Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial.

BACKGROUND: In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. METHODS: A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. RESULTS: Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. CONCLUSIONS: Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. TRIAL REGISTRATION: CTRI/2021/09/036130.

Public cervical cancer screening recommendations from US cancer centers: Assessing adherence to national guidelines.

Though widespread adoption of cervical cancer screening (CCS) in the US has been associated with a reduction in cervical cancer incidence and mortality, screening also carries with it potential risks. Newer national guidelines recommend decreased screening frequency to optimize the benefit/risk balance and to prevent over-screening. Here, we examined the alignment of US cancer center websites' public recommendations on CCS with national guidelines. We reviewed the websites of 1024 cancer centers accredited by the US Commission on Cancer during January-August 2022. We recorded the recommended frequency and type of CCS and any screening risks mentioned, comparing against national US Preventive Service Task Force (USPSTF) and American Cancer Society (ACS) guidelines. Of 1024 US cancer centers, 60% (610) provided CCS recommendations. Most centers are in alignment with the screening starting age (96%, 544/565) and stopping age (94%, 440/470) recommended by national guidelines. Of 508 centers specifying the frequency of standalone cervical cytology, 83% (419) recommended a screening interval of three years; however, 14% (73) recommended cervical cytology more frequently than the three-year interval recommended by the ACS/USPSTF. Screening risks were mentioned by 20% (124/610) of centers. Our findings highlight the importance of education on screening benefits and risks for physicians and patients to enable shared decision making based on evidence-based guidelines.

What Do Global Health Practitioners Think about Decolonizing Global Health?

The growing awareness of colonialism's role in global health partnerships between HICs and LMICs and the associated calls for decolonization in global health has led to discussion for a paradigm shift that would lead to new ways of engagement and partnerships, as well as an acknowledgement that colonialism, racism, sexism, and capitalism contribute to inequity. While there is general agreement among those involved in global health partnerships that the current system needs to be made more equitable, suggestions for how to address the issue of decolonization vary greatly, and moving from rhetoric to reform is complicated. Based on a comprehensive (but not exhaustive) review of the literature, there are several recurring themes that should be addressed in order for the inequities in the current system to be changed. The degree to which decolonization of global health will be successful depends on how the global health community in both the HICs and LMICs move forward to discuss these issues. Specifically, as part of a paradigm shift, attention needs to be paid to creating a more equal and equitable representation of researchers in LMICs in decision-making, leadership roles, authorship, and funding allocations. There needs to be agreement in defining basic principles of best practices for global partnership, including a universal definition of 'decolonization of global health'; the extent to which current policies allow the perpetuation of power imbalance between HICs and LMICs; a set of principles, best practices, and models for equitable sharing of funds and institutional costs among partners; a mechanism to monitor progress prospectively the equitable sharing of credits (e.g., leadership, authorship), including a set of principles, best practices, and models; and, a mechanism to monitor progress prospectively the extent to which decolonialization will contribute to strengthening institutional capacity in the LMIC institutions.

Improved Water and Waste Management Practices Reduce Diarrhea Risk in Children under Age Five in Rural Tanzania: A Community-Based, Cross-Sectional Analysis.

Diarrhea remains a significant cause of morbidity and mortality among children in developing countries. Water, sanitation, and hygiene practices (WASH) have demonstrated improved diarrhea-related outcomes but may have limited implementation in certain communities. This study analyzes the adoption and effect of WASH-based practices on diarrhea in children under age five in the rural Busiya chiefdom in northwestern Tanzania. In a cross-sectional analysis spanning July-September 2019, 779 households representing 1338 under-five children were surveyed. Among households, 250 (32.1%) reported at least one child with diarrhea over a two-week interval. Diarrhea prevalence in under-five children was 25.6%. In per-household and per-child analyses, the strongest protective factors against childhood diarrhea included dedicated drinking water storage (OR 0.25, 95% CI 0.18−0.36; p < 0.001), improved waste management (OR 0.37, 95% CI 0.27−0.51; p < 0.001), and separation of drinking water (OR 0.38, 95% CI 0.24−0.59; p < 0.001). Improved water sources were associated with decreased risk of childhood diarrhea in per-household analysis (OR 0.72, 95% CI 0.52−0.99, p = 0.04), but not per-child analysis (OR 0.83, 95% CI 0.65−1.05, p = 0.13). Diarrhea was widely treated (87.5%), mostly with antibiotics (44.0%) and oral rehydration solution (27.3%). Targeting water transportation, storage, and sanitation is key to reducing diarrhea in rural populations with limited water access.

Unconventional natural gas development and human health: thoughts from the United States.

