Predicting short- to medium-term care home admission risk in older adults: a systematic review of externally validated models.

INTRODUCTION: Predicting risk of care home admission could identify older adults for early intervention to support independent living but require external validation in a different dataset before clinical use. We systematically reviewed external validations of care home admission risk prediction models in older adults. METHODS: We searched Medline, Embase and Cochrane Library until 14 August 2023 for external validations of prediction models for care home admission risk in adults aged ≥65 years with up to 3 years of follow-up. We extracted and narratively synthesised data on study design, model characteristics, and model discrimination and calibration (accuracy of predictions). We assessed risk of bias and applicability using Prediction model Risk Of Bias Assessment Tool. RESULTS: Five studies reporting validations of nine unique models were included. Model applicability was fair but risk of bias was mostly high due to not reporting model calibration. Morbidities were used as predictors in four models, most commonly neurological or psychiatric diseases. Physical function was also included in four models. For 1-year prediction, three of the six models had acceptable discrimination (area under the receiver operating characteristic curve (AUC)/c statistic 0.70-0.79) and the remaining three had poor discrimination (AUC < 0.70). No model accounted for competing mortality risk. The only study examining model calibration (but ignoring competing mortality) concluded that it was excellent. CONCLUSIONS: The reporting of models was incomplete. Model discrimination was at best acceptable, and calibration was rarely examined (and ignored competing mortality risk when examined). There is a need to derive better models that account for competing mortality risk and report calibration as well as discrimination.

Participation-related constructs and participation of children with additional support needs in schools.

AIM: To investigate associations between participation-related constructs and participation frequency and involvement in inclusive schools. METHOD: In this cross-sectional study, teachers of children with additional support needs, including intellectual disability, autism, and learning difficulties, completed measures. Participation-related constructs were measured using the School Participation Questionnaire; participation frequency and involvement were measured using the Participation and Environment Measure for Children and Youth. A series of multilevel linear mixed-effects regression models with maximum likelihood estimates and bootstrap confidence intervals with p-values were obtained. Final models included participation-related constructs and participation, controlling for demographic and diagnostic confounders (including age, sex, language, level of school support, and autism). RESULTS: Six hundred and eighty-eight children (448 [65.1%] males; mean age 8 years 7 months [range 4 years 10 months-12 years 13 months, standard deviation 2 years 1 months]) were assessed by 252 teachers. Across a series of models, participation-related constructs were consistently associated with more intensive participation (competence, environment, identity p < 0.001; symptoms p = 0.007), independent of confounders. More frequent participation remained associated with three of four participation-related constructs (competence, identity p < 0.001; environment p = 0.021). Age (p = 0.046), language (p = 0.002), and level of school support (p = 0.039) also remained significantly associated with frequency of participation. INTERPRETATION: Children with additional support needs in inclusive schools may have several participation barriers. Policies and interventions to improve participation are needed. WHAT THIS PAPER ADDS: Across a series of models, participation-related constructs were associated with frequency and intensity of participation. Only participation-related constructs were associated with participation intensity. Demographic and diagnostic variables were associated with frequency, not intensity, of participation. Teacher assessment is valid for assessment of participation and participation-related constructs.

Social determinants of psychological distress in Sierra Leone.

PURPOSE: Growing evidence demonstrates that daily stressors such as family violence, unemployment, and living conditions play an important part in causing psychological distress. This paper investigates the impact of distressing events and day-to-day living conditions on psychological distress in the fragile context of Sierra Leone. METHODS: A cross-sectional survey was conducted with 904 adults (454 men, 450 women) in 5 districts of Sierra Leone. The survey questionnaire comprised the Sierra Leone Psychological Distress scale and measures of demographic variables and personal characteristics, current life circumstances and potentially distressing events. RESULTS: Multiple regression results identified three factors to be the greatest contributors to psychological distress: family conflict (ß = 0.185, p < 0.001) and inability to afford basic needs (ß = 0.175, p < 0.001). Gender differences were evident: factors predicting men's psychological distress included severe sickness or injury (ß = 0.203, p < 0.001) and being unable to afford basic needs (ß = 0.190, p < 0.001); for women, predicting factors were family conflict (ß = 0.212, p < 0.001), perceived poor health (ß = 0.192, p < 0.001) and inability to afford basic needs (ß = 0.190, p < 0.001). CONCLUSION: Initiatives to promote good mental health and psychosocial wellbeing in Sierra Leone should focus on enhancing income-generating and employment opportunities, promoting access to education, and strengthening family relationships.

