Novel approaches to screening for noncommunicable diseases: Lessons from Neno, Malawi

Background: As Malawi continues to suffer from a large burden of noncommunicable diseases (NCDs), models for NCD screening need to be developed that do not overload a health system that is already heavily burdened by communicable diseases.Methods: This descriptive study examined 3 screening programmes for NCDs in Neno, Malawi, that were implemented from June 2015 to December 2016. The NCD screening models were integrated into existing platforms, utilising regular mass screening events in the community, patients awaiting to be seen in a combined NCD and HIV clinic, and patients awaiting treatment at outpatient departments (OPDs). Focusing on hypertension and diabetes, we screened all adults 30 years and above for hypertension using a single blood pressure cut-off of 160/110 mmHg, as well as adults 40 years and above for diabetes, measuring either random blood sugar (RBS) or fasting blood sugar (FBS), with referral criteria of FBS > 126 mg/dL and RBS > 200 mg/dL. Data were collected on specifically designed screening registers, then entered and analysed in Excel.Results: Over 14,000 adults (≥ 12 years old) were screened for an array of common conditions at community screening events. Of these adults, 58% (n = 8133) and 29% (n = 4016) were screened for hypertension and diabetes, respectively. Nine percent (n = 716) and 3% ( n = 113) were referred for further hypertension and diabetes assessment respectively. At one OPD, 5818 patients (60%) had their blood pressures measured, and among adults 30 years and above, 168 eligible adults were referred for further hypertension assessment. Since the initiation of the screening programmes, the number of patients ever enrolled for NCD care every 3 months has nearly tripled, from 40 to 114.Conclusions: The screening models have shown that it is not only feasible to introduce NCD screening into a public system, but screening may have also contributed to increased enrolment in NCD care in Neno, Malawi

Revising ethical guidance for the evaluation of programmes and interventions not initiated by researchers

Public health and service delivery programmes, interventions and policies (collectively, ‘programmes’) are typically developed and implemented for the primary purpose of effecting change rather than generating knowledge. Nonetheless, evaluations of these programmes may produce valuable learning that helps determine effectiveness and costs as well as informing design and implementation of future programmes. Such studies might be termed ‘opportunistic evaluations’, since they are responsive to emergent opportunities rather than being studies of interventions that are initiated or designed by researchers. However, current ethical guidance and registration procedures make little allowance for scenarios where researchers have played no role in the development or implementation of a programme, but nevertheless plan to conduct a prospective evaluation. We explore the limitations of the guidance and procedures with respect to opportunistic evaluations, providing a number of examples. We propose that one key missing distinction in current guidance is moral responsibility: researchers can only be held accountable for those aspects of a study over which they have control. We argue that requiring researchers to justify an intervention, programme or policy that would occur regardless of their involvement prevents or hinders research in the public interest without providing any further protections to research participants. We recommend that trial consent and ethics procedures allow for a clear separation of responsibilities for the intervention and the evaluation

Evaluating the impact of a community health worker program on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi : protocol for a stepped-wedge, cluster randomized controlled trial

Introduction: This protocol concerns the implementation and evaluation of an intervention designed to realign the existing cadre of Community Health Workers (CHWs) in Neno District, Malawi to better support the care needs of the clients they serve. The proposed intervention is a ‘Household Model’ where CHWs will be reassigned to households, rather than to specific patients with HIV and/or TB. Methods and Analysis: Using a stepped-wedge, cluster-randomized design, this study investigates whether high HIV retention rates can be replicated for non-communicable diseases (NCDs), and the Model’s impact on TB and pediatric malnutrition case-finding, as well as the uptake of family planning and antenatal care. Eleven sites (health centres and hospitals) were arranged into six clusters (average cluster population 21,800). Primary outcomes include retention in care for HIV and chronic NCDs, TB case finding, pediatric malnutrition case finding, and utilization of early and complete antenatal. Clinical outcomes are based on routinely collected data the Ministry of Health’s District Health Information System 2 and an OpenMRS Electronic Medical Record supported by Partners In Health. Additionally, semi-structured qualitative interviews with various stakeholders will assess community perceptions and context of the Household Model. Ethics and dissemination: Ethics approval has been obtained from the Malawian National Health Science Research Committee (#16/11/1694) in Lilongwe, Malawi; Partners Healthcare Human Research Committee (#2017P000548/PHS) in Somerville, Massachusetts; and by the Biomedical and Scientific Research Ethics Sub-Committee (REGO-2017-2060) at the University of Warwick in Coventry, United Kingdom. Dissemination will include manuscripts for peer-reviewed publication as well as a full report detailing the findings of the intervention for the Malawian Ministry of Health. Registration: Registered on ClinicalTrials.gov in April 2017. Identifier: NCT0310672

An Efficient Method of Modeling Material Properties Using a Thermal Diffusion Analogy: An Example Based on Craniofacial Bone

The ability to incorporate detailed geometry into finite element models has allowed researchers to investigate the influence of morphology on performance aspects of skeletal components. This advance has also allowed researchers to explore the effect of different material models, ranging from simple (e.g., isotropic) to complex (e.g., orthotropic), on the response of bone. However, bone's complicated geometry makes it difficult to incorporate complex material models into finite element models of bone. This difficulty is due to variation in the spatial orientation of material properties throughout bone. Our analysis addresses this problem by taking full advantage of a finite element program's ability to solve thermal-structural problems. Using a linear relationship between temperature and modulus, we seeded specific nodes of the finite element model with temperatures. We then used thermal diffusion to propagate the modulus throughout the finite element model. Finally, we solved for the mechanical response of the finite element model to the applied loads and constraints. We found that using the thermal diffusion analogy to control the modulus of bone throughout its structure provides a simple and effective method of spatially varying modulus. Results compare favorably against both experimental data and results from an FE model that incorporated a complex (orthotropic) material model. This method presented will allow researchers the ability to easily incorporate more material property data into their finite element models in an effort to improve the model's accuracy

