High-impact Interventions Research Articles

Predictors of effective kangaroo mother care, exclusive breastfeeding, and skin-to-skin contact among low birthweight newborns in Amhara, Ethiopia.

Globally, 20% of all newborns are born with low birth weight (LBW). There is, therefore, an urgent need to expedite the delivery of high-impact, evidenced-based, and low-cost interventions such as kangaroo mother care (KMC (defined as continuous skin-to-skin care) and exclusive breastfeeding for this vulnerable group. A multinational World Health Organization (WHO)-supported consortium created and tested the impact of locally-specific and globally-informed phases of KMC care on KMC uptake/scale-up across multiple sites. Here we report on the study of KMC predictors that is nested within Amhara's KMC implementation trial in Amhara, Ethiopia. We used multivariate logistic regression phases to identify diverse predictors of KMC, skin-to-skin contact, and exclusive breastfeeding at hospital discharge and day 28 of life. We analysed data from 860 LBW newborns. At day 28, implementation period (adjusted odds ratio (aOR) = 3.2-5.0), hospital facility (aOR = 3.0-4.6), and having multiple births (aOR = 0.31) were the strongest predictors of effective KMC. Meanwhile, previous death of a newborn, type of health facility where delivery occurred, and previous LBW delivery were predictors of effective KMC at both time points. No single factor predicted KMC, skin-to-skin contact, and exclusive breastfeeding at all time points and across all implementation periods. Having multiple births was a negative predictor for skin-to-skin contact, while the implementation period and having older fathers (>29 years) were strong positive predictors for exclusive breastfeeding at both discharge and day 28. Mothers with a previous history of neonatal death and current skin-to-skin-care uptake strongly predicted exclusive breastfeeding uptake at both time points. At discharge, however, having a history of preterm birth and neonatal death strongly predicted exclusive breastfeeding uptake, while multiple current births, current very LBW newborns, and the use of standard binders decreased the likelihood of exclusive breastfeeding. To achieve the effective KMC coverage target of ≥80% in Ethiopia, KMC scale-up phases may have to consider the key predictors of KMC, EBF, and SSC to effectively target beneficiaries.

South African palliative care provider perspectives on emergency medical services in palliative situations

IntroductionDue to the frequent intersection of Emergency Medical Services (EMS) with palliative situations and the increasing global need for palliative care, there has been increased recognition of the need for palliative care integration with EMS. However, EMS and palliative care systems remain segregated in many Low-to-Middle Income Country contexts, as in South Africa (SA). The aim of this study was to gather perspectives of palliative care providers in SA concerning EMS in palliative situations. MethodsA qualitative design employing individual semi-structured interviews was implemented. Ten interviews with experienced doctors and nurses holding post-graduate palliative medicine qualifications were conducted. Verbatim transcriptions of interviews were subjected to content analysis with an inductive-dominant approach to develop codes and categories. ResultsFour categories were developed: (1) Disposition towards EMS, (2) Perceived EMS challenges, (3) Positive EMS impact across patients’ palliative care journeys and (4) Methods of EMS and palliative care system integration. Participants maintained an overall positive view of EMS and palliative care integration, noting the beneficial impact of EMS and suggesting various methods of integration, while also highlighting challenges and concerns. ConclusionEMS and palliative care integration would be mutually beneficial to both systems while benefiting patient well-being and the broader healthcare system. Potentially low-cost, high-impact interventions suggested by participants, such as palliative care cards for patients and enhancing EMS and palliative care system communication, represent efficacious and judicious use of limited resources within the SA context. Pilot studies investigating these suggestions should be conducted.

Cancer Care Disparities: Overcoming Barriers to Cancer Control in Low- and Middle-Income Countries.

