Supporting whanau during COVID-19 pandemic in Aotearoa New Zealand: a systems thinking case study.

BACKGROUND: The Aotearoa New Zealand COVID-19 pandemic response has been hailed as a success story, however, there are concerns about how equitable it has been. This study explored the experience of a collective of Maori health and social service providers in the greater Wellington region of Aotearoa New Zeland delivering COVID-19 responses. METHODS: The study was a collaboration between a large urban Maori health and social service provider, Takiri Mai Te Ata whanau ora collective, and public health researchers in Aotearoa New Zealand. Two online workshops were held with staff of the Maori service provider, collectively developing a qualitative causal loop diagram and generating systemic insights. The causal loop diagram showed interactions of various factors affecting COVID-19 response for supporting whanau (Maori family/households) at a community level. The iceberg model of systems thinking offered insights for action in understanding causal loop diagrams, emphasizing impactful changes at less visible levels. RESULTS: Six interacting subsystems were identified within the causal loop diagram that highlighted the systemic barriers and opportunities for effective COVID-19 response to Maori whanau. The medical model of health service produces difficulties for delivering kaupapa Maori services. Along with pre-existing vulnerability and health system gaps, these difficulties increased the risk of negative impacts on Maori whanau as COVID-19 cases increased. The study highlighted a critical need to create equal power in health perspectives, reducing dominance of the individual-focused medical model for better support of whanau during future pandemics. CONCLUSIONS: The study provided insights on systemic traps, their interactions and delays contributing to a relatively less effective COVID-19 response for Maori whanau and offered insights for improvement. In the light of recent changes in the Aotearoa New Zealand health system, the findings emphasize the urgent need for structural reform to address power imbalances and establish kaupapa Maori approach and equity as a norm in service planning and delivery.

Dietary practices, physical activity and social determinants of non-communicable diseases in Nepal: A systemic analysis.

Unhealthy dietary habits and physical inactivity are major risk factors of non-communicable diseases (NCDs) globally. The objective of this paper was to describe the role of dietary practices and physical activity in the interaction of the social determinants of NCDs in Nepal, a developing economy. The study was a qualitative study design involving two districts in Nepal, whereby data was collected via key informant interviews (n = 63) and focus group discussions (n = 12). Thematic analysis of the qualitative data was performed, and a causal loop diagram was built to illustrate the dynamic interactions of the social determinants of NCDs based on the themes. The study also involved sense-making sessions with policy level and local stakeholders. Four key interacting themes emerged from the study describing current dietary and physical activity practices, influence of junk food, role of health system and socio-economic factors as root causes. While the current dietary and physical activity-related practices within communities were unhealthy, the broader determinants such as socio-economic circumstances and gender further fuelled such practices. The health system has potential to play a more effective role in the prevention of the behavioural and social determinants of NCDs.

Individual and community experience of rising burden of non-communicable diseases in two case districts of Nepal: a qualitative exploration.

INTRODUCTION: Non-communicable diseases (NCDs) are a rapidly emerging global health challenge with multi-level determinants popularly known as social determinants. The objective of this paper is to describe the individual and community experiences of NCDs in the two case districts of Nepal from a social determinants of health perspective. METHOD: This study adopted qualitative study design to identify the experiences of NCDs. Sixty-three interviews were conducted with key informants from different sectors pertinent to NCD prevention at two case districts and at the policy level in Nepal. Twelve focus group discussions were conducted in the selected communities within those case districts. Data collection and analysis were informed by the adapted Social Determinants of Health Framework. The research team utilised the framework approach to carry out the thematic analysis. The study also involved three sense-making workshops with policy level and local stakeholders. RESULTS: Three key themes emerged during the analysis. The first theme highlighted that individuals and communities were experiencing the rising burden of NCDs and metabolic risks in both urban and rural areas. The other two themes elaborated on the participant's experiences based on their socio-economic background and gender. Disadvantaged populations were more vulnerable to the risk of NCDs. Further, being female put one into an even more disadvantaged position in experiencing NCD risks and accessing health services. CONCLUSION: The findings indicated that key social determinants such as age, geographical location, socio-economic status and gender were driving the NCD epidemic. There is an urgent need to take action on social determinants of health through multi-sectoral action, thus also translating the spirit of the recommendations made a decade ago by the Commission on Social Determinants of Health in addressing a complex challenge like NCDs in Nepal.

