Integration of non-communicable diseases in health care: tackling the double burden of disease in African settings

Mortality rate and predictors of colorectal cancer patients in Ethiopia: a systematic review and meta-analysis

INTRODUCTION

The incidence of colorectal cancer (CRC) has been increasing in Sub-Saharan countries, including Ethiopia. However, the real mortality rate for CRC patients in Ethiopia has not been established. Therefore, this systematic review and meta-analysis aimed to determine the overall mortality rate and identify predictors among CRC patients in Ethiopia.

METHODS

PubMed, EMBASE, Web of Science, Scopus, Science Direct, and Google Scholar were searched to identify relevant articles. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) were followed. The quality of the included studies was assessed using the Newcastle-Ottawa Scale Critical Appraisal checklist. A random effect model was used to estimate the pooled mortality rate and adjusted hazard ratio (AHR). Publication bias was assessed using funnel plots and Egger's regression test, while heterogeneity was evaluated through the Cochran Q test and I2 statistics.

RESULTS

After reviewing 74 articles, only 7 studies met the criteria and were included in the analysis. The analysis revealed that the overall mortality rate among CRC patients in Ethiopia was 40.5% (95% confidence interval [CI]: 32.05, 48.87) while the survival rates at 1 year, 3 years, and 5 years were 82.3% (95% CI: 73.33, 91.31), 48.8% (95% CI: 43.35, 54.32), and 26.6% (95% CI: 21.26, 31.91) respectively. Subgroup analysis indicated that studies conducted after 2017 had higher mortality rates compared to those studied earlier (43.0% vs. 38.2%). Older age (AHR: 1.89, 95% CI: 1.27, 2.82); being married (AHR: 2.53, 95% CI: 1.79, 3.57); having comorbidities (AHR: 1.84, 95% CI: 1.45, 2.35); having high CEA levels (AHR: 2.06, CI: 1.35, 3.13); being in stage II (AHR: 4.13, 95% CI: 1.85, 9.22), III (AHR: 8.62, 95% CI: 3.88, 19.15), and IV (AHR: 8.06, CI: 2.89, 22.49) were the most important predictors.

CONCLUSION

In Ethiopia, the mortality rate among individuals diagnosed with CRC is high, with two out of five patients dying from this disease. Age, marital status, CEA level, comorbidities, and cancer stage were identified as predictors of mortality in CRC patients. Therefore, early detection and screening should be prioritized, particularly for older patients, those who are married, have comorbidities, elevated CEA levels, and advanced cancer stages.

Bringing MRI to low- and middle-income countries: Directions, challenges and potential solutions

The global disparity of magnetic resonance imaging (MRI) is a major challenge, with many low- and middle-income countries (LMICs) experiencing limited access to MRI. The reasons for limited access are technological, economic and social. With the advancement of MRI technology, we explore why these challenges still prevail, highlighting the importance of MRI as the epidemiology of disease changes in LMICs. In this paper, we establish a framework to develop MRI with these challenges in mind and discuss the different aspects of MRI development, including maximising image quality using cost-effective components, integrating local technology and infrastructure and implementing sustainable practices. We also highlight the current solutions-including teleradiology, artificial intelligence and doctor and patient education strategies-and how these might be further improved to achieve greater access to MRI.

Adoption and use of immunotherapy in breast cancer management in Africa: barriers and prospect - a narrative review

Breast cancer (BC) is the world's most frequently diagnosed cancer in women, with 7.8 million women diagnosed with BC in the past 5 years. BC has the highest incidence rate of all cancers in women worldwide (1.67 million), accounting for over 500 000 deaths annually. In Africa, BC accounts for 28% of all cancers and 20% of all cancer deaths in women. The African continent has recorded an alarming increase in incidence, with the highest mortality rate globally. Despite BC being a major health concern in Africa, there is limited access to adequate healthcare services to combat the growing need. Immunotherapy, a promising treatment approach that harnesses the immune system's power to fight cancer, has shown great potential in BC management. However, in the face of the growing body of evidence supporting its effectiveness, the adoption and use of immunotherapy in BC management in Africa remain limited. Hence, this review aimed to explore the barriers and prospects of immunotherapy adoption and use in BC management in Africa. A comprehensive search across various databases and sources using specific keywords related to immunotherapy and BC to achieve the study aim was conducted. The criteria for including data in the study were based on relevance and availability in English, with no publication year restrictions. The collected data underwent narrative analysis, supplemented by information from sources like country reports, newsletters, commentaries, policy briefs, and direct Google searches. By identifying the challenges and opportunities, this review provided insights into how healthcare providers, policymakers, and other stakeholders can work together to improve the availability and accessibility of immunotherapy to BC patients in Africa.

