Changes in social mixing and attitudes and practices to precautionary measures in a maturing COVID-19 pandemic in six communities in Sudan: a qualitative study.

INTRODUCTION: With low COVID-19 vaccination coverage, non-pharmaceutical interventions were critical to mitigating the COVID-19 pandemic in Sudan. We explored changes in social contact patterns, risk perception, attitudes, and practices toward protective measures during an evolving COVID-19 outbreak in six illustrative communities in Sudan. METHODS: This qualitative study took place in six communities in five Sudanese states using focus group discussions with community members and non-participant structured observations in public spaces between March 2021 and April 2021. A total of 117 participants joined 24 group discussions. We used a two-stage thematic analysis. RESULTS: The perceived importance of compliance with individual preventative measures among those who believe in COVID-19 was higher than observed compliance with behaviors in most study sites. Adherence was consistently low and mainly driven by enforced movement restrictions. As restrictions were lifted, social contacts outside the household resumed pre-COVID-19 levels, and risk perception and individual and institutional adherence to protective measures diminished. We identified an environment that is socially and economically unsupportive of preventive practices, compounded by widespread rumours, misinformation, and mistrust in the government-led response. However, we identified new social habits that can contribute to reducing COVID-19 transmission. CONCLUSION: The unfavourable social and economic environment, coupled with the low visibility of the pandemic and pandemic response, has likely modulated the influence of higher risk perception on adopting precautionary behaviours by individuals. Governments and non-governmental actors should increase the visibility of the pandemic and pandemic response, enforce and incentivise infection control measures in public areas, promote emerging preventive social habits, and actively track and address rumours and misinformation related to COVID-19 and COVID-19 vaccines.

Dietary glycemic index and glycemic load predict longitudinal change in glycemic and cardio-metabolic biomarkers among old diabetic adults living in a resource-poor country.

This study aims to investigate longitudinal associations between the dietary glycemic index (GI) and glycemic load (GL) and changes in glycemic and cardio-metabolic outcomes. A 28-month retrospective cohort study included 110 Vietnamese diabetic patients, collecting their dietary GI and GL values along with blood biochemical data from baseline 24-h dietary recall and medical records. Latent class growth modelling identified three distinct HbA1c trajectories during the follow-up period, with 51% of patients achieving good glycemic control. The adjusted linear mixed-effect model showed that 1 unit increase in logarithms in dietary GL was associated with a 0.14% increase in the log-HbA1c. Among poorly controlled diabetic patients, baseline GL values were positively correlated with increases in HbA1c; GI showed effects on changes in fasting plasma glucose and the triglyceride-glucose (TyG) index. No significant association was observed in patients with good glycemic control.

Adult food choices in association with the local retail food environment and food access in resource-poor communities: a scoping review.

BACKGROUND: There is a growing body of research on local retail food environments globally in both urban and rural settings. Despite this, little research has been conducted on adult food choices, local retail environments, and healthy food access in resource-poor communities. The purpose of this study is therefore to provide an overview of the evidence on adult food choices (measured as dietary intake) in association with the local retail food environment and food access in resource-poor communities (defined as low-income communities and/or households). METHODS: We searched nine databases for studies published from July 2005 to March 2022 and identified 2426 records in the primary and updated search. Observational studies, empirical and theoretical studies, focused on adults ≤ 65 years, published in English peer-reviewed journals, examining local retail food environments and food access, were included. Two independent reviewers screened identified articles using the selection criteria and data extraction form. Study characteristics and findings were summarized for all studies and relevant themes summarized for qualitative and mixed methods studies. RESULTS: A total of 47 studies were included in this review. Most studies were cross sectional (93.6%) and conducted in the United States of America (70%). Nineteen (40.4%) studies assessed the association between food choice outcomes and local retail food environment exposures, and evidence on these associations are inconclusive. Associations of certain food choice outcomes with healthy food retail environments were positive for healthy foods (in 11 studies) and unhealthy foods (in 3 studies). Associations of certain food choice outcomes with unhealthy retail food environment exposures were positive for unhealthy foods in 1 study and negative for healthy foods in 3 studies. In 9 studies, some of the food choice outcomes were not associated with retail food environment exposures. A healthy food store type and lower food prices were found to be major facilitators for healthy food access in resource-poor communities, while cost and transportation were the main barriers. CONCLUSIONS: More research is needed on the local retail food environment in communities in low- and middle-income countries to develop better interventions to improve food choices and access to healthy foods in resource-poor communities.

Stroke Hexagon; Protocol for Reduction of Stroke Burden in Resource-Poor Settings.

