Community groups or mobile phone messaging to prevent and control type 2 diabetes and intermediate hyperglycaemia in Bangladesh (DMagic): a cluster-randomised controlled trial

The Role of Digital Health Technology Interventions in the Prevention of Type 2 Diabetes Mellitus: A Systematic Review

Objectives

Diabetes in the 21st century presents one of the greatest burdens of disease on the global population. Digitally mediated interventions have become imperative in alleviating this disease epidemic. We aimed to systematically review randomized controlled trials (RCTs) on different health technologies for preventing Type 2 diabetes mellitus, and their efficacy in decreasing diabetes risk-related outcomes in at-risk patients in comparison to standard care.

Methods

Five electronic databases were searched between October 2021 and December 2022. Studies including digital health technology interventions used for preventing diabetes development by reducing diabetes risk-related outcomes in at-risk adults (⩾18 years) were identified. Data on glycemic levels, incidence of T2DM, weight, and intervention descriptions were extracted, and the risk of bias (ROB) was assessed.

Results

Nine studies met the inclusion criteria and 5 studies (56%) achieved clinically significant outcomes in at least one of the following: decreased weight (22%), glycemic levels (22%), or incidence of T2DM (11%). Two of the 3 (67%) computer-based interventions effectively reduced the HbA1c levels and mean weight of their study population, and 3 of 6 (50%) mobile based interventions (text messages, mobile app, and telehealth) decreased the incidence of T2DM and HbA1c levels. Four studies each had an overall low ROB and one had a high ROB due to attrition.

Conclusion

Preliminary evidence identified in our review demonstrated that health technologies for diabetes prevention are effective for improving diabetes risk-related outcomes. Future research into digital technology protocol and studies of longer duration and more diverse populations are needed for clinical feasibility.

Informing nursing policy: An exploration of digital health research by nurses in England

AIMS

Digital health technologies are designed, implemented, and evaluated to support clinical practice, enable patients to self-manage illness, and further public and global health. Nursing and health policies often emphasise the importance of evidence-based digital health services to deliver better care. However, the contribution nurses make to digital health research in many countries is unknown. Hence, this study aims to examine digital health research conducted by nurses in England.

DESIGN

A bibliometric analysis.

METHODS

The CINAHL, MEDLINE, and Scopus databases were searched between 2000 and 2022, and supplemented with a hand search of nurses' research profiles. Results were screened by title, abstract, and full text against eligibility criteria. Data were extracted and bibliometric analysis used to summarise the findings.

RESULTS

Mental health nurses produced the most digital health research in England, followed by nurses working in community care, with several disciplines underrepresented or missing. Web/online health services or information was the most researched technology, followed by mobile health and telehealth. Nurses based in the south-east and north-west of England produced the most digital health research, with other regions less well represented.

CONCLUSION

Nurse leaders should support nurses to conduct more digital health research by providing dedicated time, funding, and professional development opportunities, particularly in under researched clinical areas, technologies, and geographic regions to further evidence-based practice and patient care. More digital nursing data is needed to support nurse led research in areas like artificial intelligence and data science. The findings supported the national Philips Ives Review by identifying areas of digital nursing research that need more investment in England.

Feasibility of prevention of type 2 diabetes in low- and middle-income countries

Type 2 diabetes is a leading cause of global mortality and morbidity. Nearly 80% of individuals with diabetes live in low- and middle-income countries (LMICs), where nearly half of those with the condition remain undiagnosed. The majority of known cases have sub-optimal clinical outcomes. Moreover, large populations with impaired glucose tolerance and/or impaired fasting glucose contribute to the rapid increase in type 2 diabetes. Globally, priority should be given to limit the population with diabetes, especially in LMICs, alongside actions to optimise the care of people diagnosed with diabetes. Primary prevention studies in LMICs have generated evidence to show the efficacy and scalability of strategies to fully prevent or delay the development of diabetes in high-risk groups. However, these are mainly limited to certain countries in Asia, particularly China and India. The studies have indicated that prevention policies are effective in populations with a high risk of type 2 diabetes, and they also have long-term benefits, not only for the risk of type 2 diabetes but also for the risk of associated metabolic disorders, such as CVDs. For the effective conduct of national programmes, innovative mechanisms must be implemented, such as the use of information technology, joint efforts of multiple teams implementing similar programmes, and involvement of governmental and non-governmental partnerships. Continuous monitoring and long-term studies are required to assess the utility of these programmes. The effectiveness of such programmes in LMICs has not been proven over the longer term, except in China. Despite the available evidence, the feasibility of prevention strategies for type 2 diabetes in LMICs at population level remains an enigma. There remain challenges in the form of cultural, societal and economic constraints; insufficient infrastructure and healthcare capacity; and the non-fully elucidated natural history and determinants of type 2 diabetes in LMICs.

Cost effectiveness of nonpharmacological prevention programs for diabetes: A systematic review of trial-based studies

Trial-based economic value of prevention programs for diabetes is inexplicit. We aimed to review the cost-effectiveness of nonpharmacological interventions to prevent type-2 diabetes mellitus (T2DM) for high-risk people. Six electronic databases were searched up to March 2022. Studies assessing both the cost and health outcomes of nonpharmacological interventions for people at high-risk of T2DM were included. The quality of the study was assessed by the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. The primary outcome for synthesis was incremental cost-effectiveness ratios (ICER) for quality-adjusted life years (QALYs), and costs were standardized in 2022 US dollars. Narrative synthesis was performed, considering different types and delivery methods of interventions. Sixteen studies included five based on the US diabetes prevention program (DPP), six on non-DPP-based lifestyle interventions, four on health education, and one on screening plus lifestyle intervention. Compared with usual care, lifestyle interventions showed higher potential of cost-effectiveness than educational interventions. Among lifestyle interventions, DPP-based programs were less cost-effective (median of ICERs: $27,077/QALY) than non-DPP-based programs (median of ICERs: $1395/QALY) from healthcare perspectives, but with larger decreases in diabetes incidence. Besides, the cost-effectiveness of interventions was more possibly realized through the combination of different delivery methods. Different interventions to prevent T2DM in high-risk populations are both cost-effective and feasible in various settings. Nevertheless, economic evidence from low- and middle-income countries is still lacking, and interventions delivered by trained laypersons and combined with peer support sessions or mobile technologies could be potentially a cost-effective solution in such settings with limited resources.

Enhanced or hindered research benefits? A realist review of community engagement and participatory research practices for non-communicable disease prevention in low- and middle-income countries

INTRODUCTION

Community engagement and participatory research are widely used and considered important for ethical health research and interventions. Based on calls to unpack their complexity and observed biases in their favour, we conducted a realist review with a focus on non-communicable disease prevention. The aim was to generate an understanding of how and why engagement or participatory practices enhance or hinder the benefits of non-communicable disease research and interventions in low- and middle-income countries.

METHODS

We retroductively formulated theories based on existing literature and realist interviews. After initial searches, preliminary theories and a search strategy were developed. We searched three databases and screened records with a focus on theoretical and empirical relevance. Insights about contexts, strategies, mechanisms and outcomes were extracted and synthesised into six theories. Five realist interviews were conducted to complement literature-based theorising. The final synthesis included 17 quality-appraised articles describing 15 studies.

RESULTS

We developed six theories explaining how community engagement or participatory research practices either enhance or hinder the benefits of non-communicable disease research or interventions. Benefit-enhancing mechanisms include community members' agency being realised, a shared understanding of the benefits of health promotion, communities feeling empowered, and community members feeling solidarity and unity. Benefit-hindering mechanisms include community members' agency remaining unrealised and participation being driven by financial motives or reputational expectations.

CONCLUSION

Our review challenges assumptions about community engagement and participatory research being solely beneficial in the context of non-communicable disease prevention in low- and middle-income countries. We present both helpful and harmful pathways through which health and research outcomes are affected. Our practical recommendations relate to maximising benefits and minimising harm by addressing institutional inflexibility and researcher capabilities, managing expectations on research, promoting solidarity in solving public health challenges and sharing decision-making power.