The femtech revolution-A new approach to pregnancy management: Digital transformation of maternity care-The hybrid e-health perinatal clinic addressing the unmet needs of low- and middle-income countries

Prenatal care and infant mortality rates are crucial indicators of healthcare quality. However, millions of women in low-income countries lack access to adequate care. Factors such as high-risk pregnancies and unmanaged diet increase the risk of developing complications during pregnancy, highlighting the need for continuous monitoring of maternal health. The increasing burden of non-communicable diseases represents a significant threat to fragile health systems. The lack of access to appropriate prenatal care and poor maternal and newborn health outcomes are major concerns in low- and middle-income countries (LMICs). It emphasizes the need for innovative, integrative approaches to healthcare delivery, especially in pregnant women. The health services need to be reorganized holistically and effectively, focusing on factors that directly impact maternal, neonatal, and infant mortality, resulting in improved access to maternity services and survival of "at-risk" mothers and their offspring in many LMICs. Based on the FIGO (the International Federation of Gynecology & Obstetrics) recommendations of extending preconception care to the postpartum stage, the authors of this review have developed a new model of care-PregCare-based on the triple-intervention-based holistic and multidisciplinary maternal and fetal medicine model for low-risk pregnancies. This model will help transform the traditional model's high visitation frequency into a safe and reduced office visit, while increasing virtual connections, point of care and self-care with doctors, nurses, and community-based providers of self-care. This shall be based on a sophisticated central PregCare call center powered by innovative technologies combined with experienced personnel in perinatal management (doctors and nurses/midwives).

"I tell you, getting data for this is hell"-Exploring the use of evidence for noncommunicable disease policies in Ghana

After several years of over concentration on communicable diseases, Ghana has finally made notable strides in the prevention of NCDs by introducing key policies and programmes. Evident shows that there is limited NCD-related data on mortality and risk factors to inform NCD policy, planning, and implementation in Ghana. We explored the evidence base for noncommunicable disease policies in Ghana. A qualitative approach was adopted using key informant interviews and documents as data sources. An adaptation of the framework method for analysing qualitative data by Gale and colleagues' (2013) was used to analyse data. Our findings show that effort has been made in terms of institutions and systems to provide evidence for the policy process with the creation of the Centre for Health Information Management and the District Health Information Management System. Although there is overreliance on routine facility data, policies have also been framed using surveys, burden of disease estimates, monitoring reports, and systematic reviews. There is little emphasis on content analysis, key informant interviews, case studies, and implementation science techniques in the policy process of Ghana. Inadequate and poor data quality are key challenges that confront policymakers. Ghana has improved its information infrastructure but access to quality noncommunicable disease data remains a daunting challenge. A broader framework for the integration of different sources of data such as verbal autopsies and natural experiments is needed while strengthening existing systems. This, however, requires greater investments in personnel and logistics at national and district levels.

Barriers to early diagnosis of cervical cancer: a mixed-method study in Côte d'Ivoire, West Africa

BACKGROUND

Cervical cancer, a major public health problem in many developing countries, is usually associated with a poor survival related to an advanced disease at diagnosis. In Côte d'Ivoire and other developing countries with high cervical cancer prevalence, little is known about factors associated with advanced cervical cancer stages in a context of limited access to screening services.

METHODS

From May to July 2019, we conducted a cross-sectional study using a mixed, quantitative and qualitative method. Information on socio-demographic and history of the disease was extracted from a rapid case ascertainement study performed by the cancer registry of Côte d'Ivoire that enrolled all women diagnosed with cervical cancer between July 2018 and June 2019. In-depth semi-structured interviews were conducted among a subset of these women (12 women) and six healthcare providers to further capture barriers to early cervical cancer diagnosis. Factors associated with an advanced stage III, IV (according to FIGO classification) were estimated by a logistic regression model. Qualitative data were analyzed using a thematic analysis technique guided by the treatment pathway model and triangulated with quantitative data.

RESULTS

In total, 95 women with cervical cancer [median age = 51 (IQR 42-59)] years, were included. Among them, 18.9% were living with HIV and only 9.5% were covered by a health insurance. The majority (71.5%) were diagnosed with advanced cervical cancer. Being HIV-uninfected (aOR = 5.4; [1.6-17.8], p = 0.006) and being uninsured (aOR = 13.1; [2.0-85.5], p = 0.007) were independently associated with advanced cervical cancer in multivariable analysis. Qualitative data raised additional factors potentially related to advanced cervical cancer stages at diagnosis, including the lack of patient information on cervical cancer by healthcare providers and inadequate national awareness and screening campaigns.

CONCLUSION

In a context of challenges in access to systematic cervical cancer screening in Côte d'Ivoire, access to health insurance or integrated healthcare program appear to be key determinants of early diagnosis of cervical cancer.

Epidemiologic transition and the double burden of disease in Ghana: What do we know at the neighborhood level?

Many developing countries including Ghana are currently experiencing dual disease burdens emerging from an unprecedented risk overlap that drive their epidemiological transitions. Yet, siloed and disintegrated approaches continue to take precedence in health research and policy programs that drive competition for limited resources to address competing health problems. The objective of this study was to offer empirical evidence in support of a cogent argument for an integrated framework for the study and management of infectious and chronic health conditions in Ghana. We did so by examining the prevalence, determinants, and neighborhoods trajectories of the double burden of disease using data from a cross-sectional neighborhood-based study in Ghana. We fitted multinomial multilevel multivariate models to a sample of 1377 individual surveys and the results presented as odds ratios. Findings show that amidst a rising burden of NCDs, infectious diseases remain the most common health condition and participants in deprived neighborhoods were significantly more likely to report poor health outcomes. Risk factors such as tobacco and alcohol consumption were significantly associated with NCDs and infectious diseases and respondents who reported being diagnosed with NCDs and infectious diseases in the past year were likely to engage in leisure time physical activities and eat healthy. Based on our findings, we recommend health reforms in Ghana and argue for the design and implementation of an integrated framework for the study and management of the double burden of disease in Ghana and similar developing country settings.

