Insurance Adjudication Simulation Across Multiple Institutions and Levels of Learners.

Objective. A virtual educational innovation was designed and implemented to have student pharmacists simulate insurance processing. This article describes the impact of this third-party payer simulation on student knowledge and confidence and reports student perceptions of the activity.Methods. First-, second-, and third-year pharmacy students (P1, P2, and P3 students, respectively) at four institutions completed the self-paced simulation. Knowledge was assessed by comparing results of multiple-choice questions on the pre- and post-assessments and evaluated by the Wilcoxon signed rank test. Confidence was assessed by students' change in self-reported confidence scale measurements and compared using the chi-square test.Results. The simulation had a significant impact on student knowledge. The largest improvement was in P1 students, with a pre- to post-assessment average score difference (scale 0-100) of 16.6 compared to 7.2 for P2 and 10.2 for P3 students. Significant improvement was seen on most of the knowledge questions, with variations for certain questions between groups. All groups had significantly improved self-rated confidence in their abilities. Most students agreed that they would recommend this activity to other students (91.7%) and that it encouraged them to think about the material in a new way (85%).Conclusions. Through an innovative simulation on prescription insurance processing, positive results were seen across all three levels of learners. Knowledge assessments significantly improved, and student confidence increased across all groups and all confidence items. Participants would recommend this activity to other students and felt it was an effective way to learn about insurance adjudication.

Uptake of permanent contraception among women in sub-Saharan Africa: a literature review of barriers and facilitators.

OBJECTIVE: Uptake of permanent contraception among women remains low in sub-Saharan Africa compared to other regions. We aimed to synthesize available evidence on barriers to, and facilitators of permanent contraception with regards to tubal ligation among women in sub-Saharan Africa. STUDY DESIGN: We reviewed literature on tubal ligation among African women published between January 1, 2000 and October 30, 2017. We searched PubMed, Global health, EMBASE, Web of science, and Google scholar for quantitative, qualitative, and mixed methods studies which reported on barriers and/or facilitators to uptake of tubal ligation in sub-Saharan Africa. Finally, we conducted a narrative synthesis and categorized our findings using a framework based on the social ecological model. RESULTS: We included 48 articles in the review. Identified barriers to tubal ligation among women included individual-level (myths and misconceptions, fear of surgery, irreversibility of procedure, religious beliefs), interpersonal-level (male partner disapproval), and organizational-level (lack of healthcare worker expertise and equipment) factors. Facilitating factors included achievement of desired family size and perceived effectiveness (individual-level), supportive male partners and knowing other women with permanent contraception experience (interpersonal-level), and finally, subsidized cost of the procedure and task-sharing with lower cadre healthcare workers (organizational-level). CONCLUSIONS: Barriers to, and facilitators of permanent contraception among women in sub-Saharan Africa are multilevel in nature. Strategies countering these barriers should be prioritized, as effective contraception can promote women's health and economic development in sub-Saharan Africa. In addition to these strategies, more quantitative research is needed to further understand patient-level factors associated with uptake of permanent contraception among women.

Timely reminder interventions to improve annual Papanicolaou (Pap) smear rates among HIV-infected women in an outpatient center of southern Nevada: a short report.

Current guidelines recommend annual Papanicolaou (Pap) smears for human immunodeficiency virus (HIV)-infected women for cervical cancer screening. Rates for such screening in Nevada are below the national rate. Our cohort includes 485 eligible HIV-infected adult women from an outpatient center in Southern Nevada of which only 12 women had obtained a Pap smear in the past year. An intervention was conducted from June 2015 to September 2015, in which reminders to schedule a Pap smear were sent to the remaining cohort of 473 women via sequential text messaging, followed by phone call attempts. Of all subjects, 94% contacted by text messages and 41% contacted by phone calls were successfully reached. There was an increase in the rate of completed Pap smears from 2.5% (12/485) at baseline to 11.8% (56/473) after interventions (p < 0.0001) in a period of three months. Out of the 68 Pap smear results, 20 (29.4%) were abnormal. Our intervention, utilizing methods of communication such as text messaging and phone calls, markedly increased the rate of completed Pap smear screening in our population.

What do You Need to Get Male Partners of Pregnant Women Tested for HIV in Resource Limited Settings? The Baby Shower Cluster Randomized Trial.

