Prevalence and Risk Factors of Distal Symmetric Polyneuropathy Among Predominantly Non-Hispanic Black, Low-Income Patients.

BACKGROUND AND OBJECTIVES: Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations. METHODS: Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97. RESULTS: Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001). DISCUSSION: DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.

Allergic Reactions to Sugammadex: A Case Series and Review of the Literature.

Sugammadex is a novel agent for the reversal of neuromuscular blockade; it acts by encapsulating -rocuronium or vecuronium, eliminating the active compound from the circulation, thereby providing rapid and complete recovery even with profound or complete neuromuscular blockade. Clinical advantages, including reduced incidence of residual blockade, decreased nausea and vomiting, decreased dry mouth, less change in heart rate, and reduced pulmonary complications, have been demonstrated when comparing sugammadex to conventional agents, such as neostigmine, that inhibit acetylcholinesterase. Although generally safe and effective, anaphylactoid and allergic reactions have been reported with sugammadex. The potential for hypersensitivity reactions with sugammadex and previous reports from the literature, as well as diagnostic and treatment strategies, are presented in 3 pediatric cases.

Kansa talk: mapping cancer terminologies in Bagamoyo, Tanzania towards dignity-based practice.

This paper reports and examines the results of qualitative research on the use of local cancer terminology in urban Bagamoyo, Tanzania. Following recent calls to unify evidence and dignity-based practices in global health, this research locates local medical sociolinguistics as a key place of entry into creating epistemologically autonomous public health practices. We used semistructured ethnographic interviews to reveal both the contextual and broader patterns related to use of local cancer terminologies among residents of Dunda Ward in urban Bagamoyo. Our findings suggest that people in Bagamoyo employ diverse terms to describe and make meanings about cancer that do not neatly fit with biomedical paradigms. This research not only opens further investigation about how ordinary people speak and make sense of the emerging cancer epidemic in places like Tanzania, but also is a window into otherwise conceptualisations of 'intervention' onto people in formerly colonised regions to improve a health situation. We argue that adapting biomedical concepts into local sociolinguistic and knowledge structures is an essential task in creating dignity-based, evidence-informed practices in global health.

Patterns, procedures, and indications for pediatric surgery in a Tanzanian Refugee Camp: a 20-year experience.

Background: There are 103 million displaced people worldwide, 41% of whom are children. Data on the provision of surgery in humanitarian settings are limited. Even scarcer is literature on pediatric surgery performed in humanitarian settings, particularly protracted humanitarian settings. Methods: We reviewed patterns, procedures, and indications for pediatric surgery among children in Nyarugusu Refugee Camp using a 20-year retrospective dataset. Results: A total of 1221 pediatric surgical procedures were performed over the study period. Teenagers between the ages of 12 and 17 years were the most common age group undergoing surgery (n=991; 81%). A quarter of the procedures were performed on local Tanzanian children seeking care in the camp (n=301; 25%). The most common procedures performed were cesarean sections (n=858; 70%), herniorrhaphies (n=197; 16%), and exploratory laparotomies (n=55; 5%). Refugees were more likely to undergo exploratory laparotomy (n=47; 5%) than Tanzanian children (n=7; 2%; p=0.032). The most common indications for exploratory laparotomy were acute abdomen (n=24; 44%), intestinal obstruction (n=10; 18%), and peritonitis (n=9; 16%). Conclusions: There is a significant volume of basic pediatric general surgery performed in the Nyarugusu Camp. Services are used by both refugees and local Tanzanians. We hope this research will inspire further advocacy and research on pediatric surgical services in humanitarian settings worldwide and illuminate the need for including pediatric refugee surgery within the growing global surgery movement.

Food safety policy enforcement and associated actions reduce lead chromate adulteration in turmeric across Bangladesh.

