69832 research outputs found
Sort by
Personalised risk-prediction tools for cryptococcal meningitis mortality to guide treatment stratification in sub-Saharan Africa: a prognostic modelling study based on pooled analysis of two randomised controlled trials.
Get PDFBACKGROUND: Cryptococcal meningitis is a major driver of global HIV-related mortality, and validated approaches to stratify mortality risk could help to target effective treatment strategies. We aimed to develop and validate models to predict risk of all-cause mortality in people with HIV-associated cryptococcal meningitis in sub-Saharan African countries. METHODS: For this prediction modelling study, we pooled individual-level data from the ACTA (ISRCTN45035509) and AMBITION-cm (ISRCTN72509687) randomised controlled trials. Data in ACTA were collected between Feb 12, 2013, and Jan 10, 2017, and data in AMBITION-cm were collected between Jan 31, 2018, and June 11, 2021. Adults aged 18 years or older with a first episode of HIV-associated cryptococcal meningitis were recruited to both trials. Exclusion criteria included pregnancy or lactation; receipt of high-dose anti-fungal treatment doses before screening; and contraindications to trial medication. Participants were recruited from nine hospitals across Cameroon, Malawi, Tanzania, and Zambia in ACTA and eight hospitals across Botswana, Malawi, South Africa, Uganda, and Zimbabwe in AMBITION-cm. We developed two primary multivariable logistic-regression models for the primary outcome of 2-week mortality: a basic model for use in a resource-limited setting that contained only candidate predictors that are routinely, programmatically obtained at hospital admission and a research model for which all predefined candidate predictors were considered for inclusion. We used internal-external cross-validation to evaluate model performance across countries within the development cohort (ie, data from all countries except Malawi participants in AMBITION-cm), before validation of discrimination, calibration, and net benefit in held-out data from Malawi. FINDINGS: We included 674 eligible participants from ACTA and 814 from AMBITION-cm in the pooled analysis (total sample size 1488). 1263 participants were included in model development, with 225 from the Malawi site in AMBITION-cm held out for validation. 222 (17·6%) of 1263 participants in the development set and 21 (9·3%) of 225 participants in the validation set met the primary model outcome of 2-week mortality. We retained five predictors in the basic model and seven in the research model. Predictors in both models were Glasgow Coma Scale score, Eastern Cooperative Oncology Group performance status, haemoglobin, blood neutrophil count, and treatment. Additional predictors in the research model were cerebrospinal fluid opening pressure and log10 cerebrospinal fluid quantitative cryptococcal culture. Discrimination was relatively consistent between study sites for both models (pooled C statistic 0·75 [95% CI 0·68-0·82] for the basic model and 0·78 [0·75-0·82] for the research model), but calibration was more heterogeneous (pooled calibration slope 0·87 [95% CI 0·57 to 1·17] and 0·83 [0·69 to 0·97], pooled calibration in the large 0·00 [-0·54 to 0·55] and -0·02 [-0·46 to 0·42], for the basic and research models, respectively). In held-out validation, discrimination of both models was slightly higher than estimates from internal-external cross-validation (C statistic 0·78 [95% CI 0·70-0·87] in the basic model and 0·85 [0·79-0·92] in the research model). Calibration assessment suggested overestimation of risk, particularly in the high-risk range: calibration slope 1·04 (95% CI 0·54 to 1·55), calibration in the large -0·55 (-1·02 to -0·07). When comparing single, high-dose liposomal amphotericin B plus 14 days of flucytosine plus fluconazole with 1 week of amphotericin B plus flucytosine in AMBITION-cm, hazard ratios were 0·50 (95% CI 0·26-0·97) in the low-risk stratum and 0·96 (0·67-1·37) in the high-risk stratum for the basic model, and 0·61 (0·31-1·18) in the low-risk stratum and 1·03 (0·72-1·47) in the high-risk stratum for the research model. INTERPRETATION: Both models accurately predicted 2-week mortality in people with HIV and have the potential to be incorporated into future treatment-stratification approaches in low-income and middle-income countries. FUNDING: National Institute for Health Research
Rising transphobia and disparities in drug-related harm experienced by transgender and gender-diverse people.
