BackgroundNeonatal sepsis is a major cause of mortality worldwide, with most deaths occurring in low-income countries. The World Health Organisation (WHO) ‘5 Moments for Hand Hygiene’ poster has been used to reduce hospital-acquired infections, but there is no similar tool to prevent community-acquired newborn infections in low-resource settings. This assessment, part of the BabyGel Pilot study, evaluated the acceptability of the ‘Newborn Moments for Hand Hygiene in the Home’ poster. This was an educational tool which aimed to remind mothers in rural Uganda to clean their hands to prevent neonatal infection.MethodsThe BabyGel pilot was a cluster randomised trial that assessed the post-partum use of alcohol-based hand rub (ABHR) to prevent neonatal infections in Mbale, Uganda. Fifty-five women in 5 village clusters received the ABHR and used it from birth to 3 months postnatally, with use guided by the new poster. Following the study, 5 focus group discussions (FGDs) were conducted consisting of 6–8 purposively sampled participants from intervention villages. FGDs were audio-recorded, transcribed then translated into English. Transcripts were inductively coded using ATLAS.ti® and qualitatively analysed using thematic content analysis.ResultsMost mothers reported that they understood the message in the poster (“The picture shows me you must use these drugs to keep your baby healthy”) and that they could adhere to the moments from the poster. Some participants used the information from the poster to encourage other caregivers to use the ABHR (“after explaining to them, they liked it”). Other potential moments for hand hygiene were introduced by participants, such as after tending to domestic animals and gardening.ConclusionThe poster was well-received, and participants reported compliance with the moments for hand hygiene (although the full body wipe of the baby has since been removed). The poster will be adapted into a sticker format on the ABHR bottle. More focus could be put into an education tool for other caregivers who wish to hold the baby. Overall, the study demonstrated the acceptability of an adapted version of the WHO Moments for Hand Hygiene poster in the introduction of an intervention in the community.Trial registrationISRCTN67852437, registered 02/03/2015.Trial fundingMedical Research Council/ Wellcome Trust/ DfID (Global Health Trials Scheme).

ObjectiveInvestigators within many disciplines are using measures of well-being, but it is not always clear what they are measuring, or which instruments may best meet their objectives. The aims of this review were to: systematically identify well-being instruments, explore the variety of well-being dimensions within instruments and describe how the production of instruments has developed over time.DesignSystematic searches, thematic analysis and narrative synthesis were undertaken.Data sourcesMEDLINE, EMBASE, EconLit, PsycINFO, Cochrane Library and CINAHL from 1993 to 2014 complemented by web searches and expert consultations through 2015.Eligibility criteriaInstruments were selected for review if they were designed for adults (≥18 years old), generic (ie, non-disease or context specific) and available in an English version.ResultsA total of 99 measures of well-being were included, and 196 dimensions of well-being were identified within them. Dimensions clustered around 6 key thematic domains: mental well-being, social well-being, physical well-being, spiritual well-being, activities and functioning, and personal circumstances. Authors were rarely explicit about how existing theories had influenced the design of their tools; however, the 2 most referenced theories were Diener's model of subjective well-being and the WHO definition of health. The period between 1990 and 1999 produced the greatest number of newly developed well-being instruments (n=27). An illustration of the dimensions identified and the instruments that measure them is provided within a thematic framework of well-being.ConclusionsThis review provides researchers with an organised toolkit of instruments, dimensions and an accompanying glossary. The striking variability between instruments supports the need to pay close attention to what is being assessed under the umbrella of ‘well-being’ measurement.

