Evaluation of a virtual, simulated international public health peer-to-peer exchange learning experience.

Introduction: Public Health's (PH) global rise is accompanied by an increasing focus on training the new generation of PH graduates in interdisciplinary skills for multisectoral and cross-cultural engagement to develop an understanding of commonalities in health system issues and challenges in multi-cultural settings. Online teaching modalities provide an opportunity to enhance global health skill development through virtual engagement and peer exchange. However, current teaching pedagogy is limited in providing innovative modes of learning global health issues outside of traditional classroom settings with limited modalities of evidence-informed implementation models. Methods: This study designed, implemented, and evaluated a novel global health online synchronous module as proof of concept that incorporated elements of virtual Practice-based learning (PBL) using a case study approach offered to currently enrolled public health students at the University of Canberra (UC) and a partnering public health university from India, the Indian Institute of Public Health Gandhinagar (IIPH-G). Using constructive learning theory and the Social Determinants of Health framework, four online sessions were designed and implemented in August-September 2022. Formal process and outcome evaluation using a quantitative adapted survey of the validated International Student Experience survey (IES) at session end and findings provided. Results: Over 100 participating public health students from Australia and India provided narrative feedback and quantitative responses from the adapted IES instrument across four key dimensions, namely "motivation," "personal development," intellectual development, and "international perspectives" reporting an overall high mean impact of 4.29 (out of 5) across all four themes seen together. In essence, the sessions supported students to explore global health issues from a different cultural perspective while developing intercultural communication skills and enhancing their global exposure in real-time. Discussions: This innovation, implemented as a proof of concept, provided evidence, and demonstrated the implementation feasibility of a flexible virtual integrated practice-based module that can supplement classroom teaching. It provides participating students with the opportunity to develop intercultural understanding and communication competence as well as support global mindedness by engaging with international peers around focused global health case studies.

Couples-based behaviour change interventions to reduce metabolic syndrome risk. A systematic review.

BACKGROUND AND AIMS: Metabolic Syndrome (MetS), is a major risk factor for non-communicable diseases including type 2 diabetes mellitus, cardiovascular disease, and cancer. Although MetS risk is transferred via the epigenome from both biological parents, periconceptional lifestyle interventions are generally directed towards mothers. There is a need for interventions to reflect the shared nature of epigenetic MetS risk between both biological parents. Couples-based lifestyle interventions have previously been used to improve adherence to behaviour change in conditions with shared risk responsibility such as sexually transmitted diseases. This systematic literature review sought to answer the research question: Are couples-based interventions more effective than individual interventions to address overweight and obesity as the primary modifiable risk for MetS in addition to other associated factors. METHODS: Couples-based studies involving randomised controlled trials, published between 01/01/1990-31/12/2021, were identified in Medline, CINAHL, PsycINFO, Psychology and Behavioural Sciences Collection, Cochrane, and Scopus. RESULTS: After screening 4742 articles, only five eligible trials remained. Statistically significant post-intervention maintenance of low glycaemic levels was observed in one study. Otherwise, no statistically significant group differences between couples' groups and control groups were observed in any of the five included studies. CONCLUSIONS: The included studies concluded that couple-based interventions can lead to weight reduction, maintenance, and adherence to modified health behaviours similar to interventions that target individuals. Overall, the findings indicate that, notwithstanding the paucity of authentic couples-based interventions, there is potential for such approaches to moderate MetS risk factors likely to flow onto epigenetic transmission of risk.

Role of cholecystokinin in satiation: a systematic review and meta-analysis.

The aim of this review was to examine: (1) the ability of cholecystokinin (CCK) or analogues of CCK to influence satiation and changes in body weight generally and (2) the efficacy of CCK in influencing satiation and eating behaviour specifically at physiological levels of dosing. A systematic review of the literature was performed following the PRISMA 2020 guidelines in five electronic databases investigating the effect of exogenous CCK or analogues on satiation and body weight. A meta-analysis of studies that infused CCK and measured satiation via changes in food/energy intake was also conducted. A total of 1054 studies were found using the search terms which were reduced to fifteen studies suitable for inclusion. Of the twelve studies measuring the effect on the weight of food ingested or energy intake, eleven showed a decrease. An analogue of CCK which can be administered orally failed to produce any weight loss at 24 weeks. The meta-analysis found the effect of CCK on satiation dosed at physiological levels was significant with a standardised mean difference of 0·57 (95 % CI 0·30, 0·85, P < 0·0001). By comparison, CCK dosed at higher, pharmacological levels also had a significant effect with a standardised mean difference of 0·91 (95 % CI 0·46, 1·36, P < 0·0001). Eight of the ten studies in the meta-analysis combined CCK infusion with some means to facilitate stomach distension. The present review found evidence that at both physiological and pharmacological levels of dosing CCK has a significant effect on satiation but no evidence for weight loss over the long term.

