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Engaging community groups to enhance healthcare access for persons with disabilities in rural Uganda: A qualitative exploration.
Get PDFCommunity participation is a promising strategy for addressing local health needs through identification of context-specific challenges and developing sustainable solutions. However, its feasibility for persons with disabilities, who are often marginalized and excluded from participation, remains uncertain. Our study examines barriers and facilitators to community group participation in improving healthcare access for persons with disabilities in Uganda. Semi-structured interviews with 27 purposively selected persons with disabilities in Luuka district, Eastern Uganda were undertaken between September and November 2022. Questions were asked about participation in existing groups and interest in joining community groups for persons with disabilities to improve healthcare access. All interviews were recorded and transcribed and analysed with a thematic approach. Our study uncovered a notable lack of active engagement among persons with disabilities in existing community groups. Participants expressed a strong desire to belong to disability-focused groups, primarily driven by the desire for unified advocacy. Facilitators for group formation included the opportunity for collaborative problem-solving, unified advocacy, and the chance to share lived experiences. Conversely, barriers to participation encompassed issues such as low self-esteem, financial constraints preventing monetary contributions, and the lack of reasonable accommodations, such as inaccessible meeting venues. Recommendations for group formation included community-wide sensitisation, stakeholder engagement, integration of health-livelihood initiatives, linkage to services, and managing group dynamics to ensure inclusiveness, a manageable group size, and realistic monetary contributions. Persons with disabilities are eager to participate in community groups and recognize the importance of strengthening community-based healthcare initiatives. Addressing barriers to group formation can unlock the potential of these groups to support persons with disabilities effectively. These findings offer valuable insights for developing community-based interventions to enhance healthcare access for persons with disabilities. Further research is essential to fully grasp the key mechanisms and dynamics within these groups to ensure their long-term sustainability
Cost-Effectiveness Analysis of Daridorexant for the Pharmacological Treatment of Chronic Insomnia Disorder in Adults.
Get PDFOBJECTIVE: Daridorexant 50 mg is recommended for treating chronic insomnia in England, Wales (NICE, 2023) and Scotland (Scottish Medicines Consortium, 2024). This study examines the model and cost-effectiveness profile that led to these positive reimbursements. METHODS: The cost-effectiveness model integrated data from daridorexant 50 mg phase III trials (studies 301 and 303) and the National Health and Wellness Survey (NHWS). Clinical parameters were the Insomnia Severity Index (ISI) score and adverse events. Using the NHWS, ISI data were mapped to utility, healthcare resource use, and work productivity. Daridorexant 50 mg was priced at £1.40/day. The base-case time horizon was 1 year. A lifetime model explored long-term effects. Parameters, data inputs, structural uncertainty, and alternative scenarios are all presented. RESULTS: In the 12-months model compared with placebo, daridorexant was estimated to have an incremental cost of £389 and generate an additional 0.024 quality-adjusted life-years (QALYs), resulting in an incremental cost-effectiveness ratio (ICER) of £16,300 per additional QALY from a health service perspective. Due to selective attrition, the ICER improved to £9580 per QALY for those continuing treatment for >12 months. Adopting a societal productivity perspective, daridorexant was estimated to offer £596 (£330-£896) total productivity savings versus £411/year in treatment costs, leading to a situation of dominance. Lifetime modeling improved the long-term cost effectiveness of daridorexant under the assumption that any waning of treatment effect led to further dropout. CONCLUSION: Daridorexant 50 mg is estimated to be a cost-effective pharmacological treatment for chronic insomnia disorder in adult patients
Evaluating impacts of improved flooring on enteric and parasitic infections in rural households in Kenya: study protocol for a cluster-randomised controlled trial.
