Gaps In Uptake Research Articles

Use of implementation science to qualitatively identify implementation determinants of COPD practice guidelines in primary care.

Objectives: Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory disease with high morbidity and mortality. COPD guidelines (CPG) are greatly underutilized and studies attempting to improve this practice gap have yielded inconsistent results. We hypothesize that using implementation science can provide a detailed understanding of these practice gaps and the reasons behind them. Methods: Since primary care (PC) manages the bulk of COPD patients, in this pilot study, we use principles of implementation science to systematically explore the reasons for this implementation gap in a PC setting. We used the Consolidated Framework of Implementation Science (CFIR), a determinant framework to design semi-structured interview guides to conduct multistakeholder interviews to explore the barriers and facilitators to four key COPD-CPG with known poor uptake: inhaler education, spirometry, pulmonary rehabilitation and COPD-specific patient education from patient and provider perspectives. Qualitative analysis was performed using rapid analysis. Results: Seventeen respondents including both, patients and providers were interviewed. All these COPD-CPG were rated as 'highly important' suggesting that perceived importance alone is insufficient to bridge gaps in uptake. Respondents were least familiar with pulmonary rehabilitation. Physician time constraint was a significant reported barrier. There exist multilevel contextual barriers to each of these COPD-CPG. Discussion: To increase uptake of COPD guidelines, implementation efforts that address multilevel barriers and promote collaborative care by use of non-physician resources are likely to have higher buy-in and greater chances for success.

Barriers and Facilitators to Heart Failure Guideline-Directed Medical Therapy in an Integrated Health System and Federally-Qualified Health Centers: A Thematic Qualitative Analysis.

Clinical guidelines recommend medications from four drug classes, collectively referred to as quadruple therapy, to improve outcomes for patients with heart failure with reduced ejection fraction (HFrEF). Wide gaps in uptake of these therapies persist across a range of settings. In this qualitative study, we identified determinants (i.e., barriers and facilitators of quadruple therapy intensification, defined as prescribing a new class or increasing the dose of a currently prescribed medication. We conducted interviews with physicians, nurse practitioners, physician assistants, and pharmacists working in primary care or cardiology settings in an integrated health system or Federally Qualified Health Centers (FQHCs). We report results with a conceptual model integrating two frameworks: 1) the Theory of Planned Behavior (TPB), which explains how personal attitudes, perception of others' attitudes, and perceived behavioral control influence intentions and behaviors; and 2) The Consolidated Framework for Implementation Research (CFIR) 2.0 to understand how multi-level factors influence attitudes toward and intention to use quadruple therapy. Thirty-one clinicians, including thirteen eighteen (58%) primary care and (42%) cardiology clinicians, participated in the interviews. Eight (26%) participants were from FQHCs. A common facilitator in both settings was the belief in the importance of quadruple therapy. Common barriers included challenges presented by patient frailty, clinical inertia, and time constraints. In FQHCs, primary care comfort and ownership enhanced the intensification of quadruple therapy while limited access to and communication with cardiology specialists presented a barrier. Results are presented using a combined TPB-CFIR framework to help illustrate the potential impact of contextual factors on individual-level behaviors. Determinants of quadruple therapy intensification vary by clinician specialty and care setting. Future research should explore implementation strategies that address these determinants by specialty and setting to promote health equity.

Trend of RTS,S vaccine uptake in the malaria vaccine implementing programme (MVIP) pilot regions, Ghana; 2019–2022

