Administration of a Bacterial Lysate to the Airway Compartment Is Sufficient to Inhibit Allergen-Induced Lung Eosinophilia in Germ-free Mice.

The nexus between eosinophils and microbes is attracting increasing attention. We previously showed that airway administration of sterile microbial products contained in dust collected from traditional dairy farms virtually abrogated broncho-alveolar lavage (BAL) eosinophilia and other cardinal asthma phenotypes in allergen-sensitized specific pathogen-free (SPF) mice. Interestingly, comparable inhibition of allergen-induced BAL eosinophilia and promotion of airway barrier integrity were found upon administration of a sterile, pharmacological grade bacterial lysate, OM-85, to the airway compartment of allergen-sensitized SPF mice. Here we asked whether intrinsic properties of airway-delivered microbial products were sufficient to inhibit allergic lung inflammation or whether these effects were mediated by reprogramming of the host microbiota. We compared germ-free (GF) mice and offspring of GF mice associated with healthy mouse gut microbiota and maintained under SPF conditions for multiple generations (Ex-GF mice). These mice were treated intra-nasally with OM-85 and evaluated in the OVA and Alternaria models of allergic asthma focusing primarily on BAL eosinophilia. Levels of allergen-induced BAL eosinophilia were comparable in GF and conventionalized Ex-GF mice. Airway administration of the OM-85 bacterial lysate was sufficient to inhibit allergen-induced lung eosinophilia in both Ex-GF and GF mice, suggesting that host microbiota are not required for the protective effects of bacterial products in these models and local airway exposure to microbial products is an effective source of protection. OM-85-dependent inhibition of BAL eosinophilia in GF mice was accompanied by suppression of lung type-2 cytokines and eosinophil-attracting chemokines, suggesting that OM-85 may work at least by decreasing eosinophil lung recruitment.

Dolichocolon (redundant colon) in a rhesus macaque (Macaca mulatta).

Dolichocolon (redundant colon) is an underdiagnosed cause of severe constipation in humans. The clinical presentation reported here in a rhesus macaque closely resembles that of intestinal adenocarcinoma, the most common neoplasia in macaques. Dolichocolon should be considered in differential diagnosis of macaques with anorexia, weight loss, and constipation.

Family planning integration in Ethiopia's primary health care system: a qualitative study on opportunities, challenges and best practices.

BACKGROUND: Family planning (FP) service integration into primary health care (PHC) is an effective approach to realize reproductive autonomy, increase the use of contraceptives, and improve maternal and child health outcomes. The Ethiopian government promotes integration of FP services into primary health care (PHC). However, there is paucity of evidence on the status of FP service integration. The aim of this study is to explore the state of FP integration into PHC services and identify facilitators and barriers to integration. METHODS: A qualitative study nested with a larger national study was conducted from July to October 2022. A total of 60 interviews were conducted with FP stakeholders including, government organizations, non-governmental organizations, donors, service providers, and clients. Interviews were audio recorded, transcribed, and coded using OpenCode 4.03. The coded data were analyzed using framework analysis approach, using the Primary Health Care Performance Initiative (PHCPI) framework. Direct quotes and results from the coding and categorization were used to develop the report. RESULTS: Family planning is largely provided in designated units by dedicated staff within PHC facilities. The provision of integrated FP service within each service unit is in its early stage. Successful examples of integration include integration of FP with postnatal care, abortion care, and youth-friendly service centers. Facilitators of integration include commitment of the government and partners, the presence of policies and guidelines, and positive attitude of service providers and clients. However, integration of FP also faces challenges that are largely related to challenges of the FP program even before integration. These include resource shortage, health workers shortage, health workers' capacity/skill gaps, misconceptions about FP, religious and socio-cultural norms, and lack of awareness. CONCLUSIONS: Integration of FP with PHC services in the Ethiopian public health facilities is viable. Pre-existing challenges of the FP program continued to be barriers to integration. Expanding the experiences of good practices in the integration of FP with post abortion care, post-natal care, and youth-friendly service centers to other components of PHC warrants attention. Addressing both supply- and demand-side challenges of the FP program is needed to facilitate the integration of FP with other PHC services.

