Coproduced, arts interventions for nurturing care (0-5 years) in low-income and middle-income countries (LMICs): a realist review.

OBJECTIVES: Community-based arts interventions have the potential to support contextually relevant nurturing care programmes and policies that adapt to different settings. Understanding the distinctive features of using the arts in local, culturally specific ways in low/middle-income countries (LMICs); how this varies by context; and gaining a better understanding of the perspectives on desirable outcomes for communities is important evidence that this review generates. DESIGN: We conducted a realist review of papers that covered outcomes related to child health or development (0-5 years) AND arts-based approaches AND community-based, participatory approaches AND based in LMICs using a range of databases and other networks. A coding framework was developed covering context, intervention, outcomes, mechanisms, study, sustainability, transferability and scalability. RESULTS: The included papers reported 18 unique interventions. Interventions covered 14 countries, with evidence lacking for South America, Arab countries and parts of Africa. Lead authors came from mostly clinical science-based disciplines and from institutions in a different country to the country/countries studied. Intended outcomes from interventions included clinical, health systems/organisation, changes in practices/behaviours/knowledge/attitudes, and wider social and educational goals. We identified three demi-regularities (semi-predictable patterns or pathways of programme functioning): participatory design based on valuing different sources of expertise; dynamic adaptation of intervention to context; and community participation in arts-based approaches. CONCLUSIONS: Our findings suggest that arts-based, nurturing care interventions have greater potential when they include local knowledge, embed into existing infrastructures and there is a clear plan for ongoing resourcing of the intervention. Studies with better documentation of the lessons learnt, regarding the intervention delivery process and the power dynamics involved, are needed to better understand what works, for whom and in which contexts.

The potential of micro- and nanoplastics to exacerbate the health impacts and global burden of non-communicable diseases.

Non-communicable diseases (NCD) constitute one of the highest burdens of disease globally and are associated with inflammatory responses in target organs. There is increasing evidence of significant human exposure to micro- and nanoplastics (MnPs). This review of environmental MnP exposure and health impacts indicates that MnP particles, directly and indirectly through their leachates, may exacerbate inflammation. Meanwhile, persistent inflammation associated with NCDs in gastrointestinal and respiratory systems potentially increases MnP uptake, thus influencing MnP access to distal organs. Consequently, a future increase in MnP exposure potentially augments the risk and severity of NCDs. There is a critical need for an integrated one-health approach to human health and environmental research for assessing the drivers of human MnP exposure and their bidirectional links with NCDs. Assessing these risks requires interdisciplinary efforts to identify and link drivers of environmental MnP exposure and organismal uptake to studies of impacted disease mechanisms and health outcomes.

Barriers and facilitators of people living with HIV receiving optimal care for hypertension and diabetes in Tanzania: a qualitative study with healthcare professionals and people living with HIV.

BACKGROUND: People living with HIV (PLWH) are at a higher risk for developing diabetes and hypertension. Often services are separate for HIV and non-communicable diseases (NCDs), but how this impacts NCD care among PLWH is unknown. We aimed to understand the barriers and facilitators for prevention, early diagnosis and safe effective care for diabetes and hypertension among PLWH. METHODS: Semi-structured interviews (SSIs) were conducted with 10 healthcare professionals (HCPs) that care for PLWH, 10 HCPs that care for people with diabetes and hypertension and 16 PLWH with a comorbidity of diabetes and/or hypertension. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and purposively sampled based on age and sex. Interviews were conducted in Swahili using pre-developed topic guides, audio recorded then translated verbatim into English. An inductive thematic analysis was conducted using The Framework Method. RESULTS: Three themes were found: organisational/healthcare system factors, individual factors and syndemic factors. Organisational/healthcare system factors comprised the only facilitators for prevention (education on lifestyle behaviours and counselling on adherence), but included the most barriers overall: fragmented services, no protocol for NCD screening and lack of access to diagnostic equipment were barriers for early diagnosis whereas the former plus lack of continuity of NCD care were barriers for safe effective care. Individual factors comprised four sub-themes, three of which were considered facilitators: HCPs' knowledge of NCDs for early diagnosis, self-monitoring of NCDs for safe effective care and HCPs' personal practice for both early diagnosis and safe effective care. HCPs' knowledge was simultaneously a barrier for prevention and PLWH knowledge was a barrier for prevention and safe effective care. Syndemic factors comprised three sub-themes; all were barriers for prevention, early diagnosis and/or safe effective care: poverty and mental health of PLWH and HIV stigma. CONCLUSIONS: Organisational/healthcare system, individual and syndemic factors were found to be interlinked with barriers and facilitators that contribute to the prevention, early diagnosis and safe effective care of diabetes and hypertension among PLWH in Tanzania; these findings can inform future initiatives for making small and large health system changes to improve the health of aging PLWH.