IntroductionThe uptake trend of a new vaccine is unpredictable and may reflect the quality of introduction process and community acceptance. The objective of this study was to conduct a trend analysis of RTS,S malaria vaccine uptake in the seven pilot regions of Ghana from 2019 to 2022. The findings are envisaged to strengthen malaria vaccine introductions in the future. MethodsA retrospective analysis was conducted on routine childhood immunisation data for 2019–2022. Coverages for the first (RTS,S1), second (RTS,S2), third (RTS,S3) and fourth (RTS,S4) doses of malaria vaccine; third dose of diphtheria, tetanus, pertussis-containing vaccine (DTP3/Penta3); first dose measles-rubella (MR1) and second dose measles-rubella (MR2) vaccines were calculated. Dropout rates and uptake gaps were estimated to assess variations in the uptake of consecutive RTS,S schedules; and the differences in the uptake of RTS,S and the comparator vaccines, respectively. ResultsNationally, the coverages of the first three doses of the RTS,S malaria vaccine rose sharply from 2019 (RTS,S1 = 54.9 %; RTS,S2 = 54.6 %; RTS,S3 = 38.6 %) through 2020 (RTS,S1 = 70.7 %; RTS,S2 = 67.4 %; RTS,S3 = 66.3 %) to peaks in 2021 (RTS,S1 = 76.0 %; RTS,S2 = 73.1 %; RTS,S3 = 74.2 %), and declined marginally in 2022 (RTS,S1 = 74.0 %; RTS,S2 = 69.9 %; RTS,S3 = 71.3 %). For the fourth dose, the low uptake in 2020 (7.5 %) was followed by a steep rise in 2021 (46.9 %) that continued, but at a reduced rate to 50.6% in 2022. The dropout rates and uptake gaps were initially high but declined consistently over the study period. Generally, the trends in vaccination coverages, and dropout rates and uptake gaps at the national level were reflected in the respective regions. ConclusionThe coverage of RTS,S malaria vaccine improved consistently over the study period despite the low uptake in the early phase of the pilot. While the decreasing dropout rates and uptake gaps may indicate improved community acceptance, strengthening immunisation service delivery is crucial in sustaining the observed trajectory.

Twice-Yearly Lenacapavir or Daily F/TAF for HIV Prevention in Cisgender Women.

There are gaps in uptake of, adherence to, and persistence in the use of preexposure prophylaxis for human immunodeficiency virus (HIV) prevention among cisgender women. We conducted a phase 3, double-blind, randomized, controlled trial involving adolescent girls and young women in South Africa and Uganda. Participants were assigned in a 2:2:1 ratio to receive subcutaneous lenacapavir every 26 weeks, daily oral emtricitabine-tenofovir alafenamide (F/TAF), or daily oral emtricitabine-tenofovir disoproxil fumarate (F/TDF; active control); all participants also received the alternate subcutaneous or oral placebo. We assessed the efficacy of lenacapavir and F/TAF by comparing the incidence of HIV infection with the estimated background incidence in the screened population and evaluated relative efficacy as compared with F/TDF. Among 5338 participants who were initially HIV-negative, 55 incident HIV infections were observed: 0 infections among 2134 participants in the lenacapavir group (0 per 100 person-years; 95% confidence interval [CI], 0.00 to 0.19), 39 infections among 2136 participants in the F/TAF group (2.02 per 100 person-years; 95% CI, 1.44 to 2.76), and 16 infections among 1068 participants in the F/TDF group (1.69 per 100 person-years; 95% CI, 0.96 to 2.74). Background HIV incidence in the screened population (8094 participants) was 2.41 per 100 person-years (95% CI, 1.82 to 3.19). HIV incidence with lenacapavir was significantly lower than background HIV incidence (incidence rate ratio, 0.00; 95% CI, 0.00 to 0.04; P<0.001) and than HIV incidence with F/TDF (incidence rate ratio, 0.00; 95% CI, 0.00 to 0.10; P<0.001). HIV incidence with F/TAF did not differ significantly from background HIV incidence (incidence rate ratio, 0.84; 95% CI, 0.55 to 1.28; P = 0.21), and no evidence of a meaningful difference in HIV incidence was observed between F/TAF and F/TDF (incidence rate ratio, 1.20; 95% CI, 0.67 to 2.14). Adherence to F/TAF and F/TDF was low. No safety concerns were found. Injection-site reactions were more common in the lenacapavir group (68.8%) than in the placebo injection group (F/TAF and F/TDF combined) (34.9%); 4 participants in the lenacapavir group (0.2%) discontinued the trial regimen owing to injection-site reactions. No participants receiving twice-yearly lenacapavir acquired HIV infection. HIV incidence with lenacapavir was significantly lower than background HIV incidence and HIV incidence with F/TDF. (Funded by Gilead Sciences; PURPOSE 1 ClinicalTrials.gov number, NCT04994509.).