Annual Research Review: A multilevel bioecological analysis of factors influencing the mental health and psychosocial well-being of refugee children.

BACKGROUND: This paper revisits the themes of an influential 1993 review regarding the factors shaping the mental health and psychosocial well-being of refugees to take stock of developments in the evidence base and conceptualisation of issues for refugee children over the last 25 years. METHODS: The study deployed a systematic search strategy. This initially identified 784 papers, which was reduced to 65 studies following application of inclusion and exclusion criteria. We used a later iteration of Bronfenbrenner's bioecological model of human development - the PPCT model - to consolidate evidence. RESULTS: We identify a range of risk and protective factors operating at individual, familial, community and institutional and policy levels that influence outcomes for refugee children. The dynamics shaping the interaction of these influences are linked to the life course principles of socio-historical time and developmental age, proximal processes and child agency. CONCLUSIONS: Actions at individual, familial, community, school, institutional and policy levels all have potential traction on mental health and psychosocial well-being of refugee children. However, evidence suggests that greatest impact will be secured by multilevel interventions addressing synergies between ecological systems, approaches engaging proximal processes (including parenting programmes) and interventions facilitating the agency of the developing refugee child.

Identifying opportunities to engage communities with social mobilisation activities to tackle NCDs in El Salvador in the context of the global COVID-19 pandemic.

BACKGROUND: Social mobilisation is potentially a key tool in the prevention of non-communicable diseases (NCDs) in fragile settings. This formative study addressed existing and potential social mobilisation mechanisms seeking behaviour to tackle NCDs in El Salvador, with an emphasis on the implications in the context of the current COVID-19 pandemic. METHODS: We conducted 19 semi-structured interviews with health workers, government officials, NGO leaders, and community members. Interviews addressed mechanisms for social mobilisation which existed prior to COVID-19, the ways in which these mechanisms tackled NCDs, the impact of COVID-19 on social mobilisation activities and new, emerging mechanisms for social mobilisation in the wake of the COVID-19 pandemic. RESULTS: Findings indicate a growing awareness of NCDs within communities, with social mobilisation activities seen as valuable in tackling NCDs. However, major barriers to NCD prevention and treatment provision remain, with COVID-19 constraining many possible social mobilisation activities, leaving NCD patients with less support. Factors linked with effective social mobilisation of communities for NCD prevention included strong engagement of community health teams within community structures and the delivery of NCD prevention and management messages through community meetings with trusted health professionals or community members. There are gender differences in the experience of NCDs and women were generally more engaged with social mobilisation activities than men. In the context of COVID-19, traditional forms of social mobilisation were challenged, and new, virtual forms emerged. However, these new forms of engagement did not benefit all, especially those in hard-to-reach rural areas. In these contexts, specific traditional forms of mobilisation such as through radio (where possible) and trusted community leaders - became increasingly important. CONCLUSIONS: New mechanisms of fostering social mobilisation include virtual connectors such as mobile phones, which enable mobilisation through platforms such as WhatsApp, Facebook and Twitter. However, traditional forms of social mobilisation hold value for those without access to such technology. Therefore, a combination of new and traditional mechanisms for social mobilisation hold potential for the future development of social mobilisation strategies in El Salvador and, as appropriate, in other fragile health contexts.

An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries.

