Contraception for women with diabetes: challenges and solutions.

Diabetes mellitus (DM), the most common of metabolic disorders, is a global public health concern. Numbers are rising with 383 million adults currently diagnosed with DM and another 175 million as yet undiagnosed. The rise in cases includes increasing numbers of women of a reproductive age whose reproductive health and contraception need careful consideration. Unintended pregnancy with poor glycemic control at the time of conception increases the chance of adverse pregnancy outcomes including stillbirth, congenital abnormalities, and perinatal mortality. In order to minimize complications, safe and effective contraception is paramount for all women with DM. This is a challenge as women have been found to be reticent to ask for advice, appear to lack understanding of risks, and are less likely to be using contraception than women without DM. The World Health Organization has developed Medical Eligibility Criteria to guide contraceptive choice. Women with DM without complications can choose from the full range of contraceptive methods including hormonal contraception as the advantages of use outweigh any risk. Women with diabetic complications may need specialist advice to assess the risk-benefit equation, particularly in respect of hormonal contraception. Women should be aware that there is no restriction to the use of oral and copper intrauterine emergency contraception methods. There is a need for an integrated approach to diabetes and reproductive health with improved communication between women with DM and their health care providers. Women need to be aware of advice and services and should make their own choice of contraception based on their needs and associated risk factors. Practitioners can offer nonjudgmental guidance working in partnership with women. This will enable discussion of risks and benefits of contraceptive methods and provision of advice dedicated to improving overall health and well-being

Exploratory study of clinician and patient views regarding the use of a preconception care app for women with diabetes

Background: Women with diabetes are at increased risk of adverse maternal and fetal outcomes. Preconception care can minimise risk of complications and improve outcomes, but current provision is inadequate. Electronic health technology, particularly apps, could improve preconception care provision but research is lacking in this area. Aim: The aim of this paper is to explore the views and experiences of clinicians and women with diabetes regarding the use of a mobile app for preconception care. Method: An exploratory study was conducted. Data were collected using focus group and interviews with 19 participants, comprising 10 clinicians and 9 women with type 1 or 2 diabetes. Data were analysed thematically. Findings: Women with diabetes and clinicians highlighted the inadequacy and challenges of current preconception care service provision and expressed a high level of enthusiasm and interest, towards a preconception care app that could support preconception care delivery for women with diabetes and overcome barriers to preconception care service provision and uptake. Conclusion: The acceptability of mobile health technology to both women and clinicians creates an important opportunity to overcome existing barriers to service provision, delivery and uptake, and improve both maternal and fetal outcomes for women with diabetes

Care planning interventions for care home residents: A scoping review

Context: Previous reviews of care planning (CP) interventions in care homes focus on higher quality research methodologies and exclusively consider advanced care planning (ACP), thereby excluding many intervention-based studies that could inform current practice. CP is concerned with residents’ current circumstances while ACP focuses on expressing preferences which relate to future care decisions. Objectives: To identify, map, and summarise studies reporting CP interventions for older people in care homes. Methods: Seven electronic databases were searched from 1 January 2012 until 1 January 2022. Studies of CP interventions, targeted at older people (>60 years) whose primary place of residence was a care home, were eligible for inclusion. Two reviewers independently screened the titles and abstracts of 3,778 articles. Following a full text review of 404 articles, data from 112 eligible articles were extracted using a predefined data extraction form. Findings: Studies were conducted in 25 countries and the majority of studies took place in the USA, Australia, and the UK. Most interventions occurred within nursing homes (61%, 68/112). More than 90% of interventions (93%, 104/112) targeted staff, and training was the most common focus (80%, 83/104), although only one included training for ancillary staff (such as cleaners and caterers). Only a third of studies (35%, 39/112) involved family and friends, and 62% (69/112) described interventions to improve CP practices through multiple means. Limitations: Only papers written in English were included and so potentially relevant studies may have been omitted. Implications: Two groups of people – ancillary workers and family and friends – who could play a valuable role in CP, were often not included in CP interventions. These oversights should be addressed in future research

Nigeria’s Relations with Her Neighbors and the Fight against Terrorism: An Analysis of the Multinational Joint Task Force

