The Role of Leadership in Sub-Saharan Africa in Promoting Maternal and Child Health

Sub-Saharan Africa (SSA) continues to face adverse maternal and child health (MCH) outcomes compared to other regions of the world. Previous research showed that SSA countries did not reach Millennium Development Goals (MDG)-4 and MDG-5. To further our understanding of levels and correlates of MCH outcomes, numerous studies have focused on socioeconomic factors, both at individual, household, and community levels. This chapter adopted a different approach and emphasized the role of leadership at regional, national, and local levels to improve MCH outcomes in SSA countries. Overall, the chapter demonstrated that without an enlightened leadership, SSA countries will be lagging behind SDG-3 targets. Additionally, evidence to guide policymaking in most countries is lacking mainly due to lack of sound data to specifically meet the needs of policymakers. There is an urgent need to focus on Research and Development (R&D) and Innovation. To achieve this goal, a crucial shift in leadership is compulsory

The long-term effects of Kerala Diabetes Prevention Program on diabetes incidence and cardiometabolic risk:a study protocol

Introduction: India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited. Objectives: The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years. Methods: The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned. Discussion: Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings. Trial registration: Australia and New Zealand Clinical Trials Registry–(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191.publishedVersionPeer reviewe

The history, geography, and sociology of slums and the health problems of people who live in slums

Massive slums have become major features of cities in many low-income and middle-income countries. Here, in the first in a Series of two papers, we discuss why slums are unhealthy places with especially high risks of infection and injury. We show that children are especially vulnerable, and that the combination of malnutrition and recurrent diarrhoea leads to stunted growth and longer-term effects on cognitive development. We find that the scientific literature on slum health is underdeveloped in comparison to urban health, and poverty and health. This shortcoming is important because health is affected by factors arising from the shared physical and social environment, which have effects beyond those of poverty alone. In the second paper we will consider what can be done to improve health and make recommendations for the development of slum health as a field of study

Multimorbidity from chronic conditions among adults in urban slums : the AWI-Gen Nairobi site study findings

Background: In the era of double burden of infectious and non-communicable diseases in sub-Saharan Africa, the burden of multimorbidity is likely to be common. However, there is limited evidence on the burden and its associated factors in the sub-Saharan African context. Objective: The aim of this study was to determine the levels and identify determinants of multimorbidity from chronic conditions in two urban slums in Nairobi. Methods: Data collected from 2003 study participants aged 40–60 years in two urban slums of the Nairobi Urban Health and Demographic Surveillance System in 2015 were used. Using self-report, anthropometry and key biomarkers, data on 16 conditions including chronic diseases, behavioral disorders and metabolic abnormalities were gathered. Lifetime multimorbidity defined by the occurrence of at least two chronic conditions in an individual at any time during their life course was computed. Factors associated with lifetime multimorbidity were identified using multiple logistic regression. Findings: A total of 2,081 chronic conditions were identified among 1,302 individuals. While 701 (35.0%) had no chronic condition, single morbidity was reported in 726 (36.2%) of the study population. The overall prevalence of lifetime multimorbidity was 28.7%. The prevalence of dyads and triads of simultaneous occurrences of conditions (episodic multimorbidity) was 20.8% and 6.1%, respectively. Single morbidity was positively associated with gender and alcohol consumption; and negatively associated with employment. Women, older people, the unemployed, current smokers and current alcohol consumers had higher levels of lifetime multimorbidity in the study population. Interpretation: The findings of this study indicate that a considerable proportion of adults living in urban slums experience multimorbidity from chronic conditions. Further studies with a better rigor to establish temporal associations between socio-demographic factors and the occurrence of chronic conditions are needed to explore the impacts and implications on health status and health system

