Cost optimisation of hybrid institutional incentives for promoting cooperation in finite populations.

In this paper, we rigorously study the problem of cost optimisation of hybrid (mixed) institutional incentives, which are a plan of actions involving the use of reward and punishment by an external decision-maker, for maximising the level (or guaranteeing at least a certain level) of cooperative behaviour in a well-mixed, finite population of self-regarding individuals who interact via cooperation dilemmas (Donation Game or Public Goods Game). We show that a mixed incentive scheme can offer a more cost-efficient approach for providing incentives while ensuring the same level or standard of cooperation in the long-run. We establish the asymptotic behaviour (namely neutral drift, strong selection, and infinite-population limits). We prove the existence of a phase transition, obtaining the critical threshold of the strength of selection at which the monotonicity of the cost function changes and providing an algorithm for finding the optimal value of the individual incentive cost. Our analytical results are illustrated with numerical investigations. Overall, our analysis provides novel theoretical insights into the design of cost-efficient institutional incentive mechanisms for promoting the evolution of cooperation in stochastic systems.

Characteristics and outcomes in patients with a prior myocardial infarction treated with extended dual antiplatelet therapy with ticagrelor 60 mg: findings from ALETHEIA, a multi-country observational study.

BACKGROUND: Guidelines recommend extended dual antiplatelet therapy, including ticagrelor 60 mg twice daily, in high-risk post-myocardial infarction (MI) patients who have tolerated 12 months and are not at high bleeding risk. The real-world utilization and bleeding and ischaemic outcomes associated with long-term ticagrelor 60 mg in routine clinical practice have not been well described. METHODS: Register and claims data from the USA (Optum Clinformatics, IBM MarketScan, and Medicare) and Europe (Sweden, Italy, UK, and Germany) were extracted. Patients initiating ticagrelor 60 mg ≥12 months after MI, meeting eligibility criteria for the PEGASUS-TIMI (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin - Thrombolysis in Myocardial Infarction 45) 54 trial, were included. The cumulative incidence of the composite of MI, stroke, or all-cause mortality and that of bleeding requiring hospitalization were calculated. Meta-analyses were performed to combine estimates from each source. RESULTS: A total of 7035 patients treated with ticagrelor 60 mg met eligibility criteria. Median age was 67 years and 29% were females; 12% had a history of multiple MIs. The majority (95%) had been treated with ticagrelor 90 mg prior to initiating ticagrelor 60 mg. At 12 months from initiation of ticagrelor 60 mg, the cumulative incidence [95% confidence interval (CI)] of MI, stroke, or mortality was 3.33% (2.73-4.04) and was approximately three-fold the risk of bleeding (0.96%; 0.69-1.33). CONCLUSIONS: This study provides insights into the use of ticagrelor 60 mg in patients with prior MI in clinical practice. Observed event rates for ischaemic events and bleeding generally align with those in the pivotal trials, support the established safety profile of ticagrelor, and highlight the significant residual ischaemic risk in this population.Clinical Trials.gov Registration NCT04568083.

Effect of temperature on sporulation and spore development of giant kelp (Macrocystis pyrifera).

Rising ocean temperature is a major driver of kelp forest decline worldwide and one that threatens to intensify over the coming decades. What is not particularly well understood are the mechanisms that drive loss and how they operate at differing life stages. This study aimed to establish an understanding of the effects of increasing temperature on the early developmental stages of the giant kelp, Macrocystis pyrifera. Sporulation was carried out across 10 temperature treatments from 9.5 to 26.2°C ± 0.2°C at approximately 2°C intervals. Spores were then incubated at these temperatures under a 20.3±1.7 µmol photons m-2 s-1, 16L:8D photoperiod for 5 days. Results indicate that spore release was positively correlated with increasing temperature, whereas an inverse trend was observed between temperature and the growth of germ-tube. The thermal threshold for spore and germling development was determined to be between 21.7°C and 23.8°C. Spore settlement was the most drastically effected developmental phase by increasing temperature. This study highlights the vulnerability of early life stages of M. pyrifera development to rising ocean temperature and has implications for modelling future distribution of this valuable ecosystem engineer in a changing ocean.

A Cadaveric Study of the Carpal Tunnel and Anatomical Variations of the Median Nerve in Vietnamese Adults: Implications for Single Portal Endoscopic Carpal Tunnel Release.

