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First trimester antidepressant use and miscarriage: a population-based cohort study using Clinical Practice Research Datalink GOLD.
Get PDFBACKGROUND: Depression and anxiety during pregnancy is on the rise, thus more pregnant women are being offered antidepressants; however, uncertainties remain surrounding safety. AIM: To investigate the association between first trimester antidepressant use and miscarriage.
DESIGN AND SETTING: Population-based cohort study using the UK Clinical Practice Research Datalink (CPRD) GOLD.
METHOD: Pregnancies included in the CPRD GOLD Pregnancy Register between 1996 and 2018 were identified. Pregnancies in those with prescriptions for antidepressants overlapping with the first trimester were defined as 'exposed' and compared with pregnancies in those who were unexposed. Cox models, adjusted hazard ratios (aHRs), and absolute risk of miscarriage were calculated adjusted for confounders including depression, anxiety, smoking, and other health, lifestyle, and obstetric factors.
RESULTS: Among the 1 021 384 eligible pregnancies, 73 540 patients were prescribed antidepressants in the first trimester (7.2%); 10 693/73 540 (14.5%) pregnancies ended in miscarriage among those prescribed antidepressants versus 116 641/947 844 (12.3%) in those not prescribed antidepressants. Antidepressant prescription during the first trimester was only modestly associated with miscarriage following adjustment (aHR 1.04, 95% confidence interval [CI] = 1.02 to 1.06). These findings translated to an absolute risk adjusted for confounders of 13.1% (95% CI = 13.0 to 13.2) for those not prescribed and 13.6% (95% CI = 13.3 to 13.8) for those prescribed antidepressants. Among those prescribed antidepressants in the 3 months before pregnancy and during the first trimester, the risk of miscarriage was the same as among those unexposed (aHR 1.00, 95% CI = 0.98 to 1.03).
CONCLUSION: First trimester antidepressant use was associated with a small, clinically insignificant increased risk of miscarriage, with no evidence suggesting taking antidepressants before pregnancy and into the first trimester increases the risk of miscarriage
Components of Family-Focused Interventions that Have Common Impacts Across Parental Domestic Violence and Abuse, Mental Ill-Health, and Substance Misuse: An Intervention Components Analysis.
Get PDFSupport for families experiencing domestic violence and abuse (DVA), mental ill-health (MH) and substance misuse (SU) is often delivered in siloes, despite the frequent co-occurrence of these public health issues. Little evidence-based guidance exists on which interventions best support families experiencing a combination of these problems. Identifying intervention components with common impacts across parental DVA, MH and SU could inform policy and practice. We conducted an Intervention Components Analysis (ICA) to identify intervention components that have common impacts across parental DVA, MH and SU. We searched ten databases for randomised controlled trials of family-focused interventions targeting, and measuring an impact on, one or more of these issues. We developed an initial coding framework using open coding to guide the coding of subsequent studies. Descriptive analyses identified common components across target outcomes (DVA/MH/SU) and robust variance meta-regressions explored the relationship between intervention components and treatment effects. A Lived Experience Advisory Group informed our presentation and interpretation of the results. We identified 164 interventions: 40 focused on a combination of DVA, MH and SU and 124 addressed one issue alone. None of the 20 components identified were unique to any specific outcome and no single component was associated with meaningful improvement in outcomes. Interventions aiming to provide integrated support across outcomes were less successful at improving MH and SU outcomes than those targeting single issues. We found no evidence of commonly effective intervention components. Better alignment between components and underlying processes driving DVA/MH/SU, and alternative intervention designs, are needed
Perceived accuracy and utilisation of DHIS2 data for health decision making and advocacy in Kenya: A Qualitative Study.
