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Contraceptive side effects are consistently given as the main reason why women are dissatisfied with contraception or choose not to use it. However, why some women suffer more from side effects remains unknown. Through inductive analysis of in-depth interviews and focus group discussions with 40 contraceptive users and 3 key informants in Central Oromia, Ethiopia, we explored women’s rationales for variation in side-effect experiences. The data first reveal the wide diversity in type and severity of side-effect experiences reported by users of contraception. Second, we found that women’s rationales for why some individuals suffer more side effects from contraception invoke economic and physical hardship (food insecurity and heavy workloads), as well as interindividual differences in biology (one’s blood must ‘fit’ with contraception). Finally, the analysis revealed the tension many women face in trying to negotiate the trade-off between the consequences of these side effects and those of an unwanted pregnancy. The results show the value of using a biosocial approach, which centres women’s voices and experiences, for informing the measurement of contraceptive side effects within population health surveys and clinical trials. Additionally, the findings help gain an understanding of how an individual’s social, biological, and cultural contexts drive variation in when and why different side effects manifest.
An estimated 609,820 child-rearing adults in 2023 died from advanced cancer, affecting 153,675 dependent children. Although children are known to suffer significant distress when a parent is diagnosed with cancer, few studies have described parents’ views of their adolescent’s behavioral response to their advanced cancer or what the parent did to interpret or manage that response.
Objectives
To describe patient-reported concerns about their adolescent and how they responded to their adolescent’s behavior.
Methods
Single occasion interviews were administered to 6 adolescent-rearing parents with Stage IV cancer. Interviews were analyzed using inductive content analysis by trained coders. Trustworthiness of results was protected through peer debriefing, coding to consensus, and maintaining an audit trail.
Results
The core construct that explained study data was Being There without Taking Over, comprised of 4 domains: Struggling to Read My Child, Attempting to Talk with My Child about My Cancer, Trying to Maintain Optimism, and Understanding My Child.
Conclusions
Parents were deeply concerned about the impact of their advanced cancer on their adolescent but were unable to distinguish between cancer-related distress and adolescent angst. They feared initiating cancer-related discussions and struggled with their own feelings of guilt and parental inadequacy but did not turn to professionals for help.
Significance of results
Adolescent-rearing patients with advanced disease need to be triaged into services that offer a framework from which parents can interpret their child’s behavior and learn ways to have adolescent-appropriate conversations about the cancer. Such services should also help parents gain skills to manage feelings of parental inadequacy and guilt. In the absence of services, parents struggle and do not know how to interpret and respond to their adolescent’s cancer-related behavior.
Aortopathy in Turner syndrome is associated with aortic dilation, and the risk of dissection is increased when the aortic size index is ≥ 2–2.5 cm/m2. We evaluated the aortic biophysical properties in paediatric Turner syndrome using cardiac MRI to determine their relationship to aortic size index.
Methods:
Turner syndrome patients underwent cardiac MRI to evaluate ventricular function, aortic dimensions, and biophysical properties (aortic stiffness index, compliance, distensibility, pulse wave velocity, and aortic and left ventricular elastance). Spearman correlation examined correlations between these properties and aortic size index. Data was compared to 10 controls.
Results:
Of 25 Turner syndrome patients, median age 14.7 years (interquartile range: 11.0–16.8), height z score −2.7 (interquartile range: −2.92 – −1.54), 24% had a bicuspid aortic valve. Turner syndrome had increased diastolic blood pressure (p < 0.001) and decreased left ventricular end-diastolic (p < 0.001) and end-systolic (p = 0.002) volumes compared to controls. Median aortic size index was 1.81 cm/m2 (interquartile range: 1.45–2.1) and 7 had an aortic size index > 2 cm/m2. Aortic and left ventricular elastance were greater in Turner syndrome compared to controls (both p < 0.001). Increased aortic size index correlated with increased aortic elastance (r = 0.5, p = 0.01) and left ventricular elastance (r = 0.59, p = 0.002) but not aortic compliance. Higher ascending aortic areas were associated with increased aortic compliance (r = 0.44, p = 0.03) and left ventricular elastance (r = 0.49, p = 0.01).
Conclusion:
Paediatric Turner syndrome with similar aortic size index to controls showed MRI evidence of abnormal aortic biophysical properties. These findings point to an underlying aortopathy and provide additional parameters that may aid in determining risk factors for aortic dissection.