Introduction: Single-portal endoscopic carpal tunnel release using modified Agee technique is widely used in Vietnam. Yet information on the anatomy of the target space of Vietnamese people regarding this technique is scarce. We aimed to characterise the anatomical landmarks and variations of the carpal tunnel to propose a safer surgery. Materials and methods: All twenty hands of ten fresh frozen, unembalmed cadavers of Vietnamese adults were included. Dissection was performed after the vertical line, Kaplan's cardinal line and the distal wrist crease were drawn. The transverse carpal ligament (TCL), ulnar neurovascular bundle and superficial palmar arch were exposed. Measurements were made using Mitutoyo calliper. The variants of the median nerve and in the course of the thenar motor branch were recorded. Results: The median distances from the TCL distal margin to the distal wrist crease and superficial palmar arch were 31.2mm and 12.7mm, respectively. The ulnar neurovascular bundle was located 5.7mm and 4.4mm ulnar to the vertical line at the level of the TCL proximal margin and at the level of the TCL distal margin, respectively. The thenar motor branch of the median nerve was extra-ligamentous in 19 hands and preligamentous in 1 hand. Conclusion: If endoscopic portal is made along the distal wrist crease, blade assembly should not be inserted beyond the 35mm mark on its scale. Instruments should be aimed toward the radial border of the patient's ring finger. Surgeons should be aware of the preligamentous course of the thenar motor branch although this variant type is rare.

Prevalence of depression among heart failure inpatients and its associated socio-demographic factors: implications for personal-and family-based treatment management in health facilities in Vietnam.

OBJECTIVE: Our objective is to identify the prevalence of depression among inpatients with heart failure (HF), and to ascertain the factors associated with the depression from a wide spectrum of sociodemographic variables. MATERIALS AND METHODS: We conducted a hospital-based cross-sectional survey of prospectively collected data in inpatients with a diagnosis of HF at Vietnam National Heart Institute, Bach Mai Hospital (Hanoi, Vietnam) from July 2020 to July 2021. A sample size of 128 inpatients with HF was finally included. Primary outcome variable was depression ICD-10. RESULTS: The mean age was 62.34 (SD = 14.76). The sex ratio was 66 males to 62 females. The overall prevalence of depression ICD-10 was 46.88% among HF inpatients. The proportion of the depressed patients fluctuated between 37.21% and 83.33% by NYHA heart failure classification. Compared to the depressive prevalence among patients with NYHA class II, the odds were 8.43 times higher for those with NYHA class IV (OR univariate 8.43; 95% CI 1.63-43.46). Patient's age was significantly associated with increased prevalence of depression (OR multivariate 1.07; 95% CI 1.003-1.14). It was significantly higher odds of depression in HF patients who felt sadness after a diagnosis of an illness (OR multivariate 18.02, 95% CI: 4.21-77.08). Individuals with higher household economic status were less likely to be diagnosed with depression compared to those with lower household economic status (OR multivariate 0.15, 95% CI: 0.02-0.92). The odds of depression were significantly higher in HF patients who reported family conflict (OR multivariate 23.45, 95% CI: 1.29-423.55), and in those having the loss of a close family member (OR multivariate 38.62, 95% CI: 1.41-1055.98). CONCLUSIONS:   The prevalence of depression by ICD-10 was relatively high. Age of patient, sadness after a diagnosis of an illness, household economic status, family conflict and loss of a close family member were significantly associated with the depression among HF inpatients. Present results suggest a need for a disease management program addressing both psychological and HF aspects with the aim of improving health outcomes for the inpatients in Vietnam health facilities.

Is there a need to widely prescribe antibiotics in patients hospitalized with COVID-19?

BACKGROUND: Debate continues regarding the usefulness and benefits of wide prescription of antibiotics in patients hospitalized with coronavirus disease 2019 (COVID-19). METHODS: All patients hospitalized in the Infectious Diseases Department, Dijon University Hospital, Dijon, France between 27 February and 30 April 2020 with confirmed COVID-19 were included in this study. Clinical, biological and radiological data were collected, as well as treatment and outcome data. An unfavourable outcome was defined as death or transfer to the intensive care unit. Patient characteristics and outcomes were compared between patients who did and did not receive antibiotic therapy using propensity score matching. FINDINGS: Among the 222 patients included, 174 (78%) received antibiotic therapy. The univariate analysis showed that patients who received antibiotic therapy were significantly older, frailer and had more severe presentation at admission compared with patients who did not receive antibiotic therapy. Unfavourable outcomes were more common in patients who received antibiotic therapy [hazard ratio (HR) 2.94, 95% confidence interval (CI) 1.07-8.11; P = 0.04]. Multi-variate analysis and propensity score matching indicated that antibiotic therapy was not significantly associated with outcome (HR 1.612, 95% CI 0.562-4.629; P = 0.37). CONCLUSION: Antibiotics were frequently prescribed in this study and this was associated with more severe presentation at admission. However, antibiotic therapy was not associated with outcome, even after adjustment. In line with recent publications, such data support the need to streamline antibiotic therapy in patients with COVID-19.