Critical collaboration model: an enhanced model to support public health collaboration.

Public health problems are often complex and 'wicked' in nature. Wicked problems have multi-factorial causation, are dynamic and often understood and acted upon differently by different actors. Multi-sectoral collaboration is increasingly emphasized for tackling wicked problems through developing a strategic multi-sectoral plan and then taking collective action. Critical systems thinking can support the development of a shared perspective of the problem, strengthen participation in collective action and foster reflective practices to continuously improve both problem understanding and action. In this paper, we present a critical collaboration model, drawing together two complementary theoretical frameworks, as well as insights from three case studies from New Zealand, to offer a systematic approach to adopting a critical systems perspective in public health collaboration. The model provides six questions to make explicit individuals' understandings or assumptions about how others perceive an issue, problem or evidence, and the process of identifying answers strengthens the dialogical and reflective aspects of the collaboration. We indicate some potential areas for the application of the model to integrate critical systems thinking in collaborative practices.

The role of tobacco and alcohol use in the interaction of social determinants of non-communicable diseases in Nepal: a systems perspective.

BACKGROUND: Tobacco and alcohol use are major behavioural risks in developing countries like Nepal, which are contributing to a rapid increase in non-communicable diseases (NCDs). This causal relationship is further complicated by the multi-level social determinants such as socio-political context, socio-economic factors and health systems. The systems approach has potential to facilitate understanding of such complex causal mechanisms. The objective of this paper is to describe the role of tobacco and alcohol use in the interaction of social determinants of NCDs in Nepal. METHOD: The study adopted a qualitative study design guided by the Systemic Intervention methodology. The study involved key informant interviews (n = 63) and focus group discussions (n = 12) at different levels (national, district and/or community) and was informed by the adapted Social Determinants of Health Framework. The data analysis involved case study-based thematic analysis using framework approach and development of causal loop diagrams. The study also involved three sense-making sessions with key stakeholders. RESULTS: Three key themes and causal loop diagrams emerged from the data analysis. Widespread availability of tobacco and alcohol products contributed to the use and addiction of tobacco and alcohol. Low focus on primary prevention by health systems and political influence of tobacco and alcohol industries were the major contributors to the problem. Gender and socio-economic status of families/communities were identified as key social determinants of tobacco and alcohol use. CONCLUSION: Tobacco and alcohol use facilitated interaction of the social determinants of NCDs in the context of Nepal. Socio-economic status of families was both driver and outcome of tobacco and alcohol use. Health system actions to prevent NCDs were delayed mainly due to lack of system insights and commercial influence. A multi-sectoral response led by the health system is urgently needed.

Cardio-metabolic disease risk factors among South Asian labour migrants to the Middle East: a scoping review and policy analysis.

This paper aims to explore the burgeoning burden of cardiovascular and metabolic disease (CMD) risk factors among South Asian labor migrants to the Middle East. We conducted a qualitative synthesis of literature using PubMed/Medline and grey literature searches, supplemented by a policy review of policies from the South Asian countries. We found a high burden of cardio-metabolic risk factors among the migrants as well as among the populations in the home and the host countries. For example, two studies reported the prevalence of diabetes mellitus (DM) ranging between 9 and 17% among South Asian migrants. Overweight and obesity were highly prevalent amongst South Asian male migrants; prevalence ranged from 30 to 66% (overweight) and 17-80% (obesity) respectively. The home country population had a significant CMD risk factor burden. Nearly 14 to 40% have three or more risk factors: such as hypertension (17 to 37%), diabetes (3 to 7%), overweight (18 to 41%), and obesity (2 to 15%). The host country also exhibited similar burden of risk factors: hypertension (13 to 38%), diabetes (8 to 17%), overweight (33 to 77%) and obesity (35 to 41%). Only Nepal, Bangladesh and Sri Lanka have some provisions related to screening of CMDs before labor migration. Further, analysis of policy papers showed that none of the reviewed documents had requirements for screening of any specific CMDs, but chronic diseases were used generically, failing to specify specific screening target. Given the high burden of risk factors, migrants' health should become an urgent priority. The lack of specific focus on screening during different stages of labor migration should receive attention. The International Labour Organization and the International Office for Migration, through their country coordination teams should engage local stakeholders to create policies and plans to address this concern. Similarly, there is a need for the host country to become an equal partner in these efforts, as migrant's better cardiometabolic health is in the benefit of both host and home countries.