This study aimed to explore the status of integrating family planning (FP) services into primary health care (PHC) in Ethiopia and identify the facilitators and barriers to integration. The study included 60 interviews with stakeholders, including government and non-government organizations, service providers, and clients. We found that while dedicated FP staff provide services in designated units within PHC facilities, the provision of integrated FP services within other PHC units is in its early stage. Integration with post-abortion care, post-natal care, and youth-friendly service centers showed exemplary results that need to be used as good practices. The study identified challenges including resource shortage, health worker shortage, misconceptions about FP, religious and socio-cultural norms, and lack of awareness. The positive attitude of service providers and the commitment of the government and partners were identified as facilitators of integration. The study recommends expanding the successful practices of FP integration to other components of PHC and addressing supply- and demand-side challenges to facilitate the integration of FP services with PHC.

Meeting the Sexual and Reproductive Health Needs of Internally Displaced Persons in Ethiopia's Somali Region: A Qualitative Process Evaluation.

INTRODUCTION: Meeting the sexual and reproductive health and rights (SRHR) needs of internally displaced persons (IDPs) is critical. Despite increased prioritization and coverage of sexual and reproductive health (SRH) services in humanitarian settings in recent decades, significant unmet needs remain. In Ethiopia, there are more than 2 million IDPs, an estimated 40% of whom have unmet need for modern contraceptives. To address this, EngenderHealth implemented a model of SRHR programming in Ethiopia's Somali region. We share the lessons learned from this project to improve access to SRH services among IDPs. METHODS: In 2021, an independent research team implemented a qualitative process evaluation among 13 key informant interviews (KIIs) with health system actors, local government partners, and organizations, and 4 focus group discussions (FGDs) with community members and community health volunteers. The team selected participants purposively following the maximum variation sampling technique and analyzed the data in NVivo 12. The team used KII and FGD guides to explore and understand what was implemented, which stakeholders were engaged in the processes and how, what was achieved, and the barriers and facilitators in implementation. RESULTS: Contributions to project achievements included strong partnerships and stakeholder engagement, an enabling environment for SRHR, improving health worker capacity, and flexibility and adaptability. Challenges included a fragile security situation, retention of providers, and difficulty in accessing gender-based violence services, exacerbated by the coronavirus disease (COVID-19) pandemic. CONCLUSION: Our article offers guidance for organizations and government entities seeking to design and implement SRHR programs in humanitarian settings. Findings highlight the importance of prioritizing SRHR programming in IDP settings and illustrate adaptable activities to assist with project implementation and minimize operational challenges.

Signs of a turning tide in social norms and attitudes toward abortion in Ethiopia: Findings from a qualitative study in four regions.

BACKGROUND: Despite the 2005 expansion in abortion legal indications in Ethiopia, which provided for abortions in cases of rape, incest, or fetal impairment and other circumstances, nearly half of abortions occurred outside health facilities in 2014. The purpose of this study is to explore and understand the social barriers women face in seeking and obtaining quality safe abortion care, as a means to generate evidence that could be used to improve access to and quality of abortion services. METHODS: Thirty-two focus group discussions with both men and women were held in four different regions of Ethiopia: Addis Ababa; Amhara; Oromia; and the Southern Nations, Nationalities, and Peoples' Region. The study team recruited participants (n = 193) aged 18-55 in each region using a purposive sample with snowball recruitment techniques. We conducted discussions in Amharic or Afaan Oromo using a semi-structured guide and transcribed and translated them into English for analysis. We used deductive coding and analysis to categorize findings into emergent themes around stigma, barriers, and the changing nature of attitudes around abortion. RESULTS: Despite changes in abortion law, findings show that women with unwanted pregnancies and those seeking abortions are still heavily stigmatized and sanctioned in a number of communities across Ethiopia. Abortion was deemed unacceptable in most cases, though respondents were more tolerant in cases of risk to the mother's life and of rape. We saw promising indications that changes are taking place in Ethiopian society's view of abortion, and several participants indicated progress toward a more supportive environment overall for women seeking abortion care. Still, this progress may be limited by variable knowledge of abortion laws and tightly held gender-based social norms, particularly in rural areas. Most participants noted the importance of education and outreach to improve abortion attitudes and norms. CONCLUSION: Policymakers should create further awareness in Ethiopia on the availability of quality abortion services in public health facilities and the indications for legal abortion. Such efforts should be based on principles of gender equality, as a means of ensuring enduring changes for women's reproductive choice throughout the country.

