Search

OBJECTIVES: The US Preventive Services Task Force recommends screening of adults aged 35-70 with a body mass index ≥25 kg/m2 for type 2 diabetes and referral of individuals who screen positive for pre-diabetes to evidence-based prevention strategies. The diabetes burden in the USA is predicted to triple by 2060 necessitating strategic diabetes prevention efforts, particularly in areas of highest need. This study aimed to identify pre-diabetes hotspots using geospatial mapping to inform targeted diabetes prevention strategies. A hotspot is defined as a cluster of 3 or more neighbouring census tracts with elevated pre-diabetes prevalence. DESIGN: A cross-sectional study using ArcGIS software to geospatially map pre-diabetes prevalence hotspots. We used health system and census data to identify pre-diabetes hotspots using a systematic five-step geoprocessing approach that made use of incremental spatial autocorrelation and Getis-Ord Gi*. SETTING: This study was set in Kaiser Permanente Northern California (KPNC), an integrated health delivery system with over four million members. PARTICIPANTS: KPNC adults ages 35-70 who underwent a haemoglobin A1c (HbA1c) or fasting plasma glucose (FPG) screening test in 2019 were mapped to census tracts in Northern California. People were considered to have pre-diabetes with an HbA1c of 5.7%-6.4% (39-46 mmol/mol) or FPG 100-125 mg/dL. PRIMARY AND SECONDARY OUTCOME MEASURES: Individual and census-level characteristics were compared between hotspots and non-hotspots using χ2 and Wilcoxon rank sum tests, as well as risk differences (RDs) and Hodges-Lehmann (HL) estimates of location shift. Individual-level characteristics were derived from electronic health records and administrative data, while census-level characteristics were derived from the 2019 American Community Survey. RESULTS: A total of 760 044 adults met the study inclusion criteria and 40% had pre-diabetes. Individuals in pre-diabetes hotspots were less likely to be non-Hispanic white (33.6% vs 50.6%, RD: -17.04%, 95% CI -17.26% to -16.81%, p

OBJECTIVE: The objective is to examine the test-retest reliability and internal reliability of six self-report questions assessing both current (past 30 days) and lifetime cannabis smoking in an internet survey in the adult US population. DESIGN: Cross-sectional national survey. PARTICIPANTS: Out of 957 US adults who completed a national 2020 survey administered through Ipsos KnowledgePanel, 557 completed a second survey (reliability survey) aimed at assessing the test-retest and internal reliability of questions asking about current and lifetime cannabis smoking. The sample size used in the analysis for the six self-report questions varied and was dependent on respondents answering the questions in both the 2020 survey and the reliability survey. PRIMARY OUTCOME MEASURE: Test-retest and internal reliability of six self-report questions asking about current and lifetime cannabis smoking. RESULTS: Among respondents who had smoked cannabis in the past 30 days, 33.8% were aged 18-34, 29.7% were 35-49, 27.7% were 50-64 and 8.8% were 65 or older. Current cannabis smokers were primarily men (59.5%) and white (63.0%). Almost half of current cannabis smokers had a high school diploma or less followed by some college and a bachelors degree or higher (45.7%, 30.6%, 23.8%, respectively). The question assessing number of days participants smoked cannabis in the past 30 days demonstrated good test-retest (r=0.87) and excellent internal reliability (α=0.94). The questions assessing the number of years, the most common form of use and the number of times participants smoked cannabis over their lifetime also demonstrated test-retest (r=0.77 (acceptable), r=0.75 (acceptable) and κ=0.65 (substantial), respectively) and excellent-to-good internal reliability (α=0.91, α=0.87 and α=0.88, respectively). CONCLUSIONS: We found simple questions assessing current and lifetime cannabis use to demonstrate both test-retest reliability and internal reliability. These questions can serve as a simple framework for clinicians to evaluate the frequency of cannabis smoking in their patients. Future work should examine if these simple frequency measures of smoking cannabis are associated with adverse health outcomes.

ObjectiveThe vast majority of the 300 000 pregnancy-related deaths every year occur in South Asia and sub-Saharan Africa. Increased access to quality antepartum and intrapartum care can reduce pregnancy-related morbidity and mortality worldwide. We used a population-based cross-sectional cohort design to: (1) examine the sociodemographic risk factors and structural barriers associated with pregnancy care-seeking and institutional delivery, and (2) investigate the influence of residential distance to the nearest primary health facility in a rural population in Mali.MethodsA baseline household survey of Malian women aged 15-49 years was conducted between December 2016 and January 2017, and those who delivereda baby in the 5 years preceding the survey were included. This study leverages the baseline survey data from a cluster-randomised controlled trial to conduct a secondary analysis. The outcomes were percentage of women who received any antenatal care (ANC) and institutional delivery; total number of ANC visits; four or more ANC visits; first ANC visit in the first trimester.ResultsOf the 8575 women in the study, two-thirds received any ANC in their last pregnancy, one in 10 had four or more ANC visits and among those that received any ANC, about one-quarter received it in the first trimester. For every kilometre increase in distance to the nearest facility, the likelihood of the outcomes reduced by 5 percentage points (0.95; 95% CI 0.91 to 0.98) for any ANC; 4 percentage points (0.96; 95% CI 0.94 to 0.98) for an additional ANC visit; 10 percentage points (0.90; 95% CI 0.86 to 0.95) for four or more ANC visits; 6 percentage points (0.94; 95% CI 0.94 to 0.98) for first ANC in the first trimester. In addition, there was a 35 percentage points (0.65; 95% CI 0.56 to 0.76) decrease in likelihood of institutional delivery if the residence was within 6.5 km to the nearest facility, beyond which there was no association with the place of delivery. We also found evidence of increase in likelihood of receiving any ANC care and its intensity increased with having some education or owning a business.ConclusionThe findings suggest that education, occupation and distance are important determinants of pregnancy and delivery care in a rural Malian context.Trial registration numberNCT02694055.

OBJECTIVES: Although guidelines recommend antiviral therapy for outpatients with COVID-19 who are at high risk of progressing to severe conditions, such as older adults, many patients do not receive appropriate treatment. Little is known, however, about the physician factors associated with the prescription of guideline-recommended antiviral therapy for patients with COVID-19. DESIGN: A cross-sectional study. SETTING: Data including outpatient visits in primary care clinics in Japan from April to August 2023. PARTICIPANTS: We analysed 30 953 outpatients aged ≥65 years treated with COVID-19 (mean (SD) age, 75.0 (7.6) years; 17 652 women (57.0%)) in 1394 primary care clinics. OUTCOME MEASURES: The primary outcome was the prescription of guideline-recommended antivirals (ie, nirmatrelvir-ritonavir or molnupiravir), adjusted for patient characteristics, months of visits and regions. RESULTS: Antiviral prescriptions were concentrated among a small proportion of physicians; for example, the top 10% of physicians that had the largest number of nirmatrelvir-ritonavir prescriptions accounted for 92.4% of all nirmatrelvir-ritonavir prescriptions. After adjusting for potential confounders, physicians with higher patient volumes were more likely to prescribe guideline-recommended antivirals to their patients (adjusted OR (aOR) for high vs low volume, 1.76; 95% CI 1.31 to 2.38; adjusted p

ObjectivesWhether the routine delivery of diabetes-related knowledge can change patients' attitudes and hence influence their self-management activities remains unknown in primary healthcare settings in China. Thus, this study aims to explore the complex transformation process between knowledge, attitude and practice (KAP) among patients with diabetes in a city in China.DesignA cross-sectional study.SettingYuhuan City, Zhejiang Province, China.ParticipantsA total of 803 patients with diabetes were invited to attend a questionnaire survey and 782 patients with type 2 diabetes completed the survey. The average age of participants was 58.47 years old, 48.21% of whom only attended primary school or below.Primary and secondary outcome measuresA questionnaire based on existing scales and expert consultation was applied to assess patients' socio-demographic information (SI), disease progression risk and diabetes-related KAP. A structural equation model was built to analyse the relationships between patients' characteristics and KAP.ResultsNo significant association was found between patients' knowledge and attitude (β=0.01, p=0.43). Better knowledge and attitude were both found to be associated with better diet and physical activities (β=0.58, p

IntroductionThere is a high burden of hypertension (HTN) among HIV-infected people in Uganda. However, capacity to prevent, diagnose and treat HTN is suboptimal. This study seeks to leverage the existing HIV-related infrastructure in primary care health facilities (HFs) using the integrated HIV/HTN care model to improve health outcomes of patients with HIV and HTN.Methods and analysisIntegrated HIV/HTN study a type-1 effectiveness/implementation cluster randomised trial, will evaluate the effectiveness of a multicomponent model intervention in 13 districts randomised to the intervention arm compared with 13 districts randomised to control. Two randomly selected HFs per district and their patients will be eligible to participate. The intervention will comprise training of primary healthcare (PHC) providers followed by regular supervision, integration of HTN care into HIV clinics, improvement of the health management information system, IT-based messaging to improve communication among frontline PHCs and district-level managers. HTN care guidelines, sphygmomanometers, patient registers and a buffer stock of essential drugs will be provided to HFs in both study arms. We will perform cross-sectional surveys at baseline, 12 and 24 months, on a random sample of patients attending HFs to measure effectiveness of the integrated care model between 2021 and 2024. We will perform in-depth interviews of providers, patients and healthcare managers to assess barriers and facilitators of integrated care. We will measure the cost of the intervention through microcosting and time-and-motion studies. The outcomes will be analysed taking the clustered structure of the data set into account.Ethics and disseminationEthics approval has been obtained from the Research Ethics Committees at London School of Hygiene and Tropical Medicine, and Makerere University School of Medicine. All participants will provide informed consent prior to study inclusion. Strict confidentiality will be applied throughout. Findings will be disseminated to public through meetings, and publications.Trial registration numberNCT04624061.

