Risk factors and predictors of violence: insights from the emergency department at a level 1 trauma center in the USA.

BACKGROUND: This study aimed to assess the risk factors and predictors of violence among patients admitted to a Level 1 trauma center in a single institution. METHODS: We conducted a retrospective analysis of patients who were admitted with a history of violence between 2012 and 2016. RESULTS: A total of 9855 trauma patients were admitted, of whom 746 (7.6%) had a history of violence prior to the index admission. Patients who had history of violence were younger and more likely to be males, Black, Hispanic and covered by low-income primary payer in comparison to non-assault trauma patients (P < 0.001 for all). Multivariate logistic regression analysis showed that covariate-adjusted predictors of violence were being Black, male having low-income primary payer, Asian, drug user, alcohol intoxicated and smoker. CONCLUSIONS: Violence is a major problem among young age subjects with certain demographic, social and ethnic characteristics. Trauma centers should establish violence injury prevention programs for youth and diverse communities.

Transitions for older people with intellectual disabilities and behaviours that challenge others: A rapid scoping review.

BACKGROUND: People with intellectual disabilities and behaviours that challenge others are living longer. This review aimed to explore what is known about the health and social care needs, experiences, service interventions and resources of and for this population as they transition to different care contexts in the UK. METHOD: A rapid scoping review of published and unpublished literature was conducted based on collaborative working with key stakeholders and using systematic methods of data searching, extraction and analysis. RESULTS: Consistent social work support, skilled staff, suitable accommodation, creative engagement with individuals and families to plan ahead, and timely access to quality healthcare are all required to promote successful transitions as people age, and to avoid unwanted/inappropriate transitions at points of crisis. CONCLUSIONS: More research is needed to assess the types of services that this population can and do access as they age, the quality of those services, and the extent to which local commissioners are planning ahead for people with intellectual disabilities and behaviours that challenge others.

"The rich will always be able to dispose of their waste": a view from the frontlines of municipal failure in Makhanda, South Africa.

A significant proportion of South African municipalities, who hold the mandate for providing solid waste management (SWM) services for millions of South Africans, appear to be on the brink of collapse. On the frontlines of municipal failure, the city of Makhanda, following two decades of poor governance and mismanagement, has found itself unable to fulfil its mandate, with the state retreating on SWM service provision, and disruptions to waste management services becoming a daily reality. Drawing on embedded, qualitative fieldwork, this article examines how differently placed residents have experienced disruptions to SWM services. This work explores how residents of Makhanda's two halves: the affluent and predominantly white neighbourhoods in the west, and the poor, non-white townships in the east, have (or have not) adapted to manage and dispose of their own waste during periods of disruption. Findings suggest that disruptions to waste management service provision have been broadly experienced by residents. However, the consequences of interruptions to municipal collection have not been evenly borne, as more resourced, western residents have been more successful at managing their own waste disposal, while the residents of Makhanda's townships are less capable of coping, with affected communities coming to resemble a dumping ground, and residents having to adopt unsafe or environmentally harmful disposal practices. These findings are important because they shed light on the challenges of creating cleaner, more equal communities without healthy municipal participation in waste management services, while raising important considerations for a South Africa facing the possibility of widespread municipal collapse.

Sludge bomb: The impending sludge emptying and treatment crisis in Blantyre, Malawi.

Blantyre, Malawi has approximately one million people who rely on pit latrines for sanitation and yet there is a limited pit-emptying sector to empty, transport and safely discharge the faecal sludge. Over three years, we monitored the volume of sludge that was safely discharged at the authorized Wastewater Treatment Plants (WWTP) and in parallel, estimated the volume of sludge that is currently buried within pit latrines of Blantyre, based on measurements at 321 households. Comparing the volumes of sludge emptied to the volumes of sludge buried, we highlight the fact that a) there is a suspiciously low volume of pit-derived faecal sludge being safely disposed; b) most safely discharged sludge is taken from the small proportion of septic tanks in the city, and not from pit latrines; and c) that the cost of safely discharging does not seem to correlate with the volumes delivered (despite an option to discharge for free). There is a large and growing amount of sludge buried beneath the city which will need to be safely emptied and treated in coming years. The city and the WWTPs must move quickly to ensure that the businesses and infrastructure are prepared for the future faecal sludge management challenges that lay ahead, especially if they are to achieve SDG 6 by 2030.

