Healthcare workers knowledge of cholera multi-stranded interventions and its determining factors in North-East Nigeria: planning and policy implications.

BACKGROUND: Healthcare workers' (HCWs) knowledge of multi-stranded cholera interventions (including case management, water, sanitation, and hygiene (WASH), surveillance/laboratory methods, coordination, and vaccination) is crucial to the implementation of these interventions in healthcare facilities, especially in conflict-affected settings where cholera burden is particularly high. We aimed to assess Nigerian HCWs' knowledge of cholera interventions and identify the associated factors. METHODS: We conducted a cross-sectional study using a structured interviewer-administered questionnaire with HCWs from 120 healthcare facilities in Adamawa and Bauchi States, North-East Nigeria. A knowledge score was created by assigning a point for each correct response. HCWs' knowledge of cholera interventions, calculated as a score, was recoded for ease of interpretation as follows: 0-50 (low); 51-70 (moderate); ≥ 71 (high). Additionally, we defined the inadequacy of HCWs' knowledge of cholera interventions based on a policy-relevant threshold of equal or lesser than 75 scores for an intervention. Multivariable logistic regression was used to identify the factors associated with the adequacy of knowledge score. RESULTS: Overall, 490 HCWs participated in the study (254 in Adamawa and 236 in Bauchi), with a mean age of 35.5 years. HCWs' knowledge score was high for surveillance/laboratory methods, moderate for case management, WASH, and vaccination, and low for coordination. HCWs' knowledge of coordination improved with higher cadre, working in urban- or peri-urban-based healthcare facilities, and secondary education; cholera case management and vaccination knowledge improved with post-secondary education, working in Bauchi State and urban areas, previous training in cholera case management and response to a cholera outbreak-working in peri-urban areas had a negative effect. HCWs' knowledge of surveillance/laboratory methods improved with a higher cadre, 1-year duration in current position, secondary or post-secondary education, previous training in cholera case management and response to a cholera outbreak. However, HCWs' current position had both positive and negative impacts on their WASH knowledge. CONCLUSIONS: HCWs in both study locations recorded a considerable knowledge of multi-stranded cholera interventions. While HCWs' demographic characteristics appeared irrelevant in determining their knowledge of cholera interventions, geographic location and experiences from the current position, training and involvement in cholera outbreak response played a significant role.

A scoping review of facilitators and barriers influencing the implementation of surveillance and oral cholera vaccine interventions for cholera control in lower- and middle-income countries.

BACKGROUND: Cholera still affects millions of people worldwide, especially in lower- and middle-income countries (LMICs). The Global Task Force on Cholera Control (GTFCC) has identified surveillance and oral cholera vaccines as two critical interventions to actualise the global roadmap goals-reduction of cholera-related deaths by 90% and decreasing the number of cholera endemic countries by half by 2030. Therefore, this study aimed to identify facilitators and barriers to implementing these two cholera interventions in LMIC settings. METHODS: A scoping review using the methods presented by Arksey and O'Malley. The search strategy involved using key search terms (cholera, surveillance, epidemiology and vaccines) in three databases (PubMed, CINAHL and Web of Science) and reviewing the first ten pages of Google searches. The eligibility criteria of being conducted in LMICs, a timeline of 2011-2021 and documents only in English were applied. Thematic analysis was performed, and the findings were presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension. RESULTS: Thirty-six documents met the predefined inclusion criteria, covering 2011 to 2021. There were two themes identified regarding the implementation of surveillance: timeliness and reporting (1); and resources and laboratory capabilities (2). As for oral cholera vaccines, there were four themes identified: information and awareness (1); community acceptance and trusted community leaders (2); planning and coordination (3); and resources and logistics (4). Additionally, adequate resources, good planning and coordination were identified to be operating at the interface between surveillance and oral cholera vaccines. CONCLUSION: Findings suggest that adequate and sustainable resources are crucial for timely and accurate cholera surveillance and that oral cholera vaccine implementation would benefit from increased community awareness and engagement of community leaders.

Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study.

