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Hoffman R, Phiri K, Kalande P, Whitehead H, Moses A, Rockers PC, Tseng CH, Talama G, Banda JC, van Oosterhout JJ, Phiri S, Moucheraud C. Preferences for Hypertension Care in Malawi: A Discrete Choice Experiment Among People Living with Hypertension, With and Without HIV. AIDS Behav 2024:10.1007/s10461-024-04492-y. [PMID: 39269593 DOI: 10.1007/s10461-024-04492-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2024] [Indexed: 09/15/2024]
Abstract
Hypertension is the most common non-communicable disease diagnosed among people in sub-Saharan Africa. However, little is known about client preferences for hypertension care. We performed a discrete choice experiment in Malawi among people with hypertension, with and without HIV. Participants were asked to select between two care scenarios, each with six attributes: distance, waiting time, provider friendliness, individual or group care, antihypertensive medication supply, and antihypertensive medication dispensing frequency (three versus one month). Eight choice sets (each with two scenarios) were presented to each individual. Mixed effects logit models quantified preferences for each attribute. Estimated model coefficients were used to predict uptake of hypothetical models of care. Between July 2021 and April 2022 we enrolled 1003 adults from 14 facilities in Malawi; half were living with HIV and on ART for a median of 11 years. Median age of respondents was 57 years (IQR 49-63), 58.2% were female, and median duration on antihypertensive medications was 4 years (IQR 2-7). Participants strongly preferred seeing a provider alone versus in a group (OR 11.3, 95% CI 10.4-12.3), with stronger preference for individual care among those with HIV (OR 15.4 versus 8.6, p < 0.001). Three-month versus monthly dispensing was also strongly preferred (OR 4.2; 95% CI 3.9-4.5). 72% of respondents would choose group care if all other facility attributes were favorable, although PLHIV were less likely to make this trade-off (66% versus 77%). These findings have implications for the scale-up of hypertension care in Malawi and similar settings.
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Affiliation(s)
- Risa Hoffman
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA.
| | - Khumbo Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
| | | | - Hannah Whitehead
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA
| | - Agnes Moses
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Chi-Hong Tseng
- David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
| | | | | | - Joep J van Oosterhout
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Sam Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Corrina Moucheraud
- Department of Public Health Policy and Management, New York University Global School of Public Health, New York, NY, USA
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Whitehead HS, Phiri K, Kalande P, van Oosterhout JJ, Talama G, Phiri S, Moucheraud C, Moses A, Hoffman RM. High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review. J Int AIDS Soc 2024; 27:e26354. [PMID: 39295131 PMCID: PMC11410859 DOI: 10.1002/jia2.26354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 08/30/2024] [Indexed: 09/21/2024] Open
Abstract
INTRODUCTION People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication. METHODS We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year. RESULTS We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year. CONCLUSIONS Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.
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Affiliation(s)
- Hannah S. Whitehead
- Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | | | | | - Joep J. van Oosterhout
- Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
| | | | - Sam Phiri
- Partners in HopeLilongweMalawi
- School of Global and Public HealthKamuzu University of Health SciencesLilongweMalawi
| | - Corrina Moucheraud
- Department of Public Health Policy and ManagementSchool of Global Public Health at NYUNew York CityNew YorkUSA
| | | | - Risa M. Hoffman
- Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
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Ibro SA, Kasim AZ, Seid SS, Abdusemed KA, Senbiro IA, Waga SS, Abamecha F, Azalework HG, Soboka M, Gebresilassie A, Tesfaye S, Abafogi AA, Merga H, Husen A, Beyene DT. Mapping the evidence on integrated service delivery for non-communicable and infectious disease comorbidity in sub-Saharan Africa: protocol for a scoping review. BMJ Open 2024; 14:e084740. [PMID: 38904125 PMCID: PMC11191815 DOI: 10.1136/bmjopen-2024-084740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/30/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION The concurrent occurrence of infectious diseases (IDs) and non-communicable diseases (NCDs) presents complex healthcare challenges in sub-Saharan Africa (SSA), where healthcare systems often grapple with limited resources. While an integrated care approach has been advocated to address these complex challenges, there is a recognised gap in comprehensive evidence regarding the various models of integrated care, their components and the feasibility of their implementation. This scoping review aims to bridge this gap by examining the breadth and nature of evidence on integrated care models for NCDs and IDs within SSA, thereby updating the current evidence base in the domain. METHODS AND ANALYSIS Based on the Joanna Briggs Institute (JBI) framework for scoping reviews, this study will include peer-reviewed and grey literature reporting on integrated care models for NCD-ID comorbidities in SSA. A comprehensive search of published sources in electronic databases (PubMed, Scopus, Embase, the Cochrane Library, Health System Evidence and Research4Life) and grey literature (Google Scholar, EBSCO Open Dissertations and relevant organisational websites) will be conducted to identify sources of information reported in English from 2018 onwards. The review will consider sources of evidence reporting on integrated care model for NCDs such as diabetes; chronic cardiovascular, respiratory and kidney diseases; cancers; epilepsy; and mental illness, and comorbid IDs such as HIV, tuberculosis and malaria. All sources of evidence will be considered irrespective of the study designs or methods used. The review will exclude sources that solely focus on the differentiated or patient-centred care delivery approach, and that focus on other conditions, populations or settings. The reviewers will independently screen the sources for eligibility and extract data using a JBI-adapted data tool on the Parsifal review platform. Data will be analysed using descriptive and thematic analyses and results will be presented in tables, figures, diagrams and a narrative summary. ETHICS AND DISSEMINATION Ethical approval is not required for this review as it will synthesise published data and does not involve human participants. The final report will be submitted for publication in a peer-reviewed journal. The findings will be used to inform future research. STUDY REGISTRATION OSF: https://doi.org/10.17605/OSF.IO/KFVEY.