Identifying and understanding the care pathway of patients with atrial fibrillation in Brazil and the impact of the COVID-19 pandemic: A mixed-methods study.

BACKGROUND: Atrial fibrillation (AF) is a major risk factor for stroke. To enable improvements to AF diagnosis and follow-up care, understanding current patient pathways and barriers to optimal care are essential. We investigated the patient care pathways and their drivers, and the impact of the COVID-19 pandemic on patient pathways in a middle-income country setting, Brazil. METHODS: This mixed-methods study in São Paulo, included adults (≥18y) with AF from 13 primary/secondary healthcare facilities. Surveys using baseline, follow-up (administered ≥two months after baseline) and COVID-19 questionnaires (quantitative), and three focus group discussions (FGDs) were conducted. Minimum sample size for the quantitative component was 236 and we aimed to reach saturation with at least three FGDs for the qualitative component. Descriptive statistics were used for quantitative data and a content analysis was used for qualitative data to identify themes related to AF diagnosis and follow-up care. RESULTS: 267 participants completed the baseline questionnaire: 25% were diagnosed in primary care, 65% in an emergency or inpatient department. At follow-up (n = 259), 31% visited more than one facility for AF care, and 7% had no follow-up. Intervals between international normalised ratio (INR) tests were increased during the pandemic, and the number of healthcare visits and availability of medication were reduced. Seventeen patients participated in three FGDs and revealed that AF diagnosis often occurred following a medical emergency and patients often delay care-seeking due to misconceptions about AF symptoms. Long waiting times, doctor/patient interactions and health system factors, such as doctor availability and the referral system, influence where participants visited for follow-up care. CONCLUSIONS: Lack of public awareness and underdeveloped primary healthcare lead to delayed diagnosis, which impacts clinical outcomes and excess patient and healthcare system costs. Health system, care-provider, and pandemic factors disrupt timely and effective continuity of care.

Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation.

BACKGROUND: Identifying existing care pathways is the first step for understanding how services can be improved to enable early diagnosis and effective follow-up care for non-communicable diseases (NCDs); however, evidence on how care pathways can and should be identified in low- and middle-income countries (LMICs) is lacking. OBJECTIVE: To describe generalisability and lessons learned from recruitment and data collection for the quantitative component of a mixed methods study designed to determine the care pathway for atrial fibrillation (AF) in Brazil, China and Sri Lanka. METHODS: Adults (≥18 years) that spoke the local language and with an AF diagnosis were eligible. We excluded anyone with a hearing or cognitive impairment or ineligible address. Eligible participants were identified using electronic records in Brazil and China; in Sri Lanka, researchers attended the outpatient clinics to identify eligible participants. Data were collected using two quantitative questionnaires administered at least 2-months apart. A minimum sample size of 238 was required for each country. RESULTS: The required sample size was met in Brazil (n = 267) and China (n = 298), but a large proportion of AF patients could not be contacted (47% and 27%, respectively) or refused to participate (36% and 38%, respectively). In Sri Lanka, recruitment was challenging, resulting in a reduced sample (n = 151). Mean age of participants from Brazil, China and Sri Lanka was 69 (SD = 11.3), 65 (SD = 12.8) and 58 (SD = 11.7), respectively. Females accounted for 49% of the Brazil sample, 62% in China and 70% in Sri Lanka. CONCLUSIONS: Generalisability was an issue in Brazil and China, as was selection bias. Recruitment bias was highlighted in Sri Lanka. Additional or alternative recruitment methods may be required to ensure generalisability and reduce bias in future studies aimed at identifying NCD care pathways in LMICs.

