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.

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.

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.

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.

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.

Incidence of Cardiometabolic Diseases in People With and Without Human Immunodeficiency Virus in the United Kingdom: A Population-Based Matched Cohort Study.

BACKGROUND: Evidence on the risk of cardiovascular disease (CVD) and CVD risk factors in people with human immunodeficiency virus (PWH) is limited. We aimed to identify the risk of composite CVD, individual CVD events, and common risk factors. METHODS: This was a nationwide, population-based, cohort study comparing adult (≥18 years old) PWH with people without human immunodeficiency virus (HIV) matched on age, sex, ethnicity, and location. The primary outcome was composite CVD comprising stroke, myocardial infarction, peripheral vascular disease, ischemic heart disease, and heart failure. The secondary outcomes were individual CVD events, hypertension, diabetes, chronic kidney disease (CKD), and all-cause mortality. Cox proportional hazard regression models were used to examine the risk of each outcome. RESULTS: We identified 9233 PWH and matched them with 35 721 HIV-negative individuals. An increased risk was found for composite CVD (adjusted hazard ratio [aHR], 1.50; 95% confidence interval [CI], 1.28-1.77), stroke (aHR, 1.42; 95% CI, 1.08-1.86), ischemic heart disease (aHR, 1.55; 95% CI, 1.24-1.94), hypertension (aHR, 1.37; 95% CI, 1.23-1.53), type 2 diabetes (aHR, 1.28; 95% CI, 1.09-1.50), CKD (aHR, 2.42; 95% CI, 1.98-2.94), and all-cause mortality (aHR, 2.84; 95% CI, 2.48-3.25). CONCLUSIONS: PWH have a heightened risk for CVD and common CVD risk factors, reinforcing the importance for regular screening for such conditions.

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.

Effectiveness of interventions to reduce household air pollution from solid biomass fuels and improve maternal and child health outcomes in low- and middle-income countries: A systematic review and meta-analysis.

Interventions to reduce household air pollution (HAP) are key to reducing associated morbidity and mortality in low- and middle- income countries (LMICs); especially among pregnant women and young children. This systematic review aims to determine the effectiveness of interventions aimed to reduce HAP exposure associated with domestic solid biomass fuel combustion, compared to usual cooking practices, for improving health outcomes in pregnant women and children under five in LMIC settings. A systematic review and meta-analysis was undertaken with searches undertaken in MEDLINE, EMBASE, CENTRAL, GIM, ClinicalTrials.gov, and Greenfile in August 2020. Inclusion criteria were experimental, non-experimental, or quasi-experimental studies investigating the impact of interventions to reduce HAP exposure and improve associated health outcomes among pregnant women or children under 5 years. Study selection, data extraction, and quality assessment using the Effective Public Health Practice Project tool were undertaken independently by two reviewers. Seventeen out of 7293 retrieved articles (seven pregnancy, nine child health outcome; 13 studies) met the inclusion criteria. These assessed improved cookstoves (ICS; n = 10 studies), ethanol stoves (n = 1 study), and Liquefied Petroleum Gas (LPG; n = 2 studies) stoves interventions. Meta-analysis showed no significant effect of ICS interventions compared to traditional cooking for risk of preterm birth (n = 2 studies), small for gestational age (n = 2 studies), and incidence of acute respiratory infections (n = 6 studies). Although an observed increase in mean birthweight was observed, this was not statistically significant (n = 4). However, ICS interventions reduced the incidence of childhood burns (n = 3; observations = 41 723; Rate Ratio: 0.66 [95% CI: 0.45-0.96]; I2 : 46.7%) and risk of low birth weight (LBW; n = 4; observations = 3456; Odds Ratio: 0.73 [95% CI: 0.61-0.87]; I2 : 21.1%). Although few studies reported health outcomes, the data indicate that ICS interventions were associated with reduced risk of childhood burns and LBW. The data highlight the need for the development and implementation of robust, well-reported and monitored, community-driven intervention trials with longer-term participant follow-up.

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.

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 attributions of causality for child undernutrition: Qualitative analysis in Lusaka, Zambia.

