Smokeless tobacco in South Asia – the measurement of dependence, sociocultural influences and cardiovascular consequences

Introduction: Despite very high smokeless tobacco (ST) consumption in South Asia (SA), there are significant gaps in our knowledge regarding the measurement of ST dependence, sociocultural influences, and consequences associated with the use of South Asian ST products. Aim: To improve our understanding of ST use and dependency, sociocultural determinants and consequences associated with their use in South Asia. Methods: My thesis comprised of three empirical studies. I carried out psychometric assessments of three ST dependency scales, using data collected from a convenience sample of adult ST users in India. In the same sample, I quantitatively measured selected sociocultural variables and assessed their association with ST use and quit practices. Finally, I conducted meta-analyses of longitudinal observational studies to examine causal associations between ever use of ST and cardiovascular outcomes, both globally and by geographical subgroups. Results: Among the scales, internal consistency was highest for Oklahoma Scale for Smokeless Tobacco Dependence (OSSTD). The scales were significantly correlated with each other, and showed positive associations with heaviness and consistency of ST use. Based on exploratory factor analyses (EFA), OSSTD was a unidimensional measure of ST dependence in an Indian context. The sociocultural survey showed that having ST users as close peers and no household restrictions on use adversely influenced quit attempts and quit intentions respectively, in adjusted models. In the meta-analyses, ever use of ST was associated with a 40% increased risk of incident ischaemic health disease (IHD) in SA, which was not found in other geographical regions. Conclusions: South Asian ST products are likely highly addictive, and sociocultural factors may be associated with fewer quit attempts made. In addition to cancer, ST use also increases the risk of cardiovascular disease outcomes. More research relevant to ST control is needed from SA, particularly given the adverse health consequences associated with use

Prevalence of mental disorders in South Asia: a systematic review of reviews

Mental disorders are increasing in South Asia (SA), but their epidemiological burden is under-researched. We carried out a systematic umbrella review to estimate the prevalence of mental disorders and intentional self-harm in the region. Multiple databases were searched and systematic reviews reporting the prevalence of at least one mental disorder from countries in SA were included. Review data were narratively synthesised; primary studies of common mental disorders (CMDs) among adults were identified from a selected subset of reviews and pooled. We included 124 reviews. The majority (n = 65) reported on mood disorders, followed by anxiety disorders (n = 45). High prevalence of mental disorders and intentional self-harm was found in general adult and vulnerable populations. Two reviews met our pre-defined criteria for identifying primary studies of CMDs. Meta-analysis of 25 primary studies showed a pooled prevalence of 16.0% (95% CI = 11.0–22.0%, I 2 = 99.9%) for depression, 12.0% (5.0–21.0%, I 2 = 99.9%) for anxiety, and 14.0% (10.0–19.0, I 2 = 99.9%) for both among the general adult population; pooled estimates varied by country and assessment tool used. Overall, reviews suggest high prevalence for mental disorders in SA, but evidence is limited on conditions other than CMDs

Understanding the costs and economic impact of mental disorders in South Asia:a systematic review

BACKGROUND: Mental disorders remain the most significant contributor to years lived with disability in South Asia, yet governmental health expenditure on mental health in South Asia remains very low with limited strategic policy development. To strengthen the case for action it is important to better understand the profound economic costs associated with poor mental health. METHODS: We conducted a systematic review on the costs of all mental disorders, as well as intentional self-harm and suicide, in the World Bank South Asia Region. Ten global and South Asian databases as well as grey literature sources were searched. RESULTS: 72 studies were identified, including 38 meeting high quality criteria for good reporting of costs. Of these, 27 covered India, five Pakistan, four Nepal and three Bangladesh and Sri Lanka. Most studies focused on depressive disorders (15), psychoses (14) and harmful alcohol use (7); knowledge of economic impacts for other conditions was limited. Profound economic impacts within and beyond health care systems were found. In 15 of 18 studies which included productivity losses to individuals and/or carers, these costs more than outweighed costs of health care. CONCLUSION: Mental disorders represent a considerable economic burden, but existing estimates are conservative as they do not consider long-term impacts or the full range of conditions. Modelling studies could be employed covering longer time periods and more conditions. Clear distinctions should be reported between out-of-pocket and health system costs, as well as between mental health service-specific and physical health-related costs

