Publications by authors named "Karen Morgan"

78 Publications

"What I thought was so important isn't really that important": international perspectives on making meaning during the first wave of the COVID-19 pandemic.

Health Psychol Behav Med 2021 11;9(1):830-857. Epub 2021 Oct 11.

Perdana University Royal College of Surgeons School of Medicine (PURCSI), Kuala Lumpur, Malaysia.

Background: The global COVID-19 pandemic has had a significant impact on the physical and mental health of people everywhere. The aim of the study is to understand how people living in 15 countries around the globe experience an unexpected crisis which threatens their health and that of loved ones, and how they make meaning of this disruption in their narratives.

Methods: Data were collected through an anonymous online survey during May-September 2020, which was during or just after the first wave of the COVID-19 pandemic, depending on the country. The questionnaire included demographic and three open-ended questions as prompts for stories about experiences during the initial months of the pandemic. The text was analyzed through inductive thematic content analysis and quantified for full sample description, demographic and subsequently international comparisons.

Results: The final qualitative dataset included stories from = 1685 respondents. The sample was 73.6% women and 26.4% men. The mean age of participants was 39.55 years (SD = 14.71). The identified four groups of overarching themes were: The presence and absence of others; Rediscovering oneself; The meaning of daily life; Rethinking societal and environmental values. We discuss the prevalence of each theme for the sample as a whole and differences by demographic groups. The most prevalent theme referred to disruptions in interpersonal contacts, made meaningful by the increased appreciation of the value of relationships, present in (45.6%) of stories. It was more prevalent in the stories of women compared to men (χ² = 24.88,  = .001).

Conclusions: The paper provides a detailed overview of the methodology, the main themes identified inductively in the stories and differences according to select demographic variables. We identify several major ways of making meaning of the pandemic. The pandemic has impacted many aspects of people's lives which give it meaning, no matter where they live.
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http://dx.doi.org/10.1080/21642850.2021.1981909DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8510597PMC
October 2021

The trajectory of COVID-19 pandemic and handwashing adherence: findings from 14 countries.

BMC Public Health 2021 10 5;21(1):1791. Epub 2021 Oct 5.

Wroclaw Faculty of Psychology, SWPS University of Social Sciences and Humanities, 30b Ostrowskiego Street, PL-53-238, Wroclaw, Poland.

Background: The COVID-19 pandemic has affected people's engagement in health behaviors, especially those that protect individuals from SARS-CoV-2 transmission, such as handwashing/sanitizing. This study investigated whether adherence to the World Health Organization's (WHO) handwashing guidelines (the outcome variable) was associated with the trajectory of the COVID-19 pandemic, as measured by the following 6 indicators: (i) the number of new cases of COVID-19 morbidity/mortality (a country-level mean calculated for the 14 days prior to data collection), (ii) total cases of COVID-19 morbidity/mortality accumulated since the onset of the pandemic, and (iii) changes in recent cases of COVID-19 morbidity/mortality (a difference between country-level COVID-19 morbidity/mortality in the previous 14 days compared to cases recorded 14-28 days earlier).

Methods: The observational study (#NCT04367337) enrolled 6064 adults residing in Australia, Canada, China, France, Gambia, Germany, Israel, Italy, Malaysia, Poland, Portugal, Romania, Singapore, and Switzerland. Data on handwashing adherence across 8 situations (indicated in the WHO guidelines) were collected via an online survey (March-July 2020). Individual-level handwashing data were matched with the date- and country-specific values of the 6 indices of the trajectory of COVID-19 pandemic, obtained from the WHO daily reports.

Results: Multilevel regression models indicated a negative association between both accumulation of the total cases of COVID-19 morbidity (B = -.041, SE = .013, p = .013) and mortality (B = -.036, SE = .014 p = .002) and handwashing. Higher levels of total COVID-related morbidity and mortality were related to lower handwashing adherence. However, increases in recent cases of COVID-19 morbidity (B = .014, SE = .007, p = .035) and mortality (B = .022, SE = .009, p = .015) were associated with higher levels of handwashing adherence. Analyses controlled for participants' COVID-19-related situation (their exposure to information about handwashing, being a healthcare professional), sociodemographic characteristics (gender, age, marital status), and country-level variables (strictness of containment and health policies, human development index). The models explained 14-20% of the variance in handwashing adherence.

Conclusions: To better explain levels of protective behaviors such as handwashing, future research should account for indicators of the trajectory of the COVID-19 pandemic.

Trial Registration: Clinical Trials.Gov, # NCT04367337.
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http://dx.doi.org/10.1186/s12889-021-11822-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8492037PMC
October 2021

Training Characteristics, Personal Factors and Coping Strategies Associated with Burnout in Junior Doctors: A Multi-Center Study.

Healthcare (Basel) 2021 Sep 14;9(9). Epub 2021 Sep 14.

Institute for Health Management, National Institutes of Health, Ministry of Health, Shah Alam 40170, Malaysia.

Physician burnout has been recognized as a public health crisis. However, there is a paucity of burnout studies in the context of medical internship. We assessed the prevalence and relationship between various training characteristics, personal variables, resilience, and coping with burnout in a cross-sectional study involving 837 interns from ten hospitals across Malaysian healthcare system. The instrument package included demographic questions, the Connor-Davidson Resilience Scale, Brief COPE and the Copenhagen Burnout Inventory. A total of 754 (90.1%) interns completed the inventories. We found a high prevalence of personal-related (73.3%), work-related (69.1%), and patient-related (43.4%) burnout among Malaysian interns. Multivariable analysis showed female gender (odds ratio (OR):1.50; 95% confidence interval (CI): 1.02-2.20), prior work experience (OR: 1.56; 95% CI: 1.05-2.30), and irregular spirituality routines (OR: 1.97; 95% CI: 1.30-2.99) were associated with increased odds of personal-related burnout. Irregular spirituality routines (OR: 2.24; 95% CI: 1.49-3.37) were associated with work-related burnout, while living with other people (OR: 1.77; 95% CI: 1.15-2.73) was associated with patient-related burnout. Lower resilience levels and avoidant copings were associated with personal-, work-, and patient-related burnout. Burnout prevalence among interns is high. The findings support the value of individual-targeted alongside organizational-targeted intervention in burnout reduction. As burnout is prevalent in both years of internship training, ongoing burnout prevention and wellbeing measures are deemed necessary.
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http://dx.doi.org/10.3390/healthcare9091208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8472197PMC
September 2021

Introducing the new Chronic Oedema Wet Leg Pathway.

