Tackling antimicrobial resistance: developing and implementing antimicrobial stewardship interventions in four African commonwealth countries through a health partnership model.

In recent years, health partnerships have shared infection prevention and control innovations between United Kingdom hospitals and Low-Middle-Income Countries. However, none had focused on antimicrobial stewardship (AMS), a core component of tackling antimicrobial resistance (AMR). This paper documents an effective approach to developing a program to increase AMS capacity in four African countries: Ghana, Tanzania, Uganda, and Zambia as part of the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) program. A systematic approach was applied to assess gaps in AMS interventions and inform the development of the CwPAMS program through deskbased assessments, including National Action Plans on AMR, online focus group meetings, and expert advisory group reviews. Twelve partnerships were selected for the CwPAMS program. AMS support tools were developed based on recommendations from the scoping, including an AMS checklist tool, a healthcare worker knowledge and attitudes questionnaire, and an antimicrobial prescribing app to support clinical decision-making. Training workshops on AMS were developed and delivered to volunteers in Africa and the UK using a train-the-trainer model. The tools and workshops facilitated capacity building for AMS through the generation and strengthening of knowledge, skills, commitment, structures, systems, and leadership among stakeholders in the UK and Africa. The overall average rating assigned to the program following independent evaluation using the Organisation for Economic Cooperation and Development Assistance Committee Evaluation Criteria was very good. The evaluation also highlighted that the majority of the HPs (75%) focused on AMS and/or improved prescribing practice; all HPs have developed and implemented AMS strategies, guidelines, and tools within their hospitals; and NHS staff were able to translate the knowledge and skills they had received early on in the program into clinical practice in response to COVID-19 challenges.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-Saharan Africa: A Co-Creation Consensus Approach.

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.

Development of and User Feedback on a Board and Online Game to Educate on Antimicrobial Resistance and Stewardship.

Antimicrobial resistance (AMR), particularly antibiotic resistance, is one of the most challenging global health threats of our time. Tackling AMR requires a multidisciplinary approach. Whether a clinical team member is a cleaner, nurse, doctor, pharmacist, or other type of health worker, their contribution towards keeping patients safe from infection is crucial to saving lives. Existing literature portrays that games can be a good way to engage communities in joint learning. This manuscript describes an educational antimicrobial stewardship (AMS) game that was co-created by a multidisciplinary team of health professionals spanning across high- and low- to middle-income countries. The online AMS game was promoted and over 100 players across 23 countries registered to participate on 2 occasions. The players were asked to share feedback on the game through a short online form. Their experiences revealed that the game is relevant for creation of awareness and understanding on antimicrobial stewardship in both high- and low-to-middle income settings worldwide.

Developing nurse medication safety training in a health partnership in Mozambique using behavioural science.

BACKGROUND: Globally, safe and effective medication administration relies on nurses being able to apply strong drug calculation skills in their real-life practice, in the face of stressors and distractions. These may be especially prevalent for nurses in low-income countries such as Mozambique and Continuing Professional Development post-registration may be important. This study aimed to 1) explore the initial impact of an international health partnership's work to develop a drug calculation workshop for nurses in Beira, Mozambique and 2) reflect upon the role of health psychologists in helping educators apply behavioural science to the training content and evaluation. METHODS: In phase one, partners developed a training package, which was delivered to 87 Portuguese-speaking nurses. The partnership's health psychologists coded the training's behaviour change content and recommended enhancements to content and delivery. In phase two, the refined training, including an educational game, was delivered to 36 nurses in Mozambique and recoded by the health psychologists. Measures of participant confidence and intentions to make changes to healthcare practice were collected, as well as qualitative data through post-training questions and 12 short follow-up participant interviews. RESULTS: In phase one six BCTs were used during the didactic presentation. Most techniques targeted participants' capability to calculate drug doses accurately; recommendations aimed to increase participants' motivation and perceived opportunity, two other drivers of practice change. Phase two training included an extra seven BCTs, such as action planning and further skills practice. Participants reported high confidence before and after the training (p = 0.25); intentions to use calculators to check drug calculations significantly increased (p = 0.031). Qualitative data suggested the training was acceptable, enjoyable and led to practice changes, through improved capability, opportunity and motivation. Opportunity barriers to medication safety were highlighted. CONCLUSIONS: Reporting and measuring medication errors and related outcomes is a complex challenge affecting global efforts to improve medication safety. Through strong partnership working, a multi-disciplinary team of health professionals including health psychologists developed, refined and begin to evaluate a locally-led drug calculation CPD workshop for nurses in a low-resource setting. Applying behavioural science helped to collect feasible evaluation data and hopefully improved impact and sustainability.