OBJECTIVES/GOALS: This study aims to assess associations over time between several area-based indices of concentration at the extremes and COVID-19 hospitalization and death in Los Angeles County, from January 2020 to June 2023. These measures reflect concentrations of racial/ethnic and economic segregation at the census tract level. METHODS/STUDY POPULATION: Indices of concentration at the extremes (ICEs) for economic segregation, racial/ethnic segregation, and a combination of the two were constructed for each Los Angeles County (LAC) census tract, using 2015-2019 ACS data. The index ranges from -1 to 1 and is the number of advantaged households (HH) minus the number of disadvantaged HH over the total number of HH measured. Economic segregation is HH income over $100,000 vs. below $25,000 per year and racial/ethnic segregation defined as White and Non-Hispanic vs. non-White or Hispanic HH. The distribution of index scores was divided into quintiles (Q1-Q5) for all LAC census tracts. Age-adjusted hospitalization and death rates were derived at the census tract level by quarter (QTR) based on Los Angeles County Department of Public Health surveillance data. RESULTS/ANTICIPATED RESULTS: Age-adjusted hospitalization and death rates were consistently higher across all quarters in Q1 (most deprived) vs. Q5 (most privileged) for all ICE measures. For ICE of economic segregation, the age-adjusted hospitalization and death rate ratios between Q1 and Q5 were 2.12 (range: 1.32 - 4.15; peak 2020 QTR2) and 2.02 (range: 1.46 - 3.21; peak 2021 QTR1), respectively. For ICE of racial segregation, the age-adjusted hospitalization and death rate ratio between Q1 and Q5 was 2.03 (range: 1.08 - 3.95; peak 2020 QTR3) and 1.77 (range: 1.03 - 2.80; peak 2021 QTR1). The ICE of economic/racial segregation combined was the highest, with averages of the age-adjusted hospitalization and death rate ratios between Q1 and Q5 being 2.26 (1.16 - 4.43; peak 2020 QTR2) and 1.99 (range: 1.22 - 3.32; peak 2021 QTR1). DISCUSSION/SIGNIFICANCE: This study assesses the impact of geographic segregation based on indices that quantify the concentration of both deprivation, privilege, and racial/ethnic group, demonstrating that segregation and economic deprivation are consistently associated with higher rates of age-adjusted hospitalization and death from COVID-19 in LAC.
The COVID-19 pandemic has had a deleterious impact on the lives of nurses who work in long-term care; however, the moral conditions of their work have been largely unexamined. The purpose of this qualitative study, therefore, was to explore registered practical nurses’ (RPNs) experiences of the moral habitability of long-term care environments in Ontario, Canada during the COVID-19 pandemic. Four themes were identified: (1) Striving to meet responsibilities in a failed system; (2) bearing the moral and emotional weight of residents’ isolation and dying in a context of strict public health measures; (3) knowing the realities of the work, yet failing to be heard, recognized, or supported by management; and (4) struggling to find a means of preservation for themselves and the profession. Attention to the moral habitability of RPNs’ work environments is necessary to achieve a high-quality, ethically attuned, and sustainable nursing workforce in long-term care.
Perinatal mental health (PMH) problems are a leading cause of maternal death and increase the risk of poor outcomes for women and their families. It is therefore important to identify the barriers and facilitators to implementing and accessing PMH care.
Aims
To develop a conceptual framework of barriers and facilitators to PMH care to inform PMH services.
Method
Relevant literature was systematically identified, categorised and mapped onto the framework. The framework was then validated through evaluating confidence with the evidence base and feedback from stakeholders (women and families, health professionals, commissioners and policy makers).
Results
Barriers and facilitators to PMH care were identified at seven levels: individual (e.g. beliefs about mental illness), health professional (e.g. confidence addressing perinatal mental illness), interpersonal (e.g. relationship between women and health professionals), organisational (e.g. continuity of carer), commissioner (e.g. referral pathways), political (e.g. women's economic status) and societal (e.g. stigma). The MATRIx conceptual frameworks provide pictorial representations of 66 barriers and 39 facilitators to PMH care.