The role of astrocytes in seizure generation: insights from a novel in vitro seizure model based on mitochondrial dysfunction.

Approximately one-quarter of patients with mitochondrial disease experience epilepsy. Their epilepsy is often severe and resistant towards conventional antiepileptic drugs. Despite the severity of this epilepsy, there are currently no animal models available to provide a mechanistic understanding of mitochondrial epilepsy. We conducted neuropathological studies on patients with mitochondrial epilepsy and found the involvement of the astrocytic compartment. As a proof of concept, we developed a novel brain slice model of mitochondrial epilepsy by the application of an astrocytic-specific aconitase inhibitor, fluorocitrate, concomitant with mitochondrial respiratory inhibitors, rotenone and potassium cyanide. The model was robust and exhibited both face and predictive validity. We then used the model to assess the role that astrocytes play in seizure generation and demonstrated the involvement of the GABA-glutamate-glutamine cycle. Notably, glutamine appears to be an important intermediary molecule between the neuronal and astrocytic compartment in the regulation of GABAergic inhibitory tone. Finally, we found that a deficiency in glutamine synthetase is an important pathogenic process for seizure generation in both the brain slice model and the human neuropathological study. Our study describes the first model for mitochondrial epilepsy and provides a mechanistic insight into how astrocytes drive seizure generation in mitochondrial epilepsy.

Trends in access to water and sanitation in Malawi: progress and inequalities (1992-2017).

Billions of people globally gained access to improved drinking water sources and sanitation in the last decades, following effort towards achieving the Millennium Development Goals. Global progress remains a general indicator as it is unclear if access is equitable across groups of the population. Agenda 2030 calling for `leaving no one behind', there is a need to focus on the variations of access in different groups of the population, especially in the context of low- and middle-income countries including Malawi. We analyzed data from Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) to describe emerging trends on progress and inequalities in water supply and sanitation services over a 25-year period (1992-2017), as well as to identify the most vulnerable populations in Malawi. Data were disaggregated with geographic and socio-economic characteristics including regions, urban and rural areas, wealth and education level. Analysis of available data revealed progress in access to water and sanitation among all groups of the population. The largest progress was generally observed in the groups that were further behind at the baseline year, which likely reflects good targeting in interventions/improvements to reduce the gap in the population. Overall, results demonstrated that some segments of the population - foremost poorest Southern rural populations - still have limited access to water and are forced to practise open defecation. Finally, we suggest including standardized indicators that address safely managed drinking water and sanitation services in future surveys and studies to increase the accuracy of national estimates.

The impact of self-advocacy organizations on the subjective well-being of people with intellectual disabilities: A systematic review of the literature.

BACKGROUND: A high sense of subjective well-being has been associated with more prosocial behaviours, better health, work productivity and positive relationships. The aim of this systematic review was to explore what impact self-advocacy has on the subjective well-being of people with intellectual disabilities. METHOD: The authors reviewed articles focusing on the perspectives of adults with intellectual disabilities engaged with self-advocacy groups. Searches were performed in PsychINFO, Web of Science, SCOPUS, MEDLINE and CIHNL databases, resulting in 16 articles meeting the inclusion criteria. A framework synthesis approach was used to extract data deductively based on the Dynamic Model of Wellbeing. RESULTS: While self-advocacy has a positive impact on all domains of the Dynamic Model of Wellbeing, negative impacts associated with participation in a self-advocacy group were also reported. CONCLUSIONS: The benefits of participating in self-advocacy groups on the well-being of individuals with intellectual disabilities outweigh the disadvantages.

What works in community health education for adults with learning disabilities: A scoping review of the literature.

BACKGROUND: Research suggests there is insufficient good quality information regarding the effectiveness of health education aimed at adults with intellectual disabilities. By analysing the literature, this review aimed to identify what constituted effectiveness in this context. METHOD: Relevant evaluations were extracted from bibliographic databases according to pre-specified criteria. Papers were analysed using QSR NVivo 11 by developing a narrative synthesis and analytic framework that identified and explored text addressing the research question. RESULTS: Twenty-two studies were included. The review identified two broad components of effective health education: mechanisms and context. Mechanisms included embedded programme flexibility, appropriate and accessible resources, and motivational delivery. An effective context included an accessible and supportive environment and longer term opportunities for reinforcement of learning. CONCLUSIONS: Important gaps in the literature highlighted a need for further research addressing community learning experiences of adults with intellectual disabilities as well as the effectiveness of infection prevention programmes.

