Behavioural support and nicotine replacement therapy for smokeless tobacco cessation in Bangladesh, India and Pakistan: A pilot randomized controlled trial

BACKGROUND AND AIMS

Smokeless tobacco (ST) use in South Asia is high, yet interventions to support its cessation are lacking. We tested the feasibility of delivering interventions for ST cessation in South Asia.

DESIGN

We used a 2 × 2 factorial design, pilot randomized controlled trial with a duration of 26 weeks, including baseline and follow-up (6, 12 and 26 weeks) assessments.

SETTING

Two primary health-care facilities each in Dhaka (Bangladesh) and Karachi (Pakistan) and a walk-in cancer screening clinic in Noida (India) took part.

PARTICIPANTS

Adult daily ST users willing to make a quit attempt within 30 days. Of 392 screened, 264 participants [mean age: 35 years, standard deviation = 12.5, 140 (53%) male] were recruited between December 2020 and December 2021; 132 from Bangladesh, 44 from India and 88 from Pakistan.

INTERVENTIONS

Participants were randomized to one of three treatment options [8-week support through nicotine replacement therapy (NRT, n = 66), a behavioural intervention for smokeless tobacco cessation in adults (BISCA, n = 66) or their combination (n = 66)] or the control condition of very brief advice (VBA) to quit (n = 66).

MEASUREMENTS

Recruitment and retention, data completeness and feasibility of intervention delivery were evaluated. Biochemically verified abstinence from tobacco, using salivary cotinine, was measured at 26 weeks.

FINDINGS

Retention rates were 94.7% at 6 weeks, dropping to 89.4% at 26 weeks. Attendance in BISCA pre-quit (100%) and quit sessions (86.3%) was high, but lower in post-quit sessions (65.9%), with variability among countries. Adherence to NRT also varied (45.5% Bangladesh, 90% India). Data completion for key variables exceeded 93% among time-points, except at 26 weeks for questions on nicotine dependence (90%), urges (89%) and saliva samples (62.7%). Among follow-up time-points, self-reported abstinence was generally higher among participants receiving BISCA and/or NRT. At 26 weeks, biochemically verified abstinence was observed among 16 (12.1%) participants receiving BISCA and 13 (9.8%) participants receiving NRT.

CONCLUSIONS

This multi-country pilot randomized controlled trial of tobacco cessation among adult smokeless tobacco users in South Asia demonstrated the ability to recruit and retain participants and report abstinence, suggesting that a future definitive smokeless tobacco cessation trial is viable.

Multicomponent Behavioural Intervention during Pregnancy to Reduce Home Exposure to Second-Hand Smoke: A Pilot Randomised Controlled Trial in Bangladesh and India

BACKGROUND

Pregnant women exposed to second-hand smoke (SHS) are at increased risk of poor birth outcomes. We piloted multicomponent behavioural intervention and trial methods in Bangalore, India, and Comilla, Bangladesh.

METHODS

A pilot individual randomised controlled trial with economic and process evaluation components was conducted. Non-tobacco-using pregnant women exposed to SHS were recruited from clinics and randomly allocated to intervention or control (educational leaflet) arms. The process evaluation captured feedback on the trial methods and intervention components. The economic component piloted a service use questionnaire. The primary outcome was saliva cotinine 3 months post-intervention.

RESULTS

Most pregnant women and many husbands engaged with the intervention and rated the components highly, although the cotinine report elicited some anxiety. Forty-eight (Comilla) and fifty-four (Bangalore) women were recruited. The retention at 3 months was 100% (Comilla) and 78% (Bangalore). Primary outcome data were available for 98% (Comilla) and 77% (Bangalore).

CONCLUSIONS

The multicomponent behavioural intervention was feasible to deliver and was acceptable to the interventionists, pregnant women, and husbands. With the intervention, it was possible to recruit, randomise, and retain pregnant women in Bangladesh and India. The cotinine data will inform sample size calculations for a future definitive trial.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Behavioral Activation for Comorbid Depression in People With Noncommunicable Disease in India: Protocol for a Randomized Controlled Feasibility Trial

BACKGROUND

The increasing burden of depression and noncommunicable disease (NCD) is a global challenge, especially in low- and middle-income countries, considering the resource constraints and lack of trained human resources in these settings. Effective treatment of depression in people with NCDs has the potential to enhance both the mental and physical well-being of this population. It will also result in the effective use of the available health care resources. Brief psychological therapies, such as behavioral activation (BA), are effective for the treatment of depression. BA has not been adapted in the community health care services of India, and the feasibility of using BA as an intervention for depression in NCD and its effectiveness in these settings have not been systematically evaluated.

OBJECTIVE

Our objective is to adapt BA for the Indian NCD context and test the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]). Additionally, we aim to test the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with enhanced usual care.

METHODS

Following well-established frameworks for intervention adaptation, we first adapted BA (to fit the linguistic, cultural, and resource context) for delivery in India. The intervention was also adapted for potential remote delivery by telephone. In a randomized controlled trial, we will be testing the acceptability, feasibility, and implementation of the adapted BA intervention (BIP). We shall also test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters (eg, recruitment and retention rates and completeness of follow-up) needed to design a future definitive trial.

RESULTS

Following the receipt of approval from all the relevant agencies, the development of the BIP was started on November 28, 2020, and completed on August 18, 2021, and the quantitative data collection was started on August 23, 2021, and completed on December 10, 2021. Process evaluation (qualitative data) collection is ongoing. Both the qualitative and quantitative data analyses are ongoing.

CONCLUSIONS

This study may offer insights that could help in closing the gap in the treatment of common mental illness, particularly in nations with limited resources, infrastructure, and systems such as India. To close this gap, BEACON tries to provide BA for depression in NCDs through qualified NCD (BA) counselors integrated within the state-run NCD clinics. The results of this study may aid in understanding whether BA as an intervention is acceptable for the population and how feasible it will be to deliver such interventions for depression in NCD in South Asian countries such as India. The BIP may also be used in the future by Indian community clinics as a brief intervention program.

TRIAL REGISTRATION

Clinical Trials Registry of India CTRI/2020/05/025048; https://tinyurl.com/mpt33jv5.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41127.

Outcomes of Brain Metastases with Suspicious Imaging Undergoing Resection to Evaluate for Radionecrosis vs. Tumor Progression

PURPOSE/OBJECTIVE(S)

In patients treated with stereotactic radiosurgery (SRS) for brain metastases, radiographic changes on surveillance imaging may result from treatment effect/radionecrosis (RN) or tumor progression. Distinguishing between these processes is critical to appropriate management. We report long-term outcomes for a cohort of patients who demonstrated radiographic progression on serial imaging after initial radiation and ultimately underwent resection to inform further management.

MATERIALS/METHODS

A retrospective chart review identified 76 patients with an associated 82 brain lesions between 2009 and 2022 that were initially treated with SRS, then demonstrated suspicious imaging changes developing through at least two scan time points that led to pathologic confirmation of either tumor or RN. We report clinical outcomes and details of further treatments.

RESULTS

Of the 82 lesions, 55 (67.1%) were found to be pathologically-confirmed viable tumor and were treated with repeat radiation and 27 (32.9%) were found to be strictly RN and conservatively managed. Over half of the lesions (14/27) ultimately found to be radionecrotic required use of steroids pre-operatively due to neurologic symptoms. Among the 27 that were found to be RN, the most common histology was melanoma (33.3%, n = 9). The most common dose fractionation regimen was 20 Gy in 1 fx (n = 11, 40.7%; range: 16-20 Gy x 1Fx), and the median BED (10) was 50.4 Gy (IQR 41.6 - 50 Gy). None of these lesions required further intervention with median post-surgery follow up of 24.4 months (range 1-104 months). There were 55 instances (in 51 patients) of pathologically-confirmed recurrent/progressive tumor who were consequently treated with repeat radiation with either Cs-131 brachytherapy (12 (21.8%)) or SRS (43 (78.2%)). The most common histology was NSCLC (37.2%, n = 19). The most common fractionation for repeat irradiation with SRS was 8 Gy x 3 fx (n = 15, 27.3%), followed by 5 Gy x 5 fx (n = 10, 18.2%), and 4 Gy x 5 fx (n = 8, 14.6%). Four individuals each had two lesions that were re-irradiated for local recurrence. Among patients treated with re-irradiation, the median follow-up to local failure was 15.2 months (95% CI 7.3-26.6 months). Radionecrosis was confirmed on pathology in 4/55 (7.2%) of lesions. The median follow-up from date of SRS2 to local failure was 14.1 months (95% CI 7.6-24.3 months). The 2-yr local control rate was 74.8% (95% CI 61.7-90.7%).

