Strengthening research capacity of early-mid career researchers: Implementation and evaluation of the Excellence in Non-COmmunicable disease REsearch (ENCORE) program

High-quality training and networking are pivotal for enhancing the research capacity of early- to mid-career researchers in the prevention and control of non-communicable diseases. Beyond building research skills, these professionals gain valuable insights from interdisciplinary mentorship, networking opportunities, and exposure to diverse cultures and health systems. Despite the significance of such initiatives, their implementation remains underexplored. Here, we describe the implementation and evaluation of the Excellence in Non-COommunicable disease REsearch (ENCORE) program, a collaborative initiative between Australia and India that was launched in 2016 and spanned a duration of 3 years. Led by a consortium that included the University of Melbourne and leading Indian research and medical institutions, ENCORE involved 15 faculty members and 20 early-mid career researchers. The program comprised various elements, including face-to-face forums, masterclasses, webinars, a health-technology conference, and roundtable events. ENCORE successfully trained the early-career researchers, resulting in over 30 peer-reviewed articles, 36 conference presentations, and the submission of seven grant applications, three of which received funding. Beyond individual achievements, ENCORE fostered robust research collaboration between Australian and Indian institutions, showcasing its broader impact on strengthening research capacities across borders.

Ten-Year Risk Equations for Incident Heart Failure in Established Atherosclerotic Cardiovascular Disease Populations

BACKGROUND

Ten-year risk equations for incident heart failure (HF) are available for the general population, but not for patients with established atherosclerotic cardiovascular disease (ASCVD), which is highly prevalent in HF cohorts. This study aimed to develop and validate 10-year risk equations for incident HF in patients with known ASCVD.

METHODS AND RESULTS

Ten-year risk equations for incident HF were developed using the United Kingdom Biobank cohort (recruitment 2006-2010) including participants with established ASCVD but free from HF at baseline. Model performance was validated using the Australian Baker Heart and Diabetes Institute Biobank cohort (recruitment 2000-2011) and compared with the performance of general population risk models. Incident HF occurred in 13.7% of the development cohort (n=31 446, median 63 years, 35% women, follow-up 10.7±2.7 years) and in 21.3% of the validation cohort (n=1659, median age 65 years, 25% women, follow-up 9.4±3.7 years). Predictors of HF included in the sex-specific models were age, body mass index, systolic blood pressure (treated or untreated), glucose (treated or untreated), cholesterol, smoking status, QRS duration, kidney disease, myocardial infarction, and atrial fibrillation. ASCVD-HF equations had good discrimination and calibration in development and validation cohorts, with superior performance to general population risk equations.

CONCLUSIONS

ASCVD-specific 10-year risk equations for HF outperform general population risk models in individuals with established ASCVD. The ASCVD-HF equations can be calculated from readily available clinical data and could facilitate screening and preventative treatment decisions in this high-risk group.

Differences in predictors of incident heart failure according to atherosclerotic cardiovascular disease status

AIMS

Heart failure (HF) is a common cause of morbidity and mortality, related to a broad range of sociodemographic, lifestyle, cardiometabolic, and comorbidity risk factors, which may differ according to the presence of atherosclerotic cardiovascular disease (ASCVD). We assessed the association between incident HF with baseline status across these domains, overall and separated according to ASCVD status.

METHODS AND RESULTS

We included 5758 participants from the Baker Biobank cohort without HF at baseline enrolled between January 2000 and December 2011. The primary endpoint was incident HF, defined as hospital admission or HF-related death, determined through linkage with state-wide administrative databases (median follow-up 12.2 years). Regression models were fitted adjusted for sociodemographic variables, alcohol intake, smoking status, measures of adiposity, cardiometabolic profile measures, and individual comorbidities. During 65 987 person-years (median age 59 years, 38% women), incident HF occurred among 784 participants (13.6%) overall. Rates of incident HF were higher among patients with ASCVD (624/1929, 32.4%) compared with those without ASCVD (160/3829, 4.2%). Incident HF was associated with age, socio-economic status, alcohol intake, smoking status, body mass index (BMI), waist circumference, waist-hip ratio, systolic blood pressure (SBP), and low- and high-density lipoprotein cholesterol (LDL-C and HDL-C), with non-linear relationships observed for age, alcohol intake, BMI, waist circumference, waist-hip ratio, SBP, LDL-C, and HDL-C. Risk factors for incident HF were largely consistent regardless of ASCVD status, although diabetes status had a greater association with incident HF among patients without ASCVD.

CONCLUSIONS

Incident HF is associated with a broad range of baseline sociodemographic, lifestyle, cardiometabolic, and comorbidity factors, which are mostly consistent regardless of ASCVD status. These data could be useful in efforts towards developing risk prediction models that can be used in patients with ASCVD.

Prevalence, correlates and common methods of non-suicidal self-injury in South Asia: a systematic review

INTRODUCTION

The dynamics of self-harm vary substantially around the world, yet it is severely under-researched outside of a small number of high-income 'Western' countries. South Asia is disproportionately impacted by suicide, yet we know less about non-suicidal self-injury (NSSI) in the region.

OBJECTIVE

To review and summarise evidence on the prevalence, correlates and common methods of NSSI in South Asia.

METHODS

We searched Medline, Embase and PsycINFO for the period 1 January 2000 to 31 August 2023, for peer-reviewed observational studies. A total of 11 studies from eight South Asian countries that reported prevalence and/or correlates of NSSI were included in this review. We assessed the quality of the studies using the Study Quality Assessment Tools for Observational Cohort and Cross-Sectional Studies. We used meta-regression to describe the sources of heterogeneity. Abstracted data were summarised using thematic synthesis.

RESULTS

For non-clinical populations, the 12-month prevalence of NSSI ranged from 3.2% to 44.8%, and the lifetime prevalence ranged from 21% to 33%. For clinical populations, the 12-month prevalence of NSSI ranged from 5% to 16.4%, while the lifetime prevalence ranged from 2% to 27%. Male sex, unemployment, financial stress, history of suicidal behaviour and depression were associated with a higher risk of NSSI. Better access to counselling services, higher self-esteem and self-knowledge were associated with a lower risk of NSSI.

CONCLUSION

The burden of NSSI in South Asia appears to be high in both clinical and non-clinical populations. Further research, especially with general population samples, is needed to build evidence on the epidemiology, context and meaning of NSSI in South Asia to inform the design of context-specific interventions.

PROSPERO REGISTRATION NUMBER

CRD42022342536.

