Key lifestyles and health outcomes across 16 prevalent chronic diseases: a network analysis of an international observational study

Background: Central and bridge nodes can drive significant overall improvements within their respective networks. We aimed to identify them in 16 prevalent chronic diseases during the coronavirus disease 2019 (COVID-19) pandemic to guide effective intervention strategies and appropriate resource allocation for most significant holistic lifestyle and health improvements. Methods: We surveyed 16 512 adults from July 2020 to August 2021 in 30 territories. Participants self-reported their medical histories and the perceived impact of COVID-19 on 18 lifestyle factors and 13 health outcomes. For each disease subgroup, we generated lifestyle, health outcome, and bridge networks. Variables with the highest centrality indices in each were identified central or bridge. We validated these networks using nonparametric and case-dropping subset bootstrapping and confirmed central and bridge variables' significantly higher indices through a centrality difference test. Findings: Among the 48 networks, 44 were validated (all correlation-stability coefficients >0.25). Six central lifestyle factors were identified: less consumption of snacks (for the chronic disease: anxiety), less sugary drinks (cancer, gastric ulcer, hypertension, insomnia, and pre-diabetes), less smoking tobacco (chronic obstructive pulmonary disease), frequency of exercise (depression and fatty liver disease), duration of exercise (irritable bowel syndrome), and overall amount of exercise (autoimmune disease, diabetes, eczema, heart attack, and high cholesterol). Two central health outcomes emerged: less emotional distress (chronic obstructive pulmonary disease, eczema, fatty liver disease, gastric ulcer, heart attack, high cholesterol, hypertension, insomnia, and pre-diabetes) and quality of life (anxiety, autoimmune disease, cancer, depression, diabetes, and irritable bowel syndrome). Four bridge lifestyles were identified: consumption of fruits and vegetables (diabetes, high cholesterol, hypertension, and insomnia), less duration of sitting (eczema, fatty liver disease, and heart attack), frequency of exercise (autoimmune disease, depression, and heart attack), and overall amount of exercise (anxiety, gastric ulcer, and insomnia). The centrality difference test showed the central and bridge variables had significantly higher centrality indices than others in their networks (P < 0.05). Conclusion: To effectively manage chronic diseases during the COVID-19 pandemic, enhanced interventions and optimised resource allocation toward central lifestyle factors, health outcomes, and bridge lifestyles are paramount. The key variables shared across chronic diseases emphasise the importance of coordinated intervention strategies

Global impacts of Covid-19 on lifestyles and health and preparation preferences: an international survey of 30 countries

Background: The health area being greatest impacted by coronavirus disease 2019 (COVID-19) and residents' perspective to better prepare for future pandemic remain unknown. We aimed to assess and make cross-country and cross-region comparisons of the global impacts of COVID-19 and preparation preferences of pandemic. Methods: We recruited adults in 30 countries covering all World Health Organization (WHO) regions from July 2020 to August 2021. 5 Likert-point scales were used to measure their perceived change in 32 aspects due to COVID-19 (-2 = substantially reduced to 2 = substantially increased) and perceived importance of 13 preparations (1 = not important to 5 = extremely important). Samples were stratified by age and gender in the corresponding countries. Multidimensional preference analysis displays disparities between 30 countries, WHO regions, economic development levels, and COVID-19 severity levels. Results: 16 512 adults participated, with 10 351 females. Among 32 aspects of impact, the most affected were having a meal at home (mean (m) = 0.84, standard error (SE) = 0.01), cooking at home (m = 0.78, SE = 0.01), social activities (m = -0.68, SE = 0.01), duration of screen time (m = 0.67, SE = 0.01), and duration of sitting (m = 0.59, SE = 0.01). Alcohol (m = -0.36, SE = 0.01) and tobacco (m = -0.38, SE = 0.01) consumption declined moderately. Among 13 preparations, respondents rated medicine delivery (m = 3.50, SE = 0.01), getting prescribed medicine in a hospital visit / follow-up in a community pharmacy (m = 3.37, SE = 0.01), and online shopping (m = 3.33, SE = 0.02) as the most important. The multidimensional preference analysis showed the European Region, Region of the Americas, Western Pacific Region and countries with a high-income level or medium to high COVID-19 severity were more adversely impacted on sitting and screen time duration and social activities, whereas other regions and countries experienced more cooking and eating at home. Countries with a high-income level or medium to high COVID-19 severity reported higher perceived mental burden and emotional distress. Except for low- and lower-middle-income countries, medicine delivery was always prioritised. Conclusions: Global increasing sitting and screen time and limiting social activities deserve as much attention as mental health. Besides, the pandemic has ushered in a notable enhancement in lifestyle of home cooking and eating, while simultaneously reducing the consumption of tobacco and alcohol. A health care system and technological infrastructure that facilitate medicine delivery, medicine prescription, and online shopping are priorities for coping with future pandemics