Pediatric asthma in developing countries: challenges and future directions

PURPOSE OF REVIEW

Asthma continues to be a significant health problem worldwide, and epidemiological studies in the last few decades have consistently shown a marked increase in childhood asthma prevalence. The International Study of Asthma and Allergies in Childhood (ISAAC) showed significant geographic variability in prevalence, and larger associations with morbidity and mortality in low-middle income countries (LMICs). The Global Burden of Disease estimated that 420,000 deaths occurred globally from asthma in 2016, and although asthma prevalence is higher in high-income countries, most asthma-related mortality occurs in LMICs. The general health of a population is measured, in part, by the under-5 childhood death rate, and developing countries still account for more than 80 percentage of child deaths in the world, highlighting the need for efforts to reduce disease burden in these regions.

RECENT FINDINGS

The burden of asthma is higher in developing countries and underserved populations. Despite this, LMICs still face many barriers to appropriate allergy and asthma care, resulting in significant morbidity, potentially preventable asthma deaths, and economic consequences. A 2017 survey of 112 countries participating in the Global Asthma Network found that only 26 countries (23%) had a national asthma plan for children, with a lower proportion in LMICs.

SUMMARY

The rising asthma prevalence and high asthma-related death rates in LMICs suggest that global efforts in improving asthma diagnosis and care are not reaching the most vulnerable communities. Lack of appropriate diagnosis, availability of viable treatment options, and access to specialised care still remain a challenge in many parts of the world. Though barriers to achieving better outcomes differ in specific populations, many LMICs share similar barriers relating to accessibility.

Exploring the mechanisms of collaboration between the Tuberculosis and Diabetes Programs for the control of TB-DM Comorbidity in Ghana

OBJECTIVES

To explore the mechanisms of collaboration between the stakeholders, including National Tuberculosis Control Program (NTP) and the Non-Communicable Disease Control and Prevention Program (NCDCP) at the national, regional, and local (health facility) levels of the health care system in Ghana. This is one of the objectives in a study on the "Barriers and Facilitators to the Implementation of the Collaborative Framework for the Care and Control of Tuberculosis and Diabetes in Ghana" RESULTS: The data analysis revealed 4 key themes. These were (1) Increased support for communicable diseases (CDs) compared to stagnant support for non-communicable diseases (NCDs), (2) Donor support, (3) Poor collaboration between NTP and NCDCP, and (4) Low Tuberculosis-Diabetes Mellitus (TB-DM) case detection.

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Despite positive NCD policies in recent years, majority of Sub-Saharan African (SSA) health systems are inadequately prepared to deliver comprehensive first-line care for NCDs. Primary health care (PHC) settings in countries like Malawi and Zambia could be a doorway to effectively manage NCDs by moving away from delivering only episodic care to providing an integrated approach over time. As part of a collaborative health system strengthening project, we assessed and compared the preparedness and operational capacity of two target networks of public PHC settings in Lilongwe (Malawi) and Lusaka (Zambia) to integrate NCD services within routine service delivery. Data was collected and analyzed using validated health facility survey tools. These baseline assessments conducted between August 2018 and March 2019, also included interviews with 20 on-site health personnel and focal persons, who described existing barriers in delivering NCD services. In both countries, policy directives to decentralize disease-specific NCD services to the primary care level were initiated to meet increased demand but lacked operational guidance. In general, the assessed PHC sites were inadequately prepared to integrate NCDs into various service delivery domains, thus requiring further support. In spite of existing multi-faceted limitations, there was motivation among healthcare staff to provide NCD services.

Glycemic control, associated factors, acute complications of Type 1 Diabetes Mellitus in children, adolescents and young adults in Tanzania

Objective

To determine the factors associated with poor glycemic control in children (1-10 years), adolescents (11-18 years) and young adults (19-40 years) with Type 1 Diabetes Mellitus (T1DM) in Kilimanjaro Christian Medical Center (KCMC) in Moshi, Mount Meru Regional Referral Hospital (MMRRH) and Meru District Hospital (MDH) in Arusha, Tanzania.

Methods

Cross sectional study of 150 participants conducted from January to June 2019, data was collected by structured questionnaire and analyzed using SPSS version 23.

Results

The mean HbA1c was 12.3 ± 2.2%, 146 had poor glycemic control (HbA1c > 7.5%). BMI, insulin regime and caretaker education were associated with poor glycemic control. There were 16 participants diagnosed in DKA and the most frequently reported complications in the prior 3 months were hyperglycemia (n = 25), DKA (n = 18) and hypoglycemia (n = 4).

Conclusions

Glycemic control is still very poor particularly in adolescents. Significant associations with glycemic control were higher BMI, insulin regime and guardian education. The study revealed lower prevalence of DKA at diagnosis compared to previous studies.

