Hybrid Approach to Estimation of Underreporting of Tuberculosis Case Notification in High-Burden Settings With Weak Surveillance Infrastructure: Design and Implementation of an Inventory Study

BackgroundThe greatest risk of infectious disease undernotification occurs in settings with limited capacity to detect it reliably. World Health Organization guidance on the measurement of misreporting is paradoxical, requiring robust, independent systems to assess surveillance rigor. Methods are needed to estimate undernotification in settings with incomplete, flawed, or weak surveillance systems. This study attempted to design a tuberculosis (TB) inventory study that balanced rigor with feasibility for high-need settings.ObjectiveThis study aims to design a hybrid TB inventory study for contexts without World Health Organization preconditions. We estimated the proportion of TB cases that were not reported to the Ministry of Health in 2015. The study sought to describe TB surveillance coverage and quality at different levels of TB care provision. Finally, we aimed to identify structural-, facility-, and provider-level barriers to notification and reasons for underreporting, nonreporting, and overreporting.MethodsRetrospective partial digitalization of paper-based surveillance and facility records preceded deterministic and probabilistic record linkage; a hybrid of health facilities and laboratory census with a stratified sampling of HFs with no capacity to notify leveraged a priori knowledge. Distinct extrapolation methods were applied to the sampled health facilities to estimate bacteriologically confirmed versus clinical TB. In-depth interviews and focus groups were used to identify causal factors responsible for undernotification and test the acceptability of remedies.ResultsThe hybrid approach proved viable and instructive. High-specificity verification of paper-based records in the field was efficient and had minimal errors. Limiting extrapolation to clinical cases improved precision. Probabilistic record linkage is computationally intensive, and the choice of software influences estimates. Record absence, decay, and overestimation of the private sector TB treatment behavior threaten validity, meriting mitigation. Data management demands were underestimated. Treatment success was modest in all sectors (R=37.9%–72.0%) and did not align with treatment success reported by the state (6665/8770, 75.99%). One-fifth of TB providers (36/178, 20%) were doubtful that the low volume of patients with TB treated in their facility merited mastery of the extensive TB notification forms and procedures.ConclusionsSubnational inventory studies can be rigorous, relevant, and efficient in countries that need them even in the absence of World Health Organization preconditions, if precautions are taken. The use of triangulation techniques, with minimal recourse to sampling and extrapolation, and the privileging of practical information needs of local decision makers yield reasonable misreporting estimates and viable policy recommendations.     

Experimental Investigation on the Strengthening of Reinforced Concrete Beams Using Externally Bonded and Near-Surface Mounted Natural Fibre Reinforced Polymer Composites—A Review

Developing more resilient and sustainable physical infrastructure increases the demand for sustainable materials and strengthening approaches. Many investigations into strengthening RC beam structures have used either externally bonded (EB) or near-surface mounted (NSM) systems with synthetic fibre reinforced polymer composites. These synthetic fibres are unsustainable since they involve the use of nonrenewable resources and a large amount of energy. Research shows that natural fibre reinforced polymer (NFRP) composites may be an alternative to synthetic FRP composites in the strengthening of concrete beams. However, there is limited literature that validates their performance in various structural applications. Hence, the purpose of this paper is to explore the advances, prospects, and gaps of using EB/NSM NFRP techniques in strengthening concrete beams to provide areas for future research directions. The NSM FRP technique provides improved strengthening effects and mitigates the concerns associated with the EB system, based on a wider range of applications using synthetic FRPs. However, the NSM NFRP strengthening technique has been underutilized, though the EB NFRP system has been more commonly explored in reviewed studies. The knowledge gaps and areas for proposed future research directions are essential in developing work in emerging NFRPs and strengthening techniques for sustainable infrastructure.     

Influence of education and knowledge on perceptions and practices to control malaria in Southeast Nigeria

The study was undertaken in southeastern Nigeria to investigate whether the people's level of education and what they know about malaria affects how they seek treatment and prevention for the disease. Pre-tested questionnaires were used to collect data from randomly selected householders and analysed using logistic regression. Higher levels of education were associated with improved knowledge and practice about the appropriate strategies for the prevention and treatment of malaria. The results thus indicate that education can have a positive impact on the malaria burden and medium/long-term improvement of overall literacy rates. As well as this, short-term health education campaigns about the causes, manifestations and control of malaria will have a positive impact on its control.     