BACKGROUND: Stroke is a neurological emergency, with high prevalence, especially in developing countries where it assumes an epidemic proportion. It is globally the second most common cause of death after ischemic heart disease. The poor indices reported in developing countries are multifactorial and related to late case presentation, ignorance, poverty, and unavailability of comprehensive and well-coordinated stroke care. OBJECTIVES: This manuscript identified and highlighted the available and cheap stroke management pillars in developing countries and recommended measures to strengthen the system to maximize the benefits in the reduction of morbidity and mortality from stroke. RESULTS: The identified stroke management pillars include stroke prevention, hyperacute stroke management, acute stroke management, stroke rehabilitation, stroke research, and stroke support. CONCLUSIONS: A coordinated and concerted stroke management protocol involving the stroke hexagon will reduce stroke morbidity and mortality in resource-poor settings. There is a need to sensitize the stakeholders in stroke management to assume more responsibility.

CONTEXTE: L'AVC est une urgence neurologique, avec une prévalence élevée, en particulier dans les pays en développement où il prend une ampleur épidémique. Il est mondialement la deuxième cause de décès la plus fréquente après la maladie cardiaque ischémique. Les mauvais indices rapportés dans les pays en développement sont multifactoriels et liés à une présentation tardive des cas, à l'ignorance, à la pauvreté et à l'absence de soins coordonnés et complets pour l'AVC. OBJECTIFS: Ce manuscrit a identifié et mis en évidence les piliers bon marché de la prise en charge de l'AVC dans les pays en développement et recommandé des mesures pour renforcer le système afin de maximiser les avantages dans la réduction de la morbidité et de la mortalité dues à l'AVC. RÉSULTATS: Les piliers identifiés de la prise en charge de l'AVC comprennent la prévention de l'AVC, la prise en charge hyperaiguë de l'AVC, la prise en charge aiguë de l'AVC, la rééducation post-AVC, la recherche sur l'AVC et le soutien aux personnes touchées par l'AVC. CONCLUSIONS: Un protocole de prise en charge de l'AVC coordonné et concerté impliquant l'hexagone de l'AVC réduira la morbidité et la mortalité liées à l'AVC dans les milieux à ressources limitées. Il est nécessaire de sensibiliser les parties prenantes à la prise en charge de l'AVC pour qu'elles assument davantage de responsabilités. Mots-clés: Hexagone de l'AVC, Protocole, Fardeau de l'AVC, Milieux à ressources limitées.

Six Sigma in blood transfusion services: A dream too big in a third world country?

BACKGROUND AND OBJECTIVES: Transfusion errors can occur anywhere from blood donation to final blood transfusion. They are a source of increased cost and patient mortality. Automated workflows can reduce transcription errors, but resource-poor centres still use semi-automated/manual method for testing including manual labelling of column agglutination cards/testing tubes. Missing out any details on these cards can lead to errors in reporting results, wastage and loss of resources and effort. The aim of this study was to implement Six Sigma DMAIC (Define, Measure, Analyse, Improve and Control) methodology to reduce transcription errors while labelling gel card in immunohaematology lab to zero defect. MATERIALS AND METHODS: In this prospective study, transcription errors while manually performing 200 tests with 1400 opportunities were analysed. Baseline variables like number of errors, defects per million opportunities and sigma level in our current setup were measured. With the application of DMAIC methodology, root cause analysis for each error using Ishikawa diagram and structured Interviews were done to identify causes. A multipronged approach to deal with errors was done to improve critical areas using brainstorming sessions and developing training sheets for practice. After implementing the changes, baseline variables were reanalysed. RESULTS: Application of DMAIC resulted in an overall reduction in defects from 34.86% to 0.56% with sigma level improvement from 1.89 to 4.08. CONCLUSION: Six Sigma methodology can be used in a resource-poor setting even with lack of automation to ensure error-free process flow.

The impact of working in COVID-19 hospital on indonesian nurses' mental health and wellbeing: a qualitative study.

BACKGROUND: The outbreak of coronavirus disease (COVID-19) has impacted the lives of more than 580 million people and killed more than six million people globally. Nurses are one of the most impacted groups as they are at the frontline to fight against the virus and to try to save the lives of everyone affected. The present study aimed to explore the impact of working in COVID-19 wards on the mental health and wellbeing of nurses in the early stage of the pandemic in a hospital in East Nusa Tenggara, Indonesia. METHODS: A qualitative study was conducted with 22 nurses, recruited using purposive sampling. Data collection was conducted from April to May 2022 and data analysis was guided by qualitative framework analysis. RESULTS: The findings show that nurses experienced a range of mental health impacts including fear of being infected and infecting loved ones; fear of early death; psychological distress related to the conflict between the lack of personal protective equipment (PPE) and both professionalism and moral responsibility for patients; stress due to long waiting period to know the result of the COVID-19 tests; stress and worry due to public indifference and lack of role models; the negative impact of community doubt and distrust around COVID-19; and distress due to stigma and discrimination towards nurses caring for COVID-19 patients and their families. CONCLUSIONS: The current findings indicate further psychological intervention programs to support nurses, especially the ones in resource poor settings and enhance their psychological resilience.

