Assessing Use, Usefulness, and Application of the High Impact Practices in Family Planning Briefs and Strategic Planning Guides.

BACKGROUND: In global health, persistent barriers and challenges to bridging the gap between research and practice remain critical to address in most health areas. The High Impact Practices (HIPs) briefs and strategic planning guides aim to bridge the know-do gap in family planning (FP) by facilitating research utilization and knowledge sharing and also providing a summary of experiential knowledge from experts. The purpose of this qualitative study was to assess the use, usefulness, and application of these 2 knowledge products developed by the HIP Partnership for decision-makers and implementers in low- and middle-income countries (LMICs). METHODS: This research used in-depth interviews with FP stakeholders from various LMICs to assess the use, usefulness, and application of 2 HIP products for FP decision-makers and implementers. The analysis was shaped by an adapted logic model framework to assess HIP product reach, engagement, usefulness, learning, and action. RESULTS: We interviewed 35 FP professionals from January to March 2021. Participants reported that HIP products have a wide reach, have garnered positive engagement, and were useful. Participants generally liked the current format of the HIP products and reported using them to inform program design, guide discussions with partners, enhance personal knowledge, support advocacy work, and strengthen the guidance they provide to colleagues in the field. The participants shared important feedback to improve the development and dissemination of HIP products, particularly a need to enhance local access and use. CONCLUSION: The study highlighted the importance of knowledge products, such as the HIP briefs and strategic planning guides, to make evidence and experiential knowledge accessible to a wide audience. These can be valuable tools for policymakers and program implementers to ensure public health practices are evidence-based and integrate experiential knowledge.

Can payment by results ensure equitable access to contraceptive services? a qualitative case study.

BACKGROUND: The Leave No One Behind (LNOB) agenda compels sexual and reproductive health and rights (SRHR) implementers to focus on the multiple and intersecting forms of discrimination and inequalities. One strategy to address these is Payment by Results (PbR). Using the Women's Integrated Sexual Health (WISH) programme as a case study, this paper examines if and how PbR can ensure equitable reach and impact. METHODS: Given the complexity of PbR mechanisms, a theory-based approach was used in the design and analysis of this evaluation, drawing on four case studies. These were conducted by reviewing global and national programme data and by interviewing 50 WISH partner staff at national level and WISH programme staff at global and regional levels. RESULTS: The case studies found that inclusion of equity-based indicators in the PbR mechanism had demonstrable effects on people's incentives, on how systems work, and on modes of working. The WISH programme was successful in achieving its desired programme indicators. The use of Key Performance Indicators (KPIs) clearly incentivised several strategies for service providers to innovate and reach adolescents and people living in poverty. However, there were trade-offs between performance indicators that increased coverage and others that increased equitable access, as well as several systemic challenges that limited the possible incentive effects. CONCLUSIONS: The use of PbR KPIs incentivised several strategies to reach adolescents and people living in poverty. However, the use of global indicators was too simplistic, resulting in several methodological issues.

Rapid Adoption of Telemedicine Along with Emergent Use of Continuous Glucose Monitors in the Ambulatory Care of Young Persons with New-Onset Type 1 Diabetes in the Time of COVID-19: A Case Series.

Aims: The COVID-19 pandemic has caused strain on hospital systems and potential delay in diagnosis of type 1 diabetes (T1D). Outpatient diagnosis and treatment of metabolically stable young persons with new-onset T1D have been shown to be equivalent to inpatient. We describe an approach to outpatient management of newly diagnosed T1D during the COVID-19 pandemic using an interdisciplinary team, telemedicine, and diabetes technologies including rapid implementation of continuous glucose monitoring (CGM). Methods: Following the onset of the COVID-19 pandemic, new-onset cases of T1D were tracked. After laboratory confirmation of diagnosis and metabolic stability, patients and families were referred for ambulatory initiation of insulin therapy and diabetes education. These cases were reviewed using data extracted from the electronic health record, comments from multidisciplinary team members, and cloud-based glucose data. Results: We report on seven young people with new-onset T1D without diabetic ketoacidosis from April to June 2020, during the COVID-19 pandemic. Ages ranged 9-23 years with presenting hemoglobin A1c (HbA1c) values 10-14.5%. Initial evaluation was generally face-to-face, followed by frequent telemedicine visits. Five patients had a family history of T1D. Two patients had access to at-home HbA1c kits prompting evaluation in the absence of symptoms. Four patients required emergency department evaluation. Five patients presented with ketosis. All patients were prescribed CGM at the first visit, most starting within 1 month. Conclusions: Technology is extraordinarily useful for the care of young persons with new-onset T1D in the ambulatory setting during the COVID-19 pandemic. Large observational studies are needed to better understand outcomes of an outpatient, technology-focused approach.

Associations of nutrient intake with glycemic control in youth with type 1 diabetes: differences by insulin regimen.

BACKGROUND: Type 1 diabetes management has evolved from meal plans towards flexible eating with carbohydrate counting. With this shift, youth with type 1 diabetes may consume excess fat and insufficient fiber, which may impact glycemic control. Few studies consider whether insulin regimen influences associations between dietary intake and hemoglobin A1c. PATIENTS AND METHODS: In this cross-sectional study, 252 youth (52% male; age, 13.2 ± 2.8 years; body mass index z-score [z-BMI], 0.7 ± 0.8) with type 1 diabetes completed 3-day food records. Dietary intake was compared with published guidelines. Logistic regression predicted the odds of suboptimal glycemic control (an A1c level of ≥ 8.5%) related to fat and protein intake or fiber intake according to insulin regimen (pump vs. injection) adjusting for age, sex, diabetes duration, z-BMI, insulin dose, glucose monitoring frequency, and total energy intake (TEI). RESULTS: Youth had a mean TEI of 40.9 ± 15.4 kcal/kg/day and excess fat and insufficient fiber intake compared against published guidelines. Pump-treated youth consuming the highest quartile of fat intake (as percentage TEI) had 3.6 (95% confidence interval, 1.3-9.7) times the odds of a suboptimal A1c than those in the lowest quartile. No such association was found in injection-treated youth. In the total sample, youth with the lowest quartile of fiber intake had 3.6 (95% confidence interval, 1.4-9.0) times the odds of a suboptimal A1c, but this association did not differ by insulin regimen. There was no association between protein intake and A1c. CONCLUSIONS: Higher fat intake in pump-treated youth and lower fiber intake in all youth were associated with an A1c level of ≥ 8.5%. Improving dietary quality may help improve A1c.

Vocal local versus pharmacological treatments for pain management in tubal ligation procedures in rural Kenya: a non-inferiority trial.

BACKGROUND: Vocal local (VL) is a non-pharmacological pain management technique for gynecological procedures. In Africa, it is usually used in combination with pharmacological analgesics. However, analgesics are associated with side-effects, and can be costly and subject to frequent stock-outs, particularly in remote rural settings. We compared the effectiveness of VL + local anesthesia + analgesics (the standard approach), versus VL + local anesthesia without analgesics, on pain and satisfaction levels for women undergoing tubal ligations in rural Kenya. METHODS: We conducted a site-randomised non-inferiority trial of 884 women receiving TLs from 40 Marie Stopes mobile outreach sites in Kisii and Machakos Districts. Twenty sites provided VL + local anesthesia + analgesics (control), while 20 offered VL + local anesthesia without additional analgesics (intervention). Pain was measured using a validated 11-point Numeric Rating Scale; satisfaction was measured using 11-point scales. RESULTS: A total of 461 women underwent tubal ligations with VL + local anesthesia, while 423 received tubal ligations with VL + local anesthesia + analgesics. The majority were aged ≥30 years (78%), and had >3 children (99%). In a multivariate analysis, pain during the procedure was not significantly different between the two groups. The pain score after the procedure was significantly lower in the intervention group versus the control group (by 0.40 points; p = 0.041). Satisfaction scores were equally high in both groups; 96% would recommend the procedure to a friend. CONCLUSION: VL + local anesthesia is as effective as VL + local anesthesia + analgesics for pain management during tubal ligation in rural Kenya. Avoiding analgesics is associated with numerous benefits including cost savings and fewer issues related to the maintenance, procurement and monitoring of restricted opioid drugs, particularly in remote low-resource settings where these systems are weak. TRIAL REGISTRATION: Pan-African Clinical Trials Registry PACTR201304000495942.

Safety and acceptability of tubal ligation procedures performed by trained clinical officers in rural Uganda.

OBJECTIVE: To assess safety associated with tubal ligation performed by trained clinical officers (COs) in rural Uganda. METHODS: Between March and June 2012, 518 women in 4 regions of Uganda were recruited into a prospective cohort study and followed at days 3, 7, and 45 after undergoing tubal ligation performed by a trained CO. Intraoperative and postoperative adverse events (minor, moderate, or major), and acceptability were assessed. RESULTS: Mean age was 36 years (range, 20-49 years) and mean number of living children was 6.7 (range, 0-15). The overall rate of major adverse events was 1.5%: 0.4% intraoperatively; 1.9% at day 3; and 0.2% at day 7. The majority of women who underwent tubal ligation reported a good/very good experience at the facility (range, 94%-99%) and would recommend the health services to a friend (range, 93%-98%). CONCLUSION: In the present study, task sharing of tubal ligation to trained COs in private facilities was safe. Women reported high levels of satisfaction with the procedure. Training COs could be an effective strategy for expanding family-planning services to rural Uganda.