Social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples in Aboriginal controlled social housing

BACKGROUND

Little is known about the wellbeing and aspirations of Aboriginal and Torres Strait Islander peoples living in social housing. Aboriginal and Torres Strait Islander peoples living in social housing face common social housing challenges of low income, higher incidence of mental health issues and poorer health along with specific challenges due to the impacts of colonisation and its ongoing manifestations in racism and inequity. A greater understanding of social and emotional wellbeing needs and aspirations is essential in informing the provision of appropriate support.

METHODS

Surveys of social and emotional wellbeing (SEWB) were completed by 95 Aboriginal people aged 16 years and older living in Aboriginal Housing Victoria social housing in 2021. The survey addressed a range of domains reflecting social and emotional wellbeing, as defined by Aboriginal and Torres Strait Islander peoples.

RESULTS

Most respondents demonstrated a strong sense of identity and connection to family however 26% reported having 6 or more health conditions. Ill health and disability were reported to be employment barriers for almost a third of people (32%). Improving health and wellbeing (78%) was the most cited aspiration. Experiences of racism and ill health influenced engagement with organisations and correspondingly education and employment.

CONCLUSION

Strong connections to identity, family and culture in Aboriginal peoples living in social housing coexist along with disrupted connections to mind, body and community. Culturally safe and appropriate pathways to community services and facilities can enhance these connections. Research aimed at evaluating the impact of strengths-based interventions that focus on existing strong connections will be important in understanding whether this approach is effective in improving SEWB in this population.

TRIAL REGISTRATION

This trial was retrospectively registered with the ISRCTN Register on the 12/7/21 with the study ID:ISRCTN33665735.

Transition to a first suicide attempt among young and middle-aged males with a history of suicidal thoughts: A two-year cohort study

INTRODUCTION

Although many studies have examined the risk and protective factors associated with suicidal behavior, little is known about the probability of transition from suicidal thoughts to suicidal attempts and the factors that distinguish those who have suicidal thoughts from those who progress to a suicide attempt.

OBJECTIVES

To determine the probability and predictors of transition to a suicide attempt among young and middle-aged males with a history of suicidal thoughts but no prior history of attempting suicide.

METHODS

We used data from the first two waves of the Australian Longitudinal Study on Male Health, approximately two years apart. We followed the cohort of males aged 18-55 years who, at wave 1, reported a lifetime history of suicidal ideation but no history of a prior suicide attempt. We report transition probabilities to a first suicide attempt at Wave 2 and used logistic regression models to examine baseline predictors of transition to a first suicide attempt over the two-year period among males aged 18 years and older.

RESULTS

From the 1,564 males with suicidal thoughts at wave 1,140 participants (8.9%; 95% CI:7.6,10.5) reported to have had their first suicide attempt in the two-year period. In multivariate analyses, males aged 30-39 (OR=0.31; 95% CI: 0.16,0.60), 40-49 (OR=0.47; 95% CI:0.24,0.91) and 50-55 (OR=0.31; 95% CI: 0.13,0.73) all had lower odds of a first suicide attempt compared to males aged 18-29 years. The odds of a first suicide attempt were significantly higher for males who were: living in inner regional areas (ref: major cities) (OR=2.32; 95% CI: 1.33,4.04); homosexual or bisexual (OR=2.51; 95% CI: 1.17,5.36); working night shift as their main job (OR=1.75; 95% CI: 1.05,2.91); and, living with a disability (OR=1.99; 95% CI: 1.07,3.65). Clinical indicators such as symptoms of depression and illicit substance use were not significant predictors of transition to a first suicide attempt in multivariate models, nor were indicators of social connection.

CONCLUSION

We estimated that 8.9% of Australian males aged 15-55 years with a history of suicidal thoughts and no prior history of suicide attempts will progress to a first suicide attempt within two-years. Neither psychological distress, illicit substance use nor social connection indicators were correlated with transition to a first suicide attempt. Rather, it was socio-demographic indicators that were associated with transition to a first suicide attempt.

A peer support program results in greater health benefits for peer leaders than other participants: evidence from the Kerala diabetes prevention program

BACKGROUND

Peer support programs are promising approaches to diabetes prevention. However, there is still limited evidence on the health benefits of peer support programs for lay peer leaders.

PURPOSE

To examine whether a peer support program designed for diabetes prevention resulted in greater improvements in health behaviors and outcomes for peer leaders as compared to other participants.

METHODS

51 lay peer leaders and 437 participants from the Kerala Diabetes Prevention Program were included. Data were collected at baseline, 12 months, and 24 months. We compared behavioral, clinical, biochemical, and health-related quality of life parameters between peer leaders and their peers at the three time-points.

RESULTS

After 12 months, peer leaders showed significant improvements in leisure time physical activity (+ 17.7% vs. + 3.4%, P = 0.001) and health-related quality of life (0.0 vs. + 0.1, P = 0.004); and a significant reduction in alcohol use (-13.6% vs. -6.6%, P = 0.012) and 2-hour plasma glucose (-4.1 vs. + 9.9, P = 0.006), as compared to participants. After 24 months, relative to baseline, peer leaders had significant improvements in fruit and vegetable intake (+ 34.5% vs. + 26.5%, P = 0.017) and leisure time physical activity (+ 7.9% vs. -0.9%, P = 0.009); and a greater reduction in alcohol use (-13.6% vs. -4.9%, P = 0.008), and waist-to-hip ratio (-0.04 vs. -0.02, P = 0.014), as compared to participants. However, only the changes in fruit and vegetable intake and waist-to-hip ratio were maintained between 12 and 24 months.

CONCLUSION

Being a peer leader in a diabetes prevention program was associated with greater health benefits during and after the intervention period. Further studies are needed to examine the long-term sustainability of these benefits.

Functional limitation as a mediator of the relationship between multimorbidity on health-related quality of life in Australia: evidence from a national panel mediation analysis

Objective

The inverse relationships between chronic disease multimorbidity and health-related quality of life (HRQoL) have been well-documented in the literature. However, the mechanism underlying this relationship remains largely unknown. This is the first study to look into the potential role of functional limitation as a mediator in the relationship between multimorbidity and HRQoL.

Methods

This study utilized three recent waves of nationally representative longitudinal Household, Income, and Labor Dynamics in Australia (HILDA) surveys from 2009 to 2017 (n = 6,814). A panel mediation analysis was performed to assess the role of functional limitation as a mediator in the relationship between multimorbidity and HRQoL. The natural direct effect (NDE), indirect effect (NIE), marginal total effect (MTE), and percentage mediated were used to calculate the levels of the mediation effect.

