Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries.

BACKGROUND: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Stillbirth rates and their determinants in a national maternity hospital in Phnom Penh, Cambodia in 2017-2020: a cross-sectional assessment with a nested case-control study.

BACKGROUND: In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts. METHODS: This was a retrospective cross-sectional analysis with a nested case-control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017-2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age. RESULTS: Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case-control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5). CONCLUSIONS: Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases.

In Cambodia, there is very little information published on stillbirths to know precisely how many there are and to understand the underlying reasons they occur so they can be prevented in the future. Our study aimed to quantify the number of stillborn babies and identify some underlying risk factors from one of the largest maternity referral hospitals in Phnom Penh, Cambodia. We examined data from almost 30,000 health facility medical files of women who gave birth between 2017 and 2020 which included 938 stillbirths. We found that about 3.2% of births ended in a stillbirth and that this percentage increased between 2017 and 2020. Women who had preterm babies, or whose babies were small in weight for their gestational age, and babies that were born breech had a higher chance of being stillborn. Women who had abnormal vaginal discharge, which can indicate a possible infection, also had a higher odds of having a stillbirth. We also found that women who had a stillbirth previously had almost three times higher chance of having another stillborn baby. Having a caesarean section reduced the likelihood of having a stillborn baby by about half. These findings suggest that efforts are needed to better identify and manage women with preterm births and monitor fetal growth as well as ensure breech births are managed adequately.

Enabling factors and barriers to the sustainability and scale-up of drowning reduction interventions in Vietnam: a qualitative assessment.

BACKGROUND: Vietnam has some of the highest rates of drowning deaths in the Western Pacific Region, particularly among children aged 19 years or younger. Several policies aimed at drowning prevention have been developed over the last decade; however, despite policy support, generally these have not been sustained beyond a pilot phase or have been limited to small geographical regions. The present study aims to explore barriers and facilitators for sustainability and scale-up of drowning prevention initiatives in Vietnam, identifying ways forward for future implementation. METHODS: This was a qualitative study using semistructured indepth interviews with key stakeholders (n=12) engaged in drowning prevention in Vietnam. The Framework Method was used to analyse the data drawing on Schell's theoretical framework for public health programme sustainability. The Framework Method is most commonly used for the thematic analysis of semistructured interview transcripts, particularly as the data were fairly homogeneous. RESULTS: Four key factors were identified that facilitated implementation of drowning reduction activities in Vietnam. Strong political support at all levels, underpinned by policy; effective partnerships with the community; widespread communication; and programme adaptation to local contexts and application of innovative approaches, for example, strengthening organisational capacity in limited resource settings, were the key enablers. Barriers include the instability of the funding sources; inadequate programme evaluations to generate evidence of effectiveness and lack of consistent and timely data collection; and insufficient strategic planning for long-term implementation of drowning prevention interventions. CONCLUSION: Ensuring the sustainability and scale-up of drowning prevention programmes in Vietnam requires a continued focus on enablers such as on community engagement, communication activities and partnership approaches, and importantly concerted efforts to mobilise resources for continued long-term funding, improvements in planning and intersectoral coordination, and ensuring that future programmes are robustly evaluated for effectiveness.

Potential for establishing an injury surveillance system in India: a review of data sources and reporting systems.

BACKGROUND: Unintentional injuries account for 10% of deaths worldwide; the majority due to road traffic injuries, falls, drowning, poisoning and burns. Effective surveillance systems provide evidence for informed injury prevention and treatment and improve recovery outcomes. Our objectives were to review existing sources of unintentional injury data, and quality of the data on the burden, distribution, risk factors and trends of unintentional injuries in India and to describe strengths and limitations of health facility-based data for potential use in injury surveillance systems. METHODS: We searched national and international organisations' websites to identify unintentional injury-related mortality and morbidity data sources in India. We reviewed and evaluated data collection methods for surveillance attributes recommended by World Health Organization (WHO). We visited health facilities at all levels from public and private sectors, emergency transport centres, insurance offices and police stations in settings reporting significant number of injuries. In these sites, we interviewed key stakeholders using an explorative approach on current data collection processes and challenges to establishing an injury surveillance system based on WHO guidelines. RESULTS: Major gaps were highlighted in injury mortality and morbidity data in India, including ill-defined causes of injury deaths and lack of standardisation in classification and coding. Site visits revealed that reporting standards of injuries varied, with issues around clarity of definitions, accountability, time points and lack of reporter/coder training. Major challenges were lack of dedicated staff and training. CONCLUSIONS: There is an important need to build human resource capacity, integrate data sources, standardise and streamline data collected, ensure accountability and capitalise on digital health information systems including insurance databases.

