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Objective To identify the associated factors affecting the decision regarding institutional delivery for pregnant women in 14 low- and middle-income countries (LMICs). Design A special mixed-method design was used to combine cross-sectional studies for harmonising data from Bangladesh and 13 other countries to obtain extended viewpoints on non-utilisation of institutional healthcare facilities during childbirth. BAY 2402234 Dehydrogenase inhibitor Setting Demographic and Health Survey (DHS) data for 14 LMICs were used for the study. Participants There are several kinds of datasets in the DHS. Among them 'Individual Women's Records' was used as this study is based on all ever-married women. Results In the binary logistic and meta-analysis models for Bangladesh, ORs for birth order were 0.57 and 0.51 and for respondents' age were 1.50 and 1.07, respectively. In all 14 LMICs, the most significant factors for not using institutional facilities during childbirth were respondents' age (OR 0.903, 95% CI 0.790 to 1.032) and birth order (OR 0.371, 95% CI 0.327 to 0.421). Conclusion Birth order and respondents' age were the two most significant factors for non-utilisation of healthcare facilities during childbirth in 14 LMICs. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Objective The objectives of this study were to estimate influenza vaccination coverage among patients with diabetes mellitus in an Italian 250 000-inhabitant area in the 2017-2018 season and to assess whether glycaemic control and pharmacological treatment were associated with the likelihood of being vaccinated. Design In this cross-sectional study, we analysed anonymous health administrative databases, linked with each other at the individual patient level through a stochastic key diabetes mellitus registry, vaccinations, drug prescriptions and laboratory database. Setting The study was conducted in the catchment area of the University Hospital of Udine ('the Udine area'), a 250 000-inhabitant area in the northeast of Italy. Participants The study included all subjects included in the regional registry of patients with diabetes mellitus, living in the Udine area as of 1 October 2017. Main outcome measures Vaccination coverage in the 2017-2018 influenza season was calculated. The association between patients'BMJ.Objective The aim of this study was to analyse the factors associated with the intention of Indonesian nursing students to work in rural areas. Design This was a cross-sectional study. The instrument used was a self-developed questionnaire consisting of 13 questions. The data were analysed using the χ2 statistics test and binary logistic regression with a level of significance less then 0.05. Setting The study was conducted at a public nursing school located in urban Surabaya, East Java, Indonesia, in December 2017. Participants A total of 714 nursing students from four different programmes were involved. Results This study found that almost 60% of nursing students were reluctant to work in rural areas. Of the three variables which were significant in the χ2 analysis, only two were significant following the logistic regression test, namely the class programmes of undergraduate regulars (OR=2.274; 95% CI 1.326 to 3.900), profession regulars (OR=2.262; 95% CI 1.110 to 4.607) and rural place of origin (OR=1.405; 95% CI 1.036 to 1.906). Conclusion The education programme and place of origin were associated with the intention of nursing students to work in rural areas. Therefore, the recruitment of prospective nurses should consider these factors by considering the local context. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Background There are concerns with the extent of dispensing of antibiotics among community pharmacists in Pakistan often without a prescription adding to antimicrobial resistance (AMR) rates. Objective To explore the determinants of AMR and the pattern of antimicrobial dispensing among community pharmacists. Design In this qualitative study design, a semistructured interview guide was developed based on an in-depth review of published papers. Audio-recorded interviews with transcripts were analysed by thematic content analysis. Setting Interviews were conducted among community pharmacists in Lahore, Pakistan. Participants In order to obtain individual points of view, in-depth face-to-face interviews with purposively selected pharmacists were conducted. Results A total of 12 pharmacists were interviewed for the study. After analysis, four major themes emerged (1) knowledge and perception of community pharmacists about antimicrobials, (2) antimicrobial dispensing practices of community pharmacists, (3) determinants of AMR, (4) potential interventions to control AMR. Most of the pharmacists have limited knowledge about AMR, antimicrobial stewardship programmes and related guidelines. However, all the pharmacists strongly agreed that different appropriate actions should be taken in order to rationalise future antimicrobial use. Conclusion The results indicated that irrational antimicrobial dispensing and use is common among community pharmacists in Pakistan owing to lack of knowledge. The community pharmacists perceived that behaviour of patients and the societal environment contributed to irrational antimicrobial use and subsequent development of AMR. They suggested a need for a multidisciplinary framework in order to improve future antimicrobial use and reduce AMR in Pakistan. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Unilateral rhinorrhoea in the paediatric age group could be an alarming sign that warrants a clinician attention. These patients are routinely brought to see general practitioner as parents may not be aware of the urgency to intervene surgically. Herein we describe a case of a toddler who presented initially to a general practitioner with unilateral nasal discharge. He was subsequently referred to the otorhinolaryngology department for unresolved rhinitis. The child was examined, and the diagnosis of an embedded foreign body was made. X-ray of the paranasal sinus unveiled an embedded button battery. An emergency endoscopic retrieval of the button battery was performed under general anaesthesia. Unfortunately, the case was complicated with a huge septal perforation. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.The purpose of this study was to develop a tool for community-based health organisations (CBHOs) to evaluate the preparedness in biohazards concerning epidemics or bioterrorism. We searched concepts on partnerships of CBHOs with health systems in guidelines of the Centers for Disease Control and Prevention and literature. Then, we validated the researcher-made tool by face validity, content validity, exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and criterion validity. Data were collected by sending the tool to 620 CBHOs serving under supervision of Iran's ministry of health. Opinions of health professionals and stakeholders in CBHOs were used to assess face and content validity. Factor loads in EFA were based on three-factor structure that verified by CFA. We used SPSS V.18 and Mplus7 software for statistical analysis. About 105 health-based CBHOs participated. After conducting face validity and calculating content validity ratio and content validity index, we reached 54 items in the field of planning, training and infrastructure. We conducted construct validity using 105 CBHOs. Three items exchanged between the fields according to factor loads in EFA, and CFA verified the model fit as Comparative Fit Index, Tucker-Lewis index and root mean square error of approximation were 0.921, 0918 and 0.052, respectively. The Cronbach's of the whole tool was 0.944. Spearman correlation coefficient confirmed criterion validity as coefficient was 0.736. Planning, training and infrastructure fields are the most important aspects of preparedness in health-based CBHOs. Applying the new assessment tool in future studies will show the weaknesses and capabilities of health-based CBHOs in biohazard and clear necessary intervention actions for health authorities. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Introduction The International Family Medicine Clinic (IFMC) was established in 2002 by the University of Virginia Department of Family Medicine to provide comprehensive, timely, culturally sensitive and high-quality healthcare to the growing refugee and special immigrant population in Central Virginia, USA. Methods The purpose of this paper is to describe the IFMC, with a specific focus on interprofessional roles, interprofessional collaboration, community partnerships and the services and resources available to IFMC patients. Results The clinic has served over 3100 refugees from 60 countries in its 16-year history. In 2019, the clinic staff now includes 4 attending physicians, 2 nurse practitioners and 14 residents who have dedicated clinic time to see refugees; a registered nurse care coordinator and a social worker dedicated to the IFMC refugee population; 2 clinical psychologists and doctoral students in clinical psychology; and a clinical pharmacist. The IFMC also provides onsite psychiatric care. A process flow map depicts the interconnectivity of interprofessional team members working together with other specialty care providers within the medical centre and with community partners on behalf of refugee patients through the resettlement process. Conclusion Individuals who arrive in the USA as refugees are a particularly vulnerable patient group and often require an interprofessional team approach. The IFMC may serve as a model for other institutions interested in starting a similar interprofessional, refugee-centred medical home. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Objective This study aimed to explore how new family medicine graduates who want to include obstetrics in their scope of practice identify and select jobs and to understand how employment influences scope of practice in family medicine, particularly the ability to provide maternity care and deliver babies. Design Mixed-methods study including a survey and qualitative interviews conducted in 2017. Setting We electronically surveyed US family physicians and followed up with a purposeful subsample of these physicians to conduct in-depth, semistructured telephone interviews. Participants 1016 US family medicine residency graduates 2014-2016 who indicated that they intended to deliver babies in practice completed a survey; 56 of these were interviewed. Main outcome measures The survey measured the reasons for not doing obstetrics as a family physician. To identify themes regarding finding family medicine jobs with obstetrics, we used a team-based, immersion-crystallisation approach to analyse the transcribed qualitative interviews.