Burnout among healthcare providers in the complex environment of the Middle East: a systematic review.

BACKGROUND: Burnout is a syndrome characterized by emotional exhaustion, increased depersonalization, and a diminished sense of personal accomplishment due to chronic emotional stress at work. Burnout impacts job satisfaction, job performance, vulnerability to illnesses, and interpersonal relationships. There is a gap in the systematic data on the burden of burnout among healthcare professionals from different sectors of healthcare in Middle Eastern countries. Our objective was to examine the burden of burnout among healthcare providers in the Middle East, how it was assessed, which sectors were included, and what interventions have been used. METHODS: Articles were found through a systematic review of search results including PubMed, Web of Science (Thomson Reuters), and PsycINFO (EBSCO) using search terms reflecting burnout in Middle Eastern countries among populations of healthcare providers. Studies were included if they examined a quantitative measure of burnout among healthcare providers in the Middle East. RESULTS: There were 138 articles that met our inclusion criteria for this systematic review. Studies focused on burnout in the Middle East among physicians (N = 54 articles), nurses (N = 55), combined populations of healthcare workers (N = 22), and medical students (N = 7). The Maslach Burnout Inventory was the most common tool to measure burnout. Burnout is common among physicians, nurses, and other healthcare professionals, with prevalence estimates predominantly ranging between 40 and 60%. Burnout among healthcare providers in the Middle East is associated with characteristics of their work environments, exposure to violence and terror, and emotional distress and low social support. CONCLUSIONS: Burnout is highly prevalent among healthcare providers across countries in the Middle East. Previous studies examining burnout in this region have limitations in their methodology. More thoroughly developed epidemiologic studies of burnout are necessary. Health system strengthening is needed in a region that has endured years of ongoing conflict, and there is an urgency to design and implement programs that tackle burnout among health professionals.

Genetic association study of preterm birth and gestational age in a population-based case-control study in Peru.

BACKGROUND: Preterm birth (PTB) affects ∼15 million pregnancies worldwide. Genetic studies have identified several candidate loci for PTB, but results remain inconclusive and limited to European populations. Thus, we conducted a genome-wide association study (GWAS) of PTB and gestational age at delivery (GA) among 2,212 Peruvian women. METHODS: PTB cases delivered≥20 weeks' but < 37 weeks' gestation, while controls delivered at term (≥37 weeks but <42 weeks). Multivariable regressions were used to identify genetic markers for PTB and GA (∼6 million SNPs), adjusting for maternal age and the first two genetic principal components. In silico functional analysis was conducted among top signals detected with an arbitrary P < 1.0×10-5 . We sought to replicate genetic markers for PTB and GA identified in Europeans, and we developed a genetic risk score for GA based on European markers. RESULTS: Mean GA was 30 ± 4 weeks in PTB cases (N = 933) and 39 ± 1 in the controls (N = 1,279). No associatiosn were identified at genome-wide level. Nominal PTB variants were enriched for biological pathways associated with polyketide, progesterone, steroid hormones, and glycosyl metabolism. Nominal GA variants were enriched in intronic regions and cancer pathways. Variants in WNT4 associated with GA in Europeans were replicated in our study. A genetic risk score was associated with a 2-day longer GA (P = 0.002) in our sample. CONCLUSIONS: This study identified various signals suggestively associated with PTB and GA in pregnant Peruvian women. None of these variants overlapped with signals previously identified in Europeans.

Intestinal parasitic infection and nutritional status among school children in Angolela, Ethiopia.