CONCLUSION

We recommend cautious monitoring of possible progression after radiosurgery, with consideration of resection for continuous progression, as a significant proportion of radiographic progression are ultimately pure RN. Management determined by pathology (observation for RN; additional radiation for confirmed tumor) leads to excellent control.

Treatment of Recurrent Orbital Rhabdomyosarcoma with Exenteration and HDR Brachytherapy in a Custom Mold

PURPOSE/OBJECTIVE(S)

Rhabdomyosarcoma (RMS) is the most frequent cancer affecting the orbit in children. The orbit is classified as a favorable site for RMS as treatment with chemotherapy and radiation is effective. Local failure for patients with RMS of the orbit has ranged from 2-16% on IRS and COG protocols. In the event of local recurrence, survival is poor, and management is difficult. We report four patients with local recurrence of orbital RMS managed with orbital exenteration followed by high dose rate (HDR) brachytherapy.

MATERIALS/METHODS

Four patients were treated from 2016-2022. HDR brachytherapy with Ir-192 was delivered in a custom mold of the orbit made after the orbital exenteration procedure. Brachytherapy was given in 6-7 twice daily (BID) fractions starting 1 week after the orbital exenteration.

RESULTS

At the time of brachytherapy, patient ages were 3, 1, 7, and 7 years. Three patients had embryonal histology and underwent initial systemic therapy with ARST0331 regimen A. The fourth patient had alveolar, FOXO1 fusion positive RMS and was initially treated as per COG D9803 regimen A. All patients had received proton radiotherapy as part of initial treatment. Three received 50.40 Gy and one received 45 Gy. Patients developed biopsy-proven, recurrent disease an average of 56 weeks (range 38-77) after initial diagnosis. All patients received salvage chemotherapy before undergoing orbital exenteration at an average of 12 weeks after recurrence (range 5-16). Three patients received 30 Gy in 6 BID fractions, and one patient received 28 Gy in 7 fractions with HDR brachytherapy using an Ir-192 source. All four patients are alive without evidence of disease at an average of 27 months (range 6-70) from recurrence and 39 months (range 21-78) from initial diagnosis. All patients have acceptable orbit healing. Two patients have asymptomatic evidence of frontal lobe edema (and in one case possible necrosis) extending 1-2 cm above the orbit. This appears to be beyond the range of the brachytherapy dosimetry, but the combination of proton beam and brachytherapy are implicated. No other toxicities have occurred.

CONCLUSION

Orbital RMS has a favorable prognosis, but local failure after initial combined modality therapy can be fatal. Options for successful local salvage are limited. Orbital exenteration with HDR brachytherapy in a custom mold is an effective and safe procedure for local control in these difficult cases.

Low Dose Splenic Radiotherapy for Myeloproliferative Neoplasms prior to Allogeneic Hematopoietic Stem Cell Transplant

PURPOSE/OBJECTIVE(S)

Myeloproliferative neoplasms including primary and secondary myelofibrosis (MF) are a rare spectrum of chronic myeloproliferative disorders in which nearly 90% of patients experience splenomegaly. Importantly, splenic radiotherapy (SRT) may be used in combination with allogeneic stem cell transplant (alloSCT) to improve symptoms related to splenomegaly, though there currently is no consensus SRT dose/fractionation protocol reported in the literature for use in combination with alloSCT. We sought to report our institutional experience utilizing low dose SRT prior to alloSCT in the post-Jakafi era.

MATERIALS/METHODS

We performed a retrospective review of all patients diagnosed with MF at our institution from 2017-2022 who received reduced intensity alloHCT. Patients who underwent total lymphoid or body irradiation were excluded. Descriptive demographic and clinical characteristics of patients were summarized by means, medians, standard deviations, ranges and proportions as appropriate.

RESULTS

We identified 39 patients with MF who underwent reduced intensity conditioning (RIC) consisting of fludarabine/melphalan in preparation for alloHCT (median age 64.5, 12/16 males, median follow up 21 months). 16 patients with Jakafi-resistant splenomegaly completed low dose SRT prior to transplant (median spleen size: 24.5cm) with a median dose of 5Gy delivered in 5 fractions. 3D conformal therapy was used for all patients. All patients completed the planned total radiation course without treatment break or dose limiting acute toxicity. Thrombocytopenia was the most reported toxicity (CTCAE v5.0; 2 patients experienced grade 1, 1 patient experienced grade 2). No patients experienced grade 3 or higher acute cytopenias nor required transfusion during radiotherapy. All patients successfully received alloHCT a median of 7 days (range: 2-11) after the completion of SRT with a 94% (15/16) engraftment rate. Median neutrophil recovery (ANC > 500 × 3 days) time was 18 days (range: 13-31); median length of hospital stay was 23 days (range: 20-129). Overall survival was 75% in the SRT cohort (12/16, 2 with persistent disease, 2 due to other causes). Symptom burden data was available for 14/16 patients; 79% (11/14) of patients reported improvement in symptoms associated with splenomegaly or reduction in splenic size on physical examination.

CONCLUSION

In the largest reported experience of a low dose SRT only cohort to date, we observe low dose SRT is feasible, safe in combination with alloHCT with high engraftment rates, and may reduce symptoms related to splenomegaly thereby improving patient quality of life without compromising transplant related outcomes. A prospective study validating this protocol is currently underway.

Children Learning About Secondhand Smoke (CLASS III): a protocol for a cluster randomised controlled trial of a school-based smoke-free intervention in Bangladesh and Pakistan

INTRODUCTION

Secondhand smoke (SHS) exposure is a major cause of premature death and disease, especially among children. Children in economically developing countries are particularly affected as smoke-free laws are typically only partially implemented and private homes and cars remain a key source of SHS exposure. Currently, firm conclusions cannot be drawn from the available evidence on the effectiveness of non-legislative interventions designed to protect children from SHS exposure. Following the success of two feasibility studies and a pilot trial, we plan to evaluate a school-based approach to protect children from SHS exposure in Bangladesh and Pakistan-countries with a strong commitment to smoke-free environments but with high levels of SHS exposure in children. We will conduct a two-arm cluster randomised controlled trial in Bangladesh and Pakistan to assess the effectiveness and cost effectiveness of a school-based smoke-free intervention (SFI) in reducing children's exposure to SHS and the frequency and severity of respiratory symptoms.

METHODS AND ANALYSIS

We plan to recruit 68 randomly selected schools from two cities-Dhaka in Bangladesh and Karachi in Pakistan. From each school, we will recruit approximately 40 students in a year (9-12 years old) with a total of 2720 children. Half of the schools will be randomly allocated to the intervention arm receiving SFI and the other half will receive usual education. Salivary cotinine concentration-a highly sensitive and specific biomarker of SHS exposure-is the primary outcome, which will be measured at month 3 post-randomisation. Secondary outcomes will include frequency and severity of respiratory symptoms, healthcare contacts, school absenteeism, smoking uptake and quality of life. Embedded economic and process evaluations will also be conducted.

ETHICS AND DISSEMINATION

The trial has received ethics approval from the Research Governance Committee at the University of York. Approvals have also been obtained from Bangladesh Medical Research Council and Pakistan Health Research Council. If SFI is found effective, we will use a variety of channels to share our findings with both academic and non-academic audiences. We will work with the education departments in Bangladesh and Pakistan and advocate for including SFI within the curriculum.

TRIAL REGISTRATION NUMBER

ISRCTN28878365.