The rising global burden of cancer disproportionately affects low- and middle-income countries (LMICs), which account for over half of new patients and cancer deaths worldwide. However, LMIC health systems face profound challenges in implementing comprehensive cancer control programs because of limited health care resources and infrastructure. This analytical review explores contemporary evidence on barriers undermining cancer control efforts in resource-constrained LMIC settings. We conducted a comprehensive literature review of peer-reviewed evidence on cancer control challenges and solutions tailored to resource-limited settings. We provide a conceptual framework categorizing these barriers across the cancer care continuum, from raising public awareness to palliative care. We also appraise evidence-based strategies proposed to overcome identified obstacles to cancer control in the published literature, including task-shifting to nonspecialist health workers, strategic prioritization of high-impact interventions, regional collaborations, patient navigation systems, and novel financing mechanisms. Developing strong primary care delivery platforms integrated with specialized oncology care, alongside flexible and resilient health system models tailored to local contexts, will be critical to curb the rising tide of cancer in resource-limited settings. Urgent global commitments and investments are needed to dismantle barriers and expand access to prevention, early detection, diagnosis, treatment, and palliation services for all patients with cancer residing in LMICs as an ethical imperative. The review elucidates priority areas for policy actions, health systems strengthening, and future research to guide international efforts toward more equitable cancer control globally.

The cost of inaction: a global tool to inform nutrition policy and investment decisions on global nutrition targets.

At present, the world is off-track to meet the World Health Assembly global nutrition targets for 2025. Reducing the prevalence of stunting and low birthweight (LBW) in children, and anaemia in women, and increasing breastfeeding rates are among the prioritized global nutrition targets for all countries. Governments and development partners need evidence-based data to understand the true costs and consequences of policy decisions and investments. Yet there is an evidence gap on the health, human capital, and economic costs of inaction on preventing undernutrition for most countries. The Cost of Inaction tool and expanded Cost of Not Breastfeeding tool provide country-specific data to help address the gaps. Every year undernutrition leads to 1.3 million cases of preventable child and maternal deaths globally. In children, stunting results in the largest economic burden yearly at US$548 billion (0.7% of global gross national income [GNI]), followed by US$507 billion for suboptimal breastfeeding (0.6% of GNI), US$344 billion (0.3% of GNI) for LBW and US$161 billion (0.2% of GNI) for anaemia in children. Anaemia in women of reproductive age (WRA) costs US$113 billion (0.1% of GNI) globally in current income losses. Accounting for overlap in stunting, suboptimal breastfeeding and LBW, the analysis estimates that preventable undernutrition cumulatively costs the world at least US$761 billion per year, or US$2.1 billion per day. The variation in the regional and country-level estimates reflects the contextual drivers of undernutrition. In the lead-up to the renewed World Health Assembly targets and Sustainable Development Goals for 2030, the data generated from these tools are powerful information for advocates, governments and development partners to inform policy decisions and investments into high-impact low-cost nutrition interventions. The costs of inaction on undernutrition continue to be substantial, and serious coordinated action on the global nutrition targets is needed to yield the significant positive human capital and economic benefits from investing in nutrition.

The Relationship Between College Interventions and First-Generation College Students’ Academic Success at a Large Urban Tier I Institution

ABSTRACT Success in higher education has been a challenge for many first-generation college students (FGCS). Unfortunately, higher education institutions have adopted the “one-size-fits-all” approach to addressing low retention and graduation rates. This approach is alarming because it does not address the specific constraints of academic success for FGCS. This study investigated how college interventions programs impact the academic success of first-generation college students. The results show that FGCS who participated in a first-year seminar or lived in on-campus student housing had higher GPAs than FGCS who lived off-campus. Overall, these findings highlight the influence of high-impact interventions on FGCS’ academic success.

Continuities and change in alcohol policy at the global level: a documentary analysis of the 2010 Global Strategy for Reducing the Harmful Use of Alcohol and the Global Alcohol Action Plan 2022–2030

BackgroundThere are only two major statements which define alcohol policy development at the global level. There has not been any comparative analysis of the details of these key texts, published in 2010 and 2022 respectively, including how far they constitute similar or evolving approaches to alcohol harm.MethodsPreparatory data collection involved examination of documents associated with the final policy statements. A thematic analysis across the two policy documents was performed to generate understanding of continuity and change based on comparative study. Study findings are interpreted in the contexts of the evolving conceptual and empirical literatures.ResultsBoth documents exhibit shared guiding principles and identify similar governance challenges, albeit with varying priority levels. There is more emphasis on the high-impact interventions on price, availability and marketing in 2022, and more stringent targets have been set for 2030 in declaring alcohol as a public health priority therein, reflecting the action-oriented nature of the Plan. The identified roles of policy actors have largely remained unchanged, albeit with greater specificity in the more recent statement, appropriately so because it is concerned with implementation. The major exception, and the key difference in the documents, regards the alcohol industry, which is perceived primarily as a threat to public health in 2022 due to commercial activities harmful to health and because policy interference has slowed progress.ConclusionsThe adoption of the Global Alcohol Action Plan 2022-30 potentially marks a pivotal moment in global alcohol policy development, though it is unclear how fully it may be implemented. Perhaps, the key advances lie in advancing the ambitions of alcohol policy and clearly identifying that the alcohol industry should not be seen as any kind of partner in public health policymaking, which will permit progress to the extent that this influences what actually happens in alcohol policy at the national level.

