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Barriers to cataract surgeries as perceived by visually impaired 50 years and older cataract blind participants of Nepal survey for rapid assessment of avoidable blindness.
Get PDFPURPOSE: To identify the main barriers and determinants to cataract surgery as perceived by 50 years and older Nepali people with severe visual impairment & blind due to cataracts. METHODS: This was part of the Rapid Assessment for Avoidable Blindness (RAAB), held in all provinces of Nepal from 2018 to 2021. Cataract blindness was defined as a person having the best-corrected vision, < 6/60 in the better eye, and an unoperated cataract, which was the principal cause of visual disability. The participants were interviewed using a pretested questionnaire with seven known barriers. The demographic information was correlated with the barrier score. RESULTS: We surveyed 718 cataract blind. Two-thirds of the participants were females. Four in ten were aged 50-59 years. The main barriers perceived were 'need is not felt' (237; 33%), cost associated with surgery (218; 30%), lack of access (93; 13%), fear of surgery (88; 12%), nobody to accompany (40; 6%), unaware of surgery (18; 3%), and treatment denied (24; 3%). The barriers were not significantly different in females than in males. (P = 0.85). The provincial variations of barriers were significant. (P < 0.001). High cost was a perceived barrier in all provinces except Gandaki. Access to treatment was a barrier in the Gandaki province (38%). One in four participants in the Madhesh and Bagmati provinces feared surgery. Nearly half of the cataract blind in the Madhesh and Lumbini province did not feel 'need for restoring vision'. CONCLUSIONS: To improve cataract surgery uptake, identified barriers, like lack of awareness, low visual need, and high cost must be addressed. The strategies could be devised according to provincial barriers but similar to both genders and all 50 years and older cataract blind. Offering low-cost cataract surgery, financial assistance and health promotion to improve awareness and remove fear were recommended
Affordability of healthy and water-saving dietary patterns in The Gambia.
Get PDFDietary modification has the potential to improve nutritional status and reduce environmental impacts of the food system. However, for many countries, the optimal composition of locally contextualized healthy and sustainable diets is unknown. The Gambia is vulnerable to climate-change-induced future water scarcity which may affect crop yields and the ability to supply healthy diets. This study identifies potential shifts in Gambian diets that could make diets healthier and reduce the associated agricultural water footprint (WF), and assesses the cost and affordability implications of such dietary changes. Gambian Integrated Household Survey (IHS) food consumption data was combined with market prices, food expenditure and agricultural WF data. Current dietary patterns were compared with World Health Organization (WHO) dietary guidelines and optimized using linear programming to identify least-cost diets that met nutrition recommendations and reduced agricultural water use. Optimization scenarios explored the maximum reduction in green water use that could be achieved with 'culturally-acceptable' dietary shifts, and the magnitude of shifts required to maintain green water use at current levels. On average, current diets provide adequate energy and have appropriate macronutrient composition. However, only 14% of households consume enough fruit and vegetables (F&Vs), and consumption of added sugars exceeds recommendations. With 'culturally-acceptable' changes in consumption, agricultural water use could decrease by 10%-13% or increase by 9%, depending on the baseline dietary pattern. Extreme dietary shifts will be required to maintain water use at 2015 levels with projected population growth. To meet WHO recommendations, dietary costs would increase by 43% compared to the current baseline. Healthy and green water-saving diets would require 48%-63% of average household expenditure to purchase, which is unaffordable for almost half of the population. F&Vs alone account for 31%-40% of the cost of optimized diets compared to 12% of current diets. Dietary modification has the potential to improve the nutritional quality of Gambian diets while reducing agricultural water use, but the required changes are likely to be unaffordable for a large proportion of the population. Improving availability and affordability of nutritious foods-particularly F&Vs-will be crucial for the accessibility of healthy and sustainable diets in the Gambian population
Multimorbidity in tuberculosis (TB) and its impact on patient care (MITICare): a cross-sectional study nested within a prospective cohort study protocol.
