Nile tilapia (Oreochromis niloticus) show high tolerance to acute ammonia exposure but lose metabolic scope during prolonged exposure at low concentration.

Ammonia is a respiratory gas that is produced during the process of protein deamination. In the unionised form (NH3), it readily crosses biological membranes and is highly toxic to fish. In the present study we examined the effects of unionized ammonia (UIA), on the resting oxygen consumption (MO2), ventilation frequency (fV), heart rate (HR) and heart rate variability (HRV) in Nile tilapia (Oreochromis niloticus). Fish were either exposed to progressively increasing UIA concentrations, up to 97 µM over a 5 h period, or to a constant UIA level of 7 µM over a 24 h period. For both treatment groups resting MO2, HR and fV were recorded as physiological variables. Relative to the control group, the fish groups exposed to the incremental UIA levels did not exhibit significant changes in their MO2, HR and fV at UIA concentrations of 4, 10, 35, or 61 µM compared to control fish. Exposure to 97 µM UIA, however, elicited abrupt and significant downregulations (p < 0.05) in all three responses, as MO2, HR and fv decreased by 25, 54 and 76 % respectively, compared to control measurements. Heart rate became increasingly irregular with increasing UIA concentrations, and heart rate variability was significantly increased at 61 and 97 µM UIA. Prolonged exposure elicited significant changes at exposure 7 µM UIA. Standard (SMR) and maximum metabolic rate (MMR) were significantly reduced, as was the corresponding fV and HR. It is evident from this study that Nile tilapia is tolerant to short term exposure to UIA up to 61 µM but experience a significant metabolic change under conditions of prolonged UIA exposures even at low concentrations.

Survival trends among people living with human immunodeficiency virus on antiretroviral treatment in two rural districts in Ghana.

BACKGROUND: The human immunodeficiency virus (HIV) has caused a lot of havoc since the early 1970s, affecting 37.6 million people worldwide. The 90-90-90 treatment policy was adopted in Ghana in 2015 with the overall aim to end new infections by 2030, and to improve the life expectancy of HIV seropositive individuals. With the scale-up of Highly Active Antiretroviral Therapy, the lifespan of People Living with HIV (PLWH) on antiretrovirals (ARVs) is expected to improve. In rural districts in Ghana, little is known about the survival probabilities of PLWH on ARVs. Hence, this study was conducted to estimate the survival trends of PLWH on ARVs. METHODS: A retrospective evaluation of data gathered across ARV centres within Tatale and Zabzugu districts in Ghana from 2016 to 2020 among PLWH on ARVs. A total of 261 participants were recruited for the study. The data was analyzed using STATA software version 16.0. Lifetable analysis and Kaplan-Meier graph were used to assess the survival probabilities. "Stptime" per 1000 person-years and the competing risk regression were used to evaluate mortality rates and risk. RESULTS: The cumulative survival probability was 0.8847 (95% CI: 0.8334-0.9209). The overall mortality rate was 51.89 (95% CI: 36.89-72.97) per 1000 person-years. WHO stage III and IV [AHR: 4.25 (95%CI: 1.6-9.71) p = 0.001] as well as age group (50+ years) [AHR: 5.02 (95% CI: 1.78-14.13) p = 0.002] were associated with mortality. CONCLUSION: Survival probabilities were high among the population of PLWH in Tatale and Zabzugu with declining mortality rates. Clinicians should provide critical attention and care to patients at HIV WHO stages III and IV and intensify HIV screening at all entry points since early diagnosis is associated with high survival probabilities.

No Evidence for an Association of HIV and Antiviral Treatment With Changes in Framingham Cardiovascular Risk Score in the Ndlovu Cohort Study.

