Practical dietary interventions to prevent cardiovascular disease suitable for implementation in primary care: an ADAPTE-guided systematic review of international clinical guidelines.

PURPOSE: Cardiovascular diseases (CVD) are the leading cause of death globally. The current model of care for high-income countries involves preventive medication and highly trained healthcare professionals, which is expensive and not transposable to low-income countries. An innovative, effective approach adapted to limited human, technical, and financial resources is required. Measures to reduce CVD risk factors, including diet, are proven to be effective. The survey "Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa" aims to develop non-pharmacological cardiovascular prevention and control programs in primary care and community settings in high, middle, and low-income countries. This review aims to identify the existing, validated dietary interventions for primary CVD prevention from national and international clinical guidelines that can be implemented in primary care and communities. METHODS: A systematic review of CVD prevention guidelines was conducted between September 2017 and March 2023 using the Turning Research Into Practice medical database, the Guidelines International Network, and a purposive search. The ADAPTE procedure was followed. Two researchers independently conducted the searches and appraisals. Guidelines published after 01/01/2012 addressing non-pharmacological, dietary interventions for primary CVD prevention or CVD risk factor management, in the adult general population in primary care or in community settings were included and appraised using the Appraisal of Guidelines Research and Evaluation II score. Individual dietary recommendations and the studies supporting them were extracted. Then supporting data about each specific dietary intervention were extracted into a matrix. RESULTS: In total, 1375 guidelines were identified, of which 39 were included. From these, 383 recommendations, covering 10 CVD prevention themes were identified. From these recommendations, 165 studies for effective dietary interventions for CVD prevention were found. Among these, the DASH diet was the most effective on multiple CVD risk factors. Combining diet with other interventions such as exercise and smoking cessation increased efficacy. No guidelines provided detailed implementation strategies. CONCLUSION: The DASH diet combined with other interventions was the most effective on an individual basis. However, expansion in the wider population seems difficult, without government support to implement regulations such as reducing salt content in processed food. TRIAL REGISTRATION: Clinical Trials NCT03886064.

Heart disease is the leading cause of death around the world. Strategies to prevent heart disease in high-income countries rely on medications and the skills of highly trained healthcare professionals. However, this is expensive and unsuitable for low-income countries. Consequently, an innovative, effective approach, which can be adapted to countries with limited human, technical and financial resources is needed. A program called SPICES was developed to identify strategies other than medication to prevent and control heart disease. This program reviewed the evidence for smoking cessation, physical activity, and dietary strategies, which may be useful to prevent heart disease in communities with limited resources.In this review, the investigators searched online databases to find clinical guidelines that recommended dietary strategies to manage heart disease worldwide. The information found from this search revealed that the DASH diet, inspired by the Mediterranean diet, helps with weight loss, and improves blood pressure and cholesterol levels making it the most effective diet for preventing heart disease. It is even more effective if it is combined with other strategies such as exercise, stopping smoking or reducing the amount of alcohol consumed. However, this works well for individuals but is difficult to expand to the wider population. Therefore, government support is needed to implement regulations such as reducing salt content in processed food.

Effect of malaria prevention education on bed net utilization, incidence of malaria and treatment seeking among school-aged children in Southern Ethiopia; cluster randomized controlled trial.