Females fall more from heights but males survive less among a geriatric population: insights from an American level 1 trauma center.

BACKGROUND: Approximately one third of subjects ≥65 year old and half of subjects ≥80 years old sustain a fall injury each year. We aimed to study the outcomes of fall from a height (FFH) among older adults. We hypothesized that in an elderly population, fall-related injury and mortality are the same in both genders. METHODS: A retrospective analysis was conducted between January 2012 and December 2016 in patients who sustained fall injury at age of at least 60 years and were admitted into a Level 1 Trauma center. Patients were divided into 3 groups: Gp-I: 60-69, Gp-II: 70-79 and Gp-III: ≥80 years old. Data were analyzed and compared using Chi-square, one-way analysis of variance (ANOVA) and logistic regression analysis tests. RESULTS: Forty-three percent (3665/8528) of adult trauma patients had FFH and 59.5% (2181) were ≥ 60 years old and 52% were women. The risk of fall increased with age with an Odd ratio (OR) 1.52 for age 70-79 and an OR 3.40 for ≥80. Females fell 1.2 times more (age-adjusted OR 1.24; 95% CI 1.05-1.45) and 47% of ≥80 years old suffered FFH. Two-thirds of FFH occurred at a height ≤ 1 m. Injury severity (ISS, NISS and GCS) were worse in Gp-II, lower extremities max Abbreviated Injury score (max AIS) was higher in Gp-III. Overall mortality was 8.7% (Gp-I 3.6% vs. 11.3% in Gp-II and 14% in Gp- III). Males showed higher mortality than females in the entire age groups (Gp-I: 4.6% vs 1%, Gp-II: 12.9% vs 4.2% and Gp-III: 17.3% vs 6.9% respectively). On multivariate analysis, shock index (OR 3.80; 95% CI 1.27-11.33) and male gender (OR 2.70; 95% CI 1.69-4.16) were independent predictors of mortality. CONCLUSIONS: Fall from a height is more common in older adult female patients, but male patients have worse outcomes. Preventive measures for falls at home still are needed for the older adults of both genders.

The clinical utility of shock index to predict the need for blood transfusion and outcomes in trauma.

BACKGROUND: We aimed to evaluate the clinical utility of shock index (SI) to assess the need for blood transfusion and predict the outcomes in trauma. MATERIALS AND METHODS: We conducted a retrospective analysis for trauma patients between 2012 and 2016 in a level-1 trauma center. Data included patient demographics, vital signs, mechanism of injury, Injury Severity Score (ISS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS), blood transfusion, hospital length of stay (HLOS), and mortality. Patients were classified into group I (SI < 0.8) and group II (SI ≥ 0.8). RESULTS: Out of 8710 admitted patients, 1535 (22%) had SI ≥ 0.8 and 976 (12.5%) received blood transfusion (89 received massive transfusion, following massive blood transfusion protocol [MTP]). In comparison to lower SI, patients with SI ≥ 0.8 were mostly female patients, 8 y younger (43 ± 22 versus 51 ± 23), had greater ISS (15 ± 12 versus 10.5 ± 8), higher NISS (19 ± 15 versus 14 ± 11), lower pulse pressure (43 ± 14 versus 62 ± 18), lower TRISS (0.892 ± 0.20 versus 0.953 ± 0.11), and received more blood transfusion (28.6% versus 9.0%) or MTP (17.7% versus 3%), P = 0.001. Also, they had mostly exploratory laparotomy (13.3% versus 6.6%, P = 0.001), longer HLOS (11.3 versus 7.0 d, P = 0.001), and higher mortality (7.0% versus 3.1%, P = 0.001). SI was correlated with age (r = -0.188), pulse pressure (r = -0.51), HLOS (r = 0.168), ISS (r = 0.251), NISS (r = 0.211), amount of blood transfused (r = 0.27), Glasgow Coma Scale (r = -0.96), and TRISS (r = -0.230). After adjusting for age and sex, ISS, and Glasgow Coma Scale in two multivariable analyses, high SI was found to be an independent predictor for mortality (odd ratio, 2.553; 95% confidence intervals: 1.604-4.062) and blood transfusion (odd ratio, 3.57; 95% confidence intervals: 3.012-4.239). The cutoff point of SI for predicting MTP is 0.81 (sensitivity, 85%; specificity, 64%; positive predictive value, 16%; and negative predictive value, 98%). CONCLUSIONS: The SI after injury can be used early to predict the need for MTP and laparotomy and mortality. It correlates with other physiological and anatomical variables. However, its cutoff values for risk stratification and prognostication need further evaluation.