Get PDFBACKGROUND: Transgender (trans) and gender-diverse (TGD) people are a small but increasingly visible population who experience worsening marginalisation characterised by toxic political and media discourse, violent hate crimes and discriminatory laws targeting healthcare and public access. Governments in both the United Kingdom (UK) and the United States (US) have pushed anti-trans policies which threaten to further exclude TGD people. Understanding the public health impacts of transphobia is vital, especially regarding disproportionate drug-related harms. MAIN BODY: TGD people are more likely than their cisgender counterparts to experience both acute and chronic drug-related harm. This is, in part, driven by rising transphobia and perpetuated by limited access to gender-affirming and harm reduction services. Current health data systems fail to accurately capture the scale of drug-related harms faced by TGD people due to suboptimal gender measurement. Inclusive data collection and culturally competent harm reduction services are urgently needed to address these disparities. Digital interventions, such as telehealth, and peer-led support may improve the accessibility and effectiveness of care for this group. CONCLUSION: Evidence suggests that TGD individuals face disproportionate drug-related harm compared to cisgender people, a disparity likely to widen as government-led hostility increases in countries such as the UK and the US. Immediate action is required to ensure TGD people are fully represented in research, public health monitoring, and support services
Role and experiences of youth community health volunteers in a community health coaching programme for older adults in Singapore: a qualitative study.
Get PDFINTRODUCTION: Older adults are often faced with a multitude of physical and social challenges that impede their ability to age healthily. To tackle this issue, the use of trained lay volunteers as health advocates has become increasingly popular; however, their perceptions and experiences remain to be explored. This study aimed to explore the experiences of youth community health volunteers (YCHVs) who participated in HealthStart, a community health coaching programme for older adults in Singapore.
METHODS: We conducted purposive sampling and carried out semi-structured interviews with 16 YCHVs and eight healthcare volunteers. Data were analysed thematically using deductive and inductive coding.
RESULTS: We generated four themes: (1) structured training, resources, and in-person mentorship helped YCHVs effectively support older adults in their health journeys, (2) facilitators and barriers influenced older adults' receptiveness to YCHVs, (3) YCHV motivations to volunteer, and (4) YCHVs becoming trained health advocates and contributing to preventive health strategies. Findings illustrated the facilitators and challenges experienced by YCHVs and the contributions they can make to preventive health strategies.
CONCLUSION: The exploration of YCHVs' motivation and experience can potentially improve the uptake, acceptability, and satisfaction of using trained youth health advocates in community health coaching programmes for older adults
"I'm Pregnant, What Do I Do?": Exploring How People Having Abortions in Britain Find and Use Online Sources of Information.
Get PDFBACKGROUND: Accurate, timely, and supportive information is important for high-quality abortion care. Limited research explores how people find and use online sources of information (OSI) during the abortion process, particularly in Britain. Understanding experiences of using OSI is important for the development of person-centered services and resources. METHODS: We conducted a thematic analysis of qualitative data from 41 semi-structured interviews carried out in 2021/2022 with people who had recent experience of abortion in Britain. RESULTS: Using OSI was common amongst participants. Our analysis generated four distinct motivations for doing so. People used OSI to find information about accessing abortion services. OSI was also used to demystify abortion, as many participants did not understand what the process involved or know what to expect. Connection and solidarity were sought through OSI, and some participants felt supported by the content they found, particularly through the accounts of others. Finally, people used OSI to explore their relationship with their pregnancy during the abortion process. Using OSI brought benefits-including finding non-judgmental and supportive resources-and challenges, including struggling to find relevant information or encountering negative stories and anti-abortion views. Nonetheless, participants appreciated OSI and expressed a desire for more real-life stories and online spaces where they could connect with others. CONCLUSIONS: People having abortions want and need different things from the online resources they consult. However, OSI have the potential to provide valuable information, connection, and a place for exploration around the topic of abortion. Future work should explore how OSI can meet these different needs, guided by the motivations of users
"I want to chat with a person": a qualitative longitudinal cohort study in England exploring drivers of sub-optimal childhood vaccination uptake.