Increasing coverage and uptake of voluntary family planning in Uganda's emerging municipalities and secondary cities: An implementation research study protocol.

While urban areas are often perceived to have better access to healthcare services, including modern family planning (FP) services, urban dwellers including those with better socioeconomic status are faced with multidimensional challenges that shape their access to appropriate FP services. In Uganda's urban spaces, there is currently a lack of understanding among service providers, civil society organizations, and individuals/communities regarding the implementation of interventions that promote informed choice and voluntary use of family planning services. This knowledge gap has profound implications for reproductive rights. This study seeks to enhance existing efforts towards increasing coverage and uptake of Voluntary Family Planning (VFP) in Jinja City and Iganga Municipality, central eastern Uganda. Our primary question is, "What interventions can effectively be packaged and delivered to increase the uptake of VFP among different segments of urban residents?" We propose to use the Human-Centered Design (HCD) approach to understand the needs and challenges of users and community capabilities in ensuring access to VFP services. Co-creating with stakeholders' engagement and a data-driven-centric approach will steer design and adaptation that respond to the different population segments within the urban space. As such, the study will be implemented in three phases: formative assessment, design and implementation, and implementation monitoring and evaluation. The implementation process will incorporate robust monitoring, learning, and adaptation mechanisms. The primary focus of these mechanisms will be to utilize gathered information effectively to inform the design of the implementation and facilitate continuous learning throughout the process. The study will apply a process monitoring and evaluation approach to address questions related to what package of FP interventions work, for whom, under what circumstances and why. Guided by strong learning and implementation flexibility, we hypothesize that our implementation will provide segmentation-specific high-impact interventions in an urban context. This implementation research protocol has been registered on the Open Science Framework (OSF) repository Registries (https://osf.io/vqxu9; DOI: 10.17605/OSF.IO/VQXU9).

The cyclical cascade of HIV care: Temporal care engagement trends within a population-wide cohort.

The traditional HIV treatment cascade aims to visualise the journey of each person living with HIV from diagnosis, through initiation on antiretroviral therapy (ART) to treatment success, represented by virological suppression. This representation has been a pivotal tool in highlighting and quantifying sequential gaps along the care continuum. There is longstanding recognition, however, that this may oversimplify the complexity of real-world engagement with HIV services in settings with mature high-burden HIV epidemics. A complementary "cyclical" cascade has been proposed to represent the processes of disengagement at different points on the care continuum, with multiple pathways to re-engagement, although the feasibility of implementing this at scale has been uncertain. This study aimed to populate, refine, and explore the utility of a cyclical representation of the HIV cascade, using routine data from a high-burden HIV setting. This observational cohort study leveraged person-level data on all people living with HIV in the Western Cape (WC), South Africa, who accessed public health services in the 2 years prior to 31 December 2023. Programme data from disease registers were complemented by data from pharmacy and laboratory systems. At study closure, 494 370 people were included, constituting 93% of those of those estimated to be living with HIV in the province, of whom 355 104 were on ART. Substantial disengagement from HIV care was evident at every point on the cascade. Early treatment emerged as a period of higher risk of disengagement, but it did not account for the majority of disengagement. Almost all those currently disengaged had prior experience of treatment. While re-engagement was also common, overall treatment coverage had increased slowly over 5 years. The transition to dolutegravir-based regimens was dramatic with good virological outcomes for those in care, notwithstanding a clearly discernible impact of the Coronavirus Disease 2019 (COVID-19) pandemic on viral load (VL) testing. People currently engaged and disengaged in care are similar with respect to age and gender. Those who died or disengaged recently were previously distributed across a range of cascade statuses, and a substantial proportion of those newly initiating and re-initiating treatment were no longer on treatment 6 months later. The main limitation of this study was incomplete evidence of HIV testing, linkage to HIV-specific services, and out-of-facility mortality. Using routine data, it was possible to populate and automate a cyclical cascade of HIV care that continuously captured the nonlinear care journeys of individuals living with HIV. In this generalised mature HIV epidemic, most people are treatment experienced. Disengagement is common and occurs at various points along the cascade, making it challenging to identify high-impact intervention opportunities. While historical HIV cascades remain valuable for target setting and service monitoring, they can be complemented with insights from more detailed cyclical cascades.

