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Open tibia fractures result in substantial lifelong disability for patients, and are expensive to treat. As the injury typically affects young working men, the societal costs from open tibia fractures are likely to also be high in low income countries, but remain largely unknown. We therefore investigated the overall societal costs and cost-effectiveness of different orthopaedic treatments at one year following an open tibia fracture in Malawi. This study was a cost-utility analysis nested in a prospective cohort study from the healthcare- and societal-payer perspectives with a one-year time horizon. We obtained quality-adjusted life years (QALYs) from the EuroQoL 5 Dimension 3 Level (EQ-5D-3L) and patient lost productivity estimates at 6 weeks, and 3, 6, and 12 months post-injury. QALYs were calculated from utility scores were modelled within a hierarchical Bayesian multivariate modelling framework that jointly estimated individual-level trajectories in EQ-5D-3L scores and costs over follow-up. Direct treatment costs were obtained from a micro-costing study, and staff interviews at tertiary and district hospitals. Cost-effectiveness was reported in terms of societal cost per quality-adjusted life year (QALY). All costs were reported in 2021 United States dollars (USD). Between February 2021 and March 2022, 287 participants with open tibia fractures were included. There were substantial costs to participants one year following injury with 42% (n = 112) working with a median monthly household income of US$40 (IQR: US$7-90) compared to 89% (n = 255) working pre-injury, with a median monthly household income of US$60 (IQR: US$36-144). The posterior median of societal costs at one year varied between US$751 (80% credible intervals [CrIs]: US$-751-2,389) for treatment with plaster of Paris (POP) in a district hospital for a Gustilo III injury, to US$2,428 (80% CrIs: US$995-5027) for intramedullary nail in central hospital for a Gustilo III injury. The largest cost-effectiveness from a societal perspective was between an intramedullary nail and amputation for a Gustilo III injury with a posterior mean of US$2,290 (95%HDI: 36-4,547) per QALY. The main finding was that open tibia fractures result in significant costs to patients, the healthcare system and society in Malawi. Although the funding of orthopaedic treatment can be difficult in countries with very limited healthcare budgets, the costs to society of ignoring this issue are very high. A re-balancing of health budgets (including from government and donors) is needed to prioritise trauma care to reduce the growing societal economic burden from injury.

The Adolescent Health Quality of Care (AHQOC) index is a tool designed to evaluate the quality of facility-based adolescent sexual and reproductive health (ASRH) services. This descriptive cross-sectional study aimed to validate the AHQOC index in 27 primary and secondary public health facilities located in a rural and an urban local government area (LGA) of Ogun State, Nigeria. To conduct the study, 12 mystery clients (MCs) were recruited and performed 144 visits to the health facilities. The MCs were young males and females who were seeking information on premarital sex, pregnancy prevention, sexually transmitted infections (STIs), and contraception. The validity, and reliability of the AHQOC index were evaluated using exploratory factor analysis, Cronbach’s Alpha, and intra-class correlation coefficient tests. The Kaiser-Meyer-Olkin test result for the initial 37-item pool was 0.7169, and the final tool retained 27 items with a Cronbach’s Alpha of 0.80. Two subscales of the index had Cronbach’s Alpha of 0.76 and 0.85. The intra-rater consistency assessed by the intra-class correlation coefficient was 0.66 (0.10–0.92) p = 0.001 for the urban LGA and 0.72 (0.37–0.91) p = 0.001 for the rural LGA. Positive and statistically significant relationships were observed between the full scales and subscales and the validity item (MC ranking of health worker on proficiency from 1 to 10). The results of this study demonstrate that the validated AHQOC index is a valuable tool for assessing the quality of ASRH services in public health facilities.

