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BACKGROUND: Kerala, a southern state in India, is known to be atypical due to its high literacy rate and advanced social development indicators. Facing competition from a dominant private healthcare system, recent government health system reforms have focused on providing free, high-quality universal healthcare in the public sector. We carried out an analysis to ascertain the initial impacts of these measures among 'hard to reach groups' as part of a larger health policy and systems research study, with a focus on public sector health service utilisation. METHODS: We conducted Focus Group Discussions (FGDs) among identified vulnerable groups across four districts of Kerala between March and August of 2022. The FGDs explored community perspectives on the use of public healthcare facilities including enablers and barriers to healthcare access. Transliterated English transcripts were coded using ATLAS.ti software and thematically analyzed using the AAAQ framework, supplemented with inductive code generation. RESULTS: A total of 34 FGDs were conducted. Availability and cost-effectiveness were major reasons for choosing public healthcare, with the availability of public insurance in inpatient facilities influencing this preference. However, accessibility of public sector facilities posed challenges due to long journeys and queues. Uneven roads and the non-availability of public transport further restricted access. Gaps in acceptability were also observed: participants noted the need for the availability of special treatments available, reduced waiting times for special groups like those from tribal communities or the elderly mindful of their relatively greater travel and need for prompt care. Although quality improvements resulting from health reform measures were acknowledged, participants articulated the need for further enhancements in the availability and accessibility of services so as to make public healthcare systems truly acceptable. CONCLUSION: The 'Kerala Model of Development' has been applauded internationally for its success in recent years. However, this has not inured the state from the typical barriers to public sector health care use articulated by participants in the study, which match global evidence. In order to deepen the impact of public sector reforms, the state must try to meet service user expectations- especially among those left behind. This requires attention to quality, timeliness, outreach and physical access. Longer term impacts of these reforms - as we move to a post-COVID scenario - should also be evaluated.
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Grupos Focais , Acessibilidade aos Serviços de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Setor Público , Pesquisa Qualitativa , Humanos , Índia , Feminino , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Pessoa de Meia-Idade , Populações Vulneráveis , IdosoRESUMO
Background and objectives: Antibiotic use in paediatric surgical specialties is understudied. We investigated the antibiotic prescribing practices of paediatric general and cardiovascular surgical teams in a tertiary hospital in South India. Methods: Mixed-methods study including observations from ward rounds, semi-structured interviews, and review of antibiotic prescribing. Field notes from observations and interview transcripts were coded using NVivo and thematically analysed. Data collection and analysis were iterative and continued until thematic saturation. Quantitative data were analysed using descriptive statistics. Results: Data included 62 h of observation, 24 interviews, one case study and 200 patient chart reviews (100/specialty). Senior surgeons make key decisions, referring to their own experience when prescribing antibiotics. Being outcome-driven, the doctors often prescribe antibiotics at the earliest indication of infection with a reluctance to de-escalate, even when an infection is not diagnosed. This practice is more acute among surgeons who consider themselves responsible for their patients' health and attribute the consistently low surgical site infection rates to this practice.In general surgery, 83.3% (80/96; 4 lost to follow-up) of patients were prescribed antibiotics for the duration of their stay with oral antibiotics prescribed at discharge. The surgeons use antibiotics prophylactically for patients who may be vulnerable to infection. The antimicrobial stewardship team was considered to have limited influence in the decision-making process. Conclusions: Outcome-driven decision-making in surgery leads to overprescription of antibiotics and prolonged surgical prophylaxis. The rationale for suboptimal practices is complicated by the surgeons' beliefs about the contextual determinants of health in India.
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Background: Accredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts. Methods: We conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software. Results: Our study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local self-governments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done. Conclusion: The CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge.
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Mentorship in global health remains an overlooked dimension of research partnerships. Commitment to effective mentorship models requires value-driven approaches. This includes having an understanding of (1) what mentorship means across different cultural and hierarchical boundaries in the health research environment, and (2) addressing entrenched power asymmetries across different aspects including funding, leadership, data and outputs, and capacity strengthening. Existing guidance towards equity and sustainability fails to inform how to navigate complex relationships which hinder effective mentorship models. We focus this perspective piece on human capacity strengthening in research partnerships through mentorship. Using a case study of a research partnership, we describe the lessons learnt and the challenges faced in the mentor mentee relationship while maintaining an effective and sustainable partnership. Human capacity strengthening must research projects and collaborations, and recognise local leadership and ownership. To be transformative and effective, practices need to be driven by common values across research teams.