BACKGROUND: HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease (CVD) risk in high-income countries. The authors studied the longitudinal association between HIV and ART and nonlaboratory Framingham Risk Score (FRS) in a middle-income country. METHODS AND RESULTS: This longitudinal analysis of the NCS (Ndlovu Cohort Study), South Africa used baseline to 36-month follow-up data. Demographics, HIV, ART status, and cardiometabolic measures were obtained. FRS was used as a CVD risk measure. Through linear mixed models, FRS trends over time and the association with HIV were studied. Analysis included 1136 participants, with 609 (54%) having HIV, and 495 (81%) taking ART. At baseline, 9.8% of participants had a high FRS. People living with HIV (PLHIV) had a 3.2% lower FRS than HIV-negative participants (P<0.001). FRS increased similarly for both groups over time. Other factors associated with FRS were secondary and higher education (ß value: -0.075, P<0.001; ß value: -0.084, P<0.001) and alcohol consumption (ß value: 0.011, P<0.001). CONCLUSIONS: CVD risk increased for all participants over 36 months, suggesting classic risk factors rather than HIV status or ART to be drivers of CVD risk. People living with HIV had a significantly lower FRS than their HIV-negative counterparts, possibly related to HIV itself or a more frequent interaction with healthcare services. No association of HIV and ART with changes in FRS over 36 months was observed, suggesting the need for research using clinical endpoints to elucidate the effects of HIV and ART on CVD risk. Population-based prevention of CVD risk factors in sub-Saharan Africa is warranted, regardless of HIV status.

Prevalence, patterns, and determinants of multimorbidity among childhood and adult cancer survivors: A systematic review.

Development of multimorbidity is common among cancer survivors due to their previous cancer, treatments, or changes in lifestyle. We summarized evidence on the prevalence, patterns, and determinants of multimorbidity among childhood and adult cancer survivors. We searched PubMed and EMBASE databases for articles reporting prevalence, patterns, and determinants of multimorbidity in cancer survivors. Finally, 23/500 articles were included. There was a large variation in the prevalence of multimorbidity (13-89%) among cancer survivors. Bone marrow transplantation, radiation, female sex, lower level of physical activity, increasing age, minority ethnicity, low-income, and low-education were associated with a higher prevalence of multimorbidity. Patterns of multimorbidity were both concordant and discordant. In conclusion, multimorbidity is highly prevalent and a major concern among cancer survivors. A personalized care plan that takes into account the identified risk may be beneficial to reduce the burden of multimorbidity and improve the quality of life among cancer survivors.

Using the multiple streams model to elicit an initial programme theory: from policy dialogues to a roadmap for scaling up integrated care.

INTRODUCTION: The 'SCale-Up diaBetes and hYpertension care' Project aims to support the scale-up of integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium through the co-creation, implementation and evaluation of contextualised roadmaps. These roadmaps offer avenues for action and are built on evidence as well as stakeholder engagement in policy dialogues. Roadmaps and policy dialogues are very much intertwined and considered to be key elements for successful stakeholder-supported scale-up in integrated chronic care. Yet, little is known about how, why and under which conditions policy dialogue leads to successful roadmap implementation and scale-up of integrated care. Therefore, this study aims to use a realist approach to elicit an initial programme theory (IPT), using political science theories on the policy process. METHODS: To develop the IPT, information from different sources was collected. First, an exploratory literature review on policy dialogue and scale-up definitions and success factors was performed, identifying theoretical frameworks, empirical (case) studies and realist studies (information gleaning). Second, research workshops on applying theory to the roadmap for scale-up (theory gleaning) were conducted with a multidisciplinary expert team. We used the intervention-context-actors-mechanism-outcome configuration to synthesise information from the sources into a configurational map. RESULTS: The information and theory gleaning resulted into an IPT, hypothesising how policy dialogues can contribute to roadmap success in different policy stages. The IPT draws on political science theory of the multiple streams model adapted by Howlett et al to include five streams (problem, solution, politics, process and programme) that can emerge, converge and diverge across all five policy stages. CONCLUSION: This paper aims to extend the knowledge base on the use of policy dialogues to build a roadmap for scale-up. The IPT describes how (dynamics) and why (theories) co-created roadmaps are expected to work in different policy stages.

Acute hyperthermia and hypoxia tolerance of two improved strains of nile tilapia (Oreochromis niloticus).

