Development of the Family Togetherness Scale: A Mixed-Methods Validation Study in Kenya

Family functioning is an important target of clinical intervention and research given its close ties with mental health outcomes of both children and adults. However, we lack family functioning measures validated for use in many low- and middle-income country (LMIC) settings. In this mixed-methods prospective diagnostic accuracy study, we first used formative qualitative data to develop an extensive battery of screening items to measure family functioning in Kenya. We then recruited 30 Kenyan families (N = 44 adults; 30 youth aged 8–17 years) to complete the questionnaires and participate in clinical interviews conducted by local interviewers. Quantitative and qualitative analyses were then conducted to select a subset of screening items that balanced conceptual understanding of family distress with diagnostic efficiency and accuracy to yield a brief but valid scale. The final index test consisting of 30 items correctly identified distressed families in 89% of cases according to adult-report and 76% of cases according to child-report. The optimal cutoffs are associated with estimates of sensitivity/specificity of 0.88/0.90 and 0.75/0.77 for adult-report and child-report measures, respectively. The final measure—the Family Togetherness Scale (FTS)—assesses global family functioning, including items related to family organization, emotional closeness, and communication/problem-solving. In addition to general items, the scale also includes items explicitly assessing family responses to stressors common in LMIC settings. Results establish a strong rationale for larger-scale validation studies.

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Discriminating Malignancy in Thyroid Nodules: The Nomogram Versus the Kwak and ACR TI-RADS

Otolaryngology ◽

10.1177/0194599820939071 ◽

2020 ◽

Vol 163 (6) ◽

pp. 1156-1165

Author(s):

Juan Xiao ◽

Qiang Xiao ◽

Wei Cong ◽

Ting Li ◽

Shouluan Ding ◽

...

Keyword(s):

Thyroid Nodules ◽

Characteristic Curve ◽

Area Under The Curve ◽

Diagnostic Study ◽

Diagnostic Efficiency ◽

Training Set ◽

Multivariable Logistic Regression Model ◽

Predictive Values ◽

Validation Set ◽

Sensitivity Specificity

Objective To develop an easy-to-use nomogram for discrimination of malignant thyroid nodules and to compare diagnostic efficiency with the Kwak and American College of Radiology (ACR) Thyroid Imaging, Reporting and Data System (TI-RADS). Study Design Retrospective diagnostic study. Setting The Second Hospital of Shandong University. Subjects and Methods From March 2017 to April 2019, 792 patients with 1940 thyroid nodules were included into the training set; from May 2019 to December 2019, 174 patients with 389 nodules were included into the validation set. Multivariable logistic regression model was used to develop a nomogram for discriminating malignant nodules. To compare the diagnostic performance of the nomogram with the Kwak and ACR TI-RADS, the area under the receiver operating characteristic curve, sensitivity, specificity, and positive and negative predictive values were calculated. Results The nomogram consisted of 7 factors: composition, orientation, echogenicity, border, margin, extrathyroidal extension, and calcification. In the training set, for all nodules, the area under the curve (AUC) for the nomogram was 0.844, which was higher than the Kwak TI-RADS (0.826, P = .008) and the ACR TI-RADS (0.810, P < .001). For the 822 nodules >1 cm, the AUC of the nomogram was 0.891, which was higher than the Kwak TI-RADS (0.852, P < .001) and the ACR TI-RADS (0.853, P < .001). In the validation set, the AUC of the nomogram was also higher than the Kwak and ACR TI-RADS ( P < .05), each in the whole series and separately for nodules >1 or ≤1 cm. Conclusions When compared with the Kwak and ACR TI-RADS, the nomogram had a better performance in discriminating malignant thyroid nodules.

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Psychosocial influences on help-seeking behaviour for cancer in low-income and lower middle-income countries: a mixed-methods systematic review

BMJ Global Health ◽

10.1136/bmjgh-2020-004213 ◽

2021 ◽

Vol 6 (2) ◽

pp. e004213

Author(s):

Grace McCutchan ◽

Bahr Weiss ◽

Harriet Quinn-Scoggins ◽

Anh Dao ◽

Tom Downs ◽

...

