Background Cholera continues to pose a problem for low-resource, fragile and humanitarian contexts. Evidence suggests that 2.86 million cholera cases and 95,000 deaths due to cholera are reported annually. Without quick and effective diagnosis and treatment, case-fatality may be 50%. In line with the priorities of the Global Task Force on Cholera Control, we undertook a systematic review and meta-analysis of diagnostic test accuracy and other test characteristics of current tests for cholera detection in stool and water. Methods We searched 11 bibliographic and grey literature databases. Data was extracted on test sensitivity, specificity and other product information. Meta-analyses of sensitivity and specificity were conducted for tests reported in three or more studies. Where fewer studies reported a test, estimates were summarised through narrative synthesis. Risk of Bias was assessed using QUADAS-2. Results Searches identified 6,637 records; 41 studies reporting on 28 tests were included. Twenty-two tests had both sensitivities and specificities reported above 95% by at least one study, but there was, overall, wide variation in reported diagnostic accuracy across studies. For the three tests where meta-analyses were possible the highest sensitivity meta-estimate was found in the Cholera Screen test (98.6%, CI: 94.7%-99.7%) and the highest specificity meta-estimate in the Crystal VC on enriched samples (98.3%, CI: 92.8%-99.6%). There was a general lack of evidence regarding field use of tests, but where presented this indicated trends for lower diagnostic accuracy in field settings, with lesser-trained staff, and without the additional process of sample enrichment. Where reported, mean test turnaround times ranged from over 50% to 130% longer than manufacturer’s specification. Most studies had a low to unclear risk of bias. Conclusions Currently available Rapid Diagnostic Tests can potentially provide high diagnostic and detection capability for cholera. However, stronger evidence is required regarding the conditions required to secure these levels of accuracy in field use, particularly in low-resource settings. Registration PROSPERO (CRD42016048428).

Background Tuberculosis infection prevention and control (TB-IPC) measures are consistently reported to be poorly implemented globally. TB-IPC guidelines provide limited recognition of the complexities of implementing TB-IPC within routine health systems, particularly those facing substantive resource constraints. This scoping review maps documented system influences on TB-IPC implementation in health facilities of low/middle-income countries (LMICs). Methods We conducted a systematic search of empirical research published before July 2018 and included studies reporting TB-IPC implementation at health facility level in LMICs. Bibliometric data and narratives describing health system influences on TB-IPC implementation were extracted following established methodological frameworks for conducting scoping reviews. A best-fit framework synthesis was applied in which extracted data were deductively coded against an existing health policy and systems research framework, distinguishing between social and political context, policy decisions, and system hardware (eg, information systems, human resources, service infrastructure) and software (ideas and interests, relationships and power, values and norms). Results Of 1156 unique search results, we retained 77 studies; two-thirds were conducted in sub-Saharan Africa, with more than half located in South Africa. Notable sociopolitical and policy influences impacting on TB-IPC implementation include stigma against TB and the availability of facility-specific TB-IPC policies, respectively. Hardware influences on TB-IPC implementation referred to availability, knowledge and educational development of staff, timeliness of service delivery, availability of equipment, such as respirators and masks, space for patient separation, funding, and TB-IPC information, education and communication materials and tools. Commonly reported health system software influences were workplace values and established practices, staff agency, TB risk perceptions and fears as well as staff attitudes towards TB-IPC. Conclusion TB-IPC is critically dependent on health system factors. This review identified the health system factors and health system research gaps that can be considered in a whole system approach to strengthen TB-IPC practices at facility levels in LMICs.

