Midwives' experiences with PPE during the COVID-19 pandemic: The Birth in the Time of COVID (BITTOC) study.

BACKGROUND: The COVID-19 pandemic resulted in rapid changes aimed at reducing disease transmission in maternity services in Australia. An increase in personal protective equipment (PPE) in the clinical and community setting was a key strategy. There was variation in the type of PPE and when it was to be worn in clincial practice. AIM: This paper reports on Australian midwives' experiences of PPE during the pandemic. METHODS: This sequential mixed methods study was part of the Birth in the Time of COVID-19 (BITTOC 2020) study. Data were obtained from in-depth semi-structured interviews with midwives in 2020 followed by a national survey undertaken at two time points (2020 and 2021). Qualitative open-text survey responses and interview data were analysed using content analysis. FINDINGS: 16 midwives were interviewed and 687 midwives provided survey responses (2020 n = 477, 2021 n = 210). Whilst midwives largley understood the need for increased PPE, and were mainly happy with this, as it was protective, they reported a number of concerns. These included: inconsistency with PPE type, use, availability, quality, fit and policy; the impact of PPE on the physical and psychological comfort of midwives; and the barriers PPE use placed on communication and woman centred care. This at times resulted in midwives working outside of policy. CONCLUSION: These findings highlight the need for future comprehensive pandemic preparedness that ensures policy and procedure recommendations are consistent and PPE is available, of approriate quality, and individually fitted in order to ensure that Australian maternity services are well placed to manage future pandemics.

Randomized Evaluation of a Remote Management Program to Improve Guideline-directed Medical Therapy: The Diabetes Remote Intervention to Improve Use of Evidence-based Medications (DRIVE) Trial.

BACKGROUND: Several sodium-glucose transport protein 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) reduce cardiovascular (CV) events and improve kidney outcomes in patients with type 2 diabetes (T2D); however, utilization remains low despite guideline recommendations. METHODS: A randomized, remote implementation trial in the Mass General Brigham network enrolled patients with T2D at high CV and /or kidney risk. Patients eligible for, but not prescribed, SGLT2i or GLP-1 RA were randomly assigned to simultaneous virtual patient education with concurrent prescription of SGLT2i or GLP-1 RA ("simultaneous") or two months of virtual education followed by medication prescription ("education-first") delivered by a multi-disciplinary team driven by non-licensed navigators and clinical pharmacists who prescribed SGLT2i or GLP-1 RA using a standardized treatment algorithm. The primary outcome was the proportion of patients with prescriptions for either SGLT2i or GLP-1 RA by 6 months. RESULTS: Between March 2021 and December 2022, 200 patients were randomized. Mean age was 66.5 years, 36.5% were female, 22.0% were non-White. Overall, 30.0% had cardiovascular CV disease, 5.0% had cerebrovascular disease, and 1.5% had both. Mean estimated glomerular filtration rate (eGFR) 77.9 mL/min/1.73m2 and mean urine/albumin creatinine ratio (UACR) 88.6mg/g. After two months, 69/200 (34.5%) patients received a new prescription for either SGLT2i or GLP-1 RA: 53.4% of patients in the simultaneous arm vs. 8.3% of patients were in the education-first arm (p<0.001). After six months, 128/200 (64.0%) received a new prescription: 69.8 % of patients in the simultaneous arm vs. 56.0% of patients in education-first (p<0.001). Patient self-report of taking SGLT2i or GLP-1 RA within six months of trial entry was similarly higher in the simultaneous versus education-first arm (69 /116; 59.5% vs 37/84; 44.0%; p<0.001) Median time to first prescription was 24 (IQR 13, 50) vs 85 days (IQR 65, 106), respectively (p<0.001). CONCLUSIONS: In this randomized trial, a remote team-based program that identifies patients with T2D and high CV or kidney risk, provides virtual education, and prescribes SGLT2i or GLP-1 RA improves GDMT. These findings support greater utilization of virtual team-based approaches to optimize chronic disease management.

Dynamic interactions between SPX proteins, the ubiquitination machinery, and signalling molecules for stress adaptation at a whole-plant level.