Keyword(s):

Systematic Review ◽

Mixed Methods ◽

Cancer Treatment ◽

Help Seeking ◽

Middle Income ◽

Cancer Symptoms ◽

Middle Income Countries ◽

Help Seeking Behaviour ◽

Psychosocial Influences

IntroductionStarting cancer treatment early can improve outcomes. Psychosocial factors influencing patients’ medical help-seeking decisions may be particularly important in low and lower middle-income countries (LMIC) where cancer outcomes are poor. Comprehensive review evidence is needed to understand the psychosocial influences on medical help-seeking for cancer symptoms, attendance for diagnosis and starting cancer treatment.MethodsMixed-methods systematic review registered on PROSPERO (CRD42018099057). Peer-reviewed databases were searched until April 2020 for studies assessing patient-related barriers and facilitators to medical help-seeking for cancer symptoms, diagnosis and treatment in adults (18+ years) living in LMICs. Quality of included studies was assessed using the Critical Appraisal Skills Programme tool. Data were synthesised using meta-analytic techniques, meta-ethnography or narrative synthesis as appropriate.ResultsOf 3963 studies identified, 64 were included. In quantitative studies, use of traditional, complementary and alternative medicine (TCAM) was associated with 3.60 higher odds of prolonged medical help-seeking (95% CI 2.06 to 5.14). Qualitative studies suggested that use of TCAM was a key barrier to medical help-seeking in LMICs, and was influenced by causal beliefs, cultural norms and a preference to avoid biomedical treatment. Women face particular barriers, such as needing family permission for help-seeking, and higher stigma for cancer treatment. Additional psychosocial barriers included: shame and stigma associated with cancer such as fear of social rejection (eg, divorce/disownment); limited knowledge of cancer and associated symptoms; and financial and access barriers associated with travel and appointments.ConclusionDue to variable quality of studies, future evaluations would benefit from using validated measures and robust study designs. The use of TCAM and gender influences appear to be important barriers to help-seeking in LMIC. Cancer awareness campaigns developed with LMIC communities need to address cultural influences on medical help-seeking behaviour.

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Development and Evaluation of a Novel Fast Broad-Range ITS/LSU DNA PCR and Sequencing Assay (FBR-PCR/S) for Rapid Diagnosis of Invasive Fungal Diseases: Multi-Year Experience in a Large Canadian Healthcare Zone and a Literature Review

10.21203/rs.3.rs-1009236/v1 ◽

2021 ◽

Author(s):

B Chow ◽

M Groeschel ◽

J Carson ◽

Thomas Griener ◽

Deirdre Church

Keyword(s):

