"Caught In Each Other's Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry.

BACKGROUND: Despite known adverse impacts on patients and health systems, 'incentive-linked prescribing', which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. We investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors), using Pakistan as a case study. METHODS: Our mixed-methods study synthesised insights from a survey of 419 systematically samples private doctors and 68 semi-structured interviews with private doctors (n=28), pharmaceutical sales representatives (n=12), and provincial and national policy actors (n=28). For the survey, we built a verified database of all registered private doctors within Karachi, Pakistan's most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. Semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach. RESULTS: Our survey showed that 90% of private doctors met pharmaceutical sales representatives weekly. Three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate and an over-saturated pharmaceutical market. CONCLUSION: Regular interactions between pharmaceutical companies and private doctors are normalised in our study setting, and progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and the pharmaceutical industry employees. A first step towards addressing the entrenchment of incentive-linked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policymakers concerned about curtailing growth of the pharmaceutical industry.

What happens when private general practitioners receive incentivisation offers from pharmaceutical sales representatives? A qualitative study in Pakistan.

OBJECTIVES: Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan. METHODS: We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes. RESULTS: We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later. CONCLUSIONS: The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

Feasibility of a peer-supported, WhatsApp-assisted, lifestyle modification intervention for weight reduction among adults in an urban slum of Karachi, Pakistan: a mixed-methods, single-group, pretest-post-test, quasi-experimental study.

OBJECTIVES: This pilot study assessed whether a peer-supported, WhatsApp-assisted lifestyle modification intervention for weight reduction is feasible to execute a definitive trial. DESIGN: A mixed-methods, single group, pretest and post-test, quasi-experimental study. SETTING: Azam Basti, an urban slum in Karachi, Pakistan. PARTICIPANTS: Fifty participants (males and females aged 20-60) with a body mass index of >23 kg/m2, along with their nominated peers from the same family. INTERVENTION: Using motivational interviewing techniques, a trained nutritionist delivered the lifestyle modification intervention to the participants and peers for 3 days after the baseline assessment and then once monthly for 1 year. The intervention was delivered in groups using WhatsApp voice calls. The education sessions mainly focused on dietary modifications, physical activity advice and peer-support assignments to achieve a 5% wt loss from the participant's initial body weight. OUTCOMES: The feasibility measures included screening, recruitment, retention and monthly interview response rates. At 1 year, in-depth interviews (IDIs) with participants and peers were conducted to explore the facilitators, barriers, acceptability and experiences of the intervention. Changes in weight, calorie intake/day and calorie expenditure/day were also assessed. RESULTS: The recruitment and retention rates were 32% (n=50/156) and 78% (n=39/50), respectively, while the response rate for monthly interviews ranged between 66% (n=33) and 94% (n=47). The mean weight loss at 1 year was 2.2 kg, and the reduction in mean calorie intake was 386 kcal/day. There were no changes in the mean calorie expenditure. During the IDIs, participants and peers reported intervention via WhatsApp and peer support as convenient, flexible and supportive. CONCLUSIONS: The quantitative and qualitative findings of the current pilot study support the scale-up of this work with minor modifications to the screening method as well as close monitoring and motivational interviewing to improve adherence in terms of physical activity. TRIAL REGISTRATION NUMBER: NCT05928338.

Socioecological factors linked with pharmaceutical incentive-driven prescribing in Pakistan.

