Factors Influencing Exam Performance of Surgical Trainees in Sub-Saharan Africa: A Retrospective Analysis of the College of Surgeons in East, Central, and Southern Africa Membership Examination.

INTRODUCTION: The College of Surgeons of East, Central, and Southern Africa (COSECSA) has been expanding surgical training in sub-Saharan Africa to respond to the shortage in the region. However, acquiring surgical skills requires rigorous training, and these skills are repeatedly assessed throughout training. Therefore, understanding the factors influencing these assessments is crucial. Previous research has identified individual characteristics, educational background, curriculum structure and previous exam outcomes to influence performance. However, COSECSA's Membership of the College of Surgeons (MCS) exam has not been investigated for factors influencing performance, which this study aims to investigate. METHODS: Data from MCS trainees who took the exam between 2015 and 2021 were analyzed. Trainee demographics, institutional affiliation, operative experience, and exam performance were considered. Linear regression models were used to analyze the factors related to written and clinical exam performance. RESULTS: Out of 354 trainees, 228 were included in the study. Factors such as training duration, the ratio of emergency surgeries, institutional funding source, and country language were associated with written exam performance. Training duration, funding source, exposure to major surgeries, and the ratio of performing operations were significant factors for the clinical exam. DISCUSSION: Operative experience, institutional affiliation, training duration, and language proficiency influence exam performance. Hospitals funded by faith-based organizations or nongovernmental organizations had trainees with higher scores. Prolonged training did not guarantee improved performance. Lastly, having English as an official language improved written exam scores. Gender and country of training did not significantly impact performance. CONCLUSION: This study highlights the importance of operative experience, institutional affiliation, and language proficiency in the exam performance of surgical trainees in COSECSA. Interventions to enhance surgical training and improve exam outcomes in sub-Saharan Africa should consider these factors. Further research is needed to explore additional outcome measures and gather comprehensive data on trainee and hospital characteristics.

The relative roles of early life, physical activity, sedentarism and diet in social and economic inequalities in body mass index and obesity risk between 9 and 18.

Background: Studies in many middle and high-income countries describe an increasing prevalence of adiposity and obesity among children and adolescents. Prevalence is higher among families of low socioeconomic position (SEP) and systematic reviews have identified relevant factors, but have not quantified their relative importance to SEP differentials. This paper examines the relative importance of different factors to Body Mass Index (BMI) and obesity trajectories from age 9 to age 17/18. Methods: Multi-level models of child BMI/obesity risk trajectory by maternal education were conducted using a nationally representative cohort of children born in Ireland in 1998 and aged 9 at baseline (N = 8568), with follow-up at 13 and 17/18 years (88% and 73% response rate respectively). Models were stratified by sex and both time-varying (e.g. child physical activity, diet, sedentary activity) and time-invariant (e.g. early life) factors were tested. Results: Significant inverse gradients in BMI and obesity risk by level of maternal education were present across both sexes and at each age; unadjusted absolute differentials in obesity risk between highest/lowest education groups increased by 56% for males and 42% for females between age 9 and 17/18. Early life factors accounted for 22% of the differential in obesity risk between the lowest and highest education groups among males at age 9, falling to 13% at 17/18. Among females the proportion fell from 33 to 23%. Unadjusted absolute high/low maternal education group differentials in BMI were 7.5 times higher among males and 11 times higher among females at 17/18 than at age 9. Conclusions: Given the importance of early life exposures to subsequent differentials in BMI and obesity risk our findings suggest that policy makers should focus resources on primary prevention during the prenatal and early life period if they wish to reduce the prevalence of child and adolescent obesity.

Quality Metrics and Indicators for Surgical Training: A Scoping Review.