Background As antiretroviral treatment (ART) for HIV/AIDS is scaled-up globally, information on per-person costs is critical to improve efficiency in service delivery and maximize coverage and health impact. Objective To review studies on delivery unit costs for adult and pediatric ART provision per-patient-year, and prevention of mother-to-child transmission (PMTCT) interventions per mother-infant pair screened or treated, in low- and middle-income countries. Methods Systematic review of English, French and Spanish publications from 2001 to 2009, reporting empirical costing that accounted for at least antiretroviral (ARV) medicines, laboratory testing and personnel. Expenditures were analyzed by country income level and cost component. All costs were standardized to 2009 US dollars. Results Analyses covered 29 eligible, comprehensive costing studies. In the base case, in low-income countries (LIC), median, ART cost per patient-year was $792 (mean: $839, range: $682-$1089); for lower-middle-income countries (LMIC), the median was $932 (mean: $1246, range: $156-$3904); and for upper-middle-income countries (UMIC) the median was $1454 (mean: $2783, range: $1230-$5667). ARV drugs were largest component of overall ART cost in all settings (62%, 50% and 47% in LIC, LMIC and UMIC respectively). Out of 26 ART studies, 14 report which drug regimes were used, and only one study explicitly reported second line treatment costs. The second cost driver was laboratory cost in LIC and LMIC (14% and 19.5%) whereas it was personnel costs in UMIC (26%). Two studies specified the types of laboratory tests costed, and three studies specifically included above-facility-level personnel costs. Three studies reported detailed PMTCT costs, and two studies reported on pediatric ART. Conclusions There is a paucity of data on the full ART and PMTCT delivery unit costs, in particular for low-and middle-income countries. Heterogeneity in activities costed and insufficient detail regarding components included in the costing hampers standardization of unit cost measures. Evaluation of program-level unit costs would benefit from international guidance on standardized costing methods, and expenditure categories and definitions. Future work should help elucidate the sources for the large variations in delivery unit costs across settings with similar income and epidemiological characteristics.

BackgroundDecision-support tools quantify the risk of undiagnosed cancer in symptomatic patients, and may help GPs when making referrals.AimTo quantify the availability and use of cancer decision-support tools (QCancer® and risk assessment tools) and to explore the association between tool availability and 2-week-wait (2WW) referrals for suspected cancer.Design and settingA cross-sectional postal survey in UK primary care.MethodsOut of 975 UK randomly selected general practices, 4600 GPs and registrars were invited to participate. Outcome measures included the proportions of UK general practices where cancer decision-support tools are available and at least one GP uses the tool. Weighted least-squares linear regression with robust errors tested the association between tool availability and number of 2WW referrals, adjusting for practice size, sex, age, and Index of Multiple Deprivation.ResultsIn total, 476 GPs in 227 practices responded (response rates: practitioner, 10.3%; practice, 23.3%). At the practice level, 83/227 (36.6%, 95% confidence interval [CI] = 30.3 to 43.1) practices had at least one GP or registrar with access to cancer decision-support tools. Tools were available and likely to be used in 38/227 (16.7%, 95% CI = 12.1 to 22.2) practices. In subgroup analyses of 172 English practices, there was no difference in mean 2WW referral rate between practices with tools and those without (mean adjusted difference in referrals per 100 000: 3.1, 95% CI = −5.5 to 11.7).ConclusionThis is the first survey of cancer decision-support tool availability and use. It suggests that the tools are an underused resource in the UK. Given the cost of cancer investigation, a randomised controlled trial of such clinical decision-support aids would be appropriate.

This European study contributes to establishing that the QALY multiplicative model is an invalid measure. This explains why costs/QALY estimates may vary greatly, leading to inconsistent recommendations relevant to providing access to innovative medicines and health technologies. HTA agencies should consider other more robust methodological approaches to guide reimbursement decisions.

BackgroundOver 133,000 children present to hospitals with Acute Encephalitis Syndrome (AES) annually in Asia. Japanese encephalitis (JE) accounts for approximately one-quarter of cases; in most cases no pathogen is identified and management is supportive. Although JE is known to result in neurological impairment, few studies have examined the wider impact of JE and AES on patients and their families.Methodology/Principal FindingsChildren (aged 1 month–14 years) with AES were assessed 5–12 months after discharge from two Nepali hospitals. Assessment included clinical examination, the Liverpool Outcome Score (LOS) - a validated assessment of function following encephalitis, questionnaires about the child's social participation since discharge, and out-of-pocket costs to the family. Children were classified as JE or ‘other AES’ based on anti-JE virus antibody titres during acute illness. Contact was made with the families of 76% (73/96) of AES children. Six children had died and one declined participation. 48% (32/66) reported functional impairment at follow-up, most frequently affecting behaviour, language or limb use. Impairment was more frequent in JE compared to ‘other AES’ cases (68% [13/19] versus 40% [19/47]; p = 0.06). 49% (26/53) had improvement in LOS between discharge and follow-up. The median out-of-pocket cost to families, including medical bills, medication and lost earnings was US$ 1151 (10 times their median monthly income) for children with severe/moderate impairment and $524 (4.6 times their income) for those with mild/no impairment (P = 0.007). Acute admission accounted for 74% of costs. Social participation was limited in 21% of children (n = 14).Conclusions/SignificanceProlonged functional impairment was common following AES. Economic impact to families was substantial. Encouragingly, almost half the children improved after discharge and most reported sustained social participation. This study highlights a need for long-term medical support following AES. Rationalisation of initial expensive hospital treatments may be warranted, especially since only supportive treatment is available.

