Women's perceptions of and experiences with the use of misoprostol for treatment of incomplete abortion in central Malawi: a mixed methods study.

BACKGROUND: Abortion-related complications are among the common causes of maternal mortality in Malawi. Misoprostol is recommended for the treatment of first-trimester incomplete abortions but is seldom used for post-abortion care in Malawi. METHODS: A descriptive cross-sectional study that used mixed methods was conducted in three hospitals in central Malawi. A survey was done on 400 women and in-depth interviews with 24 women receiving misoprostol for incomplete abortion. Convenience and purposive sampling methods were used and data were analysed using STATA 16.0 for quantitative part and thematic analysis for qualitative part. RESULTS: From the qualitative data, three themes emerged around the following areas: experienced effects, support offered, and women's perceptions. Most women liked misoprostol and reported that the treatment was helpful and effective in expelling retained products of conception. Quantitative data revealed that the majority of participants, 376 (94%) were satisfied with the support received, and 361 (90.3%) believed that misoprostol was better than surgical treatment. The majority of the women 364 (91%) reported they would recommend misoprostol to friends. CONCLUSIONS: The use of misoprostol for incomplete abortion in Malawi is acceptable and regarded as helpful and satisfactory among women.

One of the major causes of maternal mortality is complications after abortion and miscarriages. The importance of post-abortion care in preventing such deaths justifies the necessity of making treatment accessible and available to every woman in need. Misoprostol is one of the approved treatments for incomplete abortion but is rarely used in developing countries. A study was conducted in three hospitals in central Malawi where women filled in a questionnaire and were interviewed after receiving misoprostol for incomplete abortion. The study's goal was to investigate women's experiences and feelings about using misoprostol. The findings showed that the majority of the women received medication and counselling as a form of support. They expressed satisfaction with the support and described misoprostol as being useful in removing retained products of conception from the womb. The medication was preferred and regarded as a reliable treatment that was also good for women. The majority of the women reported tolerable side effects of the drug and would recommend it to friends. In conclusion, the use of misoprostol for early incomplete abortion in Malawi is acceptable and is regarded as helpful, and satisfactory to women receiving post-abortion care. The research findings support expanding use of misoprostol in post-abortion care in Malawi.

Temporal trends in associations between severe mental illness and risk of cardiovascular disease: A systematic review and meta-analysis.

BACKGROUND: Severe mental illness (SMI; schizophrenia, bipolar disorders (BDs), and other nonorganic psychoses) is associated with increased risk of cardiovascular disease (CVD) and CVD-related mortality. To date, no systematic review has investigated changes in population level CVD-related mortality over calendar time. It is unclear if this relationship has changed over time in higher-income countries with changing treatments. METHODS AND FINDINGS: To address this gap, a systematic review was conducted, to assess the association between SMI and CVD including temporal change. Seven databases were searched (last: November 30, 2021) for cohort or case-control studies lasting ≥1 year, comparing frequency of CVD mortality or incidence in high-income countries between people with versus without SMI. No language restrictions were applied. Random effects meta-analyses were conducted to compute pooled hazard ratios (HRs) and rate ratios, pooled standardised mortality ratios (SMRs), pooled odds ratios (ORs), and pooled risk ratios (RRs) of CVD in those with versus without SMI. Temporal trends were explored by decade. Subgroup analyses by age, sex, setting, world region, and study quality (Newcastle-Ottawa scale (NOS) score) were conducted. The narrative synthesis included 108 studies, and the quantitative synthesis 59 mortality studies (with (≥1,841,356 cases and 29,321,409 controls) and 28 incidence studies (≥401,909 cases and 14,372,146 controls). The risk of CVD-related mortality for people with SMI was higher than controls across most comparisons, except for total CVD-related mortality for BD and cerebrovascular accident (CVA) for mixed SMI. Estimated risks were larger for schizophrenia than BD. Pooled results ranged from SMR = 1.55 (95% confidence interval (CI): 1.33 to 1.81, p < 0.001), for CVA in people with BD to HR/rate ratio = 2.40 (95% CI: 2.25 to 2.55, p < 0.001) for CVA in schizophrenia. For schizophrenia and BD, SMRs and pooled HRs/rate ratios for CHD and CVD mortality were larger in studies with outcomes occurring during the 1990s and 2000s than earlier decades (1980s: SMR = 1.14, 95% CI: 0.57 to 2.30, p = 0.71; 2000s: SMR = 2.59, 95% CI: 1.93 to 3.47, p < 0.001 for schizophrenia and CHD) and in studies including people with younger age. The incidence of CVA, CVD events, and heart failure in SMI was higher than controls. Estimated risks for schizophrenia ranged from HR/rate ratio 1.25 (95% CI: 1.04 to 1.51, p = 0.016) for total CVD events to rate ratio 3.82 (95% CI: 3.1 to 4.71, p < 0.001) for heart failure. Incidence of CHD was higher in BD versus controls. However, for schizophrenia, CHD was elevated in higher-quality studies only. The HR/rate ratios for CVA and CHD were larger in studies with outcomes occurring after the 1990s. Study limitations include the high risk of bias of some studies as they drew a comparison cohort from general population rates and the fact that it was difficult to exclude studies that had overlapping populations, although attempts were made to minimise this. CONCLUSIONS: In this study, we found that SMI was associated with an approximate doubling in the rate ratio of CVD-related mortality, particularly since the 1990s, and in younger groups. SMI was also associated with increased incidence of CVA and CHD relative to control participants since the 1990s. More research is needed to clarify the association between SMI and CHD and ways to mitigate this risk.

