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Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO's Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael's Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these. We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers). Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators. This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.

To explore similarities and differences in challenges to maternal health and evidence implementation in general across several low- and middle-income countries (LMICs) and to identify common and unique themes representing barriers to and facilitators of evidence implementation in LMIC health care settings. Secondary analysis of qualitative data. Meeting reports and articles describing projects undertaken by the authors in five LMICs on three continents were analyzed. Projects focused on identifying barriers to and facilitators of implementation of evidence products: five World Health Organization maternal health guidelines, and a knowledge translation strategy to improve adherence to tuberculosis treatment. Data were analyzed using thematic content analysis. Among identified barriers to evidence implementation, a high degree of commonality was found across countries and clinical areas, with lack of financial, material, and human resources most prominent. In contrast, few facilitators were identified varied substantially across countries and evidence implementation products. By identifying common barriers and areas requiring additional attention to ensure capture of unique barriers and facilitators, these findings provide a starting point for development of a framework to guide the assessment of barriers to and facilitators of maternal health and potentially to evidence implementation more generally in LMICs.

The outcome of well-performed clinical research is essential for evidence-based patient management during pandemics. However, conducting clinical research amidst a pandemic requires researchers to balance clinical and research demands. We seek to understand the values, experiences, and beliefs of physicians working at the onset of the COVID-19 pandemic in order to inform clinical research planning. We aim to understand whether pandemic settings affect physician comfort with research practices, and how physician experiences shape their understanding of research in a pandemic setting. A survey tool was adapted to evaluate familiarity and comfort with research during a pandemic. A cross-sectional, online questionnaire was distributed across Canadian research networks early in the COVID-19 outbreak. The survey was administered between March 11th and 17th, 2020, during a time of local transmission but prior to the surge of cases. We aimed to recruit into the survey physicians in infectious disease and critical care research networks across Canada. Of the 133 physician respondents, 131 (98%) considered it important to conduct clinical research during the COVID-19 pandemic. Respondents were more accepting of adaptations to the research process in during a pandemic compared to in a non-pandemic setting, including conducting research with deferred consent (χ2 = 8.941, 95% CI: -0.264, -0.085, p = 0.003), using non-identifiable observational data with a waiver of consent with a median score of 97 out of 100 (IQR: 79.25-100) vs median 87 out of 100 (IQR: 63-79) (95% CI: -12.43, 0.054, p = 0.052). The majority felt that research quality is not compromised during pandemics. Physicians consider it important to conduct research during a pandemic, highlighting the need to expedite research activities in pandemic settings. Respondents were more accepting of adaptations to the research process for research conducted during a pandemic, compared to that conducted in its absence of a pandemic.

Objectives 1 in 7 Canadians with Human Immunodeficiency Virus (HIV) do not know their status. Patients at increased risk of HIV routinely access the emergency department (ED), yet few are tested, representing a missed opportunity for diagnosis and linkage-to-care. Rapid HIV testing provides reliable results within the same ED encounter but is not routinely implemented. The objective of this study was to identify barriers and facilitators to rapid HIV testing in Ontario EDs. Methods We employed a mixed-methods, convergent, parallel design study including online surveys and semi-structured interviews of physicians, nurses, and allied health across four hospitals in Toronto and Thunder Bay, Ontario. Data were analyzed in equal priority using descriptive statistics for quantitative data and thematic analysis for qualitative data guided by the Theoretical Domains framework and Capability, Opportunity, Motivation Behaviour change model. Results Among 187 survey respondents, 150 (80%) felt implementing rapid HIV testing would be helpful in the ED. Facilitators included availability of resources to link patients to care after testing (71%), testing early in patient encounters (41%), and having dedicated staff with lived experience support testing (34%). Motivation to offer testing included opportunities to support an underserved population (66%). Challenges to implementation included limited time during ED patient encounters (51%) and a lack of knowledge around HIV testing (42%) including stigma. Interview themes confirmed education, and integration of people with lived experience being essential to provide rapid HIV testing and linkage-to-care in the ED. Conclusions Implementation of rapid HIV testing in the ED is perceived to be important irrespective of practice location or profession. Intrinsic motivations to support underserved populations and providing linkage-to-care are novel insights to facilitate testing in the ED. Streamlined implementation, including clear testing guidelines and improved access to follow-up care, is felt to be necessary for implementation.