Barriers and facilitators for the provision of radiology services in Zimbabwe: A qualitative study based on staff experiences and observations.

Despite its fundamental role in diagnostic and curative care, radiology has been described as a neglected essential service in many low and middle-income countries (LMICs). Previous studies have demonstrated basic equipment and infrastructure shortages in LMIC settings, but no studies to date have gone further in understanding the perceptions and experiences of staff delivering radiology services, as a way of identifying their perspectives on barriers and facilitators for delivering services, and the potential for where improvements can be made. Our qualitative study aimed to: (a) identify barriers for delivering radiology services, and (b) suggest potential facilitators for improvement of radiology service delivery in the Zimbabwean context; from the perspective of radiology staff. We conducted semi-structured interviews (n = 13) and three focus groups (n = 24 radiographers), followed by four half- to full- days of field observations to validate insights from the interviews and focus groups in all three public hospitals and one private hospital in the Harare metropolitan area. Our study identified four main barriers for delivering radiology services: (i) poor basic infrastructure, equipment, and consumables; (ii) suboptimal equipment maintenance; (iii) shortage of radiology staff and skills development; and (iv) lack of wider integration and support for radiology services. We also identified a strong sense of motivation among staff to keep radiology services, pointing to what may be an enabler and facilitator for improving radiology services. These findings point to potential risks to patient safety and quality of delivering radiology services. More importantly, we found a strong sense of personal motivation displayed by the staff, suggesting there is the potential to maintain and improve existing practices, but this would require investments to train and remunerate more radiology staff, as well as investing in continuing professional development.

Impact assessment of a raw coal ban on maternal and child health outcomes in Ulaanbaatar: a protocol for an interrupted time series study.

INTRODUCTION: Despite a decade of policy actions, Ulaanbaatar's residents continue to be exposed to extreme levels of air pollution, a major public health concern, especially for vulnerable populations such as pregnant women and children. In May 2019, the Mongolian government implemented a raw coal ban (RCB), prohibiting distribution and use of raw coal in households and small businesses in Ulaanbaatar. Here, we present the protocol for an interrupted time series (ITS; a strong quasi-experimental study design for public health interventions) that aims to assess the effectiveness of this coal ban policy on environmental (air quality) and health (maternal and child) outcomes. METHODS AND ANALYSIS: Routinely collected data on pregnancy and child respiratory health outcomes between 2016 and 2022 in Ulaanbaatar will be collected retrospectively from the four main hospitals providing maternal and/or paediatric care as well as the National Statistics Office. Hospital admissions data for childhood diarrhoea, an unrelated outcome to air pollution exposure, will be collected to control for unknown or unmeasured coinciding events. Retrospective air pollution data will be collected from the district weather stations and the US Embassy. An ITS analysis will be conducted to determine the RCB intervention impact on these outcomes. Prior to the ITS, we have proposed an impact model based on a framework of five key factors, which were identified through literature search and qualitative research to potentially influence the intervention impact assessment. ETHICS AND DISSEMINATION: Ethical approval has been obtained via the Ministry of Health, Mongolia (No.445) and University of Birmingham (ERN_21-1403). To inform relevant stakeholders of our findings, key results will be disseminated on both (inter)national and population levels through publications, scientific conferences and community briefings. These findings are aimed to provide evidence for decision-making in coal pollution mitigation strategies in Mongolia and similar settings throughout the world.

Socioeconomic and urban-rural inequalities in the population-level double burden of child malnutrition in the East and Southern African Region.

Socioeconomic and urban-rural inequalities in the population-level double burden of child malnutrition threatens global nutrition targets 2025, especially in East and Southern Africa. We aimed to quantify these inequalities from nationally representative household surveys in the East and Southern African region. 13 Demographic and Health Surveys between 2006 and 2018 including 72,231 children under five years old were studied. Prevalence of stunting, wasting and overweight (including obesity) were disaggregated by wealth quintiles, maternal education categories and urban-rural residence for visual inspection of inequalities. The slope index of inequality (SII) and the relative index of inequality (RII) were estimated for each country. Regional estimates of child malnutrition prevalence and socioeconomic and urban-rural inequalities were generated from pooling country-specific estimates using random-effects meta-analyses. Regional stunting and wasting prevalence were higher among children living in the poorest households, with mothers with the lowest educational level and in rural areas. In contrast, regional overweight (including obesity) prevalence was higher among children living in the richest households, with mothers with the highest educational level and urban areas. This study indicates pro-poor inequalities are present in child undernutrition and pro-rich inequalities are present in child overweight including obesity. These findings re-emphasise the need for an integrated approach to tackling the population-level double burden of child malnutrition in the region. Policy makers must target specific populations that are vulnerable to child malnutrition, to avoid further widening of socioeconomic and urban-rural inequalities.