Male partner involvement has the potential to increase uptake of interventions to prevent mother-to-child transmission of HIV (PMTCT). Finding cultural appropriate strategies to promote male partner involvement in PMTCT programs remains an abiding public health challenge. We assessed whether a congregation-based intervention, the Healthy Beginning Initiative (HBI), would lead to increased uptake of HIV testing among male partners of pregnant women during pregnancy. A cluster-randomized controlled trial of forty churches in Southeastern Nigeria randomly assigned to either the HBI (intervention group; IG) or standard of care referral to a health facility (control group; CG) was conducted. Participants in the IG received education and were offered onsite HIV testing. Overall, 2498 male partners enrolled and participated, a participation rate of 88.9%. Results showed that male partners in the IG were 12 times more likely to have had an HIV test compared to male partners of pregnant women in the CG (CG = 37.71% vs. IG = 84.00%; adjusted odds ratio = 11.9; p < .01). Culturally appropriate and community-based interventions can be effective in increasing HIV testing and counseling among male partners of pregnant women.

Using a Cultural Framework to Understand Factors Influencing HIV Testing in Nigeria.

With support from the U.S. President's Emergency Plan for AIDS Relief and the global fund for HIV, tuberculosis, and malaria, Nigeria offers free services for prevention of mother-to-child transmission of HIV. However, uptake of these services is low, and pediatric transmission of HIV remains a significant public health challenge. Using the PEN-3 cultural model as the theoretical framework, we examined social, cultural, and contextual factors that influenced uptake of HIV counseling and testing among pregnant women and their male partners. This was a qualitative study of participants in the Healthy Beginning Initiative (HBI), a congregation-based program to prevent mother-to-child transmission of HIV in Enugu, southeast Nigeria. We conducted eight focus group discussion sessions with 83 pregnant women and their male partners. Participants' perspectives on why they did or did not test for HIV were obtained. The most cited reasons for getting tested for HIV included the following: "the need to know one's status", "the role of prenatal testing" (positive perceptions); "the role of the church", "personal rapport with healthcare worker" (positive enablers); and the "influence of marriage" (positive nurturer). The most cited reason for not testing were: "fear of HIV test", "shame associated with HIV+ test results", "conspiratorial beliefs about HIV testing" (negative perceptions); "lack of confidentiality with HIV testing", (negative enabler); and "HIV-related stigma from family and community systems" (negative nurturer). Overall, numerous facilitators and barriers influence uptake of HIV testing in the study setting. Public health practitioners and policymakers need to consider how sociocultural and religious factors unique to specific local contexts may promote or hinder uptake of available HIV/AIDS prevention and care interventions.

Prevalence of Sickle Cell Trait and Reliability of Self-Reported Status among Expectant Parents in Nigeria: Implications for Targeted Newborn Screening.

BACKGROUND/AIMS: Sickle cell disease (SCD) is a life-threatening, autosomal recessive blood disorder prevalent in sub-Saharan Africa. We identified the prevalence of sickle cell trait (SCT) among pregnant women and their male partners in Enugu State, Nigeria, and determined the accuracy of self-reported sickle cell status and its reliability for identifying high-risk newborns for targeted screening. METHODS: We conducted a nested cohort study of expectant parents enrolled in the Healthy Beginning Initiative (HBI). The HBI is a cluster-randomized trial of a congregation-based approach designed to increase HIV testing. Participants completed a survey regarding self-awareness of their sickle cell genotype and consented to genotype screening by cellulose acetate electrophoresis. RESULTS: SCT prevalence (HbAS) was 22% (746/3,371). Only 50% of participants provided an accurate self-report. Self-report accuracy was significantly different (p < 0.0001) between individuals who reported having SCT or SCD (61% accuracy) versus those who reported not having SCT or SCD (86% accuracy). Demographic variables including gender, age, household size, employment, education, and home location were significantly associated with providing an accurate self-report. CONCLUSIONS: Low numbers of accurate parental self-reports, coupled with a high SCT prevalence in Nigeria, could limit the efficacy of targeted newborn screening. However, our data indicate that it is feasible to integrate sickle cell screening for pregnant women with existing, community-based health care programs developed by the President's Emergency Plan for AIDS Relief (PEPFAR), such as the HBI. Expanding screening programs could enable the development of targeted newborn screening based on maternal genotype that could identify all newborns with SCD in resource-limited settings.