Tilapia production in Ghana has been hit with episodes of stress and pathogen-induced mass fish kills which have anecdotally been linked to the culture of illegally imported Genetically Improved Farmed Tilapia (GIFT) strains of Nile tilapia, Oreochromis niloticus. This study was thus set up to comprehensively assess the stress tolerance of the GIFT strain and a native strain of Nile tilapia (the Akosombo strain) following exposures to hyperthermic and hypoxic stressors. In a series of experiments, oxygen consumption (MO2), aquatic surface respiration (ASR), thermal limits and hypoxia tolerance were assessed. The effects of these stressors on haematological parameters were also assessed. The GIFT strain was less tolerant of hypoxia and performed ASR at higher O2 levels than the Akosombo strain. Under progressive hypoxia, the GIFT strain exhibited higher gill ventilations frequencies (fV) than the Akosombo strain. The thermal tolerance trial indicated that the Akosombo strain of O. niloticus has higher thermotolerance than the GIFT strain and this was reflective in the higher LT50 (45.1℃) and LTmax (48℃), compared to LT50 and LTmax of 41.5℃ and 46℃ respectively. These results imply that it is crucial to consider how the GIFT strain performs under various environmental conditions and changes during culture. Particularly, raising the GIFT strain of Nile tilapia in earthen ponds rich in phytoplankton and subject to protracted episodes of extreme hypoxia may have a detrimental physiological impact on its growth and welfare.

Cardiovascular Risk Estimation Based on Country-of-Birth- and Country-of-Residence-Specific Scores among Migrants in the Netherlands: The HELIUS Study.

BACKGROUND: Regional and country-specific cardiovascular risk algorithms have been developed to improve CVD risk prediction. But it is unclear whether migrants' country-of-residence or country-of-birth algorithms agree in stratifying the CVD risk of these populations. We evaluated the risk stratification by the different algorithms, by comparing migrant country-of-residence-specific scores to migrant country-of-birth-specific scores for ethnic minority populations in the Netherlands. METHOD: data from the HELIUS study was used in estimating the CVD risk scores for participants using five laboratory-based (Framingham, Globorisk, Pool Cohort Equation II, SCORE II, and WHO II) and three nonlaboratory-based (Framingham, Globorisk, and WHO II) risk scores with the risk chart for the Netherlands. For the Globorisk, WHO II, and SCORE II risk scores, we also computed the risk scores using risk charts specified for the migrant home country. Risk categorization was first done according to the specification of the risk algorithm and then simplified to low (green), moderate (yellow and orange), and high risk (red). RESULTS: we observed differences in risk categorization for different risk algorithms ranging from 0% (Globorisk) to 13% (Framingham) for the high-risk category, as well as differences in the country-of-residence- and country-of-birth-specific scores. Agreement between different scores ranged from none to moderate. We observed a moderate agreement between the Netherlands-specific SCORE II and the country-of-birth SCORE II for the Turkish and a nonagreement for the Dutch Moroccan population. CONCLUSION: disparities exist in the use of the country-of-residence-specific, as compared to the country-of-birth, risk algorithms among ethnic minorities living in the Netherlands. Hence, there is a need for further validation of country-of-residence- and country-of-birth-adjusted scores to ascertain appropriateness and reliability.

Validation of the GetReal Trial Tool - Facilitating discussion and understanding more pragmatic design choices and their implications.

BACKGROUND: The GetReal Trial Tool is a decision support tool to assess the impact of design choices on generalizability of clinical trials to routine clinical practice, while taking into account the risk of bias, precision, acceptability and operational feasibility. This study describes the validation of the GetReal Trial Tool. METHODS: Twelve experts took part in the GetReal Trial tool validation using the protocols of 6 trials conducted with pragmatic elements. The tool entails 7 domains with a total of 43 questions. A pooled Kappa statistic (95% CI) using random effects model was estimated using Open Meta (analyst) software. The possible operational challenges were collated and discussed with the trialists that conducted the trials. RESULTS: Agreement in the design choices made for the trial protocols was >50% for all the trials and all teams reached consensus during discussion. The pooled Kappa statistic (95% CI) was 0.236 (0.154-0.318). The GetReal Trial tool highlighted several operational challenges, of which almost half had been experienced previously by the trialists. Out of 25 additional operational challenges mentioned by the trialists, 76% were already highlighted by the tool. The tool was considered helpful to optimize trials right from the design stage. CONCLUSION: The GetReal Trial Tool helps to scrutinize the choice of study design in the light of Real World Evidence generation. The tool identifies most of the operational challenges experienced by trialists to date. The tool serves the intended purpose of facilitating discussion and understanding more pragmatic design choices and their implications.