DRIVE: Diversity, Representation, and Inclusion for Value in Education – interprofessional faculty development for a bias-free curriculum at UMass Chan Medical School

Abstract Objective: The DRIVE Initiative engages interprofessional faculty and learners at UMass Chan Medical School to build tools and support for educators to identify and mitigate bias in their educational materials and teaching. Methods: Key DRIVE resources include a core skills workshop, taught by representatives from the Graduate, Nursing and Medical schools. To encourage active application of these skills, there is a printable curriculum appraisal tool and an independent learning module. The DRIVE team also offers individual consultation for faculty as well as discussion across our academic community through weekly DRIVE-in cafés. Results: In 2021, 16 core skills workshops were held with 84 faculty attending. Monday DRIVE-in cafés were started; the associated interactive library guide which links to curated resources and the anonymous reporting tool was accessed 922 times. Discussion: While the workshop is required for core faculty in the School of Medicine and highly encouraged for all others, we have noted gaps in uptake particularly in basic sciences (Graduate School) and are increasing efforts in that area. Challenges have included demonstrating relevance to faculty across disciplines e.g., loose connection to basic science teaching. To increase adoption, materials and programs have been continuously updated and improved based on feedback, and workshops tailored to specific audiences. Recruiting compensated faculty from multiple schools has been vital to our success. Conclusion: Biased curricula harm our learning environments and those who teach and learn within them, and lead to the perpetuation of disparities: the interprofessional approach of DRIVE has demonstrated success in mitigating this.

Determinants of ethnic differences in the uptake of child healthcare services in New Zealand: a decomposition analysis

BackgroundThere are persistent ethnic gaps in uptake of child healthcare services in New Zealand (NZ), despite increasing policy to promote equitable access. We examined ethnic differences in the uptake of immunisation and primary healthcare services at different ages and quantified the contribution of relevant explanatory factors, in order to identify potential points of intervention.MethodsWe used data from the Growing Up in New Zealand birth cohort study, including children born between 2009 and 2010. Econometric approaches were used to explore underlying mechanisms behind ethnic differences in service uptake. Multivariable regression was used to adjust for mother, child, household, socioeconomic, mobility, and social factors. Decomposition analysis was used to assess the proportion of each ethnic gap that could be explained, as well as the main drivers behind the explained component. These analyses were repeated for four data time-points.ResultsSix thousand eight hundred twenty-two mothers were enrolled during the antenatal survey, and children were followed up at 9-months, 2-years and 4-years. In univariable models, there were ethnic gaps in uptake of immunisation and primary care services. After adjusting for covariates in multivariable models, compared to NZ Europeans, Asian and Pacific children had higher timeliness and completeness of immunisation at all time-points, while indigenous Māori had lower timeliness of first-year vaccines despite high intentions to immunise. Asian and Pacific mothers were less likely to have their first-choice lead maternity caregiver (LMC) than NZ Europeans mothers, and Māori and Asian mothers were less likely to be satisfied with their general practitioner (GP) at 2-years. Healthcare utilisation was strongly influenced by socio-economic, mobility and social factors including ethnic discrimination. In decomposition models comparing Māori to NZ Europeans, the strongest drivers for timely first-year immunisations and GP satisfaction (2-years) were household composition and household income. Gaps between Pacific and NZ Europeans in timely first-year immunisations and choice of maternity carer were largely unexplained by factors included in the models.ConclusionsEthnic gaps in uptake of child healthcare services vary by ethnicity, service, and time-point, and are driven by different factors. Addressing healthcare disparities will require interventions tailored to specific ethnic groups, as well as addressing underlying social determinants and structural racism. Gaps that remain unexplained by our models require further investigation.