Patients', carers' and healthcare providers' views of patient-held health records in Kerala, India: A qualitative exploratory study.

INTRODUCTION: Poor medical information transfer across healthcare visits and providers poses a potential threat to patient safety. Patient-held health records (PHRs) may be used to facilitate informational continuity, handover communication and patient self-management. However, there are conflicting opinions on the effectiveness of PHRs, other than in maternal and child care. Moreover, the experiences of users of PHRs in low- and middle-income countries are critical in policy decisions but have rarely been researched. AIM: This study aimed to explore similarities and differences in the perspectives of patients, carers and healthcare providers (HCPs) on the current PHRs for diabetes and hypertension in Kerala. METHODS: A qualitative design was used comprising semistructured interviews with patients with diabetes/hypertension (n = 20), carers (n = 15) and HCPs (n = 17) in Kerala, India. Data were analysed using thematic analysis. RESULTS: Themes generated regarding the experiences with PHRs from each user group were compared and contrasted. The themes that arose were organized under three headings: use of PHRs in everyday practice; the perceived value of PHR and where practice and value conflict. We found that in the use of PHRs in everyday practice, multiple PHRs posed challenges for patients carrying records and for HCPs locating relevant information. Most carers carried all patients' past PHRs, while patients made decisions on which PHR to take along based on the purpose of the healthcare visit. HCPs appreciated having PHRs but documented limited details in them. The perceived value of PHRs by each group for themselves was different. While HCPs placed value on PHRs for enabling better clinical decision-making, preventing errors and patient safety, patients perceived them as transactional tools for diabetes and hypertension medications; carers highlighted their value during emergencies. CONCLUSION: Our findings suggest that users find a variety of values for PHRs. However, these perceived values are different for each user group, suggesting minimal functioning of PHRs for informational continuity, handover communication and self-management. PATIENT AND PUBLIC INVOLVEMENT: Patients and carers were involved during the pilot testing of topic guides, consent and study information sheets. Patients and carers gave their feedback on the materials to ensure clarity and appropriateness within the context.

Safety and efficacy of tuberculosis vaccine candidates in low- and middle-income countries: a systematic review of randomised controlled clinical trials.

BACKGROUND: Tuberculosis (TB) remains a leading cause of death worldwide, with 98% of cases occurring in low- and middle-income countries (LMICs). The only vaccine licenced for the prevention of TB has limited protection for adolescents, adults and vulnerable populations. A safe and effective vaccine for all populations at risk is imperative to achieve global elimination of TB. We aimed to systematically review the efficacy and safety of TB vaccine candidates in late-phase clinical trials conducted in LMICs. METHODS: Medline, Embase, CENTRAL, PubMed, Clinicaltrials.gov and Greylit.org were searched in June 2021 to identify phase 2 or later clinical randomised controlled trials that report the efficacy or safety (adverse events) of TB vaccine candidates with participants of any age living in an LMIC. TB vaccine candidates listed in the 2020 WHO Global TB Report were eligible for inclusion aside from BCG revaccination. Trials were excluded if all participants had active TB at baseline. Two reviewers independently assessed papers for eligibility, and for bias and quality using the Risk of Bias 2 tool and GRADE guidelines, respectively. We report efficacy rates and frequencies of adverse events from each included trial where available and qualitatively synthesise the findings. RESULTS: Thirteen papers representing eleven trials met our inclusion criteria. Seven vaccine candidates were reviewed across seven countries: M72/AS01, RUTI, VPM1002, H56:IC31, MTBVAC, DAR-901 and ID93 + GLA-SE. Two trials reported on efficacy: an efficacy rate of 54% (95% CI 11.5, 76.2) was reported for M72/AS01 in adults with latent TB and 3% (95% CI -13.9, 17.7) for DAR-901 in healthy adolescents. However, the latter trial was underpowered. All vaccine candidates had comparable occurrences of adverse events between treatment arms and demonstrated acceptable safety profiles; though, RUTI resulted in one serious complication in a person living with HIV. M72/AS01 was the only vaccine considered safe across a diverse group of people including people living with HIV or latent TB and healthy infants and adolescents. CONCLUSION: Further efficacy trials for M72/AS01 are warranted to include additional populations at risk where safety has been demonstrated. Further safety trials are needed for the remaining vaccine candidates to confirm safety in vulnerable populations.

Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022).

BACKGROUND: Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition. METHODS: We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done. CONCLUSIONS: The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts. TRIAL REGISTRATION: ISRCTN14390796. Registration date December 13, 2021.

A matched cohort study investigating premature, accentuated, and accelerated aging in people living with HIV.

INTRODUCTION: The impact of HIV infection on the aging process is disputed and largely unknown. We aimed to identify whether people living with HIV experience premature, accelerated, and/or accentuated aging by investigating the development of four age-related non-communicable diseases in people living with versus without HIV. METHODS: This population-based matched cohort study design used UK-based primary care electronic health records from the IQVIA Medical Research Database. Between January 2000 and January 2020, all people living with and without HIV aged ≥18 years were eligible. Outcomes included cardiovascular disease (CVD), hypertension, type 2 diabetes mellitus (T2DM), and chronic kidney disease (CKD), which were identified by Read codes. We used age at diagnosis to investigate premature aging and age at exit date to investigate accentuation and acceleration. For each outcome, people with and without HIV were excluded if they had the outcome of interest at baseline. Participants were matched based on propensity scores (1:1 ratio). Linear regression was used to report any difference in age at diagnosis between the two groups and to report the prevalence trends for age at exit date. RESULTS: In total, 8880 people living with HIV were matched with 8880 people without HIV and were found to have an earlier onset of CVD (54.5 vs. 56.8; p = 0.002). Similarly, people living with HIV had an earlier onset of hypertension (49.7 vs. 51.4; p = 0.002). No difference was found for T2DM or CKD (53.4 vs. 52.6; p = 0.368 and 57.6 vs. 58.1; p = 0.483, respectively). The burden of CKD increased over time, whereas no difference in the burden was found for the other conditions. CONCLUSION: The earlier development of CVD and hypertension in people living with HIV than in those without HIV indicates premature aging, whereas the increased burden of CKD indicates accelerated aging.

Carbon monoxide levels in households using coal-briquette fuelled stoves exceed WHO air quality guidelines in Ulaanbaatar, Mongolia.

In 2019, a domestic raw coal ban (RCB) was introduced in Ulaanbaatar, Mongolia. Coal-briquettes have since been promoted in Ger district households, however implications for carbon monoxide (CO) exposure remains uncertain. We obtained 48-hour indoor CO concentrations in 23 Ger district households and compared these to 10 raw-coal households. Information on household characteristics, fuel use behaviour and stove venting practices was collected by survey. Mean 48-hour CO concentrations in coal-briquette households was 6.1 ppm (range 1.5-35.8 ppm) with no signfiicant differences by household, stove or venting factors. Peak time-weighted average CO concentrations exceeded WHO Indoor Air Quality guidelines in 9 (39%) households; with all surpassing the 8-hour guideline (>8.6 ppm); 3(13%) the 24-hour guideline (>6 ppm) and 2(9%) the 1-hour guideline (>30 ppm). Median CO levels were significantly lower in coal-briquette compared to raw coal households (p = 0.049). Indoor CO reduction was associated with RCB implementation although hazardous levels persist in this setting.

Health care professionals' perceptions about atrial fibrillation care in the Brazilian public primary care system: a mixed-methods study.