Conclusions
The MATRIx frameworks highlight the complex interplay of individual and system-level factors across different stages of the care pathway that influence women accessing PMH care and effective implementation of PMH services. Recommendations are made for health policy and practice. These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to PMH care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services and quality training for health professionals, with protected time to complete it.
Vegan and vegetarian diets are widely supported and adopted, but individuals following such diets remain at greater risk of iodine deficiency. This systematic review and meta-analysis was conducted to assess the iodine intake and status in adults following a vegan or vegetarian diet in the modern day. A systematic review and quality assessment were conducted from October 2020 to December 2022 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidance. Studies were identified in Ovid MEDLINE, Web of Science, PubMed, and Scopus. Eleven articles were eligible for review containing 4421 adults (aged ≥ 18 years). Vegan groups had the lowest median urinary iodine concentration (mUIC) (12·2/l). None of the dietary groups had mUIC within the optimal range for iodine status (100–200 µg/l) (WHO). Vegan diets had the poorest iodine intake (17·3 µg/d) and were strongly associated with lower iodine intake (P = < 0·001) compared with omnivorous diets. Lower intake in vegan diets was influenced by sex (P = 0·007), the presence of voluntary or absence of Universal Salt Iodisation (USI) programmes (P = 0·01 & P = < 0·001), and living in a country with adequate iodine nutrition (P = < 0·001). Vegetarians and particularly vegans living in countries with no current USI programme continue to have increased risk of low iodine status, iodine deficiency and inadequate iodine intake. Further research into the usefulness of mandatory fortification of vegan appropriate foods is required.
Data suggest poorer bereavement outcomes for lesbian, gay and bisexual people, but this has not been estimated in population-based research. This study compared bereavement outcomes for partners of same-gender and different-gender decedents.
Methods
In this population-based, cross-sectional survey of people bereaved of a civil partner or spouse 6–10 months previously, we used adjusted logistic and linear regression to investigate outcomes of interest: (1) positive screen on Inventory of Complicated Grief (ICG), (2) positive screen on General Health Questionnaire (GHQ), (3) grief intensity (ICG) and (4) psychiatric symptoms (GHQ-12).
Results
Among 233 same-gender partners and 329 of different-gender partners, 66.1% [95% confidence interval (CI) 60.0–72.2] and 59.2% [95% CI (53.9–64.6)] respectively screened positive for complicated grief on the ICG, whilst 76.0% [95% CI (70.5–81.5)] and 69.3% [95% CI (64.3–74.3)] respectively screened positive on the GHQ-12. Same-gender bereaved partners were not significantly more likely to screen positive for complicated grief than different-gender partners [adjusted odds ratio (aOR) 1.56, 95% CI (0.98–2.47)], p = 0.059, but same-gender bereaved partners were significantly more likely to screen for psychiatric caseness [aOR 1.67 (1.02, 2.71) p = 0.043]. We similarly found no significant association of partner gender with grief intensity [B = 1.86, 95% CI (−0.91to 4.63), p = 0.188], but significantly greater psychological distress for same-gender partners [B = 1.54, 95% CI (−0.69–2.40), p < 0.001].
Conclusions
Same-gender bereaved partners report significantly more psychological distress. In view of their poorer sub-clinical mental health, clinical and bereavement services should refine screening processes to identify those at risk of poor mental health outcomes.
Background: The COVID-19 pandemic disrupted essential health services (EHS) delivery worldwide; however, there are limited data for healthcare facility (HCF)–level EHS disruptions in low- and middle-income countries. We surveyed HCFs in 3 counties in Kenya to understand the extent of and reasons for EHS disruptions occurring during February 2020–May 2021. Methods: We included 3 counties in Kenya with high burden of COVID-19 at the time of study initiation. Stratified sampling of HCFs occurred by HCF level. HCF administrators were interviewed to collect information on types of EHS disruptions that occurred and reasons for disruptions, including those related to infection prevention and control (IPC). Analyses included descriptive statistics with proportions for categorical variables and median with interquartile range (IQR) for continuous variables. Results: In total, 59 HCFs in Kenya provided complete data. All 59 HCFs (100%) reported EHS disruptions due to COVID-19. Among all HCFs, limiting patient volumes was the most common disruption reported (97%), while 56% of HCFs reduced staffing of EHS and 52% suspended EHS. Median duration of disruptions ranged from 7 weeks (IQR, 0–15) for inpatient ward closures to 25 weeks (IQR, 14–37) for limiting patient volumes accessing EHS. Among HCFs that reported disruptions, the most cited reason (ie, 95% of HCFs) was fewer patients receiving services. The most common IPC-related reason for disruption was diversion of resources to accommodate physical distancing measures (76%) followed by COVID-19 outbreaks among patients or staff (34%); staff shortages due to COVID-19 illness (25%) or perceived infection risk (19%); and lack of adequate personal protective equipment (20%). Conclusions: Most HCFs reported disruptions to EHS during the pandemic, including many that were related to IPC. Some disruptions may be mitigated by strengthening IPC infrastructure and practices, including protecting healthcare personnel to prevent staffing shortages.