Get PDFReliable health information systems (HIS) are critical for effective decision-making in the delivery of Primary Health Care and Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (PHC/RMNCAH+N) services. In Kenya, the District Health Information Software 2 (DHIS2) platform serves as the primary HIS for tracking health indicators. This qualitative study explored perceptions of DHIS2 data accuracy and use for decision-making among PHC/RMNCAH+N stakeholders across 15 counties in Kenya. 89 Key Informant Interviews were conducted with PHC/RMNCAH+N stakeholders, to explore experiences, barriers, and facilitators of DHIS2 data use. Thematic network analysis was employed to identify recurrent themes and generate insights into the utility of DHIS2-generated information. Sociotechnical challenges included limited technical capacity among health staff, inadequate analytical skills, and reliance on a small pool of Health Records Information Officers (HRIOs). However, positive practices emerged, such as the use of DHIS2 dashboards and user-friendly outputs, which were valued for supporting evidence-based decision-making and advocacy, particularly at higher levels of health management. In some counties, visual displays of data, including scorecards and performance trends, facilitated budget advocacy and community engagement. Contextual challenges and constraints, such as use of inconsistent data collection tools across counties post-devolution, human resource shortages, and limited integration of private sector data, contributed to incomplete reporting. These challenges underpinned perceived inaccuracy of DHIS2 data, arguably, hindering the complete reliance on DHIS2 data for planning and decision making. The study highlights the need for targeted investments to improve DHIS2 data accuracy and use through stronger stakeholder coordination, enhanced data synthesis skills, and fostering a culture of data ownership among a wide range of stakeholders in health, including political actors.. Addressing these gaps will contribute to improvement in DHIS2 data quality, enhanced ownership and reliance on DHIS2 data by PHC/RMNCAH+N stakeholders for decision making in Kenya
Exit strategies for health interventions in low- and middle-income countries: a systematic review.
Get PDFBACKGROUND: Sustaining the benefits of externally funded interventions in low- and middle-income countries (LMICs) remains a concern in global health. As many initiatives depend on time-limited official development assistance (ODA) or philanthropic funding, exit strategies are increasingly recognised as key to ensuring positive impact. This systematic review examines how exit strategies have been conceptualised and implemented across a range of global health initiatives. We aim to identify, categorise and analyse the components of exit strategies during or after the implementation of health interventions in LMICs and their effectiveness. The results of this review will inform future global health programme design and research, including mental health.
METHODS: Database searches were conducted in Embase, Scopus, PubMed, PsycINFO (Elsevier), HMIC Health Management Information Consortium, MEDLINE, Social Policy and Practice, Web of Science and Global Health. The latest searches were run in January 2023. Data on study characteristics were descriptively synthesised. Extracted data regarding exit strategy processes and components were analysed using thematic synthesis.
RESULTS: Twenty-three articles (reflecting 22 studies) were identified for inclusion. Within these, eight key components of successful exit strategies were identified: (1) shared principles and values, (2) resource stability, (3) operational linkages, (4) local champions, (5) staff care and capacity, (6) leadership promotion, (7) mentoring and evaluation and (8) context-sensitive flexibility of exit. The studies showcased the complexity and interdependent nature of exit strategies in varied health contexts and provided insights into effective processes for sustained implementation.
CONCLUSIONS: This review highlights the importance of planning for sustainability from the outset of health programmes in LMICs. The application of effective, contextually adaptive exit strategies is critical to ensuring the continuity of health gains after external support ends. It emphasises the need for collaborative research focused on long-term impacts and offers concrete recommendations for policy and practice.
TRIAL REGISTRATION: PROSPERO Registration: (ref. CRD42021236969)
Occupation, displacement, and violence in the West Bank: A retrospective analysis of data from 2014-2024.
Get PDFIsraeli settlement expansion in the West Bank has intensified violence in the occupied Palestinian territories (oPt). This violence escalated after attacks by Hamas on Israel on 7 October 2023 and the subsequent military campaign in Gaza. This study examines the possible impacts of military and land occupation on displacement, injuries, and deaths in the West Bank. This cross-sectional observational study analyses casualties and displacement data in the West Bank and Israel from May 1, 2014, to June 30, 2024. Sources include the United Nations Office of Coordination of Humanitarian Affairs, Statista, and the Palestinian Central Bureau of Statistics. Death and injury rates per 100,000 person-years were calculated and compared across populations. Interrupted time-series analysis compared observed Palestinian deaths, injuries, and displacement to expected levels since October 2023. Chi-square analysis examined demolition patterns by West Bank area. GIS mapping methods visualized spatial variations in casualties and demolitions. Death and injury rates were substantially higher for Palestinians than Israelis: RR = 5.72 (95% CI 2.38, 13.75; p < 0.001) for deaths and RR = 16.47 (6.86, 39.56; p < 0.001) for injuries. Refugee camps had increased death rates: IRR = 7.91 (5.26, 11.89; p < 0.0001) compared to non-refugee camp populations. Since October 2023, West Bank deaths were 25% higher than expected: RR = 1.25 (1.15, 1.36; p < 0.0001) and displacement 17% higher: RR = 1.17 (1.12, 1.21; p < 0.0001). Nablus and Jenin recorded the highest fatalities. Jabal al-Mukkabir in East Jerusalem experienced the highest number of demolitions. Our study confirms a significant disparity in rates of conflict-related traumatic injuries and deaths between Palestinians and Israelis. The findings emphasize the need to limit military force against civilians, to hold the Israeli government accountable for demolitions and displacement, and to instigate protective measures in refugee communities. Policy efforts should prioritize conflict de-escalation, including reaching a sustainable political solution
Management of microbial keratitis by private pharmacies in Uganda: a study of knowledge, attitude, and practice.
