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Lule SA, Kushitor SB, Grijalva-Eternod CS, Adjaye-Gbewonyo K, Sanuade OA, Kushitor MK, Okoibhole L, Awuah R, Baatiema L, Kretchy IA, Arhinful D, de-Graft Aikins A, Koram K, Fottrell E. The contextual awareness, response and evaluation (CARE) diabetes project: study design for a quantitative survey of diabetes prevalence and non-communicable disease risk in Ga Mashie, Accra, Ghana. Glob Health Action 2024; 17:2297513. [PMID: 38323339 PMCID: PMC10851827 DOI: 10.1080/16549716.2023.2297513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/16/2023] [Indexed: 02/08/2024] Open
Abstract
Diabetes is estimated to affect between 3.3% and 8.3% of adults in Ghana, and prevalence is expected to rise. The lack of cost-effective diabetes prevention programmes designed specifically for the Ghanaian population warrants urgent attention. The Contextual Awareness, Response and Evaluation (CARE): Diabetes Project in Ghana is a mixed methods study that aims to understand diabetes in the Ga Mashie area of Accra, identify opportunities for community-based intervention and inform future diabetes prevention and control strategies. This paper presents the study design for the quantitative survey within the CARE project. This survey will take place in the densely populated Ga Mashie area of Accra, Ghana. A household survey will be conducted using simple random sampling to select households from 80 enumeration areas identified in the 2021 Ghana Population and Housing Census. Trained enumerators will interview and collect data from permanent residents aged ≥ 25 years. Pregnant women and those who have given birth in the last six months will be excluded. Data analysis will use a combination of descriptive and inferential statistics, and all analyses will account for the cluster sampling design. Analyses will describe the prevalence of diabetes, other morbidities, and associated risk factors and identify the relationship between diabetes and physical, social, and behavioural parameters. This survey will generate evidence on drivers and consequences of diabetes and facilitate efforts to prevent and control diabetes and other NCDs in urban Ghana, with relevance for other low-income communities.
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Affiliation(s)
| | - Sandra Boatemaa Kushitor
- Department of Community Health, Ensign Global College, Kpong, Ghana
- Department of Food Science and Centre for Sustainability Studies, Stellenbosch University, Stellenbosch, South Africa
| | - Carlos S. Grijalva-Eternod
- Institute for Global Health, University College London, London, UK
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Olutobi Adekunle Sanuade
- Department of Population Health Sciences, Division of Health System Innovation and Research, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | - Mawuli Komla Kushitor
- Department of Health Policy, Fred Binka School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Lydia Okoibhole
- Institute for Global Health, University College London, London, UK
| | - Raphael Awuah
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Leonard Baatiema
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Accra, Ghana
- Center for Tropical Medicine and Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Irene Akwo Kretchy
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, University of Ghana, Accra, Ghana
| | - Daniel Arhinful
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | | | - Kwadwo Koram
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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Akter K, Kuddus A, Jeny T, Nahar T, Shaha S, Ahmed N, King C, Pires M, Haghparast-Bidgoli H, Azad K, Fottrell E, Morrison J. Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study. BMC Public Health 2023; 23:719. [PMID: 37081438 PMCID: PMC10116471 DOI: 10.1186/s12889-023-15551-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/28/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Engaging communities is an important component of multisectoral action to address the growing burden of non-communicable diseases (NCDs) in low- and middle-income countries. We conducted research with non-communicable disease stakeholders in Bangladesh to understand how a community-led intervention which was shown to reduce the incidence of type 2 diabetes in rural Bangladesh could be scaled-up. METHODS We purposively sampled any actor who could have an interest in the intervention, or that could affect or be affected by the intervention. We interviewed central level stakeholders from donor agencies, national health policy levels, public, non-governmental, and research sectors to identify scale-up mechanisms. We interviewed community health workers, policy makers, and non-governmental stakeholders, to explore the feasibility and acceptability of implementing the suggested mechanisms. We discussed scale-up options in focus groups with community members who had attended a community-led intervention. We iteratively developed our data collection tools based on our analysis and re-interviewed some participants. We analysed the data deductively using a stakeholder analysis framework, and inductively from codes identified in the data. RESULTS Despite interest in addressing NCDs, there was a lack of a clear community engagement strategy at the government level, and most interventions have been implemented by non-governmental organisations. Many felt the Ministry of Health and Family Welfare should lead on community engagement, and NCD screening and referral has been added to the responsibilities of community health workers and health volunteers. Yet there remains a focus on reproductive health and NCD diagnosis and referral instead of prevention at the community level. There is potential to engage health volunteers in community-led interventions, but their present focus on engaging women for reproductive health does not fit with community needs for NCD prevention. CONCLUSIONS Research highlighted the need for a preventative community engagement strategy to address NCDs, and the potential to utilise existing cadres to scale-up community-led interventions. It will be important to work with key stakeholders to address gender issues and ensure flexibility and responsiveness to community concerns. We indicate areas for further implementation research to develop scaled-up models of community-led interventions to address NCDs.
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Affiliation(s)
- Kohenour Akter
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Tasnova Jeny
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Sanjit Shaha
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Naveed Ahmed
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Carina King
- Karolinska Institutet, K9 Global Folkhälsa, K9 GPH Stålsby Lundborg Alfvén, Stockholm, 171 77, Sweden
| | - Malini Pires
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | | | - Kishwar Azad
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Edward Fottrell
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Joanna Morrison
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
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King C, Pires M, Ahmed N, Akter K, Kuddus A, Copas A, Haghparast-Bidgoli H, Morrison J, Nahar T, Shaha SK, Khan AKA, Azad K, Fottrell E. Community participatory learning and action cycle groups to reduce type 2 diabetes in Bangladesh (D:Clare): an updated study protocol for a parallel arm cluster randomised controlled trial. Trials 2023; 24:218. [PMID: 36959617 PMCID: PMC10034243 DOI: 10.1186/s13063-023-07243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 03/13/2023] [Indexed: 03/25/2023] Open
Abstract
The "Diabetes: Community-led Awareness, Response and Evaluation" (D:Clare) trial aims to scale up and replicate an evidence-based participatory learning and action cycle intervention in Bangladesh, to inform policy on population-level T2DM prevention and control.The trial was originally designed as a stepped-wedge cluster randomised controlled trial, with the interventions running from March 2020 to September 2022. Twelve clusters were randomly allocated (1:1) to implement the intervention at months 1 or 12 in two steps, and evaluated through three cross-sectional surveys at months 1, 12 and 24. However, due to the COVID-19 pandemic, we suspended project activities on the 20th of March 2020. As a result of the changed risk landscape and the delays introduced by the COVID-19 pandemic, we changed from the stepped-wedge design to a wait-list parallel arm cluster RCT (cRCT) with baseline data. We had four key reasons for eventually agreeing to change designs: equipoise, temporal bias in exposure and outcomes, loss of power and time and funding considerations.Trial registration ISRCTN42219712 . Registered on 31 October 2019.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Malini Pires
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Andrew Copas
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK
| | | | - Joanna Morrison
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - AKAzad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK.
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Fottrell E, King C, Ahmed N, Shaha SK, Morrison J, Pires M, Kuddus A, Nahar T, Haghparast-Bidgoli H, Khan AA, Azad K. Intermediate hyperglycaemia, diabetes and blood pressure in rural Bangladesh: five-year post-randomisation follow-up of the DMagic cluster-randomised controlled trial. Lancet Reg Health Southeast Asia 2023; 10:100122. [PMID: 36938333 PMCID: PMC10015271 DOI: 10.1016/j.lansea.2022.100122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
Abstract
Background The DMagic trial showed that participatory learning and action (PLA) community mobilisation delivered through facilitated community groups, and mHealth voice messaging interventions improved diabetes knowledge in Bangladesh and the PLA intervention reduced diabetes occurrence. We assess intervention effects three years after intervention activities stopped. Methods Five years post-randomisation, we conducted a cross-sectional survey among a random sample of adults aged ≥30-years living in the 96 DMagic villages, and a cohort of individuals identified with intermediate hyperglycaemia at the start of the DMagic trial in 2016. Primary outcomes were: 1) the combined prevalence of intermediate hyperglycaemia and diabetes; 2) five-year cumulative incidence of diabetes among the 2016 cohort of individuals with intermediate hyperglycaemia. Secondary outcomes were: weight, BMI, waist and hip circumferences, blood pressure, knowledge and behaviours. Primary analysis compared outcomes at the cluster level between intervention arms relative to control. Findings Data were gathered from 1623 (82%) of the randomly selected adults and 1817 (87%) of the intermediate hyperglycaemia cohort. 2018 improvements in diabetes knowledge in mHealth clusters were no longer observable in 2021. Knowledge remains significantly higher in PLA clusters relative to control but no difference in primary outcomes of intermediate hyperglycaemia and diabetes prevalence (OR (95%CI) 1.23 (0.89, 1.70)) or five-year incidence of diabetes were observed (1.04 (0.78, 1.40)). Hypertension (0.73 (0.54, 0.97)) and hypertension control (2.77 (1.34, 5.75)) were improved in PLA clusters relative to control. Interpretation PLA intervention effect on intermediate hyperglycaemia and diabetes was not sustained at 3 years after intervention end, but benefits in terms of blood pressure reduction were observed. Funding Medical Research Council UK: MR/M016501/1 (DMagic trial); MR/T023562/1 (DClare study), under the Global Alliance for Chronic Diseases (GACD) Diabetes and Scale-up Programmes, respectively.
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Key Words
- ADS, Appraisal of Diabetes Scale
- BADAS, Diabetic Association of Bangladesh
- BMI, Body Mass Index
- Bangladesh
- CVD, Cardiovascular disease(s)
- Cardiovascular risk
- Cluster randomised controlled trial
- Community intervention
- Control
- DBP, Diastolic blood pressure
- DDS, Dietary Diversity Score
- Diabetes
- GAD-7, Generalised Anxiety Disorder Assessment
- IQR, Inter-quartile range
- NCD, Non-communicable disease(s)
- PHQ-9, Patient Health Questionnaire 9
- PLA, Participatory Learning and Action
- PP, Pulse pressure
- Prevention
- Rural
- SBP, Systolic blood pressure
- T2DM, Type-2 diabetesmellitus
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Affiliation(s)
- Edward Fottrell
- UCL Institute for Global Health, University College London, London, UK
- Corresponding author. UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Naveed Ahmed
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Sanjit Kumer Shaha
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Joanna Morrison
- UCL Institute for Global Health, University College London, London, UK
| | - Malini Pires
- UCL Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A.K. Azad Khan
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Yargawa J, Hill Z, Fottrell E. Self-reported vomiting during pregnancy in North-east Nigeria: perceptions, prevalence, severity and impacts. BMC Pregnancy Childbirth 2022; 22:614. [PMID: 35927673 PMCID: PMC9351193 DOI: 10.1186/s12884-022-04916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 03/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background Vomiting is a common ailment during pregnancy, often linked to negative impacts on women’s quality of life. Very little is known about the issue in low income settings, particularly Sub-Saharan Africa, with studies from high income settings predominantly informing the evidence base. This study aimed to explore how women perceive vomiting during pregnancy and to measure its prevalence, severity and impacts in North-east Nigeria. Methods Qualitative in-depth interviews, focus group discussions, family interviews and a cross-sectional household survey were carried out between December 2015 and November 2016 with women who had given birth within the past two years. Purposive sampling and thematic analysis were used in the qualitative studies. A three-staged cluster sampling with 640 women and descriptive analyses were used in the survey. Results Women in the qualitative studies reported that vomiting was a normal part of pregnancy, unless a woman vomits after eating, has poor appetite, is not well-nourished, cannot perform chores, is overwhelmed by it or has to go to hospital. In the survey, 35.4% (95% CI 26.5–45.5) of women reported any vomiting during their last pregnancies and of these only 21.1% said it had stopped entirely within the first trimester. Over half of women who reported vomiting did so at least three times per day most days and 34.7% were vomiting five or more times per day during the most severe period. Care-seeking was reported by 61.5%. Both the qualitative and quantitative data found that vomiting impacted women in multiple ways including nutritionally, physiologically, mentally, financially and martially; 50.8% of women with any vomiting in the survey perceived the overall severity of the condition negatively. Conclusion Vomiting during pregnancy is dually seen as normal and problematic depending on its characteristics and impacts. The burden appears to be high with many women seeking care for the condition. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04916-4.
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Affiliation(s)
- Judith Yargawa
- Institute for Global Health, University College London, London, UK.
| | - Zelee Hill
- Institute for Global Health, University College London, London, UK
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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Fottrell E, King C, Azad K. Data processing in the DMagic cluster randomised controlled trial. Lancet Diabetes Endocrinol 2022; 10:241-242. [PMID: 35325596 DOI: 10.1016/s2213-8587(22)00014-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Edward Fottrell
- UCL Institute for Global Health, University College London, London, WC1N 1EH, UK.