We conducted a study to explore and understand the social barriers women face in seeking and obtaining quality safe abortion care in Ethiopia. We implemented focus group discussions with both men and women in four different regions of Ethiopia. We analyzed our findings into themes around stigma, barriers, and the changing nature of attitudes around abortion. Our results show that women seeking abortions are still heavily stigmatized. We found that abortion was deemed unacceptable in most cases. However, we also saw promising indications that changes are taking place in Ethiopian society's view of abortion, and several participants indicated progress toward a more supportive environment overall for women seeking abortion care. Still, this progress may be limited by variable knowledge of abortion laws. Most participants noted the importance of education and outreach to improve abortion attitudes and norms. We concluded that further awareness is needed in Ethiopia on the availability of quality abortion services in public health facilities and the indications for legal abortion. These efforts should consider gender equality to ensure enduring changes for women's reproductive choice throughout the country.

The effects of interventions to integrate long-acting reversible contraception with treatment for incomplete abortion: Results of a 6-year interrupted time series analysis in hospitals in mainland Tanzania and Zanzibar.

OBJECTIVE: To evaluate an intervention that aimed at strengthening voluntary access to long-acting reversible contraception (LARC) within postabortion care (PAC) in hospitals in mainland Tanzania and Zanzibar. METHODS: From 2016 to 2018, we conducted PAC quality improvement interventions, emphasizing family planning (FP) counseling and voluntary access to LARC. Researchers conducted an interrupted time-series analysis of service statistics compiled from 2014 to 2020 using segmented linear mixed effects regression models to assess the interventions' effect on postabortion contraceptive uptake. RESULTS: The intervention in mainland Tanzania was associated with an immediate 38% increase in postabortion LARC uptake, a trend that declined from late 2016 to mid-2020 to 34%. In Zanzibar, the intervention was associated with a gradual increase in LARC uptake that peaked in late 2018 at 23% and stabilized at approximately 15% by mid-2020. Whereas the interventions in mainland facilities did not generate significant changes in postabortion FP uptake overall, the launch of interventions in Zanzibar in mid-2016 was associated with a precipitous rise in that outcome over time, which plateaued at approximately 54% by 2019. CONCLUSION: Increased voluntary uptake of postabortion contraception was associated with the introduction of training in PAC, including FP, and quality improvement interventions and gains were sustained over time.

Strengthening access to long-acting reversible contraception within postabortion care in Tanzania: A pre-post evaluation.

Postabortion care services provide lifesaving treatment for abortion-related complications and addresses women's needs by offering family planning (FP) counseling and voluntary access to contraception. Between 2016 and 2020, the Government of Tanzania sought to strengthen its PAC program by enhancing FP counseling and clients' access to a wide range of contraceptive options. The project team conducted a pre-post evaluation in 17 public sector healthcare facilities in mainland Tanzania and 8 in Zanzibar. It comprised structured client exit interviews (CEIs), completed first in 2016 (n=412) and again in 2020 (n=484). These data complemented an evaluation that used routine service statistics to demonstrate the intervention's effects on client-reported outcomes. Primary outcomes of the CEIs reflected client experience and satisfaction with services, and researchers compared pre-post differences using chi-square tests. There were improvements in numerous indicators, including client waiting times, recall of emergency procedure counseling, contraceptive uptake, and satisfaction with the quality of overall counseling and FP information and services; however, triangulation of CEI data with service statistics indicated that some outcomes, though still improved since baseline, attenuated. Strengthening the FP component of PAC is feasible in Tanzania and Zanzibar, but strategies to sustain quality improvements over time are needed.