BACKGROUND: Atrial fibrillation (AF) negatively impacts health systems worldwide. We aimed to capture perceptions of and barriers and facilitators for AF care in Brazilian primary care units (PCUs) from the perspective of healthcare professionals (HCPs). METHODS: This mixed-methods, cross-sectional study utilised an exploratory sequential design, beginning with the quantitative data collection (up to 18 closed questions) immediately followed by a semi-structured interview. HCPs were recruited from 11 PCUs in the Sao Paulo region and included managers, physicians, pharmacists, nurses and community health agents. Descriptive statistics were used to present findings from the quantitative questionnaire and inductive analysis was used to identify themes from the qualitative data. RESULTS: One hundred seven HCPs were interviewed between September 2019 and May 2020. Three main themes were identified that encapsulated barriers and facilitators to AF care: access to care (appointments, equipment/tests and medication), HCP and patient roles (HCP/patient relationship and patient adherence) and the role of the organisation/system (infrastructure, training and protocols/guidelines). Findings from the qualitative analysis reinforced the quantitative findings, including a lack of AF-specific training for HCPs, protocols/guidelines on AF management, INR tests in the PCUs, patient knowledge of AF management and novel oral anticoagulants (NOACs) as key barriers to optimal AF care. CONCLUSIONS: Development and implementation of AF-specific training for PCU HCPs are needed in Brazil, along with evidence-based protocols and guidelines, educational programmes for patients, better access to INR tests for patients taking warfarin and availability of NOACs.

Clinical handover communication at maternity shift changes and women's safety in Banjul, the Gambia: a mixed-methods study.

BACKGROUND: Clinical handover is a vital communication process for patient safety; transferring patient responsibility between healthcare professionals (HCPs). Exploring handover processes in maternity care is fundamental for service quality, addressing continuity of care and maternal mortality. METHODS: This mixed-methods study was conducted in all three maternity hospitals in Banjul, The Gambia. Shift-to-shift maternity handovers were observed and compared against a standard investigating content and environment. Semi-structured interviews and focus group discussions with doctors, midwives and nurses explored handover experience. RESULTS: One hundred ten nurse/midwife shift-to-shift handovers were observed across all shift times and maternity wards; only 666 of 845 women (79%) were handed over. Doctors had no scheduled handover. Shift-leads alone gave/received handover, delayed [median 35 min, IQR 24-45] 82% of the time; 96% of handovers were not confidential and 29% were disrupted. Standardised guidelines and training were lacking. A median 6 of 28 topics [IQR 5-9] were communicated per woman. Information varied significantly by time, high-risk classification and location. For women in labour, 10 [IQR 8-14] items were handed-over, 8 [IQR 5-11] for women classed 'high-risk', 5 [IQR 4-7] for ante/postnatal women (p < 0.001); > 50% had no care management plan communicated. Twenty-one interviews and two focus groups were conducted. Facilitators and barriers to effective handover surrounding three health service factors emerged; health systems (e.g. absence of formalised handover training), organisation culture (e.g. absence of multidisciplinary team handover) and individual clinician factors (e.g. practical barriers such as transportation difficulties in getting to work). CONCLUSION: Maternity handover was inconsistent, hindered by contextual barriers including lack of team communication and guidelines, delays, with some women omitted entirely. Findings alongside HCPs views demonstrate feasible opportunities for enhancing handover, thereby improving women's safety.

A systematic review of home-based records in maternal and child health for improving informational continuity, health outcomes, and perceived usefulness in low and middle-income countries.

BACKGROUND: Evidence shows that a gap in the documentation of patients' past medical history leads to errors in, or duplication of, treatment and is a threat to patient safety. Home-based or patient-held records (HBR) are widely used in low and middle-income countries (LMIC) in maternal and childcare. The aim is to systematically review the evidence on HBRs in LMICs for (1) improving informational continuity for providers and women/families across health care visits and facilities, (2) to describe the perceived usefulness by women/families and healthcare providers, and (3) maternal and child health outcomes of using HBRs for maternal and child health care. METHODS: The protocol was registered in PROSPERO (CRD42019139365). We searched MEDLINE, EMBASE, CINAHL, and Global Index Medicus databases for studies with home-based records from LMICs. Search terms pertained to women or parent-held records and LMICs. Two reviewers assessed studies for inclusion using a priori study selection criteria- studies explaining the use of HBRs in LMIC for maternal and child health care. The included study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Results from all study designs were summarised narratively. RESULTS: In total, 41 papers were included in the review from 4514 potential studies. Included studies represented various study designs and 16 countries. The least evaluated function of HBR was information continuity across health care facilities (n = 6). Overall, there were limited data on the usefulness of HBRs to providers and mothers/families. Home-based records were mostly available for providers during health care visits. However, the documentation in HBRs varied. The use of HBRs is likely to lead to improved antenatal visits and immunisation uptake, and skilled birth delivery in some settings. Mothers' knowledge of breastfeeding practices and danger signs in pregnancy improved with the use of HBRs. One randomised trial found the use of HBRs reduced the risk of cognitive development delay in children and another reported on trial lessened the risk of underweight and stunted growth in children. CONCLUSION: There is limited literature from LMICs on the usefulness of HBRs and for improving information transfer across healthcare facilities, or their use by women at home. Current HBRs from LMICs are sub-optimally documented leading to poor informational availability that defeats the point of them as a source of information for future providers.