Br J Community Nurs 2021 Oct;26(Sup10):S16-S21

National Lymphoedema Community Educator Lead in Wales; Lymphoedema Clinical Nurse.

Reticence to apply compression therapy has been widely observed in clinical practice, compounded by an absence of evidenced-based pathways for application of prompt compression prior to measuring ankle brachial pressure index (ABPI). Importantly, delaying compression therapy for patients with chronic oedema and lymphorrhoea causes many avoidable complications. In 2017, Lymphoedema Network Wales (LNW) developed an evidenced-based pathway to improve the management of chronic oedema and wet legs (lymphorrhoea) for community nurses. During the past 4 years, the Chronic Oedema Wet Leg Pathway has been presented, published and used internationally, as well as being translated into different languages. It is commonly used in community nursing Teams as an evidenced-based document. However, like all documents and guidelines, when more evidence becomes available, the pathway needs updating. Therefore, this clinical focus article will present the new and enhanced Chronic Oedema Wet Leg Pathway, introducing a new level four compression section, which increases the layers of compression bandaging for patients with venous insufficiency or who are morbidly obese.
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http://dx.doi.org/10.12968/bjcn.2021.26.Sup10.S16DOI Listing
October 2021

Reflections on lymphoedema deployment into community services during the pandemic.

Br J Community Nurs 2021 Oct;26(Sup10):S30-S35

National Lymphoedema Education Lead in Wales: Lymphoedema Network Wales.

During the second wave of the COVID-19 pandemic, district nursing teams were overwhelmed with their caseload due to the palliative care needs of their patients. This led to patients with wet legs and chronic wounds deteriorating due to staffing levels. Therefore, the Swansea Bay University Health Board and Lymphoedema Network Wales teams redeployed two working time equivalents (WTE) into the community to take over the management of these patients with chronic wounds for 4 months. The clinicians came from a variety of different backgrounds, including nursing, physiotherapy, emergency medicine and occupational therapy. Between the teams, 866 visits were carried out over the 4-month period, where patients' compression therapy was altered to promote healing and reduce oedema. At the end of the 4-month period, 21% of the patients were discharged off the district nursing caseload completely, while of the 60% who were still active caseload patients, 35% were in increased compression and 20% had reduced need for visits.
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http://dx.doi.org/10.12968/bjcn.2021.26.Sup10.S30DOI Listing
October 2021

Health Care Provider Perceptions of Facilitators and Barriers to Human Papillomavirus Vaccination Delivery in Five Countries.

Sex Transm Dis 2021 08;48(8):557-564

Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: National human papillomavirus (HPV) vaccination programs could reduce global cervical cancer morbidity and mortality with support from health care providers. We assessed providers' perceptions of HPV vaccination in 5 countries.

Methods: We identified providers from 5 countries where national HPV vaccination programs were at various stages of implementation: Argentina, Malaysia, South Africa, South Korea, and Spain. Providers authorized to administer adolescent vaccines completed an in-depth survey, reporting perceptions of barriers and facilitators to initiating and completing HPV vaccination, and logistical challenges to HPV vaccination.

Results: Among 151 providers, common barriers to HPV vaccination initiation across all countries were parents' lack of awareness (39%), concerns about vaccine safety or efficacy (33%), and cost to patients (30%). Vaccination education campaign (70%) was the most commonly cited facilitator of HPV vaccination initiation. Common barriers to series completion included no reminder system or dosing schedule (37%), loss to follow-up or forgetting appointment (29%), and cost to patients (25%). Cited facilitators to completing the vaccine series were education campaigns (45%), affordable vaccination (32%), and reminder/recall systems (22%). Among all countries, high cost of vaccination was the most common logistical challenge to offering vaccination to adolescents (33%).

Conclusions: Incorporating provider insights into future HPV vaccination programs could accelerate vaccine delivery to increase HPV vaccination rates globally.
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http://dx.doi.org/10.1097/OLQ.0000000000001389DOI Listing
August 2021

Asian medical students' attitudes towards professionalism.

Med Educ Online 2021 Dec;26(1):1927466

Perdana University - Royal College of Surgeons in Ireland, Perdana University, Malaysia.

Professionalism is the basis of trust in patient-physician relationships; however, there is very limited evidence focusing on attitudes towards professionalism among medical students. Hence, the main aim of our study was to investigate Malaysian medical students' attitudes towards professionalism with specific emphasis on the comparison between pre-clinical and clinical students. Our secondary aim was to compare the differences in perception of medical students in Malaysia (pre-clinical and clinical) with Asian medical students studying in Dublin, Ireland This study utilized the Professionalism Mini-Evaluation Exercise (P-MEX) instrument which consists of 25 items that represent four skill categories: Doctor-Patient Relationship skills, Reflective skills, Time Management and Inter-Professional Relationship skills. Descriptive statistics were used to describe the demographic information of students and given the ordinal nature of the data, Mann-Whitney U-tests were used. Overall, students have positive attitudes to all the professionalism items with more than 80% of the students agreeing that each of the professionalism attributes is important or very important. There was evidence of a significant difference between Malaysian pre-clinical and clinical students in relation to 'avoiding derogatory language' only (p = 0.015). When comparing between Malaysian and Dublin Asian students, there was a statistically significant difference in relation to 'show interest in patient as a person' (p < 0.003) for clinical students. Our results point to several curriculum implications such as 1) assessing students' attitudes towards professional attributes is essential when developing the professionalism curriculum, 2) integrating more effective clinical modules early in the curriculum and 3) considering geographical and cultural factors when assessing perception towards professional attributes.
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http://dx.doi.org/10.1080/10872981.2021.1927466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8143598PMC
December 2021

Simulation Based Educational Intervention for Enhancing Irrigation Skills of Nurses Caring for Patients With Cutaneous Continent Urinary Diversions and Orthotopic Neobladders.

J Wound Ostomy Continence Nurs 2021 May-Jun 01;48(3):232-237

Kyle Merandy, DNP, ANP-BC, Department of Urology, New York Presbyterian Hospital/Weill Cornell Medical College, New York.

Purpose: The purpose of this study was to investigate the effect of a nurse practitioner-led simulation-based education program on nursing knowledge and confidence in the care of patients with a cutaneous continent urinary diversion (Indiana pouch) or orthotopic neobladder.

Design: Single-group, before-after study.

Subjects And Setting: The sample comprised 11 RNs practicing at New York Presbyterian Hospital in New York City. Subjects were predominantly female, ethnically diverse, and held a bachelor's degree. About half of the subjects had less than 3 years of experience, and more than half reported prior experience caring for patients with a urinary diversion.