Proteomic analysis demonstrates adolescent vulnerability to lasting hippocampal changes following chronic alcohol consumption.

BACKGROUND: Excessive teenage alcohol consumption is of great concern because alcohol may adversely alter the developmental trajectory of the brain. The aim of the present study was to assess whether chronic intermittent alcohol intake during the adolescent period alters hippocampal protein expression to a greater extent than during adulthood. METHODS: Adolescent [postnatal day (PND) 27] and adult (PND 55) male Wistar rats were given 8 hours daily access to beer (4.44% ethanol v/v) in addition to ad libitum food and water for 4 weeks. From a large subject pool, subgroups of adolescent and adult rats were selected that displayed equivalent alcohol intake (average of 6.1 g/kg/day ethanol). The 4 weeks of alcohol access were followed by a 2-week alcohol-free washout period after which the hippocampus was analyzed using 2-DE proteomics. RESULTS: Beer consumption by the adult group resulted in modest hippocampal changes relative to alcohol naïve adult controls. The only changes observed were an up-regulation of citrate synthase (a precursor to the Krebs cycle) and fatty acid binding protein (which facilitates fatty acid metabolism). In contrast, adolescent rats consuming alcohol showed more widespread hippocampal changes relative to adolescent controls. These included an increase in cytoskeletal protein T-complex protein 1 subunit epsilon (TCP-1) and a decrease in the expression of 10 other proteins, including glyceraldehyde-3-phosphate dehydrogenase (GAPDH), triose phosphate isomerise, alpha-enolase, and phosphoglycerate kinase 1 (all involved in glycolysis); glutamate dehydrogenase 1 (an important regulator of glutamate); methylmalonate-semialdehyde dehydrogenase (involved in aldehyde detoxification); ubiquitin carboxyl-terminal hydrolase isozyme L1 (a regulator of protein degradation); and synapsin 2 (involved in synaptogenesis and neurotransmitter release). CONCLUSIONS: These results suggest the adolescent hippocampus is more vulnerable to lasting proteomic changes following repeated alcohol exposure. The proteins most affected include those related to glycolysis, glutamate metabolism, neurodegeneration, synaptic function, and cytoskeletal structure.

Adolescent rats find repeated Delta(9)-THC less aversive than adult rats but display greater residual cognitive deficits and changes in hippocampal protein expression following exposure.

The current study examined whether adolescent rats are more vulnerable than adult rats to the lasting adverse effects of cannabinoid exposure on brain and behavior. Male Wistar rats were repeatedly exposed to Delta-9-tetrahydrocannabinol (Delta(9)-THC, 5 mg/kg i.p.) in a place-conditioning paradigm during either the adolescent (post-natal day 28+) or adult (post-natal day 60+) developmental stages. Adult rats avoided a Delta(9)-THC-paired environment after either four or eight pairings and this avoidance persisted for at least 16 days following the final Delta(9)-THC injection. In contrast, adolescent rats showed no significant place aversion. Adult Delta(9)-THC-treated rats produced more vocalizations than adolescent rats when handled during the intoxicated state, also suggesting greater drug-induced aversion. After a 10-15 day washout, both adult and adolescent Delta(9)-THC pretreated rats showed decreased social interaction, while only Delta(9)-THC pretreated adolescent rats showed significantly impaired object recognition memory. Seventeen days following their last Delta(9)-THC injection, rats were euthanased and hippocampal tissue processed using two-dimensional gel electrophoresis proteomics. There was no evidence of residual Delta(9)-THC being present in blood at this time. Proteomic analysis uncovered 27 proteins, many involved in regulating oxidative stress/mitochondrial functioning and cytoarchitecture, which were differentially expressed in adolescent Delta(9)-THC pretreated rats relative to adolescent controls. In adults, only 10 hippocampal proteins were differentially expressed in Delta(9)-THC compared to vehicle-pretreated controls. Overall these findings suggest that adolescent rats find repeated Delta(9)-THC exposure less aversive than adults, but that cannabinoid exposure causes greater lasting memory deficits and hippocampal alterations in adolescent than adult rats.