The impact of accredited social health activists in India on uptake of modern contraception: A nationally representative multilevel modelling study.

The government of India introduced the Accredited Social Health Activist (ASHA) programme in 2006 to connect marginalised communities to the health system. ASHAs are mandated to increase the uptake of modern contraception through the doorstep provision of services. There is currently no evidence on the impact of ASHAs on the uptake of contraception at the national level. This paper examines the impact of ASHAs on the uptake of modern contraception using nationally representative National and Family Health Survey data collected in 2019-21 in India. A multilevel logistic regression analysis was performed to determine the effect of contact with ASHAs on the uptake of modern contraception, controlling for regional variability and socio-demographic variables. The data provide strong evidence that ASHAs have succeeded in increasing modern contraceptive use. Women exposed to ASHAs had twice the odds of being current users of modern contraception compared to those with no contact, even after controlling for household and individual characteristics. However, only 28.1% of women nationally reported recent contact with ASHA workers. The ASHA programme should remain central to the strategy of the government of India and should be strengthened to achieve universal access to modern contraception and meet sustainable development goals by 2030.

Heterogeneity in the prevalence of subclinical malaria, other co-infections and anemia among pregnant women in rural areas of Myanmar: a community-based longitudinal study.

BACKGROUND: Due to the low prevalence of clinically suspected malaria among pregnant women in Myanmar, little is known about its impact on mothers and newborns. Helminth and Human Immuno-deficiency Virus (HIV) co-infections cause anemia in pregnant women. This study assessed the prevalence of subclinical malaria and co-infections among pregnant women, and its association with adverse outcomes of pregnancy in the presence of infection. METHODS: A prospective longitudinal study was conducted in 12 villages in two townships in Myanmar between 2013 to 2015. A total of 752 pregnant women, with a mean age of 27 years, were enrolled and followed up once a month until six weeks after childbirth. Prevalence ratio was calculated in the multivariable analysis. RESULTS: The prevalence of subclinical malaria as measured by nested PCR was 5.7% for either P. falciparum or P. vivax, 2.7% prevalence of P. falciparum and 2.8% prevalence of P. vivax. Helminth infections were prevalent in 17% of women, and one woman with an HIV infection was found in our study. The burden of anemia was high, with an overall prevalence of 37% with or without helminth infection, 42% of the women were malaria positive and 43% had dual infections (both malaria and helminth). Only 11 abnormal pregnancy outcomes (7 stillbirths, 2 premature, 2 twins) were identified. Poisson regression showed that women in their first trimester had a 2.9 times higher rate of subclinical malaria compared to women in the third trimester (PR:2.9, 95%CI 1.19, 7.31, p = 0.019), women who were enrolled during the wet season were 2.5 times more likely to be malaria positive than the women enrolled in the dry season (PR: 2.5, 95%CI 1.27, 4.88, p = 0.008), and the malaria positivity rate decreased by 5% when increased in one year of woman's age (PR:0.95, 95%CI 0.91, 0.99, p = 0.02). In the multivariable regression, the age of respondents was the only significant factor associated with subclinical malaria in pregnancy. CONCLUSIONS: A comprehensive approach of integrating interventions for malaria, anemia, and helminths should be delivered during antenatal care services for pregnant women in rural areas of Myanmar.

Effect of contacts with health professionals on modern contraceptives uptake during the first 6 weeks after child birth: a prospective cohort study in Arsi Zone.