IntroductionArthrogryposis multiplex congenita (AMC) is an umbrella term including hundreds of conditions with the common clinical manifestation of multiple congenital contractures. AMC affects 1 in 3000 live births and is caused by lack of movement in utero. To understand the long-term needs of individuals diagnosed with a rare condition, it is essential to know the prevalence, aetiology and functional outcomes in a large sample. The development and implementation of a multicentre registry is critical to gather this data. This registry aims to improve health through genetic and outcomes research, and ultimately identify new therapeutic targets and diagnostics for treating children with AMC.Methods and analysisParticipants for the AMC registry will be recruited from seven orthopaedic hospitals in North America. Enrollment occurs in two phases; Part 1 focuses on epidemiology, aetiology and interventions. For this part, retrospective and cross-sectional data will be collected using a combination of patient-reported outcomes and clinical measures. Part 2 focuses on core subset of the study team, including a geneticist and bioinformatician, identifying causative genes and linking the phenotype to genotype via whole genome sequencing to identify genetic variants and correlating these findings with pedigree, photographs and clinical information. Descriptive analyses on the sample of 400 participants and logistic regression models to evaluate relationships between outcomes will be conducted.Ethics and disseminationEthical approval has been granted from corresponding governing bodies in North America. Dissemination of findings will occur via traditional platforms (conferences, manuscripts) for the scientific community. Other modalities will be employed to ensure that all stakeholders, including youth, families and patient support groups, may be provided with findings derived from the registry. Ensuring the findings are circulated to a maximum amount of interested parties will ensure that the registry can continue to serve as a platform for hypothesis-driven research and further advancement for AMC.

ObjectiveTo examine factors associated with accrual rate in industry sponsored clinical trials supporting US Food and Drug Administration (FDA) cancer drug approvals from 2015 to 2020.Design, setting and participantsRetrospective cross-sectional study included 194 pivotal trials supporting cancer drug approvals by the US FDA from 2015 to 2020.InterventionsClinical trials were analysed for the type of blinding, primary endpoint, whether crossover was specified in the publication, study phase, line of therapy, response rate, investigational sites, manufacturer and randomisation ratio.Main outcome measuresThe main outcome was the rate of accrual, which is the number of patients accrued in the study per open month of enrolment.ResultsThe study consisted of 133 randomised (68%) and 61 (32%) non-randomised clinical trials. In randomised studies, we found the accrual rate was higher in trials investigating first and second line drugs (adjusted rate ratios (aRR): 1.55, 95% CI 1.18 to 2.09), phase III trials (aRR: 2.13, 95% CI 1.48 to 2.99), and for studies sponsored by Merck (aRR: 1.47, 95% CI 1.18 to 2.37), adjusting for other covariates. In contrast, the primary endpoint of a study, presence of crossover, single agent response rate, the number of investigational sites, population disease burden and skewed randomisation ratios were not associated with the rate of accrual. In the non-randomised adjusted model, the accrual rate was 2.03 higher (95% CI 1.10 to 3.92) for clinical trials sponsored by manufacturer, specifically Merck. Primary endpoint, crossover, trial phase, response rate, the number of investigational sites, disease burden or line of therapy were not associated with the rate of accrual.ConclusionIn this cross-sectional study, line of therapy, study phase and manufacturer were the only factors associated with accrual rate. These findings suggest many proffered factors for speedy trial accrual are not associated with greater enrolment rates.

ObjectivesIn late 2014, an HIV outbreak occurred in rural Cambodia among villagers who received medical injections from unlicensed medical providers, justifying the need to assess medical injection practices among those who are at risk of acquiring and/or transmitting HIV. This study examined medical injection/infusion behaviours among people living with HIV (PLWH) and those who were HIV negative in Cambodia. These behaviours should be properly assessed, especially among PLWH, as their prevalence might influence a future risk of other outbreaks.DesignA cross-sectional survey was conducted in order to examine injection behaviours and estimate injection prevalence and rates by HIV status. Unsafe injections/infusions were those received from village providers who do not work at a health centre or hospital, or traditional providers at the participant's (self-injection included) or provider's home. Logistic regression was performed to examine the relationship between unsafe injection/infusion and HIV, adjusting for sex, age, education, occupation, residence location and other risk factors.SettingThe survey was conducted in 10 HIV testing and treatment hospitals/clinics across selected provinces in Cambodia, from February to March 2017.ParticipantsA total number of 500 volunteers participated in the survey, 250 PLWH and 250 HIV-negative individuals.Outcome measuresMeasures of injection prevalence and other risk behaviours were based on self-reports.ResultsBoth groups of participants reported similar past year's injection/infusion use, 47% (n=66) among PLWH and 54% (n=110) HIV-negative participants (p=0.24). However, 15% (n=11) of PLWH reported having received unsafe last injection compared with only 7% (n=11) of HIV-negative participants. In logistic regression, this association remained numerically positive, but was not statistically significant (adjusted OR 1.84 (95% CI: 0.71 to 4.80)).ConclusionsThe inclination for medical injections and infusions (unsafe at times) among PLWH and the general population in Cambodia was common and could possibly represent yet another opportunity for parenteral transmission outbreak.

ObjectivesTo describe face mask use among pregnant women seeking antenatal care (ANC) in Kinshasa, Democratic Republic of Congo and to identify factors associated with masking adherence in this population.DesignFacility-based cross-sectional study nested within a prospective cohort study.SettingRandom sample of 10 health facilities, including 5 primary health centers and 5 secondary facilities or hospitals.ParticipantsA total of 934 pregnant women aged 18 years or above with a gestational age of at least 32 weeks were consecutively surveyed from 17 August 2020 to 31 January 2021.Primary and secondary outcome measuresWe estimated the proportions of pregnant women wearing a face mask and masking correctly (ie, over the mouth and nose), and assessed their knowledge regarding the COVID-19 pandemic. Multivariable logistic regression was employed to identify factors associated with overall and correct face mask use.ResultsOverall, 309 (33.1%) women wore a mask during the interview after their antenatal appointments, but only 33 (10.7%) wore a mask correctly. The odds of masking and correct mask use were significantly higher among women who had their ANC visit in a facility that provided COVID-19 care. Additionally, women who experienced COVID-19-like symptoms in the past 6 months had higher odds of wearing a mask correctly compared with those reporting no recent symptoms. Although 908 (97.2%) women were aware of the COVID-19 pandemic, only 611 (67.3%) thought that COVID-19 was circulating locally in Kinshasa.ConclusionOverall and correct face mask adherence levels were low among pregnant women attending ANC in Kinshasa. Our study highlights the need for improving adherence to correct face mask use in order to help control the spread of COVID-19 within Kinshasa alongside other control measures, like vaccination.

BackgroundSurgical antibiotic prophylaxis (SAP) is one of the most effective measures to prevent surgical site infections (SSIs). According to WHO SAP guidelines, SAP requires appropriate indication for administration and delivery of the antimicrobial agent to the operative site through intravenous administration within 60-120 min before the initial surgical incision is made. In Liberia, it is unknown how surgeons practice and there has been anecdotal observation of antibiotic overuse.ObjectiveTo elucidate baseline SAP compliance, particularly appropriate SAP use based on wound class and time of antibiotic administration.MethodsAn observational, cross-sectional study was conducted from November to December 2017. One-day training was provided on SAP/SSI to 24 health workers by the Ministry of Health and WHO. Following this training, surgical cases (general surgery and obstetrics and gynaecology (OB/GYN) underwent chart review with focus on time of SAP administration and appropriate SAP based on Centers for Disease Control and Prevention (CDC) wound classification.ResultsA total of 143 charts were reviewed. Twenty-nine (20.3%) cases showed appropriate prophylaxis through administrations of antibiotics 120 min before surgical incision, resulting in SAP compliance. One hundred and fourteen cases (79.7%) showed SAP noncompliance with timing of antibiotic administration. Of the OB/Gyn cases, 109 wounds were classified as Class I (clean) and one wound was classified as Class III (contaminated). For General Surgical cases, 32 wounds were classified as Class I and one as Class III. Of the 109 Class I OB/Gyn surgeries, 24 (22%) were appropriately given antibiotics based on the CDC wound guidelines while 78% were non-compliant with recommendations. Of the 32 Class I General surgery cases, 4 (12.5%) were compliant with antibiotics guidelines while 28 (87.5%) were not.ConclusionCompliance with SAP is low. More studies need to be done to explore the contributing factors to this. Implementing mechanisms to achieve proper use of SAP is needed.