Improving the health and welfare of people who live in slums

In the first paper in this Series we assessed theoretical and empirical evidence and concluded that the health of people living in slums is a function not only of poverty but of intimately shared physical and social environments. In this paper we extend the theory of so-called neighbourhood effects. Slums offer high returns on investment because beneficial effects are shared across many people in densely populated neighbourhoods. Neighbourhood effects also help explain how and why the benefits of interventions vary between slum and non-slum spaces and between slums. We build on this spatial concept of slums to argue that, in all low-income and-middle-income countries, census tracts should henceforth be designated slum or non-slum both to inform local policy and as the basis for research surveys that build on censuses. We argue that slum health should be promoted as a topic of enquiry alongside poverty and health

Strengthening Capacity for Implementation Research Amid COVID-19 Pandemic : Learnings From the Global Alliance for Chronic Diseases Implementation Science School

Objective: To describe the design, delivery and evaluation of the 3rd Global Alliance for Chronic Diseases (GACD) Implementation Science School (ISS), delivered virtually in 2020 for the first time. Methods: Since 2014, GACD has supported the delivery of more than ten Implementation Science Workshops for more than 500 international participants. It has also been conducting an annual ISS since 2018. In this study, we described the design, delivery and evaluation of the third ISS. Results: Forty-six participants from 23 countries in five WHO regions attended the program. The virtual delivery was well-received and found to be efficient in program delivery, networking and for providing collaborative opportunities for trainees from many different countries. The recently developed GACD Implementation Science e-Hub was found to be an instrumental platform to support the program by providing a stand-alone, comprehensive online learning space for knowledge and skill development in implementation research. Conclusion: The delivery of the virtual GACD ISS proved to be feasible, acceptable and effective and offers greater scalability and sustainability as part of a future strategy for capacity strengthening in implementation research globally.publishedVersionPeer reviewe

Blood Pressure and Arterial Stiffness in Kenyan Adolescents With α+Thalassemia.

BACKGROUND: Recent studies have discovered that α-globin is expressed in blood vessel walls where it plays a role in regulating vascular tone. We tested the hypothesis that blood pressure (BP) might differ between normal individuals and those with α+thalassemia, in whom the production of α-globin is reduced. METHODS AND RESULTS: The study was conducted in Nairobi, Kenya, among 938 adolescents aged 11 to 17 years. Twenty-four-hour ambulatory BP monitoring and arterial stiffness measurements were performed using an arteriograph device. We genotyped for α+thalassemia by polymerase chain reaction. Complete data for analysis were available for 623 subjects; 223 (36%) were heterozygous (-α/αα) and 47 (8%) were homozygous (-α/-α) for α+thalassemia whereas the remaining 353 (55%) were normal (αα/αα). Mean 24-hour systolic BP ±SD was 118±12 mm Hg in αα/αα, 117±11 mm Hg in -α/αα, and 118±11 mm Hg in -α/-α subjects, respectively. Mean 24-hour diastolic BP ±SD in these groups was 64±8, 63±7, and 65±8 mm Hg, respectively. Mean pulse wave velocity (PWV)±SD was 7±0.8, 7±0.8, and 7±0.7 ms-1, respectively. No differences were observed in PWV and any of the 24-hour ambulatory BP monitoring-derived measures between those with and without α+thalassemia. CONCLUSIONS: These data suggest that the presence of α+thalassemia does not affect BP and/or arterial stiffness in Kenyan adolescents

Low physical activity is associated with adverse health outcome and higher costs in Indonesia: A national panel study

AimsTo assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia.MethodsIn this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40–80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables.ResultsThe prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51–2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07–1.96) and inpatient care (AOR 1.45, 95% CI: 1.07–1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21–2.28), and have lower labor participation (AOR: 0.24, 95% 0.20–0.28).ConclusionsLow physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits

Community Control of Hypertension and Diabetes (CoCo-HD) program in the Indian states of Kerala and Tamil Nadu : a study protocol for a type 3 hybrid trial

