Evaluating the long-term impact of large-scale trainings: an exposure based cross-sectional study on female genital mutilation-related knowledge, attitudes and practices among Sudanese midwives in Khartoum State.

OBJECTIVES: To examine the long-term impact of large-scale training targeting midwives in a setting where they are the main female genital mutilation (FGM) practitioners. We hypothesised that trained midwives would have significantly higher knowledge, greater opposition to midwives' involvement in this practice, and improved clinical practice in FGM prevention and care compared with non-trained midwives. DESIGN: We conducted an exposure based cross-sectional study, using closed-ended and open-ended questions during phone interviews. SETTING: Khartoum State in Sudan has a high prevalence of FGM (88%) mainly performed by midwives. PARTICIPANTS: Midwives who received (n=127) and did not receive FGM training (n=55). PRIMARY AND SECONDARY OUTCOME MEASURES: We developed primary outcomes aligned to the three levels (reaction, learning and behaviour) of Kirkpatrick's training evaluation model for descriptive and multivariable analyses in Stata. RESULTS: All the midwives interviewed were female, mostly village midwives (92%) and worked in health centres (89%). The mean age and midwifery experience was 51 years (SD=10) and 23 years (SD=12), respectively. Overall, most midwives (>90%) reported being supportive of FGM discontinuation. Midwives who had FGM training were more aware that performing FGM violates code of conduct (p=0.001) and reported to always counsel patients to abandon FGM (p<0.001) compared with midwives who did not report training. However, these associations were not statistically significant in multivariable logistic regression model adjusting for age. Exploratory analysis of training curricula showed higher knowledge, correct attitude and practices among those who reported in-service training before 2016. CONCLUSION: Though past trainings were associated with higher knowledge and greater opposition to midwives' involvement in FGM, this was not translated into appropriate corrective clinical procedures among affected women during labour. The Sudan Ministry of Health invested heavily in training midwives and it would be important to investigate why trained midwives do not implement recommended FGM-related clinical management.

Lessons learnt in scaling up evidence-based comprehensive health sector responses addressing female genital mutilation in highly prevalent settings.

Female genital mutilation (FGM) affects over 200 million girls and women. Its health complications include acute and potentially lifelong urogenital, reproductive, physical, mental health complications with estimated health treatment costs of US$1.4 billion per year. Moreover, there is a concerning rise in the trend of FGM medicalisation with almost one in five FGM cases being performed by a health worker.The WHO developed several evidence-based resources to apply a comprehensive health approach to strengthen FGM prevention and care services. However, there has been limited uptake of this comprehensive approach in FGM prevalent settings. To address this, a three-step multicountry participatory process was used to engage health sector players from FGM prevalent settings to develop comprehensive action plans, implement foundational activities and harness the learnings to inform subsequent planning and implementation. Support to adapt evidence-based resources and seed funding were also provided to initiate foundational activities that had potential for scale up.A total of 15 countries participated in this three-step this approach between 2018 and 2022. Ten countries developed comprehensive national action plans and eight WHO resources were adapted for foundational activities.This scale up approach can be strengthened by increasing the frequency of multicountry experience sharing meetings, identifying in-country champions to continuously advocate for FGM integration within (public and private) health services and securing stable funding to implement foundational activities. Documentation of each country's experience as case studies including monitoring and evaluation are essential to expand the learning and quality of the health interventions addressing FGM.

National and international programmatic perspective on facilitators and barriers for Sudan's health sector response on female genital mutilation (2016-2018): a qualitative study.