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Saúde Global , Mentores , Humanos , Fortalecimento InstitucionalRESUMO
BACKGROUND: The link between healthcare worker (HCW) communication, teamwork and patient safety is well-established. Infection prevention and control (IPC) and antimicrobial stewardship (AMS) require multidisciplinary teamwork and communication. OBJECTIVES: We conducted a scoping review of published evidence on effective mechanisms of HCW team communication in hospitals with the intention of transferring and tailoring learning to IPC and AMS team communication. METHODS: PubMed, Scopus, Web of Science, and CINAHL were searched for studies that investigated HCW team communication across in-hospital patient pathways. Studies published between 2000 and 2021 that provided evidence on/or described the effect of communication on team and patient outcomes in hospital were included. Through a process of inductive qualitative content analysis, key themes in the included studies were identified. RESULTS: Of 537 studies identified, 53 (from high-income countries) were included in the data extraction. Fifty one percent (27/53) of studies were conducted in high acuity settings e.g., intensive care units. Standardizing or structuring the content and/or process of team communication was the most common goal of interventions (34/53, 64%). The key outcome measures were either team communication focused (25/34,74%) or patient and process outcome focused (8/34, 24%), such as reduced length of mechanical ventilation days, length of hospital stay, and shorter empiric antibiotic duration. Four studies (4/53, 8%) associated improved communication with positive IPC and AMS outcome measures. Mixed method intervention studies primarily facilitated collaborative input from HCWs and applied structures to standardize the content of patient care discussions, whereas observational studies describe component of team communication. CONCLUSIONS: A communication strategy that formalizes input from multidisciplinary team members can lead to optimized and consistent clinical discussion including in IPC and AMS-related care. Although we were unable to assess the effectiveness of interventions, the existing evidence suggests that optimizing team communication can have a positive effect on infection-related patient outcomes.
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Gestão de Antimicrobianos , Humanos , Controle de Infecções , Atenção à Saúde , Hospitais , ComunicaçãoRESUMO
BACKGROUND: Publicly Funded Health Insurance Schemes (PFHIS) are intended to play a role in achieving Universal Health Coverage (UHC). In countries like India, PFHISs have low penetrance and provide limited coverage of services and of family members within households, which can mean that women lose out. Gender inequities in relation to financial risk protection are understudied. Given the emphasis being placed on achieving UHC for all in India, this paper examined intersecting gender inequalities and changes in PFHIS coverage in southern India, where its penetrance is greater and of longer duration. DATA AND METHODS: This study used the fourth (NFHS-4, 2015-16) and fifth (NFHS-5, 2019-21) rounds of India's National Family Health Survey for five southern states: namely, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana. The World Health Organization's Health Equity Assessment Toolkit (HEAT) Plus and Stata were used to analyse PFHIS coverage disaggregated by seven dimensions of inequality. Ratios and differences for binary dimensions; Between Group Variance and Theil Index for unordered dimensions; Absolute and Relative Concentration Index (RCI) for ordered dimensions were computed separately for women and men. RESULTS: Overall, PFHIS coverage increased significantly (p < 0.001) among women and men in Andhra Pradesh, and Kerala from NFHS-4 to NFHS-5. Overall, men had higher PFHIS coverage than women, especially in Andhra Pradesh, Tamil Nadu, and Telangana in both surveys. In both absolute and relative terms, PFHIS coverage was concentrated among older women and men across all states; age-related inequalities were higher among women than men in both surveys in Andhra Pradesh, Kerala, and Telengana. The magnitude of education-related inequalities was twice as high as among women in Telangana (RCINFHS-4: -12.23; RCINFHS-5: -9.98) and Andhra Pradesh (RCINFHS-4: -8.05; RCINFHS-5: -7.84) as compared to men in Telangana (RCINFHS-4: -5.58; RCINFHS-5: -2.30) and Andhra Pradesh (RCINFHS-4: -4.40; RCINFHS-5: -3.12) and these inequalities remained in NFHS-5, suggesting that lower education level women had greater coverage. In the latter survey, a high magnitude of wealth-related inequality was observed in women (RCINFHS-4: -15.78; RCINFHS-5: -14.36) and men (RCINFHS-4: -20.42; RCINFHS-5: -13.84) belonging to Kerala, whereas this inequality has decreased from NFHS-4 to NFHS-5., again suggestive of greater coverage among poorer populations. Caste-related inequalities were higher in women than men in both surveys, the magnitude of inequalities decreased between 2015-16 and 2019-20. CONCLUSIONS: We found gender inequalities in self-reported enrolment in southern states with long-standing PFHIS. Inequalities favoured the poor, uneducated and elderly, which is to some extend desirable when rolling out a PFHIS intended for harder to reach populations. However, religion and caste-based inequalities, while reducing, were still prevalent among women. If PFHIS are to truly offer financial risk protection, they must address the intersecting marginalization faced by women and men, while meeting eventual goals of risk pooling, indicated by high coverage and low inequality across population sub-groups.