BACKGROUND: Healthy timing and spacing of pregnancy refers to the spacing between deliveries and subsequent pregnancies. The World Health Organization recommends waiting at least 24 months between the date of the live birth and the conception of the subsequent pregnancy in order to lower the risk of unfavorable maternal, perinatal, and newborn outcomes. Low use of contraception contributes to the high level of short inter-pregnancy intervals. Different studies conclusively demonstrate that this is a reality existing in Ethiopia right now. Limited data is available regarding the effects of contacts with health professionals on the use of contraception during the postnatal period. METHODS: A prospective cohort study was performed from October 01, 2020 to March 01, 2021. The study included 418 postnatal women who gave birth during the previous week. They were followed throughout the full postnatal period. A pre-tested structured questionnaire was used to gather the data. Data were gathered twice: once during the first week following birth and once again from the eighth to the 42nd day after birth. Epi-Info version 7 was used to enter data, which was subsequently exported to SPSS version 21 for analysis. The effect of contacts with health professionals where contraceptives were discussed on contraception uptake was measured using adjusted relative risk and its 95% confidence interval. RESULTS: Modern contraceptive uptake rate during the postnatal period was 16% (95% CI: 12.50-19.50%). Contraceptive use was 3.56 times more likely in women who were counseled about contraceptives during a contacts with health professionals at a health facility compared to those who did not have a contact (aRR = 3.56, 95% CI: 1.97-6.32). Women's age, place of residence, knowledge of whether they can become pregnant before menses return, menses return after birth, and resuming sexual activity after birth were all significantly associated with contraceptive use during the first six weeks following child birth. CONCLUSIONS: Modern contraceptive uptake rate during the postnatal period among women in the study area was low. Contacts with health professionals where contraception is discussed was the main factor associated with contraception uptake during the postnatal period. We recommend that the Arsi Zone Health Office, the Weardas Health Office in the Arsi Zone, and the health care providers in the Arsi Zone health facilities strengthen contraceptive counseling in postnatal health services to reduce the proportion of women with short inter-pregnancy intervals.

Effectiveness of a complex, pre-conception intervention to reduce the risk of diabetes by reducing adiposity in young adults in Malaysia: The Jom Mama project - A randomised controlled trial.

Background: Pre-conception interventions have the potential to lower non-communicable disease risk in prospective parents and reduce transmission of risk factors such as obesity to the next generation. The Jom Mama project in Malaysia investigated the effectiveness of a combined behaviour change communication and e-health intervention in young married couples prior to first pregnancy. This paper reports the evaluation of the effectiveness of this trial. Methods: Jom Mama was a non-blinded, randomised controlled trial (RCT) conducted in Seremban, Malaysia, over a period of 33 weeks, covering six contact points between trained community health workers and newly married couples before the conception of a first child. Out of 2075 eligible nulliparous women, 549 participated and 305 completed the intervention, with 145 women in the intervention and 160 in the control group. The intervention group received a complex behavioural change intervention, combining behaviour change communication provided by community health promoters and access to a habit formation mobile application, while the control group received the standard care provided by public health clinics in Malaysia. The primary outcome was a change in the woman's waist circumference. Secondary outcomes were anthropometric and metabolic measures, dietary intake (Food Frequency Questionnaire, FFQ), physical activity (International Physical Activity Questionnaire, IPAQ) and mental health (Depression Anxiety Stress Scale, DASS 21). An extensive process evaluation was conducted alongside the trial in order to aid the interpretation of the main findings. Results: There were no significant differences of change in the woman's waist circumference between intervention and control groups at the start and end of the intervention. While the weight, waist circumference and Body Mass Index (BMI) of women in both groups increased, there was a significantly lower increase in the intervention vs the control group over the period of the trial among women who are obese (0.1 kg vs 1.7 kg; P = 0.023, in the intervention and control group respectively). In terms of BMI, the obese intervention subgroup showed a slight reduction (0.01) compared to the obese control subgroup whose BMI increased by 0.7 (P = 0.015). There were no changes in the other secondary outcomes. Conclusions: The Jom Mama pre-conception intervention did not lead to a reduction in waist circumference or significant changes in other secondary outcomes over the eight months prior to conception. However, there was a significantly smaller weight gain in the intervention vs the control group, predominantly in women with pre-existing obesity.

How applicable is geospatial analysis in maternal and neonatal health in sub-Saharan Africa? A systematic review.