Background Integrating the care of adolescents and young people into existing public health facilities requires deliberate efforts to address challenges related to policy and service provision. This study assessed key informants’ perspectives on policy- and service-level challenges, and opportunities, for implementing a strategic framework for adolescent and youth-friendly health services (AYFHS) in public health facilities in a Nigerian setting. Methods Seventeen key informants were interviewed including members of the Adolescent sexual and reproductive health (ASRH) Technical Working Group (TWG), program managers of non-governmental organizations (NGO), State and local level health officials, and youth representatives, in Ogun State, Southwest Nigeria. Result Findings from this study indicate that some health workers continue to have a negative attitude toward young people’s sexual and reproductive health. There was some level of inclusion of adolescents and young people living with disabilities in ASRH programming which is welcome and extremely important. Some of the challenges in ASRH service provision included insufficient coordination of activities of donors/partners working in the adolescent health space. Also found was the missed opportunity to strengthen policy implementation with research, and the need for increased focus on mental health, substance use, and other aspects of adolescent and young people’s health. There was noted the opportunity to explore the Basic Health Care Provisions Funds (BHCPF) as a new source of funding for health services for AYP in Nigeria. Conclusion This study provided the context of the implementation of a strategic framework for adolescent reproductive health in a Nigerian setting from the perspectives of policy and service-level stakeholders. Opportunities for improving program delivery identified include ensuring research-based policy implementation and seeking program sustainability through tapping into new sources of funding.

Background Febrile neutropenia (FN) occurs following myelosuppressive chemotherapy and is associated with morbidity, mortality, costs, and chemotherapy reductions and delays. Granulocyte colony-stimulating factors (G-CSFs) stimulate neutrophil production and may reduce FN incidence when given prophylactically following chemotherapy. Methods A systematic review and meta-analysis assessed the effectiveness of G-CSFs (pegfilgrastim, filgrastim or lenograstim) in reducing FN incidence in adults undergoing chemotherapy for solid tumours or lymphoma. G-CSFs were compared with no primary G-CSF prophylaxis and with one another. Nine databases were searched in December 2009. Meta-analysis used a random effects model due to heterogeneity. Results Twenty studies compared primary G-CSF prophylaxis with no primary G-CSF prophylaxis: five studies of pegfilgrastim; ten of filgrastim; and five of lenograstim. All three G-CSFs significantly reduced FN incidence, with relative risks of 0.30 (95% CI: 0.14 to 0.65) for pegfilgrastim, 0.57 (95% CI: 0.48 to 0.69) for filgrastim, and 0.62 (95% CI: 0.44 to 0.88) for lenograstim. Overall, the relative risk of FN for any primary G-CSF prophylaxis versus no primary G-CSF prophylaxis was 0.51 (95% CI: 0.41 to 0.62). In terms of comparisons between different G-CSFs, five studies compared pegfilgrastim with filgrastim. FN incidence was significantly lower for pegfilgrastim than filgrastim, with a relative risk of 0.66 (95% CI: 0.44 to 0.98). Conclusions Primary prophylaxis with G-CSFs significantly reduces FN incidence in adults undergoing chemotherapy for solid tumours or lymphoma. Pegfilgrastim reduces FN incidence to a significantly greater extent than filgrastim.

Background A major component of the validity of the discrete choice experiment (DCE) research design lies in the correct specification of attributes and levels relevant to the research focus. In this paper, we set out the validation steps we took in designing the tool for a DCE on preferences in sexual and reproductive health (SRH) services for adolescents and young people. Methodology This study was carried out among adolescents and young people (AYP) in Ogun State, Southwest Nigeria. We used a three-step mixed-methods process in developing the attributes and attribute-levels for our DCE tool. The first was to conduct a series of 16 focus group discussions (FGD) with AYP ensuring maximal variation (by age group, sex, marital status, and location). The FGD included a priority listing process in which participants were asked to list and rank the most important characteristics of optimal SRH services for AYP. The lists were harmonized and items were scored. The main (highest scoring) themes emerging from the harmonized priority list were converted into an initial set of attributes and the subthemes as level. These initial attributes and levels were presented to a panel of methods and content experts in a virtual modified Delphi process. This was for deciding on the importance of the attributes in providing optimum sexual and reproductive health services for young people, and the appropriateness of the levels. The same set of attributes was presented to another set of AYP in a series of four FGD to clarify meanings, and test whether the wordings were well understood. We applied some decision rules for including and excluding attributes and levels in the different phases of the development process. Results We extracted an initial set of nine attributes with 2-4 levels each from the first FGD sessions. These were revised to a final set of seven attributes with 2-4 levels each based on findings from the expert review and final validation FGDs with AYP. The final attributes were: the type of staff, physical environment, health worker attitude, cost, waiting time, contraceptive availability, and opening hours. Conclusion The final set of attributes covered those relating to the services provided, the health workers providing the services, and the AYP. Our three-step process which included both quantitative and qualitative approaches ensured a rigorous process that produced a reliable combination of attributes and levels. Although we had to trade off some competing attributes to come to a final list, our decision rules helped us to conduct a transparent and reproducible process.