Pulmonary Embolism: The Battle to Save Life in a Resource Poor Setting.

INRODUCTION: Pulmonary embolism (PE) is a cardiovascular emergency caused by occlusion of one or more pulmonary arteries by thrombi that originate from a deep venous thrombosis (subsequently called an embolus), typically in the large veins of the lower limb or pelvis. It is a common cause of preventable hospital death and a cause of mortality in obstetrics setting because it largely remains under diagnosed especially in a resource poor setting. CASE REPORT: Mrs OG, a 30-year-old primigravida, had a spontaneous delivery of a baby boy. A few hours after delivery, she had two episodes of syncope and was resuscitated with intra-venous fluids and blood transfusion. Further evaluation, with an abdominopelvic ultrasound scan, showed that she had supra-levator haematoma necessitating emergency exploratory laparotomy. During the induction of anaesthesia for the surgery, she had a cardiac arrest and was again resuscitated with cardiac compression and intravenous adrenaline. She was transferred to ICU on account of cardio-respiratory instability. On the 2nd day post operation, the chest physician reviewed and noted history of cough, haemoptysis and breathlessness of two days duration. She had an associated unilateral (right) leg swelling, with presence of cyanosis, tachypnoea and tachycardia with SPO2 fluctuating between 82-92% (while on oxygen with nasal prongs). The clinical probability of PE using Well's scoring system was high (11.5). In the absence of computerized tomography (CT) pulmonary angiography and ventilation perfusion (V/Q) scan, a Doppler ultrasound of both legs was done which showed dilation of the proximal one-third of the right femoral vein with meshwork of thrombi. She was subsequently commenced on Enoxaparin and intra-venous fluids and antibiotics. She also received supplementary oxygen. The Prothrombin time and International Normalized Ratio (INR) were monitored over the period. She slowly but progressively improved and was discharged home on oral warfarin. The index patient had cardiopulmonary arrest and expectedly, needed urgent intervention with embolectomy or thrombolytic therapy. In the absence of these, anticoagulation with vasopressor agents, supplementary oxygen and close monitoring was able to sustain the patient. SUMMARY: Pulmonary embolism is a killer condition with 10% of the patients dying within one hour of onset. Most times, mortality occurs in patients who were never diagnosed. The best prospect for reducing mortality in patients with PE lies in improving diagnosis.

INRODUCTION: L'embolie pulmonaire (EP) est une urgence cardiovasculaire causée par l'occlusion d'une ou plusieurs artères pulmonaires par des thrombus provenant d'une thrombose veineuse profonde (appelée par la suite embole), généralement dans les grosses veines du membre inférieur ou du bassin. Il s'agit d'une cause fréquente de décès hospitalier évitable et d'une cause de mortalité en obstétrique car elle reste largement sous-diagnostiquée, en particulier dans un contexte de ressources limitées. RAPPORT DE CAS: Mme OG, une primigeste de 30 ans, a accouché spontanément d'un petit garçon. Quelques heures après l'accouchement, elle a eu deux épisodes de syncope et a été réanimée avec des fluides intraveineux et une transfusion sanguine. Une évaluation plus poussée, avec une échographie abdomino-pelvienne, a montré qu'elle avait un hématome supra-levatorien nécessitant une laparotomie exploratoire d'urgence. Pendant l'induction de l'anesthésie pour la chirurgie, elle a fait un arrêt cardiaque et a été réanimée par compression cardiaque et adrénaline intraveineuse. Elle a été transférée aux soins intensifs en raison de son instabilité cardio-respiratoire. Le deuxième jour après l'opération, le médecin thoracique a examiné et noté une histoire de toux, d'hémoptysie et d'essoufflement depuis deux jours. Elle présentait un gonflement unilatéral (droit) de la jambe, une cyanose, une tachypnée et une tachycardie avec une SPO2 fluctuant entre 82 et 92 % (sous oxygène avec des pinces nasales). La probabilité clinique d'EP en utilisant le système de notation de Well était élevée (11,5). En l'absence d'angiographie pulmonaire par tomodensitométrie et de scintigraphie de ventilation et de perfusion (V/Q), une échographie Doppler des deux jambes a été réalisée et a montré une dilatation du tiers proximal de la veine fémorale droite avec un maillage de thrombus. Elle a ensuite été mise sous Enoxaparine, fluides intraveineux et antibiotiques. Elle a également reçu de l'oxygène supplémentaire. Le temps de prothrombine et le rapport international normalisé (INR) ont été surveillés pendant toute la période. Elle s'est lentement mais progressivement améliorée et a été renvoyée chez elle sous warfarine orale. Le patient de référence a fait un arrêt cardio-pulmonaire et, comme on pouvait s'y attendre, a dû subir une intervention urgente avec embolectomie ou thérapie thrombolytique. En l'absence d'une telle intervention, une anticoagulation avec des agents vasopresseurs, un supplément d'oxygène et une surveillance étroite ont permis de maintenir le patient en vie. RÉSUMÉ: L'embolie pulmonaire est une maladie mortelle, 10% des patients décèdent dans l'heure qui suit son apparition. La plupart du temps, la mortalité survient chez des patients qui n'ont jamais été diagnostiqués. La meilleure perspective pour réduire la mortalité chez les patients atteints d'EP réside dans l'amélioration du diagnostic. Mots clés: Embolie pulmonaire, milieu pauvre en ressources, diagnostic, prise en charge.