Health care providers' perceptions of using misoprostol in the treatment of incomplete abortion in Malawi.

BACKGROUND: In Malawi, abortion is only legal to save a pregnant woman's life. Treatment for complications after unsafe abortions has a massive impact on the already impoverished health care system. Even though manual vacuum aspiration (MVA) and misoprostol are the recommended treatment options for incomplete abortion in the first trimester, surgical management using sharp curettage is still one of the primary treatment methods in Malawi. Misoprostol and MVA are safer and cheaper, whilst sharp curettage has more risk of complications such as perforation and bleeding and requires general anesthesia and a clinician. Currently, efforts are being made to increase the use of misoprostol in the treatment of incomplete abortions in Malawi. To achieve successful implementation of misoprostol, health care providers' perceptions on this matter are crucial. METHODS: A qualitative approach was used to explore health care providers' perceptions of misoprostol for the treatment of incomplete abortion using semi-structured in-depth interviews. Ten health care providers were interviewed at one urban public hospital. Each interview lasted 45 min on average. Health care providers of different cadres were interviewed in March and April 2021, nine months after taking part in a training intervention on the use of misoprostol. Interviews were recorded, transcribed verbatim and analyzed using 'Systematic Text Condensation'. RESULTS: The health care providers reported many advantages with the increased use of misoprostol, such as reduced workload, less hospitalization, fewer infections, and task-shifting. Availability of the drug and benefits for the patients were also highlighted as important. However, some challenges were revealed, such as deciding who was eligible for the drug and treatment failure. For these reasons, some health care providers still choose surgical treatment as their primary method. CONCLUSION: Findings in this study support the recommendation of increased use of misoprostol as a treatment for incomplete abortion in Malawi, as the health care providers interviewed see many advantages with the drug. To scale up its use, proper training and supervision are essential. A sustainable and predictable supply is needed to change clinical practice. Unsafe abortion is a major contributor to maternal mortality worldwide. Unsafe abortion is the termination of an unintended pregnancy by a person without the required skills or equipment, which might lead to serious complications. In Malawi, post-abortion complications are common, and the maternal mortality ratio is among the highest in the world. Retained products of conception, referred to as an incomplete abortion, are common after spontaneous miscarriages and unsafe induced abortions. There are several ways to treat incomplete abortion, and the drug misoprostol has been successful in the treatment of incomplete abortion in other low-income countries. This study explored perceptions among health care providers using misoprostol to treat incomplete abortions and whether the drug can be fully embraced by Malawian health care professionals. Health personnel at a Malawian hospital were interviewed individually regarding the use of the drug for treating incomplete abortions. This study revealed that health care providers interviewed are satisfied with the increased use of misoprostol. They highlighted several benefits, such as reduced workload and that it enabled task-shifting so that various hospital cadres could now treat patients with incomplete abortions. The health care workers also observed benefits for women treated with the drug compared to other treatments. The challenges mentioned were finding out who was eligible for the drug and drug failure. This study supports scaling up the use of misoprostol in the treatment of incomplete abortions in Malawi; the Ministry of Health and policymakers should support future interventions to increase its use.

The relationship between psychosocial circumstances and injuries in adolescents: An analysis of 87,269 individuals from 26 countries using the Global School-based Student Health Survey.