Prickly pear juice consumption after fat intake affects postprandial heart rate variability but not traditional risk factors of cardiovascular disease in healthy men.

OBJECTIVE: Prickly Pear (PP) fruit is proposed to have anti-atherosclerotic and anti-hyperglycemic effects. The aim of this study was to examine the effects of a single consumption of PP juice on modifiable blood and physiological markers of cardiovascular disease risk in healthy men using a postprandial hyperlipidemia model. METHODS: This was a double-blind, randomized, placebo-controlled, crossover trial with 17 healthy men (body mass index 22.6 ± 2.04 kg/m2; 29.5 ± 7.19 y of age). Participants consumed PP juice (250 mL; 45 mg betalain content; reduced fiber) or a simple placebo drink (water-based), with a high-fat muffin (50 g fat) to determine potential effects on physiologic and biological responses, for up to 3 h post-consumption (hourly, 2 sessions, 7-d washout period). Blood pressure, heart rate variability (HRV), total cholesterol (TC), triacylglycerides (TGs), low-density and high-density lipoprotein cholesterol (LDL-C and HDL-C, respectively), and glucose were measured. RESULTS: Key findings included a lower HRV measure after PP consumption (main effect for group, P ≤0.001-0.020) but no differences for TC, TG, LDL-C, or HDL-C. CONCLUSION: Consumption of PP (with high-fat muffin), did not alter traditional cardiovascular disease risk responses but rather markers of HRV, beyond an expected increase in glucose attributed to the carbohydrate content of the trials foods. Additionally, macronutrient content is important when understanding HRV responses to meals.

Identifying effective interventions to promote consumption of protein-rich foods from lower ecological footprint sources: A systematic literature review.

Addressing overconsumption of protein-rich foods from high ecological footprint sources can have positive impacts on health such as reduction of non-communicable disease risk and protecting the natural environment. With the increased attention towards development of ecologically sustainable diets, this systematic review aimed to critically review literature on effectiveness of those interventions aiming to promote protein-rich foods from lower ecological footprint sources. Five electronic databases (Medline, Web of Science, Scopus, Embase and Global Health) were searched for articles published up to January 2021. Quantitative studies were eligible for inclusion if they reported on actual or intended consumption of protein-rich animal-derived and/or plant-based foods; purchase, or selection of meat/plant-based diet in real or virtual environments. We assessed 140 full-text articles for eligibility of which 51 were included in this review. The results were narratively synthesised. Included studies were categorised into individual level behaviour change interventions (n = 33) which included education, counselling and self-monitoring, and micro-environmental/structural behaviour change interventions (n = 18) which included menu manipulation, choice architecture and multicomponent approaches. Half of individual level interventions (52%) aimed to reduce red/processed meat intake among people with current/past chronic conditions which reduced meat intake in the short term. The majority of micro-environmental studies focused on increasing plant-based diet in dining facilities, leading to positive dietary changes. These findings point to a clear gap in the current evidence base for interventions that promote plant-based diet in the general population.

Saving Lives: A Systematic Review on the Efficacy of Theory-Informed Suicide Prevention Programs.

Suicide is a global epidemic. This review assessed the scope and effectiveness of suicide prevention programs. Systematic literature searches were conducted using PsycINFO, ERIC and MEDLINE to retrieve articles published between January 2007 and March 2017 and fulfilled inclusion criteria (studies evaluating the efficacy of theory/model-informed suicide prevention programs in increasing participant knowledge or skills when presented with a peer at risk of suicide). The review is informed by PRISMA guidelines. Of 1398 studies identified, 25 were reviewed and most: targeted professionals; were 1-4-day workshops; were underpinned by 21 different theories; taught less detail to the community than professionals; and improved target outcomes. Current programs, although effective, are limited by their inaccessibility, narrow content for the community and substantial variability in theory base. Future suicide prevention programs will benefit from being informed by a more specific theory, delivered through technology, targeting more of the community and improving methodological rigour.