Telemedicine as an innovative model for rebuilding medical systems in developing countries through multipartnership collaboration: the case of Albania.

The U.S. Government and other developed nations provide billions of dollars annually in relief assistance to countries around the world. The long-term benefits of this aid, however, are often difficult to elucidate. The aim of this article is to present a model of a multipartnership collaboration among U.S. governmental, nongovernmental organizations, and academia to rebuild medical systems using telemedicine as a sustainable model of foreign aid. The International Virtual e-Hospital implemented the "initiate-build-operate-transfer" strategy to establish an effective telemedicine system in Albania that includes the National Telemedicine Center and 12 regional telemedicine centers. This nationwide telemedicine network has active clinical programs, virtual educational programs, and an electronic library that has substantially improved the access to care while advancing medical education. We propose that telemedicine is an optimal, sustainable, low-cost model for rebuilding medical systems of developing countries when implemented through a multipartnership approach.

Psychosocial factors associated with intention to pursue tertiary education among Malawian students: the moderating effect of mental health.

BACKGROUND: In Sub Saharan Africa (SSA), approximately 9 million students are enrolled in tertiary education (TE), which is 4% of the total TE enrolment globally. Barriers to higher education in SSA are numerous: poverty, food insecurity, gender, and disability, while the COVID-19 pandemic has worsened the situation. Little is known about the psychosocial factors and underlying mechanisms associated with students' intention to apply for TE. Using a psychological theory of behaviour change, our study investigated the psychosocial and context factors associated with the application to TE. METHODS: In a cross-sectional research study 821 interviews using researcher-administered questionnaires were conducted with secondary school students in rural and urban Blantyre, Malawi. A quantitative questionnaire based on the risks, attitudes, norms, abilities, and self-regulation (RANAS) model was used to assess psychosocial factors underlying application for TE. The Centre for Epidemiological Studies Depression Scale for Children (CES-DC) and household hunger scale were used to assess mental health and hunger respectively. RESULTS: More than half of the youth were at risk to develop depression (66.5%). Girls reported experiencing more depression symptoms than boys. Around 1 in every 5 interviewed youth lived in a home experiencing moderate or severe hunger. A higher intention to apply for TE was related to perceived vulnerability, affective beliefs (joy, happiness, excitement), injunctive (approval of others) and personal norms, self-efficacy, and commitment to apply. Factual knowledge about TE application was very limited. An intention to apply for TE and self-efficacy was positively associated with regular physical exercise, but negatively associated with mental health and hunger. However, mental health moderated the effects of physical exercise on the intention to apply for TE. We found significant differences between poor and good mental health groups on intention to apply for TE in perceived vulnerability, descriptive (behaviour of others) and personal norms, self-efficacy, maintenance self-efficacy and commitment factors. The results informed a behaviour change intervention strategy to increase students' intention to apply for TE. CONCLUSIONS: Our research findings are an important contribution to the long-term strategy of achieving the Sustainable Development Goals (SDGs) and contribute to the inclusion of vulnerable students with impaired mental health in higher education in Malawi and beyond.

Improving support and planning ahead for older people with learning disabilities and family carers: a mixed-methods study.