Psychological first aid (PFA) is a world-wide implemented approach to helping people affected by an emergency, disaster, or other adverse event. Controlled evaluations of PFA’s training effects are lacking. We evaluated the effectiveness of a one-day PFA training on the acquisition and retention of knowledge of appropriate responses and skills in the acute aftermath of adversity in Peripheral Health Units (PHUs) in post-Ebola Sierra Leone. Secondary outcomes were professional quality of life, confidence in supporting a distressed person, and professional attitude. PHUs in Sierra Leone (n = 129) were cluster-randomized across PFA (206 participants) and control (202 participants) in March 2017. Knowledge and understanding of psychosocial support principles and skills were measured with a questionnaire and two patient scenarios to which participants described helpful responses. Professional attitude, confidence, and professional quality of life were assessed using self-report instruments. Assessments took place at baseline and at three- and six-months post-baseline. The PFA group had a stronger increase in PFA knowledge and understanding at the post-PFA training assessment (d = 0.50; p < 0.001) and at follow-up (d = 0.43; p = 0.001). In addition, the PFA group showed better responses to the scenarios at six-months follow-up (d = 0.38; p = 0.0002) but not at the post-assessment (d = 0.04; p = 0.26). No overall significant differences were found for professional attitude, confidence, and professional quality of life. In conclusion, PFA training improved acquisition and retention of knowledge and understanding of appropriate psychosocial responses and skills in providing support to individuals exposed to acute adversity. Our data support the use of PFA trainings to strengthen capacity for psychosocial support in contexts of disaster and humanitarian crisis. Future studies should examine the effects of PFA on psychosocial outcomes for people affected by crises.

Scientific contribution in high-impact journals is largely from authors affiliated with institutions in high-income countries (HICs). Publication of papers by contribution of individual countries to leading journals can provide a picture of the most influential countries in a particular discipline. The aim of the study was to identify changes in the patterns in authorship and origin of original research articles in relation to countries' income level in the field of public health in 2016 in comparison to previous studies. A descriptive analysis was conducted based on articles published in highly ranked public health journals in 2016. Based on the inclusion criteria, 368 research articles were identified. Over 80% of these studies were conducted in HICs. Authors were mainly based in HICs (84%), especially in the USA. The majority of first, last, and corresponding authors were affiliated with HICs (over 90%). Our study might serve as a prompt for editorial and advisory boards of the leading international journals to provide more opportunities for researchers based in low and middle-income countries.

Advances in population health outcomes risk being slowed-and potentially reversed-by a range of threats increasingly presented as 'fragility'. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey literature sources, and five key journals, were searched to retrieve documents relating to fragility and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health. Data were extracted according to the protocol; all documents underwent bibliometric analysis. Narrative synthesis was then used to identify defining attributes of the concept in the field of global health. A total of 377 documents met inclusion criteria. There has been an exponential increase in applications of the concept in published literature over the last 10 years. Formal definitions of the term continue to be focused on the characteristics of 'fragile and conflict-affected states'. However, synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state to local community); emphasis on particular antecedent stressors (including factors beyond conflict and weak governance); and focus on health system or community resources (with an increasing tendency to focus on the interface between two). Amongst several themes identified, trust is noted as a key locus of fragility at this interface, with critical implications for health seeking, service utilization and health system and community resilience.

Advances in population health outcomes risk being slowed-and potentially reversed-by a range of threats increasingly presented as 'fragility'. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey literature sources, and five key journals, were searched to retrieve documents relating to fragility and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health. Data were extracted according to the protocol; all documents underwent bibliometric analysis. Narrative synthesis was then used to identify defining attributes of the concept in the field of global health. A total of 377 documents met inclusion criteria. There has been an exponential increase in applications of the concept in published literature over the last 10 years. Formal definitions of the term continue to be focused on the characteristics of 'fragile and conflict-affected states'. However, synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state to local community); emphasis on particular antecedent stressors (including factors beyond conflict and weak governance); and focus on health system or community resources (with an increasing tendency to focus on the interface between two). Amongst several themes identified, trust is noted as a key locus of fragility at this interface, with critical implications for health seeking, service utilization and health system and community resilience.