Get PDFBACKGROUND: Childhood vaccination rates in the UK have declined for the thirteenth year in a row. This study explores parents' vaccination experiences to identify key barriers affecting uptake, helping stakeholders better understand and support families. METHODS: A qualitative longitudinal study following a cohort (n = 22) of parents from birth to age one. Three waves of data collection took place in line with key vaccination due dates at approximately two (July 2023-February 2024), four (October 2023-May 2024), and twelve months of age (May 2024-December 2024). In total, the dataset comprises 63 interviews and 98 diary entries (including 119 picture submissions) across all waves of data collection. Data were analysed using temporal thematic analysis. RESULTS: Information provision was a critical temporal theme accounting for divergences in parents' experiences and, in some instances, the outcome of their vaccination journeys. Parents received minimal information in the lead up to vaccination and during the appointment itself. Parents had different relationships with vaccination (confident, curious, or concerned), however, this was subject to change between waves of data collection. In addition to a lack of proactive information provision, there was nowhere for parents to turn to having developed vaccine-related concerns leaving some stuck "on the fence". Parents were further nudged towards vaccine deferral or refusal based on a breakdown of trust with their General Practice, search engine results, and content on social media. CONCLUSION: To address declining vaccination coverage in England, it is essential that parents have opportunities to meaningfully discuss their questions with healthcare providers. For many, information provision is too little, too late, and there is no opportunity for dialogue. This study deepens our understanding of parents' experiences of information provision regarding childhood vaccinations and provides recommendations for policy and practice
Associations of municipality-level income and racial segregation with individual-level tuberculosis treatment outcomes in Brazil: a nationwide cohort study (2010-2019).
Get PDFBACKGROUND: Residential segregation is considered a social determinant of health, but there is limited evidence of its impact on tuberculosis (TB). We investigated the associations between municipality-level income and racial segregation and TB treatment outcomes in Brazil. METHODS: We studied nationwide registries of new TB cases between 1 January 2010 and 31 December 2019. TB treatment was dichotomised as unfavourable (ie, loss to follow-up, modification of treatment regimen, treatment failure and death) and favourable (ie, cured/treatment completion). We assessed individuals' municipality-level income and racial segregation (ie, dispersion of household heads earning ≤half versus those earning >half minimum wage; and of household heads identifying as black or brown/mixed race (Pardo/a) versus white). Logistic regression adjusted for sociodemographic and clinical variables was used to estimate the OR of experiencing an unfavourable treatment outcome associated with segregation overall and by self-identified race/ethnicity. RESULTS: Individuals living in highly economically and racially segregated municipalities (fifth versus first quintiles) were more likely to have an unfavourable TB treatment outcome (income segregation: adjusted OR 1.34 (95% CI 1.31 to 1.37); racial segregation: 1.13 (0.94 to 1.36)). Living in municipalities of higher income segregation (third, fourth and fifth quintiles) was associated with higher unfavourable TB treatment outcomes in all self-identified racial groups (fifth quintile: white 1.25 (0.96 to 1.64); black 1.42 (1.15 to 1.74); brown/mixed 1.37 (1.20 to 1.56); Asian=1.30 (1.00 to 1.69) and Indigenous 1.37 (1.00 to 1.87)). CONCLUSIONS: Living in highly income and racially segregated environments is associated with unfavourable TB treatment outcomes for all self-identified races in Brazil. TB programmes should account for segregation as a barrier to TB treatment completion
Effects of the Family Nurse Partnership on all eligible mothers: a data linkage cohort study in England.
