Uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa : protocol for a systematic review and meta-analysis

Background Uncontrolled hypertension is the most important risk factor and leading cause of cardiovascular diseases. It is predicted that the number of people with hypertension will increase, and a large proportion of this increase will occur in developing countries. The highest prevalence of uncontrolled hypertension is reported in sub-Saharan Africa, and treatment for hypertension is unacceptably low. Hypertension commonly co-exists with comorbidities and this is associated with poorer health outcomes for patients. This review aims to estimate the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa. Methods and analysis All published and unpublished studies on the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa will be included. MEDLINE via OVID, Embase, and Web of Science will be searched to identify all relevant articles published from January 2000 to June 2019. Experts in the field will be contacted for unpublished literature, and Open SIGLE will be reviewed for relevant information. No language restriction will be imposed. Two reviewers will select, screen, extract data, and assess the risk of bias while a third reviewer will arbitrate the disagreements. A meta-analysis will be performed on variables that are similar across the included studies. Proportions will be stabilized before estimates are pooled using a random effects model. The presence of publication bias will be assessed using Egger’s test and visual inspection of the funnel plots. This systematic and meta-analysis review protocol will be reported in accordance with the PRISMA-P protocol guidelines. Results will be stratified by country, comorbidity, and geographic region

Exploring attributions of causality for child undernutrition:qualitative analysis in Lusaka, Zambia

Child undernutrition is responsible for 45% of all under‐five deaths in low‐ and middle‐income countries (LMICs) and numerous morbidities. Although progress has been made, high levels of child undernutrition persist in Zambia. Existing studies have explored primary caretakers' (PCs) explanatory models of child undernutrition in LMICs, without comparison with those of health care providers (HCPs). This paper examines and compares the perceived causes of child undernutrition among PCs and HCPs in Zambia. We conducted a qualitative study, using semistructured one‐to‐one and group interviews, with 38 PCs and 10 HCPs to explore their perceptions of child undernutrition and its perceived causes in Lusaka district, Zambia. Interview data were analysed with thematic analysis. Our findings indicate that PCs and HCPs in Lusaka district have divergent explanatory models of child undernutrition and perceive parental agency differently. In divergently framing how they conceptualise undernutrition and who is able to prevent it, these models underpin different attributions of causality and different opportunities for intervention. PCs highlighted factors such as child food preferences, child health, and household finances. Contrarily, HCPs stressed factors such as ‘improper feeding’, only highlighting factors such as wider economic conditions when these impacted specifically on health care services. One factor, identified by both groups, was ‘inadequate mothering’. To accelerate the reduction of child undernutrition, interventions must address divergences between PCs and HCPs' explanatory models. Additionally, attention needs to be paid to how wider socio‐economic and cultural contexts not only impact childhood undernutrition but shape attributions of causality

Cumulative social risk and type 2 diabetes in US adults: The National Health and Nutrition Examination Survey (NHANES) 1999–2006

Background: The cumulative effects of adverse social factors on the diabetes risk remains to be clarified. Design: Cross-sectional analysis of the US National Health and Nutrition Examination Survey (NHANES) 1999–2006. Methods: We included 10,276 adults aged ≥20 years. Diabetes mellitus was defined by physician diagnosis or fasting plasma glucose (≥126 mg/dl) or glycated hemoglobin (≥6.5%). Social risk factors (low family income, low education level, minority racial/ethnic group status, and single-living status) and health-related behaviors (physical activity and dietary intake) were self-reported. Social risk factors were combined in a cumulative social risk index (range 0 to ≥3) and logistic regression used to assess the association of cumulative social risk and diabetes, taking into account complex survey design and sampling weights. Results: Of 10,276 participants, 1515 (weighted proportion – 10%) had diabetes, 3295 (32.3%) and 1830 (9.0%) were exposed to ≥1 adverse social risk factor and ≥3 social risk factors, respectively. Diabetes was associated with increasing cumulative social risk in a graded manner (p for trend <0.001). Compared with a cumulative social risk score of 0, the age- and sex-adjusted diabetes odds for a cumulative social risk score of ≥3 was 2.84 (95% confidence interval: 2.23–3.62), and 2.72 (95% confidence interval: 2.05–3.60) after further adjustment for family history of diabetes, body mass index, smoking, dietary intake and leisure time physical activity. Health behaviors and adiposity only partially influenced the cumulative social risk and diabetes relationship. Conclusions: Simultaneous exposure to several adverse social risk factors significantly influences the odds of diabetes. Better prevention and control of diabetes needs accounting for all aspects of social disadvantage

Intra‐household double burden of overweight/obesity and anaemia : evidence from 49 low‐and middle‐income countries

Globally, overweight/obesity is rising rapidly while anaemia persists. Nevertheless, evidence on their coexistence at the household level remains limited. Using data from the Demographic and Health Surveys, we quantified the magnitude, distribution and inequalities (i.e., estimates by wealth, education level and residence) in the intra‐household double burden (DBM) of overweight/obesity and anaemia among mothers and their children living in 49 low‐ and middle‐income countries (LMICs). The pooled prevalence of total intra‐household DBM was 17.2% (95% confidence interval [CI]: 15.6, 18.8); 16.2% (95% CI: 14.6, 17.9) for mothers with overweight/obesity and children with anaemia; and 2.8% (95% CI: 2.5, 3.1) for mothers with anaemia and children with overweight/obesity. South Africa had the highest prevalence of total DBM at the household level, affecting almost one in three households. Households with mothers with overweight/obesity and children with anaemia followed an inverse social gradient, with higher estimates found in the richest quintile, highest maternal education level and in urban areas; although with some variation across regions. The opposite was observed for mothers with anaemia and children with overweight/obesity. The largest inequality gaps were found for mothers with overweight/obesity and children with anaemia in Togo by household wealth (29.3%‐points; p < 0.001), in Ghana by maternal education level (28.0%‐points; p = 0.001) and in Niger by area of residence (25.2%‐points; p < 0.001). Although double‐duty actions might help accelerate action towards reducing malnutrition in all its forms, a comprehensive assessment of the causes of anaemia is first warranted to design effective country‐specific programmes

