Flexible resources and experiences of racism among a multi-ethnic adolescent population in Aotearoa, New Zealand: an intersectional analysis of health and socioeconomic inequities using survey data.

BACKGROUND: As societies become increasingly diverse, understanding the complex nature of racism for multiple ethnic, social, and economic identities of minority youth is required. Here we explore the experience of racism between and among privileged majority adolescent groups and targeted minority (Indigenous and ethnic) adolescents in New Zealand. Using the concept of structural and embodiment flexible resources, which act as risk and protective factors, we examine the social and health effects on minority youth. METHODS: In this intersectional analysis, we use self-reported data from the Youth2000 survey series administered in 2001, 2007, 2012, and 2019 to large, representative samples of students from mainstream state and private schools in the Auckland, Tai Tokerau, and Waikato regions of New Zealand. Students were in school years 9-13 and mostly aged 13-17 years. Ethnic or migrant group, income level of country of origin, and migrant generation were used as measures of structural resources and perceived ethnicity as a measure of embodiment resource. Racism and its effects were measured as socioeconomic inequities (household, neighbourhood, and school-level deprivation); interpersonal discrimination (unfair treatment, bullying, and safety); and health inequities (forgone health care, symptoms of depression, and attempted suicide). We used generalised linear models to explore variations in economic, interpersonal, and health outcomes for Indigenous and migrant youth, adjusting for mediating effects of household deprivation and measures of flexible resources (migration generation, income level of country of origin, and perceived ethnicity). FINDINGS: We collected data from a total of 20 410 adolescents from the four survey waves between 2001 and 2019. Participants had a median age of 15 years (IQR 14-16). Socioeconomic, interpersonal, and health inequities varied with access to flexible resources among Maori and racialised migrant youth. Maori and racialised migrants from low-income and middle-income countries in particular experienced high levels of socioeconomic inequities. Racialised migrant youth experienced persistent socioeconomic inequities extending over three generations, especially Pasifika migrant adolescents. Minorities perceived as White experienced less discrimination and had more advantages than visibly racialised groups. Regression models showed that embodiment resources, and to a lesser extent structural resources, mediated, but did not eliminate ethnic disparities in socioeconomic status and interpersonal discrimination; these resources did not strongly mediate ethnic disparities in health. Trend analyses indicate consistency in these patterns with ethnicity-based inequities persisting or increasing over time. INTERPRETATION: Indigenous and ethnic minority experiences of racism are heterogeneous. Structural flexible resources (wealth) and, more substantially, embodiment flexible resources (perceived Whiteness) mitigate individual experiences of racism. In multi-ethnic western societies, anti-racist interventions and policies must address both structural deprivation and associated intergenerational mobility and colourism (ie, implicit and explicit bias against non-White youth). FUNDING: Health Research Council of New Zealand.

Point-of-care testing in private pharmacy and drug retail settings: a narrative review.

BACKGROUND: Point-of-care testing (POCT) using rapid diagnostic tests for infectious disease can potentially guide appropriate use of antimicrobials, reduce antimicrobial resistance, and economise use of healthcare resources. POCT implementation in private retail settings such as pharmacies and drug shops could lessen the burden on public healthcare. We performed a narrative review on studies of POCTs in low- and middle-income countries (LMICs), and explored uptake, impact on treatment, and feasibility of implementation. METHODS: We searched MEDLINE/PubMed for interventional studies on the implementation of POCT for infectious diseases performed by personnel in private retail settings. Data were extracted and analysed by two independent reviewers. RESULTS: Of the 848 studies retrieved, 23 were included in the review. Studies were on malaria (19/23), malaria and pneumonia (3/23) or respiratory tract infection (1/23). Nine randomised controlled studies, four controlled, non-randomised studies, five uncontrolled interventions, one interventional pre-post study, one cross-over interventional study and three retrospective analyses of RCTs were included. Study quality was poor. Overall, studies showed that POCT can be implemented successfully, leading to improvements in appropriate treatment as measured by outcomes like adherence to treatment guidelines. Despite some concerns by health workers, customers and shop providers were welcoming of POCT implementation in private retail settings. Main themes that arose from the review included the need for well-structured training with post-training certification covering guidelines for test-negative patients, integrated waste management, community sensitization and demand generation activities, financial remuneration and pricing schemes for providers, and formal linkage to healthcare and support. CONCLUSION: Our review found evidence that POCT can be implemented successfully in private retail settings in LMICs, but comprehensive protocols are needed. High-quality randomised studies are needed to understand POCTs for infectious diseases other than malaria.

