Climate shocks and nutrition: The role of food security policies and programs in enhancing maternal and neonatal survival in Niger.

Niger is afflicted with high rates of poverty, high fertility rates, frequent environmental crises, and climate change. Recurrent droughts and floods have led to chronic food insecurity linked to poor maternal and neonatal nutrition outcomes in vulnerable regions. We analyzed maternal and neonatal nutrition trends and subnational variability between 2000 and 2021 with a focus on the implementation of policies and programs surrounding two acute climate shocks in 2005 and 2010. We used four sources of data: (a) national household surveys for maternal and newborn nutritional indicators allowing computation of trends and differences at national and regional levels; (b) document review of food security reports; (c) 30 key informant interviews and; (d) one focus group discussion. Many food security policies and nutrition programs were enacted from 2000 to 2020. Gains in maternal and neonatal nutrition indicators were more significant in targeted vulnerable regions of Maradi, Zinder, Tahoua and Tillabéri, from 2006 to 2021. However, poor access to financial resources for policy execution and suboptimal implementation of plans have hindered progress. In response to the chronic climate crisis over the last 20 years, the Nigerien government and program implementers have demonstrated their commitment to reducing food insecurity and enhancing resilience to climate shocks by adopting a deliberate multisectoral effort. However, there is more that can be achieved with a continued focus on vulnerable regions to build resilience, targeting high risk populations, and investing in infrastructure to improve health systems, food systems, agriculture systems, education systems, and social protection.

Women-centred HIV care: a scoping review to understand the current state of service delivery for women living with HIV globally.

Women living with HIV (WLWH) face unique barriers and require specialized, integrated care that focuses on women's specific needs. We conducted a scoping review to examine factors important for a women-centred HIV care (WCHC) approach. We included published peer-reviewed articles which featured WCHC services as their central focus; included study populations of girls and WLWH aged 14 years of age or older; and contributed to the understanding of WCHC for WLWH. Seven databases were reviewed and yielded 15,332 references, of which 21 fit our inclusion criteria for the scoping review. Research findings were categorized into characteristics of the study, recommendations, and target audiences. Findings revealed WCHC as care which includes the involvement of WLWH in decisions; person-centred integrated care; integrated services including mental health; sexual and reproductive health services; trauma-informed and safe space practices; healthcare provider training; and women's care self-management. In general, current systems of care do not meet the unique needs of WLWH.

Physical violence and violent threats reported by Aboriginal and Torres Strait Islander people with a disability: cross sectional evidence from a nationally representative survey.

BACKGROUND: A recent Royal Commission into the treatment of Australians living with disabilities has underscored the considerable exposure to violence and harm in this population. Yet, little is known about exposure to violence among Aboriginal and Torres Strait Islander people living with disabilities. The objective of this paper was to examine the prevalence, disability correlates and aspects of violence and threats reported by Aboriginal and Torres Strait Islander people living with disabilities. METHODS: Data from the 2014-15 National Aboriginal and Torres Strait Islander Social Survey were used to measure physical violence, violent threats and disability. Multivariable logistic and ordinal logistic regression models adjusted for complex survey design were used to examine the association between measures of disability and exposure to violence and violent threats. RESULTS: In 2014-15, 17% of Aboriginal and Torres Strait Islander people aged 15-64 with disability experienced an instance of physical violence compared with 13% of those with no disability. Approximately 22% of those with a profound or severe disability reported experiencing the threat of physical violence. After adjusting for a comprehensive set of confounding factors and accounting for complex survey design, presence of a disability was associated with a 1.5 odds increase in exposure to physical violence (OR = 1.54 p < 0.001), violence with harm (OR = 1.55 p < 0.001), more frequent experience of violence (OR = 1.55 p < 0.001) and a 2.1 odds increase (OR = 2.13 p < 0.001) in exposure to violent threats. Severity of disability, higher numbers of disabling conditions as well as specific disability types (e.g., psychological or intellectual) were associated with increased odds of both physical violence and threats beyond this level. Independent of these effects, removal from one's natural family was strongly associated with experiences of physical violence and violent threats. Aboriginal and Torres Strait Islander women, regardless of disability status, were more likely to report partner or family violence, whereas men were more likely to report violence from other known individuals. CONCLUSION: Aboriginal and Torres Strait Islander people with disability are at heightened risk of physical violence and threats compared to Aboriginal and Torres Strait Islander people without disability, with increased exposure for people with multiple, severe or specific disabilities.