Turmeric adulterated with lead chromate pigment has been previously identified as a primary source of lead exposure in Bangladesh. This study assesses the impact of a multi-faceted intervention between 2017 and 2021 to reduce lead-tainted turmeric in Bangladesh. The intervention involved: i) disseminating findings from scientific studies via news media that identified turmeric as a source of lead poisoning, ii) educating consumers and businesspeople about the risks of lead chromate in turmeric via public notices and face-to-face meetings, and iii) collaborating with the Bangladesh Food Safety Authority to utilize a rapid lead detection technology to enforce policy disallowing turmeric adulteration. Before and after the intervention, evidence of lead chromate turmeric adulteration was assessed at the nation's largest turmeric wholesale market and at turmeric polishing mills across the country. Blood lead levels of workers at two mills were also assessed. Forty-seven interviews were conducted with consumers, businesspeople, and government officials to assess changes in supply, demand, and regulatory capacity. The proportion of market turmeric samples containing detectable lead decreased from 47% pre-intervention in 2019 to 0% in 2021 (n = 631, p < 0.0001). The proportion of mills with direct evidence of lead chromate adulteration (pigment on-site) decreased from 30% pre-intervention in 2017 to 0% in 2021 (n = 33, p < 0.0001). Blood lead levels dropped a median of 30% (IQR: 21-43%), while the 90th percentile dropped 49% from 18.2 µg/dL to 9.2 µg/dL 16 months after the intervention (n = 15, p = 0.033). Media attention, credible information, rapid lead detection tools and swift government action to enforce penalties all contributed to the intervention's success. Subsequent efforts should evaluate if this is an example of an effective intervention that can be replicated to reduce lead chromate adulteration of spices globally.

How does women's empowerment relate to antenatal care attendance? A cross-sectional analysis among rural women in Bangladesh.

BACKGROUND: In South Asia, roughly half of women attend at least four antenatal care visits with skilled health personnel, the minimum number recommended by the World Health Organization for optimal birth outcomes. A much greater proportion of women attend at least one antenatal care visit, suggesting that a key challenge is ensuring that women initiate antenatal care early in pregnancy and continue to attend after their first visit. One critical barrier to antenatal care attendance may be that women do not have sufficient power in their relationships, households, or communities to attend antenatal care when they want to. The main goals of this paper were to 1) understand the potential effects of intervening on direct measures of women's empowerment-including household decision making, freedom of movement, and control over assets-on antenatal care attendance in a rural population of women in Bangladesh, and 2) examine whether differential associations exist across strata of socioeconomic status. METHODS: We analyzed data on 1609 mothers with children under 24 months old in rural Bangladesh and employed targeted maximum likelihood estimation with ensemble machine learning to estimate population average treatment effects. RESULTS: Greater women's empowerment was associated with an increased number of antenatal care visits. Specifically, among women who attended at least one antenatal care visit, having high empowerment was associated with a greater probability of ≥ 4 antenatal care visits, both in comparison to low empowerment (15.2 pp, 95% CI: 6.0, 24.4) and medium empowerment (9.1 pp, 95% CI: 2.5, 15.7). The subscales of women's empowerment driving the associations were women's decision-making power and control over assets. We found that greater women's empowerment is associated with more antenatal care visits regardless of socioeconomic status. CONCLUSIONS: Empowerment-based interventions, particularly those targeting women's involvement in household decisions and/or facilitating greater control over assets, may be a valuable strategy for increasing antenatal care attendance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04111016, Date First Registered: 01/10/2019.

Implementing a group-based multi-component early child development intervention through the government health system in rural Bangladesh: A feasibility study.

Children in low- and middle-income countries face an increased risk of impaired cognitive development due to contaminated environments, poor nutrition, and inadequate responsive stimulation from caregivers. Implementing multi-component, community-level interventions may reduce these risks; however, there is little evidence supporting implementation of these interventions at scale. We assessed the feasibility of implementing a group-based intervention that included responsive stimulation, maternal and child nutrition, water and sanitation, and childhood lead exposure prevention through the government health system in Chatmohar, Bangladesh. After implementation, we conducted 17 in-depth interviews with frontline health service providers and 12 key informant interviews with their supervisors and managers to explore the facilitators and difficulties implementing such a complex programme within the health system. Factors facilitating implementation included: high quality training and skill level of providers, support from community members, family, and supervisors, positive relationships between providers and participants, and provision of children's toys and books free of cost. Difficulties included increased workload of the providers, complicated group-based yet stage-specific delivery where providers had to manage a large group of mother-child dyads representing many different child age-groups at once, and logistics difficulties in providing toys and books through a centralised health system process. Key informants made suggestions to ensure effective government-level scale-up including engaging relevant NGOs as partners, identifying feasible ways to make toys available, and offering providers meaningful even if non-monetary rewards. These findings can be used to shape the design and delivery of multi-component child development interventions to be delivered through the health system.