Get PDFPURPOSE: To determine the knowledge, attitude, and practice of pharmacy attendants in the management of microbial keratitis. METHODS: This mixed-methods study was conducted in selected pharmacies and drug shops located in Mbarara City between March and May 2022. We administered questionnaires assessing the knowledge, attitudes, and practices (KAP) related to microbial keratitis (MK) to 140 pharmacy attendants (PAs) in the drug shops and pharmacies. We also conducted 40 in-depth interviews (IDI) and three focus group discussions (FGD) with pharmacy attendants to discuss practices, challenges, and opportunities to improve the management of MK. RESULTS: Of the 140 pharmacy attendants, almost half (49.29%) reported that they were not confident when making diagnoses in patients with eye problems, and 19.29% were uncertain of which drug to prescribe. In the IDIs and FGDs, the pharmacy attendants reported that they receive and manage patients with MK. Some immediately refer any patients they receive with eye complaints without prescribing any medication while others only refer those who are not responding to medication. The challenges faced in managing patients with MK included inadequate knowledge of managing eye diseases including MK, patients presenting with severe diseases because of delays in seeking healthcare, and the use of traditional eye medicine. The pharmacy attendants suggested ways of improving the management of MK and other eye diseases in the community including community sensitisation on eye diseases and conducting continued professional development lecture sessions on MK in pharmacies, drug shops, and clinics. CONCLUSION: The study showed that probable MK was a common presentation among patients seeking to buy drugs from pharmacies and drug shops. Pharmacies are key stakeholders in the health seeking journey of patients and hence need to be supported through capacity building and strengthening the referral network to improve the outcomes of patients with eye diseases and MK
Long term health outcomes in people with diabetes 12 months after hospitalisation with COVID-19 in the UK: a prospective cohort study.
Get PDFBACKGROUND: People with diabetes are at increased risk of hospitalisation, morbidity, and mortality following SARS-CoV-2 infection. Long-term outcomes for people with diabetes previously hospitalised with COVID-19 are, however, unknown. This study aimed to determine the longer-term physical and mental health effects of COVID-19 in people with and without diabetes.
METHODS: The PHOSP-COVID study is a multicentre, long-term follow-up study of adults discharged from hospital between 1 February 2020 and 31 March 2021 in the UK following COVID-19, involving detailed assessment at 5 and 12 months after discharge. The association between diabetes status and outcomes were explored using multivariable linear and logistic regressions.
FINDINGS: People with diabetes who survived hospital admission with COVID-19 display worse physical outcomes compared to those without diabetes at 5- and 12-month follow-up. People with diabetes displayed higher fatigue (only at 5 months), frailty, lower physical performance, and health-related quality of life and poorer cognitive function. Differences in outcomes between diabetes status groups were largely consistent from 5 to 12-months. In regression models, differences at 5 and 12 months were attenuated after adjustment for BMI and presence of other long-term conditions.
INTERPRETATION: People with diabetes reported worse physical outcomes up to 12 months after hospital discharge with COVID-19 compared to those without diabetes. These data support the need to reduce inequalities in long-term physical and mental health effects of SARS-CoV-2 infection in people with diabetes.
FUNDING: UK Research and Innovation and National Institute for Health Research. The study was approved by the Leeds West Research Ethics Committee (20/YH/0225) and is registered on the ISRCTN Registry (ISRCTN10980107)
Development partner influence on domestic health financing contributions in Senegal: a mixed-methods case study.