Background: People with learning disabilities are living longer. Despite government policy to encourage people to lead supported lives in their community, family carers often maintain support due to dissatisfaction with services. This can lead to people moving from the family home in a crisis. Objectives: (1) Find out what is known about health needs and resources for older people with learning disabilities (aged ≥ 40 years); (2) identify exemplars of good services for older people with learning disabilities; (3) explore service exemplars through ethnographic case studies; (4) evaluate support for older people with learning disabilities and their families through co-producing and testing future planning tools and (5) co-produce recommendations and resources. Design and methods: Work package 1 rapid scoping reviews - three reviews focused on the health and social care needs of older people with learning disabilities and 'behaviours that challenge others', and family carers, and the co-ordination of support for this group. Work package 2 scoping and mapping exemplars of good practice - analysis of published service standards to assess excellence criteria, by mapping services, interviews (n = 30), survey (n = 9) and informal discussion with commissioners. Work package 3 ethnography of case studies of exemplar provision; independent supported living (n = 4); residential/nursing home (n = 2); day activities (n = 1), Shared Lives (n = 2). Fieldwork (20 days per model), interviews (n = 77) with older people with learning disabilities, family carers, support staff and commissioners. Work package 4 - co-producing and testing resources for older people with learning disabilities and their families involved interviews and focus groups with 36 people with learning disabilities, parents, and siblings, and experience-based co-design with 11 participants. Eight families evaluated the resources. Work package 5 - three stakeholder workshops co-produced service recommendations. Findings: The reviews confirmed an inadequate evidence base concerning the experiences and support of family carers and older people with learning disabilities and 'behaviours that challenge others'. Criteria of excellence were produced, and a shortlist of 15 services was identified for consideration in work package 3. The ethnographic work found that environmental, organisational and social factors were important, including supporting independence and choice about who people live with, matching staff to people, consistent relationships and adapting to ageing. Practices of institutionalisation were observed. In work package 4, we found that families were worried about the future and unsupported to explore options. 'Planning Ahead' cards and a booklet to record discussions were produced, and the evaluation was positively rated. Finally, formative discussion informed recommendations. Outputs include training packages, a carers' forum, a film, a podcast and academic papers. Conclusions: There is little focus on older people with learning disabilities and family carers. Services vary in their approach to planning for older-age support. Families are unsupported to plan, leaving people without choice. 'Behaviours that challenge others' was found to be unhelpful terminology. Recommendations: A new strategy is recommended for older people with learning disabilities and family carers that encompasses commissioning practices, professional input and peer learning, proactive support in ageing well and excellent service design. Limitations: The COVID-19 pandemic created recruitment challenges. Reliance on providers for recruitment resulted in a lack of diversity in work package 3. Families' plans, and therefore change, may be frustrated by insufficient service resources. Future work: Given the lack of focus in this area, there is a range of future work to consider: experiences of older people with learning disabilities from diverse ethnic backgrounds; supporting people to age and die 'in place'; best practice regarding designing/commissioning services, including housing; the role of social workers; access to nature; accessing mainstream support; and evaluation of the 'Planning Ahead' cards. Trial registration: This trial is registered as ISRCTN74264887. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129491) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 16. See the NIHR Funding and Awards website for further award information.

People with learning disabilities are living longer, but most live with their families, who are also getting older. This is because there are not enough suitable places for people with learning disabilities to live, and family carers worry that the person will not get the right support and have a good life. Our research aimed to improve support for people with learning disabilities and their family carers to plan ahead for a good life. We focused on people who are labelled with 'behaviours that challenge others'. We read what has been written about this area. We looked for and found examples of excellent support for older people with learning disabilities. Researchers and people with learning disabilities and family carers spent time hanging out with people where they live or spend their days to see what support they get. Then we had three meetings with everyone involved and discussed our research findings with people with learning disabilities, family carers, and professionals. We found that people can be supported to live good lives as they grow older. This can be living alone or with people they choose, and it means having staff they like and who like them and being supported to be active. However, we found that ageing of people with learning disabilities is often ignored, and some people were not living good lives. We also found that the label of 'behaviours that challenge others' is unhelpful. We worked with people with learning disabilities and family carers to make a set of cards with pictures and questions to help people plan ahead for a good life. We produced resources and made recommendations to create a new plan for older people with learning disabilities to support people to lead good lives. This is very important because there is a lack of attention to and support for people with learning disabilities as they age.

"It is unbearable to breathe here": air quality, open incineration, and misinformation in Blantyre, Malawi.