Oropharyngeal and Tongue Pulse Oximetry in 2 Critically Ill Pediatric Patients: A Case Report.

Pulse oximetry has become a standard of care to monitor oxygenation. Absent or inaccurate readings can occur with varied patient states. We present preliminary experience with a modification of a standard pulse oximetry using readily available equipment (oral airway and a tongue blade) to allow for continuous pulse oximetry from the oral cavity and tongue in 2 critically ill pediatric patients when standard application of pulse oximetry was not feasible or nonfunctional. These modifications can assist in the care of critically ill patients, allowing for adaptability in monitoring techniques when other options are unavailable.

Concurrent validity of the Ages and Stages Questionnaire Inventory and the Bayley Scales of Infant and Toddler Development in rural Bangladesh.

BACKGROUND: Reliable and valid measurement of early child development are necessary for the design of effective interventions, programs, and policies to improve early child outcomes. One widely used measure in low- and middle-income countries (LMICs) is the Bayley Scales of Infant and Toddler Development III (Bayley-III). Alternatively, the Bangladeshi-adapted Ages and Stages Questionnaire Inventory (ASQ:I) can be administered more quickly, inexpensively, and with less training than the Bayley-III. We aimed to assess the concurrent validity of the Bangladeshi-adapted ASQ:I with the Bayley-III in children 4-27 months old in rural Bangladesh. METHODS: The sample was a sub-sample (n = 244) of endline participants from an evaluation of an early child development intervention (July-August 2018). We assessed concurrent validity between internally age-standardized domain-specific and total scores using Pearson correlations both overall and stratified by age and intervention status. We also assessed correlations between scores and variables theoretically related to child development including maternal education and stimulation in the home. RESULTS: The overall correlation between ASQ:I and Bayley-III total scores was moderate (r = 0.42 95% CI: 0.30-0.53), with no systematic differences by intervention status. Overall, concurrent validity was highest for the gross motor domain (r = 0.51, 0.40-0.60), and lowest for the fine motor domain (r = 0.20, 0.04-0.33). Total ASQ:I and Bayley-III scores were positively correlated with child stimulation and maternal education. CONCLUSION: The Bangladeshi-adapted ASQ:I is a low-cost tool that can be feasibly administered in rural Bangladesh, is moderately correlated with the Bayley-III, and can be used to measure child development when human, time, or financial resources are constrained.

Patient, Provider, and Health Systems Factors Leading to Lumbar Puncture Nonperformance in Zambia: A Qualitative Investigation of the "Tap Gap".

Lumbar puncture (LP) and cerebrospinal fluid (CSF) diagnostics are critical for evaluating central nervous system infections but are often not conducted, resulting in the "Tap Gap." To investigate patient, provider, and health systems factors contributing to the Tap Gap in Zambia, we conducted focus group discussions with adult caregivers of hospitalized inpatients and in-depth interviews with nurses, clinicians, pharmacy workers, and laboratory staff. Transcripts were independently thematically categorized by two investigators using inductive coding. We identified seven patient-related factors: 1) alternative understandings of CSF; 2) alternative information about LPs, including misinformation; 3) mistrust of doctors; 4) consent delays; 5) fear of blame; 6) peer pressure against consent; and 7) association between LP and stigmatized conditions. Four clinician-related factors were identified: 1) limited LP knowledge and expertise, 2) time constraints, 3) delays in LP requests by clinicians, and 4) fear of blame for bad outcomes. Finally, five health systems-related factors were identified: 1) supply shortages, 2) constrained access to neuroimaging, 3) laboratory factors, 4) availability of antimicrobial medications, and 5) cost barriers. Efforts to improve LP uptake must incorporate interventions to increase patient/proxy willingness to consent and improve clinician LP competencies while addressing both upstream and downstream health system factors. Key upstream factors include inconsistently available consumables for performing LPs and lack of neuroimaging. Critical downstream factors include laboratory services that offer poor availability, reliability, and/or timeliness of CSF diagnostics and the reality that medications needed to treat diagnosed infections are often unavailable unless the family has resources to purchase privately.