OBJECTIVES: To explore the facilitators and barriers that affected the design and implementation of the first 3 years of Sudan's largest health programme on female genital mutilation (FGM). DESIGN: We used a qualitative case study guided by the Consolidated Framework for Implementation Research to conduct in-depth interviews with programme managers and for thematic data analysis. SETTING: About 14 million girls and women in Sudan are affected by FGM, which is mainly performed by midwives (77%). Since 2016, Sudan has received substantial donor funding to develop and implement the largest global health programme to stop midwives' involvement and improve the quality of FGM prevention and care services. PARTICIPANTS: Eight Sudanese and two international programme managers representing governmental, international and national organisations and donor agencies participated in interviews. Their job positions required detailed involvement in planning, implementing and evaluating diverse health interventions in the areas of governance, building knowledge and skills of health workers, strengthening accountability, monitoring and evaluation and creating an enabling environment. RESULTS: Respondents identified funding availability and comprehensive plans, integration of FGM-related interventions within existing priority health intervention packages and presence of an evaluation and feedback culture within international organisations as implementation facilitators. The barriers were low health system functionality, low inter-organisational coordination culture, power asymmetries in decision-making during planning and implementation of nationally-funded and internationally-funded interventions, and non-supportive attitudes among health workers. CONCLUSION: Understanding the factors affecting planning and implementation of Sudan's health programme addressing FGM may potentially mitigate barriers and improve results. Interventions which change midwives' supportive values and attitudes towards FGM, strengthen health system function and increase intersectoral and multisectoral coordination including equitable decision-making among relevant actors, may be needed to address the reported barriers. The impact of these interventions on the scale, effectiveness and sustainability of the health sector response merits further study.

Advancing the measurement of knowledge, attitudes and practices of health workers who care for women and girls who have undergone female genital mutilation/ cutting (FGM/C): A qualitative exploration of expert opinion.

BACKGROUND: Female genital mutilation or cutting (FGM/C) is a social norm driven practice associated with numerous adverse health complications. Existing assessment tools for health workers are limited by lack of a clear framework for what constitutes the critical knowledge, attitudes, and practices that impact FGM/C prevention and care. The aim of this study was to explore expert opinion of the knowledge, attitudes, and practices for FGM/C-related prevention and care that can be used to inform the development of future KAP measurement tools. METHODS: We conducted 32 semi-structured individual interviews with global clinical and research experts on FGM/C from 30 countries including participants from Africa, Australia/ New Zealand, Europe, the Middle East, and North America. Interview questions explored areas of knowledge, attitudes, and practices that influence FGM/C-related prevention and care activities. We used the directed content analysis methodology for the qualitative data analysis. RESULTS: We identified six categories of knowledge, six of practice, and seven of attitudes that contribute to FGM/C-related prevention and care. Areas of knowledge included: general knowledge about FGM/C; who is at risk for experiencing FGM/C; support for FGM/C; female genital anatomy/ physiology; health complications of FGM/C; management of health complications of FGM/C; ethical and legal considerations for the treatment and prevention of FGM/C, and patient-health worker communication. Areas of practice included: clinical procedures and protocols; management of complications; defibulation; other surgical procedures for FGM/C; pediatric care (including prevention); and patient-centered care. Participants described health worker attitudes that may affect how prevention and care activities are delivered and/or received including attitudes toward: the perceived benefits of FGM/C; harms of FGM/C; ethical considerations related to FGM/C medicalization, prevention, and treatment; providing care for FGM/C-affected clients; women and girls who have experienced FGM/C; communities that practice FGM/C; and affective response to FGM/C. We also present participant perspectives on the ways in which knowledge, attitudes, and practice interact impacting the type and quality of care provided to those affected by FGM/C. CONCLUSIONS: This study identified specific areas of knowledge, attitudes, and practices in FGM/C prevention and care that are important to include in future evaluation metrics. Future KAP tools should be theoretically informed using the framework we present, and assessed for validity and reliability using psychometrically rigorous methods. Developers of KAP tools should consider the hypothesized relationships between knowledge, attitudes, and practices.

Turning the tide on female genital mutilation in a high prevalence country: a programmatic data analysis for Sudan's comprehensive health sector response, 2016-2018.