BACKGROUND: Noncommunicable diseases (NCDs), including mental health, have become a major concern in low- and middle-income countries. Despite increased attention to them over the past decade, progress toward addressing NCDs has been slow. A lack of bold policy commitments has been suggested as one of the contributors to limited progress in NCD prevention and management. However, the policies of key global actors (bilateral, multilateral, and not-for-profit organisations) have been understudied. METHODS: This study aimed to map the key global actors investing in action regarding NCDs and review their policies to examine the articulation of priorities regarding NCDs. Narrative synthesis of 70 documents and 31 policy papers was completed, and related to data collated from the Global Health Data Visualisation Tool. RESULTS: In 2019 41% of development assistance for health committed to NCDs came from private philanthropies, while that for other global health priorities from this source was just 20%. Through a range of channels, bilateral donors were the other major source of NCD funding (contributing 41% of NCD funding). The UK and the US were the largest bilateral investors in NCDs, each contributing 8%. However, NCDs are still under-prioritised within bilateral portfolios - receiving just 0.48% of US funding and 1.66% of the UK. NGOs were the key channels of funding for NCDs, spending 48% of the funds from donors in 2019. The reviewed literature generally focused on NCD policies of WHO, with policies of multilateral and bilateral donors given limited attention. The analysis of policies indicated a limited prioritisation of NCDs in policy documents. NCDs are framed in the policies as a barrier to economic growth, poverty reduction, and health system sustainability. Bilateral donors prioritise prevention, while multilateral actors offer policy options for NCD prevention and care. Even where stated as a priority, however, funding allocations are not aligned. CONCLUSION: The growing threat of NCDs and their drivers are increasingly recognised. However, global actors' policy priorities and funding allocations need to align better to address these NCD threats. Given the level of their investment and engagement, more research is needed into the role of private philanthropies and NGOs in this area.

Community-based participation of children with and without disabilities.

AIM: To describe and compare the socio-demographic characteristics and community-based participation of children with and without disabilities. METHOD: This cross-sectional study reports data on 1073 children with disabilities (663 males, 410 females) and 11 122 children without disabilities (5617 males, 5505 females) aged 10 to 12 years from the fifth sweep of the Millennium Cohort Study. χ2 was used to explore differences between the two groups. Logistic regression models were used to assess the relationships between childhood disability (dependent variable) and socio-demographic characteristics. Logistic regression models were also used to examine the associations between childhood disability (dependent variable) and participation in community-based activities. RESULTS: Children with disabilities were more likely to be male, have psychosocial and behavioural problems, live in single-parent households, and have a parent with a longstanding illness. Patterns of community-based participation were similar between children with and without disabilities. However, the extent to which the two groups participated differed. Children with disabilities participated with lower frequency in unstructured physical activities (adjusted odds ratio [OR] 2.41; 95% confidence interval [CI]: 1.95-2.99), organized physical activities (adjusted OR 2.29; 95% CI: 1.83-2.86), religious gatherings (adjusted OR 2.08; 95% CI: 1.35-3.20), and getting together with friends (adjusted OR 3.31; 95% CI: 2.61-4.20). INTERPRETATION: Socio-demographic characteristics differed between children with and without disabilities. Children with disabilities had greater restriction in participation compared to peers without disabilities. Participation promoting interventions are required to support the participation of children with disabilities in social and physical activities. WHAT THIS PAPER ADDS: Patterns of community-based participation were similar between children with and without disabilities. Children with disabilities had lower frequency of participation in physical activities, religious gatherings, and getting together with friends.

Family factors associated with participation of children with disabilities: a systematic review.

AIM: The aim of this review was to synthesize empirical evidence of family factors associated with participation of children with disabilities aged 5 to 12 years to inform the development of family-centred participation-fostering interventions. METHOD: A systematic search was performed for articles published in English between 2001 and 2017 in MEDLINE, PsycINFO, CINAHL, Scopus, and ASSIA following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Quality of evidence was appraised using the Research Triangle Institute Item Bank. Family factors associated with participation were identified and assessed using a multistage 'semi-quantitative' approach. RESULTS: Thirty studies were included in the review. Four non-modifiable 'status' factors consistently associated with participation were parental ethnicity, parental education, family type, and family socio-economic status. Six modifiable 'process' factors with consistent associations with participation were parental mental and physical health functioning, parental self-efficacy beliefs, parental support, parental time, family preferences, and activity orientation. INTERPRETATION: Rehabilitation professionals should direct their focus towards modifiable family factors as primary targets for family-centred interventions. Strategies that can improve families' access to information, counselling, and community support services are likely to support children's participation by empowering families and optimizing their health and well-being. WHAT THIS PAPER ADDS: Non-modifiable 'status' and modifiable 'process' factors are important in participation of children with disabilities. Disadvantaged family circumstances shaped by status factors are associated with reduced participation. Key process factors for intervention are parental mental and physical health and parental self-efficacy beliefs. Other important process factors for intervention are parental support and time, family preferences, and activity orientation.