BACKGROUND:In emergencies and resource-poor settings, non-specialists are increasingly being trained to provide psychosocial support to people in distress, with Psychological First Aid (PFA) one of the most widely-used approaches. This paper considers the effectiveness of short training programmes to equip volunteers to provide psychosocial support in emergencies, focusing particularly on whether the PFA training provided during the Ebola outbreak enabled non-specialists to incorporate the key principles into their practice. METHODS:Semi-structured interviews were conducted in Sierra Leone and Liberia with 24 PFA trainers; 36 individuals who participated in PFA training; and 12 key informants involved in planning and implementing the PFA roll-out. RESULTS:Findings indicate that many PFA training-of-trainers were short and rarely included content designed to develop training skills. As a result, the PFA training delivered was of variable quality. PFA providers had a good understanding of active listening, but responses to a person in distress were less consistent with the guidance in the PFA training or with the principles of effective interventions outlined by Hobfoll et al. CONCLUSIONS:There are advantages to training non-specialists to provide psychosocial support during emergencies, and PFA has all the elements of an effective approach. However, the very short training programmes which have been used to train non-specialists in PFA might be appropriate for participants who already bring a set of relevant skills to the training, but for others it is insufficient. Government/NGO standardisation of PFA training and integration in national emergency response structures and systems could strengthen in-country capacity.

Background: Globally, an estimated 257 million people are living with chronic hepatitis B (HBV) infection and an estimated 71 million people with the chronic hepatitis C virus (HCV). The true public health dimensions and impact of hepatitis epidemics are poorly understood. Case definitions are fundamental parts of disease surveillance, representing sets of standardised criteria used to assess whether or not a person has a certain disease. The study evaluated the sensitivity and specificity of hepatitis B and hepatitis C case definitions, current at the time of data collection, recommended by the European Commission (EC) and the Centers for Disease Prevention and Control (CDC). Methods: The study involved 150 hospital referrals with suspected cases of hepatitis from a Serbian clinic during 2014/2015. Case definitions of hepatitis B and C were tested for their sensitivity, specificity, positive and negative predictive values. Results: EC 2008 and the CDC 2012 case definitions for acute hepatitis B, and the CDC 2012 case definition for probable case of chronic hepatitis B have low sensitivity. Case definitions which rely on laboratory confirmation only have maximal sensitivity. EC case definitions showed maximal sensitivity and specificity for hepatitis C confirmed cases. The CDC case definition for chronic hepatitis C showed low sensitivity (36.8%) and low negative predictive value (65.6%) for probable cases and maximal sensitivity and specificity for confirmed cases. Hepatitis C case definitions requiring presence of clinical criteria have low sensitivity and high specificity, resulting from presence of infection and absence of any clinical manifestation, but have high positive and negative predictive values. Conclusion: Syndromic case definitions show low sensitivity and are of limited use. They highlight the importance of laboratory diagnostics (offering maximal sensitivity and specificity, and high positive and negative predictive values), as well as the need for universal case definitions, for confirmed cases only. (C) 2019 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences.

Cholera is a highly infectious diarrheal disease spread via fecal contamination of water and food sources; it is endemic in parts of Africa and Asia and recent outbreaks have been reported in Haiti, the Zambia and Democratic Republic of the Congo. If left untreated, the disease can be fatal in less than 24 h and result in case fatality ratios of 30–50%.

Work-related injuries occurring during informal work often go unreported, yet lead to significant mortality and contribute substantially to disease burden due to injury-related disability. In Serbia, injury is a leading cause of death, with work-related injuries comprising a significant proportion. This study explored the frequency of and risk factors for these injuries in a rural Serbian community. During the 12-month study period, physicians from a municipal Primary Care Centre reported all presenting injuries using a specific injury report form. One in four injuries reported occurred during informal work practices, accounting for 71% of all reported work-related injuries. These occurred within the household in 85% of cases, and were more severe in males (79%). Regarding work-related injuries, informal workers were significantly older than formally employed workers, regardless of sex. Public policy should address safety improvements for informal workers, via provision of relevant training and protective equipment.

Seasonal influenza vaccination is one of the most important tools of prevention. Countries currently use many different methodologies to measure national influenza vaccine coverage in populations at higher risk. The study uses two main data sources: The European Health Interview Survey (EHIS) (collected by Eurostat) and OECD statistics, and compares both results. Findings showed that the EHIS survey results observed in this study are mainly lower than OECD data. This can mean that international sources provide overestimated data of coverage compared to outcomes from population surveys.