Hydroxyurea in children with sickle cell disease in a resource-poor setting: Monitoring and effects of therapy. A practical perspective.

BACKGROUND: Although effectiveness of hydroxyurea (HU) in sickle cell disease is well established, unanswered questions persist about its use in African children. We determined real-life issues of acceptability, availability, and monitoring of HU use in Nigeria. METHODS: A retrospective longitudinal review of laboratory data of patients on HU was done from case files, followed by a cross-sectional survey that captured families' perception of medication and clinic adherence, laboratory tests, benefits, side effects, and acceptability. RESULTS: One hundred sixteen patients (1.2-17 years) received HU (mean ± SD = 18.5 ± 4.3 mg/kg/day) in 33 months. Eighty-nine had laboratory analysis. Dose escalation was the initial goal, but only 80% of patients had some form of it. Parents reported improvement in general well-being and reduction in bone pain episodes, hospital admissions, and blood transfusion. While most parents (89.5%) reported satisfaction with HU, 61% reported dissatisfaction with daily drug use, and the frequency and cost of monitoring. Sixteen percent voluntarily stopped therapy. Adherence to daily HU was 88.8%, doctor's appointments 24.5%, hematology tests 18.9%, and organ function tests 37.4%. There were no significant toxicities. Significant increases in hemoglobin, hemoglobin F and mean corpuscular volume, and reduction in absolute neutrophil count occurred despite inconsistent dose escalation. CONCLUSION: HU (10-15 mg/kg/day starting dose) is safe and seems effective and acceptable to parents. Parental commitment to therapy, pre-HU education (that continues during therapy), provision of affordable HU, and subsidized laboratory tests are important considerations for initiating therapy. Special HU clinics may facilitate dose escalation and reduce frequency of monitoring. Studies are needed on feasibility of maximum tolerable dose HU protocols in sub-Saharan Africa without compromising safety.

Acceptability and feasibility of strategies to shield the vulnerable during the COVID-19 outbreak: a qualitative study in six Sudanese communities.

BACKGROUND: Shielding of high-risk groups from coronavirus disease (COVID-19) has been suggested as a realistic alternative to severe movement restrictions during the COVID-19 epidemic in low-income countries. The intervention entails the establishment of 'green zones' for high-risk persons to live in, either within their homes or in communal structures, in a safe and dignified manner, for extended periods of time during the epidemic. To our knowledge, this concept has not been tested or evaluated in resource-poor settings. This study aimed to explore the acceptability and feasibility of strategies to shield persons at higher risk of severe COVID-19 outcomes, during the COVID-19 epidemic in six communities in Sudan. METHODS: We purposively sampled participants from six communities, illustrative of urban, rural and forcibly-displaced settings. In-depth telephone interviews were held with 59 members of households with one or more members at higher risk of severe COVID-19 outcomes. Follow-up interviews were held with 30 community members after movement restrictions were eased across the country. All interviews were audio-recorded, transcribed verbatim, and analysed using a two-stage deductive and inductive thematic analysis. RESULTS: Most participants were aware that some people are at higher risk of severe COVID-19 outcomes but were unaware of the concept of shielding. Most participants found shielding acceptable and consistent with cultural inclinations to respect elders and protect the vulnerable. However, extra-household shielding arrangements were mostly seen as socially unacceptable. Participants reported feasibility concerns related to the reduced socialisation of shielded persons and loss of income for shielding families. The acceptability and feasibility of shielding strategies were reduced after movement restrictions were eased, as participants reported lower perception of risk in their communities and increased pressure to comply with social commitments outside the house. CONCLUSION: Shielding is generally acceptable in the study communities. Acceptability is influenced by feasibility, and by contextual changes in the epidemic and associated policy response. The promotion of shielding should capitalise on the cultural and moral sense of duty towards elders and vulnerable groups. Communities and households should be provided with practical guidance to implement feasible shielding options. Households must be socially, psychologically and financially supported to adopt and sustain shielding effectively.