Get PDFINTRODUCTION: Earthen floors are often damp or dusty and difficult to clean, providing an ideal environment for faecal pathogens and parasites. Observational studies have revealed associations between household flooring and health outcomes, but robust experimental evidence is scant. This study will evaluate the impact of an improved household flooring intervention on enteric infections, soil-transmitted helminth (STH) infections and tungiasis through implementation of a cluster-randomised trial in two rural settings in Kwale and Bungoma Counties, Kenya. METHODS AND ANALYSES: 440 clusters (households) across both sites are allocated to control or intervention group, in which a low-cost, sealed, washable, cement-based floor is installed in eligible buildings of the dwelling, alongside a floor-care guide provided during an induction meeting. Following baseline assessments in both groups, all individuals over 1 year receive albendazole and those infected with tungiasis receive benzyl benzoate. Primary outcomes are as follows: prevalence of enteric infections in children under 5 years assessed via stool surveys and PCR; prevalence of tungiasis infection in children 1-14 years based on clinical exam; and prevalence of STH infection in all household members over 1 year assessed via Kato-Katz. Secondary outcomes include the following: intensity of STH and tungiasis infections; prevalence of caregiver-reported gastrointestinal illness in children under 5; quality of life and well-being measures; and environmental contamination. A process evaluation investigates intervention acceptability, durability, practicality and cost. ETHICS AND DISSEMINATION: The protocol has been approved by ethics committees of The Kenya Medical Research Institute, The Kenya National Commission for Science Technology and Innovation, and The London School of Hygiene & Tropical Medicine. Following the 12-month implementation period and final assessments, control households are offered improved floors. Results will be disseminated within Kenya, to the Ministries of Health and of Lands, Public Works, Housing and Urban Development, and to subnational leadership and communities. Dissemination will also occur through publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT05914363
Understanding stakeholder perspectives on integrating and sustaining a vertical HIV prevention programme into routine health services in Zimbabwe: a qualitative study.
Get PDFINTRODUCTION: The transition of voluntary medical male circumcision (VMMC), an HIV prevention service, in Zimbabwe from a donor-funded to a government-owned programme involves the collective efforts and alignment of national and subnational government leaders, managers, healthcare providers, village health workers, community members, donors and implementing partners. We sought to understand stakeholders' perspectives on barriers, facilitators and recommendations as a vertical HIV prevention programme transitioned to an integrated, government-led model. METHODS: We conducted 54 semistructured stakeholder interviews at the national and subnational levels. Interviews were audio recorded, transcribed and thematically analysed. RESULTS: Participants highlighted a range of psychological and structural barriers and facilitators to integrating and sustaining the VMMC programme. Respondents mentioned financing and staffing barriers to integration, particularly a lack of domestic resources, the transition from a fee-for-service to a facility-based performance model and staff attrition. Notably, resistance to changing the VMMC programme's operations was a significant barrier that may be tied to individual psychological barriers such as loss of power and job security. Donors and partners continued to control the funding for VMMC. Ideally, the Ministry of Health and Child Care should have more autonomy over these decisions. At the subnational level, there is an opportunity for increased responsibility and a greater sense of ownership through the decentralisation of governance. CONCLUSIONS: To ensure successful integration and local ownership of VMMC as an HIV prevention programme, stakeholders must address both psychological and structural barriers while aligning their perspectives on the transition. Individual providers have valid concerns about their financial security and the burden of additional responsibilities without adequate compensation. It is crucial for donors and partners to reduce their involvement and oversight. Additionally, resolving the financial barriers that prevent the government from having complete control of the programme will require empowering local government stakeholders to fully take ownership
Geographic, socioeconomic and demographic inequalities in the incidence of metastatic prostate cancer at time of diagnosis in England: a population-based evaluation.
Get PDFOBJECTIVE: To evaluate the area-based incidence of metastatic prostate cancer at diagnosis, reflecting the risk of late-stage diagnosis, and overall prostate cancer incidence, reflecting the risk of over-diagnosis, in a country without a formal screening programme. METHODS AND ANALYSIS: National study of annual prostate cancer incidence between 2015 and 2019. Mixed-effects regression estimated area-based incidence, adjusted for age, ethnicity and socioeconomic deprivation. Linear regression assessed the association between metastatic and overall cancer incidence. RESULTS: National annual incidence of metastatic prostate cancer was 5.7 per 10 000 men and overall incidence was 43.9. Higher incidence of both metastatic and overall cancer were observed in areas with older populations and with more men with black ethnicity (both p<0.0001). Greater socioeconomic deprivation was linked to higher metastatic but lower overall cancer incidence (p<0.0001). Metastatic incidence varied across the country from 4.0 to 6.8, and prostate cancer overall from 37.9 to 50.1 per 10 000 men. Areas with higher metastatic cancer incidence had lower overall cancer incidence (p<0.0001). CONCLUSIONS: There is significant geographic variation in metastatic prostate cancer incidence at diagnosis, with a higher incidence of metastatic cancer observed in areas with a lower overall prostate cancer incidence and in more socioeconomically deprived neighbourhoods, which likely contributes to poorer long-term outcomes. The findings highlight the need for a targeted, risk-based diagnostic approach as well as improved diagnostic facilities and referral pathways. Further research is needed to understand the factors driving this variation in order to reduce metastatic presentations and tackle inequalities in prostate cancer outcomes
"I have the vaccine in my body": perceptions of female sex workers after enrolling in a phase IIb HIV vaccine and pre-exposure prophylaxis trial in urban Tanzania.