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Pires M, Shaha S, King C, Morrison J, Nahar T, Ahmed N, Jennings HM, Akter K, Haghparast-Bidgoli H, Khan AKA, Costello A, Kuddus A, Azad K, Fottrell E. Equity impact of participatory learning and action community mobilisation and mHealth interventions to prevent and control type 2 diabetes and intermediate hyperglycaemia in rural Bangladesh: analysis of a cluster randomised controlled trial. J Epidemiol Community Health 2022; 76:586-594. [PMID: 35277436 PMCID: PMC9118071 DOI: 10.1136/jech-2021-217293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/21/2022] [Indexed: 11/11/2022]
Abstract
Background A cluster randomised trial of mHealth and participatory learning and action (PLA) community mobilisation interventions showed that PLA significantly reduced the prevalence of intermediate hyperglycaemia and type 2 diabetes mellitus (T2DM) and the incidence of T2DM among adults in rural Bangladesh; mHealth improved knowledge but showed no effect on glycaemic outcomes. We explore the equity of intervention reach and impact. Methods Intervention reach and primary outcomes of intermediate hyperglycaemia and T2DM were assessed through interview surveys and blood fasting glucose and 2-hour oral glucose tolerance tests among population-based samples of adults aged ≥30 years. Age-stratified, gender-stratified and wealth-stratified intervention effects were estimated using random effects logistic regression. Results PLA participants were similar to non-participants, though female participants were younger and more likely to be married than female non-participants. Differences including age, education, wealth and marital status were observed between individuals exposed and those not exposed to the mHealth intervention. PLA reduced the prevalence of T2DM and intermediate hyperglycaemia in all age, gender and wealth strata. Reductions in 2-year incidence of T2DM of at least 51% (0.49, 95% CI 0.26 to 0.92) were observed in all strata except among the oldest and least poor groups. mHealth impact on glycaemic outcomes was observed only among the youngest group, where a 47% reduction in the 2-year incidence of T2DM was observed (0.53, 95% CI 0.28 to 1.00). Conclusion Large impacts of PLA across all strata indicate a highly effective and equitable intervention. mHealth may be more suitable for targeting higher risk, younger populations. Trial registration number ISRCTN41083256.
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Affiliation(s)
- Malini Pires
- Institute for Global Health, University College London, London, UK
| | - Sanjit Shaha
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | - Tasmin Nahar
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Naveed Ahmed
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Kohenour Akter
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A K Azad Khan
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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King C, Shaha SK, Morrison J, Ahmed N, Kuddus A, Pires M, Nahar T, Hossin R, Haghparast-Bidgoli H, Khan AKA, Davies J, Azad K, Fottrell E. Changes in non-communicable diseases, diet and exercise in a rural Bangladesh setting before and after the first wave of COVID-19. PLOS Glob Public Health 2022; 2:e0001110. [PMID: 36962614 PMCID: PMC10021158 DOI: 10.1371/journal.pgph.0001110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 08/23/2022] [Indexed: 12/15/2022]
Abstract
Prevalence of non-communicable diseases (NCDs) is high in rural Bangladesh. Given the complex multi-directional relationships between NCDs, COVID-19 infections and control measures, exploring pandemic impacts in this context is important. We conducted two cross-sectional surveys of adults ≥30-years in rural Faridpur district, Bangladesh, in February to March 2020 (survey 1, pre-COVID-19), and January to March 2021 (survey 2, post-lockdown). A new random sample of participants was taken at each survey. Anthropometric measures included: blood pressure, weight, height, hip and waist circumference and fasting and 2-hour post-glucose load blood glucose. An interviewer-administered questionnaire included: socio-demographics; lifestyle and behavioural risk factors; care seeking; self-rated health, depression and anxiety assessments. Differences in NCDs, diet and exercise were compared between surveys using chi2 tests, logistic and linear regression; sub-group analyses by gender, age and socio-economic tertiles were conducted. We recruited 950 (72.0%) participants in survey 1 and 1392 (87.9%) in survey 2. The percentage of the population with hypertension increased significantly from 34.5% (95% CI: 30.7, 38.5) to 41.5% (95% CI: 38.2, 45.0; p-value = 0.011); the increase was more pronounced in men. Across all measures of self-reported health and mental health, there was a significant improvement between survey 1 and 2. For self-rated health, we observed a 10-point increase (71.3 vs 81.2, p-value = 0.005). Depression reduced from 15.3% (95% CI: 8.4, 26.1) to 6.0% (95% CI: 2.7, 12.6; p-value = 0.044) and generalised anxiety from 17.9% (95% CI: 11.3, 27.3) to 4.0% (95% CI: 2.0, 7.6; p-value<0.001). No changes in fasting blood glucose, diabetes status, BMI or abdominal obesity were observed. Our findings suggest both positive and negative health outcomes following COVID-19 lockdown in a rural Bangladeshi setting, with a concerning increase in hypertension. These findings need to be further contextualised, with prospective assessments of indirect effects on physical and mental health and care-seeking.
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Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Joanna Morrison
- Institute for Global Health, University College London, London, United Kingdom
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Malini Pires
- Institute for Global Health, University College London, London, United Kingdom
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Raduan Hossin
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, London, United Kingdom
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Seal A, Jelle M, Nemeth B, Hassan MY, Farah DA, Musili FM, Asol GS, Grijalva-Eternod C, Fottrell E. Data innovation in response to COVID-19 in Somalia: application of a syndromic case definition and rapid mortality assessment method. Glob Health Action 2021; 14:1983106. [PMID: 35377286 PMCID: PMC8986258 DOI: 10.1080/16549716.2021.1983106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background During the COVID-19 pandemic, the importance of reliable public health data has been highlighted, as well as the multiple challenges in collecting it, especially in low income and conflict-affected countries. Somalia reported its first confirmed case of COVID-19 on 16 March 2020 and has experienced fluctuating infection levels since then. Objectives To monitor the impact of COVID-19 on beneficiaries of a long-term cash transfer programme in Somalia and assess the utility of a syndromic score case definition and rapid mortality surveillance tool. Methods Five rounds of telephone interviews were conducted from June 2020 – April 2021 with 1,046–1,565 households participating in a cash transfer programme. The incidence of COVID-19 symptoms and all-cause mortality were recorded. Carers of the deceased were interviewed a second time using a rapid verbal autopsy questionnaire to determine symptoms preceding death. Data were recorded on mobile devices and analysed using COVID Rapid Mortality Surveillance (CRMS) software and R. Results The syndromic score case definition identified suspected symptomatic cases that were initially confined to urban areas but then spread widely throughout Somalia. During the first wave, the peak syndromic case rate (311 cases/million people/day) was 159 times higher than the average laboratory confirmed case rate reported by WHO for the same period. Suspected COVID-19 deaths peaked at 14.3 deaths/million people/day, several weeks after the syndromic case rate. Crude and under-five death rates did not cross the respective emergency humanitarian thresholds (1 and 2 deaths/10,000 people/day). Conclusion Use of telephone interviews to collect data on the evolution of COVID-19 outbreaks is a useful additional approach that can complement laboratory testing and mortality data from the health system. Further work to validate the syndromic score case definition and CRMS is justified.
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Affiliation(s)
- Andrew Seal
- UCL Institute for Global Health, London.,Evidence for Change (E4c), Brussels, Belgium
| | - Mohamed Jelle
- UCL Institute for Global Health, London.,Evidence for Change (E4c), Brussels, Belgium
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Calvert C, John J, Nzvere FP, Cresswell JA, Fawcus S, Fottrell E, Say L, Graham WJ. Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review. Glob Health Action 2021; 14:1974677. [PMID: 35377289 PMCID: PMC8986253 DOI: 10.1080/16549716.2021.1974677] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies. Objective To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic. Methods We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality. Results The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda. Conclusions Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development.
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Affiliation(s)
- Clara Calvert
- Centre for Global Health, Usher Institute, University of Edinburgh, UK.,Department of Population Health, London School of Hygiene and Tropical Medicine, UK
| | - Jeeva John
- Centre for Global Health, Usher Institute, University of Edinburgh, UK
| | - Farirai P Nzvere
- Centre for Global Health, Usher Institute, University of Edinburgh, UK
| | - Jenny A Cresswell
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sue Fawcus
- Department of Obstetrics and Gynaecology, University of Cape Town, Rondebosch, South Africa
| | - Edward Fottrell
- UCL Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Lale Say
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Wendy J Graham
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
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11
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Chandramohan D, Fottrell E, Leitao J, Nichols E, Clark SJ, Alsokhn C, Cobos Munoz D, AbouZahr C, Di Pasquale A, Mswia R, Choi E, Baiden F, Thomas J, Lyatuu I, Li Z, Larbi-Debrah P, Chu Y, Cheburet S, Sankoh O, Mohamed Badr A, Fat DM, Setel P, Jakob R, de Savigny D. Estimating causes of death where there is no medical certification: evolution and state of the art of verbal autopsy. Glob Health Action 2021; 14:1982486. [PMID: 35377290 PMCID: PMC8986278 DOI: 10.1080/16549716.2021.1982486] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/15/2021] [Indexed: 11/16/2022] Open
Abstract
Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.
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Affiliation(s)
- Daniel Chandramohan
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
| | - Jordana Leitao
- World Health Organization Verbal Autopsy Reference Group Secretariat, Luanda, Angola
| | - Erin Nichols
- Centers for Disease Control, National Center for Health Statistics, US Public Health Service, Hyattsville, MD, USA
| | - Samuel J. Clark
- Institute for Population Research and the Department of Sociology, Ohio State University, Columbus, Ohio, USA
| | - Carine Alsokhn
- Department of Data Analytics and Delivery for Impact, World Health Organization, Geneva, Switzerland
| | - Daniel Cobos Munoz
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Carla AbouZahr
- Consultant, Saint-Legier, Switzerland
- Vital Strategies, New York, USA
| | - Aurelio Di Pasquale
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | | | - Eungang Choi
- Institute for Population Research and the Department of Sociology, Ohio State University, Columbus, Ohio, USA
| | - Frank Baiden
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jason Thomas
- Institute for Population Research and the Department of Sociology, Ohio State University, Columbus, Ohio, USA
| | - Isaac Lyatuu
- Department of Environmental Health and Ecological Services, Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - Zehang Li
- Department of Statistics, University of California, Santa Cruz, USA
| | | | - Yue Chu
- Institute for Population Research and the Department of Sociology, Ohio State University, Columbus, Ohio, USA
| | | | - Osman Sankoh
- Statistics Sierra Leone, Freetown, Sierra Leone
- Heidelberg Institute of Global Health, Heidelberg Institute of Global Health, Heidelberg, Germany
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Azza Mohamed Badr
- Department of Data Analytics and Delivery for Impact, World Health Organization, Geneva, Switzerland
| | - Doris Ma Fat
- Department of Data Analytics and Delivery for Impact, World Health Organization, Geneva, Switzerland
| | | | - Robert Jakob
- Department of Data Analytics and Delivery for Impact, World Health Organization, Geneva, Switzerland
| | - Don de Savigny
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- Vital Strategies, New York, USA
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12
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D'Ambruoso L, Price J, Cowan E, Goosen G, Fottrell E, Herbst K, van der Merwe M, Sigudla J, Davies J, Kahn K. Refining circumstances of mortality categories (COMCAT): a verbal autopsy model connecting circumstances of deaths with outcomes for public health decision-making. Glob Health Action 2021; 14:2000091. [PMID: 35377291 PMCID: PMC8986216 DOI: 10.1080/16549716.2021.2000091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Recognising that the causes of over half the world's deaths pass unrecorded, the World Health Organization (WHO) leads development of Verbal Autopsy (VA): a method to understand causes of death in otherwise unregistered populations. Recently, VA has been developed for use outside research environments, supporting countries and communities to recognise and act on their own health priorities. We developed the Circumstances of Mortality Categories (COMCATs) system within VA to provide complementary circumstantial categorisations of deaths. OBJECTIVES Refine the COMCAT system to (a) support large-scale population assessment and (b) inform public health decision-making. METHODS We analysed VA data for 7,980 deaths from two South African Health and Socio-Demographic Surveillance Systems (HDSS) from 2012 to 2019: the Agincourt HDSS in Mpumalanga and the Africa Health Research Institute HDSS in KwaZulu-Natal. We assessed the COMCAT system's reliability (consistency over time and similar conditions), validity (the extent to which COMCATs capture a sufficient range of key circumstances and events at and around time of death) and relevance (for public health decision-making). RESULTS Plausible results were reliably produced, with 'emergencies', 'recognition, 'accessing care' and 'perceived quality' characterising the majority of avoidable deaths. We identified gaps and developed an additional COMCAT 'referral', which accounted for a significant proportion of deaths in sub-group analysis. To support decision-making, data that establish an impetus for action, that can be operationalised into interventions and that capture deaths outside facilities are important. CONCLUSIONS COMCAT is a pragmatic, scalable approach enhancing functionality of VA providing basic information, not available from other sources, on care seeking and utilisation at and around time of death. Continued development with stakeholders in health systems, civil registration, community and research environments will further strengthen the tool to capture social and health systems drivers of avoidable deaths and promote use in practice settings.