Methods: Participants completed a demographic survey, and a continent urinary diversion confidence survey and pretest measuring knowledge of nursing care of patients with a urinary diversion. Following baseline data collection, an educational session focused on the irrigation of a continent urinary diversion was made available for participants to review. An onsite simulation experience was scheduled several weeks later. Investigators provided education on proper irrigation of a continent urinary diversion and observed participants' skills when irrigating a continent urinary diversion on a high-fidelity simulated patient mannequin. The simulation intervention was followed by video replay and debrief providing feedback on each participant's performance. At the conclusion of the onsite simulation intervention, participants completed a postintervention confidence survey and a knowledge posttest related to the care of a continent urinary diversion. The Wilcoxon signed rank test was used to analyze baseline and postintervention changes in nursing knowledge and confidence.

Results: Participants achieved significant improvements in knowledge (P = .005) and confidence (P = .009) following the simulation-based educational intervention.

Conclusions: A nurse practitioner-led simulation-based educational program for RNs caring for patients with continent urinary diversions demonstrates enhanced nursing knowledge and confidence caring for patients with continent urinary diversions. We anticipate this experience will enhance care we provided to patients undergoing cystectomy and continent cutaneous urinary diversion or orthotopic neobladder construction.
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http://dx.doi.org/10.1097/WON.0000000000000752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278164PMC
July 2021

Burnout Prevalence and Its Associated Factors among Malaysian Healthcare Workers during COVID-19 Pandemic: An Embedded Mixed-Method Study.

Healthcare (Basel) 2021 Jan 17;9(1). Epub 2021 Jan 17.

Perdana University-Royal College of Surgeons in Ireland School of Medicine, Kuala Lumpur 50490, Malaysia.

Coronavirus disease 2019 (COVID-19) has become a global health threat and has placed an extraordinary demand on healthcare workers around the world. In this study, we aim to examine the prevalence of burnout and its associated factors and experience among Malaysian healthcare workers during the COVID-19 pandemic through an embedded mixed-method study design. We found that more than half of Malaysian healthcare workers in this sample experienced burnout. Direct involvement in COVID-19 screening or treatment, having a medical condition, and less psychological support in the workplace emerged to be the significant factors in personal-, work-, and patient-related burnout. Participants described their workloads, uncertainties caused by the pandemic, challenging work-family balance, and stretched workplace relationships as the sources of burnout. Exhaustion appeared to be the major symptom, and many participants utilized problem-focused coping to deal with the adversities experienced during the pandemic. Participants reported physical-, occupational-, psychological-, and social-related negative impacts resulting from burnout. As the pandemic trajectory is yet unknown, these findings provide early insight and guidance for possible interventions.
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http://dx.doi.org/10.3390/healthcare9010090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829836PMC
January 2021

Psychosocial mechanisms of change in symptoms of Persistent Complex Bereavement Disorder amongst refugees from Myanmar over the course of Integrative Adapt Therapy.

Eur J Psychotraumatol 2020 Sep 16;11(1):1807170. Epub 2020 Sep 16.

School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia.

: The ability to adapt to the psychosocial disruptions associated with the refugee experience may influence the course of complicated grief reactions. : We examine these relationships amongst Myanmar refugees relocated to Malaysia who participated in a six-week course of Integrative Adapt Therapy (IAT). : Participants (n = 170) included Rohingya, Chin, and Kachin refugees relocated to Malaysia. At baseline and six-week post-treatment, we applied culturally adapted measures to assess symptoms of Prolonged Complex Bereavement Disorder (PCBD) and adaptive capacity to psychosocial disruptions, based on the Adaptive Stress Index (ASI). The ASI comprises five sub-scales of safety/security (ASI-1); bonds and networks (ASI-2); injustice (ASI-3); roles and identity (ASI-4); and existential meaning (ASI-5). : Multilevel linear models indicated that the relationship between baseline and posttreatment PCBD symptoms was mediated by the ASI scale scores. Further, ASI scale scores assessed posttreatment mediated the relationship between baseline and posttreatment PCBD symptoms. Mediation of PCBD change was greatest for the ASI II scale representing disrupted bonds and networks. : Our findings are consistent with the informing model of IAT in demonstrating that changes in adaptive capacity, and especially in dealing with disrupted bonds and networks, may mediate the process of symptom improvement over the course of therapy.
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http://dx.doi.org/10.1080/20008198.2020.1807170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534324PMC
September 2020

Variations in prevalence and risk profiles for Common Mental Disorders amongst Rohingya, Chin and Kachin refugees from Myanmar.

Psychol Med 2020 Sep 11:1-15. Epub 2020 Sep 11.

Faculty of Medicine, School of Psychiatry, University of New South Wales, Australia.

Background: Large variations in prevalence rates of common mental disorder (CMD) amongst refugees and forcibly displaced populations have raised questions about the accuracy and value of epidemiological surveys in these cross-cultural settings. We examined the associations of sociodemographic indices, premigration traumatic events (TEs), postmigration living difficulties (PMLDs), and psychosocial disruptions based on the Adaptive Stress Index (ASI) in relation to CMD prevalence amongst the Rohingya, Chin and Kachin refugees originating from Myanmar and relocated to Malaysia.

Methods: Parallel epidemiological studies were conducted in areas where the three groups were concentrated in and around Malaysia (response rates: 80-83%).

Results: TE exposure, PMLDs and ASI were significantly associated with CMD prevalence in each group but the Rohingya recorded the highest exposure to all three of these former indices relative to Chin and Kachin (TE: mean = 11.1 v. 8.2 v. 11; PMLD: mean = 13.5 v. 7.4 v. 8.7; ASI: mean = 128.9 v. 32.1 v. 35.5). Multiple logistic regression analyses based on the pooled sample (n = 2058) controlling for gender and age, found that ethnic group membership, premigration TEs (16 or more TEs: OR, 2.00; 95% CI, 1.39-2.88; p < 0.001), PMLDs (10-15 PMLDs: OR, 4.19; 95% CI, 3.17-5.54; 16 or more PMLDs: OR, 7.23; 95% CI, 5.24-9.98; p < 0.001) and ASI score (ASI score 100 or greater: OR, 2.19; 95% CI, 1.46-3.30; p < 0.001) contributed to CMD.

Conclusions: Factors specific to each ethnic group and differences in the quantum of exposure to TEs, PMLDs and psychosocial disruptions appeared to account in large part for differences in prevalence rates of CMDs observed across these three groups.
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http://dx.doi.org/10.1017/S0033291720003104DOI Listing
September 2020

Severe lower limb lymphoedema successfully treated with a two-stage debulking procedure: a case report.