PurposeHealthcare workers must ensure effective infection prevention and control (IPC) to prevent nosocomial spread of SARS-CoV-2, the virus that causes COVID-19. This questionnaire study aims to evaluate Canadian critical care and emergency department nurses’ readiness to follow IPC guidelines in their workplace, and to understand their perceptions of trust in organizational preparedness, communication, and infection risk.MethodsWe adapted an internationally distributed survey for the Canadian context. This cross-sectional questionnaire, incorporating validated scales for items including institutional trust, was distributed by email to nurses via the Canadian Association of Critical Care Nurses and the Canadian Association of Emergency Physicians networks between 16 March and 25 May 2020. We evaluated intensive care unit and emergency department nurses’ adherence to IPC protocols, barriers and facilitators to IPC guideline adherence, and their level of institutitonal trust.ResultsThree hundred and nineteen nurses responded to the survey. There was higher trust in organizational preparedness among nurses who were older (B = 0.31, P < 0.001) and more experienced (F = 18.09, P < 0.001), and particularly among those with previous experience working in outbreak settings (F = 7.87, P = 0.005). Compared with those without experience working in outbreak settings, respondents with this experience reported higher levels of fear of becoming ill and fear of providing care for COVID-19 patients (χ2 = 21.48, P = 0.002 and χ2 = 12.61, P = 0.05, respectively). Older and more experienced nurses reported greater comfort with IPC skills and easier access to personal protective equipment. While the vast majority (96%) of respondents reported using masks and gloves, only 83% had access to isolation facilities for suspected or confirmed COVID-19 cases.ConclusionCanadian nurses had strong self-reported adherence to IPC measures and personal protective equipment use. There were high levels of trust in health system leadership to ensure protective measures are present and reliable. Trust was particularly high among older and more experienced nurses despite these populations reporting higher levels of fear of personal illness.

Background As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to assume a growing role in strengthening health systems. A growing list of tasks, some of them complex, is being shifted to community health workers’ job descriptions. Health Surveillance Assistants (HSAs) - as the community health worker cadre in Malawi is known - play a vital role in providing essential health services and connecting the community with the formal health care sector. The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs’ perspectives on their roles and responsibilities. Methods A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre’s role and to triangulate collected data. Results HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs. Conclusion This study provides insights into HSAs’ perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre’s effectiveness in addressing the country’s health priorities.

Therapies to reduce liver fibrosis and stimulate organ regeneration are urgently needed. We conducted a first-in-human, phase 1 dose-escalation trial of autologous macrophage therapy in nine adults with cirrhosis and a Model for End-Stage Liver Disease (MELD) score of 10–16 (ISRCTN 10368050). Groups of three participants received a single peripheral infusion of 10 7 , 10 8 or up to 10 9 cells. Leukapheresis and macrophage infusion were well tolerated with no transfusion reactions, dose-limiting toxicities or macrophage activation syndrome. All participants were alive and transplant-free at one year, with only one clinical event recorded, the occurrence of minimal ascites. The primary outcomes of safety and feasibility were met. This study informs and provides a rationale for efficacy studies in cirrhosis and other fibrotic diseases. A first-in-human, phase 1 dose-escalation trial demonstrates the safety and feasibility of autologous macrophage therapy in adults with liver cirrhosis.