Pharmaceutical marketing through financial incentivisation to general practitioners (GPs) is a poorly studied health system problem in Pakistan. Pharmaceutical incentivisation is seen to be distorting GPs prescribing behaviour that can compromise the health and well-being of patients. We draw on a conceptual framework outlined in the ecological system theory to identify multiple factors linked with pharmaceutical incentivisation to GPs in Pakistan. We conducted qualitative interviews with 28 policy actors to seek their views on the health system dynamics, how they sustain pharmaceutical incentivisation and their effect on the quality of care. Our analysis revealed four interlinked factors operating at different levels and how they collectively contribute to pharmaceutical incentivisation. In addition to influences such as the increasing family needs and peers' financial success, sometimes GPs may naturally be inclined to maximise incomes by engaging in pharmaceutical incentivisation. On other hand, the pharmaceutical market dynamics that involve that competition underpinned by a profit-maximisation mindset enable pharmaceutical companies to meet GPs' desires/needs in return for prescribing their products. Inadequate monitoring and health regulations may further permit the pharmaceutical industry and GPs to sustain the incentive-driven relationship. Our findings have important implications for potential health reforms such as introducing regulatory controls, and appropriate monitoring and regulation of the private health sector, required to address pharmaceutical incentivisation to GPs.

Impact of a multifaceted intervention on physicians' knowledge, attitudes and practices in relation to pharmaceutical incentivisation: protocol for a randomised control trial.

INTRODUCTION: In settings where the private sector constitutes a larger part of the health system, profit-gathering can take primacy over patients' well-being. In their interactions with pharmaceutical companies, private general practitioners (GPs) can experience the conflict of interest (COI), a situation whereby the impartiality of GPs' professional decision making may be influenced by secondary interests such as financial gains from prescribing specific pharmaceutical brands. METHODS AND ANALYSIS: This study is a randomised controlled trial to assess the impact of a multifaceted intervention on GPs' medical practice. The study sample consists of 419 registered GPs who own/work in private clinics and will be randomly assigned to intervention and control groups. The intervention group GPs will be exposed to emotive and educational seminars on medical ethics, whereas control group GPs will be given seminars on general medical topics. The primary outcome measure will be GPs' prescribing practices, whereas the secondary outcome measures will be their knowledge and attitudes regarding COI that arises from pharmaceutical incentivisation. In addition to a novel standardised pharmaceutical representatives (SPSR) method, in which field researchers will simulate pharmaceutical marketing with GPs, presurvey and postsurvey, and qualitative interviewing will be performed to collect data on GPs' knowledge, attitudes and practices in relation to COI linked with pharmaceutical incentives. Univariate and multivariate statistical analyses will be performed to measure a change in GPs' knowledge, attitudes and practices, while qualitative analysis will add to our understanding of the quantitative SPSR data. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Pakistan National Bioethics Committee (# 4-87/NBC-582/21/1364), the Aga Khan University (# 2020-4759-1129) and the London School of Hygiene and Tropical Medicine (# 26506). We will release results within 6-9 months of the study's completion. TRIAL REGISTRATION NUMBER: ISRCTN12294839.

Exploring stakeholders' experiences and perceptions regarding barriers to effective surveillance of communicable diseases in a rural district of Pakistan: a qualitative study.

OBJECTIVE: To explore the experiences and perceptions of health system stakeholders of a rural district of Sindh, Pakistan regarding the barriers to effective surveillance of communicable diseases. DESIGN: This qualitative descriptive exploratory design comprised in-depth interviews. Both inductive and deductive thematic analysis was applied to identify key themes from the data. SETTINGS: The study was conducted in public sector healthcare facilities and the district health office of the rural district of Thatta, in Sindh province, Pakistan. PARTICIPANTS: Fifteen healthcare managers and healthcare providers working in the eight public sector primary and secondary healthcare facilities were interviewed using an open-ended in-depth interview guide. RESULTS: Key themes that emerged from the data were: poor governance and absence of surveillance policy framework; fragmentation in the health system leading to lack of uniform reporting; inadequate (human) resources that weakened the infrastructure for disease surveillance; hospital-based reporting of cases that led to a predominantly passive surveillance system; paper-based surveillance system as the key determinant of delayed reporting; non-utilisation of surveillance data for decision making; absence of local laboratory capacity to complement the detection of disease outbreaks and lack of private sector integration in disease surveillance. CONCLUSIONS: Poor governance and lack of policy framework were perceived to be responsible for weak surveillance infrastructure. Resource deficiencies including inadequate human resource, paper-based reporting and the absence of local laboratory capacity were considered to result in delayed, poor quality and incomplete reporting. The lack of private sector engagement was identified as a major gap.