Exploring customers' perceptions of food adulteration at bazaars and supermarkets in Dhaka, Bangladesh; a qualitative exploration.

BACKGROUND: Food adulteration is an increasingly recognized global public health problem. In low- and middle-income countries like Bangladesh, adulteration is difficult to detect and respond to. We explored customers' perceptions on food adulteration, perception of risk and connections between information, participant characteristics and patterns of adulterated food concerns that impact risk perception in urban Bangladesh. METHODS: A formative study was conducted in Dhaka, between June and August 2015 at a supermarket and a wet market. We explored community awareness and response to chemical contaminants (adulterants) among participants from a range of socio-economic backgrounds. The team conducted 38 in-depth interviews with 12 customers and 4 staff from a supermarket, and 12 customers and 10 vendors from a wet market. Participants were selected purposively. Audio recorded data were coded based on thematic content and analyzed manually. RESULTS: We asked participants how common foods were likely adulterated, and most gave figures of 70% or more. They reported that foods were adulterated with chemicals or artificial colors, especially fish, milk, and vegetables. The supermarket more commonly sold packaged foods with nutritional and expiry information on the label; and offered convenience in terms of building size, layout, and cleanliness. All customers from the wet market thought that foods were cheaper and fresher than from supermarkets. Supermarket customers expressed greater concern about adulterated foods than wet market customers. Most participants from both markets reported that food adulteration is invisible, adulterated foods cannot be avoided, and have long-term negative health impacts including cancer, diabetes, paralysis, heart attack, and others. Nearly half of customers from both markets were concerned about the poor nutritional value of adulterated food. Participants from both settings expressed the need for access to credible information about adulteration to help choose safe foods. The majority expressed the need for government action against those who are responsible for adulteration. CONCLUSIONS: Food adulteration was considered a major health threat. The government could act on food adulteration prevention if provided credible population-based data on disease burden, a model food sampling and testing protocol, a model for inspections, organizational strengthening and training, example social and behavioral change communications with estimated costs.

Women attending antenatal care as a sentinel surveillance population for malaria in Geita region, Tanzania: feasibility and acceptability to women and providers.

BACKGROUND: Measurement of malaria prevalence is conventionally estimated through infrequent cross-sectional household surveys that do not provide continuous information regarding malaria parasitaemia. Recent studies have suggested that malaria parasitaemia prevalence among women attending antenatal care (ANC) correlates with prevalence among children under 5 years old and that pregnant women could be a sentinel population for tracking malaria prevalence. In mainland Tanzania, 97% of women are tested for malaria parasitaemia during first ANC visits. However, acceptability among pregnant women and healthcare providers of collecting malaria risk factor data during ANC visits is limited. METHODS: A tablet-based questionnaire including 15 questions on insecticide-treated net ownership and use and care-seeking for febrile children was introduced at 40 healthcare facilities in Geita Region, Tanzania. Facilities were randomly selected from among those with 15-120 first ANC visits per month. To assess perspectives regarding introduction of the questionnaire, 21 semi-structured interviews were held with providers and facility in-charges at 12 facilities. Thirty pregnant and recently delivered women participated in focus group discussions at seven facilities to assess the acceptability of spending additional time answering questions about malaria risk. RESULTS: All pregnant women reported that introduction of ANC surveillance and spending 10 more minutes with providers answering questions about their health would be neutral or beneficial. They perceived being asked about their health as standard of care. Providers and in-charges reported that introduction of ANC surveillance was within their scope of practice. Nine of 21 indicated it could potentially benefit women's health. Six providers expressed concern about staffing shortages and need for reimbursement for extra time and noted that data management occurs after hours. CONCLUSIONS: Pregnant women and providers generally perceived ANC surveillance for malaria as acceptable and positive. Pregnant and recently delivered women saw this as a reasonable and even helpful intervention. To be seen as a part of standard practice, efforts are needed to ensure providers perceive a benefit for ANC clients and that staffing concerns are addressed. In addition, staff should receive feedback related to data submissions regarding malaria prevalence and risk factors among women at their facility, with actions to take.