Prevalence and factors associated with viral non-suppression in people living with HIV receiving antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis.

Despite advances in HIV treatment, the burden of viral non-suppression (VNS) remains a treatment success concern, particularly in Sub-Saharan African (SSA) countries. We determined the prevalence and factors associated with VNS for people living with HIV (PLHIV) receiving antiretroviral therapy (ART). This review, registered with PROSPERO (CRD42023470234), conducted an extensive search for evidence, focusing on PLHIV living in SSA on ART from the year 2000 to 19th October 2023, across databases including PubMed/MEDLINE, Embase, Web of Science, and Scopus. A total of 2357 articles were screened, from which 32 studies met the criteria for the final analysis, involving 756,620 PLHIV of all ages. The pooled prevalance for VNS was found to be 20.0% (95% CI: 15.43%-25.52%, I2=100%, p-value <0.01) Children and adolescents demonstrated the highest prevalence of VNS (viral load ≥1000 copies/mL) at 27.98% (95% CI: 21.91%-34.97%, I2=94%, p-value <0.01). The study revealed various factors associated with increased odds (risk) of VNS, p-value <0.05. These factors encompassed socio-demographics such as sex, age, education level, and marital status. Additionally, aspects related to HIV care, such as the facility attended, HIV status disclosure and adherence exhibited higher odds of VNS. Suboptimal ART adherence, longer duration on ART, socio-economic factors, lack of family and social support, presence of co-morbidities, advanced WHO HIV clinical stage, ART regimens, lower CD4+ count, abnormal body mass index, history of treatment interruptions, and progression of HIV illness were associated with VNS. Furthermore, behavioural/psychological factors including depression, substance use, negative perceptions towards ART, experiences of abuse, alcohol use, stigma, and certain patterns of sexual behaviour were also identified as factors for VNS. The occurrence of two VNS to every ten PLHIV on ART poses a threat to the progress made towards reaching the third 95% UNAIDS target in SSA. Additionally, these findings highlight the intricate interplay of various factors, encompassing patient characteristics, behavioural patterns, sociocultural influences, and pharmacological factors, all impacting VNS among PLHIV. Recognising its multifaceted nature, we recommend designing and implementing high impact interventions to effectively address VNS in SSA.

Planetary Health and Radiology: Why We Should Care and What We Can Do.

Climate change adversely affects the well-being of humans and the entire planet. A planetary health framework recognizes that sustaining a healthy planet is essential to achieving individual, community, and global health. Radiology contributes to the climate crisis by generating greenhouse gas (GHG) emissions during the production and use of medical imaging equipment and supplies. To promote planetary health, strategies that mitigate and adapt to climate change in radiology are needed. Mitigation strategies to reduce GHG emissions include switching to renewable energy sources, refurbishing rather than replacing imaging scanners, and powering down unused scanners. Radiology departments must also build resiliency to the now unavoidable impacts of the climate crisis. Adaptation strategies include education, upgrading building infrastructure, and developing departmental sustainability dashboards to track progress in achieving sustainability goals. Shifting practices to catalyze these necessary changes in radiology requires a coordinated approach. This includes partnering with key stakeholders, providing effective communication, and prioritizing high-impact interventions. This article reviews the intersection of planetary health and radiology. Its goals are to emphasize why we should care about sustainability, showcase actions we can take to mitigate our impact, and prepare us to adapt to the effects of climate change. © RSNA, 2024 Supplemental material is available for this article. See also the article by Ibrahim et al in this issue. See also the article by Lenkinski and Rofsky in this issue.