ObjectivesWe assessed the relative difficulty in meeting food needs during the COVID-19 pandemic compared with before; determined the relationship between pandemic-associated difficulties in food access and household, maternal and child food security; and identified resiliency-promoting strategies.DesignA cross-sectional survey of households undertaken in November 2020.SettingRural districts of Luang Prabang Province, Lao People's Democratic Republic.ParticipantsHouseholds (N=1122) with children under 5 years.Primary and secondary outcomes measuredSurvey respondents reported the relative ease of access of food and healthcare as well as changes in income and expenditures compared with before March 2020. We determined indicators of food security and source of foods consumed for households, women and children, as well as prevalence of malnutrition in children under 5.ResultsNearly four-fifths (78.5%) found it harder to meet household food needs during the pandemic. The most common reasons were increased food prices (51.2%), loss of income (45.3%) and decreased food availability (36.6%). Adjusting for demographics, households with increased difficulty meeting food needs had lower food consumption scores and child dietary diversity. Over 85% of households lost income during the pandemic. Decreased expenditures was associated with reliance on more extreme coping strategies to meet food needs. The households who experienced no change in meeting food needs produced a greater percentage of their food from homegrown methods (4.22% more, 95% CI 1.28 to 7.15), than households who found it more difficult.ConclusionsPandemic-associated shocks may have large effects on food insecurity. Action is needed to mitigate consequences of the pandemic on nutrition. Local food production and safety net programmes that offset income losses may help.

ObjectivesGlobally, hundreds of women die daily from preventable pregnancy-related causes, with the greatest burden in sub-Saharan Africa. Five key emergencies-bleeding, infections, high blood pressure, delivery complications and unsafe abortions-account for nearly 75% of these obstetric deaths. Skilled clinicians with strategic supplies could prevent most deaths. In this study, we (1) measured facility readiness to manage common obstetric emergencies using the clinical cascades and signal function tracers; (2) compared these readiness estimates by facility characteristics; and (3) measured cascading drop-offs in resources.DesignA facility-based cross-sectional analysis of resources for common obstetric emergencies.SettingData were collected in 2016 from 23 hospitals (10 designated comprehensive emergency obstetric care (CEmOC) facilities) in Migori County, western Kenya, and Busoga Region, eastern Uganda, in the Preterm Birth Initiative study in East Africa. Baseline data were used to estimate a facility's readiness to manage common obstetric emergencies using signal function tracers and the clinical cascade model. We compared emergency readiness using the proportion of facilities with tracers (signal functions) and the proportion with resources for identifying and treating the emergency (cascade stages 1 and 2).ResultsThe signal functions overestimated practical emergency readiness by 23 percentage points across five emergencies. Only 42% of CEmOC-designated facilities could perform basic emergency obstetric care. Across the three stages of care (identify, treat and monitor-modify) for five emergencies, there was a 28% pooled mean drop-off in readiness. Across emergencies, the largest drop-off occurred in the treatment stage. Patterns of drop-off remained largely consistent across facility characteristics.ConclusionsAccurate measurement of obstetric emergency readiness is a prerequisite for strengthening facilities' capacity to manage common emergencies. The cascades offer stepwise, emergency-specific readiness estimates designed to guide targeted maternal survival policies and programmes.Trial registration numberNCT03112018.

ObjectiveTo examine the relationship between gender-based violence, HIV risks, psychological distress and binge drinking among female entertainment workers (FEWs) in Cambodia.DesignCross-sectional study.SettingPhnom Penh and three other provinces in Cambodia.ParticipantsWe recruited 600 FEWs from entertainment venues using a stratified random sampling method. Participants were eligible if they were at least 18 years old, working in the selected entertainment venues and self-identified as a FEW.Primary outcome measureBinge drinking was defined as drinking more than five units of alcoholic drinks in 24 hours on at least one occasion in the past 3 months.ResultsThe prevalence of binge drinking was 76.7%. Adjusted odds of binge drinking were significantly higher among FEWs who earned >US$250 per month than those who earned ≤US$120 per month (adjusted OR (AOR) 2.96, 95% CI: 1.40 to 6.24), had been forced to drink more than once per month in the past 3 months than those who had never been forced to drink (AOR 5.66, 95% CI: 2.19 to 14.65), worked at karaoke bars than those working at a restaurants/café (AOR 1.85, 95% CI: 1.19 to 2.88) and experienced emotional abuse in the past 6 months than those who did not experience it (AOR 2.71, 95% CI: 1.22 to 6.02). The odds of binge drinking were significantly higher among FEWs with lower psychological distress than those with higher psychological distress (AOR 1.65, 95% CI: 1.09 to 2.49).ConclusionsThis study highlights a high prevalence of binge drinking among FEWs and its associations with working environments, conditions and contexts. Our findings suggest that individual-based behavioural intervention may not effectively reduce binge drinking among FEWs. Structural and occupational health policy interventions may be needed to change the working environment.

ObjectivesNurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians.Design, setting and participantsUsing nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination.ExposuresNPs/PAs.Main outcome measuresUse of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines.ResultsBefore propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p95% of NP/PA visits including the NP/PA-physician combination.Conclusions and relevanceWhile U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

ObjectiveThe aim of this study was to assess the effects of COVID-19 on antenatal care (ANC) utilisation in Kenya, including women's reports of COVID-related barriers to ANC and correlates at the individual and household levels.DesignCross-sectional study.SettingSix public and private health facilities and associated catchment areas in Nairobi and Kiambu Counties in Kenya.ParticipantsData were collected from 1729 women, including 1189 women who delivered in healthcare facilities before the COVID-19 pandemic (from September 2019-January 2020) and 540 women who delivered during the pandemic (from July through November 2020). Women who delivered during COVID-19 were sampled from the same catchment areas as the original sample of women who delivered before to compare ANC utilisation.Primary and secondary outcome measuresTiming of ANC initiation, number of ANC visits and adequate ANC utilisation were primary outcome measures. Among only women who delivered during COVID-19 only, we explored women's reports of the pandemic having affected their ability to access or attend ANC as a secondary outcome of interest.ResultsWomen who delivered during COVID-19 had significantly higher odds of delayed ANC initiation (ie, beginning ANC during the second vs first trimester) than women who delivered before (aOR 1.72, 95% CI 1.24 to 2.37), although no significant differences were detected in the odds of attending 4-7 or ≥8 ANC visits versus

ObjectiveTo assess the impact of the Gender Roles, Equality and Transformations (GREAT) intervention: a narrative-based, resource-light, life-stage tailored intervention package designed to promote gender-equitable attitudes and behaviours, and improve sexual and reproductive health (SRH) and gender-based violence (GBV) outcomes among adolescents and their communities.DesignRepeated cross-sectional evaluation study, using propensity score matching combined with difference-in-difference estimation.SettingTwo postconflict communities in Lira and Amuru districts in Northern Uganda.ParticipantsMale and female unmarried adolescents (10-14 years, 15-19 years), married adolescents (15-19 years) and adults (over the age of 19 years) were selected using a stratified, two-stage cluster sample of primary and secondary schools and households (baseline: n=2464, endline: n=2449).Primary outcome measuresInequitable gender attitudes and behaviours; GBV; and SRH knowledge and behaviours.ResultsStatistically significant intervention effects were seen across all three outcomes-gender equity, GBV and SRH-among older and newly married adolescents and adults. Among older adolescents, intervention effects include shifts on: inequitable gender attitudes scale score: -4.2 points ((95% CI -7.1 to -1.4), p

OBJECTIVES: To determine whether experiences of off-the-job training in domestic (DT) and overseas study (OS) settings are associated with work performance and work-family conflict in physicians. DESIGN, SETTING AND PARTICIPANTS: We conducted a national cross-sectional survey in 77 public hospitals across seven provinces in China between July 2014 and April 2015. Participants were 3182 physicians. EXPOSURE: Participants were categorised into four groups: none, DT only, OS only and DT and OS. PRIMARY OUTCOME MEASURES: Work performance was assessed by work engagement, career attrition and patient-centred care. Work-family conflict was assessed by affecting care for family, feeling guilty towards family and receiving complaints from family. RESULTS: A total of 25.89% participants had experienced DT only, 8.71% OS only and 8.47% DT and OS. After adjustment for potential confounders, participants who had experiences of DT and OS compared with those with no training were more likely to report positive work performance (pride in work: OR=2.11, 95% CI: 1.43 to 3.10; enjoyment of work: OR=1.67, 95% CI: 1.11 to 2.51; turnover intention: OR=0.54, 95% CI: 0.38 to 0.77; early retirement: OR=0.63, 95% CI: 0.45 to 0.89; and exhaustion: OR=0.66, 95% CI: 0.45 to 0.98) and less work-family conflicts (feeling guilty towards family: OR=0.51, 95% CI: 0.35 to 0.74; and complaints from family: OR=0.66, 95% CI: 0.47 to 0.91). We found no obvious association between DT/OS experience with patient-centred care. CONCLUSIONS: Physicians with DT and OS experiences are more likely to have better work performance and less work-family conflict than those without such experience. Physicians face increasing pressure to pursue continuing education and experience associated distress. Therefore, hospitals and government policy-makers should promote DT and OS.