Investigating the use and awareness of artificial sweeteners among diabetic patients in Bangladesh

BACKGROUND

As with many countries around the world, the incidence of diabetes in Bangladesh is increasing significantly. Whilst there is controversy in the field regarding the health impact of artificial sweeteners in Western communities, the link between sweetener consumption and awareness in Bangladesh has not been established.

METHODS

In the present study, 260 diabetic patients completed a questionnaire survey to investigate the use and awareness of sweeteners and how this links to demographics and potential co-morbidities.

RESULTS

Findings show that daily artificial sweetener consumption is significantly associated with hypertension but not other co-morbidities such as kidney disease or obesity. We further demonstrate that there is limited checking of artificial sweeteners in food or drink products by participants. the rurality of diabetic participants was found to significantly correlates with lower awareness of any health impact of artificial sweeteners.

CONCLUSIONS

The findings from this study demonstrate that there is a need to increase the awareness of artificial sweetener use in diabetic patients in Bangladesh. Combined with a more robust understanding of the health impact of artificial sweeteners, these findings suggest that there is potential to improve outcomes for diabetic patients by improving this awareness.

The burden of diseases and risk factors in Bangladesh, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Bangladesh has made substantial progress in improving socioeconomic and health indicators over the past 50 years, but data on national disease burden are scarce. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to estimate the burden of diseases and risk factors in Bangladesh from 1990 to 2019.

METHODS

For this systematic analysis, we analysed data from vital registration systems, surveys, and censuses using multistage modelling processes to estimate life expectancy at birth, mortality rate, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs). Additionally, we compared the health status of Bangladesh with that of the other countries in the GBD south Asia region-Bhutan, India, Nepal, and Pakistan.

FINDINGS

Life expectancy at birth in Bangladesh increased from 58·2 years (95% uncertainty interval 57·1-59·2) in 1990 to 74·6 years (72·4-76·7) in 2019. Between 1990 and 2019, the age-standardised mortality rate decreased from 1509·3 (1428·6-1592·1) to 714·4 (604·9-838·2) deaths per 100 000 population. In 2019, non-communicable diseases represented 14 of the top 20 causes of death; the leading three causes were stroke, ischaemic heart disease, and chronic obstructive pulmonary disease. High blood pressure, high fasting plasma glucose, and smoking were the top three risk factors. From 1990 to 2019, the rate of all-cause DALYs decreased by 54·9% (48·8-60·4). In 2019, the leading causes of DALYs and YLLs were neonatal disorders, stroke, and ischaemic heart disease, whereas musculoskeletal disorders, depressive disorders, and low back pain were the leading causes of YLDs. Bangladesh has the lowest age-standardised rates of mortality, YLDs, and YLLs and the highest life expectancy at birth in south Asia.

INTERPRETATION

Over the past 30 years, mortality rates have reduced by more than half in Bangladesh. Bangladesh must now address the double burden of communicable and non-communicable diseases. Cost-effective, multisectoral efforts are needed to prevent and control non-communicable diseases, promote healthy lifestyles, and prevent premature mortality and disabilities.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATION

For the Bangla translation of the abstract see Supplementary Materials section.

Dietary outcomes of community-based CVD preventive interventions: a systematic review and meta-analysis

OBJECTIVE

We aimed to synthesise available evidence on the effects of community-based interventions in improving various dietary outcome measures.

DESIGN

Systematic review and meta-analysis.

SETTING

We searched databases including Medline, EMBASE, PSYCINFO, CINAHL and the Cochrane registry for studies reported between January 2000 and June 2022. The methodological quality of the included studies was evaluated using the Cochrane risk of bias tools for each study type. For some of the outcomes, we pooled the effect size using a random-effects meta-analysis.

PARTICIPANTS

A total of fifty-one studies, thirty-three randomised and eighteen non-randomised, involving 100 746 participants were included.

RESULTS

Overall, thirty-seven studies found a statistically significant difference in at least one dietary outcome measure favouring the intervention group, whereas fourteen studies found no statistically significant difference. Our meta-analyses indicated that, compared with controls, interventions were effective in decreasing daily energy intake (MJ/d) (mean difference (MD): -0·25; 95 % CI: -0·37, -0·14), fat % of energy (MD: -1·01; 95 % CI: -1·76, -0·25) and saturated fat % of energy (MD: -1·54; 95 % CI: -2·01, -1·07). Furthermore, the interventions were effective in improving fibre intake (g/d) (MD: 1·08; 95 % CI: 0·39, 1·77). Effective interventions use various strategies including tailored individual lifestyle coaching, health education, health promotion activities, community engagement activities and/or structural changes.

CONCLUSION

This review shows the potential of improving dietary patterns through community-based CVD preventive interventions. Thus, development and implementation of context-specific preventive interventions could help to minimise dietary risk factors, which in turn decrease morbidity and mortality due to CVD and other non-communicable diseases.

Understanding multilevel barriers to childhood vaccination uptake among Internally Displaced Populations (IDPs) in Mogadishu, Somalia: a qualitative study

BACKGROUND

Disparities in vaccination coverage exist in Somalia with Internally Displaced Persons (IDPs) being among the groups with the lowest coverage. We implemented an adapted Participatory Learning and Action (PLA) intervention, which focused on routine vaccinations among displaced populations living in Mogadishu IDP camps. The intervention was successful in improving maternal knowledge and vaccination coverage but unsuccessful in improving timely vaccination. We conducted a qualitative study to understand this result and analyze the multi-level barriers to routine childhood immunization uptake.

METHOD

In this qualitative study we used observation data from 40 PLA group discussions with female caregivers and purposively sampled nine vaccination service providers and six policy makers for interview. We also reviewed national-level vaccine policy documents and assessed the quality of health facilities in the study area. We used the socioecological framework to structure our analysis and analyzed the data in NVivo.

RESULTS

The barriers to childhood vaccination among IDPs at the individual level were fear due to lack of knowledge, mistrust of vaccines, concerns about side effects and misinformation; opportunity costs; and costs of transportation. At the interpersonal level, family members played an important role as did the extent of decision-making autonomy. Community factors such as cultural practices, gender roles, and household evictions influenced vaccination. Organizational issues at health facilities such as waiting times, vaccine stock-outs, distance to the facility, language differences, and hesitancy of health workers to open multi-dose vials affected vaccination. At the policy level, confusion about the eligible age for routine vaccination and age restrictions for catch-up vaccination and certain antigens such as BCG were important barriers.

CONCLUSION

Complex and interrelated factors affect childhood vaccination uptake among IDPs in Somalia. Interventions that address multiple barriers simultaneously will have the greatest impact given the complex nature of vulnerabilities in this population. There is a need to strengthen the health system and connect it with existing community structures to increase demand for services. Our research highlights the importance of formative research before implementing interventions. Further research on the integration of health service strengthening with PLA to improve childhood vaccination among IDPs is recommended.

TRIAL REGISTRATION NUMBER

ISRCTN-83,172,390. Date of registration: 03/08/2021.

Economic evaluation of self-help group interventions for health in LMICs: a scoping review

This scoping review aims to identify and critically appraise published economic evaluations of self-help group (SHG) interventions in low- and middle-income countries (LMICs) that seek to improve health and potentially also non-health outcomes. Through a systematic search of MEDLINE ALL (Ovid), EMBASE Ovid, PsychINFO, EconLit (Ovid) and Global Index Medicus, we identified studies published between 2014 and 2020 that were based in LMICs, included at least a health outcome, estimated intervention costs and reported the methods used. We critically analysed whether the methods employed can meaningfully inform decisions by ministries of health and other sectors, including donors, regarding whether to fund such interventions, and prioritized the aspects of evaluations that support decision-making and cross-sectoral decision-making especially. Nine studies met our inclusion criteria. Randomized controlled trials were the most commonly used vehicle to collect data and to establish a causal effect across studies. While all studies clearly stated one or more perspectives justifying the costs and effects that are reported, few papers clearly laid out the decision context or the decision maker(s) informed by the study. The latter is required to inform which costs, effects and opportunity costs are relevant to the decision and should be included in the analysis. Costs were typically reported from the provider or health-care sector perspective although other perspectives were also employed. Four papers reported outcomes in terms of a generic measure of health. Contrary to expectation, no studies reported outcomes beyond health. Our findings suggest limitations in the extent to which published studies are able to inform decision makers around the value of implementing SHG interventions in their particular context. Funders can make better informed decisions when evidence is presented using a cross-sectoral framework.