BACKGROUND: Surgical training quality is critical to ensure that trainees receive adequate preparation to perform surgical procedures independently and that patients receive safe, effective, and high-quality care. Numerous surgical training quality indicators have been proposed, investigated and implemented. However, the existing evidence base for these indicators is limited, with most studies originating from English-speaking, high-income countries. OBJECTIVES: This scoping review aimed to identify the range of quality indicators that have been proposed and evaluated in the literature, and to critically evaluate the existing evidence base for these indicators. METHODS: A systematic literature search was conducted using MEDLINE and Embase databases to identify studies reporting on surgical training quality indicators. A total of 68 articles were included in the review. RESULTS: Operative volume is the most commonly cited indicator and has been investigated for its effects on trainee exam performance and career progression. Other indicators include operative diversity, workplace-based assessments, regular evaluation and feedback, academic achievements, formal teaching, and learning agreements, and direct observation of procedural skills. However, these indicators are largely based on qualitative analyses and expert opinions and have not been validated quantitatively using clear outcome measures for trainees and patients. CONCLUSIONS: Future research is necessary to establish evidence-based indicators of high-quality surgical training, including in low-resource settings. Quantitative and qualitative studies are required to validate existing indicators and to identify new indicators that are relevant to diverse surgical training environments. Lastly, any approach to surgical training quality must prioritize the benefit to both trainees and patients, ensuring training success, career progression, and patient safety.

Improved cookstoves to reduce household air pollution exposure in sub-Saharan Africa: A scoping review of intervention studies.

Household air pollution (HAP), primarily from biomass fuels used for cooking, is associated with adverse health outcomes and premature mortality. It affects almost half of the world's population, especially in low-income and low-resourced communities. However, many of the 'improved' biomass cookstoves (ICS) aimed at reducing HAP lack empirical evidence of pollutant reduction and reliability in the field. A scoping review guided by the Joanna Briggs Institute framework was systematically conducted to explore and analyse the characteristics of cookstoves to assess the ICS available to meet the socio-economic and health needs of households in sub-Sahara Africa (sSA). The review searched Scopus, PubMed, Web of Science, EMBASE, Global Health Database on OVID, BASE, and conducted a grey literature search from 2014 to 2022 for all field-based ICS studies. In addition, user perspectives were explored for cookstoves analysed as available, affordable, and effective in reducing harmful biomass emissions. The search returned 1984 records. Thirty-three references containing 23 ICS brands were included. The cookstoves were analysed into seven categories: (1) efficiency in HAP reduction, (2) availability, (3) affordability, (4) sustainability, (5) safety, (6) health outcomes, and (7) user experience. Most (86.9%) of the improved cookstoves showed a reduction in harmful emission levels compared to the traditional three-stone fire. However, the levels were higher than the WHO-recommended safe levels. Only nine were priced below 40 USD. Users placed emphasis on cookstoves' suitability for cooking, fuel and time savings, safety, and price. Equality in cooking-related gender roles and psychosocial benefits were also reported. The review demonstrated limited field testing, a lack of evidence of ICS emissions in real-life settings in sSA, heterogeneity in emission measurements, and incomplete descriptions of ICS and kitchen features. Gender differences in exposure and psychosocial benefits were also reported. The review recommends improved cookstove promotion alongside additional measures to reduce HAP at a cost affordable to low-resource households. Future research should focus on detailed reporting of study parameters to facilitate effective comparison of ICS performance in different social settings with different local foods and fuel types. Finally, a more community-based approach is needed to assess and ensure user voices are represented in HAP intervention studies, including designing the cookstoves.

Factors influencing the integration of planetary health topics into undergraduate medical education in Ireland: a qualitative study of medical educator perspectives.