Iterative Development of Clinician Guides to Support Deprescribing Decisions and Communication for Older Patients in Hospital: A Novel Methodology.

BACKGROUND/OBJECTIVES: Medication review is an important component of the management of older hospital patients. Deprescribing (supervised withdrawal of inappropriate medicines) is one outcome of review. This study aimed to iteratively develop and test the usability of deprescribing guides, which support multidisciplinary clinicians to reduce inappropriate polypharmacy in older inpatients. METHODS: Deprescribing guides for hospital clinicians were developed using a novel mixed-methods, ten-step process. Iterative development and usability testing were applied. This included content development through review of the literature; expert consensus through five rounds of feedback using a modified Delphi approach; and usability testing by 16 multidisciplinary hospital clinicians on hypothetical clinical scenarios involving observations, semi-structured interviews, and administration of the System Usability Scale. RESULTS: This novel process was used to develop deprescribing guides that facilitate implementation of evidence on deprescribing in routine hospital care. The guides present evidence-based information in a format that aligns with workflows of multidisciplinary hospital clinicians. The guides were adapted for various clinical roles to navigate efficiently to suit differing workflow needs. Guides include unique communication support in the form of "preferred language". Clinicians can use the "preferred language" to apply the evidence to the individual patient and relay decisions between health providers and with patients/carers. The total System Usability Scale score was 80.6 ± 2.0 (mean ± standard error of the mean), indicating excellent usability. Guides have been developed using consistent format for nine medication classes that are common targets for deprescribing and are publicly available. CONCLUSION: This study demonstrates a novel approach to the development and implementation of evidence-based recommendations that support deprescribing in routine hospital care.

Adipocyte-conditioned medium induces resistance of breast cancer cells to lapatinib.

BACKGROUND: The existence of a cross-talk between peritumoral adipocytes and cancer cells has been increasingly investigated. Several studies have shown that these adipocytes protect tumor cells from the effect of anticancer agents. METHODS: To investigate a potential protective effect of adipocyte-conditioned medium on HER2 positive breast cancer cells exposed to tyrosine kinase inhibitors (TKI) such as lapatinib, we analyzed the sensitivity of HER2 positive breast cancer models in vitro and in vivo on SCID mice in the presence or absence of adipocytes or adipocyte-conditioned medium. RESULTS: Conditioned medium from differentiated adipocytes reduced the in vitro sensitivity of the HER2+ cell lines BT474 and SKBR3 to TKI. Particularly, conditioned medium abrogated P27 induction in tumor cells by lapatinib but this was observed only when conditioned medium was present during exposure to lapatinib. In addition, resistance was induced with adipocytes derived from murine NIH3T3 or human hMAD cells but not with fibroblasts or preadipocytes. In vivo studies demonstrated that the contact of the tumors with adipose tissue reduced sensitivity to lapatinib. Soluble factors involved in this resistance were found to be thermolabile. Pharmacological modulation of lipolysis in adipocytes during preparation of conditioned media showed that various lipolysis inhibitors abolished the protective effect of conditioned media on tumor cells, suggesting a role for adipocyte lipolysis in the induction of resistance of tumor cells to TKI. CONCLUSIONS: Overall, our results suggest that contact of tumor cells with proximal adipose tissue induces resistance to anti HER2 small molecule inhibitors through the production of soluble thermolabile factors, and that this effect can be abrogated using lipolysis inhibitors.

Social Media Research Strategy to Understand Clinician and Public Perception of Health Care Messages.