Results

This study found that functional limitation is a significant mediator in the relationship between multimorbidity and HRQoL. In the logistic regression analysis, the negative impact of multimorbidity on HRQoL was reduced after functional limitation was included in the regression model. In the panel mediation analysis, our results suggested that functional limitation mediated ~27.2% (p < 0.05) of the link between multimorbidity and the composite SF-36 score for HRQoL. Functional limitation also mediated the relationship between the number of chronic conditions and HRQoL for each of the eight SF-36 dimensions, with a proportion mediated ranging from 18.4 to 28.8% (p < 0.05).

Conclusion

Functional status has a significant impact on HRQoL in multimorbid patients. Treatment should concentrate on interventions that improve patients' functioning and mitigate the negative effects of multimorbidity.

The association between obesity, health service use, and work productivity in Australia: a cross-sectional quantile regression analysis

The burden of disease attributable to obesity is rapidly increasing and becoming a public health challenge globally. Using a nationally representative sample in Australia, this study aims to examine the association of obesity with healthcare service use and work productivity across outcome distributions. We used Household, Income and Labour Dynamics Australia (HILDA) Wave 17 (2017-2018), including 11,211 participants aged between 20 and 65 years. Two-part models using multivariable logistic regressions and quantile regressions were employed to understand variations in the association between obesity levels and the outcomes. The prevalence of overweight and obesity was 35.0% and 27.6%, respectively. After adjusting for socio-demographic factors, low socioeconomic status was associated with a higher probability of overweight and obesity (Obese III: OR = 3.79; 95% CI 2.53-5.68) while high education group was associated with a lower likelihood of being high level of obesity (Obese III OR = 0.42, 95% CI 0.29-0.59). Higher levels of obesity were associated with higher probability of health service use (GP visit Obese, III: OR = 1.42 95% CI 1.04-1.93,) and work productivity loss (number of paid sick leave days, Obese III: OR = 2.40 95% CI 1.94-2.96), compared with normal weight. The impacts of obesity on health service use and work productivity were larger for those with higher percentiles compared to lower percentiles. Overweight and obesity are associated with greater healthcare utilisation, and loss in work productivity in Australia. Australia's healthcare system should prioritise interventions to prevent overweight and obesity to reduce the cost on individuals and improve labour market outcomes.

Digital Health Solutions for Community-Based Control of Diabetes During COVID-19 Pandemic: A Scoping Review of Implementation Outcomes

BACKGROUND

The COVID-19 pandemic has added to the pre-existing challenges of diabetes management in many countries. It has accelerated the wider use of digital health solutions which have tremendous potential to improve health outcomes for people with diabetes. However, little is known about the attributes and the implementation of these solutions.

OBJECTIVE

To identify and describe digital health solutions for community-based diabetes management and to highlight their key implementation outcomes.

METHODS

We searched Ovid Medline, CINAHL, Embase, PsycINFO, and Web of Science for relevant articles. A purposive search was also used to identify grey literature. Articles that described digital health solutions that aimed to improve community-based diabetes management were included in this review. We applied a thematic synthesis of evidence to describe the characteristics of digital health solutions, and to summarize their key implementation outcomes.

RESULTS

We included 15 articles that reported digital health solutions that primarily focused on community-based diabetes management. Nine of the 15 innovations involved were mobile applications and/or web-based platforms, and five were based on social media platforms. The majority of the digital health solutions were used for diabetes education and support. High engagement, utilization, and satisfaction rates with digital health solutions were observed. The use of digital health solutions was also associated with improvement in self-management, taking medication, and reduction in glycated hemoglobin (HbA1c) levels.

CONCLUSION

COVID-19 triggered digital health solutions have tremendous potential to improve health outcomes for people with diabetes. Further studies are needed to evaluate the sustainability and scale-up of these solutions.

The long-term effects of Kerala Diabetes Prevention Program on diabetes incidence and cardiometabolic risk: a study protocol

INTRODUCTION

India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited.

OBJECTIVES

The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years.

METHODS

The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned.

DISCUSSION

Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry-(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191.

The rate of transition to a suicide attempt among people with suicidal thoughts in the general population: A systematic review

INTRODUCTION

While suicidal thoughts are relatively common in the general population, roughly affecting one in ten people during their lifetime, the transition from suicidal thoughts to a suicide attempt is rarer. There is limited consensus on the transition rate from suicidal ideation to suicide attempts.

OBJECTIVE

To review and summarize evidence on the rate of transition from suicidal ideation to a suicide attempt, and the factors associated with this transition, in the general population.

METHODS

A comprehensive search was conducted using MEDLINE, PsycINFO, and Embase for relevant articles published between January 1, 2000, and March 3, 2021. We identified 18 eligible studies that examined the transition from suicidal ideation to a suicide attempt in non-clinical populations. We assessed the quality of the included studies using the MASTER scale. The review has been registered with PROSPERO (CRD42021248325).

RESULTS

Rates of transitioning to a suicide attempt among people with suicidal ideation varied substantially across studies, from 2.6 % to 37 %. Follow-up periods also varied substantially, from 12 to 300 months, impeding reliable comparisons across studies or pooling data for further analyses. The most examined risk factors were mental health disorders such as major depressive and anxiety disorders, which were typically associated with higher odds of transition to a suicide attempt.

LIMITATIONS

High level of heterogeneity and limited quality of the studies.

CONCLUSION

The risk of transition from suicidal thoughts to a suicide attempt is moderate to high. Further longitudinal research is required to refine the rate and explore social determinants of transition from suicidal ideation to suicide attempts.

Putting non-communicable disease data to work in Vietnam: an investigation of community health surveillance capacity

INTRODUCTION

Despite the public health system's critical role in non-communicable disease (NCD) surveillance in Vietnam, limited evidence exists on the implementation of NCD surveillance activities within these systems and the need for capacity building across different system levels to meet expected NCD surveillance goals. This study aimed to evaluate the status of and describe factors affecting the implementation of NCD surveillance activities and to identify the NCD surveillance capacity building needs of the public health system in Vietnam.

METHODS

We used a mixed-methods approach in four provinces, conducting self-completed surveys of staff from six Preventive Medicine Institutes (PHI), 53 Centres for Disease Control (CDC) and 148 commune health stations (CHS), as well as 14 in-depth interviews and 22 focus group discussions at four PHI, four CDC, and eight district health centres and CHS.

RESULTS

Study findings highlighted that although Vietnam has a well-functioning NCD surveillance system, a number of quality issues related to NCD surveillance data were salient. Multifactorial reasons were identified for incomplete, unconfirmed, and inaccurate mortality data and current disease surveillance data. Data on NCD management and treatment were reported to be of better quality than data for screening, targeted treatment, and counselling communication. Main factors affected the effective implementation of NCD surveillance, namely lack of complete and specific guidelines for NCD surveillance, limitations in human resource capacity within NCD departments, and shortage of funding for NCD surveillance activities.