Determinants of ethnic differences in the uptake of child healthcare services in New Zealand: a decomposition analysis.

BACKGROUND: There are persistent ethnic gaps in uptake of child healthcare services in New Zealand (NZ), despite increasing policy to promote equitable access. We examined ethnic differences in the uptake of immunisation and primary healthcare services at different ages and quantified the contribution of relevant explanatory factors, in order to identify potential points of intervention. METHODS: We used data from the Growing Up in New Zealand birth cohort study, including children born between 2009 and 2010. Econometric approaches were used to explore underlying mechanisms behind ethnic differences in service uptake. Multivariable regression was used to adjust for mother, child, household, socioeconomic, mobility, and social factors. Decomposition analysis was used to assess the proportion of each ethnic gap that could be explained, as well as the main drivers behind the explained component. These analyses were repeated for four data time-points. RESULTS: Six thousand eight hundred twenty-two mothers were enrolled during the antenatal survey, and children were followed up at 9-months, 2-years and 4-years. In univariable models, there were ethnic gaps in uptake of immunisation and primary care services. After adjusting for covariates in multivariable models, compared to NZ Europeans, Asian and Pacific children had higher timeliness and completeness of immunisation at all time-points, while indigenous Maori had lower timeliness of first-year vaccines despite high intentions to immunise. Asian and Pacific mothers were less likely to have their first-choice lead maternity caregiver (LMC) than NZ Europeans mothers, and Maori and Asian mothers were less likely to be satisfied with their general practitioner (GP) at 2-years. Healthcare utilisation was strongly influenced by socio-economic, mobility and social factors including ethnic discrimination. In decomposition models comparing Maori to NZ Europeans, the strongest drivers for timely first-year immunisations and GP satisfaction (2-years) were household composition and household income. Gaps between Pacific and NZ Europeans in timely first-year immunisations and choice of maternity carer were largely unexplained by factors included in the models. CONCLUSIONS: Ethnic gaps in uptake of child healthcare services vary by ethnicity, service, and time-point, and are driven by different factors. Addressing healthcare disparities will require interventions tailored to specific ethnic groups, as well as addressing underlying social determinants and structural racism. Gaps that remain unexplained by our models require further investigation.

Conducting Social Science Research During Epidemics and Pandemics: Lessons Learnt.

The COVID-19 pandemic has had a significant impact on how field-based research is being conducted globally. Given the challenges of undertaking fieldwork during epidemics and the need for mixed methods research to address the social, political, and economic issues related to epidemics, there is a small but growing body of evidence in this area. To contribute to the logistical and ethical considerations for conducting research during a pandemic, we draw on the challenges and lessons learnt from adapting methods for two research studies conducted in 2021 during the COVID-19 pandemic in low- and middle-income country (LMIC) settings: (1) in-person research in Uganda and (2) combined remote and in-person research in South and Southeast Asia. Our case studies focus on data collection and demonstrate the feasibility of conducting mixed methods research, even with many logistical and operational constraints. Social science research is often used to identify the context of specific issues, to provide a needs assessment, or inform longer-term planning; however, these case studies have shown the need to integrate social science research from the start of a health emergency and in a systematic way. Social science research during future health emergencies can also inform public health responses during the emergency. It is also crucial to collect social science data after health emergencies to inform future pandemic preparedness. Finally, researchers need to continue research on other public health issues that are ongoing even during a public health emergency.

Determinants and patterns of antibiotic consumption for children under five in Nepal: analysis and modelling of Demographic Health Survey data from 2006 to 2016.

