimization algorithm. In Armenia, optimized spending on UHC interventions could avert 26% more disability-adjusted life years (DALYs), but even highly cost-effective interventions are not funded without an increase in the current health budget. In Côte d'Ivoire, surgical interventions, maternal and child health and health promotion interventions are scaled up under optimized spending with an estimated 22% increase in DALYs averted-mostly at the primary care level. In Zimbabwe, the estimated gain was even higher at 49% of additional DALYs averted through optimized spending. CONCLUSIONS: HIPtool applications can assist discussions around spending prioritization, HBP design and primary health care transformation. The analyses provided actionable policy recommendations regarding spending allocations across specific delivery platforms, disease programs and interventions. Resource constraints exacerbated by the COVID-19 pandemic increase the need for formal planning of resource allocation to maximize health benefits.

Challenges and Opportunities for Purchasing High-Quality Health Care: Lessons from Armenia.

This paper examines how purchasing decisions in Armenia may contribute to barriers in using high-quality health care, particularly for non-communicable diseases, drawing on a review of the literature and key informant interviews. The paper adapts the strategic health purchasing progress framework, to examine how characteristics of purchasing, the health system, and the political, administrative, and macro-fiscal environment may have facilitated or hindered the attainment of service delivery goals. We conclude with six lessons for reforms aimed at improving the coverage and quality of health care in Armenia. First, increasing the political priority of access to quality of health care is a pre-requisite to advancing reforms to address these issues. Second, improved purchasing governance in Armenia will require a purchaser that can make decisions without political interference, with appropriate accountability mechanisms, improvements in technical capacity, and the routine use of data systems. Third, there is a need for the regulatory framework to ensure that revisions of the benefits package contribute to reducing the disease burden and improving access to care. Fourth, regulations governing quality-related criteria for provider selection should be enforced and include considerations for process quality. Fifth, payment incentives should be revised to encourage an increase in the supply of primary health care, reduce bypassing for hospital care, and improve the quality of services. Sixth, the potential of purchasing to improve service delivery will be dependent on increased pre-paid and pooled funds and better governance of the quality of care.

Strengthening the primary health care response to COVID-19: an operational tool for policymakers.

AIMS: The aim of this paper is to introduce an operational checklist to serve as a tool for policymakers in the WHO European Region to strengthen primary health care (PHC) services and address the COVID-19 pandemic more effectively and to present the results from piloting the tool in Armenia. BACKGROUNDS: PHC has the potential to play a fundamental role in countries' responses to COVID-19. However, this potential remains unrealized in many countries. To assist countries, the WHO Regional Office for Europe developed a guidance document - Strengthening the Health Systems Response to COVID-19: Adapting Primary Health Care Services to more Effectively Address COVID-19 - that identifies strategic actions countries can take to strengthen their PHC response to the pandemic. Based on this guidance document, an operational checklist was developed to serve as a tool for policymakers to operationalize the recommended actions. METHODS: The operational checklist was developed by transforming key points in the guidance document into questions in order to identify potentially modifiable factors to strengthen PHC in response to COVID-19. The operational checklist was then piloted in Armenia in June 2020 as part of a WHO mission to provide technical advice on strengthening Armenia's PHC response to COVID-19. Two WHO experts performed semi-structured, face-to-face interviews with nine key informants (both facility managers and clinical staff) in three PHC facilities (two in a rural and one in an urban area). The data collected were analyzed to identify underlying challenges limiting PHC providers' ability to effectively and efficiently respond to COVID-19 and maintain essential health services. FINDINGS: The paper finds that making adjustments only to health services delivery will be insufficient to address most of the challenges identified by PHC providers in the context of COVID-19 in Armenia. In particular, strategic responses to the pandemic were missed, due, in part, to the absence of COVID-19 management teams at the facility level. Furthermore, the absence of PHC experts in Armenia's national pandemic response team meant that health system issues identified at the facility level could not easily be communicated to or addressed by policymakers. The checklist therefore helps policymakers identify critical challenges - at both the facility and health system level - that need to be addressed to strengthen the PHC response to the COVID-19 pandemic.

A randomized controlled trial of an HIV prevention intervention for street-based female sex workers in Yerevan, Armenia: preliminary evidence of efficacy.

This study evaluated the efficacy of an HIV intervention among female sex workers (FSWs) randomized to an intervention or wait-list control. FSWs (N = 120) completed baseline, 3- and 6-month assessments. A health educator implemented 2-hour intervention emphasized gender-empowerment, self-efficacy to persuade clients to use condoms, condom application skills, and eroticizing safer sex. Over the 6-month follow-up, FSWs in the intervention reported more consistent condom use with clients (P = .004) and were more likely to apply condoms on clients (P = .0001). Intervention effects were observed for other psychosocial mediators of safer sex. Brief, gender and culturally congruent interventions can enhance HIV-preventive behaviors among FSWs.