FACTORES FAMILIARES ASOCIADOS CON LA PARTICIPACIÓN DE NIÑOS CON DISCAPACIDAD: UN ESTUDIO SISTEMÁTICO: OBJETIVO: El objetivo de esta revisión fue sintetizar la evidencia empírica de los factores familiares asociados con la participación de niños con discapacidad entre los 5 y 12 años para informar el desarrollo de intervenciones que fomentan la participación centrada en la familia METODO: Una búsqueda sistemática fue realizada en artículos publicados en ingles entre 2001 y 2017 en MEDLINE, PsycINFO, CINAHL, Scopus, y ASSIA de acuerdo con los items reportados preferentes para guías de Búsqueda Sistemática y Meta-Análisis. La calidad de la evidencia fue evaluada utilizando el Banco de Items del Research Triangle Institute (RTI). Fueron identificados los factores familiares asociados con la participación y evaluados utilizando un enfoque semicuantitativo de varias etapas. RESULTADOS: Fueron incluidos 30 estudios en esta revisión. Cuatro factores no modificables de ¨estado¨ asociados sistemáticamente con la participación fueron la etnia de los padres, el nivel de educación de los padres, el tipo de familia, y el estatus socioeconómico de las familias. Seis factores de ¨proceso ¨modificables con asociaciones consistentes con la participación fueron el funcionamiento de salud física y mental de los padres, creencia de autoeficacia de los padres, soporte parenteral, tiempo de los padres, preferencias familiares, y orientación a la actividad. INTERPRETACION: Los profesionales de la rehabilitación deben dirigir su foco hacia los factores modificables como objetivo primario para las intervenciones centradas en la familia. Estrategias que puedan mejorar el acceso de las familias a la información , asesoramiento, y servicios de apoyo comunitario que apoyen la participación de los niños y empoderar a las familias y optimizar su salud y bienestar.

FATORES FAMILIARES ASSOCIADOS COM PARTICIPAÇÃO EM CRIANÇAS COM INCAPACIDADES: UMA REVISÃO SISTEMÁTICA: OBJETIVO: O objetivo desta revisão foi sintetizar a evidência empírica de fatores familiares associados com participação de crianças com incapacidades de 5 a 12 anos para informar o desenvolvimento de intevenções centradas na família que promovam a participação. MÉTODO: Uma busca sistemática foi realizada por artigos publicados em ingles entre 2001 e 2007 na Medline, PsycINFO, CINAHL, Scopus, e ASSIA seguindo as diretrizes para Itens preferidos a serem reportados em revisões sistemáticas. A qualidade da evidência foi avaliada usando o Banco de Itens Do Institututo do Triângulo das Pesquisas (ITR). Fatores familiares associados à participação foram identificados e avaliados usando uma abordagem semi-quantitativa multi-estágios. RESULTADOS: Trinta estudos foram incluídos na revisão. Quatro fatores com estado "não-modificável" consistentemente associados com participação foram etnia parental, educação parental, tipo de família e situação sócio-econômica da família. Seis fatores de "processo" modificáveis com associações consistentes com participação foram saúde e funcionamento mental e físico dos pais, auto-eficácia parental, apoio parental, tempo parental, preferências familiares e orientacões para atividades. INTERPRETAÇÃO: Profissionais de reabilitação devem direcionar o foco para fatores familiares potencialmente modificáveis como alvos primários para intervenções centradas na família. Estratégias que podem melhorar o acesso da família a informação, aconselhamento e serviços de suporte na comunidade têm probabilidade de apoiar a participação da criança por empoderar famílias e otimizar sua saúde e bem estar.

Barriers to access to cancer care for patients from the conflict-affected region of the Nagorno-Karabakh Republic: A qualitative study.