A Culturally Adapted Diet and Physical Activity Text Message Intervention to Prevent Type 2 Diabetes Mellitus for Women of Pakistani Origin Living in Scotland: Formative Study

BACKGROUND

Individuals of South Asian origin are at an increased risk of developing type 2 diabetes mellitus (T2DM) compared with other ethnic minority groups. Therefore, there is a need to develop interventions to address, and reduce, this heightened risk.

OBJECTIVE

We undertook formative work to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland.

METHODS

We used a stepwise approach that was informed by the Six Steps in Quality Intervention Development framework, which consisted of gathering evidence through literature review and focus groups (step 1), developing a program theory for the intervention (step 2), and finally developing the content of the text messages and an accompanying delivery plan (step 3).

RESULTS

In step 1, we reviewed 12 articles and identified 3 key themes describing factors impacting on diet and physical activity in the context of T2DM prevention: knowledge on ways to prevent T2DM through diet and physical activity; cultural, social, and gender norms; and perceived level of control and sense of inevitability over developing T2DM. The key themes that emerged from the 3 focus groups with a total of 25 women were the need for interventions to provide "friendly encouragement," "companionship," and a "focus on the individual" and also for the text messages to "set achievable goals" and include "information on cooking healthy meals." We combined the findings of the focus groups and literature review to create 13 guiding principles for culturally adapting the text messages. In step 2, we developed a program theory, which specified the main determinants of change that our text messages should aim to enhance: knowledge and skills, sense of control, goal setting and planning behavior, peer support, and norms and beliefs guiding behavior. In step 3, we used both the intervention program theory and guiding principles to develop a set of 73 text messages aimed at supporting a healthy diet and 65 text messages supporting increasing physical activity.

CONCLUSIONS

We present a theory-based approach to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. This study outlines an approach that may also be applicable to the development of interventions for other ethnic minority populations in diverse settings. There is now a need to build on this formative work and undertake a feasibility trial of a text message-based diet and physical activity intervention to prevent T2DM for women of Pakistani origin living in Scotland.

Association of CAPN10 gene (rs3842570) polymorphism with the type 2 diabetes mellitus among the population of Noakhali region in Bangladesh: a case-control study

Type 2 diabetes mellitus (T2DM) is a multifactorial, polygenic, and metabolically complicated disease. A large number of genes are responsible for the biogenesis of T2DM and calpain10 (CAPN10) is one of them. The association of numerous CAPN10 genetic polymorphisms in the development of T2DM has been widely studied in different populations and noticed inconclusive results. The present study is an attempt to evaluate the plausible association of CAPN10 polymorphism SNP-19 (rs3842570) with T2DM and T2DM-related anthropometric and metabolic traits in the Noakhali region of Bangladesh. This case-control study included 202 T2DM patients and 75 healthy individuals from different places in Noakhali. A significant association (p < 0.05) of SNP-19 with T2DM in co-dominant 2R/3R vs. 3R/3R (odds ratio [OR], 2.7; p=0.0014) and dominant (2R/3R) + (2R/2R) vs. 3R/3R (OR, 2.47; p=0.0011) genetic models was observed. High-risk allele 2R also showed a significant association with T2DM in the allelic model (OR, 1.67; p=0.0109). The genotypic frequency of SNP-19 variants showed consistency with Hardy-Weinberg equilibrium (p > 0.05). Additionally, SNP-19 genetic variants showed potential associations with the anthropometric and metabolic traits of T2DM patients in terms of body mass index, systolic blood pressure, diastolic blood pressure, total cholesterol, and triglycerides. Our approach identifies the 2R/3R genotype of SNP-19 as a significant risk factor for biogenesis of T2DM in the Noakhali population. Furthermore, a large-scale study could be instrumental to correlate this finding in overall Bangladeshi population.

Whose knowledge counts? Involving communities in intervention and trial design using community conversations

BACKGROUND

Current debates in Global Health call for expanding methodologies to allow typically silenced voices to contribute to processes of knowledge production and intervention design. Within trial research, this has typically involved small-scale qualitative work, with limited opportunities for citizens to contribute to the structure and nature of the trial. This paper reports on efforts to move past typical formative trial work, through adaptation of community conversations (CCs) methodology, an action-oriented approach that engages large numbers of community members in dialogue. We applied the CC method to explore community perspectives about pneumonia and managing the health of children under-5 in Northern Nigeria to inform our pragmatic cluster randomised controlled trial evaluating a complex intervention to reduce under-5 mortality in Nigeria.

METHODS

We conducted 12 rounds of community conversations with a total of 320 participants, in six administrative wards in Kiyawa Local Government Area, Jigawa state, our intervention site. Participants were male and female caregivers of children under five. Conversations were structured around participatory learning and action activities, using drawings and discussion to reduce barriers to entry. During activities participants were placed in subgroups: younger women (18-30 years of age), older women (31-49 years) and men (18 years above). Discussions were conducted over three 2-h sessions, facilitated by community researchers. Following an initial analysis to extract priority issues and perspectives on intervention structure, smaller focus group discussions were completed with participants in five new sites to ensure all 11 administrative wards in our study site contributed to the design.

RESULTS

We identified enabling and limiting factors which could shape the future trial implementation, including complex power relationships within households and wider communities shaping women's health decision-making, and the gendered use of space. We also noted the positive engagement of participants during the CC process, with many participants valuing the opportunity to express themselves in ways they have not been able to in the past.

CONCLUSIONS

CCs provide a structured approach to deep meaningful engagement of everyday citizens in intervention and trial designs, but require appropriate resources, and commitment to qualitative research in trials.

TRIAL REGISTRATION

ISRCTN39213655. Registered on 11 December 2019.

Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study

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.

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

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.

Use of an adapted participatory learning and action cycle to increase knowledge and uptake of child vaccination in internally displaced persons camps (IVACS): A cluster-randomised controlled trial

BACKGROUND

Vaccination is a key public health intervention that can reduce excess mortality in humanitarian contexts. Vaccine hesitancy is thought to be a significant problem requiring demand side interventions. Participatory Learning and Action (PLA) approaches have proven effective in reducing perinatal mortality in low income settings and we aimed to apply an adapted approach in Somalia.

METHODS

A randomised cluster trial was implemented in camps for internally displaced people near Mogadishu, from June to October 2021. An adapted PLA approach (hPLA) was used in partnership with indigenous 'Abaay-Abaay' women's social groups. Trained facilitators ran 6 meeting cycles that addressed topics of child health and vaccination, analysed challenges, and planned and implemented potential solutions. Solutions included a stakeholder exchange meeting involving Abaay-Abaay group members and services providers from humanitarian organisations. Data was collected at baseline and after completion of the 3 month intervention cycle.

RESULTS

Overall, 64.6% of mothers were group members at baseline and this increased in both arms during the intervention (p = 0.016). Maternal preference for getting young children vaccinated was >95% at baseline and did not change. The hPLA intervention improved the adjusted maternal/caregiver knowledge score by 7.9 points (maximum possible score 21) compared to the control (95% CI 6.93, 8.85; p < 0.0001). Coverage of both measles vaccination (MCV1) (aOR 2.43 95% CI 1.96, 3.01; p < 0.001) and completion of the pentavalent vaccination series (aOR 2.45 95% CI 1.27, 4.74; p = 0.008) also improved. However, adherence to timely vaccination did not (aOR 1.12 95% CI 0.39, 3.26; p = 0.828). Possession of a home-based, child health record card increased in the intervention arm from 18 to 35% (aOR 2.86 95% CI 1.35, 6.06; p = 0.006).