BACKGROUND: Over a million adolescents die globally each year from preventable or treatable causes, with injuries (intentional and unintentional) being the leading cause of these deaths. To inform strategies to prevent these injuries, we aimed to assess psychosocial factors associated with serious injury occurrence, type, and mechanism in adolescents. METHODS AND FINDINGS: We conducted a secondary analysis of cross-sectional survey data collected from the Global School-based Student Health Survey between 2009 and 2015. We used logistic regression to estimate associations between prevalence of serious injuries, injury type (effects of injury), and injury mechanism (cause of injury) and psychosocial factors (factors that relate to individuals socially, or their thoughts or behaviour, or the interrelation between these variables). Psychosocial factors were categorised, based on review of the literature, author knowledge, and discussion amongst authors. The categories were markers of risky behaviour (smoking, alcohol use, drug use, and physical activity), contextual factors (hunger, bullying, and loneliness), protective factors (number of friends and having a supportive family), and markers of poor mental health (planned or attempted suicide and being too worried to sleep). Models were adjusted for country factors (geographical area and income status, both using World Bank classification), demographic factors (age and sex), and factors to explain the survey design. A total of 87,269 adolescents living in 26 countries were included. The weighted majority were 14-15 years old (45.88%), male (50.70%), from a lower-middle-income country (81.93%), and from East Asia and the Pacific (66.83%). The weighted prevalence of a serious injury in the last 12 months was 36.33%, with the rate being higher in low-income countries compared to other countries (48.74% versus 36.14%) and amongst males compared to females (42.62% versus 29.87%). Psychosocial factors most strongly associated with serious injury were being bullied (odds ratio [OR] 2.45, 95% CI 1.93 to 3.13, p < 0.001), drug use (OR 2.08, 95% CI 1.73 to 2.49, p < 0.001), attempting suicide (OR 1.78, CI 1.55 to 2.04, p < 0.001), being too worried to sleep (OR 1.80, 95% CI 1.54 to 2.10, p < 0.001), feeling lonely (OR 1.61, 95% CI 1.37 to 1.89, p < 0.001), and going hungry (OR 1.61, 95% CI 1.30 to 2.01, p < 0.001). Factors hypothesised to be protective were not associated with reduced odds of serious injury: Number of close friends was associated with an increased odds of injury (OR 1.23, 95% CI 1.06 to 1.43, p = 0.007), as was having understanding parents or guardians (OR 1.13, 95% CI 1.01 to 1.26, p = 0.036). Being bullied, using drugs, and attempting suicide were associated with most types of injury, and being bullied or too worried to sleep were associated with most mechanisms of injury; other psychosocial factors were variably associated with injury type and mechanism. Limitations include the cross-sectional study design, making it not possible to determine the directionality of the associations found, and the survey not capturing children who did not go to school. CONCLUSIONS: We observed strong associations between serious injury and psychosocial factors, but we note the relationships are likely to be complex and our findings do not inform causality. Nevertheless, our findings suggest that multifactorial programmes to target psychosocial factors might reduce the number of serious injuries in adolescents, in particular programmes concentrating on reducing bullying and drug use and improving mental health.

Prevalence and socio-demographic associations of diet and physical activity risk-factors for cardiovascular disease in Bo, Sierra Leone.