Sudan has about 87% of females aged 15-49 years living with female genital mutilation (FGM), mostly performed by midwives (64%). In 2016, the Federal Ministry of Health (FMoH) adopted the WHO's global strategy to stop healthcare providers from performing FGM. Our review of activity reports from 2016 to 2018 found the format of activities (N=95) was mainly meetings (58%) and trainings (31%) with median costs of US$10 645 and US$14 964, respectively. The FMoH (57%) and student/professional associations (25%) implemented activities at national (36%) and state (62%) level. The costs of activities were highest for FMoH compared with student/professional associations and academia, respectively.Sudan addressed WHO's global strategy pillars through FGM-related policies and plans (pillar 1), trainings (pillar 2) and monitoring, evaluation and accountability materials (pillar 3) targeting mainly community midwives (N=16 183) as well as creating supportive legislative and regulatory environment (pillar 4). Governmental funding on training was comparable to donor's resulting into 31% of community midwives trained on FGM complications management. Further, 31% of community midwives signed declarations or petitions to end FGM practice, while 19% were sensitised on punitive administrative measures for conducting FGM.Although Sudan implemented a laudable health sector response to address FGM, there is a need to evaluate the quality and effectiveness of past and ongoing interventions. Particular attention to costs and quality assurance data is essential to identify cost efficient implementation approaches to reach the remaining sizeable number of health professionals to stop their involvement in FGM.

Effective recycling of disposable medical face masks for sustainable green concrete via a new fiber hybridization technique.

Global public response to the COVID-19 (SARS-CoV-2) pandemic is highly focused on human health. However, conservationists have cautioned of unprecedented threats to the natural environment from a new type of non-biodegradable microplastic waste resulting from extensive use of disposable medical face masks (DMFMs). Thus, this waste must be recycled in an eco-friendly manner on an urgent basis. In this research, we developed a new environmentally friendly recycling technique using waste DMFMs in sustainable green concrete. More explicitly, a new fiber hybridization approach has been introduced in which two types of fibers namely DMFM fiber and basalt fiber (BF) were incorporated into fiber reinforced recycled aggregate concrete (FRAC). The volume fractions of DMFM fiber were 0%, 0.1%, and 0.2% and the volume fractions of BF were 0%, 0.25%, and 0.5%. In addition, two mineral admixtures (fly ash and ground granulated blast furnace slag) were also used. Test results indicated increase of approximately 12% in compressive strength, 26% in split tensile strength, and 60% in flexural strength of FRAC containing hybrid fibers and mineral admixtures. The density and ultra-sonic pulse velocity (UPV) of DMFM fiber- and BF-modified FRAC ranged from 2406-2433 kg/m3 and 4502-4541 m/s, respectively, which meets structural concrete requirements. The water absorption rate gradually increased with an increase in the volume fractions of fibers but remained within the allowable water absorption limit for construction materials. Lastly, the microstructure investigation indicated excellent concrete quality, improved interfacial transition zones (ITZs), and good compatibility of host concrete matrix with both DMFM fiber and BF that correlates well with the experimental results reported in this study.

Involving the health sector in the prevention and care of female genital mutilation: results from formative research in Guinea.