Child undernutrition is responsible for 45% of all under-five deaths in low- and middle-income countries (LMICs) and numerous morbidities. Although progress has been made, high levels of child undernutrition persist in Zambia. Existing studies have explored primary caretakers' (PCs) explanatory models of child undernutrition in LMICs, without comparison with those of health care providers (HCPs). This paper examines and compares the perceived causes of child undernutrition among PCs and HCPs in Zambia. We conducted a qualitative study, using semistructured one-to-one and group interviews, with 38 PCs and 10 HCPs to explore their perceptions of child undernutrition and its perceived causes in Lusaka district, Zambia. Interview data were analysed with thematic analysis. Our findings indicate that PCs and HCPs in Lusaka district have divergent explanatory models of child undernutrition and perceive parental agency differently. In divergently framing how they conceptualise undernutrition and who is able to prevent it, these models underpin different attributions of causality and different opportunities for intervention. PCs highlighted factors such as child food preferences, child health, and household finances. Contrarily, HCPs stressed factors such as 'improper feeding', only highlighting factors such as wider economic conditions when these impacted specifically on health care services. One factor, identified by both groups, was 'inadequate mothering'. To accelerate the reduction of child undernutrition, interventions must address divergences between PCs and HCPs' explanatory models. Additionally, attention needs to be paid to how wider socio-economic and cultural contexts not only impact childhood undernutrition but shape attributions of causality.

Effects on childhood infections of promoting safe and hygienic complementary-food handling practices through a community-based programme: A cluster randomised controlled trial in a rural area of The Gambia.

BACKGROUND: The Gambia has high rates of under-5 mortality from diarrhoea and pneumonia, peaking during complementary-feeding age. Community-based interventions may reduce complementary-food contamination and disease rates. METHODS AND FINDINGS: A public health intervention using critical control points and motivational drivers, delivered February-April 2015 in The Gambia, was evaluated in a cluster randomised controlled trial at 6- and 32-month follow-up in September-October 2015 and October-December 2017, respectively. After consent for trial participation and baseline data were collected, 30 villages (clusters) were randomly assigned to intervention or control, stratified by population size and geography. The intervention included a community-wide campaign on days 1, 2, 17, and 25, a reminder visit at 5 months, plus informal community-volunteer home visits. It promoted 5 key complementary-food and 1 key drinking-water safety and hygiene behaviours through performing arts, public meetings, and certifications delivered by a team from local health and village structures to all villagers who attended the activities, to which mothers of 6- to 24-month-old children were specifically invited. Control villages received a 1-day campaign on domestic-garden water use. The background characteristics of mother and clusters (villages) were balanced between the trial arms. Outcomes were measured at 6 and 32 months in a random sample of 21-26 mothers per cluster. There were no intervention or research team visits to villages between 6 and 32 months. The primary outcome was a composite outcome of the number of times key complementary-food behaviours were observed as a proportion of the number of opportunities to perform the behaviours during the observation period at 6 months. Secondary outcomes included the rate of each recommended behaviour; microbiological growth from complementary food and drinking water (6 months only); and reported acute respiratory infections, diarrhoea, and diarrhoea hospitalisation. Analysis was by intention-to-treat analysis adjusted by clustering. (Registration: PACTR201410000859336). We found that 394/571 (69%) of mothers with complementary-feeding children in the intervention villages were actively involved in the campaign. No villages withdrew, and there were no changes in the implementation of the intervention. The intervention improved behaviour adoption significantly. For the primary outcome, the rate was 662/4,351(incidence rate [IR] = 0.15) in control villages versus 2,861/4,378 (IR = 0.65) in intervention villages (adjusted incidence rate ratio [aIRR] = 4.44, 95% CI 3.62-5.44, p < 0.001), and at 32 months the aIRR was 1.17 (95% CI 1.07-1.29, p = 0.001). Secondary health outcomes also improved with the intervention: (1) mother-reported diarrhoea at 6 months, with adjusted relative risk (aRR) = 0.39 (95% CI 0.32-0.48, p < 0.001), and at 32 months, with aRR = 0.68 (95% CI 0.48-0.96, p = 0.027); (2) mother-reported diarrhoea hospitalisation at 6 months, with aRR = 0.35 (95% CI 0.19-0.66, p = 0.001), and at 32 months, with aRR = 0.38 (95% CI 0.18-0.80, p = 0.011); and (3) mother-reported acute respiratory tract infections at 6 months, with aRR = 0.67 (95% CI 0.53-0.86, p = 0.001), though at 32 months improvement was not significant (p = 0.200). No adverse events were reported. The main limitations were that only medium to small rural villages were involved. Obtaining laboratory cultures from food at 32 months was not possible, and no stool microorganisms were investigated. CONCLUSIONS: We found that low-cost and culturally embedded behaviour change interventions were acceptable to communities and led to short- and long-term improvements in complementary-food safety and hygiene practices, and reported diarrhoea and acute respiratory tract infections. TRIAL REGISTRATION: The trial was registered on the 17th October 2014 with the Pan African Clinical Trial Registry in South Africa with number (PACTR201410000859336) and 32-month follow-up as an amendment to the trial.