BACKGROUND: Little is known about modifiable dietary and physical activity risk factors for cardiovascular diseases (CVDs) in Sierra Leone. This information is critical to the development of health improvement interventions to reduce the prevalence of these diseases. This cross-sectional study investigated the prevalence and socio-demographic correlates of dietary and physical activity risk behaviours amongst adults in Bo District, Sierra Leone. METHODS: Adults aged 40+ were recruited from 10 urban and 30 rural sub-districts in Bo. We examined risk factors including: ≤150 min of moderate or vigorous-intensity physical activity (MVPA) weekly, physical inactivity for ≥3 h daily, ≤5 daily portions of fruit and vegetables, and salt consumption (during cooking, at the table, and in salty snacks). We used logistic regression to investigate the relationship between these outcomes and participants' socio-demographic characteristics. RESULTS: 1978 eligible participants (39.1% urban, 55.6% female) were included in the study. The prevalence of behavioural risk factors was 83.6% for ≤5 daily portions of fruit and vegetables; 41.4 and 91.6% for adding salt at the table or during cooking, respectively and 31.1% for eating salty snacks; 26.1% for MVPA ≤150 min weekly, and 45.6% for being physically inactive ≥3 h daily. Most MVPA was accrued at work (nearly 24 h weekly). Multivariable analysis showed that urban individuals were more likely than rural individuals to consume ≤5 daily portions of fruit and vegetables (Odds Ratio (OR) 1.09, 95% Confidence Interval (1.04-1.15)), add salt at the Table (OR 1.88 (1.82-1.94)), eat salty snacks (OR 2.00 (1.94-2.07)), and do MVPA ≤150 min weekly (OR 1.16 (1.12-1.21)). Male individuals were more likely to add salt at the Table (OR 1.23 (1.20-1.27)) or consume salty snacks (OR 1.35 (1.31-1.40)) than female individuals but were less likely to report the other behavioural risk-factors examined. Generally, people in lower wealth quintiles had lower odds of each risk factor than those in the higher wealth quintiles. CONCLUSION: Dietary risk factors for CVD are highly prevalent, particularly among urban residents, of Bo District, Sierra Leone. Our findings highlight that forthcoming policies in Sierra Leone need to consider modifiable risk factors for CVD in the context of urbanisation.

Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi-disciplinary Stakeholder Exercise.

BACKGROUND: Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. METHODS: A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem. RESULTS: Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were "Training and retention of specialist staff", "Health education/awareness of injury severity", "Geographical coverage of referral trauma centres", and "Lack of protocol for bypass to referral centres". The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map. CONCLUSION: Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.

"Confidence comes with frequent practice": health professionals' perceptions of using manual vacuum aspiration after a training program.

BACKGROUND: Malawi has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. Curettage is most frequently used as the surgical method for treating incomplete abortions, even though it is costly for an impoverished health system and the less expensive and safe manual vacuum aspiration (MVA) method is recommended. METHODS: The aim of this 2016-17 study is to explore health worker's perception of doing MVA 1 year after an educational intervention. Focus group discussions were recorded, transcribed verbatim, and analyzed using content analysis for interpreting the findings. A knowledge, attitude and practice survey was administered to health professionals to obtain background information before the MVA training program was introduced. RESULTS: Prior to the training sessions, the participants demonstrated knowledge on abortion practices and had positive attitudes about participating in the service, but preferred curettage over MVA. The training was well received, and participants felt more confident in doing MVA after the intervention. However, focus group discussions revealed obstacles to perform MVA such as broken equipment and lack of support. Additionally, the training could have been more comprehensive. Still, the participants appreciated task-sharing and team work. CONCLUSION: Training sessions are considered useful in increasing the use of MVA. This study provides important insight on how to proceed in improving post-abortion care in a country where complications of unsafe abortion are common and the health system is low on resources.

The Norwegian preeclampsia family cohort study: a new resource for investigating genetic aspects and heritability of preeclampsia and related phenotypes.

BACKGROUND: Preeclampsia is a major pregnancy complication without curative treatment available. A Norwegian Preeclampsia Family Cohort was established to provide a new resource for genetic and molecular studies aiming to improve the understanding of the complex pathophysiology of preeclampsia. METHODS: Participants were recruited from five Norwegian hospitals after diagnoses of preeclampsia registered in the Medical birth registry of Norway were verified according to the study's inclusion criteria. Detailed obstetric information and information on personal and family disease history focusing on cardiovascular health was collected. At attendance anthropometric measurements were registered and blood samples were drawn. The software package SPSS 19.0 for Windows was used to compute descriptive statistics such as mean and SD. P-values were computed based on t-test statistics for normally distributed variables. Nonparametrical methods (chi square) were used for categorical variables. RESULTS: A cohort consisting of 496 participants (355 females and 141 males) representing 137 families with increased occurrence of preeclampsia has been established, and blood samples are available for 477 participants. Descriptive analyses showed that about 60% of the index women's pregnancies with birth data registered were preeclamptic according to modern diagnosis criteria. We also found that about 41% of the index women experienced more than one preeclamptic pregnancy. In addition, the descriptive analyses confirmed that preeclamptic pregnancies are more often accompanied with delivery complications. CONCLUSION: The data and biological samples collected in this Norwegian Preeclampsia Family Cohort will provide an important basis for future research. Identification of preeclampsia susceptibility genes and new biomarkers may contribute to more efficient strategies to identify mothers "at risk" and contribute to development of novel preventative therapies.