Predictive Value ◽

Patient Characteristics ◽

Invasive Fungal Disease ◽

Molecular Testing ◽

Fungal Culture ◽

Diagnostic Efficiency ◽

Molecular Assay ◽

Risk Patients ◽

Sensitivity Specificity ◽

Canadian Healthcare

Abstract BackgroundThis study evaluated the performance of a novel fast broad range PCR and sequencing (FBR-PCR/S) assay for the improved diagnosis of invasive fungal disease (IFD) in high-risk patients in a large Canadian healthcare region.MethodsA total of 114 clinical specimens (CS) including bronchoalveolar lavages (BALs) were prospectively tested from 107 patients over a 2-year period. Contrived BALs (n=33) inoculated with known fungi pathogens were also tested to increase diversity. Patient characteristics, fungal stain and culture results were collected from the laboratory information system. Dual-priming oligonucleotide (DPO) primers targeted to the ITS (~350 bp) and LSU (~550 bp) gene regions were used to perform FBR-PCR/S assays on extracted BALs/CS. The performance of the molecular test was evaluated against results of fungal stains and culture, and where available, histopathology, and clinical review for the presence of IFD.ResultsThe 107 patients were predominantly male (67, 62.6%%) with a mean age of 59 yrs. (range = 0 to 85 yrs.): 74 (69.2%) patients had at least one underlying comorbidity: 19 (34.5%) had confirmed and 12 (21.8%) had probable IFD. Culture recovered 66 fungal isolates from 55 BALs/CS with Candida spp. and Aspergillus spp. being most common. For BALs, the molecular assay vs. fungal culture had sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and efficiency of 88.5% vs.100%, 100% vs. 61.1%, 100% vs. 88.5%, 61.1% vs. 100%, and 90.2% for both. For other CS, the molecular assay had similar performance to fungal culture with sensitivity, specificity, PPV, NPV and efficiency of 66.7%, 87.0%, 66.7%, 87.0% and 81.3% for both methods. Both methods also performed similarly, regardless of whether CS stain/microscopy showed yeast/fungal elements. FBR-PCR/S assays results were reported in ~8h compared to fungal cultures that took between 4 to 6 weeks.ConclusionsRapid molecular testing compared to culture has equivalent diagnostic efficiency but improves clinical utility by reporting a rapid species-level identification the same dayshift (~8h).

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Epidemics, Lockdown Measures and Vulnerable Populations: A Mixed-Methods Systematic Review of the Evidence of Impacts on Mother and Child Health in Low-And- Lower Middle-Income Countries

International Journal of Health Policy and Management ◽

10.34172/ijhpm.2021.155 ◽

2021 ◽

Author(s):

Giuliano Russo ◽

Tiago Silva Jesus ◽

Kevin Deane ◽

Abdinasir Yusuf Osman ◽

David McCoy

Keyword(s):

Systematic Review ◽

Mixed Methods ◽

Inclusion Criteria ◽

Middle Income ◽

Middle Income Countries ◽

Premature Deaths ◽

Trade Offs ◽

Mother And Child ◽

New Research ◽

The Impact

Background: The aim of this research was to synthetise the existing evidence on the impact of epidemic-related lockdown measures on women and children’s health in low-and-lower-middle-income countries. Methods: A mixed-methods systematic review was conducted of qualitative, quantitative and mixed-methods evidence. Between November 1st-10th 2021, seven scientific databases were searched. The inclusion criteria were that the paper provided evidence on the impact of lockdown and related measures, focused on low-and-lower-middle-income countries, addressed impacts on women and child’s health, addressed epidemics from 2000-2020, was peer-reviewed, provided original evidence, and was published in English. The Joanne Briggs Institute’s critical appraisal tools were used to assess the quality of the studies, and the PRISMA guidelines for reporting. The evidence from the papers was grouped by type of lockdown measure and categories of impact, using a narrative data-based convergent synthesis design. Results: The review process identified 46 papers meeting the inclusion criteria from 17 countries whichall focussed on the COVID-19 and Ebola epidemics. The evidence on the decrease of utilisation of health services showed plummeting immunisation rates and faltering use of maternal and perinatal services, which was linked to a growth of premature deaths. Impacts on the mental health of children and women is well-established, with lockdowns associated with surges in depression, anxiety and low life satisfaction. Vulnerability may be compounded by lockdowns, as livelihoods are disrupted, and poverty levels increase. Conclusion: Limitations included that searches were conducted in late-2020 as new research was being published, and that some evidence not published in English may have been excluded. Epidemic-related lockdown measures carry consequences for the health of women and children in lower-income settings. Governments will need to weigh the trade-offs of introducing such measures and consider policies to mitigate their impacts on the most vulnerable.

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Deep Learning for Computer-aided Diagnosis of Pneumoconiosis

10.21203/rs.3.rs-460896/v1 ◽

2021 ◽

Author(s):

Zheng Wang ◽

Qingjun Qian ◽

Jianfang Zhang ◽

Caihong Duo ◽

Wen He ◽

...

