Itaconic Acid as a Comonomer in Betulin-Based Thermosets via Sequential and Bulk Preparation.

The inherent chemical functionalities of biobased monomers enable the production of renewably sourced polymers that further advance sustainable manufacturing. Itaconic acid (IA) is a nontoxic, commercially produced biobased monomer that can undergo both UV and thermal curing. Betulin is a biocompatible, structurally complex diol derived from birch tree bark that has been recently studied for materials with diverse applications. Here, betulin, IA, and biobased linear diacids, 1,12-dodecanedioic acid (C12) and 1,18-octadecanedioic acid (C18), were used to prepare thermosets using sequential and bulk curing methods. Thermoplastic polyester precursors were synthesized and formulated into polyester-methacrylate (PM) resins to produce sequential UV-curable thermosets. Bulk-cured polyester thermosets were prepared using a one-pot, solventless melt polycondensation using glycerol as a cross-linker. The structure-property relationships of the thermoplastic polyester precursors, sequentially prepared PM thermosets, and bulk-cured polyester thermosets were evaluated with varying IA content. Both types of thermosets exhibited higher storage moduli, Tgs, and thermal stabilities with greater IA comonomer content. These results demonstrate the viability of using IA as a comonomer to produce betulin-based thermosets each with tunable properties, expanding the scope of their applications and use in polymeric materials.

A process for developing a sustainable and scalable approach to community engagement: community dialogue approach for addressing the drivers of antibiotic resistance in Bangladesh.

BACKGROUND: Community engagement approaches that have impacted on health outcomes are often time intensive, small-scale and require high levels of financial and human resources. They can be difficult to sustain and scale-up in low resource settings. Given the reach of health services into communities in low income countries, the health system provides a valuable and potentially sustainable entry point that would allow for scale-up of community engagement interventions. This study explores the process of developing an embedded approach to community engagement taking the global challenge of antibiotic resistance as an example. METHODS: The intervention was developed using a sequential mixed methods study design. This consisted of: exploring the evidence base through an umbrella review, and identifying key international standards on the appropriate use of antibiotics; undertaking detailed formative research through a) a qualitative study to explore the most appropriate mechanisms through which to embed the intervention within the existing health system and community infrastructure, and to understand patterns of knowledge, attitudes and practice regarding antibiotics and antibiotic resistance; and b) a household survey - which drew on the qualitative findings - to quantify knowledge, and reported attitudes and practice regarding antibiotics and antibiotic resistance within the target population; and c) drawing on appropriate theories regarding change mechanisms and experience of implementing community engagement interventions to co-produce the intervention processes and materials with key stakeholders at policy, health system and community level. RESULTS: A community engagement intervention was co-produced and was explicitly designed to link into existing health system and community structures and be appropriate for the cultural context, and therefore have the potential to be implemented at scale. We anticipate that taking this approach increases local ownership, as well as the likelihood that the intervention will be sustainable and scalable. CONCLUSIONS: This study demonstrates the value of ensuring that a range of stakeholders co-produce the intervention, and ensuring that the intervention is designed to be appropriate for the health system, community and cultural context.

Nutrition transition, overweight and obesity among rural-to-urban migrant women in Kenya.

OBJECTIVE: To assess the effect of rural-to-urban migration on nutrition transition and overweight/obesity risk among women in Kenya. DESIGN: Secondary analysis of data from nationally representative cross-sectional samples. Outcome variables were women's BMI and nutrition transition. Nutrition transition was based on fifteen different household food groups and was adjusted for socio-economic and demographic characteristics. Stepwise backward multiple ordinal regression analysis was applied. SETTING: Kenya Demographic and Health Survey 2014. PARTICIPANTS: Rural non-migrant, rural-to-urban migrant and urban non-migrant women aged 15-49 years (n 6171). RESULTS: Crude data analysis showed rural-to-urban migration to be associated with overweight/obesity risk and nutrition transition. After adjustment for household wealth, no significant differences between rural non-migrants and rural-to-urban migrants for overweight/obesity risk and household consumption of several food groups characteristic of nutrition transition (animal-source, fats and sweets) were observed. Regardless of wealth, migrants were less likely to consume main staples and legumes, and more likely to consume fruits and vegetables. Identified predictive factors of overweight/obesity among migrant women were age, duration of residence in urban area, marital status and household wealth. CONCLUSIONS: Our analysis showed that nutrition transition and overweight/obesity risk among rural-to-urban migrants is apparent with increasing wealth in urban areas. Several predictive factors were identified characterising migrant women being at risk for overweight/obesity. Future research is needed which investigates in depth the association between rural-to-urban migration and wealth to address inequalities in diet and overweight/obesity in Kenya.