Case Reports Plast Surg Hand Surg 2020 10;7(1):38-42. Epub 2020 Mar 10.

The Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK.

Lymphoedema is a chronic condition that has significant functional and psychosocial morbidity. We report a case of severe lower limb lymphoedema successfully treated with a two-stage debulking procedure, highlighting the significant improvements in function and quality of life this operation can have with the appropriate multidisciplinary support.
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http://dx.doi.org/10.1080/23320885.2020.1736943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144239PMC
March 2020

An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial.

PLoS Med 2020 03 31;17(3):e1003073. Epub 2020 Mar 31.

School of Psychiatry, Faculty of Medicine, University of New South Wales, Australia.

Background: This randomised controlled trial (RCT) aims to compare 6-week posttreatment outcomes of an Integrative Adapt Therapy (IAT) to a Cognitive Behavioural Therapy (CBT) on common mental health symptoms and adaptive capacity amongst refugees from Myanmar. IAT is grounded on psychotherapeutic elements specific to the refugee experience.

Methods And Findings: We conducted a single-blind RCT (October 2017 -May 2019) with Chin (39.3%), Kachin (15.7%), and Rohingya (45%) refugees living in Kuala Lumpur, Malaysia. The trial included 170 participants receiving six 45-minute weekly sessions of IAT (97.6% retention, 4 lost to follow-up) and 161 receiving a multicomponent CBT also involving six 45-minute weekly sessions (96.8% retention, 5 lost to follow-up). Participants (mean age: 30.8 years, SD = 9.6) had experienced and/or witnessed an average 10.1 types (SD = 5.9, range = 1-27) of traumatic events. We applied a single-blind design in which independent assessors of pre- and posttreatment indices were masked in relation to participants' treatment allocation status. Primary outcomes were symptom scores of Post Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Major Depressive Disorder (MDD), the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor-Davidson Resilience Scale [CDRS]). Compared to CBT, an intention-to-treat analysis (n = 331) at 6-week posttreatment follow-up demonstrated greater reductions in the IAT arm for all common mental disorder (CMD) symptoms and ASI domains except for ASI-3 (injustice), as well as increases in the resilience scores. Adjusted average treatment effects assessing the differences in posttreatment scores between IAT and CBT (with baseline scores as covariates) were -0.08 (95% CI: -0.14 to -0.02, p = 0.012) for PTSD, -0.07 (95% CI: -0.14 to -0.01) for CPTSD, -0.07 for MDD (95% CI: -0.13 to -0.01, p = 0.025), 0.16 for CDRS (95% CI: 0.06-0.026, p ≤ 0.001), -0.12 (95% CI: -0.20 to -0.03, p ≤ 0.001) for ASI-1 (safety/security), -0.10 for ASI-2 (traumatic losses; 95% CI: -0.18 to -0.02, p = 0.02), -0.03 for ASI-3 (injustice; (95% CI: -0.11 to 0.06, p = 0.513), -0.12 for ASI-4 (role/identity disruptions; 95% CI: -0.21 to -0.04, p ≤ 0.001), and -0.18 for ASI-5 (existential meaning; 95% CI: -0.19 to -0.05, p ≤ 0.001). Compared to CBT, the IAT group had larger effect sizes for all indices (except for resilience) including PTSD (IAT, d = 0.93 versus CBT, d = 0.87), CPTSD (d = 1.27 versus d = 1.02), MDD (d = 1.4 versus d = 1.11), ASI-1 (d = 1.1 versus d = 0.85), ASI-2 (d = 0.81 versus d = 0.66), ASI-3 (d = 0.49 versus d = 0.42), ASI-4 (d = 0.86 versus d = 0.67), and ASI-5 (d = 0.72 versus d = 0.53). No adverse events were recorded for either therapy. Limitations include a possible allegiance effect (the authors inadvertently conveying disproportionate enthusiasm for IAT in training and supervision), cross-over effects (counsellors applying elements of one therapy in delivering the other), and the brief period of follow-up.

Conclusions: Compared to CBT, IAT showed superiority in improving mental health symptoms and adaptative stress from baseline to 6-week posttreatment. The differences in scores between IAT and CBT were modest and future studies conducted by independent research teams need to confirm the findings.

Trial Registration: The study is registered under Australian New Zealand Clinical Trials Registry (ANZCTR) (http://www.anzctr.org.au/). The trial registration number is: ACTRN12617001452381.
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http://dx.doi.org/10.1371/journal.pmed.1003073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108685PMC
March 2020

The benefits of raising awareness of lymphoedema among care home staff.

Br J Nurs 2020 Feb;29(4):190-198

Lymphoedema Specialist, Cwm Taff Morgannwg University Health Board.

Background: Patients with lymphoedema referred to a lymphoedema service from care homes in one health board area in Wales were often complex cases, with repeated cellulitis, a history of falls and other complications. A pilot project was initiated to develop education and raise awareness of lymphoedema among care home staff.

Aims: To enable care staff to identify residents with lymphoedema, promote prompt referrals, raise the importance of skin care and exercise in the management of lymphoedema and estimate the likely costs from complications associated with lymphoedema.

Methods: An education tool was developed and 47 care homes were asked to participate. A lymphoedema therapist carried out a scoping review of the residents.

Results: Forty-four care homes agreed to participate in the project with 1216 education packs being issued to care home staff. Initial findings suggest that of the 960 residents reviewed, 262 had lymphoedema (27%); 4% suffered with frequent falls, 1% had wounds and 3% had recurrent cellulitis. Only 13% (35/262) of residents with lymphoedema were known to the local lymphoedema service. Of the 31 residents reporting cellulitis, 81% had lymphoedema; of the 11 residents identified with a wound, 100% had lymphoedema and of the 40 residents reporting falls, 70% had lymphoedema.

Conclusion: This educational project has identified the value of raising awareness of lymphoedema within care homes.
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http://dx.doi.org/10.12968/bjon.2020.29.4.190DOI Listing
February 2020

Exploring the impact of lymphoedema on individuals and if lymphatic venous anastomosis surgery effects perceptions on quality of life: A qualitative study.

Eur J Oncol Nurs 2020 Feb 26;44:101720. Epub 2019 Dec 26.

National Lymphoedema Research Specialist, Swansea Bay University Health Board, Wales, United Kingdom.

Purpose: Lymphoedema is a chronic condition, a cancer consequence and causes physical, psychological, and social implications. A new super-micro surgical treatment Lymphatic Venous Anastomosis (LVA) may improve the symptoms of lymphoedema. This study aims to explore the impact of lymphoedema on individuals and if LVA Surgery changes perceptions on quality of life.

