Equity and unmet need of non-communicable diseases services in Saudi Arabia using a National Household Survey (2019).

BACKGROUND: Saudi Arabia is implementing a comprehensive health system transformation in health services provision, governance, and financing. Given the high burden of non-communicable diseases (NCD), a key objective of the transformation is to integrate NCD prevention and treatment into primary care. The study objectives were to assess primary care service use for treatment of NCDs, to quantify existing inequities in preventive services utilization, and to identify regional and sociodemographic factors associated with these inequities. METHODS: Using the 2019 Kingdom of Saudi Arabia World Health Survey, multivariable logistic regression models were conducted to identify predictors of utilization of primary care services for NCD prevention and treatment, unmet need among those with a diagnosis of diabetes, hypertension, or dyslipidemia, and unmet need in breast and cervical cancer screening. RESULTS: Among those with an NCD diagnosis, living in a high-income household was associated with a lower probability of having an unmet need compared to those in low-income households. Furthermore, rural residents were less likely to have an unmet need compared to urban residents (OR 0.58, p=0.029). Individuals without a perceived need for healthcare within the last 12 months had three times the probability of unmet need in comparison to those with such a perceived need (p<0.001). Women in all regions had a lower probability of ever having a mammogram compared to women in the central regions around Riyadh. Women with an education above a secondary level had five times the odds of undergoing cervical cancer screening and three times the likelihood of ever having a mammogram (P=0.012, p=0.02) than other women. Compared to women in low-income households, those in middle (OR 1.99, P=0.026), upper middle (OR 3.47, p<0.001), or high-income households (OR 2.59, p<0.001) had a higher probability of having had cervical cancer screening. CONCLUSIONS: Inequities in NCD treatment and prevention services' utilization in Saudi Arabia are strongly associated with region of living, population density, wealth, income, education and perceived need for health care. More research is needed to better understand the extent of unmet primary care needs for NCD and how to address the underlying contributing factors to access inequities.

Perspectives on long-acting injectable HIV antiretroviral therapy at an alternative care site: a qualitative study of people with HIV experiencing substance use and/or housing instability.

INTRODUCTION: Adherence to daily oral antiretroviral therapy (ART) and regular clinic appointments can be challenging for individuals who experience adverse social determinants of health. Long-acting injectable ART administered outside of traditional clinic settings may be a promising solution to adherence barriers, but additional research is needed to assess patients' perspectives. This study assessed perspectives of people living with HIV (PLWH) who had difficulty with adherence to traditional HIV care models and evaluated feasibility and acceptability of receiving a long-acting ART injection at a location outside of a traditional HIV clinic to address barriers to HIV care. METHODS: Qualitative interviews (n = 26) were conducted with PLWH who had experienced barriers to adherence. Participants were referred to the study by staff from Project Trust, a drop in harm reduction and sexually transmitted infection/HIV clinic. The interviews were conducted between May and November 2021. Interviews were recorded, professionally transcribed, coded, and analyzed qualitatively using the integrated-Promoting Action on Research Implementation in Health Services framework. RESULTS: We identified 6 main themes regarding the acceptability of receiving a long-acting injection to treat HIV, and the acceptability and feasibility of receiving injections at an alternative care site. Participants specified that they: (1) have a general understanding about their HIV care and the importance of ART adherence, (2) prefer a long-acting injection over a daily pill regimen, (3) expressed concerns about injection safety and efficacy, (4) had specific logistical aspects around the delivery of long-acting injections, including location of injection administration, that they believed would improve their ability to adhere, (5) have confidence that they can become undetectable and then complete the oral lead-in required to begin receiving the injection, and (6) see potential barriers that remain a concern for successful adherence to long-acting injections. CONCLUSION: To better treat HIV among people who are living with challenging social determinants of health, interventions that include a long-acting injection in a non-traditional care setting may prove to be a promising treatment option.

Effectiveness of community outreach HIV prevention programs in Vietnam: a mixed methods evaluation.