INTRODUCTION: Menstrual hygiene management can be challenging in low-income settings and among school-aged girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene management, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among school-aged girls in Thokarpa, Sindupalchowk, Nepal. METHODS: This is an exploratory study based on four focus group discussions with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk, Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribution of the menstrual cup. Participants were included in the study if they had started their menstruation and never given birth. Conventional content analysis was applied. RESULTS: Most participants perceived the menstrual cup positively. Not missing a single class in school due to problems related to menstrual hygiene management was described as a major benefit. The participants found using the menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it may "get stuck" in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to reduced fertility or losing virginity. CONCLUSION: The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advantages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and fostering peer and family support.

Structural barriers to knowledge transfer and exchange among men and women in low-, middle- and high-income countries: an international cross-sectional study with vaccine researchers in 44 countries.

BACKGROUND: Globally, women constitute 30% of researchers. Despite an increasing proportion of women in research, they are still less likely to have international collaborations. Literature on barriers to knowledge transfer and exchange (KTE) between men and women remains limited. This study aimed to assess perceived gender barriers to KTE activities in vaccination-related research in low-, middle- and high-income countries. METHODS: This was a cross-sectional data assessment from a self-administered questionnaire distributed to researchers in the field of vaccination research. The administered questionnaire was developed and validated by WHO and McMaster University. Descriptive statistics were carried out. Structural factors of KTE were assessed using 12 statements measured with a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). An index ranging from 12 to 60 points was created to assess structural factors of KTE, with higher score indicating fewer perceived barriers. Multivariable linear regression modelling was applied to examine the association between KTE barriers and gender. RESULTS: A total of 158 researchers were included in the analysis. Regardless of gender and country of affiliation, researchers experienced challenges with respect to KTE activities; particularly factors related to the availability of human and financial resources and level of technical expertise among their target audience. We were also able to identify perceived facilitators among men and women, such as the presence of structures that link researchers and target audiences, the investment of target audiences in KTE efforts and the presence of stable contacts among target audiences. Our linear regression analysis showed that women perceived more barriers than men (R2 = 0.014; B = -1.069; 95% CI -4.035; 1.897). CONCLUSIONS: Men and women shared common perspectives on barriers to KTE. KTE activities could be strengthened by improving structural efforts to reduce gender differences and increase collaborations between researchers and their target audience.

Indicators to evaluate organisational knowledge brokers: a scoping review.

BACKGROUND: Knowledge translation (KT) is currently endorsed by global health policy actors as a means to improve outcomes by institutionalising evidence-informed policy-making. Organisational knowledge brokers, comprised of researchers, policy-makers and other stakeholders, are increasingly being used to undertake and promote KT at all levels of health policy-making, though few resources exist to guide the evaluation of these efforts. Using a scoping review methodology, we identified, synthesised and assessed indicators that have been used to evaluate KT infrastructure and capacity-building activities in a health policy context in order to inform the evaluation of organisational knowledge brokers. METHODS: A scoping review methodology was used. This included the search of Medline, Global Health and the WHO Library databases for studies regarding the evaluation of KT infrastructure and capacity-building activities between health research and policy, published in English from 2005 to 2016. Data on study characteristics, outputs and outcomes measured, related indicators, mode of verification, duration and/or frequency of collection, indicator methods, KT model, and targeted capacity level were extracted and charted for analysis. RESULTS: A total of 1073 unique articles were obtained and 176 articles were qualified to be screened in full-text; 32 articles were included in the analysis. Of a total 213 indicators extracted, we identified 174 (174/213; 81.7%) indicators to evaluate the KT infrastructure and capacity-building that have been developed using methods beyond expert opinion. Four validated instruments were identified. The 174 indicators are presented in 8 domains based on an adaptation of the domains of the Lavis et al. framework of linking research to action - general climate, production of research, push efforts, pull efforts, exchange efforts, integrated efforts, evaluation and capacity-building. CONCLUSION: This review presents a total of 174 method-based indicators to evaluate KT infrastructure and capacity-building. The presented indicators can be used or adapted globally by organisational knowledge brokers and other stakeholders in their monitoring and evaluation work.