Understanding country-specific determinants of stillbirth using household surveys: The case of Afghanistan.

BACKGROUND: Stillbirth rates in Afghanistan have declined little in the past decade with no data available on key risk factors. Health care utilisation and maternal complications are important factors influencing pregnancy outcomes but rarely captured for stillbirth in national surveys from low- and middle-income countries. The 2010 Afghanistan Mortality Survey (AMS) is one of few surveys with this information. METHODS: We used data from the 2010 AMS that included a full pregnancy history and verbal autopsy. Our sample included the most recent live birth or stillbirth of 13 834 women aged 12-49 years in the three years preceding the survey. Multivariable Poisson regression was used to identify sociodemographic, maternal, and health care utilisation risk factors for stillbirth. RESULTS: The risk of stillbirth was increased among women in the Central Highlands (aRR: 3.01, 95% CI 1.35, 6.70) and of Nuristani ethnicity (aRR: 9.15, 95% CI 2.95, 28.74). Women who did not receive antenatal care had three times increased risk of stillbirth (aRR: 3.03, 95% CI 1.73, 5.30), while high-quality antenatal care was important for reducing the risk of intrapartum stillbirth. Bleeding, infection, headache, and reduced fetal movements were antenatal complications strongly associated with stillbirth. Reduced fetal movements in the delivery period increased stillbirth risk by almost seven (aRR: 6.82, 95% CI 4.20, 11.10). Facility births had a higher risk of stillbirths overall (aRR: 1.55, 95% CI 1.12, 2.16), but not for intrapartum stillbirths. CONCLUSIONS: Targeted interventions are needed to improve access and utilisation of services for high-risk groups. Early detection of complications through improved quality of antenatal and obstetric care is imperative. We demonstrate the potential of household surveys to provide country-specific evidence on stillbirth risk factors for LMICs where data are lacking.

Beyond counting stillbirths to understanding their determinants in low- and middle-income countries: a systematic assessment of stillbirth data availability in household surveys.

OBJECTIVE: To systematically map data availability for stillbirths from all countries with Demographic and Health Surveys (DHS) surveys to outline the limitations and challenges with using the data for understanding the determinants and causes of stillbirths, and for cross-country comparisons. METHODS: We assessed data sources from the DHS programme website, including published DHS reports and their associated questionnaires for surveys completed between 2005 and 2015. RESULTS: Between 2005 and 2015, the DHS programme completed 114 surveys across 70 low- and middle-income countries. Ninety-eight (86.0%) surveys from 66 countries collected stillbirth data adequately to calculate a stillbirth rate, while 16 surveys from 12 countries did not. The method used to count stillbirths varied; 96 (84.2%) surveys used a live birth history with a reproductive calendar, while 16 (14.0%) surveys from 12 countries did a full pregnancy history. Based on assessment of questionnaires, antenatal and delivery care information for stillbirths was only available in 15 surveys (13.2%) from 12 countries (17.1%). Data on maternal conditions/complications were captured in 17 surveys (16.0%), but only in six could these be linked to stillbirths. Data on other recognised risk factors were scarce, varying considerably across surveys. Upon further examination of data sets from surveys with maternity care data on non-live births, we found incomplete capture of these data; only two surveys had adequately and completely collected these for stillbirths. CONCLUSION: Substantial variation exists in DHS surveys in the measurement of stillbirths, with limited scope to examine risk factors or causes. Without immediate improvements, our understanding of country-specific trends and determinants for stillbirths will remain hampered, limiting the development and prioritisation of programmatic interventions to prevent these deaths.

Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh.

In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladesh's approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.

Travelling numbers and broken loops: A qualitative systematic review on collecting and reporting maternal and neonatal health data in low-and lower-middle income countries.

Data and indicator estimates are considered vital to document persisting challenges in maternal and newborn health and track progress towards global goals. However, prioritization of standardised, comparable quantitative data can preclude the collection of locally relevant information and pose overwhelming burdens in low-resource settings, with negative effects on the provision of quality of care. A growing body of qualitative studies aims to provide a place-based understanding of the complex processes and human experiences behind the generation and use of maternal and neonatal health data. We conducted a qualitative systematic review exploring how national or international requirements to collect and report data on maternal and neonatal health indicators are perceived and experienced at the sub-national and country level in low-income and lower-middle income countries. We systematically searched six electronic databases for qualitative and mixed-methods studies published between January 2000 and March 2023. Following screening of 4084 records by four reviewers, 47 publications were included in the review. Data were analysed thematically and synthesised from a Complex Adaptive Systems (CAS) theoretical perspective. Our findings show maternal and neonatal health data and indicators are not fixed, neutral entities, but rather outcomes of complex processes. Their collection and uptake is influenced by a multitude of system hardware elements (human resources, relevancy and adequacy of tools, infrastructure, and interoperability) and software elements (incentive systems, supervision and feedback, power and social relations, and accountability). When these components are aligned and sufficiently supportive, data and indicators can be used for positive system adaptivity through performance evaluation, prioritization, learning, and advocacy. Yet shortcomings and broken loops between system components can lead to unforeseen emergent behaviors such as blame, fear, and data manipulation. This review highlights the importance of measurement approaches that prioritize local relevance and feasibility, necessitating participatory approaches to define context-specific measurement objectives and strategies.

Uncovering community needs regarding violence against women and girls in southern Ethiopia: An explorative study.

BACKGROUND: Violence against women and girls (VAWG) is a significant global public health problem and a violation of human rights experienced by one in three women worldwide. This study explores community perceptions of and responses to VAWG and challenges in accessing support services among female violence survivors in Arbaminch City. METHODS: We adopted a phenomenological explorative qualitative study design. A total of 62 participants including female violence survivors, religious leaders, service providers, police, women, and men in participated in interviews, focus group discussions, and observations in August 2022. Participants were selected purposively, and the findings were analyzed thematically. We applied data source and respondent triangulation to increase the findings' trustworthiness. RESULTS: Community perceptions of VAWG, specifically of intimate partner violence (IPV) and non-partner sexual violence (NPSV), varied depending on gender, age, and social position. IPV and NPSV were normalized through tolerance and denial by young and married men, while resistance to all forms of violence was common among women. Survivors of violence responded to the act of violence by leaving their homes, separating from their husbands, or taking harsh actions against their husbands, such as murder. Support for VAWG survivors was available through health care, free legal services, and a temporary shelter. Yet factors ranging from individual to societal levels, such as fear, lack of knowledge, lack of family and community support, and social and legal injustice, were barriers to accessing existing services. Nonetheless, violence survivors desired to speak about their experiences and seek psychosocial support. CONCLUSIONS: Our qualitative evidence gathered here can inform tailored VAWG prevention and response services such as interventions to shift social norms and the perception towards VAWG among different population group through raising awareness in schools, health care settings, faith-based venues, and using social media.

Missed opportunities in educating Aboriginal Australians about bowel cancer screening: whose job is it anyway?