Healthcare provider and patient perspectives on access to and management of atrial fibrillation in the Northern Province, Sri Lanka: a rapid evaluation of barriers and facilitators to care.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia that affects 60 million people worldwide. Limited evidence on AF management exists from low- and middle-income countries and none from Sri Lanka. We aimed to investigate the existing AF care pathway and patients' perception on AF management to identify barriers and enablers for optimal AF care in Northern Province, Sri Lanka. METHODS: A rapid evaluation was undertaken with use of qualitative methods. Local healthcare providers (HCPs) mapped the intended pathway of care for AF patients which was then explored and annotated through 12 iterative sessions with additional HCPs. Topics of inefficiencies identified from the finalised map were used to guide focus group discussions (FGDs) with AF patients. AF patients who were attending the anticoagulation clinic at the only tertiary hospital in Northern Province were recruited and invited to participate using purposive sampling. The topic guide was developed in collaboration with local clinicians and qualitative experts. FGDs were conducted in the native Tamil language and all sessions were recorded, transcribed verbatim and thematically analysed using a deductive approach. RESULTS: The mapped pathway revealed inefficiencies in referral, diagnosis and ongoing management. These were explored through three FGDs conducted with 25 AF patients aged 25 to 70 years. Two key themes that contributed to and resulted in delays in accessing care and ongoing management were health seeking behaviours and atomistic healthcare structures. Four cross-cutting sub-themes identified were decision making, paternalistic approach to care, cost impacts and lifestyle impacts. These are discussed across 10 unique categories with consideration of the local context. CONCLUSIONS: Strengthening primary healthcare services, improving public health literacy regarding AF and building patient autonomy whilst understanding the importance of their daily life and family involvement may be advantageous in tackling the inefficiencies in the current AF care pathway in Sri Lanka.

Exploring Factors Affecting Health Care Providers' Behaviors for Maintaining Continuity of Care in Kerala, India; A Qualitative Analysis Using the Theoretical Domains Framework.

Introduction: Access to patients' documented medical information is necessary for building the informational continuity across different healthcare providers (HCP), particularly for patients with non-communicable diseases (NCD). Patient-held health records (PHR) such as NCD notebooks have important documented medical information, which can contribute to informational continuity in the outpatient settings for patients with diabetes and hypertension in Kerala. We aimed to use the theoretical domains framework (TDF) to identify the perceived HCP factors influencing informational and management continuity for patients with diabetes and hypertension. Methods: We re-analyzed semi-structured interview data for 17 HCPs with experience in the NCD programme in public health facilities in Kerala from a previous study, using the TDF. The previous study explored patients, carers and HCPs experiences using PHRs such as NCD notebooks in the management of diabetes and hypertension. Interview transcripts were deductively coded based on a coding framework based on the 14 domains of TDF. Specific beliefs were generated from the data grouped into the domains. Results: Data were coded into the 14 domains of TDF and generated 33 specific beliefs regarding maintaining informational and management continuity of care. Seven domains were judged to be acting as facilitators for recording in PHRs and maintaining continuity. The two domains "memory, attention and decision process" and "environmental context and resources" depicted the barriers identified by HCPs for informational continuity of care. Conclusion: In this exploration of recording and communicating patients' medical information in PHRs for patients with diabetes and hypertension, HCPs attributions of sub-optimal recording were used to identify domains that may be targeted for further development of supporting intervention. Overall, nine domains were likely to impact the barriers and facilitators for HCPs in recording in PHRs and communicating; subsequently maintaining informational and management continuity of care. This study showed that many underlying beliefs regarding informational continuity of care were based on HCPs' experiences with patient behaviors. Further research is needed for developing the content and appropriate support interventions for using PHRs to maintain informational continuity.