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

Abstract Background By 2015, Malawi had not achieved Millennium Development Goal 4, reducing maternal mortality by about 35% from 675 to 439 deaths per 100,000 livebirths. Hypothesised reasons included low uptake of antenatal care (ANC), intrapartum care, and postnatal care. Involving community health workers (CHWs) in identification of pregnant women and linking them to perinatal services is a key strategy to reinforce uptake of perinatal care in Neno, Malawi. We evaluated changes in uptake after deployment of CHWs between March 2014 and June 2016. Methods A CHW intervention was implemented in Neno District, Malawi in a designated catchment area of about 3100 women of childbearing age. The pre-intervention period was March 2014 to February 2015, and the post-intervention period was March 2015 to June 2016. A 5-day maternal health training package was delivered to 211 paid and supervised CHWs. CHWs were deployed to identify pregnant women and escort them to perinatal care visits. A synthetic control method, in which a “counterfactual site” was created from six available control facilities in Neno District, was used to evaluate the intervention. Outcomes of interest included uptake of first-time ANC, ANC within the first trimester, four or more ANC visits, intrapartum care, and postnatal care follow-up. Results Women enrolled in ANC increased by 18% (95% Credible Interval (CrI): 8, 29%) from an average of 83 to 98 per month, the proportion of pregnant women starting ANC in the first trimester increased by 200% (95% CrI: 162, 234%) from 10 to 29% per month, the proportion of women completing four or more ANC visits increased by 37% (95% CrI: 31, 43%) from 28 to 39%, and monthly utilisation of intrapartum care increased by 20% (95% CrI: 13, 28%) from 85 to 102 women per month. There was little evidence that the CHW intervention changed utilisation of postnatal care (− 37, 95% CrI: − 224, 170%). Conclusions In a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care

When Helping Hurts: A Zemiological Analysis of a Child Protection Intervention in Adolescence—Implications for a Critical Child Protection Studies

This paper presents data from a three-year, mixed methods study into the rate and impact of ‘relocation’ as a response to extra-familial harm in adolescence by children’s social care teams. Participatory approaches to research design, data collection and analysis are used to gain insights from young people, parents/carers and professionals about the impact of relocations on safety. Professionals and young people report a range of harms implicated in the use of relocations, whilst sharing that the intervention often increases safety. Data are analysed zemiologically to understand this ambivalence, connecting micro accounts of harm with meso, institutional and macro structures that determine child protection intervention. Zemiology is put forward as a promising approach for a Critical Child Protection Studies

When Helping Hurts: A Zemiological Analysis of a Child Protection Intervention in Adolescence—Implications for a Critical Child Protection Studies

This paper presents data from a three-year, mixed methods study into the rate and impact of ‘relocation’ as a response to extra-familial harm in adolescence by children’s social care teams. Participatory approaches to research design, data collection and analysis are used to gain insights from young people, parents/carers and professionals about the impact of relocations on safety. Professionals and young people report a range of harms implicated in the use of relocations, whilst sharing that the intervention often increases safety. Data are analysed zemiologically to understand this ambivalence, connecting micro accounts of harm with meso, institutional and macro structures that determine child protection intervention. Zemiology is put forward as a promising approach for a Critical Child Protection Studies

Relationship of trust and surveillance in the first national piloting of Contextual Safeguarding in England and Wales

This article analyses data collected as part of a three-year study supporting the implementation of Contextual Safeguarding across nine children’s social care teams in England and Wales as an approach to safeguarding adolescents at risk of harm in ‘extra-familial’ contexts. The article asks to what extent the first national testing of Contextual Safeguarding features relationships of trust or relationships of surveillance with young people, families and communities. Data collected for the National Scale Up study are analysed against the Watching Over Working With framework. Findings indicate that further guidance is required to support an uptake of Contextual Safeguarding that aligns with the framework’s values and with children’s rights

‘Already doing the work’: social work, abolition and building the future from the present

Social work internationally is currently subject to debate. Some call for the abolition of social work, detailing legacies of harm, inadequate practices and theoretical limitations. Central to abolitionist thought is the tradition of community work to build alternative futures in the present, an area currently receiving less attention. This article adopts an auto-ethnographic method, drawing on the authors’ experiences of social work in the UK – in childhood and as a professional career, respectively – to consider the limitations of social work responses to childhood harm, alongside existing community harm-reduction practices. Four themes are identified that capture the limitations of social work intervention, as well as acts of community care and resistance. These are: the extent of engagement with context and community knowledge; resources for caring; legacies of harm; and the role of social work in relation to community harm-reduction work. Implications for research methods and social work practice are discussed

Watching over or Working with? Understanding Social Work Innovation in Response to Extra-Familial Harm

This paper critically reflects on the role of surveillance and trusted relationships in social work in England and Wales. It explores the characteristics of relationships of trust and relationships of surveillance and asks how these approaches apply to emerging policy and practices responses to extra-familial forms of harm (EFH). Five bodies of research that explore safeguarding responses across a range of public bodies are drawn on to present an analytical framework that explores elements of safeguarding responses, constituting relationships of trust or relationships of surveillance and control. This analytic framework is applied to two case studies, each of which detail a recent practice innovation in response to EFH studied by the authors, as part of a larger body of work under the Contextual Safeguarding programme. The application of this framework signals a number of critical issues related to the focus/rationale, methods and impact of interventions into EFH that should be considered in future work to address EFH, to ensure young people’s rights to privacy and participation are upheld