Transitioning food environments and diets of African migrants: implications for non-communicable diseases.

Non-communicable diseases disproportionately affect African migrants from sub-Saharan Africa living in high-income countries (HICs). Evidence suggests this is largely driven by forces that include migration, globalisation of unhealthy lifestyles (poor diet, physical inactivity and smoking), unhealthy food environments, socio-economic status and population ageing. Changes in lifestyle behaviours that accompany migration are exemplified primarily by shifts in dietary behaviours from more traditional diets to a diet that incorporates that of the host culture, which promotes the development of obesity, diabetes, hypertension and CVD. The current paper presents a critical analysis of dietary change and how this is influenced by the food environment and the socio-economic context following migration. We used a food systems framework to structure the discussion of the interaction of factors across the food system that shape food environments and subsequent dietary changes among African migrant populations living in HICs.

Process evaluation of the scale-up of integrated diabetes and hypertension care in Belgium, Cambodia and Slovenia (the SCUBY Project): a study protocol.

INTRODUCTION: Integrated care interventions for type 2 diabetes (T2D) and hypertension (HT) are effective, yet challenges exist with regard to their implementation and scale-up. The 'SCale-Up diaBetes and hYpertension care' (SCUBY) Project aims to facilitate the scale-up of integrated care for T2D and HT through the co-creation and implementation of contextualised scale-up roadmaps in Belgium, Cambodia and Slovenia. We hereby describe the plan for the process and scale-up evaluation of the SCUBY Project. The specific goals of the process and scale-up evaluation are to (1) analyse how, and to what extent, the roadmap has been implemented, (2) assess how the differing contexts can influence the implementation process of the scale-up strategies and (3) assess the progress of the scale-up. METHODS AND ANALYSIS: A comprehensive framework was developed to include process and scale-up evaluation embedded in implementation science theory. Key implementation outcomes include acceptability, feasibility, relevance, adaptation, adoption and cost of roadmap activities. A diverse range of predominantly qualitative tools-including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping-were developed to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. The role of context is considered relevant, and barriers and facilitators to scale-up will be continuously assessed. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Institutional Review Board (ref. 1323/19) at the Institute of Tropical Medicine (Antwerp, Belgium). The SCUBY Project presents a comprehensive framework to guide the process and scale-up evaluation of complex interventions in different health systems. We describe how implementation outcomes, mechanisms of impact and scale-up outcomes can be a basis to monitor adaptations through a co-creation process and to guide other scale-up interventions making use of knowledge translation and co-creation activities.

Maternal near-miss and mortality associated with hypertensive disorders of pregnancy remote from term: a multicenter observational study in Ghana.