The plant macronutrient phosphorus is a scarce resource and plant-available phosphate is limiting in most soil types. Generally, a gene regulatory module called the phosphate starvation response (PSR) enables efficient phosphate acquisition by roots and translocation to other organs. Plants growing on moderate to nutrient-rich soils need to co-ordinate availability of different nutrients and repress the highly efficient PSR to adjust phosphate acquisition to the availability of other macro- and micronutrients, and in particular nitrogen. PSR repression is mediated by a small family of single SYG1/Pho81/XPR1 (SPX) domain proteins. The SPX domain binds higher order inositol pyrophosphates that signal cellular phosphorus status and modulate SPX protein interaction with PHOSPHATE STARVATION RESPONSE1 (PHR1), the central transcriptional regulator of PSR. Sequestration by SPX repressors restricts PHR1 access to PSR gene promoters. Here we focus on SPX4 that primarily acts in shoots and sequesters many transcription factors other than PHR1 in the cytosol to control processes beyond the classical PSR, such as nitrate, auxin, and jasmonic acid signalling. Unlike SPX1 and SPX2, SPX4 is subject to proteasomal degradation not only by singular E3 ligases, but also by SCF-CRL complexes. Emerging models for these different layers of control and their consequences for plant acclimation to the environment will be discussed.

Telehealth use in maternity care during a pandemic: A lot of bad, some good and possibility.

BACKGROUND: To reduce transmission risk during the COVID-19 pandemic, 'telehealth' (health care delivered via telephone/video-conferencing) was implemented into Australian maternity services. Whilst some reports on telehealth implementation ensued, there was scant evidence on women and midwives' perspectives regarding telehealth use. METHODS: A qualitative study was conducted in Australia during 2020-2021 using two data sources from the Birth in the Time of COVID-19 (BITTOC) study: i) interviews and ii) surveys (open-text responses). Content analysis was utilised to analyse the data and explore telehealth from the perspective of midwives and women accessing maternity care services. In-depth interviews were conducted with 20 women and 16 midwives. Survey responses were provided from 687 midwives and 2525 women who were pregnant or gave birth in 2021, generating 212 and 812 comments respectively. FINDINGS: Telehealth delivery was variable nationally and undertaken primarily by telephone/videoconferencing. Perceived benefits included: reduced COVID-19 transmission risk, increased flexibility, convenience and cost efficiency. However, women described inadequate assessment, and negative impacts on communication and rapport development. Midwives had similar concerns and also reported technological challenges. CONCLUSION: During the COVID-19 pandemic, telehealth offered flexibility, convenience and cost efficiency whilst reducing COVID-19 transmission, yet benefits came at a cost. Telehealth may particularly suit women in rural and remote areas, however, it also has the potential to further reduce equitable, and appropriate care delivery for those at greatest risk of poor outcomes. Telehealth may play an adjunct role in post-pandemic maternity services, but is not a suitable replacement to traditional face-to-face maternity care.

Genomic surveillance of Anopheles mosquitoes on the Bijagós Archipelago using custom targeted amplicon sequencing identifies mutations associated with insecticide resistance.

BACKGROUND: Insecticide resistance is reducing the efficacy of vector control interventions, consequently threatening efforts to control vector-borne diseases, including malaria. Investigating the prevalence of molecular markers of resistance is a useful tool for monitoring the spread of insecticide resistance in disease vectors. The Bijagós Archipelago (Bijagós) in Guinea-Bissau is a region of stable malaria transmission where insecticide-treated nets are the mainstay for malaria control. However, the prevalence of molecular markers of insecticide resistance in malaria vectors is not well understood. METHODS: A total of 214 Anopheles mosquitoes were analysed from 13 islands across the Bijagós. These mosquitoes were collected using CDC light traps in November 2019, during the peak malaria transmission season. High-throughput multiplex amplicon sequencing was used to investigate the prevalence of 17 different molecular markers associated with insecticide resistance in four genes: vgsc, rdl, ace1 and gste2. RESULTS: Of the 17 screened mutations, four were identified in mosquitoes from the Bijagós: vgsc L995F (12.2%), N1570Y (6.2%) and A1746S (0.7%) and rdl A269G (1.1%). This study is the first to report the L995F knock-down resistance (kdr)-west allele in Anopheles melas on the Archipelago. An additional eight non-synonymous single-nucleotide polymorphisms were identified across the four genes which have not been described previously. The prevalences of the vgsc L995F and N1570Y mutations were higher on Bubaque Island than on the other islands in this study; Bubaque is the most populous island in the archipelago, with the greatest population mobility and connection to continental Guinea-Bissau. CONCLUSIONS: This study provides the first surveillance data for genetic markers present in malaria vectors from islands across the Bijagós Archipelago. Overall prevalence of insecticide resistance mutations was found to be low. However, the identification of the vgsc L995F and N1570Y mutations associated with pyrethroid resistance warrants further monitoring. This is particularly important as the mainstay of malaria control on the islands is the use of pyrethroid insecticide-treated nets.