Being pregnant and becoming a parent during the COVID-19 pandemic: a longitudinal qualitative study with women in the Born in Bradford COVID-19 research study

BACKGROUND

Uncertainty around the risk of COVID-19 to pregnant women and their babies prompted precautionary restrictions on their health and care during the pandemic. Maternity services had to adapt to changing Government guidance. Coupled with the imposition of national lockdowns in England and restrictions on daily activities, women's experiences of pregnancy, childbirth and the postpartum period, and their access to services, changed rapidly. This study was designed to understand women's experiences of pregnancy, labour and childbirth and caring for a baby during this time.

METHODS

This was an inductive longitudinal qualitative study, using in-depth interviews by telephone with women in Bradford, UK, at three timepoints during their maternity journey (18 women at timepoint one, 13 at timepoint two and 14 at timepoint three). Key topics explored were physical and mental wellbeing, experience of healthcare services, relationships with partners and general impact of the pandemic. Data were analysed using the Framework approach. A longitudinal synthesis identified over-arching themes.

RESULTS

Three longitudinal themes captured what was important to women: (1) women feared being alone at critical points in their maternity journey, (2) the pandemic created new norms for maternity services and women's care, and (3) finding ways to navigate the COVID-19 pandemic in pregnancy and with a baby.

CONCLUSIONS

Modifications to maternity services impacted significantly on women's experiences. The findings have informed national and local decisions about how best to direct resources to reduce the impact of COVID-19 restrictions and the longer-term psychological impact on women during pregnancy and postnatally.

Exploring support, experiences and needs of older women and health professionals to inform a self-management package for urinary incontinence: a qualitative study

OBJECTIVES

Many women attempt to manage urinary incontinence (UI) independently with variable success while health professionals may be unaware of their needs. This study aimed to (1) understand older women's experiences of UI, their self-management strategies and support needs; (2) explore health professionals' experiences of supporting women and providing relevant services and (3) combine their experiences contribute to development of a theory-based and evidence-based self-management package for UI.

DESIGN

Qualitative semi-structured interviews were conducted with 11 older women with UI and 11 specialist health professionals. Data were analysed independently using the framework approach, then synthesised in a triangulation matrix to identify implications for content and delivery of the self-management package.

SETTING

Community centres, community continence clinic and urogynaecology centre of a local teaching hospital in northern England.

PARTICIPANTS

Women aged 55 years and over who self-reported symptoms of UI and health professionals delivering UI services.

RESULTS

Three overarching themes emerged. Older women see UI as a 'fact of life' but many struggle with it: women typically considered UI as part of ageing yet expressed annoyance, distress, embarrassment and had made significant lifestyle changes. Access to information and limited high-quality professional support: health professionals provided specialist UI care and information. Yet less than half of women accessed specialist services, those who had, highly valued these services. 'Trial and error' with different self-management strategies: women had tried or were using different strategies (continence pads, pelvic floor exercises, bladder management and training, fluid management and medication), with mixed success. Health professionals provided evidence-based, personalised support and motivation.

CONCLUSIONS

Findings informed the content of the self-management package that focused on providing facts, acknowledging challenges of living with/self-managing UI, sharing others' experiences, using motivational strategies and self-management tools. Delivery preferences were independent use by women or working through the package with a health professional.

IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S): A protocol for a randomised controlled feasibility trial of a combined behavioural and pharmacological support intervention

INTRODUCTION

The prevalence of smoking is high among people living with severe mental illness (SMI). Evidence on feasibility, acceptability and effectiveness of smoking cessation interventions among smokers with SMI is lacking, particularly in low- and middle-income countries. We aim to test the feasibility and acceptability of delivering an evidence-based intervention,i.e., the IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S) intervention that is a combination of behavioural support and smoking cessation pharmacotherapies among adult smokers with SMI in India and Pakistan. We will also test the feasibility and acceptability of evaluating the intervention in a randomised controlled trial.

METHODS

We will conduct a parallel, open label, randomised controlled feasibility trial among 172 (86 in each country) adult smokers with SMI in India and Pakistan. Participants will be allocated 1:1 to either Brief Advice (BA) or the IMPACT 4S intervention. BA comprises a single five-minute BA session on stopping smoking. The IMPACT 4S intervention comprises behavioural support delivered in upto 15 one-to-one, face-to-face or audio/video, counselling sessions, with each session lasting between 15 and 40 minutes; nicotine gum and/or bupropion; and breath carbon monoxide monitoring and feedback. Outcomes are recruitment rates, reasons for ineligibility/non-participation/non-consent of participants, length of time required to achieve required sample size, retention in study and treatments, intervention fidelity during delivery, smoking cessation pharmacotherapy adherence and data completeness. We will also conduct a process evaluation.

RESULTS

Study will address- uncertainty about feasibility and acceptability of delivering smoking cessation interventions, and ability to conduct smoking cessation trials, among adult smokers with SMI in low- and middle-income countries.

CONCLUSIONS

This is to inform further intervention adaptation, and the design and conduct of future randomised controlled trials on this topic. Results will be disseminated through peer-review articles, presentations at national, international conferences and policy-engagement forums.

TRIAL REGISTRATION

ISRCTN34399445 (Updated 22/03/2021), ISRCTN Registry https://www.isrctn.com/.

"Everything the hujur tells is very educative but if I cannot apply those in my own life then there is no meaning": a mixed-methods process evaluation of a smoke-free homes intervention in Bangladesh

BACKGROUND

Second-hand smoke exposure from tobacco significantly contributes to morbidity and mortality worldwide. A cluster RCT in Bangladesh compared a community-based smoke-free home (SFH) intervention delivered in mosques, with or without indoor air quality (IAQ) feedback to households to no intervention. Neither was effective nor cost-effective compared to no intervention using an objective measure of second-hand smoke. This paper presents the process evaluation embedded within the trial and seeks to understand this.

METHODS

A mixed method process evaluation comprising interviews with 30 household leads and six imams (prayer leader in mosque), brief questionnaire completed by 900 household leads (75% response), fidelity assessment of intervention delivery in six (20%) mosques and research team records. Data were triangulated using meta-themes informed by three process evaluation functions: implementation, mechanisms of impact and context.

RESULTS

IMPLEMENTATION: Frequency of SFH intervention delivery was judged moderate to good. However there were mixed levels of intervention fidelity and poor reach. Linked Ayahs (verses of the Qur'an) with health messages targeting SHS attitudes were most often fully implemented and had greatest reach (along with those targeting social norms). Frequency and reach of the IAQ feedback were good.

MECHANISMS OF IMPACT

Both interventions had good acceptability. However, views on usefulness of the interventions in creating a SFH were mixed. Individual drivers to behaviour change were new SFH knowledge with corresponding positive attitudes, social norms and intentions. Individual barriers were a lack of self-efficacy and plans.

CONTEXT

Social context drivers to SFH intervention implementation in mosques were in place and important. No context barriers to implementation were reported. Social context drivers to SHS behaviour change were children's requests. Barriers were women's reluctance to ask men to smoke outside alongside general reluctance to request this of visitors. (Not) having somewhere to smoke outside was a physical context (barrier) and driver.

CONCLUSIONS

Despite detailed development and adaption work with relevant stakeholders, the SFH intervention and IAQ feedback became educational interventions that were motivational but insufficient to overcome significant context barriers to reduce objectively measured SHS exposure in the home. Future interventions could usefully incorporate practical support for SFH behaviour change. Moreover, embedding these into community wide strategies that include practical cessation support and enforcement of SFH legislation is needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49975452.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation: protocol for a pilot randomised-controlled multi-country trial

BACKGROUND

Smokeless tobacco (ST) is consumed globally by more than 350 million people, with approximately 85% of all users based in South and Southeast Asia. In this region, ST products are cheap and easily accessible. Evidence-based interventions to people quit ST use are lacking. This study aims to test the feasibility of conducting a future definitive trial of ST cessation, using a culturally adapted behavioural intervention, and/or nicotine replacement therapy (NRT) in three South Asian countries.