Method: Semi-structured interviews were conducted with sixteen individual's pre-LVA surgery and repeated six months later post-LVA with ten of the participants. Transcripts were analysed using thematic analysis.

Results: Themes identified pre-LVA included: Impact of Living with Lymphoedema, Being Different, and Future Hopes and Emotions. Participants reported making significant changes to 'normal' life due to living with lymphoedema. Changes included alteration in shopping, cleaning, hobbies, familial roles, employment and sexual intimacy. The wearing of compression garments engendered feelings of being unattractive. Themes found post-LVA were: I am one of the Lucky Ones and Returning to Former Self. Post-LVA, participants described how life had become more normalised with fear and apprehension of developing cellulitis reduced. Positive changes had enabled usual activities of daily living to recommence. Some participants had decreased pain, aching, heaviness, stiffness and were wearing their compression garments less.

Conclusion: The findings suggest that the real impact of living with lymphoedema is much more challenging than previously identified. The findings suggest that LVA can give a future of greater choice for some of its recipients, but further research should explore longer-term benefits. LVA could offer hope to some people with lymphoedema, but a realistic expectation is essential.
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http://dx.doi.org/10.1016/j.ejon.2019.101720DOI Listing
February 2020

Are you handling genital oedema confidently?

Br J Community Nurs 2019 Oct;24(Sup10):S19-S22

Lymphoedema Network Wales, Swansea Bay University Health Board.

Men, women or children can suffer from oedema (swelling) of the genitalia. When differential diagnosis has excluded acute trauma or pathology and swelling remains, the condition may be diagnosed as genital lymphoedema, a chronic condition that increases the relative risk of cellulitis. Diagnosis of genital oedema is often delayed due to problems with patient and health professional behaviour, in terms of embarrassment, lack of confidence or lack of knowledge. Awareness of this condition and knowledge on how to manage it will go a long way in helping both patients and clinicians overcome the challenges of addressing genital oedema. This article describes the authors' experiences in managing genital oedema. It also briefly discusses a new international project that seeks to identify the knowledge and training that health professionals need to manage this condition more confidently.
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http://dx.doi.org/10.12968/bjcn.2019.24.Sup10.S19DOI Listing
October 2019

Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia.

Transl Psychiatry 2019 09 2;9(1):213. Epub 2019 Sep 2.

Faculty of Medicine, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.

A major challenge in the refugee field is to ensure that scarce mental health resources are directed to those in greatest need. Based on data from an epidemiological survey of 959 adult Rohingya refugees in Malaysia (response rate: 83%), we examine whether a brief screening instrument of functional impairment, the WHO Disability Assessment Schedule (WHODAS), prove useful as a proxy measure to identify refugees who typically attend community mental health services. Based on estimates of mental disorder requiring interventions from analyses of epidemiological studies conducted worldwide, we selected a WHODAS cutoff that identified the top one-fifth of refugees according to severity of functional impairment, the remainder being distributed to moderate and lower impairment groupings, respectively. Compared to the lower impairment grouping, the severe impairment category comprised more boat arrivals (AOR: 5.96 [95% CI 1.34-26.43); stateless persons (A20·11 [95% CI 7.14-10); those with high exposure to pre-migration traumas (AOR: 4.76 [95% CI 1.64-13.73), peri-migration stressors (AOR: 1.26 [95% CI 1.14-1.39]) and postmigration living difficulties (AOR: 1.43 [95% CI 1.32-1.55); persons with single (AOR: 7.48 [95% CI 4.25-13.17]) and comorbid (AOR: 13.54 [95% CI 6.22-29.45]) common mental disorders; and those reporting poorer general health (AOR: 2.23 [95% CI 1-5.02]). In addition, half of the severe impairment grouping (50.6%) expressed suicidal ideas compared to one in six (16.2 percent) of the lower impairment grouping (OR: 2.39 [95% CI 1.94-2.93]). Differences between the severe and moderate impairment groups were similar but less extreme. In settings where large-scale epidemiological studies are not feasible, the WHODAS may serve as readily administered and brief public health screening tool that assists in stratifying the population according to urgency of mental health needs.
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http://dx.doi.org/10.1038/s41398-019-0537-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718407PMC
September 2019

Process evaluation of specialist nurse implementation of a soft opt-out organ donation system in Wales.

BMC Health Serv Res 2019 Jun 24;19(1):414. Epub 2019 Jun 24.

NHS Blood and Transplant, South Wales, South West and South Central, Unit 3 Cae Gwyrdd, Greenmeadow Springs Business Park, Tongwynlais, Cardiff, CF15 7AB, UK.

Background: Wales introduced a soft opt-out organ donation system on 1st December 2015 with the aim of improving consent rates. In the first 18 months consent rates improved but the difference could not solely be attributed to the soft opt-out system when compared with similar improvements in consent rates in other UK nations.

Methods: We conducted an 18 month post-intervention qualitative process evaluation involving 88 family members of 60/211 potential organ donor cases, and 19 professionals. Views and experiences of Specialist Nurses in Organ Donation who implemented the new system and family members who were involved in decision making were collected to see how their respective behaviours impacted on implementation. Data collection included interviews, focus groups and qualitative questionnaire data.

Results: Implementation was considered a success by Specialist Nurses in Organ Donation. The bespoke retraining programme and responsive approach to addressing initial implementation issues were identified as examples of best practice. Specialist Nurses in Organ Donation were valued by family members. Six implementation issues had an impact on consent rates - the media campaign had gaps, the system was more complex, challenges in changing professional behaviours, inability to obtain the required standard of evidence from family members to overturn a donation decision, increased complexity of consent processes, and additional health systems issues.

Conclusion: This is the first comprehensive process evaluation of implementing a soft opt-out system of organ donation. Specific elements of good implementation practice (such as investment in the retraining programme and the responsiveness of Specialist Nurses in Organ Donation and managers to feedback) were identified. The key message is that despite retraining, nursing practice did not radically change overnight to accommodate the new soft opt-out system. Policy makers and health service managers should not assume that nurses simply need more time to implement the soft-out as intended. Additional responsive modification of processes, ongoing training and support is required to help with implementation as originally intended. Scotland, England and the Netherlands are introducing soft opt-out systems. There is an opportunity to learn from initial implementation in Wales, by acknowledging gaps, good practice and opportunities to further improve processes and nursing practices.
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http://dx.doi.org/10.1186/s12913-019-4266-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591913PMC
June 2019

Validation of the Malay Version of the De Jong Gierveld Loneliness Scale.