Drawing on extensive survey data and written accounts of citizen engagement, this pioneering book charts change and continuity in voluntary activity since 1981. It is part of the Third Sector Research Series.
To assess the sexual and reproductive health (SRH) needs of women admitted to a psychiatric intensive care unit (PICU), and acceptability of delivering specialist SRH assessments and interventions in this setting. Within a quality improvement framework, staff were trained, a clinical protocol developed and clinical interventions made accessible.
Results
Thirty per cent of women were identified as having unmet SRH needs and proceeded to a specialist appointment, representing a 2.5-fold increase in unmet need detection. Forty-two per cent of women were assessed, representing a 3.5-fold increase in uptake. Twenty-one per cent of women initiated SRH interventions, of which 14% had all their SRH needs met. Staff, patients and carers highlighted the acceptability and importance of SRH care, if interventions were appropriately timed and patients’ individual risk profiles were considered. Barriers to access included lack of routine enquiry, illness acuity and impact of the COVID-19 pandemic.
Clinical implications
SRH needs for PICU admissions are greater than previously realised. Providing a nurse-led SRH assessment is acceptable, feasible and beneficial for PICU patients.
To assess the sexual and reproductive health (SRH) needs of women admitted to a psychiatric intensive care unit (PICU), and acceptability of delivering specialist SRH assessments/interventions in this setting. Secondary aims were to explore the barriers to access and the feasibility of providing SRH assessments and interventions in the PICU.
Method
A retrospective analysis of fifteen months’ activity data found that only 25 SRH referrals had been made across 205 PICU admissions. This low referral rate of 12% likely reflected pathway barriers and was unlikely to represent the actual clinical need in female PICU patients. A bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on the PICU over a seven-month period. Within a quality improvement framework, a staff training needs assessment was performed, training delivered, a protocol developed, staff attitudes explored, and patient and carer engagement sought.
Result
A quality improvement approach streamlined SRH assessments on the PICU and resulted in 42% of women being assessed and a 3.5-fold increase in uptake. At least 30% of the women in the PICU had unmet SRH needs identified and proceeded to a specialist appointment. This amounts to a minimum 2.5-fold increase in SRH unmet need detection.
The most common SRH needs were complex gynaecological issues (such as period problems, pelvic pain, vaginal discharge), STI advice/testing and contraception advice/options. 21% of women initiated SRH interventions, and 14% completed all the interventions required for their needs. The most common interventions were in the areas of contraception advice/family planning and STI advice/testing.
Staff confidence on assessing SRH topics was identified as a barrier to access with a positive shift noted after bespoke SRH training was implemented and a protocol introduced: on a scale of 0-10 (with 10 being high), 81.3% of staff rated their confidence 8 or above in relation to discussing contraception/sexually transmitted infections (pre-training: 25.0%), and 93.8% in relation to discussing risky behaviours (pre-training: 18.8%). All 11 patient and carer participants felt it was important to have a forum to talk about SRH and 8 (72.7%) agreed it was important in the PICU.
Conclusion
Results identify that SRH needs for PICU admissions are greater than previously realised. Staff highlighted the acceptability and importance of SRH care, if interventions are appropriately timed and the patient's individual risk profile considered. Providing a nurse led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients.
To compare two sexual and reproductive health (SRH) clinical pathways (a priority appointment at a mainstream SRH clinic versus assertive community outreach), and to explore how each improves access to care for people with psychotic mental illness, severe addictions and/or learning disability.
Method
Observational, descriptive study of two clinical access pathways within SHRINE (Sexual and Reproductive Health Rights, Inclusion and Empowerment), a specialist SRH programme to improve SRH care for severely marginalised people.