Analysis of loss to follow-up in 4099 multidrug-resistant pulmonary tuberculosis patients.

Loss to follow-up (LFU) of ≥2 consecutive months contributes to the poor levels of treatment success in multidrug-resistant tuberculosis (MDR-TB) reported by TB programmes. We explored the timing of when LFU occurs by month of MDR-TB treatment and identified patient-level risk factors associated with LFU.We analysed a dataset of individual MDR-TB patient data (4099 patients from 22 countries). We used Kaplan-Meier survival curves to plot time to LFU and a Cox proportional hazards model to explore the association of potential risk factors with LFU.Around one-sixth (n=702) of patients were recorded as LFU. Median (interquartile range) time to LFU was 7 (3-11) months. The majority of LFU occurred in the initial phase of treatment (75% in the first 11 months). Major risk factors associated with LFU were: age 36-50 years (HR 1.3, 95% CI 1.0-1.6; p=0.04) compared with age 0-25 years, being HIV positive (HR 1.8, 95% CI 1.2-2.7; p<0.01) compared with HIV negative, on an individualised treatment regimen (HR 0.7, 95% CI 0.6-1.0; p=0.03) compared with a standardised regimen and a recorded serious adverse event (HR 0.5, 95% CI 0.4-0.6; p<0.01) compared with no serious adverse event.Both patient- and regimen-related factors were associated with LFU, which may guide interventions to improve treatment adherence, particularly in the first 11 months.

Leveraging Spatial Variation in Tumor Purity for Improved Somatic Variant Calling of Archival Tumor Only Samples.

Archival tumor samples represent a rich resource of annotated specimens for translational genomics research. However, standard variant calling approaches require a matched normal sample from the same individual, which is often not available in the retrospective setting, making it difficult to distinguish between true somatic variants and individual-specific germline variants. Archival sections often contain adjacent normal tissue, but this tissue can include infiltrating tumor cells. As existing comparative somatic variant callers are designed to exclude variants present in the normal sample, a novel approach is required to leverage adjacent normal tissue with infiltrating tumor cells for somatic variant calling. Here we present lumosVar 2.0, a software package designed to jointly analyze multiple samples from the same patient, built upon our previous single sample tumor only variant caller lumosVar 1.0. The approach assumes that the allelic fraction of somatic variants and germline variants follow different patterns as tumor content and copy number state change. lumosVar 2.0 estimates allele specific copy number and tumor sample fractions from the data, and uses a to model to determine expected allelic fractions for somatic and germline variants and to classify variants accordingly. To evaluate the utility of lumosVar 2.0 to jointly call somatic variants with tumor and adjacent normal samples, we used a glioblastoma dataset with matched high and low tumor content and germline whole exome sequencing data (for true somatic variants) available for each patient. Both sensitivity and positive predictive value were improved when analyzing the high tumor and low tumor samples jointly compared to analyzing the samples individually or in-silico pooling of the two samples. Finally, we applied this approach to a set of breast and prostate archival tumor samples for which tumor blocks containing adjacent normal tissue were available for sequencing. Joint analysis using lumosVar 2.0 detected several variants, including known cancer hotspot mutations that were not detected by standard somatic variant calling tools using the adjacent tissue as presumed normal reference. Together, these results demonstrate the utility of leveraging paired tissue samples to improve somatic variant calling when a constitutional sample is not available.

Changing stigmatisation of leprosy: an exploratory, qualitative life course study in Western Nigeria.

INTRODUCTION: Renewed interest in health-related stigma has invigorated calls to understand factors and processes underlying stigma. However, few empirical studies explore the influences of structural discrimination and moral status on leprosy-related stigma. We investigated how sociocultural context and organisational policies and practices influenced the connotations of leprosy, sources of stigma and the changing social responses to leprosy in Western Nigeria. METHODOLOGY: Ethnographic research conducted between 2008 and 2012 combined documents review with life history interviews of 21 individuals affected by leprosy and semistructured interviews with 26 community members in Western Nigeria. Interviews were audiotaped, transcribed verbatim and coded. Theoretical frameworks used to deepen social understandings of leprosy and responses to stigma included Link's and Phelan's conceptualisation of stigma and the concepts of structural discrimination and moral status. RESULTS: Findings showed that connotations of leprosy in Yorùbá culture included the following: (i) perception of leprosy as the most shameful and detested condition and (ii) symbolic association with filth and immoral behaviour that is dishonouring to Yorùbá identity. Secondary analysis of archival materials revealed four sources of stigma: cultural beliefs about leprosy, health promotion messages embedded in primary school books, religious teachings about leprosy and campaigns conducted by the leprosy service in 1950s. Contrary to the portrayal of Yorùbá attitudes to leprosy as entirely negative, we identified that people affected by leprosy were creating new life courses to counter existing cultural accounts of marginalisation. Emerging narratives of inclusion outlined five facilitators of acceptance namely, antileprosy treatment, good moral character, supportive family networks, livelihoods, and contribution to community survival. CONCLUSION: Gaps highlighted by this study suggest that the global target of zero stigma and discrimination of leprosy will remain unattainable without better understanding of cultural significance(s) of leprosy and the local sources and underlying drivers of stigma that are crucial for developing context-specific stigma reduction interventions.