AIMS: Planetary health is a transdisciplinary field that explores the relationship between the escalating climate and environmental crises and human health. In light of the human health cost arising from planetary health issues, there is a need to educate future medical practitioners accordingly. This study investigates the factors influencing the integration of planetary health into undergraduate medical education at an Irish university and makes recommendations for future practice. METHODS: A qualitative descriptive study design was employed. Twelve semi-structured interviews were conducted with academic staff actively involved in teaching on the undergraduate medical curriculum at Royal College of Surgeons in Ireland University of Medicine and Health Sciences. Both barriers and facilitators to integrating planetary heath into the curriculum were explored. Braun and Clarke's thematic analysis was used to analyse the findings. RESULTS: Barriers to integration include: a lack of curricular space, a perceived lack of awareness among students and educators and a potential lack of knowledge among educators and senior management in relation to these issues. These barriers were tempered by significant facilitators suggesting a shifting paradigm within institutions, innovative approaches to content delivery and an increasing demand from undergraduate medical students. CONCLUSION: This study found a demand from medical educators for the integration of planetary health topics into the medical curriculum. It is suggested that significant adaptation of existing medical curricula is required both in Ireland and further afield, to meet this need. Recommendations based on the barriers and facilitators that emerged during the analysis include: emphasising the clinical relevance of these topics, as suggested by the current evidence base; promoting senior and departmental leadership; and emphasising the potential for improvements in institutional prestige.

Verification of the Goldilocks Hypothesis: the association between screen use, digital media and psychiatric symptoms in the Growing Up in Ireland study.

AIMS: This study aims to replicate Przybylski and Weinstein (Psychol Sci 28(2):204-215, 2017), using a large population cohort to examine the validity of the proposed Goldilocks Hypothesis, which states that moderate digital media engagement may be beneficial and that both high and low usage may have a negative relationship with mental wellbeing. METHODS: Using the GUI98 cohort, we used separate weekday and weekend time-based categorical variables indicating time spent online, playing video games, watching TV/films as well as a frequency variable indicating multiscreening, and their associations with SDQ internalizing and externalizing symptoms using linear and quadratic regression parameters. We followed procedures for confounder adjustments outlined in Przybylski and Weinstein (Psychol Sci 28(2):204-215, 2017). RESULTS: As hypothesized by the Goldilocks Hypothesis, time spent online watching TV/films at the weekend and multiscreening all had curvilinear relationships with internalizing and externalizing symptoms with significantly higher symptoms for no time as well as for higher exposures. internalizing and externalizing symptoms increased with time spent playing video games. CONCLUSIONS: This brief report supports the Goldilocks Hypothesis, that suggests that moderate use of digital technology is not intrinsically harmful and may instead be beneficial, even necessary in a world becoming ever more increasingly reliant on digital media (Przybylski and Weinstein in Psychol Sci 28(2):204-215, 2017).

Ending tuberculosis: the cost of missing the World Health Organization target in a low-incidence country.

BACKGROUND: Ending tuberculosis (TB) is a global priority and targets for doing so are outlined in the World Health Organization (WHO) End TB Strategy. For low-incidence countries, eliminating TB requires high levels of wealth, low levels of income inequality and effective TB programmes and services that can meet the needs of people who have not benefited from these and are still at risk of TB. In Ireland, numerous reports have noted a need for more funding for TB prevention and control. AIM: The aim of this research was to estimate the cost of not meeting the WHO End TB target of a 90% reduction in TB incidence in Ireland between 2015 and 2035. METHODS: The cost of projected TB cases between 2022 and 2035 is estimated based on trends in surveillance data for the period 2015 to 2019 and outcomes reported in the literature. RESULTS: Between 2022 and 2035, it is projected that a failure to meet the WHO End TB Strategy target will result in an additional 989 cases of TB, 577.3 disability-adjusted life years and 35 deaths with TB in Ireland. The cost of this is estimated to be €70.779 million. CONCLUSION: Given the estimated cost, Ireland's current prospects of eliminating TB and the tendency towards programmatic funding internationally, greater investment in TB prevention and control in Ireland is justifiable. A national elimination strategy with actions at the levels of the social determinants of health, the health system and the TB programme should be funded.

Public Health Measures to Address the Impact of Climate Change on Population Health-Proceedings from a Stakeholder Workshop.