OBJECTIVES: Our aims were to examine AMR-specific and AMR-sensitive factors associated with antibiotic consumption in Nepal between 2006 and 2016, to explore health care-seeking patterns and the source of antibiotics. METHODS: Cross-sectional data from children under five in households in Nepal were extracted from the 2006, 2011 and 2016 Demographic Health Surveys (DHS). Bivariable and multivariable analyses were carried out to assess the association of disease prevalence and antibiotic use with age, sex, ecological location, urban/rural location, wealth index, household size, maternal smoking, use of clean fuel, sanitation, nutritional status, access to health care and vaccinations. RESULTS: Prevalence of fever, acute respiratory infection (ARI) and diarrhoea decreased between 2006 and 2016, whilst the proportion of children under five receiving antibiotics increased. Measles vaccination, basic vaccinations, nutritional status, sanitation and access to health care were associated with antibiotic use. Those in the highest wealth index use less antibiotics and antibiotic consumption in rural areas surpassed urban regions over time. Health seeking from the private sector has overtaken government facilities since 2006 with antibiotics mainly originating from pharmacies and private hospitals. Adherence to WHO-recommended antibiotics has fallen over time. CONCLUSIONS: With rising wealth, there has been a decline in disease prevalence but an increase in antibiotic use and more access to unregulated sources. Understanding factors associated with antibiotic use will help to inform interventions to reduce inappropriate antibiotic use whilst ensuring access to those who need them.

Plans for Nationwide Serosurveillance Network in Vietnam.

In recent years, serosurveillance has gained momentum as a way of determining disease transmission and immunity in populations, particularly with respect to vaccine-preventable diseases. At the end of 2017, the Oxford University Clinical Research Unit and the National Institute of Hygiene and Epidemiology held a meeting in Vietnam with national policy makers, researchers, and international experts to discuss current seroepidemiologic projects in Vietnam and future needs and plans for nationwide serosurveillance. This report summarizes the meeting and the plans that were discussed to set up nationwide serosurveillance in Vietnam.

Burden of injuries in Vietnam: emerging trends from a decade of economic achievement.

BACKGROUND: Vietnam has been one of the fastest-growing world economies in the past decade. The burden of injuries can be affected by economic growth given the increased exposure to causes of injury as well as decreased morbidity and mortality of those that experience injury. It is of interest to evaluate the trends in injury burden that occurred alongside Vietnam's economic growth in the past decade. METHODS: Results from Global Burden of Disease 2017 were obtained and reviewed. Estimates of incidence, cause-specific mortality, years lived with disability, years of life lost, disability-adjusted life years were analysed and reported for 30 causes of injury in Vietnam from 2007 to 2017. RESULTS: Between 2007 and 2017, the age-standardised incidence rate of all injuries increased by 14.6% (11.5%-18.2%), while the age-standardised mortality rate decreased by 11.6% (3.0%-20.2%). Interpersonal violence experienced the largest increase in age-standardised incidence (28.3% (17.6%-40.1%)), while exposure to forces of nature had the largest decrease in age-standardised mortality (47.1% (37.9%-54.6%)). The five leading causes of injury in both 2007 and 2017 were road injuries, falls, exposure to mechanical forces, interpersonal violence and other unintentional injuries, all of which increased in incidence from 2007 to 2017. Injury burden varied markedly by age and sex. CONCLUSIONS: The rapid expansions of economic growth in Vietnam as well as improvements in the Sociodemographic Index have occurred alongside dynamic patterns in injury burden. These results should be used to develop and implement prevention and treatment programme.

Impact of mother's education on full immunization of children aged 12-23 months in Eritrea: population and health survey 2010 data analysis.

BACKGROUND: Although vaccination coverage in Eritrea has improved in recent years, some children are still missing out, and it's important to identify risk factors for lower coverage in order to target campaigns and interventions. The objective of this study was to assess: (1) the impact of maternal education on full immunization of children aged 12-23 months, and (2) whether the association was confounded or modified by other factors. METHODS: This study was a secondary data analysis of the Eritrean Population and Health Survey 2010 (EPHS 2010). In this analysis 1323 mothers of children aged 12-23 months were included. The outcome of the study was full immunization, defined as receiving all the WHO recommended basic vaccines: one dose of Bacillus Calmette-Gué rin (BCG), three doses of diphtheria-pertussis-tetanus(DPT), three doses of polio, and one dose of measles vaccine. The primary exposure was maternal education. Data on immunization coverage came from vaccination cards and from mothers' or caretakers' verbal reports. Bivariate and multivariable logistic regression analyses were performed. RESULT: Full vaccination coverage among children aged 12-23 months was 83%. Most children received BCG (95%), DPT1 (97%), DPT2 (96%), DPT3 (93%), polio1 (97%), polio2 (97%), polio3 (91%) and measles (92%). In unadjusted analyses, children of mothers with primary (OR = 2.75, 95% CI 1.74-4.37), and middle or above (OR = 3.16, 95% CI 2.09-4.78) education were more likely to be fully immunised. However, after adjusting for wealth, region, ANC visit, and vaccination card ownership, only the effect for primary education remained significant (OR = 2.34, 95% CI 1.30-4.21). CONCLUSION: The result of this study suggested that children of mothers who attained primary level were more likely to be fully vaccinated than children of mothers with no education. The association was influenced by wealth index of household, mothers ANC visit, region, and possession of vaccination card. The Expanded Program on Immunization of the Ministry of Health should target strategies to enhance full immunization among children of mothers with no education.