Developing a socio-ecological model of dietary behaviour for people living with diabetes or high blood glucose levels in urban Nepal: A qualitative investigation.

Instances of non-communicable diseases such as diabetes are on the rise globally leading to greater morbidity and mortality, with the greatest burden in low and middle income countries [LMIC]. A major contributing factor to diabetes is unhealthy dietary behaviour. We conducted 38 semi structured interviews with patients, health professionals, policy-makers and researchers in Kathmandu, Nepal, to better understand the determinants of dietary behaviour amongst patients with diabetes and high blood glucose levels. We created a social ecological model which is specific to socio-cultural context with our findings with the aim of informing culturally appropriate dietary behaviour interventions for improving dietary behaviour. Our findings show that the most influential determinants of dietary behaviour include cultural practices (gender roles relating to cooking), social support (from family and friends), the political and physical environment (political will, healthy food availability) and individuals' motivations and capabilities. Using these most influential determinants, we suggest potentially effective dietary interventions that could be implemented by policy makers. Our findings emphasise the importance of considering socio-cultural context in developing interventions and challenges one-size-fits-all approaches which are often encouraged by global guidelines. We demonstrate how multifaceted and multi layered models of behavioural influence can be used to develop policy and practice with the aim of reducing mortality and morbidity from diabetes.

Long-term outcomes of an educational intervention to reduce antibiotic prescribing for childhood upper respiratory tract infections in rural China: Follow-up of a cluster-randomised controlled trial.

BACKGROUND: Inappropriate antibiotic prescribing causes widespread serious health problems. To reduce prescribing of antibiotics in Chinese primary care to children with upper respiratory tract infections (URTIs), we developed an intervention comprising clinical guidelines, monthly prescribing review meetings, doctor-patient communication skills training, and education materials for caregivers. We previously evaluated our intervention using an unblinded cluster-randomised controlled trial (cRCT) in 25 primary care facilities across two rural counties. When our trial ended at the 6-month follow-up period, we found that the intervention had reduced antibiotic prescribing for childhood URTIs by 29 percentage points (pp) (95% CI -42 to -16). METHODS AND FINDINGS: In this long-term follow-up study, we collected our trial outcomes from the one county (14 facilities and 1:1 cluster randomisation ratio) that had electronic records available 12 months after the trial ended, at the 18-month follow-up period. Our primary outcome was the antibiotic prescription rate (APR)-the percentage of outpatient prescriptions containing any antibiotic(s) for children aged 2 to 14 years who had a primary diagnosis of a URTI and had no other illness requiring antibiotics. We also conducted 15 in-depth interviews to understand how interventions were sustained. In intervention facilities, the APR was 84% (1,171 out of 1,400) at baseline, 37% (515 out of 1,380) at 6 months, and 54% (2,748 out of 5,084) at 18 months, and in control facilities, it was 76% (1,063 out of 1,400), 77% (1,084 out of 1,400), and 75% (2,772 out of 3,685), respectively. After adjusting for patient and prescribing doctor covariates, compared to the baseline intervention-control difference, the difference at 6 months represented a 6-month intervention-arm reduction in the APR of -49 pp (95% CI -63 to -35; P < 0.0001), and compared to the baseline difference, the difference at 18 months represented an 18-month intervention-arm reduction in the APR of -36 pp (95% CI -55 to -17; P < 0.0001). Compared to the 6-month intervention-control difference, the difference at 18 months represented no change in the APR: 13 pp (95% CI -7 to 33; P = 0.21). Factors reported to sustain reductions in antibiotic prescribing included doctors' improved knowledge and communication skills and focused prescription review meetings, whereas lack of supervision and monitoring may be associated with relapse. Key limitations were not including all clusters from the trial and not collecting returned visits or sepsis cases. CONCLUSIONS: Our intervention was associated with sustained and substantial reductions in antibiotic prescribing at the end of the intervention period and 12 months later. Our intervention may be adapted to similar resource-poor settings. TRIAL REGISTRATION: ISRCTN registry ISRCTN14340536.