AIM:To assess and compare general practitioners' (GPs') views of diagnosing and treating depression in five southeastern European countries. METHODS:A cross-sectional study was conducted in Albania, Bulgaria, Moldova, Romania, and Serbia. The sample included 467 GPs who completed a hard-copy self-administered questionnaire, consisting of self-assessment questions related to diagnosing and treating depression. RESULTS:The most common barriers to managing depression in general practice reported by GPs were: patients' unwillingness to discuss depressive symptoms (92.3%); appointment time too short to take an adequate history (91.9%), barriers for prescribing appropriate treatment (90.6%); and patients' reluctance to be referred to a psychiatrist (89.1%). Most GPs (78.4%) agreed that recognizing depression was their responsibility, 71.7% were confident in diagnosing depression, but less than one-third (29.6%) considered that they should treat it. CONCLUSIONS:Improvements to the organization of mental healthcare in all five countries should consider better training for GPs in depression diagnosis and treatment; the availability of mental healthcare specialists at primary care level, with ensured equal and easy access for all patients; and the removal of potential legal barriers for diagnosis and treatment of depression.

Dramatic changes have occurred during my 40+ years of teaching research methods to nurses and nursing students, including important transformations within the profession, an explosive growth in published research by nurses, greater inter-professional collaboration, increased funding opportunities, and stunning methodologic and technologic advances.In this talk I will describe some of the major ways in which nursing research has evolved over the past 4 decades by tracing content revisions in my textbook Nursing Research: Generating and Assessing Evidence for Nursing Practice-now in its 10th edition and still the world's #1 textbook on research methods for nurses.The earliest editions of this book had no mention of such key concepts as evidence-based practice, mixedmethods research, complex interventions, and systematic reviews; now, entire chapters are devoted to these topics.Indeed, it was not until the 3rd edition of the book (1987) that qualitative research was given serious coverage, and now many chapters of the book describe methods for conducting high-quality qualitative inquiry.My presentation will focus especially on the key revisions I introduced in the 10th edition, which was published in 2016 (2017 copyright date).In particular, I will discuss a topic about which I have become passionate-the measurement and interpretation of clinical significance (distinct from statistical significance) in nursing studies.I will also describe revisions that I am planning to make in the 11th edition, which will be published in early 2020.In all editions published thus far, I have strived to provide guidance on how to do research with rigor and integrity-that is, how to "get it right" when answering a research question.In the 11th edition I plan to devote considerably more attention to what nurse researchers can do to "get it right" in asking their research questions.In this regard, I will provide an overview of strategies for improving the relevance and applicability of nursing research.

Osteoporosis is highly prevalent worldwide and is associated with increased risk of low trauma fracture (LTF) [1], increased morbidity and mortality [2]. Major advances in diagnosis, management and BMC Nursing 2017, 16(Suppl 1):32 Page 3 of 11 prevention of secondary fractures have occurred [3] but implications for acute nursing care are less well documented. This project investigated practitioners’ experiences of caring for people with osteoporosis, knowledge of the disease, explored implications for moving and handling, reported patients’ care experiences, and developed education for frontline staff.