ObjectiveTo measure test accuracy of non-invasive prenatal testing (NIPT) for Down, Edwards and Patau syndromes using cell-free fetal DNA and identify factors affecting accuracy.DesignSystematic review and meta-analysis of published studies.Data sourcesPubMed, Ovid Medline, Ovid Embase and the Cochrane Library published from 1997 to 9 February 2015, followed by weekly autoalerts until 1 April 2015.Eligibility criteria for selecting studiesEnglish language journal articles describing case–control studies with ≥15 trisomy cases or cohort studies with ≥50 pregnant women who had been given NIPT and a reference standard.Results41, 37 and 30 studies of 2012 publications retrieved were included in the review for Down, Edwards and Patau syndromes. Quality appraisal identified high risk of bias in included studies, funnel plots showed evidence of publication bias. Pooled sensitivity was 99.3% (95% CI 98.9% to 99.6%) for Down, 97.4% (95.8% to 98.4%) for Edwards, and 97.4% (86.1% to 99.6%) for Patau syndrome. The pooled specificity was 99.9% (99.9% to 100%) for all three trisomies. In 100 000 pregnancies in the general obstetric population we would expect 417, 89 and 40 cases of Downs, Edwards and Patau syndromes to be detected by NIPT, with 94, 154 and 42 false positive results. Sensitivity was lower in twin than singleton pregnancies, reduced by 9% for Down, 28% for Edwards and 22% for Patau syndrome. Pooled sensitivity was also lower in the first trimester of pregnancy, in studies in the general obstetric population, and in cohort studies with consecutive enrolment.ConclusionsNIPT using cell-free fetal DNA has very high sensitivity and specificity for Down syndrome, with slightly lower sensitivity for Edwards and Patau syndrome. However, it is not 100% accurate and should not be used as a final diagnosis for positive cases.Trial registration numberCRD42014014947.

Background: Expanding access to screening through primary care is essential to address changes in disease patterns, patients’ needs, and demographics. Point‐of‐care test (POCT) devices play a crucial role in providing primary care and have positive operational and economic impacts compared to central laboratories. Despite their importance, the implementation of POCT devices in primary care remains low. This scoping review aims to map the current evidence on POCT types and their current uses in primary care. Methods: A scoping review was conducted using the framework proposed by Arksey and O’Malley, and further refined by Levac et al. and the Joanna Briggs Institute. Our process included five stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. We searched MEDLINE (Ovid), CINAHL, Embase, Web of Science, Cochrane Library, and Google Scholar for studies published between 2018 and 2023 on the use of POCTs in primary care settings for adult populations. Our findings were summarized using descriptive statistics and thematic analysis. Results: The search yielded 43,913 publications, of which, 167 met the inclusion criteria. From these studies, biomarker detection tests were used in 33.5%, antibody tests in 21.6%, other POCTs in 17.4%, POC technologies in 11.4%, antigen tests in 8.4%, and POC molecular tests in 7.8%. Across studies, 46.7% targeted communicable diseases, 39.5% targeted noncommunicable diseases, and 13.8% for other diseases. POC devices are mainly used for communicable diseases in urban healthcare settings, particularly in low‐ and middle‐income countries (LMIC). POC devices are used primarily for noncommunicable diseases in urban healthcare settings, particularly in high‐income countries. Conclusion: This scoping review has mapped the evidence and highlighted gaps regarding POCTs used in primary care. The findings can be used to design and effectively implement sustainable patients’ healthcare journeys to accommodate the changes in patients’ demographics and healthcare needs.