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Características da Família , Seguro Saúde , Masculino , Humanos , Feminino , Idoso , Índia/epidemiologia , Inquéritos e Questionários , Inquéritos Epidemiológicos , Fatores SocioeconômicosRESUMO
A cross-sectional survey among participants in India and South Africa to explore perceptions and awareness of SARS-CoV-2-related risks. Main outcome measures-proportion of participants aware of SARS-CoV-2, and their perception of infection risks as it related to their views and perceptions on vaccination, i.e., using COVID-19 vaccine uptake as proxy for awareness level. Self-administered questionnaires were used to collect data via web- and paper-based surveys over three months. Pearson's Chi-squared test assessed relationships between variables; a p-value less than 0.05 was considered significant. There were 844 respondents (India: n = 660, South Africa: n = 184; response rate 87.6%), with a 61.1% vs 38.3% female to male ratio. Post-high-school or university education was the lowest qualification reported by most respondents in India (77.3%) and South Africa (79.3%). Sources of pandemic information were usually media and journal publications (73.2%), social media (64.6%), family and friends (47.7%) and government websites (46.2%). Most respondents correctly identified infection prevention measures (such as physical distancing, mask use), with 90.0% reporting improved hand hygiene practices since the pandemic. Hesitancy or refusal to accept the SARS-CoV-2 vaccine was reported among 17.9% and 50.9% of respondents in India and South Africa, respectively; reasons cited included rushed vaccine development and the futility of vaccines for what respondents considered a self-limiting flu-like illness. In South Africa, vaccine acceptance was associated with improved hand hygiene practices since the pandemic and flu vaccination in the preceding year. No relationship was noted between awareness and practice of infection prevention measures (such as hand hygiene) and socio-demographic factors such as employment status or availability of amenities. Pandemic response and infection prevention and control measures through vaccination campaigns should consider robust public engagement and contextually-fit communication strategies with multimodal, participatory online and offline initiatives to address public concerns, specifically towards vaccines developed for this pandemic and general vaccine hesitancy.
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BACKGROUND: Kerala, a south Indian state, has a long and strong history of mobilisation of people's participation with institutionalised mechanisms as part of decentralisation reforms introduced three decades ago. This history formed the backdrop of the state's COVID-19 response from 2020 onwards. As part of a larger health equity study, we carried out an analysis to understand the contributions of people's participation to the state's COVID-19 response, and what implications this may have for health reform as well as governance more broadly. METHODS: We employed in-depth interviews with participants from four districts of Kerala between July and October, 2021. Following written informed consent procedures, we carried out interviews of health staff from eight primary health care centres, elected Local Self Government (LSG, or Panchayat) representatives, and community leaders. Questions explored primary health care reforms, COVID responses, and populations left behind. Transliterated English transcripts were analysed by four research team members using a thematic analysis approach and ATLAS.ti 9 software. For this paper, we specifically analysed codes and themes related to experiences of community actors and processes for COVID mitigation activities. RESULTS: A key feature of the COVID-19 response was the formation of Rapid Response Teams (RRTs), groups of lay community volunteers, who were identified and convened by LSG leaders. In some cases, pre-pandemic 'Arogya sena' (health army) community volunteer groups were merged with RRTs. RRT members were trained and supported by the health departments at the local level to distribute medicine and essential items, provided support for transportation to health facilities, and assisted with funerary rites during lockdown and containment period. RRTs often comprised youth cadres of ruling and opposition political parties. Existing community networks like Kudumbashree (Self Help Groups) and field workers from other departments have supported and been supported by RRTs. As pandemic restrictions eased, however, there was concern about the sustainability of this arrangement as well. CONCLUSION: Participatory local governance in Kerala allowed for the creation of invited spaces for community participation in a variety of roles as part of the COVID 19 response, with manifest impact. However, the terms of engagement were not decided by communities, nor were they involved more deeply in planning and organising health policy or services. The sustainability and governance features of such involvement warrant further study.