Exploring Barriers to Accessing Adolescents Sexual and Reproductive Health Services in South Ethiopia Regional State: A Phenomenological Study Using Levesque's Framework.

Evidence suggests that adolescents face multiple barriers to accessing Sexual and Reproductive Health (SRH) services. However, there remains a notable gap in the literature regarding the nuanced interplay between supply-side and demand-side barriers. Therefore, this study aimed to examine barriers to accessing SRH services in the Gamo Zone of South Ethiopia Regional State. A descriptive phenomenology study was conducted from September 04 to October 15, 2023. A total of seven Focus Group Discussions (FGDs), four with girls and three with boys, with a total of 75 adolescents, and ten Key informant interviews (KIIs)with healthcare providers participated in the study. A semi-structured interview guide was used to explore their lived experiences. All interviews and discussions were audio-recorded. To analyze and manage data framework analysis approach was applied using ATLAS Ti version 7 software. The major barriers preventing adolescents from accessing SRH services are related to the interplay between supply and demand-side barriers across all five domains of the Levesque framework. Despite the high need for access to health care, lack of SRH literacy, lack of outreach activities, and integration of SRH information in health facilities often hampered adolescents' healthcare need. Additionally, fear of stigma from family and community, social norms, and lack of discussion of SRH issues hindered their ability to seek health care. Shortage of supplies and healthcare providers' behaviors further hindering adolescents' ability to access health care services. Furthermore, the limited involvement of adolescents in decision-making and the lack of effective coordination further complicate the appropriateness of services for adolescents. The finding of this study reveals that adolescents face multifaceted barriers. Therefore, there is a need for high-impact complex interventions, program and policy that address both supply and demand side barriers needs to give due intention to improve access to SRH services for adolescents.

Design of a multiple criteria decision analysis framework for prioritizing high-impact health technologies in a regional health service.

This study aims to develop a framework for establishing priorities in the regional health service of Murcia, Spain, to facilitate the creation of a comprehensive multiple criteria decision analysis (MCDA) framework. This framework will aid in decision-making processes related to the assessment, reimbursement, and utilization of high-impact health technologies. Based on the results of a review of existing frameworks for MCDA of health technologies, a set of criteria was proposed to be used in the context of evaluating high-impact health technologies. Key stakeholders within regional healthcare services, including clinical leaders and management personnel, participated in a focus group (n=11) to discuss the proposed criteria and select the final fifteen. To elicit the weights of the criteria, two surveys were administered, one to a small sample of healthcare professionals (n=35) and another to a larger representative sample of the general population (n=494). The responses obtained from health professionals in the weighting procedure exhibited greater consistency compared to those provided by the general public. The criteria more highly weighted were "Need for intervention" and "Intervention outcomes." The weights finally assigned to each item in the multicriteria framework were derived as the equal-weighted sum of the mean weights from the two samples. A multi-attribute function capable of generating a composite measure (multicriteria) to assess the value of high-impact health interventions has been developed. Furthermore, it is recommended to pilot this procedure in a specific decision context to evaluate the efficacy, feasibility, usefulness, and reliability of the proposed tool.

Effect of post-discharge postnatal educational intervention on postnatal practices among low-income primiparas in Nairobi informal settlements, Kenya: a post-test quasi-experiment.