Non-communicable disease prevention in Nepal: systemic challenges and future directions.

Developing countries such as Nepal are experiencing a double burden of communicable and non-communicable diseases (NCDs) resulting in social and economic losses. In Nepal, more than half of the disease burden is due to NCDs. The major NCDs in Nepal are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. Behavioural factors such as tobacco use, alcohol consumption, physical inactivity and unhealthy diet are driving the epidemic of NCDs, which are further influenced by social, economic and environmental determinants. The health system of Nepal has not been able to address the ever-increasing burden of NCDs. With the formulation of the Multisectoral Action Plan for Prevention and Control of NCDs 2014-2020, there has been some hope for tackling the NCDs and their social determinants in Nepal through a primary prevention approach. This paper discusses the systemic challenges and recommends two key actions for the prevention and control of NCDs in Nepal.

Social determinants of common metabolic risk factors (high blood pressure, high blood sugar, high body mass index and high waist-hip ratio) of major non-communicable diseases in South Asia region: a systematic review protocol.

BACKGROUND: Prevalence of non-communicable diseases has been increasing at a greater pace in developing countries and, in particular, the South Asia region. Various behavioral, social and environmental factors present in this region perpetuate common metabolic risk factors of non-communicable diseases. This study will identify social determinants of common metabolic risk factors of major non-communicable diseases in the context of the South Asian region and map their causal pathway. METHODS: A systematic review of selected articles will be carried out following Cochrane guidelines. Review will be guided by Social Determinants of Health Framework developed by the World Health Organization to extract social determinants of metabolic risk factors of non-communicable diseases from studies. A distinct search strategy will be applied using key words to screen relevant studies from online databases. Primary and grey literature published from the year 2000 to 2016 and studies with discussion on proximal and distal determinants of non-communicable risk factors among adults of the South Asia region will be selected. They will be further checked for quality, and a matrix illustrating contents of selected articles will be developed. Thematic content analysis will be done to trace social determinants and their interaction with metabolic risk factors. Findings will be illustrated in causal loop diagrams with social determinants of risk factors along with their interaction (feedback mechanism). DISCUSSION: The review will describe the interplay of social determinants of common NCD metabolic risk factors in the form of causal loop diagram. Findings will be structured in two parts: the first part will explain the linkage between proximal determinants with the metabolic risk factors and the second part will describe the linkage among the risk factors, proximal determinants and distal determinants. Evidences across different regions will be discussed to compare and validate and/or contrast the findings. Possible bias and limitations of this study will also be discussed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017067212.

Low birth weight at term and its determinants in a tertiary hospital of Nepal: a case-control study.

Birth weight of a child is an important indicator of its vulnerability for childhood illness and chances of survival. A large number of infant deaths can be averted by appropriate management of low birth weight babies and prevention of factors associated with low birth weight. The prevalence of low birth weight babies in Nepal is estimated to be about 12-32%.Our study aimed at identifying major determinants of low birth weight among term babies in Nepal. A hospital-based retrospective case control study was conducted in maternity ward of Tribhuvan University Teaching Hospital from February to July 2011. A total of 155 LBW babies and 310 controls were included in the study. Mothers admitted to maternity ward during the study period were interviewed, medical records were assessed and anthropometric measurements were done. Risk factors, broadly classified into proximal and distal factors, were assessed for any association with birth of low-birth weight babies. Regression analysis revealed that a history of premature delivery (adjusted odds ratio; aOR5.24, CI 1.05-26.28), hard physical work during pregnancy (aOR1.48, CI 0.97-2.26), younger age of mother (aOR1.98, CI 1.15-3.41), mothers with haemoglobin level less than 11gm/dl (aOR0.51, CI0.24-1.07) and lack of consumption of nutritious food during pregnancy (aOR1.99, CI 1.28-3.10) were significantly associated with the birth of LBW babies. These factors should be addressed with appropriate measures so as to decrease the prevalence of low birth weight among term babies in Nepal.