BACKGROUND: The World Health Organization identified climate change as the 21st century's biggest health threat. This study aimed to identify the current knowledge base, evidence gaps, and implications for climate action and health policymaking to address the health impact of climate change, including in the most underserved groups. METHODS: The Horizon-funded project ENBEL ('Enhancing Belmont Research Action to support EU policy making on climate change and health') organised a workshop at the 2021-European Public Health conference. Following presentations of mitigation and adaptation strategies, seven international researchers and public health experts participated in a panel discussion linking climate change and health. Two researchers transcribed and thematically analysed the panel discussion recording. RESULTS: Four themes were identified: (1) 'Evidence is key' in leading the climate debate, (2) the need for 'messaging about health for policymaking and behaviour change' including health co-benefits of climate action, (3) existing 'inequalities between and within countries', and (4) 'insufficient resources and funding' to implement national health adaptation plans and facilitate evidence generation and climate action, particularly in vulnerable populations. CONCLUSION: More capacity is needed to monitor health effects and inequities, evaluate adaptation and mitigation interventions, address current under-representations of low- or middle-income countries, and translate research into effective policymaking.

The role of family, school and neighbourhood in explaining inequalities in physical activity trajectories between age 9 and 18.

Differentials in physical activity (PA) between social and economic groups has been shown to contribute significantly to social gradients in health and life expectancy, yet relatively little is known about why differentials in PA emerge. This paper uses longitudinal data on a nationally representative sample of 6,216 young people aged between 9 and 18, from Ireland, to measure the role of family, school and neighbourhood level factors in accounting for differentials in PA trajectories between groups of young people, defined by level of maternal education, whilst adjusting for the individual characteristics of the young person (sex, age, personality, body mass index and health-status). Levels of PA fall significantly across the sample between 9 and 18, and the decline in PA is larger for the children of lower educated mothers. We find a clear gradient in PA at each age by maternal education for both males and females. Descriptive analyses found social gradients in the majority of our risk factors. Using multi-level, linear spline regression models to decompose differentials between groups, we find that family-level mechanisms account for the biggest proportion of the differential in PA for both males (50.8%) and females (35.1%). Differences in income across maternal education categories accounted for 24.1% of the differential for males and 14.7% among females, making it the second most effective mechanism in explaining the social patterning of PA. Neighbourhood-level processes resulted in a modest reduction in the same differential, while school level processes had the effect of equalising differences in PA across maternal education groups.

Mediators of socioeconomic differences in overweight and obesity among youth in Ireland and the UK (2011-2021): a systematic review.

BACKGROUND: By 2025, adult obesity prevalence is projected to increase in 44 of 53 of European-region countries. Childhood obesity tracks directly onto adult obesity, and children of low socioeconomic position families are at disproportionately higher risk of being obese compared with their more affluent peers. A previous review of research from developed countries identified factors mediating this relationship. This systematic review updates and extends those findings specifically within the context of Ireland and the United Kingdom. OBJECTIVE: The aim of this systematic review is to summarise peer-reviewed research completed in Ireland and the United Kingdom between 2011-2021 examining mediators of socioeconomic differentials in adiposity outcomes for youth. DESIGN: An electronic search of four databases, Ovid MEDLINE, Embase, Web of Science and EBSCOhost was conducted. Quantitative studies, published in the English language, examining mediators of socioeconomic differentials in adiposity outcomes in youth, and conducted in Ireland and the United Kingdom between 2011-2021 were included. An appraisal of study quality was completed. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Following screening, a total of 23 papers were eligible for inclusion. Results indicate socioeconomic differentials for Ireland and the United Kingdom follow similar patterns to other developed countries and have similar mediating factors including early life and parent-level factors. However, this review identified additional factors that mediate the relationship, namely access to green space and favorable neighborhood conditions. Identifying these factors present further opportunities for potential interventions and confirm the requirement for tailored and appropriate research and interventions for Ireland and the United Kingdom. CONCLUSION: This review identified several modifiable factors that should be considered when planning interventions aimed at reducing socioeconomic differentials in adiposity among youth in Ireland and the United Kingdom. Support was found for interventions to be made as early as possible in an at-risk child's life, with the prenatal and preschool periods considered the most efficacious. Results were equivocal about the role of physical activity in the risk of childhood overweight and obesity. While multi-country analyses provide excellent overviews, country- or area-specific research may produce more nuanced, and potentially more powerful findings, which can help better inform policy responses and interventions.