IntroductionCommunity participatory modelling merges participatory research approaches with mathematical modelling. Participatory approaches are grounded in the engagement of people with lived experience (eg, who are affected by the health condition under study) throughout the research process. Mathematical modelling of infectious disease (ID) dynamic transmissions is increasingly used as a tool for public health decision-making, generating predictions, inferring mechanisms and estimating the impact of potential interventions—all of which guide policies, strategies and resource allocation as part of the preparation and response to ID epidemics. However, little is known about the engagement of people with lived experience and affected communities in the ID modelling process. We will map the literature to explore participatory approaches undertaken in ID modelling (practical aspects of formalising participatory modelling), levels of participation and the potential influence from the perspective of communities engaged.Methods and analysisThe scoping review will follow the Joanna Briggs Institute Manual for Evidence Synthesis. The search strategy includes three electronic bibliographic databases (MEDLINE, Scopus and Embase), no language restrictions and sources published from 2000 to present. We will implement the search with and without the participatory keyword, as we recognise that some studies do not explicitly term community engagement as participatory modelling. After deduplication, two authors will independently screen the titles, abstracts and full texts, with discrepancies resolved with a third team member. We will extract the relevant information from the main text, parameter tables, supplemental files, bibliography, acknowledgment and author affiliation sections. The data extraction will follow a deductive content analysis where we draw from community-based participatory research approaches and established mathematical modelling steps. We will also extract data to assess whether there was equitable engagement of knowledge users by checking for indicators of three equitable engagement domains as outlined by the Ward framework (equity within partnership (eg, whether knowledge user influenced modelling decisions or remuneration), capacity to engage in future partnerships and shift in power/influence (eg, coauthorship). We will supplement our narrative analyses with summaries in tabular format and using appropriate data visualisations.Ethics and disseminationNo ethics approval will be required for this scoping review because we will map evidence from publicly available literature sources. We will develop multilingual abstracts or one-page lay summaries of the findings (English, French and Swahili), a policy brief and will coauthor an open-access journal article. A summary of the findings will be shared via knowledge user-led presentations at the Maisha HIV and AIDS Conference and with other community-based organisations at the quarterly peer-to-peer support meetings.RegistrationThe protocol has been registered in Open Science Framework, DOI: https://doi.org/10.17605/OSF.IO/XQ2WP (December 2024).

Background The Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) is a bi-institutional partnership between the University of Toronto (UofT) and Addis Ababa University (AAU) focused on addressing the need for emergency medicine (EM) postgraduate training and care in Ethiopia. Toxicology is a key competency in EM. EM physicians are often the first and sole clinicians to identify and treat patients presenting with a wide range of intoxications. The goal of this project was to conduct an educational needs assessment to inform the development of a context-specific toxicology curriculum for the AAU EM training program. Methods Our needs assessment employed a survey (available electronically and in paper format) and face-to-face interviews conducted with Ethiopian EM faculty (all graduates of the AAU EM residency training program) and current AAU EM residents. The survey was distributed in October 2018 and the interviews were conducted in November 2018. Results Of the 63 surveys distributed, we received 17 complete responses and completed 11 interviews with AAU EM faculty and residents. The survey conducted on toxicology training highlighted overall satisfaction with current training, with thematic analysis revealing key areas for growth. System-related themes focused on resource availability, healthcare access, and public health education. Provider-related themes emphasized the need for context-specific training, including common local toxins, and for advanced toxicology training such as poison center rotations. Patient-related themes centered on specific toxicological presentations in Ethiopia, highlighting the importance of public health advocacy, education on safe handling, and governmental regulation of toxic substances. Both survey and interview data highlighted challenges stemming from inconsistent availability of resources and underscored the need for tailored education to manage poisoned patients with locally available resources. Conclusions Our findings indicate the need to focus on the most prevalent local toxicological presentations and practical management challenges in local contexts, including resource limitations and delayed presentations. Moreover, it emphasizes the importance of public health initiatives such as regulation of the sale and promotion of safe handling of toxic substances to mitigate toxicological risks. These findings are likely relevant to other resource-constrained settings outside of Ethiopia.

To identify candidate quality indicators from existing tools that provide guidance on how to practice knowledge translation and implemenation science (KT practice tools) across KT domains (dissemination, implementation, sustainability, and scalability). We conducted a scoping review using the Joanna Briggs Institute Manual for Evidence Synthesis. We systematically searched multiple electronic databases and the gray literature. Documents were independently screened, selected, and extracted by pairs of reviewers. Data about the included articles, KT practice tools, and candidate quality indicators were analyzed, categorized, and summarized descriptively. Of 43,060 titles and abstracts that were screened from electronic databases and gray literature, 850 potentially relevant full-text articles were identified, and 253 articles were included in the scoping review. Of these, we identified 232 unique KT practice tools from which 27 unique candidate quality indicators were generated. The identified candidate quality indicators were categorized according to the development (n = 17), evaluation (n = 5) and adaptation (n = 3) of the tools, and engagement of knowledge users (n = 2). No tools were identified that appraised the quality of KT practice tools. The development of a quality appraisal instrument of KT practice tools is needed. The results will be further refined and finalized in order to develop a quality appraisal instrument for KT practice tools. [Display omitted]