Effect of a congregation-based intervention on uptake of HIV testing and linkage to care in pregnant women in Nigeria (Baby Shower): a cluster randomised trial.

BACKGROUND: Few effective community-based interventions exist to increase HIV testing and uptake of antiretroviral therapy (ART) in pregnant women in hard-to-reach resource-limited settings. We assessed whether delivery of an intervention through churches, the Healthy Beginning Initiative, would increase uptake of HIV testing in pregnant women compared with standard health facility referral. METHODS: In this cluster randomised trial, we enrolled self-identified pregnant women aged 18 years and older who attended churches in southeast Nigeria. We randomised churches (clusters) to intervention or control groups, stratified by mean annual number of infant baptisms (<80 vs ≥80). The Healthy Beginning Initiative intervention included health education and on-site laboratory testing implemented during baby showers in intervention group churches, whereas participants in control group churches were referred to health facilities as standard. Participants and investigators were aware of church allocation. The primary outcome was confirmed HIV testing. This trial is registered with ClinicalTrials.gov, identifier number NCT 01795261. FINDINGS: Between Jan 20, 2013, and Aug 31, 2014, we enrolled 3002 participants at 40 churches (20 per group). 1309 (79%) of 1647 women attended antenatal care in the intervention group compared with 1080 (80%) of 1355 in the control group. 1514 women (92%) in the intervention group had an HIV test compared with 740 (55%) controls (adjusted odds ratio 11·2, 95% CI 8·77-14·25; p<0·0001). INTERPRETATION: Culturally adapted, community-based programmes such as the Healthy Beginning Initiative can be effective in increasing HIV screening in pregnant women in resource-limited settings. FUNDING: US National Institutes of Health and US President's Emergency Plan for AIDS Relief.

Impact of male partner's awareness and support for contraceptives on female intent to use contraceptives in southeast Nigeria.

BACKGROUND: Despite the growing body of evidence on use of modern contraceptives among women in sub-Saharan African countries, little is known about the broader context in which female decision-making concerning contraceptive use occurs, particularly the role of their male partners' awareness and support of modern contraceptives. METHODS: We conducted a cross-sectional survey of 2468 pregnant women and their male partners enrolled in the Healthy Beginning Initiative (HBI), an intervention to increase HIV testing among pregnant women in Enugu, southeast Nigeria. The aims of this study were to determine: 1) male partners' awareness of, and support for, female contraceptive methods, and 2) influence of male partners' contraceptive awareness and support on pregnant women's expressed desire to use contraception. We used logistic regression models to examine the association between male partners' awareness and support of modern contraceptives on their spouses' desire to use contraceptives. RESULTS: Men's awareness of, and support for, use of modern contraceptives were significantly associated with their female partners' desire to use contraception. A majority of the men who were aware of modern contraceptives (66.5 %) and those who supported their spouses' use of contraception (72.5 %) had partners who expressed a desire to use contraception. Men who were aware of female contraception were 3 times more likely to have spouses who desired to use contraception (AOR = 3.17, 95 % C.I: 2.70-3.75). In addition, men who showed support for their spouses' use of contraception were over 5 times more likely to have spouses who indicated a desire to use contraception (AOR = 5.76, 95 % C.I: 4.82-6.88). Living in a household of 5 or more people (AOR = 1.45, 95 % C.I: 1.23-1.72) and residing in an urban area (AOR = 0.81, 95 % C.I: 0.67-0.97) were also significantly associated with women's expressed desire to use modern contraception. CONCLUSION: Men's awareness of, and support for, use of modern contraceptives were markedly associated with their spouses' desire to use contraception. This underscores the need for men's involvement in programs that seek to address women's uptake of contraception in low and middle income countries.

Ebola Outbreak in Nigeria: Increasing Ebola Knowledge of Volunteer Health Advisors.