Acetaminophen pharmacokinetics in infants and children with congenital heart disease.

BACKGROUND: Acetaminophen is routinely used for perioperative analgesia in children undergoing major surgical procedures. There are few estimates of acetaminophen pharmacokinetic parameters in children with congenital heart disease, especially those with cyanotic heart disease. AIMS: The current study prospectively investigated differences in acetaminophen pharmacokinetics following surgery using cardiopulmonary bypass in children with cyanotic and acyanotic congenital heart disease. METHODS: Children (2-6 years, 9-23 kg) presenting for median sternotomy for Fontan palliation (cyanotic patients) or two ventricle surgical repair (acyanotic patients) were eligible for inclusion. A single intravenous dose of acetaminophen (15 mg/kg) was administered at the start of sternal closure after separation from cardiopulmonary bypass. The time-course of acetaminophen concentrations were described using non-linear mixed effects models. One and two-compartment disposition models with first-order elimination were tested. Pharmacokinetic parameter estimates were scaled using allometry and standardized to a 70 kg person. RESULTS: There were 208 acetaminophen concentrations assayed from 30 children, 15 with cyanotic, and 15 with acyanotic heart disease. A 2-compartment model best described acetaminophen PK. Parameter estimates (population parameter variability, PPV%; 95% confidence interval, CI) were clearance CL 15.3 L.h-1.70 kg-1 (22.2%; 13.8-16.7), intercompartment clearance Q 45.4 L.h-1.70 kg-1 (22.4%; 25.2-61.9), central volume of distribution V1 33.5 L.70 kg-1 (23.2%; 25.9-38.8), peripheral volume of distribution V2 32.1 L.70 kg-1 (21.7%; 25.9-38.8). Neither clearance nor volume parameters differed between cyanotic and acyanotic patients. CONCLUSIONS: Acetaminophen pharmacokinetics were characterized using a 2-compartment model with first-order elimination following cardiac bypass surgery in children. Population pharmacokinetic parameter estimates were similar to other studies in children. No differences were detected between patients with cyanotic and acyanotic heart disease.

Unplanned Postoperative Reintubation in Children with Bronchial Asthma.

Unplanned postoperative reintubation is a serious complication that may increase postsurgical hospital length of stay and mortality. Although asthma is a risk factor for perioperative adverse respiratory events, its association with unplanned postoperative reintubation in children has not been comprehensively examined. Our aim was to determine the association between a preoperative comorbid asthma diagnosis and the incidence of unplanned postoperative reintubation in children. This was a retrospective cohort study comprising of 194,470 children who underwent inpatient surgery at institutions participating in the National Surgical Quality Improvement Program-Pediatric. The primary outcome was the association of preoperative asthma diagnosis with early, unplanned postoperative reintubation (within the first 72 hours following surgery). We also evaluated the association between bronchial asthma and prolonged hospital length of stay (longer than the 75th percentile for the cohort). The incidence of unplanned postoperative reintubation in the study cohort was 0.5% in patients with a history of asthma compared with 0.2% in patients without the diagnosis (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.71-2.89). This association remained significant after controlling for several clinical characteristics (OR: 1.54, 95% CI: 1.17-2.20). Additionally, asthmatic children were more likely to require a hospital length of stay longer than the 75th percentile for the study cohort (adjusted OR: 1.05, 95% CI: 1.01-1.10). Children with preoperative comorbid asthma diagnosis have an increased incidence of early, unplanned postoperative reintubation and prolonged postoperative hospitalization following inpatient surgery. By identifying these patients as having higher perioperative risks, it may be possible to institute strategies to improve their outcomes.

The West Africa ICEMR Partnerships for Guiding Policy to Improve the Malaria Prevention and Control.

