Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement

Pharmaceutical intervention for hypertension in a rural district of the Republic of Zambia: a model-based economic evaluation

OBJECTIVES

In Zambia, 19.1% of the adult population had elevated blood pressure. Hence, the Ministry of Health in Zambia designated the improvement of hypertension (HTN) care services as a priority policy. However, there are limited data on cost-effective interventions to address HTN and their budget impact in sub-Saharan Africa. The objective of this paper is to investigate the cost-effectiveness of primary-level interventions for HTN (pharmaceutical treatments) compared with no treatment, and the budget impact, in the Chongwe District, rural Zambia.

METHODS

A cost-utility analysis was undertaken from the perspective of healthcare provider, employing a cohort Markov model with a lifetime horizon. The model was developed and populated with evidence from the literature, including novel locally collected cost data. The analysis was run for the overall population aged 40 years and above and for subpopulations stratified by three levels of risk and gender in Chongwe District by using cost data directly collected. A probabilistic analysis was performed to assess the probability of cost-effectiveness.

RESULTS

The dominant treatment for the general population was a combination therapy of diuretics and calcium blockers. The incremental cost-effectiveness ratio was US$1114 compared with no treatment. This was the most cost-effective first-line medication for HTN for all subgroup populations, except for the subgroups classified as low-risk defined by WHO. The estimated annual budget impact was US$1 015 605 in total if all HTN patients in Chongwe District received the most cost-effective treatment. Considering only material costs, the annual total budget was US$29 435.

CONCLUSION

The most cost-effective first-line medication for HTN in rural Zambia was the combination therapy of diuretics and calcium blockers for the general population. From the perspective of budget impact, local government could need to secure approximately US$30 000 to facilitate the delivery of the most cost-effective HTN medications to the entire population over 40 years in need.

Effectiveness of public health spending: Investigating the moderating role of governance using partial least squares structural equation modelling (PLS-SEM)

BACKGROUND

The link between public health spending (PHS) and population health outcomes (PHO) has been extensively studied. However, in sub-Saharan Africa (SSA), the moderating effects of governance in this relationship are little known. Furthermore, studies have focused on mortality as the main health outcome. This study contributes to this literature by investigating the moderating role of governance in the relationship by simultaneously assessing three dimensions of governance (corruption control, government effectiveness and voice accountability) using disability-adjusted life years (DALYs) as a measure of outcomes.

METHODS

The study applies the two-stage moderation approach using partial least squares structural equation modelling (PLS-SEM) to panel data from 43 SSA nations from 2013 to 2019. The study also uses domestic general government health expenditure (DGGHE) as an independent variable and disability-adjusted life years (DALY) as the dependent variable in this relationship.

RESULTS

The analysis reveals that DGGHE affects DALY negatively and that governance improves the effect of DGGHE on DALY, with bigger improvements among countries with worse governance.

CONCLUSION

These findings provide evidence that good governance is crucial to the effectiveness of PHS in SSA nations. Sub-Saharan Africa (SSA) countries should improve governance to improve population health.

Cross-sectional study of the burden and determinants of non-medical and opportunity costs of accessing chronic disease care in rural Tanzania

OBJECTIVES

Countries in sub-Saharan Africa are seeking to improve access to healthcare through health insurance. However, patients still bear non-medical costs and opportunity costs in terms of lost work days. The burden of these costs is particularly high for people with chronic diseases (CDs) who require regular healthcare. This study quantified the non-medical and opportunity costs faced by patients with CD in Tanzania and identified factors that drive these costs.

METHODS

From November 2020 to January 2021, we conducted a cross-sectional patient survey at 35 healthcare facilities in rural Tanzania. Using the human capital approach to value the non-medical cost of seeking healthcare, we employed multilevel linear regression to analyse the impact of CDs and health insurance on non-medical costs and negative binomial regression to investigate the factors associated with opportunity costs of illness among patients with CDs.

RESULTS

Among 1748 patients surveyed, 534 had at least one CD, 20% of which had comorbidities. Patients with CDs incurred significantly higher non-medical costs than other patients, with an average of US$2.79 (SD: 3.36) compared with US$2.03 (SD: 2.82). In addition, they incur a monthly illness-related opportunity cost of US$10.19 (US$0-59.34). Factors associated with higher non-medical costs included multimorbidities, hypertension, health insurance and seeking care at hospitals rather than other facilities. Patients seeking hypertension care at hospitals experienced 35% higher costs compared with those visiting other facilities. Additionally, patients with comorbidities, older age, less education and those requiring medication more frequently lost workdays.

CONCLUSION

Outpatient care in Tanzania imposes considerable non-medical costs, particularly for people with CDs, besides illness-related opportunity costs. Despite having health insurance, patients with CDs who seek outpatient care in hospitals face higher financial burdens than other patients. Policies to improve the availability and quality of CD care in dispensaries and health centres could reduce these costs.

Exploring the Prevalence and Components of Metabolic Syndrome in Sub-Saharan African Type 2 Diabetes Mellitus Patients: A Systematic Review and Meta-Analysis

Background

Type 2 diabetes mellitus and metabolic syndrome represent two closely intertwined public health challenges that have reached alarming epidemic proportions in low- and middle-income countries, particularly in sub-Saharan Africa. Therefore, the current study aimed to determine the weighted pooled prevalence of metabolic syndrome and its components among individuals with type 2 diabetes mellitus in sub-Saharan Africa as defined by the 2004 National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP III 2004) and/or the International Diabetes Federation (IDF) criteria.

Methods

A systematic search was conducted to retrieve studies published in the English language on the prevalence of metabolic syndrome among type 2 diabetic individuals in sub-Saharan Africa. Searches were carried out in PubMed, Embase, Scopus, Google Scholar, African Index Medicus, and African Journal Online from their inception until July 31, 2023. A random-effects model was employed to estimate the weighted pooled prevalence of metabolic syndrome in sub-Saharan Africa. Evidence of between-study variance attributed to heterogeneity was assessed using Cochran's Q statistic and the I2 statistic. The Joanna Briggs Institute quality appraisal criteria were used to evaluate the methodological quality of the included studies. The summary estimates were presented with forest plots and tables. Publication bias was checked with the funnel plot and Egger's regression test.

Results

Overall, 1421 articles were identified and evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and 30 studies that met the inclusion criteria were included in the final analysis. The weighted pooled prevalence of metabolic syndrome among individuals with type 2 diabetes mellitus in sub-Saharan Africa was 63.1% (95% CI: 57.9-68.1) when using the NCEP-ATP III 2004 criteria and 60.8% (95% CI: 50.7-70.0) when using the IDF criteria. Subgroup analysis, using NCEP-ATP III 2004 and IDF criteria, revealed higher weighted pooled prevalence among females: 73.5% (95% CI: 67.4-79.5), 71.6% (95% CI: 60.2-82.9), compared to males: 50.5% (95% CI: 43.8-57.2), 44.5% (95% CI: 34.2-54.8), respectively. Central obesity was the most prevalent component of metabolic syndrome, with a pooled prevalence of 55.9% and 61.6% using NCEP-ATP III 2004 and IDF criteria, respectively. There was no statistical evidence of publication bias in both the NCEP-ATP III 2004 and IDF pooled estimates.

Conclusions

The findings underscore the alarming prevalence of metabolic syndrome among individuals with type 2 diabetes mellitus in sub-Saharan Africa. Therefore, it is essential to promote lifestyle modifications, such as regular exercise and balanced diets, prioritize routine obesity screenings, and implement early interventions and robust public health measures to mitigate the risks associated with central obesity.

The Zanzibar Heart Survey: A special report from a humanitarian cardiology program at the Mnazi Mmoja referral hospital, Zanzibar, United Republic of Tanzania by Haukeland University Hospital in Bergen, Norway

A Norwegian cardiology delegation comprised of Cardiologists and Researchers travelled voluntarily to Zanzibar to undertake 4 humanitarian missions in 2022. The principal aims of this were to: 1) Train local cardiologists in transthoracic echocardiography and perform echocardiographic screening in patients with cardiac symptoms who had not undergone any prior cardiac imaging, 2) Conduct a hypertension survey to improve awareness, treatment and control of hypertension and 3) Implant permanent pacemakers in patients with significant bradyarrhythmias for the first time in the Archipelago. The current report details our experience at the Mnazi Mmoja Referral Hospital. We describe the challenges in managing common cardiovascular conditions such as hypertension, cardiomyopathies, coronary artery disease and rhythm disturbances. Furthermore, we propose that improvement to care may be achieved by implementing systematic access to echocardiography and hypertension services to the island. In our survey, we found that hypertension and hypertension-mediated target organ damage were highly prevalent and hypertension was poorly controlled in Zanzibar. The common reasons for poor BP control were reported to be partly the issue of cost, affordability and availability of antihypertensive medications, and partly due to lack of awareness. Women were on average 10 years younger than men and were more likely to be obese, while men had higher burden of established cardiovascular disease (CAD, stroke, chronic kidney disease, and atrial fibrillation). Humanitarian healthcare missions by Western countries provide invaluable contributions to the healthcare of patients elsewhere in the world. Although their impact can be felt immediately, there is the propensity for these benefits to dissipate rapidly following the departure of visiting delegations. There is a need for more sustainable solutions whereby local healthcare systems are empowered to develop their own local capacities and initiate a system whereby local training can occur, the utilisation of facilities can be maximised and new skills can be transferred to health care practitioners to ensure universal access to diagnostics and treatments of cardiovascular diseases in Zanzibar. Our report indicates that measurable changes can be achieved in a relatively short time frame. These may in turn translate to improvements in access and quality of healthcare to the local population.

Barriers and facilitators of people living with HIV receiving optimal care for hypertension and diabetes in Tanzania: a qualitative study with healthcare professionals and people living with HIV

BACKGROUND

People living with HIV (PLWH) are at a higher risk for developing diabetes and hypertension. Often services are separate for HIV and non-communicable diseases (NCDs), but how this impacts NCD care among PLWH is unknown. We aimed to understand the barriers and facilitators for prevention, early diagnosis and safe effective care for diabetes and hypertension among PLWH.

METHODS

Semi-structured interviews (SSIs) were conducted with 10 healthcare professionals (HCPs) that care for PLWH, 10 HCPs that care for people with diabetes and hypertension and 16 PLWH with a comorbidity of diabetes and/or hypertension. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and purposively sampled based on age and sex. Interviews were conducted in Swahili using pre-developed topic guides, audio recorded then translated verbatim into English. An inductive thematic analysis was conducted using The Framework Method.

RESULTS

Three themes were found: organisational/healthcare system factors, individual factors and syndemic factors. Organisational/healthcare system factors comprised the only facilitators for prevention (education on lifestyle behaviours and counselling on adherence), but included the most barriers overall: fragmented services, no protocol for NCD screening and lack of access to diagnostic equipment were barriers for early diagnosis whereas the former plus lack of continuity of NCD care were barriers for safe effective care. Individual factors comprised four sub-themes, three of which were considered facilitators: HCPs' knowledge of NCDs for early diagnosis, self-monitoring of NCDs for safe effective care and HCPs' personal practice for both early diagnosis and safe effective care. HCPs' knowledge was simultaneously a barrier for prevention and PLWH knowledge was a barrier for prevention and safe effective care. Syndemic factors comprised three sub-themes; all were barriers for prevention, early diagnosis and/or safe effective care: poverty and mental health of PLWH and HIV stigma.

CONCLUSIONS

Organisational/healthcare system, individual and syndemic factors were found to be interlinked with barriers and facilitators that contribute to the prevention, early diagnosis and safe effective care of diabetes and hypertension among PLWH in Tanzania; these findings can inform future initiatives for making small and large health system changes to improve the health of aging PLWH.

Hypertension and diabetes patients' perspective of challenges and their coping mechanisms in Mukono and Buikwe districts in Uganda - a qualitative study

Background: In sub-Saharan Africa, the burden of non-communicable diseases is steadily rising amidst a high prevalence of communicable diseases stretching the healthcare system. This study explored hypertension and diabetes patients' perspective of challenges and their coping mechanisms in Mukono and Buikwe districts in Uganda. Methods: This descriptive qualitative study involved four focus group discussions with 26 patients at four selected health facilities. All interviews were audio recorded, transcribed verbatim and data analysed following the thematic content analysis guided by the semantic approach with the aid of Atlas ti 6.0.15 software. Results: Five themes were identified regarding challenges and coping mechanisms of patients in managing their conditions. 1) Inadequate opportunities for diagnosis, with community screening supporting identification of patients. 2) Accessing care came amidst transport challenges, absence of health workers and the lack of essential supplies for monitoring conditions. Patients borrowed transport funds or trekked to health facilities and some formed groups to contribute resources to buy equipment and supplies. 3) Access to medications was affected by frequent drug stockouts at public health facilities which pushed patients to purchase own drugs or obtain these through friends and networks. However, other patients resorted to cheaper herbal remedies. 4) Monitoring and managing conditions was affected by insufficient knowledge and opportunities for self-monitoring. Information from health workers and experiences from peers bridged the knowledge gap while private facilities or community health workers supported self-monitoring. 5) Adopting changes in behaviour was challenging but patients fitted these within their usual routines and mobilised family members to also adopt lifestyle changes while ignoring those they deemed unrealistic. Conclusions: The coping mechanisms patients adopted to manage their chronic conditions reflects self-care initiatives at the individual and community levels which could be reinforced and supplemented to better support and empower patients as steps are taken to address existing challenges.

Health Equity and Respiratory Diseases in Low- and Middle-Income Countries

Over 80% of the morbidity and mortality related to acute and chronic respiratory diseases occur in low- and middle-income countries (LMICs), a reflection of vast disparities in care for these conditions. Over the next decade, the prevalence of respiratory diseases is expected to increase, as population growth in LMICs exceeds high-income countries (HICs). Pediatric morbidity and mortality from lower respiratory tract infections and asthma occur almost exclusively in LMICs, contributing to a greater loss of quality adjusted life years from these conditions when compared with HICs.

Cord Blood FGF-21 and GDF-15 Levels Are Affected by Maternal Exposure to Moderate to Severe Anemia and Malaria

Context

Anemia and malaria are global health problems affecting >50% of pregnant women in sub-Saharan Africa and are associated with intrauterine growth restriction. The hormones fibroblast growth factor 21 (FGF-21) and growth differentiation factor 15 (GDF-15) are involved in metabolic regulation and are expressed in the placenta. No studies exist on FGF-21 and GDF-15 responses to exposures of malaria and anemia in pregnancy.

Objective and Methods

Using a prospective, longitudinal pregnancy and birth cohort of women with an average age of 26 years from a rural region in northeastern Tanzania, we examined if FGF-21 and GDF-15 levels in maternal blood at week 33 ± 2 (n = 301) and in cord blood at birth (n = 353), were associated with anemia and malaria exposure at different time points in pregnancy and with neonatal anthropometry.

Results

Among mothers at gestation week 33 ± 2, lower FGF-21 levels were observed after exposure to malaria in the first trimester, but not anemia, whereas GDF-15 levels at week 33 ± 2 were not associated with malaria nor anemia. In cord blood, moderate to severe anemia at any time point in pregnancy was associated with higher levels of FGF-21, whereas malaria exposure in the third trimester was associated with lower FGF-21 levels in cord blood. Negative associations were observed between cord blood FGF-21 and GDF-15 levels and neonatal skinfold thicknesses and birthweight.

Conclusion

Our results suggest that moderate to severe anemia throughout pregnancy associates with higher FGF-21 levels, and malaria in last trimester associates with lower FGF-21 levels, in the neonates, thereby potentially affecting the future cardiometabolic health of the child.

Cardiovascular disease prevention and management in the COVID-19 era and beyond: An international perspective

Despite some indicators of a localized curtailing of cardiovascular disease (CVD) prevalence, CVD remains one of the largest contributors to global morbidity and mortality. While the magnitude and impact of the coronavirus disease 2019 (COVID-19) pandemic have yet to be realized in its entirety, an unquestionable impact on global health and well-being is already clear. At a time when the global state of CVD is perilous, we provide a continental overview of prevalence data and initiatives that have positively influenced CVD outcomes. What is clear is that despite attempts to address the global burden of CVD, there remains a lack of collective thinking and approaches. Moving forward, a coordinated global infrastructure that, if developed with appropriate and relevant key stakeholders, could provide significant and longstanding benefits to public health and yield prominent and consistent policy resulting in impactful change. To achieve global impact, research priorities that address multi-disciplinary social, environmental, and clinical perspectives must be underpinned by unified approaches that maximize public health.

National and subnational survey on diabetes burden and quality of care index in Iran: a systematic analysis of the global burden of disease study 1990-2019

Purpose

Diabetes care is one of the major healthcare problems . This study aimed to introduce a recently-developed Quality of Care Index (QCI) for type 2 diabetes and utilized it to compare different genders, age groups, and Iranian provinces.

Methods

From the Global Burden of Disease 1990-2019 database, we obtained primary epidemiologic measures and combined them to build four secondary indices, all indicating the quality of care provided to patients. We utilized the principal component analysis (PCA) method to calculate the substantial component named QCI (with a scale of 0-100). Gender inequality was shown by the gender disparity ratio (GDR), defining female to male QCI.

Results

National QCI ranged from 43.0 in 1990 to 38.6 in 2019. By excluding the more frequent outlier province; Tehran as the Capital of Iran, the QCI score reached 50.27 in 2019. The GDR decreased from 1.04 to 0.95. QCI indicated rather more favorable conditions in Iranian provinces with a higher socio-demographic index (SDI). Conversely, provinces with a lower SDI had worse QCI. In 2019, Tehran, the capital of Iran, with the highest (58.5), and South Khorasan with the lowest QCIs (0.4) were the two Iranian provinces' extremes. Moreover, the elderly QCI improved in 2019.

Conclusion

During 1990-2019, there are remarkable disparities between Iran's provinces, genders and age groups. The equitable and widespread provision of facilities should be considered along with the decentralization of healthcare resources.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01108-x.

Informal Support Networks of Tanzanians With Chronic Diseases: Predictors of Support Provision and Treatment Adherence

Objectives: To examine the role of NCD patients' social ties as informal caregivers and whether receiving their support is associated with engagement in care. Methods: NCD outpatients (N2 = 100) in rural Tanzania completed a cross-sectional questionnaire to characterize the support role of their social ties (N1 = 304). Bivariate analyses explored predictors of social support and whether social support is associated with engagement in care. Results: This study found that 87% of participants had health insurance, yet 25% received financial support for financing healthcare. Patient gender, age and marital status were found to be important predictors of social support, with NCD-related disability and disease severity being predictive to a lesser degree. Monthly receipt of both material and non-material support were associated with increased odds of adherence to prescribed medications. Conclusion: These findings indicate that patients' social ties play an important role in filling the gaps in formal social health protection and incur substantial costs by doing so. The instrumental role of even non-material social support in promoting engagement in care deserves greater attention when developing policies for improving this population's engagement in care.

Status of the management of hypertension and diabetes in rural Kenya: a multi-institutional joint intervention of cross-sectional surveys

Introduction

the aim of this study was to analyze the status of the management of vascular risk factors (hypertension and diabetes) at hospital level (3, 4 and 5) in Murang'a County (Kenya) health system.

Methods

between July and December 2018 we performed a joint intervention about the strategies for improving care management of hypertension and diabetic patients in Murang'a (Kenya). A survey based on the recommendations from WHO about management of diabetes and hypertension was completed for 9 health-care centers. The survey made use of a semi-structured questionnaire, while the units of analysis for the survey were households.

Results

the number of patients recorded at medical registers with diabetes and hypertension registered in public hospitals in Murang'a County were 6628 (0.45%) and y 6694 (0.45%), respectively. In the surveyed health-care centers, no hospital use electrogram and only one had troponin test. No hospital stocked Isosorbide dinitrate and Glicerine trinitate to prevent chest pain in patients with a heart condition. Only 3 of the clinics performed visual acuity examination and no facility did neurologic examination for neuropathy complications. No public hospital had HbA1 and did microalbuminuria test available.

Conclusion

it is necessary to improve to establish screening methods, diagnosis, treatment and follow-up of patients with hypertension and diabetes in Murang'a County at the various levels of health care.

Prevalence of overweight and obesity and associated factors among people living with HIV attending a tertiary care clinic in Uganda

Background:

Overweight and obesity are significantly increasing among people living with HIV (PLWH), contributing to the risk of major adverse cardio-metabolic events. However, little is known on its prevalence among PLWH in sub-Saharan Africa. In this study, we report the prevalence and factors associated with overweight and obesity among PLWH in a large tertiary HIV clinic in Kampala, Uganda.

Methods:

A cross-sectional, retrospective review of electronic database of all PLWH that attended the Adult Infectious Diseases Institute clinic between November 2018 and April 2019 was conducted. Demographic, body mass index (BMI) [kg/m²] and clinical variables were extracted. Based on BMI, nutritional status was classified as undernutrition (< 18.5kg/m²), normal (≥ 18.5 < 25kg/m²), overweight (≥ 25 < 30kg/m²) and obesity (≥ 30kg/m²). Poisson regression analysis was performed to determine factors associated with overweight and obesity.

Results:

Overall, 7,818 participants were included in the analysis, 64% (n = 4,976) were female, with a median age of 44 years (interquartile range (IQR): 36–51) and a median BMI of 24.2 (IQR: 21.2–28.1). The prevalence of overweight and obesity combined was 46% (55% female versus 30% male), obesity 18.2% (24.6% female versus 7.1% male) and overweight 27.8% (30.4% female versus 22.9% male). Factors associated with overweight and obesity were: Females (adjusted prevalence ratio [aPR]: 1. 8, 95%CI:1.69–1.87), age category 25—59 years (aPR: 1.9, 95%CI: 1.63–2.24) and ≥ 60 years (aPR: 1.8, 95%CI:1.49–2.12); duration on antiretroviral therapy (ART) for 6—10 years (aPR: 1.1, 95%CI:1.08–1.18), CD4 count 200–500 (aPR:0.08, 95%CI:0.01–0.15) and > 500 (aPR:0.46, 95%CI:0.39–0.54) and having at least one noncommunicable disease (NCD) (aPR: 1.1, 95%CI:1.07–1.18).

Conclusion

There is a high burden of overweight and obesity among PLWH in Uganda. Nutrition and weight management programs particularly targeting high risk groups such as females and persons with underlying NCDs should be integrated into HIV care.

Readiness of health facilities to deliver non-communicable diseases services in Kenya: a national cross-sectional survey

BACKGROUND

Non-communicable diseases (NCDs) account for an estimated 71% of all global deaths annually and nearly 80% of these deaths occur in low- and middle-income countries. This study aimed to assess the readiness of existing healthcare systems at different levels of health care in delivering NCDs management and prevention services in Kenya.

METHODS

A cross-sectional survey of 258 facilities was conducted between June 2019 and December 2020 using multistage sampling, examining facility readiness based on the availability of indicators such as equipment, diagnostic capacity, medicines and commodities, trained staff and guidelines for NCDs management. Readiness scores were calculated as the mean availability of tracer items expressed as a percentage and a cut-off threshold of ≥ 70% was used to classify facilities as "ready" to manage NCDs. Descriptive and bivariate analyses were performed to assess the readiness of facilities by type, level, and location settings. Logistic regressions were used to identify factors associated with the readiness of facilities to provide disease-specific services.

RESULTS

Of the surveyed facilities, 93.8% offered chronic respiratory disease (CRD) diagnosis and/or management services, 82.2% diabetes mellitus, 65.1% cardiovascular disease (CVD), and only 24.4% cervical cancer screening services. The mean readiness scores for diabetes mellitus (71%; 95% CI: 67-74) and CVD (69%; 95% CI: 66-72) were relatively high. Although CRD services were reportedly the most widely available, its mean readiness score was low (48%; 95% CI: 45-50). The majority of facilities offering cervical cancer services had all the necessary tracer items available to provide these services. Modeling results revealed that private facilities were more likely to be "ready" to offer NCDs services than public facilities. Similarly, hospitals were more likely "ready" to provide NCDs services than primary health facilities. These disparities in service readiness extended to the regional and urban/rural divide.

CONCLUSIONS

Important gaps in the current readiness of facilities to manage NCDs in Kenya at different levels of health care were revealed, showing variations by disease and healthcare facility type. A collective approach is therefore needed to bridge the gap between resource availability and population healthcare needs.

Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruption

Many implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians' opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians' beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation.

County Health Leadership Practices and Readiness for Noncommunicable Disease Services in Kenya

Background:

Premature mortality from noncommunicable diseases (NCDs) is a contemporary development challenge. Low-income and lower-middle-income countries are disproportionately affected, with the poorest in society considered the most vulnerable. A paucity of literature exists on how leadership practices at the implementation level relate to ensuring readiness for NCD services.

Objective:

This study investigated any relationship between leadership practices and readiness for NCD services.

Methods:

This correlational study investigated any relationship between leadership practices at the county level and readiness for NCD services in Kenya using secondary data from a 2013 Service Availability and Readiness Assessment survey. Correlation and multiple linear regression tests were used to determine the strength and direction of any relationship between leadership practices (annual work planning, therapeutic committees, and supportive supervision), and NCD readiness (county readiness score).

Findings:

The findings indicated a statistically significant relationship between therapeutic committee (p = .002) and supportive supervision practices (p = .023) and NCD readiness. Leadership practices also had a statistically significant predictive relationship with NCD readiness (p = .009).

Conclusion:

Health leaders should ensure that leadership practices that have a predictive relationship with NCD readiness, such as therapeutic committee activities and supportive supervision visits, are implemented appropriately. Further, county health leaders should pay particular attention to the implementation of these leadership practices at nonpublic and Tiers 2, 3, and 4 health facilities that had lower NCD readiness scores.

Patient preferences for facility-based management of hypertension and diabetes in rural Uganda: a discrete choice experiment

OBJECTIVE

To explore how respondents with common chronic conditions-hypertension (HTN) and diabetes mellitus (DM)-make healthcare-seeking decisions.

SETTING

Three health facilities in Nakaseke District, Uganda.

DESIGN

Discrete choice experiment (DCE).

PARTICIPANTS

496 adults with HTN and/or DM.

MAIN OUTCOME MEASURES

Willingness to pay for changes in DCE attributes: getting to the facility, interactions with healthcare providers, availability of medicines for condition, patient peer-support groups; and education at the facility.

RESULTS

Respondents were willing to pay more to attend facilities that offer peer-support groups, friendly healthcare providers with low staff turnover and greater availabilities of medicines. Specifically, we found the average respondent was willing to pay an additional 77 121 Ugandan shillings (UGX) for facilities with peer-support groups over facilities with none; and 49 282 UGX for 1 month of medicine over none, all other things being equal. However, respondents would have to compensated to accept facilities that were further away or offered health education. Specifically, the average respondent would have to be paid 3929 UGX to be willing to accept each additional kilometre they would have to travel to the facilities, all other things being equal. Similarly, the average respondent would have to be paid 60 402 UGX to accept facilities with some health education, all other things being equal.

CONCLUSIONS

Our findings revealed significant preferences for health facilities based on the availability of medicines, costs of treatment and interactions with healthcare providers. Understanding patient preferences can inform intervention design to optimise healthcare service delivery for patients with HTN and DM in rural Uganda and other low-resource settings.

High rate of left ventricular hypertrophy on screening echocardiography among adults living with HIV in Malawi

BACKGROUND

There are limited data on structural heart disease among people living with HIV in southern Africa, where the success of antiretroviral therapy (ART) has drastically improved life expectancy and where risk factors for cardiovascular disease are prevalent.

METHODS

We performed a cross-sectional study of screening echocardiography among adults (≥18 years) with HIV in Malawi presenting for routine ART care. We used univariable and multivariable logistic regression to evaluate correlates of abnormal echocardiogram.

RESULTS

A total of 202 individuals were enrolled with a median age of 45 years (IQR 39-52); 52% were female, and 27.7% were on antihypertensive medication. The most common clinically significant abnormality was left ventricular hypertrophy (LVH) (12.9%, n=26), and other serious structural heart lesions were rare (<2% with ejection fraction less than 40%, moderate-severe valve lesions or moderate-severe pericardial effusion). Characteristics associated with abnormal echocardiogram included older age (OR 1.04, 95% CI 1.01 to 1.08), higher body mass index (OR 1.09, 95% CI 1.02 to 1.17), higher mean systolic blood pressure (OR 1.03, 95% CI 1.02 to 1.05) and higher mean diastolic blood pressure (OR 1.03, 95% CI 1.01 to 1.05). In a multivariable model including age, duration on ART, body mass index, and systolic and diastolic blood pressure, only mean body mass index (adjusted OR 1.10, 95% CI 1.02 to 1.19), systolic blood pressure (aOR 1.05, 95% CI 1.03 to 1.08) and diastolic blood pressure (aOR 0.96, 95% CI 0.92 to 1.00) remained associated with abnormal echocardiogram.

CONCLUSIONS

LVH was common in this population of adults on ART presenting for routine care and was associated with elevated blood pressure. Further research is needed to characterise the relationship between chronic hypertension, LVH and downstream consequences, such as diastolic dysfunction and heart failure in people living with HIV.

The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages

BACKGROUND

Practical links between health systems and health security are historically prevalent, but the conceptual links between these fields remain under explored, with little on health system strengthening. The need to address this gap gains relevance in light of the COVID-19 pandemic as it demonstrated a crucial relationship between health system capacities and effective health security response. Acknowledging the importance of developing stronger and more resilient health systems globally for health emergency preparedness, the WHO developed a Health Systems for Health Security framework that aims to promote a common understanding of what health systems for health security entails whilst identifying key capacities required.

METHODS/ RESULTS

To further explore and analyse the conceptual and practical links between health systems and health security within the peer reviewed literature, a rapid scoping review was carried out to provide an overview of the type, extent and quantity of research available. Studies were included if they had been peer-reviewed and were published in English (seven databases 2000 to 2020). 343 articles were identified, of those 204 discussed health systems and health security (high and medium relevance), 101 discussed just health systems and 47 discussed only health security (low relevance). Within the high and medium relevance articles, several concepts emerged, including the prioritization of health security over health systems, the tendency to treat health security as exceptionalism focusing on acute health emergencies, and a conceptualisation of security as 'state security' not 'human security' or population health.

CONCLUSION

Examples of literature exploring links between health systems and health security are provided. We also present recommendations for further research, offering several investments and/or programmes that could reliably lead to maximal gains from both a health system and a health security perspective, and why these should be explored further. This paper could help researchers and funders when deciding upon the scope, nature and design of future research in this area. Additionally, the paper legitimises the necessity of the Health Systems for Health Security framework, with the findings of this paper providing useful insights and evidentiary examples for effective implementation of the framework.

Mapping the Cord Blood Transcriptome of Pregnancies Affected by Early Maternal Anemia to Identify Signatures of Fetal Programming

CONTEXT

Anemia during early pregnancy (EP) is common in developing countries and is associated with adverse health consequences for both mothers and children. Offspring of women with EP anemia often have low birth weight, which increases risk for cardiometabolic diseases, including type 2 diabetes (T2D), later in life.

OBJECTIVE

We aimed to elucidate mechanisms underlying developmental programming of adult cardiometabolic disease, including epigenetic and transcriptional alterations potentially detectable in umbilical cord blood (UCB) at time of birth.

METHODS

We leveraged global transcriptome- and accompanying epigenome-wide changes in 48 UCB from newborns of EP anemic Tanzanian mothers and 50 controls to identify differentially expressed genes (DEGs) in UCB exposed to maternal EP anemia. DEGs were assessed for association with neonatal anthropometry and cord insulin levels. These genes were further studied in expression data from human fetal pancreas and adult islets to understand their role in beta-cell development and/or function.

RESULTS

The expression of 137 genes was altered in UCB of newborns exposed to maternal EP anemia. These putative signatures of fetal programming, which included the birth weight locus LCORL, were potentially mediated by epigenetic changes in 27 genes and associated with neonatal anthropometry. Among the DEGs were P2RX7, PIK3C2B, and NUMBL, which potentially influence beta-cell development. Insulin levels were lower in EP anemia-exposed UCB, supporting the notion of developmental programming of pancreatic beta-cell dysfunction and subsequently increased risk of T2D in offspring of mothers with EP anemia.

CONCLUSIONS

Our data provide proof-of-concept on distinct transcriptional and epigenetic changes detectable in UCB from newborns exposed to maternal EP anemia.

Noncommunicable Diseases Prevention Policies and Their Implementation in Africa: A Systematic Review

Objectives: To synthesize the existing evidence on NCD policy equity, policy practices, and policy implementation gaps to prevent NCDs in African countries.

Methods: Following the PRISMA-Extension for equity-focused review guidelines, the authors systematically searched documentary evidence from seven databases (BMC, CINHAL Plus, Cochrane, Google Scholar, PubMed, Web of Science, and Scopus) to identify studies conducted and published on African countries between April 2013 and December 31, 2020.

Results: From identified 213 records, 21 studies were included in the final synthesis. Major results showed inadequate studies on NCD policy, unsatisfactory NCD-related policy development, poor policy implementation, lack of policy equity to combat NCDs, and lack of data recorded on NCDs’ prevalence, morbidity, and mortality.

Conclusion: The rigorous WHO-endorsed NCD policies and prevention strategies on the African continent might debar African policymakers and leaders from developing and implementing indigenous NCD-combating strategies. Continent-wide innovative and indigenous NCD-prevention policies and policy equity to effectively prevent, control, and manage NCDs must be developed by African scientists and policymakers.

Addressing Severe Chronic NCDs Across Africa: Measuring Demand for the Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus)

Severe chronic non-communicable diseases (NCDs) pose important challenges for health systems across Africa. This study explores the current availability of and demand for decentralization of services for four high-priority conditions: insulin-dependent diabetes, heart failure, sickle cell disease, and chronic pain. Ministry of Health NCD Programme Managers from across Africa (N = 47) were invited to participate in an online survey. Respondents were asked to report the status of clinical care across the health system. A care package including diagnostics and treatment was described for each condition. Respondents were asked whether the described services are currently available at primary, secondary and tertiary levels, and whether making the service generally available at that level is expected to be a priority in the coming 5 years. Thirty-seven (79%) countries responded. Countries reported widespread gaps in service availability at all levels. We found that just under half (49%) of respondents report that services for insulin-dependent diabetes are generally available at the secondary level (district hospital); 32% report the same for heart failure, 27% for chronic pain and 14% for sickle cell disease. Reported gaps are smaller at tertiary level (referral hospital) and larger at primary care level (health centres). Respondents report ambitious plans to introduce and decentralize these services in the coming 5 years. Respondents from 32 countries (86%) hope to make all services available at tertiary hospitals, and 21 countries (57%) expect to make all services available at secondary facilities. These priorities align with the Package of Essential NCD Interventions-Plus. Efforts will require strengthened infrastructure and supply chains, capacity building for staff and new monitoring and evaluation systems for efficient implementation. Many countries will need targeted financial assistance in order to realize these goals. Nearly all (36/37) respondents request technical assistance to organize services for severe chronic NCDs.

Availability, affordability and access to essential medications for asthma and chronic obstructive pulmonary disease in three low- and middle-income country settings

INTRODUCTION

Despite the rising burden of chronic respiratory disease globally, and although many respiratory medications are included in the World Health Organization Essential Medications List (WHO-EML), there is limited information concerning the availability and affordability of treatment drugs for respiratory conditions in low- and middle-income countries (LMICs).

METHODS

All public and private pharmacies in catchment areas of the Global Excellence in COPD outcomes (GECo) study sites in Bhaktapur, Nepal, Lima, Peru, and Nakaseke, Uganda, were approached in 2017-2019 to assess pricing and availability of medications for the management of asthma and COPD.

RESULTS

We surveyed all 63 pharmacies in respective study areas in Nepal (95.2% private), 104 pharmacies in Peru (94.2% private) and 53 pharmacies in Uganda (98.1% private). The availability of any medication for respiratory disease was higher in private (93.3%) compared to public (73.3%) pharmacies. Salbutamol (WHO-EML) monotherapy in any formulation was the most commonly available respiratory medication among the three sites (93.7% Nepal, 86.5% Peru and 79.2% Uganda) while beclomethasone (WHO-EML) was only available in Peru (33.7%) and Nepal (22%). LABA-LAMA combination therapy was only available in Nepal (14.3% of pharmacies surveyed). The monthly treatment cost of respiratory medications was lowest in Nepal according to several cost metrics: the overall monthly cost, the median price ratio comparing medication costs to international reference prices at time of survey in dollars, and in terms of days' wages of the lowest-paid government worker. For the treatment of intermittent asthma, defined as 100 mcg Salbutamol/Albuterol inhaler, days' wages ranged from 0.47 days in Nepal and Peru to 3.33 days in Uganda.

CONCLUSION

The availability and pricing of respiratory medications varied across LMIC settings, with medications for acute care of respiratory diseases being more widely available than those for long-term management.

A mixed methods needs assessment and gap analysis for establishment of a cancer research training program in East Africa

Background

The burden of non-communicable diseases (NCDs), including cancer, in Africa is rising. Policymakers are charged with formulating evidence-based cancer control plans; however, there is a paucity of data on cancers generated from within Africa. As part of efforts to enhance cancer research training in East Africa, we performed a needs assessment and gap analysis of cancer-related research training resources in Tanzania.

Methods

A mixed-methods study to evaluate existing individual, institutional, and national resources supporting cancer research training in Tanzania was conducted. Qualitative data were collected using in-depth interviews while quantitative data were collected using self-administered questionnaires and online surveys. The study also included a desk-review of policy and guidelines related to NCD research and training. Study participants were selected to represent five groups: (i) policymakers; (ii) established researchers; (iii) research support personnel; (iv) faculty members in degree training programs; and (v) post-graduate trainees.

Results

Our results identified challenges in four thematic areas. First, there is a need for coordination and monitoring of the cancer research agenda at the national level. Second, both faculty and trainees identified the need for incorporation of rigorous training to improve research competencies. Third, sustained mentoring and institutional investment in development of mentorship resources is critical to empowering early career investigators. Finally, academic institutions can enhance research outputs by providing adequate research infrastructure, prioritizing protected time for research, and recognizing research accomplishments by trainees and faculty.

Conclusions

As we look towards establishment of cancer research training programs in East Africa, investment in the development of rigorous research training, mentorship resources, and research infrastructure will be critical to empowering local health professionals to engage in cancer research activities.

Community-Based Interventions for Cardiovascular Disease Prevention in Low-and Middle-Income Countries: A Systematic Review

Objectives: To synthesize evidence on the effectiveness of community-based interventions for cardiovascular disease (CVD) prevention in low- and middle-income countries (LMICs) to inform design of effective strategies for CVD prevention. Methods: We searched MEDLINE, EMBASE, CINAHL, Cochrane register of controlled studies and PSYCINFO databases for studies published between January 2000 and June 2019. Other studies were identified from gray literature sources and review of reference lists of included studies. The primary outcomes for the review were those aimed at primary prevention of CVD targeting physical activity, diet, smoking and alcohol consumption. Results: Database searches yielded 15,885 articles and 94 articles were identified through snowball searching. After screening, the articles from LMICs were 32 emanating from 27 studies: 9 cluster randomized trials, eight randomized controlled trials and 10 controlled before and after studies. Community-based interventions successfully improved population knowledge on CVD and risk factors and influenced physical activity and dietary practices. Evidence of interventions on smoking cessation and reduced alcohol consumption was inconsistent. Conclusion: This evidence should inform policy makers in decision-making and prioritizing evidence-based interventions.

Social Support for Self-Care: Patient Strategies for Managing Diabetes and Hypertension in Rural Uganda

Background

Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings.

Objective

We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda.

Methods

Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes.

Results

Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities.

Conclusion

Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients' social support networks.

Fighting non-communicable diseases in East Africa: assessing progress and identifying the next steps

Sub-Saharan Africa has seen a rapid increase in non-communicable disease (NCD) burden over the last decades. The East African Community (EAC) comprises Burundi, Rwanda, Kenya, Tanzania, South Sudan and Uganda, with a population of 177 million. In those countries, 40% of deaths in 2015 were attributable to NCDs. We review the status of the NCD response in the countries of the EAC based on the available monitoring tools, the WHO NCD progress monitors in 2017 and 2020 and the East African NCD Alliance benchmark survey in 2017. In the EAC, modest progress in governance, prevention of risk factors, monitoring, surveillance and evaluation of health systems can be observed. Many policies exist on paper, implementation and healthcare are weak and there are large regional and subnational differences. Enhanced efforts by regional and national policy-makers, non-governmental organisations and other stakeholders are needed to ensure future NCD policies and implementation improvements.

The Role of Noncommunicable Diseases in the Pursuit of Global Health Security

Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap.

Costs of integrating hypertension care into HIV care in rural East African clinics

OBJECTIVE

Sub-Saharan Africa faces twin epidemics of HIV and noncommunicable diseases including hypertension. Integrating hypertension care into chronic HIV care is a global priority, but cost estimates are lacking. In the SEARCH Study, we performed population-level HIV/hypertension testing, and offered integrated streamlined chronic care. Here, we estimate costs for integrated hypertension/HIV care for HIV-positive individuals, and costs for hypertension care for HIV-negative individuals in the same clinics.

DESIGN

Microcosting analysis of healthcare expenditures within Ugandan HIV clinics.

METHODS

SEARCH (NCT: 01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient hypertension care costs using micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review.

RESULTS

Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29 per person per year, a 2.1% marginal increase over prior estimates for HIV care alone. For HIV-negative participants, hypertension care cost $11.39 per person per year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19 per patient per year; 98% of total) and laboratory testing ($0.10 per patient per year; 2%). Key costs for HIV-negative patients included medications ($5.09 per patient per year; 45%) and clinic staff salaries ($3.66 per patient per year; 32%).

CONCLUSION

For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics.

Noncommunicable Disease (NCD) strategic plans in low- and lower-middle income Sub-Saharan Africa: framing and policy response

Background

Global efforts to address NCDs focus primarily on 4-by-4 interventions – interventions to prevent and treat four groups of conditions affecting mainly older adults (some cardiovascular disease and cancers, type 2 diabetes, chronic respiratory disease) and four associated risk factors (alcohol, tobacco, poor diets, and physical inactivity). However, the NCD burden in Sub-Saharan Africa (SSA) is composed of a more diverse set of conditions, driven by a more complex group of risks, and impacting all segments of the population.

Objective

To document the NCD priorities identified by NCD strategic plans, to characterize the proposed policy response, and to assess the alignment between the two.

Methods

Using a two-part conceptual framework, we undertook a descriptive study to characterize the framing and overall policy response of strategic plans from 24 low- and lower-middle-income countries across SSA.

Results

The national situation assessments that ground strategic plans emphasize a diversity of conditions that range in terms of severity and frequency. These assessments also highlight a wide diversity of factors that shape this burden. Most include discussions of a broad range of behavioral, structural, genetic, and infectious risk factors. Plans endorse a more narrow response to this diverse burden, with a focus on primary and secondary prevention that is generally convergent with the objectives established in global policy documents.

Conclusions

Broadly, we observe that plans developed by countries in SSA recognize the heterogeneity of the NCD burden in this region. However, they emphasize interventions that are consistent with global strategies focused on preventing a narrower set of cardiometabolic risk factors and their associated diseases. In comparison, relatively few countries detail plans to prevent, treat, and palliate the full scope of the needs they identify. There is a need for increased support for bottom-up planning efforts to address local priorities.

COVID-19: implications for NCDs and the continuity of care in Sub-Saharan Africa

There has been a rise in non-communicable diseases (NCD) in Sub-Saharan Africa (SSA), driven by westernization, urbanization and unhealthy lifestyles. The prevalence of NCDs and their risk factors vary considerably in SSA between countries and the various sub-populations. A study documented the prevalence of stroke ranging from 0.07 to 0.3%, diabetes mellitus from 0 to 16%, hypertension from 6 to 48%, obesity from 0.4 to 43%, and current smoking from 0.4 to 71%. The numbers of these NCD cases are predicted to rise over the next decade. However, in the context of a global pandemic such as COVID-19, with the rising cases, lockdowns and deaths recorded worldwide, many people living with NCDs may find accessing care more difficult. The majority of the available resources on the subcontinent have been diverted to focus on the ongoing pandemic. This has caused interruptions in care, complication management, drug pick-up alongside the almost neglected silent NCD epidemic, with major consequences for the health system post the COVID-19 era. We explore the issues surrounding the continuity of care and offer some solutions for Sub-Saharan Africa.

Variation in the availability and cost of essential medicines for non-communicable diseases in Uganda: A descriptive time series analysis

Background

Availability of essential medicines for non-communicable diseases (NCDs) is poor in low- and middle-income countries. Availability and cost are conventionally assessed using cross-sectional data. However, these characteristics may vary over time.

Methods

We carried out a prospective, descriptive analysis of the availability and cost of essential medicines in 23 Ugandan health facilities over a five-week period. We surveyed facility pharmacies in-person up to five times, recording availability and cost of 19 essential medicines for NCDs and four essential medicines for communicable diseases.

Results

Availability of medicines varied substantially over time, especially among public facilities. Among private-for-profit facilities, the cost of the same medicine varied from week to week. Private-not-for-profit facilities experienced less dramatic fluctuations in price.

Conclusions

We conclude that there is a need for standardized, continuous monitoring to better characterize the availability and cost of essential medicines, understand demand for these medicines, and reduce uncertainty for patients.

A Novel Case-Finding Instrument for Chronic Obstructive Pulmonary Disease in Low- and Middle-Income Country Settings

Background

Low- and middle-income countries (LMICs) account for >90% of deaths and illness episodes related to COPD; however, this condition is commonly underdiagnosed in these settings. Case-finding instruments for COPD may improve diagnosis and identify individuals that need treatment, but few have been validated in resource-limited settings.

Methods

We conducted a population-based cross-sectional study in Uganda to assess the diagnostic accuracy of a respiratory symptom, exposure and functional questionnaire in combination with peak expiratory flow for COPD diagnosis using post-bronchodilator FEV1/FVC z-score below the 5th percentile as the gold standard. We included locally relevant exposure questions and statistical learning techniques to identify the most important risk factors for COPD. We used 80% of the data to develop the case-finding instrument and validated it in the remaining 20%. We evaluated for calibration and discrimination using standard approaches. The final score, COLA (COPD in LMICs Assessment), included seven questions, age and pre-bronchodilator peak expiratory flow.

Results

We analyzed data from 1,173 participants (average age 47 years, 46.9% male, 4.5% with COPD) with acceptable and reproducible spirometry. The seven questions yielded a cross-validated area-under-the-curve [AUC] of 0.68 (95% CI 0.61-0.75) with higher scores conferring greater odds of COPD. The inclusion of peak expiratory flow and age improved prediction in a validation sample (AUC=0.83, 95% CI 0.78-0.88) with a positive predictive value of 50% and a negative predictive value of 96%. The final instrument (COLA) included seven questions, age and pre-bronchodilator peak expiratory flow.

Conclusion

COLA predicted COPD in urban and rural settings in Uganda has high calibration and discrimination, and could serve as a simple, low-cost screening tool in resource-limited settings.

Self-reported activities of daily living, health and quality of life among older adults in South Africa and Uganda: a cross sectional study

BACKGROUND

Difficulties in performing the activities of daily living (ADL) are common among middle-aged and older adults. Inability to perform the basic tasks as well as increased healthcare expenditure and dependence on care can have debilitating effects on health and quality of life. The objective of this study was to examine the relationship between self-reported difficulty in activities of daily living (ADL), health and quality of life among community-dwelling, older population in South Africa and Uganda.

METHODS

We analyzed cross-sectional data on 1495 men and women from South Africa (n = 514) and Uganda (n = 981) which were extracted from the SAGE Well-Being of Older People Study (WOPS 2011-13). Outcome variables were self-reported health and quality of life (QoL). Difficulty in ADL was assessed by self-reported answers on 12 different questions covering various physical and cognitive aspects. The association between self-reported health and quality of life with ADL difficulties was calculated by using multivariable logistic regression models.

RESULTS

Overall percentage of good health and good quality of life was 40.4% and 20%, respectively. The percentage of respondents who had 1-3, 3-6, > 6 ADL difficulties were 42.4%7, 30.97% and 14.85%, respectively. In South Africa, having > 6 ADL difficulties was associated with lower odds of good health among men [Odds ratio = 0.331, 95%CI = 0.245,0.448] and quality of life among men [Odds ratio = 0.609, 95%CI = 0.424,0.874] and women [Odds ratio = 0.129, 95%CI = 0.0697,0.240]. In Uganda, having > 6 ADL difficulties was associated lower odds of good health [Odds ratio = 0.364, 95%CI = 0.159,0.835] and quality of life [Odds ratio = 0.584, 95%CI = 0.357,0.954].

CONCLUSION

This study concludes that difficulty in ADL has a significant negative association with health and quality of life among community-dwelling older population (> 50 years) in South Africa and Uganda. The sex differences support previous findings on differential health outcomes among men and women, and underline the importance of designing sex-specific health intervention programs.

Patient experiences in managing non-communicable diseases in Namibia

INTRODUCTION

The prevalence of non-communicable diseases (NCDs) is rising in Namibia, and with it, the need for pharmacists to empower patients. This research aims to 1) identify patient-reported barriers and facilitators to managing chronic NCDs for Namibians, and 2) characterize common patient-reported medication and health-related needs of Namibians with chronic NCDs.

METHODS

This qualitative study used semi-structured interviews to elicit participant perspectives regarding NCDs. The study used the conceptual frameworks of the Health Belief Model, the Theory of Planned Behavior, and the Explanatory Models of Illness to identify and understand key factors necessary to develop relevant patient-centered interventions. Participants were recruited from pharmacies throughout Namibia. Data were analyzed using thematic analysis from the transcribed interviews.

RESULTS

A total of 23 interviews were conducted, with 20 being included in the final analysis. Themes identified included: 1) participants were motivated to seek care when they were symptomatic; 2) participants felt motivated to care for their condition to improve their own lives and their families for their family's sake; 3) participants integrated information from a variety of sources into their disease knowledge; 4) participants describe wanting to be more engaged in managing their health and wanting support to help manage their condition; 5) participants describe awareness of lifestyle changes necessary to improve health, but face many barriers to achieving them.

CONCLUSION

This study identified key factors that are essential for pharmacists and other health care professionals to be aware of in order to support patients who are diagnosed with an NCD. Health care providers should consider strategies to engage patients to harness their motivations, enhance health education, and create systems to reduce barriers to addressing lifestyle.

Knowledge of cardiovascular risk factors among caretakers of outpatients attending a tertiary cardiovascular center in Tanzania: a cross-sectional survey

BACKGROUND

Health literacy on cardiovascular diseases (CVDs) plays an effective role in preventing or delaying the disease onset as well as in impacting the efficacy of their management. In view of the projected low health literacy in Tanzania, we conducted this cross-sectional survey to assess for CVD risk knowledge and its associated factors among patient escorts.

METHODS

A total of 1063 caretakers were consecutively enrolled in this cross-sectional study. An adopted questionnaire consisting of 22 statements assessing various CVD risk behaviors was utilized for assessment of knowledge. Logistic regression analyses were performed to assess for factors associated with poor knowledge of CVD risks.

RESULTS

The mean age was 40.5 years and women predominated (55.7%). Over two-thirds had a body mass index (BMI) ≥25 kg/m2, 18.5% were alcohol drinkers, 3.2% were current smokers, and 47% were physically inactive. The mean score was 78.2 and 80.0% had good knowledge of CVD risks. About 16.3% believed CVDs are diseases of affluence, 17.4% thought CVDs are not preventable, and 56.7% had a perception that CVDs are curable. Low education (OR 2.6, 95%CI 1.9-3.7, p < 0.001), lack of health insurance (OR 1.5, 95%CI 1.1-2.3, p = 0.03), and negative family history of CVD death (OR 2.2, 95%CI 1.4-3.5, p < 0.001), were independently associated with poor CVD knowledge.

CONCLUSIONS

In conclusion, despite of a good level of CVD knowledge established in this study, a disparity between individual's knowledge and self-care practices is apparent.

Illness representations of chronic obstructive pulmonary disease (COPD) to inform health education strategies and research design-learning from rural Uganda

More than 90% of chronic obstructive pulmonary disease (COPD)-related deaths occur in low- and middle-income countries; however, few studies have examined the illness experiences of individuals living with and providing treatment for COPD in these settings. This study characterizes illness representations for COPD in Nakaseke, Uganda from the perspectives of health care providers, village health teams and community members (CMs) with COPD. We conducted 40 in-depth, semi-structured interviews (16 health care providers, 12 village health teams and 12 CMs, aged 25-80 years). Interviews were analyzed using inductive coding, and the Illness Representations Model guided our analysis. Stakeholder groups showed concordance in identifying causal mechanisms of COPD, but showed disagreement in reasons for care seeking behaviors and treatment preferences. CMs did not use a distinct label to differentiate COPD from other respiratory illnesses, and described both the physical and social consequences of COPD. Local representations can inform development of adapted educational and self-management tools for COPD.

Layering and scaling up chronic non-communicable disease care on existing HIV care systems and acute care settings in Kenya: a cost and budget impact analysis

INTRODUCTION

Like many countries in sub-Saharan Africa, Kenya is experiencing a rapid rise in the burden of non-communicable diseases (NCDs): NCDs now contribute to over 50% of inpatient admissions and 40% of hospital deaths in the country. The Academic Model Providing Access to Healthcare (AMPATH) Chronic Disease Management (CDM) programme builds on lessons and capacity of HIV care to deliver chronic NCD care layered into both HIV and primary care platforms to over 24,000 patients across 69 health facilities in western Kenya. We conducted a cost and budget impact analysis of scaling up the AMPATH CDM programme in western Kenya using the International Society for Pharmacoeconomics and Outcomes Research guidelines.

METHODS

Costs of the CDM programme for the health system were measured retrospectively for 69 AMPATH clinics from 2014 to 2018 using programmatic records and clinic schedules to assign per clinic monthly costs. We quantified the additional costs to provide NCD care above those associated with existing HIV or acute care services, including clinician, staff, training, travel and equipment costs, but do not include drugs or consumables as they would be paid by the patient. We projected the budget impact of increasing CDM coverage to 50% of the eligible population from 2021 to 2025, and compared it with the county budgets from 2019.

RESULTS

The per visit cost of providing CDM care was $10.42 (SD $2.26), with costs at facilities added to HIV clinics $1.00 (95% CI: -$2:11 to $0.11) lower than at primary care facilities. The budget impact of adding 26,765 patients from 2021 to 2025 to the CDM programme was 3,088,928 under constant percent growth, and 3,451,732 under steady-state enrolment. Scaling up under the constant percent growth scenario resulted in 12% cost savings in the budget impact. The county programmatic CDM cost in 2025 was <1% of the county healthcare budgets from 2019.

CONCLUSIONS

The budget impact of scaling up AMPATH's CDM programme will be driven by annual growth scenarios, and facility/provider mix. By leveraging task shifting, referral systems and partnering with public and non-profit clinics without NCD services, AMPATH's CDM programme can provide critical NCD care to new, rural populations with minimal financial impact.

Burden of non-communicable diseases in sub-Saharan Africa, 1990-2017: results from the Global Burden of Disease Study 2017

BACKGROUND

Although the burden of disease in sub-Saharan Africa continues to be dominated by infectious diseases, countries in this region are undergoing a demographic transition leading to increasing prevalence of non-communicable diseases (NCDs). To inform health system responses to these changing patterns of disease, we aimed to assess changes in the burden of NCDs in sub-Saharan Africa from 1990 to 2017.

METHODS

We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to analyse the burden of NCDs in sub-Saharan Africa in terms of disability-adjusted life-years (DALYs)-with crude counts as well as all-age and age-standardised rates per 100 000 population-with 95% uncertainty intervals (UIs). We examined changes in burden between 1990 and 2017, and differences across age, sex, and regions. We also compared the observed NCD burden across countries with the expected values based on a country's Socio-demographic Index.

FINDINGS

All-age total DALYs due to NCDs increased by 67·0% between 1990 (90·6 million [95% UI 81·0-101·9]) and 2017 (151·3 million [133·4-171·8]), reflecting an increase in the proportion of total DALYs attributable to NCDs (from 18·6% [95% UI 17·1-20·4] to 29·8% [27·6-32·0] of the total burden). Although most of this increase can be explained by population growth and ageing, the age-standardised DALY rate (per 100 000 population) due to NCDs in 2017 (21 757·7 DALYs [95% UI 19 377·1-24 380·7]) was almost equivalent to that of communicable, maternal, neonatal, and nutritional diseases (26 491·6 DALYs [25 165·2-28 129·8]). Cardiovascular diseases were the second leading cause of NCD burden in 2017, resulting in 22·9 million (21·5-24·3) DALYs (15·1% of the total NCD burden), after the group of disorders categorised as other NCDs (28·8 million [25·1-33·0] DALYs, 19·1%). These categories were followed by neoplasms, mental disorders, and digestive diseases. Although crude DALY rates for all NCDs have decreased slightly across sub-Saharan Africa, age-standardised rates are on the rise in some countries (particularly those in southern sub-Saharan Africa) and for some NCDs (such as diabetes and some cancers, including breast and prostate cancer).

INTERPRETATION

NCDs in sub-Saharan Africa are posing an increasing challenge for health systems, which have to date largely focused on tackling infectious diseases and maternal, neonatal, and child deaths. To effectively address these changing needs, countries in sub-Saharan Africa require detailed epidemiological data on NCDs.

FUNDING

Bill & Melinda Gates Foundation, National Health and Medical Research Centre (Australia).

Pharmacotherapy for hypertension in Sub-Saharan Africa: a systematic review and network meta-analysis

BACKGROUND

The highest burden of hypertension is found in Sub-Saharan Africa (SSA) with a threefold greater mortality from stroke and other associated diseases. Ethnicity is known to influence the response to antihypertensives, especially in black populations living in North America and Europe. We sought to outline the impact of all commonly used pharmacological agents on both blood pressure reduction and cardiovascular morbidity and mortality in SSA.

METHODS

We used similar criteria to previous large meta-analyses of blood pressure agents but restricted results to populations in SSA. Quality of evidence was assessed using a risk of bias tool. Network meta-analysis with random effects was used to compare the effects across interventions and meta-regression to explore participant heterogeneity.

RESULTS

Thirty-two studies of 2860 participants were identified. Most were small studies from single, urban centres. Compared with placebo, any pharmacotherapy lowered SBP/DBP by 8.51/8.04 mmHg, and calcium channel blockers (CCBs) were the most efficacious first-line agent with 18.46/11.6 mmHg reduction. Fewer studies assessing combination therapy were available, but there was a trend towards superiority for CCBs plus ACE inhibitors or diuretics compared to other combinations. No studies examined the effect of antihypertensive therapy on morbidity or mortality outcomes.

CONCLUSION

Evidence broadly supports current guidelines and provides a clear rationale for promoting CCBs as first-line agents and early initiation of combination therapy. However, there is a clear requirement for more evidence to provide a nuanced understanding of stroke and other cardiovascular disease prevention amongst diverse populations on the continent.

TRIAL REGISTRATION

PROSPERO, CRD42019122490. This review was registered in January 2019.

Quality and barriers of outpatient diabetes care in rural health facilities in Uganda - a mixed methods study

BACKGROUND

Despite the increasing burden of diabetes in Uganda, little is known about the quality of type 2 diabetes mellitus (T2DM) care especially in rural areas. Poor quality of care is a serious limitation to the control of diabetes and its complications. This study assessed the quality of care and barriers to service delivery in two rural districts in Eastern Uganda.

METHODS

This was a mixed methods cross-sectional study, conducted in six facilities. A randomly selected sample of 377 people with diabetes was interviewed using a pre-tested interviewer administered questionnaire. Key informant interviews were also conducted with diabetes care providers. Data was collected on health outcomes, processes of care and foundations for high quality health systems. The study included three health outcomes, six elements of competent care under processes and 16 elements of tools/resources and workforce under foundations. Descriptive statistics were computed to determine performance under each domain, and thematic content analysis was used for qualitative data.

RESULTS

The mean age of participants was 49 years (±11.7 years) with a median duration of diabetes of 4 years (inter-quartile range = 2.7 years). The overall facility readiness score was 73.9%. Inadequacies were found in health worker training in standard diabetes care, availability of medicines, and management systems for services. These were also the key barriers to provision and access to care in addition to lack of affordability. Screening of clients for blood cholesterol and microvascular complications was very low. Regarding outcomes; 56.8% of participants had controlled blood glucose, 49.3% had controlled blood pressure; and 84.0% reported having at least one complication.

CONCLUSION

The quality of T2DM care provided in these rural facilities is sub-optimal, especially the process of care. The consequences include sub-optimal blood glucose and blood pressure control. Improving availability of essential medicines and basic technologies and competence of health workers can improve the care process leading to better outcomes.

Epilepsy diagnosis and management of children in Kenya: review of current literature

Introduction: The growing impact of non-communicable diseases in low- to middle-income countries makes epilepsy a key research priority. We evaluated peer-reviewed published literature on childhood epilepsy specific to Kenya to identify knowledge gaps and inform future priorities. Methodology: A literature search utilizing the terms "epilepsy" OR "seizure" as exploded subject headings AND "Kenya" was conducted. Relevant databases were searched, generating 908 articles. After initial screening to remove duplications, irrelevant articles, and publications older than 15 years, 154 papers remained for full-article review, which identified 35 publications containing relevant information. Data were extracted from these reports on epidemiology, etiology, clinical features, management, and outcomes. Results: The estimated prevalence of lifetime epilepsy in children was 21-41 per 1,000, while the incidence of active convulsive epilepsy was 39-187 cases per 100,000 children per year. The incidence of acute seizures was 312-879 per 100,000 children per year and neonatal seizures 3,950 per 100,000 live births per year. Common risk factors for both epilepsy and acute seizures included adverse perinatal events, meningitis, malaria, febrile seizures, and family history of epilepsy. Electroencephalography abnormalities were documented in 20%-41% and neurocognitive comorbidities in more than half. Mortality in children admitted with acute seizures was 3%-6%, and neurological sequelae were identified in 31% following convulsive status epilepticus. Only 7%-29% children with epilepsy were on antiseizure medication. Conclusion: Active convulsive epilepsy is a common condition among Kenyan children, remains largely untreated, and leads to extremely poor outcomes. The high proportion of epilepsy attributable to preventable causes, in particular neonatal morbidity, contributes significantly to the lifetime burden of the condition. This review reaffirms the ongoing need for better public awareness of epilepsy as a treatable disease and for national-level action that targets both prevention and management.

FOETAL for NCD-FOetal Exposure and Epidemiological Transitions: the role of Anaemia in early Life for Non-Communicable Diseases in later life: a prospective preconception study in rural Tanzania

PURPOSE

Low-income and middle-income countries such as Tanzania experience a high prevalence of non-communicable diseases (NCDs), including anaemia. Studying if and how anaemia affects growth, placenta development, epigenetic patterns and newborns' risk of NCDs may provide approaches to prevent NCDs.

PARTICIPANTS

The FOETALforNCD (FOetal Exposure and Epidemiological Transitions: the role of Anaemia in early Life for Non-Communicable Diseases in later life) Study is a population-based preconception, pregnancy and birth cohort study (n=1415, n=538, n=427, respectively), conducted in a rural region of North-East Tanzania. All participants were recruited prior to conception or early in pregnancy and followed throughout pregnancy as well as at birth. Data collection included: maternal blood, screening for NCDs and malaria, ultrasound in each trimester, neonatal anthropometry at birth and at 1 month of age, cord blood, placental and cord biopsies for stereology and epigenetic analyses.

FINDINGS TO DATE

At preconception, the average age, body mass index and blood pressure of the women were 28 years, 23 kg/m² and 117/75 mm Hg, respectively. In total, 458 (36.7%) women had anaemia (haemoglobin Hb <12 g/dL) and 34 (3.6%) women were HIV-positive at preconception. During pregnancy 359 (66.7%) women had anaemia of which 85 (15.8%) women had moderate-to-severe anaemia (Hb ≤9 g/dL) and 33 (6.1%) women had severe anaemia (Hb ≤8 g/dL). In total, 185 (34.4%) women were diagnosed with malaria during pregnancy.

FUTURE PLANS

The project will provide new knowledge on how health, even before conception, might modify the risk of developing NCDs and how to promote better health during pregnancy. The present project ended data collection 1 month after giving birth, but follow-up is continuing through regular monitoring of growth and development and health events according to the National Road Map Strategic Plan in Tanzania. This data will link fetal adverse event to childhood development, and depending on further grant allocation, through a life course follow-up.

An implementation science study to enhance cardiovascular disease prevention in Mukono and Buikwe districts in Uganda: a stepped-wedge design

BACKGROUND

Uganda is experiencing a shift in major causes of death with cases of stroke, heart attack, and heart failure reportedly on the rise. In a study in Mukono and Buikwe in Uganda, more than one in four adults were reportedly hypertensive. Moreover, very few (36.5%) reported to have ever had a blood pressure measurement. The rising burden of CVD is compounded by a lack of integrated primary health care for early detection and treatment of people with increased risk. Many people have less access to effective and equitable health care services which respond to their needs. Capacity gaps in human resources, equipment, and drug supply, and laboratory capabilities are evident. Prevention of risk factors for CVD and provision of effective and affordable treatment to those who require it prevent disability and death and improve quality of life. The aim of this study is to improve health profiles for people with intermediate and high risk factors for CVD at the community and health facility levels. The implementation process and effectiveness of interventions will be evaluated.

METHODS

The overall study is a type 2-hybrid stepped-wedge (SW) design. The design employs mixed methods evaluations with incremental execution and adaptation. Sequential crossover take place from control to intervention until all are exposed. The study will take place in Mukono and Buikwe districts in Uganda, home to more than 1,000,000 people at the community and primary healthcare facility levels. The study evaluation will be guided by; 1) RE-AIM an evaluation framework and 2) the CFIR a determinant framework. The primary outcomes are implementation - acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, coverage, and sustainability.

DISCUSSION

The study is envisioned to provide important insight into barriers and facilitators of scaling up CVD prevention in a low income context. This project is registered at the ISRCTN Registry with number ISRCTN15848572. The trial was first registered on 03/01/2019.

Challenges and opportunities to tackle the rising prevalence of diet-related non-communicable diseases in Africa

Africa is experiencing a sharp rise in non-communicable diseases (NCD) related to rapid globalisation and urbanisation leading to shifts in dietary and lifestyle patterns characterised by increased energy intake and physical inactivity. However, unlike more resource-endowed regions, Africa has a double burden of disease: NCD co-exist with infectious diseases including lower respiratory tract infections, HIV/AIDS and diarrhoeal diseases. The African economy is also relatively weaker, making it difficult to cope with this burden. It is postulated that NCD will soon overtake infectious diseases as the number one cause of death in the African region. The recognition of NCD as diseases and obesity as a related risk factor is weak in Africa, compounded by stigma associated with wasting in HIV/AIDS and obesity being perceived as a sign of wealth, achievement and care. There is also a dearth of data on overweight and obesity in the region and little knowledge that infant feeding practices, such as breast-feeding, are linked to reduced risk of NCD in both children and mothers. While complex multi-sectoral approaches to address this NCD menace are needed, Africa may benefit from taking simple initial steps to address NCD risk factors including: (1) behaviour change communication to challenge perceptions on NCD; (2) promoting and protecting breast-feeding; (3) formulating policies and regulations limiting wide availability of unhealthy foods; (4) mainstream nutrition education in school curricula and (5) collection of accurate data based on indicators that can reflect the double burden of disease and malnutrition; and fostering multi-sectoral actions against NCD.

Health disparities across the counties of Kenya and implications for policy makers, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Background

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease.

Methods

We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016.

Findings

The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8–871·1) deaths per 100 000 in 1990 to 579·0 (562·1–596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1–101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9–51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9–399·4) deaths per 100 000 in 1990 to 257·6 (195·1–335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7–7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016.

Interpretation

Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary.

Funding

Bill & Melinda Gates Foundation.