BACKGROUND: Maternal death rates remain high in many low- and middle-income countries. Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana. The maternal near-miss approach was designed to evaluate severe (acute) complications in pregnancy, which is useful to detect potential areas for clinical care improvement. OBJECTIVE: This study aimed (1) to determine the incidence of severe maternal complications, maternal near-miss cases, and mortality cases associated with hypertensive disorders of pregnancy remote from term and (2) to assess the health system's performance indicators for the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals. STUDY DESIGN: This study was nested in the ongoing Severe Preeclampsia adverse Outcome Triage study, a multicenter observational cohort study, and included women recruited from December 1, 2017, to May 31, 2020, from 5 referral hospitals in Ghana. Women aged >16 years, admitted to the hospital with hypertensive disorders of pregnancy, with gestational age between 26 and 34 weeks were eligible. Near miss was defined according to the World Health Organization and sub-Saharan African near-miss criteria. Descriptive statistics of pregnancy and maternal and perinatal outcomes up to 6 weeks after delivery of women with severe maternal outcomes were presented for maternal deaths and maternal near-miss casigurees and compared with that of women without severe maternal outcomes. The health system's maternal and perinatal performance indicators were calculated. RESULTS: Overall, 447 women with hypertensive disorders of pregnancy were included in the analyses with a mean maternal age of 32 (±5.8) years and mean gestational age at recruitment of 30.5 (±2.4) weeks. Of these patients, 46 (10%) had gestational hypertension, 338 (76%) had preeclampsia, and 63 (14%) had eclampsia. There were 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%). Severe maternal outcomes constituted complications from severe preeclampsia (80/160 [50%]) and eclampsia (63/160 [39.4%]). Concerning organ dysfunction, hematologic and respiratory dysfunctions constituted 59/160 [38.6%] and 23/160 [14.8%] respectively. Nearly all women had a cesarean delivery (347/447 [84%] and 140/160 [93%] in the severe maternal outcome group) and delivered prematurely (83%, with 178/379 [93%] at <32 weeks of gestation). Stillbirth and neonatal deaths occurred in 63 of 455 women (14%) and 81 of 392 women (19%), respectively, constituting a stillbirth ratio of 161 per 1000 live births and neonatal mortality rate of 207 per 1000 live births as there were 392 live births in this cohort. Overall, the intensive care unit admission rate was 12.7% (n=52/409); moreover, 45 of 52 women (86.5%) admitted to the intensive care unit had severe maternal outcomes. The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss-to-mortality ratio was 12.3, and the mortality index was 8%. CONCLUSION: Maternal near miss and maternal and perinatal mortalities were common in women with hypertensive disorders of pregnancy remote from term in referral hospitals in Ghana. Providing appropriate patient-centered and multidisciplinary quality care for these women is crucial in improving pregnancy outcomes. Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings. Further research on interventions to improve timely referral and reduce in-hospital delays in care provision is recommended to facilitate emergency care services for women with hypertensive emergencies.

Multimorbidity of communicable and non-communicable diseases in low- and middle-income countries: A systematic review.

Objective: The aim of this systematic review is to analyse existing evidence on prevalence, patterns, determinants, and healthcare challenges of communicable and non-communicable disease multimorbidity in low- and middle-income countries (LMICs). Methods: PubMed, Cochrane, and Embase databases were searched from 1st January 2000 to 31st July 2020. The National Institute of Health (NIH) quality assessment tool was used to critically appraise studies. Findings were summarized in a narrative synthesis. The review was registered with PROSPERO (CRD42019133453). Results: Of 3718 articles screened, 79 articles underwent a full text review of which 11 were included for narrative synthesis. Studies reported on 4 to 20 chronic communicable and non-communicable diseases; prevalence of multimorbidity ranged from 13% in a study conducted among 242,952 participants from 48 LMICS to 87% in a study conducted among 491 participants in South Africa. Multimorbidity was positively associated with older age, female sex, unemployment, and physical inactivity. Significantly higher odds of multimorbidity were noted among obese participants (OR 2.33; 95% CI: 2.19-2.48) and those who consumed alcohol (OR 1.44; 95% CI: 1.25-1.66). The most frequently occurring dyads and triads were HIV and hypertension (23.3%) and HIV, hypertension, and diabetes (63%), respectively. Women and participants from low wealth quintiles reported higher utilization of public healthcare facilities. Conclusion: The identification and prevention of risk factors and addressing evidence gaps in multimorbidity clustering is crucial to address the increasing communicable and non-communicable disease multimorbidity in LMICs. To identify communicable and non-communicable diseases trends over time and identify causal relationships, longitudinal studies are warranted.

PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone.

BACKGROUND: Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic. METHODS: This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members. RESULTS: A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4-7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery. CONCLUSION: PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013-2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment.