The Mali National Malaria Control Program (NMCP) recently established a phased set of goals for eliminating malaria in Mali by 2030. Over the past decade, the scale-up of NMCP-led malaria control interventions has led to considerable progress, as evidenced by multiple malariometric indicators. The West Africa International Center of Excellence in Malaria Research (WA-ICEMR) is a multidisciplinary research program that works closely with the NMCP and its partners to address critical research needs for malaria control. This coordinated effort includes assessing the effectiveness of control interventions based on key malaria research topics, including immune status, parasite genetic diversity, insecticide and drug resistance, diagnostic accuracy, malaria vector populations and biting behaviors, and vectorial capacity. Several signature accomplishments of the WA-ICEMR include identifying changing malaria age demographic profiles, testing innovative approaches to improve control strategies, and providing regular reporting on drug and insecticide resistance status. The NMCP and WA-ICEMR partnership between the WA-ICEMR and the NMCP offers a comprehensive research platform that informs the design and implementation of malaria prevention and control research programs. These efforts build local expertise and capacity for the next generation of malaria researchers and guide local policy, which is crucial in sustaining efforts toward eliminating malaria in West Africa.

Development and validation of the Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS-26) in Bangladeshi schools: A measure of girls' menstrual care confidence.

OBJECTIVE: Qualitative studies have described girls' varying levels of confidence in managing their menstruation, with greater confidence hypothesized to positively impact health, education, and social participation outcomes. Yet, measurement of this and other psychosocial components of adolescent girls' menstrual experiences has been weak in global health research, in part due to a dearth of appropriate psychometric tools. We describe the development and validation of the Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS-26). METHODS: We conducted nine focus group discussions with girls in schools in rural and urban Bangladesh to identify tasks involved in menstrual self-care. This informed our creation of an initial pool of 50 items, which were reviewed by menstrual health experts and refined through 21 cognitive interviews with schoolgirls. Using a self-administered survey, we administered 34 refined items plus additional validation measures to a random sample of 381 post-menarcheal girls (ages 9-17) and retested a subsample of 42 girls two weeks later. We examined the measure's dimensionality using exploratory factor analysis and assessed internal consistency, temporal stability, and construct validity. RESULTS: Exploratory factor analysis suggested a 26-item scale comprising three correlated sub-scales: the 17-item Menstrual Hygiene Preparation and Maintenance (α = 0.86), the 5-item Menstrual Pain Management (α = 0.87), and the 4-item Executing Stigmatized Tasks (α = 0.77). Sub-scales exhibited good temporal stability. SAMNS-26 scores correlated negatively with measures of anxiety, and girls who preferred to stay at home during their periods had lower SAMNS-26 scores than those who did not. CONCLUSION: The SAMNS-26 provides a reliable measure of a schoolgirl's confidence in her capabilities to address her menstrual needs. There is initial evidence to support the measure's construct validity in the Bangladesh context as indicated by its relationships with other factors in its theorized nomological network. The tool enables incorporation of self-efficacy into multivariate models for exploring the relationships among antecedents to menstrual experiences and hypothesized impacts on health, wellbeing, and education attainment. Further testing of the tool is recommended to strengthen evidence of its validity in additional contexts.

A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo.

OBJECTIVE: In this evaluation of COVID-19 preventative response programs in South Kivu, Democratic Republic of the Congo (DRC), we aimed to explore community understandings of COVID-19, assess operational successes and challenges of COVID response activities, and identify barriers to practicing COVID-19 preventative behaviors. METHODS: Thirty-one semi-structured interviews were conducted from April to September 2021 in South Kivu, DRC, with community members (n = 16) and programmatic stakeholders (n = 15) (healthcare providers, government officials, and developmental and NGO staff engaged in COVID-19 response). FINDINGS: Most community members were aware of COVID-19 and its global burden, but few were aware of local transmission in their area. Some community members attributed COVID-19 to actions of malevolent neighbors, miasma ("bad air"), or spirits. Awareness of COVID-19 preventative measures was widespread, largely because of radio and TV health promotion programs. Community members and programmatic stakeholders both said community-level non-compliance to COVID-19 preventative measures was high despite high awareness of preventative methods. Community members expressed concern that face masks distributed as part of preventative programs contained the COVID-19 virus. Programmatic stakeholders emphasized the need for broader health system strengthening with improved coordination, provision of resources to health facilities at the provincial level, and prioritization of research. Lessons learned from addressing Ebola were leveraged for COVID-19 health promotion, rapid training of healthcare personnel, and surveillance. CONCLUSIONS: Community-informed approaches are needed for effective COVID-19 preventative response programs in South Kivu, DRC. Our study identified successes and challenges in COVID-19 response activities. Future research should assess the effectiveness of integrating preventive programs with COVID-19 vaccination efforts.