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Affiliation(s)
- Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science (ACHDS), Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland.,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Public Healtlh, National Health Service (NHS), Scotland
| | - Jessica Price
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eilidh Cowan
- Aberdeen Centre for Health Data Science (ACHDS), Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland.,School of Geosciences, College of Science and Engineering, University of Edinburgh, Scotland
| | | | | | - Kobus Herbst
- Africa Health Research Institute, Durban, South Africa.,DSI-MRC South African Population Research Infrastructure Network (SAPRIN), South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science (ACHDS), Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Independent Consultant, South Africa
| | | | - Justine Davies
- Institute for Applied Health Research, University of Birmingham, UK
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,International Network for the Demographic Evaluation of Populations and Their Health (Indepth), Accra, Ghana
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13
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Yargawa J, Fottrell E, Hill Z. Women's perceptions and self-reports of excessive bleeding during and after delivery: findings from a mixed-methods study in Northern Nigeria. BMJ Open 2021; 11:e047711. [PMID: 34635515 PMCID: PMC8506868 DOI: 10.1136/bmjopen-2020-047711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore lay perceptions of bleeding during and after delivery, and measure the frequency of self-reported indicators of bleeding. SETTING Yola, North-East Nigeria. PARTICIPANTS Women aged 15-49 years who delivered in the preceding 2 years of data collection period (2015-2016), and their family members who played key roles. METHODS Data on perceptions of bleeding were collected through 7 focus group discussions, 21 in-depth interviews and 10 family interviews. Sampling was purposive and data were analysed thematically. A household survey was then conducted with 640 women using cluster sampling on postpartum bleeding indicators developed from the qualitative data; data were analysed descriptively. RESULTS Perceptions of excessive bleeding fell under four themes: quantity of blood lost; rate/duration of blood flow; symptoms related to blood loss and receiving birth interventions/hearing comments from birth attendants. Young and less educated rural women had difficulty quantifying blood loss objectively, including when shown quantities using bottles. Respondents felt that acceptable blood loss levels depended on the individual woman and whether the blood is 'good' or 'diseased/bad.' Respondents believed that 'diseased' blood was a normal result of delivery and universally took steps to help it 'come out.' In the quantitative survey, indicators representing less blood loss were reported more frequently than those representing greater loss, for example, more women reported staining their clothes (33.6%) than the bed (18.1%) and the floor (6.2%). Overall, indicators related to quantity and rate of blood flow had higher frequencies compared with symptom and intervention-related/comment-related indicators. CONCLUSION Women quantify bleeding during and after delivery in varied ways and some women do not see bleeding as problematic. This suggests the need for standard messaging to address subjectivity. The range of indicators and varied frequencies highlight the challenges of measuring excessive bleeding from self-reports. More work is needed in improving and testing validity of questions.
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Affiliation(s)
- Judith Yargawa
- Institute for Global Health, University College London, London, UK
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
| | - Zelee Hill
- Institute for Global Health, University College London, London, UK
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14
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Seal AJ, Jelle M, Grijalva-Eternod CS, Mohamed H, Ali R, Fottrell E. Use of verbal autopsy for establishing causes of child mortality in camps for internally displaced people in Mogadishu, Somalia: a population-based, prospective, cohort study. Lancet Glob Health 2021; 9:e1286-e1295. [PMID: 34416214 DOI: 10.1016/s2214-109x(21)00254-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND People in humanitarian emergencies are likely to experience excess mortality but information on the causes of death is often unreliable or non-existent. This study aimed to provide evidence on the causes of death among children younger than 5 years in camps for internally displaced people in southern Somalia, during periods of protracted displacement and emergency influx amid the 2017 drought and health emergency. METHODS We did a prospective, cohort study in 25 camps in the Afgooye corridor, on the outskirts of Mogadishu, Somalia. All internally displaced children aged 6-59 months were included and followed up with monthly household visits by community health workers. Nutrition, health, and vaccination status were ascertained and verbal autopsy interviews were done with the caregivers of deceased children. We calculated death rates in these children and used verbal autopsy to establish the cause-specific mortality fraction (CSMF). Bayesian InterVA software was used to assign likely causes to each death. FINDINGS Between March, 2016, and March, 2018, 3898 children were followed up. 153 deaths were recorded during 34 746 person-months of observation. The death rate among children younger than 5 years exceeded emergency thresholds (>2 deaths per 10 000 children per day), reaching a peak of seven deaths per 10 000 children per day during the emergency influx. Verbal autopsy data were gathered for 80% of deaths, and the CSMF for the three leading causes of death were diarrhoeal diseases (25·9%), measles (17·8%), and severe malnutrition (8·8%). Coverage of measles vaccination during the first 3 months of the emergency was 42% and the CSMF for measles doubled during the influx. During protracted displacement, symptoms that could be attributable to HIV/AIDS related deaths accounted for 1·6% of the CSMF. INTERPRETATION It is feasible to establish a health and nutrition surveillance system that ascertains causes of death, using verbal autopsy, in this humanitarian context. These data can inform policy, response planning, and priority setting. The high mortality rate from infectious diseases and malnutrition among children younger than 5 years suggests the need for strengthening a range of public health interventions, including vaccination and provision of water, sanitation, and hygiene. FUNDING UK Department of International Development.
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Affiliation(s)
- Andrew J Seal
- Institute for Global Health, University College London, London, UK.
| | - Mohamed Jelle
- Institute for Global Health, University College London, London, UK
| | | | | | - Raha Ali
- Concern Worldwide Somalia, Mogadishu, Somalia
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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15
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Pulkki-Brännström AM, Haghparast-Bidgoli H, Batura N, Colbourn T, Azad K, Banda F, Banda L, Borghi J, Fottrell E, Kim S, Makwenda C, Ojha AK, Prost A, Rosato M, Shaha SK, Sinha R, Costello A, Skordis J. Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability. Health Policy Plan 2021; 35:1280-1289. [PMID: 33085753 PMCID: PMC7886438 DOI: 10.1093/heapol/czaa081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 11/14/2022] Open
Abstract
WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.
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Affiliation(s)
- Anni-Maria Pulkki-Brännström
- Department of Epidemiology and Global Health, Umeå University, Umeå S-901 87, Sweden.,UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Hassan Haghparast-Bidgoli
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Neha Batura
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Tim Colbourn
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh
| | | | - Lumbani Banda
- Parent and Child Health Initiative (PACHI), Area 14 Plot 171, Lilongwe, Malawi
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Edward Fottrell
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Sungwook Kim
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Charles Makwenda
- Parent and Child Health Initiative (PACHI), Area 14 Plot 171, Lilongwe, Malawi
| | - Amit Kumar Ojha
- Ekjut, Plot no. - 556B, Potka Chakradharpur, West Singhbhum, Pin - 833102, Jharkhand, India
| | - Audrey Prost
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Mikey Rosato
- Women and Children First (UK), United House, North Road, London, N7 9DP, UK
| | - Sanjit Kumer Shaha
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh
| | - Rajesh Sinha
- Ekjut, Plot no. - 556B, Potka Chakradharpur, West Singhbhum, Pin - 833102, Jharkhand, India
| | - Anthony Costello
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Jolene Skordis
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
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16
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Jennings HM, Morrison J, Akter K, Haghparast-Bidgoli H, King C, Ahmed N, Kuddus A, Shaha SK, Nahar T, Azad K, Fottrell E. Care-seeking and managing diabetes in rural Bangladesh: a mixed methods study. BMC Public Health 2021; 21:1445. [PMID: 34294059 PMCID: PMC8299577 DOI: 10.1186/s12889-021-11395-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/25/2021] [Indexed: 11/26/2022] Open
Abstract
Background Type 2 diabetes mellitus poses a major health challenge worldwide and in low-income countries such as Bangladesh, however little is known about the care-seeking of people with diabetes. We sought to understand the factors that affect care-seeking and diabetes management in rural Bangladesh in order to make recommendations as to how care could be better delivered. Methods Survey data from a community-based random sample of 12,047 adults aged 30 years and above identified 292 individuals with a self-reported prior diagnosis of diabetes. Data on health seeking practices regarding testing, medical advice, medication and use of non-allopathic medicine were gathered from these 292 individuals. Qualitative semi-structured interviews and focus group discussions with people with diabetes and semi-structured interviews with health workers explored care-seeking behaviour, management of diabetes and perceptions on quality of care. We explore quality of care using the WHO model with the following domains: safe, effective, patient-centred, timely, equitable and efficient. Results People with diabetes who are aware of their diabetic status do seek care but access, particularly to specialist diabetes services, is hindered by costs, time, crowded conditions and distance. Locally available services, while more accessible, lack infrastructure and expertise. Women are less likely to be diagnosed with diabetes and attend specialist services. Furthermore costs of care and dissatisfaction with health care providers affect medication adherence. Conclusion People with diabetes often make a trade-off between seeking locally available accessible care and specialised care which is more difficult to access. It is vital that health services respond to the needs of patients by building the capacity of local health providers and consider practical ways of supporting diabetes care. Trial registration ISRCTN41083256. Registered on 30/03/2016.
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Affiliation(s)
- Hannah Maria Jennings
- Department of Health Sciences, University of York and Hull York Medical School, York, UK. .,Institute for Global Health, University College London, London, UK.
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | | | | | - Carina King
- Institute for Global Health, University College London, London, UK.,Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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17
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Morrison J, Akter K, Jennings H, Ahmed N, Kumer Shaha S, Kuddus A, Nahar T, King C, Haghparast-Bidgoli H, Khan AKA, Costello A, Azad K, Fottrell E. Learning from a diabetes mHealth intervention in rural Bangladesh: what worked, what did not and what next? Glob Public Health 2021; 17:1299-1313. [PMID: 33966607 PMCID: PMC9487863 DOI: 10.1080/17441692.2021.1923776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
There is an urgent need for population-based interventions to slow the growth of the diabetes epidemic in low-and middle-income countries. We tested the effectiveness of a population-based mHealth voice messaging intervention for T2DM prevention and control in rural Bangladesh through a cluster randomised controlled trial. mHealth improved knowledge and awareness about T2DM but there was no detectable effect on T2DM occurrence. We conducted mixed-methods research to understand this result. Exposure to messages was limited by technological faults, high frequency of mobile phone number changes, message fatigue and (mis)perceptions that messages were only for those who had T2DM. Persistent social norms, habits and desires made behaviour change challenging, and participants felt they would be more motivated by group discussions than mHealth messaging alone. Engagement with mHealth messages for T2DM prevention and control can be increased by (1) sending identifiable messages from a trusted source (2) using participatory design of mHealth messages to inform modelling of behaviours and increase relevance to the general population (3) enabling interactive messaging. mHealth messaging is likely to be most successful if implemented as part of a multi-sectoral, multi-component approach to address T2DM and non-communicable disease risk factors.
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Affiliation(s)
- Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | | | | | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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18
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King C, Pires M, Ahmed N, Akter K, Kuddus A, Copas A, Haghparast-Bidgoli H, Morrison J, Nahar T, Shaha SK, Khan AKA, Azad K, Fottrell E. Community participatory learning and action cycle groups to reduce type 2 diabetes in Bangladesh (D:Clare trial): study protocol for a stepped-wedge cluster randomised controlled trial. Trials 2021; 22:235. [PMID: 33781315 PMCID: PMC8006505 DOI: 10.1186/s13063-021-05167-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/02/2021] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND An estimated 463 million people globally have diabetes, with the prevalence growing in low-and middle-income settings, such as Bangladesh. Given the need for context-appropriate interventions to prevent type 2 diabetes mellitus (T2DM), the 'Diabetes: Community-led Awareness, Response and Evaluation' (D:Clare) trial will rigorously evaluate the replication and scale-up of a participatory learning and action (PLA) cycle intervention in Bangladesh, to inform policy on population-level T2DM prevention and control. METHODS This is a stepped-wedge cluster randomised controlled trial, with integrated process and economic evaluations, conducted from March 2020 to September 2022. The trial will evaluate a community-based four-phase PLA cycle intervention focused on prevention and control of T2DM implemented over 18 months, against a control of usual care. Twelve clusters will be randomly allocated (1:1) to implement the intervention at project month 1 or 12. The intervention will be evaluated through three cross-sectional surveys at months 1, 12 and 24. The trial will be conducted in Alfadanga Upazila, Faridpur district, with an estimated population of 120,000. Clusters are defined as administrative geographical areas, with approximately equal populations. Each of the six unions in Alfadanga will be divided into two clusters, forming 12 clusters in total. Given the risk of inter-cluster contamination, evaluation surveys will exclude villages in border areas. Participants will be randomly sampled, independently for each survey, from a population census conducted in January 2020. The primary outcome is the combined prevalence of intermediate hyperglycaemia and T2DM, measured through fasting and 2-h post-glucose load blood tests. A total of 4680 participants provide 84% power to detect a 30% reduction in the primary outcome, assuming a baseline of 30% and an ICC of 0.07. The analysis will be by intention-to-treat, comparing intervention and control periods across all clusters, adjusting for geographical clustering. DISCUSSION This study will provide further evidence of effectiveness for community-based PLA to prevent T2DM at scale in a rural Bangladesh setting. However, we encountered several challenges in applying the stepped-wedge design to our research context, with particular consideration given to balancing seasonality, timing and number of steps and estimation of partial versus full effect. TRIAL REGISTRATION ISRCTN: ISRCTN42219712 . Registered on 31 October 2019.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Malini Pires
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Andrew Copas
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
| | | | - Joanna Morrison
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | | | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
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Loh P, Fottrell E, Beard J, Bar-Zeev N, Phiri T, Banda M, Makwenda C, Bird J, King C. Added value of an open narrative in verbal autopsies: a mixed-methods evaluation from Malawi. BMJ Paediatr Open 2021; 5:e000961. [PMID: 33614993 PMCID: PMC7871275 DOI: 10.1136/bmjpo-2020-000961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The WHO standardised verbal autopsy (VA) instrument includes closed questions, ascertaining signs and symptoms of illness preceding death, and an optional open narrative. As VA analyses increasingly use automated algorithms, inclusion of narratives should be justified. We evaluated the role of open narratives on VA processes, data quality and respondent's emotional stress. METHODS A mixed-methods analysis was conducted using VA data for child deaths (0-59 months), between April 2013 and November 2016 in Mchinji district, Malawi. Deaths were prospectively randomised to receive closed questions only or open narrative followed by closed questions. On concluding the VA, interviewers self-completed questions on respondents' emotional stress. Logistic regression was used to determine associations with visible emotional distress during VAs. A group discussion with interviewers was conducted at the project end, to understand field experiences and explore future recommendations; data were coded using deductive themes. RESULTS 2509 VAs were included, with 49.8% (n=1341) randomised to open narratives. Narratives lasted a median of 7 minuntes (range: 1-113). Interviewers described improved rapport and felt narratives improved data quality, although there was no difference in the proportion of deaths with an indeterminate cause using an automated algorithm (5.3% vs 6.1%). The majority of respondents did not display visible emotional stress (81%). Those with a narrative had higher, but not statistically significant, odds of emotional distress (adjusted OR: 1.20; 95% CI: 0.98 to 1.47). Factors associated with emotional stress were: infant deaths versus neonates; deaths at a health centre or en-route to hospital versus home; and higher socioeconomic status. Non-parental respondents and increased time between death and interview were associated with lower odds of emotional distress. CONCLUSION Conducting an open narrative may help build rapport, something valued by the interviewers. However, additional time and emotional burdens should be further justified, with quality and utility of narratives promoted through standardised recommendations.