Background: Sub-Saharan Africa (SSA) has the world's highest maternal and neonatal morbidity and mortality and has shown the slowest progress in reducing them. In addition, there is substantial inequality in terms of maternal and neonatal morbidity and mortality in the region. Geospatial studies can help prioritize scarce resources by pinpointing priority areas for implementation. This systematic review was conducted to explore the application of geospatial analysis to maternal and neonatal morbidity and mortality in SSA. Methods: A systematic search of PubMed, SCOPUS, EMBASE, and Web of Science databases was performed. All observational and qualitative studies that reported on maternal or neonatal health outcomes were included if they used a spatial analysis technique and were conducted in a SSA country. After removing duplicates, two reviewers independently reviewed each study's abstract and full text for inclusion. Furthermore, the quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Finally, due to the heterogeneity of studies, narrative synthesis was used to summarize the main findings, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed to report the review results. A total of 56 studies were included in the review. Results: We found that geospatial analysis was used to identify inequalities in maternal and neonatal morbidity, mortality, and health care utilization and to identify gaps in the availability and geographic accessibility of maternal health facilities. In addition, we identified a few studies that used geospatial analysis for modelling intervention areas. We also detected challenges and shortcomings, such as unrealistic assumptions used by geospatial models and a shortage of reliable, up-to-date, small-scale georeferenced data. Conclusions: The use of geospatial analysis for maternal and neonatal health in SSA is still limited, and more detailed spatial data are required to exploit the potential of geospatial technologies fully.

Investigating feasibility of 2021 WHO protocol for cervical cancer screening in underscreened populations: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC).

BACKGROUND: High-risk human papillomavirus (hrHPV) testing has been recommended by the World Health Organization as the primary screening test in cervical screening programs. The option of self-sampling for this screening method can potentially increase women's participation. Designing screening programs to implement this method among underscreened populations will require contextualized evidence. METHODS: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC) will use a multi-method approach to investigate the feasibility of implementing a cervical cancer screening strategy with hrHPV self-testing as the primary screening test in Bangladesh, India, Slovak Republic and Uganda. The primary outcomes of study include uptake and coverage of the screening program and adherence to follow-up. These outcomes will be evaluated through a pre-post quasi-experimental study design. Secondary objectives of the study include the analysis of client-related factors and health system factors related to cervical cancer screening, a validation study of an artificial intelligence decision support system and an economic evaluation of the screening strategy. DISCUSSION: PRESCRIP-TEC aims to provide evidence regarding hrHPV self-testing and the World Health Organization's recommendations for cervical cancer screening in a variety of settings, targeting vulnerable groups. The main quantitative findings of the project related to the impact on uptake and coverage of screening will be complemented by qualitative analyses of various determinants of successful implementation of screening. The study will also provide decision-makers with insights into economic aspects of implementing hrHPV self-testing, as well as evaluate the feasibility of using artificial intelligence for task-shifting in visual inspection with acetic acid. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05234112 . Registered 10 February 2022.

Prevalence of early childhood obesity in Ireland: Differences over time, between sexes and across child growth criteria.

BACKGROUND: Various child growth criteria exist for monitoring overweight and obesity prevalence in young children. OBJECTIVES: To estimate early overweight and obesity prevalence in Ireland and compare the differences in prevalence across ages, growth criteria and sexes. METHODS: Longitudinal body mass index data from the nationally representative Growing Up in Ireland infant cohort (n = 11 134) were categorized ('under-/normal weight', 'risk of overweight', 'overweight', 'obesity') using the sex- and age-specific International Obesity Task Force growth reference, World Health Organization growth standard and World Health Organization growth reference criteria. Differences in prevalences between criteria and sexes, and changes in each weight category and criterion across ages (9 months, 3 years, 5 years), were investigated. RESULTS: Across criteria, 11%-40% of children had overweight or obesity at 9 months, 14%-46% at 3 years and 8%-32% at 5 years of age. Prevalence estimates were highest using the World Health Organization growth reference, followed by International Obesity Task Force estimates. Within each criterion, prevalence decreased significantly over time (p < 0.05). However, when combining both World Health Organization criteria, as recommended for population studies, prevalence increased, due to differences in definitions between them. Significantly more boys than girls had overweight/obesity using either World Health Organization criterion, which was reversed using the International Obesity Task Force growth reference. CONCLUSIONS: To increase transparency and comparability, studies of childhood obesity need to consider differences in prevalence estimates across growth criteria. Effective prevention, intervention and policy-making are needed to control Ireland's high overweight and obesity prevalence.

Assessing quality of family planning counseling and its determinants in Kenya: Analysis of health facility exit interviews.