Knowledge, attitudes and practices with regard to schistosomiasis prevention and control: Two cross-sectional household surveys before and after a Community Dialogue intervention in Nampula province, Mozambique.

BACKGROUND: The Community Dialogue Approach is a promising social and behaviour change intervention, which has shown potential for improving health seeking behaviour. To test if this approach can strengthen prevention and control of schistosomiasis at community level, Malaria Consortium implemented a Community Dialogue intervention in four districts of Nampula province, Mozambique, between August 2014 and September 2015. METHODOLOGY/PRINCIPAL FINDINGS: Cross-sectional household surveys were conducted before (N = 791) and after (N = 792) implementation of the intervention to assess its impact on knowledge, attitudes and practices at population level. At both baseline and endline, awareness of schistosomiasis was high at over 90%. After the intervention, respondents were almost twice as likely to correctly name a risk behaviour associated with schistosomiasis (baseline: 18.02%; endline: 30.11%; adjusted odds ratio: 1.91; 95% confidence interval: 1.14-2.58). Increases were also seen in the proportion of people who knew that schistosomiasis can be spread by infected persons and who could name at least one correct transmission route (baseline: 25.74%; endline: 32.20%; adjusted odds ratio: 1.36; 95% confidence interval: 1.01-1.84), those who knew that there is a drug that treats the disease (baseline: 29.20%, endline: 47.55%; adjusted odds ratio: 2.19; 95% confidence interval: 1.67-2.87) and those who stated that they actively protect themselves from the disease and cited an effective behaviour (baseline: 40.09%, endline: 59.30%; adjusted odds ratio: 2.14; 95% confidence interval: 1.40-3.28). The intervention did not appear to lead to a reduction in misconceptions. In particular, the belief that the disease is sexually transmitted continued to be widespread. CONCLUSIONS/SIGNIFICANCE: Given its overall positive impact on knowledge and behaviour at population level, Community Dialogue can play an important role in schistosomiasis prevention and control. The intervention could be further strengthened by better enabling communities to take suitable action and linking more closely with community governance structures and health system programmes.

Using behaviour change theory to train health workers on tobacco cessation support for tuberculosis patients: a mixed-methods study in Bangladesh, Nepal and Pakistan.

BACKGROUND: Low- and middle-income countries (LMICs) are disproportionately impacted by interacting epidemics of tuberculosis (TB) and tobacco consumption. Research indicates behavioural support delivered by health workers effectively promotes tobacco cessation. There is, however, a paucity of training to support LMIC health workers deliver effective tobacco cessation behavioural support. The TB and Tobacco Consortium undertook research in South Asia to understand factors affecting TB health workers' delivery of tobacco cessation behavioural support, and subsequently developed a training package for LMICs. METHODS: Using the "capability, opportunity, and motivation as determinants of behaviour" (COM-B) framework to understand any issues facing health worker delivery of behaviour support, we analysed 25 semi-structured interviews and one focus group discussion with TB health workers, facility in-charges, and national tuberculosis control programme (NTP) staff members in each country. Results were integrated with findings of an adapted COM-B questionnaire on health worker confidence in tobacco cessation support delivery, administered to 36 TB health workers. Based on findings, we designed a guide and training programme on tobacco cessation support for health workers. RESULTS: Qualitative results highlighted gaps in the majority of health workers' knowledge on tobacco cessation and TB and tobacco interaction, inadequate training on patient communication, insufficient resources and staff support, and NTPs' non-prioritization of tobacco cessation in all three countries. Questionnaire results reiterated the knowledge deficits and low confidence in patient communication. Participants suggested strengthening knowledge, skills, and competence through training and professional incentives. Based on findings, we developed an interactive two-day training and TB health worker guide adaptable for LMICs, focusing on evidence of best practice on TB and tobacco cessation support, communication, and rapport building with patients. CONCLUSIONS: TB health workers are essential in addressing the dual burden of TB and tobacco faced by many LMICs. Factors affecting their delivery of tobacco cessation support can be identified using the COM-B framework, and include issues such as individuals' knowledge and skills, as well as structural barriers like professional support through monitoring and supervision. While structural changes are needed to tackle the latter, we have developed an adaptable and engaging health worker training package to address the former that can be delivered in routine TB care. TRIAL REGISTRATION: ISRCTN43811467 .

Partnering with Private Providers to Promote Long-Acting Contraceptives in Urban Bangladesh: A Mixed-Methods Feasibility Study.