Beyond coverage: Rural-urban disparities in the timeliness of childhood vaccinations in Tanzania

BackgroundTimely vaccination maximizes efficacy for preventing infectious diseases. In the absence of national vaccination registries, representative sample survey data hold vital information on vaccination coverage and timeliness. This study characterizes vaccination coverage and timeliness in Tanzania and provides an analytic template to inform contextually relevant interventions and evaluate immunization programs. MethodsCross-sectional data on 6,092 children under age 3 from the 2015–16 Tanzania Demographic and Health Survey were used to examine coverage and timeliness for 14 vaccine doses recommended in the first year of life. The Kaplan-Meier method was used to model time to vaccination. Cox proportional hazard models were used to examine factors associated with timely vaccination. ResultsSubstantial rural–urban disparities in vaccination coverage and timeliness were observed for all vaccines. Across 14 recommended doses, documented coverage ranged from 52 % to 79 %. Median vaccination delays lasted up to 35 days; gaps were larger among rural than urban children and for later doses in vaccine series. Among rural children, median delays exceeded 35 days for the 3rd doses of the polio, pentavalent, and pneumococcal vaccines. Median delays among urban children were < 21 days for all doses. Among rural and urban children, lower maternal education and delivery at home were associated with increased risk of delayed vaccination. In rural settings, less household wealth and greater distance to a health facility were also associated with increased risk of delayed vaccination. DiscussionThis study highlights persistent gaps in uptake and timeliness of childhood vaccinations in Tanzania and substantial rural–urban disparities. While the results provide an informative situation assessment and outline strategies for identifying unvaccinated children, a national electronic registry is critical for comprehensive assessments of the performance of vaccination programs. The timeliness measure employed in this study—the amount of time children are un- or undervaccinated—may serve as a sensitive performance metric for these programs.

Abstract 6259: Molecular biomarker testing and targeted therapy patterns in patients with acute myelogenous leukemia (AML): A real-world data analysis