An assessment of implementation science research capacity in Uganda.

BACKGROUND: In Uganda and other resource-poor countries, relevant research findings face a tortuous path to translation into policy and routine practice. Implementation science (ImSc) research could facilitate faster translation. Presently it is unclear what ImSc research capacity and possible training needs exist among Ugandan researchers. To assess both components, we interviewed potential trainees in Kampala, Uganda. METHODS: We used a cross-sectional design to survey potential ImSc trainees who had some research training and involvement in generating or utilizing research. Using a questionnaire, we documented eligibility for ImSc training, knowledge and interest in training, existing self-assessed confidence in initiating clinical research (SCICR) and self-assessed confidence in initiating ImSc research (SCIIR), availability for training and preferred modes of training. We developed scores from the Likert scales and used descriptive statistics, logistic regression and ordinal logistic regression to evaluate predictors of SCIIR. RESULTS: Between November 2016 and April 2017, we interviewed 190 participants; 60% were men, with a median age of 37 years. Among participants, 33% comprised faculty, 37% were graduate students and 30% were project staff. The majority of respondents knew about ImSc (73%) and were research-trained (80%). Only 9% reported any ImSc-related training. Previous ImSc training was associated with higher odds of a SCIIR score ≥ 75th percentile. Previous ImSc training compared to not having any training was associated with higher odds of reporting abilities in behaviour change theory integration (OR: 3.3, 95% CI: 1.3-8.5, p = 0.01) and framework use in intervention design and implementation (OR: 2.9, 95% CI: 1.1-7.4, p = 0.03), accounting for age, sex and current employment. In addition, 53% of participants preferred in-person (face-to-face) short ImSc courses compared to a year-long training, while 33% preferred online courses. Participants reported median availability of 6 hours per week (IQR: 4, 10) for training. CONCLUSION: Most participants had some understanding of ImSc research, had research training and were interested in ImSc training. Those with previous ImSc training had better skills and SCIIR, compared to those without previous training. A hybrid approach with modular face-to-face training and online sessions would suit the preferences of most potential trainees.

Bioethical Issues in Antarctica.

This paper describes the Antarctic environment, the mission and work setting at the U.S. research stations, the general population and living conditions, and the healthcare situation. It also dispels some common misconceptions that persist about this environment and about the scope and quality of medicine practiced there. The paper then describes specific ethical issues that arise in this environment, incorporating examples drawn from both the author's experiences and those of his colleagues. The ethics of providing healthcare in resource-poor environments implies two related questions. The first is: What can we do with the available resources? This suggests that clinicians must not only know how to use all available equipment and supplies in the standard manner, but also that they must be willing and able to go beyond standard procedures and improvise, when necessary. The second question is: Of all the things we can do, which ones should we do? This paper addresses both questions in relation to Antarctic medical care. It describes the wide range of activities required of healthcare providers and some specific ethical issues that arise. Finally, it suggests some remedies to ameliorate some of those issues.

Efficacy of neem (Azadirachta indica) aqueous fruit extracts against Sarcoptes scabiei var. suis in grower pigs.

The acaricidal activity of Azadirachta indica (neem) aqueous fruit extracts was evaluated against Sarcoptes scabiei var. suis (mange mites) in an on-farm trial using grower pigs. Aqueous neem fruit extracts of three concentrations 5%, 10%, and 25% w/v and a commercial acaricide, 12.5% amitraz-based Triatix spray (positive control), were compared with pigs that received no treatment (negative control). Thirty grower pigs of the Dalland breed were allocated to the five treatments in a completely randomized experiment. Each experimental animal was sprayed on day 0 and again on day 7. Counts of mange mites, scoring of lesion index, and calculation of rubbing index were done weekly. Topical application of 25% aqueous neem fruit extract had a higher efficacy ratio (p < 0.05) than the other fruit extract concentrations, and performed similarly to an amitraz-based acaricide, suggesting a dose-dependent response. Amitraz (positive control) cured clinical mange on grower pigs after 5 weeks and 25% aqueous neem fruit extract 6 weeks post-treatment. The results indicated that aqueous neem fruit extracts have acaricidal effects against mange mites and can provide a cheaper, safer, and more eco-friendly alternative for the control of Sarcoptes mange in pigs.