Get PDFMultimorbidity, defined as two or more co-existing long-term health conditions, is increasing in low- and middle-income countries, overlapping with ongoing high tuberculosis (TB) incidence. It is known that there is a high prevalence of multimorbidity in patients with TB in South Africa, but our understanding of how common TB-multimorbidity is in other African countries, and its effect on the trajectories of TB care, is limited. This cross-sectional study nested within a prospective cohort (co-designed between the Infectious Diseases Institute, Uganda and the University of St Andrews, United Kingdom) aims to describe the burden and evaluate the consequences of multimorbidity among patients with TB disease in Kampala, Uganda. The primary objective is to describe the prevalence of multimorbidity at the start of treatment for TB. The secondary objectives are to determine the effect of multimorbidity on clinical characteristics at the start of treatment, progress through TB care, and end of TB treatment outcomes. 254 adults commencing treatment for TB shall be recruited. Multimorbidity shall be assessed using structured questionnaires, simple examination and blood analysis. Th clinical characteristics of TB shall be determined using health and quality of life scores and, in patients with pulmonary TB, the degree of chest X-ray abnormalities and sputum bacillary burden. Patients shall be followed-up at two and six months and their response to treatment determined. The analysis of the prevalence of multimorbidity at baseline shall be reported using a proportion and 95% confidence interval. For the secondary objectives, regression models adjusting for confounders identified through directed acyclic graphs will be used. This study has been developed in close collaboration with a core patient and public involvement group, who will also be actively involved in the dissemination of study results. Ugandan and St Andrews University ethical approval has been prospectively granted (IDI-REC-2023-82, MD17720 and HS3888ES)
Falling prevalence of gastrointestinal malignancy in adults with iron deficiency anaemia, and identification of additional predictive clinical variables: the IDIOM V study
Get PDFObjective
(1) To determine whether the prevalence of gastrointestinal (GI) cancer in adults presenting with iron deficiency anaemia (IDA) is continuing to fall, and (2) to identify clinical variables with the potential to improve the accuracy of an established system for predicting cancer risk in IDA—the Iron Deficiency as an Indicator Of Malignancy (IDIOM) score.
Method
(1) An audit of 1253 consecutive adults to the IDA service of a single general hospital in 2022/2023, with analysis of the outcome of investigation for GI cancer, and the relationship between this outcome and a series of eight clinical variables. (2) Refinement of the IDIOM score using an imputation method to combine the development and new predictor data sets.
Results
The prevalence of GI cancer in those undergoing full investigation for IDA was 5.6% (52/934). On univariate logistic regression analysis, there were strong negative associations between GI cancer risk and (1) previous colonic imaging within the last 5 years (OR 0.31, 95% CI 0.08 to 0.87), and (2) long-term exposure to proton pump inhibitor (PPI) therapy (OR 0.18, 95% CI 0.09 to 0.34). Model extension analysis suggested that adding PPI exposure status could improve the accuracy of the IDIOM score: c-statistic—0.84 vs 0.77, calibration slope—1.01 vs 1.05.
Conclusion
The prevalence of GI cancer in adults presenting with IDA continues to fall, strengthening the case for risk stratification and targeting of invasive investigation at those at higher risk. Adding PPI exposure status may improve the value of the IDIOM score, though this requires confirmation in prospective studies
Cost-effectiveness of the CV-polypill strategy versus standard care for secondary cardiovascular prevention in Spain: an analysis based on the SECURE trial
Get PDFBackground: The SECURE trial (NCT02596126) demonstrated the efficacy of the cardiovascular polypill (“CV-Polypill”–acetyl salicylic acid, atorvastatin and ramipril) in reducing the risk of recurrent major cardiovascular events compared with standard care when initiated within six months of a myocardial infarction. This analysis aimed to estimate the cost-effectiveness of the CV-Polypill from the Spanish healthcare perspective using SECURE trial data.
Methods: A decision analytic Markov modelling approach was conducted to compare the CV-Polypill with standard care over a lifetime time horizon. Six parametric distributions were fitted to SECURE trial data on time to reinfarction, stroke or death (cardiovascular or non-cardiovascular). Cost and utility data were sourced from literature. Respective model outputs were discounted at 3%. The model captured direct medical costs associated with treatment acquisition and acute/ongoing cardiovascular events. Probabilistic sensitivity analyses (PSA) and scenario analyses were conducted.
Findings: The CV-Polypill is dominant (improves health outcomes and reduces costs) in 84·8% of PSA iterations (848/1000 iterations), and cost effective in 89·3% of PSA iterations (893/1000 iterations) at a €30,000 threshold. Secondary prevention with the CV-Polypill reduces the recurrence of cardiovascular events and costs over the time horizon, from the Spanish healthcare perspective. A range of scenario analyses were conducted, demonstrating the robustness of the results when different inputs and assumptions were varied.