BACKGROUND: In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization's 90-90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam's efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, in 2007-2008 we conducted a nationwide evaluation of PEPFAR-supported outreach programs in Vietnam. The evaluation focused on assessing program effect on HIV knowledge, high-risk behaviors, and HIV testing among high-risk populations-results relevant to Vietnam's push to meet global HIV goals. METHODS: We used a mixed-methods cross-sectional evaluation design. Data collection encompassed a quantitative survey of 2199 individuals, supplemented by 125 in-depth interviews. Participants were members of high-risk populations who reported recent contact with an outreach worker (intervention group) or no recent contact (comparison group). We assessed differences in HIV knowledge, risky behaviors, and HIV testing between groups, and between high-risk populations. RESULTS: Intervention participants knew significantly more about transmission, prevention, and treatment than comparison participants. We found low levels of injection drug-use-related risk behaviors and little evidence of program impact on such behaviors. In contrast, a significantly smaller proportion of intervention than comparison participants reported risky sexual behaviors generally and within each high-risk population. Intervention participants were also more likely to have undergone HIV testing (76.1% vs. 47.0%, p < 0.0001) and to have received pre-test (78.0% vs. 33.7%, p < 0.0001) and post-test counseling (80.9% vs. 60.5%, p < 0.0001). Interviews supported evidence of high impact of outreach among all high-risk populations. CONCLUSIONS: Outreach programs appear to have reduced risky sexual behaviors and increased use of HIV testing services among high-risk populations in Vietnam. These programs can play a key role in reducing gaps in the HIV care cascade, achieving the global 90-90-90 goals, and creating an AIDS-free generation.

Unpacking the "Black Box": How an SMS-Based Continuing Medical Education Intervention Improved Medical Knowledge Among HIV Clinicians in Vietnam.

BACKGROUND: A mobile-based continuing medical education (mCME) intervention implemented over 6 months between 2016 and 2017, consisting of daily SMS multiple choice quizzes and access to online daily readings and CME courses, was shown to be effective in increasing medical knowledge among HIV providers in Vietnam. We hypothesized this improvement was a result of "lateral learning," a process in which the daily SMS quizzes acted as a stimulus for interacting with other study materials. METHODS: We explored how study materials directly provided by the intervention-the daily readings and the online CME courses-and independent study behaviors, such as using medical textbooks and reviewing national guidelines, contributed to medical knowledge as measured by baseline and endline exams. At baseline, there were 53 participants each in the intervention and control groups (N=106). Using linear regression models, we estimated the association between intervention-prompted and independent study behaviors and endline test scores. We also conducted a series of interaction analyses to test the extent to which the effect of daily quiz performance on endline test scores depended on use of the intervention-prompted or independent study materials. Finally, we estimated the proportion of variance in endline test scores explained by each of the intervention-prompted behaviors. RESULTS: The average medical knowledge test score among all participants was 46% at baseline and 54% at endline. Among the intervention group, 82% of the daily quizzes were answered, although only about half were answered correctly. Responding to the daily quizzes (ß=0.24; P=.05), quiz performance (ß=0.42; P<.001), and accessing daily readings (ß=0.22; P=.06) were statistically significantly associated with higher endline test scores. While accessing the online CME courses and some of the independent study behaviors, such as use of medical textbooks, had positive associations with endline test scores, none reached statistical significance. Quiz performance explained 51% of the variation in endline test scores. Interaction analysis found that quiz performance had a stronger, but not statistically significant, association with endline test scores when both daily readings (ß=0.87; P=.08) and online CME courses (ß=0.25; P=.09) were accessed more frequently. CONCLUSION: In mCME interventions, daily SMS quizzes can effectively act as a stimulus for uptake of study behaviors when paired with access to relevant readings and online courses. While further investigation is needed to more fully understand the role of outside study materials, we believe this model has the potential for further use in Vietnam and other low-resource settings.

Etiology of severe pneumonia in Ecuadorian children.

BACKGROUND: In Latin America, community-acquired pneumonia remains a major cause of morbidity and mortality among children. Few studies have examined the etiology of pneumonia in Ecuador. METHODS: This observational study was part of a randomized, double blind, placebo-controlled clinical trial conducted among children aged 2-59 months with severe pneumonia in Quito, Ecuador. Nasopharyngeal and blood samples were tested for bacterial and viral etiology by polymerase chain reaction. Risk factors for specific respiratory pathogens were also evaluated. RESULTS: Among 406 children tested, 159 (39.2%) had respiratory syncytial virus (RSV), 71 (17.5%) had human metapneumovirus (hMPV), and 62 (15.3%) had adenovirus. Streptococcus pneumoniae was identified in 37 (9.2%) samples and Mycoplasma pneumoniae in three (0.74%) samples. The yearly circulation pattern of RSV (P = 0.0003) overlapped with S. pneumoniae, (P = 0.03) with most cases occurring in the rainy season. In multivariable analysis, risk factors for RSV included younger age (adjusted odds ratio [aOR] = 1.9, P = 0.01) and being underweight (aOR = 1.8, P = 0.04). Maternal education (aOR = 0.82, P = 0.003), pulse oximetry (aOR = 0.93, P = 0.005), and rales (aOR = 0.25, P = 0.007) were associated with influenza A. Younger age (aOR = 3.5, P = 0.007) and elevated baseline respiratory rate were associated with HPIV-3 infection (aOR = 0.94, P = 0.03). CONCLUSION: These results indicate the importance of RSV and influenza, and potentially modifiable risk factors including undernutrition and future use of a RSV vaccine, when an effective vaccine becomes available. TRIAL REGISTRATION: ClinicalTrials.gov NCT 00513929.

