Process evaluation of implementation of the early stages of a whole systems approach to obesity in a small Island.

BACKGROUND: The small Atlantic island of St Helena is a United Kingdom Overseas Territory (UKOT) with a high prevalence of childhood obesity (over a quarter of 4-5 and 10-11 year olds) and, anecdotally, adulthood obesity and its associated health detriments. St Helena have taken a whole systems approach to obesity (WSAO) to address the issue. A WSAO recognises the factors that impact obesity as a complex system and requires a 'health in all policies' approach. UK academic and public health technical support was provided to the local St Helena delivery team. This process evaluation sought to explore the early stages of the WSAO implementation and implications for the transferability of the approach to other small island developing states and UKOT. METHODS: Data was collected via eight semi-structured interviews, paper based and online surveys, and document analysis. Thematic analysis was used to analyse the data. RESULTS: The analysis identified three factors which aided the first phase of WSAO implementation: (1) senior leaders support for the approach; (2) the academic support provided to establish and develop the approach; and (3) effective adaptation of UK Government resources to suit the local context. Key challenges of early implementation included: maintaining and broadening stakeholder engagement; limited local workforce capacity and baseline knowledge related to obesity and systems thinking; and limited capacity for support from the UK-based academic team due to contract terms and COVID-19 restrictions. CONCLUSIONS: Early stages of implementation of a WSAO in a UKOT can be successful when using UK's resources as a guide and adapting them to a small island context. All participants recommended other small islands adopt this approach. Continued senior support, dedicated leadership, and comprehensive community engagement is needed to progress implementation and provide the foundation for long-term impact. Small island developing states considering adopting a WSAO should consider political will, senior level buy-in and support, funding, and local workforce knowledge and capacity to enable the best chances of successful and sustainable implementation.

National or population level interventions addressing the social determinants of mental health - an umbrella review.

BACKGROUND: Social circumstances in which people live and work impact the population's mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198). RESULTS: We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk. CONCLUSION: This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health.

Analysis of loss to follow-up in 4099 multidrug-resistant pulmonary tuberculosis patients.

Loss to follow-up (LFU) of ≥2 consecutive months contributes to the poor levels of treatment success in multidrug-resistant tuberculosis (MDR-TB) reported by TB programmes. We explored the timing of when LFU occurs by month of MDR-TB treatment and identified patient-level risk factors associated with LFU.We analysed a dataset of individual MDR-TB patient data (4099 patients from 22 countries). We used Kaplan-Meier survival curves to plot time to LFU and a Cox proportional hazards model to explore the association of potential risk factors with LFU.Around one-sixth (n=702) of patients were recorded as LFU. Median (interquartile range) time to LFU was 7 (3-11) months. The majority of LFU occurred in the initial phase of treatment (75% in the first 11 months). Major risk factors associated with LFU were: age 36-50 years (HR 1.3, 95% CI 1.0-1.6; p=0.04) compared with age 0-25 years, being HIV positive (HR 1.8, 95% CI 1.2-2.7; p<0.01) compared with HIV negative, on an individualised treatment regimen (HR 0.7, 95% CI 0.6-1.0; p=0.03) compared with a standardised regimen and a recorded serious adverse event (HR 0.5, 95% CI 0.4-0.6; p<0.01) compared with no serious adverse event.Both patient- and regimen-related factors were associated with LFU, which may guide interventions to improve treatment adherence, particularly in the first 11 months.

Lessons on food security from the COVID-19 pandemic in Bermuda.