Development of an international sexual and reproductive health survey instrument: results from a pilot WHO/HRP consultative Delphi process.

Population health surveys are rarely comprehensive in addressing sexual health, and population-representative surveys often lack standardised measures for collecting comparable data across countries. We present a sexual health survey instrument and implementation considerations for population-level sexual health research. The brief, comprehensive sexual health survey and consensus statement was developed via a multi-step process (an open call, a hackathon, and a modified Delphi process). The survey items, domains, entire instruments, and implementation considerations to develop a sexual health survey were solicited via a global crowdsourcing open call. The open call received 175 contributions from 49 countries. Following review of submissions from the open call, 18 finalists and eight facilitators with expertise in sexual health research, especially in low- and middle-income countries (LMICs), were invited to a 3-day hackathon to harmonise a survey instrument. Consensus was achieved through an iterative, modified Delphi process that included three rounds of online surveys. The entire process resulted in a 19-item consensus statement and a brief sexual health survey instrument. This is the first global consensus on a sexual and reproductive health survey instrument that can be used to generate cross-national comparative data in both high-income and LMICs. The inclusive process identified priority domains for improvement and can inform the design of sexual and reproductive health programs and contextually relevant data for comparable research across countries.

Understanding factors associated with continuation of intrauterine device use in Gujarat and Rajasthan, India: a cross-sectional household study.

The Government of India has promoted the expansion of access to and uptake of intrauterine devices (IUDs), during both the interval (IIUD) and postpartum (PPIUD) periods, as part of its Family Planning 2020 initiative. This study, conducted by EngenderHealth as part of the Expanding Access to IUD Services in India project, examines IIUD and PPIUD continuation rates over time and investigates factors associated with IUD continuation. We recruited respondents (N = 5024) through a repeated cross-sectional household study between February and December 2019. We identified respondents using IUD client data from public health facility registers in 20 districts of Gujarat and Rajasthan. We compared continuation rates for IIUD and PPIUD adopters and used regression analyses to measure the association between continuation and demographic, quality of care, and counselling variables. IIUD continuation rates decreased from 85.6% to 78.3% and PPIUD rates decreased from 78.5% to 70.7% between month 3 and month 12. Clients experiencing side effects or other problems were 15 times more likely to discontinue IUD use than clients who did not. Clients who received IUD counselling prior to insertion were more likely to continue than those who did not. IUD continuation increased significantly in cases where both partners jointly selected the method compared to situations where women decided alone. Several sociodemographic factors were associated with continuation. Our study demonstrates the value and benefits of programmes offering IUD services emphasising quality counselling and client-centred care to increase access, uptake, and continuation.

Evaluation of In-cage Filter Paper as a Replacement for Sentinel Mice in the Detection of Murine Pathogens.

Recent studies have evaluated alternatives to the use of live animals in colony health monitoring. Currently, an alternative method that is suitable for all rack types and that has been verified to detect the infectious agents most commonly excluded from mouse colonies is unavailable. We compared the use of filter paper placed on the inside floor of mouse cages to the traditional use of sentinel mice in the detection of several prevalent murine pathogens including mouse hepatitis virus (MHV), murine norovirus (MNV), minute virus of mice (MVM), mouse parvovirus (MPV), Theiler murine encephalomyelitis virus (TMEV), Helicobacter spp., Syphacia obvelata, and Aspiculuris tetraptera. Experimental groups comprised 7 cages containing either 2 pieces of filter paper on the cage floor or 2 ICR sentinel mice. Soiled bedding from pet-store mice was transferred to the experimental cages weekly for 8 wk. At 1 and 2 mo after bedding transfer, the filter papers were evaluated by PCR and sentinel mice were tested by serology and fecal PCR. Filter papers detected all pathogens as effectively (MHV, MNV, MPV, MVM, TMEV S. obvelata, and A. tetraptera) or more effectively (Helicobacter spp.) than sentinel mice at both time points. Filter papers more readily detected pathogens with a high copy number per RT-PCR analysis than a low copy number. Helicobacter spp. were not detected by sentinel mice at either time point. These results indicate that the use of filter paper placed on the interior floor of empty mouse cages and exposed to soiled bedding is efficient in detecting bacteria, endoparasites, and most of the common mouse viruses included in an animal health monitoring program.