Keyword(s):

Deep Learning ◽

Computer Aided Diagnosis ◽

Chest Radiographs ◽

Diagnostic Sensitivity ◽

Junior Doctors ◽

Diagnostic Efficiency ◽

Test Set ◽

Computer Aided ◽

Sensitivity Specificity ◽

Aided Diagnosis

Abstract Background: The diagnosis of pneumoconiosis relies primarily on chest radiographs and exhibits significant variability between physicians. Computer-aided diagnosis (CAD) can improve the accuracy and consistency of these diagnoses. However, CAD based on machine learning requires extensive human intervention and time-consuming training. As such, deep learning has become a popular tool for the development of CAD models. In this study, the clinical applicability of CAD based on deep learning was verified for pneumoconiosis patients.Methods: Chest radiographs were collected from 5424 occupational health examiners who met the inclusion criteria. The data were divided into training, validation, and test sets. The CAD algorithm was then trained and applied to processing of the validation set, while the test set was used to evaluate diagnostic efficacy. Three junior and three senior physicians provided independent diagnoses using images from the test set and a comprehensive diagnosis for comparison with the CAD results. A receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficiency of the proposed CAD system. A McNemar test was used to evaluate diagnostic sensitivity and specificity for pneumoconiosis, both before and after the use of CAD. A kappa consistency test was used to evaluate the diagnostic consistency for both the algorithm and the clinicians.Results: ROC results suggested the proposed CAD model achieved high accuracy in the diagnosis of pneumoconiosis, with a kappa value of 0.90. The sensitivity, specificity, and kappa values for the junior doctors increased from 0.86 to 0.98, 0.68 to 0.86, and 0.54 to 0.84, respectively (p<0.05), when CAD was applied. However, metrics for the senior doctors were not significantly different.Conclusion: DL-based CAD can improve the diagnostic sensitivity, specificity, and consistency of pneumoconiosis diagnoses, particularly for junior physicians.

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Assessing determinants of programmatic performance of community management of malaria, pneumonia, and diarrhea in children in Africa: Protocol and data collection for a mixed-methods evaluation of iCCM (Preprint)

10.2196/preprints.33076 ◽

2021 ◽

Author(s):

Aliya Karim ◽

Don de Savigny ◽

Serge Ngaima ◽

Daniel Mäusezahl ◽

Daniel Cobos Muñoz ◽

...

Keyword(s):

Mixed Methods ◽

Focus Group ◽

Child Health ◽

Data Collection ◽

Intervention Effectiveness ◽

Focus Group Discussions ◽

Group Discussions ◽

Middle Income ◽

Key Informant ◽

Low And Middle Income

BACKGROUND Integrated community case management (iCCM) is a child health program designed to provide integrated, community-based care for pneumonia, malaria and diarrhea for children in hard-to-reach areas of low- and middle-income countries (LMICs). The foundation of the intervention is service-delivery by community health workers (CHWs) who depend on reliable provision of drugs and supplies, consistent supervision, comprehensive training, and community acceptance and participation to perform optimally. The effectiveness of the program may also depend on a number of other elements, including an enabling policy environment, financing mechanisms from the national to the local level, data transmission systems, and appropriate monitoring and evaluation. The extent to which these factors act upon each other to influence the effectiveness and viability of iCCM is both variable and challenging to assess, especially across different implementation contexts. OBJECTIVE In this paper, we describe a mixed-methods systems-based study protocol to assess the programmatic components of iCCM which are associated with intervention effectiveness, and report preliminary results of data collection. METHODS This protocol employs a mixed qualitative and quantitative study design based on a Systems Thinking approach within four iCCM programs in Malawi, Democratic Republic of the Congo, Niger State, and Abia State, Nigeria. Routine monitoring data is collected to determine intervention effectiveness, namely testing, treatment and referral outcomes. Surveys with CHWs, supervisors, and caregivers are performed to collect quantitative data on their demographics, activities, and experiences within the program, and how these relate to the areas of intervention effectiveness. Focus group discussions are conducted with these stakeholders as well as local traditional leaders to contextualize this data. Key informant interviews are undertaken with national and district-level program stakeholders and officers knowledgeable in critical program processes. RESULTS We performed 3,836 surveys and 45 focus group discussions with CHWs, supervisors, and caregivers, and traditional leaders; 120 key informant interviews with district and national-level program managers, health officers, and ministry officials. Policy and program documents were additionally collected for review. CONCLUSIONS Evidence from this study will inform child health programs and practice in low- and middle-income settings, and future policy development within the iCCM intervention.