Australas J Ageing 2020 Mar 21;39(1):e9-e15. Epub 2019 May 21.

Perdana University-Royal College of Surgeons in Ireland School of Medicine, Perdana University, Serdang, Malaysia.

Objective: This study aims to determine the psychometric properties of the Bahasa Malaysia (BM) version of the 6-item De Jong Gierveld Loneliness Scale (DJGLS) among older adults in Malaysia.

Methods: A total of 200 participants aged 50 years and older completed the questionnaire in which 81 participants completed in BM. A subsample of 30 participants was retested after a period of 2 weeks.

Results: The DJGLS showed good internal consistency (Cronbach's alpha 0.71) and high test-retest reliability (r = 0.93). Convergent validity was demonstrated by moderate positive correlation between total DJGLS loneliness score and UCLA loneliness scale (ULS-8) (r = 0.56, n = 81, P < 0.001). Significant associations were found between loneliness and sex, ethnicity, geographic area and marital status.

Conclusion: The BM version of the 6-item DJGLS is a reliable and valid loneliness measure for use among older adults in Malaysia.
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http://dx.doi.org/10.1111/ajag.12672DOI Listing
March 2020

Designing a co-productive study to overcome known methodological challenges in organ donation research with bereaved family members.

Health Expect 2019 08 6;22(4):824-835. Epub 2019 May 6.

NHS Blood and Transplant, South Wales, South West and South Central, Cardiff, UK.

Background: Co-production of research into public health services has yet to demonstrate tangible benefits. Few studies have reported the impact of co-production on research outcomes. The previous studies of organ donation have identified challenges in engaging with public organizations responsible, gaining ethical approval for sensitive studies with the recently bereaved and difficulty in recruiting bereaved family members who were approached about organ donation.

Objective: To address these challenges, we designed the first large co-productive observational study to evaluate implementation of a new system of organ donation in Wales. This paper outlines the co-productive strategies that were designed to overcome known methodological challenges and reports what impact they had on resolving these challenges.

Design: Two-year co-produced study with multiple stakeholders with the specific intention of maximizing engagement with the National Health Service arm in Wales responsible for organ donation, and recruitment of bereaved family members whose perspectives are essential but commonly absent from studies.

Setting And Participants: NHS Blood and Transplant, Welsh Government and multiple patient and public representatives who served as co-productive partners with the research team.

Results: Co-productive strategies enabled a smooth passage through four different ethics processes within the 10-week time frame, family member recruitment targets to be surpassed, sharing of routinely collected data on 100% of potential organ donor cases and development of further research capacity and capability in a critically under researched area.

Discussion And Conclusion: Although expensive and time consuming, co-production was effective and added value to research processes and study outcomes.
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http://dx.doi.org/10.1111/hex.12894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737840PMC
August 2019

Theory Content, Question-Behavior Effects, or Form of Delivery Effects for Intention to Become an Organ Donor? Two Randomized Trials.

Int J Environ Res Public Health 2019 04 11;16(7). Epub 2019 Apr 11.

Department of Psychology, University of Stirling, Stirling, FK9 4LA, UK.

Eliciting different attitudes with survey questionnaires may impact on intention to donate organs. Previous research used varying numbers of questionnaire items, or different modes of intervention delivery, when comparing groups. We aimed to determine whether intention to donate organs differed among groups exposed to different theoretical content, but similar questionnaire length, in different countries. We tested the effect of excluding affective attitudinal items on intention to donate, using constant item numbers in two modes of intervention delivery. Study 1: A multi-country, interviewer-led, cross-sectional randomized trial recruited 1007 participants, who completed questionnaires as per group assignment: including all affective attitude items, affective attitude items replaced, negatively-worded affective attitude items replaced. Study 2 recruited a UK-representative, cross-sectional sample of 616 participants using an online methodology, randomly assigned to the same conditions. Multilevel models assessed effects of group membership on outcomes: intention to donate (primary), taking a donor card, following a web-link (secondary). In study 1, intention to donate did not differ among groups. Study 2 found a small, significantly higher intention to donate in the negatively-worded affective attitudes replaced group. Combining data yielded no group differences. No differences were seen for secondary outcomes. Ancillary analyses suggest significant interviewer effects. Contrary to previous research, theoretical content may be less relevant than number or valence of questionnaire items, or form of intervention delivery, for increasing intention to donate organs.
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http://dx.doi.org/10.3390/ijerph16071304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479820PMC
April 2019

Short-term impact of introducing a soft opt-out organ donation system in Wales: before and after study.

BMJ Open 2019 04 3;9(4):e025159. Epub 2019 Apr 3.

Department of Nephrology and Transplantation, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK.

Objectives: To determine the short-term impact of a soft opt-out organ donation system on consent rates and donor numbers.

Design: Before and after observational study using bespoke routinely collected data.

Setting: National Health Service Blood and Transplant.

Participants: 205 potential organ donor cases in Wales.

Interventions: The Act and implementation strategy.

Primary And Secondary Outcomes: Consent rates at 18 months post implementation compared with 3 previous years, and organ donor numbers 21 months before and after implementation. Changes in organ donor register activity post implementation for 18 months.

Results: The consent rate for all modes of consent was 61.0% (125/205), showing a recovery from the dip to 45.8% in 2014/2015. 22.4% (46/205) were deemed consented donors: consent rate 60.8% (28/46). Compared with the 3 years before the switch there was a significant difference in Welsh consent rates (χ p value=0.009). Over the same time period, rest of the UK consent rates also significantly increased from 58.6% (5256/8969) to 63.1% (2913/4614) (χ p value<0.0001), therefore the Wales increase cannot be attributed to the Welsh legislation change. Deceased donors did not increase: 101 compared with 104. Organ donation registration increased from 34% to 38% with 6% registering to opt-out.

Conclusion: This is the first rigorous initial evaluation with bespoke data collected on all cases. The longer-term impact on consent rates and donor numbers is unclear. Concerns about a potential backlash and mass opting out were not realised. The move to a soft opt-out system has not resulted in a step change in organ donation behaviour, but can be seen as the first step of a longer journey. Policymakers should not assume that soft opt-out systems by themselves simply need more time to have a meaningful effect. Ongoing interventions to further enhance implementation and the public's understanding of organ donation are needed to reach the 2020 target of 80% consent rates. Further longitudinal monitoring is required.
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http://dx.doi.org/10.1136/bmjopen-2018-025159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500329PMC
April 2019

Acceptability of Women Self-Sampling versus Clinician-Collected Samples for HPV DNA Testing: A Systematic Review.