This chapter examines Nigeria’s relationship with her immediate neighboring countries in the fight against terrorism. It probed the challenges of national security following the internationalization of Boko Haram terrorist threats, particularly around the Lake Chad basin, and the responses of countries such as Cameroon, Chad, and Niger. These countries, like Nigeria, share borders around the Lake Chad and are the core contributors to the Multinational Joint Task Force (MNJTF). Nigeria is an English-speaking country (former British colony), while these other neighbors are historically French colonial territories. Hence, their political, cultural, military, and economic affinities are with France. The varying backgrounds have accounted for the challenges in the subregion including the Boko Haram insurgency and the efforts at military cooperation in tackling it. Consequently, these questions are examined: what factors led to the formation of MNJTF and what role has it played in the counterterrorism strategies of the country? In what ways has the nature of Nigeria’s relations with these countries impacted on the operation of the body? What are the roles of external powers such as France with her domineering influence on these countries in the war against terrorism and how has it promoted Nigeria’s national security interest? The chapter relies on documented materials to interrogate the questions and proffer necessary policy recommendations premised on the findings

Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda

Background: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. Methods: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Results: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women’s access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. Conclusions: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced

Contraception for women with diabetes: challenges and solutions

Ann Robinson, Chidiebere Nwolise, Jill Shawe School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK Abstract: Diabetes mellitus (DM), the most common of metabolic disorders, is a global public health concern. Numbers are rising with 383 million adults currently diagnosed with DM and another 175 million as yet undiagnosed. The rise in cases includes increasing numbers of women of a reproductive age whose reproductive health and contraception need careful consideration. Unintended pregnancy with poor glycemic control at the time of conception increases the chance of adverse pregnancy outcomes including stillbirth, congenital abnormalities, and perinatal mortality. In order to minimize complications, safe and effective contraception is paramount for all women with DM. This is a challenge as women have been found to be reticent to ask for advice, appear to lack understanding of risks, and are less likely to be using contraception than women without DM. The World Health Organization has developed Medical Eligibility Criteria to guide contraceptive choice. Women with DM without complications can choose from the full range of contraceptive methods including hormonal contraception as the advantages of use outweigh any risk. Women with diabetic complications may need specialist advice to assess the risk–benefit equation, particularly in respect of hormonal contraception. Women should be aware that there is no restriction to the use of oral and copper intrauterine emergency contraception methods. There is a need for an integrated approach to diabetes and reproductive health with improved communication between women with DM and their health care providers. Women need to be aware of advice and services and should make their own choice of contraception based on their needs and associated risk factors. Practitioners can offer nonjudgmental guidance working in partnership with women. This will enable discussion of risks and benefits of contraceptive methods and provision of advice dedicated to improving overall health and well-being. Keywords: diabetes mellitus, gestational diabetes, contraception, education, preconception counselin

Burden of cancer trial participation: A qualitative sub-study of the INTERIM feasibility RCT

Objective A qualitative sub-study was carried out within a larger phase II feasibility trial, to identify and describe the burden experienced by advanced melanoma patients participating in a clinical trial and the factors affecting their capacity to cope with the burden. Methods Semi-structured interviews were conducted with fourteen patients with advanced melanoma recruited from National Health Service hospitals in the United Kingdom. Qualitative analysis was undertaken using a framework analysis approach. Normalisation process theory was applied to the concept of research participation burden in order to interpret and categorise findings. Results Burdens of participation were identified as arising from making sense of the trial and treatment; arranging transport, appointment and prescriptions; enacting management strategies and enduring side effects; reflecting on trial documents and treatment efficacy, and emotional and mental effects of randomisation and treatment side effects. Factors reported as influencing capacity include personal attributes and skills, physical and cognitive abilities and support network. Discussion This is the first study to highlight the substantial burden faced by patients with advanced melanoma in a clinical trial and factors that may lessen or worsen the burden. Consideration of identified burdens during trial design and execution will reduce the burden experienced by research participants

Multi-disciplinary training hubs in North West England: the training hub lead perspective

Introduction: Increasing the capacity of Primary Care to meet the challenge of providing future complex and multi-disciplinary care in England has led to the increasing establishment of ‘Training Hubs’ [TH]. Other terms are used interchangeably to refer to TH activity: Advanced Training Practices, Enhanced Training Practices and Community Education Providers. The aim of this study was to gather the perceptions of TH Leads in North West England on how they established their TH and lessons learned. Methods: Five semi-structured telephone interviews were undertaken with TH Leads. Thematic analysis of the transcripts was undertaken. Findings: Four themes were identified: Motivation and Expectations of Establishing THs; Benefits to Learners and Practice Staff; Implementation Challenges and Barriers to Scale-Up; Sustainability and Wider Implementation. Discussion: TH Leads highlighted that the establishment of THs enhanced the multi-disciplinary learning experience. However, several barriers for sustaining the quality of the TH learning environments were identified. Difficulties recruiting ‘Spoke Practices’ were greater than expected. Findings identified the following factors for consideration for wider implementation: the maintenance of TH Lead support networks; appropriateness of funding to encourage practices who may be reluctant to take on this additional responsibility; the importance of communication channels between THs and HEIs; careful management of students numbers