CONCLUSION

A hPLA approach, run in partnership with indigenous social groups, can achieve important changes in public health knowledge and practice in a humanitarian context. Further work to scale up the approach and address other vaccines and population groups is warranted.

Intermediate hyperglycaemia, diabetes and blood pressure in rural Bangladesh: five-year post-randomisation follow-up of the DMagic cluster-randomised controlled trial

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.

Accelerating UN Sustainable Development Goals with AI-Driven Technologies: A Systematic Literature Review of Women's Healthcare

In this paper, we critically examine if the contributions of artificial intelligence (AI) in healthcare adequately represent the realm of women's healthcare. This would be relevant for achieving and accelerating the gender equality and health sustainability goals (SDGs) defined by the United Nations. Following a systematic literature review (SLR), we examine if AI applications in health and biomedicine adequately represent women's health in the larger scheme of healthcare provision. Our findings are divided into clusters based on thematic markers for women's health that are commensurate with the hypotheses that AI-driven technologies in women's health still remain underrepresented, but that emphasis on its future deployment can increase efficiency in informed health choices and be particularly accessible to women in small or underrepresented communities. Contemporaneously, these findings can assist and influence the shape of governmental policies, accessibility, and the regulatory environment in achieving the SDGs. On a larger scale, in the near future, we will extend the extant literature on applications of AI-driven technologies in health SDGs and set the agenda for future research.

Effect of a Nurse-Led Intervention on Knowledge of the Modifiable Risk Behaviors of Cardiovascular Disease: A Randomized Controlled Trial

Introduction

Cardiovascular disease (CVD) has disproportionately burdened the low- and middle-income countries where awareness and detection rates remain very low. Interventions directed to promote the community's awareness of CVD may help reduce the public's exposure to behavioral risk factors. However, the effectiveness of interventions implemented through a nurse on knowledge of the modifiable behavioral risk factors and preventive measures of CVD has not been determined in Kenya.

Objective

To establish the effect of a nurse-led intervention on knowledge of the modifiable risk behaviors of CVD in adults with metabolic syndrome (MetS) attending a mission-based hospital in Kenya.

Methods

A two-armed parallel-group randomized controlled trial design was conducted among 352 adults aged 18-64 years with MetS. The participants were recruited from a faith-based hospital in Nairobi, Kenya and randomly allocated to either a nurse-led lifestyle intervention or a control group. The intervention group received a comprehensive health education intervention using the World Health Organization (WHO) guideline recommendations for CVD control and prevention. Individuals in the control group were exposed to the usual CVD care according to hospital protocol. The duration of the intervention was 12 months. The primary outcome measure was a change in levels of knowledge on the modifiable risk factors and preventive measures of CVD. Outcome measures were assessed at baseline and at 15 months postintervention. Pre- and postintervention difference in the level of knowledge between the two groups was determined using the chi-square test of independence.

Results

The knowledge level of CVD risk factors and preventive measures was very low in both groups at baseline without significant difference. A significant improvement in the level of knowledge on CVD risk factors (78.2% vs. 30.4%, p < .001) and preventive measures (74.4% vs. 29.0%, p < .001) was observed in the intervention group relative to the control at the end-line.

Conclusions

The nurse-led lifestyle intervention significantly improved participants' level of knowledge on CVD risk factors and preventive measures. It is highly recommended that nurses incorporate routine health education interventions for patients with cardio-metabolic abnormalities.

The effectiveness of lifestyle interventions on type 2 diabetes and gestational diabetes incidence and cardiometabolic outcomes: A systematic review and meta-analysis of evidence from low- and middle-income countries

BACKGROUND

As lifestyle modification offers a unique strategy to prevent diabetes, we evaluated the effectiveness of lifestyle interventions in the prevention of type 2 diabetes and gestational diabetes in low- and middle-income countries (LMICs).

METHODS

We did a systematic literature review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and Cochrane Library for randomised controlled trials published in English, Spanish, French, and Portuguese between 1 January 2000 and 15 June 2022, evaluating multi-target and multi-component lifestyle interventions in at-risk populations conducted in LMICs. The main outcomes were incidence of type 2 diabetes and gestational diabetes, and indicators of glycaemic control. We assessed the methodological quality of the studies using the Cochrane risk of bias tool. Inverse-variance random-effects meta-analyses estimated the overall effect sizes. Sources of heterogeneity and study bias were evaluated. The study protocol was registered in PROSPERO (CRD42021279174).

FINDINGS

From 14 330 abstracts, 48 (0·3%) studies with 50 interventions were eligible of which 56% were conducted in lower-middle-income countries, 44% in upper-middle, and none in low-income. 54% of the studies were assessed as moderate risk of bias and 14% as high risk. A median of 246 (IQR 137-511) individuals participated in the interventions with a median duration of 6 (3-12) months. Lifestyle interventions decreased the incidence risk ratio of type 2 diabetes by 25% (0·75 [95% CI 0·61 to 0·91]), and reduced the levels of HbA1c by 0·15% [-0·25 to -0·05], fasting plasma glucose by 3·44 mg/dL [-4·72 to -2·17], and 2-hr glucose tolerance by 4·18 mg/dL [-7·35 to -1·02]. No publication bias was suggested for these outcomes. High levels of heterogeneity (I²≥ 81%) were found in most meta-analyses. Exploration using meta-regressions could not identify any explanatory variable, except for fasting glucose for which the quality score of the articles seems to be an effect modifier decreasing slightly the heterogeneity (72%) in the low risk of bias pooled estimate. The effect on gestational diabetes could not be evaluated due to the scarcity of available studies.

INTERPRETATION

Comprehensive lifestyle interventions are effective strategies to prevent type 2 diabetes among at-risk populations in LMICs. The heterogeneity identified in our results should be considered when using these interventions to address the onset of type 2 diabetes.

FUNDING

None.

Association of admission hyperglycemia and all-cause mortality in acute myocardial infarction with percutaneous coronary intervention: A dose–response meta-analysis

Objective

The aim of this study is to evaluate the associations between admission hyperglycemia and the risk of all-cause mortality in patients with acute myocardial infarction (AMI) with or without diabetes, to find optimal admission glucose intervention cut-offs, and to clarify the shape of the dose–response relations.

Methods

Medline/PubMed and EMBASE were searched from inception to 1 April 2022. Cohort studies reporting estimates of all-cause mortality risk in patients with admission hyperglycemia with AMI were included. The outcomes of interest include mortality and major adverse cardiac events (MACEs). A random effect dose–response meta-analysis was conducted to access linear trend estimations. A one-stage linear mixed effect meta-analysis was used for estimating dose–response curves. Relative risks and 95% confidence intervals were pooled using a random-effects model.

Results

Of 1,222 studies screened, 47 full texts were fully reviewed for eligibility. The final analyses consisted of 23 cohort studies with 47,177 participants. In short-term follow-up, admission hyperglycemia was associated with an increased risk of all-cause mortality (relative risk: 3.12, 95% confidence interval 2.42–4.02) and MACEs (2.34, 1.77–3.09). In long-term follow-up, admission hyperglycemia was associated with an increased risk of all-cause mortality (1.97, 1.61–2.41) and MACEs (1.95, 1.21–3.14). A linear dose–response association was found between admission hyperglycemia and the risk of all-cause mortality in patients with or without diabetes.

Conclusion

Admission hyperglycemia was significantly associated with higher all-cause mortality risk and rates of MACEs. However, the association between admission hyperglycemia and long-term mortality risk needs to be determined with caution. Compared with current guidelines recommendations, a lower intervention cut-off and more stringent targets for admission hyperglycemia may be appropriate.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022317280], identifier [CRD42022317280].