Emergence and Magnitude of ML336 Resistance in Venezuelan Equine Encephalitis Virus Depend on the Microenvironment.

Venezuelan equine encephalitis virus (VEEV) is a New World Alphavirus that can cause neurological disease and death in humans and equines following transmission from infected mosquitoes. Despite the continued epidemic threat of VEEV, and its potential use as a bioterrorism agent, there are no FDA-approved antivirals or vaccines for treatment or prevention. Previously, we reported the discovery of a small molecule, ML336, with potent antiviral activity against VEEV. To further explore the population-level resistance profiles of ML336, we developed a whole-genome next-generation sequencing (NGS) approach to examine single nucleotide polymorphisms (SNPs) from virus passaged in dose escalation studies in a nonhuman primate kidney epithelial and a human astrocyte cell line, Vero 76 and SVGA, respectively. We passaged VEEV TC-83 in these two cell lines over seven concentrations of ML336, starting at 50 nM. NGS revealed several prominent mutations in the nonstructural protein (nsP) 3 and nsP4 genes that emerged consistently in these two distinct in vitro environments-notably, a mutation at Q210 in nsP4. Several of these mutations were stable following passaging in the absence of ML336 in Vero 76 cells. Network analyses showed that the trajectory of resistance differed between Vero and SVGA. Moreover, the penetration of SNPs was lower in SVGA. In conclusion, we show that the microenvironment influenced the SNP profile of VEEV TC-83. Understanding the dynamics of resistance in VEEV against newly developed antiviral compounds will guide the design of optimal drug candidates and dosing regimens for minimizing the emergence of resistant viruses.IMPORTANCE RNA viruses, including Venezuelan equine encephalitis virus (VEEV), have high mutation rates that allow for rapid adaptation to selective pressures in their environment. Antiviral compounds exert one such pressure on virus populations during infections. Next-generation sequencing allows for examination of viruses at the population level, which enables tracking of low levels of single-nucleotide polymorphisms in the population over time. Therefore, the timing and extent of the emergence of resistance to antivirals can be tracked and assessed. We show here that in VEEV, the trajectory and penetration of antiviral resistance reflected the microenvironment in which the virus population replicates. In summary, we show the diversity of VEEV within a single population under antiviral pressure and two distinct cell types, and we show that population dynamics in these viruses can be examined to better understand how they evolve over time.

Potential for Improving Intrauterine Device (IUD) Service Delivery Quality: Results from a Secondary Data Analysis.

Background: To accelerate progress toward Family Planning 2020 (FP2020) goals, the government of India focused on improving the quality of intrauterine device (IUD) services. EngenderHealth, an international sexual and reproductive health and rights organization, has been supporting the governments of Gujarat and Rajasthan since 2014 through the Expanding Access to IUD Services in India (EAISI) project by building the capacity of service providers, monitoring compliance with standard practices, and strengthening health systems. This study sought to assess whether EAISI-trained providers offer higher quality IUD services than non-EAISI-trained providers, as indicated by a reduction in confirmed IUD complications. Methods: The study team conducted an analytical cross-sectional study of secondary data collected from follow-up registers at 176 intervention facilities (38 in Gujarat and 138 in Rajasthan) during Phase I of the EAISI project. The analysis included follow-up clients who returned to the same facility between April 2018 and March 2019. We performed a multivariate logistic regression to determine factors associated with IUD complications. Results: During the period of assessment, 56,733 clients received IUD insertions, and 10,747 (18.9%) clients returned for follow-up services. Of the returning clients, 49.4% (N=5,305) had received IUDs from EAISI-trained providers, while 50.6% (N=5,442) had received IUDs from non-EAISI-trained providers. A total of 4.0% (N=432) of all returning clients experienced complications (expulsion: 1.3%, missing strings: 1.7%, infection: 1.1%). Clients who received IUDs from non-EAISI-trained providers were 55.5% more likely (95% CI [26.2%, 91.5%], p<0.0005) to have experienced complications than clients who received insertions from EAISI-trained providers. The type of IUD, the timing of the insertion, and the timing of the follow-up visit also affected complication prevalence. Conclusion: Our findings indicate that intensive, practical clinical skills training for IUD insertion can reduce the prevalence of complications.

The Affordable Medicines Facility-malaria (AMFm): are remote areas benefiting from the intervention?

BACKGROUND: To assess the availability, price and market share of quality-assured artemisinin-based combination therapy (QAACT) in remote areas (RAs) compared with non-remote areas (nRAs) in Kenya and Ghana at end-line of the Affordable Medicines Facility-malaria (AMFm) intervention. METHODS: Areas were classified by remoteness using a composite index computed from estimated travel times to three levels of service centres. The index was used to five categories of remoteness, which were then grouped into two categories of remote and non-remote areas. The number of public or private outlets with the potential to sell or distribute anti-malarial medicines, screened in nRAs and RAs, respectively, was 501 and 194 in Ghana and 9980 and 2353 in Kenya. The analysis compares RAs with nRAs in terms of availability, price and market share of QAACT in each country. RESULTS: QAACT were similarly available in RAs as nRAs in Ghana and Kenya. In both countries, there was no statistical difference in availability of QAACT with AMFm logo between RAs and nRAs in public health facilities (PHFs), while private-for-profit (PFP) outlets had lower availability in RA than in nRAs (Ghana: 66.0 vs 82.2 %, p < 0.0001; Kenya: 44.9 vs 63.5 %, p = <0.0001. The median price of QAACT with AMFm logo for PFP outlets in RAs (USD1.25 in Ghana and USD0.69 in Kenya) was above the recommended retail price in Ghana (US$0.95) and Kenya (US$0.46), and much higher than in nRAs for both countries. QAACT with AMFm logo represented the majority of QAACT in RAs and nRAs in Kenya and Ghana. In the PFP sector in Ghana, the market share for QAACT with AMFm logo was significantly higher in RAs than in nRAs (75.6 vs 51.4 %, p < 0.0001). In contrast, in similar outlets in Kenya, the market share of QAACT with AMFm logo was significantly lower in RAs than in nRAs (39.4 vs 65.1 %, p < 0.0001). CONCLUSION: The findings indicate the AMFm programme contributed to making QAACT more available in RAs in these two countries. Therefore, the AMFm approach can inform other health interventions aiming at reaching hard-to-reach populations, particularly in the context of universal access to health interventions. However, further examination of the factors accounting for the deep penetration of the AMFm programme into RAs is needed to inform actions to improve the healthcare delivery system, particularly in RAs.

Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries.

BACKGROUND: Private for-profit outlets are important treatment sources for malaria in most endemic countries. However, these outlets constitute only the last link in a chain of businesses that includes manufacturers, importers and wholesalers, all of which influence the availability, price and quality of antimalarials patients can access. We present evidence on the composition, characteristics and operation of these distribution chains and of the businesses that comprise them in six endemic countries (Benin, Cambodia, Democratic Republic of Congo, Nigeria, Uganda and Zambia). METHODS AND FINDINGS: We conducted nationally representative surveys of antimalarial wholesalers during 2009-2010 using an innovative sampling approach that captured registered and unregistered distribution channels, complemented by in-depth interviews with a range of stakeholders. Antimalarial distribution chains were pyramidal in shape, with antimalarials passing through a maximum of 4-6 steps between manufacturer and retailer; however, most likely pass through 2-3 steps. Less efficacious non-artemisinin therapies (e.g. chloroquine) dominated weekly sales volumes among African wholesalers, while volumes for more efficacious artemisinin-based combination therapies (ACTs) were many times smaller. ACT sales predominated only in Cambodia. In all countries, consumer demand was the principal consideration when selecting products to stock. Selling prices and reputation were key considerations regarding supplier choice. Business practices varied across countries, with large differences in the proportions of wholesalers offering credit and delivery services to customers, and the types of distribution models adopted by businesses. Regulatory compliance also varied across countries, particularly with respect to licensing. The proportion of wholesalers possessing any up-to-date licence from national regulators was lowest in Benin and Nigeria, where vendors in traditional markets are important antimalarial supply sources. CONCLUSIONS: The structure and characteristics of antimalarial distribution chains vary across countries; therefore, understanding the wholesalers that comprise them should inform efforts aiming to improve access to quality treatment through the private sector.