METHODS

We will conduct a factorial design, randomised-controlled pilot trial in Bangladesh, India and Pakistan. Daily ST users will be recruited from primary health care settings in Dhaka, Noida and Karachi. Participants will be individually randomised to receive intervention A (4 or 6 mg NRT chewing gum for 8-weeks), intervention B (BISCA: face-to-face behavioural support for ST cessation), a combination of interventions A and B or usual care (Very Brief Advice - VBA). The participants will provide demographic and ST use related data at baseline, and at 6, 12 and 26 weeks of follow-up. Salivary cotinine samples will be collected at baseline and 26 weeks. The analyses will undertake an assessment of the feasibility of recruitment, randomisation, data collection and participant retention, as well as the feasibility of intervention delivery. We will also identify potential cessation outcomes to inform the main trial, understand the implementation, context and mechanisms of impact through a process evaluation and, thirdly, establish health resource use and impact on the quality of life through health economic data.

DISCUSSION

The widespread and continued use of ST products in South Asia is consistent with a high rate of associated diseases and negative impact on the quality of life. The identification of feasible, effective and cost-effective interventions for ST is necessary to inform national and regional efforts to reduce ST use at the population level. The findings of this pilot trial will inform the development of larger trials for ST cessation among South Asian users, with relevance to wider regions and populations having high rates of ST use.

TRIAL REGISTRATION

ISRCTN identifier 65109397.

Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): a combined evidence and theory-based plus partnership intervention development approach

Introduction

Deaths from second-hand smoke (SHS) exposure are increasing, but there is not sufficient evidence to recommend a particular SHS intervention or intervention development approach. Despite the available guidance on intervention reporting, and on the role and nature of pilot and feasibility studies, partial reporting of SHS interventions is common. The decision-making whilst developing such interventions is often under-reported. This paper describes the processes and decisions employed during transitioning from the aim of adapting an existing mosque-based intervention focused on public health messages, to the development of the content of novel community-based Smoke-Free Home (SFH) intervention. The intervention aims to promote smoke-free homes to reduce non-smokers’ exposure to SHS in the home via faith-based messages.

Methods

The development of the SFH intervention had four sequential phases: in-depth interviews with adults in households in Dhaka, identification of an intervention programme theory and content with Islamic scholars from the Bangladesh Islamic Foundation (BIF), user testing of candidate intervention content with adults, and iterative intervention development workshops with Imams and khatibs who trained at the BIF.

Results

It was judged inappropriately to take an intervention adaptation approach. Following the identification of an intervention programme theory and collaborating with stakeholders in an iterative and collaborative process to identify barriers, six potentially modifiable constructs were identified. These were targeted with a series of behaviour change techniques operationalised as Quranic verses with associated health messages to be used as the basis for Khutbahs. Following iterative user testing, acceptable intervention content was generated.

Conclusion

The potential of this community-based intervention to reduce SHS exposure at home and improve lung health among non-smokers in Bangladesh is the result of an iterative and collaborative process. It is the result of the integration of behaviour change evidence and theory and community stakeholder contributions to the production of the intervention content. This novel combination of intervention development frameworks demonstrates a flexible approach that could provide insights for intervention development in related contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01100-5.

An Impulsive Suicide Attempt in a Patient with No Psychiatric History and a Recent COVID-19 Diagnosis: A case report

Introduction

The coronavirus disease 19 (COVID-19) pandemic has prompted concerns regarding increased suicide rates and exacerbation of underlying mental illness symptoms. •There is evidence suggesting neurocognitive changes as well as immune response in COVID-19 infection may increase a patient’s propensity for suicidal ideation. • Patients who are diagnosed with COVID-19 may be affected by psychological factors of anxiety, stress related to having this novel virus as well as depression, post-traumatic stress disorder and sleep disorders throughout treatment and post-treatment of continued concerns. •The combination of psychiatric, neurological, and physical symptoms associated with COVID-19 may elevate suicide risk

Objectives

We present a case of a female with no prior psychiatric history who impulsively attempted suicide after a recent COVID-19 diagnosis and subsequent quarantine. Will explore possible link between increase of suicidal ideation and COVID-19 infection.

Methods

A case report.

Results

Link between increase of suicidal ideation and COVID-19 infection has not been clearly established but there have been reports, as in our case, of the possible vulnerability to mental illness and new onset suicidal ideation that COVID-19 survivors may experience. It may be useful to screen all patients for depressive symptoms after a COVID-19 infection. Early identification and treatment of depression in recovered COVID-19 patients will help to improve psychological impact on COVID-19 survivors and potentially reduce suicide rates.

Conclusions

As COVID-19 infection may trigger new onset mental illness, exacerbate symptoms of underlying mental illness, and may increase suicidal ideation, further research is needed to evaluate links between COVID-19 infection and depression with suicidal ideation

Disclosure

No significant relationships.

Protocol for a feasibility study of longitudinal surveys to assess the impact of policies on tobacco use among school-going adolescents in South Asia

Background: Smokeless tobacco (ST) use is common among youth in South Asia where 85% of the world’s 300 million ST users live and use the most lethal ST forms. Little is known about the impact of tobacco control policies on the youth ST uptake in those countries. We planned to conduct longitudinal surveys among school going adolescents to evaluate existing tobacco control policies on tobacco uptake and use, and a feasibility study for that prospective, observational cohort study.

Study objectives: (1) To demonstrate the feasibility of selection, recruitment and retention of schools and of study participants; (2) To assess the feasibility and acceptability of the study procedure and study tool (questionnaire); (3) To evaluate if the questionnaire can assess tobacco uptake and use, and their potential predictors.

Methods and analysis: The feasibility study will be conducted in two administrative areas within each of three South Asian countries: Bangladesh, India and Pakistan. We will use both quantitative and qualitative data collection methods. Eight eligible schools will be randomly selected within purposively selected sub-districts from each country. We plan to conduct one baseline and one follow up survey among students of grade 6-8, one year apart. At each time point, data on tobacco uptake and potential predictors will be collected from students via self-administered questionnaires that were designed for the longitudinal study. The qualitative component will be embedded into the study with each round of data collection to assess the acceptability of the study instrument (questionnaire) and data collection methods, via focus group discussions with students and semi-structured interviews with schoolteachers.

Recruitment and retention rates, completeness of the questionnaires, frequencies and associations of tobacco use and explanatory variables will be reported. Data gathered from the focus group and interviews will be analysed using the framework approach.

Barriers to initiating and maintaining participation in parkrun

Interventions that increase population physical activity are required to promote health and wellbeing. parkrun delivers community-based, 5 km events worldwide yet 43% who register never participate in a parkrun event. This research had two objectives; i) explore the demographics of people who register for parkrun in United Kingdom, Australia, Ireland, and don’t initiate or maintain participation ii) understand the barriers to participating in parkrun amongst these people. Mandatory data at parkrun registration provided demographic characteristics of parkrun registrants. A bespoke online survey distributed across the three countries captured the reasons for not participating or only participating once. Of 680,255 parkrun registrants between 2017 and 19, 293,542 (43%) did not participate in any parkrun events and 147,148 (22%) only participated in one parkrun event. Females, 16–34 years and physically inactive were more likely to not participate or not return to parkrun. Inconvenient start time was the most frequently reported barrier to participating, with females more likely than males to report the psychological barrier of feeling too unfit to participate. Co-creating strategies with and for people living with a chronic disease, women, young adults, and physically inactive people, could increase physical activity participation within parkrun.

Measles outbreak in Romania: understanding factors related to suboptimal vaccination uptake

Background

A large measles outbreak started in Romania in 2016. Current study aimed to (i) clarify who was affected by the outbreak, (ii) identify their barriers and drivers to vaccination and (iii) explore variation by population group.

Methods

This was a two-component study. Outbreak surveillance data for 6743 measles cases were reviewed to identify key characteristics. A survey was administered via telephone to 704 caregivers of measles cases (520 respondents) to explore capability, opportunity and motivation barriers to vaccination. Data were summarized descriptively for respondent characteristics and statements. Differences by population group (education, household income, ethnicity, setting and mobility) were explored using χ² tests, Fisher’s exact tests or regression models.

Results

Most cases were unvaccinated and lived in low coverage areas. Ethnic minorities were disproportionally affected. Most caregivers felt welcome at health facilities. Some were less satisfied with the waiting time and had found the vaccine out of stock. Not everybody knew that vaccines were free of charge. Less than half knew the child’s next vaccination date, some had not been informed and did not know where to seek this information. Some said their peers did not vaccinate. Beliefs were generally supportive of vaccination; but many were concerned about vaccine safety and found they had not received good information about this. Conclusions varied greatly between minorities and less educated groups, compared with people with higher education levels.