Abstract Background and Objective: Molecular testing and targeted treatments for patients (pts) diagnosed with AML have evolved in recent years. Real-world testing patterns, including next-generation sequencing (NGS), and clinical management of pts with AML were analyzed in 2 large U.S. community health systems. Methods: Pts &amp;gt;18 years, diagnosed with AML from January 1, 2015 to December 31, 2020, were identified in a database containing clinical and genomic data from integrated community delivery networks. Study end was March 31, 2021, allowing for 3 months minimum follow up. Actionable biomarkers were defined by NCCN guidelines version 3, 2021. Results: The study included 685 pts, median age of 70 and median follow up of 5.4 months; 55% were male, 73% non-Hispanic White (NHW), 10% non-Hispanic Black (NHB). 69% had de novo AML. Cytogenetic prognostic classification was: 4% favorable; 33% intermediate; 30% adverse; and 33% unknown. 541 (79%) pts, median age of 69, received NGS or single gene/small panel tests. 144 (21%) pts with no testing had a median age of 78. Pts with de novo AML were more likely to be tested compared to secondary AML (84% vs. 67%, p&amp;lt;0.001). No significant difference was found in testing receipt between NHW and NHB pts (82% vs. 76%, p=0.3). 80% of pts received NGS testing in upfront setting, 15% in relapse setting (&amp;gt;30 days after diagnosis), 5% were unknown. 77% of pts diagnosed in 2020 received NGS tests (Table 1). 52/100 (52%) of pts with FLT3 (ITD or TKD) mutation, 5/27 (19%) with IDH1 mutation and 11/44 (25%) with IDH2 mutation received targeted therapy. Conclusions: Molecular biomarker testing has increased over time with NGS becoming the dominant modality. Testing uptake did not differ by race. Half of pts with FLT3 mutation received targeted therapy, one fifth with IDH1 and one quarter with IDH2 mutations. Future research should explore targeted therapy receipt over time and address gaps in uptake for pts with AML in the community setting. Table 1. Proportion of patients with molecular biomarker testing by diagnosis year among (n=685) Diagnosis Year 2015(N = 77) 2016(N = 92) 2017(N = 113) 2018(N = 138) 2019(N = 129) 2020(N = 136) Overall(N = 685) NGS testing, n (%) 7 (9%) 17 (18%) 46 (41%) 100 (72%) 100 (78%) 105 (77%) 375 (55%) Other non-NGS molecular biomarker testing only, n (%) 48 (62%) 52 (57%) 38 (34%) 14 (10%) 14 (11%) 0 (0%) 166 (24%) Molecular biomarker testing (NGS and/or other), n (%) 55 (71%) 69 (75%) 84 (74%) 114 (83%) 114 (88%) 105 (77%) 541 (79%) Proportion tested by actionable biomarker, n (%) FLT3-ITD 51 (66%) 64 (70%) 77 (68%) 108 (78%) 106 (82%) 94 (69%) 500 (73%) FLT3-TKD 50 (65%) 63 (68%) 76 (67%) 105 (76%) 106 (82%) 90 (66%) 490 (72%) IDH2 5 (6%) 10 (11%) 34 (30%) 95 (69%) 100 (78%) 102 (75%) 346 (51%) IDH1 5 (6%) 10 (11%) 28 (25%) 91 (66%) 101 (78%) 102 (75%) 337 (49%) Citation Format: Jeanna Wallenta Law, Zartash Gul, Anna Berry, Michael A. Thompson, Christopher Willner, Sowjanya Vuyyala, Haley McCracken, Katherine Geverd, Frank M. Wolf, Thomas D. Brown, Philip Kuriakose. Molecular biomarker testing and targeted therapy patterns in patients with acute myelogenous leukemia (AML): A real-world data analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6259.

Antiretroviral therapy experience, satisfaction, and preferences among a diverse sample of young adults living with HIV

ABSTRACT Youth and young adults living with HIV (YLWH) have a high HIV infection rate and suboptimal oral medication adherence. Biomedical researchers hope that long-acting antiretroviral therapy (LAART) modalities can help those who struggle with daily oral adherence. While adults living with HIV have expressed interest in LAART, little research has explored perspectives of YLWH. This study explores ART experiences and perspectives on LAART through qualitative interviews with twenty diverse YLWH (18–29) in the United States. Data were analyzed using framework analysis. Most participants were satisfied with their current ART yet had experienced side effects or had struggled with daily adherence. Preferences for improving daily oral ART included making pills smaller and reformulating ART into flavored chewable gummies. Most expressed enthusiasm for LAART, although needle aversion and previous injection drug use were potential barriers for some. Approximately half were interested in an ART patch, though its visibility and fear of stigmatization was concerning. Few expressed interest in implantable ART, calling it unappealing. Although younger people are most likely to benefit from these advancements in HIV treatment, additional research is needed to identify gaps in uptake and to further explore perspectives of YLWH to improve the success of new treatment modalities.

Study protocol: Yarning about HPV Vaccination: a qualitative study of factors influencing HPV vaccination among Aboriginal and Torres Strait Islander adolescents in Australia

IntroductionAboriginal and Torres Strait Islander women experience a higher burden of cervical cancer than non-Indigenous women in Australia. Cervical cancer is preventable partly through human papillomavirus (HPV) vaccination; in Australia,...

Could a Low-Dose Diuretic Polypill Improve Outcomes in Heart Failure With Preserved Ejection Fraction?

Could a Low-Dose Diuretic Polypill Improve Outcomes in Heart Failure With Preserved Ejection Fraction?

Designing Futuristic Telemedicine Using Artificial Intelligence and Robotics in the COVID-19 Era.