The Effect of Surgical Intervention on Pediatric Burn Injury Survival in a Resource-Poor Setting.

INTRODUCTION: Burns are one of the most common injuries sustained globally. Low- and middle-income countries (LMICs) are disproportionately affected by burn injury morbidity and mortality; African children have the highest burn mortality globally. In high-income countries, early surgical intervention has shown to improve survival. However, when applied to burn victims in LMICs, improved survival in the early excision cohort (≤5 d) was not seen. Therefore, we aimed to determine the magnitude of the effect of surgical intervention on burn injury survival. METHODS: A retrospective analysis of a prospectively collected data, utilizing the Kamuzu Central Hospital Burn Database from May 2011 to July 2019, was performed. Pediatric patients (≤12 y) were included. Patients were excluded if they underwent surgical intervention for nonacute burn care management. Bivariate analyses stratifying by type of surgical intervention was performed, comparing demographics, burn characteristics, surgical intervention, and patient mortality. Standardized estimates were adjusted using the inverse-probability of treatment weights to account for confounding. Weighted logistic regression modeling was performed to determine the odds of mortality based on if a patient underwent surgical intervention. RESULTS: During the study, 2364 patients were seen at the Kamuzu Central Hospital, 1785 (75.5%) were children ≤12 y who met inclusion criteria. In the overall cohort, 342 (19.2%) underwent operations, including split-thickness skin graft (n = 196, 57.3%), debridement (n = 116, 33.9%), escharotomy (n = 19, 5.6%), and amputation (n = 1, 0.3%). The surgery cohort was older (4.2 ± 3.1 versus 3.1 ± 2.6 y, P < 0.001) with larger percent total body surface area burns (16%, interquartile range: 10-24 versus 13%, interquartile range: 8-20, P < 0.001) than those who did not have surgery. In the propensity score-weighted logistic regression predicting survival, patients undergoing surgery after burn injury had an increased odds of survival (odds ratio: 5.24, 95% confidence interval: 2.40-11.44, P = 0.003) when compared with patients not undergoing surgery. CONCLUSIONS: In this propensity-weighted analysis, surgical intervention following burn injury increases the odds of survival by a factor of 5.24 when compared with patients not undergoing surgical intervention. Efforts to enhance burn infrastructure to deliver surgical care is imperative to attenuate burn mortality in resource-poor settings.

Mobile Texting and Lay Health Supporters to Improve Schizophrenia Care in a Resource-Poor Community in Rural China (LEAN Trial): Randomized Controlled Trial Extended Implementation.

BACKGROUND: Schizophrenia is a severe and disabling condition that presents a dire health equity challenge. Our initial 6-month trial (previously reported) using mobile texting and lay health supporters, called LEAN, significantly improved medication adherence from 0.48 to 0.61 (adjusted mean 0.11, 95% CI 0.03 to 0.20, P=.007) for adults with schizophrenia living in a resource-poor village in rural China. OBJECTIVE: We explored the effectiveness of our texting program in improving participants' medication adherence, functioning, and symptoms in an extended implementation of the intervention after its initial phase. METHODS: In an approximated stepped-wedge wait-list design randomized controlled trial, 277 community-dwelling villagers with schizophrenia were assigned 1:1 in phase 1 into intervention and wait-list control groups. The intervention group received (1) lay health supporters (medication or care supervisors), (2) e-platform (mobile-texting reminders and education message) access, (3) a token gift for positive behavioral changes, and (4) integration with the existing government community-mental health program (the 686 Program) while the wait-listed control group initially only received the 686 Program. Subsequently (in the extended period), both groups received the LEAN intervention plus the 686 Program. The primary outcome was antipsychotic medication adherence (percentage of dosages taken over the past month assessed by unannounced home-based pill counts). The secondary outcomes were symptoms measured during visits to 686 Program psychiatrists using the Clinical Global Impression scale for schizophrenia and functioning measured by trained student assessors using the World Health Organization Disability Assessment Schedule 2.0. Other outcomes included data routinely collected in the 686 Program system (refill records, rehospitalization due to schizophrenia, death for any reason, suicide, wandering, and violent behaviors). We used intention-to-treat analysis and missing data were imputed. A generalized estimating equation model was used to assess program effects on antipsychotics medication adherence, symptoms, and functioning. RESULTS: Antipsychotics medication adherence improved from 0.48 in the control period to 0.58 in the extended intervention period (adjusted mean difference 0.11, 95% CI 0.04 to 0.19; P=.004). We also noted an improvement in symptoms (adjusted mean difference -0.26, 95% CI -0.50 to -0.02; P=.04; Cohen d effect size 0.20) and a reduction in rehospitalization (0.37, 95% CI 0.18 to 0.76; P=.007; number-needed-to-treat 8.05, 95% CI 4.61 to 21.41). There was no improvement in functioning (adjusted mean difference 0.02, 95% CI -0.01 to 0.06; P=.18; Cohen d effect size 0.04). CONCLUSIONS: In an extended implementation, our intervention featuring mobile texting messages and lay health workers in a resource-poor community setting was more effective than the 686 Program alone in improving medication adherence, improving symptoms, and reducing rehospitalization. TRIAL REGISTRATION: Chinese Clinical Trial Registry; ChiCTR-ICR-15006053 https://tinyurl.com/y5hk8vng.

