Associations between female genital mutilation/cutting and early/child marriage: A multi-country DHS/MICS analysis

Over the last several decades, global efforts to end female genital mutilation/cutting (FGM/C) have intensified through the combined efforts of international and nongovernmental organizations (NGOs), governments, and religious and civil society groups. Evidence of the wider impacts of FGM/C and interventions for its abandonment is small but emerging. The practice of FGM/C has frequently been linked to a girl’s marriageability and is thought to be associated with child marriage, either directly, as a cause of early/child marriage, or vice versa, or indirectly, resulting from common causes. Evidence of the relationships between these two practices to inform programming and policy for abandonment interventions is limited at best, however. This study investigates the relationship between FGM/C and early/child marriage; investigates the possible correlates of early/child marriage; compares FGM/C practice across the region; and examines the correlates for FGM/C

Directly observed therapy for treating tuberculosis

Background Tuberculosis (TB) requires at least six months of treatment. If treatment is incomplete, patients may not be cured and drug resistance may develop. Directly Observed Therapy (DOT) is a specific strategy, endorsed by the World Health Organization, to improve adherence by requiring health workers, community volunteers or family members to observe and record patients taking each dose. Objectives To evaluate DOT compared to self-administered therapy in people on treatment for active TB or on prophylaxis to prevent active disease. We also compared the effects of different forms of DOT. Search methods We searched the following databases up to 13 January 2015: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; EMBASE; LILACS and mRCT. We also checked article reference lists and contacted relevant researchers and organizations. Selection criteria Randomized controlled trials (RCTs) and quasi-RCTs comparing DOT with routine self-administration of treatment or prophylaxis at home. Data collection and analysis Two review authors independently assessed risk of bias of each included trial and extracted data. We compared interventions using risk ratios (RR) with 95% confidence intervals (CI). We used a random-effects model if meta-analysis was appropriate but heterogeneity present (I2 statistic > 50%). We assessed the quality of the evidence using the GRADE approach. Main results Eleven trials including 5662 participants met the inclusion criteria. DOT was performed by a range of people (nurses, community health workers, family members or former TB patients) in a variety of settings (clinic, the patient's home or the home of a community volunteer). DOT versus self-administered Six trials from South Africa, Thailand, Taiwan, Pakistan and Australia compared DOT with self-administered therapy for treatment. Trials included DOT at home by family members, community health workers (who were usually supervised); DOT at home by health staff; and DOT at health facilities. TB cure was low with self-administration across all studies (range 41% to 67%), and direct observation did not substantially improve this (RR 1.08, 95% CI 0.91 to 1.27; five trials, 1645 participants, moderate quality evidence). In a subgroup analysis stratified by the frequency of contact between health services in the self-treatment arm, daily DOT may improve TB cure when compared to self-administered treatment where patients in the self-administered group only visited the clinic every month (RR 1.15, 95% CI 1.06 to 1.25; two trials, 900 participants); but with contact in the control becoming more frequent, this small effect was not apparent (every two weeks: RR 0.96, 95% CI 0.83 to 1.12; one trial, 497 participants; every week: RR 0.90, 95% CI 0.68 to 1.21; two trials, 248 participants). Treatment completion showed a similar pattern, ranging from 59% to 78% in the self-treatment groups, and direct observation did not improve this (RR 1.07, 95% CI 0.96 to 1.19; six trials, 1839 participants, moderate quality evidence). DOT at home versus DOT at health facility In four trials that compared DOT at home by family members, or community health workers, with DOT by health workers at a health facility there was little or no difference in cure or treatment completion (cure: RR 1.02, 95% CI 0.88 to 1.18, four trials, 1556 participants, moderate quality evidence; treatment completion: RR 1.04, 95% CI 0.91 to 1.17, three trials, 1029 participants, moderate quality evidence). DOT by family member versus DOT by community health worker Two trials compared DOT at home by family members with DOT at home by community health workers. There was also little or no difference in cure or treatment completion (cure: RR 1.02, 95% CI 0.86 to 1.21; two trials, 1493 participants, moderate quality evidence; completion: RR 1.05, 95% CI 0.90 to 1.22; two trials, 1493 participants, low quality evidence). Specific patient categories A trial of 300 intravenous drug users in the USA evaluated direct observation with no observation in TB prophylaxis to prevent active disease and showed little difference in treatment completion (RR 1.00, 95% CI 0.88 to 1.13; one trial, 300 participants, low quality evidence). Authors' conclusions From the existing trials, DOT did not provide a solution to poor adherence in TB treatment. Given the large resource and cost implications of DOT, policy makers might want to reconsider strategies that depend on direct observation. Other options might take into account financial and logistical barriers to care; approaches that motivate patients and staff; and defaulter follow-up

Rapid evidence assessment: Quality of studies assessing interventions to support FGM/C abandonment