If unconventional gas development (UGD) continues to expand in Australia, the potential health and environmental impacts should be adequately addressed and preventive public health measures should be implemented. The United States has embraced UGD and has decades of experience that could be beneficial to Australia as stakeholders debate the potential benefits and harms of the technique. Additional research on the health impacts of UGD is necessary. Baseline and trend morbidity and mortality data need to be collected to assess changes in population health over time. To date, few health or epidemiological studies have been conducted, so it remains difficult to assess actual health outcomes. In the absence of scientific consensus, there are two possible risks: failing to develop unconventional natural gas when the harms are manageable; or developing it when the harms are substantial. Many government bodies around the world have chosen to minimise the risk of the latter until the impacts of UGD are better understood. Policies should be informed by empirical evidence based on actual experience rather than assurance of best practices. There is a strong rationale for precautionary measures based on the health and environmental risks identified in the scientific literature.

Considerations for the development of shale gas in the United Kingdom.

The United States shale gas boom has precipitated global interest in the development of unconventional oil and gas resources. Recently, government ministers in the United Kingdom started granting licenses that will enable companies to begin initial exploration for shale gas. Meanwhile, concern is increasing among the scientific community about the potential impacts of shale gas and other types of unconventional natural gas development (UGD) on human health and the environment. Although significant data gaps remain, there has been a surge in the number of articles appearing in the scientific literature, nearly three-quarters of which has been published since the beginning of 2013. Important lessons can be drawn from the UGD experience in the United States. Here we explore these considerations and argue that shale gas development policies in the UK and elsewhere should be informed by empirical evidence generated on environmental, public health, and social risks. Additionally, policy decisions should take into account the measured effectiveness of harm reduction strategies as opposed to hypothetical scenarios and purported best practices that lack empirical support.

Environmental public health dimensions of shale and tight gas development.

BACKGROUND: The United States has experienced a boom in natural gas production due to recent technological innovations that have enabled this resource to be produced from shale formations. OBJECTIVES: We reviewed the body of evidence related to exposure pathways in order to evaluate the potential environmental public health impacts of shale gas development. We highlight what is currently known and identify data gaps and research limitations by addressing matters of toxicity, exposure pathways, air quality, and water quality. DISCUSSION: There is evidence of potential environmental public health risks associated with shale gas development. Several studies suggest that shale gas development contributes to ambient air concentrations of pollutants known to be associated with increased risk of morbidity and mortality. Similarly, an increasing body of studies suggest that water contamination risks exist through a variety of environmental pathways, most notably during wastewater transport and disposal, and via poor zonal isolation of gases and fluids due to structural integrity impairment of cement in gas wells. CONCLUSION: Despite a growing body of evidence, data gaps persist. Most important, there is a need for more epidemiological studies to assess associations between risk factors, such as air and water pollution, and health outcomes among populations living in close proximity to shale gas operations.

The role of ethics in shale gas policies.

The United States has experienced a boom in natural gas production due to recent technological innovations that have enabled natural gas to be produced from unconventional sources, such as shale. There has been much discussion about the costs and benefits of developing shale gas among scientists, policy makers, and the general public. The debate has typically revolved around potential gains in economics, employment, energy independence, and national security as well as potential harms to the environment, the climate, and public health. In the face of scientific uncertainty, national and international governments must make decisions on how to proceed. So far, the results have been varied, with some governments banning the process, others enacting moratoria until it is better understood, and others explicitly sanctioning shale gas development. These policies reflect legislature's preferences to avoid false negative errors or false positive ones. Here we argue that policy makers have a prima facie duty to minimize false negatives based on three considerations: (1) protection from serious harm generally takes precedence over the enhancement of welfare; (2) minimizing false negatives in this case is more respectful to people's autonomy; and (3) alternative solutions exist that may provide many of the same benefits while minimizing many of the harms.

Marcellus Shale Drilling's Impact on the Dairy Industry in Pennsylvania: A Descriptive Report.

Unconventional natural gas drilling in Pennsylvania has accelerated over the past five years, and is unlikely to abate soon. Dairy farming is a large component of Pennsylvania's agricultural economy. This study compares milk production, number of cows, and production per cow in counties with significant unconventional drilling activity to that in neighboring counties with less unconventional drilling activity, from 1996 through 2011. Milk production and milk cows decreased in most counties since 1996, with larger decreases occurring from 2007 through 2011 (when unconventional drilling increased substantially) in five counties with the most wells drilled compared to six adjacent counties with fewer than 100 wells drilled. While this descriptive study cannot draw a causal association between well drilling and decline in cows or milk production, given the importance of Pennsylvania's dairy industry and the projected increase in unconventional natural gas drilling, further research to prevent unintended economic and public health consequences is imperative.