INTRODUCTION: Gastrointestinal parasitic infections are most prevalent in populations with low household income, poor handling of personal and environmental sanitation, overcrowding, and limited access to clean water. We conducted this study to estimate the prevalence of parasitic infection and nutritional status, and to evaluate the extent to which the two are associated among schoolchildren in rural Ethiopia. METHODS: This is a cross sectional study of 664 students aged from 6 to 19 years old from Angolela, Ethiopia. Socio-demographic information was collected using a structured questionnaire. Anthropometric measurements were taken at the time of interview. Examinations of fecal samples for helminthic and protozoan parasitic infections were performed. Logistic regression procedures were employed to evaluate the association between stunting, underweightedness, and wasting with parasitic infections. RESULTS. One-third of the participants were found to have a protozoan infection, while 7.1% were found to have a helminthic infection. Approximately 11% of the students were stunted, 19.6% were wasted, and 20.8% were underweight. Severely underweight boys were 3.88-times as likely as boys of adequate weight (odds ratio OR = 3.88, 95% confidence interval CI: 1.12-13.52) to be diagnosed with protozoan infections. Among girls, those who were severely stunted were approximately 12 times (OR = 11.84, 95%CI: 1.72-81.62) as likely to be infected with a helminthic parasite, than those who were not. Overall, there was a deficit in normal growth patterns as indicated by lower than average anthropometric measures. DISCUSSION AND CONCLUSIONS. There is a high prevalence of intestinal parasitic infections. Stunting, wasting, and underweightedness were also prevalent, and showed patterns of associations with intestinal parasitic infections. Efforts should be made to strengthen and expand school and community-based programs that promote inexpensive, though effective, practices to prevent the spread of parasitic diseases. Initiatives aimed at improving the nutritional status of school children are also needed.

Laboratory reference values of complete blood count for apparently healthy adults in Ethiopia.

BACKGROUND: The objective of this study was to evaluate reference intervals for complete blood cell count parameters among apparently healthy 1,807 adults from Addis Ababa, Ethiopia. METHODS: Blood specimens were collected from each participant using standard procedures. The collected aliquots were processed according to standard operating procedures to determine participants' complete blood counts. Non-parametric methods were employed to calculate the reference intervals and 90% confidence intervals for complete blood counts. RESULTS: Overall the results show that reference ranges for women are lower than men. The white blood cell count, neutrophil, lymphocyte, monocyte, eosinophil, and basophil reference values appear to be lower than values reported elsewhere. CONCLUSIONS: Our study is the first comprehensive study on reference intervals of complete blood count among apparently healthy adults in Ethiopia. Future studies that assess other hematological parameters and studies that assess reference values for African pediatric populations are warranted.

Knowledge, attitudes and practices (KAP) of hygiene among school children in Angolela, Ethiopia.

INTRODUCTION: Poor hygiene practices and inadequate sanitary conditions play major roles in the increased burden of communicable diseases within developing countries. This study evaluated the KAP of hygiene among rural school children in Ethiopia and assessed the extent to which proper knowledge of hygiene was associated with personal hygiene characteristics. METHODS: This cross-sectional study was comprised of 669 students who were interviewed by trained staff Participants were in grades 1-6 at Angolela Primary School, located in rural Ethiopia. Data consisted of hygiene and hand washing practices, knowledge about sanitation, personal hygiene characteristics, and presence of gastrointestinal parasitic infection. Results. Approximately 52% of students were classified as having adequate knowledge of proper hygiene. Most students reported hand washing before meals (99.0%), but only 36.2% reported using soap. Although 76.7% of students reported that washing hands after defecation was important, only 14.8% reported actually following this practice. Students with adequate knowledge of proper hygiene were more likely to have clean clothes (AOR 1.62, CI 1.14-2.29) and to have a lower risk of parasitic infection (AOR 0.78, CI 0.56-1.09) although statistical significance was not achieved for the latter DISCUSSION AND CONCLUSION: Study findings underscore the need for more hand washing and hygiene education in schools; and provide objective evidence that may guide the development of comprehensive health and hygiene intervention programs in rural Ethiopian schools. Successful implementation of these programs is likely to substantially attenuate the transmissible disease burden borne by school children in rural settings.

Chronic HPA activity in mothers with preterm delivery: A pilot nested case-control study.