Enhancing Community Suicide Risk Assessment and Protective Intervention Action Plans Through a Bystander Intervention Model-Informed Video.

Aim: The effects of a bystander intervention model (BIM)-informed intervention (video) for the general community on participant risk of suicide assessment ability (ROSAA) and protective intervention ability (PIA) were compared with an active control (non-BIM-informed video). Method: Video interventions with 628 participants (Mage = 47.99, SDage = 17.34, range = 18-85 years) were conducted online. ROSAA and PIA were assessed immediately preintervention, postintervention, and at 2 months follow-up (n = 126). Results: Linear mixed model analyses indicated that the experimental and control conditions improved on both outcome variables postintervention/Time 2 (T2); however, the former yielded better outcomes than the latter (moderate ESs in both variables). Follow-up/Time 3 (T3) experimental ROSAA scores were higher than Time 1 (T1) and lower than T2 scores. Follow-up experimental PIA scores were higher than T1 and lower than T2 scores. Follow-up control ROSAA scores were higher than those of T1 and similar to T2. Follow-up control PIA scores were similar to T1 and T2 scores. Limitations: Limitations of the study include: sample homogeneity, small n at follow-up, self-report data only (no observable behavior was tested), fair inter-rater reliability, and a brief follow-up time frame. Conclusion: Current community information increased ROSAA and PIA. A BIM-informed intervention significantly enhanced these effects, which seemed to wane somewhat over time with the effect being lower at follow-up compared with postintervention. The BIM should be explored further as a basis for community suicide prevention interventions.

Maternal body mass index and country of birth in relation to the adverse outcomes of large for gestational age and gestational diabetes mellitus in a retrospective cohort of Australian pregnant women.

BACKGROUND: The prevalence of gestational diabetes mellitus in Australia has been rising in line with the increased incidence of maternal overweight and obesity. Women with gestational diabetes mellitus, high body mass index or both are at an elevated risk of birthing a large for gestational age infant. The aim was to explore the relationship between country of birth, maternal body mass index with large for gestational age, and gestational diabetes mellitus. In addition to provide additional information for clinicians when making a risk assessment for large for gestational age babies. METHOD: A retrospective cohort study of 27,814 women residing in Australia but born in other countries, who gave birth to a singleton infant between 2008 and 2017 was undertaken. Logistic regression analysis was used to examine the association between the aforementioned variables. RESULTS: A significantly higher proportion of large for gestational age infants was born to overweight and obese women compared to those who were classified as underweight and healthy weight. Asian-born women residing in Australia, with a body mass index of ≥40 kg/m2, had an adjusted odds ratio of 9.926 (3.859-25.535) for birthing a large for gestational age infant. Conversely, Australian-born women with a body mass index of ≥40 kg/m2 had an adjusted odds ratio of 2.661 (2.256-3.139) for the same outcome. Women born in Australia were at high risk of birthing a large for gestational age infant in the presence of insulin-requiring gestational diabetes mellitus, but this risk was not significant for those with the diet-controlled type. Asian-born women did not present an elevated risk of birthing a large for gestational age infant, in either the diet controlled, or insulin requiring gestational diabetes mellitus groups. CONCLUSIONS: Women who are overweight or obese, and considering a pregnancy, are encouraged to seek culturally appropriate nutrition and weight management advice during the periconception period to reduce their risk of adverse outcomes.

Promoting the Community's Ability to Detect and Respond to Suicide Risk Through an Online Bystander Intervention Model-Informed Tool.