Get PDFBACKGROUND: An intensive programme of home visiting, the Family Nurse Partnership (FNP), is received by around one in four first-time adolescent mothers in selected areas in England. During home visits, nurses support mothers to make choices about healthy pregnancies, improving child development, and fulfilling their own aspirations and ambitions. Evidence is needed of the wider effects of the FNP, including for mothers not enrolled in the programme (who might experience unintended effects). We evaluated child and maternal outcomes for all eligible mothers giving birth before, during, and after the period in which FNP was active in local areas. METHODS: We created a linked cohort of 237,185 eligible mothers, aged 13-19, who gave birth between April 2010 and March 2019, and who had a first antenatal booking appointment (or a date of 28 completed weeks of gestation, if missing) when FNP was active in their area. We used administrative hospital data to identify unplanned maternal/child hospitalisations up to 2 years after birth for children born and mothers delivering before, during and after FNP was active. Generalised linear models were used to adjust for background regional time trends, maternal characteristics, and clustering of outcomes within residential areas. RESULTS: We found no evidence of differences in unplanned hospital admissions for children born during the FNP period (36.9% versus 36.0%, relative risk [RR] 1.01; 95% CI 0.99-1.02), or after FNP was active (37.1%, RR 1.0; 95% CI 0.95-1.06), compared with those born before FNP was active. There was no evidence of differences in child admissions for maltreatment/injury-related diagnoses or for maternal admissions for adversity-related diagnoses. CONCLUSION: Child and maternal outcomes were similar before, during and after FNP active periods, suggesting that the FNP did not have a wider impact on outcomes in all eligible mothers, including those not participating in the FNP
Participant perceptions of disability training for health workers: a qualitative study in Ghana.
Get PDFBACKGROUND: Disabled people often report poor treatment by health workers, and health workers often report wanting more training about how to care for disabled people. However, existing disability training for health workers is usually delivered in one-off interventions, with little follow-up, evaluation, and focus on long-term learning. This insufficiency makes it important to understand how disability training for health workers can be more effective. Therefore, we interviewed stakeholders involved in an existing disability training intervention in Ghana. The aim of the study was to understand how disability training for health workers could be improved by exploring the perspectives of individuals who were involved in previous training interventions. METHODS: A phenomenological study was conducted. In-depth, qualitative interviews were conducted with 33 people (17 trainers and 16 trainees) involved in disability training in Ghana. Data were analysed using thematic analysis. RESULTS: Participants spoke about the challenges with existing training, namely how the current approach was insufficient, the consequences of informality in running training and the need for more sign language instruction. Several participants suggested improvements for training, including having external motivation (i.e., professional development credits, monetary benefits, etc.), more collaborative initiatives across institutions and government, and curriculum integration. We developed a theory of change model to show how different components of disability training support learning. CONCLUSIONS: These results show that disability training for health workers is important and that there is scope to refine and standardize training. In particular, the findings demonstrate how future initiatives to train health workers can be developed and implemented. They also emphasize the need to solicit perspectives from individuals who have experienced training in order to improve future iterations
Public health agencies need to be ‘Kennedy ready’
Get PDFThe Secretary of the US Department of Health & Human Services, Robert Kennedy Jr is leading a political agenda against vaccination. This is undermining the delivery of life-saving vaccination programmes and provision of evidence-based information on the safety and effectiveness of vaccines for the public and health professionals. Inconsistent and conflicting messaging between health practitioners and government health agencies erodes trust in public health programmes, creating a vacuum which is often filled with mis/disinformation that presents severe consequences for families. Due to the transnational spread of diseases, we consider the implications of events in the US for routine childhood vaccination programmes in the UK. Public health agencies across the world need to be ‘Kennedy ready’; pragmatic steps must be taken to mitigate threats posed to vaccine confidence and the control of vaccine preventable diseases
A global living systematic review and meta-analysis hub of emerging vaccines in pregnancy and childhood.
Get PDFThe COVID-19 pandemic accelerated vaccine development and generated a rapidly evolving body of evidence before and after the vaccine rollout. We developed a robust online platform to efficiently synthesize this emerging information for current and future challenges. Expanding upon our interactive living systematic review-initially focused on COVID-19- we now include chikungunya and Lassa fever (with protocols presented in this issue), Mpox, and Disease X ( https://www.safeinpregnancy.org ). We aim to continuously monitor and periodically update and disseminate high-quality data on vaccine safety, efficacy, effectiveness, and immunogenicity in pregnancy and childhood. This platform computes real-time meta-analyses and features a visualization tool to present findings in a clear and accessible manner, supporting decision-making, vaccine development pipelines, and implementation strategies worldwide. It is also designed to integrate data on a hub of emerging vaccines in pregnancy and childhood and reflects a collaborative effort among multiple organizations