Blantyre, Malawi's Queen Elizabeth Central Hospital (QECH), or Queen's, as it's known locally, is the country's largest public hospital. However, Queen's is not served by regular municipal waste collection. Rather, most hospital waste (infectious and non-infectious) is gathered by grounds staff and openly burned, in several constantly smouldering piles, sending up clouds of smoke. Speaking directly to an identified knowledge gap on air quality impacts linked to trash burning and the paucity of African urban dwellers' voices on air quality issues, this study employed a mixed-methods approach to both quantitatively measure the air quality around QECH, and to qualitatively investigate the perceived impacts amongst staff and caregivers. Low-cost sensors measuring particulate matter (PM) with particle sizes less than 10 µm (PM10) and less than 2.5 µm (PM2.5), expressed as the mass of PM per volume of air (µg PMx/m3 air) were recorded every 5 min at 8 locations across the QECH for 2 months. Qualitative data collection consisted of 56 interviews with patients, caregivers and hospital staff (including janitorial and maintenance staff, nurses, doctors, and administrators). Our results show that safe air quality thresholds are consistently exceeded across space and time and that the most problematic air quality surrounds the shelter for caregivers and those receiving treatment for HIV/AIDS. Moreover, staff and visitors are severely impacted by the poor air quality within the space, but feel powerless to make changes or address complaints. Waste management interventions are desperately needed lest the patients who arrive at Queen's leave with more health issues than the ones with which they arrived.

Impact of fathers on risky sexual behavior in daughters: a genetically and environmentally controlled sibling study.

Girls receiving lower quality paternal investment tend to engage in more risky sexual behavior (RSB) than peers. Whereas paternal investment theory posits that this effect is causal, it could arise from environmental or genetic confounds. To distinguish between these competing explanations, the current authors employed a genetically and environmentally controlled sibling design (N = 101 sister pairs; ages 18-36), which retrospectively examined the effects of differential sibling exposure to family disruption/father absence and quality of fathering. Consistent with a causal explanation, differences between older and younger sisters in the effects of quality of fathering on RSB were greatest in biologically disrupted families when there was a large age gap between the sisters (thus maximizing differential exposure to fathers), with greater exposure within families to higher quality fathering serving as a protective factor against RSB. Further, variation around the lower end of fathering quality appeared to have the most influence on RSB. In contrast, differential sibling exposure to family disruption/father absence (irrespective of quality of fathering) was not associated with RSB. The differential sibling-exposure design affords a new quasi-experimental method for evaluating the causal effects of fathers within families.

A compatibility-based procedure designed to generate potential sanitation system alternatives.

Regarding multi-criteria decision analysis (MCDA), the problem of generating alternatives has not received the attention it deserves. Most research is currently devoted to the problem of alternative selection, where it is assumed that a set of appropriate alternatives is already given. This paper addresses the generation of potential alternatives in the domain of sanitation systems planning and decision-making. A compatibility assessment procedure is proposed to determine the set of technically feasible or potential sanitation system alternatives. This is based on a clear definition of such an alternative containing sub-processes that include a user interface, storage, conveyance treatment and reuse/disposal. A newly developed compatibility matrix is applied to identify incompatibilities between the options of the sub-processes. A potential sanitation system alternative is therefore defined by the absence of two-by-two incompatibility between all its options. The compatibility assessment acts as a first filter on the set of sanitation system alternatives to eliminate those that are inoperable before the feasibility assessment. The objective of both steps is to obtain a set of alternatives that are of reasonable and manageable size from which the final solution may be selected.

"You need to dispose of them somewhere safe": Covid-19, masks, and the pit latrine in Malawi and South Africa.

The ongoing Covid-19 pandemic has generated an immense amount of potentially infectious waste, primarily face masks, which require rapid and sanitary disposal in order to mitigate the spread of the disease. Yet, within Africa, large segments of the population lack access to reliable municipal solid waste management (SWM) services, both complicating the disposal of hazardous waste, and public health efforts. Drawing on extensive qualitative fieldwork, including 96 semi-structured interviews, across four different low-income communities in Blantyre, Malawi and Durban, South Africa, the purpose of this article is to respond to a qualitative gap on mask disposal behaviours, particularly from within low-income and African contexts. Specifically, our purpose was to understand what behaviours have arisen over the past year, across the two disparate national contexts, and how they have been influenced by individual risk perceptions, established traditional practice, state communication, and other media sources. Findings suggest that the wearing of cloth masks simplifies disposal, as cloth masks can (with washing) be reused continuously. However, in communities where disposable masks are more prevalent, primarily within Blantyre, the pit latrine had been adopted as the most common space for 'safe' disposal for a used mask. We argue that this is not a new behaviour, however, and that the pit latrine was already an essential part of many low-income households SWM systems, and that within the Global South, the pit latrine fulfils a valuable and uncounted solid waste management function, in addition to its sanitation role.