ObjectivesSickle cell disease (SCD) leads to chronic and acute complications that require specialised care to manage symptoms and optimise clinical results. The National Heart Lung and Blood Institute (NHLBI) evidence-based guidelines assist providers in caring for individuals with SCD, but adoption of these guidelines by providers has not been optimal. The objective of this study was to identify barriers to treating individuals with SCD.MethodsThe SCD Implementation Consortium aimed to investigate the perception and level of comfort of providers regarding evidence-based care by surveying providers in the regions of six clinical centres across the USA, focusing on non-emergency care from the providers' perspective.ResultsRespondents included 105 providers delivering clinical care for individuals with SCD. Areas of practice were most frequently paediatrics (24%) or haematology/SCD specialist (24%). The majority (77%) reported that they were comfortable managing acute pain episodes while 63% expressed comfort with managing chronic pain. Haematologists and SCD specialists showed higher comfort levels prescribing opioids (100% vs 67%, p=0.004) and managing care with hydroxyurea (90% vs 51%, p=0.005) compared with non-haematology providers. Approximately 33% of providers were unaware of the 2014 NHLBI guidelines. Nearly 63% of providers felt patients' medical needs were addressed while only 22% felt their mental health needs were met.ConclusionsA substantial number of providers did not know about NHLBI's SCD care guidelines. Barriers to providing care for patients with SCD were influenced by providers' specialty, training and practice setting. Increasing provider knowledge could improve hydroxyurea utilisation, pain management and mental health support.

ObjectivesVaccine hesitancy may represent a barrier to effective COVID-19 immunisation campaigns. This study assesses individual, disease-specific and contextual factors associated with COVID-19 vaccine acceptance among a nationally representative sample of older Brazilian adults.DesignCross-sectional analysis of data from household interviews and a supplementary telephone survey.SettingBrazil and its five geographic regions.ParticipantsData are derived from 6584 individuals aged 50 years and over who participated in the second wave of the Brazilian Longitudinal Study of Aging.Primary and secondary outcome measuresSurvey-weighted multinomial logistic regression assesses factors associated with intending, not intending or being uncertain about one's intention to vaccinate against COVID-19.FindingsSeventy-one per cent of study participants intend to receive a COVID-19 vaccine once available, while 17% (representative of nearly 9 million people) have no intention to vaccinate, and 12% are still undecided. Besides age, demographic and health-related factors related to COVID-19 severity and complications were not associated with intention to vaccinate. Those who most trusted social media or friends and family for COVID-19 information and those who did not trust any information source were 68% and 78% more likely to refuse vaccination, respectively, as compared with those who trusted official information sources. People who inconsistently used face masks when outside were 3.4 times more likely than consistent face mask users to intend to refuse vaccination. Higher municipal COVID-19 fatality rates were negatively associated with vaccine refusal.ConclusionsMost national COVID-19 immunisation strategies identify older individuals as among those prioritised for early vaccination, given their increased risk of more severe symptoms and complications of the disease. Because individual, disease-specific, and contextual factors were associated with vaccine acceptance, there is a clear need for multilevel and multichannel information and outreach campaigns to increase COVID-19 vaccine acceptance among vulnerable older populations.

ObjectiveMusculoskeletal problems like hip and knee osteoarthritis and low-back pain are preference sensitive conditions. Patient engagement strategies (PES), such as shared decision-making and motivational interviewing, can help align patients' preferences with treatment options and potentially reduce spending. We assess the association of physician practice-level adoption of PES with utilisation and spending.DesignCross-sectional study in which patients were matched across low, moderate and high levels of PES via coarsened exact matching.SettingPrimary and secondary care in 2190 physician practices.Participants39 336 hip, 48 362 knee and 67 940 low-back patients who were Medicare beneficiaries were matched to the 2017-2018 National Survey of Healthcare Organizations and Systems.Primary and secondary outcome measuresTotal hip replacement (THR), total knee replacement (TKR), 1-2 level posterior lumbar fusion (LF), total annual spending, components of total annual spending.ResultsTotal annual spending for patients with musculoskeletal problems did not differ for practices with low versus moderate PES, low versus high PES or moderate versus high PES, but spending was significantly lower in some categories for practices with relatively higher PES adoption. For hospital-owned and health system-owned practices, the ORs of receiving LF were 0.632 (95% CI 0.396 to 1.009) for patients attributed to practices with high PES compared with patients attributed to practices with moderate PES. For independent practices, the odds of receiving THR were 1.403 (95% CI 1.035 to 1.902) for patients attributed to practices with moderate PES compared with patients attributed to practices with low PES.ConclusionsPractice-level adoption of PES for patients with musculoskeletal problems was generally not associated with total spending. PES, however, may steer patients toward evidence-based treatments. Opportunities for overall spending reduction exist as indicated by the variation in the subcomponents of total spending by PES adoption.

ObjectivesIn February 2020, the US Food and Drug Administration issued a guidance restricting the sales and distribution of cartridge-based e-cigarettes with flavours other than tobacco and menthol. Disposable devices were exempt from this guidance. This study examined the prevalence of disposable pod use and flavour preference compared with refillable pod and other e-cigarette users among vape shop customers.DesignCross-sectional study.SettingIn July 2019-March 2020, trained data collectors visited 44 vape shops in California with permission to recruit customers from shop owners.ParticipantsIntercept interviews with 276 customers were conducted.Outcomes and proceduresCustomers were grouped based on self-reported device type used most often (disposable pod, refillable pod and other e-cigarettes). Groups were compared on self-reported demographics, flavours preferred, daily e-cigarette use, preferred nicotine concentration levels and cigarette use.ResultsOf the 276 customers surveyed, 11.2% used disposable pods in the past 30 days. Among disposable pod users, fruit/candy (80.7%), mint (77.4%) and menthol (67.7%) were common preferred flavours, while tobacco flavours were less commonly preferred (19.4%). When compared with refillable pod and other non-pod e-cigarette device users, disposable pod users were younger, used higher nicotine concentration levels, were more likely to prefer mint and menthol flavours and use e-cigarettes as their first product, while less likely to ever use cigarettes and use e-cigarettes daily.DiscussionDespite using higher nicotine levels and preferred menthol/mint flavours more often than users of other devices, disposable pod users reported lower prevalence of lifetime smoking and daily vaping and were younger. Given the current findings, regulations addressing non-tobacco flavours and nicotine concentration in disposable pod devices merit consideration in efforts to reduce vaping in younger adult never smokers.

ObjectivesTo estimate the health characteristics and racial/ethnic health disparities among a probation cohort in Hennepin County. We hypothesised the probation population would have higher health needs compared with the general population as well as significant racial/ethnic health disparities.DesignCross-sectional study using linked administrative records.ParticipantsOf 7992 eligible individuals, 5873 met inclusion criteria of 6 or more months of eligibility for a full-benefit Minnesota healthcare plan.SettingProbation system in Hennepin County in 2016.OutcomesWe compared health condition prevalence among our probation cohort with survey data from the general population and analysed by race/ethnicity. We also measured sociodemographic characteristics, including the use of safety-net services.ResultsIndividuals were predominantly male (80.5%), young (mean age: 35.5 years), and disproportionately black or African American (52.9%). A majority of individuals enrolled in Medicaid were eligible via Medicaid expansion (65.9%). Compared with the general population, individuals on probation had higher rates of substance use disorders (66.5% vs 8.1%), mental illness (55.3% vs 14.4%) and many physical conditions (eg, asthma: 17.0% vs 12.5%, chronic kidney disease: 5.8% vs 0.2%). White individuals on probation were significantly more likely than black or African American individuals to have a diagnosed substance use disorder (71.6% vs 62.0%) or mental health disorder (64.9% vs 48.5%), but fewer chronic physical health conditions (average: 0.52 vs 0.73 chronic physical conditions).ConclusionsIndividuals on probation have high health needs, which vary substantially by race/ethnicity. Without attention to this variation, interventions to address health conditions in this population could worsen racial/ethnic disparities.