Access to essential health services is a basic human right, yet many cancer patients living in conflict-affected regions face multiple obstacles to service use. The (former) Nagorno-Karabakh Republic was a conflict-affected region in the South Caucasus populated predominantly by ethnic Armenians. Multiple acute armed conflicts, the recent military occupation of the region, and the prolonged military blockade of the Lachin Corridor (a humanitarian corridor connecting Nagorno-Karabakh to Armenia) exacerbated existing social, health, economic, and political fragilities in this region. As a result, cancer services were disrupted, with limited clarity on how the ongoing military blockade of a humanitarian corridor affected cancer patients' experiences of accessing cancer care locally and in bordering Armenia. Our study aimed to describe the experiences of patients from Nagorno-Karabakh in accessing the cancer care services they needed. We conducted remote semi-structured interviews with adult (aged ≥18 years) cancer patients receiving cancer care from three university hospitals in Armenia and face-to-face interviews with cancer care professionals from these hospitals. Interviews were conducted during the blockade of the Lachin Corridor between March and May 2023. Data were analysed thematically using a deductive approach. Twelve adult cancer patients (9 women) and 12 cancer care professionals participated. A key barrier to accessing cancer services was attributed to the Azerbaijani military occupation of the region and the blockade of a major roadway connecting Nagorno-Karabakh to Armenia. Patients talked in length about the challenges of finding transport and travelling long distances to reach essential cancer services in Armenia. Policies of free anti-cancer medication provision and decentralised medication supply were paused because of the military occupation, affecting patients' timely access to anti-cancer medication. Out-of-pocket expenses for treatment, anti-cancer medication, travel, and temporary accommodation in Armenia placed a significant financial burden on cancer patients, exacerbated by the humanitarian crisis. Conflict-affected regions blockaded by military forces lack the capacity and targeted support to sustain their essential health services and provide care to those in need of life-saving treatments. Coordinated action from national and international organisations and governments is urgently needed to enhance humanitarian assistance and healthcare support to patients, their families and wider communities affected by military blockades and armed conflicts.

Barriers and Opportunities for WHO "Best Buys" Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review.

BACKGROUND: Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. METHODS: We conducted a complex systematic review of articles discussing the adoption and implementation of World Health Organization's (WHO's) "best buys" NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. RESULTS: Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape, and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. CONCLUSION: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.

Performance of models for predicting 1-year to 3-year mortality in older adults: a systematic review of externally validated models.

Mortality prediction models support identifying older adults with short life expectancy for whom clinical care might need modifications. We systematically reviewed external validations of mortality prediction models in older adults (ie, aged 65 years and older) with up to 3 years of follow-up. In March, 2023, we conducted a literature search resulting in 36 studies reporting 74 validations of 64 unique models. Model applicability was fair but validation risk of bias was mostly high, with 50 (68%) of 74 validations not reporting calibration. Morbidities (most commonly cardiovascular diseases) were used as predictors by 45 (70%) of 64 of models. For 1-year prediction, 31 (67%) of 46 models had acceptable discrimination, but only one had excellent performance. Models with more than 20 predictors were more likely to have acceptable discrimination (risk ratio [RR] vs <10 predictors 1·68, 95% CI 1·06-2·66), as were models including sex (RR 1·75, 95% CI 1·12-2·73) or predicting risk during comprehensive geriatric assessment (RR 1·86, 95% CI 1·12-3·07). Development and validation of better-performing mortality prediction models in older people are needed.

The role of financial security in loneliness or sadness among Medicare-enrolled cancer survivors during the COVID-19 pandemic.

