Nevin Manimala

BMJ Open. 2021 Aug 12;11(8):e049000. doi: 10.1136/bmjopen-2021-049000.

ABSTRACT

OBJECTIVE: Antimicrobial resistance is a global public health challenge. Dispensing of antibiotics without prescription (DAWP), a major contributor to antibiotic resistance, is extensive in Eritrea. This study was, therefore, aimed at deeply understanding, qualitatively, the pharmacy professionals’ perspective on the factors that trigger DAWP and how this practice could be mitigated.

DESIGN: A qualitative exploratory study design was employed.

SETTING: Drug retail outlets of Asmara, capital of Eritrea, and pharmaceutical services of Eritrea.

PARTICIPANTS: Thirty pharmacy professionals who were owners and employees of the drug retail outlets stationed in Asmara and six key informants from the pharmaceutical services of all administrative regions of Eritrea, selected purposively, were the study participants.

DATA COLLECTION AND ANALYSIS: The data were collected using focus group discussions and key informant interviews between March and September 2020. The collected data were transcribed verbatim, translated to English and finally thematically analysed using an inductive approach.

RESULTS: The main triggering factors were related to the drug retail outlet owners, dispensers, healthcare system and patients. Knowledge and attitude-based motivation, economic interest, inadequate services in health facilities, weak regulatory enforcement, inadequate training, trust and satisfaction of patients, previous successful experience, seriousness of a condition and saving time and money were reported among others as determinants of DAWP.

CONCLUSIONS: The triggering factors to DAWP were found to be very complex and some of them were important that might require immediate attention from policymakers. Ensuring readily available and accessible healthcare services, empowering medicines regulation and continuing sensitisation of dispensers are highly recommended to minimise DAWP.

PMID:34385252 | DOI:10.1136/bmjopen-2021-049000

BMJ Open. 2021 Aug 12;11(8):e047995. doi: 10.1136/bmjopen-2020-047995.

ABSTRACT

OBJECTIVES: To design, deliver and evaluate a programme of training workshops for biomedical researchers aimed at building confidence and skills in actively involving patients and the public (PPI) in research.

DESIGN: A bespoke programme of training workshops in PPI aimed at researchers.

SETTING: A large National Institute for Health Research Biomedical Research Centre in London and several partner organisations.

PARTICIPANTS: 721 scientists, clinicians and research managers attending dedicated training in PPI at a major London NHS (National Health Service)-university partnership.

INTERVENTIONS: A programme of 72 training workshops, designed to build practical skills and confidence for researchers working with patients and the public in research, was delivered at a major research-active NHS:university partnership. An iterative approach was taken to the programme, with the content of the workshops continually reviewed and refreshed to respond to the needs of researchers. Surveys before, immediately following and 6 months after training investigated the impact on researchers’ confidence and skills in PPI work, and the kind of PPI they subsequently carried out.

RESULTS: Training brought about immediate marked increases in researchers’ self-reported confidence to carry out PPI activities within their research, and in their knowledge of good practice. The evaluation indicates that workshop attendees were more likely to involve patients in their research following training. Researchers tended to involve patients and the public in a range of areas, including input to study design and patient information, in particular.

CONCLUSIONS: When positioned within a broader organisational strategy for PPI in research, such training has an important role to play in progressing PPI in a major research partnership. Training appeared to provide the confidence needed to carry out PPI which enabled further development of confidence and skills. Involving researchers who have attended the training in the ongoing development of the programme and bringing in patients to the training programme are key next steps.

PMID:34385250 | DOI:10.1136/bmjopen-2020-047995

BMJ Open. 2021 Aug 12;11(8):e046957. doi: 10.1136/bmjopen-2020-046957.

ABSTRACT

OBJECTIVES: People who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk.

DESIGN: We employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis.

SETTING: Tijuana, Mexico; San Diego, USA; Vancouver, Canada.

PARTICIPANTS: A total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825).

MEASUREMENTS: The outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models.

RESULTS: Evidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I²: 52%), recent housing insecurity (I²: 39%) and recent non-injection heroin use (I²: 78%).

CONCLUSION: We identified common and site-specific factors related to PWID’s risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.

PMID:34385244 | DOI:10.1136/bmjopen-2020-046957

BMJ Open. 2021 Aug 12;11(8):e046707. doi: 10.1136/bmjopen-2020-046707.