Introduction: India grapples with a formidable health challenge, with an estimated 315 million adults afflicted with hypertension and 100 million living with diabetes mellitus. Alarming statistics reveal rates for poor treatment and control of hypertension and diabetes. In response to these pressing needs, the Community Control of Hypertension and Diabetes (CoCo-HD) program aims to implement structured lifestyle interventions at scale in the southern Indian states of Kerala and Tamil Nadu. Aims: This research is designed to evaluate the implementation outcomes of peer support programs and community mobilisation strategies in overcoming barriers and maximising enablers for effective diabetes and hypertension prevention and control. Furthermore, it will identify contextual factors that influence intervention scalability and it will also evaluate the program’s value and return on investment through economic evaluation. Methods: The CoCo-HD program is underpinned by a longstanding collaborative effort, engaging stakeholders to co-design comprehensive solutions that will be scalable in the two states. This entails equipping community health workers with tailored training and fostering community engagement, with a primary focus on leveraging peer supportat scale in these communities. The evaluation will undertake a hybrid type III trial in, Kerala and Tamil Nadu states, guided by the Institute for Health Improvement framework. The evaluation framework is underpinned by the application of three frameworks, RE-AIM, Normalisation Process Theory, and the Consolidated Framework for Implementation Research. Evaluation metrics include clinical outcomes: diabetes and hypertension control rates, as well as behavioural, physical, and biochemical measurements and treatment adherence. Discussion: The anticipated outcomes of this study hold immense promise, offering important learnings into effective scaling up of lifestyle interventions for hypertension and diabetes control in low- and middle-income countries (LMICs). By identifying effective implementation strategies and contextual determinants, this research has the potential to lead to important changes in healthcare delivery systems. Conclusions: The project will provide valuable evidence for the scaling-up of structured lifestyle interventions within the healthcare systems of Kerala and Tamil Nadu, thus facilitating their future adaptation to diverse settings in India and other LMICs.Peer reviewe

National disability-adjusted life years(DALYs) for 257 diseases and injuries in Ethiopia, 1990–2015: findings from the global burden of disease study 2015

Background: Disability-adjusted life years (DALYs) provide a summary measure of health and can be a critical input to guide health systems, investments, and priority-setting in Ethiopia. We aimed to determine the leading causes of premature mortality and disability using DALYs and describe the relative burden of disease and injuries in Ethiopia. Methods: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for non-fatal disease burden, cause-specific mortality, and all-cause mortality to derive age-standardized DALYs by sex for Ethiopia for each year. We calculated DALYs by summing years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs) for each age group and sex. Causes of death by age, sex, and year were measured mainly using Causes of Death Ensemble modeling. To estimate YLDs, a Bayesian meta-regression method was used. We reported DALY rates per 100,000 for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases, and injuries, with 95% uncertainty intervals (UI) for Ethiopia. Results: Non-communicable diseases caused 23,118.1 (95% UI, 17,124.4–30,579.6), CMNN disorders resulted in 20,200.7 (95% UI, 16,532.2–24,917.9), and injuries caused 3781 (95% UI, 2642.9–5500.6) age-standardized DALYs per 100,000 in Ethiopia in 2015. Lower respiratory infections, diarrheal diseases, and tuberculosis were the top three leading causes of DALYs in 2015, accounting for 2998 (95% UI, 2173.7–4029), 2592.5 (95% UI, 1850.7–3495.1), and 2562.9 (95% UI, 1466.1–4220.7) DALYs per 100,000, respectively. Ischemic heart disease and cerebrovascular disease were the fourth and fifth leading causes of age-standardized DALYs, with rates of 2535.7 (95% UI, 1603.7–3843.2) and 2159.9 (95% UI, 1369.7–3216.3) per 100,000, respectively. The following causes showed a reduction of 60% or more over the last 25 years: lower respiratory infections, diarrheal diseases, tuberculosis, neonatal encephalopathy, preterm birth complications, meningitis, malaria, protein-energy malnutrition, iron-deficiency anemia, measles, war and legal intervention, and maternal hemorrhage