BACKGROUND: A culturally relevant educational flipchart targeting Aboriginal people was distributed across Western Australia to support education on bowel cancer screening and encourage participation in the National Bowel Cancer Screening Program. METHODS: Respondents sampled from the flipchart distribution list were surveyed on the appropriateness, usefulness, and the extent to and manner in which they used the flipchart for educating Aboriginal clients. RESULTS: Despite praising the resource, few respondents used the flipchart as intended for various reasons, including the view that Aboriginal health education was the responsibility of Aboriginal health workers. CONCLUSIONS: Greater recognition by all health service providers is needed of their potential role in Aboriginal health education. Promoting a national health program of under-appreciated importance for a marginalised population is challenging. Effective utilisation of an educational tool is predicated on factors beyond its production quality and wide dissemination. Intended users require awareness of the underlying problem, and adequate time for and specific training in implementation of the tool.

Out of sight, out of mind? Evidence from cross-sectional surveys on hidden caesarean sections among women with stillbirths in Ghana, 2007 and 2017.

BACKGROUND: Caesarean section (CS) rates in women experiencing stillbirth have not been studied with nationally representative data. Two Ghana Maternal Health Surveys (GMHS) have captured pregnancy and mode of birth data for all women including those with stillbirths. We compared CS rates between women with live births and stillbirths, and identified socio-economic and pregnancy-related factors associated with CS in stillbirths. METHODS: A population-based cross-sectional study was conducted in a pooled sample of 17 138 women who had given birth within 5 years preceding the 2007 and 2017 GMHS. CS rates were compared between women with stillbirths and very early neonatal deaths (SBVENDs) and women with live births who survived the first day. Bivariate and multivariable logistic regressions explored variables associated with CS. Effect modification of household's wealth and maternal educational level by birth outcome was assessed using multivariable logistic regression with interaction terms. RESULTS: CS rate in women with SBVEND was 19.3% compared with 9.6% in women with live births who survived the first day (rate ratio 2.2; 95% CI 1.6 to 2.9). In multivariable analysis, attaining middle school compared with no formal education (adjusted OR, aOR 2.8; 95% CI 1.1 to 7.1), having had five or more births compared with nulliparity (aOR 3.7; 95% CI 1.3 to 10.7) and reporting prolonged or obstructed labour (aOR 3.3; 95% CI 1.3 to 8.3) were associated with CS in women with SBVEND. Higher household wealth and educational levels were associated with an increased risk of CS in both study groups, with no statistically significant difference in effect. CONCLUSION: Disaggregating CS rates by birth outcome revealed a high rate among women with SBVEND, twice the overall rate compared with live births. Exclusion of these 'hidden' CSs from rate calculations may lead to underestimation of (inter)national CS rates and potentially conceals CS overuse or misuse.

Neonatal and perinatal mortality in the urban continuum: a geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania.

INTRODUCTION: Recent studies suggest that the urban advantage of lower neonatal mortality in urban compared with rural areas may be reversing, but methodological challenges include misclassification of neonatal deaths and stillbirths, and oversimplification of the variation in urban environments. We address these challenges and assess the association between urban residence and neonatal/perinatal mortality in Tanzania. METHODS: The Tanzania Demographic and Health Survey (DHS) 2015-2016 was used to assess birth outcomes for 8915 pregnancies among 6156 women of reproductive age, by urban or rural categorisation in the DHS and based on satellite imagery. The coordinates of 527 DHS clusters were spatially overlaid with the 2015 Global Human Settlement Layer, showing the degree of urbanisation based on built environment and population density. A three-category urbanicity measure (core urban, semi-urban and rural) was defined and compared with the binary DHS measure. Travel time to the nearest hospital was modelled using least-cost path algorithm for each cluster. Bivariate and multilevel multivariable logistic regression models were constructed to explore associations between urbanicity and neonatal/perinatal deaths. RESULTS: Both neonatal and perinatal mortality rates were highest in core urban and lowest in rural clusters. Bivariate models showed higher odds of neonatal death (OR=1.85; 95% CI 1.12 to 3.08) and perinatal death (OR=1.60; 95% CI 1.12 to 2.30) in core urban compared with rural clusters. In multivariable models, these associations had the same direction and size, but were no longer statistically significant. Travel time to the nearest hospital was not associated with neonatal or perinatal mortality. CONCLUSION: Addressing high rates of neonatal and perinatal mortality in densely populated urban areas is critical for Tanzania to meet national and global reduction targets. Urban populations are diverse, and certain neighbourhoods or subgroups may be disproportionately affected by poor birth outcomes. Research must capture, understand and minimise risks specific to urban settings.