The SHRINE programme delivers effective, ethical, accessible and user-centred SRH care for people with severe addiction, serious mental illness and/or learning disability in the deprived inner London boroughs of Lambeth and Southwark. These individuals often find accessing conventional SRH clinics very difficult. SHRINE clients can self-refer but most of them are referred by their health or social worker.
Clients or referrers indicate their preferred pathway: priority appointment at the mainstream clinic or assertive community outreach. The priority appointment pathway at Camberwell Sexual Health Centre (CSHC) is as flexible as possible, with minimal waiting times, reminders, invitation to bring a friend or care worker and active follow-up of non-attenders via key workers. Assertive community outreach can be in an addiction clinic, postnatal ward, mental health centre, psychiatric ward, outpatient clinic, homeless hostel or the client's home.
Time allocation for outreach and priority appointment-based care was 8 and 4 hours per week respectively. Care in both pathways was provided by senior doctors. Content of care was similar but facility for provision of gynaecological care including cervical smears and investigations for abnormal uterine bleeding e.g. pelvic ultrasound scans and endometrial biopsies were only available in the mainstream clinic setting at CSHC.
Result
From May 2016 to December 2020 SHRINE received 1367 referrals from 125+ teams. We offered 1591 first or follow-up appointments of which 1369 (86%) were attended. A total of 1153 (84%) of our patient contacts occurred in the outreach setting where 93% the appointments were attended. Of the 358 appointments at CSHC 316 (60%) were attended.
Conclusion
Making clinic access as simple and convenient as possible is not a sufficient strategy to meet the SRH needs of marginalised people. To enable them to realise their human right to sexual and reproductive health we need to leave our clinics and meet our clients where they are. A combined model of outreach and priority access clinic pathways is essential for provision of SRH care for people with mental illness.
This study compared the level of education and tests from multiple cognitive domains as proxies for cognitive reserve.
Method:
The participants were educationally, ethnically, and cognitively diverse older adults enrolled in a longitudinal aging study. We examined independent and interactive effects of education, baseline cognitive scores, and MRI measures of cortical gray matter change on longitudinal cognitive change.
Results:
Baseline episodic memory was related to cognitive decline independent of brain and demographic variables and moderated (weakened) the impact of gray matter change. Education moderated (strengthened) the gray matter change effect. Non-memory cognitive measures did not incrementally explain cognitive decline or moderate gray matter change effects.
Conclusions:
Episodic memory showed strong construct validity as a measure of cognitive reserve. Education effects on cognitive decline were dependent upon the rate of atrophy, indicating education effectively measures cognitive reserve only when atrophy rate is low. Results indicate that episodic memory has clinical utility as a predictor of future cognitive decline and better represents the neural basis of cognitive reserve than other cognitive abilities or static proxies like education.
We examined the association of generational status and age at immigration with later life cognitive outcomes in a diverse sample of Latinos and Asian Americans.
Design:
Baseline data were obtained from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study, and a prospective cohort is initiated in 2017.
Setting:
Older adults in Northern California.
Participants:
Our cohort consisted of Asians (n = 411) and Latinos (n = 340) who were on average 76 years old (SD = 6.8).
Measurements:
We used multivariable linear regression models to estimate associations between generational status and age at immigration (collapsed into one five-level variable) with measures of verbal episodic memory, semantic memory, and executive function, adjusting for age, gender, race and ethnicity, and own- and parental education.
Results:
Generational status and age at immigration were associated with cognitive outcomes in a graded manner. Compared to third-generation or higher immigrants, first-generation immigration in adulthood was associated with lower semantic memory (β = −0.96; 95% CI: −1.12, −0.81) than immigration in adolescence (β = −0.68; 95% CI: −0.96, −0.41) or childhood (β = −0.28; 95% CI: −0.49, −0.06). Moreover, immigration in adulthood was associated with lower executive function (β = −0.63; 95% CI: −0.78, −0.48) than immigration in adolescence (β = −0.49; 95% CI: −0.75, −0.23). Similarly, compared to third-generation individuals, first-generation immigrants had lower executive functioning scores.
Conclusions:
Our study supports the notion that sociocontextual influences in early life impact later life cognitive scores. Longitudinal studies are needed to further clarify how immigration characteristics affect cognitive decline.