Increasing compliance with alcohol service laws in a developing country: intervention trial in the Kingdom of Bhutan.

AIM: Bhutan is a low-middle income country that, like many others, experiences significant alcohol-related harm and low compliance with laws restricting availability and promotion. This study assessed changes in compliance of alcohol outlets with sales restrictions following a multi-sector programme aimed at improving this. DESIGN: Pre-post design with covert observation of service practices. SETTING: Thimphu, Bhutan, June-November 2013. Alcohol is not permitted for sale except from 1 to 10 p.m. Wednesday-Monday. Serving minors (< 18 years old) or intoxicated patrons is illegal. PARTICIPANTS: Seventy-one outlets selected randomly from all 209 on-premises outlets in downtown Thimphu. INTERVENTION: Multi-sector programme involving visits to outlets, education of owners and staff, a toolkit and implementation checks. MEASUREMENTS: Ten mystery-shopper visits were made to each outlet both before and after the intervention. We assessed compliance in five purchasing scenarios: (1) before 1 p.m., (2) after 10 p.m., (3) on Tuesdays and (4) shoppers who appeared to be underage or (5) intoxicated. Changes in compliance rates were assessed using multi-variable logistic regression models. FINDINGS: Overall compliance increased from 20 to 34% [difference: 14%; 95% confidence interval (CI) = 7-22%]. Improvement was found in refusals of service before 1 p.m.: 10-34% (difference(adj) = 24%; 95% CI = 12-37%) and on Tuesdays: 43-58% (difference(adj) = 14%; 95% CI = 1-28%). Differences in refusal to serve alcohol: after 10 p.m. (difference(adj) = 15%; 95% CI = -8 to 37%); to underage patrons (difference(adj) = -5%; 95% CI = 14 to 4%); and to intoxicated patrons (difference(adj) = 7%; 95% CI = -7-20%) were not statistically significant. Younger servers, stand-alone bars and outlets permitting indoor smoking were each less likely to comply with the alcohol service laws. CONCLUSION: A multi-sector programme to improve compliance with legal restrictions on serving alcohol in Bhutan appeared to have a modest effect but even after the programme, in two-thirds of the occasions tested, the laws were broken.

Association between wood cooking fuel and maternal hypertension at delivery in central East India.

OBJECTIVE: Smoke from burning of biomass fuels has been linked with adverse pregnancy outcomes and hypertension among nonpregnant subjects; association with hypertension during pregnancy has not been well studied. We evaluated whether the use of wood cooking fuel increases the risk of maternal hypertension at delivery compared to gas which burns with less smoke. METHODS: Information on fuel use and blood pressure was available for analysis from a cross-sectional survey of 1369 pregnant women recruited at delivery in India. RESULTS: Compared to gas users, women using wood as fuel had on average lower mean arterial pressure (adjusted effect size - 2.0 mmHg; 95% CI: -3.77, -0.31) and diastolic blood pressure (adjusted effect size -1.96 mmHg; 95% CI: -3.60, -0.30) at delivery. Risk of hypertension (systolic >139 mmHg or diastolic >89 mmHg) was 14.6% for wood users compared to 19.6% for gas users although this did not reach significance after adjustment, using propensity score techniques, for factors that make wood and gas users distinct (adjusted prevalence ratio 0.76; 95% CI: 0.49, 1.17). CONCLUSIONS: Combustion products from the burning of biomass fuels are similar to those released with tobacco smoking, which has been linked with a reduced risk for preeclampsia. The direction of our findings suggests the possibility of a similar effect for biomass cook smoke. Whether clean cooking interventions being promoted by international advocacy organizations will impact hypertension in pregnancy warrants further analysis as hypertension remains a leading cause of maternal death worldwide and cooking with biomass fuels is widespread.

Reconsidering empirical cotrimoxazole prophylaxis for infants exposed to HIV infection.

Infants with HIV infection are vulnerable to Pneumocystis carinii pneumonia (PCP) during their first year of life. WHO and the Joint United Nations Programme on HIV/AIDS now recommend that all children of HIV-positive mothers receive prophylactic cotrimoxazole against PCP from six weeks of age and continue this therapy until exposure through breast milk ceases-and the infant is confirmed to be HIV-negative (rarely before one year of age). Empirical prophylaxis invokes a trade-off between possible benefit to the infant versus the risk of resistance to antibiotics and antimalarials. From a critical analysis of the literature, we offer a conceptual model demonstrating how, under certain circumstances, a policy of mass cotrimoxazole prophylaxis may be counterproductive.