Delayed Tuberculosis Treatment and Cost of Care in a Low-Incidence Country.

Background: Tuberculosis (TB) elimination requires high-quality, timely care. In countries with a low incidence of TB, such as Ireland, delayed diagnosis is common. This evaluation aimed to determine the factors that predict patient-related and health care provider-related delays in TB management and to establish how TB care cost is affected by care delays. Methods: Health care records of patients with signs and symptoms of TB evaluated by a tertiary service in Ireland between July 1, 2018, and December 31, 2019, were reviewed to measure and determine predictors of patient-related delays, health care provider-related delays, and the cost of TB care. Outcomes were compared against benchmarks derived from the literature. Results: Thirty-seven patients were diagnosed with TB, and 51% (19/37) had pulmonary TB (PTB). The median patient-related delay was 60 days among those with PTB, greater than the benchmark derived from the literature (38 days). The median health care provider-related delay among patients with PTB was 16 days and, although similar to the benchmark (median, 22 days; minimum, 11 days; maximum, 36 days), could be improved. The health care provider-related delay among patients with EPTB was 66 days, greater than the benchmark (42 days). The cost of care was €8298 and, while similar to that reported in the literature (median, €9319; minimum, €6486; maximum, €14 750), could be improved. Patient-related delays among those with PTB predicted care costs. Conclusions: Patient-related and health care provider-related delays in TB diagnosis in Ireland must be reduced. Initiatives to do so should be resourced.

Planetary health education in medical curricula in the Republic of Ireland.

BACKGROUND: The World Health Organization considers climate change an urgent global health challenge requiring prioritised action. A recent global survey reported that only 15% of medical schools have incorporated climate change and health into the curriculum. OBJECTIVES: This research study was carried out from November 2020 and April 2021 using the Planetary Health Report Card (PHRC) initiative to assess the current level of planetary health teaching in medical schools in the Republic of Ireland. PHRC is a student-led international public initiative, which aims to compare medical schools using a planetary health report card. The assessment was submitted as a final report to the Irish Medical Council and to the medical schools involved. RESULTS: Very few learning outcomes in Irish medical curricula directly address or include the concept of planetary health. Inclusion of specific topics remains reliant on individual lecturer interest. While most universities have excellent research centres which cover specific aspects of planetary health, the links between these institutes and medical schools have not been created. CONCLUSIONS: Overall, there are promising examples of planetary health themes throughout the current Irish medical curricula, however, these remain poorly implemented or embedded within the curricula. Medical schools should incorporate education on planetary health to ensure graduates are equipped as to become medical leaders practising in a changing world.

Use, cost-effectiveness, and end user perspectives of a home solar lighting intervention in rural Uganda: a mixed methods, randomized controlled trial.

Energy poverty is prevalent in resource-limited settings, leading households to use inefficient fuels and appliances that contribute to household air pollution. Randomized controlled trials of household energy interventions in low and middle income countries have largely focused on cooking services. Less is known about the adoption and impact of clean lighting interventions. We conducted an explanatory sequential mixed methods study as part of a randomized controlled trial of home solar lighting systems in rural Uganda in order to identify contextual factors determining the use and impact of the solar lighting intervention. We used sensors to track usage, longitudinally assessed household lighting expenditures and health-related quality of life, and performed cost-effectiveness analyses. Qualitative interviews were conducted with all 80 trial participants and coded using reflexive thematic analysis. Uptake of the intervention solar lighting system was high with daily use averaging 8.23 ± 5.30 hours per day. The intervention solar lighting system increased the EQ5D index by 0.025 [95% CI 0.002 - 0.048] and led to an average monthly reduction in household lighting costs by -1.28 [-2.52, -0.85] US dollars, with higher savings in users of fuel-based lighting. The incremental cost-effectiveness ratio for the solar lighting intervention was $2025.72 US dollars per quality adjusted life year (QALY) gained making the intervention cost-effective when benchmarked against the gross domestic product (GDP) per capita in Uganda. Thematic analysis of qualitative data from individual interviews showed that solar lighting was transformative and associated with numerous benefits that fit within a Social Determinants of Health (SDOH) framework. The benefits included improved household finances, improved educational performance of children, increased household safety, improved family and community cohesion, and improved perceived household health. Our findings suggest that household solar lighting interventions may be a cost-effective approach to improve health-related quality of life by addressing SDOH.