Lost or fond? Effects of nostalgia on sad mood recovery vary by attachment insecurity.

Nostalgia involves a fond recollection of people and events lost to time. Growing evidence indicates that nostalgia may ameliorate negative affective states such as loneliness and boredom. However, the effect of nostalgia on sadness is unknown, and there is little research on how social connectedness might impact nostalgia's effects. Grounded in a theoretical framework whereby people with lower levels of attachment insecurity benefit more from nostalgia, we exposed participants to a mortality-related sad mood and then randomly assigned them to reflect on a nostalgic or an ordinary event memory. We examined changes in mood and electrodermal activity (EDA) and found that nostalgic versus ordinary event memories led to a blunted recovery from sad mood, but that this effect was moderated by degree of attachment insecurity, such that participants with low insecurity benefited from nostalgia whereas people with high insecurity did not. These findings suggest that nostalgia's benefits may be tied to the degree of confidence one has in one's social relationships.

Uninstructed emotion regulation choice in four studies of cognitive reappraisal.

In emotion regulation (ER) research, participants are often trained to use specific strategies in response to emotionally evocative stimuli. Yet theoretical models suggest that people vary significantly in strategy use in everyday life. Which specific strategies people choose to use, and how many, may partially depend on contextual factors like the emotional intensity of the situation. It is thus possible - even likely - that participants spontaneously use uninstructed ER strategies in the laboratory, and that these uninstructed choices may depend on contextual factors like emotional intensity. We report data from four studies in which participants were instructed to use cognitive reappraisal to regulate their emotions in response to pictures, the emotional intensity of which varied across studies. After the picture trials, participants described which and how many strategies they used by way of open-ended responses. Results indicated that while a substantial proportion of participants in all studies described strategies consistent with cognitive reappraisal, a substantial proportion also endorsed uninstructed strategies. Importantly, they did so more often in the context of studies in which they viewed higher-intensity pictures. These findings underscore the importance of considering uninstructed ER choice in instructed paradigms and situational context in all studies of ER.

Emotion reactivity and regulation are associated with psychological functioning following the 2011 earthquake, tsunami, and nuclear crisis in Japan.

Frequent and successful use of cognitive reappraisal, an emotion regulation strategy that involves rethinking the meaning of an emotional event in order to change one's emotional response, has been linked in everyday life to positive outcomes such as higher well-being. Whether we should expect this association to be maintained in a strong, temporally and spatially close emotional context is an unexplored question that might have important implications for our understanding of emotion regulation and its relations to psychological functioning. In this study of members of the U. S. Embassy Tokyo community in the months following the March 2011 earthquake, tsunami, and nuclear crisis in Japan, self-reported use of cognitive reappraisal was not related to psychological functioning, but demonstrated success using cognitive reappraisal to decrease feelings of unpleasantness in response to disaster-related pictures on a performance-based task was associated with fewer symptoms of depression and posttraumatic stress. Moreover, emotional reactivity to these pictures was associated with greater symptomatology. These results suggest that situational intensity may be an important moderator of reappraisal and psychological functioning relationships.

Mood-induced shifts in attentional bias to emotional information predict ill- and well-being.