Morbidity and mortality conferences in general surgery: a narrative systematic review.

Background: In medical and surgical departments around the world, morbidity and mortality conferences (MMC) serve dual roles: they are cornerstones of quality-improvement programs and provide timely opportunities for education within the urgent context of clinical care. Despite the widespread adoption of MMCs, adverse events and preventable errors remain high or incompletely characterized, and opportunities to learn from and adjust to these events are frequently lost. This review examines the published literature on strategies to improve surgical MMCs. Methods: We searched OVID Medline, PubMed, Embase and CENTRAL. We defined our combination of search terms using a PICO (population, intervention, comparison, outcome) model, focusing on the use of MMCs in general surgery. Results: The MMC literature focused on 5 themes: educational value, error analysis, case selection and representation, attendance and dissemination. Strategies used to increase educational value included limiting case presentation time to 15-20 minutes, mandatory brief literature reviews, increasing audience interaction, and standardizing presentations using a PowerPoint template or SBAR (situation, background, assessment, recommendation) format. Interventions to improve error analysis included focused discussion on causative factors and taxonomic error analysis. Case selection was improved by using an electronic clinical registry, such as the National Surgery Quality Improvement Program, to better capture incidence of morbidity and mortality. Attendance was improved with teleconferencing. Dissemination strategies included MMC newsletters, incorporating MMCs into plan-do-check-act cycles, and surgeon report cards. Conclusion: Greater standardization of best practices may increase the quality improvement and educational impact of MMCs and provide a baseline to measure the effect of new MMC format innovations on the clinical and educational performance of surgical systems.

Contexte: Dans les services de médecine et de chirurgie du monde entier, les conférences sur la morbidité et la mortalité (CMM) jouent 2 rôles : elles forment la pierre angulaire des programmes d'amélioration de la qualité de soins et fournissent l'occasion de faire de l'enseignement dans le contexte même des soins cliniques immédiats. Malgré la popularité grandissante des CMM, le nombre d'événements indésirables et d'erreurs évitables demeure élevé ou mal caractérisé et on perd beaucoup d'occasions d'apprendre de ces événements et d'apporter les changements qui s'imposent. La présente revue analyse la littérature publiée sur les stratégies d'amélioration des CMM en chirurgie. Méthodes: Nous avons interrogé OVID Medline, PubMed, Embase et CENTRAL. Nous avons défini nos combinaisons de mots clés à l'aide du modèle PICO (population, intervention, comparaison et résultat [outcome]), en mettant l'accent sur l'utilisation des CMM en chirurgie générale. Résultats: La littérature sur les CMM se concentrait sur 5 thèmes : valeur didactique, analyse des erreurs, sélection et représentation des cas, participation et dissémination. Les stratégies utilisées pour accroître la valeur didactique incluaient limiter la durée des présentations de cas à 15­20 minutes, présenter de brèves revues de la littérature, favoriser les interactions avec l'auditoire et standardiser les présentations au moyen de modèles PowerPoint ou SBAR (situation, background, assessment, recommendation). Les interventions visant à améliorer l'analyse des erreurs incluaient une discussion sur les facteurs causaux et l'analyse des erreurs taxonomiques. La sélection des cas a été améliorée au moyen d'un registre clinique électronique comme le National Surgery Quality Improvement Program, pour mieux suivre l'incidence de la morbidité et de la mortalité. Les systèmes de téléconférences ont amélioré la participation. Parmi les stratégies de dissémination, mentionnons les bulletins sur les CMM, leur intégration aux cycles planifier/faire/vérifier/agir et les relevés de notes des chirurgiens. Conclusion: Une meilleure standardisation des pratiques optimales pourrait améliorer davantage la qualité des soins et augmenter l'impact didactique des CMM en plus d'offrir une base de référence pour mesurer l'effet des nouvelles mesures appliquées aux CMM sur le rendement clinique et didactique des systèmes chirurgicaux.