Methods for implementing a medicine outlet survey: lessons from the anti-malarial market.

BACKGROUND: In recent years an increasing number of public investments and policy changes have been made to improve the availability, affordability and quality of medicines available to consumers in developing countries, including anti-malarials. It is important to monitor the extent to which these interventions are successful in achieving their aims using quantitative data on the supply side of the market. There are a number of challenges related to studying supply, including outlet sampling, gaining provider cooperation and collecting accurate data on medicines. This paper provides guidance on key steps to address these issues when conducting a medicine outlet survey in a developing country context. While the basic principles of good survey design and implementation are important for all surveys, there are a set of specific issues that should be considered when conducting a medicine outlet survey. METHODS: This paper draws on the authors' experience of designing and implementing outlet surveys, including the lessons learnt from ACTwatch outlet surveys on anti-malarial retail supply, and other key studies in the field. Key lessons and points of debate are distilled around the following areas: selecting a sample of outlets; techniques for collecting and analysing data on medicine availability, price and sales volumes; and methods for ensuring high quality data in general. RESULTS AND CONCLUSIONS: The authors first consider the inclusion criteria for outlets, contrasting comprehensive versus more focused approaches. Methods for developing a reliable sampling frame of outlets are then presented, including use of existing lists, key informants and an outlet census. Specific issues in the collection of data on medicine prices and sales volumes are discussed; and approaches for generating comparable price and sales volume data across products using the adult equivalent treatment dose (AETD) are explored. The paper concludes with advice on practical considerations, including questionnaire design, field worker training, and data collection. Survey materials developed by ACTwatch for investigating anti-malarial markets in sub-Saharan Africa and Asia provide a helpful resource for future studies in this area.

Introducing the WHOQOL-SRPB BREF: developing a short-form instrument for assessing spiritual, religious and personal beliefs within quality of life.

PURPOSE: The aim was to develop and conduct preliminary testing of a short-form measure to assess spiritual, religious and personal beliefs (SRPB) within quality of life (QoL). METHODS: Existing data from the 132 items of the WHOQOL-SRPB (n = 5087) obtained in 18 cultures were first analysed to select the 'best' performing item from each of the eight SRPB facets. These were integrated with the 26 WHOQOL-BREF items to give 34 items in the WHOQOL-SRPB BREF. A focus group of hospital chaplains reviewed this new short-form. The WHOQOL-SRPB BREF was administered to a UK community sample (n = 230) either with an adapted WHOQOL-SRPB Importance measure or the SWBQ. A subset received both WHOQOL measures twice. RESULTS: Completed in 8 mins, the WHOQOL-SRPB BREF was acceptable and feasible; Importance 5.5 mins. Good internal consistency reliability was found overall (α = 0.85), for the SRPB domain (α = 0.83), and Importance (α = 0.90). Domains were moderately correlated. Domain test-retest reliability was acceptable in both WHOQOL measures, except for SRPB Importance. Sleep was linked with religious beliefs. Hope and wholeness were widely associated with non-spiritual facets. Factor analysis (maximum likelihood) of items largely confirmed the WHOQOL domain structure, adding SRPB as a significant fifth domain. Internally, SRPB distinguished religious from existential beliefs, and was validated by association with personal and transcendental well-being from the SWBQ. CONCLUSION: Preliminary evidence shows that the WHOQOL-SRPB BREF is sound for use in, and beyond health care. Extracted from a measure already available in 18 languages, this short-form can be immediately used where such translations exist.