Technological innovations such as artificial intelligence and robotics may be of potential use in telemedicine and in building capacity to respond to future pandemics beyond the current COVID-19 era. Our international consortium of interdisciplinary experts in clinical medicine, health policy, and telemedicine have identified gaps in uptake and implementation of telemedicine or telehealth across geographics and medical specialties. This paper discusses various artificial intelligence and robotics-assisted telemedicine or telehealth applications during COVID-19 and presents an alternative artificial intelligence assisted telemedicine framework to accelerate the rapid deployment of telemedicine and improve access to quality and cost-effective healthcare. We postulate that the artificial intelligence assisted telemedicine framework would be indispensable in creating futuristic and resilient health systems that can support communities amidst pandemics.

Design Matters Most: Changing Social Gaps in the Use of Fathers’ Leave in Spain

This article addresses how the use of the Spanish paternity leave from 2008 until 2018 was conditioned by the social and economic context. In particular, we focus on how economic and institutional changes may have contributed to an increase in fathers’ uptake rates and to an alteration in social patterns of uptake. In 2007, Spain introduced a 2-week non-transferable paternity leave with 100% wage replacement. Despite the Great Recession, this leave has been widely used, although differently according to fathers’ socio-economic background. The objective is to analyse how the economic recovery and the subsequent extension of paternity leave to 4/5 weeks have impacted on the social gaps in uptake. Using a representative sample of 10,171 employed fathers with children 3 months or younger, obtained from a pool of 44 quarters of the Spanish Labour Force Survey, logistic regression models are estimated to analyse by fathers’ socio-economic backgrounds the impact of three historical moments on the likelihood of leave being used. Results show that the economic recovery did not change social gaps in leave uptake, but extension of leave has been the decisive event. It has narrowed or reversed the gaps in terms of social class, type of worker, type of contract and education. We conclude that the Spanish ‘daddy month’ has become a social norm for 80% of employed fathers, because of its design. Social gaps in uptake have changed because the new legislation has legitimised men using leave, and not because of lower opportunity costs during economic recovery.

Social inequities in vaccination coverage among infants and pre-school children in Europe and Australia \u2013 a systematic review

BackgroundHerd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children.MethodsA systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0–5 years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics).ResultsThe review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large.ConclusionThis review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.

Artificial radionuclides in neon flying squid from the northwestern Pacific in 2011 following the Fukushima accident

Abstract. In order to better understand the impact of the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident on a commercial marine species, neon flying squid (Ommastrephes bartramii) samples obtained from the northwestern Pacific in November 2011 were analyzed for a range of artificial and natural radionuclides (Cs-134, Cs-137, Ag-110m, U-238, Ra-226, and K-40). Short-lived radionuclides Cs-134 and Ag-110m released from the FDNPP accident were found in the samples, with an extremely high water-to-organism concentration ratio for Ag-110m (&gt;2.9×104). While accident-derived radionuclides were present, their associated dose rates for the squid were far lower than the relevant benchmark of 10 µGy h−1. For human consumers ingesting these squid, the dose contribution from natural radionuclides, including Po-210, was far greater (&gt;99.9 %) than that of Fukushima-accident radionuclides (&lt;0.1 %). The whole-body to tissue and whole-body to gut concentration ratios were calculated and reported, providing a simple method to estimate the whole-body concentration in environmental monitoring programs, and filling a data gap for concentration ratios in cephalopods. Our results help fill data gaps in uptake of nuclear power plant radionuclides in the commercially important Cephalopoda class and add to scarce data on open-ocean nekton in the northwestern Pacific shortly after the Fukushima accident.