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Affiliation(s)
- Patricia Loh
- Institute for Global Health, University College London, London, UK
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
| | - James Beard
- Institute for Global Health, University College London, London, UK
| | - Naor Bar-Zeev
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,International Vaccine Access Center, Department of International Health, Bloomberg School of Public Health Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | - Jon Bird
- Department of Computer Science, University of Bristol, Bristol, UK
| | - Carina King
- Institute for Global Health, University College London, London, UK.,Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
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Mannell J, Davis K, Akter K, Jennings H, Morrison J, Kuddus A, Fottrell E. Visual Participatory Analysis: A Qualitative Method for Engaging Participants in Interpreting the Results of Randomized Controlled Trials of Health Interventions. J Mix Methods Res 2021; 15:18-36. [PMID: 33456409 PMCID: PMC7770211 DOI: 10.1177/1558689820914806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
This article contributes to the field of mixed methods by introducing a new method for eliciting participant perspectives of the quantitative results of randomized controlled trials. Participants are rarely asked to interpret trial results, obscuring potentially valuable information about why a trial either succeeds or fails. We introduce a unique method called visual participatory analysis and discuss the insights gained in its use as part of a trial to prevent risk and reduce the prevalence of diabetes in Bangladesh. Findings highlight benefits such as elucidating contextualized explanations for null results and identifying causal mechanisms, as well as challenges around communicating randomized controlled trial methodologies to lay audiences. We conclude that visual participatory analysis is a valuable method to use after a trial.
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Affiliation(s)
- Jenevieve Mannell
- University College London, UK
- Jenevieve Mannell, Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.
| | | | | | | | | | - Abul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Pulkki-Brännström AM, Haghparast-Bidgoli H, Batura N, Colbourn T, Azad K, Banda F, Banda L, Borghi J, Fottrell E, Kim S, Makwenda C, Ojha AK, Prost A, Rosato M, Shaha SK, Sinha R, Costello A, Skordis J. Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability. Health Policy Plan 2020; 36:226. [PMID: 33355346 PMCID: PMC7996644 DOI: 10.1093/heapol/czaa164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Mohebbi D, Haghparast-Bidgoli H, Fottrell E, Kuddus A, Azad K. PDB13 The Cost-Effectiveness of Diabetes Prevention Programmes in Bangladesh. Value Health Reg Issues 2020. [DOI: 10.1016/j.vhri.2020.07.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Uphoff E, Pires M, Barbui C, Barua D, Churchill R, Cristofalo D, Ekers D, Fottrell E, Mazumdar P, Purgato M, Rana R, Wright J, Siddiqi N. Behavioural activation therapy for depression in adults with non-communicable diseases. Cochrane Database Syst Rev 2020; 8:CD013461. [PMID: 32841367 PMCID: PMC8094508 DOI: 10.1002/14651858.cd013461.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Depression is common in people with non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. The co-existence of depression and NCDs may affect health behaviours, compliance with treatment, physiological factors, and quality of life. This in turn is associated with worse outcomes for both conditions. Behavioural activation is not currently indicated for the treatment of depression in this population in the UK, but is increasingly being used to treat depression in adults. OBJECTIVES To examine the effects of behavioural activation compared with any control group for the treatment of depression in adults with NCDs. To examine the effects of behavioural activation compared with each control group separately (no treatment, waiting list, other psychological therapy, pharmacological treatment, or any other type of treatment as usual) for the treatment of depression in adults with NCDs. SEARCH METHODS We searched CCMD-CTR, CENTRAL, Ovid MEDLINE, Embase, four other databases, and two trial registers on 4 October 2019 to identify randomised controlled trials (RCTs) of behavioural activation for depression in participants with NCDs, together with grey literature and reference checking. We applied no restrictions on date, language, or publication status to the searches. SELECTION CRITERIA We included RCTs of behavioural activation for the treatment of depression in adults with one of four NCDs: cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. Only participants with a formal diagnosis of both depression and an NCD were eligible. Studies were included if behavioural activation was the main component of the intervention. We included studies with any comparator that was not behavioural activation, and regardless of reported outcomes. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane, including independent screening of titles/abstracts and full-text manuscripts, data extraction, and risk of bias assessments in duplicate. Where necessary, we contacted study authors for more information. MAIN RESULTS We included two studies, contributing data from 181 participants to the analyses. Both studies recruited participants from US hospital clinics; one included people who were recovering from a stroke and the other women with breast cancer. For both studies, the intervention consisted of eight weeks of face-to-face behavioural therapy, with one study comparing to poststroke treatment as usual and the other comparing to problem-solving therapy. Both studies were at risk of performance bias and potential conflict of interest arising from author involvement in the development of the intervention. For one study, risks of selection bias and reporting bias were unclear and the study was judged at high risk of attrition bias. Treatment efficacy (remission) was greater for behavioural activation than for comparators in the short term (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.98 to 2.38; low-certainty evidence) and medium term (RR 1.76, 95% CI 1.01 to 3.08; moderate-certainty evidence), but these estimates lacked precision and effects were reduced in the long term (RR 1.42, 95% CI 0.91 to 2.23; moderate-certainty evidence). We found no evidence of a difference in treatment acceptability in the short term (RR 1.81, 95% CI 0.68 to 4.82) and medium term (RR 0.88, 95% CI 0.25 to 3.10) (low-certainty evidence). There was no evidence of a difference in depression symptoms between behavioural activation and comparators (short term: MD -1.15, 95% CI -2.71 to 0.41; low-certainty evidence). One study found no difference for quality of life (short term: MD 0.40, 95% CI -0.16 to 0.96; low-certainty evidence), functioning (short term: MD 2.70, 95% CI -6.99 to 12.39; low-certainty evidence), and anxiety symptoms (short term: MD -1.70, 95% CI -4.50 to 1.10; low-certainty evidence). Neither study reported data on adverse effects. AUTHORS' CONCLUSIONS Evidence from this review was not sufficient to draw conclusions on the efficacy and acceptability of behavioural activation for the treatment of depression in adults with NCDs. A future review may wish to include, or focus on, studies of people with subthreshold depression or depression symptoms without a formal diagnosis, as this may inform whether behavioural activation could be used to treat mild or undiagnosed (or both) depressive symptoms in people with NCDs. Evidence from low-resource settings including low- and middle-income countries, for which behavioural activation may offer a feasible alternative to other treatments for depression, would be of interest.
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Affiliation(s)
- Eleonora Uphoff
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Malini Pires
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Doriana Cristofalo
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - David Ekers
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
- Lanchester Road Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust, Durham, UK
| | - Edward Fottrell
- Centre for Health Policy, Institute of Global Health Innovation, University College London, London, UK
| | - Papiya Mazumdar
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Rusham Rana
- Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi, Pakistan
| | - Judy Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
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Morrison J, Akter K, Jennings HM, Nahar T, Kuddus A, Shaha SK, Ahmed N, King C, Haghparast-Bidgoli H, Costello A, Khan AKA, Azad K, Fottrell E. Participatory learning and action to address type 2 diabetes in rural Bangladesh: a qualitative process evaluation. BMC Endocr Disord 2019; 19:118. [PMID: 31684932 PMCID: PMC6830002 DOI: 10.1186/s12902-019-0447-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Diabetes is 7th largest cause of death worldwide, and prevalence is increasing rapidly in low-and middle-income countries. There is an urgent need to develop and test interventions to prevent and control diabetes and develop the theory about how such interventions can be effective. We conducted a participatory learning and action (PLA) intervention with community groups in rural Bangladesh which was evaluated through a cluster randomised controlled trial. There was a large reduction in the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the PLA group compared with the control group. We present findings from qualitative process evaluation research to explore how this intervention was effective. METHODS We conducted group interviews and focus group discussions using photovoice with purposively sampled group attenders and non-attenders, and intervention implementers. Data were collected before the trial analysis. We used inductive content analysis to generate theory from the data. RESULTS The intervention increased the health literacy of individuals and communities - developing their knowledge, capacity and self-confidence to enact healthy behaviours. Community, household and individual capacity increased through social support and social networks, which then created an enabling community context, further strengthening agency and enabling community action. This increased opportunities for healthy behaviour. Community actions addressed lack of awareness about diabetes, gendered barriers to physical activity and lack of access to blood glucose testing. The interaction between the individual, household, and community contexts amplified change, and yet there was limited engagement with macro level, or 'state', barriers to healthy behaviour. CONCLUSIONS The participatory approach enabled groups to analyse how context affected their ability to have healthy behaviours and participants engaged with issues as a community in the ways that they felt comfortable. We suggest measuring health literacy and social networks in future interventions and recommend specific capacity strengthening to develop public accountability mechanisms and health systems strengthening to complement community-based interventions. TRIAL REGISTRATION Registered at ISRCTN on 30th March 2016 (Retrospectively Registered) Registration number: ISRCTN41083256 .
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Affiliation(s)
- Joanna Morrison
- University College London Institute for Global Health, London, UK
| | | | | | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Carina King
- University College London Institute for Global Health, London, UK
| | | | - Anthony Costello
- University College London Institute for Global Health, London, UK
| | | | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- University College London Institute for Global Health, London, UK
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Uphoff E, Pires M, Barbui C, Barua D, Churchill R, Ekers D, Fottrell E, Mazumdar P, Purgato M, Rana R, Wright J, Siddiqi N. Behavioural activation therapies for depression in adults with non-communicable diseases. Hippokratia 2019. [DOI: 10.1002/14651858.cd013461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Eleonora Uphoff
- University of York; Cochrane Common Mental Disorders; Heslington York - None - UK YO10 5DD
- University of York; Centre for Reviews and Dissemination; York UK
| | - Malini Pires
- University of York; Mental Health and Addiction Research Group, Department of Health Sciences; York UK
| | - Corrado Barbui
- University of Verona; Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; Verona Italy
| | | | - Rachel Churchill
- University of York; Cochrane Common Mental Disorders; Heslington York - None - UK YO10 5DD
- University of York; Centre for Reviews and Dissemination; York UK
| | - David Ekers
- University of York; Mental Health and Addiction Research Group, Department of Health Sciences; York UK
- Tees, Esk and Wear Valleys NHS Foundation Trust; Lanchester Road Hospital; Durham UK
| | - Edward Fottrell
- University College London; Centre for Health Policy, Institute of Global Health Innovation; London UK
| | - Papiya Mazumdar
- University of York; Mental Health and Addiction Research Group, Department of Health Sciences; York UK
| | - Marianna Purgato
- University of Verona; Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; Verona Italy
| | - Rusham Rana
- Benazir Bhutto Hospital; Institute of Psychiatry; Rawalpindi Pakistan
| | - Judy Wright
- University of Leeds; Leeds Institute of Health Sciences; Leeds UK
| | - Najma Siddiqi
- Hull York Medical School, University of York; Department of Health Sciences; Heslington York North Yorkshire UK Y010 5DD
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Jennings HM, Morrison J, Akter K, Kuddus A, Ahmed N, Kumer Shaha S, Nahar T, Haghparast-Bidgoli H, Khan AA, Azad K, Fottrell E. Developing a theory-driven contextually relevant mHealth intervention. Glob Health Action 2019; 12:1550736. [PMID: 31154988 PMCID: PMC6338268 DOI: 10.1080/16549716.2018.1550736] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: mHealth interventions have huge potential to reach large numbers of people in resource poor settings but have been criticised for lacking theory-driven design and rigorous evaluation. This paper shares the process we developed when developing an awareness raising and behaviour change focused mHealth intervention, through applying behavioural theory to in-depth qualitative research. It addresses an important gap in research regarding the use of theory and formative research to develop an mHealth intervention. Objectives: To develop a theory-driven contextually relevant mHealth intervention aimed at preventing and managing diabetes among the general population in rural Bangladesh. Methods: In-depth formative qualitative research (interviews and focus group discussions) were conducted in rural Faridpur. The data were analysed thematically and enablers and barriers to behaviour change related to lifestyle and the prevention of and management of diabetes were identified. In addition to the COM-B (Capability, Opportunity, Motivation-Behaviour) model of behaviour change we selected the Transtheoretical Domains Framework (TDF) to be applied to the formative research in order to guide the development of the intervention. Results: A six step-process was developed to outline the content of voice messages drawing on in-depth qualitative research and COM-B and TDF models. A table to inform voice messages was developed and acted as a guide to scriptwriters in the production of the messages. Conclusions: In order to respond to the local needs of a community in Bangladesh, a process of formative research, drawing on behavioural theory helped in the development of awareness-raising and behaviour change mHealth messages through helping us to conceptualise and understand behaviour (for example by categorising behaviour into specific domains) and subsequently identify specific behavioural strategies to target the behaviour.