Background: The public health sector has advocated for more innovative, technology-based, suicide prevention education for the community, to improve their ability to detect and respond to suicide risk. Emerging evidence suggests addressing the bystander effect through the Bystander Intervention Model (BIM) in education material may have potential for suicide prevention. Aims: The current study aimed to assess whether BIM-informed tools can lead to improved readiness, confidence and intent in the community to detect and respond to suicide risk in others. Method: A sample of 281 adults recruited from the community participated in a randomized controlled trial comprising a factsheet designed according to the BIM (intervention group) and a standard factsheet about suicide and mental health (control group). Participants' self-reported detecting and responding to suicide risk readiness, confidence, and intent when presented with a suicidal peer was tested pre- and postintervention and compared across time and between groups. Results: The intervention group had significantly higher levels of detecting and responding to suicide risk readiness, confidence, and intent than the control group at postintervention (all p < .001) with moderate-to-large effect sizes. Limitations: The study was limited by a homogenous sample, too low numbers at follow-up to report, and self-report data only. Conclusion: This study demonstrates BIM-informed suicide prevention training may enhance the community's intervention readiness, confidence, and intent better than current standard material. Further testing in this area is recommended. While results were statistically significant, clinical significance requires further exploration.

Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries.

Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.

Metformin use in prediabetes: is earlier intervention better?

AIM: The aim of this study was to investigate the effectiveness of metformin in diabetes prevention in a prediabetic population across a range of fasting plasma glucose (FPG) levels at baseline. A secondary aim was to assess the effectiveness of metformin in preventing diabetes in those participants where impaired fasting glucose (IFG) was relatively more pronounced as opposed to impaired glucose tolerance (IGT). METHODS: Participants randomised to metformin and placebo arms in the Diabetes Prevention Program study were stratified into cohorts according to level of FPG at baseline. Cumulative incidence of diabetes for the different cohorts was assessed. Change in FPG, insulin sensitivity, and levels of fasting insulin and proinsulin for the different cohorts were also calculated. RESULTS: The largest reductions in incidence of diabetes and FPG occurred within prediabetic persons with a higher level of FPG at baseline. Metformin was able to stabilise insulin sensitivity in every stratified sub-cohort except one. Sub-cohorts which had higher levels of insulin sensitivity at baseline experienced the largest increases in insulin sensitivity. Metformin reduced the incidence of diabetes by 43% (RR 0.57, CI 0.4-0.9) in those prediabetic persons whose IFG was more pronounced compared to a 26% (RR 0.74 CI 0.7-0.8) when all participants in the study were included. CONCLUSION: The largest reductions in both incidence of diabetes and FPG occurred in prediabetic persons with a higher level of FPG at baseline. Metformin was able to stabilise insulin sensitivity and was more effective in persons with more pronounced IFG.

Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health-care professionals' perspectives.

BACKGROUND AND OBJECTIVE: Efforts to improve the adoption of evidence-based interventions for optimal patient outcomes in low-/middle-income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals' views on strategies to improve quality stroke care for people who had a stroke in a LMIC. METHODS: A qualitative interview study design was adopted. A semi-structured interview guide was used to conduct in-depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data. RESULTS: A number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers. CONCLUSION: Closing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context-specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.

New digital media interventions for sexual health promotion among young people: a systematic review.

New digital media platforms (e.g. social networking sites, web pages and text messaging) have dramatically changed interpersonal communication and present novel opportunities for health interventions. Due to the high uptake and use of digital media among young people, advances in digital media provide potential new opportunities in delivering health interventions to this audience to reduce sexually transmissible infection (STI) risk. The aim of this study was to assess the effectiveness of sexual health interventions delivered via new digital media to young people (aged 13-24 years). A systematic search was conducted of seven databases for peer-reviewed literature published between January 2010 and April 2017 that evaluated a sexual health intervention delivered to young people (aged 13-24 years). Of 2017 papers reviewed, 25 met the inclusion criteria and were assessed. Sixteen studies used web-based platforms to deliver their intervention. A large proportion of studies (11/25) specifically focused on HIV prevention. Seven studies found a statistically significant effect of the intervention on knowledge levels regarding the prevention HIV and other STI, as well as general sexual health knowledge, but only one-fifth of interventions evaluating intentions to use condoms reported significant effects due to the intervention. Nine studies focused on individuals from an African American background. Although new media has the capacity to expand efficiencies and coverage, the technology itself does not guarantee success. It is essential that interventions using new digital media have high-quality, evidence-based content that engages with individual participants.

Associations between Flavonoid Intakes and Gut Microbiota in a Group of Adults with Cystic Fibrosis.