CONCLUSION

Study findings provide practical strategies for strengthening health system capacity for NCD surveillance through developing policies, guidelines, and standardised tools to guide NCD surveillance and a road map for integrated NCD surveillance, developing training packages and manuals for all levels of the health system, and conducting utilisation-focused surveillance training programs.

Suicide stigma measures: A scoping review

BACKGROUND

Worldwide, approximately 800,000 people die by suicide every year, and non-fatal suicidal thoughts and behaviours are common. Stigma is likely a major barrier to preventing suicide. The purpose of our review is to scope the development, psychometric properties and use of measures that explicitly seek to measure the construct of suicide stigma.

METHODS

We conducted a scoping review. We searched PubMed, PsycINFO, Embase and CINAHL using search terms related to suicide, stigma and measures/scales with no date limits. We included any measure the authors defined as measuring suicide-related stigma. Only peer-reviewed articles published in English were included.

RESULTS

We included 106 papers discussing 23 measures of suicide stigma; 82 provided data on psychometric properties. Measures assessed personal or public stigma; and stigma toward a range of suicidal phenomena (e.g., suicidal thoughts, those bereaved by suicide). 'Stigma' definitions varied and were not always provided. The Grief Experience Questionnaire, Suicide Opinion Questionnaire and Stigma of Suicide Scale were the most commonly cited. Measures varied in the strength of their psychometric properties.

LIMITATIONS

We only included papers in English. Because we included any measures authors defined as measuring suicide stigma, we may have included measures not commonly considered as measures of suicide stigma, and conversely we might have excluded relevant measures because they did not use the term 'stigma'.

DISCUSSION

This review aimed to assist in better understanding available suicide stigma measures, their strengths and weaknesses and current uses, and will inform the development of future suicide stigma measures.

Practical Strategies for Improving Sustainability and Scale-up of Noncommunicable Disease-related Public Health Interventions: Lessons from the Better Health Program in Southeast Asia

Introduction

The Better Health Program has been addressing key health system issues in the prevention and control of noncommunicable diseases (NCDs) in Malaysia, Thailand, Vietnam, and the Philippines. As the program comes to an end, the sustainability and scaling-up of issues have assumed importance.

Objectives

The objective is to assess how well sustainability and scale-up strategies have been integrated into the design and implementation of a 3-year multicountry technical program; to explore enablers and barriers of sustainability and scaling up; and to identify practical strategies that can improve sustainability and scale-up of Better Health Program interventions.

Methods

We applied a staged approach to explore barriers and enablers and to identify practical strategies to improve sustainability and scale-up of four NCD interventions: community-based obesity prevention, front-of-pack labeling, local learning networks (LLNs), and NCD surveillance. We extracted evidence from peer-reviewed literature and local documents. We also conducted in-depth interviews with the implementation teams and key stakeholders. We conducted a thematic synthesis of the resulting information to identify practical strategies that improve sustainability and scale-up of the four interventions.

Results

Strong engagement of stakeholders at higher levels of the health system was identified as the main enabler, while limited funding and commitment from local governments were identified as a key barrier to sustainability and scale-up. Strengthening the social and institutional anchors of community health volunteers, enhancing evidence-based advocacy for front-of-pack labeling, trailblazing the LLN innovation, and securing the commitment of local governments in the implementation of NCD surveillance were among the key strategies for improving sustainability and scale-up of Better Health Program interventions in Malaysia, Thailand, Philippines, and Vietnam, respectively.

Conclusions

This study identified practical strategies for improving sustainability and scale-up of NCD-related interventions. Implementation of the strategies that had high priority and feasibility will improve the sustainability of critical elements of the program in the respective countries.

Effects of a lifestyle intervention on depression and anxiety among adults at risk for diabetes in India: A secondary analysis of the Kerala Diabetes Prevention Program

The impact of lifestyle interventions on diabetes and mental health conditions have been documented among people with diabetes. However, the mental health benefits of lifestyle interventions designed for diabetes prevention have not been systematically investigated among people at high risk of diabetes, particularly in low- and middle-income countries. We examined the effects of a 12-month peer support lifestyle intervention designed for diabetes prevention on depression and anxiety symptomology in the sample population of the Kerala Diabetes Prevention Program. Mixed-effects linear regression models were used to examine the effect of the intervention on depression and anxiety scores at 12 and 24 months in the total sample of 1007 adults at risk for diabetes and among those with mild-severe depressive or anxiety symptoms at baseline (n = 326 for depression; n = 203 for anxiety). Among all participants, the intervention group had a significantly higher reduction of depressive symptoms as compared to the control group at 12 months (mean diff score = -0.51; 95% CI: -0.95, -0.07; P = 0.02). This effect was not sustained at 24 months. There were no significant intervention effects for anxiety. Among those with mild-severe symptoms at baseline, the intervention group had a significantly higher reduction of depressive symptoms (mean diff score = -1.55; 95% CI -2.50, -0.6; P = 0.001) and anxiety symptoms (mean diff score = -1.64; 95% CI -2.76, -0.52; P = 0.004) at 12 months. The effect was sustained at 24 months for depression, but not anxiety. Lifestyle interventions designed for prevention of diabetes might improve depressive and anxiety symptoms in the short-term, particularly among those with mild-severe symptoms.

Strengthening Capacity for Implementation Research Amid COVID-19 Pandemic: Learnings From the Global Alliance for Chronic Diseases Implementation Science School

Objective: To describe the design, delivery and evaluation of the 3rd Global Alliance for Chronic Diseases (GACD) Implementation Science School (ISS), delivered virtually in 2020 for the first time.

Methods: Since 2014, GACD has supported the delivery of more than ten Implementation Science Workshops for more than 500 international participants. It has also been conducting an annual ISS since 2018. In this study, we described the design, delivery and evaluation of the third ISS.

Results: Forty-six participants from 23 countries in five WHO regions attended the program. The virtual delivery was well-received and found to be efficient in program delivery, networking and for providing collaborative opportunities for trainees from many different countries. The recently developed GACD Implementation Science e-Hub was found to be an instrumental platform to support the program by providing a stand-alone, comprehensive online learning space for knowledge and skill development in implementation research.

Conclusion: The delivery of the virtual GACD ISS proved to be feasible, acceptable and effective and offers greater scalability and sustainability as part of a future strategy for capacity strengthening in implementation research globally.

Discrimination experienced by Aboriginal and Torres Strait Islander males in Australia: Associations with suicidal thoughts and depressive symptoms

INTRODUCTION

Globally, Indigenous populations have higher rates of suicidal behavior and psychological distress compared to non-Indigenous populations. Indigenous populations also report high rates of exposure to discrimination, which could potentially contribute to poor mental health outcomes. The objectives of this paper were to estimate the prevalence of discrimination among Aboriginal and Torres Strait Islander males in Australia and to examine the role of discrimination in the association between Aboriginal and Torres Strait Islander status and suicidal thoughts and depressive symptoms.