Identification of two insecticide resistance markers in Ethiopian Anopheles stephensi mosquitoes using a multiplex amplicon sequencing assay.

Since its first detection in 2012 in Djibouti, Anopheles stephensi has invaded and established in the Horn of Africa, and more recently Nigeria. The expansion of this vector poses a significant threat to malaria control and elimination efforts. Integrated vector management is the primary strategy used to interrupt disease transmission; however, growing insecticide resistance is threatening to reverse gains in global malaria control. We present a next-generation amplicon-sequencing approach, for high-throughput monitoring of insecticide resistance genes (ace1, GSTe2, vgsc and rdl), species identification and characterization of genetic diversity (its2 and cox1) in An. stephensi. Ninety-five An. stephensi mosquitoes, collected in Ethiopia, were screened, identifying 104 SNPs, including the knock-down mutation L958F (L1014F in Musca domestica), and for the first time in this vector species, the A296S substitution (A301S in Drosophila melanogaster) in the rdl locus. Two other amino acid substitutions (ace1-N177D, GSTe2-V189L) were also identified but have not been previously implicated in insecticide resistance. Genetic diversity in the mitochondrial cox1 gene revealed shared haplotypes between Ethiopian An. stephensi with samples from Pakistan, Sudan, and Djibouti. Overall, we present a reliable, cost-effective strategy using amplicon-sequencing to monitor known insecticide resistance mutations, with the potential to identify new genetic variants, to assist in the high-throughput surveillance of insecticide resistance in An. stephensi populations.

Supporting Bystanders and Other Staff Exposed to Negative Workplace Behaviour: Developing and Testing the IMO Intervention Framework in the Clinical Workplace.

Background: Medical student and health-care staff bullying remain international concerns. Our understanding about what might solve such problems is still developing. A common approach suggested for bystanders to bullying is that they challenge or "stand up" to the bully. At the same time, the considerable risks should they act (eg, verbal rebuke) are rarely acknowledged, and neither is the potential for considerable cognitive dissonance should they choose not to. Methods: Drawing on a substantial literature review, we developed an interventional program, initially with medical student bullying in mind, that generally employed a discourse for values cultivation. We implemented and evaluated this program through 6 cycles of action research methodology in 6 different departments of one tertiary teaching hospital. Data include individual interviews, discussions with key participants plus freehand comments from wider staff's workshop evaluations. Results: Alongside others, an early serendipitous finding was the "IMO" [Indirect, focus on Me, focus on Outcome] framework, intended for bystanders to student bullying. From using this framework, participants reported developing confidence in tackling negative behaviours, that interactions had better outcomes and that the workplace atmosphere felt more relaxed. It's use also significantly reduced cognitive dissonance. Encouragingly, participants went on to use IMO for staff-staff bullying incidents, and other common negative behaviours. We attribute IMO's utility to its memorability, simplicity and for catering to the many possible causes of bullying, including values issues, without perpetuating or creating conflict. Conclusion: The IMO framework is offered as a widely usable framework for all staff in a clinical environment - a useful addition to popular frameworks used in the clinical workplace, ideas from which might also help these be further refined. Further evaluation would establish whether IMO invites long-term change and its utility in other contexts.

Towards environmental detection, quantification, and molecular characterization of Anopheles stephensi and Aedes aegypti from experimental larval breeding sites.

The invasion and establishment of An. stephensi mosquitoes in the Horn of Africa represents a significant regional threat, which may jeopardise malaria control, particularly in urban areas which were formally free from disease transmission. Novel vector surveillance methods are urgently needed, both agnostic to mosquito larval morphology, and simple to implement at the sampling stage. Using new multiplex TaqMan assays, specifically targeting An. stephensi and Ae. aegypti, we validated the use of environmental DNA (eDNA) for simultaneous vector detection in shared artificial breeding sites. Study findings demonstrated that An. stephensi and Ae. aegypti eDNA deposited by as few as one second instar larva in 1L of water was detectable. Characterization of molecular insecticide resistance mechanisms, using novel amplicon-sequencing panels for both vector species, was possible from eDNA shed by as few as 16-32 s instar larvae in 50 ml of water. An. stephensi eDNA, derived from emergent pupae for 24 h, was remarkably stable, and still detectable ~ 2 weeks later. eDNA surveillance has the potential to be implemented in local endemic communities and at points of country entry, to monitor the spread of invasive vector species. Further studies are required to validate the feasibility of this technique under field conditions.