Get PDFBACKGROUND: HIV continues to be a significant global public health problem in low and middle-income countries. Efforts to search for an effective and affordable preventative HIV vaccine are on-going. We investigated the understanding of perceived risk for acquiring HIV and the experience of female sex workers (FSW) in Tanzania, before and after enrolling in an HIV vaccine and Pre-Exposure Prophylaxis Trial. METHODS: This was a descriptive qualitative study design nested in a multicentre Phase IIb three-arm, two-stage HIV prophylactic vaccine trial with a second randomization to compare two pre-exposure prophylaxes (PrEPVacc trial) regimens. We present findings from Dar es Salaam site in Tanzania. Fifteen in-depth interviews and four focus group discussions were conducted among FSW who participated in the HIV vaccine and Pre-Exposure Prophylaxis Trial between 2021 and 2023. Data analysis was done manually using the Framework and thematic content analysis approaches. RESULTS: Two themes emerged from the findings: `Apparent risk' of acquiring HIV infection before enrolling in the HIV vaccine trial and `Balancing perceived risk' of acquiring HIV infection and preventive measures after enrolling in the HIV Vaccine and Pre-Exposure Prophylaxis Trial. Before enrolling in the trial, the participants perceived themselves at high risk of acquiring HIV infection. They reported inconsistent condom use in multiple relationships with clients whose HIV status was unknown. After enrolling in the trial, the participants reported improved knowledge of HIV prevention, particularly the use of pre-exposure prophylaxis and compliance with preventive measures. However, some participants perceived that the experimental vaccine was an established HIV preventive measure. In addition, condomless sex was still practiced, mainly to get higher payments from the clients. CONCLUSION AND RECOMMENDATIONS: The knowledge gained on HIV preventive measures by FSW after participation in the trial was valued. However, continued engagement in risky sexual practices and poor compliance with HIV preventive measures highlights the need for continued risk-reduction interventions while searching for an effective HIV vaccine
Counting general practitioners: a comparative repeat cross-sectional analysis of GPs in NHS general practice in England.
Get PDFBACKGROUND: There have been successive government promises to increase general practitioner (GP) numbers in England. AIM: To compare how NHS general practice GP numbers and trends differ depending on how GPs are defined and data are analysed. DESIGN AND SETTING: This was a comparative repeat cross-sectional study of NHS general practice GP numbers in England. METHOD: The study compared NHS England's General Practice Workforce GP data quarterly between September 2015 and September 2024 by headcount and full-time equivalent (FTE); with and without general practice trainees; and relative to population size. RESULTS: Between September 2015 and September 2024, if counting fully qualified GPs and general practice trainees, there was an 18% (41 193 to 48 758) rise in numbers; whereas if fully qualified FTE GPs alone were counted there was a 5% reduction (29 364 to 27 966). Once growth of the population registered with an NHS general practice was considered, the trend in GPs per capita varied between a 6% rise or 15% reduction. There was an increasing difference in the number of patients per GP between practices, with a 5th to 95th percentile range of 1204 and 4139 patients per fully qualified FTE GP in 2015; by 2024 these percentiles increased to 1357 and 5559. Using Office for National Statistics (ONS) mid-year population estimates produced different results as their population estimates are lower than the total number of patients registered with an NHS general practice. CONCLUSION: How GPs are defined, whether working hours are considered, and what measure of population size is used affects the interpretation of workforce trends. Using fully qualified FTE GPs per capita most closely reflects GP capacity, although there are limitations to current NHS data. Reporting the spread of patients per GP at practice level is necessary to capture the widening variation in GP provision in England
Determinants of malnutrition among children under 5 years in refugee and internally displaced person populations: a protocol for systematic review and meta-analysis.