BACKGROUND: Chronic hypothalamic-pituitary-adrenal (HPA) axis activity role in the pathogenesis of preterm birth (PTB) remains unclear due to inconsistent measures with limited ability to monitor long-term cortisol concentrations. We explored this relationship using the novel method of assessing cortisol in hair, which is a valid and reliable measure of chronic HPA axis activity. METHODS: 137 participants (40 PTB cases and 97 controls from a birth cohort of pregnant women in Peru) were interviewed and invited to provide a 9-cm hair sample from the posterior vertex position of the scalp (mean = 13 weeks gestation). Hair cortisol concentration (HCC) was determined using luminescence immunoassay and values were natural-log transformed. PTB cases were defined as women who delivered before 37 gestational weeks. Case-control differences were assessed using multivariable linear and logistic regressions. RESULTS: Overall, combined pre-conception and first-trimester HCC was 13% lower among cases as compared with controls (p-value = 0.01). Compared with controls, maternal HCC among PTB cases were 14% (p = 0.11), 10% (p = 0.22) and 14% (p = 0.08) lower for 3-6 months pre-conception, 0-3 months pre-conception, and first trimester, respectively. After adjusting for putative confounders, a 1-unit increase in HCC was associated with 55% reduced odds of PTB (aOR = 0.45; 95% CI: 0.17-1.17). For a 1-unit increase in HCC in the scalp-intermediate and scalp-distal segments (representing HCC concentrations in 0-3 months pre-conception and first trimester), the corresponding odds for PTB were 0.53 (95% CI: 0.19-1.48) and 0.39 (95% CI: 0.13-1.13), respectively. CONCLUSIONS: Women who deliver preterm, as compared with those who deliver at term, have lower preconception and first trimester HCC. Our findings suggest that HPA axis activation, integral to the adaptive stress-response system, may be chronically dysregulated in women at increased risk of PTB.

Prevalence of metabolic syndrome and its relationship with leisure time physical activity among Peruvian adults.

BACKGROUND: Metabolic syndrome (MetS) is an important risk factor of cardiovascular disease (CVD) and type 2 diabetes. Previous studies have suggested an inverse relationship between physical activity and MetS. However, these findings were inconsistent, and few investigators have examined these associations among South Americans. We estimated the prevalence of MetS and its association with leisure time physical activity (LTPA) among Peruvian adults. MATERIALS AND METHODS: This cross-sectional study of 1675 individuals (619 men and 1056 women) was conducted among residents in Lima and Callao, Peru. Information about LTPA, socio-demographical and other lifestyle characteristics was collected by interview. The presence of MetS was defined using the Adult Treatment Panel III criteria. RESULTS: Overall, the prevalence of MetS was 26.9% and was more common among women (29.9%) than men (21.6%). Habitual participation in LTPA was associated with a 23% reduced risk of MetS (OR = 0.77; 95% CI: 0.60-1.03). There was an inverse trend of MetS risk with amount of LTPA (P = 0.016). Compared with non-exercisers, those who exercised <150 min/week had a 21% reduced risk of MetS (AOR = 0.79; 95% CI 0.60-1.04). Individuals who exercised > or = 150 min/week, compared with non-exercisers, had a 42% reduced risk of MetS (AOR = 0.58; 95% CI: 0.36-0.93). Associations of similar magnitudes were observed when men and women were studied separately. CONCLUSION: These data document a high prevalence of MetS and suggest an association with LTPA among urban dwelling Peruvians. Further prospective studies are needed to confirm these observations and to examine interventions that may promote increased physical activity in this population.

Analysis of polygenic risk score usage and performance in diverse human populations.

A historical tendency to use European ancestry samples hinders medical genetics research, including the use of polygenic scores, which are individual-level metrics of genetic risk. We analyze the first decade of polygenic scoring studies (2008-2017, inclusive), and find that 67% of studies included exclusively European ancestry participants and another 19% included only East Asian ancestry participants. Only 3.8% of studies were among cohorts of African, Hispanic, or Indigenous peoples. We find that predictive performance of European ancestry-derived polygenic scores is lower in non-European ancestry samples (e.g. African ancestry samples: t = -5.97, df = 24, p = 3.7 × 10-6), and we demonstrate the effects of methodological choices in polygenic score distributions for worldwide populations. These findings highlight the need for improved treatment of linkage disequilibrium and variant frequencies when applying polygenic scoring to cohorts of non-European ancestry, and bolster the rationale for large-scale GWAS in diverse human populations.

Metabolomics signatures associated with an oral glucose challenge in pregnant women.