Compared with other OECD countries, Bermuda ranks third globally in terms of income inequality globally. During the COVID-19 pandemic, anecdotal evidence suggested, significant fluctuations in the food demand and supply. We aimed to examine the impact of the COVID-19 pandemic on food insecurity, with a focus on the availability and affordability of various foods in Bermuda. We utilized a cross-sectional study design to investigate potential drivers of food insecurity within the local population. To gauge the level of household food insecurity we relied on the Bermuda Omnibus survey (N = 400) undertaken by Total Research Associates Ltd via telephone. To assess changes in food availability and affordability we conducted semi-structured interviews with key stakeholders who played pivotal roles in shaping food accessibility availability and affordability of food in Bermuda. These interviews were systematically analysed using the framework method. We performed analyses of food retail and import data to evaluate fluctuations in food prices and their impact on food availability and affordability. We found statistically significant associations between changes in food consumption, household income, and government aid. Food aid beneficiaries ate fewer fruits and vegetables by 50% [95% CI:17%-83%] and less fresh meat and fish by 39% [95 CI:3%-75%] compared with residents who did not receive any aid during the COVID-19 period from March 2020 to March 2021. Although we did not identify statistically significant food price increases feeding programmes played a pivotal role in preventing food insecurity during the pandemic in Bermuda. However, a lack of monitoring regarding the nutritional quality within the programmes, allowed a wide availability of foods high in sugar, salts, and fats, disproportionately affected low-income populations. In conclusion, food availability in Bermuda remained largely unaffected during the pandemic. Nevertheless, the surge in demand for feeding programs underscores underlying food security challenges in Bermuda and warrants further attention.

Integrating mental health and psychosocial support (MHPSS) into infectious disease outbreak response: Results of an expert consensus study.

Objectives: Outbreaks are associated with increased risk of anxiety disorders, depression, and severe mental conditions. Integrating mental health and psychosocial support (MHPSS) into outbreak response facilitates the delivery of holistic care to the affected community. As there is an increasing incidence of outbreaks globally, integrating MHPSS into preparedness and response plans is paramount to strengthen the capacity of existing health systems and respond to mental health and psychosocial needs. However, the attention given to MHPSS during outbreak response is critically low. The objectives of this study were to identify areas of MHPSS integration and explore the challenges that hinder the delivery of an integrated care during outbreak response. Methods: A participatory qualitative study was conducted to explore how MHPSS can be incorporated into outbreak preparedness and response plans as a cross-cutting intervention in the context of low- and middle-income countries. We brought together civil society representatives, key stakeholders, and public health experts to explore areas of MHPSS integration during outbreak response. Results: Systematic integration of MHPSS into outbreak response was perceived to be feasible. Study participants strongly agreed that MHPSS can be integrated into most of the outbreak response pillars including partner coordination, case management, infection prevention and control, staff health and well-being, and risk communication and community engagement. However, the effort requires multi-sectoral collaboration, political commitment, and adequate recognition in planning and financing. Conclusions: Despite complex challenges, integrating MHPSS into outbreak pillars is possible. Moreover, emphasis should be placed on cultural adaptation of MHPSS guidelines and strong leadership in coordinating MHPSS into outbreak planning and response.

Evaluation of a Depression Intervention in People With HIV and/or TB in Eswatini Primary Care Facilities: Implications for Southern Africa.

INTRODUCTION: Depression associated with chronic illnesses is common in Southern Africa, yet there are major treatment gaps. This study assesses the feasibility and acceptability of the Healthy Activity Program intervention for depression among people with HIV and/or TB. The intervention involves training nonspecialist nurses in depression, including identification, counseling based on behavioral activation theory, and structured referral. METHODS: This is a mixed methods evaluation of a pilot counseling service integrated within routine HIV and TB care from 2018 to 2019. Participants included people living with HIV and/or patients with TB in rural Eswatini. RESULTS: A total of 324 people living with HIV and/or TB were screened for depression, with 19% (62/324) screening positive. The median number of sessions attended was 3 (interquartile range: 1-5), with 16/60 (26%) attending the minimum 5 sessions. Qualitative results indicated acceptability, but there were concerns about feasibility. CONCLUSIONS: The Healthy Activity Program is a promising option to manage the treatment gap for depression in people with HIV and/or TB. However, task-shifting to nonspecialist health care professionals without increasing staff capacity is a barrier to implementation. Realistic and pragmatic assessments of capacity and workforce are essential.