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Affiliation(s)
| | | | | | | | | | | | - Fira Abamecha
- Health, Behavior and Society, Jimma University, Jimma, Ethiopia
| | | | | | | | | | | | - Hailu Merga
- Epidemiology, Jimma University, Jimma, Ethiopia
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Ogugu EG, Bidwell JT, Ruark A, Butterfield RM, Weiser SD, Neilands TB, Mulauzi N, Rambiki E, Mkandawire J, Conroy AA. Barriers to accessing care for cardiometabolic disorders in Malawi: partners as a source of resilience for people living with HIV. Int J Equity Health 2024; 23:83. [PMID: 38678232 PMCID: PMC11055364 DOI: 10.1186/s12939-024-02181-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND People living with HIV (PLWH) are at increased risk of cardiometabolic disorders (CMD). Adequate access to care for both HIV and CMD is crucial to improving health outcomes; however, there is limited research that have examined couples' experiences accessing such care in resource-constrained settings. We aimed to identify barriers to accessing CMD care among PLWH in Malawi and the role of partners in mitigating these barriers. METHODS We conducted a qualitative investigation of barriers to CMD care among 25 couples in Malawi. Couples were eligible if at least one partner was living with HIV and had hypertension or diabetes (i.e., the index patient). Index patients were recruited from HIV care clinics in the Zomba district, and their partners were enrolled thereafter. Interviews were conducted separately with both partners to determine barriers to CMD care access and how partners were involved in care. RESULTS Participants framed their experiences with CMD care by making comparisons to HIV treatment, which was free and consistently available. The main barriers to accessing CMD care included shortage of medications, cost of tests and treatments, high cost of transportation to health facilities, lengthy wait times at health facilities, faulty or unavailable medical equipment and supplies, inadequate monitoring of patients' health conditions, some cultural beliefs about causes of illness, use of herbal therapies as an alternative to prescribed medicine, and inadequate knowledge about CMD treatments. Partners provided support through decision-making on accessing medical care, assisting partners in navigating the healthcare system, and providing financial assistance with transportation and treatment expenses. Partners also helped manage care for CMD, including communicating health information to their partners, providing appointment reminders, supporting medication adherence, and supporting recommended lifestyle behaviors. CONCLUSIONS Couples identified many barriers to CMD care access, which were perceived as greater challenges than HIV care. Partners provided critical forms of support in navigating these barriers. With the rise of CMD among PLWH, improving access to CMD care should be prioritized, using lessons learned from HIV and integrated care approaches. Partner involvement in CMD care may help mitigate most barriers to CMD care.
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Affiliation(s)
- Everlyne G Ogugu
- Betty Irene Moore School of Nursing, University of California Davis, Davis, CA, USA.
- Betty Irene Moore School of Nursing, University of California Davis, 2570 48th Street, Sacramento, CA, 95817, USA.
| | - Julie T Bidwell
- Betty Irene Moore School of Nursing, University of California Davis, Davis, CA, USA
| | - Allison Ruark
- Wheaton College, Biological and Health Sciences, Wheaton, IL, USA
| | - Rita M Butterfield
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sheri D Weiser
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Torsten B Neilands
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Amy A Conroy
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Gobezie MY, Hassen M, Tesfaye NA, Solomon T, Demessie MB, Fentie Wendie T, Tadesse G, Kassa TD, Berhe FT. Prevalence of uncontrolled hypertension and contributing factors in Ethiopia: a systematic review and meta-analysis. Front Cardiovasc Med 2024; 11:1335823. [PMID: 38660480 PMCID: PMC11040565 DOI: 10.3389/fcvm.2024.1335823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Background Uncontrolled hypertension (HTN) is a major risk factor for cardiovascular and cerebrovascular disease. The prevalence of HTN in the Ethiopian adult population is almost 20%.This study aimed to determine the prevalence of uncontrolled HTN and its contributing factors among patients with HTN in Ethiopia undergoing treatment. Methods Electronic bibliographic databases such as PubMed, Google Scholar, Hinari (Research4Life), Embase, and Scopus were searched for original records in the English language that assessed HTN control in Ethiopia and were available before 29 June 2023. The data were extracted using a format prepared in Microsoft Excel and exported to the software STATA 17.0 for analysis. The study protocol was registered at PROSPERO with the reference number CRD42023440121. Results A total of 26 studies with 9,046 patients with HTN were included in the systematic review and meta-analysis, of which 11 studies were used to assess factors contributing to uncontrolled blood pressure (BP) in patients in Ethiopia. The estimated prevalence of uncontrolled HTN in the population of Ethiopia is 51% [95% confidence interval (CI), 42%-60%]. The subgroup analysis, based on the assessment tools, region, and follow-up period, revealed that the prevalence of uncontrolled BP was highest following the guidelines of the American Heart Association/American College of Cardiology (AHA/ACC) (89%; 95% CI: 87%-91%) and in Addis Ababa (58%; 95% CI: 40%-76%), and the lowest proportion of uncontrolled BP was in the 3-month follow-up period (34%; 95% CI: 29%-39%). The presence of diabetes mellitus showed the highest impact (pooled odds ratio: 5.19; CI: 1.41-19.11) for uncontrolled HTN. The univariate meta-regression method confirmed that the sample size, year of publication, and subgroups were not sources of heterogeneity in the pooled estimates. Egger's regression test did not indicate the presence of publication bias. Conclusion More than half of the hypertensive patients in Ethiopia have uncontrolled BP. Diabetes mellitus, advanced age, male sex, and the presence of comorbidities are among the factors contributing to uncontrolled HTN in Ethiopia. The concerned bodies working in this area should implement interventional strategies and recommendations that might be helpful in achieving optimal BP in hypertensive patients. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023440121, PROSPERO (CRD42023440121).
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Affiliation(s)
- Mengistie Yirsaw Gobezie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Minimize Hassen
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Nuhamin Alemayehu Tesfaye
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Tewodros Solomon
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Mulat Belete Demessie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Teklehaimanot Fentie Wendie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Getachew Tadesse
- Department of Statistics, College of Natural Sciences, Wollo University, Dessie, Ethiopia
| | - Tesfaye Dessale Kassa
- Department of Clinical Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Fentaw Tadese Berhe
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
- Public Health & Economics Modeling Group, School of Medicine & Dentistry, Griffith University, Gold Coast, QLD, Australia
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Ruark A, Bidwell JT, Butterfield R, Weiser SD, Neilands TB, Mulauzi N, Mkandawire J, Conroy AA. "I too have a responsibility for my partner's life": Communal coping among Malawian couples living with HIV and cardiometabolic disorders. Soc Sci Med 2024; 342:116540. [PMID: 38199009 PMCID: PMC10913151 DOI: 10.1016/j.socscimed.2023.116540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024]
Abstract
RATIONALE HIV and cardiometabolic disorders including hypertension and diabetes pose a serious double threat in Malawi. Supportive couple relationships may be an important resource for managing these conditions. According to the theory of communal coping, couples will more effectively manage illness if they view the illness as "our problem" (shared illness appraisal) and are united in shared behavioral efforts. METHODS This study qualitatively investigated communal coping of 25 couples living with HIV and hypertension or diabetes in Zomba, Malawi. Partners were interviewed separately regarding relationship quality, shared illness appraisal, communal coping, and dyadic management of illness. RESULTS Most participants (80%) were living with HIV, and more than half were also living with hypertension. Most participants expressed high levels of unity and the view that illness was "our problem." In some couples, partners expected but did not extend help and support and reported little collaboration. Communal coping and dyadic management were strongly gendered. Some women reported a one-sided support relationship in which they gave but did not receive support. Women were also more likely to initiate support interactions and offered more varied support than men. In couples with poor relationship quality and weak communal coping, dyadic management of illness was also weak. Partner support was particularly crucial for dietary changes, as women typically prepared meals for the entire family. Other lifestyle changes that could be supported or hindered by a partner included exercise, stress reduction, and medication adherence. CONCLUSION We conclude that gendered power imbalances may influence the extent to which couple-level ideals translate into actual communal coping and health behaviors. Given that spouses and families of patients are also at risk due to shared environments, we call for a shift from an illness management paradigm to a paradigm of optimizing health for spouses and families regardless of diabetes or hypertension diagnosis.