Using a co-design process to develop an integrated model of care for delivering self-management intervention to multi-morbid COPD people in rural Nepal

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) in Nepal are not receiving adequate support to self-manage their chronic conditions, and primary health care can play a key role in the effective management of these. In this study, we aimed to develop a model of care, using a co-design approach, for delivering evidence-based biomedical and psycho-social care to support self-management for people with multi-morbid COPD in rural Nepal.

METHODS

A co-design approach, guided by the five stages of the design thinking model, was used for this study. Layering on "empathize" and "define" phases, we ideated a model of care that was further refined in a "prototype" stage, which included a series of consultative meetings and a 1-day co-design workshop with stakeholders. This co-design process involved a wide range of stakeholders from Nepal, including people with COPD and their families, community representatives, local government representatives, primary care practitioners, community health workers, policymakers, state-level government representatives and academics.

RESULTS

Through our co-design approach, a model of integrated care for delivering evidence-based biomedical and psycho-social care to support self-management for people with multi-morbid COPD was designed. The integrated model of care included: screening of the community members aged > 40 years or exhibiting symptoms for COPD and management of symptomatic patients within primary health care, establishing referral pathways for severe cases to and from secondary/tertiary-level health care and establishing a community-based support system. It involved specific roles for community health workers, patients and their caregivers and community representatives. It was built on existing services and programmes linking primary health care centres and tertiary-level health facilities.

CONCLUSION

The co-design approach is different from the currently dominant approach of rolling out models of care, which were designed elsewhere with minimal community engagement. In our study, the co-design approach was found to be effective in engaging various stakeholders and in developing a model of care for rural Nepal. This grassroots approach is more likely to be acceptable, effective and sustainable in rural Nepal. Further research is required to test the effectiveness of an integrated model of care in delivering self-management support for people with multi-morbid COPD in rural Nepal.

Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study

Background

Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework.

Methods

A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis.

Results

Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation.

Conclusions

Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.

Setting up a nurse-led model of care for management of hypertension and diabetes mellitus in a high HIV prevalence context in rural Zimbabwe: a descriptive study

Background

In the light of the increasing burden of non-communicable diseases (NCDs) on health systems in low- and middle-income countries, particularly in Sub-Saharan Africa, context-adapted, cost-effective service delivery models are now required as a matter of urgency. We describe the experience of setting up and organising a nurse-led Diabetes Mellitus (DM) and Hypertension (HTN) model of care in rural Zimbabwe, a low-income country with unique socio-economic challenges and a dual disease burden of HIV and NCDs.

Methods

Mirroring the HIV experience, we designed a conceptual framework with 9 key enablers: decentralization of services, integration of care, simplification of management guidelines, mentoring and task-sharing, provision of affordable medicines, quality assured laboratory support, patient empowerment, a dedicated monitoring and evaluation system, and a robust referral system. We selected 9 primary health care clinics (PHC) and two hospitals in Chipinge district and integrated DM and HTN either into the general out-patient department, pre-existing HIV clinics, or an integrated chronic care clinic (ICCC). We provided structured intensive mentoring for staff, using simplified protocols, and disease-specific education for patients. Free medication with differentiated periodic refills and regular monitoring with point of care (POC) glycosylated haemoglobin (HbA1c) were provided.

Results

Nurses in 7 PHC facilities and one hospital developed sufficient knowledge and skills to diagnose, initiate treatment and monitor DM and HTN patients, and 3094 patients were registered in the programme (188 with DM only, 2473 with HTN only, 433 with both DM and HTN). Major lessons learned from our experience include: the value of POC devices in the management of diabetes; the pressure on services of the added caseload, exacerbated by the availability of free medications in supported health facilities; and the importance of leadership in the successful implementation of care in health facilities.

Conclusion

Our experience demonstrates a model for nurse-led decentralized integrated DM and HTN care in a high HIV prevalence rural, low-income context. Developing a context-adapted efficient model of care is a dynamic process. We present our lessons learned with the intention of sharing experience which may be of value to other public health programme managers.

Exploring the Perceptions of Women from Under-Resourced South African Communities about Participating in a Low-Carbohydrate High-Fat Nutrition and Health Education Program: A Qualitative Focus Group Study

Scientific evidence suggests that low-carbohydrate high-fat (LCHF) diets may be effective for managing non-communicable diseases (NCDs). Eat Better South Africa (EBSA) is an organization that runs LCHF nutrition education programs for women from low-income communities. Three focus group discussions (FGDs) were held with 18 women who had taken part in an EBSA program between 2015 and 2017, to explore their perceptions and to identify the facilitators and barriers they faced in implementing and sustaining dietary changes. Thematic analysis of the focus groups was conducted using NVivo 12 software. Women reported that they decided to enroll in the program because they suffered from NCDs. Most women said that the EBSA diet made them feel less hungry, more energetic and they felt that their health had improved. Most women spoke of socioeconomic challenges which made it difficult for them to follow EBSA’s recommendations, such as employment status, safety issues in the community, and lack of support from relatives and doctors. Hence, women felt they needed more support from EBSA after the program. The social determinants that affected these women’s ability to change their health behavior are also NCD risk factors, and these should be assessed to improve the program for other communities.