informal settlements exhibit disproportionately worse maternal and newborn outcomes. Postnatal care (PNC) is a high-impact intervention for populations contributing to higher mortalities. Postnatal education is crucial to adopting evidence-based postnatal practices (PNPs) thus its post-discharge reinforcement is vital for low-income primiparas. This study aimed to determine the effect of post-discharge follow-up postnatal education intervention (PNE) on the adoption of recommended PNPs among low-income primiparas. quasi-experimental study in Nairobi informal settlements with 118 primiparas discharged early after normal delivery on each arm. Facility and demographic data collected using an interviewer-administered questionnaire. Study arm received the intervention for 6 weeks in addition to routine PNC while control received routine PNC only. An interviewer-administered exit questionnaire was applied after 6 weeks. Focus group discussions were conducted for qualitative data then analyzed thematically. SPSS used to analyze quantitative data then descriptive statistics, t-tests, Chi-square, Mann-Whitney, and multiple linear or logistic regressions derived. PNPs composed of health-seeking for maternal and newborn danger signs, self and baby care practices, and utilization of PNC contacts. the intervention was a positive predictor of adoption of composite PNPs (β=0.26, p=0.00), self-care practices (β=0.39, p=0.00) and mothers' two weeks PNC contact (OR=4.64, p=0.00, 95% CI=1.9-11.2). Neither a significant predictor of health-seeking for maternal (β=-0.11, p=0.31) nor newborns danger signs (β=-0.04, p=0.73) though inversely related. No influence on baby care practices, two weeks of newborn contact and six weeks contact for the dyad. Multi-pronged approaches are appreciated. follow-up post-discharge PNE intervention enhances adoption of PNPs among low-income primiparas thus a worthwhile supplement to routine PNC.

Understanding the lived experience of idiopathic pulmonary fibrosis and how this shapes views on home-based pulmonary rehabilitation in Delhi, India.

Pulmonary Rehabilitation (PR) is a high-impact intervention for individuals with idiopathic pulmonary fibrosis (IPF) but access is limited in India. PR barriers include distance to travel, lack of service provision and lack of healthcare professionals to deliver PR, thus it is disproportionate to the immense burden of IPF in India. We explored the lived experiences of people living with IPF, family caregivers (CGs) and healthcare workers (HCWs) as well as their views towards home-based PR (HBPR) in Delhi, India. A qualitative study using semi-structured interviews with individuals with IPF (n = 20), CGs (n = 10) and HCWs (n = 10) was conducted. Data were analysed using codebook thematic analysis. Three major themes were generated: (i) Health impact, which included pathophysiological changes, range of symptoms experienced, disease consequences and impact of comorbidities; (ii) Disease management, which described strategies to control the progression and overall management of IPF, such as medications and exercises; (iii) Mode of Pulmonary Rehabilitation, which described perceptions regarding HBPR, comparisons with centre-based programmes, and how HBPR may fit as part of a menu of PR delivery options. People living with IPF, family caregivers and healthcare workers were positive about the potential implementation of HBPR and suggested the development of a paper-based manual to facilitate HBPR over digital/online approaches. The content of HBPR should be sensitive to the additional impact of non-IPF health issues and challenges of reduced interactions with healthcare professionals.

THE FINANCIAL AND EMOTIONAL IMPACT OF COVID-19 FOR DEMENTIA CAREGIVERS: A COMPARISON OF THE NHATS AND HISPANIC EPESE

Abstract During the COVID-19 pandemic, older adults and their caregivers/care partners (hereafter referred to as “caregivers”) experienced social isolation, reduced autonomy, disruptions in medical care and barriers to community-based services such as adult day centers. We compare the extent to which these disruptions affected white, Black, and Hispanic caregivers. We utilize newly released data on adult children caregivers from the Caregiver Supplement to the Hispanic Establish Population for the Epidemiologic Study of the Elderly (HEPESE CG, 2021) and the National Health and Aging Trends COVID-19 Family Members and Friends Dataset (NHATS FF, 2020/2021) to compare caregiver emotional well-being and financial strain among non-Hispanic White (NH White, n=327), non-Hispanic Black (NH Black, n=57), and Mexican American (n=57) adult children caregivers. Results reveal that a larger fraction of NH Black and Mexican American caregivers reported financial strain than NH White caregivers, and that more Mexican American caregivers reported loneliness and depression than other groups of caregivers. For Mexican American caregivers, those reporting lower financial well-being tended to be younger. For NH Black caregivers, there were no significant predictors of financial strain or wellbeing. Finally, NH White caregivers were younger, and more likely to be female and NH White dementia caregivers reported more financial strain and loneliness than NH White non-dementia caregivers. Taken together, this work provides valuable insight into the role of the COVID-19 pandemic in exacerbating caregiver health disparities among caregivers and provides valuable insight as well as to the high-impact intervention points for caregivers from minoritized populations.