Molecular epidemiology of bovine tuberculosis in Northern Ghana identifies several uncharacterized bovine spoligotypes and suggests possible zoonotic transmission.

OBJECTIVE: We conducted an abattoir-based cross-sectional study in the five administrative regions of Northern Ghana to determine the distribution of bovine tuberculosis (BTB) among slaughtered carcasses and identify the possibility of zoonotic transmission. METHODS: Direct smear microscopy was done on 438 tuberculosis-like lesions from selected cattle organs and cultured on Lowenstein-Jensen media. Acid-fast bacilli (AFB) isolates were confirmed as members of the Mycobacterium tuberculosis complex (MTBC) by PCR amplification of IS6110 and rpoß. Characterization and assignment into MTBC lineage and sub-lineage were done by spoligotyping, with the aid of the SITVIT2, miruvntrplus and mbovis.org databases. Spoligotype data was compared to that of clinical M. bovis isolates from the same regions to identify similarities. RESULTS: A total of 319/438 (72.8%) lesion homogenates were smear positive out of which, 84.6% (270/319) had microscopic grade of at least 1+ for AFB. Two hundred and sixty-five samples (265/438; 60.5%) were culture positive, of which 212 (80.0%) were MTBC. Approximately 16.7% (34/203) of the isolates with correctly defined spoligotypes were negative for IS6110 PCR but were confirmed by rpoß. Spoligotyping characterized 203 isolates as M. bovis (198, 97.5%), M. caprae (3, 1.5%), M. tuberculosis (Mtbss) lineage (L) 4 Cameroon sub-lineage, (1, 0.5%), and M. africanum (Maf) L6 (1, 0.5%). A total of 53 unique spoligotype patterns were identified across the five administrative regions (33 and 28 were identified as orphan respectively by the SITVIT2 and mbovis.org databases), with the most dominant spoligotype being SIT1037/ SB0944 (77/203, 37.93%). Analysis of the bovine and human M. bovis isolates showed 75% (3/4) human M. bovis isolates sharing the same spoligotype pattern with the bovine isolates. CONCLUSION: Our study identified that approximately 29% of M. bovis strains causing BTB in Northern Ghana are caused by uncharacterized spoligotypes. Our findings suggest possible zoonotic transmission and highlight the need for BTB disease control in Northern Ghana.

Availability and Affordability of Primary Health Care Among Vulnerable Populations in Urban Kumasi Metropolis: Family Health Perspective.

Purpose: Health-related expenditures pose a significant burden on vulnerable populations. This study assessed the availability and affordability of primary health care among disadvantaged populations in urban Kumasi Metropolis, Ghana. Methods: This study was a descriptive cross-sectional study conducted among multi-level participants of vulnerable populations ≥18 years of age (n=710) constituting the older adults/aged, pregnant women, head porters, sex workers, and other vulnerable groups (people with disabilities and the homeless). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to assess the association between vulnerability and access to health care. Results: There were significant differences in the availability and adequacy of health care among the vulnerable groups studied. Distance to the source of care was >5 km for majority of the vulnerable groups and the average expenditure on a visit to the health facility was GH¢ 27.04 (∼US$ 5.55 as at January 2019). Challenges to health care among the vulnerable groups included monetary (37.9%), stigmatization (18.6%), and staff attitude (25.9%). Head porters and other vulnerable groups were less likely to view health care as affordable compared with older adults. The difference in the perception of health care affordability was, however, explained by sociodemographic characteristic and health care-related factors. Conclusion: Despite the introduction of a National Health Insurance Scheme in Ghana, this study highlights challenges in health care access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to adopt other innovative care strategies that may have broader applicability for all populations.

Carotid Atherosclerosis, Microalbuminuria, and Estimated 10-Year Atherosclerotic Cardiovascular Disease Risk in Sub-Saharan Africa.