CONTEXT: Bangladesh's pluralistic health system has diversified opportunities for clients to obtain family planning, but public-private partnerships could improve access to services, particularly in urban areas. METHOD: Sixteen providers, clients and program managers were interviewed to assess perspectives on a family planning orientation and demand-side financing referral program tested in Mirpur, Bangladesh. The 15-month program, conducted in 2015-2016, was designed to encourage private providers to identify non-family planning clients with unmet contraceptive needs, promote choice of a broader contraceptive mix and refer clients to one of three public or nonprofit clinics for provision of their preferred method. Use of the system was assessed by tracking referral slips. RESULTS: Most stakeholders reported that it was acceptable and feasible to discuss fertility intentions with clients presenting for non-family planning matters. Providers were able to alleviate clients' misconceptions and fears concerning long-acting contraceptive methods, but were unable to address patriarchal and religious barriers. The majority of referrals were done by private providers who had a pre-existing relationship with one of the family planning clinics and referred clients to that clinic; overall, documented referrals accounted for 13% of provision of reversible and permanent methods at that clinic during the study period. CONCLUSIONS: Providing private practitioners with appropriate training on contraceptives and referral could improve Bangladeshi women's access to long-acting and other contraceptive methods in urban areas, and may be useful for other types of health workers. Further study of suitable referral systems is warranted.

RESUMEN Contexto: El sistema de salud pluralista de Bangladesh diversificó las oportunidades para que las clientas obtuvieran servicios de planificación familiar, pero las alianzas público-privadas podrían mejorar el acceso a los servicios de planificación familiar, particularmente en las zonas urbanas. Método: Dieciséis proveedores de servicios, clientes y gerentes de programas fueron entrevistados para evaluar las perspectivas sobre un programa de orientación de planificación familiar y de referencia financiado por el lado de la demanda, que fue probado en Mirpur, Bangladesh. El programa de 15 meses, realizado en 2015­2016, fue diseñado para alentar a los proveedores privados a identificar clientas de servicios distintos a la planificación familiar con necesidades anticonceptivas insatisfechas, promover la elección de una mezcla de anticonceptivos más amplia y referir a las clientas a una de las tres clínicas públicas o sin fines de lucro para la obtención de su método preferido. El uso del sistema se evaluó mediante el seguimiento de los recibos de referencia. Resultados: La mayoría de las partes interesadas informó que era aceptable y factible discutir las intenciones de fecundidad con las clientas que se presentan para asuntos distintos a la planificación familiar. Los proveedores pudieron atenuar las ideas falsas y los temores de las clientas sobre los métodos anticonceptivos de acción prolongada, pero no pudieron abordar las barreras patriarcales y religiosas. La mayoría de las referencias fueron realizadas por proveedores privados que tenían una relación preexistente con una de las clínicas de planificación familiar y refirieron a las clientas a esa clínica; en general, las referencias documentadas representaron el 13% de la provisión de métodos reversibles y permanentes en esa clínica durante el período de estudio. Conclusiones: Brindar a los profesionales privados capacitación adecuada sobre anticonceptivos y referencias podría mejorar el acceso de las mujeres de Bangladesh a métodos anticonceptivos de larga duración y de otro tipo en áreas urbanas; y puede ser útil para otros tipos de trabajadores de la salud. Se justifica el estudio adicional de sistemas de referencia adecuados.

RÉSUMÉ Contexte: Au Bangladesh, le système de santé pluraliste a diversifié, pour les clientes, les possibilités d'obtention de la planification familiale, mais les partenariats public-privé pourraient améliorer l'accès aux services, en particulier dans les milieux urbains. Méthode: Des entretiens ont été organisés avec 16 prestataires, clientes et gestionnaires de programme afin d'évaluer les points de vue concernant un programme d'orientation sur la planification familiale et d'aiguillage à financement du côté de la demande testé à Mirpur (Bangladesh). Mené en 2015­2016 sur une période de 15 mois, ce programme était conçu pour encourager les prestataires privés à identifier les clientes hors planification familiale qui présentaient un besoin de contraception non satisfait, à promouvoir le choix d'un éventail de contraception plus large et à orientation les clientes vers l'une de trois cliniques publiques ou à but non lucratif pour l'obtention de leur méthode préférée. L'utilisation du système a été évaluée par suivi des fiches de recommandation. Résultats: La plupart des intervenants ont déclaré qu'il était acceptable et faisable de parler des intentions de fécondité avec les clientes se présentant pour des raisons autres que la planification familiale. Les prestataires ont réussi à dissiper les idées fausses et les craintes des clientes concernant les méthodes contraceptives de longue durée, mais ils n'ont pas pu résoudre les obstacles de nature patriarcale et religieuse. Dans la majorité des cas, les orientations provenaient de prestataires privés qui avaient une relation préexistante avec l'une des cliniques de planification familiale et aiguillaient leurs clientes vers cette clinique. Globalement, les recommandations documentées ont représenté 13% de la prestation de méthodes réversibles et permanentes dans cette clinique pendant la période de l'étude. Conclusions: L'offre aux praticiens privés d'une formation appropriée sur la contraception et l'aiguillage pourrait améliorer l'accès des Bangladaises aux méthodes contraceptives longue durée ou autres dans les milieux urbains. Elle pourrait être utile aussi à d'autres types d'agents de santé. Il y a lieu de procéder à une étude approfondie des systèmes d'aiguillage appropriés.