AIM: The oral glucose tolerance test (OGTT), widely used as a gold standard for gestational diabetes mellitus (GDM) diagnosis, provides a broad view of glucose pathophysiology in response to a glucose challenge. We conducted the present study to evaluate metabolite changes before and after an oral glucose challenge in pregnancy; and to examine the extent to which metabolites may serve to predict GDM diagnosis in pregnant women. METHODS: Peruvian pregnant women (n=100) attending prenatal clinics (mean gestation 25 weeks) participated in the study with 23% of them having GDM diagnosis. Serum samples were collected immediately prior to and 2-hours after administration of a 75-g OGTT. Targeted metabolic profiling was performed using a LC-MS based metabolomics platform. Changes in metabolite levels were evaluated using paired Student's t-tests and the change patterns were examined at the level of pathways. Multivariate regression procedures were used to examine metabolite pairwise differences associated with subsequent GDM diagnosis. RESULTS: Of the 306 metabolites detected, the relative concentration of 127 metabolites were statistically significantly increased or decreased 2-hours after the oral glucose load (false discovery rate [FDR] corrected P-value<0.001). We identified relative decreases in metabolites in acylcarnitines, fatty acids, and diacylglycerols while relative increases were noted among bile acids. In addition, we found that C58:10 triacylglycerol (ß=-0.08, SE=0.04), C58:9 triacylglycerol (ß=-0.07, SE=0.03), adenosine (ß=0.70, SE=0.32), methionine sulfoxide (ß=0.36, SE=0.13) were significantly associated with GDM diagnosis even after adjusting for age and body mass index. CONCLUSIONS: We identified alterations in maternal serum metabolites, representing distinct cellular and metabolic pathways including fatty acid metabolism, in response to an oral glucose challenge. These findings offer novel perspectives on the pathophysiological mechanisms underlying GDM.

Preparing to launch the 'Thinking Healthy Programme' perinatal depression intervention in Urban Lima, Peru: experiences from the field.

BACKGROUND: An estimated 19-25% of perinatal women in low- and middle-income countries are affected by depression which, untreated, is associated with multiple health problems for mothers and children. Nonetheless, few perinatal women have access to depression care. The Thinking Healthy Programme (THP), promoted by the World Health Organization (WHO), is an evidence-based, non-specialist delivered depression intervention that addresses this care gap. However, the WHO THP manual explains intervention delivery but not the antecedents to implementation. Here, we describe a principled, planned approach leading to the implementation of THP in Lima, Peru by the non-profit organization Socios En Salud with community health workers (CHW) to inform its implementation in other settings. METHODS: The Replicating Effective Programs (REP) framework guided THP implementation, following four phases: (I) pre-conditions; (II) pre-implementation; (III) implementation; and (IV) maintenance and evolution. This paper centers on REP phases I and II, including (1) documented high perinatal depression rates in Peru; (2) designation of perinatal depression as a government priority; (3) THP Implementation Team orientation and training; (4) data collection plan development; (5) public health system coordination; (6) CHW selection and training; and (7) THP launch. RESULTS: Between December 2016 and March 2017, a THP training program was developed and seven CHW were trained to deliver the intervention to 10 perinatal women, the first of whom was enrolled on 17 April 2017. CONCLUSIONS: THP was rapidly implemented by a community-based organization with no prior experience in delivering non-specialist perinatal depression care. The steps followed may inform the implementation of THP in other settings.

Associations of Maternal Urinary Cadmium with Trimester-Specific Blood Pressure in Pregnancy: Role of Dietary Intake of Micronutrients.

Previous studies revealed associations of urinary Cd (U-Cd), a chronic Cd exposure biomarker, with blood pressure (BP) in non-pregnant adults. However, the evidence regarding trimester-specific blood pressure in pregnancy and U-Cd and effect modification by dietary intake of micronutrients is scarce. We randomly selected 653 women from the Omega Study cohort. U-Cd was quantified by inductively coupled plasma mass spectrometry. Trimester-specific, systolic (SBP) and diastolic blood pressure (DBP) were determined employing standard protocols and mean arterial pressure (MAP) was also calculated. Associations of SBP, DBP, and MAP with U-Cd tertiles (≤0.21; 0.22-0.41; ≥0.42 µg/g Cr) were assessed using multivariable linear regression models. We also explored effect modification by pre-pregnancy BMI (≤25 or >25 kg/m2) or low/high micronutrients intake. After adjusting confounders in women with elevated (upper tertile) as compared with those with low (lowest tertile) U-Cd (≥0.42 vs. ≤0.21 µg/g Cr, respectively) had reduced third trimester MAP (-1.8; 95 % confidence interval (CI) = -3.1, -0.5 mmHg) and second trimester MAP (-1.1; 95 % CI = -2.3, -0.03 mmHg). A significant decrease in third-trimester MAP associated with increased U-Cd was observed only among normal/underweight women (BMI ≤ 25 kg/m2) and women with high dietary intake of micronutrients (calcium, magnesium, zinc, and selenium). Notably, U-Cd concentrations increased with the increased consumption of zinc and non-heme iron food sources. No significant differences in U-Cd concentrations were found in preeclamptic women compared with non-preeclamptic women. Our study provides evidence that dietary intake of micronutrients should be taken into account when assessing the health effects of Cd in pregnant women.