Unassigned Complex Unique Recombinant Forms Related to CRF36_cpx in Children Identified in an HIV-1 Outbreak in Pakistan.

In 2019, an outbreak of HIV infection predominantly affecting children occurred in Larkana district, Pakistan. This is the largest outbreak ever reported in this age group in Pakistan. In this study, we report two HIV-1 unique recombinant forms identified during the outbreak. Blood samples were collected from HIV-positive children as part of a case-control study to investigate the outbreak. The pol gene was sequenced and used to detect HIV subtype/recombinant forms using subtype, recombination, and phylogenetic analyses. Drug resistance mutation (DRM) analysis was performed to characterize the DRMs in each sequence. We observed the emergence of two unassigned unique recombinant forms related to CRF36_cpx in 15 individuals of the 344 samples collected. Genotype analysis revealed the presence of multiple DRMs associated with resistance to reverse transcriptase inhibitors. The discovery of these unassigned unique recombinant forms in our population highlights the need for comprehensive molecular epidemiological studies to fully understand the distribution and drug resistance patterns to aid control efforts.

The Impact of Disease Control Measures on the Spread of COVID-19 in the Province of Sindh, Pakistan.

The province of Sindh reported the first COVID-19 case in Pakistan on 26th February 2020. The Government of Sindh has employed numerous control measures to limit its spread. However, for low-and middle-income countries such as Pakistan, the management protocols for controlling a pandemic are not always as definitive as they would be in other developed nations. Given the dire socio-economic conditions of Sindh, continuation of province-wise lockdowns may inadvertently cause a potential economic breakdown. By using a data driven SEIR modelling framework, this paper describes the evolution of the epidemic projections because of government control measures. The data from reported COVID-19 prevalence and google mobility is used to parameterize the model at different time points. These time points correspond to the government's call for advice on the prerequisite actions required to curtail the spread of COVID-19 in Sindh. Our model predicted the epidemic peak to occur by 18th June 2020 with approximately 3500 reported cases at that peak, this projection correlated with the actual recorded peak during the first wave of the disease in Sindh. The impact of the governmental control actions and religious ceremonies on the epidemic profile during this first wave of COVID-19 are clearly reflected in the model outcomes through variations in the epidemic peaks. We also report these variations by displaying the trajectory of the epidemics had the control measures been guided differently; the epidemic peak may have occurred as early as the end of May 2020 with approximately 5000 reported cases per day had there been no control measures and as late as August 2020 with only around 2000 cases at the peak had the lockdown continued, nearly flattening the epidemic curve.

Determinants of hepatitis B vaccination status in health care workers of two secondary care hospitals of Sindh, Pakistan: a cross-sectional study.

BACKGROUND: Health care workers (HCWs) are at high risk of Hepatitis B virus (HBV) transmission. Hepatitis B vaccination is effective in protecting against HBV infection. Different factors influence HCW vaccination status such as lack of knowledge & awareness, cost, availability, and hesitancy. This study aimed to determine Hepatitis B vaccination status and factors influencing vaccination status in HCWs of two secondary care hospitals at Sindh, Pakistan. METHODS: A cross-sectional study was conducted in two secondary care hospitals of Sindh, Pakistan. A total of 252 doctors, nurses, laboratory, and other HCWs were asked about the HBV vaccination coverage using a structured tool. Multivariable ordinal logistic regression was used to determine the association of participant's characteristics, vaccination knowledge with HBV vaccination coverage considering p-value ≤0.05 significant. Odds ratios with 95% confidence interval (CI) were reported. RESULTS: Our study found that 64.9% doctors, 75.18% nurses, 58.3% allied HCWs, 40.0% laboratory staff, and 70.8% housekeeping staff were completely vaccinated. HCWs stated job entry requirement as the primary reason for complete vaccination (AOR 4.6, 95% CI 1.5-5.3) from the disease. HCWs working in Aga Khan hospital Karachi and who have received vaccination before working in that hospital had four-time higher odds for hepatitis B vaccination (AOR 4.3, 95% CI 1.7-4.9). CONCLUSION: Two-third of the HCWs were completely vaccinated in secondary care hospitals in Sindh, Pakistan. Hepatitis B vaccination should be made a job entry requirement to achieve more complete vaccination numbers. Vaccination policies require to implement for all part-timers and full-timer health care workers.