METHODS

We used cross-sectional data on 13,697 males aged 18-55 years from the Australian Longitudinal Study on Male Health. We undertook a Poisson regression with robust standard error analyses to examine Aboriginal and Torres Strait Islander status and self-perceived exposure to discrimination in the past 2 years as correlates of recent suicidal ideation. We used zero-inflated negative binomial regression to assess Aboriginal and Torres Strait Islander status and self-perceived exposure to discrimination as correlates of recent depressive symptoms.

RESULTS

Aboriginal and Torres Strait Islander males have a twofold higher prevalence of self-perceived discrimination (39.2% vs 19.3%, p < 0.001), suicidal ideation (21.8% vs 9.4%, p < 0.001) and moderate or worse depressive symptoms (24.0% vs 12.2%, p < 0.001) as compared to their non-Indigenous counterparts. After adjusting for sociodemographics and substance use, Aboriginal and Torres Strait Islander status was significantly associated with suicidal thoughts (odds ratio = 1.49, p = 0.019) and depressive symptoms (prevalence rate ratio = 1.19, p = 0.018). About 15.3% and 28.7% of the association between Aboriginal and Torres Strait Islander status and suicidal thoughts and depressive symptoms, respectively, was explained by discrimination.

CONCLUSION

Our analyses add to evidence that discrimination is a contributor to mental health disparities between Aboriginal and Torres Strait Islander and non-Indigenous populations in Australia. Reducing discrimination ought to be considered as part of strategies to improve the social and emotional well-being of Aboriginal and Torres Strait Islander people.

Discrimination experienced by sexual minority males in Australia: Associations with suicidal ideation and depressive symptoms

INTRODUCTION

Discrimination has been under-examined as a social determinant of the higher rates of poor mental health experienced by sexual minorities. The objectives of our study were to: 1) assess whether discrimination was independently associated with poor mental health among sexual minority males, and 2) assess the potential mediation role of discrimination in the associations between sexual minority status and poor mental health.

METHODS

We used cross-sectional data on 13,230 males aged 18-55 years from the Australian Longitudinal Study on Male Health; bisexual and homosexual males comprised 1.5% and 1.6% of the sample, respectively. We fit Poisson regression and zero-inflated negative binomial regression models to examine suicidality, depressive symptoms and perceived discrimination in the past two years as correlates of suicidality and depressive symptoms.

RESULTS

Statistically significant differences were observed in the prevalence of perceived discrimination by sexual orientation (p < 0.001), with the highest prevalence among bisexual (29.3%) and homosexual (40.4%) males, and the lowest prevalence among heterosexual males (18.6%). After adjusting for confounding, bisexual/homosexual males had higher rates of perceived discrimination (IRR = 1.88, p < 0.001), recent suicidal ideation (IRR = 1.51, p = 0.008), lifetime suicide attempt (IRR = 2.09, p < 0.001) and recent depressive symptoms (IRR = 1.34, p < 0.001) than heterosexual males. Analysis of β-coefficients suggested that discrimination may mediate a small to moderate proportion of the association between sexual minority status and poor mental health.

LIMITATIONS

Use of cross-sectional data.

CONCLUSION

Poor mental health is more common among sexual minority males, and discrimination may be a contributor to these mental health disparities. Reducing discrimination should be considered as part of a strategy to improve the mental wellbeing of sexual minority males.

What are the effects of ethnicity, sexuality, disability and obesity on the odds of experiencing discrimination among Australian males? A nationwide cross-sectional survey

OBJECTIVES

The global public health community has been slow to acknowledge the important role of discrimination in health inequality. Existing evidence on discrimination is largely based on studies of specific subpopulations and specific forms of discrimination, with limited evidence from general population samples. We assessed the individual and combined effects of ethnicity, sexuality, disability and obesity on the likelihood of discrimination among a general population sample of Australian males.

DESIGN AND SETTING

We used data from The Australian Longitudinal Study on Male Health (n=15 988, with response rate of 35%) to estimate the prevalence of self-perceived discrimination within the preceding 2 years and we used binary logistic regression models to assess the individual and combined effects of ethnicity, sexuality, disability and obesity on discrimination.

PARTICIPANTS

13 763 adult males were included in this analysis.

RESULTS

One in five (19.7%) males reported experiencing discrimination in the preceding 2 years. Aboriginal and/or Torres Strait Islander males were nearly three times (OR=2.97, p<0.001) more likely to experience discrimination. Those born in Southern/Eastern Europe, Asia or Africa were at least twice more likely to report discrimination. Homosexual or bisexual males (35.2%; OR=2.23, p=<0.001), men with morbid obesity (29.2%; OR=1.91, p<0.001) and men with a disability (33.8%; OR=2.07, p<0.001) also had higher odds of experiencing discrimination. Those belonging to one (30.4%; OR=2.60, p<0.001) or two or more (38.2%; OR=3.50, p<0.001) risk groups were increasingly more likely to experience discrimination.

CONCLUSIONS

Discrimination was correlated with ethnicity, sexuality, obesity and disability. Belonging to two or more of the risk groups was associated with substantial increases in the likelihood of experiencing discrimination. Approaches to preventing discrimination need to acknowledge and address the impact of this intersectionality.

Determinants of Health Service Utilization Among Adults at High Risk of Developing Type 2 Diabetes in Kerala, India

The purpose of this study was to examine the determinants of health service utilization in a population at high risk of developing type 2 diabetes mellitus in India. Using Andersen's behavioral model of healthcare utilization, multivariate logistic regression analysis was performed on baseline data of the Kerala Diabetes Prevention Program. We examined the association between predisposing, enabling, and need factors with outpatient health service use in the past four weeks and inpatient health service use in the past 12 months. More than a quarter (27.9%) and 12.9% of 1007 participants used outpatient services and inpatient services, respectively. Men were less likely to use outpatient services (odds ratio [OR] = 0.56; 95% confidence interval [CI] [0.39, 0.82]). Outpatient service utilization was positively associated with low social support (OR = 1.69; 95% CI [1.09, 2.62]), low general health status (OR = 5.71; 95% CI [2.42, 13.47]), and time off from work due to illness (OR = 8.01; 95% CI [5.32, 12.07]). Higher educational status (OR = 0.63; 95% CI [0.41, 0.95]), low general health status (OR = 3.59; 95% CI [1.54, 8.34]), and time off from work due to illness (OR = 1.21; 95% CI [0.76,1.93]) were associated with increased utilization of inpatient services. Although gender, educational status, and social support had important roles, health service utilization in this study population was largely dependent on general health status and presence of illness.