A Systematic Review and Meta-analysis of Ventilator-associated Pneumonia in Adults in Asia: An Analysis of National Income Level on Incidence and Etiology.

Background: Ventilator-associated pneumonia (VAP) is the commonest hospital-acquired infection (HAI) in intensive care. In Asia, VAP is increasingly caused by resistant gram-negative organisms. Despite the global antimicrobial resistance crisis, the epidemiology of VAP is poorly documented in Asia. Methods: We systematically reviewed literature published on Ovid Medline, Embase Classic, and Embase from 1 January 1990 to 17 August 2017 to estimate incidence, prevalence, and etiology of VAP. We performed a meta-analysis to give pooled rates and rates by country income level. Results: Pooled incidence density of VAP was high in lower- and upper-middle-income countries and lower in high-income countries (18.5, 15.2, and 9.0 per 1000 ventilator-days, respectively). Acinetobacter baumannii (n = 3687 [26%]) and Pseudomonas aeruginosa (n = 3176 [22%]) were leading causes of VAP; Staphylococcus aureus caused 14% (n = 1999). Carbapenem resistance was common (57.1%). Conclusions: VAP remains a common cause of HAI, especially in low- and middle-income countries, and antibiotic resistance is high.

Clinical Manifestations and Molecular Diagnosis of Scrub Typhus and Murine Typhus, Vietnam, 2015-2017.

Rickettsioses are endemic to Vietnam; however, only a limited number of clinical studies have been performed on these vectorborne bacteria. We conducted a prospective hospital-based study at 2 national referral hospitals in Hanoi to describe the clinical characteristics of scrub typhus and murine typhus in northern Vietnam and to assess the diagnostic applicability of quantitative real-time PCR assays to diagnose rickettsial diseases. We enrolled 302 patients with acute undifferentiated fever and clinically suspected rickettsiosis during March 2015-March 2017. We used a standardized case report form to collect clinical information and laboratory results at the time of admission and during treatment. We confirmed scrub typhus in 103 (34.1%) patients and murine typhus in 12 (3.3%) patients. These results highlight the need for increased emphasis on training for healthcare providers for earlier recognition, prevention, and treatment of rickettsial diseases in Vietnam.

Effects of women's groups practising participatory learning and action on preventive and care-seeking behaviours to reduce neonatal mortality: A meta-analysis of cluster-randomised trials.

BACKGROUND: The World Health Organization recommends participatory learning and action (PLA) in women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women's groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction. METHODS AND FINDINGS: We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women's group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women's groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02-4.22; I2 = 63.7%, 95% CI 4.4%-86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25-2.82; 67.6%, 16.1%-87.5%), birth attendant washing hands prior to delivery (1.87, 1.19-2.95; 79%, 53.8%-90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09-1.99; 68.0%, 29.2%-85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02-1.60; 0.0%, 0%-79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77-1.38; I2 = 86.3%, 95% CI 73.8%-92.8%), facility delivery (1.02, 0.93-1.12; 21.4%, 0%-65.8%), initiating breastfeeding within 1 hour (1.08, 0.85-1.39; 76.6%, 50.9%-88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93-1.48; 72.9%, 37.8%-88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women's groups and context-specific effects. CONCLUSIONS: This meta-analysis suggests that women's groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents.

The association between socioeconomic deprivation and secondary school students' health: findings from a latent class analysis of a national adolescent health survey.