Phylogenetic and Drug-Resistance Analysis of HIV-1 Sequences From an Extensive Paediatric HIV-1 Outbreak in Larkana, Pakistan.

INTRODUCTION: In April 2019, an HIV-1 outbreak among children occurred in Larkana, Pakistan, affecting more than a thousand children. It was assumed that the outbreak originated from a single source, namely a doctor at a private health facility. In this study, we performed subtype distribution, phylogenetic and drug-resistance analysis of HIV-1 sequences from 2019 outbreak in Larkana, Pakistan. METHODS: A total of 401 blood samples were collected between April-June 2019, from children infected with HIV-1 aged 0-15 years recruited into a case-control study to investigate the risk factors for HIV-1 transmission. Partial HIV-1 pol sequences were generated from 344 blood plasma samples to determine HIV-1 subtype and drug resistance mutations (DRM). Maximum-likelihood phylogenetics based on outbreak and reference sequences was used to identify transmission clusters and assess the relationship between outbreak and key population sequences between and within the determined clusters. Bayesian analysis was employed to identify the time to the most recent common recent ancestor (tMRCA) of the main Pakistani clusters. RESULTS: The HIV-1 circulating recombinant form (CRF) 02_AG and subtype A1 were most common among the outbreak sequences. Of the treatment-naïve participants, the two most common mutations were RT: E138A (8%) and RT: K219Q (8%). Four supported clusters within the outbreak were identified, and the median tMRCAs of the Larkana outbreak sequences were estimated to 2016 for both the CRF02_AG and the subtype A1 clusters. Furthermore, outbreak sequences exhibited no phylogenetic mixing with sequences from other high-risk groups of Pakistan. CONCLUSION: The presence of multiple clusters indicated a multi-source outbreak, rather than a single source outbreak from a single health practitioner as previously suggested. The multiple introductions were likely a consequence of ongoing transmission within the high-risk groups of Larkana, and it is possible that the so-called Larkana strain was introduced into the general population through poor infection prevention control practices in healthcare settings. The study highlights the need to scale up HIV-1 prevention programmes among key population groups and improving infection prevention control in Pakistan.

Factors associated with HIV infection among children in Larkana District, Pakistan: a matched case-control study.

BACKGROUND: In April, 2019, an HIV outbreak predominantly affecting children occurred in Larkana District, Sindh, Pakistan. By December, 2019, 881 (4·0%) of 21 962 children screened for HIV had tested positive. We aimed to assess factors associated with HIV infection in this outbreak. METHODS: In this individually matched case-control study, we sampled 406 cases (individuals aged <16 years who had registered for paediatric HIV care at the HIV Treatment Centre at Shaikh Zayed Children's Hospital in Larkana City, Pakistan) and 406 controls (individuals without HIV matched by age, sex, and neighbourhood residence, recruited through doorknocking at houses adjacent to case participants). An interviewer-administered questionnaire was used to collect data on possible risk factors for HIV acquisition and a blood sample was collected from all participants for hepatitis B and hepatitis C serology. Mothers of all participants underwent HIV testing. Odds ratios were estimated using conditional logistic regression to assess factors associated with HIV infection. FINDINGS: 406 case-control pairs were recruited between July 3 and Dec 26, 2019. Five pairs were excluded (three pairs had an age mismatch and two pairs were duplicate cases) and 401 were analysed. The prevalence of hepatitis B surface antigen was 18·2% (95% CI 14·5-22·3) among cases and 5·2% (3·3-7·9) among controls, and the prevalence of hepatitis C antibodies was 6·5% (95% CI 4·3-9·4) among cases and 1·0% (0·3-2·5) among controls. 28 (7%) of 397 mothers of cases for whom we had data, and no mothers of 394 controls, were HIV positive. In the 6 months before recruitment, 226 (56%) of 401 cases and 32 (8%) of 401 controls reported having more than ten injections, and 291 (73%) cases and 78 (19%) controls had received an intravenous infusion. At least one blood transfusion was reported in 56 (14%) cases and three (1%) controls in the past 2 years. HIV infection was associated with a history of more injections and infusions (adjusted odds ratio 1·63; 95% CI 1·30-2·04, p<0·0001), blood transfusion (336·75; 23·69-4787·01, p<0·0001), surgery (399·75, 13·99-11 419·39, p=0·0005), the child's mother being HIV positive or having died (3·13, 1·20-8·20, p=0·020), and increased frequency of private clinic (p<0·0001) and government hospital visits (p<0·0001), adjusting for confounders. INTERPRETATION: The predominant mode of HIV transmission in this outbreak was parenteral, probably due to unsafe injection practices and poor blood safety practices. General practitioners across Pakistan need training and systems support in reducing injection use, and in providing safe injections and transfusions only when necessary. FUNDING: Department of Pediatrics and Child Health, the Aga Khan University, Karachi, Pakistan.