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why

Background: Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub–Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme. Methods: We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme. Results: N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts. Conclusions: The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006 , identifier: CRD42020214006

Core outcome sets for trials of interventions to prevent and to treat multimorbidity in adults in low- and middle-income countries: the COSMOS study

Introduction: the burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. Core outcome sets (COS) appropriate for the study of multimorbidity in LMICs do not presently exist. These are required to standardise reporting and contribute to a consistent and cohesive evidence-base to inform policy and practice. We describe the development of two COS for intervention trials aimed at preventing and treating multimorbidity in adults in LMICs.Methods: to generate a comprehensive list of relevant prevention and treatment outcomes, we conducted a systematic review and qualitative interviews with people with multimorbidity and their caregivers living in LMICs. We then used a modified two-round Delphi process to identify outcomes most important to four stakeholder groups (people with multimorbidity/caregivers, multimorbidity researchers, healthcare professionals, and policy makers) with representation from 33 countries. Consensus meetings were used to reach agreement on the two final COS. Registration: https://www.comet-initiative.org/Studies/Details/1580. Results: the systematic review and qualitative interviews identified 24 outcomes for prevention and 49 for treatment of multimorbidity. An additional 12 prevention, and six treatment outcomes were added from Delphi round one. Delphi round two surveys were completed by 95 of 132 round one participants (72.0%) for prevention and 95 of 133 (71.4%) participants for treatment outcomes. Consensus meetings agreed four outcomes for the prevention COS: (1) Adverse events, (2) Development of new comorbidity, (3) Health risk behaviour, and (4) Quality of life; and four for the treatment COS: (1) Adherence to treatment, (2) Adverse events, (3) Out-of-pocket expenditure, and (4) Quality of life.Conclusion: following established guidelines, we developed two COS for trials of interventions for multimorbidity prevention and treatment, specific to adults in LMIC contexts. We recommend their inclusion in future trials to meaningfully advance the field of multimorbidity research in LMICs

Core outcome sets for trials of interventions to prevent and to treat multimorbidity in adults in low- and middle-income countries: the COSMOS study.

Introduction: The burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. A core outcome set (COS) appropriate for the study of multimorbidity in LMIC contexts does not presently exist. This is required to standardise reporting and contribute to a consistent and cohesive evidence-base to inform policy and practice. We describe the development of two COS for intervention trials aimed at the prevention and treatment of multimorbidity in LMICs.Methods: To generate a comprehensive list of relevant prevention and treatment outcomes, we conducted a systematic review and qualitative interviews with people with multimorbidity and their caregivers living in LMICs. We then used a modified two-round Delphi process to identify outcomes most important to four stakeholder groups with representation from 33 countries (people with multimorbidity/caregivers, multimorbidity researchers, healthcare professionals, and policy makers). Consensus meetings were used to reach agreement on the two final COS. Registration: https://www.comet-initiative.org/Studies/Details/1580.Results: The systematic review and qualitative interviews identified 24 outcomes for prevention and 49 for treatment of multimorbidity. An additional 12 prevention, and six treatment outcomes were added from Delphi round one. Delphi round two surveys were completed by 95 of 132 round one participants (72.0%) for prevention and 95 of 133 (71.4%) participants for treatment outcomes. Consensus meetings agreed four outcomes for the prevention COS: (1) Adverse events, (2) Development of new comorbidity, (3) Health risk behaviour, and (4) Quality of life; and four for the treatment COS: (1) Adherence to treatment, (2) Adverse events, (3) Out-of-pocket expenditure, and (4) Quality of life.Conclusion: Following established guidelines, we developed two COS for trials of interventions for multimorbidity prevention and treatment, specific to LMIC contexts. We recommend their inclusion in future trials to meaningfully advance the field of multimorbidity research in LMICs

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana:a history and systematic review of what works, for whom and why

Background: Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub–Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme.Methods: We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme.Results: N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts.Conclusions: The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006, identifier: CRD42020214006