Internal fixation of shaft humerus fractures by dynamic compression plate or interlocking intramedullary nail: a prospective, randomised study.

Compare the results of internal fixation of shaft of humerus fractures using dynamic compression plating (DCP) or antegrade interlocking intramedullary nail (IMN). Fifty patients with diaphyseal fracture of the shaft of the humerus and fulfilling the inclusion criterion were randomly assigned to one of the two groups. Twenty-five patients were managed with closed antegrade interlocking intramedullary nail, and 25 underwent open reduction and internal fixation using dynamic compression plating. The mean age of patients with IMN fixation was 37.28 years (SD 12.26) and 37.72 years (SD 12.70) for those who underwent plating. Road traffic accident was the most common mode of injury in both groups. There was a statistically significant difference between the two groups with respect to duration of hospital stay, operative time and blood loss. There was no significant difference between the two groups in terms of union or complications. The functional assessment at the end of 1 year between the two groups did not show any significant difference in outcome. Antegrade interlocking IMN and DCP fixation are comparable when managing diaphyseal shaft of humerus fractures with respect to union rates and complications. Although shoulder related complications are more in the IMN group, however, it is associated with shorter hospital stay, lesser operative time and less blood loss. This makes interlocking IMN an effective option in managing these fractures.

Factors associated with place of delivery in rural Nepal.

BACKGROUND: Promotion of institutional delivery is a key intervention in reducing maternal mortality and improving maternal and neonatal health. This study explored factors associated with institutional delivery in rural Nepal. METHOD: A household survey was conducted in three rural Village Development Committees of Kavrepalanchowk district to identify the individual, household and health service factors associated with the institutional delivery. All 240 eligible mothers from the study area were interviewed during the study period. Multiple logistic regression analysis was applied to establish the factor associated with the institutional delivery, the outcome variable. RESULTS: Antenatal care practice, adverse pregnancy outcome, ethnicity and time taken to reach the health institution were significantly associated with the institutional delivery. Utilization of an antenatal care service had the greatest effect on institutional delivery. CONCLUSION: Universal antenatal care service utilization may be a critical intervention for increasing institutional delivery. There is a need to raise awareness in hard-to-reach areas where adverse pregnancy outcomes is not considered a serious event.

Influence of iodothyronine conjugates of bovine serum albumin and horseradish peroxidase on enzyme immunosorbent assay of thyroid hormones.

Enzyme-linked immunosorbent assays (ELISA's) reported for thyroxine (T4) and 3,5,3'-triiodothyronine (T3), involved coupling of the haptens through (i) carboxylic group to carrier protein for producing antibodies and (ii) amino group to detection labels. To improve the titer and specificity of antibodies, immunogens were prepared by coupling of carboxyl group to bovine serum albumin (BSA) either directly or through adipic acid dihydrazide (ADH), after protecting amino group through acetylation of T4 and T3. Direct coupling resulted in the incorporation of 40-50 moles of T4 and T3 per BSA molecule and helped in improving immunogenic response and specificity, especially of T4. High epitope density of immunogens evoked better antibody response, since attachement of ADH as spacer, introduced 18-27 moles of haptens into carrier protein and had less effect on antibody development, with T3 being exception. Detection labels were prepared by coupling horseradish peroxidase (HRP) to amino group of thyroid hormones directly and after preparing their methyl esters, which provided sensitive displacement curves in combination with the antibodies developed against N-acetylated-T4 and T3. Unlike methyl esters, T4-HRP and T3-HRP showed higher sensitivity and seemed to be related to the affinity of the labels for binding the antibody.

Effect of different combinations of antibodies and enzyme labels on ELISA of progesterone.