Cereal yield gaps across Europe

Abstract Europe accounts for around 20% of the global cereal production and is a net exporter of ca. 15% of that production. Increasing global demand for cereals justifies questions as to where and by how much Europe’s production can be increased to meet future global market demands, and how much additional nitrogen (N) crops would require. The latter is important as environmental concern and legislation are equally important as production aims in Europe. Here, we used a country-by-country, bottom-up approach to establish statistical estimates of actual grain yield, and compare these to modelled estimates of potential yields for either irrigated or rainfed conditions. In this way, we identified the yield gaps and the opportunities for increased cereal production for wheat, barley and maize, which represent 90% of the cereals grown in Europe. The combined mean annual yield gap of wheat, barley, maize was 239 Mt, or 42% of the yield potential. The national yield gaps ranged between 10 and 70%, with small gaps in many north-western European countries, and large gaps in eastern and south-western Europe. Yield gaps for rainfed and irrigated maize were consistently lower than those of wheat and barley. If the yield gaps of maize, wheat and barley would be reduced from 42% to 20% of potential yields, this would increase annual cereal production by 128 Mt (39%). Potential for higher cereal production exists predominantly in Eastern Europe, and half of Europe’s potential increase is located in Ukraine, Romania and Poland. Unlocking the identified potential for production growth requires a substantial increase of the crop N uptake of 4.8 Mt. Across Europe, the average N uptake gaps, to achieve 80% of the yield potential, were 87, 77 and 43 kg N ha−1 for wheat, barley and maize, respectively. Emphasis on increasing the N use efficiency is necessary to minimize the need for additional N inputs. Whether yield gap reduction is desirable and feasible is a matter of balancing Europe’s role in global food security, farm economic objectives and environmental targets.

On farm analysis of the effect of the preceding crop on N uptake and grain yield of durum wheat (Triticum durum Desf.) in Mediterranean conditions

ABSTRACTOne of the challenges of eco-efficient agriculture is the development of operational farming practices to increase the level of agricultural production, maximize the efficiency of resource use and reduce environmental impacts. Based on the efficiency frontier concept and the decomposition of resource use efficiency, we used a three-quadrant framework allowing to carry a functional analysis of the cropping system. Using a data envelope approach, we established boundary curves which represent the maximum achievable performances (yield, N uptake) when N is the only limiting factor. This framework has been first implemented and tested using published data from 112 agronomic situations of rainfed durum wheat in experimental fields in northern Syria and then further applied on a data set of 245 agronomic situations of durum wheat in farmers’ fields in two grain-producing regions of Tunisia. The results demonstrated the impact of preceding crops: durum wheat following legumes or vegetable showed a higher potential for N uptake but with only a minor effect on its conversion into grains. This positive effect of diversified rotation on potential N uptake by durum wheat is partly of-set by increased N uptake gaps in farmer’s fields indicating a higher effect of other limiting factors.

"They don't like us….": Barriers to antiretroviral and opioid substitution therapy among homeless HIV positive people who inject drugs in Delhi: A mixed method study.

BackgroundProvision of Anti-Retroviral Therapy (ART) and Opioid Substitution Therapy (OST) are important components of the targeted intervention (TI) programme for people who inject drugs (PWID). Homeless HIV positive PWIDs in Delhi is a key population experiencing gaps in uptake of these services, especially the ART uptake which is reportedly far from 90%, UNAIDS’ 90-90-90 target to end the AIDS epidemic.ObjectiveTo assess the gaps and barriers in accessing the ART and OST services uptake among HIV positive homeless PWID in Delhi and to explore experiences and perspectives of the PWIDs and service providers.MethodologyWe used a convergent parallel mixed methods design which included a cross-sectional quantitative survey and a qualitative study. Two hundred thirty five homeless HIV positive PWID were interviewed and in-depth interviews were conducted with five PWIDs and nine health providers.ResultsWhile only 12% of PWIDs were on ART, 80% were availing OST services. The top individual, health system related and structural barriers for ART service access were insufficient and incorrect knowledge (63%), long waiting time (86%) and lack of family support (44%) respectively. Inconvenient timings, stringent registration requirements and negative attitude of health providers were expressed as major barriers of accessing ART services during the interviews while these were not a concern in OST services. Homelessness, poverty, stigma were common barriers for both services. Integrated, ‘single window’ service and provision of additional support like nutrition and shelter were suggested as measures to improve access by both health providers and the PWIDs themselves.ConclusionThere is an urgent need for structural and health systems changes to improve access to ART and OST services. These include integrated service delivery, flexibility in timing of the centers, accelerated ART initiation, simplification of bureaucratic procedures, nutritional and social support to all homeless HIV positive PWIDs.