INTRODUCTION: Despite the potential of social media to influence public health and generate insights, the process of monitoring and analyzing the dissemination of health care messages on social media has been described as difficult and in need of improvement. OBJECTIVES: The objective of this study was to describe and demonstrate a reproducible methodology for cataloging and analyzing health care-related social media comments and provide insight into how clinicians and members of the general public respond to health care messaging on social media. METHODS: We collected social media comments related to the American Dental Association's 2016 "Evidence-Based Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants" between April 10, 2017, and October 31, 2017, from Facebook, Twitter, LinkedIn, Reddit, and online message boards for the New York Times, FiveThirtyEight, and Dentaltown. Using data provided in the comments, we conducted engagement analysis as well as content, network, and sentiment analysis across 8 categories. RESULTS: We collected 671 comments. Among our findings, Facebook (472 of 671) was the most popular platform among commentators; almost half of all comments (335 of 671) aligned with the recommendations of the 2016 American Dental Association sealants guideline; clinicians were more likely than the general public to like a comment that suggested an improvement to the guideline; and >75% of comments (521 of 671) were supported by anecdotal evidence. CONCLUSION: As the prevalence of anecdotes on social media suggests, the likelihood of falsehoods spreading on social media is high. Insights gleaned from the methodology described in this research could help combat the spread of such misinformation by providing disseminators of health care messaging with insight into their target audiences. Armed with this knowledge, disseminators can craft health care messages that more effectively engage clinicians and the general public. KNOWLEDGE TRANSFER STATEMENT: The methodology used in this research provides a reproducible strategy for tracking social media engagement with health care messages. Engagement results can assist future delivery of health care messages to key stakeholders and ensure better implementation and adoption of these communications.

Convolutional Neural Network for Automated FLAIR Lesion Segmentation on Clinical Brain MR Imaging.

BACKGROUND AND PURPOSE: Most brain lesions are characterized by hyperintense signal on FLAIR. We sought to develop an automated deep learning-based method for segmentation of abnormalities on FLAIR and volumetric quantification on clinical brain MRIs across many pathologic entities and scanning parameters. We evaluated the performance of the algorithm compared with manual segmentation and existing automated methods. MATERIALS AND METHODS: We adapted a U-Net convolutional neural network architecture for brain MRIs using 3D volumes. This network was retrospectively trained on 295 brain MRIs to perform automated FLAIR lesion segmentation. Performance was evaluated on 92 validation cases using Dice scores and voxelwise sensitivity and specificity, compared with radiologists' manual segmentations. The algorithm was also evaluated on measuring total lesion volume. RESULTS: Our model demonstrated accurate FLAIR lesion segmentation performance (median Dice score, 0.79) on the validation dataset across a large range of lesion characteristics. Across 19 neurologic diseases, performance was significantly higher than existing methods (Dice, 0.56 and 0.41) and approached human performance (Dice, 0.81). There was a strong correlation between the predictions of lesion volume of the algorithm compared with true lesion volume (ρ = 0.99). Lesion segmentations were accurate across a large range of image-acquisition parameters on >30 different MR imaging scanners. CONCLUSIONS: A 3D convolutional neural network adapted from a U-Net architecture can achieve high automated FLAIR segmentation performance on clinical brain MR imaging across a variety of underlying pathologies and image acquisition parameters. The method provides accurate volumetric lesion data that can be incorporated into assessments of disease burden or into radiologic reports.

Pesticides and antibiotics in permanent rice, alternating rice-shrimp and permanent shrimp systems of the coastal Mekong Delta, Vietnam.

BACKGROUND: Salinity intrusion into coastal regions is an increasing threat to agricultural production of salt sensitive crops like paddy rice. In the coastal Mekong Delta, farmers respond by shifting to more salinity tolerant agricultural production systems such as alternating rice-shrimp and permanent shrimp. While shrimps are sensitive to pesticide residues used on rice, the use of antibiotics in shrimp farming can cause contamination in rice crops. These patterns of cross-contamination are not well documented empirically in the rapidly changing agricultural landscape. OBJECTIVE AND METHODS: Our objective was to understand changing pollution patterns induced by shifts in agricultural land use system. We addressed this by i) documenting pesticide and antibiotic use in three different agriculture land use systems (permanent rice, alternating rice-shrimp and permanent shrimp), and by ii) determining residues of pesticides and antibiotics in top soil layers of these three land use systems. Samples were taken in Sóc Trang and Ben Tre province in the Mekong Delta, Vietnam. Chemical analyses comprised 12 of the most commonly used pesticides in rice paddies and six common antibiotics used in shrimp production. RESULTS: Results showed that residues of pesticides were present in all agricultural land use systems, including shrimp aquaculture. Active ingredients were mostly fungicides with a maximum concentration of 67 µg kg-1 found for isoprothiolane in permanent rice systems, followed by alternating rice-shrimp and permanent shrimp systems. Furthermore, antibiotics were present ubiquitously, with fluoroquinolones accumulating to larger amounts than sulfonamides and diaminopyrimidines. All concentrations were below critical lethal threshold values. CONCLUSION: Overall, farmers were most conscious of agrochemical use in alternating rice-shrimp systems to prevent harm to shrimps, which was reflected in overall lower concentrations of agrochemicals when compared to rice systems. Thus, alternating rice-shrimp systems present a low risk option in terms of food safety, which may bring additional benefits to this so far rather low-input system in brackish water transition zone.