"Who Will Marry a Diseased Girl?" Marriage, Gender, and Tuberculosis Stigma in Asia.

In a qualitative study on the stigma associated with tuberculosis (TB), involving 73 interviews and eight focus groups conducted in five sites across three countries (Bangladesh, Nepal, and Pakistan), participants spoke of TB's negative impact on the marriage prospects of women in particular. Combining the approach to discovering grounded theory with a conceptualization of causality based on a realist ontology, we developed a theory to explain the relationships between TB, gender, and marriage. The mechanism at the heart of the theory is TB's disruptiveness to the gendered roles of wife (or daughter-in-law) and mother. It is this disruptiveness that gives legitimacy to the rejection of marriage to a woman with TB. Whether or not this mechanism results in a negative impact of TB on marriage prospects depends on a range of contextual factors, providing opportunities for interventions and policies.

Dealing with context in logic model development: Reflections from a realist evaluation of a community health worker programme in Nigeria.

Logic models (LMs) have been used in programme evaluation for over four decades. Current debate questions the ability of logic modelling techniques to incorporate contextual factors into logic models. We share experience of developing a logic model within an ongoing realist evaluation which assesses the extent to which, and under what circumstances a community health workers (CHW) programme promotes access to maternity services in Nigeria. The article contributes to logic modelling debate by: i) reflecting on how other scholars captured context during LM development in theory-driven evaluations; and ii) explaining how we explored context during logic model development for realist evaluation of the CHW programme in Nigeria. Data collection methods that informed our logic model development included documents review, email discussions and teleconferences with programme stakeholders and a technical workshop with researchers to clarify programme goals and untangle relationships among programme elements. One of the most important findings is that, rather than being an end in itself, logic model development is an essential step for identifying initial hypotheses for tentative relevant contexts, mechanisms and outcomes (CMOs) and CMO configurations of how programmes produce change. The logic model also informed development of a methodology handbook that is guiding verification and consolidation of underlying programme theories.

Improving household surveys and use of data to address health inequities in three Asian cities: protocol for the Surveys for Urban Equity (SUE) mixed methods and feasibility study.

INTRODUCTION: As rapid urbanisation transforms the sociodemographic structures within cities, standard survey methods, which have remained unchanged for many years, under-represent the urban poorest. This leads to an overly positive picture of urban health, distorting appropriate allocation of resources between rural and urban and within urban areas. Here, we present a protocol for our study which (i) tests novel methods to improve representation of urban populations in household surveys and measure mental health and injuries, (ii) explores urban poverty and compares measures of poverty and 'slumness' and (iii) works with city authorities to understand, and potentially improve, utilisation of data on urban health for planning more equitable services. METHODS AND ANALYSIS: We will conduct household surveys in Kathmandu, Hanoi and Dhaka to test novel methods: (i) gridded population sampling; (ii) enumeration using open-access online maps and (iii) one-stage versus two-stage cluster sampling. We will test reliability of an observational tool to categorise neighbourhoods as slum areas. Within the survey, we will assess the appropriateness of a short set of questions to measure depression and injuries. Questionnaire data will also be used to compare asset-based, consumption-based and income-based measures of poverty. Participatory methods will identify perceptions of wealth in two communities in each city. The analysis will combine quantitative and qualitative findings to recommend appropriate measures of poverty in urban areas. We will conduct qualitative interviews and establish communities of practice with government staff in each city on use of data for planning. Framework approach will be used to analyse qualitative data allowing comparison across city settings. ETHICS AND DISSEMINATION: Ethical approvals have been granted by ethics committees from the UK, Nepal, Bangladesh and Vietnam. Findings will be disseminated through conference papers, peer-reviewed open access articles and workshops with policy-makers and survey experts in Kathmandu, Hanoi and Dhaka.

Impact of using eHealth tools to extend health services to rural areas of Nigeria: protocol for a mixed-method, non-randomised cluster trial.