HIV testing and prevention among foreign-born Men Who have Sex with Men: an online survey from Sweden.

BACKGROUND: There is an increasing trend toward international migration worldwide. With it comes a challenge for public health and public funded health care systems to meet the migrating population's health needs. Men who have sex with men are a key population for HIV, contributing an estimated 42% of new HIV cases in Europe in 2013. HIV monitoring data suggest that foreign-born MSM are not only exposed to a high risk of HIV before migration but also while living in Sweden. The aim of this study is to examine HIV testing prevalence and uptake of HIV prevention interventions among foreign-born MSM living in Sweden. METHODS: A web survey available in English and Swedish was conducted from October 1 to October 30, 2013 via a Scandinavian Web community for Lesbian, Gay, Bisexual, Transgender and Intergender people. The web survey included modules on sociodemographics, condom use, sexual risk behaviour and HIV/STI testing experience. 244 eligible MSM participants born abroad and living in Sweden participated in the study. Descriptive and inferential analysis was performed. RESULTS: Half of the foreign-born MSM participants in this study had been tested for HIV during the last 12 months. Participants who had lived in Sweden less than or equal to 5 years were more likely to have been tested for HIV during the last 12 months. Having talked about HIV/STI with a prevention worker during the past year was associated with having been tested for HIV. Requested services among the majority of participants were HIV rapid test, anonymous HIV testing, HIV/STI testing outside of the health care setting and MSM-friendly clinics. CONCLUSION: Efforts are needed to promote HIV testing among foreign-born MSM. Peer outreach, individual and group counselling may be preferred interventions to do so. In addition, it is critically important to increase HIV testing among foreign-born MSM who have lived in Sweden for more than five years. Further research should explore if scale up of implementation of requested services may increase frequency of HIV testing and detection of new cases linked to treatment among foreign-born MSM living in Sweden.

Slow progress in diarrhea case management in low and middle income countries: evidence from cross-sectional national surveys, 1985-2012.

BACKGROUND: Diarrhea remains to be a main cause of childhood mortality. Diarrhea case management indicators reflect the effectiveness of child survival interventions. We aimed to assess time trends and country-wise changes in diarrhea case management indicators among under-5 children in low-and-middle-income countries. METHODS: We analyzed aggregate data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys done from 1986 to 2012 in low-and-middle-income countries. Two-week prevalence rates of diarrhea, caregiver's care seeking behavior and three case management indicators were analyzed. We assessed overall time trends across the countries using panel data analyses and country-level changes between two sequential surveys. RESULTS: Overall, yearly increase in case management indicators ranged from 1 · 3 to 2 · 5%. In the year 2012, <50% of the children were given correct treatment (received oral rehydration and increased fluids) for diarrhea. Annually, an estimated 300 to 350 million children were not given oral rehydration solutions, or recommended home fluids or 'increased fluids' and 304 million children not taken to a healthcare provider during an episode of diarrhea. Overall, care seeking for diarrhea, increased from pre-2000 to post-2000, i.e. from 35 to 45%; oral rehydration rates increased by about 7% but the rate of 'increased fluids' decreased by 14%. Country-level trends showed that care seeking had decreased in 15 countries but increased in 33 countries. Care seeking from a healthcare provider increased by ≥10% in about 23 countries. Oral rehydration rates had increased by ≥10% in 15 countries and in 30 countries oral rehydration rates increased by <10%. CONCLUSIONS: Very limited progress has been made in the case management of childhood diarrhea. A better understanding of caregiver's care seeking behavior and health care provider's case management practices is needed to improve diarrhea case management in low- and-middle-income countries.

Surgery in district hospitals in rural Uganda-indications, interventions, and outcomes.