Process Evaluation of "The Hygienic Family" Intervention: A Community-Based Water, Sanitation, and Hygiene Project in Rural Malawi.

Process evaluations of environmental health interventions are often under-reported and under-utilized in the development of future programs. The "Hygienic Family" intervention targeted improvements in hygiene behaviors of caregivers with under five-year-old children in rural Malawi. Delivered through a combination of open days, cluster meetings, household visits, and prompts, data were collected from two intervention areas for ten months. A process evaluation framework provided indicators that were measured through intervention implementation and expenditure reports, focus groups discussions, interviews, and household surveys. The collected data assessed the intervention fidelity, dose, reach, acceptability, impact, and cost. Results indicated that all planned hygiene promotion messages were delivered, and study participants were better reached primarily through household visits (78% attended over 75% of the intervention) than cluster meetings (57% attended over 75% of the intervention). However, regression found that the number of household visits or cluster meetings had no discernible effect on the presence of some household hygiene proxy indicators. Intervention implementation cost per household was USD 31.00. The intervention delivery model provided good fidelity, dose, and reach and could be used to strengthen the scope of child health and wellbeing content. The intensive face-to-face method has proven to be effective but would need to be adequately resourced through financial support for community coordinator remuneration.

Development and implementation of a pharmacist-led telehealth medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act.

PURPOSE: Veterans prescribed oral antineoplastic therapies (OATs) by community providers outside the Veterans Health Administration (VA) may lack access to comprehensive medication management. To address this, our multidisciplinary team developed and implemented a pharmacist-led telehealth medication management program for veterans prescribed OATs by community providers. SUMMARY: The program exclusively uses telehealth to connect veterans with a dedicated board-certified clinical oncology pharmacist who provides comprehensive medication management. The program is based on established pharmacy models found in the research literature. We developed a standard operating procedure, communication templates, patient education materials, and a suite of health information technology tools to help streamline pharmacy processes. The Consolidated Framework for Implementation Research was used to design implementation strategies to promote the adoption of the program. In the first year, 64 veterans from 3 VA medical centers were enrolled in the program. The oncology clinical pharmacist performed 342 encounters and 101 interventions. The program saved an estimated $200,724 in medication-related costs. The veterans we surveyed reported high levels of satisfaction with the pharmacy services provided by the program. CONCLUSION: The delivery of comprehensive medication management through telehealth is feasible from a healthcare system perspective and beneficial for patients. The board-certified oncology clinical pharmacist provided remote pharmacy services to Veterans across three sites in a large and rural service area for the VA. The program realized several benefits, including positive clinical outcomes, high levels of patient satisfaction, and cost savings on medication-related costs.

Evaluating self-reported measures and alternatives to monitor access to drinking water: A case study in Malawi.

Monitoring access to drinking water is complex, especially in settings where on premises water supply is not available. Although self-reported data are generally used to estimate coverage of access to drinking water, the relationship between self-reported time travelled and true time travelled is not well known in the context of water fetching. Further, water fetching is likely to impact the quantity and quality of water a household uses, but data and measures supporting this relationship are not well documented. The objective of this study was to appraise the validity and reliability of self-reported measurements used to estimate access coverage. A case study was conducted in Malawi to enhance understanding of the self-reported measures and alternatives available to assess and monitor access to drinking water in view of generating global estimates. Self-reported data were compared with objective observations and direct measurements of water quantity, quality and accessibility. Findings from this study highlight the variations between different measures such as self-reported and recorded collection time and raise awareness with regard to the use of self-reported data in the context of fetching water. Alternatives to self-reported indicators such as GPS-based or direct observations could be considered in surveys in view of improving data accuracy and global estimates.