INTRODUCTION: This study aims to estimate the relative decreased rate of financial security and increased rate of loneliness or sadness during the COVID-19 pandemic and investigate the association between financial security and loneliness or sadness among Medicare beneficiaries with a cancer history. MATERIAL AND METHODS: We examined population-based, cross-sectional data from the Medicare Current Beneficiary Survey COVID-19 Winter 2021 survey. The study cohort included 1,632 Medicare beneficiaries (aged ≥65 years) with self-reported cancer history. The outcome was feelings of loneliness or sadness, and the independent variable was financial security during the 2020-2021 winter surge of COVID-19. We conducted weighted descriptive statistics, a cross-tabulation analysis, and multivariable logistic regression analyses. RESULTS: Overall, 18.8% of cancer survivors reported increased feelings of loneliness or sadness and 11.2% reported decreased financial security during the 2020-2021 winter surge of COVID-19. Cancer survivors who reported decreased financial security had 93% higher odds of increased feelings of loneliness or sadness compared to those who reported feeling more or about the same financial security (Adjusted odds ratio [AOR] = 1.93; 95% Confidence Interval [CI] 1.25-3.01; p <0.004). DISCUSSION: Decreased financial security and increased feelings of loneliness or sadness were prevalent among cancer survivors. Additional screenings and interventions beyond what are currently available are needed to ease the socioeconomic vulnerabilities experienced by cancer survivors.

Social, health and economic impact of COVID-19: Healthy Ageing In Scotland (HAGIS) - a protocol for a mixed-methods study.

INTRODUCTION: Public health responses to the COVID-19 pandemic have reaped adverse physical, psychological, social and economic effects, with older adults disproportionally affected. Psychological consequences of the pandemic include fear, worry and anxiety. COVID-19 fear may impact individuals' mitigation behaviours, influencing their willingness to (re)engage in health, social and economic behaviours. This study seeks (1) to develop a robust and evidence-based questionnaire to measure the prevalence of COVID-19 fear among older adults (aged ≥50) in Scotland and (2) to examine the impact of COVID-19 fear on the willingness of older adults to (re)engage across health, social and economic domains as society adjusts to the 'new normal' and inform policy and practice. METHODS AND ANALYSIS: This mixed-method study includes a large-scale multimodal survey, focus groups and interviews with older adults (aged ≥50) living in Scotland, and an email-based 'e-Delphi' consultation with professionals working with older adults. The COVID-19 fear scale was developed and validated using exploratory and confirmatory factor analyses. Survey data will be analysed using descriptive and inferential statistics. Thematic analysis will be used to analyse qualitative data. Survey and qualitative findings will be triangulated and used as the starting point for an 'e-Delphi' consensus consultation with expert stakeholders. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the University of Stirling for multimodal survey development, fieldwork methodology and data management. Anonymised survey data will be deposited with the UK Data Service, with a link provided via the Gateway to Global Ageing. Qualitative data will be deposited with the University of Stirling online digital repository-DataSTORRE. A dedicated work package will oversee dissemination via a coproduced project website, conference presentations, rapid reports and national and international peer-reviewed journal articles. There is planned engagement with Scottish and UK policy makers to contribute to the UK government's COVID-19 recovery strategy.

Effectiveness of holistic assessment-based interventions for adults with multiple long-term conditions and frailty: an umbrella review of systematic reviews.

Holistic assessment-based interventions (HABIs) are effective in older people admitted to hospital, but it is unclear whether similar interventions are effective in adults with multiple long-term conditions or frailty in the community. We conducted an umbrella review to comprehensively evaluate the literature on HABIs for adults (aged ≥18 years) with multiple long-term conditions, and frailty. We searched eight databases for systematic reviews reporting on experimental or quasi-experimental studies. Of 9803 titles screened, we identified 29 eligible reviews (14 with meta-analysis) reporting on 14 types of HABIs. The evidence for the effectiveness of HABIs was largely inconsistent across different types of interventions, settings, and outcomes. We found evidence of no benefit from hospital HABIs on health-related quality of life (HRQoL) and emergency department re-attendance, and evidence of no benefit from community HABIs on overall health-care utilisation rates, emergency department attendance, nursing home admissions, and mortality. The best evidence of effectiveness was for hospital comprehensive geriatric assessment (CGA) on nursing home admissions, keeping patients alive and in their own homes. There was some evidence of benefit from community CGA on hospital admissions, and from CGA spanning community and hospital settings on HRQoL. Patient-centred medical homes had beneficial effects on HRQoL, mental health, self-management, and hospital admissions.

Effectiveness of holistic assessment-based interventions in improving outcomes in adults with multiple long-term conditions and/or frailty: an umbrella review protocol.