Secular trend, seasonality and effects of a community-based intervention on neonatal mortality: follow-up of a cluster-randomised trial in Quang Ninh province, Vietnam.

BACKGROUND: Little is know about whether the effects of community engagement interventions for child survival in low-income and middle-income settings are sustained. Seasonal variation and secular trend may blur the data. Neonatal mortality was reduced in a cluster-randomised trial in Vietnam where laywomen facilitated groups composed of local stakeholders employing a problem-solving approach for 3 years. In this analysis, we aim at disentangling the secular trend, the seasonal variation and the effect of the intervention on neonatal mortality during and after the trial. METHODS: In Quang Ninh province, 44 communes were allocated to intervention and 46 to control. Births and neonatal deaths were assessed in a baseline survey in 2005, monitored during the trial in 2008-2011 and followed up by a survey in 2014. Time series analyses were performed on monthly neonatal mortality data. RESULTS: There were 30 187 live births and 480 neonatal deaths. The intervention reduced the neonatal mortality from 19.1 to 11.6 per 1000 live births. The reduction was sustained 3 years after the trial. The control areas reached a similar level at the time of follow-up. Time series decomposition analysis revealed a downward trend in the intervention areas during the trial that was not found in the control areas. Neonatal mortality peaked in the hot and wet summers. CONCLUSIONS: A community engagement intervention resulted in a lower neonatal mortality rate that was sustained but not further reduced after the end of the trial. When decomposing time series of neonatal mortality, a clear downward trend was demonstrated in intervention but not in control areas. TRIAL REGISTRATION NUMBER: ISRCTN44599712, Post-results.

The cost-effectiveness of bevacizumab for the treatment of advanced ovarian cancer in Canada.

BACKGROUND: The overall survival (os) analysis of the icon7 trial demonstrated that frontline ovarian cancer patients with a high risk of progression (stage iii suboptimally debulked, and stage iii or iv with unresectable disease) benefited from the addition of bevacizumab to standard chemotherapy compared with standard chemotherapy alone. The objective of the present study was to investigate the cost-effectiveness, from a Canadian publicly funded perspective, of adding bevacizumab to frontline treatment of ovarian cancer at high risk of progression. METHODS: An area-under-the-curve, Markov-structured model was used to estimate the cost-effectiveness of the treatments. Long-term progression-free survival (pfs) and os were extracted from the icon7 trial (subgroup at high risk of relapse) and extrapolated by parametric time-to-event functions over a time horizon of 10 years. Canadian pfs health state utility values were obtained from the EQ-5D (EuroQoL Group, Rotterdam, Netherlands) questionnaires in the icon7 high-risk patient population. Canadian post-progression utility values were consistent with those for other gynecologic cancers. Cost inputs were informed by public sources. An annual 5% efficacy and cost discount rate was applied. A probabilistic sensitivity analysis and one-way sensitivity analyses were conducted. RESULTS: Ovarian cancer patients at high risk of progression receiving bevacizumab plus standard chemotherapy experienced a mean incremental quality-adjusted life year (qaly) gain of 0.374 years. At an additional cost of $35,901.54, the incremental cost-effectiveness ratio (icer) for the addition of bevacizumab to standard chemotherapy, relative to standard chemotherapy alone, was $95,942 per qaly. CONCLUSIONS: No formal health technology assessment willingness-to-pay threshold exists in Canada. However, at a threshold of $100,000 per qaly, bevacizumab in addition to chemotherapy is a cost-effective alternative for ovarian cancer patients who are at high risk of progression (stage iii suboptimally debulked, and stage iii or iv with unresectable disease). Using the $100,000 per qaly threshold in a probabilistic sensitivity analysis, it was determined that, compared with standard chemotherapy, the addition of bevacizumab to chemotherapy is cost-effective in 56% of tested scenarios.