Challenges and experience of the Ethiopian rural health extension program: implications for reform and revitalization

BackgroundDespite remarkable gains over the past decade, mounting evidence suggests that Ethiopia’s rural health extension program (HEP) is facing serious implementation challenges. We investigated the current and potential future program design and implementation challenges of Ethiopia’s rural HEP based on the lived experiences of health extension workers (HEW) implementing the program at the grassroots level.MethodsWe employed a longitudinal qualitative exploration linked to a larger cluster-randomized trial (RCT) which was implemented in 282 villages randomly selected from 18 Kebeles of the Gedeo zone, southern Ethiopia. Data were collected using in-depth interviews with key informants, focus group discussion, and passive observation of program implementation. The data were analyzed manually using a thematic framework analysis approach. Themes and sub-themes were generated by condensing, summarizing, and synthesizing data collected in the field in the form of extended notes and field observation checklists.FindingsDespite considerable gains in availing basic health services to the rural population, HEP seems to suffer serious design and implementation flaws that demand thoughtful and immediate adjustment. The design constraints span from the number and type of intervention packages to the means of dissemination (vehicle) as well as the target population emphasized. As such, some low-cost high-impact interventions that were strongly desired by the community were overlooked, while others were inappropriately packed. The means of distribution - female health extension workers trained with basic prevention skills, were lacking essential skills. They also had high burnout rates and with little engagement with men, were repeatedly mentioned flaws of the program demanding revitalization. Furthermore, the sheer structure of HEP precluded adult and adolescent men, non-reproductive women, and the elderly.ConclusionDespite significant gains over the last couple of months, Ethiopia’s rural HEP appears to have reached a tipping point that requires a comprehensive revamp of the program package, means of distribution, and target beneficiaries rather than the “usual” tweaks to reap maximum benefits.

High viral suppression and detection of dolutegravir-resistance associated mutations in treatment-experienced Tanzanian adults living with HIV-1 in Dar es Salaam

To curb HIV infection rate in Tanzania, antiretroviral therapy (ART) has been scaled up since 2006, and in 2019, the country shifted to regimen including dolutegravir as a default first line. We assessed the success of ART and the contribution of HIV drug resistance (HIVDR) to unsuppressed viral loads. Between February and May 2023 a cross-sectional survey with random sampling was conducted in the six clinics in an urban cohort in Dar es Salaam. Patients with unsuppresed viral loads (local criteria viral load (VL) ≥ 1000 copies/mL) were tested for HIVDR mutations using the WHO adapted protocol for plasma samples. Mutations were interpreted using the Stanford HIVDR database. In total 600 individuals participated in this survey, the majority were female (76.83%), mean age (pm standard deviation) was 44.0 (pm 11.6) years. The median duration on ART (interquartile range) was 6.5 (3.9–10.2) years. Approximately 99% were receiving tenofovir + lamivudine + dolutegravir as a fixed dose combination. VL testing was successful in 99.67% (598/600) of survey patients and only 33 had VL ≥ 1000 copies/mL, resulting in a viral suppression level of 94.48% (565/598, 95% CI 92.34–96.17%). For 23 samples, protease and reverse transcriptase (RT) genotyping were successful, with 13 sequences containing RT inhibitor surveillance drug resistance mutations (SDRMs) (56.5%). No SDRM against protease inhibitors were detected. Thirty samples were successfully genotyped for integrase with 3 sequences (10.08%) containing integrase strand transfer inhibitor (INSTI) SDRMs. In samples successfully genotyped in the three genetic regions, 68.18% (16/22) had a genotypic susceptibility score (GSS) ≥ 2.5 for the concurrent regimen, implying factors beyond drug resistance caused the unsuppressed viral load. For five patients, GSS indicated that HIVDR may have caused the unsuppressed viral load. All three patients with INSTI resistance mutations were highly resistant to dolutegravir and accumulated nucleoside and non-nucleoside RT inhibitor HIVDR mutations. Although in this cohort the last 95 UNAIDS target was almost achieved, HIVDR mutations, including INSTIs resistance mutations were detected in HIV-positive individuals taking ART for at least one year. We recommend the design and implementation of high-impact interventions to prevent the increase of HIVDR, failure of dolutegravir and address the non-resistance factors in the study area.