BACKGROUND: There is a vast unmet need for surgical interventions in resource scarce settings. The poorest 2 billion people share 3·5% of the world's operations. The highest burden of surgical disease is seen in Africa where surgery could avert many deaths. Prospective studies investigating interventions, indications, and outcomes including perioperative mortality rates (POMR) after surgery are scant. The aim of the study was to describe the situation of surgery in a low-income setting in sub-Saharan Africa. METHODS: In this descriptive, facility-based study, data were prospectively collected in questionnaires by 41 staff employed at two hospitals (Iganga General Hospital and Buluba Mission Hospital) in eastern Uganda during 4 months (major surgeries) and 3 months (minor surgeries) in 2011. Data included patient characteristics, interventions, indications for surgery, and in-hospital mortality after surgery. Descriptive statistical methods were used to analyse the data. FINDINGS: 2701 patients underwent 2790 surgical interventions. Of these, 1051 patients underwent major surgery, which corresponds to a major surgery rate of 224·8 per 100 000 population. Most patients undergoing major surgery were women (n=923, 88%). Pregnancy related complications (n=747, 66%) leading to caesarean section (n=496, 47%) and evacuation (n=244, 22%) or gynaecological conditions (n=114, 10%) were common indications for surgery. General surgery interventions registered were herniorrhaphy (n=103, 9%), explorative laparotomy (n=60, 5%), and appendicectomy (n=31, 3%). Overall, the POMR was 0·6% (16 deaths); for major surgery it was 1·3% (14 deaths) and for minor surgeries it was 0·1% (two of 1650 patients). High POMR were seen following explorative laparotomy (13·3%, eight deaths) and caesarean section (0·8%, four deaths). Of the 510 babies delivered through caesarean section, 59 (12%) were still born or died before discharge. INTERPRETATION: Rates of surgery are low in the study setting compared with in high-income settings where surgical rates exceed 11 000 per 100 000 population. POMR are high after exploratory laparotomy and caesarean section. Although very detailed, a larger study could be undertaken to investigate the situation in other settings. Underlying reasons leading to death and quality of surgical care should be investigated further so that POMR can be reduced in this setting. FUNDING: The Swedish Society of Medicine and the Golje Foundation.

Experimentals, bottoms, risk-reducers and clubbers: exploring diverse sexual practice in an Internet-active high-risk behaviour group of men who have sex with men in Sweden.

This study aimed to identify sub-groups of men who have sex with men at high risk of HIV infection. Data from the Swedish MSM2013 survey were analysed with a focus on respondents (n = 714) who reported having had unprotected anal intercourse with male casual partner(s) in the past 12 months. Weighted Latent Class Analysis with covariates and distal outcomes was conducted to identify sub-groups of men sharing the same sexual practice characteristics. Four latent classes emerged: experimentals, bottoms, risk-reducers and clubbers. Experimentals appeared to differ most from the other classes. They had extensive experience of barebacking, the use of poppers and fisting. Higher number of casual male sex partners and reporting having HIV were predictors for belonging to experimentals. No evidence for an association between self-rated HIV prevention knowledge and taking less part in risky practices was found. Hence, knowledge-intensive interventions may not be the best fit for reducing HIV transmission. This diversity of men based on similar sexual practice patterns should be taken into account when designing future HIV prevention interventions.

Motivators and barriers for HIV testing among men who have sex with men in Sweden.

AIMS AND OBJECTIVES: To explore motivators and barriers to HIV testing and to assess the factors associated with testing among men who have sex with men. BACKGROUND: Previous research has considered fear, worries and structural barriers as hindrances to HIV testing among men who have sex with men. However, few studies have included assessments of actual HIV testing when exploring barriers or motivators for such testing. DESIGN: The design of the study was a stratified cross-sectional online survey (n = 2373). METHOD: Factor analysis was conducted to analyse the barriers and motivators for HIV testing. Logistic regression analysis was conducted to assess predictors for HIV testing. RESULTS: Many men who have sex with men test for HIV regularly, and specific reasons for testing were having unprotected sex or starting/ending a relationship. A lack of awareness and a perception of being at low risk for exposure were common reasons for never being tested. Fear and anxiety as well as barriers related to the use of test services remain important hindrances for testing. Predictors associated with having been tested within the past 12 months were: younger age (15-25 years old compared with 47+); knowledge on where to take an HIV test on short notice as well as having talked with a counsellor, having received condoms for free, or having had unprotected anal intercourse with casual partners within the last 12 months. CONCLUSION: Easily accessible test services offering testing and counselling on short notice should be available for all men who have sex with men. Outreach activities, distribution of free condoms and testing at venues where men who have sex with men meet are important prevention add-ons that can contribute to increased awareness about HIV and testing. RELEVANCE TO CLINICAL PRACTICE: Test services must ensure confidentiality and health care professionals who meet men who have sex with men for testing need competency with regards to men who have sex with men sexual health needs.