Response process and test-retest reliability of the Context Assessment for Community Health tool in Vietnam.

BACKGROUND: The recently developed Context Assessment for Community Health (COACH) tool aims to measure aspects of the local healthcare context perceived to influence knowledge translation in low- and middle-income countries. The tool measures eight dimensions (organizational resources, community engagement, monitoring services for action, sources of knowledge, commitment to work, work culture, leadership, and informal payment) through 49 items. OBJECTIVE: The study aimed to explore the understanding and stability of the COACH tool among health providers in Vietnam. DESIGNS: To investigate the response process, think-aloud interviews were undertaken with five community health workers, six nurses and midwives, and five physicians. Identified problems were classified according to Conrad and Blair's taxonomy and grouped according to an estimation of the magnitude of the problem's effect on the response data. Further, the stability of the tool was examined using a test-retest survey among 77 respondents. The reliability was analyzed for items (intraclass correlation coefficient (ICC) and percent agreement) and dimensions (ICC and Bland-Altman plots). RESULTS: In general, the think-aloud interviews revealed that the COACH tool was perceived as clear, well organized, and easy to answer. Most items were understood as intended. However, seven prominent problems in the items were identified and the content of three dimensions was perceived to be of a sensitive nature. In the test-retest survey, two-thirds of the items and seven of eight dimensions were found to have an ICC agreement ranging from moderate to substantial (0.5-0.7), demonstrating that the instrument has an acceptable level of stability. CONCLUSIONS: This study provides evidence that the Vietnamese translation of the COACH tool is generally perceived to be clear and easy to understand and has acceptable stability. There is, however, a need to rephrase and add generic examples to clarify some items and to further review items with low ICC.

Process evaluation of a knowledge translation intervention using facilitation of local stakeholder groups to improve neonatal survival in the Quang Ninh province, Vietnam.

BACKGROUND: Annually, 2.8 million neonatal deaths occur worldwide, despite the fact that three-quarters of them could be prevented if available evidence-based interventions were used. Facilitation of community groups has been recognized as a promising method to translate knowledge into practice. In northern Vietnam, the Neonatal Health - Knowledge Into Practice trial evaluated facilitation of community groups (2008-2011) and succeeded in reducing the neonatal mortality rate (adjusted odds ratio, 0.51; 95 % confidence interval 0.30-0.89). The aim of this paper is to report on the process (implementation and mechanism of impact) of this intervention. METHODS: Process data were excerpted from diary information from meetings with facilitators and intervention groups, and from supervisor records of monthly meetings with facilitators. Data were analyzed using descriptive statistics. An evaluation including attributes and skills of facilitators (e.g., group management, communication, and commitment) was performed at the end of the intervention using a six-item instrument. Odds ratios were analyzed, adjusted for cluster randomization using general linear mixed models. RESULTS: To ensure eight active facilitators over 3 years, 11 Women's Union representatives were recruited and trained. Of the 44 intervention groups, composed of health staff and commune stakeholders, 43 completed their activities until the end of the study. In total, 95 % (n = 1508) of the intended monthly meetings with an intervention group and a facilitator were conducted. The overall attendance of intervention group members was 86 %. The groups identified 32 unique problems and implemented 39 unique actions. The identified problems targeted health issues concerning both women and neonates. Actions implemented were mainly communication activities. Communes supported by a group with a facilitator who was rated high on attributes and skills (n = 27) had lower odds of neonatal mortality (odds ratio, 0.37; 95 % confidence interval, 0.19-0.73) than control communes (n = 46). CONCLUSIONS: This evaluation identified several factors that might have influenced the outcomes of the trial: continuity of intervention groups' work, adequate attributes and skills of facilitators, and targeting problems along a continuum of care. Such factors are important to consider in scaling-up efforts. TRIAL REGISTRATION: ISRCTN ISRCTN44599712 .

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings.

BACKGROUND: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. METHODS: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. RESULTS: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. CONCLUSIONS: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

Factors associated with four or more antenatal care services among pregnant women: a cross-sectional survey in eight South Central Coast provinces of Vietnam.