The ongoing impact on global mental health of the COVID-19 pandemic and the isolation measures used to combat its spread is increasingly acknowledged. This reflection focuses on the effect the pandemic has had specifically on the mental health of women in the peripartum period, using recent case examples from a busy and diverse south London community perinatal psychiatry service.
Background:Candida auris is an emerging pathogen associated with nosocomial outbreaks. During January to May 2019, 11 invasive cases of C. auris were identified in the intensive care unit (ICU) and high-dependency unit (HDU) at a hospital in Nairobi, Kenya. We report on the interventions implemented to control the outbreak. Methods: Intensified infection prevention and control (IPC) interventions were implemented. All patients infected or colonized with C. auris were placed in single-patient rooms with strict contact precautions. Cleaning of the patient care environment was enhanced by instituting a 3-step procedure of cleaning with soap and water, disinfecting with 0.5% chlorine, and rinsing with water. Glo-Germ gel was used to evaluate the cleaning processes, and percentage of missed surfaces was calculated. Hand hygiene training and compliance observations were conducted to enforce adherence to hand hygiene. The IPC team provided training and observational feedback of IPC to staff, patients, and their families. The IPC interventions were guided by screening activities. To monitor ongoing transmission, a biweekly point-prevalence survey (PPS) was performed to screen all previously negative ICU and HDU patients for C. auris. Furthermore, admission and contact screening were added to guide patient placement. Screening was conducted by collecting a composite swab from the bilateral axilla and groin. Samples were incubated in salt dulcitol broth for 5 days at 40°C then subcultured onto Sabouraud dextrose agar. Colony identification was performed using a Vitek 2 system (bioMérieux). Results: In total, 177 patients were placed in single-patient rooms under contact precautions during May–August 2019. We conducted 123 environmental cleaning observations, and the percentage of missed surfaces decreased from 71% (10 of 14) in June to 7% (1 of 16) in August. Hand hygiene compliance among ICU and HDU staff was 79% (204 of 257) in May, 71% (159 of 223) in June, 73% (170 of 233) in July, and 81% (534 of 657) in August. In total, 283 screening swabs from 234 patients were processed during May–August 2019. Overall, 18 of 88 PPS swabs (20%), 13 of 180 admission screening swabs (7%), and 0 of 15 contact screening swabs (0%) were positive for C. auris. The PPS results showed a rapid decrease in colonization: 6 of 14 (43%) in May, 12 of 54 (22%) in June, 9 of 98 (9%) in July, and 1 of 70 (2%) in August. No new C. auris infections were identified from June to October 2019. Conclusions: The control of C. auris in a hospital outbreak requires multimodal interventions, including enhanced IPC interventions, PPS, admission and contact screening for colonization, rigorous monitoring, and team effort.
The life stories of more than 1,000 women who shaped Scotland's historyThe New Biographical Dictionary of Scottish Women is a fully revised and extended edition of a highly regarded reference work that illuminates the lives of Scottish women in history. It includes more than 180 additional entries on women who died before 2018, forty new photographs, and an extended thematic index. With fascinating lives on every page, the concise entries illustrate the lives of Scottish women from the distant past to our own times, as well as the worldwide Scottish diaspora. Written by experts, the book provides a striking narrative of how women's actions and influence have always helped to shape Scotland's identity.This dictionary is dedicated to the memory of co-editor Sue Innes (1948–2005), who gave to it all the enthusiasm, dedication and flair she brought to everything in her life, and who was still working on it, and inspiring others, to the very end.
The Indian pharmaceutical industry has experienced rapid growth, becoming the world's largest provider of generic drugs, based on product and process innovation. The industry has undergone dynamic changes in recent decades, operating in a rapidly evolving environment affected by domestic and global policies; a key example of the latter is the TRIPS agreement. Taking an intellectual property perspective, we describe how changes in the innovation ecosystem have affected companies’ strategies related to international activity and accessing knowledge from both internal and external knowledge sources, during the transitional- and post-TRIPS periods (1995–2004 and 2005–2014, respectively). Combining intellectual property arguments with contextual aspects of the innovation ecosystem, we conjecture that, in the post-TRIPS period, externally-sourced knowledge will be more important than internally-sourced knowledge, for Indian pharmaceutical firms’ international business activity.