Implementation of Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention Among Men Who Have Sex With Men at a New England Sexually Transmitted Diseases Clinic

Preexposure prophylaxis (PrEP) is efficacious in preventing human immunodeficiency virus (HIV) among men who have sex with men (MSM). We assessed PrEP uptake among MSM presenting for services at a sexually transmitted diseases (STD) clinic. Men who have sex with men presenting to the Rhode Island STD Clinic between October 2013 and November 2014 were educated about, and offered, PrEP. We categorized PrEP engagement using an implementation cascade to describe gaps in uptake which described MSM who: (1) were educated about PrEP, (2) indicated interest, (3) successfully received follow-up contact, (4) scheduled an appointment, (5) attended an appointment, and (6) initiated PrEP (ie, received a prescription). Bivariate and multivariable logistic regression models were used to examine predictors of PrEP initiation. A total of 234 MSM were educated about PrEP; of these, 56% expressed interest. Common reasons for lack of interest were low HIV risk perception (37%), wanting more time to consider (10%), concern about side effects (7%), and financial barriers (3%). Among those interested, 53% followed up. Of those, 51% scheduled an appointment. The most common reason patients did not schedule an appointment was low HIV risk perception (38%). Seventy-seven percent of those with an appointment attended the appointment; of those, 93% initiated PrEP. Patients with higher HIV-risk perception (adjusted odds ratios, 2.17; 95% confidence interval, 1.29-3.64) and a history of sex with an HIV-positive partner (adjusted odds ratios, 7.08; 95% confidence interval, 2.35-21.34) had significantly higher odds of initiating PrEP. Low HIV-risk perception was the most significant barrier to PrEP uptake among MSM attending a public STD clinic.

Successes and gaps in uptake of regular, voluntary HIV testing for hidden street- and off-street sex workers in Vancouver, Canada

Despite evidence globally of the heavy HIV burden among sex workers (SWs) as well as other poor health outcomes, including violence, SWs are often excluded from accessing voluntary, confidential and non-coercive health services, including HIV prevention, treatment, care and support. This study therefore assessed the prevalence and association with regular HIV testing among street- and off-street SWs in Vancouver, Canada. Cross-sectional baseline data were used from a longitudinal cohort known as “An Evaluation of Sex Worker’s Health Access” (AESHA; January 2010–July 2012). This cohort included youth and adult SWs (aged 14+ years). We used multivariable logistic regression to assess the relationship between explanatory variables and having a recent HIV test (in the last year). Of the 435 seronegative SWs included, 67.1% reported having a recent HIV test. In multivariable logistic regression analysis, having a recent HIV test remained significantly independently associated with elevated odds of inconsistent condom use with clients [adjusted (multivariable) odds ratios, AOR: 2.59, 95% confidence intervals [95% CIs]: 1.17–5.78], injecting drugs (AOR: 2.33, 95% CIs: 1.17–4.18) and contact with a mobile HIV prevention programme (AOR: 1.76, 95% CIs: 1.09–2.84) within the last six months. Reduced odds of having a recent HIV test was also significantly associated with being a migrant/new immigrant to Canada (AOR: 0.33, 95% CIs: 0.19–0.56) and having a language barrier to health care access (AOR: 0.26, 95% CIs: 0.09–0.73). Our results highlight successes of reaching SWs at high risk of HIV through drug and sexual pathways. To maximize the effectiveness of including HIV testing as part of comprehensive HIV prevention and care to SWs, increased mobile outreach and safer-environment interventions that facilitate access to voluntary, confidential and non-coercive HIV testing remain a critical priority, in addition to culturally safe services with language support.