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Affiliation(s)
| | - Joanna Morrison
- a Institute for Global Health , University College London , London , UK
| | - Kohenour Akter
- b Perinatal Care Project , The Diabetic Association of Bangladesh , Dhaka , Bangladesh
| | - Abdul Kuddus
- b Perinatal Care Project , The Diabetic Association of Bangladesh , Dhaka , Bangladesh
| | - Naveed Ahmed
- b Perinatal Care Project , The Diabetic Association of Bangladesh , Dhaka , Bangladesh
| | - Sanjit Kumer Shaha
- b Perinatal Care Project , The Diabetic Association of Bangladesh , Dhaka , Bangladesh
| | - Tasmin Nahar
- b Perinatal Care Project , The Diabetic Association of Bangladesh , Dhaka , Bangladesh
| | | | - Ak Azad Khan
- c The Diabetic Association of Bangladesh , Dhaka , Bangladesh
| | - Kishwar Azad
- b Perinatal Care Project , The Diabetic Association of Bangladesh , Dhaka , Bangladesh
| | - Edward Fottrell
- a Institute for Global Health , University College London , London , UK
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Morrison J, Jennings H, Akter K, Kuddus A, Mannell J, Nahar T, Shaha SK, Ahmed N, Haghparast-Bidgoli H, Costello A, Khan AKA, Azad K, Fottrell E. Gendered perceptions of physical activity and diabetes in rural Bangladesh: a qualitative study to inform mHealth and community mobilization interventions. WHO South East Asia J Public Health 2019; 8:104-111. [PMID: 31441446 DOI: 10.4103/2224-3151.264855] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Diabetes prevalence is increasing rapidly in Bangladesh, and there is an urgent need to promote preventive behaviours for type 2 diabetes, such as maintaining a healthy body weight, eating healthily, avoiding tobacco and being active for 150 minutes per week. Methods We used a qualitative methodology informed by the capability, opportunity, motivation theory of behaviour change to explore the factors affecting physical activity among men and women in rural Bangladesh. We conducted semi-structured interviews and focus group discussions with 64 purposively sampled participants with and without diabetes, and five health workers. From the results of descriptive content analysis, we identified key capabilities, opportunities and motivations to engage with in our mHealth and community mobilization interventions. Results Men and women without diabetes lacked awareness about the need to remain physically active to prevent diabetes, and most felt that their activity levels were sufficient. Housework was not commonly perceived as physical activity among all respondents. These knowledge and capability gaps could be addressed through mHealth messaging and community mobilization providing information on sufficiency and types of physical activity to prevent and control diabetes. Men were physically active while working outside the home, whereas women felt unsafe and conspicuous, and were constrained by family commitments and social expectations of appropriate behaviour. Women engaged in strategies to protect their own and their family’s reputations. These opportunity factors affecting physical activity indicated the need for strategies developed through participatory processes to challenge unhealthy gender norms and increase women’s safety. Conclusion Formative research data can enable the development of contextually relevant interventions. Data show that mHealth interventions should consider gendered barriers to physical activity, tailoring information to meet men’s and women’s needs, and that community mobilization interventions should enable unhealthy, gendered community norms to be challenged. Participatory interventions can enable communities to push the boundaries of socially acceptable behaviours to increase physical activity, helping to prevent and control diabetes.
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Affiliation(s)
- Joanna Morrison
- .University College London Institute for Global Health, London, United Kingdom
| | - Hannah Jennings
- .University College London Institute for Global Health, London, United Kingdom
| | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Jenevieve Mannell
- .University College London Institute for Global Health, London, United Kingdom
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Anthony Costello
- .University College London Institute for Global Health, London, United Kingdom
| | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- .University College London Institute for Global Health, London, United Kingdom
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Affiliation(s)
| | - Edward Fottrell
- Centre for Global Non-Communicable Diseases, Institute for Global Health, University College London, London, UK
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Mackinnon E, Ayah R, Taylor R, Owor M, Ssempebwa J, Olago LD, Kubalako R, Dia AT, Gaye C, C Campos L, Fottrell E. 21st century research in urban WASH and health in sub-Saharan Africa: methods and outcomes in transition. Int J Environ Health Res 2019; 29:457-478. [PMID: 30545246 DOI: 10.1080/09603123.2018.1550193] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/15/2018] [Indexed: 06/09/2023]
Abstract
Tackling global inequalities in access to Water, Sanitation and Hygiene (WASH) remains an urgent issue - 58% of annual diarrhoeal deaths are caused by inadequate WASH provision. A global context of increasing urbanisation, changing demographics and health transitions demands an understanding and impact of WASH on a broad set of health outcomes. We examine the literature, in terms of health outcomes, considering WASH access and interventions in urban sub-Saharan Africa from 2000 to 2017. Our review of studies which evaluate the effectiveness of specific WASH interventions, reveals an emphasis of WASH research on acute communicable diseases, particularly diarrhoeal diseases. In contrast, chronic communicable and non-communicable health outcomes were notable gaps in the literature as well as a lack of focus on cross-cutting issues, such as ageing, well-being and gender equality. We recommend a broader focus of WASH research and interventions in urban Africa to better reflect the demographic and health transitions happening. Abbreviations: CBA: Controlled Before and After; GSD: Government Service Delivery; IWDSSD: International Drinking-Water, Supply and Sanitation Decade (IDWSSD); KAP: Knowledge, Attitudes and Practices; IBD: Irritable Bowel Diseases; MDG: Millennium Development Goals; NTD: Neglected Tropical Diseases; PSSD: Private Sector Service Delivery; SDG: Sustainable Development Goals; SSA: Sub Saharan Africa; SODIS: Solar Disinfection System; STH: Soil Transmitted Helminths; RCT: Randomised Control Trial; WASH: Water Sanitation and Hygiene; WHO: World Health Organization.
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Affiliation(s)
- Eve Mackinnon
- a Civil, Environmental and Geomatic Engineering , University College London , London , United Kingdom of Great Britain and Northern Ireland
| | - Richard Ayah
- b Faculty of Science Engineering and Health , Daystar University Nairobi , Nairobi , Kenya
| | - Richard Taylor
- c Department of Geography , University College London , London , United Kingdom of Great Britain and Northern Ireland
| | - Michael Owor
- d Department of Geology and Petroleum Studies , Makerere University , Kampala , Uganda
| | - John Ssempebwa
- e College of Agricultural and Environmental Sciences , Makerere University , Kampala , Uganda
| | - L Daniel Olago
- b Faculty of Science Engineering and Health , Daystar University Nairobi , Nairobi , Kenya
| | - Robinah Kubalako
- e College of Agricultural and Environmental Sciences , Makerere University , Kampala , Uganda
| | - Anta Tal Dia
- f Department of Geology, FST , Universite Cheikh Anta Diop , Dakar , Senegal
| | - Cheikh Gaye
- f Department of Geology, FST , Universite Cheikh Anta Diop , Dakar , Senegal
| | - Luiza C Campos
- a Civil, Environmental and Geomatic Engineering , University College London , London , United Kingdom of Great Britain and Northern Ireland
| | - Edward Fottrell
- g University College, London Institute of Global Health , London , United Kingdom of Great Britain and Northern Ireland
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Morrison J, Akter K, Jennings HM, Kuddus A, Nahar T, King C, Shaha SK, Ahmed N, Haghparast-Bidgoli H, Costello A, Khan AKA, Azad K, Fottrell E. Implementation and fidelity of a participatory learning and action cycle intervention to prevent and control type 2 diabetes in rural Bangladesh. Glob Health Res Policy 2019; 4:19. [PMID: 31312722 PMCID: PMC6610980 DOI: 10.1186/s41256-019-0110-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/18/2019] [Indexed: 01/30/2023] Open
Abstract
Introduction There is an urgent need to address the growing type 2 diabetes disease burden. 20–30% of adults in rural areas of Bangladesh have intermediate hyperglycaemia and about 10% have diabetes. We report on the implementation and fidelity of a Participatory Learning and Action (PLA) intervention, evaluated through a three-arm cluster randomised controlled trial which reduced the incidence of diabetes and intermediate hyperglycaemia in rural Bangladesh. PLA interventions have been effective in addressing population level health problems in low income country contexts, and therefore we sought to use this approach to engage communities to identify and address community barriers to prevention and control of type 2 diabetes. Methods We used a mixed methods approach collecting quantitative data through field reports and qualitative data through observations and focus group discussions. Through descriptive analysis, we considered fidelity to the participatory approach and implementation plans. Results One hundred twenty-two groups per month were convened by 16 facilitators and supervised by two coordinators. Groups worked through a four phase PLA cycle of problem identification, planning together, implementation and evaluation to address the risk factors for diabetes – diet, physical activity, smoking and stress. Groups reported a lack of awareness about diabetes prevention and control, the prohibitive cost of care and healthy eating, and gender barriers to exercise for women. Groups set targets to encourage physical activity, kitchen-gardening, cooking with less oil, and reduced tobacco consumption. Anti-tobacco committees operated in 90 groups. One hundred twenty-two groups arranged blood glucose testing and 74 groups organized testing twice. Forty-one women’s groups established funds, and 61 communities committed not to ridicule women exercising. Experienced and committed supervisors enabled fidelity to a participatory methodology. A longer intervention period and capacity building could enable engagement with systems barriers to behaviour change. Conclusion Our complex intervention was implemented as planned and is likely to be valid in similar contexts given the flexibility of the participatory approach to contextually specific barriers to prevention and control of type 2 diabetes. Fidelity to the participatory approach is key to implementing the intervention and effectively addressing type 2 diabetes in a low-income country.
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Affiliation(s)
- Joanna Morrison
- 1University College London Institute for Global Health, London, UK
| | | | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Carina King
- 1University College London Institute for Global Health, London, UK.,3Department for Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | | | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Anthony Costello
- 1University College London Institute for Global Health, London, UK
| | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- 1University College London Institute for Global Health, London, UK
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Byass P, Hussain-Alkhateeb L, D'Ambruoso L, Clark S, Davies J, Fottrell E, Bird J, Kabudula C, Tollman S, Kahn K, Schiöler L, Petzold M. An integrated approach to processing WHO-2016 verbal autopsy data: the InterVA-5 model. BMC Med 2019; 17:102. [PMID: 31146736 PMCID: PMC6543589 DOI: 10.1186/s12916-019-1333-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Verbal autopsy is an increasingly important methodology for assigning causes to otherwise uncertified deaths, which amount to around 50% of global mortality and cause much uncertainty for health planning. The World Health Organization sets international standards for the structure of verbal autopsy interviews and for cause categories that can reasonably be derived from verbal autopsy data. In addition, computer models are needed to efficiently process large quantities of verbal autopsy interviews to assign causes of death in a standardised manner. Here, we present the InterVA-5 model, developed to align with the WHO-2016 verbal autopsy standard. This is a harmonising model that can process input data from WHO-2016, as well as earlier WHO-2012 and Tariff-2 formats, to generate standardised cause-specific mortality profiles for diverse contexts. The software development involved building on the earlier InterVA-4 model, and the expanded knowledge base required for InterVA-5 was informed by analyses from a training dataset drawn from the Population Health Metrics Research Collaboration verbal autopsy reference dataset, as well as expert input. RESULTS The new model was evaluated against a test dataset of 6130 cases from the Population Health Metrics Research Collaboration and 4009 cases from the Afghanistan National Mortality Survey dataset. Both of these sources contained around three quarters of the input items from the WHO-2016, WHO-2012 and Tariff-2 formats. Cause-specific mortality fractions across all applicable WHO cause categories were compared between causes assigned in participating tertiary hospitals and InterVA-5 in the test dataset, with concordance correlation coefficients of 0.92 for children and 0.86 for adults. The InterVA-5 model's capacity to handle different input formats was evaluated in the Afghanistan dataset, with concordance correlation coefficients of 0.97 and 0.96 between the WHO-2016 and the WHO-2012 format for children and adults respectively, and 0.92 and 0.87 between the WHO-2016 and the Tariff-2 format respectively. CONCLUSIONS Despite the inherent difficulties of determining "truth" in assigning cause of death, these findings suggest that the InterVA-5 model performs well and succeeds in harmonising across a range of input formats. As more primary data collected under WHO-2016 become available, it is likely that InterVA-5 will undergo minor re-versioning in the light of practical experience. The model is an important resource for measuring and evaluating cause-specific mortality globally.
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Affiliation(s)
- Peter Byass
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden. .,Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK. .,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa.
| | - Laith Hussain-Alkhateeb
- Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lucia D'Ambruoso
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK.,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Samuel Clark
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Sociology, The Ohio State University, Columbus, OH, USA.,INDEPTH Network, Accra, Ghana
| | - Justine Davies
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
| | - Jon Bird
- Department of Computing, University of Bristol, Bristol, UK
| | - Chodziwadziwa Kabudula
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,INDEPTH Network, Accra, Ghana
| | - Stephen Tollman
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,INDEPTH Network, Accra, Ghana
| | - Linus Schiöler
- Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Max Petzold
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Zamawe C, King C, Jennings H, Fottrell E. How Comfortable are Herbal Medicine Users to Engage Health Practitioners? The Case of Pregnant Women in Malawi. Advances in Integrative Medicine 2019. [DOI: 10.1016/j.aimed.2019.03.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Daivadanam M, Ingram M, Sidney Annerstedt K, Parker G, Bobrow K, Dolovich L, Gould G, Riddell M, Vedanthan R, Webster J, Absetz P, Mölsted Alvesson H, Androutsos O, Chavannes N, Cortez B, Devarasetty P, Fottrell E, Gonzalez-Salazar F, Goudge J, Herasme O, Jennings H, Kapoor D, Kamano J, Kasteleyn MJ, Kyriakos C, Manios Y, Mogulluru K, Owolabi M, Lazo-Porras M, Silva W, Thrift A, Uvere E, Webster R, van der Kleij R, van Olmen J, Vardavas C, Zhang P. The role of context in implementation research for non-communicable diseases: Answering the 'how-to' dilemma. PLoS One 2019; 14:e0214454. [PMID: 30958868 PMCID: PMC6453477 DOI: 10.1371/journal.pone.0214454] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 03/13/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Understanding context and how this can be systematically assessed and incorporated is crucial to successful implementation. We describe how context has been assessed (including exploration or evaluation) in Global Alliance for Chronic Diseases (GACD) implementation research projects focused on improving health in people with or at risk of chronic disease and how contextual lessons were incorporated into the intervention or the implementation process. Methods Using a web-based semi-structured questionnaire, we conducted a cross-sectional survey to collect quantitative and qualitative data across GACD projects (n = 20) focusing on hypertension, diabetes and lung diseases. The use of context-specific data from project planning to evaluation was analyzed using mixed methods and a multi-layered context framework across five levels; 1) individual and family, 2) community, 3) healthcare setting, 4) local or district level, and 5) state or national level. Results Project teams used both qualitative and mixed methods to assess multiple levels of context (avg. = 4). Methodological approaches to assess context were identified as formal and informal assessments, engagement of stakeholders, use of locally adapted resources and materials, and use of diverse data sources. Contextual lessons were incorporated directly into the intervention by informing or adapting the intervention, improving intervention participation or improving communication with participants/stakeholders. Provision of services, equipment or information, continuous engagement with stakeholders, feedback for personnel to address gaps, and promoting institutionalization were themes identified to describe how contextual lessons are incorporated into the implementation process. Conclusions Context is regarded as critical and influenced the design and implementation of the GACD funded chronic disease interventions. There are different approaches to assess and incorporate context as demonstrated by this study and further research is required to systematically evaluate contextual approaches in terms of how they contribute to effectiveness or implementation outcomes.