Evaluating the Quality of Latent Tuberculosis Infection Screening in Ireland: A Single-Centre Retrospective Cohort Study.

Ireland is a country with a low incidence of tuberculosis (TB) (5.6 cases per 100,000 population in 2019) that should be aiming for TB elimination (fewer than 1 case per million of population). To achieve TB elimination in low-incidence countries, programmatic latent tuberculosis infection (LTBI) management is important. This requires high-quality latent tuberculosis infection (LTBI) screening. AIM: To assess the quality of LTBI screening in a tertiary centre in Ireland using a framework. METHODS: A retrospective review of the health care records of patients screened for TB in a tertiary centre in Ireland using an interferon-gamma release assay (IGRA) between 2016 and 2018 was performed. Three domains from the Institute of Medicine framework for health care quality, effectiveness, efficiency, and equity, were applied to measure the quality of LTBI screening. RESULTS: Forty patients had LTBI and an indication for treatment, of whom 20% (8/40) were not offered treatment by the health care provider, 2.5% (1/40) did not accept treatment, and 10% (4/40) did not complete treatment. Seventy-five percent (6/8) of patients not offered treatment were non-Irish. The cost of screening per LTBI case identified was EUR 2048. CONCLUSIONS: This study evaluated the quality of LTBI screening using a framework and identified that LTBI screening in this tertiary centre needs to be scaled and expanded, and that treatment initiation needs to be improved, particularly among non-Irish nationals.

Which Biomass Stove(s) Capable of Reducing Household Air Pollution Are Available to the Poorest Communities Globally?

Globally, household and ambient air pollution (HAAP) leads to approximately seven million premature deaths per year. One of the main sources of household air pollution (HAP) is the traditional stove. So-called improved cookstoves (ICS) do not reduce emissions to levels that benefit health, but the poorest communities are unlikely to have access to cleaner cooking in the medium term. Therefore, ICS are being promoted as an intermediate step. This paper summarises the current evidence on the ICS available to the global poorest, utilising data from the Clean Cookstoves Catalog and systematic review evidence from the field. The cheapest stoves offer little reduction in HAP. Only one ICS, available at US$5 or less, (the canarumwe) minimally reduced pollutants based on ISO testing standards and no studies included in the systematic reviews reported tested this stove in the field. We recommend field testing all ICS as standard, and clear information on stove characteristics, sustainability, safety, emissions efficiency, in-field performance, affordability, availability in different settings, and the ability of the stove to meet community cooking needs. In addition, ICS should be promoted alongside a suite of measures, including improved ventilation and facilities to dry wood, to further reduce the pollutant levels.

Do improved biomass cookstove interventions improve indoor air quality and blood pressure? A systematic review and meta-analysis.