BACKGROUND: In Vietnam, four or more antenatal care (ANC4+) visits/services among pregnant women have not been officially reported in the health system. Moreover, the factors associated with the use of ANC4+ services have not been studied in previous studies. In this study, we conducted an exploratory analysis to identify the rate of utilization of ANC4+ services and factors associated with use of ANC4+ services among pregnant women in rural areas of Vietnam. METHODS: The study was conducted in eight provinces in the South Central Coast region of Vietnam between August 2013 and May 2014. A total of 907 women, who delivered in the past 1 year, participated in the study. Multivariate logistic regression model was used to examine the association between all potential factors and utilization of ANC4+ services. RESULTS: The rate of utilization of ANC4+ services by women in eight South Central Coast provinces was 53.9%. Factors negatively associated with using ANC4+ services were belonging to ethnic minority groups having lower education, doing informal works, having lower income, having lower knowledge on ANC4+ services, and receiving no financial support from the husband. In particular, financial support from the husband was considered important in improving the use of ANC4+ services by women in rural areas. CONCLUSION: The study asserted an inadequacy for ANC4+ utilization and can contribute to missed opportunities to achieve better maternal outcomes for women in rural areas of Vietnam. The necessity of introducing ANC4+ services in the national guidelines on maternal health care should be disseminated to health policy-makers. Strategies to increase ANC4+ utilization should focus on knowledge improvement and on poor, low-income, and ethnic minority women.

Policy processes underpinning universal health insurance in Vietnam.

BACKGROUND: In almost 30 years since economic reforms or 'renovation' (Doimoi) were launched, Vietnam has achieved remarkably good health results, in many cases matching those in much higher income countries. This study explores the contribution made by Universal Health Insurance (UHI) policies, focusing on the past 15 years. We conducted a mixed method study to describe and assess the policy process relating to health insurance, from agenda setting through implementation and evaluation. DESIGN: The qualitative research methods implemented in this study were 30 in-depth interviews, 4 focus group discussions, expert consultancy, and 420 secondary data review. The data were analyzed by NVivo 7.0. RESULTS: Health insurance in Vietnam was introduced in 1992 and has been elaborated over a 20-year time frame. These processes relate to moving from a contingent to a gradually expanded target population, expanding the scope of the benefit package, and reducing the financial contribution from the insured. The target groups expanded to include 66.8% of the population by 2012. We characterized the policy process relating to UHI as incremental with a learning-by-doing approach, with an emphasis on increasing coverage rather than ensuring a basic service package and financial protection. There was limited involvement of civil society organizations and users in all policy processes. Intertwined political economy factors influenced the policy processes. CONCLUSIONS: Incremental policy processes, characterized by a learning-by-doing approach, is appropriate for countries attempting to introduce new health institutions, such as health insurance in Vietnam. Vietnam should continue to mobilize resources in sustainable and viable ways to support the target groups. The country should also adopt a multi-pronged approach to achieving universal access to health services, beyond health insurance.

Informal consultation at a teaching hospital infectious diseases department.

INTRODUCTION: Informal consultations for advice in the infectious diseases department (IDD) induce a significant workload for physicians. Our aim was to retrospectively quantify and describe this activity in our institution. METHOD: The data was obtained from files documented and faxed by physicians from October 2009 to May 2012. One thousand nine hundred and seventy-two files were included. The file was faxed to the IDD specialist, analyzed, then a telephone conversation allowed making precisions, and the documented form was faxed back. RESULTS: The requests for advice concerned 39% of female and 61% of male patients with a mean age of 64±21 years. Twenty-nine percent of requests came from surgical departments and 71% from medical departments (P<0.01). The departments most frequently concerned were cardiology (10%), gastro-enterology (10%) and cardiovascular surgery (9.7%). The most frequent infections were urogenital (19%), osteoarticular (14%), and cardiovascular (11%). Forty-nine percent were considered as nosocomial and 25.3% were bacteremic. The requests concerned diagnostic aid in 16.2% of cases and therapeutic issues in 95.6%. The IDD specialist made therapeutic recommendation in 96.5% of cases and gave diagnostic advice in 43.7%. Treatment modification was suggested in 38.5% of cases. Twenty-two percent of consultations required a second one. CONCLUSION: This study documented the importance of antibiotic changes among medical and surgical units, the increasing need of these units to be helped, and also the complexity of the medical cases, all requiring the advice of an ID specialist. Our fax-phone-fax procedure seems to prevent the bias associated with informal consultations by phone, which is the most commonly used in other institutions.