Explanatory models of stillbirth among bereaved parents in Afghanistan: Implications for stillbirth prevention.

Local perceptions and understanding of the causes of ill health and death can influence health-seeking behaviour and practices in pregnancy. We aimed to understand individual explanatory models for stillbirth in Afghanistan to inform future stillbirth prevention. This was an exploratory qualitative study of 42 semi-structured interviews with women and men whose child was stillborn, community elders, and healthcare providers in Kabul province, Afghanistan between October-November 2017. We used thematic data analysis framing the findings around Kleinman's explanatory framework. Perceived causes of stillbirth were broadly classified into four categories-biomedical, spiritual and supernatural, extrinsic factors, and mental wellbeing. Most respondents attributed stillbirths to multiple categories, and many believed that stillbirths could be prevented. Prevention practices in pregnancy aligned with perceived causes and included engaging self-care, religious rituals, superstitious practices and imposing social restrictions. Symptoms preceding the stillbirth included both physical and non-physical symptoms or no symptoms at all. The impacts of stillbirth concerned psychological effects and grief, the physical effect on women's health, and social implications for women and how their communities perceive them. Our findings show that local explanations for stillbirth vary and need to be taken into consideration when developing health education messages for stillbirth prevention. The overarching belief that stillbirth was preventable is encouraging and offers opportunities for health education. Such messages should emphasise the importance of care-seeking for problems and should be delivered at all levels in the community. Community engagement will be important to dispel misinformation around pregnancy loss and reduce social stigma.

How has Guinea learnt from the response to outbreaks? A learning health system analysis.

INTRODUCTION: Learning is a key attribute of a resilient health system and, therefore, is central to health system strengthening. The main objective of this study was to analyse how Guinea's health system has learnt from the response to outbreaks between 2014 and 2021. METHODS: We used a retrospective longitudinal single embedded case study design, applying the framework conceptualised by Sheikh and Abimbola for analysing learning health systems. Data were collected employing a mixed methods systematic review carried out in March 2022 and an online survey conducted in April 2022. RESULTS: The 70 reports included in the evidence synthesis were about the 2014-2016 Ebola virus disease (EVD), Measles, Lassa Fever, COVID-19, 2021 EVD and Marburg virus disease. The main lessons were from 2014 to 2016 EVD and included: early community engagement in the response, social mobilisation, prioritising investment in health personnel, early involvement of anthropologists, developing health infrastructure and equipment and ensuring crisis communication. They were learnt through information (research and experts' opinions), action/practice and double-loop and were progressively incorporated in the response to future outbreaks through deliberation, single-loop, double-loop and triple-loop learning. However, advanced learning aspects (learning through action, double-loop and triple-loop) were limited within the health system. Nevertheless, the health system successfully controlled COVID-19, the 2021 EVD and Marburg virus disease. Survey respondents' commonly reported that enablers were the creation of the national agency for health security and support from development partners. Barriers included cultural and political issues and lack of funding. Common recommendations included establishing a knowledge management unit within the Ministry of Health with representatives at regional and district levels, investing in human capacities and improving the governance and management system. CONCLUSION: Our study highlights the importance of learning. The health system performed well and achieved encouraging and better outbreak response outcomes over time with learning that occurred.

Colorectal cancer screening knowledge, attitudes and behavioural intention among Indigenous Western Australians.