Type and effectiveness of community-based interventions in improving knowledge related to cardiovascular diseases and risk factors: A systematic review

Background: Despite an improvement in the healthcare system, cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality worldwide. Improving knowledge is a key for behavioral change towards prevention of CVDs. However, up-to-date evidence is limited on the effect of interventions on CVD knowledge. Thus this study aimed to synthesize comprehensive evidence on the type and effectiveness of community-based interventions (CBIs) to improve knowledge related to CVDs. Methods: We performed a systematic review of studies that tested the effectiveness of CBIs in improving CVD knowledge. International databases including MEDLINE, EMBASE, CINAHL, PSYCINFO and Cochrane register of controlled studies were searched for studies published between January 2000 and December 2019. The Cochrane risk of bias tools were used to assess the methodological quality of included studies. Since CVD knowledge was measured using various tools, results were synthesized narratively and reported in line with the reporting guideline for Synthesis Without Meta-analysis (SWiM). The review protocol is registered in the PROSPERO database (CRD42019119885). Results: 7 randomized and 9 non-randomized controlled trials involving 34,845 participants were included. Most of the interventions targeted the general population and majorities delivered the intervention to groups of individuals. Likewise, most of the interventions employed various intervention components including health education using different strategies. Overall, most studies showed that CBIs significantly improved knowledge related to CVDs. Conclusion: Community-based CVD preventive interventions are effective in improving knowledge related to CVD and risk factors. Measures to scale up CBIs are recommended to improve an individual's level of CVD knowledge, which potentially helps to counter the growing burden of CVDs.

The impact of telehealth on self-management of patients with type 2 diabetes: A systematic review on interventional studies

BACKGROUND AND AIMS

Self-management is critical to manage the glycemic and metabolic outcomes for patients with diabetes. Telehealth applications are recognized as a potential approach to promote self-management of people with type 2 diabetes. This study aimed to investigate the impact of telehealth on self-management among patients with type 2 diabetes.

METHODS

A systematic review was conducted on several databases, including PubMed, EbscoHost Medline, and Science Direct, with the keywords: Diabetes Mellitus AND Mobile-phone based OR Telemedicine OR Telehealth OR Web-based OR Telenursing AND Self-management. Inclusion criteria were articles with type 2 diabetic respondents, published between 2015 and 2020, open-access articles, and had self-management as outcomes. Hence, qualitative, protocol, or review articles, commentaries, letters to editors, and case study/reports were excluded. The Joanna Briggs Institute critical appraisal tools and Cochrane collaboration's tools were used for assessing risk of bias.

RESULTS

The total of six studies were included in the qualitative synthesis, with five randomized control trials and one cross-sectional study. Telehealth applications were formed as an online or app-based platform with the key features of educational programs, text or voice messages, consultations and counseling, and active participation of the subjects. Besides improving the self-management outcomes, the telehealth also indicated improvements in positive behaviors, attitudes, and the intention of self-management.

CONCLUSION

The study concluded that implementation of telehealth provided positive self-management results among patients with type 2 diabetes. The users need to consider an intensive training, peer or family support, and provision of full support for the patients during the implementation of telehealth.

Effects of technology-based interventions on dietary intake or anthropometrics among adolescents and adults in South Asia - A systematic review of intervention studies

INTRODUCTION

Mobile technology has been increasingly used as part of dietary interventions, but the effects of such interventions have not been systematically evaluated in the South Asian context. The systematic review aimed to determine the effects of technology-based interventions on dietary intake or anthropometrics among adolescents and adults in South Asia.

METHODS

Five electronic databases were searched (PubMed, Scopus, Web of Science, Global Health Library and Health Technology Assessment). Studies published in English between 1st January 2011 and 31st December 2021were included. Interventions that evaluated the effects of dietary interventions using technology on dietary outcomes and anthropometrics in adolescents or adults in the age group of 13-44 years (or a broader age group) from South Asia were eligible for inclusion. The risk of bias was assessed using the Cochrane Risk-of-bias 2 tool and ROBINS-I tool. A narrative synthesis was conducted.

RESULTS

Twenty-one studies met the inclusion criteria (20,667 participants). Eleven of the 17 randomised controlled trials (RCTs) had a high overall risk of bias. The four non-randomised intervention studies had a serious or critical overall risk of bias. When including studies with low risk or some concern for bias, the interventions had a beneficial effect on at least one dietary outcome in four of the six RCTs that measured changes in diet, and no effect on the anthropometric outcomes in the six RCTs that measured changes in anthropometric outcomes.

DISCUSSION

Technology-based dietary interventions have had some positive effects on dietary intake, but no effects on anthropometry in South Asia. More evidence is needed as the overall risk of bias was high in a majority of the studies.

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

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.

Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women's groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal

BACKGROUND

Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes.

METHODS

This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression.

DISCUSSION

Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy.

TRIAL REGISTRATION

ISRCTN 12272130 .

Participatory learning and action (PLA) to improve health outcomes in high-income settings: a systematic review protocol

INTRODUCTION

Participatory learning and action (PLA) is a form of group reflection and learning with documented efficacy in low-income countries to improve social and health outcomes. PLA represents both a learning philosophy and a practical framework that could be applied to a variety of contexts. To date, PLA has not been widely implemented within high-income countries (HICs) to improve health and health-related outcomes. We aim to synthesise the literature currently available by means of a systematic review to form a foundation for future applications of PLA methodology in HICs.

METHODS AND ANALYSIS

Two reviewers will independently search predefined terms in the following electronic bibliographic databases: MEDLINE, EMBASE, CINAHL and Cochrane Library. The search terms will encompass PLA and PDSA (Plan-Do-Study-Act) projects, as well as studies using the Triple/Quadruple Aim model. We will include randomised controlled trials that incorporate online or face-to-face components using the PLA/PDSA methodology. Our data will be extracted into a standardised prepiloted form with subsequent narrative review according to the SWiM (Synthesis Without Meta-Analysis) guidelines.

ETHICS AND DISSEMINATION

No ethics approval is required for this study. The results of this study will be submitted for publication in a leading peer-reviewed academic journal in this field. Additionally, a report will be produced for the funders of this review, which can be viewed for free on their website.

PROSPERO REGISTRATION NUMBER

CRD42020187978.

Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) through whole system strengthening in Jigawa, Nigeria: study protocol for a cluster randomised controlled trial

BACKGROUND

Child mortality remains unacceptably high, with Northern Nigeria reporting some of the highest rates globally (e.g. 192/1000 live births in Jigawa State). Coverage of key protect and prevent interventions, such as vaccination and clean cooking fuel use, is low. Additionally, knowledge, care-seeking and health system factors are poor. Therefore, a whole systems approach is needed for sustainable reductions in child mortality.

METHODS

This is a cluster randomised controlled trial, with integrated process and economic evaluations, conducted from January 2021 to September 2022. The trial will be conducted in Kiyawa Local Government Area, Jigawa State, Nigeria, with an estimated population of 230,000. Clusters are defined as primary government health facility catchment areas (n = 33). The 33 clusters will be randomly allocated (1:1) in a public ceremony, and 32 clusters included in the impact evaluation. The trial will evaluate a locally adapted 'whole systems strengthening' package of three evidence-based methods: community men's and women's groups, Partnership Defined Quality Scorecard and healthcare worker training, mentorship and provision of basic essential equipment and commodities. The primary outcome is mortality of children aged 7 days to 59 months. Mortality will be recorded prospectively using a cohort design, and secondary outcomes measured through baseline and endline cross-sectional surveys. Assuming the following, we will have a minimum detectable effect size of 30%: (a) baseline mortality of 100 per 1000 livebirths, (b) 4480 compounds with 3 eligible children per compound, (c) 80% power, (d) 5% significance, (e) intra-cluster correlation of 0.007 and (f) coefficient of variance of cluster size of 0.74. Analysis will be by intention-to-treat, comparing intervention and control clusters, adjusting for compound and trial clustering.

DISCUSSION

This study will provide robust evidence of the effectiveness and cost-effectiveness of community-based participatory learning and action, with integrated health system strengthening and accountability mechanisms, to reduce child mortality. The ethnographic process evaluation will allow for a rich understanding of how the intervention works in this context. However, we encountered a key challenge in calculating the sample size, given the lack of timely and reliable mortality data and the uncertain impacts of the COVID-19 pandemic.

TRIAL REGISTRATION

ISRCTN 39213655 . Registered on 11 December 2019.