The last decade has seen increased focus and investment in interventions to eliminate female genital mutilation/cutting (FGM/C), along with the need to accelerate its abandonment. The UK Department for International Development (DFID) commissioned the Evidence to End FGM/C: Research to Help Girls and Women Thrive project to: 1) assess the quality of studies that have evaluated different interventions for the prevention of FGM/C, and 2) describe the FGM/C interventions that were evaluated by high-quality studies. The quality of evidence on the effectiveness and impact of FGM/C interventions is generally moderate to low. In addition, few baseline surveys are conducted prior to implementing interventions, making assessment of effect and generalizability difficult. Despite a high concentration of studies evaluating anti-FGM/C interventions from sub-Saharan Africa, few emphasize adequate reporting on cultural sensitivity and contexts during the design stage, or interpretation of findings for local policy. This rapid evidence assessment provides valuable methodological lessons for the design of future high-quality assessments or evaluations of FGM/C interventions

Self medication using antibiotics at community pharmacies in low and middle income countries : a systematic review and meta-analysis

Background: Self medication with antibiotics has become increasingly common in low and middle income countries. It has been identified as a key driver to antimicrobial resistance. Factors contributing to self purchasing of antibiotics include: low socioeconomic status, lack of access to prescribers and weak legislation, among others. Objectives: To establish the extent of antibiotic self-medication in low and middle income countries especially Africa and the impact of potential policies to address this. Methods: Potential studies for inclusion in the review were identified through direct searches on the Cochrane Library, EMBASE, Scopus, University of Strathclyde Library and PubMed. Google Scholar was also used to complement our searches. The search terms used were "self-medication", "non-prescription", 'self-treatment', "antimicrobial", "antimalarial", "antibiotic", "antibacterial" and combining them using Boolean operators. We searched for studies published between January 2007 to March 2018. Study results were summarized narratively for a sub-set of studies where the data on outcomes and methodology varied significantly. The quality of the available evidence about the pre-specified outcomes to support a given intervention was assessed Critical Appraisal Skills Programme (CASP) cross sectional study Checklist. Two reviewers independently assessed study quality; disagreements were resolved by discussion. Results: A total of 64 potentially relevant articles were identified from literature searches. 21 studies were deemed eligible for inclusion. There is a huge variation in the prevalence of self-medication using antibiotics across low and middle income countries. It ranged from a low of 12% in Iran to as high as 93% in Uganda. Data on the type of antibiotics used for self-medication was not commonly reported. Some of the recurrent reasons for self-medication included inaccessible health facilities, long waiting time for consultation, familiarity of patients with symptoms, bad experience with doctors and ambiguous professional boundaries. Conclusions: Generally the prevalence of self medication with antibiotics was high, with variations across countries. Reasons for self medication should be addressed to reduce the prevalence. Policies should be put in place to address these as there was scanty data on this

Exploring the association between FGM/C and early/child marriage: A review of the evidence

Female genital mutilation/cutting (FGM/C) has been frequently linked to marriageability and thought to be associated with child marriage, yet there is remarkably little rigorous research to clarify the relationship between these two practices to inform discussions and responses. Furthermore, trends are also shifting in the timing of FGM/C from adolescence to early childhood, and the implications this might have on the links between early/child marriage and FGM/C are not well understood. This review of current available evidence aims to assess the association between FGM/C and early/child marriage in contexts where both practices are carried out. The social and cultural norms that underpin both practices and thus their continuation may vary across cultures and countries and even change over time; the challenge is to understand how social norms will and could be changed to end harmful practices that affect the lives of girls and women

Preventing female genital mutilation in high income countries: A systematic review of the evidence

© 2019 The Author(s). Background: Female genital mutilation (FGM) is prevalent in communities of migration. Given the harmful effects of the practice and its illegal status in many countries, there have been concerted primary, secondary and tertiary prevention efforts to protect girls from FGM. However, there is paucity of evidence concerning useful strategies and approaches to prevent FGM and improve the health and social outcomes of affected women and girls. Methods: We analysed peer-reviewed and grey literature to extract the evidence for FGM prevention interventions from a public health perspective in high income countries by a systematic search of bibliographic databases and websites using appropriate keywords. Identified publications were screened against selection criteria, following the PRISMA guidelines. We examined the characteristics of prevention interventions, including their programmatic approaches and strategies, target audiences and evaluation findings using an apriori template. Findings: Eleven documents included in this review described primary and secondary prevention activities. High income countries have given attention to legislative action, bureaucratic interventions to address social injustice and protect those at risk of FGM, alongside prevention activities that favour health persuasion, foster engagement with the local community through outreach and the involvement of community champions, healthcare professional training and capacity strengthening. Study types are largely process evaluations that include measures of short-term outcomes (pre- and post-changes in attitude, knowledge and confidence or audits of practices). There is a dearth of evaluative research focused on empowerment-oriented preventative activities that involve individual women and girls who are affected by FGM. Beattie's framework provides a useful way of articulating negotiated and authoritative prevention actions required to address FGM at national and local levels. Conclusion: FGM is a complex and deeply rooted sociocultural issue that requires a multifaceted response that encompasses socio-economic, physical and environmental factors, education and learning, health services and facilities, and community mobilisation activities. Investment in the rigorous longitudinal evaluation of FGM health prevention efforts are needed to provide strong evidence of impact to guide future decision making. A national evidence-based framework would bring logic, clarity, comprehension, evidence and economically more effective response for current and future prevention interventions addressing FGM in high income countries