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COVID-19 , Reforma dos Serviços de Saúde , Humanos , Adolescente , COVID-19/epidemiologia , Controle de Doenças Transmissíveis , Instalações de Saúde , GovernoRESUMO
OBJECTIVE: The irrational use of antibiotics is a leading contributor to antibiotic resistance. Antibiotic stewardship (AS) interventions predominantly focus on prescribers. This study investigated the influence and participation of inpatients in infection-related care, including antibiotic decision-making, within and across two tertiary hospitals in South Africa (Cape Town) and India (Kerala). METHODS: Through ethnographic enquiry of clinical practice in surgical pathways, including direct nonparticipant observation of clinical practices, healthcare worker (HCW), patient and carer interactions in surgical ward rounds and face-to-face interviews with participants (HCWs and patients), we sought to capture the implicit and explicit influence that patients and carers have in infection-related care. Field notes and interview transcripts were thematically coded, aided by NVivo 12® Pro software. RESULTS: Whilst observational data revealed the nuanced roles that patients/carers play in antibiotic decision-making, HCWs did not recognize these roles. Patients and carers, though invested in patient care, are not routinely involved, nor are they aware of the opportunities for engagement in infection-related decision-making. Patients associated clinical improvement with antibiotic use and did not consider hospitalization to be associated with infection acquisition or transmission, highlighting a lack of understanding of the threat of infection and antibiotic resistance. Patients' economic and cultural positionalities may influence their infection-related behaviours. In the study site in India, cultural norms mean that carers play widespread but unrecognized roles in inpatient care, participating in infection prevention activities. CONCLUSION: For patients to have a valuable role in AS and make informed decisions regarding their infection-related care, a mutual understanding of their role in this process among HCWs and patients is crucial. The observed differences between the two study sites indicate the critical need for understanding and addressing the contextual drivers that impact effective patient-centred healthcare delivery. PATIENT OR PUBLIC CONTRIBUTION: Ethnographic observations and interviews conducted in this study involved patients as participants. Patients were recruited for interviews after obtaining signed informed consent forms. Patients' identities were completely anonymized when presenting the study findings.
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Pessoal de Saúde , Pacientes Internados , Humanos , África do Sul , Antibacterianos , Centros de Atenção TerciáriaRESUMO
Objective: To identify perceptions and awareness of changes in infection prevention and control (IPC) and antimicrobial stewardship (AMS) practices among healthcare workers (HCWs) during the COVID-19 pandemic in India and South Africa (SA). Method: A self-administered online survey which included participant demographics, knowledge and sources of COVID-19 infection, perceived risks and barriers, and self-efficacy. Data were analysed using descriptive statistics. Results: The study received 321 responses (response rate: 89.2%); 131/321 (40.8%) from India and 190/321 (59.2%) from SA; male to female response rate was 3:2, with majority of respondents aged 40-49 (89/321, 27.7%) and 30-39 (87/321, 27.1%) years. Doctors comprised 47.9% (57/119) of respondents in India and 74.6% (135/181) in SA. Majority of respondents in India (93/119, 78.2%) and SA (132/181, 72.9%) were from the private and public sectors, respectively, with more respondents in SA (123/174, 70.7%) than in India (38/104, 36.5%) involved in antimicrobial prescribing.Respondents reported increased IPC practices since the pandemic and noted a need for more training on case management, antibiotic and personal protective equipment (PPE) use. While they noted increased antibiotic prescribing since the pandemic, they did not generally associate their practice with such an increase. A willingness to be vaccinated, when vaccination becomes available, was expressed by 203/258 (78.7%) respondents. Conclusions: HCWs reported improved IPC practices and changes in antibiotic prescribing during the COVID-19 pandemic. Targeted education on correct use of PPE was an identified gap. Although HCWs expressed concerns about antimicrobial resistance, their self-perceived antibiotic prescribing practices seemed unchanged. Additional studies in other settings could explore how our findings fit other contexts.