BACKGROUND: Available evidence suggests that provision of quality of care in family planning services is crucial to increasing uptake and continuation of use of contraception. Kenya achieved a modern contraceptive prevalence rate of 60% in 2018, surpassing its 2020 target of 58%. With the high prevalence, focus is geared towards improved quality of family planning services. The objective of this study is to examine the quality of family planning counseling and its associated factors in health facilities in Kenya. METHODS: We conducted a secondary analysis of the 2019 Kenya Performance Monitoring and Action, client exit data of women who had received family planning services. Quality of counseling was assessed using the Method Information Index Plus. We conducted a multivariable ordinal logistic regression analysis of data from 3,731 women to establish determinants of receiving quality family planning services. RESULTS: The Method Information Index Plus score for higher-quality counseling was 56.7%, lower-quality counseling 32.4%, and no counseling 10.9%. Women aged 15-24 years (aOR = 0.69, 95% CI = 0.56-0.86, p = 0.001) had lower odds of receiving better counseling compared to women aged 35 years and above. Those with no education (aOR = 0.52, 95% CI = 0.33-0.82, p = 0.005), primary (aOR = 0.56, 95% CI = 0.44-0.71, p<0.001) and secondary (aOR = 0.79, 95% CI = 0.65-0.98, p = 0.028) were less likely to receive better counseling compared to those with tertiary education. Women who received long acting and reversible contraception methods (aOR = 1.75, 95% CI = 1.42-2.17, p<0.001), and those who were method switchers (aOR = 1.24, 95% CI = 1.03-1.50, p = 0.027), had a higher likelihood of receiving better quality of counseling as compared to those on short-term methods and those who were continuers, respectively. CONCLUSION: The quality of family planning counseling in Kenya is still sub-optimal considering that some women receive no form of counseling at service delivery point. There is need to review the existing FP guidelines and training packages to increase focus on the quality of counseling services offered by health providers. Social accountability strategies that empower women to demand quality services should be included in community-level family planning interventions.

Stakeholder Perspectives on Barriers and Facilitators on the Implementation of the 1000 Days Plus Nutrition Policy Activities in Ghana.

Optimizing nutrition in the preconception and 1000 days periods have long-term benefits such as higher economic productivity, reduced risk of related non-communicable diseases and increased health and well-being. Despite Ghana's recent progress in reducing malnutrition, the situation is far from optimal. This qualitative study analyzed the maternal and child health nutrition policy framework in Ghana to identify the current barriers and facilitators to the implementation of nutrition policies and programs relating to the first 1000 days plus. Data analyzed included in-depth interviews and focus group discussions conducted in Ghana between March and April 2019. Participants were composed of experts from government agencies, civil society organizations, community-based organizations and international partners at national and subnational levels. Seven critical areas were identified: planning policy implementation, resources, leadership and stakeholders' engagement, implementation guidance and ongoing communication, organizational culture, accountability and governance and coverage. The study showed that, to eradicate malnutrition in Ghana, priorities of individual stakeholders have to be merged and aligned into a single 1000 days plus nutrition policy framework. Furthermore, this study may support stakeholders in implementing successfully the 1000 days plus nutrition policy activities in Ghana.

Eating behaviour, physical activity, TV exposure and sleeping habits in five year olds: a latent class analysis.

BACKGROUND: Diet, physical activity, sedentary behaviours, and sleep time are considered major contributory factors of the increased prevalence of childhood overweight and obesity. The aims of this study were to (1) identify behavioural clusters of 5 year old children based on lifestyle behaviours, (2) explore potential determinants of class membership, and (3) to determine if class membership was associated with body measure outcomes at 5 years of age. METHODS: Data on eating behaviour, engagement in active play, TV watching, and sleep duration in 1229 5 year old children from the Cork BASELINE birth cohort study was obtained through in-person interviews with parent. Latent class analysis was used to identify behavioural clusters. Potential determinants of cluster membership were investigated using multinomial logistic regression. Associations between the identified classes and cardio metabolic body measures were examined using multivariate logistic and linear regression, with cluster membership used as the independent variable. RESULTS: 51% of children belonged to a normative class, while 28% of children were in a class characterised by high scores on food avoidance scales in combination with low enjoyment of food, and 20% experienced high scores on the food approach scales. Children in both these classes had lower conditional probabilities of engaging in active play for at least 1 hour per day and sleeping for a minimum of 10 h, and higher probability of watching TV for 2 hours or more, compared to the normative class. Low socioeconomic index (SEI) and no breastfeeding at 2 months were found to be associated with membership of the class associated with high scores on the food avoidance scale, while lower maternal education was associated with the class defined by high food approach scores. Children in the class with high scores on the food approach scales had higher fat mass index (FMI), lean mass index (LMI), and waist-to-height ratio (WtHR) compared to the normative class, and were at greater risk of overweight and obesity. CONCLUSION: Findings suggest that eating behaviour appeared to influence overweight and obesity risk to a greater degree than activity levels at 5 years old. Further research of how potentially obesogenic behaviours in early life track over time and influence adiposity and other cardio metabolic outcomes is crucial to inform the timing of interventions.

