Exploring the role of socioeconomic factors in the development and spread of anti-malarial drug resistance: a qualitative study

Malaria remains a global health issue with the burden unevenly distributed to the disadvantage of the developing countries of the world. Poverty contributes to the malaria burden as it has the ability to affect integral aspects of malaria control. There have been renewed efforts in the global malaria control, resulting in reductions in the global malaria burden over the last decade. However, the development of resistance to artemisinin-based combination therapy threatens the sustainability of the present success in malaria control. Anti-malarial drug use practices/behaviours remain very important drivers of drug resistance. This study adopted a social epidemiological stance in exploring the underlying socioeconomic factors that determine drug use behaviours promoting anti-malarial drug resistance. Methods A qualitative approach, involving the use of interviews, was used in this inquiry to explore the existing anti-malarial drug use practices in the Nigerian population; and the different socioeconomic factors influencing the behaviours. Results The significant malaria treatment behaviours influenced by socioeconomic factors in this study were the practice of ‘mixing’ drugs for malaria treatment, presumptive treatment, sharing of malaria treatment course, and the use of anti-malaria monotherapies. All the rural dwellers in this study reported they have mixed drugs for malaria treatment. When symptoms were experienced, socio-economic factors, like type of settlement, income level and occupation, tended to determine the treatment behaviour and, therefore, informed and determined the experience of the illness. Discussion Social and economic contexts can influence behaviours as they contribute in shaping norms and in creating opportunities that promote certain behaviours. As shown in this study, income level and type of settlement, as structural factors, affect the decision on where to seek malaria treatment and whether or not a malaria diagnostic test will be used prior to treatment. One of the dangers of using the mixed anti-malarial drugs is that it offers a safe route for the sale of expired and fake anti-malarial drugs as the mixed drugs are not sold or dispensed in their original packets. Conclusions and recommendations Population-wide improvements in income, education, environmental and structural conditions of rural dwellers in malaria-endemic settings will encourage behavioural change on how anti-malarial drugs are used

Knowledge and perception of young adults in Nigeria on effectiveness of condom use in prevention of sexually transmitted infections

Background: Although sexually transmitted infections (STIs) are a global health problem affecting every region of the world, the higher prevalence and mortality rate of STIs in developing countries of the world, like Nigeria, make them serious public health issues in this region. Objective: The aim of this study is to assess the knowledge and perception of young adults in Nigeria on the role of condom (both male and female condoms) as a preventive measure against STIs during heterosexual and homosexual intercourse. Materials and methods: Data was collected from participants selected from the northern and southern Nigeria using self-administered questionnaire specifically designed for this study. Results: Knowledge of condom efficacy in STI prevention was satisfactory. However, knowledge and practice of the correct use of condom was poor. Only 47.1% of the 102 participants in this study reported correct condom use of wearing condoms before staring intercourse and removing condoms after ejaculation. As a strategy to include the experiences, knowledge and perception of men who have sex with men, this study asked the question on condom use during anal sex. Only 24.4% of the male participants indicated they have never had anal sex while for females, the percentage was more than half (53.5%). Condom use during anal sex was low with only 20.6% of participants reporting condom use during anal sex. Negative perceptions about condom use – such as that condom use promotes sexual promiscuity, and not using condoms with steady sexual partners – were significant in this study. Also, condom use errors were common in this study. Conclusion: There is a wide gap in knowledge of correct condom use in this population. There is need for interventions that address the issue of condom use during anal and same-sex sexual intercourse in this population

Socioeconomic inequalities in the adoption of antimalarial resistance-promoting behaviours: a quantitative study of the use of mixed drugs for malaria treatment

Antimalarial drug use behaviours remain critical drivers of drug resistance as they can affect some of the other important factors implicated in the development of resistance. The overall aim of this study is to investigate the use of mixed drugs for malaria treatment and how (if any) the prevalence is patterned along the socioeconomic stratification of the population. A cross-sectional survey of 415 malaria patients was analyzed using multivariate logistic regression models to examine the effects of the socioeconomic factors in the use of mixed drugs for malaria treatment; and the association between the use of mixed drugs and the experience of treatment failure. Household income, living in a rural area, and the type of health facility used were associated with the use of mixed drugs for malaria treatment. Patients who used informal health facilities were 70% more likely to get mixed drugs compared to those who used formal health facilities. The use of mixed drugs for last malaria treatment was associated with the experience of treatment failure. The fact that the use of mixed drugs for malaria treatment is socially patterned is the corollary of the determinant effect of socioeconomic factors on this behaviour

Impact of UK tobacco control policies on inequalities in youth smoking uptake: a natural experiment study