Depression among adult patients with primary brain tumour: a cross-sectional study of risk factors in a low-middle-income country.

OBJECTIVE: The prevalence of depression among patients with primary brain tumour ranges from 15% to 40% globally. Several individual and clinical factors contribute to the development of depression. However, their association with depression in Pakistani setting has not yet been assessed. Thus, we aim to study the factors associated with depression among adult patients with primary brain tumour at a tertiary care hospital in Karachi, Pakistan. STUDY DESIGN: A prospective cross-sectional study. SETTING: This study was conducted at a tertiary care hospital of Karachi, Pakistan. PARTICIPANTS: This study included 132 patients with confirmed diagnosis of primary brain tumour (initially diagnosed on MRI of the brain with contrast and later confirmed on histology of surgical specimen) in various stages of treatment. PRIMARY OUTCOME: The primary outcome of this study was to assess depression and its associated factors among adult patients with primary brain tumour. Depression was assessed using a validated screening tool Patient Health Questionnaire-9 (PHQ-9). Scores of 10-27 on PHQ-9 were indicative of screen positive for depressive symptoms. A set of the structured pre-tested questions was used to evaluate patient-related, tumor-related and treatment-related factors. RESULTS: Fifty-one (39%, CI: 33.33-46.94) patients in our study screened positive for depressive symptoms on PHQ-9. There was a significant association between depressive symptoms and Karnofsky Performance Scores (KPS) (prevalence ratio: 3.25 and CI: 1.87-5.62) after controlling covariates. Propensity scores predicted a positive association between KPS (functional status) and unemployment, treatment stage, and tumour recurrence. Tumor-related and treatment-related factors including tumour grade, location, type and hemispheric lateralisation were found insignificant. CONCLUSION: Depression is common in patients with primary brain tumour. Impaired functional status has a direct impact on depression in these patients. Incorporating the psychosocial domain earlier in the course of treatment needs to be considered for better neuro-oncology management of patients with primary brain tumour.

Lifestyle changes and glycemic control in type 1 diabetes mellitus: a trial protocol with factorial design approach.