Exploring terminology for puerperal sepsis and its symptoms in urban Karachi, Pakistan to improve communication, care-seeking, and illness recognition.

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols.

Evaluation of a menstrual hygiene intervention in urban and rural schools in Bangladesh: a pilot study.

Girls' menstrual experiences impact their social and educational participation, physical and psychological health. We conducted a pilot study to assess the acceptability and feasibility of a multi-component intervention intended to support menstruating girls; improve menstrual care knowledge, practices, and comfort; and increase school attendance.We conducted a pre/post evaluation of a 6-month pilot intervention in four schools (2 urban, 2 rural) in Dhaka, Bangladesh. We selected 527 schoolgirls (grades 5 to 10; aged 10 to 17 years) for a baseline survey and 528 girls at endline. The intervention included: 1) Menstrual Hygiene Management (MHM) packs- reusable cloth pads, underwear, carry bags and menstrual cycle tracking calendars, 2) education curriculum- pictorial flipcharts, puberty related-booklets, and teachers' training to deliver puberty and MHM sessions, 3) maintenance- improvements to school sanitation, provision of disposable pads in the school office, provision of chute disposal systems for disposable pads, and gender committees to promote a gender-friendly school environment and maintenance of intervention facilities. We estimated intervention uptake and intervention effect by calculating prevalence differences and 95% confidence intervals using fixed-effects logistic regression.The intervention uptake was more than 85% for most indicators; 100% reported receiving puberty education, 85% received MHM packs, and 92% received booklets. Reusable cloth pads uptake was 34% by endline compared with 0% at baseline. Knowledge about menstrual physiology and knowledge of recommended menstrual management practices significantly improved from baseline to endline. Reported improvements included more frequent changing of menstrual materials (4.2 times/day at endline vs. 3.4 times/day at baseline), increased use of recommended disposal methods (prevalence difference (PD): 8%; 95% Confidence Interval: 1, 14), and fewer staining incidents (PD: - 12%; 95% CI: - 22, - 1). More girls reported being satisfied with their menstrual materials (59% at endline vs. 46% at baseline, p < 0.005) and thought school facilities were adequate for menstrual management at endline compared to baseline (54% vs. 8%, p < 0.001). At endline, 64% girls disagreed/strongly disagreed that they felt anxious at school due to menstruation, compared to 33% at baseline (p < 0.001). Sixty-five percent girls disagreed/strongly disagreed about feeling distracted or trouble concentrating in class at endline, compared to 41% at baseline (p < 0.001). Self-reported absences decreased slightly (PD: - 8%; 95% CI: - 14, - 2).Uptake of cloth pads, improved maintenance and disposal of menstrual materials, and reduced anxiety at school suggest acceptability and feasibility of the intervention aiming to create a supportive school environment.

A qualitative study of factors resulting in care delays for adults with meningitis in Zambia.

BACKGROUND: Meningitis causes significant mortality in regions with high comorbid HIV and TB. Improved outcomes are hindered by limited understanding of factors that delay adequate care. METHODS: In-depth interviews of patients admitted to the University Teaching Hospital with suspected meningitis, their caregivers, doctors and nurses were conducted. Patient/caregiver interviews explored meningitis understanding, treatment prior to admission and experiences since admission. Provider interviews addressed current and prior experiences with meningitis patients and hospital barriers to care. A conceptual framework based on the Three Delays Model identified factors that delayed care. RESULTS: Twenty-six patient/caregiver, eight doctor and eight nurse interviews occurred. Four delays were identified: in-home care; transportation to a health facility; clinic/first-level hospital care; and third-level hospital. Overcrowding and costly diagnostic testing delayed outpatient care; 23% of patients began with treatment inside the home due to prior negative experiences with biomedical care. Admission occurred after multiple clinic visits, where subsequent delays occurred during testing and treatment. CONCLUSIONS: Delays in care from home to hospital impair quality meningitis care in Zambia. Interventions to improve outcomes must address patient, community and health systems factors. Patient/caregiver education regarding signs of meningitis and indications for care-seeking are warranted to reduce treatment delays.