Adapting and implementing breast cancer follow-up in primary care: protocol for a mixed methods hybrid type 1 effectiveness-implementation cluster randomized study

BackgroundAdvances in detection and treatment for breast cancer have led to an increase in the number of individuals managing significant late and long-term treatment effects. Primary care has a role in caring for patients with a history of cancer, yet there is little guidance on how to effectively implement survivorship care evidence into primary care delivery.MethodsThis protocol describes a multi-phase, mixed methods, stakeholder-driven research process that prioritizes actionable, evidence-based primary care improvements to enhance breast cancer survivorship care by integrating implementation and primary care transformation frameworks: the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Practice Change Model (PCM). Informed by depth interviews and a four round Delphi panel with diverse stakeholders from primary care and oncology, we will implement and evaluate an iterative clinical intervention in a hybrid type 1 effectiveness-implementation cluster randomized design in twenty-six primary care practices. Multi-component implementation strategies will include facilitation, audit and feedback, and learning collaboratives. Ongoing data collection and analysis will be performed to optimize adoption of the intervention. The primary clinical outcome to test effectiveness is comprehensive breast cancer follow-up care. Implementation will be assessed using mixed methods to explore how organizational and contextual variables affect adoption, implementation, and early sustainability for provision of follow-up care, symptom, and risk management activities at six- and 12-months post implementation.DiscussionStudy findings are poised to inform development of scalable, high impact intervention processes to enhance long-term follow-up care for patients with a history of breast cancer in primary care. If successful, next steps would include working with a national primary care practice-based research network to implement a national dissemination study. Actionable activities and processes identified could also be applied to development of organizational and care delivery interventions for follow-up care for other cancer sites.Trial registrationRegistered with ClinicalTrials.gov on June 2, 2022: NCT05400941.

Office Green Building Modeling Based on EDGE and SketchUp Applications

The importance of the concept of sustainable development and its application in office green buildings, since in the design process, since the modeling of 3D buildings with decisions on design elements applied in the finished building the office building as a one of commercial building type which require a slightly approach to productivity.The purpose of the study is to find out what factors determine office green buildings by using the EDGE and Sketch Up applications. EDGE is a green building simulation and SketchUp is 3D building modelling tool.This research is expected to strengthen the quality of the learning process in the implementation of an efficient design of energy use with the concept of orientation for the realization of green buildings in design. This research uses mix methods, which use of quantitative methods for simulation on SketchUp dan EDGE application, and use of qualitative methods for its advanced stage in an analysis that explains narratively and descriptively. Building modelling factors for SketchUp application are building dimensions, orientations, layout and openings. Design factors for EDGE application are the efficiency of water, electricity and Embodied Energy (EE) use in materials.EDGE application simulations show active and passive building design that high impact intervention on this building are passive cooling and ventilation design, daylighting, lighting control, low energy lighting, high efficiency chillers such as ground source heat pumps and solar PVs on roof which could generate significant energy.

Knowledge of Ventilator Care Bundles among Registered Nurses in the Intensive Care Unit at Sarawak General Hospital, Malaysia

INTRODUCTION: Ventilator Care Bundles (VCB) is a group of evidence-based highimpact interventions for mechanically ventilated patients. The study aims to identify the knowledge of VCB among Intensive Care Unit (ICU) nurses at the local hospital in Sarawak, Malaysia. MATERIALS AND METHODS: A quantitative cross-sectional survey was conducted among 30 nurses who worked in the ICU at Sarawak General Hospital, Malaysia. A modified questionnaire with 20 items was used to measure the level of knowledge. Data analysis was performed using the Statistical Package for the Social Sciences Statistics 26.0 for Windows with p&lt; 0.05 was considered statistically significant. RESULTS: The results revealed that 86.7% (n=30) of respondents had a high-level knowledge of the VCB. There is a significant relationship between the level of knowledge of VCB and qualification as a Registered Nurse (p=0.03), ICU post-basic qualification (p=0.02), and level of nursing education (p&lt;0.001). The level of knowledge was significantly related to the level of education (r=0.71; p&lt;0.001), the number of years qualified as a registered nurse (r=0.38; p=0.03), and post-basic qualification (r=0.42; p=0.02). CONCLUSION: The good level of knowledge regarding VCB implementation among registered nurses indicates that they are well-equipped with the proper knowledge for caring for mechanically ventilated patients.