BACKGROUND: Despite efforts to reduce the burden of female genital mutilation (FGM) in Guinea, the practice remains prevalent, and health care providers are increasingly being implicated in its medicalization. This formative study was conducted to understand the factors that facilitate or impede the health sector in providing FGM prevention and care services to inform the development of health sector-based interventions. METHODS: Between April and May 2018, a mixed methods formative study was carried out using a rapid assessment methodology in three regions of Guinea-Faranah, Labe and Conakry. A structured questionnaire was completed by one hundred and fifty health care providers of different cadres and 37 semi-structured interviews were conducted with health care providers, women seeking services at public health clinics and key stakeholders, including health systems managers, heads of professional associations and schools of nursing, midwifery, and medicine as well as representatives of the Ministry of Health. Eleven focus group discussions were conducted with female and male community members. RESULTS: This study revealed health systems factors, attitudinal factors held by health care providers, and other factors, that may not only promote FGM medicalization but also impede a comprehensive health sector response. Our findings confirm that there is currently no standardized pre-service training on how to assess, document and manage complications of FGM nor are there interventions to promote the prevention of the practice within the health sector. This research also demonstrates the deeply held beliefs of health care providers and community members that perpetuate this practice, and which need to be addressed as part of a health sector approach to FGM prevention. CONCLUSION: As integral members of FGM practicing communities, health care providers understand community beliefs and norms, making them potential change agents. The health sector can support them by incorporating FGM content into their clinical training, ensuring accountability to legal and policy standards, and promoting FGM abandonment as part of a multi-sectoral approach. The findings from this formative research have informed the development of a health sector intervention that is being field tested as part of a multi-country implementation research study in Guinea, Kenya, and Somalia.

Despite the implementation of various interventions to prevent female genital mutilation (FGM), it is still widely practiced in Guinea, and health care providers are increasingly being implicated in the practice. We conducted research in three regions of Guinea, namely, Faranah, Labe and Conakry, to understand factors that might be addressed to strengthen the role of the health sector in prevention and care of women and girls who have undergone FGM. Our findings highlight the need to strengthen the capacity of health care providers to be able to identify cases of FGM and manage complications. The study also highlights the importance of engaging health care providers in efforts to prevent FGM, which will require that any trainings include an opportunity to discuss their own values and beliefs around FGM so that they are better equipped to communicate with their clients and patients in a sensitive and non-judgmental manner, whether during consultation visits or community health outreach activities. The results of this research have informed the development of a health system strengthening intervention package for the prevention and care of FGM, which is being tested in Kenya, Somalia, and Guinea.

Role of green innovation, trade and energy to promote green economic growth: a case of South Asian Nations.

The objective of this study is to contribute to the existing debate of green economic growth by empirically investigating the role of cleaner energy production, green innovation, and green trade in green economic growth in the context of South Asian countries. For this purpose, the study collects the data of South Asian Economies for 2000-2018 from different sources such as world development indicators (WDI), International Energy Statistics (IES), and Organization for Economic Co-operation and Development (OECD) statistics. The study applied Pesaran's (2007) second-generation unit root test to test the stationarity of the data. Wasteland's (2007) test of cointegration was applied to examine the long-run association among modeled variables. The study confirmed the long-run association among modeled variables that turn to be stationary at the first differences. Moreover, the study applied fully modified least square (FMOLS) and dynamic least square (DOLS) to estimate the empirical results of the study. Results of the study show that the production of clean energy, green innovation, and green trade positively contributes to the green economic growth of South Asian Economies Graphical abstract.

A hybrid, effectiveness-implementation research study protocol targeting antenatal care providers to provide female genital mutilation prevention and care services in Guinea, Kenya and Somalia.

BACKGROUND: In settings with high prevalence of female genital mutilation (FGM), the health sector could play a bigger role in its prevention and care of women and girls who have undergone this harmful practice. However, ministries of health lack clear policies, strategic plans or dedicated funding to implement anti-FGM interventions. Along with limited relevant knowledge and skills to prevent the practice of FGM and care for girls and women living with FGM, health providers have limited interpersonal communication skills and self-efficacy, while some may have supportive attitudes towards FGM and its medicalization. We propose to test the effectiveness of a health system strengthening intervention that includes training antenatal care (ANC) providers on person-centred communication (PCC) for FGM prevention. METHODS: This will be a two-level, hybrid, effectiveness-implementation research study using a cluster randomized trial design in Guinea, Kenya and Somalia conducted over a 6 months period. In each country, within pre-selected regions/counties, 60 ANC clinics will be randomized to intervention and control arms. At baseline, all clinics will receive the level one intervention involving provision of FGM-related clinical guidelines and handbook as well as anti-FGM policies and posters. At month 3, intervention clinics will receive the level two intervention comprising of a training for ANC providers on PCC to challenge their FGM-related attitudes and build their communication skills to effectively provide FGM prevention counselling. A process evaluation will be conducted to understand 'how' and 'why' the intervention package achieves intended results. Multi-level regression modelling will be used for quantitative data analysis while qualitative data will be assessed using thematic content analysis to determine the effectiveness, feasibility and acceptability of the different intervention levels. DISCUSSION: The proposed study will strengthen the knowledge base regarding how to effectively involve health providers in FGM prevention and care. TRIAL REGISTRATION: Trial registration and date: PACTR201906696419769 (June 3rd, 2019).