Mental toughness in surgeons: Is there room for improvement?

Background: Mental toughness is crucial to high-level performance in stressful situations. However, there is no formal evaluation or training in mental toughness in surgery. Our objective was to examine differences in mental toughness between staff and resident surgeons, and whether there is an interest in improving this attribute. Methods: We distributed a survey containing the Mental Toughness Index (domains of self-belief, attention regulation, emotion regulation, success mindset, context knowledge, buoyancy, optimism and adversity capacity) among general surgery residents and staff at 3 Canadian academic institutions. Responses were recorded on a 7-point Likert scale. Participants were also asked about techniques they used to help them perform under pressure and interest in further developing mental toughness. Results: Eighty-three of 193 surgeons participated: 56/105 (52.8%) residents and 27/87 (31.0%) staff. The average age was 29 (standard deviation 5) years and 42 (standard deviation 8) years, respectively. Residents scored significantly lower than staff in all mental toughness domains. Men scored significantly higher than women in attention regulation and emotion regulation. Age, staff experience and resident postgraduate year were not significantly associated with mental toughness scores. Twenty residents (36%) and 17 staff (63%) reported using specific techniques to deal with stressful situations; 49 (88%) and 15 (56%), respectively, were interested in further developing mental toughness. Conclusion: Staff surgeons scored significantly higher than residents in all mental toughness domains measured. Both groups expressed a desire to improve mental toughness. There are many techniques to improve mental toughness, and further research is needed to assess their effectiveness in surgical training.

Contexte: La force mentale est indispensable à un rendement de haut niveau en situation de stress. Par contre, il n'existe pas de méthode d'évaluation formelle ni de formation pour promouvoir la force mentale en chirurgie. Notre objectif était de comparer la force mentale des chirurgiens en poste à celle des résidents, et de vérifier si l'amélioration de cette compétence suscite l'intérêt. Méthodes: Nous avons distribué un questionnaire sur les divers domaines qui constituent l'indice de force mentale (confiance en soi, régulation de l'attention et des émotions, attitude gagnante, connaissances du contexte, dynamisme, optimisme et résistance à l'adversité) aux résidents et aux chirurgiens en poste en chirurgie générale dans 3 établissements universitaires canadiens. Les réponses étaient consignées sur une échelle de Likert en 7 points. Les participants ont aussi été interrogés sur les techniques qu'ils utilisent pour mieux composer avec la pression et sur leur intérêt pour l'acquisition d'une plus grande force mentale. Résultats: Quatre-vingt-trois chirurgiens sur 193 ont participé : 56/105 (52,8 %) résidents et 27/87 (31,0 %) chirurgiens en poste. L'âge moyen était de 29 ans (écarttype 5) et de 42 ans (écart-type 8), respectivement. Les résidents ont obtenu un score significativement moindre que les chirurgiens en poste pour tous les domaines constitutifs de la force mentale. Les hommes ont obtenu des scores significativement plus élevés que les femmes pour la régulation de l'attention et des émotions. L'âge, l'expérience des chirurgiens en poste et l'année de formation postdoctorale des résidents n'ont pas été significativement associés aux scores de force mentale. Vingt résidents (36 %) et 17 chirurgiens en poste (63 %) ont indiqué utiliser des techniques spécifiques pour affronter les situations stressantes; 49 (88 %) et 15 (56 %), respectivement, se sont montrés intéressés à acquérir davantage de force mentale. Conclusion: Les chirurgiens en poste ont obtenu des scores significativement plus élevés que les résidents pour tous les domaines de la force mentale mesurés. Les 2 groupes ont exprimé un intérêt pour l'amélioration de leur force mentale. Il existe plusieurs techniques à cet effet et il faudra approfondir la recherche pour en évaluer l'efficacité chez les chirurgiens en formation.

Examining State Licensing Requirements for Select Master's-Level Behavioral Health Providers for Children.