J Low Genit Tract Dis 2019 Jul;23(3):193-199

Centre for Population Health (CePH), Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.

Objectives: Female self-sampling for human papillomavirus (HPV) DNA testing is an alternative screening method that can potentially increase cervical cancer screening coverage. This review addresses the acceptability of HPV DNA testing using self-sampling compared with conventional clinician-collected sampling. Barriers to and others factors associated with acceptability of either method were also examined.

Methods: The following electronic resources were searched: Medline @EBSCOHOST(Medline), Embase, PubMed, and CINAHL databases. Manual searches were also conducted. The main outcome of interest was the acceptability of HPV DNA testing by self-sampling in comparison with clinician-collected sampling.

Results: In total, 23 articles were included in this systematic review. The majority (19 studies) were quantitative intervention studies and 4 studies were qualitative observational studies. Eleven studies reported a preference for self-sampling by women compared with clinician-collected sampling (64.7%-93%). The remaining studies found that women preferred clinician-collected sampling because mainly of respondents' lack of confidence in their ability to complete self-sampling correctly. In most articles reviewed, the studied associated factors, such as demographic factors (age, marital status, and ethnicity), socioeconomic factors (income, education level), reproductive factors (condom use, number of children, current use of contraception, and number of partners), and habits (smoking status) were not found to be significantly associated with preference.

Conclusions: Both methods of sampling were found to be acceptable to women. Self-sampling is cost-effective and could increase the screening coverage among underscreened populations. However, more information about the quality, reliability, and accuracy of self-sampling is needed to increase women's confidence about using to this method.
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http://dx.doi.org/10.1097/LGT.0000000000000476DOI Listing
July 2019

Persuasive messaging for human papillomavirus vaccination by adolescent providers in a five-country multi-site study.

Int J Gynecol Cancer 2019 02 4;29(2):250-256. Epub 2019 Jan 4.

Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA

Objective: Strong persuasive messaging by providers is a key predictor for patient acceptance of prophylactic human papillomavirus vaccination. We aimed to determine optimal messaging to promote human papillomavirus adolescent vaccination across different geographical sites.

Methods: Adolescent providers (n = 151) from Argentina, Malaysia, South Africa, South Korea, and Spain were surveyed on messages, family decision makers, and sources of communication to best motivate parents to vaccinate their adolescent daughters overall, and against human papillomavirus. Multivariate logistic regression assessed the likelihood of recommending messages specifically targeted at cervical cancer with providers' characteristics: gender, medical specialization, and previous administration of human papillomavirus vaccination.

Results: Mothers were considered the most important human papillomavirus vaccination decision makers for their daughters (range 93%-100%). Television was cited as the best source of information on human papillomavirus vaccination in surveyed countries (range 56.5%-87.1%), except Spain where one-on-one discussions were most common (73.3%). Prevention messages were considered the most likely to motivate parents to vaccinate their daughters overall, and against human papillomavirus, in all five countries (range 30.8%-55.9%). Optimal messages emphasized cervical cancer prevention, and included strong provider recommendation to vaccinate, vaccine safety and efficacy, timely vaccination, and national policy for human papillomavirus vaccination. Pediatricians and obstetricians/gynecologists were more likely to cite that the best prevention messages should focus on cervical cancer (OR: 4.2, 95% CI: 1.17 to 15.02 vs other medical specialists).

Conclusions: Provider communication messages that would motivate parents to vaccinate against human papillomavirus were based on strong recommendation emphasizing prevention of cervical cancer. To frame convincing messages to increase vaccination uptake, adolescent providers should receive updated training on human papillomavirus and associated cancers, while clearly addressing human papillomavirus vaccination safety and efficacy.
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http://dx.doi.org/10.1136/ijgc-2018-000004DOI Listing
February 2019

Adolescent providers' knowledge of human papillomavirus vaccination age guidelines in five countries.

Hum Vaccin Immunother 2019 4;15(7-8):1672-1677. Epub 2019 Apr 4.

a Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina , Chapel Hill , NC , USA.

: To examine provider knowledge of HPV vaccination age guidelines in five countries. : A total of 151 providers of adolescent vaccinations in Argentina, Malaysia, South Africa, South Korea, and Spain were interviewed between October 2013 and April 2014. Univariate analyses compared providers' understanding of recommended age groups for HPV vaccination to that of each country's national guidelines. : In three of five countries surveyed, most providers (97% South Africa, 95% Argentina, 87% Malaysia) included all nationally recommended ages in their target age group. However, a relatively large proportion of vaccinators in some countries (83% Malaysia, 55% Argentina) believed that HPV vaccination was recommended for women above age 26, far exceeding national guidelines, and beyond the maximum recommended age in the United States. National median minimum and maximum age recommendations cited by the respondents for HPV vaccination were 11 and 29 years in Argentina (national guideline: 11-14), 13 and 48 years in Malaysia (guideline 13-14), 8 and 14 years in South Africa (guideline 9-14), 10 and 20 years in South Korea (guideline 11-14), and 11 and 12 years in Spain (guideline 11-14). In all countries, a higher percentage of vaccinators included all nationally recommended ages for vaccination, as compared to providers who did not administer HPV vaccination. : Overall, a substantial proportion of providers incorrectly reported their country's age guidelines for HPV vaccination, particularly the upper age limit. As provider recommendation is among the strongest predictors of successful vaccination uptake among adolescents, improved education and clarification of national guidelines for providers administering HPV vaccination is essential to optimize prevention of infection and associated disease.
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http://dx.doi.org/10.1080/21645515.2018.1558688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746518PMC
February 2020

Validation of the Brief Ageing Perceptions Questionnaire (B-APQ) in Malaysia.

Aging Ment Health 2020 04 31;24(4):620-626. Epub 2018 Dec 31.

Perdana University Royal College of Surgeons in Ireland, Perdana University, Serdang, Malaysia.

The Brief Ageing Perceptions Questionnaire (B-APQ) has five domains that explore views about own ageing. The aim of this study was to validate the B-APQ for use among older adults in Malaysia and to explore socio-demographic variations in ageing self-perceptions. Older adults aged 50 years and above were randomly selected to complete a set of questionnaires. Cronbach's α was used to measure internal consistency, while corrected item-total correlations and correlation with DASS-21 and the CASP-19 scores were employed to assess convergent and discriminant validity. Confirmatory Factor Analysis (CFA) was conducted to confirm the factorial structure of the B-APQ. Difference in self-perceptions of ageing across socio-demographic variables was assessed. Internal consistency for each of the domains was good. Item-total correlations within each domain were strong (>0.6) or very strong (>0.8). Convergent and discriminant validity were supported by significant correlations with DASS-21 depression and CASP-19 scores. CFA results indicated good model fit with the original B-APQ model. Presence of chronic illness also has a significant impact on B-APQ domain scores. The B-APQ is a valid and reliable instrument which can be used to assess self-perceptions of ageing among older Malaysian adults.
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http://dx.doi.org/10.1080/13607863.2018.1550631DOI Listing
April 2020

Acceptability of two- versus three-dose human papillomavirus vaccination schedule among providers and mothers of adolescent girls: a mixed-methods study in five countries.