Importance: Carotid atherosclerosis and microalbuminuria are associated with atherosclerotic cardiovascular disease (ASCVD) but are understudied in sub-Saharan Africa. Objective: To evaluate the association of carotid atherosclerosis and microalbuminuria with 10-year ASCVD risk in middle-aged sub-Saharan African individuals. Design, Setting, and Participants: This cross-sectional study conducted analyses of baseline data from the African-Wits-INDEPTH (International Network for the Demographic Evaluation of Populations and Their Health in Low- and Middle-Income Countries) genomic study (AWI-Gen). Women and men aged 40 to 60 years without baseline CVD and drawn from Burkina Faso, Ghana, Kenya, and South Africa were included. Main Outcomes and Measures: Hypotheses for the analyses were formulated after data collection. The main exposures were carotid atherosclerosis, assessed using carotid intima-media thickness (CIMT) using B-mode ultrasonography, and microalbuminuria, measured using spot urine albumin (SUA) and urine albumin-creatinine ratio (uACR). The main outcome was high ASCVD risk, defined as a 2018 Pooled Cohort Equations score of 7.5% or greater. Associations were estimated using adjusted multivariable logistic regression analyses. Findings: A total of 9010 participants with a mean (SD) age of 50 (6) years and 4533 (50.3%) women were included. High CIMT, SUA, and uACR were each associated with older age (eg, mean [SD] age of participants with high vs reference range CIMT: 55 [5] years vs 50 [6] years; P < .001) and high prevalence of both diabetes and hypertension (eg, hypertension among those with high vs reference range SUA: 213 of 1117 [19.1%] vs 356 of 2549 [14.0%]; P < .001). Smokers were likely to have higher vs reference range SUA (210 [18.8%] vs 407 [16.0%]) and uACR (138 of 707 [19.5%] vs 456 of 2797 [16.3%]). Carotid atherosclerosis was common in Burkina Faso (82 of 262 [31.3%]) and Ghana (91 [34.7%]), while microalbuminuria, measured by SUA, was common in Kenya (272 [24.4%]) and South Africa (519 [46.5%]). SUA was associated with higher odds of carotid atherosclerosis (odds ratio [OR], 1.77; 95% CI, 1.04-3.01) compared with uACR (OR, 0.51; 95% CI, 0.27-0.95). Common CIMT, SUA, and uACR were associated with 10-year ASCVD risk, with CIMT having a stronger association with 10-year ASCVD risk in both women (OR, 1.95; 95% CI, 1.78-2.14) and men (OR, 1.73; 95% CI, 1.55-1.93) than SUA (women: OR, 1.29; 95% CI, 1.12-1.43; men: OR, 1.46; 95% CI, 1.26-1.55) and uACR (women: OR, 1.32; 95% CI, 1.10-1.54; men: OR, 1.35; 95% CI, 1.15-1.46). Conclusions and Relevance: The presence of microalbuminuria measured by SUA may indicate risk of subclinical carotid atherosclerosis and high 10-year ASCVD risk in middle-aged residents of sub-Saharan Africa. These data should be confirmed in longitudinal studies of cardiovascular events.

Contribution of diabetes to amputations in sub-Sahara Africa: A systematic review and meta-analysis.

Diabetes related amputations remain a major global problem, with devastating complications. We critically appraised relevant literature to quantify the prevalence of diabetes related amputations in sub-Saharan Africa (SSA). An electronic search was performed using the EMBASE and PubMed databases until 2020. Twenty-four out of 834 studies retrieved were included. The pooled prevalence of diabetic-related amputations was 36.9% (95%CI: 32.9%-40.8%). Complications of diabetes related amputations included infection, anaemia, foot deformity and mortality. The study revealed a substantial contribution of diabetes to the burden of amputations in SSA and suggests the need for further studies to assess how to reduce the incidence of diabetes, reduce the incidence of and or delay the progression of macro and microvascular complications of diabetes in SSA.

Socioeconomic Determinants of Cardiovascular Diseases, Obesity, and Diabetes among Migrants in the United Kingdom: A Systematic Review.