Cost-effectiveness of a weaning food safety and hygiene programme in rural Gambia.

OBJECTIVE: The main objective of the economic evaluation was to determine the cost-effectiveness of a weaning food safety and hygiene programme in reducing rates of diarrhoea compared with the control in rural Gambia. METHODS: The public health intervention, using critical control points and motivational drivers, was evaluated in a cluster randomised controlled trial at 6- and 32-month follow-up. An economic evaluation was undertaken alongside the RCT with data collected prospectively from a societal perspective. Decision-analytic modelling was used to explore cost-effectiveness over a longer time period (4 years). RESULTS: Direct out-of-pocket healthcare expenditure for households due to diarrhoea was large. The intervention significantly reduced reported childhood diarrhoeal episodes after 6 months (incident risk ratio = 0.40, 95% CI 0.33, 0.49) and 2 years after the intervention (incident risk ratio = 0.68, 95% CI 0.46, 1.02). The within-trial analysis found that the intervention led to total savings of 8064 dalasi 6 months after the intervention and 4224 dalasi 2 years after the intervention. Based on the model results, if the intervention is successful in maintaining the reduction in the risk of diarrhoea, the ICER is US$ 814 per DALY avoided over 4 years. This is cost-effective. CONCLUSIONS: This study suggests that there are substantial household costs associated with diarrhoeal episodes in children. The within-trial analysis and model results suggest that the community-based approach to improving weaning food hygiene and safety is likely to be cost-effective compared with control.

The effect of vitamin D supplementation and nutritional intake on skeletal maturity and bone health in socio-economically deprived children.

PURPOSE: 1. To determine the effect of vitamin D supplementation on bone age (BA), a marker of skeletal maturity, and Bone Health Index (BHI), a surrogate marker of bone density. 2. To characterise the differences in nutritional intake and anthropometry between children with advanced vs. delayed BA. METHODS: The current study is a post hoc analysis of radiographs obtained as part of a randomised controlled trial. In this double-blind, placebo-controlled trial, deprived Afghan children (n = 3046) aged 1-11 months were randomised to receive six doses of oral placebo or vitamin D3 (100,000 IU) every 3 months for 18 months. Dietary intake was assessed through semi-quantitative food frequency questionnaires at two time points. Anthropometric measurements were undertaken at baseline and 18 months. Serum 25OHD was measured at five time points on a random subset of 632 children. Knee and wrist radiographs were obtained from a random subset (n = 641), of which 565 wrist radiographs were digitised for post-hoc analysis of BA and BHI using BoneXpert version 3.1. RESULTS: Nearly 93% (522, male = 291) of the images were analysable. The placebo (n = 258) and vitamin D (n = 264) groups were comparable at baseline. The mean (± SD) age of the cohort was 2 (± 0.3) years. At study completion, there was no difference in mean 25-hydroxy vitamin D concentrations [47 (95% CI 41, 56) vs. 55 (95% CI 45, 57) nmol/L, p = 0.2], mean (± SD) BA SDS [- 1.04 (1.36) vs. - 1.14 (1.26) years, p = 0.3] or mean (± SD) BHI SDS [- 0.30 (0.86) vs. - 0.31 (0.80), p = 0.8] between the placebo and vitamin D groups, respectively. Children with advanced skeletal maturity (BA SDS ≥ 0) when compared to children with delayed skeletal maturity (BA SDS < 0), had consumed more calories [mean (± SD) calories 805 (± 346) vs 723 (± 327) kcal/day, respectively, p < 0.05], were significantly less stunted (height SDS - 1.43 vs. - 2.32, p < 0.001) and underweight (weight SDS - 0.82 vs. - 1.45, p < 0.001), with greater growth velocity (11.57 vs 10.47 cm/ year, p < 0.05). CONCLUSION: Deprived children have significant delay in skeletal maturation but no substantial impairment in bone health as assessed by BHI. BA delay was influenced by total calorie intake, but not bolus vitamin D supplementation.

Facilitating better postnatal care with women-held documents in The Gambia: a mixed-methods study.