ABSTRACT

INTRODUCTION: Chimeric antigen receptor T-cell (CAR-T) therapy is a class of immunotherapy. An economic evaluation conducted at an early stage of development of CAR-T therapy for treatment of adult relapsed or refractory acute lymphoblastic leukaemia could provide insight into factors contributing to the cost of treatment, the potential clinical benefits, and what the health system can afford. Traditionally, stakeholders are engaged in certain parts of health technology assessment processes, such as in the identification and selection of technologies, formulation of recommendations, and implementation of recommendations; however, little is known about processes for stakeholder engagement during the conduct of the assessment. This is especially the case for economic evaluations. Stakeholders, such as clinicians, policy-makers, patients, and their support networks, have insight into factors that can enhance the validity of an economic evaluation model. This research outlines a specific methodology for stakeholder engagement and represents an avenue to enhance health economic evaluations and support the use of these models to inform decision making for resource allocation. This protocol may inform a tailored framework for stakeholder engagement processes in future economic evaluation model development.

METHODS AND ANALYSIS: We will involve clinicians, healthcare researchers, payers, and policy-makers, as well as patients and their support networks in the conduct and verification of an early economic evaluation of a novel health technology to incorporate stakeholder-generated knowledge. Three stakeholder-specific focus groups will be conducted using an online adaptation of the nominal group technique to elicit considerations from each. This study will use CAR-T therapy for adults with relapsed or refractory B-cell acute lymphoblastic leukaemia as a basis for investigating broader stakeholder engagement processes.

ETHICS AND DISSEMINATION: This study received ethics approval from the Ottawa Hospital Research Institute Research Ethics Board (REB 20200320-01HT) and the results will be shared via conference presentations, peer-reviewed publications, and ongoing stakeholder engagement.

PMID:34385243 | DOI:10.1136/bmjopen-2020-046707

BMJ Open. 2021 Aug 12;11(8):e046206. doi: 10.1136/bmjopen-2020-046206.

ABSTRACT

INTRODUCTION: The increase in international travel brought about by globalisation has enabled the rapid spread of emerging pathogens with epidemic and pandemic potential. While travel connectivity-based assessments may help understand patterns of travel network-mediated epidemics, such approaches are rarely carried out in sufficient detail for Oceania where air travel is the dominant method of transportation between countries.

DESIGN: Travel data from the Australian Bureau of Statistics, Stats NZ and the United Nations World Tourism Organization websites were used to calculate travel volumes in 2018 within Oceania and between Oceania and the rest of the world. The Infectious Disease Vulnerability Index (IDVI) was incorporated into the analysis as an indicator of each country’s capacity to contain an outbreak. Travel networks were developed to assess the spread of infectious diseases (1) into and from Oceania, (2) within Oceania and (3) between each of the Pacific Island Countries and Territories (PICTs) and their most connected countries.

RESULTS: Oceania was highly connected to countries in Asia, Europe and North America. Australia, New Zealand and several PICTs were highly connected to the USA and the UK (least vulnerable countries for outbreaks based on the IDVI), and to China (intermediate low vulnerable country). High variability was also observed between the PICTs in the geographical distribution of their international connections. The PICTs with the highest number of international connections were Fiji, French Polynesia, Guam and Papua New Guinea.

CONCLUSION: Travel connectivity assessments may help to accurately stratify the risk of infectious disease importation and outbreaks in countries depending on disease transmission in other parts of the world. This information is essential to track future requirements for scaling up and targeting outbreak surveillance and control strategies in Oceania.

PMID:34385235 | DOI:10.1136/bmjopen-2020-046206

BMJ Open. 2021 Aug 12;11(8):e045506. doi: 10.1136/bmjopen-2020-045506.

ABSTRACT

OBJECTIVE: The main objective of this study is to investigate how the direction and strength of the association between infant mortality and its predictors are changing over time in Bangladesh using a nationally representative sample for the period 2011-2014.

DESIGN, SETTING AND PARTICIPANTS: Data from two repeatedly cross-sectional Bangladesh Demographic and Health Surveys (BDHSs) for the years 2011 and 2014 were used. A total of 7664 (with 312 infant death) and 7048 (with 264 infant death) complete cases, respectively, from BDHS 2011 and 2014 datasets were included in the study.