AimsTo explore the potential impact of a minimum unit price (MUP: 50 pence per UK unit) on the alcohol consumption of ill Scottish heavy drinkers.MethodsParticipants were 639 patients attending alcohol treatment services or admitted to hospital with an alcohol-related condition. From their reported expenditure on alcohol in their index week, and assuming this remained unchanged, we estimated the impact of a MUP (50 ppu) on future consumption. (Around 15% purchased from both the more expensive on-sale outlets (hotels, pubs, bars) and from off-sales (shops and supermarkets). For them we estimated the change in consumption that might follow MUP if (i) they continued this proportion of 'on-sales' purchasing or (ii) their reported expenditure was moved entirely to off-sale purchasing (to maintain consumption levels)).ResultsAround 69% of drinkers purchased exclusively off-sale alcohol at <50 ppu. Their drinking, post MUP, may reduce by a mean of 33%. For this group, from a population of very heavy, ill consumers, we were unable to show a differential effect across multiple deprivation quintiles. For other drinkers there might be no reduction, especially if after MUP there were many products priced close to 50 ppu. Moving away from on-sales purchases could support, for some, an increase in consumption.ConclusionsWhile a proportion of our harmed, heavy drinkers might be able to mitigate the impact of MUP by changing purchasing habits, the majority are predicted to reduce purchasing. This analysis, focusing specifically on harmed drinkers, adds a unique dimension to the evidence base informing current pricing policy.Short SummaryFrom drink purchasing data of heavy drinkers, we estimated the impact of legislating £0.50 minimum unit price. Over two thirds of drinkers, representing all multiple deprivation quintiles, were predicted to decrease alcohol purchasing; remainder, hypothetically, could maintain consumption. Our data address an important gap within the evidence base informing policy.

Sheron et al [1][1] suggested strong cider (>6.0% alcohol by volume) in the UK was particularly associated with alcohol-related illnesses. Beeston et al 2reported that in 2012 in Scotland 326,975 litres of pure alcohol were sold as strong cider off-licence, excluding unknown sales in discount

The irrefutable consequence of Scottish excessive alcohol consumption has prompted implementation and proposal of alcohol policy measures. The purpose of this study is to explore with heavy drinkers their awareness of and identify potential implications of policy introducing alcohol minimum unit pricing (MUP). Face-to-face semi-structured interviews were conducted with drinkers with alcohol-related harm (n = 20; 15 males, five females; aged 34 to 67 years old) in Scotland's two largest cities (drinkers were participants within a larger quantitative study, through attendance for treatment for alcohol-related harms at National Health Service [NHS] centers). Median weekly consumption among participants was 130.7 units (range: 28-256.3 U.K. units). Views regarding the impact of increased alcohol prices, through MUP, were mixed. While some drinkers indicated potential reduction in intake, thus possibly reducing alcohol harms in the long term, the expected, or even desired, from a public health perspective, effects on consumption and associated harms might not be fully realized in this group. To mitigate possible unintended short-term detrimental effects of MUP on the most vulnerable, careful planning and appropriate resourcing may be required prior to implementation.

INTRODUCTION AND AIMS Research highlights the need to better understand the impact of alcohol-related harm on families and communities. Scottish policy initiatives to reduce alcohol consumption and alcohol-related harm include the planned introduction of a minimum unit price for alcohol. We aimed to explore existing and proposed changes in alcohol policy, from the standpoint of heavy drinkers, through accounts of their involvement and repercussions for family and friends. DESIGN AND METHODS Interviews were conducted with 20 heavy drinkers, recruited from hospital alcohol treatment centres in Scotland's two largest cities. Participants were part of a larger longitudinal mixed methods study. Interviews explored experiences of alcohol-related harm and the impact, or potential impact, of alcohol policy changes on drinking patterns, risk-taking, consumption and wellbeing. Data coded for 'family and friends' were thematically analysed using a constant comparison method. RESULTS Family and friends were portrayed as important for aiding moderation and abstinence, but more often for sustaining continued heavy drinking. Heavy drinkers with complex needs and those living in deprived communities suggested that increased alcohol prices could exacerbate the detrimental effect on their health and social circumstances, and that of their family, should their consumption remain excessive. DISCUSSION AND CONCLUSIONS Population level policy initiatives to reduce alcohol consumption, such as minimum unit pricing, will impact on the families and social networks of heavy drinkers in addition to the drinker. The most vulnerable may be affected disproportionately. Alcohol policy changes and evaluations need to consider consequences for drinkers, families and communities. [O'May F, Whittaker A, Black H, Gill J. The families and friends of heavy drinkers: Caught in the cross-fire of policy change? Drug Alcohol Rev 2017;36:192-199].