Promoting Compassionate Responses to Disclosures of Sexual Violence in University Settings: Exploring the Impact of a Social Marketing Campaign.

This study explores a social marketing campaign aimed to promote compassionate responses to disclosures of sexual violence from peers and raise awareness of university-based formal support services. Findings from a survey (n = 189) and follow-up focus groups (n = 11) conducted with university students in Australia indicated that exposure to the campaign may support students' self-perceived confidence in responding compassionately to disclosures of sexual violence and raise awareness of university-based formal support services. These findings suggest social marketing may be a useful tool to form part of universities' sexual violence response and prevention strategies. These findings may help inform future university campaigns.

A next generation targeted amplicon sequencing method to screen for insecticide resistance mutations in Aedes aegypti populations reveals a rdl mutation in mosquitoes from Cabo Verde.

Aedes mosquito vectors transmit many viruses of global health concern, including dengue, chikungunya and Zika. These vector-borne viral diseases have a limited number of treatment options, and vaccines vary in their effectiveness. Consequently, integrated vector management is a primary strategy for disease control. However, the increasing emergence and spread of insecticide resistance is threatening the efficacy of vector control methods. Identifying mutations associated with resistance in vector populations is important to monitor the occurrence and evolution of insecticide resistance and inform control strategies. Rapid and cost-effective genome sequencing approaches are urgently needed. Here we present an adaptable targeted amplicon approach for cost-effective implementation within next generation sequencing platforms. This approach can identify single nucleotide polymorphisms (SNPs) and small insertions and deletions (indels) in genes involved in insecticide resistance in Aedes aegypti mosquitoes. We designed and tested eleven amplicons, which included segments of the ace-1 (carbamate target), the Voltage-Gated Sodium Channel (vgsc; pyrethroids, DDT and organochlorines), and rdl (dieldrin) genes; thereby covering established knockdown resistance (kdr) mutations (e.g., S989P, I1011M/V, V1016G/I and F1534C), with the potential to identify novel ones. The amplicon assays were designed with internal barcodes, to facilitate multiplexing of large numbers of mosquitoes at low cost, and were sequenced using an Illumina platform. Our approach was evaluated on 152 Ae. aegypti mosquitoes collected in Cabo Verde, an archipelago with a history of arbovirus outbreaks. The amplicon sequence data revealed 146 SNPs, including four non-synonymous polymorphisms in the vgsc gene, one in ace-1 and the 296S rdl mutation previously associated with resistance to organochlorines. The 296S rdl mutation was identified in 98% of mosquitoes screened, consistent with the past use of an organochlorine compound (e.g., DDT). Overall, our work shows that targeted amplicon sequencing is a rapid, robust, and cost-effective tool that can be used to perform high throughput monitoring of insecticide resistance.

High-throughput barcoding method for the genetic surveillance of insecticide resistance and species identification in Anopheles gambiae complex malaria vectors.

Surveillance of malaria vector species and the monitoring of insecticide resistance are essential to inform malaria control strategies and support the reduction of infections and disease. Genetic barcoding of mosquitoes is a useful tool to assist the high-throughput surveillance of insecticide resistance, discriminate between sibling species and to detect the presence of Plasmodium infections. In this study, we combined multiplex PCR, custom designed dual indexing, and Illumina next generation sequencing for high throughput single nucleotide polymorphism (SNP)-profiling of four species from the Anopheles (An.) gambiae complex (An. gambiae sensu stricto, An. coluzzii, An. arabiensis and An. melas). By amplifying and sequencing only 14 genetic fragments (500 bp each), we were able to simultaneously detect Plasmodium infection; insecticide resistance-conferring SNPs in ace1, gste2, vgsc and rdl genes; the partial sequences of nuclear ribosomal internal transcribed spacers (ITS1 and ITS2) and intergenic spacers (IGS), Short INterspersed Elements (SINE), as well as mitochondrial genes (cox1 and nd4) for species identification and genetic diversity. Using this amplicon sequencing approach with the four selected An. gambiae complex species, we identified a total of 15 non-synonymous mutations in the insecticide target genes, including previously described mutations associated with resistance and two new mutations (F1525L in vgsc and D148E in gste2). Overall, we present a reliable and cost-effective high-throughput panel for surveillance of An. gambiae complex mosquitoes in malaria endemic regions.

Identifying How to Support Nurse Educators Nationally to Teach Nursing Informatics.