BACKGROUND: The aims of this study were to examine indicators of socioeconomic deprivation among secondary school students and to determine associations between household poverty, neighbourhood deprivation and health indicators. METHODS: Data were from a nationally representative sample of 8500 secondary school students in New Zealand who participated in a health survey in 2012. Latent class analyses were used to group students by household poverty based on nine indicators of household socioeconomic deprivation: no car; no phone; no computer; their parent/s worry about not having enough money for food; more than two people sharing a bedroom; no holidays with their families; moving home more than twice that year; garages or living rooms used as bedrooms; and, no parent at home with employment. Multilevel generalized linear models were used to estimate the cross-level interaction between household poverty and neighbourhood deprivation with depressive symptoms, cigarette smoking and overweight/ obesity. RESULTS: Three groups of students were identified: 80 % of students had low levels of household poverty across all indicators; 15 % experienced moderate poverty; and 5 % experienced high levels of poverty. Depressive symptoms and cigarette smoking were 2-3 times higher in the poverty groups compared to student's not experiencing poverty. There were also higher rates of overweight/ obesity among students in the poverty groups compared to students not experiencing poverty, but once covariates were accounted for the relationship was less clear. Of note, students experiencing poverty and living in affluent neighbourhoods reported higher levels of depressive symptoms and higher rates of cigarette smoking than students experiencing poverty and living in low socioeconomic neighbourhoods. This cross-level interaction was not seen for overweight/ obesity. CONCLUSIONS: Measures of household socioeconomic deprivation among young people should not be combined with neighbourhood measures of socioeconomic deprivation due to non-linear relationships with health and behaviour indicators. Policies are needed that address household poverty alongside efforts to reduce socioeconomic inequalities in neighbourhoods.

Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial.

BACKGROUND: Women's groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi. METHODS: We did a 2×2 factorial, cluster-randomised trial in 185,888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women's group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126. FINDINGS: We monitored outcomes of 26,262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women's group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0.93, 0.64-1.35) and MMR (0.54, 0.28-1.04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0.85, 0.59-1.22) and MMR (0.48, 0.26-0.91). Because of the interaction between the two interventions, a stratified analysis was done. For women's groups, in adjusted analyses, MMR fell by 74% (0.26, 0.10-0.70), and NMR by 41% (0.59, 0.40-0.86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1.09, 0.40-2.98, and 1.38, 0.75-2.54). Factorial analysis for the peer counselling intervention for years 1-3 showed a fall in IMR of 18% (0.82, 0.67-1.00) and an improvement in EBF rates (2.42, 1.48-3.96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0.64, 0.48-0.85) but no effect on EBF (1.18, 0.63-2.25) in areas without women's groups, and in areas with women's groups there was no effect on IMR (1.05, 0.82-1.36) and an increase in EBF (5.02, 2.67-9.44). The cost of women's groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons. INTERPRETATION: Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa. FUNDING: Saving Newborn Lives, UK Department for International Development, and Wellcome Trust.

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.

BACKGROUND: Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. METHODS: We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries. FINDINGS: Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries. INTERPRETATION: With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. FUNDING: Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Social cohesion among healthcare workers during COVID-19: Qualitative research in Indonesia, Nepal, and Vietnam.

Existing literature has portrayed numerous challenges that healthcare workers (HCWs) faced during the COVID-19 pandemic, such as heightened risks of transmission against the scarcity of protective equipment, burgeoning workload, and emotional distress, to name a few. However, most studies explored HCWs' experiences at the individual level rather than examining the collective responses. Exploring these experiences could reveal the social-cultural locality of the pandemic while identifying the system constraints in public health emergencies. As part of a mixed-method study on COVID-19 pandemic impacts, we analysed qualitative interview data with 129 HCWs and health-related staff to explore their experiences during the pandemic between 2020 and 2021 in Vietnam, Indonesia, and Nepal. Using Bahers' sociological framework, Community of Fate, we describe five themes reflecting the formation of a community of HCWs and the social cohesion underlying their efforts to survive hardship. The first three themes characterise the HCW community of fate, including (1) Recognition of extreme work-related danger, (2) physical and figurative closures where HCWs restrict themselves from the outside world, (3) chronic ordeals with overwhelming workload and responsibilities, encompassing recurrent mental health challenges. Against such extreme hardship, cohesive bonding and social resilience are reflected through two additional themes: (4) a mutual sense of moral and professional duty to protect communities, (5) the vertical and horizontal convergence among HCWs across levels and among government departments. We discuss these HCWs' challenges in relation to systemic vulnerabilities while advocating for increasing investment in public health and collaboration across government sectors to prepare for emergency situations.

Health and well-being of secondary school students in New Zealand: trends between 2001, 2007 and 2012.