In steroid immunoassays, selection of right combination of antibody and enzyme-labeled antigen determine the sensitivity and specificity of ELISA. Antibodies raised against different positions of progesterone adopting heterologous systems were reported to provide better assays for progesterone. Four different antibodies developed against progesterone-11α-hemiglutarate-BSA (P-11-HG-BSA), progesterone-11α-hemisuccinate-BSA (P-11-HS-BSA), progesterone-3-O-carboxymethyloxime-BSA (P-3-CMO-BSA), and progesterone-3-O-carboxymethyloxime-ovalbumin (P-3-CMO-ova) were tested in combination with enzyme-labeled P-11-HG, P-11-HS, progesterone-11α-carboxymethyl ether (P-11-CME), P-3-CMO, 17-hydroxyprogesterone-3-O-carboxymethyl oxime (17-P-3-CMO), and progesterone-4-carboxymethyl thioether (P-4-CMTE). These were variously labeled with penicillinase, alkaline phosphatase (ALP), and horseradish peroxidase (HRP). When antibody developed against P-11-HS-BSA was tested with P-3-CMO labeled separately with penicillinase, ALP, and HRP, the type of enzyme used had no effect on the performance of the assay. It was found that a homologous assay using P-3-CMO-ova as immunogen and P-3-CMO-HRP as label, as well as a heterologous ELISA with antibody raised against P-11-HS-BSA in combination with P-3-CMO-HRP, provided sensitive assays for progesterone. The use of 17α-hydroxy progesterone-3-O-carboxymethyl oxime-HRP with the same antibodies against P-3-CMO-BSA and P-11-HS-BSA also proved to be better than P-3-CMO-HRP. These findings implied that the sensitivity and specificity of ELISA to a great extent depended on the nature of the antibody produced, while the choice of enzyme labels could be manipulated.

The posterior to anterior controlled technique of percutaneous Achilles tenotomy in the correction of idiopathic clubfoot: a technical report.

Percutaneous tenotomy of the Achilles tendon is an integral part of the Ponseti technique of clubfoot correction. Although originally described by Ponseti as an office procedure that was performed under local anaesthesia, serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation have been reported. We describe a new tenotomy technique, the posterior to anterior controlled technique, that may decrease the possibility of neurovascular damage, does not require exposure of the Achilles tendon and can be performed as an office procedure under local anaesthesia.

Congenital Insensitivity to Pain with Anhidrosis (HSAN Type IV), Extremely Rare Syndrome that Can Be Easily Missed by Bone and Joint Surgeons: A Case Report.

BACKGROUND: Congenital insensitivity to pain with anhidrosis is an extremely rare disorder in which injuries can often be missed by patient, parents and even by orthopedic surgeon. Pain and tenderness, on which a trauma team so much depends to make a clinical diagnosis and to decide whether to go for radiological evaluation can be misleading in this rare syndrome. So complete clinical examination still forms the corner stone to avoid misdiagnosis and pick up the rare disorders. CASE PRESENTATION: We present a 5 year old girl child, who was brought to us as a case of one and a half month old neglected trauma left leg and was diagnosed to be suffering from congenital insensitivity to pain with anhidrosis (HSAN Type IV). CONCLUSION: Congenital insensitivity to pain with anhidrosis is extremely rare entity, in which patients are subjected to repeated injuries which are often neglected. There is no specific treatment but patient training and parent education are key to avoid further neglect and damage.

Room temperature ferromagnetism in Co-incorporated TiO2 thin films.

Observation of room temperature ferromagnetism (RTFM) in nano-crystalline Co-incorporated titanium dioxide [Ti(1-x)Co(x)O2(x = 0.05)] thin films prepared by spray pyrolysis technique is reported. While only the anatase phase was detected in as-deposited 5 at.% Co-incorporated TiO2 film, a small amount of rutile phase developed following its vacuum annealing. Besides, no X-ray diffraction peak corresponding to cobalt metal could be detected in any of the two films. SQUID magnetometry of both pristine and Co-doped thin films at room temperature elucidated distinct ferromagnetic behavior in 5 at.% Co-incorporated as-deposited film with saturation moment M(s) approximately 5.6 emu/cm3 which got enhanced up to 11.8 emu/cm3 on subsequent vacuum annealing. From the zero field cooled magnetization measurement we confirmed the absence of Co-metal clusters. The electrical resistivity was found to be greater than 108 omega-cm for the films. Based on the magnetic and electrical measurements the origin of RTFM has been attributed to the bound magnetic polaron (BMP) model.