Characteristics and Outcomes of Community Health Worker Training to Improve the Prevention and Control of Cardiometabolic Diseases in Low and Middle-Income Countries: A Systematic Review

Community health workers (CHWs) play an important role in controlling non-communicable diseases in low- and middle-income countries. The aim of this review was to describe the characteristics and outcomes of CHW training programs that focused on the prevention and control of cardiometabolic diseases in low- and middle-income countries (LMICs). Medline, CINAHL Complete, Academic Search Complete, Directory of Open Access Journal, ScienceDirect, ERIC, Gale Academic, and OneFile). Studies that described the training programs used to train CHWs for prevention and control of cardiovascular diseases and type2 diabetes mellitus in LMICs. Only studies that evaluated the outcomes of training programs in at least one of the 4 levels of Kirkpatrick’s training evaluation model were included in the review. CHWs who underwent training focused on the prevention and control of cardiovascular disease and type 2 diabetes mellitus. We summarized the resulting evidence using qualitative synthesis through a narrative review. Training outcomes were assessed in relation to (1) CHW reactions to training, their degree of learning, and their behaviors following training, and (2) changes in biochemical and anthropometric indicators in target populations following the CHW program implementation. PROSPERO (CRD42020162116). Thirty-two studies were included. Methods used to train CHWs included: face-to-face lectures, interactive group activities, and blended teaching with online support. Training focused on identifying people with elevated risk of cardiometabolic diseases and their risk factors as well as supporting people to adopt healthy lifestyles. Many studies that utilized trained CHWs did not publish CHW training methods and evaluations, and therefore could not be included in this study. Training programs resulted in an increase in knowledge and skills among CHWs demonstrating that there are certain activities that can be shifted to CHWs following training.

Impact of COVID-19 on emergency department attendance in an Australia hospital: a parallel convergent mixed methods study

OBJECTIVES

The COVID-19 pandemic has changed the way people are accessing healthcare. The aim of this study was to examine the impact of COVID-19 on emergency department (ED) attendance for frequent attenders and to explore potential reasons for changes in attendance.

DESIGN

This convergent parallel mixed methods study comprised two parts.

SETTING

An interrupted time-series analysis evaluated changes in ED presentation rates; interviews investigated reasons for changes for frequent ED users in a culturally and linguistically diverse setting.

PARTICIPANTS

A total of 4868 patients were included in the time series. A subgroup of 200 patients were interviewed, mean age 66 years (range 23-99).

RESULTS

Interrupted time-series analysis from 4868 eligible participants showed an instantaneous decrease in weekly ED presentations by 36% (p<0.001), with reduction between 45% and 67% across emergency triage categories. 32% did not know they could leave home to seek care with differences seen in English versus non-English speakers (p<0.001). 35% reported postponing medical care. There was a high fear about the health system becoming overloaded (mean 4.2 (±2) on 6-point scale). Four key themes emerged influencing health-seeking behaviour: fear and/or avoidance of hospital care; use of telehealth for remote assessment; no fear or avoidance of hospital care; not leaving the house for any reason.

CONCLUSIONS

This study demonstrated reduced ED use by a vulnerable population of previously frequent attenders. COVID-19 has resulted in some fear and avoidance of hospitals, but has also offered new opportunity for alternative care through telehealth.

Factors Associated With Hypertension Awareness, Treatment, and Control Among Adults in Kerala, India

Background: Hypertension, the most significant risk factor for cardiovascular disease, is an increasing contributor to global health burden, particularly in low- and middle-income countries (LMICs) such as India. While the rates of hypertension awareness, treatment, and control in India have been reported in several studies, the factors associated with these rates are less well-understood. Existing studies are predominantly cross-sectional, and the factors examined are limited. Understanding the predictors associated with these rates, using more rigorous study designs, is crucial for the development of strategies to improve hypertension management.

Aims: To examine a range of factors associated with hypertension awareness, treatment, and control using both cross-sectional and longitudinal analyses.

Methods: Data was derived from a population-based sample of 1,710 participants from Kerala, aged 30–60 years. We examined a comprehensive range of factors, including demographic, behavioral factors, anthropometric, clinical measures, psychosocial factors and healthcare utilization. Multilevel mixed effects logistic regression was used for both cross-sectional and longitudinal analyses (repeated measures for all variables across 2 years) to determine the factors associated with awareness, treatment, and control of hypertension.

Results: A total of 467 (27.3%) participants had hypertension at baseline. Among those, the rates of awareness, treatment, and control of hypertension were 54.4, 25.5, and 36.4%, respectively. Being male (OR 0.27, 95% CI 0.14–0.53) and consumption of alcohol (OR 0.49, 95% CI 0.31–0.80) were significant predictors of poorly controlled hypertension (longitudinal analysis). Depression (OR 2.04, 95% CI 1.15–3.61) and fair-to-poor self-perceived health status (OR 1.87, 95% CI 1.15–3.04) were associated with increased hypertension awareness, whereas anxiety (OR 1.97, 95% CI 1.04–3.71) was associated with increased hypertension treatment (cross-sectional analysis). Seeking outpatient service in the past 4 weeks was associated with higher awareness (OR 1.09, 95% CI 1.27–2.87), treatment (OR 1.73, 95% CI 1.20–2.50) and control (OR 1.96, 95% CI 1.37–2.80) (longitudinal analysis).

Conclusion: Our findings suggest the importance of considering psychosocial factors and better engagement with health services in hypertension management, as well as giving more attention to body fat control and largely male-related behaviors such as alcohol consumption, taking into account of some Indian specific attributes.

The relationship between common mental disorders and incident diabetes among participants in the Kerala Diabetes Prevention Program (K-DPP)

This study aims to describe the prevalence of depression and anxiety among a population sample of people at high risk for type 2 diabetes in Kerala, India, and examine the relationship between depressive symptoms, anxiety, and incident Type 2 Diabetes Mellitus (T2DM) over a two-year period. We used data from the Kerala Diabetes Prevention Program, a cluster-randomized controlled trial for diabetes prevention among 1007 high-risk individuals. The prevalence of depression and anxiety were estimated using the 9-item Patient Health Questionnaire and the Generalized Anxiety Disorder 7-item scale, respectively. We calculated proportions for depression and anxiety and performed generalized estimating equations (GEE) to examine the relationship between baseline mental health status and incident T2DM. The prevalence of depression and anxiety at baseline were 7.5% and 5.5%, respectively. Compared with those reporting none/low symptoms, the odds ratio for incident diabetes was 1.07 (95% CI 0.54–2.12) for participants with moderate to severe depression and 0.73 (95% CI 0.23–2.28) for participants with moderate to severe anxiety, after adjusting for potential confounders. Our findings suggest that the prevalence of depression and anxiety were higher than those previously reported in the general population in India. However, among this sample of community-based adults at high risk of developing T2DM, the presence of moderate to severe depression and/or anxiety symptoms was not significantly associated with the risk of developing T2DM.