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INTRODUCTION: Postoperative infections represent a significant burden of disease, demanding antibiotic prescriptions, and are contributing to antimicrobial resistance. The burden of infection as a surgical complication is greater in low- and middle-income countries (LMICs). We report the protocol of a pilot study for the co-design, implementation and evaluation of two infection prevention and control (IPC) and antimicrobial stewardship (AMS) interventions across the surgical pathway in a teaching hospital in India. METHODS AND ANALYSIS: The two interventions developed following in-depth qualitative enquiry are (i) surveillance and feedback of postoperative infections to optimise the use of antibiotics in two surgical departments (gastrointestinal and cardiovascular and thoracic surgery) and (ii) raising awareness amongst patients, carers and members of public about IPC and AMS. We will conduct a prospective study, formatively evaluating the implementation process of delivering the two co-designed interventions using implementation science frameworks. The study will systematically assess the context of intervention delivery, so that implementation support for the interventions may be adapted to the needs of stakeholders throughout the study. Analysis of implementation logs and interviews with stakeholders upon completion of the implementation period, will offer insights into the perceived acceptability, appropriateness, feasibility and sustainability of the interventions and their implementation support. Implementation costs will be captured descriptively. Feasibility of clinical data collection to investigate effectiveness of interventions will also be assessed for a future larger study. Thematic framework analysis and descriptive statistics will be used to report the qualitative and quantitative data, respectively. STRENGTHS AND LIMITATIONS OF THIS STUDY: ⢠The paired interventions have been co-designed from their inception with involvement of stakeholders at different stages in the surgical pathway. ⢠Simultaneous evaluation of implementation and clinical outcomes will inform the development of a future larger study to enable/assess the scalability of interventions ⢠The study offers a novel combination of implementation theory-informed, stakeholder-driven and clinically relevant evaluation, carried out in the context of a middle-income country hospital. ⢠The project may not be applicable to every low-resource setting and surgical context due to differences in healthcare systems and cultures. However, the application of implementation science concepts may facilitate transferability and adaptation to other settings.
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BACKGROUND: Non-Communicable Diseases (NCDs) constitute a significant danger to the nation's public health system, both in terms of morbidity and mortality, as well as the financial burden they inflict. Kerala is undergoing an epidemiologic transition, which has significantly impacted the state's morbidity and mortality figures. For decades, the state has been putting in place myriad programs to reduce the burden of NCDs across population groups. Socioeconomic inequalities in NCD testing have been documented in India, although they are understudied in Kerala. The study aimed to estimate and characterize districtwise socioeconomic inequality in Blood Pressure (BP) and Blood Glucose (BG) testing. METHODS: A cross-sectional household survey was conducted between July-October 2019 in Kasaragod, Alappuzha, Kollam and Thiruvananthapuram districts of Kerala, India. A total of 6383 participants aged 30 years and above were interviewed using multistage random sampling. Descriptive statistics were derived district-wise. We computed ratios, differences, equiplots, and Erreygers concentration indices for each district to measure socioeconomic inequality in BP and BG testing. Erreygers decomposition techniques were used to estimate the relative contribution of covariates to socioeconomic inequality. RESULTS: There was a significant concentration of BP and BG testing favouring wealthier quintiles in Alappuzha, Kollam, and Thiruvananthapuram districts. The inequality in BP and BG testing was highest in Thiruvananthapuram (0.087 and 0.110), followed by Kollam (0.077 and 0.090), Alappuzha (0.083 and 0.073) and Kasaragod (0.026 and 0.056). Decomposition analysis revealed that wealth quintile and education contributed substantially to socioeconomic inequality in BP and BG testing in all four districts. It was also found that family history of NCDs significantly contributed to observed socioeconomic inequality in BP testing (29, 11, 16, and 27% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram, respectively). Similarly, in BG testing, family history of NCDs substantially contributed to observed socioeconomic inequality, explaining 16-17% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram respectively of the total inequality. CONCLUSION: While the magnitude of socioeconomic inequality in NCD risk factor testing did not appear to be very high in four Kerala districts, although levels were statistically significant in three of them. Greater exploration is needed on how education and caste contribute to these inequalities and their relationship to NCD risk factors such as family history. From such analyses, we may be able to identify entry points to mitigate inequalities in testing access, as well as burden.
