Well-being and quality of life in people with disabilities practicing sports, athletes with disabilities, and para-athletes: Insights from a critical review of the literature

Global well-being (GWB) is a complex, multi-dimensional, and multi-faceted construct that can be explored from two different, but often overlapping, complementary perspectives: the subjective and the objective ones. The subjective perspective, in turn, is comprised of two dimensions: namely, the hedonic and the eudaimonic standpoints. Within the former dimension, researchers have developed the concept of subjective hedonic well-being (SHWB), whereas, within the latter, they have built the framework of psychological and social well-being (PSWB). Disabled people have poorer well-being due to their pathology and may more frequently suffer from anxiety and depressive disorders than their able-bodied counterparts. Sports participation is an essential way to cope with disability. On the other hand, compared with their able-bodied peers, athletes with disabilities and para-athletes undergo a unique series of stressors. Little is known in terms of hedonic and eudaimonic well-being and quality of life in this specific population. Here, we review the literature, with an emphasis on the current state-of-art and gaps in knowledge that need to be addressed by future research. High-quality, large-scale investigations are needed to have a better understanding of the self-perceived (hedonic) and objective (eudaimonic) well-being and quality of life of disabled people practicing sports, athletes with disabilities, and para-athletes.

To conquer cervical and breast cancer in little charted waters: Synergistic and integrated approaches to identify early breast and cervical cancer in Cameroon

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Background: Across Africa, several governments have put in place policies to promote prevention of cervical and breast cancers. (Njunguna 2020, Njiru 2013, WHO 2017) These include routine screening at consultations, sensitization programs, HPV vaccination programs, and creation of cancer treatment centers. However there still exists a policy to practice gap and clinicians do not routinely screen for cancers and sensitization messages are not reaching those who need it most. Therefore, on the one hand the clinicians are not supplying these services and the women who need the services are not demanding for them. Methods: We used existing guidance for cervical and breast cancer screening and treatment including local policies and ASCO guidelines. We screened 64 women in the Ntasen and Ntanka communities of Cameroon. We then used the results to create sensitization and education programmes for community members using culturally relevant approach of storytelling. Results: We reported 11 out of 64 positive cervical conditions (VIA pos = 8; VILI pos = 10; both VIA/VILI pos = 7) making a 17.2% prevalence. The median age for VIA/VILI positive was 35.5 years (Range 21-60 years). 3 out of 11 (27.3%) were HIV positive. We reported 4 out of 64 positive breast conditions (BIRADS 2 (2); BIRADS 3 (1); BIRADS 4 (1)). We reported 12 out of 64 STIs (gonorrhea (4); Syphilis (2); HPV (6)). Treatment could not be initiated for breast and cervical conditions due to lack of health technologies needed. Patients were therefore referred for treatment. All participants with gonorrhea and syphilis were immediately initiated treatment. Conclusions: Considering the high burden of disease from cervical and breast cancer in Cameroon, Africa, and LMIC, exploring cost effective approaches for screening like VIA/VILI will be helpful in reducing disease burden. However, access to low-cost health technologies to provide treatment for positive cases, use of culturally relevant approaches to sensitize communities to uptake these health technologies, inclusion of patient representatives in decision making, and capacity building for clinicians and community health workers for diagnosis and treatment are needed to complete the recipe for conquering cancers in LMIC. A combined approach of routinely screening for breast, cervical, and STIs is useful for integrating a common cause for these conditions.

Developing Guidelines Before, During, and After the COVID-19 Pandemic

These authors discuss several challenges and solutions for developers of COVID-19–related guidelines and recommendations.

Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future

Background

There has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention.

Objective

Document ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases.

Our Approach

Contextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance.

Ongoing Activities

A number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities.

Conclusion

There are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care.

Artemisinin based combination therapy for uncomplicated malaria management among children under five in Cameroon: a best practice implementation project

OBJECTIVE

The aim of this evidence implementation project is to promote evidence-based practice in artemisinin-based combination therapy for managing uncomplicated malaria in children under five, thereby improving patient outcomes and resource utilization in the Bali Health District, Cameroon.

INTRODUCTION

The burden of disease attributable to malaria has significantly improved in the last three years, however morbidity and mortality risks are still present, especially for children under five. In children with uncomplicated P. falciparum malaria, there is strong evidence to suggest that artemisinin-based combination therapy (ACT) is effective in treating malaria. The World Health Organization has strong recommendations with high-quality evidence guiding practice in the "test, treat and track" approach using microscopy, rapid diagnostics tests and ACTs.

METHODS

This evidence implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) audit and feedback tool for promoting evidence-based healthcare involving three phases of activity.

RESULTS

We compared compliance with best practice recommendations at baseline against a follow-up compliance at four months, following implementation of strategies identified. Compliance rates improved overall by 31% (R: 20-42) for all criteria and sites, with differences noticed between sites. Nineteen barriers were identified, stratified into clinician, community health worker, patient and policy maker related barriers.

CONCLUSIONS

Despite existing barriers to evidence implementation, getting research into practice is possible and does improve quality of care.

Evaluation of all African clinical practice guidelines for hypertension: Quality and opportunities for improvement

RATIONALE, AIMS, AND OBJECTIVES

Good-quality clinical practice guidelines (CPGs) provide recommendations based on current best-evidence summaries. Hypertension is a prevalent noncommunicable disease in Africa, with disastrous sequelae (stroke, heart, and kidney disease). Its effective management relies on good quality, current, locally relevant evidence. This paper reports on an all African review of the guidance documents currently informing hypertension management.

METHODS

Attempts were made to contact 62 African countries for formal guidance documents used nationally to inform diagnosis and management of hypertension. Their quality was assessed by using Appraisal of Guidelines for Research & Evaluation (AGREE) II, scored by 2 independent reviewers. Differences in domain scores were compared between documents written prior to 2011 and 2011 onward. Findings were compared with earlier African CPG reviews.

RESULTS

Guidelines and protocols were provided by 26 countries. Six used country-specific stand-alone hypertension guidelines, and 10 used protocols embedded in Standard Treatment Guidelines for multiple conditions. Six used guidelines developed by the World Health Organization, and 4 indicated ad hoc use of international guidance (US, Portugal, and Brazil). Only 1 guidance document met CPG construction criteria, and none scored well on all AGREE domain scores. The lowest-scoring domain was rigour of development. There was no significant quality difference between pre-2011 and post-2011 guidance documents, and there were variable AGREE II scores for the same CPGs when comparing the African reviews.

CONCLUSIONS

The quality of hypertension guidance used by African nations could be improved. The need for so many guidance documents is questioned. Adopting a common evidence base from international good-quality CPGs and layering it with local contexts offer 1 way to efficiently improve African hypertension CPG quality and implementation.

Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline

CLINICAL QUESTION

What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.

CURRENT PRACTICE

Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.

RECOMMENDATION

The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).

HOW THIS GUIDELINE WAS CREATED

A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.

THE EVIDENCE

The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years' follow-up.

UNDERSTANDING THE RECOMMENDATION

The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.

Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline

Approximately 1.4 million women living with HIV become pregnant every year. Most women use antiretroviral therapy, to reduce the risk of vertical transmission or for personal health reasons. Using the GRADE framework according to the BMJ Rapid Recommendation process, we make recommendations for optimal choice of combination antiretroviral regimen considering patient values and preferences, the balance of desirable and undesirable outcomes, their uncertainty, and practical issues. We suggest a zidovudine and lamivudine-based regimen over one that includes tenofovir or emtricitabine (weak recommendation). We recommend alternatives over the combination of tenofovir, emtricitabine, and lopinavir/ritonavir (strong recommendation).