Clinical and patient-centered implementation outcomes of mHealth interventions for type 2 diabetes in low-and-middle income countries: a systematic review

BACKGROUND

The prevalence of Type 2 Diabetes is rising in Low- and Middle-Income Countries (LMICs), affecting all age categories and resulting in huge socioeconomic implications. Mobile health (mHealth) is a potential high-impact approach to improve clinical and patient-centered outcomes despite the barriers of cost, language, literacy, and internet connectivity. Therefore, it is valuable to examine the clinical and implementation outcomes of mHealth interventions for Type 2 Diabetes in LMICs.

METHODS

The Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines were applied in framing and reporting the review criteria. A systematic search of Cochrane Library, Web of Science, PubMed, Scopus, and Ovid databases was performed through a combination of search terms. Randomized Controlled Trials (RCTs) and cohort studies published in English between January 2010 and August 2021 were included. Risk of bias for missing results in the included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2). Quantitative and qualitative methods were used to synthesize the results.

RESULTS

The search identified a total of 1161 articles. Thirty studies from 14 LMICs met the eligibility criteria. On clinical outcomes, 12 and 9 studies reported on glycated hemoglobin (HbA1c )and fasting blood glucose (FBG) respectively. Text messages was the most commonly applied mHealth approach, used in 19 out of the 30 studies. Ten out of the 12 studies (83.3%) that reported on HbA1c had a percentage difference of <0.3% between the mHealth intervention and the comparison group. Additionally, studies with longer intervention periods had higher effect size and percentage difference on HbA1c (1.52 to 2.92%). Patient-centred implementation outcomes were reported variedly, where feasibility was reported in all studies. Acceptability was reported in nine studies, appropriateness in six studies and cost in four studies. mHealth evidence reporting and assessment (mERA) guidelines were not applied in all the studies in this review.   CONCLUSION: mHealth interventions in LMICs are associated with clinically significant effectiveness on HbA1 but have low effectiveness on FBG. The application of mERA guidelines may standardize reporting of patient-centered implementation outcomes in LMICs.

TRIAL REGISTRATION

PROSPERO: Registration ID 154209.

Ethnic differences in response to lifestyle intervention for the prevention of type 2 diabetes in adults: A systematic review and meta-analysis

The risk of type 2 diabetes mellitus (T2DM) varies by ethnicity, but ethnic differences in response to diabetes prevention interventions remain unclear. This systematic review and meta-analysis assessed ethnic differences in the effects of lifestyle interventions on T2DM incidence, glycemic outcomes (fasting glucose, 2-h glucose, HbA_1c ), anthropometric measures (weight, BMI, waist circumference), and lifestyle behaviors (physical activity, energy intake, energy from fat, fiber intake). MEDLINE, EMBASE, and other databases were searched (to June 15, 2020) for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American, and African groups. Forty-four studies were included in meta-analyses. Overall, lifestyle interventions resulted in significant improvement in T2DM incidence, glycemic outcomes, anthropometric measures, physical activity, and energy intake (all P < 0.01). Significant subgroup differences by ethnicity were found for 2-h glucose, weight, BMI, and waist circumference (all P < 0.05) but not for T2DM incidence, fasting glucose, HbA_1c , and physical activity (all P > 0.05). Few studies in non-European groups reported dietary intake. Lifestyle interventions in different ethnic groups may have similar effects in reducing incidence of T2DM although this needs to be confirmed in further studies.

Understanding the sociodemographic factors associated with intention to receive SMS messages for health information in a rural area of Bangladesh

Background

The use of digital interventions for managing chronic diseases is significantly increasing. The aim of this study was to estimate the proportion of ownership of a mobile phone, and factors associated with the ability to read and access SMS delivered health information, and willingness to pay for it among people with hypertension in a rural area in Bangladesh.

Methods

Data were collected from 307 participants aged 30 to 75 years with hypertension from a rural area in Bangladesh from December 2020 to January 2021. Outcome measures included ownership of a mobile phone, ability to read SMS, willingness to receive and pay for health information by SMS. Associated factors included age, gender, level of education, occupation, and socioeconomic status. We used regression analysis to identify variables associated with the outcome variables.

Results

Overall, 189 (61.6%) people owned a mobile phone which was higher in men (73.3% vs. 50%, p < 0.001), younger people (82.6% aged 30–39 years vs. 53.5% aged 60–75 years, p < 0.001). Of the total participants, 207 (67.4%) were willing to receive SMS, and 155 (50.5%) were willing to pay for receiving SMS for health information. The prevalence was significantly higher among professionals (odds ratio (OR), 95% confidence interval (CI): 4.58, 1.73–12.1) and businesspersons (OR 3.68, 95% CI 1.49–9.10) compared to farmers, respectively. The median (interquartile range [IQR]) of willingness to pay for health information SMS was 10 (28) Bangladesh Taka (BDT) (1 BDT ~ 0.013 US$), and there were no specific factors that were associated with the willingness of any higher amounts of payment. In terms of reading SMS of people who own a mobile, less than half could read SMS. The proportion of people who could read SMS was significantly higher among men, younger people, educated people, middle class or rich people, professionals or businesspersons. Of people who could read SMS, the majority read SMS occasionally.

Conclusion

A significant proportion of people are unable to read SMS. However, people are willing to receive and pay to receive SMS for health information. Education and awareness programs should be conducted among targeted groups, including people with low education and women.

The Effectiveness of Telemedicine Solutions for the Management of Type 2 Diabetes: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

Previous systematic reviews have aimed to clarify the effect of telemedicine on diabetes. However, such reviews often have a narrow focus, which calls for a more comprehensive systematic review within the field. Hence, the objective of the present systematic review, meta-analysis, and meta-regression is to evaluate the effectiveness of telemedicine solutions versus any comparator without the use of telemedicine on diabetes-related outcomes among adult patients with type 2 diabetes (T2D).

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We considered telemedicine randomized controlled trials (RCT) including adults (≥18 years) diagnosed with T2D. Change in glycated hemoglobin (HbA1c, %) was the primary outcome. PubMed, EMBASE, and the Cochrane Library Central Register of Controlled Trials (CENTRAL) were searched on October 14, 2020. An overall treatment effect was estimated using a meta-analysis performed on the pool of included studies based on the mean difference (MD). The revised Cochrane risk-of-bias tool was applied and the certainty of evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

The final sample of papers included a total of 246, of which 168 had sufficient information to calculate the effect of HbA1c%. The results favored telemedicine, with an MD of -0.415% (95% confidence interval [CI] = -0.482% to -0.348%). The heterogeneity was great (I² = 93.05%). A monitoring component gave rise to the higher effects of telemedicine.

CONCLUSIONS

In conclusion, telemedicine may serve as a valuable supplement to usual care for patients with T2D. The inclusion of a telemonitoring component seems to increase the effect of telemedicine.

Effectiveness of community-based cardiovascular disease prevention interventions to improve physical activity: A systematic review and meta-regression

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality globally. Despite preventive community-based interventions (CBIs) seem efficacious in reducing CVD risks, a comprehensive up-to-date synthesis on the effectiveness of such interventions in improving physical activity (PA) is lacking. We performed a systematic review and meta-analysis of community-based CVD preventive interventions aimed at improving PA level. MEDLINE, EMBASE, CINAHL, Cochrane register and PSYCINFO databases were searched in October 2019 for studies reported between January 2000 and June 2019. We assessed the methodological quality of included studies using the Cochrane risk of bias tools. We performed a random-effects meta-analysis and meta-regression to pool estimates of various effect measures. Results are reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline. Our study protocol was registered in the PROSPERO database (CRD42019119885). A total of 44 randomized and 20 non-randomized controlled studies involving 98,919 participants were included. Meta-analyses found that CBIs improved the odds of attaining the recommended PA level (at least 150 min of moderate and vigorous PA (MVPA)/week) at 12 month (OR: 1.62; 95%CI: 1.25-2.11) and 18 to 24 months of follow-up (OR: 1.46; 95%CI: 1.12-1.91). Furthermore, interventions were effective in improving metabolic equivalents of task at 12 month (standardized mean difference (SMD): 0.28; 95% CI: 0.03-0.53), MVPA time at 12 to 18 months (SMD: 0.34; 95%CI: 0.05-0.64), steps per day (SMD: 0.32; 95%CI: 0.08-0.55), and sitting time (SMD: -0.25; 95%CI: -0.34 to -0.17). Subgroup analyses found that interventions in low- and middle-income countries showed a greater positive effect on attainment of recommended PA level (OR: 1.40; 95%CI: 1.02-1.92) than those in high-income countries (OR: 1.31; 95%CI: 0.96-1.78). Moreover, interventions targeting high-risk groups showed greater effectiveness than those targeting the general population (OR: 1.76; 95%CI: 1.30-2.39 vs. 1.17; 95%CI: 0.89-1.55). In conclusion, community-based CVD preventive interventions have a positive impact on improving the PA level, albeit that relevant studies in lower-middle and low-income countries are limited. With the rising burden of CVDs, rolling out CBIs targeting the general population and high-risk groups are needed to control the growing CVD-burden.