[Health care in Sweden rates high in international comparison]. / Det finns skäl att lyfta fram den svenska vårdens höga kvalitet.

Swedish health care rates high in international comparisons of health systems performance. Indicators show that medical outcomes are good and that most patients are satisfied with their reception in the health care services. Waiting times in Sweden are however longer than in many other European countries. Factors behind the good quality of Swedish health care could well be high level of general development, well trained and often highly motivated health staff and well developed support systems for clinical decision making.

Assessment of Childhood Stunting Prevalence over Time and Risk Factors of Stunting in the Healthy Village Programme Areas in Bangladesh.

Childhood stunting is a significant public health concern in Bangladesh. This study analysed the data from the Healthy Village programme, which aims to address childhood stunting in southern coastal Bangladesh. The aim was to assess childhood stunting prevalence over time and explore the risk factors in the programme areas. A cross-sectional, secondary data analysis was conducted for point-prevalence estimates of stunting from 2018 to 2021, including 132,038 anthropometric measurements of under-five children. Multivariate logistic regression analyses were conducted for risk factor analysis (n = 20,174). Stunting prevalence decreased from 51% in 2018 to 25% in 2021. The risk of stunting increased in hardcore poor (aOR: 1.46, 95% CI: 1.27, 1.68) and poor (aOR: 1.50, 95% CI: 1.33, 1.70) versus rich households, children with mothers who were illiterate (aOR: 1.25, 95% CI: 1.09, 1.44) and could read and write (aOR: 1.35, 95% CI: 1.16, 1.56) versus mothers with higher education, and children aged 1-2 years compared with children under one year (aOR: 1.32, 95% CI: 1.20, 1.45). The stunting rate was halved over three years in programme areas, which is faster than the national trend. We recommend addressing socioeconomic inequalities when tackling stunting and providing targeted interventions to mothers during the early weaning period.

Exploring different health care providers´ perceptions on the management of diarrhoea in cholera hotspots in the Democratic Republic of Congo: A qualitative content analysis.

Global cholera guidelines support wider healthcare system strengthening interventions, alongside vertical outbreak responses, to end cholera. Well-trained healthcare providers are essential for a resilient health system and can create synergies with childhood diarrhoea, which has higher mortality. We explored how the main provider groups for diarrhoea in cholera hotspots interact, decide on treatment, and reflect on possible limiting factors and opportunities to improve prevention and treatment. We conducted focus group discussions in September 2022 with different healthcare provider types in two urban and two rural cholera hotspots in the North Kivu and Tanganyika provinces in the Eastern Democratic Republic of Congo. Content analysis was used with the same coding applied to all providers. In total 15 focus group discussions with medical doctors (n = 3), nurses (n = 4), drug shop vendors (n = 4), and traditional health practitioners (n = 4) were performed. Four categories were derived from the analysis. (i) Provider dynamics: scepticism between all cadres was prominent, whilst also acknowledging the important role all provider groups have in current case management. (ii) Choice of treatment: affordability and strong caregiver demands shaped by cultural beliefs strongly affected choice. (iii) Financial consideration on access: empathy was strong, with providers finding innovative ways to create access to treatment. Concurrently, financial incentives were important, and providers asked for this to be considered when subsiding treatment. (iv) How to improve: the current cholera outbreak response approach was appreciated however there was a strong wish for broader long-term interventions targeting root causes, particularly community access to potable water. Drug shops and traditional health practitioners should be considered for inclusion in health policies for cholera and other diarrhoeal diseases. Financial incentives for the provider to improve access to low-cost treatment and investment in access to potable water should furthermore be considered.