Conclusions

Identifying characteristics of the population affected and underlying factors can inform a strategy to avoid future outbreaks and further research to obtain deeper insights.

A qualitative interview study with parents to identify barriers and drivers to childhood vaccination and inform public health interventions

Vaccination coverage in the Federation of Bosnia and Herzegovina, in Bosnia and Herzegovina, has been declining since 2014. This qualitative study aimed to identify barriers and drivers to childhood vaccination for parents. The COM-B (capability-opportunity-motivation-behavior) model was the underpinning theoretical framework. Face-to-face interviews with 22 parents of fully (n = 6), delayed/partially vaccinated (n = 9) and unvaccinated (n = 7) children were conducted. Interviews explored individual factors (capability-knowledge and skills; motivation-attitudes, confidence and trust) and context factors (physical opportunity-information, access, health systems; and social opportunity - social support, norms). Data were analyzed in NVivo using content analysis exploring differences in COM factors by vaccination status and location. Parents of fully vaccinated children typically reported individual and context drivers to vaccination. They accepted vaccination, trusted health workers, and were content with services. Parents of delayed/partially vaccinated children fell into two subgroups: (1) Those who accepted vaccination and attributed delays to their organizational skills or frustration with appointment times. (2) Those fitting the profile of "vaccine hesitant" - generally valuing vaccination and health worker advice, yet with concerns often triggered by media/social media. Parents of unvaccinated children mentioned individual and context barriers to vaccination, notably significant concerns about safety, some distrust of health workers and resentment of mandatory vaccination. Urban/rural differences included urban parents being more likely to report experiences with vaccine shortages and very few had received information leaflets. The study identified complex and inter-related barriers and drivers to parents' childhood vaccination behaviors. These insights have informed the development of tailored interventions to improve coverage.

Understanding vaccination communication between health workers and parents: a Tailoring Immunization Programmes (TIP) qualitative study in Serbia

Vaccine communication between health workers and parents affects parental acceptance, so understanding this is particularly important when vaccination rates drop. This paper presents the findings of a qualitative research study conducted in Serbia as part of a Tailoring Immunization Programmes (TIP) project. The aims were to explore the process of vaccination communication between health workers and parents (accepting, indecisive, delaying, refusing), and identify barriers and drivers to effective communication. In-depth interviews with 14 health workers were supplemented and qualified by observations of 40 consultations, using thematic analysis. Study sites were two community health centers in two Belgrade municipalities where a significant drop in childhood vaccination rates had occurred. Key findings were: (1) communication mainly took place between pediatricians and parents, while nurses focused on administering vaccines. (2) Health workers were confident in their skills to communicate and address concerns of accepting and indecisive parents, successfully applying specific strategies. (3) When interacting with delaying and refusing parents, they sometimes agreed to delay vaccination to maintain relationships, confident that most parents would vaccinate in due course. (4) Some refusing parents asked questions grounded in a socio-political agenda regarding vaccines or vaccination. Such questions exceeded the domain of health workers' expertise, which affected the communication between them. (5) Health workers' behavior in consultations was sometimes affected by parents' (dis) trust in their recommendations about vaccination. The study revealed that health workers in Serbia require additional skills and techniques to respond to parents who refuse and wish to delay vaccination, to secure timely vaccination.

Children Learning About Second-hand Smoke (CLASS II): a mixed methods process evaluation of a school-based intervention

BACKGROUND

Children are vulnerable to the effects of second-hand smoke exposure. Creating smoke-free homes is an effective strategy to limit exposure. We developed a smoke-free intervention (SFI) using children as a catalyst for change and teaching skills to negotiate a smoke-free home. In this paper, we present the process evaluation conducted within a pilot trial.

METHODS

This was a mixed-methods study comprising qualitative interviews and quantitative fidelity assessment of SFI delivery. Interviews in the six intervention schools were conducted with six headteachers and 12 teachers. These explored experiences of delivering the SFI, perceived impact, barriers and facilitators to success, and ideas for improvement and for scaling up. The data were analysed using framework analysis. Delivery of the SFI was observed and fidelity scores calculated.

RESULTS

The SFI was acceptable to headteachers and teachers. Fidelity scores ranged from 27/40 to 37/40. Didactic components were more fully implemented than interactive components. Time to complete the sessions, timing in the school day and school calendar were key challenges. Embedding the SFI into the curriculum was a potential solution.

CONCLUSIONS

These findings provide useful information to finalise the content and delivery and inform the scale-up of the SFI for our definitive trial, which is now underway.

TRIAL REGISTRATION

ISRCTN68690577.

Smokeless Tobacco Initiation, Use, and Cessation in South Asia: A Qualitative Assessment

Introduction

Smokeless tobacco (ST) is a significant South Asian public health problem. This paper reports a qualitative study of a sample of South Asian ST users.

Methods

Interviews, using a piloted topic guide, with 33 consenting, urban dwelling adult ST users explored their ST initiation, continued use, and cessation attempts. Framework data analysis was used to analyze country specific data before a thematic cross-country synthesis was completed.

Results

Participants reported long-term ST use and high dependency. All reported strong cessation motivation and multiple failed attempts because of ease of purchasing ST, tobacco dependency, and lack of institutional support.

Conclusions

Interventions to support cessation attempts among consumers of South Asian ST products should address the multiple challenges of developing an integrated ST policy, including cessation services.

Implications

This study provides detailed understanding of the barriers and drivers to ST initiation, use, and cessation for users in Bangladesh, India, and Pakistan. It is the first study to directly compare these three countries. The insight was then used to adapt an existing behavioral support intervention for ST cessation for testing in these countries.

Informing the public health response to COVID-19: a systematic review of risk factors for disease, severity, and mortality

BACKGROUND

Severe Acute Respiratory Syndrome coronavirus-2 (SARS-CoV-2) has challenged public health agencies globally. In order to effectively target government responses, it is critical to identify the individuals most at risk of coronavirus disease-19 (COVID-19), developing severe clinical signs, and mortality. We undertook a systematic review of the literature to present the current status of scientific knowledge in these areas and describe the need for unified global approaches, moving forwards, as well as lessons learnt for future pandemics.

METHODS

Medline, Embase and Global Health were searched to the end of April 2020, as well as the Web of Science. Search terms were specific to the SARS-CoV-2 virus and COVID-19. Comparative studies of risk factors from any setting, population group and in any language were included. Titles, abstracts and full texts were screened by two reviewers and extracted in duplicate into a standardised form. Data were extracted on risk factors for COVID-19 disease, severe disease, or death and were narratively and descriptively synthesised.

RESULTS

One thousand two hundred and thirty-eight papers were identified post-deduplication. Thirty-three met our inclusion criteria, of which 26 were from China. Six assessed the risk of contracting the disease, 20 the risk of having severe disease and ten the risk of dying. Age, gender and co-morbidities were commonly assessed as risk factors. The weight of evidence showed increasing age to be associated with severe disease and mortality, and general comorbidities with mortality. Only seven studies presented multivariable analyses and power was generally limited. A wide range of definitions were used for disease severity.

CONCLUSIONS

The volume of literature generated in the short time since the appearance of SARS-CoV-2 has been considerable. Many studies have sought to document the risk factors for COVID-19 disease, disease severity and mortality; age was the only risk factor based on robust studies and with a consistent body of evidence. Mechanistic studies are required to understand why age is such an important risk factor. At the start of pandemics, large, standardised, studies that use multivariable analyses are urgently needed so that the populations most at risk can be rapidly protected.

REGISTRATION

This review was registered on PROSPERO as CRD42020177714 .

Randomised controlled feasibility trial of an active communication education programme plus hearing aid provision versus hearing aid provision alone (ACE To HEAR)

OBJECTIVE

To establish the acceptability and feasibility of delivering the Active Communication Education (ACE) programme to increase quality of life through improving communication and hearing aid use in the UK National Health Service.

DESIGN

Randomised controlled, open feasibility trial with embedded economic and process evaluations.

SETTING

Audiology departments in two hospitals in two UK cities.

PARTICIPANTS

Twelve hearing aid users aged 18 years or over who reported moderate or less than moderate benefit from their new hearing aid.