Dietary flavonoid intakes can influence gut microbiota (GM), which in turn can affect immune function and host metabolism, both vital considerations in cystic fibrosis (CF) management. In CF, GM may be altered and link to CF respiratory events. This study explored the relationship between flavonoid intakes and GM in free-living adults with CF. Associations between the overall GM variations (unweighted and weighted UniFrac distances between pyrosequencing results of bacterial 16-ss rDNA from frozen faecal samples of sixteen CF adults) and standardised dietary flavonoid intakes (a validated flavonoid-specific food frequency questionnaire) were analysed using adonis tests. Flavonoid intakes that were significant at a false discovery rate (FDR) < 0.3 were subjected to Spearman correlation tests with standardised bacterial relative abundances (FDR < 0.3). Gallocatechin intakes (p = 0.047, q = 0.285) were associated with unweighted UniFrac distances. Intakes of apigenin (p = 0.028, q = 0.227) and kaempferol (p = 0.029, q = 0.227), and % flavonoid intake as flavones (p = 0.013, q = 0.227) and flavonols (p = 0.016, q = 0.227) (both excluding contribution of tea) were associated with weighted UniFrac distances. Among these, gallocatechin correlated with the genus Actinomyces and family Actinomycetaceae (Actinobacteria). Gallocatechin correlated negatively with class Coriobacteriia (Actinobacteria). Intakes of some flavonoids may be associated with GM variations with potential consequences for metabolism, immune function, and inflammation, which are important in CF lung disease and co-morbidity management.

Folate supplementation to prevent birth abnormalities: evaluating a community-based participatory action plan for refugees and migrant workers on the Thailand-Myanmar border.

OBJECTIVES: Preconception folic acid (PFA) taken at least 3 months before conception can decrease the incidence of neural tube defects (NTDs) by approximately 46%. NTDs contribute significantly to neonatal morbidity and mortality in migrant and refugee populations on the Thailand-Myanmar border (incidence 1.57/1000 live births). This audit aimed to assess uptake of PFA among migrant and refugee women, evaluate knowledge about PFA among local healthcare workers and implement a participatory community intervention to increase PFA uptake and decrease NTD incidence in this population. STUDY DESIGN: A mixed-methods baseline evaluation was followed by an intervention involving health worker education and a community outreach program. A follow-up audit was performed 18 months post-intervention. METHODS: Data were gathered via surveys, short interviews and focus group discussions. The intervention program included community-based workshops, production and distribution of printed flyers and posters, and outreach to various local organisations. RESULTS: Uptake of PFA was <2% both before and after the intervention. Despite a substantial increase in local healthcare worker knowledge of PFA, no significant improvement in PFA uptake after the intervention was detected. Most pregnancies in this local community sample were reported to be unplanned. CONCLUSIONS: High rates of NTDs with low PFA uptake remains a major public health challenge in this transient population. Results indicate that improved health worker knowledge alone is not sufficient to enhance PFA uptake in this population. Integration of PFA education within expanded family planning programs and broad-based food fortification may be more effective.

Clinical effects of probiotics in cystic fibrosis patients: A systematic review.

Cystic fibrosis (CF) is characterised by a build-up of thick, intransient mucus linings of the digestive and respiratory mucosa, which disrupts digestive system functioning and microbiota composition. In view of the potential for probiotics to enhance microbiota composition in other contexts, this study investigated the current evidence for probiotics as an adjunct to usual therapy for CF. Electronic clinical databases were interrogated for human randomised, controlled, intervention trials (1985-2015) testing the effects of probiotics on clinical endpoints in CF were reviewed. From 191 articles identified in initial searches, six studies met the critical inclusion criteria, and were reviewed in detail. These studies varied in size (n = 22 to 61) but were generally small and showed substantial diversity in protocol, specific probiotic species used and range of clinical outcomes measured. Probiotic administration showed beneficial effects on fecal calprotectin levels, pulmonary exacerbation risk, and quality of life indicators. In one study, such changes were associated with variations in gut microbiota composition. Despite encouraging preliminary results, the limited number of small and highly varied studies to date do not justify the addition of probiotics as an adjunct to current CF treatment protocols. Importantly, very minimal adverse effects of probiotics have been reported.