BACKGROUND: Women-held documents are a basic component of continuity of maternity care. The use and completion of women-held documents following discharge could improve treatment and care for postnatal women. Using a mixed-methods study design, we aimed to assess the number, type, quality and completeness of women-held discharge documents, identify factors contributing to document completeness and facilitators or barriers for effective use of the documents. METHODS: Documents given to women at discharge from three hospitals in the Greater Banjul Area, The Gambia, were reviewed for content and quality. All women completed a questionnaire on the use of the documents. Poisson regression was used to estimate factors predicting document completion. Semi-structured interviews (n = 21) and focus groups (n = 2) were carried out with healthcare professionals (HCPs). RESULTS: Nearly all (n = 211/212; 99%) women were given a document to take home. The most complete document (maternal record) had on average 17/26 (65%) items completed and 10% of women held an illegible document. None of the women's sociodemographic or clinical characteristics predicted document completeness. The following facilitators for effective use of documents were identified from the women's responses to the questionnaire and interviews with HCPs: 94% of women thought written information is important, 99% plan to have postnatal check-ups and 67% plan to use their documents, HCPs understand the importance of the documents and were familiar with the document's use and content. The following barriers for effective use of documents were identified: HCPs had too many women-held documents to complete at discharge, there is no national protocol and HCPs think women do not understand the documents due to a lack of education and that women often lose or forget their documents. CONCLUSIONS: Women-held documents are well established in The Gambia; though quality and completeness needs improving. Future research should determine the impact of using only one document at discharge, protocols and training on completeness, among other outcomes, and on ways to ensure all women are using the documents for their postnatal care.

Ranking Hospitals Based on Preventable Hospital Death Rates: A Systematic Review With Implications for Both Direct Measurement and Indirect Measurement Through Standardized Mortality Rates.

Policy Points The use of standardized mortality rates (SMRs) to profile hospitals presumes differences in preventable deaths, and at least one health system has suggested measuring preventable death rates of hospitals for comparison across time or in league tables. The influence of reliability on the optimal review number per case note or hospital for such a program has not been explored. Estimates for preventable death rates using implicit case note reviews by clinicians are quite low, suggesting that SMRs will not work well to rank hospitals, and any misspecification of the risk-adjustment models will produce a high risk of mislabelling outliers. Most studies achieve only fair to moderate reliability of the direct assessment of whether a death is preventable, and thus it is likely that substantial numbers of reviews of deaths would be required to distinguish preventable from nonpreventable deaths as part of learning from individual cases, or for profiling hospitals. Furthermore, population- and hospital system-specific data on the variation in preventable deaths or adverse events across the hospitals and providers to be compared are required in order to design a measurement procedure and the number of reviews needed to distinguish between the patients or hospitals. CONTEXT: There is interest in monitoring avoidable or preventable deaths measured directly or indirectly through standardized mortality rates (SMRs). While there have been numerous studies in recent years on adverse events, including preventable deaths, using implicit case note reviews by clinicians, no systematic reviews have aimed to summarize the estimates or the variations in methodologies used to derive these estimates. We reviewed studies that use implicit case note reviews to estimate the range of preventable death rates observed, the measurement characteristics of those estimates, and the measurement procedures used to generate them. We comment on the implications for monitoring SMRs and illustrate a way to calculate the number of reviews needed to establish a reliable estimate of the preventability of one death or the hospital preventable death rate. METHODS: We conducted a systematic review of the literature supplemented by a reanalysis of authors' previously published and unpublished data and measurement design calculations. We conducted initial searches in PubMed, MEDLINE (OvidSP), and ISI Web of Knowledge in June 2010 and updated them in June 2012 and December 2017. Eligibility criteria included studies of hospital-wide admissions from general and acute medical wards where preventable death rates are provided or can be estimated and that can provide interobserver variations. FINDINGS: Twenty-three studies were included from 1985 to 2017. Recent larger studies suggest consistently low rates of preventable deaths (interquartile range of 3.0%-6.0% since 2008). Reliability of a single review for distinguishing between individual cases with regard to the preventability of death had a Kappa statistic of 0.10-0.50 for deaths and 0.21-0.76 for adverse events. A Kappa of 0.35 would require an average of 8 to 17 reviews of a single case to be precise enough to have confidence in high-stakes decisions to change care procedures or impose sanctions within a hospital as a result. No study estimated the variation in preventable deaths across hospitals, although we were able to reanalyze one study to obtain an estimate. Based on this estimate, 200 to 300 total case note reviews per hospital could be required to reliably distinguish between hospitals. The studies displayed considerable heterogeneity: 13/23 studies defined preventable death with a threshold of greater than or equal to four in a six-category Likert scale and 11/24 involved a two-stage screening process with nurses at the first stage and physicians at the second. Fifteen studies provided expert clinical review support for reviewer disagreements, advice, and quality control. A "generalist/internist" was the modal physician specialty for reviewers and they received one to three days of generic tools orientation and case note review practice. Methods did not consider the influence of human or environmental factors. CONCLUSIONS: The literature provides limited information about the measurement characteristics of preventable deaths, suggesting that substantial numbers of reviews may be needed to create reliable estimates of preventable deaths at the individual or hospital level. Any operational program would require population-specific estimates of reliability. Preventable death rates are low, which is likely to make it difficult to use SMRs based on all deaths to validly profile hospitals. The literature provides little information to guide improvements in the measurement procedures.

Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis.

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36-55%), 24% (95% CI 17-32%), and 1.4% (95% CI 1.2-1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.

Correction to: Social and environmental determinants of child health in Mongolia across years of rapid economic growth: 2000-2010.

Unfortunately, after publication of this article [1], it was noticed that an error during the production process resulted in an incorrect author name. The author Semira Manaseki-Holland is incorrectly displayed as Semira Manaseki-Hollan. The full, corrected author list can be seen above.

Social and environmental determinants of child health in Mongolia across years of rapid economic growth: 2000-2010.

BACKGROUND: To understand the effect of economic growth on health, we investigated the trend in socio-economic and regional determinants of child health in Mongolia. This Central Asian country had the fastest economic growth amongst low and middle-income countries (LMICs) from 2000 to 2010 and a healthcare system in transition. METHODS: Data was from Mongolian multiple indicator cluster surveys (MICS) in 2000, 2005 and 2010. Child nutrition/growth was measured by height-for-age z-score (HAZ), weight-for-age z-score (WAZ), prevalence of stunted (HAZ < -2) and underweight (WAZ < -2) children. Access to health care was measured by prevalence of fully immunised children <5 years. Multivariate multi-level logistic mixed modelling was used to estimate the effect of socio-economic and environmental health determinants on each outcome in each year; 2000, 2005 and 2010. T-tests were used to measure significant change in HAZ and WAZ over the decade. RESULTS: Overall, from 2000 to 2010, there was a significant improvement (p < 0.001) in all three outcomes, but the effect of socio-economic factors increased on both stunting and weight. In 2000, region was a significant determinant: children living in three provinces were significantly more likely to be stunted and less likely to be immunised than Ulaanbaatar, but this was not significant by 2010. By 2010, none of the factors were significant determinants of immunisation in children. In 2000, economic status had no effect on stunting (OR = 0.91; 95%CI:0.49,1.66), however by 2010, children in the poorest economic quintile were 4 times more likely to be stunted than the richest (OR = 0.24; 95% CI:0.13,0.45; p < 0.001). The effect of maternal education on stunting prevalence continued over the 10 years, in both 2000 and 2010 children were twice as likely to be stunted if their mother had no education compared to university education (2000 OR = 0.45; 95% CI:0.28,0.73, p < 0.01,2010 OR =0.55; 95% CI:0.35,0.87, p < 0.05). CONCLUSION: Economic growth in Mongolia from 2000 to 2010 resulted in an increase in the effect of social determinants of child health; whilst focused policy improved access to immunisation. Children with less educated mothers and lower household incomes should be targeted in interventions to reduce health inequity.

Methods for medical device and equipment procurement and prioritization within low- and middle-income countries: findings of a systematic literature review.

BACKGROUND: Forty to 70 % of medical devices and equipment in low- and middle-income countries are broken, unused or unfit for purpose; this impairs service delivery to patients and results in lost resources. Undiscerning procurement processes are at the heart of this issue. We conducted a systematic review of the literature to August 2013 with no time or language restrictions to identify what product selection or prioritization methods are recommended or used for medical device and equipment procurement planning within low- and middle-income countries. We explore the factors/evidence-base proposed for consideration within such methods and identify prioritization criteria. RESULTS: We included 217 documents (corresponding to 250 texts) in the narrative synthesis. Of these 111 featured in the meta-summary. We identify experience and needs-based methods used to reach procurement decisions. Equipment costs (including maintenance) and health needs are the dominant issues considered. Extracted data suggest that procurement officials should prioritize devices with low- and middle-income country appropriate technical specifications - i.e. devices and equipment that can be used given available human resources, infrastructure and maintenance capacity. CONCLUSION: Suboptimal device use is directly linked to incomplete costing and inadequate consideration of maintenance services and user training during procurement planning. Accurate estimation of life-cycle costing and careful consideration of device servicing are of crucial importance.