Championing women working in health across regional and rural Australia - a new dual-mentorship model.

BACKGROUND: Mentoring is a critical component of career development and job satisfaction leading to a healthier workforce and more productive outputs. However, there are limited data on mentorship models in regional areas and in particular for women aspiring to leadership positions. Mentorship programs that leverage off experienced mentors from diverse disciplines have the potential to foster the transfer of knowledge and to positively influence job satisfaction and build capacity within the context of workforce shortage. METHODS: This study describes a dual-mentorship model of professional development for women working in health in regional and rural Australia. We present the framework and describe the evaluation findings from a 12-month pilot program. RESULTS: Both academic and corporate mentors provided diverse perspectives to the mentees during the 12-month period. On average, corporate mentors met with mentees more often, and focused these discussions on strategy and leadership skills whilst academic mentors provided more technical advice regarding academic growth. Mentees reported an improvement in workplace interconnectedness and confidence at the completion of the program. CONCLUSION: We developed a framework for establishing a professional mentorship program that matches women working in regional health with mentors from diverse sectors including business, government, philanthropy and health, to provide a holistic approach to improving career satisfaction, institutional productivity and supporting a diverse workforce in regional or resource-poor settings.

Healthcare in Extreme and Austere Environments: Responding to the Ethical Challenges.

Clinicians may increasingly find themselves practicing, by choice or necessity, in resource-poor or extreme environments. This often requires altering typical patterns of practice with a different set of medical and ethical considerations than are usually faced by clinicians practicing in hospitals in the United States and Europe. Practitioners may be required to alter their usual scope of practice or their standard ways of medically treating patients. Limited resources will also often place clinicians in the position of having to make decisions about fairly allocating healthcare, which will alter the physician-patient relationship. This does not absolve physicians and other healthcare practitioners of providing the best quality of care that can be given under the circumstances. In addition, the lack of a well-developed healthcare infrastructure and limited resources will require working with established providers to determine the needs of the community, and what types of healthcare are feasible given these limitations. The essays in this issue of HEC Forum encourage readers to reflect on the unique ethical challenges faced in the extreme or austere environment.

Providing Ethical Healthcare in Resource-Poor Environments.

The ethics of providing health care in resource-poor environments is a complex topic. It implies two related questions: What can we do with the resources on hand? Of all the things we can do, which ones should we do? "Resource-poor" (i.e., resource-challenged, resource-constrained) environments are situations in which clinicians, organizations, or healthcare systems have the knowledge and skills, but not the means, to carry out highly effective and beneficial interventions. Determinants of a population's health often rely less on disease and injury management than on recognizing and meeting their basic needs. Many of the world's people with the greatest health problems live in fragile contexts and remote areas. Their access to food, safe water, personal safety, improved sanitation facilities, and health care remains elusive, with availability often based on socioeconomic status, gender, ethnicity, or geography. Of course, ethical international healthcare work also requires an understanding of the illnesses and injuries that most frequently plague the population. To function ethically and to know both what can and what should be done with available resources, individuals and organizations involved in international healthcare must be experienced, adaptable, culturally sensitive, inspired, situationally aware, beneficent, courageous, honest, and fair.

Risk factors associated with occurrence of anthelmintic resistance in sheep of resource-poor farmers in Limpopo province, South Africa.