INTERVENTIONS

Consenting participants (along with a significant other) were to be randomised by a remote, centralised randomisation service in groups to ACE plus treatment-as-usual (intervention group) or treatment-as-usual only (control group).

PRIMARY OUTCOME MEASURES

The primary outcomes were related to feasibility: recruitment, retention, treatment adherence and acceptability to participants and fidelity of treatment delivery.

SECONDARY OUTCOME MEASURES

International Outcomes Inventory for Hearing Aids, Self-Assessment of Communication, EQ-5D-5L and Short-Form 36. Blinding of the participants and facilitator was not possible.

RESULTS

Twelve hearing aid users and six significant others consented to take part. Eight hearing aid users were randomised: four to the intervention group; and four to treatment-as-usual only. Four significant others participated alongside the randomised participants. Recruitment to the study was very low and centres only screened 466 hearing aid users over the 15-month recruitment period, compared with the approximately 3500 anticipated. Only one ACE group and one control group were formed. ACE could be delivered and appeared acceptable to participants. We were unable to robustly assess attrition and attendance rates due to the low sample size.

CONCLUSIONS

While ACE appeared acceptable to hearing aid users and feasible to deliver, it was not feasible to identify and recruit participants struggling with their hearing aids at the 3-month posthearing aid fitting point.

TRIAL REGISTRATION NUMBER

ISRCTN28090877.

A behaviour change intervention to reduce home exposure to second hand smoke during pregnancy in India and Bangladesh: a theory and evidence-based approach to development

BACKGROUND

Home exposure to secondhand smoke (SHS) is highly prevalent amongst pregnant women in low- and middle-income countries like India and Bangladesh. The literature on the efficacy of behaviour change interventions to reduce home exposure to SHS in pregnancy is scarce.

METHODS

We employed a theory and evidence-based approach to develop an intervention using pregnant women as agents of change for their husband's smoking behaviours at home. A systematic review of SHS behaviour change interventions led us to focus on developing a multicomponent intervention and informed selection of behaviour change techniques (BCTs) for review in a modified Delphi survey. The modified Delphi survey provided expert consensus on the most effective BCTs in reducing home exposure to SHS. Finally, a qualitative interview study provided context and detailed understanding of knowledge, attitudes and practices around SHS. This insight informed the content and delivery of the proposed intervention components.

RESULTS

The final intervention consisted of four components: a report on saliva cotinine levels of the pregnant woman, a picture booklet containing information about SHS and its impact on health as well strategies to negotiate a smoke-free home, a letter from the future baby to their father encouraging him to provide a smoke-free home, and automated voice reminder and motivational messages delivered to husbands on their mobile phone. Intervention delivery was in a single face-to-face session with a research assistant who explained the cotinine report, discussed key strategies for ensuring a smoke-free environment at home and practised with pregnant women how they would share the booklet and letter with their husband and supportive family members.

CONCLUSION

A theory and evidence-based approach informed the development of a multicomponent behaviour change intervention, described here. The acceptability and feasibility of the intervention which was subsequently tested in a pilot RCT in India and Bangladesh will be published later.

Smokeless tobacco products, supply chain and retailers' practices in England: a multimethods study to inform policy

BACKGROUND

In England, many people of South Asian origin consume smokeless tobacco (ST). ST use can lead to oral cancer, which is disproportionately high in South Asians. Our aims were to assess the compliance of ST product retailers with statutory regulations and to explore the supply chain of ST.

METHODS

We undertook a multimethods study between August 2017 and July 2019 in five English boroughs with a high proportion of ethnic South Asians. We purchased ST products and conducted field surveys with ST retailers at point of sale. Qualitative interviews were conducted with ST retailers and suppliers. ST packs were assessed for regulatory compliance, while quantitative and qualitative data triangulated information on retailers' practices and the ST supply chain.

RESULTS

We collected 41 unique ST products, which included dry snuff, naswar, gutka, chewing tobacco and zarda. ST products were not registered, and demonstrated low compliance with health warning (14.6%) and packaging (56.1%) requirements. ST availability in surveyed boroughs was high (38.2%-69.7%); dry snuff, naswar and zarda were most commonly available. ST retailers demonstrated limited knowledge of regulations, and one-third were found to advertise ST at point of sale. Qualitative insights revealed illicit supply and distribution networks, as well as ST production in discreet locations.

CONCLUSION

ST products are widely available in England, yet non-compliant with statutory regulations. In order to safeguard consumers, in particular ethnic South Asians, stronger efforts are needed to regulate the supply chain of ST at both national and international levels.

Identifying interventions with Gypsies, Roma and Travellers to promote immunisation uptake: methodological approach and findings

BACKGROUND

In the UK, Gypsy, Roma and Traveller (GRT) communities are generally considered to be at risk of low or variable immunisation uptake. Many strategies to increase uptake for the general population are relevant for GRT communities, however additional approaches may also be required, and importantly one cannot assume that "one size fits all". Robust methods are needed to identify content and methods of delivery that are likely to be acceptable, feasible, effective and cost effective. In this paper, we describe the approach taken to identify potential interventions to increase uptake of immunisations in six GRT communities in four UK cities; and present the list of prioritised interventions that emerged.

METHODS

This work was conducted in three stages: (1) a modified intervention mapping process to identify ideas for potential interventions; (2) a two-step prioritisation activity at workshops with 51 GRTs and 25 Service Providers to agree a prioritised list of potentially feasible and acceptable interventions for each community; (3) cross-community synthesis to produce a final list of interventions. The theoretical framework underpinning the study was the Social Ecological Model.

RESULTS

Five priority interventions were agreed across communities and Service Providers to improve the uptake of immunisation amongst GRTs who are housed or settled on an authorised site. These interventions are all at the Institutional (e.g. cultural competence training) and Policy (e.g. protected funding) levels of the Social Ecological Model.

CONCLUSIONS

The "upstream" nature of the five interventions reinforces the key role of GP practices, frontline workers and wider NHS systems on improving immunisation uptake. All five interventions have potentially broader applicability than GRTs. We believe that their impact would be enhanced if delivered as a combined package. The robust intervention development and co-production methods described could usefully be applied to other communities where poor uptake of immunisation is a concern.

STUDY REGISTRATION

Current Controlled Trials ISRCTN20019630, Date of registration 01-08-2013, Prospectively registered.

The first case of HIV-2 in Scotland

HIV-1 infects an estimated 37 million people worldwide, while the rarer HIV-2 infects 1–2 million worldwide. HIV-2 is mainly restricted to West African countries. The majority of patients in Scotland are diagnosed with HIV-1, but in 2013 the West of Scotland Specialist Virology Centre (WoSSVC) diagnosed Scotland’s first HIV-2 positive case in a patient from Côte d’Ivoire. HIV-2 differs from HIV-1 in terms of structural viral proteins, viral transmissibility, prolonged period of latency, intrinsic resistance to certain antivirals and how to monitor the effectiveness of treatment. Over the course of 5 years the patient has required several changes in treatment due to both side effects and pill burden. This case highlights the complexity of HIV-2 patient management over time.

Integrating depression care within NCD provision in Bangladesh and Pakistan: a qualitative study

Background

Co-morbidity of depression with other non-communicable diseases (NCDs) worsens clinical outcomes for both conditions. Low- and middle-income countries need to strengthen mechanisms for detection and management of co-morbid depression within NCDs. The Behavioural Activation for Comorbid Depression in Non-communicable Disease (BEACON) study explored the acceptability and feasibility of integrating a brief depression intervention (behavioural activation, BA) into NCD services in healthcare facilities in Bangladesh and Pakistan.

Methods

Face-to-face qualitative interviews were conducted with 43 patients and 18 health workers attending or working in NCD centres in four healthcare facilities in Bangladesh and Pakistan, and with three policy makers in each country. The interviews addressed four research questions (1) how NCD care is delivered, (2) how NCD patients experience distress, (3) how depression care is integrated within NCD provision, and (4) the challenges and opportunities for integrating a brief depression intervention into usual NCD care. The data were analysed using framework analysis, organised by capability, opportunity and motivation factors, cross-synthesised across countries and participant groups.