INTRODUCTION: eHealth solutions that use internet and related technologies to deliver and enhance health services and information are emerging as novel approaches to support healthcare delivery in sub-Saharan Africa. Using digital technology in this way can support cost-effectiveness of care delivery and extend the reach of services to remote locations. Despite the burgeoning literature on eHealth approaches, little is known about the effectiveness of eHealth tools for improving the quality and efficiency of health systems functions or client outcomes in resource-limited countries. eHealth tools including satellite communications are currently being implemented at scale, to extend health services to rural areas of Nigeria, in Ondo and Kano States and the Federal Capital Territory. This paper shares the protocol for a 2-year project ('EXTEND') that aims to evaluate the impact of eHealth tools on health system functions and health outcomes. METHODOLOGY AND ANALYSIS: This multisite, mixed-method evaluation includes a non-randomised, cluster trial design. The study comprises three phases-baseline, midline and endline evaluations-that involve: (1) process evaluation of video training and digitisation of health data interventions; (2) evaluation of contextual influences on the implementation of interventions; and (3) impact evaluation of results of the project. A convergent mixed-method model will be adopted to allow integration of quantitative and qualitative findings to achieve study objectives. Multiple quantitative and qualitative datasets will be repeatedly analysed and triangulated to facilitate better understanding of impact of eHealth tools on health worker knowledge, quality and efficiency of health systems and client outcomes. ETHICS AND DISSEMINATION: Ethics approvals were obtained from the University of Leeds and three States' Ministries of Health in Nigeria. All data collected for this study will be anonymised and reports will not contain information that could identify respondents. Study findings will be presented to Ministries of Health at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN32105372; Pre-results.

Embedded health service development and research: why and how to do it (a ten-stage guide).

In a world of changing disease burdens, poor quality care and constrained health budgets, finding effective approaches to developing and implementing evidence-based health services is crucial. Much has been published on developing service tools and protocols, operational research and getting policy into practice but these are often undertaken in isolation from one another. This paper, based on 25 years of experience in a range of low and middle income contexts as well as wider literature, presents a systematic approach to connecting these activities in an embedded development and research approach. This approach can circumvent common problems such as lack of local ownership of new programmes, unrealistic resource requirements and poor implementation.We lay out a ten-step process, which is based on long-term partnerships and working within local systems and constraints and may be tailored to the context and needs. Service development and operational research is best prioritised, designed, conducted and replicated when it is embedded within ministry of health and national programmes. Care packages should from the outset be designed for scale-up, which is why the piloting stage is so crucial. In this way, the resulting package of care will be feasible within the context and will address local priorities. Researchers must be entrepreneurial and responsive to windows of funding for scale-up, working in real-world contexts where funding and decisions do not wait for evidence, so evidence generation has to be pragmatic to meet and ensure best use of the policy and financing cycles. The research should generate tested and easily usable tools, training materials and processes for use in scale-up. Development of the package should work within and strengthen the health system and other service delivery strategies to ensure that unintended negative consequences are minimised and that the strengthened systems support quality care and effective scale up of the package.While embedded development and research is promoted in theory, it is not yet practiced at scale by many initiatives, leading to wasted resources and un-sustained programmes. This guide presents a systematic and practical guide to support more effective engagements in future, both in developing interventions and supporting evidence-based scale-up.

Capacity to conduct health research among NGOs in Malawi: Diverse strengths, needs and opportunities for development.

BACKGROUND: The role of non-governmental organisations (NGOs) in health research has attracted growing attention. NGOs are important service providers and advocates in international health, and conducting research can help NGOs to strengthen these service delivery and advocacy activities. However, capacity to conduct research varies among NGOs. There is currently limited evidence on NGOs' research capacity that can explain why capacity varies or indicate potential areas for support. We examined NGOs' capacity to conduct research, identifying factors that affect their access to the funds, time and skills needed to undertake research. METHODS: We examined research capacity through qualitative case studies of three NGOs in Malawi, including one national and two international NGOs. Data were generated through interviews and focus groups with NGO staff, observation of NGO activities, and document reviews. RESULTS: Availability of funding, skills and time to conduct research varies considerably between the case NGOs. Access to these resources is affected by internal processes such as sources of funding and prioritisation of research, and by the wider environment and external relationships, including the nature of donor support. Constraints include limited ability to apply for research funding, a perception that donors will not support research costs, lack of funding to hire or train research staff, and prioritisation of service delivery over research in funding proposals and staff schedules. CONCLUSION: The findings suggest strategies for NGOs and for donors interested in supporting NGOs' research capacity. Above all, the findings reinforce the importance of initial capacity assessments to identify organisational needs and opportunities. In addition, the need for time and funding as well as skills suggests that strengthening NGOs' research capacity will often require more than research training.

Implementation of a psychosocial support package for people receiving treatment for multidrug-resistant tuberculosis in Nepal: A feasibility and acceptability study.