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Affiliation(s)
- Meena Daivadanam
- Department of Food, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Maia Ingram
- Department of Community, Environment and Policy, University of Arizona, Tucson, Arizona, United States of America
| | | | - Gary Parker
- Global Alliance for Chronic Diseases, University College London, London, United Kingdom
| | - Kirsty Bobrow
- Department of Medicine, University of Cape Town, Rondebosch, South Africa
| | - Lisa Dolovich
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gillian Gould
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Michaela Riddell
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Rajesh Vedanthan
- Department of Population Health, New York University School of Medicine, New York City, New York, United States of America
| | - Jacqui Webster
- The George Institute for Global Health, The University of New South Wales, Australia, Newtown New South Wales, Australia
| | - Pilvikki Absetz
- Collaborative Care Systems Finland, Helsinki, Finland
- University of Eastern Finland, Helsinki, Finland
| | | | - Odysseas Androutsos
- Department of Nutrition and Dietetics, Harokopio University, School of Health Sciences & Education, Kallithea, Athens, Greece
| | - Niels Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Briana Cortez
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, United States of America
| | - Praveen Devarasetty
- Population Health Division, The George Institute for Global Health- India, New Delhi, Delhi, India
| | - Edward Fottrell
- Global Alliance for Chronic Diseases, University College London, London, United Kingdom
| | - Francisco Gonzalez-Salazar
- Department of Basic Sciences, Universidad de Monterrey, Monterrey, Nuevo Leon, Mexico
- Centro de Investigacion Biomedica, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Jane Goudge
- Faculty of Health Sciences, University of the Witwatersrand, Centre for Health Policy, School of Public Health, Braamfontein, Johannesburg, South Africa
| | - Omarys Herasme
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, United States of America
| | - Hannah Jennings
- Global Alliance for Chronic Diseases, University College London, London, United Kingdom
| | - Deksha Kapoor
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, Delhi, India
| | - Jemima Kamano
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Marise J. Kasteleyn
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | | | - Yannis Manios
- Department of Nutrition and Dietetics, Harokopio University, School of Health Sciences & Education, Kallithea, Athens, Greece
| | - Kishor Mogulluru
- Population Health Division, The George Institute for Global Health- India, New Delhi, Delhi, India
| | - Mayowa Owolabi
- Department of Medicine, University of Ibadan, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Maria Lazo-Porras
- Unidad de Conocimiento y Evidencia (CONEVID), CRONICAS Center of Excellence in Chronic Disease, Universidad Peruana Cayetano Heredia, Miraflores, Lima, Peru
| | - Wnurinham Silva
- School of Public Health, Imperial College London, London, United Kingdom
| | - Amanda Thrift
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Ezinne Uvere
- Department of Medicine, University of Ibadan, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Ruth Webster
- The George Institute for Global Health, The University of New South Wales, Australia, Newtown New South Wales, Australia
| | - Rianne van der Kleij
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Josefien van Olmen
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
- University of Antwerp, Antwerpen, Belgium
| | | | - Puhong Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
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Fottrell E, Ahmed N, Morrison J, Kuddus A, Shaha SK, King C, Jennings H, Akter K, Nahar T, Haghparast-Bidgoli H, Khan AKA, Costello A, Azad K. Community groups or mobile phone messaging to prevent and control type 2 diabetes and intermediate hyperglycaemia in Bangladesh (DMagic): a cluster-randomised controlled trial. Lancet Diabetes Endocrinol 2019; 7:200-212. [PMID: 30733182 PMCID: PMC6381080 DOI: 10.1016/s2213-8587(19)30001-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/14/2018] [Accepted: 12/20/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Strategies are needed to prevent and control type 2 diabetes and intermediate hyperglycaemia, which together affect roughly a third of adults in Bangladesh. We aimed to assess the effects of mHealth and community mobilisation on the prevalence of intermediate hyperglycaemia and diabetes among the general adult population in rural Bangladesh, and to assess the effect of these interventions on the incidence of type 2 diabetes among people with intermediate hyperglycaemia within the study population. METHODS DMagic was a three-arm, cluster-randomised trial of participatory community mobilisation, mHealth mobile phone messaging, and usual care (control) in 96 villages (population roughly 125 000) in Bangladesh. Community mobilisation involved 18 monthly group meetings, led by lay facilitators, applying a participatory learning and action (PLA) cycle focused on diabetes prevention and control. mHealth involved twice-weekly voice messages over 14 months promoting behaviour change to reduce diabetes risk. The primary outcomes were the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the overall population at the end of the intervention implementation period, and 2-year cumulative incidence of type 2 diabetes in a cohort with intermediate hyperglycaemia at baseline. Primary outcomes were assessed through fasting blood glucose concentrations and 2-h oral glucose tolerance tests among a cross-section of adults aged 30 years and older and a cohort of individuals identified with intermediate hyperglycaemia. Prevalence findings are based on a cross-sectional survey at the end of the study; incidence findings are based on 2-year follow-up survey of a cohort of individuals identified with intermediate hyperglycaemia through a cross-sectional survey at baseline. We also assessed the cost-effectiveness of the interventions. This trial is registered with the ISRCTN registry, number ISRCTN41083256, and is completed. FINDINGS The study took place between June 27, 2015, and June 28, 2018, with the PLA intervention running in 32 villages from June, 2016, to December, 2017, and the mHealth intervention running in 32 villages from Oct 21, 2016, to Dec 24, 2017. End-of study prevalence was assessed in 11 454 individuals and incidence in 2100 individuals. There was a large reduction in the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the PLA group compared with the control group at the end of the study (adjusted [for stratification, clustering, and wealth] odds ratio [aOR] 0·36 [0·27-0·48]), with an absolute reduction of 20·7% (95% CI 14·6-26·7). Among 2470 adults with intermediate hyperglycaemia at baseline, 2100 (85%) were followed-up at 2 years. The 2-year cumulative incidence of diabetes in this cohort was significantly lower in the PLA group compared with control (aOR 0·39, 0·24-0·65), representing an absolute incidence reduction of 8·7% (3·5-14·0). There was no evidence of effect of mHealth on combined prevalence of intermediate hyperglycaemia and diabetes (aOR 0·93, 0·74-1·16) or the incidence of diabetes (1·02, 0·73-1·43). The incremental cost-effectiveness ratios for PLA were INT$316 per case of intermediate hyperglycaemia or type 2 diabetes prevented and $6518 per case of type 2 diabetes prevented among individuals with intermediate hyperglycaemia. INTERPRETATION Our data provide strong evidence to support the use of community mobilisation based on PLA to prevent type 2 diabetes in this rural Bangladeshi population. Despite raising knowledge and awareness of diabetes, the mHealth intervention did not change disease outcomes in our population. Replication studies in other populations should be a priority. FUNDING UK Medical Research Council.
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Affiliation(s)
- Edward Fottrell
- UCL Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK.
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Joanna Morrison
- UCL Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Carina King
- UCL Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Hannah Jennings
- UCL Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | | | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Hassan Haghparast-Bidgoli
- UCL Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- UCL Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Fottrell E, Ahmed N, Shaha SK, Jennings H, Kuddus A, Morrison J, Akter K, Nahar B, Nahar T, Haghparast-Bidgoli H, Khan AKA, Costello A, Azad K. Distribution of diabetes, hypertension and non-communicable disease risk factors among adults in rural Bangladesh: a cross-sectional survey. BMJ Glob Health 2018; 3:e000787. [PMID: 30498584 PMCID: PMC6242007 DOI: 10.1136/bmjgh-2018-000787] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/14/2018] [Accepted: 09/24/2018] [Indexed: 12/27/2022] Open
Abstract
Background Non-communicable diseases (NCDs) are increasing in low-income settings. We conducted a survey of risk factors, blood pressure and blood glucose in rural Bangladesh and assessed variations by age, sex and wealth. Methods We surveyed a random sample of 12 280 adults aged >30 years in 96 villages in rural Bangladesh. Fieldworkers measured blood glucose and conducted an glucose tolerance test with a repeat blood test 120 min post glucose ingestion. Blood pressure, anthropometric, socioeconomic, lifestyle and behavioural risk factors data were also collected. Data were analysed to describe the prevalence of diabetes, intermediate hyperglycaemia, hypertension and NCD risk factors by age, sex and wealth. Results Women had higher levels of overweight or obesity and lower levels of physical activity and fruit and vegetable consumption than men; 63% of men used tobacco compared with 41.3% of women. Overweight or obesity and abdominal obesity (waist to hip ratio) increased with socioeconomic status (least poor vs most poor: OR (95% CI) 3.21 (2.51 to 4.11) for men and 2.83 (2.28 to 3.52) for women). Tobacco use, passive smoke exposure and salt consumption fell with increasing socioeconomic status in both sexes. Clustering of risk factors showed more than 70% of men and women reported at least three risk factors. Women in the least poor group were 33% more likely to have three or more risk factors compared with women in the most poor group (1.33 (95% CI 1.17 to 1.58)). The combined prevalence of impaired fasting glucose, impaired glucose tolerance and diabetes was 26.1% among men and 34.9% among women, and increased with age. The prevalence of prehypertension and hypertension was 30.7% and 15.9% among men and 27.2% and 22.5% among women, with similar rising prevalence with age. Conclusion NCD risk factors, hyperglycaemia and raised blood pressure are an immediate health threat in rural Bangladesh. Initiatives to improve detection, treatment and prevention strategies are needed.
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Affiliation(s)
- Edward Fottrell
- Institute for Global Health, University College London, London, UK
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Hannah Jennings
- Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | | | - Badrun Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK.,Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Zamawe C, King C, Jennings HM, Mandiwa C, Fottrell E. Effectiveness and safety of herbal medicines for induction of labour: a systematic review and meta-analysis. BMJ Open 2018; 8:e022499. [PMID: 30337313 PMCID: PMC6196873 DOI: 10.1136/bmjopen-2018-022499] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 07/20/2018] [Accepted: 09/14/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The use of herbal medicines for induction of labour (IOL) is common globally and yet its effects are not well understood. We assessed the efficacy and safety of herbal medicines for IOL. DESIGN Systematic review and meta-analysis of published literature. DATA SOURCES We searched in MEDLINE, AMED and CINAHL in April 2017, updated in June 2018. ELIGIBILITY CRITERIA We considered experimental and non-experimental studies that compared relevant pregnancy outcomes between users and non-user of herbal medicines for IOL. DATA EXTRACTION AND SYNTHESIS Data were extracted by two reviewers using a standardised form. A random-effects model was used to synthesise effects sizes and heterogeneity was explored through I2 statistic. The risk of bias was assessed using 'John Hopkins Nursing School Critical Appraisal Tool' and 'Cochrane Risk of Bias Tool'. RESULTS A total of 1421 papers were identified through the searches, but only 10 were retained after eligibility and risk of bias assessments. The users of herbal medicine for IOL were significantly more likely to give birth within 24 hours than non-users (Risk Ratio (RR) 4.48; 95% CI 1.75 to 11.44). No significant difference in the incidence of caesarean section (RR 1.19; 95% CI 0.76 to 1.86), assisted vaginal delivery (RR 0.73; 95% CI 0.47 to 1.14), haemorrhage (RR 0.84; 95% CI 0.44 to 1.60), meconium-stained liquor (RR 1.20; 95% CI 0.65 to 2.23) and admission to nursery (RR 1.08; 95% CI 0.49 to 2.38) was found between users and non-users of herbal medicines for IOL. CONCLUSIONS The findings suggest that herbal medicines for IOL are effective, but there is inconclusive evidence of safety due to lack of good quality data. Thus, the use of herbal medicines for IOL should be avoided until safety issues are clarified. More studies are recommended to establish the safety of herbal medicines.