OBJECTIVE: The authors examined licensing requirements for select children's behavioral health care providers. METHODS: Statutes and regulations as of October 2021 were reviewed for licensed clinical social workers, licensed professional counselors, and licensed marriage and family therapists for all 50 U.S. states and the District of Columbia. RESULTS: All jurisdictions had laws regarding postgraduate training and license portability. No jurisdiction included language about specialized postgraduate training related to serving children and families or cultural competence. Other policies that related to the structure, composition, and authority of licensing boards varied across states and licensure types. CONCLUSIONS: In their efforts to address barriers to licensure, expand the workforce, and ensure that children have access to high-quality and culturally responsive care, states could consider their statutes and regulations.

Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh.

BACKGROUND: Bangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health factors that drove Bangladesh's success in mortality reduction. METHODS: We operationalised a comprehensive conceptual framework and analysed available household surveys for trends and inequalities in mortality, intervention coverage and quality of care. These include 12 household surveys totalling over 1.3 million births in the 15 years preceding the surveys. Literature and desk reviews permitted a reconstruction of policy and programme development and financing since 1990. These were supplemented with key informant interviews to understand implementation decisions and strategies. RESULTS: Bangladesh prioritised early population policies to manage its rapidly growing population through community-based family planning programmes initiated in mid-1970s. These were followed in the 1990s and 2000s by priority to increase access to health facilities leading to rapid increases in facility delivery, intervention coverage and access to emergency obstetric care, with large contribution from private facilities. A decentralised health system organisation, from communities to the central level, openness to private for-profit sector growth, and efficient financing allocation to maternal and newborn health enabled rapid progress. Other critical levers included poverty reduction, women empowerment, rural development, and culture of data generation and use. However, recent empirical data suggest a slowing down of mortality reductions. CONCLUSION: Bangladesh demonstrated effective multi-sectoral approach and persistent programming, testing and implementation to achieve rapid gains in maternal and neonatal mortality reduction. The slowing down of recent mortality trends suggests that the country will need to revise its strategies to achieve the Sustainable Development Goals. As fertility reached replacement level, further gains in maternal and neonatal mortality will require prioritising universal access to quality facility delivery, and addressing inequalities, including reaching the rural poor.

Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study.

INTRODUCTION: Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges. METHODS: We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation. RESULTS: Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change. CONCLUSIONS: Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.

Assessment of Spending for Patients Initiating Dialysis Care.

Importance: Despite a widespread belief that private insurers spend large amounts on health care for enrollees receiving dialysis, data limitations over the past decade have precluded a comprehensive analysis of the topic. Objective: To examine the amount and types of increases in health care spending for privately insured patients associated with initiating dialysis care. Design, Setting, and Participants: A cohort study covering calendar years 2012 to 2019 included patients with kidney failure who had employer-sponsored insurance for 12 months following dialysis initiation. Data analysis was performed from August 27, 2021, to August 18, 2022. The data cover the entirety of the US and were obtained from the Health Care Cost Institute. The data include all medical claims for enrollees in employer-sponsored health insurance plans offered by multiple major health care insurers within the US. Participants included patients younger than 65 years who were continuously enrolled in these plans in the 12 months before and after their first claim for dialysis care. Patients also had to have nonmissing documented key characteristics, such as sex, race and ethnicity, and health characteristics. Exposures: A claim for dialysis care. Main Outcomes and Measures: Out-of-pocket, inpatient, outpatient, physician services, prescription medication, and total health care spending. The hypothesis tested was formulated before data collection. Results: The sample included 309 800 enrollee-months, which was a balanced panel of 25 months for 12 392 enrollees. At baseline, 7534 patients (61%) were male, 5415 (44%) were aged 55 to 64 years, and patients had been enrolled with their insurer for a mean of 30 months (95% CI, 29.9-30.1 months). In the 12 months before initiating dialysis care, total monthly health care spending was $5025 per patient per month (95% CI, $4945-$5106). Dialysis care initiation was associated with an increase in total monthly spending of $14 685 (95% CI, $14 413-$14 957). This increase occurred across all spending categories (dialysis, nondialysis outpatient, inpatient, physician services, and prescription drugs). Monthly patient out-of-pocket spending increased by $170 (95% CI, $162-$178). These spending increases occurred abruptly, beginning about 2 months before dialysis initiation, and remained increased for the subsequent 12 months. Conclusions and Relevance: In this cohort study, evidence that private insurers experience significant, sustained increases in spending when patients initiated dialysis was noted. The findings suggest that proposed policies aimed at limiting the amount dialysis facilities charge private insurers and the enrollees has the potential to reduce health care spending in this high-cost population.