BACKGROUND AND OBJECTIVES: People receiving treatment for multidrug-resistant tuberculosis (MDR-TB) have high rates of depression. Psychosocial support in general, and treatments for depression in particular, form an important but neglected area of patient-centred care, and a key pillar in the global End TB strategy. We assessed the feasibility and acceptability of a psychosocial support package for people receiving treatment for MDR-TB in Nepal. METHODS: This feasibility study used a mixed quantitative and qualitative approach. We implemented the intervention package in two National Tuberculosis Programme (NTP) MDR-TB treatment centres and 8 sub-centres. We screened patients monthly for depression and anxiety (cut-off ≥24 and ≥17 respectively on the Hopkins Symptom Checklist) and also for low social support (cut-off ≤3 on the Multidimensional Scale of Perceived Social Support). Those who screened positive on either screening tool received the Healthy Activity Program (HAP), which uses brief counselling based on behavioural activation theory. Other aspects of the psychosocial package were information/education materials and group interactions with other patients. RESULTS: We screened 135 patients, of whom 12 (9%) received HAP counselling, 115 (85%) received information materials, 80 (59%) received an education session and 49 (36%) received at least one group session. Eight group sessions were conducted in total. All aspects of the intervention package were acceptable to patients, including the screening, information, group work and counselling. Patients particularly valued having someone to talk to about their concerns and worries. We were able to successfully train individuals with no experience of psychological counselling to deliver HAP. CONCLUSION: This psychosocial support package is acceptable to patients. The information materials we developed are feasible to deliver in the current NTP. However, the structured psychological counselling (HAP), is not feasible in the current NTP due to time constraints. This requires additional investment of counsellors in TB clinics.

How effective are interventions in improving dietary behaviour in low- and middle-income countries? A systematic review and meta-analysis.

Several interventions encouraging people to change their diet have been tested in low- and middle-income countries (LMICs) but these have not been meta-synthesised and it is not known which elements of these interventions contribute to their effectiveness. The current review addressed these issues. Randomised controlled trials of dietary interventions in LMICs were eligible and identified via eight publication databases. Elements of both the intervention and comparison groups (e.g., behaviour change techniques (BCTs), delivery mode), participant characteristics and risk of bias were coded. Random effects meta-analysis of 76 randomised controlled trials found, on average, small- to medium-sized but highly heterogeneous improvement in dietary behaviour following an intervention. Small and homogeneous improvements were found for BMI/weight, waist- and hip-circumference, with medium-sized, but heterogeneous, improvements in blood pressure and cholesterol. Although many BCTs have yet to be tested in this context, meta-regressions suggested some BCTs (action planning, self-monitoring of outcome(s) of behaviour; demonstration of behaviour) as well as individually randomised trials, adult- or hypertensive-samples and lack of blinding were associated with larger dietary behaviour effect sizes. Interventions to encourage people from LMICs to change their diet produce, on average, small-to-medium-sized effects. These effects may possibly be increased through the inclusion of specific BCTs and other study elements.

The safety, effectiveness and cost-effectiveness of cytisine in achieving six-month continuous smoking abstinence in tuberculosis patients-protocol for a double-blind, placebo-controlled randomized trial.

BACKGROUND AND AIMS: Tuberculosis (TB) patients who quit smoking have much better disease outcomes than those who continue to smoke. In general populations, behavioural support combined with pharmacotherapy is the most effective strategy in helping people to quit. However, there is no evidence for the effectiveness of this strategy in TB patients who smoke. We will assess the safety, effectiveness and cost-effectiveness of cytisine-a low-cost plant-derived nicotine substitute-for smoking cessation in TB patients compared with placebo, over and above brief behavioural support. DESIGN: Two-arm, parallel, double-blind, placebo-controlled, multi-centre (30 sites in Bangladesh and Pakistan), individually randomized trial. SETTING: TB treatment centres integrated into public health care systems in Bangladesh and Pakistan. PARTICIPANTS: Newly diagnosed (in the last 4 weeks) adult pulmonary TB patients who are daily smokers (with or without dual smokeless tobacco use) and are interested in quitting (n = 2388). MEASUREMENTS: The primary outcome measure is biochemically verified continuous abstinence from smoking at 6 months post-randomization, assessed using Russell Standard criteria. The secondary outcome measures include continuous abstinence at 12 months, lapses and relapses; clinical TB outcomes; nicotine dependency and withdrawal; and adverse events. COMMENTS: This is the first smoking cessation trial of cytisine in low- and middle-income countries evaluating both cessation and TB outcomes. If found effective, cytisine could become the most affordable cessation intervention to help TB patients who smoke.