In many low-income countries, volunteer health advisors (VHAs) play an important role in disseminating information, especially in rural or hard-to-reach locations. When the world's largest outbreak of Ebola virus disease (EVD) occurred in 2014, a majority of cases were concentrated in the West African countries of Guinea, Liberia, and Sierra Leone. Twenty cases were reported in Nigeria initially and there was a need to rapidly disseminate factual information on Ebola virus. In southeast Nigeria, a group of VHAs was being used to implement the Healthy Beginning Initiative [HBI], a congregation based intervention to increase HIV testing among pregnant women and their male partners. The purpose of this study was to assess the baseline and post EVD training knowledge of VHAs during the outbreak in Nigeria. In September 2014, 59 VHAs attending a HBI training workshop in the Enugu State of Nigeria participated in an Ebola awareness training session. Participants completed a 10-item single-answer questionnaire that assessed knowledge of Ebola epidemiology, symptoms, transmission, prevention practices, treatment and survival prior to the Ebola awareness training. After the training, the VHAs repeated the questionnaire. Answers to pre and post questionnaires were analyzed using paired t-tests. Multiple linear regression was used to examine the relationship between pre and post total questionnaire scores and age, education, current location and employment. The average pre-test score was 7.3 and average post-test score was 7.8 which was a significant difference (t=-2.5, p=0.01). Prior to the training, there was a significant difference in Ebola knowledge based on the VHAs education only (p<0.01). After training, education was no longer significant for Ebola knowledge. Existing community health programs can be used as a platform to train VHAs in times of epidemics for quick dissemination of vital health information in areas lacking adequate health infrastructure and personnel.

Evolution of coordinated mutagenesis and somatic hypermutation in VH5.

The VH5 human antibody gene was analyzed using a computer program (mfg) which simulates transcription, to better understand transcription-driven mutagenesis events that occur during "phase 1" of somatic hypermutation. Results show that the great majority of mutations in the non-transcribed strand occur within loops of two predicted high-stability stem-loop structures, termed SLSs 14.9 and 13.9. In fact, 89% of the 2505 mutations reported are within the encoded complementarity-determining region (CDR) and occur in loops of these high-stability structures. In vitro studies were also done and verified the existence of SLS 14.9. Following the formation of SLSs 14.9 and 13.9, a sustained period of transcriptional activity occurs within a window size of 60-70 nucleotides. During this period, the stability of these two SLSs does not change, and may provide the substrate for base exchanges and mutagenesis. The data suggest that many mutable bases are exposed simultaneously at pause sites, allowing for coordinated mutagenesis.

The roles of transcription and genotoxins underlying p53 mutagenesis in vivo.

Transcription drives supercoiling which forms and stabilizes single-stranded (ss) DNA secondary structures with loops exposing G and C bases that are intrinsically mutable and vulnerable to non-enzymatic hydrolytic reactions. Since many studies in prokaryotes have shown direct correlations between the frequencies of transcription and mutation, we conducted in silico analyses using the computer program, mfg, which simulates transcription and predicts the location of known mutable bases in loops of high-stability secondary structures. Mfg analyses of the p53 tumor suppressor gene predicted the location of mutable bases and mutation frequencies correlated with the extent to which these mutable bases were exposed in secondary structures. In vitro analyses have now confirmed that the 12 most mutable bases in p53 are in fact located in predicted ssDNA loops of these structures. Data show that genotoxins have two independent effects on mutagenesis and the incidence of cancer: Firstly, they activate p53 transcription, which increases the number of exposed mutable bases and also increases mutation frequency. Secondly, genotoxins increase the frequency of G-to-T transversions resulting in a decrease in G-to-A and C mutations. This precise compensatory shift in the 'fate' of G mutations has no impact on mutation frequency. Moreover, it is consistent with our proposed mechanism of mutagenesis in which the frequency of G exposure in ssDNA via transcription is rate limiting for mutation frequency in vivo.

II. Correlations between secondary structure stability and mutation frequency during somatic hypermutation.

The role of secondary structures and base mutability at different levels of transcription and supercoiling is analyzed in variable region antibody genes VH5, VH94 and VH186.2. The data are consistent with a model of somatic hypermutation in which increasing levels of transcription and secondary structure stability correlate with the initial formation of successive mutable sites. Encoded differences exist in stem length and the number of GC pairs at low versus high levels of transcription in CDRs. These circumstances simplify the complexities of coordinating mutagenesis by confining this process to each mutable site successively, as they form in response to increasing levels of transcription during affinity maturation.