A MIXED METHODS STUDY TO EXPLORE THE HEALTH SYSTEM, CLINICIAN, AND PATIENT FACTORS INFLUENCING HYPERTENSION CARE AND OUTCOMES IN GHANA

Background: Hypertension is the leading risk factor for cardiovascular disease and a significant cause of premature deaths globally, with increasing impact in developing countries. While hypertension can be prevented and managed through healthy lifestyle behaviors and pharmacological therapy, health systems in low-resource settings are ill-equipped to educate the population regarding hypertension, regularly screen high-risk individuals for elevated blood pressure (BP), and treat patients diagnosed with hypertension. This dissertation explored the multi-level health system determinants of hypertension care and outcomes in Kumasi, Ghana, West Africa. Methods: We conducted a sequential explanatory mixed methods study guided by the Chronic Care Model and the World Health Organization Health Systems Framework. We recruited 15 health facilities in Kumasi, Ghana, which have hypertension care services, clinicians involved in hypertension management, and adult patients on hypertension treatment. We used the Service Availability and Readiness Assessment data collection tool at the health facility level, the provider hypertension knowledge and attitude survey at the provider level, and measured patient BP and adherence to BP treatment. We used descriptive statistics and mixed effects regression models during the analysis. We designed the focus group discussion guide using preliminary quantitative findings in which we invited health facility leaders and clinicians. The focus group discussions further explored clinicians’ and facility leaders’ perceptions of the health system facilitators and barriers to hypertension management. Results: From 15 health facilities, we successfully recruited 67 clinicians with a mean (SD) age of 32 (7) years and 224 adult patients with a mean (SD) age of 60.5 (12.7) years. Forty-nine percent of the patients had controlled BP (<140/90 mmHg). At the patient level, secondary education (Coeff.: -7.69, 95% CI: -15.13, -0.26) was associated with lower systolic BP than a lower level of education, and traveling for 30 minutes to 1 hour to the health facility was associated with lower odds of BP control (OR: 0.51, 95% CI: 0.28, 0.92) than traveling less than 30 minutes. The five focus group discussions involving 23 clinicians and nine health facility leaders revealed positive patients’ self-management practices, such as home BP monitoring, and negative ones, such as using traditional medicines. Despite high provider knowledge and confidence in adhering to hypertension guidelines from quantitative surveys, providers expressed (in the focus group discussions) a lack of training opportunities in hypertension management. At the health facility level, receiving care at government health facilities was associated with less systolic BP (Coeff.: -19.4; 95% CI: -33.58, -5.22) than at private health facilities; a higher patient-to-physician or physician-assistant ratio was associated with lower odds of controlled BP. In the focus group discussions, emergent themes included financial and geographic inaccessibility of hypertension services and a dire shortage of physicians. Conclusion: Poor accessibility of hypertension care services, and health workforce shortage are some of the significant barriers to hypertension management in Ghana. There is a need to decentralize hypertension care services, revise insurance coverage by the national health insurance scheme, and adopt a task-shifting strategy to vital professions such as nurses willing to take on more roles in hypertension management

Heterogeneity in the Prevalence of Cardiovascular Risk Factors by Ethnicity and Birthplace Among Asian Subgroups: Evidence From the 2010 to 2018 National Health Interview Survey

Background Asian people in the United States have different sociodemographic and health‐related characteristics that might affect cardiovascular disease (CVD) risk by ethnicity and birthplace. However, they are often studied as a monolithic group in health care research. This study aimed to examine heterogeneity in CVD risk factors on the basis of birthplace among the 3 largest Asian subgroups (Chinese, Asian Indian, and Filipino) compared with US‐born non‐Hispanic White (NHW) adults. Methods and Results A cross‐sectional analysis was conducted using the 2010 to 2018 National Health Interview Survey data from 125 008 US‐born and foreign‐born Chinese, Asian Indian, Filipino, and US‐born NHW adults. Generalized linear models with Poisson distribution were used to examine the prevalence and prevalence ratios of self‐reported hypertension, diabetes, high cholesterol, physical inactivity, smoking, and overweight/obesity among Asian subgroups compared with US‐born NHW adults. The study included 118 979 US‐born NHW and 6029 Asian adults who self‐identified as Chinese (29%), Asian Indian (33%), and Filipino (38%). Participants' mean (±SD) age was 49±0.1 years, and 53% were females. In an adjusted analysis, foreign‐born Asian Indians had significantly higher prevalence of diabetes, physical inactivity, and overweight/obesity; foreign‐born Chinese had higher prevalence of physical inactivity, and foreign‐born Filipinos had higher prevalence of all 5 CVD risk factors except smoking compared with NHW adults. Conclusions This study revealed significant heterogeneity in the prevalence of CVD risk factors among Asian subgroups by ethnicity and birthplace, stressing the necessity of disaggregating Asian subgroup data. Providers should consider this heterogeneity in CVD risk factors and establish tailored CVD prevention plans for Asian subgroups