OBJECTIVES: This systematic review and meta-analysis evaluates the most recent evidence to examine whether use of improved biomass cookstoves in households in low-middle income countries results in reduction in mean concentrations of carbon monoxide (CO) and particulate matter of size 2.5 µm (PM2.5) in the cooking area, as well as reduction in mean systolic (SBP) and diastolic blood pressure (DBP) of adults using the cookstoves when compared to adults who use traditional three stone fire or traditional biomass cookstoves. METHODS: We searched databases of scientific and grey literature. We included studies if published between January 2012 and June 2021, reported impact of ICS interventions in non-pregnant adults in low/middle-income countries, and reported post-intervention results along with baseline of traditional cookstoves. Outcomes included 24- or 48-h averages of kitchen area PM2.5, CO, mean SBP and DBP. Meta-analyses estimated weighted mean differences between baseline and post-intervention values for all outcome measures. RESULTS: Eleven studies were included; ten contributed estimates for HAP and four for BP. Interventions lead to significant reductions in PM2.5 (-0.73 mg/m3, 95% CI: -1.33, -0.13), CO (-8.37 ppm, 95%CI: -13.20, -3.54) and SBP (-2.82 mmHg, 95% CI: -5.53, -0.11); and a non-significant reduction in DBP (-0.80 mmHg, 95%CI: -2.33, 0.73), when compared to baseline of traditional cookstoves. Except for DBP, greatest reductions in all outcomes came from standard combustion ICS with a chimney, compared to ICS without a chimney and advanced combustion ICS. CONCLUSION: Among the reviewed biomass stove types, ICS with a chimney feature resulted in greatest reductions in HAP and BP.

E-Cigarette-Only and Dual Use among Adolescents in Ireland: Emerging Behaviours with Different Risk Profiles.

E-cigarette-only use and dual-use are emerging behaviours among adolescent nicotine product users which have not yet been sufficiently explored. This study examines the prevalence of, and the factors associated with, nicotine product use in adolescence. The study is a cross-sectional analysis of the 2018 Planet Youth survey completed by 15-16 year olds in the West of Ireland in 2018. The outcome of interest was current nicotine product use, defined as use at least once in the past 30 days. A main effects multinomial logistic regression model was used to examine the association between potential risk and protective factors and nicotine product use. Among 4422 adolescents 22.1% were current nicotine product users, consisting of 5.1% e-cigarette only users, 7.7% conventional cigarette only users, and 9.3% dual-users. For risk factors, the odds of association were weaker for e-cigarette only use compared to conventional cigarette and dual use. Participating in team sport four times/week or more significantly reduced the odds of conventional cigarette and dual use but had no association with e-cigarette only use (Cig: adjusted odds ratio (AOR) 0.63, 95% confidence interval (CI) 0.44-0.90; Dual-use: AOR 0.63, 95% CI 0.43-0.93). Similarly, having higher value for conventional social norms reduced the odds of conventional cigarette and dual use but not e-cigarette only use. This is the first study to show, among a generalisable sample, that dual-use is the most prevalent behaviour among adolescent nicotine product users in Ireland. Risk factor profiles differ across categories of use and prevention initiatives must be cognisant of this.

Barriers and Facilitators to the Adoption and Sustained Use of Cleaner Fuels in Southwest Cameroon: Situating 'Lay' Knowledge within Evidence-Based Policy and Practice.

Approximately four million people die each year in low- and middle-income countries from household air pollution (HAP) due to inefficient cooking with solid fuels. Liquid Petroleum Gas (LPG) offers a clean energy option in the transition towards renewable energy. This qualitative study explored lay knowledge of barriers and facilitators to scaling up clean fuels in Cameroon, informed by Quinn et al.'s Logic Model. The model has five domains and we focused on the user and community needs domain, reporting the findings of 28 semi-structured interviews (SSIs) and four focus group discussions (FGDs) that explored the reasons behind fuel use choices. The findings suggest that affordability, safety, convenience, and awareness of health issues are all important influences on decision making to the adoption and sustained use of LPG, with affordability being the most critical issue. We also found the ability of clean fuels to meet cooking needs to be central to decision-making, rather than an aspect of convenience, as the logic model suggests. Local communities provide important insights into the barriers and facilitators to using clean fuels. We adapt Quinn et al.'s logic model accordingly, giving more weight to lay knowledge so that it is better positioned to inform policy development.

A Fully Integrated Real-Time Detection, Diagnosis, and Control of Community Diarrheal Disease Clusters and Outbreaks (the INTEGRATE Project): Protocol for an Enhanced Surveillance System.