ObjectiveHousehold food insufficiency (HFIS) is a major public health threat to children. Children may be particularly vulnerable to HFIS as a psychological stressor due to their rapid growth and accelerated behavioural and cognitive states, whereas data focusing on HFIS and childhood mental disorders are as-yet sparse. We aimed to examine the associations of HFIS with depression and anxiety in US children.DesignCross-sectional study.SettingThe 2016-2018 National Survey of Children's Health, a nationally-representative study.ParticipantsPrimary caregivers of 102 341 children in the USA.Primary and secondary outcome measuresPhysician diagnosed depression and anxiety were assessed by questionnaires administered to primary caregivers of 102 341 children. Multivariable logistic regression models estimated adjusted OR (aOR) for current depression or anxiety associated with HFIS measured through a validated single-item instrument.ResultsAmong children aged 3-17 years, 3.2% and 7.4% had parent-reported physician-diagnosed current depression and anxiety, respectively. Compared with children without HFIS, children with HFIS had approximately twofold higher weighted prevalence of anxiety or depression. After adjusting for covariates, children with versus without HFIS had a 1.53-fold (95% CI 1.15 to 2.03) and 1.48-fold (95% CI 1.20 to 1.82) increased odds of current depression and anxiety, respectively. Associations were slightly more pronounced among girls (aOR (95% CI): depression 1.69 (1.16 to 2.48); anxiety 1.78 (1.33 to 2.38)) than boys (1.42 (0.98 to 2.08); 1.32 (1.00 to 1.73); both P-for-interaction

ObjectivesPeople who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk.DesignWe employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis.SettingTijuana, Mexico; San Diego, USA; Vancouver, Canada.ParticipantsA total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825).MeasurementsThe outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models.ResultsEvidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I2: 52%), recent housing insecurity (I2: 39%) and recent non-injection heroin use (I2: 78%).ConclusionWe identified common and site-specific factors related to PWID's risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.

ObjectivesTo estimate the seroprevalence of anti-SARS-CoV-2 IgG and IgM among Massachusetts residents and to better understand asymptomatic SARS-CoV-2 transmission during the summer of 2020.DesignMail-based cross-sectional survey.SettingMassachusetts, USA.ParticipantsPrimary sampling group: sample of undergraduate students at the University of Massachusetts, Amherst (n=548) and a member of their household (n=231).Secondary sampling group: sample of graduate students, faculty, librarians and staff (n=214) and one member of their household (n=78). All participants were residents of Massachusetts without prior COVID-19 diagnosis.Primary and secondary outcome measuresPrevalence of SARS-CoV-2 seropositivity. Association of seroprevalence with variables including age, gender, race, geographic region, occupation and symptoms.ResultsApproximately 27 000 persons were invited via email to assess eligibility. 1001 households were mailed dried blood spot sample kits, 762 returned blood samples for analysis. In the primary sample group, 36 individuals (4.6%) had IgG antibodies detected for an estimated weighted prevalence in this population of 5.3% (95% CI: 3.5 to 8.0). In the secondary sampling group, 10 participants (3.4%) had IgG antibodies detected for an estimated adjusted prevalence of 4.0% (95% CI: 2.2 to 7.4). No samples were IgM positive. No association was found in either group between seropositivity and self-reported work duties or customer-facing hours. In the primary sampling group, self-reported febrile illness since February 2020, male sex and minority race (Black or American Indian/Alaskan Native) were associated with seropositivity. No factors except geographic regions within the state were associated with evidence of prior SARS-CoV-2 infection in the secondary sampling group.ConclusionsThis study fills a critical gap in estimating the levels of subclinical and asymptomatic infection. Estimates can be used to calibrate models estimating levels of population immunity over time, and these data are critical for informing public health interventions and policy.

ObjectivesThe Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide.SettingA cross-sectional global survey.ParticipantsKey stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included.Primary outcomesPrimary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries.Results160 countries (covering 98% of the world's population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries.ConclusionSignificant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.

ObjectiveTo investigate the factors associated with serious psychological distress (SPD) during the COVID-19 pandemic in Japan.DesignNationwide cross-sectional study using survey data.SettingInternet survey using sampling weights for national estimates conducted between 25 August and 30 September 2020 in Japan.ExposuresDemographics (age, gender), socioeconomic status (income level, employment type, educational attainment, marital status, family composition and caregiving burden); the experience of domestic violence (DV), the state of emergency and fear of and stigma related to COVID-19.Main outcome measuresPrevalence of SPD, defined as Kessler 6 Scale score ≥13.ResultsAmong 25 482 respondents, 10.0% met the criteria of SPD. Overall, women (adjusted OR (aOR) 1.59; 95% CI 1.17 to 2.16; p=0.003), ages 15-29 (aOR 2.35 compared with ages 45-59 years; 95% CI 1.64 to 3.38; p

ObjectiveTo simultaneously examine multiple individual-level neighbourhood perceptions and psychosocial characteristics and their relationships with cardiovascular health (CVH) among blacks.DesignCross-sectional study.SettingSubjects were recruited between 2016 and 2018 via convenience sampling.Participants385 Black men and women, age 30-70 living in the Atlanta metropolitan area (Georgia, USA).Primary outcome measureIndividual's CVH was summarised as a composite score using American Heart Association's Life's Simple 7 (LS7) metrics.MethodsWe implemented unsupervised learning (k-means) and supervised learning (Bayesian Dirichlet process clustering) to identify clusters based on 11 self-reported neighbourhood perception and psychosocial characteristics. We also performed principal component analysis to summarise neighbourhood perceptions and psychosocial variables and assess their associations with LS7 scores.ResultsK-means and Bayesian clustering resulted in 4 and 5 clusters, respectively. Based on the posterior distributions, higher LS7 scores were associated with better neighbourhood perceptions and psychosocial characteristics, including neighbourhood safety, social cohesion, activities with neighbours, environmental mastery, purpose in life, resilient coping and no depression. Taken together, the first principal components of neighbourhood perceptions and psychosocial characteristics were associated with an increase of 0.07 (95% CI -0.17 to 0.31) and 0.31 (95% CI 0.06 to 0.55) in LS7 score, respectively, after accounting for age, sex, household income and education level.ConclusionBoth neighbourhood perception and psychosocial domains were related to CVH, but individual psychosocial characteristics appeared to contribute to CVH most. Approaches that acknowledge the importance of factors in both domains may prove most beneficial for enhancing resilience and promoting CVH among black communities.

ObjectiveTo investigate the association between participation in government subsidies for domestic travel (subsidise up to 50% of all travel expenses) introduced nationally in Japan on 22 July 2020 and the incidence of symptoms indicative of COVID-19 infections.DesignCross-sectional analysis of nationally representative survey data.SettingInternet survey conducted between 25 August and 30 September 2020 in Japan. Sampling weights were used to calculate national estimates.Participants25 482 survey respondents (50.3% (12 809) women; mean (SD) age, 48.8 (17.4) years).Main outcome measuresIncidence rate of five symptoms indicative of the COVID-19 infection (high fever, sore throat, cough, headache, and smell and taste disorder) within the past month of the survey, after adjustment for characteristics of individuals and prefecture fixed effects (effectively comparing individuals living in the same prefecture).ResultsAt the time of the survey, 3289 (12.9%) participated in the subsidy programme. After adjusting for potential confounders, we found that participants in the subsidy programme exhibited higher incidence of high fever (adjusted rate, 4.7% for participants vs 3.7% for non-participants; adjusted OR (aOR) 1.83; 95% CI 1.34 to 2.48; p

ObjectivesEvidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals.DesignCross-sectional study.SettingData including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014.ParticipantsWe analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals.Outcome measuresRisk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects.ResultsAt safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p

ObjectiveWe sought to determine the extent of SARS-CoV-2 seroprevalence and the factors associated with seroprevalence across a diverse cohort of healthcare workers.DesignObservational cohort study of healthcare workers, including SARS-CoV-2 serology testing and participant questionnaires.SettingsA multisite healthcare delivery system located in Los Angeles County.ParticipantsA diverse and unselected population of adults (n=6062) employed in a multisite healthcare delivery system located in Los Angeles County, including individuals with direct patient contact and others with non-patient-oriented work functions.Main outcomesUsing Bayesian and multivariate analyses, we estimated seroprevalence and factors associated with seropositivity and antibody levels, including pre-existing demographic and clinical characteristics; potential COVID-19 illness-related exposures; and symptoms consistent with COVID-19 infection.ResultsWe observed a seroprevalence rate of 4.1%, with anosmia as the most prominently associated self-reported symptom (OR 11.04, p

ObjectivesTo determine the proportion of patients with extremity sarcoma who would be willing to participate in a clinical trial in which they would be randomised to one of four different postoperative sarcoma surveillance regimens. Additionally, we assessed patients' perspectives on the burden of cancer care, factors that influence comfort with randomisation and the importance of cancer research.DesignProspective, cross-sectional patient survey.SettingOutpatient sarcoma clinics in Canada, the USA and Spain between May 2017 and April 2020. Survey data were entered into a study-specific database.ParticipantsPatients with extremity sarcoma who had completed definitive treatment from seven clinics across Canada, the USA and Spain.Main outcome measuresThe proportion of patients with extremity sarcoma who would be willing to participate in a randomised controlled trial (RCT) that evaluates varying postoperative cancer surveillance regimens.ResultsOne hundred thirty complete surveys were obtained. Respondents reported a wide range of burdens related to clinical care and surveillance. The majority of patients (85.5%) responded that they would agree to participate in a cancer surveillance RCT if eligible. The most common reason to participate was that they wanted to help future patients. Those that would decline to participate most commonly reported that participating in research would be too much of a burden for them at a time when they are already feeling overwhelmed. However, most patients agreed that cancer research will help doctors better understand and treat cancer.ConclusionsThese results demonstrate that most participants would be willing to participate in an RCT that evaluates varying postoperative cancer surveillance regimens. Participants' motivation for trial participation included altruistic reasons to help future patients and deterrents to trial participation included the overwhelming burden of a cancer diagnosis. These results will help inform the development of patient-centred RCT protocols in sarcoma surveillance research.Level of evidenceV.