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Affiliation(s)
- Allison Ruark
- Wheaton College, Biological and Health Sciences, Wheaton, IL, USA.
| | - Julie T Bidwell
- University of California Davis, Betty Irene Moore School of Nursing, Sacramento, CA, USA
| | - Rita Butterfield
- University of California San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA
| | - Sheri D Weiser
- University of California San Francisco, Division of HIV, Infectious Disease, and Global Medicine, San Francisco, CA, USA
| | - Torsten B Neilands
- University of California San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA
| | | | | | - Amy A Conroy
- University of California San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA
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Jere J, Ruark A, Bidwell JT, Butterfield RM, Neilands TB, Weiser SD, Mulauzi N, Mkandawire J, Conroy AA. "High blood pressure comes from thinking too much": Understandings of illness among couples living with cardiometabolic disorders and HIV in Malawi. PLoS One 2023; 18:e0296473. [PMID: 38153924 PMCID: PMC10754453 DOI: 10.1371/journal.pone.0296473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023] Open
Abstract
Cardiometabolic disorders (CMD) such as hypertension and diabetes are increasingly prevalent in sub-Saharan Africa, placing people living with HIV at risk for cardiovascular disease and threatening the success of HIV care. Spouses are often the primary caregivers for people living with CMD, and understanding patients' and partners' conceptions of CMD could inform care. We conducted semi-structured interviews with 25 couples having a partner living with HIV and either hypertension or diabetes. Couples were recruited from HIV clinics in Malawi and were interviewed on beliefs around symptoms, causation, prevention, and treatment for CMD. Data were analyzed at the individual and dyadic levels using framework analysis and Kleinman's theory of explanatory models as a lens. On average, participants were 51 years old and married for 21 years. Approximately 57%, 14%, and 80% had hypertension, diabetes, and HIV. Couples endorsed a combination of biomedical explanatory models (beliefs around physical and mental health) and traditional explanatory models (beliefs around religion and natural remedies), although tended to emphasize the biomedical model. Half of couples believed stress was the main cause of hypertension. For diabetes, diet was believed to be a common cause. In terms of prevention, dietary changes and physical activity were most frequently mentioned. For disease management, medication adherence and diet modifications were emphasized, with some couples also supporting herbal remedies, stress reduction, and faith in God as strategies. Participants were generally more concerned about CMD than HIV due to poor access to CMD medications and beliefs that CMD could lead to sudden death. Within couples, partners often held many of the same beliefs but diverged around which etiological or preventive factors were most important (e.g., stress versus diet) and the best diet for CMD. Health education programs should involve primary partners to build knowledge of CMD and address overlap with HIV, and reinforce accurate information on lifestyle factors for the prevention and treatment of CMD.
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Affiliation(s)
- Jane Jere
- School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Allison Ruark
- Wheaton College, Biological and Health Sciences, Wheaton, IL, United States of America
| | - Julie T. Bidwell
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, California, United States of America
| | - Rita M. Butterfield
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, United States of America
| | - Torsten B. Neilands
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, United States of America
| | - Sheri D. Weiser
- Division of HIV, Infectious Disease and Global Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | | | | | - Amy A. Conroy
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, United States of America
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Lutala P, Nyasulu P, Muula AS. Perceived readiness for diabetes and cardiovascular care delivery in Mangochi, Malawi: multicentre study from healthcare providers' perspectives. BMC PRIMARY CARE 2023; 24:85. [PMID: 36973655 PMCID: PMC10042413 DOI: 10.1186/s12875-023-02033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Despite the expected prevalence rise of 98.1% for diabetes between 2010 and 2030 in sub-Saharan Africa (SSA) and the anticipated rise of both diabetes and cardiovascular diseases (CVDs) in Malawi from their current figures ( 5.6 and 8.9%; respectively), data on the readiness of health facilities to provide diabetes and cardiovascular diseases in Mangochi district is not available. Therefore, this study aimed to assess the readiness of health facilities to provide services for diabetes and cardiovascular diseases. METHODS An exploratory study was conducted from July to early September 2021 in 34 health facilities in Mangochi, Malawi. Forty-two participants were purposefully selected. They included medical officers, clinical officers, medical assistants, and registered nurses. The study used semi-structured interviews (for qualitative data) with a checklist (for quantitative data) to provide information about the readiness of services (such as guidelines and trained staff, drugs, diagnosis capacity and equipment, essential medicines, community services, and education/counseling).The thematic content analysis and basic descriptive statistics were carried out. RESULTS The following main theme emerged from the qualitative part: low use of diabetes-cardiovascular disease (CVD) services. This was due to: health facility factors (shortage of drugs and supplies, poor knowledge, few numbers and lack of training of providers, and absent copies of guidelines), patients factors (poor health-seeking behaviour, lack of education and counseling for many), and community factors (very limited community services for diabetes and CVDs, lack of transport policy and high transportation costs). Data from the checklists revealed low readiness scores across domains (below the 75% target) in diabetes and cardiovascular diseases: trained staff and guidelines (26.5% vs. 32.4%); diagnosis capacity and equipment (63.7% vs. 66.2%); essential medicines (33.5% vs. 41.9%), and community services, and education and counseling (37.5% vs. 42.5%). CONCLUSION There were several noticeable shortfalls identified in the readiness of health facilities to provide diabetes and cardiovascular disease services in Mangochi health facilities. Any future intervention in diabetes-cardiovascular disease care in these areas must include these elements in its basic package.
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Affiliation(s)
- Prosper Lutala
- Department of Family Medicine, School of Medicine and Oral Health, Kamuzu University of Health Sciences (KUHeS), Private Bag 360 Blantyre, Blantyre, Malawi.
- Department of Community & Environmental Health, School of Global and Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi.
| | - Peter Nyasulu
- Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adamson S Muula
- Department of Community & Environmental Health, School of Global and Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
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Chibwana MG, Thole HW, Anscombe C, Ashton PM, Green E, Barnes KG, Cornick J, Turner A, Witte D, Nthala S, Thom C, Kanyandula F, Ainani A, Mtike N, Tambala H, N’goma V, Mwafulirwa D, Asima E, Morton B, Gmeiner M, Gundah Z, Kawalazira G, French N, Feasey N, Heyderman RS, Swarthout TD, Jambo KC. Different clinical features in Malawian outpatients presenting with COVID-19 prior to and during Omicron variant dominance: A prospective observational study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001575. [PMID: 36963090 PMCID: PMC10022204 DOI: 10.1371/journal.pgph.0001575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 02/03/2023] [Indexed: 03/11/2023]
Abstract
The SARS-CoV-2 Omicron variant has resulted in a high number of cases, but a relatively low incidence of severe disease and deaths, compared to the pre-Omicron variants. Therefore, we assessed the differences in symptom prevalence between Omicron and pre-Omicron infections in a sub-Saharan African population. We collected data from outpatients presenting at two primary healthcare facilities in Blantyre, Malawi, from November 2020 to March 2022. Eligible participants were aged >1month old, with signs suggestive of COVID-19, and those not suspected of COVID-19, from whom we collected nasopharyngeal swabs for SARS-CoV-2 PCR testing, and sequenced positive samples to identify infecting-variants. In addition, we calculated the risk of presenting with a given symptom in individuals testing SARS-CoV-2 PCR positive before and during the Omicron variant-dominated period. Among 5176 participants, 6.4% were under 5, and 77% were aged 18 to 50 years. SARS-CoV-2 infection prevalence peaked in January 2021 (Beta), July 2021 (Delta), and December 2021 (Omicron). We found that cough (risk ratio (RR), 1.50; 95% confidence interval (CI), 1.00 to 2.30), fatigue (RR 2.27; 95% CI, 1.29 to 3.86) and headache (RR 1.64; 95% CI, 1.15 to 2.34) were associated with a high risk of SARS-CoV-2 infection during the pre-Omicron period. In comparison, only headache (RR 1.41; 95% CI, 1.07 to 1.86) did associate with a high risk of SARS-CoV-2 infection during the Omicron-dominated period. In conclusion, clinical symptoms associated with Omicron infection differed from prior variants and were harder to identify clinically with current symptom guidelines. Our findings encourage regular review of case definitions and testing policies to ensure case ascertainment.
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Affiliation(s)
| | | | - Cat Anscombe
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Philip M. Ashton
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Edward Green
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Kayla G. Barnes
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Harvard School of Public Health, Boston, MA, United States of America
- Broad Institute of MIT and Harvard, Cambridge, MA, United States of America
- University of Glasgow MRC Centre for Virus Research, Glasgow, United Kingdom
| | - Jen Cornick
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Ann Turner
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Desiree Witte
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Sharon Nthala
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
| | - Chikondi Thom
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
| | | | - Anna Ainani
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
| | - Natasha Mtike
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
| | - Hope Tambala
- Blantyre District Health Office, Ministry of Health, Blantyre, Malawi
| | | | | | - Erick Asima
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
| | - Ben Morton
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Markus Gmeiner
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
| | - Zaziwe Gundah
- Blantyre District Health Office, Ministry of Health, Blantyre, Malawi
| | - Gift Kawalazira
- Blantyre District Health Office, Ministry of Health, Blantyre, Malawi
| | - Neil French
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Nicholas Feasey
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Robert S. Heyderman
- NIHR Global Health Research Unit on Mucosal Pathogens, University College London, London, United Kingdom
| | - Todd D. Swarthout
- NIHR Global Health Research Unit on Mucosal Pathogens, University College London, London, United Kingdom
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Kondwani C. Jambo
- Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Kamuzu University of Health Sciences, Blantyre, Malawi
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Bissett M, Gray CM, Abdulla S, Bunn C, Crampin AC, Dillip A, Gill JMR, Kaare HC, Kalima S, Kambalu E, Lwanda J, Makoye HF, Mtema O, Perry M, Strachan Z, Todd H, Mtenga SM. "I see salt everywhere": A qualitative examination of the utility of arts-based participatory workshops to study noncommunicable diseases in Tanzania and Malawi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000927. [PMID: 36962765 PMCID: PMC10022006 DOI: 10.1371/journal.pgph.0000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/22/2022] [Indexed: 12/28/2022]
Abstract
The burden of noncommunicable diseases (NCDs) including hypertension, diabetes, and cancer, is rising in Sub-Saharan African countries like Tanzania and Malawi. This increase reflects complex interactions between diverse social, environmental, biological, and political factors. To intervene successfully, new approaches are therefore needed to understand how local knowledges and attitudes towards common NCDs influence health behaviours. This study compares the utility of using a novel arts-based participatory method and more traditional focus groups to generate new understandings of local knowledges, attitudes, and behaviours towards NCDs and their risk factors. Single-gender arts-based participatory workshops and focus group discussions were conducted with local communities in Tanzania and Malawi. Thematic analysis compared workshop and focus group transcripts for depth of content and researcher-participant hierarchies. In addition, semiotic analysis examined the contribution of photographs of workshop activities to understanding participants' experiences and beliefs about NCD risk factors. The arts-based participatory workshops produced in-depth, vivid, emotive narratives of participants' beliefs about NCDs and their impact (e.g., "… it spreads all over your body and kills you-snake's poison is similar to diabetes poison"), while the focus groups provided more basic accounts (e.g., "diabetes is a fast killer"). The workshops also empowered participants to navigate activities with autonomy, revealing their almost overwhelmingly negative beliefs about NCDs. However, enabling participants to direct the focus of workshop activities led to challenges, including the perpetuation of stigma (e.g., comparing smells associated with diabetes symptoms with sewage). Semiotic analysis of workshop photographs provided little additional insight beyond that gained from the transcripts. Arts-based participatory workshops are promising as a novel method to inform development of culturally relevant approaches to NCD prevention in Tanzania and Malawi. Future research should incorporate more structured opportunities for participant reflection during the workshops to minimise harm from any emerging stigma.
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Affiliation(s)
- Maria Bissett
- School of Social and Political Sciences, University of Glasgow, Glasgow, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Cindy M. Gray
- School of Social and Political Sciences, University of Glasgow, Glasgow, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Sharifa Abdulla
- Fine and Performing Arts Department, University of Malawi, Zomba, Malawi
| | - Christopher Bunn
- School of Social and Political Sciences, University of Glasgow, Glasgow, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Amelia C. Crampin
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angel Dillip
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Jason M. R. Gill
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Heri C. Kaare
- Taasisi ya Sanaa na Utamaduni Bagamoyo (TaSUBa), Bagamoyo, United Republic of Tanzania
| | | | | | - John Lwanda
- School of Social and Political Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Herbert F. Makoye
- Taasisi ya Sanaa na Utamaduni Bagamoyo (TaSUBa), Bagamoyo, United Republic of Tanzania
| | | | - Mia Perry
- School of Education, University of Glasgow, Glasgow, United Kingdom
| | - Zoë Strachan
- School of Critical Studies, University of Glasgow, Glasgow, United Kingdom
| | - Helen Todd
- Art and Global Health Centre Africa, Zomba, Malawi
| | - Sally M. Mtenga
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
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11
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Katundu KGH, Mukhula V, Phiri T, Phiri C, Filisa-Kaphamtengo F, Chipewa P, Chirambo G, Mipando M, Mwandumba HC, Muula AS, Kumwenda J. High prevalence of dyslipidaemia among persons with diabetes mellitus and hypertension at a tertiary hospital in Blantyre, Malawi. BMC Cardiovasc Disord 2022; 22:557. [PMID: 36544081 PMCID: PMC9771776 DOI: 10.1186/s12872-022-03011-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Dyslipidaemia drives the process of atherosclerosis, and hence a significant modifiable risk factor complicating hypertension and diabetes. In Malawi, the prevalence, screening and management of dyslipidaemia among persons with diabetes mellitus have not been reported. This study aimed to investigate the prevalence, biochemical characteristics, screening and management practices for dyslipidaemia among persons with diabetes mellitus, hypertension, and diabetes mellitus and hypertension comorbidity at Queen Elizabeth Central hospital in Blantyre, Malawi. METHODS This was a cross-sectional study conducted in 2021. A total of 256 adult participants (diabetes mellitus = 100); hypertension = 100; both conditions = 56) were included. Medical data and anthropometric measurements were recorded. Blood samples were analysed for HbA1C and serum lipids. Associated risk factors for dyslipidaemia were also assessed. RESULTS Dyslipidaemia was prevalent in 58%, 55%, and 70% of participants with diabetes mellitus, hypertension, and both conditions. Low-density lipoprotein cholesterol (LDL-C) dyslipidaemia was the most common in all participant groups. Participants with both diabetes and hypertension had 2.4 times (95% CI 1.2-4.6) increased risk of LDL-C dyslipidaemia than those with diabetes alone (p < 0.02). Being overweight or obese and age over 30 years were risk factors for dyslipidaemia in participants with diabetes mellitus alone (OR 1.3 (95% CI 1.1-1.6), p < 0.04, and OR 2.2 (95% CI 1.2-4.7) (p < 0.01), respectively. Overweight and obesity predicted LDL-C dyslipidaemia in hypertensive patients (OR 3.5 (95% CI 1.2-9.9) p < 0.001). Poorly controlled hypertension and the use of beta-blockers and thiazide diuretics predicted dyslipidaemia among patients with both diabetes mellitus and hypertension (OR 6.50 CI 1.45-29.19; and OR 5.20 CI 1.16-23.36 respectively). None of the participants had a lipogram performed before the study or were on lipid-lowering therapy. CONCLUSIONS Dyslipidaemia with LDL-C derangement was highly prevalent, especially in individuals with both diabetes mellitus and hypertension, and there was absent use of lipid-lowering therapy. Screening and managing dyslipidaemia should be reinforced to reduce the risk of cardiovascular complications in this population at increased risk.
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Affiliation(s)
- Kondwani G H Katundu
- Department of Biomedical Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi.
- Malawi-Liverpool Wellcome Clinical Research Program, Kamuzu University of Health Sciences, Blantyre, Malawi.
| | - Victoria Mukhula
- Malawi-Liverpool Wellcome Clinical Research Program, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tamara Phiri
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Chimota Phiri
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - Pascal Chipewa
- Department of Biomedical Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - George Chirambo
- Department of Biomedical Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre to Blantyre Research Facility, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Mwapatsa Mipando
- Department of Biomedical Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre to Blantyre Research Facility, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Henry C Mwandumba
- Malawi-Liverpool Wellcome Clinical Research Program, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Adamson S Muula
- Department of Community and Environmental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Johnstone Kumwenda
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
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Lutala P, Nyasulu P, Muula A. Salient beliefs about modifiable risk behaviours among patients living with diabetes, hypertension or both: A qualitative formative study. Afr J Prim Health Care Fam Med 2022; 14:e1-e12. [PMID: 36226929 PMCID: PMC9558168 DOI: 10.4102/phcfm.v14i1.3327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background Although there is evidence of the key role played by focusing on local knowledge in designing appropriate interventions regarding modifiable risk behaviours among patients living with diabetes and hypertension in Mangochi (and Malawi), little is known about local salient beliefs. Aim With a focus on the theory of planned behaviour as a theoretical lens, this study aimed to identify salient beliefs about modifiable risk behaviours among patients with diabetes, hypertension or both in Mangochi, south-eastern Malawi. Specifically, the objectives were to identify advantages and disadvantages (behavioural salient beliefs), people who approve or disapprove (normative salient beliefs) and enablers and barriers (control salient beliefs) for measures to change modifiable risk behaviours among patients with diabetes, hypertension or both in Mangochi, Malawi. Setting A hypertension diabetes clinic at Mangochi District Hospital, south-eastern Malawi. Methods A formative qualitative study of a quasi-experimental trial was conducted among 25 patients, purposefully sampled, who were living with diabetes, hypertension or both at Mangochi District Hospital in February 2019. Researchers conducted in-depth interviews with patients using an interview guide informed by the theory of planned behaviour’s elicitation interview guide. Thematic content analysis was used to identify emerging themes. Results A total of 25 participants were recruited, of which 12 (48%) were living with diabetes. Five thematic areas emerged from this analysis: physical and psychological fitness, social disconnection, perceived support systems, perceived enablers and perceived barriers to change. Conclusion Appropriate words for each salient belief were identified. Future researchers should use the identified salient beliefs when designing interventions based on the theory of planned behaviour in diabetes and hypertension. Contribution The paper adds to the body of knowledge informing the use of theory of planned behavior in addressing modifiable risk factors among practitioners, specialists and academics in primary care and Family Medicine in the field of noncommunicable diseases in Mangochi Malawi and beyond.
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Affiliation(s)
- Prosper Lutala
- Department of Family Medicine, Faculty of Medicine and Oral Health, Kamuzu University of Health Sciences, Blantyre; and NCD-BRITE Consortium, Faculty of Public and Global Health, Kamuzu University of Health Sciences, Blantyre.
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13
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Giacaman RA, Fernández CE, Muñoz-Sandoval C, León S, García-Manríquez N, Echeverría C, Valdés S, Castro RJ, Gambetta-Tessini K. Understanding dental caries as a non-communicable and behavioral disease: Management implications. FRONTIERS IN ORAL HEALTH 2022; 3:764479. [PMID: 36092137 PMCID: PMC9448953 DOI: 10.3389/froh.2022.764479] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
New paradigms in caries conceptualization have emerged during the last decades, leading to intense debate and discussion on how to approach the disease, both from a preventive and a therapeutic perspective. Among many new ideas, research discoveries and technologies, one major concept can be highlighted that created a deep frontier between the old and the new paradigm in caries conceptualization; the non-communicable nature of the disease, firmly associated with behaviors and lifestyles. This article synthetizes the conceptual construction of dental caries as a non-communicable disease (NCD) based on the current evidence and discusses the appropriate management of the disease in this context. Dental caries has shifted from being considered transmissible and infectious to an ecological and non-communicable disease. Environmental factors such as frequent sugars intake, disrupt the symbiosis of the dental biofilm leading to a dysbiosis, which favors caries lesion initiation and progression. As an NCD, dental caries shares characteristics with other NCDs such as cardiovascular and chronic respiratory diseases, cancer and diabetes, including long duration and slow progression, not being transmissible from person-to-person, being strongly related to modifiable behavioral risk factors, and affecting preferentially disadvantaged populations with a strong inequality gradient. Given the high prevalence of dental caries, and its consequences on people's health and quality of life, a recognizable conceptual view of caries as a NCD is required to target an effective management. Current understanding of dental caries supports prevention through acting on the modifiable risk factors (behaviors) and involves management based on an interdisciplinary approach. Communicating these modern concepts among researchers, clinicians and policymakers is needed to decrease the global high burden of the disease.
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Affiliation(s)
- Rodrigo A. Giacaman
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Gerodontology Research Group, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Interuniversity Center on Healthy Aging, Punta Arenas, Chile
- Centro de Epidemiología y Vigilancia de las Enfermedades Orales, University of Chile and University of Talca, Santiago, Chile
- *Correspondence: Rodrigo A. Giacaman
| | - Constanza E. Fernández
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Gerodontology Research Group, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
| | - Cecilia Muñoz-Sandoval
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
| | - Soraya León
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Gerodontology Research Group, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Interuniversity Center on Healthy Aging, Punta Arenas, Chile
- Centro de Epidemiología y Vigilancia de las Enfermedades Orales, University of Chile and University of Talca, Santiago, Chile
| | - Natalia García-Manríquez
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
| | - Constanza Echeverría
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
| | - Sebastián Valdés
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
| | - Ramiro J. Castro
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Gerodontology Research Group, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Interuniversity Center on Healthy Aging, Punta Arenas, Chile
| | - Karla Gambetta-Tessini
- Cariology Unit, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Gerodontology Research Group, Department of Oral Rehabilitation, Faculty of Dentistry, University of Talca, Talca, Chile
- Centro de Epidemiología y Vigilancia de las Enfermedades Orales, University of Chile and University of Talca, Santiago, Chile
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Tesfay FH, Zorbas C, Alston L, Backholer K, Bowe SJ, Bennett CM. Prevalence of chronic non-communicable diseases in Ethiopia: A systematic review and meta-analysis of evidence. Front Public Health 2022; 10:936482. [PMID: 35991039 PMCID: PMC9385028 DOI: 10.3389/fpubh.2022.936482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundNon-communicable diseases (NCDs) are a growing global health challenge disproportionately impacting low- and middle-income settings, including Ethiopia. Currently, the body of evidence describing the burden of NCDs is fragmented, inconsistent, health facility- or institution-based, and out-dated in Ethiopia. We conducted a systematic review of the literature and meta-analysis of the prevalence of NCDs in community settings in Ethiopia.Review methodologyCommunity-based quantitative studies published in English between January 1st, 2012, and June 30th, 2022, that reported on the prevalence of NCDs in Ethiopia were included. A systematic search of Medline, Embase, Scopus, CINAHL, and Global Health using pretested search terms related to NCDs was conducted, and data were extracted using a piloted data extraction proforma adapted from the Joanna Briggs Institute tool. Meta-analysis was performed using Stata 16. While the pooled prevalence of Diabetes Mellitus (DM) and undiagnosed (DM) was computed and presented using forest plots, then overall prevalence of NCDs and other various types of NCDs were narratively synthesized. I2 was used to assess heterogeneity. Studies that did not fulfill the criteria (used similar tool to measure the types of NCDs) for meta-analysis were narratively synthesized.ResultsTwenty-two studies met the inclusion criteria. Five studies measured the prevalence of NCDs (all NCDs together), ranging from 29 to 35% (prevalence estimates not pooled). The pooled prevalence of Diabetes Mellitus (DM) across ten studies was 5% (95% CI: 4–7%). Three studies each reported on the prevalence of undiagnosed DM (pooled prevalence 5%, 95% CI: 4–7%) and pre-DM (pooled prevalence 7%, 95% CI: 3–14%%). In a narrative analysis the prevalence of cardiovascular conditions ranged from 13.4 to 32.2% (n = 3 studies), cancer mortality ranged from 4 to 18% (n = 3 studies) and respiratory conditions ranged from 1 to 18% (n = 3 studies). Some studies have determined more than one NCDs and that is why the total number of studies are exceeding more than twenty studies.Conclusion and recommendationsOur analysis found that approximately one-third of Ethiopians have an NCD, with cardiovascular diseases the most common of all NCDs. The prevalence of respiratory conditions also appears high, but there are insufficient data for a pooled estimate. Whilst the prevalence of DM appears relatively low, there is evidence that the magnitude is increasing. Public health actions to address the high burden of cardiovascular and respiratory diseases, as well as the increasing magnitude of DM in Ethiopia, must be prioritized.Systematic review registrationPROSPERO [CRD42020196815].
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Affiliation(s)
- Fisaha Haile Tesfay
- Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
- College of Medicine and Health Sciences, School of Public Health, Mekelle University, Mekelle, Ethiopia
- *Correspondence: Fisaha Haile Tesfay
| | - Christina Zorbas
- Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Laura Alston
- Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Kathryn Backholer
- Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Steven J. Bowe
- Deakin Biostatistics Unit, Faculty of Health, Deakin University, Geelong, VIC, Australia
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Lutala P, Muula A. Brief behaviour change counselling in non-communicable diseases in Mangochi, Southern Malawi: a hypothetical acceptability study. Pilot Feasibility Stud 2022; 8:69. [PMID: 35331326 PMCID: PMC8944110 DOI: 10.1186/s40814-022-01032-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Brief behaviour change counselling (BBCC) approaches have shown some potential in reversing and/or decreasing the effects of behavioural risk factors (harmful alcohol, smoking, physical inactivity and unhealthy diets). However, BBCC is new in Malawi. Thus, we explored the acceptability of brief behaviour change counselling using 5 As and a guiding style from motivational interviewing (BBCC + 5 As + GS) among health providers, policy-makers and patients living with noncommunicable diseases (NCDs) in the Mangochi district located in Malawi. METHODS An exploratory qualitative cross-sectional study used purposive sampling to select 44 respondents. We conducted group discussions with five focus groups that included patients. We also carried out nine key-informant interviews with healthcare providers and policy-makers. Data were managed and organized with Atlas.ti. cloud and analysed using the thematic framework approach. FINDINGS Several themes, categories, and their subcategories emerged from the interviews. Participants perceived the introduction and delivery of BBCC + 5As + GS in Mangochi as smooth. However, they predicted a few challenges such as time and space to conduct the intervention, cultural bottlenecks caused by low education level, age differences between healthcare providers and patients, low provider- to- patient ratio and high provider turnover. For this method to be adopted, a simplified format is deemed necessary to improve effectiveness with patients. This technique can only be sustained if training opportunities are provided and if positive testimonies are given by beneficiaries. Incorporation of a continuous quality improvement cycle targeting challenges must be part of the intervention. Participants perceived that BBCC will contribute to developing the listening ability of healthcare providers. This would help in providing personalized and cost-effective care relevant to Mangochi. The participants also perceived that BBCC + 5As + GS will be affordable, credible and useful. CONCLUSION We found a high acceptability rate of BBCC among stakeholders in NCDs clinics in Mangochi. There are a number of areas where BBCC + 5As + GS could be improved to increase the acceptability. Accordingly, a study of feasibility and preliminary efficacy is warranted to determine other prerequisites for the implementation of a large-scale trial using this BBCC+ 5 As + GS, and to fully understand the implementation requirements of a full trial in Mangochi.