BACKGROUND: Diarrheal disease, which affects 1 in 4 people in the United Kingdom annually, is the most common cause of outbreaks in community and health care settings. Traditional surveillance methods tend to detect point-source outbreaks of diarrhea and vomiting; they are less effective at identifying low-level and intermittent food supply contamination. Furthermore, it can take up to 9 weeks for infections to be confirmed, reducing slow-burn outbreak recognition, potentially impacting hundreds or thousands of people over wide geographical areas. There is a need to address fundamental problems in traditional diarrheal disease surveillance because of underreporting and subsequent unconfirmed infection by patients and general practitioners (GPs); varying submission practices and selective testing of samples in laboratories; limitations in traditional microbiological diagnostics, meaning that the timeliness of sample testing and etiology of most cases remains unknown; and poorly integrated human and animal surveillance systems, meaning that identification of zoonoses is delayed or missed. OBJECTIVE: This study aims to detect anomalous patterns in the incidence of gastrointestinal disease in the (human) community; to target sampling; to test traditional diagnostic methods against rapid, modern, and sensitive molecular and genomic microbiology methods that identify and characterize responsible pathogens rapidly and more completely; and to determine the cost-effectiveness of rapid, modern, sensitive molecular and genomic microbiology methods. METHODS: Syndromic surveillance will be used to aid identification of anomalous patterns in microbiological events based on temporal associations, demographic similarities among patients and animals, and changes in trends in acute gastroenteritis cases using a point process statistical model. Stool samples will be obtained from patients' consulting GPs, to improve the timeliness of cluster detection and characterize the pathogens responsible, allowing health protection professionals to investigate and control outbreaks quickly, limiting their size and impact. The cost-effectiveness of the proposed system will be examined using formal cost-utility analysis to inform decisions on national implementation. RESULTS: The project commenced on April 1, 2013. Favorable approval was obtained from the Research Ethics Committee on June 15, 2015, and the first patient was recruited on October 13, 2015, with 1407 patients recruited and samples processed using traditional laboratory techniques as of March 2017. CONCLUSIONS: The overall aim of this study is to create a new One Health paradigm for detecting and investigating diarrhea and vomiting in the community in near-real time, shifting from passive human surveillance and management of laboratory-confirmed infection toward an integrated, interdisciplinary enhanced surveillance system including management of people with symptoms. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13941.

Using photovoice methods as a community-based participatory research tool to advance uptake of clean cooking and improve health: The LPG adoption in Cameroon evaluation studies.

Each year up to 2.6 million people die prematurely from household air pollution (HAP) due to cooking with polluting fuels such as wood and charcoal, particularly in low and middle-income countries (LMICs). The World Health Organisation recommends scaling the adoption of clean fuels to improve maternal and child health. Liquefied Petroleum Gas (LPG) represents a scalable clean fuel that provides health and environmental benefits when used for household energy in LMICs. In Cameroon, over 70% of people rely on biomass for cooking, and the Government aims to increase LPG use from <20% to 58% by 2030. Supporting households make this transition requires involvement of multiple stakeholders and an understanding of perspectives from the community's perspective. We used visual participatory methods 'Photovoice' to explore households' perceptions of factors influencing the uptake of LPG for cooking in South-West Cameroon. Two groups of participants from rural (n = 7) and peri-urban (n = 8) areas photographed subjects they identified as preventing and facilitating LPG uptake in their communities. Subsequently, individual interviews (n = 15) and group discussions (n = 5) explored participants' reflections on the photographs. Thematic analysis was conducted using NVivo 10 software. The main barriers identified included difficulty in affording the initial LPG equipment and ongoing refills, scarcity of LPG retail shops and refills, and safety concerns. Facilitators included (i) increasing awareness of the benefits of LPG (e.g. health), (ii) increasing retail outlet density in rural areas, (iii) addressing safety concerns (e.g. replacing damaged cylinders), and (iv) reducing the price of LPG refills. Participants presented their photos at a public exhibition, which generated discussions with key stakeholders (e.g. government ministries) about how best to assist communities in this transition. Photovoice was found to be an innovative and effective approach for exploring how to advance equitable access to LPG from a community perspective and successfully engage with key stakeholders.