Capabilities, opportunities and motivations for integrating evidence-based strategy for hypertension control into HIV clinics in Southwest Nigeria

Background

Given the growing burden of cardiovascular diseases in sub-Saharan Africa, global donors and governments are exploring strategies for integrating evidence-based cardiovascular diseases prevention into HIV clinics. We assessed the capabilities, motivations and opportunities that exist for HIV clinics to apply evidence-based strategies for hypertension control among people living with HIV (PLHIV) in Nigeria.

Methods

We used a concurrent Quan-Qual- study approach (a quantitative first step using structured questionnaires followed by a qualitative approach using stakeholder meetings).We invited key stakeholders and representatives of HIV and non-communicable disease organizations in Lagos, Nigeria to 1) assess the capacity of HIV clinics (n = 29) to, and; 2) explore their attitudes and perceptions towards implementing evidence-based strategies for hypertension management in Lagos, Nigeria (n = 19)The quantitative data were analyzed using SPSS whereas responses from the stakeholders meeting were coded and analyzed using thematic approach and an implementation science framework, the COM-B (Capabilities, Opportunities, Motivations and Behavior) model, guided the mapping and interpretation of the data.

Results

Out of the 29 HIV clinics that participated in the study, 28 clinics were public, government-owned facilities with 394 HIV patients per month with varying capabilities, opportunities and motivations for integrating evidence-based hypertension interventions within their services for PLHIV. Majority of the clinics (n = 26) rated medium-to-low on the psychological capability domains, while most of the clinics (n = 25) rated low on the physical capabilities of integrating evidence-based hypertension interventions within HIV clinics. There was high variability in the ratings for the opportunity domains, with physical opportunities rated high in only eight HIV clinics, two clinics with a medium rating and nineteen clinics with a low rating. Social opportunity domain tended to be rated low in majority of the HIV clinics (n = 21). Lastly, almost all the HIV clinics (n = 23) rated high on the reflective motivation domain although automatic motivations tended to be rated low across the HIV clinics.

Conclusion

In this study, we found that with the exception of motivations, the relative capabilities whether physical or psychological and the relative opportunities for integrating evidence-based hypertension intervention within HIV clinics in Nigeria were minimal. Thus, there is need to strengthen the HIV clinics in Lagos for the implementation of evidence-based hypertension interventions within HIV clinics to improve patient outcomes and service delivery in Southwest Nigeria.

Trends of mortality attributable to child and maternal undernutrition, overweight/obesity and dietary risk factors of non-communicable diseases in sub-Saharan Africa, 1990-2015: findings from the Global Burden of Disease Study 2015

OBJECTIVE

To assess trends of mortality attributable to child and maternal undernutrition (CMU), overweight/obesity and dietary risks of non-communicable diseases (NCD) in sub-Saharan Africa (SSA) using data from the Global Burden of Disease (GBD) Study 2015.

DESIGN

For each risk factor, a systematic review of data was used to compute the exposure level and the effect size. A Bayesian hierarchical meta-regression analysis was used to estimate the exposure level of the risk factors by age, sex, geography and year. The burden of all-cause mortality attributable to CMU, fourteen dietary risk factors (eight diets, five nutrients and fibre intake) and overweight/obesity was estimated.

SETTING

Sub-Saharan Africa.ParticipantsAll age groups and both sexes.

RESULTS

In 2015, CMU, overweight/obesity and dietary risks of NCD accounted for 826204 (95 % uncertainty interval (UI) 737346, 923789), 266768 (95 % UI 189051, 353096) and 558578 (95 % UI 453433, 680197) deaths, respectively, representing 10·3 % (95 % UI 9·1, 11·6 %), 3·3 % (95 % UI 2·4, 4·4 %) and 7·0 % (95 % UI 5·8, 8·3 %) of all-cause mortality. While the age-standardized proportion of all-cause mortality accounted for by CMU decreased by 55·2 % between 1990 and 2015 in SSA, it increased by 63·3 and 17·2 % for overweight/obesity and dietary risks of NCD, respectively.

CONCLUSIONS

The increasing burden of diet- and obesity-related diseases and the reduction of mortality attributable to CMU indicate that SSA is undergoing a rapid nutritional transition. To tackle the impact in SSA, interventions and international development agendas should also target dietary risks associated with NCD and overweight/obesity.

Association Between HIV Infection and Cancer Stage at Presentation at the Uganda Cancer Institute

PURPOSE

The HIV epidemic has contributed to the increasing incidence of cancer in sub-Saharan Africa, where most patients with cancer present at an advanced stage. However, improved access to HIV care and treatment centers in sub-Saharan Africa may facilitate earlier diagnosis of cancer among patients who are HIV positive. To test this hypothesis, we characterized the stage of cancer and evaluated the factors associated with advanced stage at presentation among patients in Uganda.

METHODS

We conducted a retrospective analysis of adult patients with any of four specific cancers who presented for care in Kampala, Uganda, between 2003 and 2010. Demographic, clinical, and laboratory data were abstracted from the medical record, together with the outcome measure of advanced stage of disease (clinical stage III or IV). We identified measures for inclusion in a multivariate logistic regression model.