Background Barriers to utilization of sexual and reproductive health (SRH) services by adolescents and young people (AYP) have persisted despite evidence that youth-friendly services have a positive effect on contraceptive use, and patient knowledge and satisfaction. Objective The objective of this study was to elicit, and derive relative valuations for, attributes of SRH services that adolescents and young people value, and their willingness to pay for these services, in public health facilities. Methods A discrete-choice-experiment (DCE) that was developed using a mixed methods approach was administered to AYP from Ogun State, Southwest Nigeria. The DCE attributes were: the type of staff; physical environment; health worker attitude; cost; waiting time; contraceptive availability; and opening hours. The choice tasks had two unlabeled alternatives and an opt-out option. Panel mixed logit choice model was used to fit the choice data, along with estimation of willingness to pay (WTP). Also, a latent class logit model was used to detect underlying preference heterogeneity among the respondents. Finally, the uptake of the services in health facilities was investigated by estimating the probabilities for selecting hypothetical health facilities under different scenarios. Results A total of 859 AYP participated resulting in 6872 choice observations. The physical environment attribute had the highest utility rating relative to the other attributes, followed by preference for a doctor and for a service provider who was open and friendly. The cost and time coefficients were negative, revealing preference for lower cost and shorter waiting time. The latent class model had three classes that varied by their background characteristics. Probability of choosing any of the facility alternatives increased with introduction of more favorable facility characteristics. Conclusion The pattern of preferences identified are potential targets for service design and delivery optimization that may result in improvements in service acceptability and utilization. These results strengthen the call for involving AYP in decision-making in health interventions for them and developing context-specific SRH programs for AYP in public health facilities.

IntroductionSuicide has a substantial economic burden, yet in low- or middle-income countries, the analysis is constrained by the absence of disaggregated economic data. Existing studies primarily rely on gross costing methods, overlooking sector-specific costs such as healthcare, law enforcement and productivity losses at the family and community levels. Furthermore, the societal perspective, essential for understanding the multifaceted economic impacts of suicide, remains insufficiently explored in the Indian context.Methods and analysisThis study will quantify the economic burden of suicide and suicide attempts in India. The initial phase will involve developing a resource-use measure instrument to capture the societal costs associated with suicide. Subsequently, a retrospective, incidence-based study will be conducted in India using the developed instrument. This will also be complemented with the Health-Related Quality of Life Assessment using EuroQOL (EQ-5D-5L). Exploratory subgroup cost comparisons (eg, suicide methods, healthcare facility type) will use non-parametric tests, including the Mann–Whitney U and Kruskal–Wallis tests. Generalised linear mixed models (gamma distribution and log link) will analyse longitudinal cost and HRQoL data, besides bootstrapping techniques and sensitivity analyses.Ethics and disseminationEthics approval was obtained for the study from the institutional review board of the Indian Law Society (ILS/141/2024). All data collected during the study will adhere to ethical guidelines, taking informed consent. The findings of the study will be disseminated through peer-reviewed journals to aid data-driven decision-making.Trial registrationClinical Trial Registry of India (CTRI/2025/02/080380), date of registration: 12/02/2025.

To support the policy drive for the promotion of sexual and reproductive health (SRH) of adolescents and young people (AYP), it is necessary to understand the characteristics of the existing SRH services available to them. To assess the provision and experiences of care in SRH services for AYP in a Nigerian setting. Twelve male and female mystery clients (MCs) conducted 144 visits at 27 selected primary and secondary health facilities in two Local Government Areas (LGA) in Ogun State, Nigeria. A 27-item adolescent quality of care (AHQOC) index with a Cronbach's Alpha of 0.7 was used to obtain a quality-of-care score for each clinic visit. Linear panel-data random-effects regression models using the generalised least square estimator were used to assess quality associated factors. Sentiment analysis was done on the qualitative narrative summaries provided by MCs after each visit. There was an absence of the use of educational materials during the 60.4% of the visits. The MCs' medical history (90.3%), social record (63.9%), sexual/reproductive history (53.5%), and contraceptive experience (66.0%) were not obtained in most of the visits. Female MC visits had a lower AHQOC index rating on average compared to males (β=-0.3, CI −1.6 - 1.0 p = 0.687), rural health facilities had a lower AHQOC index rating on average compared to urban (β=-2.7, CI −5.1 - −0.2, p = 0.031), and a higher ranking of the health worker on the scale of 1-10 corresponded to a higher AHQOC index of the MC visit (β = 1.9, CI 1.6-2.1, p < 0.001). There were more positive than negative sentiments about the clinic encounters. This study found gaps in the competencies of the health workers, non-usage of educational materials in clinic encounters with young people, as well as the differential perception of quality of care by male and female AYP.