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To explore the barriers to and facilitators of adolescents in Low-Middle-Income- Countries (LMICs) seeking mental health care: Protocol for a Mixed-Methods Systematic Review

10.21203/rs.3.rs-215110/v1 ◽

2021 ◽

Author(s):

Sudha Subhadra Kallakuri ◽

Pallab K Maulik ◽

Prachi Kaistha ◽

Maree Hackett

Keyword(s):

Mental Health ◽

Systematic Review ◽

Mixed Methods ◽

Study Design ◽

Critical Appraisal ◽

Mental Illnesses ◽

World Health ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries

Abstract Background: Adolescence is a very important transitional phase for an individual as they move from childhood to adulthood. In 2007, the World Health Organization reported that 16% of the global burden of disease and injuries occur among adolescents i.e. those aged between 10 and 19 years, most of them starting by the age of 14 years and usually become serious; if left unrecognised or unattended at that point in time. Several risk factors are associated with increases in the mental health disorders. It is pertinent to promote interventions which teach life skills like regulating one’s emotions, building resilience, and dealing with difficult situations with confidence and strength. This mixed-methods systematic review aims to synthesise best available evidence on the barriers and facilitators to help seeking for mental illnesses among adolescents in Low-Middle-Income Countries Methods and Analyses: The systematic review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Systematic searches will be carried out in electronic databases like PubMed,EMBASE, PsychINFO, Sociofile, CINAHL to identify studies relevant to the review question. At the first stage, titles and abstracts of articles retrieved through the searches will be examined against the eligibility criteria. The second stage will involve independent full-text screening of included articles by two reviewers. All qualitative, quantitative, and mixed method research studies which explicitly answer the research questions will be considered in this review. Methodological appraisal (Risk of Bias) will be conducted using the Joanna Briggs Institute's standardized critical appraisal tools or other standardized critical appraisal tools contingent on the study design by two reviewers. Data will be extracted on the aims/purpose, study design, geographical location, study population, study duration, interventions (if applicable) outcomes, and results of included studies. Data analyses will be conducted using the convergent approach to analysis of mixed methods research using JBI guidance. Discussion: The research will help to identify gaps in knowledge and generate evidence for health departments to look more specifically at the mental health of adolescents and challenges of addressing them. Systematic Review Registration: PROSPERO: CRD42020214349

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A protocol for evaluating a multi-level implementation theory to scale up obstetric triage in referral hospitals in Ghana

10.21203/rs.3.rs-16855/v2 ◽

2020 ◽

Author(s):

Caitlin Rain Williams ◽

Stephanie Bogdewic ◽

Medge Owen ◽

Emmanuel K. Srofe ◽

Rohit Ramaswamy

Keyword(s):

Mixed Methods ◽

Scale Up ◽

Implementation Strategies ◽

Clinical Intervention ◽

Interactive Systems ◽

Interactive Systems Framework ◽

Implementation Theory ◽

Care Plans ◽

Implementation Approach ◽

Multi Level

Abstract Background: Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan. Methods: An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions.A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability.Discussion: The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the “know-do” gap.

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The impact of the Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia training course in Ethiopia: A mixed methods longitudinal cohort study

Anaesthesia and Intensive Care ◽

10.1177/0310057x20940330 ◽

2020 ◽

Vol 48 (4) ◽

pp. 297-305

Author(s):

Jolene N Moore ◽

Wayne W Morriss ◽

Gebrehiwot Asfaw ◽

Gosa Tesfaye ◽

Aaliya R Ahmed ◽

...