RESULTS

We analyzed 731 patients with both AIDS-defining cancers (cervical [43.1%], and non-Hodgkin lymphoma [18.3%]), and non-AIDS-defining cancers (breast [30.0%] and Hodgkin lymphoma [8.6%]). Nearly 80% of all patients presented at an advanced stage and 37% had HIV infection. More than 90% of patients were symptomatic and the median duration of symptoms before presentation was 5 months. In the multivariate model, HIV-positive patients were less likely to present at an advanced stage as were patients with higher hemoglobin and fewer symptoms.

CONCLUSION

Patients with limited access to primary care may present with advanced cancer because of a delay in diagnosis. However, patients with HIV now have better access to clinical care. Use of this growing infrastructure to increase cancer screening and referral is promising and deserves continued support, because the prognosis of HIV-positive patients with advanced cancer is characterized by poor survival globally.

Assessing capacity and readiness to manage NCDs in primary care setting: Gaps and opportunities based on adapted WHO PEN tool in Zambia

Introduction

Sub-Saharan Africa is experiencing an epidemiological transition as the burden of NCDs overtake communicable diseases. However, it is unknown what capacity and gaps exist at primary care level to address the growing burden of NCDs. This study aimed to assess the Zambian health system’s capacity to address in NCDs, using an adapted WHO Essential Non Communicable Disease Interventions (WHO PEN) tool.

Methodology

This was a cross-sectional facility survey in the three districts conducted from September 2017 to October 2017. We defined facility readiness along five domains: basic equipment, essential services, diagnostic capacity, counseling services, and essential medicines. For each domain, we calculated an index as the mean score of items expressed as percentage. These indices were compared to an agreed cutoff at 70%, meaning that a facility index or district index below 70% off was considered as ‘not ready’ to manage NCDs at that level. All analysis were performed using Stata 15 MP.

Results

There appeared to be wide heterogeneity between facilities in respect of readiness to manage NCDs. Only 6 (including the three 1^st level hospitals) out of the 46 facilities were deemed ready to manage NCDs. Only the first level hospitals scored a mean index higher than the 70% cut off; With regard to medications needed to manage NCDs, urban and rural health facilities were comparably equipped. However, there was evidence that calcium channel blockers (p = 0.013) and insulin (p = 0.022) were more likely to be available in urban and semi-urban health facilities compared to rural facilities.

Conclusion

Our study revealed gaps in primary health care capacity to manage NCDs in Zambia, with almost all health facilities failing to reach the minimum threshold. These results could be generalized to other similar districts in Zambia and the sub-region, where health systems remain focused on infectious rather than non-communicable Disease. These results should attract policy attention and potentially form the basis to review current approach to NCD care at the primary care level in Zambia and Sub-Saharan Africa.

An assessment of critical care capacity in the Gambia

PURPOSE

Critical illnesses are a major cause of morbidity and mortality in The Gambia, yet national data on critical care capacity is lacking.

MATERIALS AND METHODS

We surveyed eight of the eleven government-owned health facilities providing secondary and tertiary care in The Gambia's public health sector. At each hospital, a designated respondent completed a questionnaire reporting information on the presence of an intensive care unit, the number of critical care beds where available, monitoring equipment, and the ability to provide basic critical care services at their respective hospitals.

RESULTS

The response rate was 88% (7/8 hospitals). Only one hospital had a dedicated intensive care unit with eight ICU beds, resulting in an estimated 0.4 ICU beds/100,000 population in the country. All hospitals reported treating more than 50 critically ill patients a month, with trauma, obstetric emergencies, hypertensive emergencies and stroke accounting for the leading causes of admission respectively. The country lacks any trained specialists and resources to diagnose and treat critically ill patients.

CONCLUSIONS

The Gambia has a very low ICU bed capacity and lacks the human resources and equipment necessary to diagnose and treat the large number of critically ill patients admitted to public hospitals in the country.

Prevalence and sociodemographic determinants of adult obesity: a large representative household survey in a resource-constrained African setting with double burden of undernutrition and overnutrition

BACKGROUND

The obesity epidemic has continued to spread across the globe involving even poor nations of the world.

METHOD

Household population survey of adults aged 20-60 years. Multistage stratified cluster randomised sampling involving both urban and rural statewide representative population samples. Anthropometric measurements were taken using standard methods. Prevalences were weighted and multinomial regression analyses were done.

RESULTS

A total of 6628 individuals from 2843 households were surveyed. The weighted overall prevalence for underweight was 9.1% (95% CI 8.1 to 10.1), 65.1% (95% CI 63.6 to 66.6) for normal weight, 19.0% (95% CI 17.8 to 20.3) for overweight and 6.8% (95% CI 6.0 to 7.5) for obese. Men were less likely to be overweight (adjusted OR (AOR) 0.79; 95% CI 0.68 to 0.92) and obese (AOR 0.24; 95% CI 0.19 to 0.31) than women. Urban residents were more likely to be overweight (AOR 1.42; 95% CI 1.18 to 1.71) and obese (AOR 2.09; 95% CI 1.58 to 2.76) than rural residents. Each additional 1-year increase in age increased the risk of overweight by 1.012 (AOR 1.012; 95% CI 1.005 to 1.018) and that of obesity by 1.03 (AOR 1.03; 95% CI 1.02 to 1.04). The low-income class was less likely to be overweight (AOR 0.694; 95% CI 0.507 to 0.951) and obese (AOR 0.44; 95% CI 0.28 to 0.67).