There has been little agreement on the role that socioeconomic factors play in the aetiology of cardiovascular diseases (CVDs), obesity, and diabetes among migrants in the United Kingdom (UK). We systematically reviewed the existing evidence on this association to contribute to filling this gap in the literature. Two reviewers were involved at each stage of the review process to ensure validity. We comprehensively searched through several electronic databases and grey literature sources to identify potentially eligible papers for our review. We extracted data from our finally included studies and appraised the methodological rigour of our studies. A narrative synthesis approach was used to synthesise and interpret the extracted data. We sieved through 2485 records identified from our search and finally obtained 10 studies that met our inclusion criteria. The findings of this review show that there is a trend towards an association between socioeconomic factors and CVDs, diabetes, and obesity among migrants in the UK. However, the picture was more complex when specific socioeconomic variables and migrant subgroups were analysed. The evidence for this association is inconclusive and its causal relationship remains speculative. There is, therefore, the need for further research to understand the exact association between socioeconomic factors and CVD, diabetes, and obesity among migrants in the UK.

Structured diabetes self-management education and glycaemic control in low- and middle-income countries: A systematic review.

AIM: To determine the association between structured diabetes self-management education (DSME) and glycaemic control in persons living with diabetes (PLD) in low- and middle-income countries (LMICs). METHODS: PubMed, Embase and Cochrane databases were searched up to June 2020 for intervention studies on the effect of structured DSME on glycaemic control in PLD in LMICs (PROSPERO registration CRD42020164857). The primary outcome was reduction in glycated haemoglobin. Included studies were assessed for risk of bias (RoB) with the Cochrane RoB tool for randomised trials. Findings were summarized in a narrative synthesis. RESULTS: Out of 154 abstracts retrieved and screened for eligibility, nine studies with a total of 1389 participants were included in the review. The structured DSME interventions were culturally tailored and were delivered in-person. They were associated with reductions in glycated haemoglobin in all studies: mean/median reduction ranged between 0.5% and 2.6% relative to baseline. CONCLUSIONS: There is a dearth of literature on the association between structured DSME and glycaemic control among PLD in LMICs. The evidence available suggests that in LMICs; particularly in sub-Saharan Africa, structured DSME is associated with reduction in glycated haemoglobin. We recommend further intervention studies on the effects of structured DSME in LMICs.

Multimorbidity of non-communicable diseases in low-income and middle-income countries: a systematic review and meta-analysis.

INTRODUCTION: Multimorbidity is a major public health challenge, with a rising prevalence in low/middle-income countries (LMICs). This review aims to systematically synthesise evidence on the prevalence, patterns and factors associated with multimorbidity of non-communicable diseases (NCDs) among adults residing in LMICs. METHODS: We conducted a systematic review and meta-analysis of articles reporting prevalence, determinants, patterns of multimorbidity of NCDs among adults aged >18 years in LMICs. For the PROSPERO registered review, we searched PubMed, EMBASE and Cochrane libraries for articles published from 2009 till 30 May 2020. Studies were included if they reported original research on multimorbidity of NCDs among adults in LMICs. RESULTS: The systematic search yielded 3272 articles; 39 articles were included, with a total of 1 220 309 participants. Most studies used self-reported data from health surveys. There was a large variation in the prevalence of multimorbidity; 0.7%-81.3% with a pooled prevalence of 36.4% (95% CI 32.2% to 40.6%). Prevalence of multimorbidity increased with age, and random effect meta-analyses showed that female sex, OR (95% CI): 1.48, 1.33 to 1.64, being well-off, 1.35 (1.02 to 1.80), and urban residence, 1.10 (1.01 to 1.20), respectively were associated with higher odds of NCD multimorbidity. The most common multimorbidity patterns included cardiometabolic and cardiorespiratory conditions. CONCLUSION: Multimorbidity of NCDs is an important problem in LMICs with higher prevalence among the aged, women, people who are well-off and urban dwellers. There is the need for longitudinal data to access the true direction of multimorbidity and its determinants, establish causation and identify how trends and patterns change over time. PROSPERO REGISTRATION NUMBER: CRD42019133453.