Interpretation: The CV-Polypill is a dominant strategy in secondary cardiovascular prevention, compared with standard care, from the Spanish healthcare perspective. The CV-Polypill should be considered as a secondary prevention for Spanish patients, like those enrolled in SECURE, at hospital discharge.
Funding: By Ferrer International
The Association of Mental Health With Menstrual Health Among Secondary School Students in Uganda: A Longitudinal Cohort Study.
Get PDFPURPOSE: Poor menstrual health can affect mental health through multiple biopsychosocial pathways. Few studies have examined the associations using multiple dimensions of menstrual health. METHODS: We analyzed longitudinal data collected from female secondary school students in Uganda enrolled in a cluster-randomized trial. We administered a baseline survey from March to July 2022 and an endline survey from June to August 2023. We used the Strengths and Difficulties Questionnaire (SDQ) total difficulties score to assess mental health problems. We used mixed-effects linear regression to estimate adjusted mean differences (aMDs) for the effect of baseline menstrual-related exposures on the endline SDQ score. Models were adjusted for the baseline SDQ score and school-level clustering. RESULTS: At baseline, we enrolled 3741 postmenarche participants from 60 schools (mean age 15.6 years, standard deviation = 0.9). Of these, 2829 (75.5%) completed the endline survey. We found evidence for an association between multiple dimensions of poor baseline menstrual health and endline mental health problems, after adjusting for sociodemographic factors and the baseline SDQ score. Dimensions of menstrual health associated with mental health included lack of social support related to menstruation (aMD = 0.74, 95% confidence interval [CI] 0.26-1.21), poorer attitudes to menstruation (aMD = 0.38, 95% CI 0.03-0.73), lower menstrual health self-efficacy (aMD = 0.60, 95% CI 0.15-1.05 for lowest vs. highest tertile) and more unmet menstrual practice needs (aMD = 1.11, 95% CI 0.61-1.60). DISCUSSION: Negative menstrual experiences were associated with subsequent mental health problems among in-school Ugandan adolescents, but effect sizes were small. Interventions would need to achieve large improvements in multiple dimensions of menstrual health to lead to measurable improvements in mental health
Influenza vaccine delivery models in secondary care (hospital) settings: What approaches are used to enhance access for clinical risk groups in England?
Get PDFBACKGROUND: Influenza vaccine uptake rates in England remain suboptimal among adults with clinical conditions that predispose to severe influenza. Influenza vaccines are predominantly delivered in primary care settings, but complementary delivery via a broader range of secondary care settings is recommended to enhance access. This qualitative study aimed to document current influenza vaccine delivery models in hospital-based settings and to compare the opportunities and limitations associated with those delivery models. METHODS: Semi-structured interviews (n = 28) were conducted with healthcare professionals based in secondary care, and with National Health Service commissioners to understand current vaccine delivery practices within hospital settings in two regions of England. RESULTS: Most hospitals who offered patient vaccination had invested in dedicated staff and processes to support influenza vaccine delivery. A variety of interventions were used to navigate the steps in the vaccination pathway. Challenges included engagement of medical staff, access to vaccination records and managing vaccine stocks. CONCLUSION: Secondary care vaccination is possible with the appropriate investment in staff and processes. Focusing on staff engagement, addressing logistic challenges and providing adequate invesment would support the sustainability of vaccination in secondary care
Developing and evaluating a community-driven intervention to promote uptake of HIV and contraception services among students enrolled in colleges and universities in Zimbabwe.