The Cardiometabolic Health of African Immigrants in High-Income Countries: A Systematic Review

In recent decades, the number of African immigrants in high-income countries (HICs) has increased significantly. However, the cardiometabolic health of this population remains poorly examined. Thus, we conducted a systematic review to examine the prevalence of cardiometabolic risk factors among sub-Saharan African immigrants residing in HICs. Studies were identified through searches in electronic databases including PubMed, Embase, CINAHL, Cochrane, Scopus, and Web of Science up to July 2021. Data on the prevalence of cardiometabolic risk factors were extracted and synthesized in a narrative format, and a meta-analysis of pooled proportions was also conducted. Of 8655 unique records, 35 articles that reported data on the specific African countries of origin of African immigrants were included in the review. We observed heterogeneity in the burden of cardiometabolic risk factors by African country of origin and HIC. The most prevalent risk factors were hypertension (27%, range: 6&ndash;55%), overweight/obesity (59%, range: 13&ndash;91%), and dyslipidemia (29%, range: 11&ndash;77.2%). The pooled prevalence of diabetes was 11% (range: 5&ndash;17%), and 7% (range: 0.7&ndash;14.8%) for smoking. Few studies examined kidney disease, hyperlipidemia, and diagnosed cardiometabolic disease. Policy changes and effective interventions are needed to improve the cardiometabolic health of African immigrants, improve care access and utilization, and advance health equity

Migration-Related Weight Changes among African Immigrants in the United States

(1) Background: people who migrate from low-to high-income countries are at an increased risk of weight gain, and excess weight is a risk factor for cardiovascular disease. Few studies have quantified the changes in body mass index (BMI) pre- and post-migration among African immigrants. We assessed changes in BMI pre- and post-migration from Africa to the United States (US) and its associated risk factors. (2) Methods: we performed a cross-sectional analysis of the African Immigrant Health Study, which included African immigrants in the Baltimore-Washington District of the Columbia metropolitan area. BMI category change was the outcome of interest, categorized as healthy BMI change or maintenance, unhealthy BMI maintenance, and unhealthy BMI change. We explored the following potential factors of BMI change: sex, age at migration, percentage of life in the US, perceived stress, and reasons for migration. We performed multinomial logistic regression adjusting for employment, education, income, and marital status. (3) Results: we included 300 participants with a mean (±SD) current age of 47 (±11.4) years, and 56% were female. Overall, 14% of the participants had a healthy BMI change or maintenance, 22% had an unhealthy BMI maintenance, and 64% had an unhealthy BMI change. Each year of age at immigration was associated with a 7% higher relative risk of maintaining an unhealthy BMI (relative risk ratio [RRR]: 1.07; 95% CI 1.01, 1.14), and compared to men, females had two times the relative risk of unhealthy BMI maintenance (RRR: 2.67; 95% CI 1.02, 7.02). Spending 25% or more of life in the US was associated with a 3-fold higher risk of unhealthy BMI change (RRR: 2.78; 95% CI 1.1, 6.97). (4) Conclusions: the age at immigration, the reason for migration, and length of residence in the US could inform health promotion interventions that are targeted at preventing unhealthy weight gain among African immigrants

Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda

Introduction: Injury accounts for 9.6% of the global mortality burden, disproportionately affecting those living in low- and middle-income countries. In an effort to improve trauma care in Rwanda, the Ministry of Health developed a prehospital service, Service d’Aide Médicale Urgente (SAMU), and established an emergency medicine training program. However, little is known about patients receiving prehospital and emergency trauma care or their outcomes. The objective was to develop a linked prehospital–hospital database to evaluate patient characteristics, mechanisms of injury, prehospital and hospital resource use, and outcomes among injured patients receiving acute care in Kigali, Rwanda. Methods: A retrospective cohort study was conducted at University Teaching Hospital – Kigali, the primary trauma centre in Rwanda. Data was included on all injured patients transported by SAMU from December 2012 to February 2015. SAMU’s prehospital database was linked to hospital records and data were collected using standardised protocols by trained abstractors. Demographic information, injury characteristics, acute care, hospital course and outcomes were included. Results: 1668 patients were transported for traumatic injury during the study period. The majority (77.7%) of patients were male. The median age was 30 years. Motor vehicle collisions accounted for 75.0% of encounters of which 61.4% involved motorcycles. 48.8% of patients sustained injuries in two or more anatomical regions. 40.1% of patients were admitted to the hospital and 78.1% required surgery. The overall mortality rate was 5.5% with nearly half of hospital deaths occurring in the emergency centre. Conclusion: A linked prehospital and hospital database provided critical epidemiological information describing trauma patients in a low-resource setting. Blunt trauma from motor vehicle collisions involving young males constituted the majority of traumatic injury. Among this cohort, hospital resource utilisation was high as was mortality. This data can help guide the implementation of interventions to improve trauma care in the Rwandan setting