Challenges and possible improvements for healthcare teams at outreach clinics in Nepal - a qualitative study.

BACKGROUND: All Nepalese citizens have the right to high-quality healthcare services free of charge. To achieve this, healthcare services for the rural population in Nepal need to be improved in terms of personnel, medicines, and medical equipment. OBJECTIVES: To explore challenges and possible improvements healthcare personnel experience when travelling to rural parts of Nepal to provide healthcare. METHOD: Data was collected from various health professionals using focus group discussions at Dhulikhel Hospital in Nepal. The data were transcribed and analysed using Systematic text condensation. RESULTS: Twenty-two professional healthcare personnel participated in five group discussions. Four categories emerged from the collected material: Finding ORC services being underutilised, Wanting to fulfil tasks and do a good job, Facing inadequate resources, and Seeing the need for improved organisation and cooperation. There was consensus that rural clinics are important to maintaining health for the rural population of Nepal. However, there was frustration that the rural population was not benefitting from all available healthcare services due to underutilisation. CONCLUSION: Rural healthcare clinics are not utilised appropriately, according to healthcare workers at the rural outreach clinics. Potential ways of overcoming the perceived challenges of underutilising available healthcare services include financial and human resources. The rural population´s health awareness needs to be increased, and the work environment for rural healthcare workers needs to be improved. These issues need to be prioritised by the government and policymakers.

Main findings: Outreach clinics in Nepal are perceived as underutilised by health providers.Added knowledge: Increased awareness among rural people on when to seek healthcare, improved work conditions for health providers and collaboration with other health facilities may strengthen the utilisation of offered care.Global health impact for policy and action: Updated policies reflecting these Nepalese suggestions on strengthening rural healthcare may be useful and benefit other rural populations in similar settings.

Exploring the priorities of ageing populations in Pakistan, comparing views of older people in Karachi City and Thatta.

As a lower middle-income country, Pakistan faces multiple issues that influence the course of healthy ageing. Although there is some understanding of these issues and the objective health outcomes of people in Pakistan, there is less knowledge on the perceptions, experiences, and priorities of the ageing population and their caretakers (hereafter, "stakeholders"). The aim of the study was to identify the needs and priorities of older adults and stakeholders across both urban and rural locations. We sought to explore the views of two groups of people, older adults and stakeholders on topics including the definition of ageing as well as areas of importance, services available, and barriers to older people living well. Two-day workshops were conducted in one rural city, Thatta and one urban city, Karachi. The workshops were designed using the Nominal Group Technique, which included plenary and roundtable discussions. The responses were ranked through rounds of voting and a consensus priority list was obtained for each topic and group. Responses were categorized using the socio-ecological framework. Responses were compared between stakeholders and older people and between different geographical areas. 24 urban and 26 rural individuals aged over 60 years and 24 urban and 26 rural stakeholders attended the workshops. There were few areas of agreement with respect to both geographical region and participant group. Comparing older adults' definition of ageing, there was no overlap between the top five ranked responses across urban and rural locations. With respect to areas of importance, there was agreement on free health care as well as financial support. In terms of barriers to healthy ageing, only nation-wide inflation was ranked highly by both groups. In addition, there were relatively few areas of congruence between stakeholder and older adult responses, irrespective of location, although engagement with family, adequate nutrition and monetary benefits were responses ranked by both groups as important for healthy ageing. Both groups ranked issues with the pension system and financial difficulties as barriers. When categorized using the socio-ecological model, across all questions, societal factors were prioritized most frequently (32 responses), followed by individual (27), relationship (15), and environment (14). Overcoming barriers to facilitate healthy ageing will require a multi-faceted approach and must incorporate the priorities of older individuals. Our results may serve as a guide for researchers and policymakers for future engagement and to plan interventions for improving the health of the ageing population in Pakistan.

Priorities and barriers for ageing well; results from stakeholder workshops in rural and urban Rwanda.