Interventions for acute stroke management in Africa: a systematic review of the evidence.

BACKGROUND: The past decades have witnessed a rapid evolution of research on evidence-based acute stroke care interventions worldwide. Nonetheless, the evidence-to-practice gap in acute stroke care remains variable with slow and inconsistent uptake in low-middle income countries (LMICs). This review aims to identify and compare evidence-based acute stroke management interventions with alternative care on overall patient mortality and morbidity outcomes, functional independence, and length of hospital stay across Africa. METHODS: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. An electronic search was conducted in six databases comprising MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Academic Search Complete and Cochrane Library for experimental and non-experimental studies. Eligible studies were abstracted into evidence tables and their methodological quality appraised using the Joanna Briggs Institute checklist. Data were analysed and presented narratively with reference to observed differences in patient outcomes, reporting p values and confidence intervals for any possible relationship. RESULTS: Initially, 1896 articles were identified and 37 fully screened. Four non-experimental studies (three cohort and one case series studies) were included in the final review. One study focused on the clinical efficacy of a stroke unit whilst the remaining three reported on thrombolytic therapy. The results demonstrated a reduction in patient deaths attributed to stroke unit care and thrombolytic therapy. Thrombolytic therapy was also associated with reductions in symptomatic intracerebral haemorrhage (SICH). However, the limited eligible studies and methodological limitations compromised definitive conclusions on the extent of and level of efficacy of evidence-based acute stroke care interventions across Africa. CONCLUSION: Evidence from this review confirms the widespread assertion of low applicability and uptake of evidence-based acute stroke care in LMICs. Despite the limited eligible studies, the overall positive patient outcomes following such interventions demonstrate the applicability and value of evidence-based acute stroke care interventions in Africa. Health policy attention is thus required to ensure widespread applicability of such interventions for improved patients' outcomes. The review findings also emphasises the need for further research to unravel the reasons for low uptake. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016051566.

Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review.

BACKGROUND: Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings. METHODOLOGY: A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used. RESULTS: Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers. CONCLUSIONS: Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings. TRIAL REGISTRATION: The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).

Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals.

OBJECTIVE: Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings. DESIGN: A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes. SETTING: A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana. PARTICIPANTS: A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian. RESULTS: Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals. CONCLUSION: Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.

Towards best practice in acute stroke care in Ghana: a survey of hospital services.

BACKGROUND: Stroke and other non-communicable diseases are important emerging public health concerns in sub-Saharan Africa where stroke-related mortality and morbidity are higher compared to other parts of the world. Despite the availability of evidence-based acute stroke interventions globally, uptake in low-middle income countries (LMIC) such as Ghana is uncertain. This study aimed to identify and evaluate available acute stroke services in Ghana and the extent to which these services align with global best practice. METHODS: A multi-site, hospital-based survey was conducted in 11 major referral hospitals (regional and tertiary - teaching hospitals) in Ghana from November 2015 to April 2016. Respondents included neurologists, physician specialists and medical officers (general physicians). A pre-tested, structured questionnaire was used to gather data on available hospital-based acute stroke services in the study sites, using The World Stroke Organisation Global Stroke Services Guideline as a reference for global standards. RESULTS: Availability of evidence-based services for acute stroke care in the study hospitals were varied and limited. The results showed one tertiary-teaching hospital had a stroke unit. However, thrombolytic therapy (thrombolysis) using recombinant tissue plasminogen activator for acute ischemic stroke care was not available in any of the study hospitals. Aspirin therapy was administered in all the 11 study hospitals. Although eight study sites reported having a brain computed tomographic (CT) scan, only 7 (63.6%) were functional at the time of the study. Magnetic resonance imaging (MRI scan) services were also limited to only 4 (36.4%) hospitals (only functional in three). Acute stroke care by specialists, especially neurologists, was found in 36.4% (4) of the study hospitals whilst none of the study hospitals had an occupational or a speech pathologist to support in the provision of acute stroke care. CONCLUSION: This study confirms previous reports of limited and variable provision of evidence based stroke services and the low priority for stroke care in resource poor settings. Health policy initiatives to enhance uptake of evidence-based acute stroke services is required to reduce stroke-related mortality and morbidity in countries such as Ghana.