CONCLUSION

The prevalence of obesity and overweight in Enugu Nigeria is high and fast approaching that of underweight. Women, urban dwellers, older adults and high-income earners are at higher risk for obesity and overweight. The study provides robust information for public health policies towards the prevention of obesity in Nigeria.

Alteration of serum immunoglobins, C-reactive protein, vitamin D, and electrolyte by atenolol and amlodipine in stress-induced hypertensive rats

The present study is designed for the assessment of various pathological changes like immunoglobins, C-reactive protein, vitamin D, sodium, potassium, calcium in stress-induced hypertensive rats. Albino Wistar rats of sex male were grouped into six. Each group consists of six animals. Groups were Group I (normal control), Group II (disease control), Group III (amlodipine control), Group IV (atenolol control), Group V (amlodipine treatment), and Group VI (atenolol treatment). Group II, V, and VI animals exposed to regular stress by placing them in cages individually and giving foot electric shocks (1 mA, 50 ms duration with 0.5-1 min of intervals regulated randomly by a computer) along with forced swimming (30 min) in order to induce hypertension in rats. This stress was given two times daily (morning and evening) for regular 15 days. Induction of hypertension was confirmed by measuring the tail arterial pressure of blood and angiotensin II. For next 1 month, Group III and V animals are treated with amlodipine with 1 mg/kg, s.c. dose while Group IV and VI animals were given 10 mg/kg, s.c. the dose of atenolol once daily. At the end of the experimental work, blood collected, rats sacrificed, and serum separated. Serum sodium, potassium, immunoglobins, C-reactive protein, vitamin D, and calcium were measured by semi-auto-analyzer. Stress-induced hypertension in rats produced altered serum sodium, potassium, immunoglobins, C-reactive protein, vitamin D, and calcium level which is restored by atenolol. Administration of amlodipine in animals without hypertension shows alteration in the level of immunoglobins, calcium, vitamin D, and electrolytes.

Community Health Workers in Diabetes Prevention and Management in Developing Countries

BACKGROUND

There is limited evidence regarding the effect of community health worker (CHW) interventions for prevention and management of the burgeoning epidemic of noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs). The objective of this review was to critically appraise evidence regarding the effectiveness of CHW interventions for prevention and management of type 2 diabetes mellitus (T2DM) in LMICs.

METHODS

To identify studies that reported the effect of CHW interventions for prevention and management of T2DM in LMICs, Medline/PubMed, EMBASE, Web of Science (Science and Social Science Citation Indices), EBSCO (PsycINFO and CINAHL), POPLINE, the Cochrane Metabolic and Endocrine Disorders Group's Specialized Register, the Cochrane Central Register of Controlled Trials, the Grey literature (Google, Google Scholar), and reference lists of identified articles were searched from inception to May 31, 2017.

FINDINGS

Ten studies were included (4 pre- and post-studies, 2 randomized controlled trials, 2 cohort studies, 1 cross-sectional study, and 1 case-control study). The role of CHWs consisted of patient education, identification and referral of high-risk individuals to physicians, and provision of social support through home visits. Positive outcomes were reported in 7 of 10 studies. These outcomes included increased knowledge of T2DM symptoms and prevention measures; increased adoption of treatment-seeking and prevention measures; increased medication adherence; and improved fasting blood sugar, glycated hemoglobin, and body mass index. Three studies showed no significant outcomes.

CONCLUSIONS

CHWs have the potential to improve knowledge, health behavior, and health outcomes related to prevention and management of T2DM in LMICs. Given the limited number of studies included in this review, robust conclusions cannot be drawn at the present time.

Headache in Resource-Limited Settings

PURPOSE OF REVIEW

This review summarizes the unmet need of headache burden and management in resource-limited settings. It provides a general overview of the nuances and peculiarities of headache disorders in resource-limited settings. The review delivers perspectives and explanations for the emerging burden of both primary and secondary headache disorders. Important discussion on demographic and epidemiologic transition pertinent to low-resource settings is included. A critical analysis of headache disorders is made within the context of growing burden non-communicable disorders in low-resource countries. Challenges are examined and prospective feasible solutions tailored to existing resources are provided to address headache disorders in resource-limited settings.