Keyword(s):

Cohort Study ◽

Mixed Methods ◽

Maternal Mortality ◽

Longitudinal Cohort Study ◽

Structured Interviews ◽

Middle Income ◽

Longitudinal Cohort ◽

Obstetric Anaesthesia ◽

The Impact

Summary Reducing maternal mortality remains a global priority, particularly in low- and middle-income countries (LMICs). The Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia (OB) course is a three-day refresher course for trained anaesthesia providers addressing common causes of maternal mortality in LMICs. This aim of this study was to investigate the impact of SAFE training for a cohort of anaesthesia providers in Ethiopia. We conducted a mixed methods longitudinal cohort study incorporating a behavioural questionnaire, multiple-choice questionnaires (MCQs), structured observational skills tests and structured interviews for anaesthesia providers who attended one of four SAFE-OB courses conducted in two regions of Ethiopia from October 2017 to May 2018. Some 149 participants from 60 facilities attended training. Behavioural questionnaires were completed at baseline ( n = 101, 69% response rate). Pre- and post-course MCQs ( n = 121, n = 123 respectively) and pre- and post-course skills tests ( n = 123, n = 105 respectively) were completed, with repeat MCQ and skills tests, and semi-structured interviews completed at follow-up ( n = 88, n = 76, n = 49 respectively). The mean MCQ scores for all participants improved from 80.3% prior to training to 85.4% following training ( P < 0.0001) and skills test scores improved from 56.5% to 83.2% ( P < 0.0001). Improvements in MCQs and skills were maintained at follow-up 3–11 months post-training compared to baseline ( P = 0.0006, < 0.0001 respectively). Participants reported improved confidence, teamwork and communication at follow-up. This study suggests that the SAFE-OB course can have a sustained impact on knowledge and skills and can improve the confidence of anaesthesia providers and communication within surgical teams.

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Health-related quality of life in adult CHD surgical patients in a low middle-income country: a mixed-methods study

Cardiology in the Young ◽

10.1017/s1047951120001663 ◽

2020 ◽

Vol 30 (8) ◽

pp. 1126-1137

Author(s):

Laila A. Ladak ◽

Robyn Gallagher ◽

Babar S. Hasan ◽

Khadija Awais ◽

Ahmed Abdullah ◽

...

Keyword(s):

Quality Of Life ◽

Mixed Methods ◽

Mixed Methods Study ◽

Income Country ◽

Surgical Patients ◽

Health Related Quality ◽

Middle Income ◽

Related Quality ◽

Health Related

AbstractBackground and objectives:This mixed-methods study aimed to assess health-related quality of life in young adults with CHD following surgery in a low middle-income country, Pakistan. Despite the knowledge that geographic, cultural and socio-economic factors may shape the way health and illness is experienced and managed and consequently determine a person’s health-related quality of life, few health-related quality of life studies are conducted in low middle-income countries. This deficit is pronounced in CHD, so there is little guidance for patient care.Methods:The study utilised concurrent, mixed methods. Adults with CHD (n = 59) completed health-related quality of life surveys (PedsQLTM 4.0 Generic Core Scale, PedsQLTM Cognitive Functioning Scale and PedsQLTM 3.0 Cardiac Module). Semi-structured interview data were collected from a nested sub-sample of 17 participants and analysed using qualitative content analysis, guided by the revised Wilson–Cleary model of health-related quality of life.Results:The lowest health-related quality of life domain was emotional with the mean score (71.61 ± 20.6), followed by physical (78.81 ± 21.18) and heart problem (79.41 ± 18.05). There was no statistical difference in general or cardiac-specific health-related quality of life between mild, moderate or complex CHD. Qualitative findings suggested low health-related quality of life arose from a reduced capacity to contribute to family life including family income and gender. A sense of reduced marriageability and fear of dependency were important socio-cultural considerations.Conclusions:CHD surgical patients in this low-income country experience poor health-related quality of life, and contributing factors differ to those reported for high-income countries. Socio-cultural understandings should underpin assessment, management and care-partnering with young adults with CHD following surgical correction.

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