The Rx-HEART Framework to Address Health Equity and Racism Within Pharmacy Education

Objective. To identify gaps in health equity and anti-racism education across the pharmacy curriculum, define the key health equity and anti-racism concepts that are suggested to be included across the pharmacy curriculum, and recommend a framework with steps to integrate health equity and anti-racism education across the pharmacy curriculum.Findings. Other professions, such as social work, nursing, and medicine, have taken steps to address social injustice by integrating anti-racism into their curriculum. The National Association of Social Workers (NASW) advocates for “social justice and social change with and on behalf of clients” and included racism and health equity in its mission to eradicate “discrimination, oppression, poverty, and other forms of social injustice.” The American Association of Colleges of Nursing (AACN) curricular standards for baccalaureate nursing education provided four key changes for immediate implementation to overcome structural, individual, and ideological racism (SIIR). In October 2020, the Association of American Medical Colleges (AAMC) released a four-pillar framework to address racism.Summary. The Academy must also actively engage in efforts to eradicate social injustices by incorporating into its curriculum topics that would result in the graduation of culturally and linguistically sensitive and structurally competent pharmacists. The five-phase framework, Pharmacy Health Equity Anti-Racism Training (Rx-HEART) provides guidance on how to accomplish the objectives described in this paper and the theme issue on social injustice.     

Correlation Between Pharmacy Students’ Implicit Bias Scores,Explicit Bias Scores,and Responses to Clinical Cases

Objective. The purpose of this study was to identify the extent of implicit and explicit bias in a sample of pharmacy students and to determine whether there is an association between implicit bias, explicit bias, and responses to clinical cases.Methods. Investigators sent links to two online surveys to students at six US schools and colleges of pharmacy. In the first survey, students responded to two clinical cases. Students were presented with a picture of a White or Black patient with each clinical case. On the second survey, students indicated their level of racial implicit bias as assessed by the Harvard Implicit Association Test and their level of racial explicit bias. Pearson’s correlation was used to determine the correlation between bias and responses to the clinical cases.Results. Three hundred fifty-seven first, second, and third year pharmacy students responded to both surveys (response rate 52%). The students who were presented with the picture of a Black patient rated the patient’s pain and the reliability of the patient’s family as higher than students presented with the picture of a White patient. Students had more negative implicit and explicit bias towards Black patients. Neither implicit nor explicit bias correlated with student responses to the clinical cases.Conclusion. Evidence of slight to moderate negative implicit bias and slight negative explicit bias towards Black patients was identified in this group of pharmacy students. Future studies that include a more representative population and heighten the stakes of the clinical scenario should be done to investigate a possible correlation between bias and clinical behaviors.     

Feasibility of a community health worker strategy for providing near and appropriate treatment of malaria in southeast Nigeria: an analysis of activities, costs and outcomes

RATIONALE: Community health workers (CHWs) could be used to bring appropriate and timely treatment of malaria closer to home and there is the need to increase the body of knowledge about the feasibility of implementing the strategy. OBJECTIVE: To determine the processes, costs and outcomes of design and implementation of a strategy based on use of CHWs for near and appropriate treatment of malaria. METHODS: The CHW strategy was implemented in two villages (Adu and Ahani) in Enugu state, southeast Nigeria. Adu and Ahani have a population of approximately 3500 and 5000 residents, respectively. The study was conducted in four phases: (1) baseline survey; (2) design; (3) implementation, supervision and monitoring; and (4) evaluation. Interactive meeting with all the stakeholders were used to fine-tune the design of the CHW strategy. Community members that were selected by the project team with the help of community leaders were trained to become CHWs and their remuneration was through commissions on their drug sales. Community and provider's financial and non-financial costs of the startegy were computed. RESULTS: Non-financial costs were the highest contributor to consumer costs, while financial costs constituted more than 90% of provider costs. The total consumer cost in Ahani was US$2548, while the consumer cost in Adu was US$1585. The total provider cost in Ahani was US$4515, while in Adu it was US$4302. The unit cost cost per villager was US$1.40 in Ahani and US$1.70 in Adu, while the unit financial consumer cost per treated patient was $0.05 in both villages, respectively. The CHWs were acceptable to the people and had an increased market share out of existing malaria treatment provision strategies. CONCLUSION: The cost of starting up the CHW strategy is low and should be affordable to malaria control programs and communities. The CHW strategy is also economically viable and a potential cost-effective source for providing timely, and appropriate treatment of malaria in rural areas. It should be fine-tuned and added to malaria control armamenterium in Nigeria and other parts of sub-Saharan Africa.     

Conceptualizing Social Ecological Model in Pharmacy to Address Racism as a Social Determinant of Health

Racism has been declared a public health crisis. The COVID-19 pandemic has highlighted inequities in the US health care system and presents unique opportunities for the pharmacy Academy to evaluate the training of student pharmacists to address social determinants of health among racial and ethnic minorities. The social ecological model, consisting of five levels of intervention (individual, interpersonal, organizational, community, and public policy) has been effectively utilized in public health practice to influence behavior change that positively impacts health outcomes. This paper adapted the social ecological model and proposed a framework with five intervention levels for integrating racism as a social determinant of health into pharmacy curricula. The proposed corresponding levels of intervention for pharmacy education are the curricular, interprofessional, institutional, community, and accreditation levels. Other health professions such as dentistry, medicine, and nursing can easily adopt this framework for teaching racism and social determinants of health within their respective curricula.