Trial registration: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909. Registered 10 March 2011.

Are the PHQ-9 and GAD-7 Suitable for Use in India? A Psychometric Analysis

BACKGROUND

Cross-cultural evidence on the factorial structure and invariance of the PHQ-9 and the GAD-7 is lacking for South Asia. Recommendations on the use of unit-weighted scores of these scales (the sum of items' scores) are not well-founded. This study aims to address these contextual and methodological gaps using data from a rural Indian population.

METHODS

The study surveyed 1,209 participants of the Kerala Diabetes Prevention Program aged 30-60 years (n at risk of diabetes = 1,007 and n with diabetes = 202). 1,007 participants were surveyed over 2 years using the PHQ-9 and the GAD-7. Bifactor-(S - 1) modeling and multigroup confirmatory factor analysis were used.

RESULTS

Factor analysis supported the existence of a somatic and cognitive/affective subcomponent for both scales, but less explicitly for the GAD-7. Hierarchical omega values were 0.72 for the PHQ-9 and 0.76 for the GAD-7. Both scales showed full scalar invariance and full or partial residual invariance across age, gender, education, status of diabetes and over time. Effect sizes between categories measured by unit-weighted scores versus latent means followed a similar trend but were systematically higher for the latent means. For both disorders, female gender and lower education were associated with higher symptom severity scores, which corresponds with regional and global trends.

CONCLUSIONS

For both scales, psychometric properties were comparable to studies in western settings. Distinct clinical profiles (somatic-cognitive) were supported for depression, and to a lesser extent for anxiety. Unit-weighted scores of the full scales should be used with caution, while scoring subscales is not recommended. The stability of these scales supports their use and allows for meaningful comparison across tested subgroups.

CLINICAL TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336603&isReview=true.

Retention and outcomes for clients attending a methadone clinic in a resource-constrained setting: a mixed methods prospective cohort study in Imphal, Northeast India

Background

Opioid substitution therapy (OST) with buprenorphine has been widely available in India since 2007, but the introduction of methadone occurred much later in 2012, and availability remains limited. Illicit injecting drug use is a long-standing public health problem in Manipur, a state in Northeast India characterised by major resource constraints and political unrest. We investigated retention and outcomes for clients attending a methadone-based OST program in Manipur with the aim of strengthening the evidence base for development of relevant policies and programs.

Methods

All clients enrolling in the methadone clinic over a 1 year period were invited to be part of a prospective cohort study, which followed up and surveyed both retained and defaulting clients for 12 months post-enrollment to assess retention as well as social, behavioural and mental health outcomes. Additionally, we conducted semi-structured qualitative interviews to supplement quantitative information and identify factors contributing to retention and drop-out.

Results

Of the 74 clients enrolled, 21 had dropped out and three had died (all defaulters) by 12 months post-enrollment, leaving 67.6% still in the program. Using an intention-to-treat analysis, meaningful and statistically significant gains were observed for all social, behavioural and mental health variables. Between baseline and 12 months there were reductions in needle sharing, drug use, property crime, anxiety, depression and suicidal thoughts; and improvements in physical health, mental health, quality of family relationships, employment and hopefulness. Factors contributing to retention and drop-out were identified, including the centrality of family, and general lack of awareness of and misunderstanding about methadone.

Conclusion

Even in parts of India where resources are constrained, methadone is an effective treatment for opioid dependence. Scaling up the availability of methadone elsewhere in Manipur and in other areas of India experiencing problematic opioid dependence is indicated.

High prevalence of health and social risk behaviours among men experiencing suicidal thoughts and behaviour: The imperative to undertake holistic assessments

OBJECTIVE

We aimed to examine whether suicidal thoughts and behaviour were independently associated with a wide range of health and social risk behaviours.

METHODS

We conducted cross-sectional analyses of data collected from 13,763 adult males who participated in The Australian Longitudinal Study on Male Health. We fit generalised linear models to estimate the relative risk of engaging in a range of health and social risk behaviours across several domains by suicidal thoughts and behaviour status.

RESULTS

Men with recent suicidal ideation (relative risk range, 1.10-5.25) and lifetime suicide attempts (relative risk range, 1.10-7.65) had a higher risk of engaging in a broad range of health and social risk behaviours. The associations between suicidal thoughts and behaviour and health and social risk behaviours were typically independent of socio-demographics and in many cases were also independent of depressive symptoms.

CONCLUSION

Suicidal thoughts and behaviour overlaps with increased risk of engagement in a wide range of health and social risk behaviours, indicating the need for an alignment of broader public health interventions within clinical and community-based suicide prevention activities. The experience of suicidality may be an important catalyst for a broader psychosocial conversation and assessment of health and social risk behaviours, some of which may be modifiable. These behaviours may not carry an imminent risk of premature death, such as from suicide, but they carry profound health and social consequences if left unaddressed.

Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya

BACKGROUND

Hypertension is the most important risk factor for cardiovascular diseases and the leading cause of death worldwide. Despite growing evidence that the prevalence of hypertension is rising in sub-Saharan Africa, national data on hypertension that can guide programming are missing for many countries. In this study, we estimated the prevalence of hypertension, awareness, treatment, and control. We further examined the factors associated with hypertension and awareness.

METHOD

We used data from the 2015 Kenya STEPs survey, a national cross-sectional household survey targeting randomly selected people aged 18-69 years. Demographic and behavioral characteristics as well as physical measurements were collected using the World Health Organization's STEPs Survey methodology. Descriptive statistics were used to estimate the prevalence, awareness, treatment and control of hypertension. Multiple logistic regression models were used to identify the determinants of hypertension and awareness.

RESULTS

The study surveyed 4485 participants. The overall age-standardized prevalence for hypertension was 24.5% (95% confidence interval (CI) 22.6% to 26.6%). Among individuals with hypertension, only 15.6% (95% CI 12.4% to 18.9%) were aware of their elevated blood pressure. Among those aware only 26.9%; (95% CI 17.1% to 36.4%) were on treatment and 51.7%; (95% CI 33.5% to 69.9%) among those on treatment had achieved blood pressure control. Factors associated with hypertension were older age (p < 0.001), higher body mass index (BMI) (p < 0.001) and harmful use of alcohol (p < 0.001). Similarly, factors associated with awareness were older age (p = 0.013) and being male (p < 0.001).