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Glicemia , Doenças não Transmissíveis , Pressão Sanguínea , Estudos Transversais , Escolaridade , Humanos , ÍndiaRESUMO
OBJECTIVES: We investigated the roles of patient carers in infection-related care on surgical wards in a South Indian hospital from the perspective of healthcare workers (HCWs), patients, and their carers. METHODS: Ethnographic study included ward-round observations (138 hours) and face-to-face interviews (44 HCWs, 6 patients/carers). Data (field notes, interview transcripts) were coded in NVivo 12 and thematically analyzed. Data collection and analysis were iterative, recursive, and continued until thematic saturation. RESULTS: Carers have important, unrecognized roles. At the study site, institutional expectations are formalized in policies, demanding a carer to always accompany in-patients. Such intense presence embeds families in the patient care environment, as demonstrated by their high engagement in direct personal (bathing patients) and clinical care (wound care). Carers actively participate in discussions on patient progress with HCWs, including therapeutic options. There is a misalignment between how carers are positioned by the organization (through policy mandates, institutional practices, and HCWs expectations), and the role that they play in practice, resulting in their role, though indispensable, remaining unrecognized. CONCLUSION: Current models of patient and carer involvement in infection prevention and control are poorly aligned with sociocultural and contextual aspects of care. Culture-sensitive infection prevention and control policies which embrace the roles that carers play are urgently needed.
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Cuidadores , Pessoal de Saúde , Hospitais , HumanosRESUMO
This article summarizes the consequences of the COVID-19 pandemic, on an international project to tackle antimicrobial resistance (AMR). The research leadership and process, the access to data, and stakeholders were deeply disrupted by the national and international response to the pandemic, including the interruption of healthcare delivery, lockdowns, and quarantines. The key principles to deliver the research through the pandemic were mainly the high degree of interdisciplinary engagement with integrated teams, and equitable partnership across sites with capacity building and leadership training. The level of preexisting collaboration and partnership were also keys to sustaining connections and involvements throughout the pandemic. The pandemic offered opportunities for realigning research priorities. Flexibility in funding timelines and projects inputs are required to accommodate variance introduced by external factors. The current models for research collaboration and funding need to be critically evaluated and redesigned to retain the innovation that was shown to be successful through this pandemic.
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COVID-19 , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Controle de Doenças Transmissíveis , Países em Desenvolvimento , Farmacorresistência Bacteriana , Humanos , Pandemias , PesquisaRESUMO
BACKGROUND: Whilst antimicrobial stewardship (AMS) is being implemented globally, contextual differences exist. We describe how the use of a massive open online course (MOOC) platform provided an opportunity to gather diverse narratives on AMS from around the world. METHODS: A free 3 week MOOC titled 'Tackling antimicrobial resistance: a social science approach' was launched in November 2019. Learners were asked specific questions about their experiences of AMS via 38 optional free-text prompts dispersed throughout the modules. Content analysis was used to identify key emerging themes from the learners' responses in the first three runs of the MOOC. RESULTS: Between November 2019 and July 2020, 1464 learners enrolled from 114 countries. Overall, 199 individual learners provided a total of 1097 responses to the prompts. The diverse perspectives describe unique challenges present in different contexts including ill-defined roles for pharmacists and nurses in AMS; inadequate governance and policy inconsistencies in surveillance for antibiotic consumption and antimicrobial resistance (AMR) in some countries; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties; and human resource and technological constraints. Patients' knowledge, experiences and perspectives were recognized as a valuable source of information that should be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics. CONCLUSIONS: Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician healthcare workers, resource limitations, gaps in knowledge of AMR, and patient engagement and involvement in AMS.