Exposure to multiple childhood social risk factors and adult body mass index trajectories from ages 20 to 64 years

Background: While childhood social risk factors appear to be associated with adult obesity, it is unclear whether exposure to multiple childhood social risk factors is associated with accelerated weight gain during adulthood. / Methods: We used the Medical Research Council National Survey of Health and Development, a British population-based birth cohort study of participants born in 1946, height and weight were measured by nurses at ages 36, 43, 53 and 60–64 and self-reported at 20 and 26 years. The 9 childhood socioeconomic risk factors and 8 binary childhood psychosocial risk factors were measured, with 13 prospectively measured at age 4 years (or at 7 or 11 years if missing) and 3 were recalled when participants were age 43. Multilevel modelling was used to examine the association between the number of childhood social risk factors and changes in body mass index (BMI) with age. / Results: Increasing exposure to a higher number of childhood socioeconomic risk factors was associated with higher mean BMI across adulthood for both sexes and with a faster increase in BMI from 20 to 64 years, among women but not men. Associations remained after adjustment for adult social class. There was no evidence of an association between exposure to childhood psychosocial risk factors and mean BMI in either sex at any age. / Conclusions: Strategies for the prevention and management of weight gain across adulthood may need to tailor interventions in consideration of past exposure to multiple socioeconomic disadvantages experienced during childhood

Global primary care research challenges

Healthcare needs are changing globally as people live longer, but not necessarily in better health. Increased population migration is leading to culturally diverse patient populations with more diverse health needs and expectations. The provision of accessible and equitable primary care poses workforce, infrastructure and management challenges for high- and lower-middle income countries that transcend national borders. In this special issue, we describe ‘global primary care’ as primary care training, research and service delivery that places a priority on the needs and overall health of individuals and their communities, to advance health equity worldwide. Given this nascent definition, what should ‘global primary care research’ look like? The following case demonstrates the breadth of physical, mental, and social issues a primary care practitioner must consider when faced with a patient from a marginalised group in an inner-city practice and why training and research must have a focus on equity

Tobacco use in pregnant women: analysis of data from Demographic and Health Surveys from 54 low-income and middle-income countries

Background Worldwide, use of tobacco is viewed as an important threat to the health of pregnant women and their children. However, the extent of tobacco use in pregnant women in low-income and middle-income countries (LMICs) remains unclear. We assessed the magnitude of tobacco use in pregnant women in LMICs. Methods We used data from Demographic and Health Surveys (DHS) done in 54 LMICs between Jan 1, 2001, and Dec 1, 2012, comprising 58 922 pregnant women (aged 15–49 years), which were grouped by WHO region. Prevalence of current tobacco use (smoked and smokeless) was estimated for every country. Pooled estimates by regions and overall were obtained from random-eff ects meta-analysis. Findings Pooled prevalence of any tobacco use in pregnant women in LMICs was 2·6% (95% CI 1·8–3·6); the lowest prevalence was in the African region (2·0%, 1·2–2·9) and the highest was in the Southeast Asian region (5·1%, 1·3–10·9). The pooled prevalence of current tobacco smoking in pregnant women ranged from 0·6% (0·3–0·8) in the African region to 3·5% (1·5–12·1) in the Western Pacifi c region. The pooled prevalence of current smokeless tobacco use in pregnant women was lowest in the European region (0·1%, 0·0–0·3) and highest in the Southeast Asian region (2·6%, 0·0–7·6). Interpretation Overall, tobacco use in pregnant women in LMICs was low; however high prevalence estimates were noted in some LMICs. Prevention and management of tobacco use and exposure to second-hand smoke in pregnancy is crucial to protect maternal and child health in LMICs

Exposure to household air pollution from solid cookfuels and childhood stunting: a population-based, cross-sectional study of half a million children in low- and middle-income countries

BACKGROUND: Household air pollution from the incomplete combustion of solid cookfuels in low- and middle-income countries (LMICs) has been largely ignored as a potentially important correlate of stunting. Our objective was to examine the association between solid cookfuel use and stunting in children aged <5 y. METHODS: We used data from 59 LMICs' population-based cross-sectional demographic and health surveys; 557 098 children aged <5 y were included in our analytical sample. Multilevel logistic regression was used to examine the association between exposure to solid cookfuel use and childhood stunting, adjusting for child sex, age, maternal education and number of children living in the household. We explored the association across key subgroups. RESULTS: Solid cookfuel use was associated with child stunting (adjusted OR 1.58, 95% CI 1.55 to 1.61). Children living in households using solid cookfuels were more likely to be stunted if they lived in rural areas, the poorest households, had a mother who smoked tobacco or were from the Americas. CONCLUSIONS: Focused strategies to reduce solid cookfuel exposure might contribute to reductions in childhood stunting in LMICs. Trial evidence to assess the effect of reducing solid cookfuel exposure on childhood stunting is urgently needed