Body Mass Index Trajectories in the First 5 Years and Associated Antenatal Factors.

Background: The increasing prevalence of childhood obesity is an important public health issue and the development of obesity in early life and associated risk factors need to be better understood. The aim of this study was to identify distinct body mass index trajectories in the first 5 years of life and to examine their associations with factors identified in pregnancy, including metabolic parameters. Methods: BMI measurements from 2,172 children in Ireland enrolled in the BASELINE cohort study with BMI assessments at birth, 2, 6, and 12 months, and 2 and 5 years were analyzed. Growth mixture modeling was used to identify distinct BMI trajectories, and multivariate multinomial logistic regression was used to assess the association between these trajectories and antenatal factors. Results: Three distinct BMI trajectories were identified: normal (89.6%); rapid gain in the first 6 months (7.8%); and rapid BMI after 12 months (2.6%). Male sex and higher maternal age increased the likelihood of belonging to the rapid gain in the first 6 months trajectory. Raised maternal BMI at 15 weeks of pregnancy and lower cord blood IGF-2 were associated with rapid gain after 1 year. Conclusion: Sex, maternal age and BMI, and IGF-2 levels were found to be associated with BMI trajectories in early childhood departing from normal growth. Further research and extended follow-up to examine the effects of childhood growth patterns are required to understand their relationship with health outcomes.

A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya.

BACKGROUND: Addressing the unmet need for modern contraception underpins the goal of all family planning and contraception programs. Contraceptive discontinuation among those in need of a method hinders the attainment of the fertility desires of women, which may result in unintended pregnancies. This paper presents experiences of contraceptive use, reasons for discontinuation, and future intentions to use modern contraceptives. METHODS: Qualitative data were collected in two rural counties in Kenya in 2019 from women with unmet need for contraception who were former modern contraceptive users. Additional data was collected from male partners of some of the women interviewed. In-depth interviews and focus group discussions explored previous experience with contraceptive use, reasons for discontinuation, and future intentionality to use. Following data collection, digitally recorded data were transcribed verbatim, translated, and coded using thematic analysis through an inductive approach. RESULTS: Use of modern contraception to prevent pregnancy and plan for family size was a strong motivator for uptake of contraceptives. The contraceptive methods used were mainly sourced from public health facilities though adolescents got them from the private sector. Reasons for discontinued use included side effects, method failure, peer influence, gender-based violence due to covert use of contraceptives, and failure within the health system. Five reasons were provided for those not willing to use in the future: fear of side effects, cost of contraceptive services, family conflicts over the use of modern contraceptives, reduced need, and a shift to traditional methods. CONCLUSION: This study expands the literature by examining reasons for contraceptive discontinuation and future intentionality to use among women in need of contraception. The results underscore the need for family planning interventions that incorporate quality of care in service provision to address contraceptive discontinuation. Engaging men and other social influencers in family planning programs and services will help garner support for contraception, rather than focusing exclusively on women. The results of this study can inform implementation of family planning programs in Kenya and beyond to ensure they address the concerns of former modern contraception users.

Barriers and facilitators to accessing insulin pump therapy by adults with type 1 diabetes mellitus: a qualitative study.