Get PDFINTRODUCTION: Malnutrition is a critical global health issue, particularly among the vulnerable children whose socioeconomic, sociocultural and environmental characteristics are unique. Malnutrition significantly increases the risk of mortality and non-communicable diseases, impairs physical growth, hinders cognitive development and limits children's potential. While a number of earlier studies explored the determinants of malnutrition among children under 5 years of age in refugee and internally displaced person (IDP) populations, comprehensive reviews are scarce. A systematic synthesis of existing data is essential to better understand its prevalence and associated risk factors, informing more effective interventions. METHOD AND ANALYSIS: This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will conduct a comprehensive search in PubMed, Scopus and ProQuest. Additionally, relevant grey literature will be explored using Google Scholar and Google Advanced Search. We will include cross-sectional, cohort and case-control studies published in English that report the prevalence of malnutrition and associated factors among children under 5 years of age in refugee and/or IDP populations. Two reviewers will screen and extract data independently. The quality of the included studies will be assessed using the Joanna Briggs Institute critical appraisal tool. Meta-analysis will estimate pooled prevalence of malnutrition, as well as the pooled OR for associated factors, using a random-effects model with 95% CIs. Heterogeneity will be assessed using the χ² test and I² value. ETHICS AND DISSEMINATION: Ethical approval is not required. The results will be published in a peer-review journal and presented at conferences. PROSPERO REGISTRATION NUMBER: CRD42024611728
The Weight of Cardiovascular Diseases: Addressing the Global Cardiovascular Crisis Associated with Obesity.
Get PDFObesity is a growing global epidemic with significant implications for cardiovascular diseases (CVD). It couples as an independent risk factor and driver for multiple pathways leading to CVDs. Here we examine obesity's impact on CVD and propose actionable strategies. Data from the NCD Risk Factor Collaboration (NCD-RisC), Global Burden of Disease (GBD) survey, and regional health surveys databases were used. We examined trends in obesity prevalence and CVD mortality attributable to high body mass index (BMI), disaggregated by sex, geography, socioeconomic status, and urban-rural residence. Evidence from national policy initiatives and clinical management guidelines was also reviewed. As of 2022, over 1 billion people globally were living with obesity. Since 1990 the age-standardised obesity prevalence has doubled among women (from 8.8% to 18.5%) and tripled among men (from 4.8% to 14%). Globally, the number of annual CVD deaths attributable to high BMI (25 kg/m2 or over) more than doubled between 1990 and 2021, reaching 1.9 million in 2021. Reducing global obesity to 2019 levels could save an estimated US$2.2 trillion annually by 2060. Positive steps have been made in recent years, with the implementation of several global, national and local initiatives that show promise in tackling obesity and CVDs, in addition to the emergence of potentially game-changing medical interventions, such as glucagon-like peptide-1 receptor agonists (GLP-1RAs). Yet, to tackle obesity and associated CVD, there is a need for a holistic approach across clinical and public health interventions that accounts for the multiple determinants of obesity. We recommend the implementation of evidence-based, cost-effective public health measures, and the incorporation of obesity-specific recommendations into cardiovascular guidelines. Addressing the global cardiovascular crisis linked to obesity will require coordinated efforts from policymakers, healthcare systems, and global health organisations
Effectiveness of psychological crisis interventions during infectious disease outbreaks in low- and middle-income countries: a systematic review of Randomized Control Trials.
Get PDFThe huge mental health treatment gap in low- and middle-income countries (LMICs) is further exacerbated when infectious disease outbreaks occur. To address the increasing mental health needs during outbreaks, the availability of flexible and efficient mental health interventions is paramount, especially in low-resource settings where outbreaks are more common. Psychological interventions may help to address these mental health needs with efficient implementation costs. However, there is a huge paucity of quality evidence to inform psychosocial interventions during outbreaks. This systematic review sought to update the existing evidence to inform the effectiveness of psychological interventions that addresses mental health issues during outbreaks in LMICs. Six electronic databases were searched - Scopus, PubMed, PsycINFO, Embase, Cochrane library and CINAHL. We included randomised controlled trials of psychological interventions aimed to address common mental health conditions among adults affected by infectious disease outbreaks in LMICs. Studies were excluded if they were done among all age groups, used mixed interventions with pharmacotherapies, addressed severe mental health conditions and were published other than in English. The quality of evidence in the included trials was assessed using the Cochrane Collaboration risk of bias tool. We included 17 trials that examined the effectiveness of psychological interventions among outbreak-affected adults in LMICs. The quality of studies was generally average but tended to provide evidence that brief psychoeducational interventions based on cognitive restructuring, mindfulness, relaxation and stress management techniques were effective in reducing perceived stress and anxiety symptoms, and in improving resilience and self-efficacy. Similarly, mindfulness-based interventions and mindfulness stress reduction treatments were effective in addressing depression, anxiety and generalised anxiety disorder. Brief psychological interventions that can be delivered by non-specialists could have value in addressing the huge mental health needs in outbreak contexts