BACKGROUND: The National Older Person's Policy of 2021 in Rwanda highlights the need for social protection of older populations. However, there is a lack of local knowledge regarding the priorities and challenges to healthy aging faced by older people and their caregivers. OBJECTIVES: This study aimed to identify and compare the needs and priorities of older people and other stakeholders involved in caring for them in rural and urban areas of Rwanda. METHODS: The study was conducted in two locations, Kigali (urban) and Burera district (rural). Each site hosted two separate one-day workshops with older people (≥60 years) and stakeholders (all ages). Discussions were held in plenary and roundtable-groups to generate a list of the top 4 prioritized responses on areas of importance, priorities/enablers to be addressed, and obstacles to living a healthy and active life for older people. The research team identified similarities between stakeholder and older people's responses in each area and a socio-ecological model was used to categorize findings. RESULTS: There were substantial differences in responses between rural and urban areas and between older people and stakeholders. For each question posed, in each rural or urban area, there was only agreement between stakeholders and older people for a maximum of one response. Whereas, when comparing responses from the same participant groups in urban or rural settings, there was a maximum agreement of two responses, with two questions having no agreement in responses at all. Responses across all discussion-areas were mostly categorized within the Societal level, with Individual, Relationship, and Environment featuring less frequently. CONCLUSION: This study highlights the need for contextually curated interventions to address the concerns of older adults and their caregivers in rural and urban settings. An inclusive and multidimensional approach is needed to conquer the barriers that impede healthy aging, with input from various stakeholders.

Identification of the needs and priorities of older people and stakeholders in rural and urban areas of Santo Andre, Brazil.

BACKGROUND: There are few data reporting the needs and priorities of older adults in Brazil. This hampers the development and/or implementation of policies aimed at older adults to help them age well. The aim of this study was to understand areas of importance, priorities, enablers and obstacles to healthy ageing as identified by older adults and key stakeholders in both urban and rural environments. METHODS: Two locations were selected, one urban and one rural in the municipality of Santo André, in the metropolitan region of São Paulo (SP). Workshops for older adults (>60 y) and stakeholders were conducted separately in each location. The workshops incorporated an iterative process of discussion, prioritisation and ranking of responses, in roundtable groups and in plenary. Areas of commonality and differences between older adult and stakeholder responses were identified by comparing responses between groups as well as mapping obstacles and enablers to healthy ageing identified by older adults, to the priorities identified by stakeholder groups. The socio-ecologic model was used to categorise responses. RESULTS: There were few shared responses between stakeholders and older adults and little overlap between the top ranked responses of urban and rural groups. With respect to areas of importance, both stakeholder groups ranked policies for older people within their top five reponses. Both older adult groups ranked keeping physically and mentally active, and nurturing spirituality. There was a marked lack of congruence between older adults' obstacles and enablers to healthy ageing and stakeholder priorities, in both urban and rural settings. Most responses were located within the Society domain of the socio-ecologic model, although older adults also responded within the Individual/ Relationships domains, particularly in ranking areas of most importance for healthy ageing. CONCLUSIONS: Our results highlight substantial differences between older adults and stakeholders with respect to areas of importance, priorities, enablers and obstacles to healthy ageing, and point to the need for more engagement between those in advocacy and policymaking roles and the older people whose needs they serve.

Commonalities and differences in injured patient experiences of accessing and receiving quality injury care: a qualitative study in three sub-Saharan African countries.

OBJECTIVES: To understand commonalities and differences in injured patient experiences of accessing and receiving quality injury care across three lower-income and middle-income countries. DESIGN: A qualitative interview study. The interviews were audiorecorded, transcribed and thematically analysed. SETTING: Urban and rural settings in Ghana, South Africa and Rwanda. PARTICIPANTS: 59 patients with musculoskeletal injuries. RESULTS: We found five common barriers and six common facilitators to injured patient experiences of accessing and receiving high-quality injury care. The barriers encompassed issues such as service and treatment availability, transportation challenges, apathetic care, individual financial scarcity and inadequate health insurance coverage, alongside low health literacy and information provision. Facilitators included effective information giving and informed consent practices, access to health insurance, improved health literacy, empathetic and responsive care, comprehensive multidisciplinary management and discharge planning, as well as both informal and formal transportation options including ambulance services. These barriers and facilitators were prevalent and shared across at least two countries but demonstrated intercountry and intracountry (between urbanity and rurality) variation in thematic frequency. CONCLUSION: There are universal factors influencing patient experiences of accessing and receiving care, independent of the context or healthcare system. It is important to recognise and understand these barriers and facilitators to inform policy decisions and develop transferable interventions aimed at enhancing the quality of injury care in sub-Saharan African nations.

Serum Concentrations of Selected Poly- and Perfluoroalkyl Substances (PFASs) in Pregnant Women and Associations with Birth Outcomes. A Cross-Sectional Study from Southern Malawi.