BACKGROUND: Type 1 diabetes (T1D) has been increasing globally over the past three decades. Self-monitoring of blood glucose is a challenge in both developed as well as developing countries. Self-management guidelines include maintaining logbooks for blood glucose, physical activity, and dietary intake that affect glycated hemoglobin (HbA1c) and a multitude of life-threatening acute complications. Innovative, cost-effective interventions along with beneficial lifestyle modifications can improve home-based self-monitoring of blood glucose in T1D patients. The overall objective of this study is to evaluate the relationship between maintaining log books for blood glucose levels, reinforcement by e-messages, and/or daily step count and changes in HbA1c. METHODS/DESIGN: A randomized controlled trial will enroll participants aged 15 years and above in four groups. Each group of 30 participants will be working with a newly designed standard log book for documenting their blood glucose. The first group will be entirely on routine clinical care, the second group will be on routine care and will receive an additional e-device for recording step count (fit bit), the third group will receive routine care and daily motivational e-messages to maintain the log book, and the fourth group along with routine care will receive an e-device for measuring step count (fit bit) and e-messages about maintaining the log book. Patients will be enrolled from pediatric and endocrine clinics of a tertiary care hospital in Karachi. All groups will be followed up for a period of 6 months to evaluate outcomes. Log book data will be obtained every 3 months electronically or during a patient's clinic visit. HbA1c as a main outcome will be measured at baseline and will be evaluated twice every 3 months. A baseline questionnaire will determine the socio-demographic, nutritional, and physical activity profile of patients. Clinical information for T1D and other co-morbidities for age of onset, duration, complications, hospitalizations, habits for managing T1D, and other lifestyle characteristics will be ascertained. Behavioral modifications for maintaining daily log books as a routine, following e-messages alone, fit bit alone, or e-messages plus using fit bit will be assessed for changes in HbA1c using a generalized estimated equation. DISCUSSION: The proposed interventions will help identify whether maintaining log books for blood glucose, motivational e-messages, and/or daily step count will reduce HbA1c levels. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03864991. March 6, 2019.

HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak.

BACKGROUND: In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care. METHODS: In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ2 tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV. FINDINGS: Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions. INTERPRETATION: This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies. FUNDING: None.

Sedentary lifestyle and Framingham risk scores: a population-based study in Riyadh city, Saudi Arabia.

BACKGROUND: Studies from Saudi Arabia have reported a continued increase in the prevalence of cardiovascular diseases and their associated risk factors. The objective of this study was to measure the gender differences in the cardiovascular disease (CVD) risk based on Framingham risk scores (FRS) and to explore the association of FRS with sedentary life style including physical inactivity, sitting time and central obesity among Saudi adults. METHODS: A cross-sectional survey was conducted on 2997 Saudi adults (males = 968, females = 2029) selected from 18 primary health care centres in Riyadh city, from December 2014 to August 2015. A detailed interview that evaluated lifestyle and past medical history was conducted; furthermore, anthropometric measurements and blood samples were collected for lipid profiling. The FRS were calculated based on the age, gender, systolic blood pressure, treatment for hypertension, diabetes, smoking status, total blood cholesterol and high-density lipoprotein levels. These scores were categorized into low risk (FRS < 10) and high/intermediate risk (≥10). A multivariable logistic regression analysis was performed. RESULTS: The mean (±SD) age of the males and females was 43.1(±11.7) vs 43.8(±10.9) years (p = 0.07), respectively. The number of Saudi male participants with intermediate-to-high FRS scores (≥10) was almost twice that of females (males 33% vs 17%). The multivariable logistic regression model after adjusting for education level and housing type, found that low physical activity (aOR & 95%CI for males 2.91 (1.45, 5.80); females 1.38 (1.06, 1.81); prolonged sitting time (aOR &95%CI for males 1.36 (0.98, 1.90) females 1.58 (1.20, 2.07), high central obesity (defined as waist circumference in males > 102 cms, and females > 88 cms) (aOR & 95%CI for males 2.38 (1.67, 3.41); females 3.35 (1.92, 5.87) were associated with high/ intermediate risk for CVD. CONCLUSIONS: A significant percentage of Saudi population revealed FRS ≥10. Females beyond the age of 50 were found to have a higher prevalence for CVD risk compared with males of the same age group. Modifiable risk factors like low physical activity, prolonged sitting time and central obesity have strong implications for primary prevention and management services that can change the risk profile of the Saudi population.

Medical Doctors' Offline Computer-Assisted Digital Education: Systematic Review by the Digital Health Education Collaboration.