AIMS: Uptake of continuous subcutaneous insulin infusion (CSII) by people with diabetes (PwD) in Ireland is low and exhibits regional variation. This study explores barriers and facilitators to accessing CSII by adults with Type 1 diabetes mellitus. RESEARCH DESIGN AND METHODS: A qualitative study employing focus groups with adults with Type 1 diabetes mellitus (n = 26) and semi-structured interviews with health care professionals (HCP) and other key stakeholders (n = 21) was conducted. Reflexive thematic analysis was used to analyze data, using NVivo. RESULTS: Four main themes comprising barriers to or facilitators of CSII uptake were identified. These included: (1) awareness of CSII and its benefits, (2) the structure of diabetes services, (3) the capacity of the diabetes service to deliver the CSII service, and (4) the impact of individuals' attitudes and personal characteristics-both PwD, and HCP. Each of these themes was associated with a number of categories, of which 18 were identified and explored. If the structure of the health-service is insufficient and capacity is poor (e.g., under-resourced clinics), CSII uptake appears to be impacted by individuals': interest, attitude, willingness and motivation, which may intensify the regional inequality in accessing CSII. CONCLUSIONS: This study identified factors that contribute to gaps in the delivery of diabetes care that policy-makers may use to improve access to CSII for adult PwD.

Effectiveness of a quality improvement intervention to increase adherence to key practices during female sterilization services in Chhattisgarh and Odisha states of India.

BACKGROUND: In response to longstanding concerns around the quality of female sterilization services provided at public health facilities in India, the Government of India issued standards and quality assurance guidelines for female sterilization services in 2014. However, implementation remains a challenge. The Maternal and Child Survival Program rolled out a package of competency-based trainings, periodic mentoring, and easy-to-use job aids in parts of five states to increase service providers' adherence to key practices identified in the guidelines. METHODS: The study employed a before-and-after quasi-experimental design with a matched comparison arm to examine the effect of the intervention on provider practices in two states: Odisha and Chhattisgarh. Direct observations of female sterilization services were conducted in selected public health facilities, using a checklist of 30 key practices, at two points in time. Changes in adherence to key practices from baseline to endline were compared at 12 intervention and 12 comparison facilities using a difference in difference analysis. RESULTS: Several key practices were well-established prior to the intervention, with adherence levels over 90% at baseline, including hemoglobin and urine testing, use of sterile surgical gloves and instruments, and recommended surgical technique. However, adherence to many other practices was extremely low at baseline. The program significantly increased adherence to nine practices, including those related to ascertaining client's medical eligibility, client-provider interaction, the consent process, and post-operative care. The greatest improvement was observed in the provision of written instructions for clients prior to discharge. At endline, however, adherence remained below 50% for 14 practices. CONCLUSION: Low adherence to key practices at baseline confirmed the need for quality improvement interventions in female sterilization services. While the intervention improved adherence to certain practices around admission and post-operative care, inadequate human resources and infrastructure, among other factors, may have blunted the impact of the intervention.

Mental Health and Quality of Life of Women One Year after Maternal Near-Miss in Low and Middle-Income Countries: The Case of Zanzibar, Tanzania.

Women who experienced a maternal near-miss are at risk of mental health complications and lower quality of life, but long-term consequences are largely unknown. The aim of this study is to assess whether mental health symptoms and quality of life change over time and to examine associations with risk factors among post-partum women. In this cohort study, women with maternal near-miss were matched to women without or with mild complications at Mnazi Mmoja Hospital in Zanzibar. Depressive and post-traumatic stress disorder symptoms, and quality of life were measured at three, six, and twelve-months follow-up. A linear mixed-effects model was used for data analysis. Postpartum women in Zanzibar reported low levels of depressive and post-traumatic stress disorder symptoms. While depressive symptoms and quality of life trajectories were similar among women with and without maternal near-miss, differences for trajectories of post-traumatic stress disorder symptoms and physical quality of life were found. Social support, perinatal loss, and intercurrent illness were strongly associated with both depressive symptoms and quality of life in this group of Islamic women. These findings suggest that social support, embedded in the cultural context, should be considered in helping women cope with mental health issues in the aftermath of severe maternal complications.

Low uptake of continuous subcutaneous insulin infusion therapy in people with type 1 diabetes in Ireland: a retrospective cross-sectional study.