Pervasive exposure to per-and polyfluoroalkyl substances (PFASs) shows associations with adverse pregnancy outcomes. The aim of the present study was to examine the determinants of different serum PFAS concentrations in late pregnancy and their relationship with birth outcomes in southern Malawi. The sample included 605 pregnant women with a mean age of 24.8 years and their offspring from three districts in the southern region of Malawi. Six PFAS were measured in serum from third-trimester women. The serum PFAS concentrations were assessed with head circumference, birth length, birth weight, gestational age and ponderal index. Participants living in urban areas had significantly higher serum levels of PFOA, PFNA and SumPFOS, while SumPFHxS concentrations were higher in women from rural settings. High PFOA, PFNA and SumPFHxS concentrations were generally inversely associated with head circumference. Birth length was negatively associated with PFOA and PFNA while SumPFHxS was negatively associated with birth weight. SumPFOS was inversely associated with gestational age. Urban area of residence was the strongest predictor for high PFAS concentrations in the maternal serum and was generally associated with adverse birth outcomes. The results highlight the need to investigate SumPFHxS further as it follows a pattern that is different to similar compounds and cohorts.

Accuracy of upper respiratory tract samples to diagnose Mycobacterium tuberculosis: a systematic review and meta-analysis.

BACKGROUND: Pulmonary tuberculosis due to Mycobacterium tuberculosis can be challenging to diagnose when sputum samples cannot be obtained, which is especially problematic in children and older people. We systematically appraised the performance characteristics and diagnostic accuracy of upper respiratory tract sampling for diagnosing active pulmonary tuberculosis. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Cinahl, Web of Science, Global Health, and Global Health Archive databases for studies published between database inception and Dec 6, 2022 that reported on the accuracy of upper respiratory tract sampling for tuberculosis diagnosis compared with microbiological testing of sputum or gastric aspirate reference standard. We included studies that evaluated the accuracy of upper respiratory tract sampling (laryngeal swabs, nasopharyngeal aspirate, oral swabs, saliva, mouth wash, nasal swabs, plaque samples, and nasopharyngeal swabs) to be tested for microbiological diagnosis of tuberculous (by culture and nucleic acid amplification tests) compared with a reference standard using either sputum or gastric lavage for a microbiological test. We included cohort, case-control, cross-sectional, and randomised controlled studies that recruited participants from any community or clinical setting. We excluded post-mortem studies. We used a random-effects meta-analysis with a bivariate hierarchical model to estimate pooled sensitivity, specificity, and diagnostics odds ratio (DOR; odds of a positive test with disease relative to without), stratified by sampling method. We assessed bias using QUADAS-2 criteria. This study is registered with PROSPERO (CRD42021262392). FINDINGS: We screened 10 159 titles for inclusion, reviewed 274 full texts, and included 71, comprising 119 test comparisons published between May 13, 1933, and Dec 19, 2022, in the systematic review (53 in the meta-analysis). For laryngeal swabs, pooled sensitivity was 57·8% (95% CI 50·5-65·0), specificity was 93·8% (88·4-96·8), and DOR was 20·7 (11·1-38·8). Nasopharyngeal aspirate sensitivity was 65·2% (52·0-76·4), specificity was 97·9% (96·0-99·0), and DOR was 91·0 (37·8-218·8). Oral swabs sensitivity was 56·7% (44·3-68·2), specificity was 91·3% (CI 81·0-96·3), and DOR was 13·8 (5·6-34·0). Substantial heterogeneity in diagnostic accuracy was found, probably due to differences in reference and index standards. INTERPRETATION: Upper respiratory tract sampling holds promise to expand access to tuberculosis diagnosis. Exploring historical methods using modern microbiological techniques might further increase options for alternative sample types. Prospective studies are needed to optimise accuracy and utility of sampling methods in clinical practice. FUNDING: UK Medical Research Council, Wellcome, and UK Foreign, Commonwealth and Development Office.

Barriers to equitable access to quality trauma care in Rwanda: a qualitative study.