The Effect of Lifestyle Intervention on Diabetes Prevention by Ethnicity: A Systematic Review of Intervention Characteristics Using the TIDieR Framework

Lifestyle intervention is effective in preventing type 2 diabetes mellitus (T2DM), but the efficacy of intervention components across different ethnic groups is less clear. This systematic review examined the effects of intervention characteristics of lifestyle interventions on diabetes incidence and weight loss by ethnicity using the Template for Intervention Description and Replication (TIDieR) framework. MEDLINE, EMBASE and other databases were searched for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American and African groups. Forty-five studies (18,789 participants) were included in the systematic review and 41 studies in meta-analysis. Meta-analysis showed a high number of intervention sessions was significantly associated with a greater reduction in diabetes incidence (P = 0.043) and weight (P = 0.015), while other intervention characteristics including intervention provider and delivery format did not alter the outcomes (all P > 0.05). Additionally, narrative synthesis showed long-term interventions (≥12 months) were associated with significant diabetes risk reduction for all ethnic groups, while short-term interventions (<12 months) were more effective in weight loss in most ethnic groups. There may be ethnic preferences for the optimal number of intervention sessions.

Effectiveness of participatory women's groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India: a pragmatic cluster non-randomised controlled trial

INTRODUCTION

The WHO recommends community mobilisation with women's groups practising participatory learning and action (PLA) to improve neonatal survival in high-mortality settings. This intervention has not been evaluated at scale with government frontline workers.

METHODS

We did a pragmatic cluster non-randomised controlled trial of women's groups practising PLA scaled up by government front-line workers in Jharkhand, eastern India. Groups prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies and evaluated progress. Intervention coverage and quality were tracked state-wide. Births and deaths to women of reproductive age were monitored in six of Jharkhand's 24 districts: three purposively allocated to an early intervention start (2017) and three to a delayed start (2019). We monitored vital events prospectively in 100 purposively selected units of 10 000 population each, during baseline (1 March 2017-31 August 2017) and evaluation periods (1 September 2017-31 August 2019). The primary outcome was neonatal mortality.

RESULTS

We identified 51 949 deliveries and conducted interviews for 48 589 (93.5%). At baseline, neonatal mortality rates (NMR) were 36.9 per 1000 livebirths in the early arm and 39.2 in the delayed arm. Over 24 months of intervention, the NMR was 29.1 in the early arm and 39.2 in the delayed arm, corresponding to a 24% reduction in neonatal mortality (adjusted OR (AOR) 0.76, 95% CI 0.59 to 0.98), including 26% among the most deprived (AOR 0.74, 95% CI 0.57 to 0.95). Twenty of Jharkhand's 24 districts achieved adequate meeting coverage and quality. In these 20 districts, the intervention saved an estimated 11 803 newborn lives (min: 1026-max: 20 527) over 42 months, and cost 41 international dollars per life year saved.

CONCLUSION

Participatory women's groups scaled up by the Indian public health system reduced neonatal mortality equitably in a largely rural state and were highly cost-effective, warranting scale-up in other high-mortality rural settings.

TRIAL REGISTRATION

ISRCTN99422435.

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

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

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

BACKGROUND

As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs.

METHODS AND FINDINGS

We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings.

CONCLUSIONS

Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs-calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.

Effects of Mobile Phone-based Telemedicine Management in Patients with Type 2 Diabetes Mellitus: A Randomized Clinical Trial

BACKGROUND

This study aims to explore the effect of mobile phone-based telemedicine management of glycemic control of type 2 diabetes mellitus (T2DM).

METHODS

Patients with T2DM were followed up in Chongqing Jiulongpo District Yuzhoulu Community Health Center, and randomly divided into the telemedicine group (n=47) and the control group (n=50). The control group received regularly routine intervention. The telemedicine management group used the mobile phone to manage their health condition remotely.

RESULTS

Both groups had similar baseline characteristics. After a follow-up period of 12 months intervention, the weight, body mass index, waist circumference, systolic blood pressure, body fat percentage, body fat mass, body water and muscle mass, fasting blood glucose, glycosylated hemoglobin, total costs of diabetes treatment for 1 month and the quality-of-life score were significantly improved in the telemedicine group (P<0.05). And compared with the control group, body fat composition, fasting blood glucose, glycosylated hemoglobin and the cost of change shows a significant improvement (P<0.05). Positive correlation was detected between fasting blood glucose and body composition parameters, such as body fat percentage, lean body mass and body fat mass in the telemedicine group (r=0.56, P<0.05; r=0.37, P<0.05; r=0.56, P<0.05).

CONCLUSIONS

Compared with conventional intervention, the mobile phone-based telemedicine management can help patients with diabetes to improve glycemic level and quality of life.

Process evaluation of a brief messaging intervention to improve diabetes treatment adherence in sub-Saharan Africa

Background

The SMS text Adherence suppoRt for people with type 2 diabetes (StAR2D) intervention is a pragmatic randomised controlled trial, testing the effectiveness of brief text messaging for improving clinical outcomes and medication adherence. The intervention did not impact glycaemic control. We conducted a pre-and post-trial process evaluation alongside the StAR2D study in Malawi and South Africa, exploring the experiences and perceptions of patient participants, to better understand potential underlying reasons for the trial outcomes.

Methods

We employed a qualitative research design, including conducting semi structured in-depth interviews and focus groups at both trial sites. Purposive sampling was used to ensure representation of a wide range of patients with type 2 diabetes with regards to age, gender, ethnicity, language, and duration of diabetes. We interviewed the same participants at baseline and at the end of the trial. We used within-case and across-case thematic analysis to identify key themes.

Results

Brief messages delivered by text were acceptable and useful for addressing informational and support needs for participants. Some participants reported behaviour changes because of the text reminders and advice on a healthy lifestyle. Both participating in the trial and the messages were experienced as a source of support, caring, and motivation. Participants’ ability to act on the messages was limited. A common theme was frustration over the lack of ability to effectively control one’s blood glucose level. They reported a range of routinised, partial diabetes care adherence behaviours, shaped by complex and interacting individual, social, and health service factors. Participant responses and intervention impact were similar across sites, despite differences in health services.

Conclusion

This process evaluation provided context and insight into the factors influencing participants’ engagement with the text messaging intervention. The complex context in which patients take their diabetes medication, may explain in part, why brief text messaging may have been insufficient to bring about changes in health outcomes. The scale of need for self-management and health service support, suggests that health system strengthening, and other forms of self-management support should accompany digital communication interventions. (Current Controlled Trials ISRCTN70768808, registered 03/08/2015.)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11552-8.

Engaging communities in non-communicable disease research and interventions in low- and middle-income countries: a realist review protocol

INTRODUCTION

Engaging communities and intended beneficiaries at various stages of health research is a recommended practice. The contribution of community engagement to non-communicable disease research in low- and middle-income countries has not yet been extensively studied or synthesised. This protocol describes the steps towards generating an understanding of community engagement in the context of non-communicable disease research, prevention and health promotion using a realist review approach. A realist lens enables a rich explanatory approach to causation while capturing complexity, and an openness to multiple outcomes, including unintended consequences. The review will thus develop an understanding of community engagement without assuming that such practices result in more ethical research or effective interventions.