Results

Patients and health workers described NCD centres as crowded and time pressured, with waiting times as long as five hours, and consultation times as short as five minutes; resulting in some patient frustration. They did not perceive direct links between their distress and their NCD conditions, instead describing worries about family and finance including affordability of NCD services. Health worker and policy maker accounts suggested these NCD centres lacked preparedness for treating depression in the absence of specific guidelines, standard screening tools, recording systems or training. Barriers and drivers to integrating a brief depression intervention reflected capability, opportunity and motivation factors for all participant groups. While generally valuing the purpose, significant challenges included the busy hospital environment, skill deficits and different conceptions of depression.

Conclusions

Given current resource constraints and priorities, integrating a brief psychological intervention at these NCD centres appears premature. An opportune first step calls for responding to patients’ expressed concerns on service gaps in provisioning steady and affordable NCD care. Acknowledging differences of conceptions of depression and strengthening psychologically informed NCD care will in turn be required before the introduction of a specific psychological intervention such as BA.

Improving immunization uptake rates among Gypsies, Roma and Travellers: a qualitative study of the views of service providers

BACKGROUND

Gypsies, Roma and Travellers are at risk of low uptake of routine immunizations. Interventions to improve uptake in these communities are seldom evaluated. As part of a qualitative study exploring barriers and facilitators to immunization uptake in Travellers, we report service provider (SP) perspectives.

METHODS

We interviewed immunization SPs working with six Traveller communities across four UK cities. Participants included frontline staff and those with strategic or commissioning roles. Semi-structured interviews explored perceived attitudes of Travellers to vaccinations, local service delivery, and opportunities and challenges to improving uptake. Audio-recordings were transcribed, analyzed thematically and mapped to a socio-ecological model of health.

RESULTS

39 SPs participated. Four overarching themes were identified: building trusting relationships between SPs and Travellers; facilitating attendance at appointments; improving record keeping and monitoring and responding to local and national policy change. Travellers were perceived as largely supportive of immunizations, though system and organizational processes were recognized barriers to accessing services.

CONCLUSIONS

Findings were broadly consistent across Traveller groups and settings. The barriers identified could often be addressed within existing infrastructure, though require system or policy change. Development of a culturally competent system appears important to enable equity in access to immunizations for Travellers.

Tailoring Immunization Programmes: using patient file data to explore vaccination uptake and associated factors

Vaccination uptake in the Federation of Bosnia and Herzegovina (FBiH), in Bosnia and Herzegovina, is suboptimal. This study aimed to (1) assess vaccination coverage, timeliness and drop-out for children born in 2015 and 2016 and compare these with official administrative coverage estimates, (2) identify associations between characteristics of children/caregivers and vaccination uptake. This was a cross-sectional study based on patient files for children 12–23 months (n = 1800) and 24–35 months (n = 1800). Methods were adapted from the World Health Organization cluster survey methodology. A two-stage stratified sampling procedure was conducted in urban and rural strata. A structured paper-based form was completed by a pediatrician/nurse from randomly selected primary care centers and patient files. Estimates were based on weighted analysis with a 95% confidence interval to account for the survey sampling design. Vaccination coverage was consistent with administrative coverage levels for BCG, DTP and MMR, and lower for HepB; all considerably lower than regional targets. Children in urban areas had lower vaccination uptake. An assumption that anti-vaccination sentiment prevails among caregivers was not confirmed; only 2% of children were not vaccinated at all, instead challenges related to delays and drop-out. An assumption of caregiver concerns for the MMR vaccine was confirmed with low uptake and delays. The FBiH has experienced vaccination schedule changes due to supply issues; findings confirmed that sustainability in supply and schedule is high priority. These data are new and provide important information for developing strategies to increase uptake.

Compliance of smokeless tobacco supply chain actors and products with tobacco control laws in Bangladesh, India and Pakistan: protocol for a multicentre sequential mixed-methods study

INTRODUCTION

South Asia is home to more than 300 million smokeless tobacco (ST) users. Bangladesh, India and Pakistan as signatories to the Framework Convention for Tobacco Control (FCTC) have developed policies aimed at curbing the use of tobacco. The objective of this study is to assess the compliance of ST point-of-sale (POS) vendors and the supply chain with the articles of the FCTC and specifically with national tobacco control laws. We also aim to assess disparities in compliance with tobacco control laws between ST and smoked tobacco products.

METHODS AND ANALYSIS

The study will be carried out at two sites each in Bangladesh, India and Pakistan. We will conduct a sequential mixed-methods study with five components: (1) mapping of ST POS, (2) analyses of ST samples packaging, (3) observation, (4) survey interviews of POS and (5) in-depth interviews with wholesale dealers/suppliers/manufacturers of ST. We aim to conduct at least 300 POS survey interviews and observations, and 6-10 in-depth interviews in each of the three countries. Data collection will be done by trained data collectors. The main statistical analysis will report the frequencies and proportions of shops that comply with the FCTC and local tobacco control policies, and provide a 95% CI of these estimates. The qualitative in-depth interview data will be analysed using the framework approach. The findings will be connected, each component informing the focus and/or design of the next component.

ETHICS AND DISSEMINATION

Ethical approvals for the study have been received from the Health Sciences Research Governance Committee at the University of York, UK. In-country approvals were taken from the National Bioethics Committee in Pakistan, the Bangladesh Medical Research Council and the Indian Medical Research Council. Our results will be disseminated via scientific conferences, peer-reviewed research publications and press releases.

Children Learning About Secondhand Smoke (CLASS II): A Pilot Cluster Randomized Controlled Trial

Introduction

Children exposed to secondhand smoke (SHS) are at increased risk of respiratory illnesses. We piloted a Smoke Free Intervention (SFI) and trial methods before investigating its effectiveness and cost-effectiveness in primary school children.

Methods

In a pilot cluster randomized controlled trial in Bangladesh, primary schools were allocated to usual education (control) or SFI, using minimization. Year-5 children were recruited. Masking treatment allocation was not possible. Delivered by schoolteachers, SFI consisted of two 45-min and four 15-min educational sessions. Our primary outcome was SHS exposure at two months post randomization, verified by children’s salivary cotinine. The trial is registered at ISRCTN.com; ISRCTN68690577.

Results

Between April 1, 2015 and June 30, 2015, we recruited 12 schools. Of the 484 children present in Year-5, 481 consented. Six schools were allocated to both SFI (n = 245) and to usual education only (n = 236). Of them, 450 children (SFI = 229; control = 221) who had cotinine levels indicative of SHS exposure were followed-up. All schools were retained, 91% children (208/229) in SFI and 88% (194/221) in the control arm completed primary outcome assessment. Their mean cotinine at the cluster level was 0.53 ng/ml (SD 0.36) in SFI and 1.84 ng/ml (SD 1.49) in the control arm—a mean difference of −1.31 ng/ml (95% CI = −2.86 to 0.24).

Conclusion

It was feasible to recruit, randomize, and retain primary schools and children in our trial. Our study, though not powered to detect differences in mean cotinine between the two arms, provides estimates to inform the likely effect size for future trials.

Implications

In countries with high smoking prevalence, children remain at risk of many conditions due to secondhand smoke exposure. There is little empirical evidence on the effectiveness and cost-effectiveness of interventions that can reduce their exposure to secondhand smoke at homes. CLASS II trial found that a school-based intervention (SFI) has the potential to reduce children’s exposure to SHS—an approach that has been rarely used, but has considerable merit in school-based contexts. CLASS II trial provides key information to conduct a future definitive trial in this area of public health, which despite its importance has so far received little attention.