The Structured Operational Research and Training Initiative (SORT IT), second workshop using the national tuberculosis routinely collected program data

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Assessment of neonatal care in clinical training facilities in Kenya.

OBJECTIVE: An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya. DESIGN: Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data. SETTING: Neonatal units of 22 public hospitals. PATIENTS: Neonates aged 20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively. CONCLUSIONS: Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training

Dysregulated Zn2+ homeostasis impairs cardiac type-2 ryanodine receptor and mitsugumin 23 functions, leading to sarcoplasmic reticulum Ca2+ leakage

SJP is supported by a Royal Society of Edinburgh Biomedical Fellowship. Benedict Reilly-O’Donnell is supported by a University of St Andrews 600th Anniversary Scholarship. This work was supported by the British Heart Foundation (grant no: FS/14/69/31001 to SJP) and the Japan Society for the Promotion of Science (Core-to-Core Program awarded to HT).Aberrant Zn2+ homeostasis is associated with dysregulated intracellular Ca2+ release, resulting in chronic heart failure. In the failing heart a small population of cardiac ryanodine receptors (RyR2) displays sub-conductance-state gating leading to Ca2+ leakage from sarcoplasmic reticulum (SR) stores, which impairs cardiac contractility. Previous evidence suggests contribution of RyR2-independent Ca2+ leakage through an uncharacterized mechanism. We sought to examine the role of Zn2+ in shaping intracellular Ca2+ release in cardiac muscle. Cardiac SR vesicles prepared from sheep or mouse ventricular tissue were incorporated into phospholipid bilayers under voltage-clamp conditions, and the direct action of Zn2+ on RyR2 channel function was examined. Under diastolic conditions, the addition of pathophysiological concentrations of Zn2+ (≥2 nm) caused dysregulated RyR2-channel openings. Our data also revealed that RyR2 channels are not the only SR Ca2+-permeable channels regulated by Zn2+. Elevating the cytosolic Zn2+ concentration to 1 nm increased the activity of the transmembrane protein mitsugumin 23 (MG23). The current amplitude of the MG23 full-open state was consistent with that previously reported for RyR2 sub-conductance gating, suggesting that in heart failure in which Zn2+ levels are elevated, RyR2 channels do not gate in a sub-conductance state, but rather MG23-gating becomes more apparent. We also show that in H9C2 cells exposed to ischemic conditions, intracellular Zn2+ levels are elevated, coinciding with increased MG23 expression. In conclusion, these data suggest that dysregulated Zn2+ homeostasis alters the function of both RyR2 and MG23 and that both ion channels play a key role in diastolic SR Ca2+ leakage.Publisher PDFPeer reviewe

Quality of comprehensive emergency obstetric care through the lens of clinical documentation on admission to labour ward

Background: Clinical documentation gives a chronological order of procedures and activities that a patient is given during their management.Objective: To determine the level of quality of comprehensive emergency obstetric care, through the lens of clinical documentation of process indicators of selected emergency obstetric conditions that mostly cause maternal mortality on admission to labour wardDesign: Multi-site cross sectional survey.Setting: Twenty two Government Hospitals in Kenya with capacity to offer comprehensive emergency obstetric care.Subjects: Process variables were abstracted from patient’ case records with a diagnosis of normal vaginal delivery, obstetric haemorrhage, severe pre eclampsia/eclampsia and emergency cesarean section.Results: Availability of structure indicators were graded excellent and good except for long gloves, misoprostol, ergometrin and parenteral cefuroxime that were graded low. A total of 1,216 records were abstracted for process analysis. The median (IQR) for the: six variables of obstetric history was five (4-5); five variables of antenatal profile was four (1-5); five variables of vital signs documentation was three (2-4); five variables for obstetric exam was four (4-5); seven variables of vaginal examination one (0-2); ten variables for partograph was seven (2-9); five variables for obstetric hemorrhage was three (2-4) and eleven variables for severe pre-eclampsia/eclampsia was five (3-6). The median (IQR) from decision-to-operate to caesarean section was three (2-4) hours.Conclusion: Quality of emergency obstetric care based on documentation depicts inadequacy. There is an urgent need to objectively address the need for proper clinical documentation as an indicator of quality performance