Get PDFSustainable and equitably contributed domestic health financing is essential for improving health and making progress towards Universal Health Coverage (UHC) in low- and middle-income countries. In this study, we explore the pathways through which development partners influence the combination of domestic health financing sources in Senegal. We performed a qualitative case study that comprised 32 key stakeholder interviews and a purposive document review, supplemented by descriptive statistical analysis of World Health Organization and Organization for Economic Cooperation and Development data on health financing sources in Senegal. We developed a novel framework to analyse the different mechanisms and directions of development partner influence on domestic health financing contributions. We identified development partner influence via four mechanisms: setting aims and standards, lobbying/negotiation, providing policy/technical advice, and providing external financing. Overall, development partners worked to increase tax-based government contributions and expand Community-Based Health Insurance (CBHI), which is seemingly equity enhancing. Fungibility and intrinsic equity issues related to CBHI may, however, limit equity gains. We encourage stakeholders in the health financing sphere to use our framework and analysis to unpack how development partners affect domestic health financing in other settings. This could help identify dynamics that do not optimally enhance equity and support progress towards UHC to help achieve more coherent policy-making across all domains of development partner activities in support of UHC. Future research should investigate the role of international creditors, lending, and loan conditionalities on domestic health financing in recipient countries, including equity implications
Prognostic impact of inducible ischaemia in ischaemic left ventricular dysfunction: the REVIVED-BCIS2 trial.
Get PDFRetrospective observational data suggest that the presence and extent of inducible myocardial ischaemia predict future adverse cardiac events in patients with ischaemic heart disease. However, several randomized trials have failed to identify an association between the burden of inducible ischaemia and outcomes in patients with stable coronary artery disease (CAD) assigned to medical therapy alone or revascularization.1,2 Despite this, the presence and extent of ischaemia are commonly used to guide revascularization of stable patients. Notably, many of these analyses excluded patients with impaired left ventricular (LV) function.
REVIVED-BCIS2 was a prospective, multi-centre, randomized controlled trial, investigating whether percutaneous coronary intervention (PCI) improved clinical outcomes in patients with severe ischaemic LV dysfunction (ILVD), compared with optimal medical therapy (OMT) alone.3,4 Whilst ischaemia testing was not mandated by protocol, it was performed as part of routine clinical practice in selected patients. Based on these data, we sought to determine whether the presence and extent of ischaemia detected on stress perfusion cardiac magnetic resonance (CMR) imaging predict clinical outcomes and response to PCI, in patients with ILVD
Community transmission of mpox clade Ib not driven through sexual exposures, Uvira, eastern Democratic Republic of the Congo, June to October 2024.
Get PDFBACKGROUND: In September 2023, monkeypox virus (MPXV) clade Ib emerged in Kamituga, a mining zone in South Kivu, Democratic Republic of the Congo (DRC), primarily through sexual transmission.AIMWe aimed to investigate cases in a MPXV clade Ib outbreak in Uvira, eastern DRC.
METHODS: From June to October 2024, we collected demographic, exposure and clinical data from suspected mpox cases at Uvira hospital and in households. The virus was identified by PCR. We investigated putative transmission patterns, disease severity and risk factors.
RESULTS: We identified 973 suspected cases: 415 (42.7%) were tested with PCR and 322 (77.6%) were confirmed. The median age of suspected cases was 9 years (interquartile range (IQR): 3-20 years), with 620 (63.7%) aged < 15 and 344 (35.4%) < 5 years. Severe disease (≥ 100 lesions) was more common in cases aged < 15 years (25.6%; 142/554) than others (16.1%; 49/304; p < 0.001). Twenty-two (12.2%) of 181 cases aged < 5 years had acute malnutrition. Seven cases died; the overall case-fatality ratio was 0.7%, and in infants (aged < 1 year) it was 3.9% (5/127). Of 329 suspected cases tested for HIV, six (1.8%) were positive. Nineteen (14.5%) of 131 females aged 15-49 years were pregnant. Most reported exposures to suspected mpox cases occurred in households (67.9%; 298/439). Sexual (6.0%; 19/318) or healthcare-related occupational exposures (1.4%; 6/417) were less common. Animal exposures were few (5.0%; 39/776) and predominantly domestic (97.4%; 38/39).
CONCLUSION: This child-centred outbreak, driven by non-sexual transmission, underscores the need for paediatric vaccines, nutritional support and household interventions. Adult-focused responses alone may be insufficient to control the outbreak