OBJECTIVES: Using the 'Four Delay' framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients', caregivers' and community leaders' perspectives. DESIGN: A qualitative study assessing barriers to trauma care comprising 20 in-depth semistructured interviews and 4 focus group discussions was conducted. The data were analysed thematically. SETTING: This qualitative study was conducted in Rwanda's rural Burera District, located in the Northern Province, and in Kigali City, the country's urban capital, to capture both the rural and urban population's experiences of being injured. PARTICIPANTS: Purposively selected participants were individuals from urban and rural communities who had accessed injury care in the previous 6 months or cared for the injured people, and community leaders. Fifty-one participants, 13 females and 38 males ranging from 21 to 68 years of age participated in interviews and focus group discussions. Thirty-six (71%) were former trauma patients with a wide range of injuries including fractured long bones (9, 45%), other fractures, head injury, polytrauma (3, 15% each), abdominal trauma (1, 5%), and lacerations (1, 5%), while the rest were caregivers and community leaders. RESULTS: Multiple barriers were identified cutting across all levels of the 'Four Delays' framework, including barriers to seeking, reaching, receiving and remaining in care. Key barriers mentioned by participants in both interviews and focus group discussions were: lack of community health insurance, limited access to ambulances, insufficient number of trauma care specialists and a high volume of trauma patients. The rigid referral process and lack of decentralised rehabilitation services were also identified as significant barriers to accessing quality care for injured patients. CONCLUSIONS: Future interventions to improve access to injury care in Rwanda must be informed by the identified barriers along the spectrum of care, from the point of injury to receipt of care and rehabilitation.

Governance for injury care systems in Ghana, South Africa and Rwanda: development and pilot testing of an assessment tool.

OBJECTIVES: This study aims to evaluate health systems governance for injury care in three sub-Saharan countries from policymakers' and injury care providers' perspectives. SETTING: Ghana, Rwanda and South Africa. DESIGN: Based on Siddiqi et al's framework for governance, we developed an online assessment tool for health system governance for injury with 37 questions covering health policy and implementation under 10 overarching principles of strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness of institutions, equity, effectiveness or efficiency, accountability, ethics and intelligence and information. A literature review was also done to support the scoring. We derived scores using two methods-investigator scores and respondent scores. PARTICIPANTS: The tool was sent out to purposively selected stakeholders, including policymakers and injury care providers in Ghana, Rwanda and South Africa. Data were collected between October 2020 and February 2021. PRIMARY AND SECONDARY OUTCOMES: Investigator-weighted and respondent percentage scores for health system governance for injury care. This was calculated for each country in total and per principle. RESULTS: Rwanda had the highest overall investigator-weighted percentage score (70%), followed by South Africa (59%). Ghana had the lowest overall investigator score (48%). The overall results were similar for the respondent scores. Some areas, such as participation and consensus, scored high in all three countries, while other areas, such as transparency, scored very low. CONCLUSION: In this multicountry governance survey, we provide insight into and evaluation of health system governance for trauma in three low- and middle-income countries (LMICs) in sub-Saharan Africa. It highlights areas of improvement that need to be prioritised, such as transparency, to meet the high burden of trauma and injuries in LMICs.

Predictors of Maternal Serum Concentrations for Selected Persistent Organic Pollutants (POPs) in Pregnant Women and Associations with Birth Outcomes: A Cross-Sectional Study from Southern Malawi.

Population exposure to persistent organic pollutants (POPs) may result in detrimental health effects, especially to pregnant women, developing foetuses and young children. We are reporting the findings of a cross-sectional study of 605 mothers in their late pregnancy, recruited between August 2020 and July 2021 in southern Malawi, and their offspring. The aim was to measure the concentrations of selected POPs in their maternal serum and indicate associations with social demographic characteristics and birth outcomes. A high level of education was the main predictor of p,p'-DDE (p = 0.008), p,p'-DDT (p < 0.001), cis-NC (p = 0.014), o,p'-DDT (p = 0.019) and o,p'-DDE (p = 0.019) concentrations in maternal serum. Multiparity was negatively associated with o,p'-DDE (p = 0.021) concentrations. Maternal age was also positively associated (p,p'-DDE (p = 0.013), o,p'-DDT (p = 0.017) and o,p'-DDE (p = 0.045) concentrations. Living in rural areas was inversely associated with high maternal serum concentrations of p,p'-DDT (p < 0.001). Gestational age was positively associated with p,p'-DDE (p = 0.031), p,p'-DDT (p = 0.010) and o,p'-DDT (p = 0.022) concentrations. Lastly, an inverse association was observed between head circumference and t-NC (p = 0.044), Oxychlordane (p = 0.01) and cis-NC (p = 0.048). These results highlight the need to continue monitoring levels of POPs among vulnerable populations in the southern hemisphere.