AIM: To describe indicators of health and well-being for New Zealand secondary school students; explore changes between 2001, 2007 and 2012; and compare these findings to international estimates. METHODS: Three national health and well-being surveys of randomly selected New Zealand secondary school students were conducted. Data are presented as prevalence and variation over time (adjusted odds ratio (aOR)). Comparisons with international estimates were made with subsets of the data. RESULTS: Between 2001 and 2012, students reported reductions in cigarette use (aOR 0.27, 95% confidence interval (CI) 0.23-0.32), alcohol use (aOR 0.39, 95% CI 0.33-0.46), marijuana use (aOR 0.37, 95% CI 0.31-0.43), sexual abuse (aOR 0.52, 95% CI 0.46-0.58), fighting (aOR 0.63, 95% CI 0.55-0.73), seatbelt use (aOR 1.47, 95% CI 1.31-1.65) and risky driving behaviours (aOR 0.39, 95% CI 0.33-0.45). Positive connections to school (perception that the school cares, aOR 1.22, 95% CI 1.10-1.35; liking school, aOR 1.55, 95% CI 1.33-1.82) and family (good family relationship, aOR 1.83, 95% CI 1.70-1.97) also improved. Indicators that did not improve and compared poorly with international estimates were protected sex (condom use at last sexual intercourse, aOR 0.77, 95% CI 0.68-0.87) and healthy life-style (daily physical activity, aOR 0.88, 95% CI 0.78-0.99; overweight/obese, aOR 1.09, 95% CI 0.92-1.31). Exposure to family violence (aOR 1.37, 95% CI 1.11-1.68) and depressive symptoms (aOR 1.03, 95% CI 0.91-1.17) also did not improve. CONCLUSIONS: There have been important improvements in the health and well-being of New Zealand adolescents over a relatively short period. These findings demonstrate that population rates of adolescent risk behaviours are amenable to change. Current policy efforts should not lose momentum, while identified priority areas must be adequately resourced to ensure young people have opportunities to thrive now and in the future.

Indonesian healthcare professionals' experiences in rural and urban settings during the first wave of COVID-19: A qualitative study.

INTRODUCTION: During the COVID-19 pandemic, healthcare workers (HCWs) faced unprecedented challenges, increased workload, and often struggled to provide healthcare services. We explored the experiences faced by HCWs working at primary healthcare centers (PHCs) and hospitals across urban and rural settings in Indonesia. METHODS: As part of a larger multi-country study, we conducted semi-structured in-depth interviews with a purposive sample of Indonesian HCWs. We used thematic analysis to identify the main challenges described by the participants. RESULTS: We interviewed 40 HCWs between December 2020 and March 2021. We identified that challenges varied depending on their role. i) For those in clinical roles, challenges included maintaining trust with communities, and patient referral issues; ii) for those in non-clinical roles, sub-optimal laboratory capacity and logistics, and lack of training were the main challenges; iii) for managerial roles, challenges included access to budget and supplies, and staff shortages due to isolation and overwork. There were also several cross-cutting challenges across all the roles including limited or rapidly changing information (in urban settings), and culture and communication (in rural settings). All of these challenges contributed to mental health issues among all HCW cadres. CONCLUSIONS: HCWs across roles and settings were confronted with unprecedented challenges. Understanding the various challenges across different healthcare cadres and within different settings is crucial for supporting HCWs during pandemic times. In rural areas, in particular, HCWs should be more sensitive to cultural and linguistic differences to enhance the effectiveness and awareness of public health messages.

Outpatient antibiotic prescribing for acute respiratory infections in Vietnamese primary care settings by the WHO AWaRe (Access, Watch and Reserve) classification: An analysis using routinely collected electronic prescription data.