The global health curriculum of Weill Cornell Medical College: how one school developed a global health program.

Since 2009, a multidisciplinary team at Weill Cornell Medical College (WCMC) has collaborated to create a comprehensive, elective global health curriculum (GHC) for medical students. Increasing student interest sparked the development of this program, which has grown from ad hoc lectures and dispersed international electives into a comprehensive four-year elective pathway with over 100 hours of training, including three courses, two international experiences, a preceptorship with a clinician working with underserved populations in New York City, and regular lectures and seminars by visiting global health leaders. Student and administrative enthusiasm has been strong: In academic years 2009, 2010, and 2011, over half of the first-year students (173 of 311)participated in some aspect of the GHC, and 18% (55 of 311) completed all first-year program requirements.The authors cite the student-driven nature of GHC as a major factor in its success and rapid growth. Also important was the foundation previously established by WCMC global health faculty, the serendipitous timing of the GHC's development in the midst of curricular reform and review, as well as the presence of a full-time, nonclinical Global Health Fellow who served as a program coordinator. Given the enormous expansion of medical student interest in global health training throughout the United States and Canada over the past decade, the authors hope that medical schools developing similar programs will find the experience at Weill Cornell informative and helpful.

The rush to drill for natural gas: a public health cautionary tale.

Efforts to identify alternative sources of energy have focused on extracting natural gas from vast shale deposits. The Marcellus Shale, located in western New York, Pennsylvania, and Ohio, is estimated to contain enough natural gas to supply the United States for the next 45 years. New drilling technology-horizontal drilling and high-volume hydraulic fracturing of shale (fracking)-has made gas extraction much more economically feasible. However, this technique poses a threat to the environment and to the public's health. There is evidence that many of the chemicals used in fracking can damage the lungs, liver, kidneys, blood, and brain. We discuss the controversial technique of fracking and raise the issue of how to balance the need for energy with the protection of the public's health.

Risk factors for pediatric asthma in the South Bronx.

We identified main asthma risk factors for children living in the South Bronx, where asthma rates are eight times higher than the national average. This case-control study enrolled 261 children at Lincoln Medical and Mental Health Center from 2002 to 2003. We questioned the mothers on medical history and home environment. The most important risk factors for asthma in the South Bronx pediatric population are Hispanic ethnicity, family history of asthma, and exposure to tobacco smoke. South Bronx children limited to breast-feeding during the first 3 months of age are less likely to develop asthma.

Initiating abortion training in residency programs: issues and obstacles.

OBJECTIVES: Early abortion is a common outpatient procedure, but few family medicine residencies provide abortion training. We wished to assess experiences and obstacles among residency programs that have worked to establish early abortion services. METHODS: From 2001-2004, 14 faculty participated in a collaborative program to initiate abortion training at seven family medicine residencies. Ten focus groups with all trainees were followed by individual semi-structured interviews with a smaller group (n=9) that explored the progress and obstacles they experienced. Individual interviews were recorded and analyzed to identify major themes and sub-themes related to initiating abortion training. RESULTS: Five of seven sites established abortion training. Five major themes were identified: (1) establishing support, (2) administration, (3) finance, (4) legal matters, and (5) security/demonstrators. Faculty from sites where training was ultimately established rated the sub-themes of billing/reimbursement, obtaining staff support, and state/hospital regulations as most difficult. Gaining support from within the department and institution was most difficult for the two sites that could not establish training. None experienced difficulty with security/demonstrators. CONCLUSIONS: Developing the clinical and administrative capacity to provide early abortion services in family medicine residency programs is feasible. Support from leadership within departments and from the wider institution is important for implementation.

Teaching medical students about different health care systems: an international exchange program.

Understanding how different health care systems are organized and financed is rarely taught in medical school. In 1997, several U.S. and European medical schools formed an ongoing, innovative, and collaborative exchange program to enable their medical students to gain an insight into the dynamics of another country's health care system. One student from each participating institution completes a month-long rotation at a host medical school under the supervision of a faculty mentor. Selected target diagnoses serve as the basis for comparative case studies. To enable the student to effectively study the host country's health care system, each is assigned a patient with the preselected specific diagnosis. The students view the patient's care within the context of the host country's delivery system rather than being limited to the clinical diagnosis and treatment of the disease. Matching the student with a patient permits the student to see how medical care is delivered and financed in the host country. Each student is required to prepare a written report focusing on costs; organization and delivery of care; quality and outcomes of care; politics, culture, and ethics; and learning. The case studies permit comparisons of health care systems among the participating U.S. and European Union countries, as well as opportunities for institutional and individual learning.