METHODS: Cox’s proportional hazard model with robust standard error (SE) that adjusts for the complex survey design characteristics was implemented to assess how the risk factors associated with infant mortality change their paths.

RESULTS: Results reflected that administrative division remained as a potential risk factor of infant death for both periods. Household’s socioeconomic status, father’s employment status, age difference between parents turned out to be potential risk factors in 2014, though they did not show any significant association with infant death in the year 2011. In contrast to 2011, mothers’ individual-level characteristics such as age at childbirth, education, media exposure, employment status did not remain as significant risk factors for infant death in 2014. Younger fathers increased the burden of death among infants of adolescent mothers. At higher order births, the burden of infant death significantly shifted from rural to urban areas. From the year 2011 to 2014, urban areas achieved socioeconomic equity in infant survival, while the extent of inequity was increased in rural areas.

CONCLUSION: Community-based programmes should be designed for urban mothers who are expecting higher order births. To eradicate the socioeconomic inequity in infant survival, the government should design strong and sustainable maternal and child healthcare facilities, especially for rural areas.

PMID:34385233 | DOI:10.1136/bmjopen-2020-045506

BMJ Open. 2021 Aug 12;11(8):e045313. doi: 10.1136/bmjopen-2020-045313.

ABSTRACT

INTRODUCTION: COVID-19 pandemic has an impact on mortality indicators worldwide. Mitigation and repression actions to reduce the morbidity and mortality associated with the disease are necessary. However, they are criticised in the economic, social and psychological spheres. This social isolation, increased unemployment, routine changes, news of health complications and deaths related to COVID-19 can cause psychological repercussions that will certainly intensify in the coming months, and suicidal behaviour presents itself as a fatal outcome. It is necessary to know factors associated with suicidal behaviour in adults during the pandemic. Although there are studies, there is no systematic review to assess these factors, specifically in adults. The objective is to critically synthesise the scientific evidence on the factors associated with suicidal behaviour in adults in the COVID-19 pandemic.

METHODS AND ANALYSES: A systematic review will be carried out, recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, in seven databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), ISI of Knowledge, Excerpta Medica Database (EMBASE), SCOPUS, Latin American and Caribbean Health Sciences Literature (LILACS), Chinese National Knowledge Infrastructure (PsycINFO), Chinese National Knowledge Infrastructure (CNKI) and ScienceDirect. Preliminary search was carried out on 30 July 2020 and will be updated in March 2021. No restrictions on publication date, study location or languages will be considered in this review. The preliminary research strategies were carried out on 30 July 2020 and will be updated in February 2021. To measure the agreement between reviewers at each screening stage, Cohen’s Kappa will be calculated. Primary outcome will be factors related to suicidal behaviour in adults during COVID-19 pandemic. Grouped standardised mean differences and 95% CIs will be calculated. The risk of bias in observational studies will be assessed using the Methodological Index for Non-Randomised Studies (MINORS). Statistical heterogeneity will be assessed with the I2 statistic.

ETHICS AND DISCLOSURE: Ethical approval is not required, as primary data will not be collected. The findings will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER: CRD42020208816.

PMID:34385230 | DOI:10.1136/bmjopen-2020-045313

BMJ Open. 2021 Aug 12;11(8):e044698. doi: 10.1136/bmjopen-2020-044698.

ABSTRACT

BACKGROUND: Drug-resistant tuberculosis (DR-TB) continues to be a major public health threat posing a critical challenge to TB treatment and control worldwide. The present study was conducted among patients with DR-TB of the Saharia tribe residing in Madhya Pradesh state of Central India to document their experiences and needs, and to identify gaps for treatment adherence as this population is known to be poor because of migration and other factors.

METHODS: We conducted 16 in-depth interviews on purposively selected patients with DR-TB among the Saharia tribe using a predesigned open-ended in-depth interview guide, which included questions on domains like general physical health, diagnosis, treatment adherence, side-effects of drugs and experience related to the health facility. Out of these interviews, various subthemes were extracted. The obtained qualitative data were subjected to thematic analysis.

RESULTS: The study helped to understand the experiences and needs of the patients with DR-TB in various stages from diagnosis to treatment. Also, there was the impact of factors like lack of education and awareness, poor living conditions and lack of healthcare facilities on predominance of the disease in the community. Poor access to a healthcare facility, high pill burden and related side-effects, longer duration of treatment, financial burden, misbeliefs and misconceptions were prominent issues posing a challenge to treatment adherence. The narratives pointed out their struggle at every stage be it with diagnosis, treatment initiation or treatment adherence.