Background: This study aims to investigate patterns of antibiotic prescribing and to determine patient-specific factors associated with the choice of antibiotics by the World Health Organization's Access-Watch-Reserve (WHO AWaRe) class for acute respiratory infections (ARIs) in rural primary care settings in northern Vietnam. Methods: We retrospectively reviewed health records for outpatients who were registered with the Vietnamese Health Insurance Scheme, visited one of 112 commune health centres in 6 rural districts of Nam Dinh province, Vietnam during 2019, and were diagnosed with ARIs. Patient-level prescription data were collected from the electronic patient databases. We used descriptive statistics to investigate patterns of antibiotic prescribing, with the primary outcomes including total antibiotic prescriptions and prescriptions by WHO AWaRe group. We identified patient-specific factors associated with watch-group antibiotic prescribing through multivariable logistic regression analysis. Findings: Among 193,010 outpatient visits for ARIs observed in this study, 187,144 (97.0%) resulted in an antibiotic prescription, of which 172,976 (92.5%) were access-antibiotics, 10,765 (5.6%) were watch-antibiotics, 3366 (1.8%) were not-recommended antibiotics. No patients were treated with reserve-antibiotics. The proportion of watch-antibiotic prescription was highest amongst children under 5-years old (18.1%, compared to 9.5% for 5-17-years, 4.9% for 18-49-years, 4.3% for 50-64-years, and 3.7% for 65-and-above-years). In multivariable logistic regression, children, district, ARI-type, comobid chronic respiratory illness, and follow-up visit were associated with higher likelihood of prescribing watch-group antibiotics. Interpretation: The alarmingly high proportion of antibiotic prescriptions for ARIs in primary care, and the frequent use of watch-antibiotics for children, heighten concerns around antibiotic overuse at the community level. Antimicrobial stewardship interventions and policy attention are needed in primary care settings to tackle the growing threat of antibiotic resistance. Funding: This work was supported through Australian government and UK aid from the UK government funding to FIND (Foundation for Innovative New Diagnostics) grant number FO17-0015, in addition to a Wellcome Trust grant (213920/Z/18/Z), and an Oxford University Clinical Research Unit internal grant from the Wellcome Trust Africa Asia Programme core grant in Vietnam (106680/Z/14/Z).

Implementation of point-of-care testing of C-reactive protein concentrations to improve antibiotic targeting in respiratory illness in Vietnamese primary care: a pragmatic cluster-randomised controlled trial.

BACKGROUND: In previous trials, point-of-care testing of C-reactive protein (CRP) concentrations safely reduced antibiotic use in non-severe acute respiratory infections in primary care. However, these trials were done in a research-oriented context with close support from research staff, which could have influenced prescribing practices. To better inform the potential for scaling up point-of-care testing of CRP in respiratory infections, we aimed to do a pragmatic trial of the intervention in a routine care setting. METHODS: We did a pragmatic, cluster-randomised controlled trial at 48 commune health centres in Viet Nam between June 1, 2020, and May 12, 2021. Eligible centres served populations of more than 3000 people, handled 10-40 respiratory infections per week, had licensed prescribers on site, and maintained electronic patient databases. Centres were randomly allocated (1:1) to provide point-of-care CRP testing plus routine care or routine care only. Randomisation was stratified by district and by baseline prescription level (ie, the proportion of patients with suspected acute respiratory infections to whom antibiotics were prescribed in 2019). Eligible patients were aged 1-65 years and visiting the commune health centre for a suspected acute respiratory infection with at least one focal sign or symptom and symptoms lasting less than 7 days. The primary endpoint was the proportion of patients prescribed an antibiotic at first attendance in the intention-to-treat population. The per-protocol analysis included only people who underwent CRP testing. Secondary safety outcomes included time to resolution of symptoms and frequency of hospitalisation. This trial is registered with ClinicalTrials.gov, NCT03855215. FINDINGS: 48 commune health centres were enrolled and randomly assigned, 24 to the intervention group (n=18 621 patients) and 24 to the control group (n=21 235). 17 345 (93·1%) patients in the intervention group were prescribed antibiotics, compared with 20 860 (98·2%) in the control group (adjusted relative risk 0·83 [95% CI 0·66-0·93]). Only 2606 (14%) of 18 621 patients in the intervention group underwent CRP testing and were included in the per-protocol analysis. When analyses were restricted to this population, larger reductions in prescribing were noted in the intervention group compared with the control group (adjusted relative risk 0·64 [95% CI 0·60-0·70]). Time to resolution of symptoms (hazard ratio 0·70 [95% CI 0·39-1·27]) and frequency of hospitalisation (nine in the intervention group vs 17 in the control group; adjusted relative risk 0·52 [95% CI 0·23-1·17]) did not differ between groups. INTERPRETATION: Use of point-of-care CRP testing efficaciously reduced prescription of antibiotics in patients with non-severe acute respiratory infections in primary health care in Viet Nam without compromising patient recovery. The low uptake of CRP testing suggests that barriers to implementation and compliance need to be addressed before scale-up of the intervention. FUNDING: Australian Government, UK Government, and the Foundation for Innovative New Diagnostics.