BACKGROUND: The widening gap between innovations in the medical field and the dissemination of such information to doctors may affect the quality of care. Offline computer-based digital education (OCDE) may be a potential solution to overcoming the geographical, financial, and temporal obstacles faced by doctors. OBJECTIVE: The objectives of this systematic review were to evaluate the effectiveness of OCDE compared with face-to-face learning, no intervention, or other types of digital learning for improving medical doctors' knowledge, cognitive skills, and patient-related outcomes. Secondary objectives were to assess the cost-effectiveness (CE) of OCDE and any adverse effects. METHODS: We searched major bibliographic databases from 1990 to August 2017 to identify relevant articles and followed the Cochrane methodology for systematic reviews of intervention. RESULTS: Overall, 27 randomized controlled trials (RCTs), 1 cluster RCT (cRCT), and 1 quasi-RCT were included in this review. The total number of participants was 1690 in addition to the cRCT, which included 24 practices. Due to the heterogeneity of the participants, interventions, and outcomes, meta-analysis was not feasible, and the results were presented as narrative summary. Compared with face-to-face learning, the effect of OCDE on knowledge gain is uncertain (ratio of the means [RM] range 0.95-1.17; 8 studies, 495 participants; very low grade of evidence). From the same comparison, the effect of OCDE on cognitive skill gain is uncertain (RM range 0.1-0.9; 8 studies, 375 participants; very low grade of evidence). OCDE may have little or no effect on patients' outcome compared with face-to-face education (2 studies, 62 participants; low grade of evidence). Compared with no intervention, OCDE may improve knowledge gain (RM range 1.36-0.98; 4 studies, 401 participants; low grade of evidence). From the same comparison, the effect of OCDE on cognitive skill gain is uncertain (RM range 1.1-1.15; 4 trials, 495 participants; very low grade of evidence). One cRCT, involving 24 practices, investigated patients' outcome in this comparison and showed no difference between the 2 groups with low-grade evidence. Compared with text-based learning, the effect of OCDE on cognitive skills gain is uncertain (RM range 0.91-1.46; 3 trials with 4 interventions; 68 participants; very low-grade evidence). No study in this comparison investigated knowledge gain or patients' outcomes. One study assessed the CE and showed that OCDE was cost-effective when compared with face-to-face learning if the cost is less than or equal to Can $200. No trial evaluated the adverse effect of OCDE. CONCLUSIONS: The effect of OCDE compared with other methods of education on medical doctors' knowledge and cognitive skill gain is uncertain. OCDE may improve doctors' knowledge compared with no intervention but its effect on doctors' cognitive skills is uncertain. OCDE may have little or no effect in improving patients' outcome.

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors.

BACKGROUND: Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. METHOD: Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. FINDINGS: The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. CONCLUSION: There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.

Childhood and adolescent obesity: Primary Health Care Physicians' perspectives from Riyadh, Saudi Arabia.

BACKGROUND & OBJECTIVES: Primary health care (PHC) physicians are foremost to confront childhood and adolescent obesity. Our objective was to evaluate PHC Physicians perspectives for managing overweight/obesity in children and adolescents. METHODS: PHC services from eight public hospitals in Riyadh participated. A self-administered tool maintaining anonymity evaluated facilitators and barriers for managing overweight/obese children and adolescent patients. Physicians who 'always' recommended weight management for an overweight / obese patient during past year, by involving patient, parents, and others were classified as having positive and appropriate practice. RESULTS: Of the 58 respondents, 51.7% had appropriate practices. Lack of patient motivation (82.2%), and parental involvement (70.7%) were the major barriers. Physicians with appropriate practices differed in perspectives from those with less appropriate practices by attending continued education forums (p<0.026), referring patients to sub-specialty (p< 0.041), clinical knowledge (p<0.039), convinced on interventions (p<0.017), low concern for precipitating eating disorders (p<0.019), comfortable in examining obese patients (p<0.020), and considered patient's readiness for weight change (p< 0.007). CONCLUSION: Efforts are needed to equip PHC physicians in managing overweight and obesity in Saudi children and adolescents.