Previous research has suggested that biased attention toward emotional (typically threatening) stimuli contributes to ill-being (e.g., high levels of anxiety), but its contribution to well-being is less clear. The researchers assessed naturalistic shifts in attentional bias toward threatening and pleasant schematic face cues in response to five induced mood states in college students. They also assessed state anxiety and satisfaction with life concurrently and 3 weeks later. Controlling for concurrent anxiety, a fear-induced shift in attention to threatening cues was associated with increased levels of later anxiety. Controlling for concurrent life satisfaction, a happiness-induced shift in attention to emotional cues (both threatening and pleasant) was associated with increased levels of later life satisfaction. These results suggest that mood-induced changes in deployment of attention to emotional information may accumulate in ways that impact psychological functioning, yet these effects depend on mood state and the emotional cues afforded by the context.

Evidence-based assessment of cognitive functioning in pediatric psychology.

OBJECTIVE: To review the evidence base for measures of cognitive functioning frequently used within the field of pediatric psychology. METHODS: From a list of 47 measures identified by the Society of Pediatric Psychology (Division 54) Evidence-Based Assessment Task Force Workgroup, 27 measures were included in the review. Measures were organized, reviewed, and evaluated according to general domains of functioning (e.g., attention/executive functioning, memory). RESULTS: Twenty-two of 27 measures reviewed demonstrated psychometric properties that met "Well-established" criteria as set forth by the Assessment Task Force. Psychometric properties were strongest for measures of general cognitive ability and weakest for measures of visual-motor functioning and attention. CONCLUSIONS: We report use of "Well-established" measures of overall cognitive functioning, nonverbal intelligence, academic achievement, language, and memory and learning. For several specific tests in the domains of visual-motor functioning and attention, additional psychometric data are needed for measures to meet criteria as "Well established."

Psychiatric and emotional sequelae of surgical amputation.

The prevalence of posttraumatic stress symptoms after the experience of amputation is not well established. The current study gathered data on the prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders after amputation. Participants were recruited from a large Northeastern rehabilitation hospital and were assessed with structured clinical interviews. The data suggest that planned surgical amputations resulting from chronic illness do not frequently lead to PTSD symptoms. In contrast, data suggest that amputation resulting from accidental injury may lead to a higher prevalence of PTSD, in part because of the emotional stress surrounding the accident.

A functional magnetic resonance imaging study of amygdala and medial prefrontal cortex responses to overtly presented fearful faces in posttraumatic stress disorder.

BACKGROUND: Previous functional neuroimaging studies have demonstrated exaggerated amygdala responses and diminished medial prefrontal cortex responses during the symptomatic state in posttraumatic stress disorder (PTSD). OBJECTIVES: To determine whether these abnormalities also occur in response to overtly presented affective stimuli unrelated to trauma; to examine the functional relationship between the amygdala and medial prefrontal cortex and their relationship to PTSD symptom severity in response to these stimuli; and to determine whether responsivity of these regions habituates normally across repeated stimulus presentations in PTSD. DESIGN: Case-control study. SETTING: Academic medical center. PARTICIPANTS: Volunteer sample of 13 men with PTSD (PTSD group) and 13 trauma-exposed men without PTSD (control group). MAIN OUTCOME MEASURES: We used functional magnetic resonance imaging (fMRI) to study blood oxygenation level-dependent signal during the presentation of emotional facial expressions. RESULTS: The PTSD group exhibited exaggerated amygdala responses and diminished medial prefrontal cortex responses to fearful vs happy facial expressions. In addition, in the PTSD group, blood oxygenation level-dependent signal changes in the amygdala were negatively correlated with signal changes in the medial prefrontal cortex, and symptom severity was negatively related to blood oxygenation level-dependent signal changes in the medial prefrontal cortex. Finally, relative to the control group, the PTSD group tended to exhibit diminished habituation of fearful vs happy responses in the right amygdala across functional runs, although this effect did not exceed our a priori statistical threshold. CONCLUSIONS: These results provide evidence for exaggerated amygdala responsivity, diminished medial prefrontal cortex responsivity, and a reciprocal relationship between these 2 regions during passive viewing of overtly presented affective stimuli unrelated to trauma in PTSD.