Challenges and Opportunities for Mental Health and Psychosocial Support in the COVID-19 Response in Africa: A Mixed-Methods Study.

This research aimed to (1) assess the extent to which mental health and psycho-social support (MHPSS) was included in the national response to the COVID-19 pandemic in African countries, and (2) explore barriers and enablers to MHPSS integration into the COVID-19 response. A mixed-methods study, using an online survey and in-depth interviews, was conducted. Participants included Mental Health Focal Points at the Ministries of Health, the World Health Organization (WHO) country and regional offices, and civil society representatives. Responses were received from 28 countries out of 55 contacted. The implementation level, based on standard guidelines, of MHPSS activities was below 50% in most countries. The most implemented MHPSS activities were establishing coordination groups (57%) and developing MHPSS strategy (45%), while the least implemented activities included implementing the developed MHPSS strategy (32%) and establishing monitoring and evaluation mechanisms (21%). Key factors that hindered implementing MHPSS activities included lack of political commitment and low prioritisation of mental health during emergencies, as it was seen as a "less important" issue during the COVID-19 pandemic, when more importance was given to infection prevention and control (IPC). However, there are signs of optimism, as mental health gained some attention during COVID-19. It is imperative to build on the attention gained by integrating MHPSS in emergency preparedness and response and strengthening mental health systems in the longer term.

Mental health systems in six Caribbean small island developing states: a comparative situational analysis.

BACKGROUND: Small island developing states (SIDS) have particular mental health system needs due to their remoteness and narrow resource base. We conducted situational analyses to support mental health system strengthening in six SIDS: Anguilla, Bermuda, British Virgin Islands, Cayman Islands, Montserrat and Turks and Caicos Islands. METHODS: The situational analyses covered five domains: 1. Socio-economic context and burden of mental disorders, 2. Leadership and governance for mental health 3. Mental health and social care services 4. Strategies for promotion and prevention in mental health and 5. Information systems, evidence and research for mental health. First, a desk-based exercise was conducted, in which data was drawn from the public domain. Second, a field visit was conducted at each site, comprising visits to facilities and consultation meetings with key stakeholders. RESULTS: Our key findings were 1. Despite most of these SIDS being high-income economies, social inequalities within states exist. There was no population-level data on mental health burden. 2. All SIDS have a mental health policy or plan, but implementation is typically limited due to lack of funds or staff shortages. There was minimal evidence of service user involvement in policy or service development. 3. All SIDS have a specialist, multi-disciplinary mental health workforce, however Montserrat and Anguilla rely on visiting psychiatrists. Child and adolescent and dedicated crisis intervention services were found in only two and one SIDS respectively. A recovery-oriented ethos was not identified in any SIDS. 4. Mental illness stigma was prevalent in all SIDS. Promotion and prevention were objectives of mental health strategies for all SIDS, however activities tended to be sporadic. No mental health non-Governmental organisations were identified in three SIDS. 5. Health information systems are generally underdeveloped, with paper-based systems in three SIDS. There has been no rigorous local mental health research. CONCLUSION: Cross-cutting recommendations include: to develop mental health action plans that include clear implementation indicators; to facilitate community surveys to ascertain the prevalence of mental disorders; to explore task-sharing approaches to increase access to primary mental health care; and to develop programmes of mental health promotion and prevention.

The Economic Costs of Cardiovascular Disease, Diabetes Mellitus, and Associated Complications in South Asia: A Systematic Review.

BACKGROUND: More than 80% of global deaths caused by cardiovascular disease (CVD) and diabetes mellitus (DM) occur in developing countries. The burden of noncommunicable disease in South Asia is increasing rapidly. OBJECTIVES: To estimate the costs of CVD and the costs of DM to individuals and society in Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. METHODS: We systematically searched six health and economic databases for studies identifying costs related to CVD or DM and their respective complications. Costs were extracted from included studies and converted to US $ for the price year 2015 to enable meaningful comparisons. RESULTS: Of the 71 articles suitable for full-text review, 29 studies met the inclusion criteria. Most were cost-of-illness studies (n = 27) and were from the patient perspective (n = 23). Most collected data since 2000 (n = 23) and included data from India (n = 24). No studies included longitudinal costs at the patient level. Medical costs for routine management of CVD and DM were broadly similar. These costs escalate significantly once complications occur, which require treatment, particularly for stroke, major coronary events, and amputations. Costs are mainly borne by the individual and family. Some included studies modeled rapidly rising future costs. Most studies included had methodological weaknesses. CONCLUSIONS: Marked increases in costs have been identified when complications of these chronic diseases occur, underlining the importance of secondary prevention approaches in disease management in South Asia. Higher quality studies, especially those that include longitudinal costs, are required to establish more robust cost estimates.

Implementation of a psychosocial support package for people receiving treatment for multidrug-resistant tuberculosis in Nepal: A feasibility and acceptability study.

BACKGROUND AND OBJECTIVES: People receiving treatment for multidrug-resistant tuberculosis (MDR-TB) have high rates of depression. Psychosocial support in general, and treatments for depression in particular, form an important but neglected area of patient-centred care, and a key pillar in the global End TB strategy. We assessed the feasibility and acceptability of a psychosocial support package for people receiving treatment for MDR-TB in Nepal. METHODS: This feasibility study used a mixed quantitative and qualitative approach. We implemented the intervention package in two National Tuberculosis Programme (NTP) MDR-TB treatment centres and 8 sub-centres. We screened patients monthly for depression and anxiety (cut-off ≥24 and ≥17 respectively on the Hopkins Symptom Checklist) and also for low social support (cut-off ≤3 on the Multidimensional Scale of Perceived Social Support). Those who screened positive on either screening tool received the Healthy Activity Program (HAP), which uses brief counselling based on behavioural activation theory. Other aspects of the psychosocial package were information/education materials and group interactions with other patients. RESULTS: We screened 135 patients, of whom 12 (9%) received HAP counselling, 115 (85%) received information materials, 80 (59%) received an education session and 49 (36%) received at least one group session. Eight group sessions were conducted in total. All aspects of the intervention package were acceptable to patients, including the screening, information, group work and counselling. Patients particularly valued having someone to talk to about their concerns and worries. We were able to successfully train individuals with no experience of psychological counselling to deliver HAP. CONCLUSION: This psychosocial support package is acceptable to patients. The information materials we developed are feasible to deliver in the current NTP. However, the structured psychological counselling (HAP), is not feasible in the current NTP due to time constraints. This requires additional investment of counsellors in TB clinics.

Variations in dementia diagnosis in England and association with general practice characteristics.

OBJECTIVES: Improving dementia diagnosis rates in England has been a key strategic aim of the UK Government but the variation and low diagnosis rates are poorly understood. The aim of this study was to explore the variation in actual versus expected diagnosis of dementia across England, and how these variations were associated with general practice characteristics. METHOD: A cross-sectional, ecological study design using secondary data sources and median regression modelling was used. Data from the year 2011 for 7711 of the GP practices in England (92.7%). Associations of dementia diagnosis rates (%) per practice, calculated using National Health Service England's 'Dementia Prevalence Calculator' and various practice characteristics were explored using a regression model. RESULTS: The median dementia diagnosis rate was 41.6% and the interquartile range was 31.2-53.9%. Multivariable regression analysis demonstrated positive associations between dementia diagnosis rates and deprivation of the population, overall Quality and Outcomes Framework performance, type of primary care contract and size of practice list. Negative associations were found between dementia diagnosis rates and average experience of GPs in the practice and the proportion of the practice caseload over 65 years old. CONCLUSION: Dementia diagnosis rates vary greatly across GP practices in England. This study has found independent associations between dementia diagnosis rates and a number of patient and practice characteristics. Consideration of these factors locally may provide targets for case-finding interventions and so facilitate timely diagnosis.