Introduction: UK countries implemented smoke-free public places legislation and increased the legal age for tobacco purchase from 16 to 18 years between 2006 and 2008. We evaluated the immediate and long-term impacts of these UK policy changes on youth smoking uptake and inequalities therein. Aims and Methods: We studied 74 960 person-years of longitudinal data from 14 992 youths (aged 11–15 years) in annual UK household surveys between 1994 and 2016. Discrete-time event history analyses examined whether changes in rates of youth smoking transitions (initiation, experimentation, and escalation to daily smoking or quitting) or their inequalities (by parental education) were associated with policy implementation. Parallel analyses examined smoke-free legislation and the change in legal age. We interpret the results as a combined effect of the two pieces of legislation as their implementation dates were too close to identify separate effects. Models were adjusted for sex, age, UK country, historical year, tobacco taxation, and e-cigarette prevalence, with multiple imputation for missing data. Results: For both policies, smoking initiation reduced following implementation (change in legal age odds ratio [OR]: 0.67; 95% confidence interval [CI]: 0.55 to 0.81; smoke-free legislation OR: 0.68; 95% CI: 0.56 to 0.82), while inequalities in initiation narrowed over subsequent years. The legal age change was associated with annual increases in progression from initiation to occasional smoking (OR: 1.26; 95% CI: 1.07 to 1.50) and a reduction in quitting following implementation (OR: 0.57; 95% CI: 0.35 to 0.94). Similar effects were observed for smoke-free legislation but CIs overlapped the null. Conclusions: Policies such as these may be highly effective in preventing and reducing socioeconomic inequalities in youth smoking initiation. Implications: UK implementation of smoke-free legislation and an increase in the legal age for tobacco purchase from 16 to 18 years were associated with an immediate reduction in smoking initiation and a narrowing of inequalities in initiation over subsequent years. While the policies were associated with reductions in the initiation, progression to occasional smoking increased and quitting decreased following the legislation

Self-reported knowledge attitude and practice of healthcare professionals in the management of infection and antimicrobial stewardship:a systematic review

Objectives: This review synthesizes studies on health and social care professionals’ (HCPs) knowledge, attitudes and practices (KAP) related to infection management, prevention, antimicrobial use, stewardship and resistance, to inform future research and policy.Method: In January 2024, a comprehensive search was conducted in Medline, Embase, Web of Science and CINAHL to identify relevant studies on HCPs’ KAP in infection management and antimicrobial resistance (AMR). After deduplication, initial screening was done using Rayyan, with 10% checked for accuracy. Two reviewers independently assessed full texts, and data extraction was verified by another reviewer. Quality assessment was conducted by one reviewer, with 20% of studies double-checked. Studies published from 2016 onwards, focusing on the UK and comparable settings, were included. A narrative synthesis was performed due to heterogeneity between studies.Results: Of 10 990 records, 113 studies were included. KAP measures varied, complicating direct comparisons. Some studies assessed objective knowledge while most measured perceived knowledge, revealling discrepancies between the two. While most participants acknowledged the harms of inappropriate antimicrobial use, willingness to engage in antimicrobial stewardship (AMS) varied by profession. Practice behaviour assessment indicated varying hand-hygiene compliance and AMS implementation, along with significant concerns about inappropriate antibiotic prescribing.Conclusion: The review highlights significant gaps in HCPs’ KAP regarding infection prevention and AMS, with variations across professions. This underscores the need for targeted interventions. Additionally, standardized KAP assessment measures are essential to enhance comparability across different contexts. These findings provide a foundation for future research and policy initiatives aimed at combating AMR

Assessing patient-level risk factors for evidence-based early diagnosis of maternal sepsis

Background: Maternal sepsis is a leading cause of maternal death, with the burden higher in low- and middle-income countries (LMICs). Early Warning Systems (EWS) combine clinical observations to identify a pattern consistent with an increased risk of clinical deterioration and have been introduced for monitoring sepsis risk. Maternal sepsis risks in LMICs are driven by factors at the health system and patient levels. This study assessed patient-level risk factors -age, health-seeking behaviour, comorbidities and procedures- associated with maternal sepsis in an urban tertiary hospital in Nigeria. Methods: We conducted a retrospective study using health records of 4,510 patients from obstetrics and gynaecology units at a tertiary hospital in southwestern Nigeria from 2016 to 2020. To examine the association between patient-level risk factors and sepsis, we analysed data for the 565 maternal patients with a record of infection using a multiple logistic regression model. We extended the model by introducing interaction terms to assess whether the association between the risk factors and maternal sepsis varied by socio-demographic factors. Results: About one-fifth of the 565 maternal patients with an infection had sepsis. Patients with sepsis had the lowest rate of live birth (29.7%) compared to those with (41.8%) and without (82.1%) an infection. Proportions of stillbirth (intrauterine fetal death) and early neonatal deaths were highest among patients with sepsis (15.3% and 1.8%) compared to those with (13.2% and 2.1%) and without (4.5% and 1.7%) an infection. Antenatal care booking status (OR: 0.17; 95% CI: 0.08–0.38) and having a catheter (OR: 2.60; 95% CI: 1.35–5.01) were significantly associated with maternal sepsis in the adjusted model. Conclusion: Our results suggest that improving access to antenatal care services for pregnant women will substantially reduce the risk of maternal sepsis in the Nigerian population. Guidelines for maternal sepsis management should consider subgroups of patients at higher risk, such as those with urethral catheters

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries