Demographic, epidemiological, and health transitions: are they relevant to population health patterns in Africa?

Cardiac patients' surgery outcome and associated factors in Ethiopia: application of machine learning

INTRODUCTION

Cardiovascular diseases are a class of heart and blood vessel-related illnesses. In Sub-Saharan Africa, including Ethiopia, preventable heart disease continues to be a significant factor, contrasting with its presence in developed nations. Therefore, the objective of the study was to assess the prevalence of death due to cardiac disease and its risk factors among heart patients in Ethiopia.

METHODS

The current investigation included all cardiac patients who had cardiac surgery in the country between 2012 and 2023. A total of 1520 individuals were participated in the study. Data collection took place between February 2022 and January 2023. The study design was a retrospective cohort since the study track back patients' chart since 2012. Machine learning algorithms were applied for data analysis. For machine learning algorithms comparison, lift and AUC was applied.

RESULTS

From all possible algorithms, logistic algorithm at 90%/10% was the best fit since it produces the maximum AUC value. In addition, based on the lift value of 3.33, it can be concluded that the logistic regression algorithm was performing well and providing substantial improvement over random selection. From the logistic regression machine learning algorithms, age, saturated oxygen, ejection fraction, duration of cardiac center stays after surgery, waiting time to surgery, hemoglobin, and creatinine were significant predictors of death.

CONCLUSION

Some of the predictors for the death of cardiac disease patients are identified as such special attention should be given to aged patients, for patients waiting for long periods of time to get surgery, lower saturated oxygen, higher creatinine value, lower ejection fraction and for patients with lower hemoglobin values.

Sex-based tuberculosis mortality in Newfoundland, 1900-1949: Implications for populations in transition

OBJECTIVE

During the second epidemiological transition, tuberculosis (TB) is one disease that declined substantially enough to reduce all-cause mortality. Sex-based differences in TB mortality may reveal an important dimension of population health transitions between the urbanizing and rural regions of Newfoundland.

MATERIALS AND METHODS

For the island of Newfoundland, yearly age-standardized sex-based TB mortality rates were calculated using individual death records from 1900 to 1949 (n = 30 393). Multiple linear regression models predict the relative rates (RR) of sex-based mortality and the absolute difference between males and females while controlling for time and region (the urbanizing Avalon Peninsula or rural Newfoundland). Multiple linear regression models also predict the median age at death from TB while controlling for time, region, and sex to assess if TB was shifting to an older adult disease compared to those typically afflicted in ages 20-44.

RESULTS

Female TB mortality was relatively and absolutely higher than males; additionally, RR and absolute differences between male and female mortality were significantly lower in rural Newfoundland than the Avalon Peninsula. Median age at death for males was significantly higher than females, and differences in median age at death increased over time.

DISCUSSION

The historically high prevalence of TB throughout Newfoundland, including domestic, social, and public health responsibilities of women, likely contributed to increased exposure and transmission, leading to higher observed mortality. Sex-based TB outcomes should be considered in the discussion of the progression of the epidemiological transition as dynamic inequalities that do not necessarily fit contemporary generalizations of sex-based TB epidemiology.

Post-surgery survival and associated factors for cardiac patients in Ethiopia: applications of machine learning, semi-parametric and parametric modelling

INTRODUCTION

Living in poverty, especially in low-income countries, are more affected by cardiovascular disease. Unlike the developed countries, it remains a significant cause of preventable heart disease in the Sub-Saharan region, including Ethiopia. According to the Ethiopian Ministry of Health statement, around 40,000 cardiac patients have been waiting for surgery in Ethiopia since September 2020. There is insufficient information about long-term cardiac patients' post-survival after cardiac surgery in Ethiopia. Therefore, the main objective of the current study was to determine the long-term post-cardiac surgery patients' survival status in Ethiopia.

METHODS

All patients attended from 2012 to 2023 throughout the country were included in the current study. The total number of participants was 1520 heart disease patients. The data collection procedure was conducted from February 2022- January 2023. Machine learning algorithms were applied. Gompertz regression was used also for the multivariable analysis report.

RESULTS

From possible machine learning models, random survival forest were preferred. It emphasizes, the most important variable for clinical prediction was SPO2, Age, time to surgery waiting time, and creatinine value and it accounts, 42.55%, 25.17%,11.82%, and 12.19% respectively. From the Gompertz regression, lower saturated oxygen, higher age, lower ejection fraction, short period of cardiac center stays after surgery, prolonged waiting time to surgery, and creating value were statistically significant predictors of death outcome for post-cardiac surgery patients' survival in Ethiopia.

CONCLUSION

Some of the risk factors for the death of post-cardiac surgery patients are identified in the current investigation. Particular attention should be given to patients with prolonged waiting times and aged patients. Since there were only two fully active cardiac centers in Ethiopia it is far from an adequate number of centers for more than 120 million population, therefore, the study highly recommended to increase the number of cardiac centers that serve as cardiac surgery in Ethiopia.

The Link between Overweight/Obesity and Noncommunicable Diseases in Ethiopia: Evidences from Nationwide WHO STEPS Survey 2015

Background

Noncommunicable diseases (NCDs) are the leading cause of death worldwide. Each year, 15 million adults die from NCDs; more than 85% of these premature deaths occur in low- and middle-income nations. Evidence indicates that overweight and obesity are the main risk factors for NCDs. Although the literature indicates that the burden of NCDs is increasing in Ethiopia, no research has been conducted to demonstrate a link between overweight/obesity and NCDs. Therefore, the aim of this study is to examine the association between overweight/obesity and the common NCDs while adjusting for other important factors.

Methods

We analysed data from the 2015 Ethiopia WHO STEPS survey, which was conducted in 2015. A total weighted sample of 9,800 participants (15-69 years) was included. The relationship between nutritional status and NCDs was assessed using bivariate and multivariable logistic regression models while adjusting for covariates.

Results

Among the 9,800 participants, 2053 (21% with (95% CI: 19.8-22.1) had hypertension and 1368 (14% with (95% CI: 13.1-15.0) had high cholesterol levels. According to the multivariable logistic regression analysis, being overweight/obese (AOR = 2.0; 95% CI: 1.7-2.3), alcohol consumption, received lifestyle advice, being female, living in urban areas, increased age, having government occupation, and living in SNNP region were positively associated with hypertension. While being underweight (AOR = 0.6; 95% CI: 0.5-0.7), living in the Afar, Somali, and Tigray regions were negatively associated with hypertension. Being overweight/obese (AOR = 1.4; 95% CI: 1.1-1.7), being female, having older age, and living in Somali region were positively associated with a high cholesterol level. Whereas being underweight (AOR = 0.7; 95% CI: 0.6-0.9), received lifestyle advice, reside in rural areas, being farmer, student, and housewife, and living in Gambela region were negatively associated with a high cholesterol level.

Conclusion

This study found a statistically positive association between the common NCDs, namely, overweight/obesity, hypertension, and high cholesterol levels. Our findings imply that there is a need for effective interventions to prevent overweight/obesity by encouraging people to increase physical activity, minimize sedentary behavior, and maintain a healthy dietary pattern in order to reduce the risk of hypertension and high cholesterol levels.

Development and validation of a screening tool for SPondyloArthritis Screening in Sub-Saharan Africa: SpASSS questionnaire

OBJECTIVE

To develop and validate a screening tool to identify patients with a high likelihood for Spondyloarthritis (SpA) in the Democratic Republic of the Congo (DR Congo).

METHODS

The development of the SpA Screening questionnaire in Sub Saharian Africa (SpASSS) questionnaire followed 3 steps: The item generation was carried out by a systematic literature review according to the PRISMA guidelines on the clinical manifestations of SpA, interviewing clinical experts and the classification criteria for Spondyloarthritis. The candidate questions were tested in a population of 50 consecutive patients with confirmed diagnosis of spondyloarthritis, in a control population of rheumatic disease excluding SpA and in a group of 200 non-rheumatic participants, randomly chosen in the general population for question reduction and validation. Descriptive statistical analyses were performed to assess socio-demographic characteristics and response distribution for each item. Their diagnostic performance was investigated using ROC curves. For validation, principal component analysis was performed using factor analysis. Referral strategy score for SpA was determined by adjusted Cronbach's alpha coefficient.

RESULTS

Mean ± SD age of SpA cases was 41.8 ± 14.4 years, 56% were men compared to diseased controls 60.0 ± 12.5 years, 28.7% men (p < 0.001). 14/20 items showed a statistically significant difference (p < 0.05) between SpA cases and control groups. All items were factorable and 6 components were identified. Only the two first components (C1 with 8 items, C2 with 3 items) showed a significant threshold for reliability in detection of suspected SpA with a Cronbach's alpha of 0.830 and 0.708. All validated items of these two components showed the global reliability threshold with α-adjusted Cronbach calculated at 66.9%. The performance for correctly screening SpA was demonstrated with an area under the curve of 0.938 (0.884-0.991) and 0.794 (0.728-0.861) for C1 and C2 respectively.

CONCLUSIONS

This validation and item reduction of the SpASSS questionnaire for SpA might identify patients to refer for case ascertainment and will help conducting future epidemiological and clinical studies in the DR Congo.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• To the best of our knowledge, this is the first study in Sub-Saharan Africa based on local data to develop a screening tool for SpA in the population for epidemiological and clinical use. • Referral strategies based on context-specific data are necessary to provide accurate case definition and epidemiological data, thus reducing methodological bias. • In the SpA group, no discrimination was made regarding SpA subtypes, disease duration, activity and severity.

HIV status and survival of patients with pulmonary hypertension due to left heart disease: the Pan African Pulmonary Hypertension Cohort

In sub-Saharan Africa, little is known about pulmonary hypertension in left heart disease (PH-LHD). We used multivariate logistic and cox-hazard proportional regression models to examine factors associated with increased right ventricular systolic pressure (RVSP) and the effect of real-world HIV status scenarios on 6-month survival rate in the Pan African Pulmonary Hypertension Cohort (PAPUCO) study, a prospective cohort from four African countries. Exposure to biomass fuel smoke (aOR, 95%CI 3.07, 1.02-9.28), moderate to severe NYHA/FC III/IV (aOR, 95%CI 4.18, 1.01-17.38), and unknown HIV status (aOR, 95%CI 2.73, 0.96-7.73) predicted moderate to severe RVSP at the time of presentation. Six months later, HIV infection, moderate-to-severe NYHA/FC, and alcohol consumption were associated with decreased survival probabilities. Upon adjusting for HIV infection, it was observed that an incremental rise in RVSP (1 mmHg) and inter-ventricular septal thickness (1 mm) resulted in an 8% (aHR, 95%CI 1.08, 1.02-1.13) and 20% (aHR, 95%CI 1.2, 1.00-1.43) increase in the probability of mortality due to PH-LHD. In contrast, the risk of death from PH-LHD was reduced by 23% for each additional unit of BMI. (aHR, 95%CI 0.77, 0.59-1.00). In conclusion, the present study offers insights into the determinants that are notably linked to unfavorable survival outcomes in patients with pulmonary hypertension due to left heart disease. Certain factors identified in this study are readily evaluable and amenable to modification, even in settings with limited resources.

The association between the timing, intensity and magnitude of adolescent growth and body composition in early adulthood

OBJECTIVES

There's paucity of longitudinal studies assessing the role of adolescent growth on adult body composition in developing countries. The aims of this study were to assess the association between adolescent change in height, weight and BMI and early adult height, weight, body fat and lean mass.

METHODS

Magnitude, timing and intensity of height, weight and BMI growth were modelled for participants from the Birth to Thirty (Bt30) cohort (7-23 years). Early adult height, weight, BMI and DXA-derived body composition were obtained 1881 black participants (21-24 years). Linear regression analyses were used to assess associations.

RESULTS

Adolescents with an earlier onset of puberty were heavier in childhood and had an earlier timing and faster weight gain velocity in late adolescence. The intensity of adolescent weight gain was positively associated with adult BMI and fat mass index (FMI) in females. Early timing of adolescent BMI gain was associated with increased weight and BMI in adult females and FMI in adult males. Achieving peak weight velocity around age at peak height velocity was associated with lower BMI and fat mass in both sexes.

CONCLUSION

This study confirms the adverse consequences of excessive weight gain prior to puberty, which is associated with an earlier and faster resurgence in weight gain velocity in early adulthood. Factors that contribute to an asynchronous timing of ages of peak weight and peak height velocities may accentuate the risk of adult obesity.

The burden of suspected strokes in uMgungundlovu - Can biomarkers aid prognostication?

Background

The burden of stroke is increasing worldwide. The hierarchical healthcare referral system in South Africa (SA) poses unique challenges to clinicians when caring for people with suspected strokes (PsS). To improve health outcomes, novel strategies are required to provide adequate care, including prognostication, in SA.

Aim

To determine the subjective burden of and challenges posed by suspected stroke cases and the potential usefulness of biomarkers in prognostication.

Setting

This study was conducted in the uMgungundlovu Health District (UHD), KwaZulu-Natal, SA.

Methods

An online questionnaire was distributed to doctors within the UHD. Demographic data and answers to a series of 5-point-Likert-type statements were collected.

Results

Seventy-seven responses were analysed. A third of doctors worked in primary healthcare facilities (PHCare) and saw ≥ 2.15 suspected strokes-per-doctor-per-week, compared to ≥ 1.38 seen by doctors working in higher levels of healthcare. Neuroimaging was relied upon by > 85% of doctors, with nearly half of PHCare doctors having to refer patients to facilities 5 km - 20 km away, with resultant delays. Knowledge about prognostic biomarkers in strokes was poor, yet most doctors believed that a biomarker would assist in the prognostication process and they would use it routinely.

Conclusion

Doctors in this study faced a significant burden of strokes and rely on neuroimaging to guide their management; however, many challenges exist in obtaining such imaging, especially in the PHCare setting. The need for prognostic biomarkers was clear.

Contribution

This research lays the platform for further studies to investigate prognostic biomarkers in stroke in our clinical setting.

Sustainable dietary weight loss intervention and its effects on cardiometabolic parameters and greenhouse gas emissions: study protocol of a randomised controlled trial with overweight and obese adults in Ouagadougou, Burkina Faso

INTRODUCTION

The global obesity epidemic and its adverse health effects have reached sub-Saharan Africa. In some urban settings, like Burkina Faso's capital Ouagadougou, up to 43% of the adult population are overweight or obese. At the same time, modernised food systems are responsible for 26% of global greenhouse gas emissions, 50% of land use and 70% of freshwater use. International guidelines on the treatment of overweight and obesity recommend dietary intervention programmes that promote reduced calorie intake and increased physical activity. So far, weight loss interventions rarely consider sustainable dietary concepts, including healthfulness, affordability, cultural appropriateness and environmental friendliness. Therefore, we present a study protocol of a novel randomised controlled trial that aims to establish the effects of a sustainable weight loss intervention on cardiometabolic and environmental outcomes in urban Burkina Faso.

METHODS AND ANALYSIS

We conduct a non-blinded randomised controlled trial, comparing a 6-month sustainable diet weight loss intervention programme (n=125) with a standard weight loss information material and 5 min oral counselling at baseline (n=125). Primary outcome is a reduction in fasting plasma glucose of ≥0.1 mmol/L. Outcome measures are assessed at baseline, after 6 months and after 12 months.

ETHICS AND DISSEMINATION

Ethical approval for the study has been obtained from the Medical Faculty of Heidelberg University (S-376/2019) and from the Ministry of Health and the Ministry of Higher Education, Scientific Research and Innovation in Ouagadougou, Burkina Faso (No 2021-01-001). The results of the study will be disseminated to local stakeholders at a final project meeting and to the wider research community through peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

DRKS00025991.

Risk, lifestyle and non-communicable diseases of poverty

Common discourse in public health and preventive medicine frames non-communicable diseases, including cardiovascular and metabolic diseases, as diseases of 'lifestyle'; the choice of terminology implies that their prevention, control and management are amenable to individual action. In drawing attention to global increases in the incidence and prevalence of non-communicable disease, however, we increasingly observe that these are non-communicable diseases of poverty. In this article, we call for the reframing of discourse to emphasize the underlying social and commercial determinants of health, including poverty and the manipulation of food markets. We demonstrate this by analysing trends in disease, which indicate that diabetes- and cardiovascular-related DALYS and deaths are increasing particularly in countries categorized as low-middle to middle levels of development. In contrast, countries with very low levels of development contribute least to diabetes and document low levels of CVDs. Although this might suggest that NCDs track increased national wealth, the metrics obscure the ways in which the populations most affected by these diseases are among the poorest in many countries, and hence, disease incidence is a marker of poverty not wealth. We also illustrate variations in five countries - Mexico, Brazil, South Africa, India and Nigeria - by gender, and argue that these differences are associated with gender norms that vary by context rather than sex-specific biological pathways.We tie these trends to shifts in food consumption from whole foods to ultra-processed foods, under colonialism and with continued globalization. Industrialization and the manipulation of global food markets influence food choice in the context of limited household income, time, and household and community resources. Other factors that constitute risk factors for NCDs are likewise constrained by low household income and the poverty of the environment for people with low income, including the capacity of individuals in sedentary occupations to engage in physical activity. These contextual factors highlight extremely limited personal power over diet and exercise. In acknowledging the importance of poverty in shaping diet and activity, we argue the merit in using the term non-communicable diseases of poverty and the acronym NCDP. In doing so, we call for greater attention and interventions to address structural determinants of NCDs.

Prevalence of post-traumatic stress disorder and validity of the Impact of Events Scale - Revised in primary care in Zimbabwe, a non-war-affected African country

BACKGROUND

A critical step in research on the epidemiology of post-traumatic stress disorder (PTSD) in low-resource settings is the validation of brief self-reported psychometric tools available in the public domain, such as the Impact Event Scale - Revised (IES-R).

AIMS

We aimed to investigate the validity of the IES-R in a primary healthcare setting in Harare, Zimbabwe.

METHOD

We analysed data from a survey of 264 consecutively sampled adults (mean age 38 years; 78% female). We estimated the area under the receiver operating characteristic curve and sensitivity, specificity and likelihood ratios for different cut-off points of the IES-R, against a diagnosis of PTSD made using the Structured Clinical Interview for DSM-IV. We performed factor analysis to evaluate construct validity of the IES-R.

RESULTS

The prevalence of PTSD was 23.9% (95% CI 18.9-29.5). The area under the curve for the IES-R was 0.90. At a cut-off of ≥47, the sensitivity of the IES-R to detect PTSD was 84.1 (95% CI 72.7-92.1) and specificity was 81.1 (95% CI 75.0-86.3). Positive and negative likelihood ratios were 4.45 and 0.20, respectively. Factor analysis revealed a two-factor solution, with both factors showing good internal consistency (Cronbach's factor-1 α = 0.95, factor-2 α = 0.76). In a post hoc analysis, we found the brief six-item IES-6 also performed well, with an area under the curve of 0.87 and optimal cut-off of 15.

CONCLUSIONS

The IES-R and IES-6 had good psychometric properties and performed well for indicating possible PTSD, but at higher cut-off points than those recommended in the Global North.

Biocultural perspectives of infectious diseases and demographic evolution: Tuberculosis and its comorbidities through history

Anthropologists recognize the importance of conceptualizing health in the context of the mutually evolving nature of biology and culture through the biocultural approach, but biocultural anthropological perspectives of infectious diseases and their impacts on humans (and vice versa) through time are relatively underrepresented. Tuberculosis (TB) has been a constant companion of humans for thousands of years and has heavily influenced population health in almost every phase of cultural and demographic evolution. TB in human populations has been dramatically influenced by behavior, demographic and epidemiological shifts, and other comorbidities through history. This paper critically discusses TB and some of its major comorbidities through history within a biocultural framework to show how transitions in human demography and culture affected the disease-scape of TB. In doing so, I address the potential synthesis of biocultural and epidemiological transition theory to better comprehend the mutual evolution of infectious diseases and humans.

Healthcare providers' and policymakers' experiences and perspectives on barriers and facilitators to chronic disease self-management for people living with hypertension and diabetes in Cameroon

BACKGROUND

Hypertension and diabetes are chronic noncommunicable diseases ranked among the leading causes of morbidity and mortality in resource-limited settings. Interventions based on patient empowerment (PE) have been shown to be effective in the management of these diseases by improving a variety of important health outcomes. This study aims to examine from the healthcare providers' and policymakers' experiences and perspectives, the facilitators and barriers in the management of hypertension and diabetes for patient empowerment to achieve better health outcomes in the context of the healthcare system in Cameroon.

METHODS

We carried out a qualitative study involving three levels of embedded analysis in a public primary healthcare delivery system in Cameroon, through 22 semi-structural interviews with healthcare providers and policymakers and 36 observations of physicians' consultations. We combined thematic and lexicometric analyses to identify robust patterns of differences and similarities in the experiences and perspectives of healthcare providers and policymakers about direct and indirect factors associated with patients' self-management of disease.

RESULTS

We identified 89 barriers and 42 facilitators at the central, organizational, and individual levels; they were preponderant at the organizational level. Factors identified by healthcare providers mainly related to self-management of the disease at the organizational and individual levels, whereas policymakers reported factors chiefly at the central and organizational levels. Healthcare providers involved in the decision-making process for the delivery of healthcare tended to have a sense of ownership and responsibility over what they were doing to help patients develop self-management abilities to control their disease.

CONCLUSION

While interventions focused on improving patient-level factors are essential to PE, there is a need for interventions paying more attention to organizational and political barriers to PE than so far. Interventions targeting simultaneously these multilevel factors may be more effective than single-level interventions.

Famine exposure in adolescence is associated with a higher risk of overweight/obesity and abdominal obesity in adulthood: A meta-analysis

Some studies have shown that famine exposure during adolescence can increase cardiovascular disease and diabetes susceptibility in later life. The association between famine exposure in adolescence and overweight/obesity and abdominal obesity in adulthood has been inconsistent. Based on previous studies, we hypothesized that famine exposure in adolescence increases the risk of overweight/obesity and abdominal obesity in adulthood. Eight databases, including PubMed, Embase, Cochrane Library, and Web of Science, were searched from their inception until November 2021. We initially identified 3982 records and finally included 7 articles after screening. The included articles were of moderate to high quality, containing 16 estimates of overweight/obesity and 3 estimates of abdominal obesity. Pooled odds ratios (ORs) with 95% CIs were used to estimate the association between them. The random effects model was adopted as the pooling method. There was a significant association between famine exposure in adolescence and overweight/obesity in adulthood (OR, 1.17; 95% CI, 1.02-1.33). Adolescents exposed to famine had a greater risk of abdominal obesity in adulthood than their unexposed counterparts (OR, 1.35; 95% CI, 1.03-1.76). These results were more pronounced in females than in males. In summary, our meta-analysis indicates that famine exposure during adolescence increases the risk of overweight/obesity and abdominal obesity in adulthood. This suggests that we need to pay timely attention to the nutritional status of adolescents to prevent adverse health consequences of malnutrition. More high-quality studies are needed to confirm these conclusions, given the limitations of this study.

A protocol for monitoring fidelity of a preconception-life course intervention in a middle-income setting: the Healthy Life Trajectories Initiative (HeLTI), South Africa

INTRODUCTION

Despite the importance of intervention fidelity in interpreting the outcomes of complex public health interventions, there is a lack of both reporting fidelity trial protocols and uniformity. In evaluating complex, adaptable/pragmatic interventions in resource-strapped settings with systemic issues, unique challenges to intervention adherence and monitoring are introduced, increasing the importance of a fidelity protocol. We aim to describe the intervention fidelity and monitoring protocol for the Healthy Life Trajectories Initiative (HeLTI) South Africa, a complex four-phase intervention set in urban Soweto, starting preconceptionally and continuing through to pregnancy, infancy, and early childhood to improve the health of young women and reduce the intergenerational risk of obesity.

METHODS

The HeLTI SA fidelity protocol was based on the NIH Behaviour Change Consortium (NIH BCC) Treatment Fidelity Framework, outlining the following components of intervention fidelity: study design, provider training, intervention delivery, intervention receipt, and intervention enactment. Context-specific fidelity challenges were identified. The intervention fidelity components and associated monitoring strategies were developed to align with HeLTI SA. Strategies for fidelity monitoring include, amongst others, qualitative process evaluation methods, reviewing observed and recorded intervention sessions, monitoring of activity logs, standardized training, and intervention session checklists. Possible challenges to fidelity and fidelity monitoring include high provider turnover, lack of qualification amongst providers, difficulty tracing participants for follow-up sessions, participant health literacy levels, and the need to prioritize participants' non-health-related challenges. Solutions proposed include adapting intervention delivery methods, recruitment methods, and provider training methods.

DISCUSSION

The NIH BCC Treatment Fidelity Framework provided a solid foundation for reporting intervention fidelity across settings to improve intervention validity, ability to assess intervention effectiveness, and transparency. However, context-specific challenges to fidelity (monitoring) were identified, and transparency around such challenges and possible solutions in low- and middle-income settings could help foster solutions to improve adherence, reporting, and monitoring of intervention fidelity in this setting.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201903750173871 . Registered on 27 March 2019.

Incidence of infant mortality and its predictors in East Africa using Gompertz gamma shared frailty model

Background

Globally, infant mortality is a major public health concern and a sensitive indicator of countries' socio-economic and health status. Despite the substantial reduction of under-five mortality in sub-Saharan African countries specifically in East Africa, the infant mortality rate remains highest and too far below to achieve the WHO target. As to our search of the literature is concerned, there is a dearth of evidence on the incidence and predictors of infant mortality in East Africa. Therefore, this study investigated the incidence of infant mortality and its predictors in East Africa.

Methods

The present study has utilized 138,803 weighted samples from Demographic and Health Surveys (DHSs) of 12 East African countries. Considering the hierarchical nature of DHS data shared frailty parametric survival models were fitted and compared based on deviance (-2LLR), AIC, and BIC. Gompertz gamma shared frailty model was the best-fitted model for the data since it had the lowest deviance, AIC, and BIC values. Variables with a p-value < 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable Gompertz gamma shared analysis, the Adjusted Hazard Ratio (AHR) with 95% Confidence Interval (CI) was reported to declare the significant predictors of infant mortality.

Results

The infant mortality rate in East Africa was 41.41 per 1000 live births. Mothers aged 25–34 years, wanted birth, health facility delivery, 1–3 ANC visit, being 2nd- 4th birth order, 5th and above, the birth interval of 24–48 months, and birth interval of 49 months and above were significantly associated with lower risk of infant mortality. Whereas women who didn’t have formal education, women who didn't participate in making health care decisions making, being male children, cesarean delivery, small size at birth, and large size at birth were significantly associated with a higher risk of infant mortality.

Conclusion

Despite the substantial progress in improving maternal and child health, this study showed that infant mortality is still a major public health concern in East Africa. Maternal age, place of delivery, maternal education, birth size, sex of the child, mode of delivery, women's autonomy, birth order, birth interval, and ANC visit were found to be significant predictors of infant mortality. Therefore, public health interventions enhancing health facility delivery, ANC visit, maternal education, birth spacing, and empowering women are crucial for reducing the incidence of infant mortality in East Africa.

Ganoderma lucidum: Unutilized natural medicine and promising future solution to emerging diseases in Africa

Ganoderma lucidum is a well-known medicinal mushroom that has been used for the prevention and treatment of different ailments to enhance longevity and health specifically in China, Japan, and Korea. It was known as "God's herb" in ancient China as it was believed to prolong life, enhance the youthful spirit and sustain/preserve vitality. G. lucidum is seldom collected from nature and is substantially cultivated on wood logs and sawdust in plastic bags or bottles to meet the international market demand. Both in vitro and in vivo studies on the copious metabolic activities of G. lucidum have been carried out. Varied groups of chemical compounds including triterpenoids, polysaccharides, proteins, amino acids, nucleosides, alkaloids, steroids, lactones, lectins, fatty acids, and enzymes with potent pharmacological activities have been isolated from the mycelia and fruiting bodies of G. lucidum. Several researchers have reported the abundance and diversification of its biological actions triggered by these chemical compounds. Triterpenoids and polysaccharides of G. lucidum have been reported to possess cytotoxic, hepatoprotective, antihypertensive, hypocholesterolemic, antihistaminic effects, antioxidant, antimicrobial, anti-inflammatory, hypoglycemic antiallergic, neuroprotective, antitumor, immunomodulatory and antiangiogenic activities. Various formulations have been developed, patented, and utilized as nutraceuticals, cosmeceuticals, and pharmaceuticals from G. lucidum extracts and active compounds. Thus, this review presents current updates on emerging infectious diseases and highlights the scope, dynamics, and advances in infectious disease management with a particular focus on Ganoderma lucidum, an unutilized natural medicine as a promising future solution to emerging diseases in Africa. However, details such as the chemical compound and mode of action of each bioactive against different emerging diseases were not discussed in this study.

Differential effect of prenatal exposure to the Great Ethiopian Famine (1983-85) on the risk of adulthood hypertension based on sex: a historical cohort study

Background

The consequence of the Great Ethiopian Famine (1983–1985) on mortality had been well documented. However, the long term assaults of the famine on adulthood health, particularly on the risk of hypertension, has never been documented. The aim of this study was twofold: to examine the association of prenatal-exposure to the Great Ethiopian Famine and hypertension in adulthood and investigate if there existed sex difference in the risk estimate.

Methods

Participants were recruited using multistage stratified random sampling and grouped as prenatal famine exposed and non-exposed cohorts based on their reported date of birth and current age. Independent sample T test was employed to compare continuous outcomes between the groups. A multivariable logistic regression was used to examine the association between prenatal famine exposure and risk of hypertension in adults.

Results

Compared to the non-exposed groups, prenatal famine exposed cohorts had higher systolic blood pressure by 1.05 mmHg, (95% CI 0.29, 4.42) and diastolic by 2.47 mmHg (95% CI 1.01, 3.95). In multivariable logistic regression analysis, both unadjusted (COR = 2.50; 1.575, 3.989) and adjusted model for covariates (OR: 2.306 95% CI (1.426, 3.72) indicated a positive association between prenatal famine exposure and the risk of adult hypertension. However, in sex disaggregated analysis, the positive association was only significant in females (AOR = 3.95 95% CI 1.76, 8.85) indicating nearly four folds of odds of hypertension among females, while the corresponding figure for males was not significant (AOR = 1.201 (0.69, 2.07).

Conclusions

Famine exposure during prenatal period could have differential impact on the development of hypertension based on sex, where adult exposed females had higher risk of hypertension as compared to males. Contextualized primary prevention programs with special focus on gender is critical undertaking in hunger spots and regions with historical famine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01815-w.

Then and Now: Investigating Anthropometrics and Child Mortality among Females in Malawi

Information on the concentration of body mass index and child death among females in Malawi, where the epidemics of weight gain have been disconcerting and preventable deaths among children linger, is limited. Therefore, the study examined the polarity of body mass index and the death of children among females. Using data from the Malawian Demographic and Health Survey from 2000 to 2015–2016, the study applied for the first time the index of concentration at the extremes and indirect demographic techniques to estimate the polarity of body mass index and child mortality among 65,499 females aged 15 to 49 years. The preponderance of obesity more than doubled from 2000 to 2015–2016 and was highest among females who were older (35–49 years), urban dwellers, rich, and located in districts within the central and southern regions. In addition, child survival was low among underweight, overweight, and obese females. While national-, regional-, and individual-level statistics are in development, these findings provide helpful information for health experts and other stakeholders to initiate appropriate age-region specific programs and interventions in Malawi, including targeting females in the high socio-economic bracket.

Studying SARS-CoV-2 vaccine hesitancy among health professionals in Tunisia

Background

People's lives were seriously affected by the emergence and the spread of the COVID-19 disease. Several vaccines were developed in record time to overcome this pandemic. However, putting an end to this public health problem requires substantial vaccination coverage rate. This latter depends on the acceptance of these vaccines especially by health professionals; the leaders of the current war against COVID-19. In fact, they have a central role in promoting vaccination against the SARS-CoV-2. In the developed countries, hesitancy rates towards these vaccines among health professionals vary from 4.3% to 72%. In the developing countries, few studies focused on this issue.

Objective

To estimate the prevalence and the predictors of SARS-CoV-2 vaccine hesitancy among the Tunisian health professionals.

Methods

A cross-sectional study was led online between the 7th and the 21th of January 2021 among Tunisian health professionals. At least 460 participants were required. Snowball sampling method served to recruit participants. Data were collected using a pre-established and pre-tested questionnaire recorded in a free Google form. The link of the questionnaire was disseminated online to be self-administered anonymously to the participants. The generated online Google Sheet was uploaded and exported to SPSS software for analysis.

Results

Of the 546 responses, 493 were retained. The mean age of participants was 37.4 (± 9.5) years. Females represented 70.2% of participants. Social media represented the most frequently used source of information about COVID-19. The prevalence of SARS-CoV-2 vaccine hesitancy among participants was 51.9% (95% CI_: 47.5–56.3)). Female sex, working far from the capital and having concerns about the vaccines components predicted more hesitancy among participants. In contrast, the use of the national COVID-19 information website predicted less hesitancy among them.

Conclusions

The current Tunisian communication plan about COVID-19 vaccines must be reinforced. Social media represent a cost effective communication channel that can serve to reassure Tunisian health professionals regarding the safety of COVID-19 vaccines. Special interest should be paid to females, paramedical professionals and those working far from the capital.

Knowledge of diabetes among Gambian adults: evidence from a nation-wide survey

Background

Diabetes is increasingly becoming a public health problem in developing countries like The Gambia. Prevention of diabetes and appropriate management of the disease largely depends on correct knowledge of the risk factors and signs and symptoms of the condition. However, studies that have assessed knowledge of diabetes at population level are limited. We examined the knowledge of diabetes risk factors, and signs and symptoms among Gambian adults.

Methods

The 2019–2020 Gambia demographic and health survey data was used to analyze 4, 436 men and 6, 186 women. Knowledge of diabetes was assessed two-fold: (1) diabetes risk factors and (2) diabetes signs and symptoms. Several sociodemographic factors were considered for analysis. A generalized estimating equation model was fitted to test the association between the selected sociodemographic factors and diabetes knowledge.

Results

Among the men, 7.6% and 3.1% had knowledge about diabetes risk factors, and signs and symptoms, respectively. Approximately 3.1% and 1.2% of the women included in the analysis had knowledge of diabetes risk factors, and signs and symptoms, respectively. Men who were aged ≥ 35 years were more likely to have knowledge regarding diabetes risk factors (adjusted odds ratio (AOR) = 1.90, 95% confidence interval (CI) = 1.12–3.22), and signs and symptoms (AOR = 2.59, 95% CI = 1.08–6.17). Having access to media was associated with increased odds of having knowledge regarding diabetes risk factors (AOR = 1.61, 95% CI = 1.09–2.37) and signs and symptoms (AOR = 2.04, 95% CI = 1.07–3.88) among men. Among other factors, educational level was positively associated with having diabetes knowledge among both men and women. Heterogeneities regarding diabetes knowledge were observed among different regions and areas of residence.

Conclusion

There is a need to improve awareness regarding diabetes in The Gambia as low knowledge has been observed. Programs aimed to improve diabetes knowledge should consider regional and area of residence variations in their designs. The use of mass media and strengthening the education sector in The Gambia may be of importance in raising diabetes knowledge among Gambian adults.

Short-term effectiveness of nutrition therapy to treat type 2 diabetes in low-income and middle-income countries: systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

This review examined the evidence arising from randomised controlled trials regarding the impact of nutrition therapy on glycaemic control in people living with type 2 diabetes mellitus (T2DM) in low/middle-income countries (LMICs).

DESIGN

Systematic review and meta-analysis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Approach.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, OpenGrey and the International Clinical Trials Registry were searched (up to July 3 2020).

ELIGIBILITY CRITERIA

Trials were included if they evaluated nutrition therapy in adults diagnosed with T2DM, were conducted in LMICs, measured glycaemic control and the trial included a 3-month post-intervention assessment. Nutrition therapy was defined according to American Diabetes Association recommendations.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened the database. Study characteristics and outcome data were extracted using a data collection form. Meta-analyses were conducted for glycated haemoglobin (HbA1c) and fasting blood glucose. Trials were assessed for risk of bias (Cochrane Risk-of-Bias, Version 2.0) and overall certainty of evidence (GRADE).

RESULTS

Four trials met inclusion criteria (total n=463), conducted in Malaysia, Iran and South Africa. All trials focused on nutrition education with no direct prescription or manipulation of diet. Mean differences between intervention and standard care were -0.63% (95% CI -1.47% to 0.21%) for HbA1c and -13.63 mg/dL (95% CI -37.61 to 10.34) for fasting blood glucose in favour of the intervention. Given the small number of eligible trials, moderate to high risk of publication bias and serious concerns regarding consistency and precision of the evidence, certainty of evidence was deemed to be very low.

CONCLUSIONS

There is a lack of well-conducted randomised controlled trials that examine the long-term impact of nutrition therapy in LMICs, preventing firm conclusions to be made on their effectiveness. Further research is essential to discover realistic, evidence-based solutions.

PROSPERO REGISTRATION NUMBER

CRD42020188435.

Integrative oncology: Addressing the global challenges of cancer prevention and treatment

The increase in cancer incidence and mortality is challenging current cancer care delivery globally, disproportionally affecting low- and middle-income countries (LMICs) when it comes to receiving evidence-based cancer prevention, treatment, and palliative and survivorship care. Patients in LMICs often rely on traditional, complementary, and integrative medicine (TCIM) that is more familiar, less costly, and widely available. However, spheres of influence and tensions between conventional medicine and TCIM can further disrupt efforts in evidence-based cancer care. Integrative oncology provides a framework to research and integrate safe, effective TCIM alongside conventional cancer treatment and can help bridge health care gaps in delivering evidence-informed, patient-centered care. This growing field uses lifestyle modifications, mind and body therapies (eg, acupuncture, massage, meditation, and yoga), and natural products to improve symptom management and quality of life among patients with cancer. On the basis of this review of the global challenges of cancer control and the current status of integrative oncology, the authors recommend: 1) educating and integrating TCIM providers into the cancer control workforce to promote risk reduction and culturally salient healthy life styles; 2) developing and testing TCIM interventions to address cancer symptoms or treatment-related adverse effects (eg, pain, insomnia, fatigue); and 3) disseminating and implementing evidence-based TCIM interventions as part of comprehensive palliative and survivorship care so patients from all cultures can live with or beyond cancer with respect, dignity, and vitality. With conventional medicine and TCIM united under a cohesive framework, integrative oncology may provide citizens of the world with access to safe, effective, evidence-informed, and culturally sensitive cancer care.

Health Monitoring Using Smart Home Technologies: A Scoping Review (Preprint)

BACKGROUND

The Internet of Things (IoT) has become integrated into everyday life, with devices becoming permanent fixtures in many homes. As countries face increasing pressure on their health care systems, smart home technologies have the potential to support population health through continuous behavioral monitoring.

OBJECTIVE

This scoping review aims to provide insight into this evolving field of research by surveying the current technologies and applications for in-home health monitoring.

METHODS

Peer-reviewed papers from 2008 to 2021 related to smart home technologies for health care were extracted from 4 databases (PubMed, Scopus, ScienceDirect, and CINAHL); 49 papers met the inclusion criteria and were analyzed.

RESULTS

Most of the studies were from Europe and North America. The largest proportion of the studies were proof of concept or pilot studies. Approximately 78% (38/49) of the studies used real human participants, most of whom were older females. Demographic data were often missing. Nearly 60% (29/49) of the studies reported on the health status of the participants. Results were primarily reported in engineering and technology journals. Almost 62% (30/49) of the studies used passive infrared sensors to report on motion detection where data were primarily binary. There were numerous data analysis, management, and machine learning techniques employed. The primary challenges reported by authors were differentiating between multiple participants in a single space, technology interoperability, and data security and privacy.

CONCLUSIONS

This scoping review synthesizes the current state of research on smart home technologies for health care. We were able to identify multiple trends and knowledge gaps-in particular, the lack of collaboration across disciplines. Technological development dominates over the human-centric part of the equation. During the preparation of this scoping review, we noted that the health care research papers lacked a concrete definition of a smart home, and based on the available evidence and the identified gaps, we propose a new definition for a smart home for health care. Smart home technology is growing rapidly, and interdisciplinary approaches will be needed to ensure integration into the health sector.

Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study

Health policies in Africa are shifting towards integrated care services for chronic conditions, but in parts of Africa robust evidence on effectiveness is limited. We assessed the integration of vertical health services for HIV, diabetes and hypertension provided in a feasibility study within five health facilities in Uganda. From November 2018 to January 2020, we conducted a series of three in-depth interviews with 31, 29 and 24 service users attending the integrated clinics within Kampala and Wakiso districts. Ten healthcare workers were interviewed twice during the same period. Interviews were conducted in Luganda, translated into English, and analysed thematically using the concepts of availability, affordability and acceptability. All participants reported shortages of diabetes and hypertension drugs and diagnostic equipment prior to the establishment of the integrated clinics. These shortages were mostly addressed in the integrated clinics through a drugs buffer. Integration did not affect the already good provision of anti-retroviral therapy. The cost of transport reduced because of fewer clinic visits after integration. Healthcare workers reported that the main cause of non-adherence among users with diabetes and hypertension was poverty. Participants with diabetes and hypertension reported they could not afford private clinical investigations or purchase drugs prior to the establishment of the integrated clinics. The strengthening of drug supply for non-communicable conditions in the integrated clinics was welcomed. Most participants observed that the integrated clinic reduced feelings of stigma for those living with HIV. Sharing the clinic afforded privacy about an individual's condition, and users were comfortable with the waiting room sitting arrangement. We found that integrating non-communicable disease and HIV care had benefits for all users. Integrated care could be an effective model of care if service users have access to a reliable supply of basic medicines for both HIV and non-communicable disease conditions.

Prevalence of Underweight, Overweight and Obesity among Adults in Urban Bissau, Western Africa

Overweight and obesity affect a large proportion of the population and are important causes of death in both developed and low- and middle-income countries. In Guinea-Bissau, there are no previous population-based studies assessing this phenomenon. Therefore, we aimed to quantify the prevalence of underweight, overweight, and obesity among adults in Bissau. A stratified and cluster sample of 935 adults was assembled in 2021 and was evaluated using standardized questionnaires and anthropometric measurements, following the World Health Organization Stepwise Approach to Chronic Disease Risk Factor Surveillance. Underweight, obesity, and overweight were defined by body mass index based on the World Health Organization definitions. The prevalence of overweight and obesity was 48.7% among women and 25.0% among men. The proportion of women with abdominal obesity was 14 times higher than it was in men (35.3% vs. 2.5%). The prevalence of overweight and obesity increased with age and income. Underweight was more prevalent in the age group of 18 to 24 years (18.4% in women and 28.9% in men) and was less frequent among individuals with higher socioeconomic status. In conclusion, the prevalence of overweight and obesity is similar to the trends that are observed in many other urbanized populations in Africa and is already a major public health issue in urban Guinea-Bissau.

Trends in obesity by socioeconomic status among non-pregnant women aged 15-49 y: a cross-sectional, multi-dimensional equity analysis of demographic and health surveys in 11 sub-Saharan Africa countries, 1994-2015

BACKGROUND

Global obesity estimates show a steadily increasing pattern across socioeconomic and geographical divides, especially among women. Our analysis tracked and described obesity trends across multiple equity dimensions among women of reproductive age (15-49 y) in 11 sub-Saharan African (SSA) countries during 1994-2015.

METHODS

This study consisted of a cross-sectional series analysis using nationally representative demographic and health surveys (DHS) data. The countries included were Cameroon, Comoros, Congo, Cote d'Ivoire, Ghana, Kenya, Lesotho, Nigeria, Senegal, Zambia and Zimbabwe. The data reported are from a reanalysis conducted using the WHO Health Equity Assessment Toolkit that assesses inter- and intra-country health inequalities across socioeconomic and geographical dimensions. We generated equiplots to display intra- and inter-country equity gaps.

RESULTS

There was an increasing trend in obesity among women of reproductive age across all 11 SSA countries. Obesity increased unequally across wealth categories, place of residence and educational measures of inequality. The wealthiest, most educated and urban dwellers in most countries had a higher prevalence of obesity. However, in Comoros, obesity did not increase consistently with increasing wealth or education compared with other countries. The most educated and wealthiest women in Comoros had lower obesity rates compared with their less wealthy and less well-educated counterparts.

CONCLUSION

A window of opportunity is presented to governments to act structurally and at policy level to reduce obesity generally and prevent a greater burden on disadvantaged subpopulation groups in sub-Saharan Africa.

Financial Protection in Health among the Elderly - A Global Stocktake

Universal Health Coverage is one of the key targets of the Sustainable Development Goals and it implies that everyone can access the healthcare they need without suffering financial hardship. In this paper, we use a large set of household surveys to examine if older populations are facing different degrees of financial hardship compared to younger populations. We find that while differences in average age structures between countries are not systematically associated with higher financial risk related to out-of-pocket health expenditures, there are large differences in financial hardship between younger and older households within countries. Households with more elderly members are more likely to face catastrophic and impoverishing out-of-pocket health payments compared to younger households, and this age gradient is stronger for the poorest segments of the population. Making progress toward Universal Health Coverage will require extension and improved targeting of benefit packages and financial protection to meet the health needs of older adults, and especially the poorest and most vulnerable segments of elderly populations.

Preexisting morbidity profile of women newly diagnosed with breast cancer in sub-Saharan Africa: African Breast Cancer-Disparities in Outcomes study

The presence of preexisting morbidities poses a challenge to cancer patient care. There is little information on the profile and prevalence of multi-morbidities in breast cancer patients across middle income countries (MIC) to lower income countries (LIC) in sub-Saharan Africa (SSA). The African Breast Cancer-Disparities in Outcomes (ABC-DO) breast cancer cohort spans upper MICs South Africa and Namibia, lower MICs Zambia and Nigeria and LIC Uganda. At cancer diagnosis, seven morbidities were assessed: obesity, hypertension, diabetes, asthma/chronic obstructive pulmonary disease, heart disease, tuberculosis and HIV. Logistic regression models were used to assess determinants of morbidities and the influence of morbidities on advanced stage (stage III/IV) breast cancer diagnosis. Among 2189 women, morbidity prevalence was the highest for obesity (35%, country-specific range 15-57%), hypertension (32%, 15-51%) and HIV (16%, 2-26%) then for diabetes (7%, 4%-10%), asthma (4%, 2%-10%), tuberculosis (4%, 0%-8%) and heart disease (3%, 1%-7%). Obesity and hypertension were more common in upper MICs and in higher socioeconomic groups. Overall, 27% of women had at least two preexisting morbidities. Older women were more likely to have obesity (odds ratio: 1.09 per 10 years, 95% CI 1.01-1.18), hypertension (1.98, 1.81-2.17), diabetes (1.51, 1.32-1.74) and heart disease (1.69, 1.37-2.09) and were less likely to be HIV positive (0.64, 0.58-0.71). Multi-morbidity was not associated with stage at diagnosis, with the exception of earlier stage in obese and hypertensive women. Breast cancer patients in higher income countries and higher social groups in SSA face the additional burden of preexisting non-communicable diseases, particularly obesity and hypertension, exacerbated by HIV in Southern/Eastern Africa.

Prevalence of rheumatic heart disease in a major referral cardiology clinic in Ethiopia: A retrospective cross-sectional study

BACKGROUND

Rheumatic Heart Disease (RHD) remains one of the major causes of death and disability in developing countries. This preventable, treatable but not curable form of cardiovascular disease is needlessly killing scores of children and youth mainly due to the misunderstanding of the burden of the disease in these countries. We sought to describe the prevalence of RHD at one of the major referral cardiology clinics in Ethiopia.

METHODS

This was a retrospective cross-sectional chart review of all patients referred for a cardiopathy at the Tikur Anbessa Referral Cardiac Clinic from June 2015 to August 2018. We excluded records of patients with a non-cardiac diagnosis and those without a clear diagnosis. A predesigned and tested EXCEL form was used to collect the data. The data was encoded directly from the patient record files. MATLAB's statistics toolbox (MATLAB2019b) was used for statistical analysis.

RESULTS

Among the total 7576 records analyzed 59.5% of the patients were women. 83.1% of the data belonged to adult patients with the largest concentration reported in the 18 to 27 age group. 69.7% of the patients were from urban areas. The median age of the study population was 30 (interquartile range = 21-50). 4151 cases were caused by RHD which showed that RHD constituted 54.8% of the cases. The median age for RHD patients was 25 (interquartile range = 19-34). The second most prevalent disease was hypertensive heart disease which constituted 13.6% that was followed by congenital heart disease with 9% prevalence rate.

CONCLUSION

The results of this study indicated the extent of the RHD prevalence in Ethiopia's cardiac hospital was 54.8%. What was more critical was that almost 70% of the RHD patients were mainly the working-age group(19 to 34 years).

Socioeconomic status and sleep disturbances among pediatric population: a continental systematic review of empirical research

To this day, no consensus has been established on the definition and the conceptualization of the socioeconomic status (SES), since all the available studies on the relation between SES and health did not use the same conceptual framework and operationalization to assess SES. While literature reported that SES markers (such as income, social support networks, education, employment or occupation) influence the health of populations by shaping living conditions; empirical research does not tell us which SES markers affect more strongly the sleep components of the individuals, as well as which sleep disorders (SD) are affected and how. Even though several original studies have tried to assess how changes in socioeconomic status of parents may affect the psychosocial environment and mental health of an individual directly or through his community, no systematic reviews on the influence of SES on children's sleep are available. This systematic review make an update on the different measures of SES and sleep disturbances used for pediatric population across the different regions of the world. Recommendations for a future standardization of SES measures is proposed, for a better understanding of its influence on sleep disturbances.

Effectiveness of interventions based on patient empowerment in the control of type 2 diabetes in sub-Saharan Africa: A review of randomized controlled trials

Background

It is estimated that 1.6 million deaths worldwide were directly caused by diabetes in 2016, and the burden of diabetes has been increasing rapidly in low- and middle-income countries. This study reviews existing interventions based on patient empowerment and their effectiveness in controlling diabetes in sub-Saharan Africa.

Method

PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO and Global Health were searched through August 2018, for randomized controlled trials of educational interventions on adherence to the medication plan and lifestyle changes among adults aged 18 years and over with type 2 diabetes. Random-effects meta-analysis was used.

Results

Eleven publications from nine studies involving 2743 participants met the inclusion criteria. The duration of interventions with group education and individual education ranged from 3 to 12 months. For six studies comprising 1549 participants with meta-analysable data on glycaemic control (HbA1c), there were statistically significant differences between intervention and control groups: mean difference was -0.57 [95% confidence interval (CI) -0.75, -0.40] (P < .00001, I2 = 27%). Seven studies with meta-analysable data on blood pressure showed statistically significant differences between groups in favour of interventions. Subgroup analyses on glycaemic control showed that long-term interventions were more effective than short-term interventions and lifestyle interventions were more effective than diabetes self-management education.

Conclusion

This review supports the findings that interventions based on patient empowerment may improve glycaemia (HbA1c) and blood pressure in patients with diabetes. The long-term and lifestyle interventions appear to be the most effective interventions for glycaemic control.

Population and Individual-Level Double Burden of Malnutrition Among Adolescents in Two Emerging Cities in Northern and Southern Nigeria: A Comparative Cross-Sectional Study

Background

Over the past three decades, double burden of malnutrition (DBM), a situation where high levels of undernutrition (stunting, thinness, or micronutrient deficiency) coexist with overnutrition (overweight and obesity), continues to rise in sub-Saharan Africa. Compared to other countries in the region, the evidence on DBM is limited in Nigeria.

Objective

This paper aimed to determine the comparative prevalence of population-level and individual-level DBM among adolescents in two emerging cities in northern and southern Nigeria.

Methods

This was a comparative cross-sectional study among apparently healthy secondary school adolescents aged 10-18 years in Gombe (northern Nigeria) and Uyo (southern Nigeria) between January 2015 and June 2017. A multistage random sampling technique was implemented to recruit adolescents from 24 secondary schools in both cities. Measures of general obesity (body mass index) and stature (height-for-age) were classified and Z-scores generated using the WHO AnthroPlus software, which is based on the WHO 2006 growth reference. Population-level DBM was defined as the occurrence of thinness and overweight/obesity within the population. Individual-level DBM was defined as the proportion of individuals who were concurrently stunted and had truncal obesity or stunted and were overweight/obese.

Findings

Overall, at the population-level in both settings, 6.8% of adolescents had thinness, while 12.4% were overweight/obese signifying a high burden of population-level DBM. Comparatively, the population-level DBM was higher in Gombe compared to Uyo (thinness: 11.98% vs 5.3% and overweight/obesity: 16.08% vs 11.27% in Gombe vs Uyo respectively). Overall, at the individual level, 6.42% of stunted adolescents had coexisting truncal obesity, while 8.02% were stunted and had coexisting general overweight/obesity. Like the trend with population-level DBM, individual-level DBM was higher in Gombe (northern Nigeria) compared to Uyo (southern Nigeria).

Conclusion

High levels of population-level and individual-level DBM exist in Gombe and Uyo. However, the level of DBM (under- and over-nutrition) is higher in Gombe located in northern Nigeria compared to Uyo in southern Nigeria.

Prevalence and risk factors of falls among community-dwelling older people: results from three consecutive waves of the national health interview survey in Taiwan

Background

An aging society incurs great losses due to fall-related injuries and mortalities. The foreseeable increased burden of fall-related injury among older people requires a regular nationwide study on the fall epidemic and prevention strategies.

Methods

The fall epidemic was examined using data from three consecutive waves of the National Health Interview Survey (2005, 2009, and 2013). Common explanatory variables across these surveys included sociodemographic factors (age, sex, and difficulty in performing activities of daily living (ADL) or instrumental ADL), biological factors (vision, comorbidities, urinary incontinence, and depressive symptoms), and behavioral risk factors (sleeping pill use, and frequency of exercise). After the univariate and bivariate analyses, the prevalence of falls was investigated using multiple linear regression models adjusted for age group, sex, and year of survey. A multivariate logistic regression model for falls with adjustments for these common explanatory variables was established across three waves of surveys. The effect of fall prevention programs was examined with the effect size in terms of age-specific and sex-specific prevalence of falls and fall-related hospitalization rates during 2005 and 2009.

Results

For each survey, there were consecutively 2722; 2900; and 3200 respondents with a mean age of 75.1, 75.6, and 76.4 years, respectively. The multiple linear regression model yielded a negative association between the prevalence of falls and year of survey. Several sociodemographic and biological factors, including female sex, difficulty in performing one basic ADL, difficulty in performing two or more instrumental ADLs, unclear vision, comorbidities, urinary incontinence, and depressive symptoms, were significantly associated with falls. In contrast to the universal positive effect on the prevalence of falls among older adults, the effect size of fall-related hospitalization rates revealed a 2% relative risk reduction only for those aged 65–74 years, but deteriorated for those aged 75–84 (− 10.9%).

Conclusion

Although the decline in fall prevalence over time supports existing fall intervention strategies in Taiwan, the differential prevention effect and identification of risk factors in older people suggest the necessity of adjusting fall prevention programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01922-z.

Prevalence of overweight/obesity among the adult population in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Overweight and obesity are emerging public health problems in Ethiopia. However, primary study findings on the prevalence of overweight and obesity in Ethiopia are inconsistent. Therefore, this study aimed to estimate the pooled prevalence of overweight and obesity among adults in Ethiopia.

METHODS

Studies that looked at overweight and obesity among adults were searched from four international databases. The search involved articles published from 1 January 2010 to 10 March 2020. The Cochran's Q χ2 and the I2 test statistics were used to check heterogeneity among the studies. The funnel plot and Egger's regression tests were also used to assess the presence of publication bias. Subgroup analysis was performed by residence, study setting, sample size and year of study. Sensitivity analysis was also done to assess the effect of a single study on the pooled estimates. Data analysis was done using STATA V.14 software program.

RESULTS

A total of 16 studies with 19 527 study participants were included in this systematic review and meta-analysis. The estimated pooled prevalence of overweight among adults in Ethiopia was 20.4%, and after adjustment for publication bias with the trim-and-fill analysis, the estimated prevalence rate was changed to 19%. Besides, the estimated pooled prevalence of obesity was 5.4%. The prevalence of overweight was higher, 22.6% in studies published since 2015, 22.4% in studies conducted only in urban settings and 24.4% in studies with small sample size (≤384 participants). Similarly, the prevalence of obesity was 6.9% in studies published since 2015, 6.2% in studies conducted only in urban settings, 6.4% in institution-based settings and 9.6% in studies with small sample size.

CONCLUSION

The prevalence of overweight and obesity is high in Ethiopia compared with previous studies. This needs large scale awareness creation campaigns and situation-based and context-specific prevention strategies.

Association Between the Level of Reported Good Medication Adherence and the Geographic Location of a Patient's Residence and Presence of a Glucometer Among Adult Patients with Diabetes in Ethiopia: A Systematic and Meta-Analysis

•

Seven thousand seven hundred fifty-six participants were included for the final analysis.

•

Reported good medication adherence among adult diabetic patients in Ethiopia was 68.59%.

•

Reported good medication adherence among adult diabetic patients in regions was 67.81%.

•

Reported good medication adherence among adult diabetic patients in Addis Ababa was 70.37%.

•

Presence of glucometer at home has positive association with reported good medication adherence among adult diabetic patients.

Background

Diabetes mellitus (DM) is a major public health problem worldwide that was estimated to have affected the lives of 425 million people globally in 2017. The prevalence and mortality rates of DM have increased rapidly in low- and middle-income countries with an estimated 2.6 million cases of DM occurring in Ethiopia alone in 2015.

Objective

Considering that Ethiopia is undergoing an epidemiological transition, it is increasingly important to understand the significant influence DM has on Ethiopians annually. A systematic review and meta-analysis of the existing studies were conducted to better understand the factors that are associated with DM medication adherence across Ethiopia and to elucidate areas for further studies.

Methods

Studies were retrieved through search engines in Cumulative Index to Nursing and Allied Health Literature, Embase, Medline, PubMed, Google Scholar, Web of Science, Science Direct, and Scopus. The Newcastle–Ottawa Scale for cross-sectional studies was used to assess the critical appraisal of the included studies. Random effects model was used to estimate the association between the level of medication adherence and the geographic location of a patient's residence and presence of a glucometer at 95% CI with its respective odds ratio. Meta-regression was also used to identify the potential source of heterogeneity. Beggs and Egger tests were performed to determine publication bias. Subgroup analyses, based on the study area, were also performed.

Results

A total of 1046 articles were identified through searching, of which 19 articles representing 7756 participants were included for the final analysis stage. Reported good medication adherence among patients with diabetes in Ethiopia was 68.59% (95% CI, 62.00%–75.18%). Subgroup analysis was performed, and the pooled estimate of reported good medication adherence among these patients in regions outside Addis Ababa was 67.81% (95% CI, 59.96%–75.65%), whereas in Addis Ababa it was 70.37% (95% CI, 57.51%–83.23%). Patients who used a glucometer at home had an odds ratio of 2.12 (95% CI, 1.42–3.16) and thus reported good adherence. We found no statistically significant association between the geographic location of a patient's residence and a good level of reported medication adherence (odds ratio, 1.81; 95% CI, 0.78–4.21).

Conclusions

Most adult patients with diabetes in these studies had a good level of reported DM medication adherence. Having a glucometer was significantly associated with reported increased medication adherence. Our findings suggest the need for interventions to improve diabetes medication adherence.

Societal risk factors for overweight and obesity in women in Zimbabwe: a cross-sectional study

BACKGROUND

Overweight and obesity are well-recognized risk factors for various non-communicable diseases. Evidence shows an increasing burden of overweight and obesity in low and middle-income countries, especially in women. Little is known about the risk factors in Zimbabwe. The aim of this study was to determine the socioeconomic risk factors for overweight and obesity in non-pregnant adult Zimbabwean women.

METHODS

A cross-sectional study was conducted using the 2015 Zimbabwe Demographic Health Survey (n = 8904) data on the adult female population aged 15 to 49. Body mass index (BMI) was calculated by dividing the body weight by height squared. The socio-economic variables studied were age, marital status, residence, province, religion, education, household wealth index, household size, access to mass media and the use of contraception. Prevalence of overweight (BMI ≥ 25-29.9 kg/m²) and obesity (BMI ≥30 kg/m²) were determined. Simple and multivariable logistic regressions were then used to ascertain any relationships.

RESULTS

The weighted prevalence of overweight and obesity in adult females was 34.2 and 12.3% respectively. The odds for being overweight and obese were significantly higher with increasing age (Adjusted Odds Ratio (AOR 2.76, 95% CI:2.45-3.11 for overweight and AOR 3.24, 95% CI:2.69-3.90 for obesity) with marriage (AOR 1.58, 95% CI:1.38-1.79 for overweight and AOR 1.54, 95% CI:1.27-1.87 for obesity), high wealth status (AOR 4.01, 95% CI:2.93-5.50 for overweight and AOR 6.97, 95% CI:4.08-11.9 for obesity), and the use of hormonal contraception (AOR 1.24, 95% CI:1.07-1.41 for overweight and AOR 1.35, 95% CI:1.10-1.64 for obesity). Additionally, having higher education increased the odds of being obese (AOR 1.44, 95% CI:1.07-1.96) while being Christian increased the odds for being overweight (AOR 1.13, 95% CI:1.00-1.28).

CONCLUSIONS

The prevalence of overweight and obesity among women in Zimbabwe was high. The key social factors associated were older age, being married, being wealthy and the use of hormonal contraception. Having a higher education and being Christian also increased the risk of being obese and overweight respectively. The design of multi-faceted overweight and obesity reduction programs for women that focus on increasing physical activity and strengthening of social support systems are necessary to combat this epidemic.

Blood pressure and burden of hypertension in Cameroon, a microcosm of Africa: a systematic review and meta-analysis of population-based studies

OBJECTIVE

To estimate national and geography-based variations in blood pressure and burden of hypertension in Cameroon, generally called 'miniature Africa'.

METHODS

PubMed, Medline, EMBASE, CINHAL, Web of Science, Popline, Scopus and BDSP were searched through November 2018, for hypertension studies among Cameroonians aged at least 18 years. Hypertension was measured as SBP at least 140 mmHg or DBP at least 90 mmHg. Random-effects meta-analysis was used.

RESULTS

Twenty studies involving 46 491 participants met inclusion criteria. Overall hypertension prevalence was 30.9% [95% confidence interval (CI) 27.0-34.8]: 29.6% (24.1-35.1) and 32.1% (27.2-37.1) in 1994-2010 and 2011-2018, respectively. Of hypertensive participants, only 24.4% (18.9-30.0) - 31.6% (21.0-42.3) and 20.8% (14.0-27.7) in 1994-2010 and 2011-2018, respectively - were aware of their status, 15.1% (10.6-19.6) were taking antihypertensive medications and 8.8% (5.7-11.9) - 10.4% (7.5-13.3) and 8.3% (4.4-12.3) in 1994-2010 and 2011-2018, respectively - were controlled. Hypertension prevalence varied by sex: 34.3% (30.0-38.6) for men and 31.3% (26.5-36.1) for women; ethnicity: from 3.3% (0.4-6.2) among Pygmies to 56.6% (49.4-63.8) among Bamileke; urbanity: 25.4% (17.1-33.7) for rural and 31.4% (27.3-35.5) for urban dwellers; agroecological zone: from 35.1% (28.9-41.3) in Tropical highlands to 28% (20.1-35.9) in Guinea-Savannah; and subnational region: from 36.3% (27.8-44.9) in the West to 17.1% (9.9-44.2) in the South.

CONCLUSION

Cameroon's hypertension prevalence is high and increasing whereas awareness, treatment and control are low and declining. Emerging patterns call urgently for effective campaigns to raise hypertension awareness alongside strategies for hypertension prevention and BP control.

[Non-communicable diseases in Southern Tunisia: morbidity, mortality profile and chronological trends]

OBJECTIVES

Non-communicable diseases (NCDs) represent a major public health problem worldwide. Giving their impact on the morbidity and mortality burden, understanding their chronological trends over time is a priority for epidemiological surveillance. We aimed to determine the epidemiological specificities of NCDs and to study their chronological trends over the period&#160;2010-2015.

METHODS

We retrospectively collected data of hospitalized&#160;patients from the regional registry of morbidity and mortality in the Southern University Hospital of Tunisia during the period 2010-2015.

RESULTS

We included 18,081 patients with NCDs aged ≥ 25 years. The distribution of NCDs was characterized by the predominance of cardiovascular disease (CVD) (10,346 cases, 57.2%). Chronological trends analysis of NCDs showed that NCDs remained globally stable between 2010 and 2015. The same result applied to the group of cancers, chronic respiratory diseases and diabetes mellitus. However, CVD increased significantly between 2010 and 2015 (ρ = 0.84; p = 0.036). The proportion of CVD increased significantly among men (ρ = 0.87; p = 0.019) and elderly (ρ = 0.88; p = 0.019). The hospital mortality rate of NCDs increased significantly (ρ = 0.85; p = 0.031), notably for CVDs (ρ = 0.94; p = 0.005).

CONCLUSION

Chronological trends analysis revealed a significant rise in the morbidity and mortality burden of CVDs during the period 2010-2015. It is imperative, therefore, to strengthen health care for these&#160;patients and to introduce the concept of integrated NCDs prevention as an essential component of the health system.

Patient-provider perspectives on self-management support and patient empowerment in chronic care: A mixed-methods study in a rural sub-Saharan setting

AIM

To explore how provision of self-management support to chronically-ill patients in resource-limited settings contributes to patient empowerment in chronic care.

DESIGN

Concurrent descriptive mixed methods research.

METHODS

A survey of 140 patients with chronic conditions administered at four time-points in 12 months. We conducted 14 interviews and four focus-group discussions with patients (N = 31); 13 healthcare provider interviews; and observations of four patient-support group meetings. Data were collected between April 2016 - May 2017 in rural Malawi. Qualitative data were analysed using a thematic approach and descriptive statistical analysis performed on survey data.

RESULTS

Healthcare professionals facilitated patient empowerment through health education, although literacy levels and environmental factors affected self-management guidance. Information exchanged during patient-provider interactions varied and discussions centred around medical aspects and health promoting behaviour. Less than 40% of survey patients prepared questions prior to clinic consultations. Health education was often unstructured and delegated to non-physician providers, mostly untrained in chronic care. Patients accessed psychosocial support from volunteer-led community home-based care programmes. HIV support-groups regularly interacted with peers and practical skills exchanged in a supportive environment, reinforcing patient's self-mangement competence and proactiveness in health care.

CONCLUSION

For optimal self-management, reforms at inter-personal and organizational level are needed including; mutual patient-provider collaboration, diversifying access to self-management support resources and restructuring patient support-groups to cater to diverse chronic conditions.

IMPACT

Our study provides insights and framing of self-management support and empowerment for patients in long-term care in sub-Saharan Africa. Lessons drawn could feed into designing and delivering responsive chronic care interventions.

Quality indicators for clinical care of patients with hypertension: scoping review protocol

INTRODUCTION

Cardiovascular diseases impose significant financial impact on countries implementing universal health coverage (UHC). Hypertension is a primary disease that will lead to more severe conditions without adequate clinical care. The quality of its clinical care must be well assessed in order to measure the effective coverage of people with hypertension in UHC. This study aims to identify indicators that can be used to measure the quality of clinical care provided to patients with hypertension in healthcare facilities.

METHODS AND ANALYSIS

This review will be conducted using the six stages of the scoping review method: identifying the research question, searching for relevant studies, selecting studies, charting the data, collating, summarising and reporting the results, and conducting consultation exercises. The review will include all quality indicators used for clinical care of patients with hypertension at any healthcare facility. All research designs will be included. Search strategies are developed using the medical subject headings and keywords related to hypertension and quality indicators. Several electronic databases, that is, MEDLINE, Cochrane, Scopus and Web of Science, including clinical-guideline databases from Agency for Healthcare Research and Quality, National Institute for Health and Care Excellence, National Health Service Evidence and Medical Information Network Distribution Service, and also grey literature will be used. Two researchers will screen the titles and abstracts and review the full text of selected articles to determine the final inclusion. The results will be summarised quantitatively, using numerical counts, and qualitatively, using thematic analysis. The data extraction will include a complete list and detailed profile of all indicators. Stakeholder consultation will be conducted at the beginning and after preliminary results to translate findings to the potential knowledge users.

ETHICAL CONSIDERATIONS AND DISSEMINATION

Reviews of published articles are considered secondary analysis and do not need ethical approval. The findings will be disseminated through various strategies, such as policy briefs, conferences, peer-reviewed journals, and on selected websites relevant to the subject.

STUDY STATUS

Data collection for the scoping review will include publications up to May 2019, and the analysis will start in June 2019.

The prevalence of selected risk factors for non-communicable diseases in Hargeisa, Somaliland: a cross-sectional study

BACKGROUND

Non-communicable diseases (NCDs), particularly cardiovascular diseases, diabetes, respiratory conditions and cancers, are the most common causes of morbidity and mortality globally. Information on the prevalence estimates of NCD risk factors such as smoking, low fruit & vegetable intake, physical inactivity, raised blood pressure, overweight, obesity and abnormal blood lipid are scarce in Somaliland. The aim of this study was to determine the prevalence of these selected risk factors for NCDs among 20-69 year old women and men in Hargeisa, Somaliland.

METHODS

A cross-sectional study was conducted in five districts of Hargeisa (Somaliland), using the STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) to collect data on demographic and behavioral characteristics and physical measurements (n = 1100). The STEPS approach is a standardized method for collecting, analysing and disseminating data on NCD risk factor burden. Fasting blood sugar, serum lipids (total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides) were collected in half of the participants.

RESULTS

The vast majority of participants had ≤1 serving of fruits daily (97.7%) and ≤ 1 serving of vegetables daily (98.2%). The proportion of participants with low physical activity levels was 78.4%. The overall prevalence of high salt intake was 18.5%. The prevalence of smoking and khat chewing among men was 27 and 37% respectively, and negligible among women. In women, the prevalence of hypertension increased from 15% in the age group 20-34 years to 67% in the age group 50-69 years, the prevalence of overweight and obesity (BMI ≥ 25 kg/m2) from 51 to 73%, and the prevalence of diabetes from 3 to 22%. Similar age-trends were seen in men.

CONCLUSION

Most of the selected risk factors for noncommunicable diseases were high and increased by age in both women and men. Overweight and obesity and low physical activity needs intervention in women, while hypertension and low fruit and vegetable consumption needs intervention in both men and women. Somaliland health authorities should develop and/or strengthen health services that can help in treating persons with hypertension and hyperlipidaemia, and prevent a future burden of NCDs resulting from a high prevalence of NCD risk factors.

Epidemiologic Trends of Viral Skin Infections in Egypt: A Cross-Sectional Hospital-Based Study

Viral skin infections (VSIs) were ranked among the top 50 prevalent diseases in 2010. The objective of this study was to determine the epidemiologic features of VSIs in patients attending a dermatology clinic in Egypt from June 2010 to May 2011. Patient's residence, occupation, housing data, and family history of similar conditions were recorded. Categorical data were recorded as frequencies and percentages and were compared by Chi square test. P value < 0.05 was significant. Diagnosis of VSIs was made in 1000/20322 (4.9%) patients. Out of the 1000 patients with VSIs, 580 (58.0%) were residents of rural areas and 420 (42.0%) were residents of urban areas (p = 0.02). Out of the 1000 patients, 489 (48.9%) were females and 511 (51.1%) were males (p = 0.25). The breakdown of 1000 patients with VSIs indicated diagnosis of viral warts in 673 (67.3%), chickenpox (CP) in 200 (20.0%), herpes simplex (HS) facialis in 50 (5.0%), herpes zoster (HZ) in 42 (4.2%), molluscum contagiosum (MC) in 27 (2.7%.0), and anogenital warts in 8 (0.8%) cases. Overcrowding (sharing a bedroom by more than 3 persons) was recorded in 652/1000 (65.2%) of the patients with VSIs [165/200 (82.5.3%) in CP, 36/50 (72%) in HS facials, 427/673 (63.4%) in viral warts, 14/27 (51.9%) in MC, and 10/42 (23.8%) in HZ]. Family history of a similar condition was positive in 329/1000 (32.9%) of the patients with VSIs [142/200 (71.0%) in CP, 177/673 (26.3%) in viral warts, 5/27 (18.5%) in MC, and 4/50 (8%) in HS facialis]. In conclusion, viral warts and CP were the commonest VSIs diagnosed in patients who attended a dermatology clinic in Egypt. Viral skin infections were more prevalent among patients who lived in rural areas and under crowded conditions. These data may have important public health implications particularly in developing countries.

Conceptualising metabolic disorder in Southern Africa: Biology, history and global health

This paper traces the history of the concept of metabolic disorder in global health and its application to the collection of health metrics relating to the 'epidemic' of non-communicable diseases in Southern Africa, with a focus on Malawi. Although the contemporary science of metabolism points to complexity and contingency, the application of a simplified version of 'metabolic disorder' or 'metabolic syndrome' as the supposed central driver of non-communicable disease in low- and middle-income countries runs the risk of obscuring the ways in which local circumstances and histories interact with global forces to produce epidemiological change. The paper discusses health data collection and its interpretation in Malawi to demonstrate how the use of this concept has led to a narrowing of the category of non-communicable disease and a neglect of the role of infectious disease in producing chronic conditions. Finally, the paper points to alternative approaches which might yield a better understanding of pressing health problems.

SMS behaviour change communication and eVoucher interventions to increase uptake of cervical cancer screening in the Kilimanjaro and Arusha regions of Tanzania: a randomised, double-blind, controlled trial of effectiveness

Background

Cervical cancer, although almost entirely preventable through cervical cancer screening (CCS) and human papillomavirus vaccination, is the leading cause of cancer deaths among women in Tanzania. Barriers to attending CCS include lack of awareness of CCS, affordability concerns regarding screening and travel cost. We aimed to compare the effectiveness of SMS (short message service) behaviour change communication (BCC) messages and of SMS BCC messages delivered with a transportation electronic voucher (eVoucher) on increasing uptake of CCS versus the control group.

Methods

Door-to-door recruitment was conducted between 1 February and 13 March 2016 in randomly selected enumeration areas in the catchment areas of two hospitals, one urban and one rural, in Northern Tanzania. Women aged 25–49 able to access a mobile phone were randomised using a computer-generated 1:1:1 sequence stratified by urban/rural to receive either (1) 15 SMS, (2) an eVoucher for return transportation to CCS plus the same SMS, or (3) one SMS informing about the nearest CCS clinic. Fieldworkers and participants were masked to allocation. All areas received standard sensitisation including posters, community announcements and sensitisation similar to community health worker (CHW) sensitisation. The primary outcome was attendance at CCS within 60 days of randomisation.

Findings

Participants (n=866) were randomly allocated to the BCC SMS group (n=272), SMS + eVoucher group (n=313), or control group (n=281), with 851 included in the analysis (BCC SMS n=272, SMS + eVoucher n=298, control group n=281). By day 60 of follow-up, 101 women (11.9%) attended CCS. Intervention group participants were more likely to attend than control group participants (SMS + eVoucher OR: 4.7, 95% CI 2.9 to 7.4; SMS OR: 3.0, 95% CI 1.5 to 6.2).

Trial registration number

NCT02680613.

Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review

A number of primary studies and systematic reviews focused on the contribution of community health workers (CHWs) in the delivery of essential health services. In many countries, a cadre of informal health workers also provide services on a volunteer basis [community health volunteers (CHV)], but there has been no synthesis of studies investigating their role and potential contribution across a range of health conditions; most existing studies are narrowly focused on a single condition. As this cadre grows in importance, there is a need to examine the evidence on whether and how CHVs can improve access to and use of essential health services in low- and middle-income countries (LMICs). We report an umbrella review of systematic reviews, searching PubMed, the Cochrane library, the database of abstracts of reviews of effects (DARE), EMBASE, ProQuest dissertation and theses, the Campbell library and DOPHER. We considered a review as 'systematic' if it had an explicit search strategy with qualitative or quantitative summaries of data. We used the Joanna Briggs Institute (JBI) critical appraisal assessment checklist to assess methodological quality. A data extraction format prepared a priori was used to extract data. Findings were synthesized narratively. Of 422 records initially found by the search strategy, we identified 39 systematic reviews eligible for inclusion. Most concluded that services provided by CHVs were not inferior to those provided by other health workers, and sometimes better. However, CHVs performed less well in more complex tasks such as diagnosis and counselling. Their performance could be strengthened by regular supportive supervision, in-service training and adequate logistical support, as well as a high level of community ownership. The use of CHVs in the delivery of selected health services for population groups with limited access, particularly in LMICs, appears promising. However, success requires careful implementation, strong policy backing and continual support by their managers.

Sex- and age-based differences in mortality during the 1918 influenza pandemic on the island of Newfoundland

OBJECTIVES

Our aim was to understand sex- and age-based differences in mortality during the 1918 influenza pandemic on the island of Newfoundland. The pandemic's impact on different age groups has been the focus of other research, but sex-based differences in mortality are rarely considered. Aspects of social organization, labor patterns, and social behaviors that contribute to mortality between males and females at all ages are used to explain observed mortality patterns.

METHODS

Recorded pneumonia and influenza deaths on the island (n = 1871) were used to calculate cause-specific death rates and to evaluate differences in sex-based mortality. Mortality levels in 17 districts and four regions (Avalon, North, South, and West) were compared using standardized mortality ratios (SMRs). A logistic regression model was fit to determine in which regions sex-based mortality could be predicted using age and region as interactive predictors.

RESULTS

Differences in sex-based mortality varied across regions; they were not significant for the aggregate population. SMRs were also variable, with no significant sex-based differences. Sex-based differences were highly variable within regions. Results from a logistic regression analysis suggest that females in the South region may have experienced a higher probability of death than other island residents.

CONCLUSIONS

Mortality analysis for aggregate populations homogenizes important epidemiologic patterns. Men and women did not experience the 1918 influenza pandemic in the same way, and by analyzing data at the regional and district geographic levels, patterns emerge that can be explained by the economies and social organization of the people who lived there.