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Affiliation(s)
- Prosper Lutala
- School of Public Health & Family Medicine, College of Medicine, University of Malawi, Zomba, Malawi.
- NCDs-Brite Consortium, College of Medicine, University of Malawi, Zomba, Malawi.
- Africa Centre of Excellence in Public Health and Herbal Medicine (ACEPHEM), Zomba, Malawi.
- College of Medicine Mangochi Campus, P.O. Box 431, Mangochi, Malawi.
| | - Adamson Muula
- School of Public Health & Family Medicine, College of Medicine, University of Malawi, Zomba, Malawi
- Africa Centre of Excellence in Public Health and Herbal Medicine (ACEPHEM), Zomba, Malawi
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16
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24-h-Ambulatory Blood Pressure Monitoring in Sub-Saharan Africa: Hypertension Phenotypes and Dipping Patterns in Malawian HIV+ Patients on Antiretroviral Therapy. Glob Heart 2021; 16:67. [PMID: 34692392 PMCID: PMC8516010 DOI: 10.5334/gh.945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Cardiovascular disease and especially hypertension are a growing problem among people living with HIV (PLHIV) on antiretroviral therapy (ART) in sub-Saharan Africa. Objectives: As robust data on hypertension phenotypes associated with distinct cardiovascular risks among PLHIV are limited, we aimed to assess the frequency of white-coat (WCH), masked (MH) hypertension, and blood pressure dipping-patterns in a group of Malawian PLHIV. Methods: As part of the prospective Lighthouse-Tenofovir-Cohort-Study, we analyzed clinical, laboratory and 24-h-ambulatory blood pressure monitoring (ABPM) data of PLHIV from urban Lilongwe with treated or untreated hypertension or raised office blood pressure (OBP) during routine study-visits. Results: 118 PLHIV were included and data of 117 participants could be analyzed. Twenty–four-hour ABPM normotension was found in a total of 73 PLHIV including 14/37 on antihypertensive treatment (37.8%). Using strict definitions, i.e. normal OBP plus normal mean BP for all periods of ABPM, controlled hypertension was found in only 4/37 (10.8%) PLHIV on antihypertensive treatment while true normotension was observed in 10/24 untreated patients (41.7%) with previously diagnosed hypertension and 22/56 patients (39.3%) without a medical history of hypertension. WCH with normal BP during all periods of 24-h-ABPM was identified in 12/64 OBP-hypertensive PLHIV (18.8%), primarily in patients with grade 1 hypertension (11/41 patients; 26.8%). MH was found in 17/53 PLHIV with OBP-normotension (32.1%), predominantly in patients with high normal BP (11/20 patients; 55%). The estimated glomerular filtration rate tended to be lower in MH compared to strictly defined normotensive PLHIV (92.0±20.4 vs. 104.8±15.7 ml/min/m²). 64.1 percent of PLHIV (59.5% with 24-h hypertension and 66.7% with 24-h normotension) had abnormal systolic dipping. Conclusion: The high prevalence of WCH and MH with signs of early renal end-organ damage and an abnormal dipping in approximately 2/3 of PLHIV warrants further investigation as these factors may contribute to the increased cardiovascular risk in PLHIV in resource-limited settings like Malawi. Clinical Trial Registration: https://clinicaltrials.gov (NCT02381275), registered March 6th, 2015.
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Mphekgwana PM, Mabila LN, Maimela E. Indirect and direct effects of factors associated with diabetes amongst the rural black population in the Dikgale Health and Demographic Surveillance System, South Africa. Afr J Prim Health Care Fam Med 2021; 13:e1-e6. [PMID: 34342480 PMCID: PMC8335786 DOI: 10.4102/phcfm.v13i1.2819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/17/2021] [Accepted: 04/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Diabetes is an enormous, growing clinical and public health problem, which together with hypertension contributes significantly to the high risk of cardiovascular diseases (CVDs) globally. Aim To examine the indirect and direct effects of risk factors simultaneously as a network of multiple pathways leading to diabetes in the rurally based adult population (aged 15+) using a household survey. Methods This investigation was based on a predictive model using a cross-sectional community-based study to identify the direct and indirect effects of diabetes risk factors in the Dikgale Health and Demographic Surveillance System (HDSS) consisting of 15 villages, with 7200 households and a total population of approximately 36 000. Fasting blood glucose and total cholesterol were measured using ILAB 300 with the following cut-off values: high fasting blood glucose 7 mmol/L and triglycerides 1.70 mmol/L. Results A total of 1407 individuals were interviewed, of whom 1281 had their blood pressure (BP) measured. The conceptual model was validated by the goodness-of-fit indexes (comparative fit index [CFI] = 1.00, Tucker Lewis index [TLI] = 1.041, root mean square error of approximation [RMSEA] = 0.001). Hypertension had the strongest direct effect of 0.0918 on diabetes, followed by age (0.0039) and high waist circumference (−0.0023). Hypertension also mediates the effects that high waist circumference (0.0005) and triglycerides (0.0060) have on diabetes status. Conclusion The results in this study confirm the conceptual model considered in the risk factors for diabetes and suggest that hypertension, age and high waist circumference are the key variables directly affecting the diabetes status in the South African rural black population. The direct effect of triglycerides on diabetes suggests mediation by some measured factor(s).
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Affiliation(s)
- Peter M Mphekgwana
- Department of Research Administration and Development, University of Limpopo, Polokwane.