Cancer Causes Control 2018 Nov 4;29(11):1115-1130. Epub 2018 Oct 4.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA.

Purpose: The World Health Organization revised its human papillomavirus (HPV) vaccination recommendations to include a two (2-) dose schedule for girls aged ≤ 15 years. We investigated acceptability of 2- versus 3-dose schedule among adolescent vaccination providers and mothers of adolescent girls in five countries.

Methods: Adolescent vaccination providers (N = 151) and mothers of adolescent girls aged 9-14 years (N = 118) were recruited from Argentina, Malaysia, South Africa, South Korea, and Spain. We assessed providers' preference for a 2- versus 3-dose HPV vaccination schedule via quantitative surveys. Mothers' attitudes towards a 2-dose schedule were assessed through focus group discussions.

Results: Most adolescent providers preferred a 2- over a 3-dose HPV vaccination schedule (overall: 74%), with preference ranging from 45.2% (South Africa) to 90.0% (South Korea). Lower cost, fewer clinic visits, and higher series completion were commonly cited reasons for 2-dose preference among providers and mothers. Safety and efficacy concerns were commonly cited barriers to accepting a 2-dose HPV vaccination schedule among providers and mothers. Mothers generally accepted the reduced schedule, however requested further information from a trusted source.

Conclusions: Adolescent vaccination providers and mothers preferred the 2-dose over 3-dose HPV vaccination schedule. Acceptability of a 2-dose HPV vaccination could be improved with additional information to providers and mothers on HPV vaccination safety and efficacy.
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http://dx.doi.org/10.1007/s10552-018-1085-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589352PMC
November 2018

Individually-tailored multifactorial intervention to reduce falls in the Malaysian Falls Assessment and Intervention Trial (MyFAIT): A randomized controlled trial.

PLoS One 2018 3;13(8):e0199219. Epub 2018 Aug 3.

Ageing and Age-Associated Disorders Research Group, University of Malaya, Kuala Lumpur, Malaysia.

Objective: To determine the effectiveness of an individually-tailored multifactorial intervention in reducing falls among at risk older adult fallers in a multi-ethnic, middle-income nation in South-East Asia.

Design: Pragmatic, randomized-controlled trial.

Setting: Emergency room, medical outpatient and primary care clinic in a teaching hospital in Kuala Lumpur, Malaysia.

Participants: Individuals aged 65 years and above with two or more falls or one injurious fall in the past 12 months.

Intervention: Individually-tailored interventions, included a modified Otago exercise programme, HOMEFAST home hazards modification, visual intervention, cardiovascular intervention, medication review and falls education, was compared against a control group involving conventional treatment.

Primary And Secondary Outcome Measures: The primary outcome was any fall recurrence at 12-month follow-up. Secondary outcomes were rate of fall and time to first fall.

Results: Two hundred and sixty-eight participants (mean age 75.3 ±7.2 SD years, 67% women) were randomized to multifactorial intervention (n = 134) or convention treatment (n = 134). All participants in the intervention group received medication review and falls education, 92 (68%) were prescribed Otago exercises, 86 (64%) visual intervention, 64 (47%) home hazards modification and 51 (38%) cardiovascular intervention. Fall recurrence did not differ between intervention and control groups at 12-months [Risk Ratio, RR = 1.037 (95% CI 0.613-1.753)]. Rate of fall [RR = 1.155 (95% CI 0.846-1.576], time to first fall [Hazard Ratio, HR = 0.948 (95% CI 0.782-1.522)] and mortality rate [RR = 0.896 (95% CI 0.335-2.400)] did not differ between groups.

Conclusion: Individually-tailored multifactorial intervention was ineffective as a strategy to reduce falls. Future research efforts are now required to develop culturally-appropriate and affordable methods of addressing this increasingly prominent public health issue in middle-income nations.

Trial Registration: ISRCTN Registry no. ISRCTN11674947.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199219PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075745PMC
January 2019

HPV Vaccination Recommendation Practices among Adolescent Health Care Providers in 5 Countries.

J Pediatr Adolesc Gynecol 2018 Dec 12;31(6):575-582.e2. Epub 2018 Jul 12.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina. Electronic address:

Study Objective: To assess adolescent health care providers' recommendations for, and attitudes towards human papillomavirus (HPV) vaccination in 5 countries.

Design: In-depth interviews of adolescent health care providers, 2013-2014.

Setting: Five countries where HPV vaccination is at various stages of implementation into national programs: Argentina, Malaysia, South Africa, South Korea, and Spain.

Participants: Adolescent health care providers (N = 151) who had administered or overseen provision of adolescent vaccinations (N = Argentina: 30, Malaysia: 30, South Africa: 31, South Korea: 30, Spain: 30).

Main Outcome Measures: Frequency of HPV vaccination recommendation, reasons providers do not always recommend the vaccine and facilitators to doing so, comfort level with recommending the vaccine, reasons for any discomfort, and positive and negative aspects of HPV vaccination.

Results: Over half of providers 82/151 (54%) recommend HPV vaccination always or most of the time (range: 20% in Malaysia to 90% in Argentina). Most providers 112/151 (74%) said they were comfortable recommending HPV vaccination, although South Korea was an outlier 10/30 (33%). Providers cited protection against cervical cancer 124/151 (83%) and genital warts 56/151 (37%) as benefits of HPV vaccination. When asked about the problems with HPV vaccination, providers mentioned high cost 75/151 (50% overall; range: 26% in South Africa to 77% in South Korea) and vaccination safety 28/151 (19%; range: 7% in South Africa to 33% in Spain). Free, low-cost, or publicly available vaccination 59/151 (39%), and additional data on vaccination safety 52/151 (34%) and efficacy 43/151 (28%) were the most commonly cited facilitators of health provider vaccination recommendation.

Conclusion: Interventions to increase HPV vaccination should consider a country's specific provider concerns, such as reducing cost and providing information on vaccination safety and efficacy.
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http://dx.doi.org/10.1016/j.jpag.2018.06.010DOI Listing
December 2018
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