CONCLUSION

This study provides the first nationally-representative estimates for hypertension in Kenya. Prevalence among adults is high, with unacceptably low levels of awareness, treatment and control. The results also reveal that men are less aware of their hypertension status hence special attention should focus on this group.

Blood Pressure and Arterial Stiffness in Kenyan Adolescents With the Sickle Cell Trait

The potential association between sickle cell trait (SCT) and increased arterial stiffness/blood pressure (BP) has not been evaluated in detail despite its association with stroke, sudden death, and renal disease. We performed 24-hour ambulatory BP monitoring and arterial stiffness measurements in adolescents raised in a malaria-free environment in Kenya. Between December 2015 and June 2016, 938 randomly selected adolescents (ages 11–17 years) who had been continuous residents of Nairobi from birth were invited to participate in the study. Standard clinic BP measurement was performed, followed by 24-hour ambulatory BP monitoring and arterial stiffness measurement using an Arteriograph24 (TensioMed Ltd., Budapest, Hungary) device. SCT status was determined using DNA genotyping in contemporaneously collected blood samples. Of the 938 adolescents invited to participate, 609 (65%) provided complete data for analysis. SCT was present in 103 (15%). Mean 24-hour systolic and diastolic BPs were 116 (standard deviation (SD), 11.5) mm Hg and 64 (SD, 7) mm Hg, respectively, in children with SCT and 117 (SD, 11.4) mm Hg and 64 (SD, 6.8) mm Hg, respectively, in non-SCT children. Mean pulse wave velocity (PWV) was 7.1 (SD, 0.8) m/second and 7.0 (SD, 0.8) m/second in SCT and non-SCT children, respectively. We observed no differences in PWV or in any clinic or ambulatory BP-derived measures between adolescents with and without SCT. These data suggest that SCT does not independently influence BP or PWV.

Blood Pressure and Arterial Stiffness in Kenyan Adolescents With α+Thalassemia

Background

Recent studies have discovered that α‐globin is expressed in blood vessel walls where it plays a role in regulating vascular tone. We tested the hypothesis that blood pressure (BP) might differ between normal individuals and those with α⁺thalassemia, in whom the production of α‐globin is reduced.

Methods and Results

The study was conducted in Nairobi, Kenya, among 938 adolescents aged 11 to 17 years. Twenty‐four‐hour ambulatory BP monitoring and arterial stiffness measurements were performed using an arteriograph device. We genotyped for α⁺thalassemia by polymerase chain reaction. Complete data for analysis were available for 623 subjects; 223 (36%) were heterozygous (−α/αα) and 47 (8%) were homozygous (−α/−α) for α⁺thalassemia whereas the remaining 353 (55%) were normal (αα/αα). Mean 24‐hour systolic BP ±SD was 118±12 mm Hg in αα/αα, 117±11 mm Hg in −α/αα, and 118±11 mm Hg in −α/−α subjects, respectively. Mean 24‐hour diastolic BP ±SD in these groups was 64±8, 63±7, and 65±8 mm Hg, respectively. Mean pulse wave velocity (PWV)±SD was 7±0.8, 7±0.8, and 7±0.7 ms⁻¹, respectively. No differences were observed in PWV and any of the 24‐hour ambulatory BP monitoring‐derived measures between those with and without α⁺thalassemia.

Conclusions

These data suggest that the presence of α⁺thalassemia does not affect BP and/or arterial stiffness in Kenyan adolescents.

Regional and Sex Differences in the Prevalence and Awareness of Hypertension: An H3Africa AWI-Gen Study Across 6 Sites in Sub-Saharan Africa

BACKGROUND

There is a high prevalence of hypertension and related cardiovascular diseases in sub-Saharan Africa, yet few large studies exploring hypertension in Africa are available. The actual burden of disease is poorly understood and awareness and treatment to control it is often suboptimal.

OBJECTIVES

The study sought to report the prevalence of measured hypertension and to assess awareness and control of blood pressure among older adults in rural and urban settings in 6 sites located in West, East, and Southern Africa. In addition, we examined regional, sex, and age differences related to hypertension.

METHODS

A population-based cross-sectional study was performed at 6 sites in 4 African countries: Burkina Faso (Nanoro), Ghana (Navrongo), Kenya (Nairobi), and South Africa (Agincourt, Dikgale, Soweto). Blood pressure measurements were taken using standardized procedures on 10,696 adults 40 to 60 years of age. Hypertension was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or taking antihypertensive medication.

RESULTS

The mean prevalence of hypertension ranged from 15.1% in Nanoro to 54.1% in Soweto. All 3 of the South African sites had a mean prevalence of hypertension of over 40.0%, significantly higher than in Nairobi (25.6%) and Navrongo (24.5%). Prevalence increased with age in both sexes and at all sites. A significantly higher prevalence of hypertension was observed in women in Agincourt, Dikgale, and Nairobi, whereas in Nanoro this trend was reversed. Within the hypertensive group the average proportion of participants who were aware of their blood pressure status was only 39.4% for men and 53.8% for women, and varied widely across sites.

CONCLUSIONS

Our study demonstrates that the prevalence of hypertension and the level of disease awareness differ not only between but also within sub-Saharan African countries. Each nation must tailor their regional hypertension awareness and screening programs to match the characteristics of their local populations.

Improving the health and welfare of people who live in slums

In the first paper in this Series we assessed theoretical and empirical evidence and concluded that the health of people living in slums is a function not only of poverty but of intimately shared physical and social environments. In this paper we extend the theory of so-called neighbourhood effects. Slums offer high returns on investment because beneficial effects are shared across many people in densely populated neighbourhoods. Neighbourhood effects also help explain how and why the benefits of interventions vary between slum and non-slum spaces and between slums. We build on this spatial concept of slums to argue that, in all low-income and-middle-income countries, census tracts should henceforth be designated slum or non-slum both to inform local policy and as the basis for research surveys that build on censuses. We argue that slum health should be promoted as a topic of enquiry alongside poverty and health.

The history, geography, and sociology of slums and the health problems of people who live in slums

Massive slums have become major features of cities in many low-income and middle-income countries. Here, in the first in a Series of two papers, we discuss why slums are unhealthy places with especially high risks of infection and injury. We show that children are especially vulnerable, and that the combination of malnutrition and recurrent diarrhoea leads to stunted growth and longer-term effects on cognitive development. We find that the scientific literature on slum health is underdeveloped in comparison to urban health, and poverty and health. This shortcoming is important because health is affected by factors arising from the shared physical and social environment, which have effects beyond those of poverty alone. In the second paper we will consider what can be done to improve health and make recommendations for the development of slum health as a field of study.