Oral rehydration therapy products - a plaque pH study under normal and dry mouth conditions.

AIM: The aim of this study was to investigate oral rehydration therapy (ORT) products and their effect on plaque pH under normal and dry mouth conditions. DESIGN: Three commercial oral rehydration therapy products, prepared according to the manufacturers' instruction, plus a 10% glucose solution, which served as control, were tested in 10 healthy subjects (mean age 25 years): (1) Electral (Arrow Pharmaceuticals), (2) Resorb Junior (Nestlé) and (3) Vätskeersättning (Semper). pH was measured in the maxillary premolar region in situ with the so-called microtouch method. The area under the pH curve was calculated. Their carbohydrate content was also analysed. RESULTS: The oral rehydration therapy products gave the same low pH values in plaque as the glucose solution. Dry mouth condition, obtained by injection of methylscopolamine nitrate in the labial sulcus, resulted in an overall more pronounced fall in pH and in a delay in the pH recovery compared with normal salivary conditions. The chemical analyses showed that all three test-products contained glucose and starch as the main carbohydrates. CONCLUSIONS: Rinsing with oral rehydration therapy products leads to a greater pH decrease in dental plaque during low compared with normal salivary conditions. As diarrhoea may result in dehydration and thereby in dry mouth, we believe that ORT products have a high cariogenic potential.

Change in economic burden of diarrhoea in children under-five in Bangladesh: 2007 vs. 2018.

Background: In Bangladesh, diarrhoea in children under-five is a major public health problem with cost implications. Although under-five diarrhoea mortality and morbidity have declined from 2007 to 2018, change in the economic burden is unknown. This study determined the change in the societal economic burden of under-five diarrhoea in Bangladesh comparing 2007 to 2018. Methods: A prevalence-based, retrospective cost analysis was conducted from a societal perspective, including costs to households, providers, and economic loss from premature deaths. Data were obtained from the previous cost of illness studies, government reports, and international databases. Direct costs for treatment were estimated by the bottom-up costing approach. Indirect costs on the loss of productivity of caretakers and loss from premature deaths were calculated by the human capital method. Total costs were presented in both local currency (Bangladeshi Taka (BDT)) and US dollars (US$)) in 2018 price. Sensitivity analyses were conducted to assess the robustness of the input parameters. Results: A 36.4% reduction was found on the economic burden of under-five diarrhoea when comparing 2007 and 2018; US$1 209 million (95% CI = 1066 million-1299 million) for 2007 and US$769 million (95% CI = 484 million-873 million) for 2018. Economic loss from premature deaths imposed the highest costs (2007 = 66%, 2018 = 66% of all) followed by indirect costs on the loss of productivity of caretakers (2007 = 21%, 2018 = 26%) and direct medical costs (2007 = 13%, 2018 = 8%). Conclusions: Societal costs from diarrhoeal diseases were reduced from 2007 to 2018 in Bangladesh. However, the economic burden was equivalent to 0.29% of country's gross domestic product in 2018 and remains a challenge. The major contributor to the costs was premature mortality from diarrhoeal diseases. Premature deaths are still prevalent though they to a large extent are avoidable. To further limit the economic burden, under-five diarrhoea mortality and morbidity reduction should be accelerated.

Influences of community engagement and health system strengthening for cholera control in cholera reporting countries.