IntroductionImproving the impact of nutrition interventions requires adequate measurement of both reach and quality of interventions, but limited evidence exists on advancing coverage measurement. We adjusted contact-based coverage estimates, taking into consideration the inputs required to deliver quality nutrition services, to calculate input-adjusted coverage of nutrition interventions across the continuum of care from pregnancy through early childhood in Bangladesh.MethodsWe used data from the 2014 Bangladesh Demographic and Health Surveys to assess use of maternal and child health services and the 2014 Service Provision Assessment to determine facility readiness to deliver nutrition interventions. Service readiness captured availability of nutrition-specific inputs (including human resources and training, equipment, diagnostics and medicines). Contact coverage was combined with service readiness to create a measure of input-adjusted coverage at the national and regional levels, across place of residence, and by maternal education and household socioeconomic quintiles.ResultsContact coverage varied from 28% for attending at least four ANC visits to 38% for institutional delivery, 35% for child growth monitoring and 81% for sick child care. Facilities demonstrated incomplete readiness for nutrition interventions, ranging from 48% to 51% across services. Nutrition input-adjusted coverage was suboptimal (18% for ANC, 23% for institutional delivery, 20% for child growth monitoring and 52% for sick child care) and varied between regions within the country. Inequalities in input-adjusted coverage were large during ANC and institutional delivery (14-17 percentage points (pp) between urban and rural areas, 15 pp between low and high education, and 28-34 pp between highest and lowest wealth quintiles) and less variable for sick child care (

IntroductionOnly international studies can provide the full variability of built environments and accurately estimate effect sizes of relations between contrasting environments and health-related outcomes. The aims of the International Physical Activity and Environment Study of Adolescents (IPEN Adolescent) are to estimate the strength, shape and generalisability of associations of the community environment (geographic information systems (GIS)-based and self-reported) with physical activity and sedentary behaviour (accelerometer-measured and self-reported) and weight status (normal/overweight/obese).Methods and analysisThe IPEN Adolescent observational, cross-sectional, multicountry study involves recruiting adolescent participants (ages 11-19 years) and one parent/guardian from neighbourhoods selected to ensure wide variations in walkability and socioeconomic status using common protocols and measures. Fifteen geographically, economically and culturally diverse countries, from six continents, participated: Australia, Bangladesh, Belgium, Brazil, Czech Republic, Denmark, Hong Kong SAR, India, Israel, Malaysia, New Zealand, Nigeria, Portugal, Spain and USA. Countries provided survey and accelerometer data (15 countries), GIS data (11), global positioning system data (10), and pedestrian environment audit data (8). A sample of n=6950 (52.6% female; mean age=14.5, SD=1.7) adolescents provided survey data, n=4852 had 4 or more 8+ hours valid days of accelerometer data, and n=5473 had GIS measures. Physical activity and sedentary behaviour were measured by waist-worn ActiGraph accelerometers and self-reports, and body mass index was used to categorise weight status.Ethics and disseminationEthical approval was received from each study site's Institutional Review Board for their in-country studies. Informed assent by adolescents and consent by parents was obtained for all participants. No personally identifiable information was transferred to the IPEN coordinating centre for pooled datasets. Results will be communicated through standard scientific channels and findings used to advance the science of environmental correlates of physical activity, sedentary behaviour and weight status, with the ultimate goal to stimulate and guide actions to create more activity-supportive environments internationally.

OBJECTIVES: To establish the prevalence of self-reported vision impairment (VI) in Southwest Cameroon and describe associated care-seeking practices, functional limitations and economic hardships. DESIGN: A three-stage clustered sampling household community-based survey. SETTING: The Southwest region of Cameroon. PARTICIPANTS: 8046 individuals of all ages residing in the Southwest region of Cameroon. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of self-reported VI, onset of vision loss, care-seeking practices, diagnosis and treatment, functional limitations, economic hardships on household, beliefs about surgical treatability of blindness and barriers to surgical care. RESULTS: The estimated prevalence of self-reported VI in Southwest Cameroon was 0.87% (95% CI 0.62 to 1.21). Among participants aged ≥40 years, the prevalence increased to 2.61% (95% CI 1.74 to 3.90). Less than a quarter of affected participants reported difficulty working (20.5%) or trouble going to school (12.0%) as a result of their VI. Yet, over half (52%, n=43) of affected households experienced significant economic hardships due to the VI. Residing in an urban setting (aOR 1.16, 95% CI 1.04 to 1.30) and belonging to a higher socioeconomic status (aOR 1.13, 95% CI 1.02 to 1.26) were factors associated with the belief that certain types of blindness were surgically reversible. Formal care was not sought by 16.3% (n=8) of affected participants. Cataracts was the leading diagnosis among participants who did seek formal care (43.2%, n=16), although 93.8% of these cases were not surgically treated, primarily due to a lack of perceived need. CONCLUSION: The prevalence of individuals who report vision impairment in Southwest Cameroon is considerably lower than prior published estimates based on visual physical examinations. Routine community-level screening and cost financing schemes could improve detection of pre-clinical eye disease and the utilisation of surgical care. It could also pre-empt disability and economic hardships associated with advanced VI in the region.

ObjectivesTo determine aetiology of illness among children and adults presenting during outbreak of severe respiratory illness in Southern Province, Sri Lanka, in 2018.DesignProspective, cross-sectional study.Setting1600-bed, public, tertiary care hospital in Southern Province, Sri Lanka.Participants410 consecutive patients, including 371 children and 39 adults, who were admitted with suspected viral pneumonia (passive surveillance) or who met case definition for acute respiratory illness (active surveillance) in May to June 2018.ResultsWe found that cocirculation of influenza A (22.6% of cases), respiratory syncytial virus (27.8%) and adenovirus (AdV) (30.7%; type B3) was responsible for the outbreak. Mortality was noted in 4.5% of paediatric cases identified during active surveillance. Virus type and viral coinfection were not significantly associated with mortality.ConclusionsThis is the first report of intense cocirculation of multiple respiratory viruses as a cause of an outbreak of severe acute respiratory illness in Sri Lanka, and the first time that AdV has been documented as a cause of a respiratory outbreak in the country. Our results emphasise the need for continued vigilance in surveying for known and emerging respiratory viruses in the tropics.

ObjectivesAlthough demand for price transparency in healthcare is growing, variation in private payors' payments to surgeons for oncologic resection has not been well characterised. Our aim was to assess variation of private payors' payments to surgeons for cancer resection using data based on fee-for-service allowed amounts, billed by a large mix of commercial payors and third-party administrators.SettingFair Health (FH), an independent, not-for-profit organisation that collects and compiles claims data from payors nationwide. FH maintains the nation's largest repository of privately billed medical and dental claims representing over 125 million covered lives in the USA.ParticipantsWe performed a cross-sectional study assessing private payer data for five common types of cancer surgery: simple mastectomy (SM), modified radical mastectomy (MRM), open lobectomy, video-assisted thoracoscopic surgery (VATS) lobectomy and radical prostatectomy during 2012 and 2013.Primary and secondary outcome measuresTo assess variation across regions, we compared regional median allowed payments. To assess intraregion variability, we evaluated the distribution of regional IQRs of allowed payments.ResultsMedian allowed payments varied substantially across regions. For SM, median allowed payments ranged from $550 in the least expensive to $1380 in the costliest region. For MRM, the range was $842-$1760, for lobectomy $326-$3066, for VATS $317-$3307 and for prostatectomy $1716-$4867. There was also substantial variation within geographic areas. For example, the mean IQRs in surgeon payment within regions were: SM $577 (25th percentile) to $1132 (75th percentile); MRM $850-$1620; lobectomy $861-$2767; VATS $1024-$3122; and prostatectomy $2286-$3563.ConclusionsThere is a wide range of variation both across and within geographic regions in allowed amounts of surgeon payments for common oncologic resections. Transparency about these allowed amounts may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care.