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Ideal Cardiovascular Health in a Nationally Representative Population-Based Sample of Adults in Malawi. Glob Heart 2021; 16:24. [PMID: 34040937 PMCID: PMC8064282 DOI: 10.5334/gh.986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Ideal cardiovascular health (ICH) measures four ideal health behaviours (non-smoking, body mass index <25 kg/m2, healthy diet, and physical activity) and three health factors (total cholesterol <200 mg/dL, blood pressure <120/<80 mmHg, and fasting blood glucose <100 mg/dL). Objective: This study aimed to determine the prevalence, distribution, and correlates of ICH among adults in Malawi. Methods: National cross-sectional survey data of 3,441 persons aged 18–69 years with complete ICH measurements in Malawi in 2017 were analysed. Results: Almost one in ten (7.4%) of respondents had 0–2 ICH metric), 21.2% 3–4 ICH metrics, and 71.5% 5–7 ICH metrics). Only 3.3% had all seven ICH metrics, 15.3% had intermediate ICH (≥1 metric in the intermediate category and none in the poor category), and 81.5% poor ICH (≥1 metric in poor category). In adjusted logistic regression analysis, older age (50–69 years) (Adjusted Odds Ratio-AOR: 0.25, 95% Confidence Interval-CI: 0.17–0.36) and urban residence (AOR: 0.56, 95% CI: 0.40–0.78) were negatively associated with meeting 5–7 ICH metrics. In addition, in unadjusted analysis, higher education was positively associated with meeting 5–7 ICH metrics. Conclusion: The proportion of meeting 5–7 ICH metrics was high in Malawian adults. Both high-risk and population-wide intervention programmes targeting older adults and urban residents should be implemented in aiding to improve cardiovascular health in Malawi. Highlights
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Muula AS, Hosseinipour MC, Makwero M, Kumwenda J, Lutala P, Mbeba M, Rylance S, Mitambo C, Nyirenda M. Mentoring upcoming researchers for non-communicable diseases' research and practice in Malawi. Trials 2021; 22:65. [PMID: 33468177 PMCID: PMC7814644 DOI: 10.1186/s13063-020-05006-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 12/27/2020] [Indexed: 11/30/2022] Open
Abstract
The Malawi College of Medicine and its partners are building non-communicable diseases’ (NCDs’) research capacity through a grant from the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health. Several strategies are being implemented including research mentorship for junior researchers interested to build careers in NCDs’ research. In this article, we present the rationale for and our experiences with this mentorship program over its 2 years of implementation. Lessons learned and the challenges are also shared.
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Affiliation(s)
- Adamson S Muula
- College of Medicine, University of Malawi, Blantyre, Malawi.
| | | | - Martha Makwero
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Prosper Lutala
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mary Mbeba
- Kamuzu College of Nursing, University of Malawi, Blantyre, Malawi
| | - Sarah Rylance
- Malawi-Liverpool-Wellcome Trust (MLW) Trust, Clinical Research Programme, University of Malawi, Blantyre, Malawi
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20
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Joubert J, Lacroix P, Preux PM, Dumas M. Hypertension in sub-Saharan Africa: A scoping review…. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2021. [DOI: 10.4103/jcpc.jcpc_55_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Xiao M, Tang X, Zhang F, Zhou L, Bu X, Liu X, Ding X, Shen Z, Chen L, Wu Y, Tang W, Qiu J. Association between self-reported snoring and hypertension among Chinese Han population aged 30-79 in Chongqing, China. Environ Health Prev Med 2020; 25:78. [PMID: 33272209 PMCID: PMC7713023 DOI: 10.1186/s12199-020-00908-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/25/2020] [Indexed: 11/10/2022] Open
Abstract
Background We aim to explore the association between self-reported snoring and hypertension among adults aged 30–79 in Chongqing, China. Methods A total of 23,342 individuals aged 30–79 were included at baseline from August 2018 to January 2019, and the final sample size for the analysis was 22,423. Face-to-face interviews and physical examinations were conducted by trained investigators. Logistic regression was performed to study age-specific and gender-specific associations between snoring and hypertension. Results Frequent snoring was associated with the risk of hypertension for each age and gender group, and the frequency of snoring was positively correlated with the risk for hypertension. For the three age groups (< 45, 45–59, ≥ 60), compared with the non-snoring group, those who snore often had a 64.5%, 53.3%, and 24.5% increased risk of hypertension (< 45: OR = 1.65, 95%CI 1.34–2.02; 45–59: OR = 1.53, 95%CI 1.37–1.72; ≥ 60: OR = 1.25, 95%CI 1.09–1.42), respectively. For men and women, those who snore often had a 46.8% and 97.2% increased risk of hypertension, respectively, than the non-snoring group (men: OR = 1.47, 95%CI 1.33–1.63; women: OR = 1.97, 95%CI 1.75–2.23). Conclusions People who snore frequently should pay close attention to their blood pressure levels in order to achieve early prevention of hypertension, particularly for snorers who are female and aged under 45; importance should be attached to their blood pressure control.
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Affiliation(s)
- Meng Xiao
- School of Public Health and Management, Collaborative Innovation Center of Social Risks Governance in Health, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Xiaojun Tang
- School of Public Health and Management, Collaborative Innovation Center of Social Risks Governance in Health, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Fan Zhang
- School of Public Health and Management, Collaborative Innovation Center of Social Risks Governance in Health, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Li Zhou
- School of Public Health and Management, Collaborative Innovation Center of Social Risks Governance in Health, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Xiaoqing Bu
- School of Public Health and Management, Collaborative Innovation Center of Social Risks Governance in Health, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Xiang Liu
- Department of Epidemiology and Health Statistics, West China School of Public Health, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xianbin Ding
- Chongqing Center for Disease Control and Prevention, Chongqing, 400042, China
| | - Zhuozhi Shen
- Chongqing Center for Disease Control and Prevention, Chongqing, 400042, China
| | - Liling Chen
- Chongqing Center for Disease Control and Prevention, Chongqing, 400042, China
| | - Yunyun Wu
- Chongqing Center for Disease Control and Prevention, Chongqing, 400042, China
| | - Wenge Tang
- Chongqing Center for Disease Control and Prevention, Chongqing, 400042, China.
| | - Jingfu Qiu
- School of Public Health and Management, Collaborative Innovation Center of Social Risks Governance in Health, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China.
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Mensah GA, Curry JS, Engelgau MM, Johnson LE. Stakeholder Engagement in Late-Stage Translation Research and Implementation Science: Perspectives From the National Heart, Lung, and Blood Institute. Glob Heart 2020; 14:191-194. [PMID: 31324374 DOI: 10.1016/j.gheart.2019.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/16/2019] [Indexed: 01/20/2023] Open
Abstract
Stakeholder engagement is crucial for turning discovery into health. Although it is a highly effective approach for research in general, it is an essential component in late-stage translation research and implementation science in which the central objective is to accelerate the sustained uptake and integration of proven-effective interventions into routine clinical and public health practice. Where the stakeholder is an entire community, the term community engagement has often been used and has traditionally been defined as "the process of working collaboratively with groups of people who are affiliated by geographic proximity, special interests, or similar situations with respect to issues affecting their well-being." More recently, this definition has been expanded to specifically incorporate pre-study needs assessment, shared decision making about study themes and specific aims, data collection and analysis, interpretation and dissemination of research findings, and plans for scale-up and spread of research findings. In this article, the authors explore the scientific foundations of stakeholder engagement in biomedical research and public health practice. They highlight the strategic vision goals and objectives of the National Heart, Lung, and Blood Institute and the commitment to advance dissemination and implementation research and community-engaged participatory research. The authors conclude with comments on the stakeholder engagement efforts in the National Heart, Lung, and Blood Institute-funded TREIN/Hy-TREC consortium's work published in this issue of Global Heart and their perspectives on the challenges and opportunities as we chart the future together.
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Affiliation(s)
- George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Jennifer S Curry
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Michael M Engelgau
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lenora E Johnson
- Office of Science Policy, Engagement, Education, and Communications, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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