Protein Content of Wheat by Near-Infrared Spectroscopy of Whole Grain: Collaborative Study

A collaborative study was performed to assess accuracy, repeatability, and reproducibility of a nearinfrared (near-IR) method for determining crude protein content (PC) of whole-grain wheat. Four types of commercially available near-IR instruments, representing various combinations of wavelength region, mode of energy capture, method of energy dispersion, and treatment of spectral data, were used. Eight, 9,10, and 11 collaborators were involved, the exact number depending on instrument type. All collaborators received 22 samples of whole-grain hard red winter (HRW) wheat. They were furnished reference PCs (i.e., protein concentrations, w/w) corrected to a 12% moisture basis for instrument standardization. AOAC Method 990.03— combustion analysis—was the reference procedure. Standardization consisted of performing one of the following treatments to the instrument manufacturer's (or federal agency's) PC equation: (1) bias correction, (2) slope and intercept correction, or (3) recalibration with inclusion of standardization sample spectra. Standardized equations were then applied to a test set of 12 unknown HRW wheat sample spectra, with 2 samples blindly duplicated. The PCs of test samples ranged from 9 to 16%. Near-IR predictions were compared with reference measurements. Averaged within instrument type, root mean square of differences were 0.22, 0.24, 0.25, and 0.26% PC, depending on instrument. Corrected for bias within the test set, standard errors became 0.22, 0.18, 0.21, and 0.24% PC, respectively. These values were approximately twice the estimated lower limit for error (representing sample inhomogeneity). Overall repeatability relative standard deviation (RSD,) values were 0.92, 0.36, 0.42, and 0.74%, respectively. Overall reproducibility relative standard deviation (RSDR) values were 1.15, 0.61,1.53, and 1.38%. Such values for within-laboratory and between-laboratory variations of the near- IR methods were equivalent to values reported for the combustion method (990.03) for wheat. An inhouse study that examined all 6 U.S. wheat classes with one of the 4 instrument types produced repeatability and reproducibility values similar to those of the collaborative study, suggesting that the near-IR technique may be applied to red, white, hard, soft, and durum wheats. The near-IR method for determination of PC of whole-grain wheat has been adopted First Action (997.06) by AOAC INTERNATIONAL.

Understanding vaccine acceptance and demand-and ways to increase them

Vaccination saves millions of lives, and the World Health Organization (WHO) European Region celebrated record high coverage in 2018. Still, national or sub-national coverage is insufficient to stop the spread of vaccine-preventable diseases. Health authorities are increasingly aware of the need to prioritize the “demand” side of vaccination. Achieving high and equitable vaccination uptake in all population groups is not a quick-fix; it requires long-term investment in multifaceted interventions, informed by research with the target groups. The WHO focuses on both individual and context determinants of vaccination behaviours. Individual determinants include risk perceptions, (dis)trust and perceived constraints; insights from psychology help us understand these. Context determinants include social norms, socioeconomic status and education level, and the way health systems are designed, operate and are financed. The WHO recommends using a proven theoretical model to understand vaccination behaviours and has adapted the “COM‑B model” for their Tailoring Immunization Programmes (TIP) approach. This adapted model is described in the article. Informed by insights into the factors affecting vaccination behaviours, interventions and policies can be planned to increase vaccination uptake. Some evidence exists on proven methods to do this. At the individual level, some interventions have been seen to increase vaccination uptake, and experimental studies have assessed how certain messages or actions affect vaccination perceptions. At the context level, there is more documentation for effective strategies, including those that focus on making vaccination the easy, convenient and default behaviour and that focus on the interaction between caregivers and health workers.

Accelerating our response: Government of Canada five-year action plan on sexually transmitted and blood-borne infections

Sexually transmitted and blood-borne infections (STBBI)-which include HIV, hepatitis B and C, chlamydia, gonorrhea, syphilis and human papillomavirus-remain significant public health issues both nationally and globally. In 2018, a Pan-Canadian STBBI Framework for Action (the Framework) was released by federal, provincial and territorial governments to provide an overarching and comprehensive approach to addressing STBBI for all those involved. This includes all levels of government, First Nations, Inuit and Métis communities and leadership, frontline service providers, clinicians, public health practitioners, non-governmental organizations and researchers. The Framework includes strategic goals, guiding principles and pillars for action to address STBBI in Canada. In response, the Government of Canada released its own action plan in July 2019: Accelerating Our Response - Government of Canada Five-Year Action Plan on Sexually Transmitted and Blood-Borne Infections (the Action Plan). This document identifies seven priority areas for federal action on STBBI over the next five years: 1) moving toward truth and reconciliation with First Nations, Inuit and Métis Peoples; 2) stigma and discrimination; 3) community innovation-putting a priority on prevention; 4) reaching the undiagnosed-increasing access to STBBI testing; 5) providing prevention, treatment and care to populations that receive health services or coverage of health care benefits from the federal government; 6) leveraging existing knowledge and targeting future research; and 7) measuring impact-monitoring and reporting on trends and results. The Government of Canada is currently working with provincial and territorial governments, First Nations, Inuit and Métis partners, and other stakeholders to develop STBBI indicators and targets for the Canadian context that are appropriate, feasible and measurable against the shared strategic goals of the Framework and the Action Plan. In addition, the Government of Canada has also committed to reporting annually on its progress in implementing the priority areas laid out in the Action Plan.

Preferences for interventions designed to increase cervical screening uptake in non-attending young women: How findings from a discrete choice experiment compare with observed behaviours in a trial

BACKGROUND

Young women's attendance at cervical screening in the UK is continuing to fall, and the incidence of invasive cervical cancer is rising.

OBJECTIVES

We assessed the preferences of non-attending young women for alternative ways of delivering cervical screening.

DESIGN

Postal discrete choice experiment (DCE) conducted during the STRATEGIC study of interventions for increasing cervical screening uptake. Attributes included action required to arrange a test, location of the test, availability of a nurse navigator and cost to the National Health Service.

SETTING AND PARTICIPANTS

Non-attending young women in two UK regions.

MAIN OUTCOME MEASURES

Responses were analysed using a mixed multinomial logit model. A predictive analysis identified the most preferable strategy compared to current screening. Preferences from the DCE were compared with observed behaviours during the STRATEGIC trial.

RESULTS

The DCE response rate was 5.5% (222/4000), and 94% of respondents agreed screening is important. Preference heterogeneity existed around attributes with strong evidence for test location. Relative to current screening, unsolicited self-sampling kits for home use appeared most preferable. The STRATEGIC trial showed this same intervention to be most effective although many women who received it and were screened, attended for conventional cytology instead.

CONCLUSIONS

The DCE and trial identified the unsolicited self-sampling kit as the most preferred/effective intervention. The DCE suggested that the decision of some women receiving the kit in the trial to attend for conventional cytology may be due to anxieties around home testing coupled with a knowledge that ignoring the kit could potentially have life-changing consequences.

Orthotic management of instability of the knee related to neuromuscular and central nervous system disorders: qualitative interview study of patient perspectives

OBJECTIVES

Adults with knee instability related to neuromuscular disorders or central nervous conditions often experience mobility problems and rely on orthoses to improve function and mobility. Patient views of device effectiveness and acceptability are underexplored. Our study aimed to elicit device users' perspectives regarding fitting, acceptability, effectiveness and use of orthoses, and identify important treatment outcomes.

DESIGN

Qualitative descriptive study using in-depth semistructured interviews. Interview transcriptions were coded and thematically analysed, using 'Framework'.

SETTING AND PARTICIPANTS

A purposive sample of 24 adult users of orthotic devices. Nineteen patients were recruited across three National Health Service sites, and five people through charities/patient support groups in England. Half of the participants had been diagnosed with poliomyelitis, and the remainder with multiple sclerosis, Charcot-Marie-Tooth disease, spinal injury or spina bifida, and stroke. The median age of participants was 64.5 years (range 36-80 years).

RESULTS

Patients' medical condition impacted significantly on daily life. Participants relied on orthotic devices to enable engagement in daily activities. Patient goals for mobility were linked to individual circumstances. Desired treatment outcomes included reduction in pain, trips and falls, with improved balance and stability. Effectiveness, reliability, comfort and durability were the most valued features of orthoses and associated with reported use. Obtaining suitable footwear alongside orthotic devices was a significant concern. Time pressures during device fitting were viewed negatively.

CONCLUSIONS

Orthotic devices for knee instability play a crucial role in promoting, maintaining and enhancing physical and psychological health and well-being, enabling patients to work, engage in family life and enjoy social activities. Future research should consider how best to measure the impact of orthotic devices on patient quality of life and daily functioning outside the clinic setting, as well as device use and any adverse effects.

TRIAL REGISTRATION NUMBER

This qualitative study was retrospectively registered as Current Controlled Trials ISRCTN65240228.