Preparing nurses for practice and ensuring nursing informatics is included in their curricula is a challenge for many nurse educators. This study asked nurse educators from around New Zealand (n=40) what they perceived as the concerns, barriers and facilitators to implementing nursing informatics within their curricula. Among the findings a key issue is the constantly evolving nature of information and communication technology in healthcare and nursing which results in the ongoing need for professional development to keep up-to-date. Outcomes from this study are recommendations which will inform our next steps in this project to support nurse educators provide the best education possible for new nurses.

Standardised Holographic Patients: An Evaluation of Their Role in Developing Clinical Reasoning Skills.

In 2019, two standardised holographic patients viewed through a mixed-reality (MR) HoloLens headset were used in a structured learning activity to develop clinical reasoning skills among second-year nursing students (N=99, 94%). Quantitative results indicated that all students felt that being able to closely view holographic patients enhanced their learning experience. Qualitative results showed that the best feature of the MR technology was being able to clinically assess the patient in a safe facilitated environment. Further analysis revealed that students were at the 'beginning' or 'developing' skill level of the vpLCJR. These findings confirm that using standardized holographic patients offers a dynamic and effective experience for students and helps students to develop clinical reasoning and judgement skills. The technology also allows educators to determine a student's development of clinical judgement skills and tailor learning experiences to further develop these skills.

Role of the HOXA cluster in HSC emergence and blood cancer.

Hematopoiesis, the process of blood formation, is controlled by a complex developmental program that involves intrinsic and extrinsic regulators. Blood formation is critical to normal embryonic development and during embryogenesis distinct waves of hematopoiesis have been defined that represent the emergence of hematopoietic stem or progenitor cells. The Class I family of homeobox (HOX) genes are also critical for normal embryonic development, whereby mutations are associated with malformations and deformity. Recently, members of the HOXA cluster (comprising 11 genes and non-coding RNA elements) have been associated with the emergence and maintenance of long-term repopulating HSCs. Previous studies identified a gradient of HOXA expression from high in HSCs to low in circulating peripheral cells, indicating their importance in maintaining blood cell numbers and differentiation state. Indeed, dysregulation of HOXA genes either directly or by genetic lesions of upstream regulators correlates with a malignant phenotype. This review discusses the role of the HOXA cluster in both HSC emergence and blood cancer formation highlighting the need for further research to identify specific roles of these master regulators in normal and malignant hematopoiesis.

Maps and metrics of insecticide-treated net access, use, and nets-per-capita in Africa from 2000-2020.

Insecticide-treated nets (ITNs) are one of the most widespread and impactful malaria interventions in Africa, yet a spatially-resolved time series of ITN coverage has never been published. Using data from multiple sources, we generate high-resolution maps of ITN access, use, and nets-per-capita annually from 2000 to 2020 across the 40 highest-burden African countries. Our findings support several existing hypotheses: that use is high among those with access, that nets are discarded more quickly than official policy presumes, and that effectively distributing nets grows more difficult as coverage increases. The primary driving factors behind these findings are most likely strong cultural and social messaging around the importance of net use, low physical net durability, and a mixture of inherent commodity distribution challenges and less-than-optimal net allocation policies, respectively. These results can inform both policy decisions and downstream malaria analyses.

Transforming postgraduate medical education during the COVID-19 pandemic: creating a trainee-led virtual teaching platform.

The COVID-19 pandemic has had a significant impact on the provision of postgraduate medical education across the country. There has been a widespread need to upskill and empower the medical workforce in order to tackle the evolving clinical situation. At Lewisham and Greenwich NHS Trust, traditional face-to-face group teaching was suspended due to the need for social distancing, but the appetite for learning was high. We recognised the need for alternative teaching methods and identified two key educational areas that required attention: topics related to COVID-19 and its management, and education for doctors being redeployed to other specialties. We developed an innovative method of education delivery to regularly provide high-quality, relevant material to hundreds of healthcare professionals at both hospital sites. We believe that our methods could help other organisations to maintain teaching as the pandemic progresses.

Spatiotemporal mapping of malaria prevalence in Madagascar using routine surveillance and health survey data.