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OBJECTIVE: To explore the existing evidence on patient understanding of and/or participation in infection-related care in surgical specialties. METHOD: A scoping review of the literature was conducted. PubMed, Web of Science, Scopus, and grey literature sources were searched using predefined search criteria for policies, guidelines, and studies in the English language. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. RESULTS: The initial search identified 604 studies, of which 41 (36 from high-income and five from low- and middle-income countries) were included in the final review. Most of the included studies focused on measures to engage patients in infection prevention and control (IPC) activities, with few examples of antimicrobial stewardship (AMS) engagement strategies. While patient engagement interventions in infection-related care varied depending on study goals, surgical wound management was the most common intervention. AMS engagement was primarily limited to needs assessment, without follow-up to address such needs. CONCLUSION: Existing evidence highlights a gap in patient participation in infection-related care in the surgical pathway. Standardization of patient engagement strategies is challenging, particularly in the context of surgery, where several factors influence how the patient can engage and retain information. Infection-related patient engagement and participation strategies in surgery need to be inclusive and contextually fit.
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Gestão de Antimicrobianos , Humanos , Controle de Infecções , Avaliação das NecessidadesRESUMO
OBJECTIVES: To investigate the drivers for infection management and antimicrobial stewardship (AMS) across high-infection-risk surgical pathways. METHODS: A qualitative study-ethnographic observation of clinical practices, patient case studies, and face-to-face interviews with healthcare professionals (HCPs) and patients-was conducted across cardiovascular and thoracic and gastrointestinal surgical pathways in South Africa (SA) and India. Aided by Nvivo 11 software, data were coded and analysed until saturation was reached. The multiple modes of enquiry enabled cross-validation and triangulation of findings. RESULTS: Between July 2018 and August 2019, data were gathered from 190 hours of non-participant observations (138 India, 72 SA), interviews with HCPs (44 India, 61 SA), patients (six India, eight SA), and case studies (four India, two SA). Across the surgical pathway, multiple barriers impede effective infection management and AMS. The existing implicit roles of HCPs (including nurses and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating infection-related care across the surgical team. Critically, the ownership of decisions remains with the operating surgeons, and entrenched hierarchies restrict the inclusion of other HCPs in decision-making. The structural foundations to enable staff to change their behaviours and participate in infection-related surgical care are lacking. CONCLUSIONS: Identifying the implicit existing HCP roles in infection management is critical and will facilitate the development of effective and transparent processes across the surgical team for optimized care. Applying a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads, is essential for integrated AMS and infection-related care.
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Gestão de Antimicrobianos , Procedimentos Cirúrgicos Cardiovasculares , Procedimentos Cirúrgicos do Sistema Digestório , Procedimentos Cirúrgicos Torácicos , Pessoal de Saúde , Humanos , Índia , Controle de Infecções , Pesquisa Qualitativa , África do Sul , CirurgiõesRESUMO
Adaptation to changing environmental conditions is crucial for the survival of microorganisms. Bacteria have evolved various mechanisms to cope with osmotic stress. Here, we report the identification and functional characterization of the osmotic stress response operon, betIBA, in Acinetobacter nosocomialis. The betIBA operon encodes enzymes that are important for the conversion of choline to the osmoprotectant, glycine betaine. The betIBA operon is polycistronic and is under the regulation of the first gene, betI, of the same operon. A bioinformatics analysis revealed the presence of a BetI-binding motif upstream of the betIBA operon, and electrophoretic mobility shift assays confirmed the specific binding of BetI. An mRNA expression analysis revealed that expression of betI, betB, and betA genes is elevated in a betI-eletion mutant compared with the wild type, confirming that the autorepressor BetI represses the betIBA operon in A. nosocomialis. We further found that the betIBA operon is under the transcriptional control of the quorum-sensing (QS) regulator, AnoR in, A. nosocomialis. A subsequent analysis of the impact of BetI on expression of the QS genes, anoR and anoI, demonstrated that BetI acts as a repressor of anoR and anoI. In addition, it was noticed that the osmotic stress response regulator, OmpR might play an important role in controlling the expression of betIBA operon in A. nosocomialis. Collectively, these data demonstrate that QS and osmotic stress-response systems are correlated in A. nosocomialis and that the expression of genes in both systems is finely tuned by various feedback loops depending on osmolarity conditions.