IntroductionIn the USA, transgender women are among the most vulnerable to HIV. In particular, transgender women of colour face high rates of infection and low uptake of important HIV prevention tools, including pre-exposure prophylaxis (PrEP). This paper describes the design, sampling methods, data collection and analyses of the TURNNT ('Trying to Understand Relationships, Networks and Neighbourhoods among Transgender women of colour') study. In collaboration with communities of transgender women of colour, TURNNT aims to explore the complex social and environmental (ie, neighbourhood) structures that affect HIV prevention and other aspects of health in order to identify avenues for intervention.Methods and analysesTURNNT is a prospective cohort study, which will recruit 300 transgender women of colour (150 Black/African American, 100 Latina and 50 Asian/Pacific Islander participants) in New York City. There will be three waves of data collection separated by 6 months. At each wave, participants will provide information on their relationships, social and sexual networks, and neighbourhoods. Global position system technology will be used to generate individual daily path areas in order to estimate neighbourhood-level exposures. Multivariate analyses will be conducted to assess cross-sectional and longitudinal, independent and synergistic associations of personal relationships (notably individual social capital), social and sexual networks, and neighbourhood factors (notably neighbourhood-level social cohesion) with PrEP uptake and discontinuation.Ethics and disseminationThe TURNNT protocol was approved by the Columbia University Institutional Review Board (reference no. AAAS8164). This study will provide novel insights into the relationship, network and neighbourhood factors that influence HIV prevention behaviours among transgender women of colour and facilitate exploration of this population's health and well-being more broadly. Through community-based dissemination events and consultation with policy makers, this foundational work will be used to guide the development and implementation of future interventions with and for transgender women of colour.

ObjectivesAs HIV-positive individuals' life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi.Design, setting and participantsA cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using 'integrated care' if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017.ResultsOnly half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US$21 in integrated care vs US$90 for non-integrated care)-mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all.ConclusionsIndividuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.

ObjectiveThis study aimed to investigate factors associated with patient experience with primary care in a large public health system in Mexico and determine the amount of variability in experience attributable to facility-level and state-level factors.MethodsWe analysed cross-sectional 2016 national satisfaction survey data from the Mexican Social Security Institute (IMSS). Patient-level data were merged with facility-level data and information on poverty by state. We assessed general contextual effects and examined the relationship of patient, facility and state factors with four patient experience measures using random effects logistic regression.Results25 745 patients' responses from 319 facilities were analysed. The majority experienced good communication (78%), the opportunity to share health concerns (91%) and resolution of doubts (85%). 29% of visits were rated as excellent. Differences between facilities and states accounted for up to 12% and 6% of the variation in patient experience, respectively. Inclusion of facility-level contextual effects improved model predictions by 8%-12%; models with facility random effects and individual covariates correctly predicted 64%-71% of individual outcomes. In adjusted models, larger patient population was correlated with worse reported communication, less opportunity to share concerns and less resolution of doubts. Men reported more positive communication; older individuals reported more positive communication and experiences overall, but less opportunity to share concerns; and more educated individuals were less likely to report positive communication but more likely to report resolution of doubts and overall positive experiences. Preventive care visits were rated higher than curative visits for resolution of doubts, but lower for opportunity to share concerns, and specific conditions were associated with better or worse reported experiences in some cases.ConclusionQuality improvement efforts at IMSS facilities might bolster individual experiences with primary care, given that up to 12% of the variation in experience was attributable to facility-level differences. The relationship between individual characteristics and experience ratings reinforces the importance of patients' expectations of care and the potential for differential treatment by providers to impact experience.

OBJECTIVE:Hispanics/Latinos, the largest immigrant population in the USA, undergo the process of acculturation and have a large burden of heart failure risk. Few studies have examined the association of acculturation on cardiac structure and function. DESIGN:Cross-sectional. SETTING:The Echocardiographic Study of Latinos. PARTICIPANTS:1818 Hispanic adult participants with baseline echocardiographic assessment and acculturation measured by the Short Acculturation Scale, nativity, age at immigration, length of US residence, generational status and language. PRIMARY AND SECONDARY OUTCOME MEASURES:Echocardiographic assessment of left atrial volume index (LAVI), left ventricular mass index (LVMI), early diastolic transmitral inflow and mitral annular velocities. RESULTS:The study population was predominantly Spanish-speaking and foreign-born with mean residence in the US of 22.7 years, mean age of 56.4 years; 50% had hypertension, 28% had diabetes and 44% had a body mass index >30 kg/m2. Multivariable analyses demonstrated higher LAVI with increasing years of US residence. Foreign-born and first-generation participants had higher E/e' but lower LAVI and e' velocities compared with the second generation. Higher acculturation and income >$20K were associated with higher LVMI, LAVI and E/e' but lower e' velocities. Preferential Spanish-speakers with an income

OBJECTIVE:To assess Chilean medical and midwifery students' attitudes and willingness to become trained to provide abortion care, shortly after abortion was decriminalised in 2017. DESIGN:We fielded a cross-sectional, web-based survey of medical and midwifery students. We used generalised estimating equations to assess differences by type of university and degree sought. SETTING:We recruited students from a combination of seven secular, religiously-affiliated, public and private universities that offer midwifery or medical degrees with a specialisation in obstetrics and gynaecology, located in Santiago, Chile. PARTICIPANTS:Students seeking medical or midwifery degrees at one of seven universities were eligible to participate. We distributed the survey link to medical and midwifery students at these seven universities; 459 eligible students opened the survey link and 377 students completed the survey. PRIMARY AND SECONDARY OUTCOMES:Intentions to become trained to provide abortion services was our primary outcome of interest. Secondary outcomes included moral views and concerns about abortion provision. RESULTS:Most students intend to become trained to provide abortion services (69%), 20% reported that they will not provide an abortion under any circumstance, half (50%) had one or more concern about abortion provision and 16% agreed/strongly agreed that providing abortions is morally wrong. Most believed that their university should train medical and midwifery students to provide abortion services (70%-79%). Secular university students reported higher intentions to provide abortion services (beta 0.47, 95% CI: 0.31 to 0.63), more favourable views (beta 0.52, CI: 0.32 to 0.72) and were less likley to report concerns about abortion provision (adjusted OR 0.47, CI: 0.23 to 0.95) than students from religious universities. CONCLUSION:Medical and midwifery students are interested in becoming trained to provide abortion services and believe their university should provide this training. Integrating high-quality training in abortion care into medical and midwifery programmes will be critical to ensuring that women receive timely, non-judgemental and quality abortion care.

OBJECTIVE:High levels of occupational physical activity (OPA) increase heart rate, blood pressure (BP) and the risk of hypertension. Older workers may be more vulnerable to high levels of OPA due to age-related degeneration of the cardiovascular system and cardiorespiratory fitness. This study investigates the association of relative aerobic workload (RAW) with resting BP and examines if this relation is moderated by age. DESIGN:Cross-sectional epidemiological study. SETTING:Data were collected among employees of 15 Danish companies in the cleaning, manufacturing and transport sectors. PARTICIPANTS:2107 employees were invited for participation, of these 1087 accepted and 562 (42% female and 4% non-Westerns) were included in the analysis based on the criteria of being non-pregnant, no allergy to bandages, sufficient amount of heart rate data corresponding to ≥4 work hours per workday or 75% of average work hours, and no missing outcome and confounder values. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome measure was BP. RESULTS:Heart rate reserve was estimated from ambulatory 24-hour heart rate measures covering 2.5 workdays per participant (SD 1.0 day). Age significantly moderated the association between RAW and BP. Mean intensity and duration of high RAW (≥30% heart rate reserve) showed positive associations with diastolic BP and negative associations with pulse pressure (PP) among participants ≥47 years old. Tendencies towards negative associations between RAW and BP were seen among participants

IntroductionAmong patients with psychotic disorders, the 'duration of untreated psychosis' (DUP) is a predictor of key outcomes such as symptom remission and quality of life. In sub-Saharan Africa, DUP is up to five times longer than in high-income countries, with many patients going without antipsychotic medication for 5 years or longer. One contributor to this high DUP may relate to cultural norms that drive use of alternative and complementary therapies (ACTs) as first-line treatment strategies, rather than biomedical care with antipsychotic medicine. We aim to1 determine the prevalence and factors associated with DUP and ACT use in Uganda, and2 Identify factors that drive patient and family choices to use ACT as a first-line treatment strategy.Methods and analysisWe will leverage on an ongoing cohort study at the national psychiatric and teaching hospital in Uganda. The parent study is an observational cohort design following antipsychotic naïve adults with a first episode of psychosis without substance use, HIV/AIDS or syphilis. The embedded study will use a mixed methods design including quantitative assessment of parent study participants with the Nottingham Onset Schedule-DUP to determine the DUP. Qualitative assessment will focus on patient and caregiver perceptions and use of ACT and its impact on DUP among patients with psychosis using in-depth interviews.Ethics and disseminationThe study has received ethical approval from the school of medicine research and ethics committee of the college of health sciences at Makerere University. It has also received institutional support to perform the study from the Infectious Diseases Institute and Butabika hospital. Besides publication of the work in reputable peer-reviewed journals, we hope that this work will lead to evidence-based discussions on the need for early interventions to reduce DUP in Uganda.