Malaria transmission in Madagascar is highly heterogeneous, exhibiting spatial, seasonal and long-term trends. Previous efforts to map malaria risk in Madagascar used prevalence data from Malaria Indicator Surveys. These cross-sectional surveys, conducted during the high transmission season most recently in 2013 and 2016, provide nationally representative prevalence data but cover relatively short time frames. Conversely, monthly case data are collected at health facilities but suffer from biases, including incomplete reporting and low rates of treatment seeking. We combined survey and case data to make monthly maps of prevalence between 2013 and 2016. Health facility catchment populations were estimated to produce incidence rates from the case data. Smoothed incidence surfaces, environmental and socioeconomic covariates, and survey data informed a Bayesian prevalence model, in which a flexible incidence-to-prevalence relationship was learned. Modelled spatial trends were consistent over time, with highest prevalence in the coastal regions and low prevalence in the highlands and desert south. Prevalence was lowest in 2014 and peaked in 2015 and seasonality was widely observed, including in some lower transmission regions. These trends highlight the utility of monthly prevalence estimates over the four year period. By combining survey and case data using this two-step modelling approach, we were able to take advantage of the relative strengths of each metric while accounting for potential bias in the case data. Similar modelling approaches combining large datasets of different malaria metrics may be applicable across sub-Saharan Africa.

Global estimation of anti-malarial drug effectiveness for the treatment of uncomplicated Plasmodium falciparum malaria 1991-2019.

BACKGROUND: Anti-malarial drugs play a critical role in reducing malaria morbidity and mortality, but their role is mediated by their effectiveness. Effectiveness is defined as the probability that an anti-malarial drug will successfully treat an individual infected with malaria parasites under routine health care delivery system. Anti-malarial drug effectiveness (AmE) is influenced by drug resistance, drug quality, health system quality, and patient adherence to drug use; its influence on malaria burden varies through space and time. METHODS: This study uses data from 232 efficacy trials comprised of 86,776 infected individuals to estimate the artemisinin-based and non-artemisinin-based AmE for treating falciparum malaria between 1991 and 2019. Bayesian spatiotemporal models were fitted and used to predict effectiveness at the pixel-level (5 km × 5 km). The median and interquartile ranges (IQR) of AmE are presented for all malaria-endemic countries. RESULTS: The global effectiveness of artemisinin-based drugs was 67.4% (IQR: 33.3-75.8), 70.1% (43.6-76.0) and 71.8% (46.9-76.4) for the 1991-2000, 2006-2010, and 2016-2019 periods, respectively. Countries in central Africa, a few in South America, and in the Asian region faced the challenge of lower effectiveness of artemisinin-based anti-malarials. However, improvements were seen after 2016, leaving only a few hotspots in Southeast Asia where resistance to artemisinin and partner drugs is currently problematic and in the central Africa where socio-demographic challenges limit effectiveness. The use of artemisinin-based combination therapy (ACT) with a competent partner drug and having multiple ACT as first-line treatment choice sustained high levels of effectiveness. High levels of access to healthcare, human resource capacity, education, and proximity to cities were associated with increased effectiveness. Effectiveness of non-artemisinin-based drugs was much lower than that of artemisinin-based with no improvement over time: 52.3% (17.9-74.9) for 1991-2000 and 55.5% (27.1-73.4) for 2011-2015. Overall, AmE for artemisinin-based and non-artemisinin-based drugs were, respectively, 29.6 and 36% below clinical efficacy as measured in anti-malarial drug trials. CONCLUSIONS: This study provides evidence that health system performance, drug quality and patient adherence influence the effectiveness of anti-malarials used in treating uncomplicated falciparum malaria. These results provide guidance to countries' treatment practises and are critical inputs for malaria prevalence and incidence models used to estimate national level malaria burden.

Measuring exposure to bullying and harassment in health professional students in a clinical workplace environment: Evaluating the psychometric properties of the clinical workplace learning NAQ-R scale.

Background: Instruments that measure exposure to bullying and harassment of students learning in a clinical workplace environment (CWE) that contain validity evidence are scarce. The aim of this study was to develop such a measure and provide some validity evidence for its use.Method: We took an instrument for detecting bullying of employees in the workplace, called the Negative Acts Questionnaire - Revised (NAQ-R). Items on the NAQ-R were adapted to align with our context of health professional students learning in a CWE and added two new factors of sexual and ethnic harassment. This new instrument, named the Clinical Workplace Learning NAQ-R, was distributed to 540 medical and nursing undergraduate students and we undertook a Confirmatory Factor Analysis (CFA) to investigate its construct validity and factorial structure.Results: The results provided support for the construct validity and factorial structure of the new scale comprising five factors: workplace learning-related bullying (WLRB), person-related bullying (PRB), physically intimidating bullying (PIB), sexual harassment (SH), and ethnic harassment (EH). The reliability estimates for all factors ranged from 0.79 to 0.94.Conclusion: This study provides a tool to measure the exposure to bullying and harassment in health professional students learning in a CWE.