"Souls of the ancestor that knock us out" and other tales. A qualitative study to identify demand-side factors influencing malaria case management in Cambodia.

BACKGROUND: Appropriate case management of suspected malaria in Cambodia is critical given anti-malarial drug resistance in the region. Improving diagnosis and the use of recommended malarial treatments is a challenge in Cambodia where self-treatment and usage of drug cocktails is widespread, a notable difference from malaria treatment seeking in other countries. This qualitative study adds to the limited evidence base on Cambodian practices, aiming to understand the demand-side factors influencing treatment-seeking behaviour, including the types of home treatments, perceptions of cocktail medicines and reasons for diagnostic testing. The findings may help guide intervention design. METHODS: The study used in-depth interviews (IDIs) (N = 16) and focus group discussions (FGDs) (N = 12) with Cambodian adults from malaria-endemic areas who had experienced malaria fever in the previous two weeks. Data were analysed using NVivo software. RESULTS: Findings suggest that Cambodians initially treat suspected malaria at home with home remedies and traditional medicines. When seeking treatment outside the home, respondents frequently reported receiving a cocktail of medicines from trusted providers. Cocktails are perceived as less expensive and more effective than full-course, pre-packaged medicines. Barriers to diagnostic testing include a belief in the ability to self-diagnose based on symptoms, cost and reliance on providers to recommend a test. Factors that facilitate testing include recommendation by trusted providers and a belief that anti-malarial treatment for illnesses other than malaria can be harmful. CONCLUSIONS: Treatment-seeking behaviour for malaria in Cambodia is complex, driven by cultural norms, practicalities and episode-related factors. Effective malaria treatment programmes will benefit from interventions and communication materials that leverage these demand-side factors, promoting prompt visits to facilities for suspected malaria and challenging patients' misconceptions about the effectiveness of cocktails. Given the importance of the patient-provider interaction and the pivotal role that providers play in ensuring the delivery of appropriate malaria care, future research and interventions should also focus on the supply side factors influencing provider behaviour.

An international quality of life instrument to assess wellbeing in adults who are HIV-positive: a short form of the WHOQOL-HIV (31 items).

Few cross-cultural measures are available to assess quality of life (QoL) in HIV/AIDS. A short form of the WHOQOL-HIV-the WHOQOL-HIV BREF-was developed and tested. Survey data from 1,923 HIV-positive adults (selected for age, gender and disease stage) were collected in 8 culturally diverse centres. The 'best' HIV-specific item was extracted from five HIV facets of the WHOQOL-HIV long form using information about item correlations with QoL, health and domains, item discriminant validity and centre problems. The five identified items were then integrated with the WHOQOL-BREF to complete the 31 item WHOQOL-HIV BREF. This short form shows good internal consistency reliability and discriminant validity for 'known' disease stages. Confirmatory Factor Analysis showed an overall good fit for a six domains model (Comparative Fit Index = 0.97), supporting scoring. Quality of life in different cultures is reported. A value of the WHOQOL-HIV short form is in monitoring QoL in multi-national clinical trials, and in clinical practice.

Using and joining a franchised private sector provider network in Myanmar.

BACKGROUND: Quality is central to understanding provider motivations to join and remain within a social franchising network. Quality also appears as a key issue from the client's perspective, and may influence why a client chooses to use a franchised provider over another type of provider. The dynamic relationships between providers of social franchising clinics and clients who use these services have not been thoroughly investigated in the context of Myanmar, which has an established social franchising network. This study examines client motivations to use a Sun Quality Health network provider and provider motivations to join and remain in the Sun Quality Health network. Taken together, these two aims provide an opportunity to explore the symbiotic relationship between client satisfaction and provider incentives to increase the utilization of reproductive health care services. METHODS AND FINDINGS: Results from a series of focus group discussions with clients of reproductive health services and franchised providers shows that women chose health services provided by franchised private sector general practitioners because of its perceived higher quality, associated with the availability of effective, affordable, drugs. A key finding of the study is associated with providers. Provider focus group discussions indicate that a principle determinate for joining and remaining in the Sun Quality Health Network was serving the poor.