The 2030 Global Task Force on Cholera Control Roadmap hinges on strengthening the implementation of multistranded cholera interventions, including community engagement and health system strengthening. However, a composite picture of specific facilitators and barriers for these interventions and any overlapping factors existing between the two, is lacking. Therefore, this study aims to address this shortcoming, focusing on cholera-reporting countries, which are disproportionately affected by cholera and may be cholera endemic. A scoping methodology was chosen to allow for iterative mapping, synthesis of the available research and to pinpoint research activity for global and local cholera policy-makers and shareholders. Using the Arksey and O'Malley framework for scoping reviews, we searched PubMed, Web of Science and CINAHL. Inclusion criteria included publication in English between 1990 and 2021 and cholera as the primary document focus in an epidemic or endemic setting. Data charting was completed through narrative descriptive and thematic analysis. Forty-four documents were included, with half relating to sub-Saharan African countries, 68% (30/44) to cholera endemic settings and 21% (9/44) to insecure settings. We identified four themes of facilitators and barriers to health systems strengthening: health system cooperation and agreement with external actors; maintaining functional capacity in the face of change; good governance, focused political will and sociopolitical influences on the cholera response and insecurity and targeted destruction. Community engagement had two themes: trust building in the health system and growing social cohesion. Insecurity and the community; cooperation and agreement; and sociopolitical influences on trust building were themes of factors acting at the interface between community engagement and health system. Given the decisive role of the community-health system interface for both sustained health system strengthening and community engagement, there is a need to advocate for conflict resolution, trust building and good governance for long-term cholera prevention and control in cholera reporting countries.

Treatment patterns of childhood diarrhoea in rural Uganda: a cross-sectional survey.

BACKGROUND: Diarrhoea is the second leading cause of death in children under five accounting for 1.8 million deaths yearly. Despite global efforts to reduce diarrhoea mortality through promotion of proper case management, there is still room for ample improvement. In order to seek options for such improvements this study explored the knowledge and practices of diarrhoea case management among health care providers at health centres and drug shops in Uganda. METHODS: Records were reviewed for case management and structured interviews concerning knowledge and practices were conducted with the staff at all health centres and at all identified drug shops in the rural district of Namutumba, Uganda. RESULTS: There was a significant gap between knowledge and documented practices among staff. Antibiotics, antimalarials and antipyretics were prescribed or recommended as frequently as Oral Rehydration Solution (ORS). In almost a third of the health facilities, ORS was out of stock. 81% of staff in health centres and 87% of staff in drug shops stated that they prescribed antibiotics for common diarrhoea. Zinc was not prescribed or recommended in any case. CONCLUSIONS: The findings indicate that many children presenting with diarrhoea are inadequately treated. As a result they may not get the rehydration they need and are at risk of potential side effects from unjustified usage of antibiotics. Practices must be improved at health centres and drug shops in order to reduce childhood mortality due to diarrhoeal diseases.

Conceptualizing safer sex in a new era: Risk perception and decision-making process among highly sexually active men who have sex with men.

BACKGROUND: Men who have sex with men (MSM) are at the epicenter of the HIV epidemic. Efforts to prevent sexually transmitted infections (STIs) and HIV transmission have traditionally focused on condoms and abstinence from high risk sexual practices. Recently, additional methods such as pre-exposure prophylaxis (PrEP) and viral load sorting have been introduced. The aim of this study was to gain understanding about risk management and risk perception strategies for HIV among highly sexually active Swedish MSM with men in Berlin. METHODS: Eighteen sexually active Swedish MSM who travelled to or lived in Berlin were recruited and interviewed in this study. The data were analyzed using content analysis. RESULTS AND DISCUSSION: These men represent a group of knowledgeable MSM in terms of HIV. They acknowledged that having sex with men in Berlin was linked to high sexual risk taking due to the higher prevalence of HIV/STIs than in Sweden, but reported that they nevertheless did not alter their risk management strategies. The analysis resulted in a conceptual model of risk assessment that allows for a deeper understanding of the complexity of the risk reduction decision-making process. Three ontological perceptions of risk were identified: accepting, minimizing and rejecting risk. Seven practiced risk reduction methods were described. Some informants applied their preferred method or set of methods to all settings and partners, while others faced complex decision-making processes. CONCLUSION: HIV is integrated into the core of MSM's sexuality, independently of how they ontologically related to the idea of risk. A constant navigation between pleasure, risk and safety, alongside having to relate to risk created a complex process. Efforts were made to remove HIV from their lives by rejecting the idea of risk, and thereby reject the idea of the homosexual body being a possible vessel for a virus and an epidemic.