Get PDFINTRODUCTION: There is a growing appreciation that community-led interventions are key to sustaining the HIV response and achieving HIV prevention and treatment targets. Together with young people in colleges/universities and Ministry of Health (MOH), we developed and evaluated a student-led intervention for promoting the uptake of HIV self-testing (HIVST), post-exposure prophylaxis (PEP) and emergency contraception (EC) among college/university students. METHODS: Over 3 months, in biweekly study team meetings, two workshops with students, two meetings with MOH, and a joint workshop with students, MOH and relevant stakeholders, we co-developed an intervention for peer-led promotion/distribution of HIVST, PEP, EC and condoms. The agreed intervention was piloted in three Zimbabwean colleges/universities from December 2023 to February 2024. Student peers distributed HIVST and condoms directly, and vouchers for PEP and EC that were redeemed at college/nearby clinics. During co-development, students strongly preferred peer distribution of all commodities but this was restricted by regulatory requirements for PEP and EC. Peer distributors (n = 14) kept daily audio diaries of their experiences. In-depth interviews were held with students (n = 18), peer distributors (n = 11) and key informants (n = 12) to explore views/preferences, with participant observations and four focus group discussions to provide additional insights. We determined the intervention development and implementation costs. RESULTS: Peer-led distribution of HIVST, PEP and EC to college/university students was acceptable, feasible, appropriate and generally implemented as intended. PEP and EC acceptability was driven by high HIV and pregnancy risk among students, who had no easy access to services. Of 100 PEP and 257 EC vouchers distributed, 30% and 40% were redeemed, respectively. The main barrier to PEP and EC uptake was moral judgement against premarital sex, which affected female students more. Judgemental health worker attitudes also limited uptake of PEP and EC. EC voucher redemption among female students was lower versus males, aOR = 0.4 (95% CI = 0.2-0.8), p = 0.019. Redemption was also higher at the college where the nearby clinic could be accessed discreetly. Total cost of the intervention per student was 7.26-$35.52). CONCLUSIONS: Student-led distribution of HIVST, PEP and EC was feasible, acceptable and affordable. Making the intervention more community-driven according to the 2024 WHO PEP guidelines will likely achieve great impact
Fitting a square peg in a round hole? A mixed-methods study on research ethics and collaborative health and social care research involving 'vulnerable' groups.
Get PDFBACKGROUND: Current research ethics frameworks that oversee health and social care research, in the United Kingdom and internationally, originated in biomedical research, having positivist underpinnings and an orientation towards experimental research. Limitations of these frameworks have been extensively documented including with regard to health and social care research that adopts collaborative approaches. This article contributes to debates about how the research ethics system deals with collaborative research with groups labelled or potentially perceived as vulnerable, and identifies practical recommendations to ensure a better fit between principles and practices of research ethics and those of collaborative research. METHODS: We conducted a two-round online Delphi study with 35 academic researchers with experience of collaborative research involving vulnerable groups and of seeking research ethics approval in England (United Kingdom), followed by a focus group with eight members of the Delphi panel. The Delphi questionnaire, organised in 12 themes, comprised 66 statements about how researchers experience research ethics review and how the research ethics system could be improved. The focus group discussed the results of the Delphi study to generate practical recommendations. RESULTS: By the end of the second Delphi round, only one statement relating to the experience of the current research ethics system reached consensus, signalling heterogeneous experiences among researchers working in this field. A total of 32 statements on potential improvements reached consensus. The focus group discussed the 14 Delphi statements with the highest levels of consensus and generated 12 practical recommendations that we grouped into three clusters (1. Endorsing the 'collaborative' dimension of collaborative research; 2. Allowing flexibility; and 3. Strengthening the relational and ongoing nature of ethical research practice). CONCLUSIONS: This work provides further empirical evidence of how the research ethics system deals with collaborative research involving 'vulnerable' groups. It also offers practical recommendations to ensure that the collaborative dimension of such research receives proper ethical scrutiny, to introduce a degree of flexibility in research ethics processes and supporting documents, and to replace formal, one-off research ethics approvals with ongoing, situated, relational ethical processes and practices
Food insecurity in South Indian households with TB during COVID-19 lockdowns and the impact of nutritional interventions: A qualitative study.
Get PDFTuberculosis (TB) mortality rose during the COVID-19 pandemic, as did food insecurity worldwide. Undernourished individuals are at increased risk for incident TB disease and TB mortality. This study examines the impact of COVID lockdowns on the food security of households with TB in Southern India. In-depth interviews and focus group discussions were conducted with household contacts enrolled in a nutritional intervention study, conducted in Puducherry and Tamil Nadu (2018-2024), which provided household contacts of persons with TB with a six-month nutritional intervention. During the COVID-19 lockdowns, 78% of households in our study had no income; 67% resorted to distress financing, such as loans, to afford food; and 44% changed their eating habits, such as buying less food or different items. Respondents reported that the provided nutritional intervention improved their food security. Crises such as the COVID-19 pandemic can reduce both food access and diversity, leading to macronutrient and micronutrient deficiencies that increase the risk of TB incidence and mortality. Undernutrition due to food insecurity may have been a driver for hastened disease progression or disease-related morbidity and increased mortality during the pandemic. Nutritional support interventions should be implemented as a part of pandemic response