Using Village Health Teams for Effective Ultrasound Education in Rural Uganda

Maternal and child health conditions, many of which can be detected by ultrasound, represent the highest burden of disease in Uganda. Imaging the World (ITW) is a not-for-profit organization which integrates high quality, affordable ultrasound services into rural health facilities. Of all the challenges faced with implementation of ITW programs in Uganda, lack of sensitization to ultrasound represented the greatest barrier. The Village Health Team (VHT) is an existing public health “train the trainer” model sponsored by the Uganda Ministry of Health which provides public health training to community volunteers. Trained VHT members were recruited to help with ultrasound community outreach and education. These VHT members were successful in achieving dramatic community acceptance and increased utilization of ultrasound services in rural communities. This has led to significant contributions in improving population health in low-resource settings

Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER Randomised Controlled Trial

BACKGROUND: There is modest evidence that exercise referral schemes increase physical activity in inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of exercise referral schemes on long-term physical activity. OBJECTIVES: To determine if adding the e-coachER intervention to exercise referral schemes is more clinically effective and cost-effective in increasing physical activity after 1 year than usual exercise referral schemes. DESIGN: A pragmatic, multicentre, two-arm randomised controlled trial, with a mixed-methods process evaluation and health economic analysis. Participants were allocated in a 1 : 1 ratio to either exercise referral schemes plus e-coachER (intervention) or exercise referral schemes alone (control). SETTING: Patients were referred to exercise referral schemes in Plymouth, Birmingham and Glasgow. PARTICIPANTS: There were 450 participants aged 16-74 years, with a body mass index of 30-40 kg/m2, with hypertension, prediabetes, type 2 diabetes, lower limb osteoarthritis or a current/recent history of treatment for depression, who were also inactive, contactable via e-mail and internet users. INTERVENTION: e-coachER was designed to augment exercise referral schemes. Participants received a pedometer and fridge magnet with physical activity recording sheets, and a user guide to access the web-based support in the form of seven 'steps to health'. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in the importance of physical activity, competence, autonomy in physical activity choices and relatedness. All participants were referred to a standard exercise referral scheme. PRIMARY OUTCOME MEASURE: Minutes of moderate and vigorous physical activity in ≥ 10-minute bouts measured by an accelerometer over 1 week at 12 months, worn ≥ 16 hours per day for ≥ 4 days including ≥ 1 weekend day. SECONDARY OUTCOMES: Other accelerometer-derived physical activity measures, self-reported physical activity, exercise referral scheme attendance and EuroQol-5 Dimensions, five-level version, and Hospital Anxiety and Depression Scale scores were collected at 4 and 12 months post randomisation. RESULTS: Participants had a mean body mass index of 32.6 (standard deviation) 4.4 kg/m2, were referred primarily for weight loss and were mostly confident self-rated information technology users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (n = 108) compared with the control group (n = 124); 11.8 weekly minutes of moderate and vigorous physical activity (95% confidence interval -2.1 to 26.0 minutes; p = 0.10). Sixty-four per cent of intervention participants logged on at least once; they gave generally positive feedback on the web-based support. The intervention had no effect on other physical activity outcomes, exercise referral scheme attendance (78% in the control group vs. 75% in the intervention group) or EuroQol-5 Dimensions, five-level version, or Hospital Anxiety and Depression Scale scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months, but not at 12 months. At 12 months, the intervention group incurred an additional mean cost of £439 (95% confidence interval -£182 to £1060) compared with the control group, but generated more quality-adjusted life-years (mean 0.026, 95% confidence interval 0.013 to 0.040), with an incremental cost-effectiveness ratio of an additional £16,885 per quality-adjusted life-year. LIMITATIONS: A significant proportion (46%) of participants were not included in the primary analysis because of study withdrawal and insufficient device wear-time, so the results must be interpreted with caution. The regression model fit for the primary outcome was poor because of the considerable proportion of participants [142/243 (58%)] who recorded no instances of ≥ 10-minute bouts of moderate and vigorous physical activity at 12 months post randomisation. FUTURE WORK: The design and rigorous evaluation of cost-effective and scalable ways to increase exercise referral scheme uptake and maintenance of moderate and vigorous physical activity are needed among patients with chronic conditions. CONCLUSIONS: Adding e-coachER to usual exercise referral schemes had only a weak indicative effect on long-term rigorously defined, objectively assessed moderate and vigorous physical activity. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000 per quality-adjusted life-year. The intervention did improve some process outcomes as specified in our logic model. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15644451. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 63. See the NIHR Journals Library website for further project information.</p

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Treatment of Major Depressive Disorder with Iyengar Yoga and Coherent Breathing: A Randomized Controlled Dosing Study