Scaling-up the All Babies Count programme to eliminate preventable neonatal deaths in Rwanda: experiences midway through implementation

Background: Rwanda has made significant reductions in child mortality; however, reductions in neonatal deaths have been slower. Despite near universal facility-based delivery, about half of neonatal deaths occur within 48 h of birth in health facilities. All Babies Count is an evidence-based 18-month change acceleration process that provides neonatal equipment and supplies, neonatal training and mentoring, and district-wide quarterly learning collaborative sessions to promote peer-to-peer learning and continuous quality improvement in interprofessional teams. The Rwanda Ministry of Health and Partners In Health are scaling-up All Babies Count to facilities in seven hospital catchment areas to improve quality of care and reduce neonatal mortality. This study describes the first year of implementation. Methods: A quality-improvement adviser provided support for All Babies Count implementation in each hospital catchment area through mentorship, training, and quality-improvement coaching. Four catchment areas launched in June and July, 2017 (phase 1) and three in October and November, 2017 (phase 2), covering 76 rural health facilities (seven hospitals and 69 health centres) located in the northern, southern, and western provinces of Rwanda. We used data from Rwanda health management information systems to monitor indicators of antenatal, intrapartum, postnatal, and inpatient neonatal care; process data were gathered from activity logs kept by quality-improvement advisers and surveys were completed at learning collaborative sessions. We used a χ2 test to measure performance differences between baseline (phase 1, April to June, 2017; phase 2, July to September, 2017) and the most recent quarter of All Babies Count implementation (April to June, 2018). Findings: The percentage of women who had their first antenatal care visit in the first trimester of pregnancy increased from 48% (4414/9141) to 60% (6296/10 486) (p<0·0001) and the proportion of women receiving first postnatal care consultation within 24 h increased from 85% (2862/3356) to 93% (3060/3282) (p<0·0001). The proportion of participants in the learning collaborative sessions who reported being “very or extremely confident” working in quality improvement rose from 54% before the sessions to 95% after the sessions (p<0·0001), with 89 quality improvement projects (69 in antenatal care, 10 intrapartum, three in postnatal care, and seven in neonatology) initiated after two learning collaborative sessions in phase 1 hospital catchment areas and one session in phase 2 catchment areas. Interpretation: Improved performance in measures targeted by All Babies Count was seen halfway through programme implementation, along with active quality-improvement activities and increased confidence in working with quality-improvement measures. These preliminary results show promise for the All Babies Count programme to improve care delivery and reduce neonatal mortality in diverse geographic areas of Rwanda. Funding: All Babies Count is funded by Saving Lives at Birth

Optimizing the Global Nursing Workforce to Ensure Universal Palliative Care Access and Alleviate Serious Health-Related Suffering Worldwide

Context: Palliative care access is fundamental to the highest attainable standard of health and a core component of universal health coverage. Forging universal palliative care access is insurmountable without strategically optimizing the nursing workforce and integrating palliative nursing into health systems at all levels. The COVID-19 pandemic has underscored both the critical need for accessible palliative care to alleviate serious health-related suffering and the key role of nurses to achieve this goal. Objectives: 1) Summarize palliative nursing contributions to the expansion of palliative care access; 2) identify emerging nursing roles in alignment with global palliative care recommendations and policy agendas; 3) promote nursing leadership development to enhance universal access to palliative care services. Methods: Empirical and policy literature review; best practice models; recommendations to optimize the palliative nursing workforce. Results: Nurses working across settings provide a considerable untapped resource that can be leveraged to advance palliative care access and palliative care program development. Best practice models demonstrate promising approaches and outcomes related to education and training, policy and advocacy, and academic-practice partnerships. Conclusion: An estimated 28 million nurses account for 59% of the international healthcare workforce and deliver up to 90% of primary health services. It has been well-documented that nurses are often the first or only healthcare provider available in many parts of the world. Strategic investments in international and interdisciplinary collaboration, as well as policy changes and the safe expansion of high-quality nursing care, can optimize the efforts of the global nursing workforce to mitigate serious health-related suffering