BACKGROUND: The uptake of continuous subcutaneous insulin infusion (CSII) therapy in those with type 1 diabetes varies internationally and is mainly determined by the national healthcare reimbursement systems. The aim of this study is to estimate national and regional uptake of CSII therapy in children, adolescents and adults with type 1 diabetes in Ireland. METHODS: A retrospective cross-sectional study was conducted utilizing the national pharmacy claims database in 2016. Individuals using CSII were identified by dispensing of infusion sets. The uptake of CSII was calculated as the percentage of people with type 1 diabetes claiming CSII sets in 2016, both in children and adolescent (age < 18 years) and adult populations (≥ 18 years). Descriptive statistics including percentages with 95% confidence intervals (CIs) are presented, stratified by age-groups and geographical regions, and chi-square tests used for comparisons. RESULTS: Of 20,081 people with type 1 diabetes, 2111 (10.5, 95% CI: 10.1-10.9%) were using CSII in 2016. Uptake was five-fold higher in children and adolescents at 34.7% (95% CI: 32.9-36.5%) than in adults at 6.8% (95% CI: 6.4-7.2%). Significant geographical heterogeneity in CSII uptake was found, from 12.6 to 53.7% in children and adolescents (p < 0.001), and 2 to 9.6% in adults (p < 0.001). CONCLUSIONS: Uptake of CSII in people with type 1 diabetes is low in Ireland, particularly in those ≥18 years. Identification of barriers to uptake, particularly in this group, is required.

Prevalence and incidence of type 1 diabetes in Ireland: a retrospective cross-sectional study using a national pharmacy claims data from 2016.

OBJECTIVES: The aim of this study is to estimate the prevalence and incidence of type 1 diabetes in the Irish population using a national pharmacy claims database in the absence of a national diabetes register. DESIGN: National, population-based, retrospective, cross-sectional study. SETTING: Community care with data available through the Health Service Executive Pharmacy Claims Reimbursement Scheme from 2011 to 2016. PARTICIPANTS: Individuals with type 1 diabetes were identified by coprescription of insulin and glucometer test strips without any prolonged course (>12 months) of oral hypoglycaemic agents prior to commencing insulin. Those claiming prescriptions for long-acting insulin only, without any prandial insulin, were excluded from the analysis. Incidence was estimated based on the first claim for insulin in 2016, with no insulin use in the preceding 12 months. MAIN OUTCOME MEASURES: Prevalence of type 1 diabetes in children (<18 years) and adults (≥18 years); incidence of type 1 diabetes in children (≤14 years) and adolescents and adults (>14 years). RESULTS: There were 20 081 prevalent cases of type 1 diabetes in 2016. The crude prevalence was 0.42% (95% CI 0.42% to 0.43%). Most prevalent cases (n=17 053, 85%) were in adults with a prevalence of 0.48% (95% CI 0.47% to 0.48%). There were 1527 new cases of type 1 diabetes in 2016, giving an incidence rate of 32 per 100 000 population/year (95% CI 30.5 to 33.7). There was a significant positive linear trend for age, for prevalence (p<0.0001) and incidence (p=0.014). The prevalence and incidence were 1.2-fold and 1.3-fold higher in men than women, respectively. Significant variations in prevalence (p<0.0001) and incidence (p<0.001) between the different geographical regions were observed. CONCLUSIONS: This study provides epidemiological estimates of type 1 diabetes across age groups in Ireland, with the majority of prevalent cases in adults. Establishing a national diabetes register is essential to enable updated epidemiological estimates of diabetes and for planning of services in Ireland.

Availability of and access to continuous subcutaneous insulin infusion therapy for adults with type 1 diabetes in Ireland.

AIMS: The uptake of continuous subcutaneous insulin infusion (CSII) is low in adults with type 1 diabetes mellitus (T1DM) in Ireland, compared to other countries where CSII is reimbursed. To explore the reasons for the low uptake, this study aims to investigate the availability of CSII in adult diabetes clinics in Ireland. METHODS: A national survey of all adult diabetes clinics (public and private) in Ireland was conducted and completed anonymously by the lead physician/diabetes nurse specialist in each clinic. Descriptive statistics and comparisons between clinics offering different levels of care for CSII are presented. RESULTS: Of 50 diabetes clinics invited, 47 (94%) participated in the study. Fifteen clinics (32%) offered no support for CSII, while 21 (45%) reported offering both training to commence CSII and ongoing support. Based on the survey findings, access to CSII was unavailable for 2426 (11%) of those with T1DM. The majority (n = 15,831, 71% of 22,321 T1DM population) received diabetes care from clinics offering CSII training, but only 2165 were using CSII (10% of T1DM population). Uptake of CSII was higher in clinics offering training than in those offering follow-up care for CSII only (12% vs. 5%, p < 0.001). Clinics offering all CSII services had more specialists (p = 0.005 for endocrinologists and p < 0.001 for dietitians). Reasons for not offering CSII services included staff shortages and heavy workload. CONCLUSIONS: This study highlights the low uptake of CSII in Ireland and demonstrates that, even when reimbursed, other barriers to uptake of CSII can limit its use.