BACKGROUND: Indigenous Australians are significantly less likely to participate in colorectal cancer (CRC) screening compared to non-Indigenous people. This study aimed to identify important factors influencing the decision to undertake screening using Faecal Occult Blood Testing (FOBT) among Indigenous Australians. Very little evidence exists to guide interventions and programmatic approaches for facilitating screening uptake in this population in order to reduce the disparity in colorectal cancer outcomes. METHODS: Interviewer-administered surveys were carried out with a convenience sample (n = 93) of Indigenous Western Australians between November 2009-March 2010 to assess knowledge, awareness, attitudes and behavioural intent in regard to CRC and CRC screening. RESULTS: Awareness and knowledge of CRC and screening were low, although both were significantly associated with exposure to media advertising (p = 0.008; p < 0.0001). Nearly two-thirds (63%; 58/92) of respondents reported intending to participate in screening, while a greater proportion (84%; 77/92) said they would participate on a doctor's recommendation. Multivariate analysis with logistic regression demonstrated that independent predictors of screening intention were, greater perceived self-efficacy (OR = 19.8, 95% CI = 5.5-71.8), a history of cancer screening participation (OR = 6.8, 95% CI = 2.0-23.3) and being aged 45 years or more (OR = 4.5, 95% CI = 1.2-16.5). A higher CRC knowledge score (medium vs. low: OR = 9.9, 95% CI = 2.4-41.3; high vs. low: 13.6, 95% CI = 3.4-54.0) and being married or in a de-facto relationship (OR = 6.9, 95% CI = 2.1-22.5) were also identified as predictors of intention to screen with FOBT. CONCLUSIONS: Improving CRC related knowledge and confidence to carry out the FOBT self-screening test through education and greater promotion of screening has the potential to enhance Indigenous participation in CRC screening. These findings should guide the development of interventions to encourage screening uptake and reduce bowel cancer related deaths among Indigenous Australians.

'I should have seen her face at least once': parent's and healthcare providers' experiences and practices of care after stillbirth in Kabul province, Afghanistan.

OBJECTIVE: This study aimed to explore bereaved parents' and healthcare providers experiences of care after stillbirth. STUDY DESIGN: Qualitative in-depth interviews with 55 women, men, female elders, healthcare providers and key informants in Kabul province, Afghanistan between October and November 2017. RESULTS: Inadequate and insensitive communication and practices by healthcare providers, including avoiding or delaying disclosing the stillbirth were recurring concerns. There was a disconnect between parents' desires and healthcare provider's perceptions. The absence of shared decision-making on seeing and holding the baby and memory-making, manifested as profound regret. Health providers' reported hospitals were not equipped to separate women who had a stillbirth and acknowledged that psychological support would be beneficial. However, the absence of trained personnel and resource constraints prevented provision of such support. CONCLUSION: Findings can inform future provision of perinatal bereavement care. Given resource constraints, communication training can be considered with longer term goals to develop context-appropriate bereavement care guidelines.

Challenges in Documenting Non-Fatal Drowning Disability in Bangladesh: A Community-Based Survey.

Limited access to health care and the lack of robust data systems means non-fatal drownings are largely missed in low-and middle-income countries. We report morbidity among individuals who experienced non-fatal drowning in the Barishal Division, Bangladesh. A representative household survey was conducted in the Barishal Division in southern Bangladesh between September 2016 and February 2017, covering a population of 386,016. The burden of non-fatal drowning was assessed using the WHODAS 2.0 disability assessment tool, a generic assessment instrument for health and disability. A total of 5164 non-fatal drowning events occurred in the one year preceding the survey. Among these 18% were multiple events. From these, 4235 people were administered the WHODAS 2.0 questionnaire. Non-fatal drowning incidence rates were highest in children aged 1-4 years at 5810 per 100,000 population, and among males. Non-fatal drowning was associated with lower socio-economic status and larger family sizes. Few respondents (6.5%; 95% CI: 4.5-8.4%) reported some level of disability (WHODAS-12 score > 8). Incidence of non-fatal drowning is high in the population, however limited impact on morbidity was found. There is a need to develop tools and methodologies for reliable and comparable data for non-fatal drowning, especially to capture post-event disability in children.