OBJECTIVE: This umbrella review will synthesize evidence on the effectiveness of holistic assessment-based interventions in improving health outcomes in adults (aged ≥18) with multiple long-term conditions and/or frailty. INTRODUCTION: Health systems need effective, evidence-based interventions to improve health outcomes for adults with multiple long-term conditions. Holistic assessment-based interventions are effective in older people admitted to hospital (usually called "comprehensive geriatric assessments" in that context); however, the evidence is inconclusive on whether similar interventions are effective in community settings. INCLUSION CRITERIA: We will include systematic reviews examining the effectiveness of community and/or hospital holistic assessment-based interventions in improving health outcomes for community-dwelling and hospitalized adults aged ≥ 18 with multiple long-term conditions and/or frailty. METHODS: The review will follow the JBI methodology for umbrella reviews. MEDLINE, Embase, PsycINFO, CINAHL Plus, Scopus, ASSIA, Cochrane Library, and the TRIP Medical Database will be searched to identify reviews published in English from 2010 till the present. This will be followed by a manual search of reference lists of included reviews to identify additional reviews. Two reviewers will independently screen titles and abstracts against the selection criteria, followed by screening of full texts. Methodological quality will be assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses and data will be extracted using an adapted and piloted JBI data extraction tool. The summary of findings will be presented in tabular format, with narrative descriptions and visual indications. The citation matrix will be generated and the corrected covered area calculated to analyze the overlap in primary studies across the reviews. REVIEW REGISTRATION: PROSPERO CRD42022363217.

Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa.

Sub-optimal implementation of infection prevention and control (IPC) measures for airborne infections is associated with a rise in healthcare-acquired infections. Research examining contributing factors has tended to focus on poor infrastructure or lack of health care worker compliance with recommended guidelines, with limited consideration of the working environments within which IPC measures are implemented. Our analysis of compromised tuberculosis (TB)-related IPC in South Africa used clinic ethnography to elucidate the enabling environment for TB-IPC strategies. Using an ethnographic approach, we conducted observations, semi-structured interviews, and informal conversations with healthcare staff in six primary health clinics in KwaZulu-Natal, South Africa between November 2018 and April 2019. Qualitative data and fieldnotes were analysed deductively following a framework that examined the intersections between health systems 'hardware' and 'software' issues affecting the implementation of TB-IPC. Clinic managers and front-line staff negotiate and adapt TB-IPC practices within infrastructural, resource and organisational constraints. Staff were ambivalent about the usefulness of managerial oversight measures including IPC protocols, IPC committees and IPC champions. Challenges in implementing administrative measures including triaging and screening were related to the inefficient organisation of patient flow and information, as well as inconsistent policy directives. Integration of environmental controls was hindered by limitations in the material infrastructure and behavioural norms. Personal protective measures, though available, were not consistently applied due to limited perceived risk and the lack of a collective ethos around health worker and patient safety. In one clinic, positive organisational culture enhanced staff morale and adherence to IPC measures. 'Hardware' and 'software' constraints interact to impact negatively on the capacity of primary care staff to implement TB-IPC measures. Clinic ethnography allowed for multiple entry points to the 'problematic' of compromised TB-IPC, highlighting the importance of capturing dimensions of the 'enabling environment', currently not assessed in binary checklists.

The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon.

Introduction: The management of NCDs is a growing challenge in low- and middle-income settings with the increasing prevalence and the associated demands that such conditions make on health systems. Fragile settings both exacerbate the risk of NCDs and undermine systems capacity. Lebanon is a setting where strategies to address rising NCDs burden have faced particularly acute contextual challenges. Methods: We conducted a cross-sectional survey with patients accessing non-communicable disease across 11 primary care centers within the Greater Beirut and Beqaa areas. Response were received from 1,700 patients. We generated a Clinical Management Index Score as a measure of quality of care, and scores related to a range of socio-demographic characteristics and other context specific variables. Results: Significantly higher clinical management index scores (better quality of care) were associated with patients living in the semi-urban/rural context of Beqaa (compared to Greater Beirut), having health insurance coverage, aged above 60, having high levels of educational attainment, and making partial or full payment for their treatment. Relatively lower index scores (poorer quality of care) were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients). Conclusion: The study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.

mHealth guideline training for non-communicable diseases in primary care facilities in Nigeria: a mixed methods pilot study.