Abstract Objectives: The aims of this study were to assess the effects of an intervention of Iyengar yoga and coherent breathing at five breaths per minute on depressive symptoms and to determine optimal intervention yoga dosing for future studies in individuals with major depressive disorder (MDD). Methods: Subjects were randomized to the high-dose group (HDG) or low-dose group (LDG) for a 12-week intervention of three or two intervention classes per week, respectively. Eligible subjects were 18–64 years old with MDD, had baseline Beck Depression Inventory-II (BDI-II) scores ≥14, and were either on no antidepressant medications or on a stable dose of antidepressants for ≥3 months. The intervention included 90-min classes plus homework. Outcome measures were BDI-II scores and intervention compliance. Results: Fifteen HDG (Mage = 38.4 ± 15.1 years) and 15 LDG (Mage = 34.7 ± 10.4 years) subjects completed the intervention. BDI-II scores at screening and compliance did not differ between groups (p = 0.26). BDI-II scores declined significantly from screening (24.6 ± 1.7) to week 12 (6.0 ± 3.8) for the HDG (–18.6 ± 6.6; p 50% decrease in BDI-II scores; p = 0.65) for the HDG (13/15 subjects) and LDG (11/15 subjects) or remission (i.e., number of subjects with BDI-II scores <14; p = 1.00) for the HDG (14/15 subjects) and LDG (13/15 subjects) after the 12-week intervention, although a greater number of subjects in the HDG had 12-week BDI-II scores ≤10 (p = 0.04). Conclusion: During this 12-week intervention of yoga plus coherent breathing, depressive symptoms declined significantly in patients with MDD in both the HDG and LDG. Both groups showed comparable compliance and clinical improvements, with more subjects in the HDG exhibiting BDI-II scores ≤10 at week 12

Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER Randomised Controlled Trial

Background: There is modest evidence that exercise referral schemes (ERS) increase physical activity (PA) of inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of ERS on long-term PA. Objectives: To determine if adding the e-coachER intervention to ERS is more effective and cost-effective in increasing PA after one year, compared to usual ERS. Design: Pragmatic, multicentre 2 arm randomised trial, with mixed methods process evaluation and health economic analysis. Participants were allocated 1:1 to either ERS plus e-coachER (intervention) or ERS alone (control). Setting: Patients referred to ERS in Plymouth, Birmingham and Glasgow. Participants: N = 450, aged 16-74 years, with BMI 30-40, hypertension, pre-diabetes, type 2 diabetes, lower limb osteoarthritis, or a current/recent history of treatment for depression; inactive; contactable via email; and an internet user. Intervention: e-coachER was designed to augment ERS. Participants received a pedometer and fridge magnet with PA recording sheets, and a User Guide to access the web-based support in the form of 7 Steps to Health. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in importance for doing PA, competence, autonomy in PA choices and relatedness. All participants were referred to a standard ERS programme. Primary outcome measure: Minutes of moderate and vigorous PA (MVPA) in ≥10 min bouts measured by accelerometer over one week at 12 months, worn ≥16 hours per day for ≥4 days including ≥1 weekend day. Secondary outcomes: Other accelerometer-derived PA measures, self-reported PA, ERS attendance, EQ-5D-5L and HADS were collected at 4 and 12 months. Results: Participants had a BMI mean (SD) of 32.6 (4.4), were primarily referred for weight loss, and were mostly confident self-rated IT users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (N=108) compared with the control group (N=124); 11.9 weekly minutes MVPA, 95% CI -2.1 to 26.0; p = 0.10. 64% of intervention participants logged on at least once with generally positive feedback on the web-based support. The intervention had no effect on other PA outcomes, ERS attendance (78% v 75% in control and intervention, respectively), EQ-5D-5L or HADS scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months but not at 12 months. At 12 months, compared to control, the intervention group incurred an additional mean cost of £439 (95% CI £-182, £1060) but generated more mean quality adjusted life years (QALYs); (0.026, 95% CI 0.013, 0.040) with an incremental cost effectiveness ratio of additional £16,885 per QALY. Limitations: A significant proportion (46%) of participants were not included in the primary analysis, due to study withdrawal, and insufficient device wear time and the results must be interpreted with caution. The regression model fit for the primary outcome was poor, because of the considerable proportion of participants (142/243 (58%)) who recorded zero minutes of ≥10 minute bouted MVPA at 12 months. Future work: The design and rigorous evaluation of cost-effective and scalable ways to increase ERS uptake and maintenance of MVPA are needed among patients with chronic conditions. Conclusion: Adding e-coachER to usual ERS had only a weak indicative effect on long-term rigorously defined, objectively assessed MVPA. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000/QALY. The intervention did improve some process outcomes as specified in our Logic Model. Study registration: ISRCTN15644451 Funding details: NIHR HTA 13/25/2