Making strides towards better mental health care in Peru: Results from a primary care mental health training.

Our program attempted to improve attitudes and confidence of Peruvian primary care physicians (PCPs) providing mental health care. The training program underwent an evaluation to determine impact of sustained confidence in performing medical and psychiatric procedures, and application of learned skills. Fifty-two Peruvian primary care practitioners were trained at the Harvard Program in Refugee Trauma (HPRT) over a two-week period. There was significant improvement in PCPs' confidence levels of performing psychiatric procedures (counseling, prescribing medications, psychiatric diagnosis, assessing the risk for violence, and treating trauma victims) when comparing baseline and post-two-week to one year follow-up. When comparing post-two-week and one-year follow-up quantitative measures, confidences levels went slightly down. This may be an implication that the frequency of trainings and supervisions are needed more frequently. In contrast, qualitative responses from the one-year follow-up revealed increase in victims of violence clinical care, advocacy, awareness, education, training, policy changes, accessibility of care, and sustainment of diagnostic tools. This study supports the feasibility of training PCP's in a culturally effective manner with sustainability over time.

Prevalence of Metabolic Syndrome among Working Adults in Ethiopia.

Objective. To evaluate the prevalence of metabolic syndrome (MetS) according to the International Diabetes Federation (IDF) and Adult Treatment Panel (ATP) III criteria among working East African adults. Design. This cross-sectional study of 1,935 individuals (1,171 men and 764 women) was conducted among working adults in Addis Ababa, Ethiopia. The study was conducted in accordance with the STEPwise approach of the World Health Organization. Results. According to ATP III and IDF definitions, the overall prevalence of MetS was 12.5% and 17.9%, respectively. Using ATP III criteria, the prevalence of MetS was 10.0% in men and 16.2% in women. Application of the IDF criteria resulted in a MetS prevalence of 14.0% in men and 24.0% in women. The most common MetS components among women were reduced high-density lipoprotein-cholesterol (HDL-C) (23.2%) and abdominal obesity (19.6%); whilst reduced HDL-C concentrations (23.4%) and high blood pressure (21.8%) were most common among men. Conclusion. MetS and its individual components are prevalent among an apparently healthy working population in Ethiopia. These findings indicate the need for evidence-based health promotion and disease prevention programs; and more robust efforts directed towards the screening, diagnosis and management of MetS and its components among Ethiopian adults.

Waist Circumference, Body Mass Index, and Other Measures of Adiposity in Predicting Cardiovascular Disease Risk Factors among Peruvian Adults.

Objectives. To examine the extent to which measures of adiposity can be used to predict selected components of metabolic syndrome (MetS) and elevated C-reactive protein (CRP). Methods. A total of 1,518 Peruvian adults were included in this study. Waist circumference (WC), body mass index (BMI), waist-hip ratio (WHR), waist-height ratio (WHtR), and visceral adiposity index (VAI) were examined. The prevalence of each MetS component was determined according to tertiles of each anthropometric measure. ROC curves were used to evaluate the extent to which measures of adiposity can predict cardiovascular risk. Results. All measures of adiposity had the strongest correlation with triglyceride concentrations (TG). For both genders, as adiposity increased, the prevalence of Mets components increased. Compared to individuals with low-BMI and low-WC, men and women with high-BMI and high- WC had higher odds of elevated fasting glucose, blood pressure, TG, and reduced HDL, while only men in this category had higher odds of elevated CRP. Overall, the ROCs showed VAI, WC, and WHtR to be the best predictors for individual MetS components. Conclusions. The results of our study showed that measures of adiposity are correlated with cardiovascular risk although no single adiposity measure was identified as the best predictor for MetS.