Training Traditional Bonesetters in Basic Principles of Fracture Treatment: A Proof of Concept in Ghana.

BACKGROUND: Our study assessed the effectiveness of a traditional bonesetter (TBS) educational program that was designed to increase knowledge, reduce complications, and promote the referral of patients to local hospitals by TBSs when necessary. METHODS: From April to December 2021, TBSs from the Northern Sector (the Northern, Savannah, and North East regions) and the Ashanti region of Ghana underwent a 4-day training course that had been designed to teach basic principles of fracture care with the use of local tools. We assessed the levels of knowledge of the TBSs both before and after training. The change in practice of the trained TBSs also was assessed at 6 months using a structured questionnaire and a checklist. RESULTS: In total, 157 TBSs were trained in 5 training sessions over a 9-month period. There was an improvement in knowledge in all of the modules of training, with an overall knowledge gain of 19.7% (from 67.2% to 86.9%). At 6 months of follow-up, the practices of TBSs that had most improved were record-keeping, hand hygiene, and patient rehabilitation. As a result of the referral system that was established by the training project, a total of 37 patients were referred to local hospitals in the 6 months following the training. CONCLUSIONS: Formal training for TBSs that was provided by a multidisciplinary team with use of a locally developed curriculum and tools was effective in improving the practice and outcomes of treatment by TBSs. There was marked knowledge retention by the trained TBSs at 6 months after training in fracture management. CLINICAL RELEVANCE: Education, training, and the establishment of referral pathways between TBSs and local hospitals could improve trauma care in Ghana.

Seeking healthcare at their 'right' time; the iterative decision process for women with breast cancer.

BACKGROUND: About 85% of breast cancer patients attending Komfo Anokye Teaching Hospital (KATH), Ghana, present with stage III/IV disease. In spite of great investments into the early diagnosis and management of breast cancer, late presentation persists and poses a barrier to realising the possible benefits of the gains made in breast cancer management. This study assessed the symptom appraisal and medical health seeking behaviour of women with either locally advanced or metastatic breast cancer attending breast clinic at KATH. METHOD: In-depth interviews of women presenting with clinical stage III/IV breast cancer were conducted to explore the women's care seeking pathways after symptom identification until arrival at KATH from May 2015 to March 2016. Thematic data analysis was conducted using the Andersen behavioural model for health service use. RESULTS: Fifteen women aged 24-79 years were interviewed. The time from symptom identification to reporting to KATH was 4-24 months. The initial symptom was a breast lump or breast swelling which all the women identified themselves. These were initially appraised as not serious because most importantly, they did not interfere with their daily function. Symptom progression such as prevented them from undertaking their usual economic, social and family function triggered seeking care from health facilities. The availability of money to pay for care and diagnostic investigations influenced the time taken to navigate the referral pathway. While the women initially deferred healthcare for reasons related to their ability to perform economic, family and social roles, ultimately, aggressively pursuing healthcare was also for the same economic, family and social reasons or goals. CONCLUSION: Deciding to seek care and pursue treatment for breast cancer symptoms may be much more complicated than it appears. Economic, family and social function significantly drive the health seeking process both at the personal and health facility phases of health seeking. Breast cancer education messages must be adapted to incorporate these functional goals and their influence on symptom appraisal and decision making to seek help and not just focus on the breast symptom as an isolated entity.

Food Insecurity Screening in Pediatric Clinical Settings: A Caregivers' Perspective.

OBJECTIVES: Food insecurity (FI) has serious academic, social, and physical health consequences for children. A recent clinical recommendation suggests FI screening during child well visits. While FI screening research has considered clinician feedback, little is known about caregivers' experience of disclosing FI to health care providers. Our paper explores caregivers' barriers and facilitators to FI disclosure. METHODS: A survey on factors influencing FI disclosure was completed in a pediatric clinic waiting room in St. Louis, MO. Among households with FI, 15 caregivers participated in a qualitative interview. Caregivers were asked about experiences discussing FI with health care providers. We calculated frequencies for survey responses and analyzed interview data using thematic content analysis. RESULTS: Caregivers highlighted stigma, fear of child being taken away, and shame as barriers to FI disclosure. Caregivers identified strong interpersonal skills, open body language, and empathy as facilitators to disclosure at the interpersonal level. Provider initiated conversations, consideration of FI disclosure in the presence of a child, and normalization of FI discussions within the clinic were described as ways to encourage FI disclosure at the organizational level. In response to FI disclosure, caregivers would like providers to offer resources including referrals to community-based resources extending beyond food. CONCLUSIONS FOR PRACTICE: Our study identifies considerations for FI screening in health care settings, spanning the social-ecological model, from the perspective of caregivers. To successfully screen and address FI, multifaceted health care interventions should address barriers and promote facilitators across multiple levels and in consideration of multiple social needs.

Screening for Food Insecurity in Pediatric Clinical Settings: Opportunities and Barriers.

Food insecurity is a serious health concern among children in the United States with 15.3 million children living in food insecure households. The American Academy of Pediatrics recommends that pediatricians screen for food insecurity at health maintenance visits as identifying children at risk is a crucial step in the amelioration of food insecurity. Two surveys were administered in a Midwest pediatric clinic. A cross-sectional survey was electronically distributed to pediatric providers to assess perceptions of food insecurity among patients, provider readiness to conduct food security screenings, and barriers to conducting those screenings. A cross-sectional caregiver survey was administered to assess demographics, household food security status, participation in nutrition assistance programs, and barriers to getting enough food to eat. Descriptive statistics and odds ratios were calculated. Eighty-eight percent of physicians believe that food insecurity is a challenge for some of their patients. Only 15 % of providers reported screening for food insecurity, while 80 % were willing to screen. Physicians were most concerned with knowing how to handle a positive screen. Among caregivers, 57 % screened positive for food insecurity. Those experiencing food insecurity were more likely to be non-white, participate in SNAP and to feel discomfort towards the idea of talking to a doctor or nurse about food needs. Caregivers reporting food insecurity were significantly less likely to have a personal vehicle. Effective food insecurity screening requires addressing caregiver and health provider barriers in order to increase the likelihood of identifying households most at risk.

An alternate targeting pathway for procathepsin L in mouse fibroblasts.

In transformed mouse fibroblasts, a significant proportion of the lysosomal cysteine protease cathepsin L remains in cells as an inactive precursor which associates with membranes by a mannose phosphate-independent interaction. When microsomes prepared from these cells were resolved on sucrose gradients, this procathepsin L was localized in dense vesicles distinct from those enriched for growth hormone, which is secreted constitutively when expressed in fibroblasts. Ultrastructural studies using antibodies directed against the propeptide to avoid detection of the mature enzyme in lysosomes revealed that the proenzyme was concentrated in dense cores within small vesicles and multivesicular endosomes which labeled with antibodies specific for CD63. Consistent with the resemblance of these cores to those of regulated secretory granules, secretion of procathepsin L from fibroblasts was modestly stimulated by phorbol, 12-myristate, 13-acetate. When protein synthesis was blocked with cycloheximide and lysosomal proteolysis inhibited with leupeptin, procathepsin L was found to gradually convert to the active single-chain protease. The data suggest that when synthesis levels are high, a portion of the procathepsin L is packaged in dense cores within multivesicular endosomes localized near the plasma membrane. Gradual activation of this proenzyme achieves targeting of the proenzyme to lysosomes by a mannose phosphate receptor-independent pathway.