ObjectivesAlthough tobacco is the leading preventable cause of death in the USA, it is routinely sold in pharmacies. In 2008, San Francisco became the first city in the USA to pass a tobacco-free pharmacy ordinance. Over the next decade, 171 municipalities enacted similar policies, and in 2018, Massachusetts banned tobacco sales in pharmacies. Our objective was to assess the perceived effects of tobacco-free pharmacy policies on displays, sales, customer visits and counselling.DesignObservational study and survey.SettingIn 2017, we visited Walgreens and CVS stores in San Francisco and nearby San Jose, which allows tobacco sales, to assess placement of tobacco and over-the-counter tobacco cessation products (nicotine replacement therapy or NRT). We surveyed an employee at each site regarding the impact that tobacco-free pharmacy policies had had on customer traffic and sales of NRT.ParticipantsWe obtained display data from 72 pharmacies and collected surveys from 55 employees (76% response rate).ResultsA majority of respondents at tobacco-free pharmacies (55%) reported that the policy had not affected customer visits. In comparison, 70% of respondents at tobacco-selling pharmacies believed that eliminating tobacco sales would reduce the number of customers visiting their stores. Pharmacies that were tobacco free and those that sold tobacco reported comparable displays, sales and counselling for NRT.ConclusionsPharmacies operating under tobacco-free policies did not report reduced customer visits. Greater awareness of this outcome could help pharmacies implement public health recommendations to eliminate tobacco sales.

ObjectivesTo investigate risk factor patterns and the simultaneous occurrence of multiple risk factors in the viral, metabolic and lifestyle domains among Asian Americans, who have had the highest mortality rates from hepatocellular carcinoma (HCC).SettingSacramento County, California, USA.ParticipantsEligible participants were county residents ages 18 and older who had not been screened for chronic hepatitis B virus (HBV) and were born in a CDC-defined endemic area or whose parent was born in that area. Of 1004 enrolled, 917 were foreign-born Chinese (130 women, 94 men), Hmong (133 women, 75 men), Korean (178 women, 90 men) or Vietnamese (136 women, 81 men) with complete risk factor data.Primary and secondary outcome measuresWe tested participants for HBV and chronic hepatitis C virus (HCV); measured haemoglobin A1c and waist circumference; and recorded self-reported history of diabetes, hypertension, alcohol use and smoking status. We identified risk factor patterns using cluster analysis and estimated gender-specific age-standardised prevalence rates.ResultsWe identified four patterns: (1) viral (chronic HBV or HCV); (2) lifestyle (current smoker or alcohol user, no viral); (3) metabolic (≥2 metabolic, no lifestyle or viral); and (4) lower risk (≤1 metabolic, no lifestyle or viral). Vietnamese men (16.3%, 95% CI 7.4% to 25.3%) and Hmong women (15.1%, 95% CI 7.8% to 22.5%) had the highest viral pattern prevalence. Hmong women had the highest metabolic (37.8%, 95% CI 29.8% to 45.9%), and Vietnamese men the highest lifestyle (70.4%, 95% CI 59.1% to 81.7%) pattern prevalence. In multiple domains, Hmong men and women were most likely to have viral+metabolic risk factors (men: 14.4%, 95% CI 6.0% to 22.7%; women: 11.9%, 95% CI 5.6% to 18.3%); Vietnamese men were most likely to have lifestyle+viral (10.7%, 95% CI 2.7% to 18.8%), and lifestyle+metabolic but not viral (46.4%, 95% CI 34.4% to 58.5%) risk factors.ConclusionsEfforts to reduce HCC must comprehensively address multiple risk factors.Trial registration numberNCT02596438.

OBJECTIVE: Examine whether glycaemic control varies according to sex and whether the latter plays a role in modifying factors associated with inadequate glycaemic control in patients with type 2 diabetes (T2D) in Brazil and Venezuela. DESIGN, SETTING AND PARTICIPANTS: This was a cross-sectional, nationwide survey conducted in Brazil and Venezuela from February 2006 to June 2007 to obtain information about glycaemic control and its determinants in patients with diabetes mellitus attending outpatient clinics. MAIN OUTCOME MEASURES: Haemoglobin A1c (HbA1c) level was measured by liquid chromatography, and patients with HbA1c ≥7.0% (53 mmol/mol) were considered to have inadequate glycaemic control. The association of selected variables with glycaemic control was analysed by multivariate linear regression, using HbA1c as the dependent variable. RESULTS: A total of 9418 patients with T2D were enrolled in Brazil (n=5692) and in Venezuela (n=3726). They included 6214 (66%) women and 3204 (34%) men. On average, HbA1c levels in women were 0.13 (95% CI 0.03 to 0.24; p=0.015) higher than in men, after adjusting for age, marital status, education, race, country, body mass index, duration of disease, complications, type of healthcare, adherence to diet, adherence to treatment and previous measurement of HbA1c. Sex modified the effect of some factors associated with glycaemic control in patients with T2D in our study, but had no noteworthy effect in others. CONCLUSIONS: Women with T2D had worse glycaemic control than men. Possible causes for poorer glycaemic control in women compared with men include differences in glucose homeostasis, treatment response and psychological factors. In addition, sex modified factors associated with glycaemic control, suggesting the need to develop specific treatment guidelines for men and women.

IntroductionPalliative care coverage and opioid consumption in India are relatively low compared with global data. The literature suggests commonplace concealment and collusion in withholding information, but these hypotheses lack evidence.ObjectivesThis study aimed to develop an explanatory evidence-based model of stigma, communication and access to cancer palliative care in India that can be used to develop, test and implement future interventions.DesignThis cross-sectional qualitative study sampled advanced cancer patients (n=10), their family caregivers (n=10) and oncologists (n=10). Grounded theory procedures were utilised to analyse transcripts, and a theoretical model generated.SettingA tertiary teaching hospital in South India.ResultsThe model explains how stigma associated with communicating a diagnosis of advanced cancer is enacted by treating oncologists, family members and community. This leads to patient expectations of cure and futile treatment uptake. Patients commonly only present needs with respect to pain, not within psychological, social or spiritual domains, likely due to the lack of patients' insight into their diagnosis and prognosis. As a result of oncologists' and families' unwillingness to disclose the prognosis, and patient focus on pain due to their lack of insight, palliative care clinicians view their services as under-utilised, and patients perceive palliative care as a pain management service that is not 'different' from other clinical services. Advanced care needs and purchase of futile treatments lead to lost employment among families, increased family debt and high care costs, which are rarely disclosed due to their unwillingness to discuss their needs.ConclusionOur novel theoretical model is an essential first step to ensure that complex interventions are plausible, with mechanisms of action that address the needs of relevant stakeholders. A family-centred approach with an oncology workforce skilled in communication and an enabled patient population could increase access to palliative care, and improved outcomes may be attainable.

ObjectiveExamine whether glycaemic control varies according to sex and whether the latter plays a role in modifying factors associated with inadequate glycaemic control in patients with type 2 diabetes (T2D) in Brazil and Venezuela.Design, setting and participantsThis was a cross-sectional, nationwide survey conducted in Brazil and Venezuela from February 2006 to June 2007 to obtain information about glycaemic control and its determinants in patients with diabetes mellitus attending outpatient clinics.Main outcome measuresHaemoglobin A1c (HbA1c) level was measured by liquid chromatography, and patients with HbA1c ≥7.0% (53 mmol/mol) were considered to have inadequate glycaemic control. The association of selected variables with glycaemic control was analysed by multivariate linear regression, using HbA1c as the dependent variable.ResultsA total of 9418 patients with T2D were enrolled in Brazil (n=5692) and in Venezuela (n=3726). They included 6214 (66%) women and 3204 (34%) men. On average, HbA1c levels in women were 0.13 (95% CI 0.03 to 0.24; p=0.015) higher than in men, after adjusting for age, marital status, education, race, country, body mass index, duration of disease, complications, type of healthcare, adherence to diet, adherence to treatment and previous measurement of HbA1c. Sex modified the effect of some factors associated with glycaemic control in patients with T2D in our study, but had no noteworthy effect in others.ConclusionsWomen with T2D had worse glycaemic control than men. Possible causes for poorer glycaemic control in women compared with men include differences in glucose homeostasis, treatment response and psychological factors. In addition, sex modified factors associated with glycaemic control, suggesting the need to develop specific treatment guidelines for men and women.