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Affiliation(s)
- Collins Zamawe
- Faculty of Population Health Sciences, Institute for Global Health, University College London, London, UK
| | - Carina King
- Faculty of Population Health Sciences, Institute for Global Health, University College London, London, UK
| | - Hannah Maria Jennings
- Faculty of Population Health Sciences, Institute for Global Health, University College London, London, UK
| | - Chrispin Mandiwa
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Edward Fottrell
- Faculty of Population Health Sciences, Institute for Global Health, University College London, London, UK
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Fottrell E, Ahmed N, Nahar B, Shaha SK, Kuddus A, Grijalva-Eternod CS, Nahar T, Fall C, Osmond C, Govoni V, Finer S, Yajnik C, Khan AKA, Costello A, Azad K, Hitman GA. Growth and body composition of children aged 2-4 years after exposure to community mobilisation women's groups in Bangladesh. J Epidemiol Community Health 2018; 72:888-895. [PMID: 29907704 DOI: 10.1136/jech-2017-210134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 04/24/2018] [Accepted: 05/16/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Women's groups interventions in Bangladesh reduced neonatal deaths by 38% and improved hygienic delivery, newborn care practices and breast feeding. We explore the longer-term impact of exposure to women's groups during pregnancy on child growth at 2-4 years. METHODS We performed a cross-sectional survey of child anthropometric measures (analysed as z-scores) among children born to women who had participated in the women's groups interventions while pregnant, compared with an age-matched and sex-matched sample of children born to control mothers. Results were stratified by maternal body mass index (BMI) and adjusted for possible confounding effects of maternal education, household asset ownership and, in a separate model, mother-child height difference, a proxy for improved survival of small babies in intervention groups. RESULTS Data were obtained from 2587 mother-child pairs (91% response). After adjustment for asset ownership, maternal education and potential survival effects, children whose mothers were exposed to the women's group intervention had higher head (0.16 (0.04 to 0.28)), mid-upper arm (0.11 (0.04 to 0.19)), abdominal (0.13 (0.00 to 0.26)) and chest (0.18 (0.08 to 0.29)) circumferences than their control counterparts. No significant differences in subcutaneous fat (subscapular and triceps skinfold thickness) were observed. When stratified by maternal BMI, intervention children had higher weight, BMI and circumferences, and these effects decreased with increasing maternal BMI category. CONCLUSIONS Women's groups appear to have had a lasting, positive impact on child anthropometric outcomes, with most significant results clustering in children of underweight mothers. Observed differences are likely to be of public health significance in terms of the nutritional and metabolic development of children.
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Affiliation(s)
- Edward Fottrell
- Institute For Global Health, University College London, London, UK
| | - Naveed Ahmed
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Badrun Nahar
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Sanjit Kumer Shaha
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Abdul Kuddus
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Tasmin Nahar
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Caroline Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Clive Osmond
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Virginia Govoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sarah Finer
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - A K Azad Khan
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute For Global Health, University College London, London, UK
- WHO Department of Maternal, Newborn, Child and Adolescent Health, Geneva, Switzerland
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Graham A Hitman
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Morrison J, Fottrell E, Budhatokhi B, Bird J, Basnet M, Manandhar M, Shrestha R, Manandhar D, Wilson J. Applying a Public Health Ethics Framework to Consider Scaled-Up Verbal Autopsy and Verbal Autopsy with Immediate Disclosure of Cause of Death in Rural Nepal. Public Health Ethics 2018. [DOI: 10.1093/phe/phy017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - Jon Bird
- Department of Computer Science, School of Mathematics, Computer Science and Engineering, City University of London
| | | | | | | | | | - James Wilson
- Department of Philosophy, University College London
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Haghparast-Bidgoli H, Shaha SK, Kuddus A, Chowdhury MAR, Jennings H, Ahmed N, Morrison J, Akter K, Nahar B, Nahar T, King C, Skordis-Worrall J, Batura N, Khan JA, Mansaray A, Hunter R, Khan AKA, Costello A, Azad K, Fottrell E. Protocol of economic evaluation and equity impact analysis of mHealth and community groups for prevention and control of diabetes in rural Bangladesh in a three-arm cluster randomised controlled trial. BMJ Open 2018; 8:e022035. [PMID: 30127051 PMCID: PMC6104763 DOI: 10.1136/bmjopen-2018-022035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2DM) is one of the leading causes of death and disability worldwide, generating substantial economic burden for people with diabetes and their families, and to health systems and national economies. Bangladesh has one of the largest numbers of adults with diabetes in the South Asian region. This paper describes the planned economic evaluation of a three-arm cluster randomised control trial of mHealth and community mobilisation interventions to prevent and control T2DM and non-communicable diseases' risk factors in rural Bangladesh (D-Magic trial). METHODS AND ANALYSIS The economic evaluation will be conducted as a within-trial analysis to evaluate the incremental costs and health outcomes of mHealth and community mobilisation interventions compared with the status quo. The analyses will be conducted from a societal perspective, assessing the economic impact for all parties affected by the interventions, including implementing agencies (programme costs), healthcare providers, and participants and their households. Incremental cost-effectiveness ratios (ICERs) will be calculated in terms of cost per case of intermediate hyperglycaemia and T2DM prevented and cost per case of diabetes prevented among individuals with intermediate hyperglycaemia at baseline and cost per mm Hg reduction in systolic blood pressure. In addition to ICERs, the economic evaluation will be presented as a cost-consequence analysis where the incremental costs and all statistically significant outcomes will be listed separately. Robustness of the results will be assessed through sensitivity analyses. In addition, an analysis of equity impact of the interventions will be conducted. ETHICS AND DISSEMINATION The approval to conduct the study was obtained by the University College London Research Ethics Committee (4766/002) and by the Ethical Review Committee of the Diabetic Association of Bangladesh (BADAS-ERC/EC/t5100246). The findings of this study will be disseminated through different means within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER ISRCTN41083256; Pre-results.
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Affiliation(s)
| | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Dhaka District, Bangladesh
| | | | - Hannah Jennings
- Institute for Global Health, University College London, London, UK
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | - Kohenour Akter
- Diabetic Association of Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Badrun Nahar
- Diabetic Association of Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Carina King
- Institute for Global Health, University College London, London, UK
| | | | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | | | - Rachael Hunter
- Institute of Epidemiology & Health, University College London, London, UK
| | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK
- World Health Organization, Geneva, Switzerland
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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Fottrell E, Ahmed N, Shaha SK, Jennings H, Kuddus A, Morrison J, Akter K, Nahar B, Nahar T, Haghparast-Bidgoli H, Khan AKA, Costello A, Azad K. Diabetes knowledge and care practices among adults in rural Bangladesh: a cross-sectional survey. BMJ Glob Health 2018; 3:e000891. [PMID: 30057800 PMCID: PMC6058170 DOI: 10.1136/bmjgh-2018-000891] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/25/2018] [Accepted: 06/16/2018] [Indexed: 11/13/2022] Open
Abstract
Background Population knowledge of how to prevent, detect and control diabetes is critical to public health initiatives to tackle the disease. We undertook a cross-sectional survey of adults in rural Bangladesh to estimate knowledge and practices related to diabetes. Methods In 96 villages in Faridpur district, trained fieldworkers surveyed 12 140 randomly selected men and women aged ≥30. They collected data on sociodemographic status, knowledge of diabetes and history of blood and urine glucose testing. Fasting and 2-hour post-glucose load capillary blood tests ascertained the diabetic status of respondents. Levels of knowledge and practices were analysed by sociodemographic characteristics and diabetic status. Results The population showed low levels of diabetes knowledge overall, with only one in three adults able to report any valid causes of the disease. Knowledge of diabetes causes, symptoms, complications, prevention and control was significantly associated with age, education, wealth and employment. Only 14% of respondents reported ever having had a blood glucose test and strong associations with wealth were observed (least poor relative to most poor 2.91 (2.32–3.66)). 78.4% of known diabetics (ie, with a prior diagnosis) reported that they did not monitor their blood glucose levels on at least a monthly basis. However, they had better knowledge of the causes (odds relative to normoglycaemic individuals 1.62 (1.23–2.09)), symptoms (5.17 (3.41–7.82)), complications (5.18 (3.75–7.14)), prevention (4.18 (3.04–5.74)) and control (8.43 (4.83–14.71)). Conclusion Knowledge of diabetes among rural adults in Faridpur is extremely poor. Levels of diabetes testing are low and monitoring of blood glucose among known diabetics infrequent. Diabetes prevention and control efforts in this population must include large-scale awareness initiatives which focus not only on high-risk individuals but the whole population. Trial registration number ISRCTN41083256; Pre-results.
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Affiliation(s)
- Edward Fottrell
- Institute for Global Health, University College London, London, UK
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Hannah Jennings
- Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | | | - Badrun Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Zamawe C, King C, Jennings HM, Fottrell E. Associations between the use of herbal medicines and adverse pregnancy outcomes in rural Malawi: a secondary analysis of randomised controlled trial data. Altern Ther Health Med 2018; 18:166. [PMID: 29801482 PMCID: PMC5970448 DOI: 10.1186/s12906-018-2203-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/16/2018] [Indexed: 12/18/2022]
Abstract
Background The use of herbal medicines during pregnancy is very high globally and previous studies have pointed out possible associations with adverse pregnancy outcomes. Nevertheless, the safety of herbal medicines in pregnancy is under-explored in low-income countries experiencing high maternal and neonatal complications. We investigated the associations between self-reported use of Mwanamphepo (a group of herbal medicines commonly used to induce or hasten labour) and adverse maternal and neonatal outcomes in rural Malawi. Methods We conducted a cross-sectional analysis of secondary household data relating to 8219 births that occurred between 2005 and 2010 in Mchinji district, Malawi. The data were collected as part of a cluster-randomised controlled trial (RCT) that evaluated community interventions designed to reduce maternal and neonatal mortality. Data were gathered on maternity history, demographic characteristics, pregnancy outcomes and exposure to Mwanamphepo. Associations between self-reported use of Mwanamphepo and maternal morbidity as well as neonatal death or morbidity were examined using mixed-effects models, adjusted for relevant covariates. All analyses were also adjusted for the clustered nature of the survey. Results Of the 8219 births, Mwanamphepo was used in 2113 pregnancies, representing an estimated prevalence of 25.7%. The self-reported use of Mwanamphepo was significantly associated with increased occurrence of maternal morbidity and neonatal death or morbidity. Specifically, the odds of maternal morbidity were 28% higher among self-reported users than non-users of Mwanamphepo (AOR = 1.28; 95% CI = 1.09–1.50) and the probabilities of neonatal death or morbidity were 22% higher (AOR =1.22; 95% CI = 1.06–1.40) among neonates whose mother reportedly used Mwanamphepo than those who did not. Conclusion The use of Mwanamphepo was associated with adverse pregnancy outcomes in rural Malawi. Thus, herbal medicines may not be safe in pregnancy. Where possible, pregnant women should be discouraged from using herbal medicines of unconfirmed safety and those who report to have used should be closely monitored by health professionals. The study was limited by the self-report of exposure and unavailability of data relating to some possible confounders.
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Seward N, Neuman M, Colbourn T, Osrin D, Lewycka S, Azad K, Costello A, Das S, Fottrell E, Kuddus A, Manandhar D, Nair N, Nambiar B, Shah More N, Phiri T, Tripathy P, Prost A. Effects of women's groups practising participatory learning and action on preventive and care-seeking behaviours to reduce neonatal mortality: A meta-analysis of cluster-randomised trials. PLoS Med 2017; 14:e1002467. [PMID: 29206833 PMCID: PMC5716527 DOI: 10.1371/journal.pmed.1002467] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 11/01/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization recommends participatory learning and action (PLA) in women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women's groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction. METHODS AND FINDINGS We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women's group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women's groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02-4.22; I2 = 63.7%, 95% CI 4.4%-86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25-2.82; 67.6%, 16.1%-87.5%), birth attendant washing hands prior to delivery (1.87, 1.19-2.95; 79%, 53.8%-90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09-1.99; 68.0%, 29.2%-85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02-1.60; 0.0%, 0%-79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77-1.38; I2 = 86.3%, 95% CI 73.8%-92.8%), facility delivery (1.02, 0.93-1.12; 21.4%, 0%-65.8%), initiating breastfeeding within 1 hour (1.08, 0.85-1.39; 76.6%, 50.9%-88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93-1.48; 72.9%, 37.8%-88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women's groups and context-specific effects. CONCLUSIONS This meta-analysis suggests that women's groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents.
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Affiliation(s)
- Nadine Seward
- Institute for Global Health, University College London, London, United Kingdom
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Melissa Neuman
- Institute for Global Health, University College London, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - David Osrin
- Institute for Global Health, University College London, London, United Kingdom
| | - Sonia Lewycka
- Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | - Sushmita Das
- Society for Nutrition, Education & Health Action, Mumbai, India
| | - Edward Fottrell
- Institute for Global Health, University College London, London, United Kingdom
| | - Abdul Kuddus
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, United Kingdom
| | - Neena Shah More
- Society for Nutrition, Education & Health Action, Mumbai, India
| | - Tambosi Phiri
- Parent and Child Health Initiative Trust, Lilongwe, Malawi
| | | | - Audrey Prost
- Institute for Global Health, University College London, London, United Kingdom
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Clarke K, Azad K, Kuddus A, Shaha S, Nahar T, Aumon BH, Hossen MM, Beard J, Costello A, Houweling TAJ, Prost A, Fottrell E. Correction: Impact of a Participatory Intervention with Women's Groups on Psychological Distress among Mothers in Rural Bangladesh: Secondary Analysis of a Cluster-Randomised Controlled Trial. PLoS One 2017; 12:e0183203. [PMID: 28796842 PMCID: PMC5552076 DOI: 10.1371/journal.pone.0183203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0110697.].