Determinants of healthcare seeking for childhood illnesses among caregivers of under-five children in urban slums in Malawi: a population-based cross-sectional study.

BACKGROUND: There is considerable evidence that health systems, in so far as they ensure access to healthcare, promote population health even independent of other determinants. Access to child health services remains integral to improving child health outcomes. Cognisant that improvements in child health have been unevenly distributed, it is imperative that health services and research focus on the disadvantaged groups. Children residing in urban slums are known to face a health disadvantage that is masked by the common view of an urban health advantage. Granted increasing urbanisation rates and proliferation of urban slums resulting from urban poverty, the health of under-five children in slums remains a public health imperative in Malawi. We explored determinants of healthcare-seeking from a biomedical health provider for childhood symptoms of fever, cough with fast breathing and diarrhoea in three urban slums of Lilongwe, Malawi. METHODS: This was a population-based cross-sectional study involving 543 caregivers of under-five children. Data on childhood morbidity and healthcare seeking in three months period were collected using face-to-face interviews guided by a validated questionnaire. Data were entered in CS-Pro 5.0 and analysed in SPSS version 20 using descriptive statistics and logistic regression analyses. RESULTS: 61% of caregivers sought healthcare albeit 53% of them sought healthcare late. Public health facilities constituted the most frequently used health providers. Healthcare was more likely to be sought: for younger than older under-five children (AOR = 0.54; 95% CI: 0.30-0.99); when illness was perceived to be severe (AOR = 2.40; 95% CI: 1.34-4.30); when the presenting symptom was fever (AOR = 1.77; 95% CI: 1.10-2.86). Home management of childhood illness was negatively associated with care-seeking (AOR = 0.54; 95% CI: 0.36-0.81) and timely care-seeking (AOR = 0.44; 95% CI: 0.2-0.74). Caregivers with good knowledge of child danger signs were less likely to seek care timely (AOR = 0.57; 95% CI: 0.33-0.99). CONCLUSIONS: Even in the context of geographical proximity to healthcare services, caregivers in urban slums may not seek healthcare or when they do so the majority may not undertake timely healthcare care seeking. Factors related to the child, the type of illness, and the caregiver are central to the healthcare decision making dynamics. Improving access to under-five child health services therefore requires considering multiple factors.

Peer assessment to improve medical student's contributions to team-based projects: randomised controlled trial and qualitative follow-up.

BACKGROUND: Medical schools increasingly incorporate teamwork in their curricula but medical students often have a negative perception of team projects, in particular when there is unequal participation. The purpose of this study is to evaluate whether a novel peer evaluation system improves teamwork contributions and reduces the risk of students "free loading". METHODS: A cluster randomised controlled trial (RCT) with qualitative follow up enrolled 37 teams (n = 223 students). Participating teams were randomised to intervention group (19 teams) or control group (18 teams). The validated Comprehensive Assessment Team Member Effectiveness (CATME) tool was used as the outcome measure, and was completed at baseline (week 2) and at the end of the project (week 10). The team contribution subscale was the primary outcome, with other subscales as secondary outcomes. Six focus group discussions were held with students to capture the team's experiences and perceptions of peer assessment and its effects on team work. RESULTS: The results of the RCT showed that there was no difference in team contribution, and other forms of team effectiveness, between intervention and control teams. The focus group discussions highlighted students' negative attitudes, and lack of implementation of this transparent, points-based peer assessment system, out of fear of future consequences for relationships with peers. The need to assess peers in a transparent way to stimulate open discussion was perceived as threatening by participants. Teams suggested that other peer assessment systems could work such as rewarding additional or floating marks to high performing team members. CONCLUSIONS: Other models of peer assessment need to be developed and tested that are non-threatening and that facilitate early acceptance of this mode of assessment.