Obstetric shift-to-shift handover in Kerala, India: A cross-sectional mixed method study.

INTRODUCTION: Beyond the provision of services, quality of care and patient safety measures such as optimal clinical handover at shift changes determine maternity outcomes. We aimed to establish the proportion of women handed over and the content of clinical handovers and communication between shifts within 3 diverse obstetrics units in Kerala, India, and to describe the handover environment. METHODS: A cross sectional study was conducted for six weeks during February and March 2015at three hospitals in Kerala, India, during nurses obstetric handover in one tertiary private, one tertiary government and one secondary government hospital. Nursing handovers in obstetric post-operative, in-patient and labour wards were sampled. An SBAR-based (situation, background, assessment and recommendation) data schedule was completed whilst observing handover at nursing shift changes. Since obstetricians had no scheduled handover, qualitative interviews were conducted with obstetricians in two hospitals to establish how they acquire information when beginning a shift. RESULTS: Data was obtained on 258 patients handed over, within 67 shift changes. The median percentage of women handed over was 100% in two of the hospitals and 27.6% in the other. The median number of information items included out of a possible 25 was 11, 5 and 4,and did not change significantly for women with high-risk status. Important items regarding assessment and recommendation for care were often missed, including high-risk status. The median number of environment items achieved was good at 7 out of 10 in all hospitals. Obstetricians sought information in various ways when required. All supported the development of structured tools, face-to-face and team handovers. CONCLUSIONS: Maternity unit handovers for doctors and nurses were inadequate. Ensuring handover of all women and including critical information, between shifts as well as between doctors, needs to be improved to increase patient safety.

The risk of mental illness in people living with HIV in the UK: a propensity score-matched cohort study.

BACKGROUND: Prevalence of mental illness is higher in people living with HIV than in the general population, but the incidence of composite mental illness and its components is unclear. We aimed to identify the risk of incident mental illness along with individual conditions of depression, anxiety, and severe mental illness in people living with HIV in the UK. METHODS: Data for this population-based cohort were extracted from the IQVIA Medical Research Database, a nationally representative UK-based database of primary care electronic health records. We included adults (aged ≥18 years) living with HIV, matched with adults without HIV using propensity score matching (1:1 ratio). The primary outcome was composite mental illness comprising a diagnosis of depression, anxiety, or severe mental illness. Secondary outcomes were individual mental health conditions. Cox proportional hazard regression models were used to compare the risk of each outcome between people with and without HIV. Each model excluded those with the outcome at baseline. Individuals were followed up prospectively. The study period was from Jan 1, 2000, to Jan 1, 2020. FINDINGS: Of 7167 people living with HIV without mental illness at baseline, 586 developed a mental illness (incidence rate 19·6 per 1000 person-years) compared with 418 of 7167 people without HIV (incidence rate 12·1 per 1000 person-years), resulting in an adjusted hazard ratio (HR) of 1·63 (95% CI 1·44-1·85). People living with HIV had higher incidence rates for depression (15·4 per 1000 person-years), anxiety (7·2 per 1000 person-years), and severe mental illness (1·6 per 1000 person-years) compared with people without HIV (7·9, 5·0, and 0·6 per 1000 person-years, respectively), with adjusted HRs of 1·94 (95% CI 1·68-2·24) for depression, 1·38 (1·15-1·66) for anxiety, and 2·18 (1·41-3·39) for severe mental illness. INTERPRETATION: People living with HIV have an increased risk for developing composite mental illness, depression, anxiety, and severe mental illness compared with people without HIV. People living with HIV should be regularly screened for mental illness; however, there is a strong need to improve prevention of mental illness in people living with HIV and for more outreach programmes to ensure that no groups of people living with HIV are being underdiagnosed. FUNDING: None.