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Jelle M, Grijalva-Eternod CS, Haghparast-Bidgoli H, King S, Cox CL, Skordis-Worrall J, Morrison J, Colbourn T, Fottrell E, Seal AJ. The REFANI-S study protocol: a non-randomised cluster controlled trial to assess the role of an unconditional cash transfer, a non-food item kit, and free piped water in reducing the risk of acute malnutrition among children aged 6-59 months living in camps for internally displaced persons in the Afgooye corridor, Somalia. BMC Public Health 2017; 17:632. [PMID: 28683834 PMCID: PMC5501117 DOI: 10.1186/s12889-017-4550-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/28/2017] [Indexed: 11/11/2022] Open
Abstract
Background The prevalence of acute malnutrition is often high in emergency-affected populations and is associated with elevated mortality risk and long-term health consequences. Increasingly, cash transfer programmes (CTP) are used instead of direct food aid as a nutritional intervention, but there is sparse evidence on their nutritional impact. We aim to understand whether CTP reduces acute malnutrition and its known risk factors. Methods/design A non-randomised, cluster-controlled trial will assess the impact of an unconditional cash transfer of US$84 per month for 5 months, a single non-food items kit, and free piped water on the risk of acute malnutrition in children, aged 6–59 months. The study will take place in camps for internally displaced persons (IDP) in peri-urban Mogadishu, Somalia. A cluster will consist of one IDP camp and 10 camps will be allocated to receive the intervention based on vulnerability targeting criteria. The control camps will then be selected from the same geographical area. Needs assessment data indicates small differences in vulnerability between camps. In each trial arm, 120 households will be randomly sampled and two detailed household surveys will be implemented at baseline and 3 months after the initiation of the cash transfer. The survey questionnaire will cover risk factors for malnutrition including household expenditure, assets, food security, diet diversity, coping strategies, morbidity, WASH, and access to health care. A community surveillance system will collect monthly mid-upper arm circumference measurements from all children aged 6–59 months in the study clusters to assess the incidence of acute malnutrition over the duration of the intervention. Process evaluation data will be compiled from routine quantitative programme data and primary qualitative data collected using key informant interviews and focus group discussions. The UK Department for International Development will provide funding for this study. The European Civil Protection and Humanitarian Aid Operations will fund the intervention. Concern Worldwide will implement the intervention as part of their humanitarian programming. Discussion This non-randomised cluster controlled trial will provide needed evidence on the role of unconditional CTP in reducing the risk of acute malnutrition among IDP in this context. Trial registration ISRCTN29521514. Registered 19 January 2016.
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Affiliation(s)
- Mohamed Jelle
- UCL Institute for Global Health, WC1N 1EH, London, UK
| | | | | | - Sarah King
- Concern Worldwide Somalia, Nairobi Office, Nairobi, Kenya
| | - Cassy L Cox
- Concern Worldwide Somalia, Nairobi Office, Nairobi, Kenya
| | | | | | | | | | - Andrew J Seal
- UCL Institute for Global Health, WC1N 1EH, London, UK
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Fottrell E, Jennings H, Kuddus A, Ahmed N, Morrison J, Akter K, Shaha SK, Nahar B, Nahar T, Haghparast-Bidgoli H, Khan AKA, Costello A, Azad K. The effect of community groups and mobile phone messages on the prevention and control of diabetes in rural Bangladesh: study protocol for a three-arm cluster randomised controlled trial. Trials 2016; 17:600. [PMID: 27993166 PMCID: PMC5170893 DOI: 10.1186/s13063-016-1738-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 12/03/2016] [Indexed: 12/14/2022] Open
Abstract
Background Increasing rates of type 2 diabetes mellitus place a substantial burden on health care services, communities, families and individuals living with the disease or at risk of developing it. Estimates of the combined prevalence of intermediate hyperglycaemia and diabetes in Bangladesh vary, and can be as high as 30% of the adult population. Despite such high prevalence, awareness and control of diabetes and its risk factors are limited. Prevention and control of diabetes and its complications demand increased awareness and action of individuals and communities, with positive influences on behaviours and lifestyle choices. In this study, we will test the effect of two different interventions on diabetes occurrence and its risk factors in rural Bangladesh. Methods/design A three-arm cluster randomised controlled trial of mobile health (mHealth) and participatory community group interventions will be conducted in four rural upazillas in Faridpur District, Bangladesh. Ninety-six clusters (villages) will be randomised to receive either the mHealth intervention or the participatory community group intervention, or be assigned to the control arm. In the mHealth arm, enrolled individuals will receive twice-weekly voice messages sent to their mobile phone about prevention and control of diabetes. In the participatory community group arm, facilitators will initiate a series of monthly group meetings for men and women, progressing through a Participatory Learning and Action cycle whereby group members and communities identify, prioritise and tackle problems associated with diabetes and the risk of developing diabetes. Both interventions will run for 18 months. The primary outcomes of the combined prevalence of intermediate hyperglycaemia and diabetes and the cumulative 2-year incidence of diabetes among individuals identified as having intermediate hyperglycaemia at baseline will be evaluated through baseline and endline sample surveys of permanent residents aged 30 years or older in each of the study clusters. Data on blood glucose level, blood pressure, body mass index and hip-to-waist ratio will be gathered through physical measurements by trained fieldworkers. Demographic and socioeconomic data, as well as data on knowledge of diabetes, chronic disease risk factor prevalence and quality of life, will be gathered through interviews with sampled respondents. Discussion This study will increase our understanding of diabetes and other non-communicable disease burdens and risk factors in rural Bangladesh. By documenting and evaluating the delivery, impact and cost-effectiveness of participatory community groups and mobile phone voice messaging, study findings will provide evidence on how population-level strategies of community mobilisation and mHealth can be implemented to prevent and control noncommunicable diseases and risk factors in this population. Trial registration ISRCTN41083256. Registered on 30 Mar 2016 (Retrospectively Registered). Trial acronym D-Magic: Diabetes Mellitus – Action through Groups or mobile Information for better Control.
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Affiliation(s)
- Edward Fottrell
- Institute for Global Health, University College London, London, UK.
| | - Hannah Jennings
- Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | | | | | - Badrun Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK.,World Health Organisation, Geneva, Switzerland
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
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47
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D'Ambruoso L, Boerma T, Byass P, Fottrell E, Herbst K, Källander K, Mullan Z. The case for verbal autopsy in health systems strengthening. Lancet Glob Health 2016; 5:e20-e21. [PMID: 27866775 DOI: 10.1016/s2214-109x(16)30332-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Affiliation(s)
| | | | | | | | - Kobus Herbst
- Africa Health Research Institute, Durban, South Africa
| | - Karin Källander
- Malaria Consortium, London, UK; Karolinska Institutet, Stockholm, Sweden
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48
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Kostkova P, Brewer H, de Lusignan S, Fottrell E, Goldacre B, Hart G, Koczan P, Knight P, Marsolier C, McKendry RA, Ross E, Sasse A, Sullivan R, Chaytor S, Stevenson O, Velho R, Tooke J. Who Owns the Data? Open Data for Healthcare. Front Public Health 2016; 4:7. [PMID: 26925395 PMCID: PMC4756607 DOI: 10.3389/fpubh.2016.00007] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 01/14/2016] [Indexed: 11/13/2022] Open
Abstract
Research on large shared medical datasets and data-driven research are gaining fast momentum and provide major opportunities for improving health systems as well as individual care. Such open data can shed light on the causes of disease and effects of treatment, including adverse reactions side-effects of treatments, while also facilitating analyses tailored to an individual's characteristics, known as personalized or "stratified medicine." Developments, such as crowdsourcing, participatory surveillance, and individuals pledging to become "data donors" and the "quantified self" movement (where citizens share data through mobile device-connected technologies), have great potential to contribute to our knowledge of disease, improving diagnostics, and delivery of -healthcare and treatment. There is not only a great potential but also major concerns over privacy, confidentiality, and control of data about individuals once it is shared. Issues, such as user trust, data privacy, transparency over the control of data ownership, and the implications of data analytics for personal privacy with potentially intrusive inferences, are becoming increasingly scrutinized at national and international levels. This can be seen in the recent backlash over the proposed implementation of care.data, which enables individuals' NHS data to be linked, retained, and shared for other uses, such as research and, more controversially, with businesses for commercial exploitation. By way of contrast, through increasing popularity of social media, GPS-enabled mobile apps and tracking/wearable devices, the IT industry and MedTech giants are pursuing new projects without clear public and policy discussion about ownership and responsibility for user-generated data. In the absence of transparent regulation, this paper addresses the opportunities of Big Data in healthcare together with issues of responsibility and accountability. It also aims to pave the way for public policy to support a balanced agenda that safeguards personal information while enabling the use of data to improve public health.
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Affiliation(s)
- Patty Kostkova
- Department of Computer Science, University College London (UCL) , London , UK
| | - Helen Brewer
- Parliamentary Office of Science and Technology , London , UK
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, and Royal College of General Practitioners Research and Surveillance Centre , London , UK
| | | | - Ben Goldacre
- Faculty of Population Health Sciences, University College London (UCL) , London , UK
| | - Graham Hart
- London School of Hygiene & Tropical Medicine , London , UK
| | - Phil Koczan
- University College London Partners (UCLP) , London , UK
| | | | - Corinne Marsolier
- Cisco Consulting Services, Life Sciences, Health and Care , Paris , France
| | - Rachel A McKendry
- The London Centre for Nanotechnology and Division of Medicine, University College London (UCL) , London , UK
| | - Emma Ross
- Chatham House Centre on Global Health Security , London , UK
| | - Angela Sasse
- Department of Computer Science, University College London (UCL) , London , UK
| | - Ralph Sullivan
- Health Informatics Group, Royal College of General Practitioners , London , UK
| | | | | | - Raquel Velho
- Department of Science and Technology Studies, UCL , London , UK
| | - John Tooke
- School of Life and Medical Sciences, UCL , London , UK
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49
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King C, Zamawe C, Banda M, Bar-Zeev N, Beard J, Bird J, Costello A, Kazembe P, Osrin D, Fottrell E. The quality and diagnostic value of open narratives in verbal autopsy: a mixed-methods analysis of partnered interviews from Malawi. BMC Med Res Methodol 2016; 16:13. [PMID: 26830814 PMCID: PMC4736636 DOI: 10.1186/s12874-016-0115-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/23/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Verbal autopsy (VA), the process of interviewing a deceased's family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews. METHODS During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative. RESULTS Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5-3.5) of an average 65 answered; mean inter-interviewer concordance was 92% (IQR: 92-99%). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather. CONCLUSIONS The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services.
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Affiliation(s)
- C King
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
| | - C Zamawe
- Parent and Child Health Initiative, Lilongwe, Malawi.
| | - M Banda
- MaiMwana Project, Mchinji, Malawi.
| | - N Bar-Zeev
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK.
| | - J Beard
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
- London School of Hygiene and Tropical Medicine, London, UK.
| | - J Bird
- Department of Computer Science, City University London, London, UK.
| | - A Costello
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
| | - P Kazembe
- MaiMwana Project, Mchinji, Malawi.
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi.
| | - D Osrin
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
| | - E Fottrell
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
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50
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Harris-Fry HA, Azad K, Younes L, Kuddus A, Shaha S, Nahar T, Hossen M, Costello A, Fottrell E. Formative evaluation of a participatory women's group intervention to improve reproductive and women's health outcomes in rural Bangladesh: a controlled before and after study. J Epidemiol Community Health 2016; 70:663-70. [PMID: 26739272 PMCID: PMC4941186 DOI: 10.1136/jech-2015-205855] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 12/14/2015] [Indexed: 01/25/2023]
Abstract
Background Women's groups using participatory methods reduced newborn mortality in rural areas of low income countries. Our study assessed a participatory women's group intervention that focused on women's health, nutrition and family planning. Methods The study was conducted in three districts in Bangladesh between October 2011 and March 2013, covering a population of around 230 000. On the basis of allocation for the preceding cluster randomised trials, three unions per district were randomly allocated to receive a women's group intervention and three per district were control clusters. Outcomes included unmet need for family planning, morbidity, dietary diversity, night blindness, healthcare decision-making and knowledge of sexual and reproductive health, nutrition and anaemia. A difference-in-difference analysis was used to adjust for secular trends and baseline differences between women taking part in the intervention and a random sample from control clusters. Results We interviewed 5355 (91% response rate) women before the intervention and 5128 after (96% response rate). There were significant improvements in women's dietary diversity score (increase of 0.2 (95% CI 0.1 to 0.3)) and participation in healthcare decision-making (proportion increase (95% CI) 14.0% (10.6% to 17.4%)). There were also increases in knowledge about: contraception (4.2% (2.0% to 6.3%)), ways to treat (55.4% (52.2% to 58.5%)) and prevent (71.0% (68.0% to 74.1%)) sexually transmitted infections, nutrition (46.6% (43.6% to 49.6%)) and anaemia prevention (62.8% (60.9% to 64.6%)). There were no significant differences in unmet need for family planning, morbidity or night blindness. Conclusions Participatory women's groups have considerable potential to improve women's health knowledge, but evidence of impact on certain outcomes is lacking. Further formative work and intervention development is needed to optimise the impact of this approach for women's health.
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Affiliation(s)
| | - Kishwar Azad
- Diabetic Association of Bangladesh (BADAS), Dhaka, Bangladesh
| | - Leila Younes
- UCL Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Diabetic Association of Bangladesh (BADAS), Dhaka, Bangladesh
| | - Sanjit Shaha
- Diabetic Association of Bangladesh (BADAS), Dhaka, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh (BADAS), Dhaka, Bangladesh
| | - Munir Hossen
- Diabetic Association of Bangladesh (BADAS), Dhaka, Bangladesh
| | - Anthony Costello
- UCL Institute for Global Health, University College London, London, UK
| | - Edward Fottrell
- UCL Institute for Global Health, University College London, London, UK
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