Tele-mentored damage-control and emergency trauma surgery: A feasibility study using live-tissue models.

BACKGROUND: Damage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge. METHODS: Canadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys. RESULTS: With no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most. CONCLUSION: The use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness.

Correction to: Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients.

The original version of this article unfortunately contained few mistakes. Under the subheading "Data extraction and review process", in line 12 the word "prospective" is incorrectly given by the author. The correct word is "retrospective". In Fig. 2D, the label should read as RA instead of LA. In Table 6, the word "ischemic/gangrenous" should read as "ischemia/gangrene" in 9th row, column 6. The revised Fig 2 and Table 6 are available in the correction article.

Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients.

PURPOSE: Our study aims to investigate the frequency and patterns of delayed manifestations of abdominal and pelvic injuries which may not be identified or which fail to manifest on the initial abdominopelvic CT in posttraumatic patients. METHODS: For our institutional review board (IRB)-approved retrospective study, our hospital trauma registry was queried for patients with blunt multitrauma and Injury Severity Score (ISS) ≥ 16 between January 2010 and August 2016, yielding 3735 patients. A total of 203 patients received a follow-up abdominopelvic CT within six months from the initial scan and those with new findings on follow-up CT were identified. A retrospective blinded review of the initial CT examinations was performed by two experienced radiologists. The retrospective readings and original reports were compared to categorize the new abnormalities detected on follow-up CT scans. The categories included missed injuries, late presentations and sequelae of trauma, and complications of surgery, hospital admission, and invasive procedures. The patients' notes were reviewed for the clinical indications, time interval for repeat CT examination, and subsequent clinical management. The software used for statistical analysis of the extracted data was Microsoft Excel for Mac (version 15.33). RESULTS: Out of 3735 patients, 203 patients received 232 follow-up abdominopelvic CTs. The average elapsed time between the initial CT and the follow-up CT was 15 ± 27 days. Evaluation for an abdominal fluid collection was the most common clinical indication, accounting for 40% of the total number (n = 243) of indications. Delayed manifestations and complications of trauma were present in 41 patients due to 47 abnormalities, most commonly related to solid organ injury, followed by abdominal collections and hematoma. Twenty-nine CT findings (62%) were only detectable on follow-up CT, while nine injuries (19%) were missed on initial CT. The findings on repeated CT warranted eight surgical and 15 interventional procedures. CONCLUSION: A small percentage of traumatic injuries may be unidentified or fail to manifest on the initial CT, resulting in delayed manifestations of abdominopelvic trauma, which may lead to subsequent readmission, delayed management, and more severe medical complications.

Exploring the responsiveness of public and private hospitals in lagos, Nigeria.

According to the World Health Report 2000, health system responsiveness is proposed as one of the three key objectives of any health system. This multi-domain concept describes how well a health system responds to the expectations of their users concerning the non-health enhancing aspects of care. In this study we aim to compare the levels of responsiveness experienced by users of private and publicly managed hospitals in Nigeria, and through these insights, to propose recommendations on how to improve performance on this measure. This quantitative, cross-sectional study uses a questionnaire that is adapted from two responsiveness surveys designed by the World Health Organization (WHO). Researchers collected responses from 520 respondents from four hospitals in Lagos, Nigeria. Analysis of the data using statistical techniques found that significant differences exist between the performance of public and private hospitals on certain domains of responsiveness, with privately operated hospitals performing better where differences exist. Users of private hospitals also reported a higher level of overall satisfaction. Private hospitals were found to perform particularly better on the domains of dignity, waiting times, and travel times. These findings have implications for the management of public hospitals in focusing their efforts on improving their performance in low scoring domains. Performance in these hospitals can be improved by emphasis on staff training and demand management.