The role of the health sector in contributing to the abandonment of female genital mutilation.

Female genital mutilation (FGM) is a harmful practice associated with a range of health complications. Achieving abandonment of FGM is an international priority, which requires multi-sectoral actions, including engagement of the health sector to provide high quality care to women and girls affected by FGM while also taking actions to promote prevention.

Idiopathic neonatal hepatitis or extrahepatic biliary atresia? The role of liver biopsy.

Cholestasis in early infancy represents a diagnostic dilemma and most of these infants suffer either from extrahepatic biliary atresia or idiopathic neonatal hepatitis. Differentiation between the two conditions may be extremely difficult both clinically and biochemically, and a diagnostic liver biopsy is usually required. We report on a Sudanese infant who presented at the age of 4 weeks with prolonged cholestatic jaundice, abdominal ultrasound was inconclusive, HIDA scan was suggestive of extrahepatic biliary atresia and the diagnosis of idiopathic neonatal hepatitis was only reached by liver biopsy. The infant made full recovery on supportive treatment during a one year follow up period.

"Addressing the impact of stroke risk factors in a case control study in tertiary care hospitals": a case control study in Tertiary Care Hospitals of Peshawar, Khyber Phukhtoonkhwa (KPK) Pakistan.

BACKGROUND: Stroke was the second most common cause of death worldwide in 2004, resulting in 5.7 million deaths. This case controlled study was conducted in Tertiary care hospitals of Peshawar, KPK Pakistan about common risk factors of stroke and the impact of these risk factors. METHOD: Study was done at Government Tertiary Care Hospitals of Peshawar namely Khyber Teaching Hospital (KTH), Lady Reading Hospital (LRH) and Hayatabad Medical Complex (HMC).The hospital based case-control study included 50 cases (stroke patients) and 100 controls (non-stroke patients). This study was accomplished from 24th April 2012 to October 2012 in tertiary care hospitals of Peshawar. A proper questionnaire was used to collect data from all the cases and controls, which was recorded in the form of tables and graphs. The risk factors studied were Hypertension, Smoking, diabetes, sedentary lifestyle, cardiac problems, B.M.I, diet, stress and family history of stroke. Anthropometric (weight, height, body mass index) measurements were done on all patients. For determination of association and impact of these risk factors, analyses were performed by calculation of Chi-Square test and confidence interval using SPSS version 16 program. RESULTS: Comparing the cases with controls, hypertension (p = 0.000), sedentary life style (p = 0.000), cardiac problems (p = 0.009), diabetes mellitus (p = 0.010), smoking (p = 0. 042) were significant risk factors whereas B.M.I (p = 0. 393), stress (p = 0.705), family history of stroke (p = 0.729), diet (p = 0.908), were not found to be statistically significant risk factors. The most significant risk factor was systemic hypertension (OR = 4.16) followed by sedentary life style (OR = 3.60), cardiac problems (OR = 2.74) diabetes (OR = 2.49) and smoking (OR = 2.05). CONCLUSION: Hypertension, Smoking, diabetes, sedentary lifestyle and cardiac problems have strong correlations and association with Stroke and are the major risk factors of stroke. Prevention of these risk factors can lead to decrease in the incidence of stroke. B.M.I, diet, stress and family history of stroke had no significant association.