OBJECTIVE: To pilot the use of a scalable innovative mobile health (mHealth) non-communicable diseases (NCDs) training application for nurses at the primary care level. DESIGN: Mixed methods pilot of mHealth training on NCD care for nurses at primary healthcare (PHC) facilities. We provide a descriptive analysis of mHealth training test scores, with trend analysis of blood pressure (BP) control using paired t-test for quantitative data and thematic analysis for qualitative data. SETTING: PHC facilities in rural and urban communities in Cross River State, south eastern Nigeria. NCDs were not part of routine training previously. As in most low-and-middle-income settings, funding for scale-up using conventional classroom in-service training for NCDs is not available in Nigeria, and onsite supervision poses challenges. PARTICIPANTS: Twenty-four health workers in 19 PHC facilities. INTERVENTION: A self-paced mHealth training module on an NCD desk guide was adapted to be applicable within the Nigerian context in collaboration with the Federal Ministry of Health. The training which focused on hypertension, diabetes and sickle cell disease was delivered via Android tablet devices, supplemented by quarterly onsite supervision and group support via WhatsApp. The training was evaluated with pre/post-course tests, structured observations and focus group discussions. This was an implementation pilot assessing the feasibility and potential effectiveness of mHealth training on NCD in primary care delivery. RESULTS: Nurses who received mHealth training recorded a statistically significant difference (p<0.001) in average pretest and post-test training scores of 65.2 (±12.2) and 86.5 (±7.9), respectively. Recordings on treatment cards indicated appropriate diagnosis and follow-up of patients with hypertension with significant improvements in systolic BP (t=5.09, p<0.001) and diastolic BP (t=5.07, p<0.001). The mHealth nurse training and WhatsApp support groups were perceived as valuable experiences and obviated the need for face-to-face training. Increased workload, non-availability of medications, facility-level conflicts and poor task shifting were identified challenges. CONCLUSIONS: This initiative provides evidence of the feasibility of implementing an NCD care package supported by mHealth training for health workers in PHCs and the strong possibility of successful scale-up nationally.

Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: a cross-sectional study from Lebanon.

OBJECTIVES: Assess and describe the health service use and delivery patterns for non-communicable disease (NCD) services in two contrasting fragility contexts and by other principal equity-related characteristics including gender, nationality and health coverage. SETTING: Primary healthcare centres located in the urbanised area of Greater Beirut and the rural area of the Beqaa Valley. DESIGN: This is a cross-sectional study using a structured survey tool between January and September 2020. PARTICIPANTS: 1700 Lebanese and Syrian refugee patients seeking primary care for hypertension and diabetes. PRIMARY AND SECONDARY OUTCOMES: The main outcome is the comprehensiveness of service delivery comparing differences in use and service delivery patterns by fragility setting, gender, nationality and health coverage. RESULTS: Compliance with routine NCD care management (eg, counselling, immunisations, diagnostic testing and referral rates) was significantly better in Beirut compared with Beqaa. Women were significantly less likely to be offered lifestyle counselling advice and referral to cardiologists (58.4% vs 68.3% in Beqaa and 58.1% vs 62% in Beirut) and ophthalmologists, compared with men. Across both settings, there was a significant trend for Lebanese patients to receive more services and more advice related to nutrition and diabetes management (89.8% vs 85.2% and 62.4% vs 55.5%, respectively). Similarly, referral rates were higher among Lebanese refugees compared with Syrian refugees. Immunisation and diagnostic testing were significantly higher in Beirut among those who have health coverage compared with Beqaa. CONCLUSIONS: The study discovered significant differences in outpatient service use by setting, nationality and gender to differentials. A rigorous and comprehensive appraisal of NCD programmes and services is imperative for providing policy makers with evidence-based recommendations to guide the design, implementation and evaluation of targeted programmes and services necessary to ensure equity in health services delivery to diabetic and hypertensive patients. Such programmes are an ethical imperative considering the protracted crises and compounded fragility.