Elevated Dnmt3a activity promotes polyposis in Apc(Min) mice by relaxing extracellular restraints on Wnt signaling.

BACKGROUND & AIMS: Aberrant DNA methylation is a common early event in neoplasia, but it is unclear how this relates to dysregulation of DNA (cytosine-5) methyltransferases (Dnmts). Here we use knock-in transgenic mice to investigate the consequences of intestinal epithelium-specific overexpression of de novo Dnmt3a. METHODS: A novel gene targeting strategy, based on the intestinal epithelium-specific, uniform expression of the A33 glycoprotein, is employed to restrict Dnmt3a overexpression in homozygous A33(Dnmt3a) mutant mice. RESULTS: A33(Dnmt3a) mice infrequently develop spontaneous intestinal polyps. However, when genetically challenged, tumor multiplicity in A33(Dnmt3a);Apc(Min) compound mice is 3-fold higher than in Apc(Min) mice. Although we observe a requirement for spontaneous loss of heterozygosity of the adenomatous polyposis coli (Apc) gene to trigger tumorigenesis in Apc(Min) mice, lesions in A33(Dnmt3a);Apc(Min) mice frequently retain the wild-type Apc allele. However, epithelia from normal mucosa and polyps of A33(Dnmt3a);Apc(Min) mice show hypermethylation-mediated transcriptional silencing of the Wnt antagonists Sfrp5, and to a lesser extent, Sfrp1 and increased nuclear beta-catenin alongside activation of the Wnt-target gene Axin2/Conductin. Conversely, enforced Sfrp5 expression suppresses canonical Wnt-signaling more effectively in wild-type than in Apc(Min) cells. CONCLUSIONS: Aberrant activation of the canonical Wnt pathway, either by mono-allelic Apc loss or transcriptional silencing of Sfrp5 is largely insufficient to promote polyposis, but epistatic interactions between these genetic and epigenetic events enables initiation and promotion of disease. This mechanism is likely to play a role in human colorectal cancer, because we also show that elevated DNMT3A expression coincides with repressed SFRP5 and enhanced AXIN2/CONDUCTIN expression in paired patient biopsies.

Australia's national bowel cancer screening program: does it work for indigenous Australians?

BACKGROUND: Despite a lower incidence of bowel cancer overall, Indigenous Australians are more likely to be diagnosed at an advanced stage when prognosis is poor. Bowel cancer screening is an effective means of reducing incidence and mortality from bowel cancer through early identification and prompt treatment. In 2006, Australia began rolling out a population-based National Bowel Cancer Screening Program (NBCSP) using the Faecal Occult Blood Test. Initial evaluation of the program revealed substantial disparities in bowel cancer screening uptake with Indigenous Australians significantly less likely to participate in screening than the non-Indigenous population.This paper critically reviews characteristics of the program which may contribute to the discrepancy in screening uptake, and includes an analysis of organisational, structural, and socio-cultural barriers that play a part in the poorer participation of Indigenous and other disadvantaged and minority groups. METHODS: A search was undertaken of peer-reviewed journal articles, government reports, and other grey literature using electronic databases and citation snowballing. Articles were critically evaluated for relevance to themes that addressed the research questions. RESULTS: The NBCSP is not reaching many Indigenous Australians in the target group, with factors contributing to sub-optimal participation including how participants are selected, the way the screening kit is distributed, the nature of the test and comprehensiveness of its contents, cultural perceptions of cancer and prevailing low levels of knowledge and awareness of bowel cancer and the importance of screening. CONCLUSIONS: Our findings suggest that the population-based approach to implementing bowel cancer screening to the Australian population unintentionally excludes vulnerable minorities, particularly Indigenous and other culturally and linguistically diverse groups. This potentially contributes to exacerbating the already widening disparities in cancer outcomes that exist among Indigenous Australians. Modifications to the program are recommended to facilitate access and participation by Indigenous and other minority populations. Further research is also needed to understand the needs and social and cultural sensitivities of these groups around cancer screening and inform alternative approaches to bowel cancer screening.