BackgroundThe REtirement in ACTion (REACT) study is a multi-centre, pragmatic, two-arm, parallel-group randomised controlled trial (RCT) with an internal pilot phase. It aims to test the effectiveness and cost-effectiveness of a community, group-based physical activity intervention for reducing, or reversing, the progression of functional limitations in older people who are at high risk of mobility-related disability.Methods/designA sample of 768 sedentary, community-dwelling, older people aged 65 years and over with functional limitations, but who are still ambulatory (scores between 4 and 9 out of 12 in the Short Physical Performance Battery test (SPPB)) will be randomised to receive either the REACT intervention, delivered over a period of 12 months by trained facilitators, or a minimal control intervention. The REACT study incorporates comprehensive process and economic evaluation and a nested sub-study which will test the hypothesis that the REACT intervention will slow the rate of brain atrophy and of decline in cognitive function assessed using magnetic resonance imaging (MRI). Outcome data will be collected at baseline, 6, 12 and 24 months for the main study, with MRI sub-study data collected at baseline, 6 and 12 months.The primary outcome analysis (SPPB score at 24 months) will be undertaken blinded to group allocation. Primary comparative analyses will be on an intention-to-treat (ITT) basis with due emphasis placed on confidence intervals.DiscussionREACT represents the first large-scale, pragmatic, community-based trial in the UK to target the non-disabled but high-risk segment of the older population with an intervention to reduce mobility-related disability. A programme that can successfully engage this population in sufficient activity to improve strength, aerobic capacity, coordination and balance would have a major impact on sustaining health and independence.REACT is also the first study of its kind to conduct a full economic and comprehensive process evaluation alongside the RCT. If effective and cost-effective, the REACT intervention has strong potential to be implemented widely in the UK and elsewhere.Trial registrationISRCTN, ID:ISRCTN45627165. Retrospectively registered on 13 June 2016.Trial sponsor: University of Bath. Protocol Version 1.5.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-2603-x) contains supplementary material, which is available to authorized users.

There appears to be an association between poor oral hygiene and increased risk of aspiration pneumoniaa leading cause of mortality post-stroke. We aim to synthesise what is known about oral care after stroke, identify knowledge gaps and outline priorities for research that will provide evidence to inform best practice. Methods: A narrative review from a multidisciplinary perspective, drawing on evidence from systematic reviews, literature, expert and lay opinion to scrutinise current practice in oral care after a stroke and seek consensus on research priorities. Findings: Oral care tends to be of poor quality and delegated to the least qualified members of the caring team. Nursing staff often work in a pressured environment where other aspects of clinical care take priority. Guidelines that exist are based on weak evidence and lack detail about how best to provide oral care. Discussion: Oral health after a stroke is important from a social as well as physical health perspective, yet tends to be neglected. Multidisciplinary research is needed to improve understanding of the complexities associated with delivering good oral care for stroke patients. Also to provide the evidence for practice that will improve wellbeing and may reduce risk of aspiration pneumonia and other serious sequelae. Conclusion: Although there is evidence of an association, there is only weak evidence about whether improving oral care reduces risk of pneumonia or mortality after a stroke. Clinically relevant, feasible, cost-effective, evidence-based oral care interventions to improve patient outcomes in stroke care are urgently needed.