RECENT FINDINGS

Many low-resource countries are entering into the third epidemiological transition featuring increasing burden of non-communicable disorders of which headache disorders contribute a significant proportion. Exponential population growth involving youthful demographic and massive rural-urban migration is taking place in low-resource countries. Youthful demographic is the natural cohort for primary headache such as migraine. Socioeconomic mobility and lifestyle changes are leading to higher levels of physical inactivity and obesity, both of which are related to headache. Life expectancy is rising in some resource-restricted countries; this increases prevalence of secondary headache attributed to neurovascular causes. Many low-resource countries are still burdened with tropical infectious causes of secondary headache. Health care facilities are primarily designed to respond to infectious epidemic and not to chronic burden such as headache. Many low-resource-restricted settings are plagued by poor and corrupt governance, ill-equipped regimes with malfunctioning health policies, war, and poverty. Many low-resource settings do not have access to generic headache medications such as triptans. Headache training and expertise is low. Healthy lifestyle changes emphasizing on improving regular exercise can be inexpensive method to reducing primary headache burden and its comorbidities (e.g. obesity). Addressing the increasing burden of headache disorders in resource-limited settings is important to avert accrued disability which in turn lowers productivity and socioeconomic performance in a young booming population.

Tuberculosis and HIV are the leading causes of adult death in northwest Ethiopia: evidence from verbal autopsy data of Dabat health and demographic surveillance system, 2007-2013

BACKGROUND

Reliable data on causes of death form the basis for building evidence on health policy, planning, monitoring, and evaluation. In Ethiopia, the majority of deaths occur at home and civil registration systems are not yet functional. The main objective of verbal autopsy (VA) is to describe the causes of death at the community or population level where civil registration and death certification systems are weak and where most people die at home without having had contact with the health system.

METHODS

Causes of death were classified and prepared based on the International Classification of Diseases (ICD-10). The cause of a death was ascertained based on an interview with next of kin or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history, and circumstances preceding death. The cause of death, or the sequence of causes that led to death, is assigned based on the data collected by the questionnaire. The complete VA questionnaires were given to two blinded physicians and reviewed independently. A third physician was assigned to review the case when disagreements in diagnosis arose.

RESULTS

Communicable diseases (519 deaths [48.0%]), non-communicable diseases (377 deaths [34.8%]), and external causes (113 deaths [10.4%]) were the main causes of death between 2007 and 2013. Of communicable diseases, tuberculosis (207 deaths [19.7%]), HIV/AIDS (96 deaths [8.9%]) and meningitis (76 deaths [7.0%]) were the most common causes of death.

CONCLUSION

Tuberculosis, HIV/AIDS, and meningitis were the most common causes of deaths among adults. Death due to non-communicable diseases showed an increasing trend. Increasing community awareness of infections and their interrelationships, tuberculosis case finding, effective local TB programs, successful treatment, and interventions for HIV are supremely important.

I've got 99 problems but a phone ain't one: Electronic and mobile health in low and middle income countries

Mobile technology is very prevalent in Kenya-mobile phone penetration is at 88% and mobile data subscriptions form 99% of all internet subscriptions. While there is great potential for such ubiquitous technology to revolutionise access and quality of healthcare in low-resource settings, there have been few successes at scale. Implementations of electronic health (e-Health) and mobile health (m-Health) technologies in countries like Kenya are yet to tackle human resource constraints or the political, ethical and financial considerations of such technologies. We outline recent innovations that could improve access and quality while considering the costs of healthcare. One is an attempt to create a scalable clinical decision support system by engaging a global network of specialist doctors and reversing some of the damaging effects of medical brain drain. The other efficiently extracts digital information from paper-based records using low-cost and locally produced tools such as rubber stamps to improve adherence to clinical practice guidelines. By bringing down the costs of remote consultations and clinical audit, respectively, these projects offer the potential for clinics in resource-limited settings to deliver high-quality care. This paper makes a case for continued and increased investment in social enterprises that bridge academia, public and private sectors to deliver sustainable and scalable e-Health and m-Health solutions.

Assessment of health system challenges and opportunities for possible integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region, Ethiopia: a qualitative study

BACKGROUND

The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem in low and middle income countries. However, despite the known synergy between the two disease conditions, services for TB and DM have separately been provided. The objective of this study was to explore health system challenges and opportunities for possible integration of DM and TB services.

METHODS

This was a descriptive qualitative study which was conducted in South-Eastern Amhara Region, Ethiopia. Study participants included health workers (HWs), program managers and other stakeholders involved in TB and DM prevention and control activities. Purposive sampling was applied to select respondents. In order to capture diversity of opinions among participants, maximum variation sampling strategy was applied in the recruitment of study subjects. Data were collected by conducting four focus group discussions and 12 in-depth interviews. Collected data were transcribed verbatim and were thematically analyzed using NVivo 10 software program.

RESULT

A total of 44 (12 in-depth interviews and 32 focus group discussion) participants were included in the study. The study participants identified a number of health system challenges and opportunities affecting the integration of TB-DM services. The main themes identified were: 1. Unavailability of system for continuity of DM care. 2. Inadequate knowledge and skills of health workers. 3. Frequent stockouts of DM supplies. 4. Patient's inability to pay for DM services. 5. Poor DM data management. 6. Less attention given to DM care. 7. Presence of a well-established TB control program up to the community level. 8. High level of interest and readiness among HWs, program managers and leaders at different levels of the health care delivery system.

CONCLUSION

The study provided insights into potential health systems challenges and opportunities that need to be considered in the integration of TB-DM services. Piloting TB and DM integrated services in selected HFs of the study area is needed to assess feasibility for possible full scale integration of services for the two comorbid conditions.