Assuntos
Acinetobacter/metabolismo , Proteínas de Bactérias/metabolismo , Óperon , Percepção de Quorum , Proteínas Repressoras/metabolismo , Acinetobacter/genética , Regulação Bacteriana da Expressão Gênica , OsmorregulaçãoRESUMO
Multidrug efflux pumps play an important role in antimicrobial resistance and pathogenicity in bacteria. Here, we report the functional characterization of the RND (resistance-nodulation- division) efflux pump, AcrAB, in Acinetobacter nosocomialis. An in silico analysis revealed that homologues of the AcrAB efflux pump, comprising AcrA and AcrB, are widely distributed among different bacterial species. Deletion of acrA and/or acrB genes led to decreased biofilm/pellicle formation and reduced antimicrobial resistance in A. nosocomialis. RNA sequencing and mRNA expression analyses showed that expression of acrA/B was downregulated in a quorum sensing (QS) regulator (anoR)-deletion mutant, indicating transcriptional activation of the acrAB operon by AnoR in A. nosocomialis. Bioassays showed that secretion of N-acyl homoserine lactones (AHLs) was unaffected in acrA and acrB deletion mutants; however, AHL secretion was limited in a deletion mutant of acrR, encoding the acrAB regulator, AcrR. An in silico analysis indicated the presence of AcrR-binding motifs in promoter regions of anoI (encoding AHL synthase) and anoR. Specific binding of AcrR was confirmed by electrophoretic mobility shift assays, which revealed that AcrR binds to positions -214 and -217 bp upstream of the translational start sites of anoI and anoR, respectively, demonstrating transcriptional regulation of these QS genes by AcrR. The current study further addresses the possibility that AcrAB is controlled by the osmotic stress regulator, OmpR, in A. nosocomialis. Our data demonstrate that the AcrAB efflux pump plays a crucial role in biofilm/pellicle formation and antimicrobial resistance in A. nosocomialis, and is under the transcriptional control of a number of regulators. In addition, the study emphasizes the interrelationship of QS and AcrAB efflux systems in A. nosocomialis.
Assuntos
Acinetobacter/fisiologia , Proteínas de Bactérias/fisiologia , Proteínas Associadas à Resistência a Múltiplos Medicamentos/fisiologia , Percepção de QuorumRESUMO
BACKGROUND: Acinetobacter has emerged recently as one of the most challenging nosocomial pathogens because of its increased rate of antimicrobial resistance. The genetic complexity and genome diversity, as well as the lack of adequate knowledge on the pathogenic determinants of Acinetobacter strains often hinder with pathogenesis studies for the development of better therapeutics to tackle this nosocomial pathogen. OBJECTIVES: In this study, we comparatively analyzed the whole genome sequence of a virulent Acinetobacternosocomialis strain NCTC 8102. METHODS: The genomic DNA of A. nosocomialis NCTC 8102 was isolated and sequenced using PacBio RS II platform. The sequenced genome was functionally annotated and gene prediction was carried out using the program, Glimmer 3. The phylogenetic analysis of the genome was performed using Mega 6 program and the comparative genome analysis was carried out by BLAST (Basic Local Alignment Search Tool). RESULTS: The complete genome analysis depicted that the genome consists of a circular chromosome with an average G + C content of 38.7%. The genome comprises 3700 protein-coding genes, 96 RNA genes (18 rRNA, 74 tRNA and 4 ncRNA genes), and 91 pseudogenes. In addition, 6 prophage regions comprising 2 intact, 1 incomplete and 3 questionable ones and 18 genomic islands were identified in the genome, suggesting the possible occurrence of horizontal gene transfer in this strain. Comparative genome analysis of A. nosocomialis NCTC 8102 genome with the already sequenced A. nosocomialis strain SSA3 showed an average nucleotide identity of 99.0%. In addition, the number of prophages and genomic islands were higher in the A. nosocomialis NCTC 8102 genome compared to that of the strain SSA3. 14 of the genomic islands were unique to A. nosocomialis NCTC 8102 compared to strain SSA3 and they harbored genes which are involved in virulence, multidrug resistance, biofilm formation and bacterial pathogenesis. CONCLUSION: We sequenced the whole genome of A. nosocomialis strain NCTC 8102 followed by comparatively genome analysis. The study provides valuable information on the genetic features of A. nosocomialis strain and the data from this study would assist in further studies for the development of control measures for this nosocomial pathogen.