METHODS AND ANALYSIS

We propose a realist approach aiming to examine how, why, under what circumstances and for whom community engagement works or does not work. The iterative review steps include clarifying the review scope; searching for evidence; appraising studies and extracting data; synthesising evidence and drawing conclusions; and disseminating, implementing and evaluating the findings. Principles of meta-narrative review (pragmatism, pluralism, historicity, contestation, reflexivity and peer review) are employed to ensure practicable and contextualised review outputs. The proposed review will draw on theoretical and empirical literature beyond specific diseases or settings, but with a focus on informing non-communicable disease research and interventions in low- and middle-income countries. The synthesis of existing literature will be complemented by qualitative realist interviews and stakeholder consultation. Through drawing on multiple types of evidence and input from both experts and intended beneficiaries, the review will provide critical and pragmatic insights for research and community engagement in low- and middle-income countries.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of the Witwatersrand. Dissemination will include traditional academic channels, institutional communications, social media and discussions with a wide range of stakeholders.

Lowering blood pressure by changing lifestyle through a motivational education program: a cluster randomized controlled trial study protocol

BACKGROUND

High blood pressure is an independent risk factor of cardiovascular disease (CVD) and is a major cause of disability and death. Managing a healthy lifestyle has been shown to reduce blood pressure and improve health outcomes. We aim to investigate the effectiveness of a lifestyle modification intervention program for lowering blood pressure in a rural area of Bangladesh.

METHODS

A single-center cluster randomized controlled trial (RCT). The study will be conducted for 6 months, a total of 300 participants of age 30 to 75 years with 150 adults in each of the intervention and the control arms. The intervention arm will involve the delivery of a blended learning education program on lifestyle changes for the management of high blood pressure. The education program comprises evidence-based information with pictures, fact sheets, and published literature about the effects of high blood pressure on CVD development, increased physical activity, and the role of a healthy diet in blood pressure management. The control group involves providing information booklets and general advice at the baseline data collection point. The primary outcome will be the absolute difference in clinic SBP and DBP. Secondary outcomes include the difference in the percentage of people adopting regular exercise habits, cessation of smoking and reducing sodium chloride intake, health literacy of all participants, and the perceived barriers and enablers to adopt behavior changes by collecting qualitative data. Analyses will include analysis of covariance to report the mean difference in blood pressure between the control and the intervention group and the difference in change in blood pressure due to the intervention.

DISCUSSION

The study will assess the effects of physical activity and lifestyle modification in controlling high blood pressure. This study will develop new evidence as to whether a simple lifestyle program implemented in a rural region of a low- and middle-income country will improve blood pressure parameters for people with different chronic diseases by engaging community people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04505150 . Registered on 7 August 2020.

Addressing anaemia in pregnancy in rural plains Nepal: A qualitative, formative study

Maternal anaemia prevalence in low-income countries is unacceptably high. Our research explored the individual-, family- and community-level factors affecting antenatal care uptake, iron folic acid (IFA) intake and consumption of micronutrient-rich diets among pregnant women in the plains of Nepal. We discuss how these findings informed the development of a home visit and community mobilisation intervention to reduce anaemia in pregnancy. We used a qualitative methodology informed by the socio-ecological framework, conducting semi-structured interviews with recently pregnant women and key informants, and focus group discussions with mothers-in-law and fathers. We found that harmful gender norms restricted women's access to nutrient-rich food, restricted their mobility and access to antenatal care. These norms also restricted fathers' role to that of the provider, as opposed to the caregiver. Pregnant women, mothers-in-law and fathers lacked awareness about iron-rich foods and how to manage the side effects of IFA. Fathers lacked trust in government health facilities affecting access to care and trust in the efficacy of IFA. Our research informed interventions by (1) informing the development of intervention tools and training; (2) informing the intervention focus to engaging mothers-in-law and men to enable behaviour change; and (3) demonstrating the need to work in synergy across individual, family and community levels to address power and positionality, gender norms, trust in health services and harmful norms. Participatory groups and home visits will enable the development and implementation of feasible and acceptable strategies to address family and contextual issues generating knowledge and an enabling environment for behaviour change.

How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India

Many public health interventions aim to promote healthful behaviours, with varying degrees of success. With a lack of existing empirical evidence on the optimal number or combination of behaviours to promote to achieve a given health outcome, a key challenge in intervention design lies in deciding what behaviours to prioritise, and how best to promote them. We describe how key behaviours were selected and promoted within a multisectoral nutrition-sensitive agriculture intervention that aimed to address maternal and child undernutrition in rural India. First, we formulated a Theory of Change, which outlined our hypothesised impact pathways. To do this, we used the following inputs: existing conceptual frameworks, published empirical evidence, a feasibility study, formative research and the intervention team’s local knowledge. Then, we selected specific behaviours to address within each impact pathway, based on our formative research, behaviour change models, local knowledge and community feedback. As the intervention progressed, we mapped each of the behaviours against our impact pathways and the transtheoretical model of behaviour change, to monitor the balance of behaviours across pathways and along stages of behaviour change. By collectively agreeing on definitions of complex concepts and hypothesised impact pathways, implementing partners were able to communicate clearly between each other and with intervention participants. Our intervention was iteratively informed by continuous review, by monitoring implementation against targets and by integrating community feedback. Impact and process evaluations will reveal whether these approaches are effective for improving maternal and child nutrition, and what the effects are on each hypothesised impact pathway.

Lifestyle Interventions to Improve Glycemic Control in Adults with Type 2 Diabetes Living in Low-and-Middle Income Countries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs)

Alongside glucose lowering therapy, clinical guidelines recommend lifestyle interventions as cornerstone in the care of people living with type 2 diabetes (T2DM). There is a specific need for an up-to-date review assessing the effectiveness of lifestyle interventions for people with T2DM living in low-and-middle income countries (MICs). Four electronic databases were searched for RCTs published between 1990 and 2020. T2DM, lifestyle interventions, LMICs and their synonyms were used as search terms. Data codebooks were developed and data were extracted. Narrative synthesis and meta-analysis were conducted using random effects models to calculate mean differences (MD) and standardized mean differences (SMD) and 95% confidence intervals (CI). Of 1284 articles identified, 30 RCTs (n = 16,670 participants) met the inclusion criteria. Pooled analysis revealed significant improvement in HBA1c (MD −0.63; CI: −0.86, −0.40), FBG (SMD −0.35; CI: −0.54, −0.16) and BMI (MD −0.5; CI: −0.8, −0.2). In terms of intervention characteristics, those that included promoted self-management using multiple education components (e.g., diet, physical activity, medication adherence, smoking cessation) and were delivered by healthcare professionals in a hospital/clinic setting were deemed most effective. However, when interpreting these results, it is important to consider that most included studies were evaluated as being of low quality and there was a significant amount of intervention characteristics heterogeneity. There is a need for further well-designed studies to inform the evidence base on which lifestyle interventions are most effective for glycemic control in adults with T2DM living in LMICs.

Lifestyle Interventions for Diabetes Prevention in South Asians: Current Evidence and Opportunities

PURPOSE OF REVIEW

This review summarizes the burden of diabetes in South Asian populations and reviews recent evidence for diabetes prevention through lifestyle modification among South Asians worldwide. We indicate important gaps in the current literature and point to opportunities for additional research in this area.

RECENT FINDINGS

Randomized, controlled, efficacy studies and implementation research show that lifestyle intervention can be an effective, cost-effective, and feasible method for reducing diabetes risk, improving cardiometabolic health, and improving lifestyle behaviors in South Asian populations, a population at high diabetes risk and elevated rates of diabetes risk factors. Additional research is needed to address diabetes risk reduction in normal-weight South Asians and individuals with impaired fasting glucose; improve community-level implementation, individual uptake, and dissemination of proven programs; and assess long-term outcomes of interventions.