CONCLUSION: It is paramount to address the needs and experiences of patients with DR-TB to develop a patient-centric and context-specific approach conducive to the sociocultural set-up of tribal people. This will scale down the attrition rate of tribal patients while adhering to the complete treatment process and reducing the high burden of TB among the Saharia community. In addition, tribal patients should be counselled at regular intervals to increase their confidence in the treatment.

PMID:34385228 | DOI:10.1136/bmjopen-2020-044698

Can Fam Physician. 2021 Aug;67(8):601-607. doi: 10.46747/cfp.6708601.

ABSTRACT

OBJECTIVE: To test the feasibility of reporting diabetes indicators at a regional and community level in order to provide feedback to local leaders on health system performance.

DESIGN: Analysis of administrative data from hospital discharges and physician billings.

SETTING: Sioux Lookout region of Ontario.

PARTICIPANTS: Residents from 30 remote communities served by the Sioux Lookout First Nations Health Authority.

MAIN OUTCOME MEASURES: Incidence and prevalence of diabetes and incidence of diabetes complications, including heart attack, stroke, retinopathy, amputations, end-stage kidney disease, diabetes-related hospitalizations, and death.

RESULTS: Data were available for 18 542 residents from the 30 remote communities. Residents were almost entirely of First Nations descent. The prevalence of diabetes was 12.9%, the annual incidence was 1.0%, and the annual rate of complications was 5.4% in 2015-2016. Prevalence increased slightly over time. We had sufficient data to report prevalence in 25 of 30 communities (average population 738; range 234 to 2626). We reported statistically significant differences in prevalence by community; 8 were above average and 2 were below average. For diabetes complications, data were pooled over 5 years, and while community-level results could be reported, the variance was too high to allow detection of significant differences. Using 2-tailed t tests for difference of proportions, we determined that grouping communities into subregions of approximately 2000 persons would permit the detection of differences of 30% from the average 5-year complication rate.

CONCLUSION: This study demonstrates the possibility of reporting diabetes prevalence by individual First Nations reserve communities. Complication rates can be reported by individual community, but estimates are more useful for comparison if the smallest communities are grouped together. Such studies could be replicated across Canada to promote local use of these data for resource planning and monitoring long-term progress of diabetes programs and services.

PMID:34385208 | DOI:10.46747/cfp.6708601

Int J Gynecol Cancer. 2021 Aug 12:ijgc-2021-002692. doi: 10.1136/ijgc-2021-002692. Online ahead of print.

ABSTRACT

OBJECTIVES: The goal of this study was to determine the impact refusal of surgery has on overall survival in patients with endometrial cancer.

METHODS: From January 2004 to December 2015, the National Cancer Database was queried for patients with pathologically proven endometrial cancer who were recommended surgery and refused. Inverse probability of treatment weighting was used to account for differences in baseline characteristics between patients who underwent surgery and those who refused. Kaplan-Meier analyses and doubly robust estimation with multivariate Cox proportional hazards modeling were used to analyze overall survival.

RESULTS: Of the 300 675 patients identified, 534 patients (0.2%) were recommended surgical treatment but refused: 18% (95/534) were age ≤40 years. The 5-year overall survival for all patients who refused surgery was significantly decreased compared with patients who underwent surgery (29.2% vs 71.9%, P<0.01). This was demonstrated at ages 41-64 years (65.5% vs 91.0%, P<0.01) and ≥65 years (23.4% vs 75.3%, P<0.01). The 5-year overall survival did not meet statistical significance at age ≤40 years (90.1% vs 87.8% P<0.19). However, there were few patients in this cohort. On multivariate analysis, factors associated with refusal of surgery included: Medicaid insurance, Black race, Hispanic Race, Charlson Comorbidity Index scores of 2 or greater, stage II or III, and if patient received external beam radiation therapy alone. Factors associated with undergoing surgery included: age greater than 41, stage IB, and if the patient received brachytherapy.

CONCLUSIONS: Refusal of surgery for endometrial cancer is uncommon and leads to decreased overall survival.

PMID:34385179 | DOI:10.1136/ijgc-2021-002692