Anthelmintic treatment is the most common way of controlling nematode infections in ruminants even though several countries have reported anthelmintic resistance (AR), resulting in limitation for sustainable small ruminant production. The aim of the present study was to evaluate the knowledge of resource-poor sheep farmers in Limpopo province of South Africa on the use of anthelmintics. A questionnaire regarding helminthosis control practices was administered to small ruminant farmers in five districts of Limpopo province namely Capricorn, Sekhukhune, Waterberg, Vhembe, and Mopani. A total of 77 resource-poor farmers were interviewed between June and August of 2017 using a structured questionnaire with a combination of qualitative and quantitative open-ended questions. The interviewed farmers were divided into three groups based on their farming experience (< 5; 6-10, and ˃ 10 years of farming experience). Limited farming experience was shown as one of the risks, as farmers that owned sheep for less than 10 years could not identify the symptoms of gastrointestinal parasites infection and did not know how nematodes are transmitted to animals. However, no significant difference (p < 0.05) was found to exist between the three groups of farmers in terms of clinical signs identification and correct application of anthelmintics. About 43% of the respondents were unaware of gastrointestinal nematodes (GI) that infect sheep, could not identify the clinical symptoms of gastrointestinal nematodes infection, and only 34% knew how animals become infected. Although 67.5% of farmers mentioned that they never dose their sheep, 32.5% use anthelmintics at varying times in a year. None of the farmers weighed their sheep before dosing them instead visual appraisal of individual weight was the most common means of estimating the anthelmintic dose. The above information is an indication of risks associated with possible occurrence of anthelmintic resistance in the study areas. There is therefore, a need to give training to resource-poor farmers of small stock on proper application of anthelmintic treatment and to educate them on how to prevent development of AR. Future studies on AR should also be conducted in the province in flocks with high-treatment frequencies to establish the occurrence of AR using both in vivo and in vitro methods. The most common risk factor associated with the occurrence of AR in all the five districts of Limpopo province was found to be the use of anthelmintics without weighing the animals to determine the correct dosage.

Type 1 Diabetes in a Resource-Poor Setting: Malnutrition Related, Malnutrition Modified, or Just Diabetes?

PURPOSE OF REVIEW: Very little is known about the occurrence of type 1 diabetes (T1DM) in resource-poor countries and particularly in their rural hinterlands. RECENT FINDINGS: Studies of the epidemiology of T1DM in Ethiopia and similar countries in sub-Saharan Africa show that the pattern of presenting disease differs substantially from that in the West. Typically, the peak age of onset of the disease is more than a decade later with a male excess and a low prevalence of indicators of islet-cell autoimmunity. It is also associated with markers of undernutrition. These findings raise the question as to whether the principal form of T1DM seen in these resource-poor communities has a different pathogenesis. Whether the disease is a direct result of malnutrition or whether malnutrition may modify the expression of islet-cell autoimmunity is unclear. However, the poor prognosis in these settings underlines the urgent need for detailed clinical and epidemiological studies.

From Procedure to Poverty: Out-of-Pocket and Catastrophic Expenditure for Pediatric Surgery in Uganda.

BACKGROUND: Financial protection from catastrophic health care expenditure (CHE) and patient out-of-pocket (OOP) spending are key indicators for sustainable surgical delivery. We aimed to calculate these metrics for a hospital stay requiring surgery in Uganda's pediatric population. METHODS: A survey was administered to family members of postoperative patients in the pediatric surgical ward at Mulago Hospital. Cost categories included direct medical costs, direct nonmedical costs, indirect costs, plus money borrowed and items sold to pay for the hospital stay. CHE was defined as spending greater than 10% of annual household expenditure. Costs were reported in Ugandan shillings and US dollars. RESULTS: One hundred and thirty-two patient families were surveyed between November 2016 and April 2017. Median direct costs were $27.55 (IQR 18.73-183.69) for diagnostics, $18.36 (IQR 9.52-41.33) for medications, $26.63 (IQR 9.19-45.92) for transportation, and $32.60 (IQR 12.85-64.29) for food and lodging. Forty-four percent of respondents were employed, and median indirect cost from productivity loss was $95.52 (IQR 55.10-243.38). Eighteen percent (16/87) borrowed money, and 9% (8/87) sold possessions to pay for the hospital stay. Total median OOP cost for patient families per hospital stay was $150.62 (IQR 65.21-339.82). Sixteen percent (21/132) of families incurred CHE from direct costs, and the proportion rose to 27% (32/132) when indirect cost was included. CONCLUSIONS: Although pediatric surgical services in Uganda are formally provided for free by the public sector, families accrue substantial OOP expenditure and almost a third of households incur CHE for a pediatric surgical procedure. This study suggests that broader financial protection must be established to meet Sustainable Development Goal targets.