BACKGROUND: School-aged children (SAC) have an increased risk to contract malaria and play a major role in its transmission dynamics. However, their malaria prevention experience is poor. Thus, the effect of malaria prevention education (MPE) on bed net utilization, treatment seeking from a health facility and cumulative incidence of malaria was evaluated in Southern Ethiopia. METHODS: A two arm cluster randomized controlled trial was conducted by recruiting 2038 SAC from 32 schools. Structured questionnaire was used to collect data on socio-demographic, economic, bed net ownership, bed net utilization, whether the participated child suffered from malaria and has got treatment from a health facility. Generalized mixed effect logistic regression using school as random variable was used to assess the effect of the intervention on the outcome variables. RESULTS: The ownership of bed net in households of the control and intervention schools was similar respectively with 84.6 and 88.6% (Crude Odds Ratio (COR): 1.5; 95%CI: 0.5-4.8). The percentage of SAC slept under the bed net the night before the survey was also similar (55.1% versus 54.0%); COR:1.04; 95%CI: 0.5-2.4). Bed net utilization was affected by household size to the bed net ratio ≤ 2 (Adjusted Odds Ratio (AOR) = 1.6; 95%CI:1.3-2.1), bed net utilization at baseline of the study (AOR = 2.3; 95%CI:1.5-3.6), and history of malaria attack in the last twelve months (AOR = 1.3; 95%CI:1.01-1.8). Reported cumulative incidence of malaria and treatment seeking from a health facility by SAC was similar between intervention and control arms: -2.1% (COR = 0.8; 95%CI: 0.5-1.5) and 9.6% (COR = 1.4; 95%CI: 0.4-4.3) respectively. The reported incidence of malaria was affected by altitude (AOR = 0.5; 95%CI: 0.3-0.8), low and medium wealth index (AOR = 0.7; 95%CI: 0.5-0.96 and AOR = 0.7; 95%CI: 0.5-0.98), adequate bed net number for household members (AOR = 0.7; 95%CI:0.5-0.9) and bed net utilization (AOR = 1.3; 95%CI:1.1-1.8). CONCLUSIONS: MPE had no significant effect on the use of malaria prevention measures considered, treatment seeking from a health facility and reported cumulative incidence of malaria though bed net use was associated with malaria incidence. Before organizing any health education program, sustainable implementation efforts have to be warranted especially in SAC, a neglected but relevant vulnerable and reservoirs. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR202001837195738, registered 21/01/2020.

Dietary outcomes of community-based CVD preventive interventions: a systematic review and meta-analysis.

OBJECTIVE: We aimed to synthesise available evidence on the effects of community-based interventions in improving various dietary outcome measures. DESIGN: Systematic review and meta-analysis. SETTING: We searched databases including Medline, EMBASE, PSYCINFO, CINAHL and the Cochrane registry for studies reported between January 2000 and June 2022. The methodological quality of the included studies was evaluated using the Cochrane risk of bias tools for each study type. For some of the outcomes, we pooled the effect size using a random-effects meta-analysis. PARTICIPANTS: A total of fifty-one studies, thirty-three randomised and eighteen non-randomised, involving 100 746 participants were included. RESULTS: Overall, thirty-seven studies found a statistically significant difference in at least one dietary outcome measure favouring the intervention group, whereas fourteen studies found no statistically significant difference. Our meta-analyses indicated that, compared with controls, interventions were effective in decreasing daily energy intake (MJ/d) (mean difference (MD): -0·25; 95 % CI: -0·37, -0·14), fat % of energy (MD: -1·01; 95 % CI: -1·76, -0·25) and saturated fat % of energy (MD: -1·54; 95 % CI: -2·01, -1·07). Furthermore, the interventions were effective in improving fibre intake (g/d) (MD: 1·08; 95 % CI: 0·39, 1·77). Effective interventions use various strategies including tailored individual lifestyle coaching, health education, health promotion activities, community engagement activities and/or structural changes. CONCLUSION: This review shows the potential of improving dietary patterns through community-based CVD preventive interventions. Thus, development and implementation of context-specific preventive interventions could help to minimise dietary risk factors, which in turn decrease morbidity and mortality due to CVD and other non-communicable diseases.

The Pre-Implementation Phase of a Project Seeking to Deliver a Community-Based CVD Prevention Intervention (SPICES-Sussex): A Qualitative Study Exploring Views and Experience Relating to Intervention Development.

BACKGROUND.: Community-led health care interventions may be an effective way to tackle cardiovascular disease (CVD) risk factors, especially in materially deprived communities where health care resources are stretched and engagement with institutions is often low. To do so effectively and equitably, interventions might be developed alongside community members through community engagement. OBJECTIVES.: The aim of this project was to carry out stakeholder mapping and partnership identification and to understand the views, needs, experiences of community members who would be involved in later stages of a community-based CVD prevention intervention's development and implementation. METHODS.: Stakeholder mapping was carried out to identify research participants in three communities in Sussex, United Kingdom. A qualitative descriptive approach was taken during the analysis of focus groups and interviews with 47 participants. FINDINGS.: Three themes were highlighted related to intervention design (a) Management: the suitability of the intervention for the community, management of volunteers, and communication; (b) Logistics: the structure and design of the intervention; and (c) Sociocultural issues, the social and cultural expectations/experiences of participants and implementers. CONCLUSIONS.: Study participants were open and willing to engage in the planned community-based intervention, particularly in elements of co-design and community-led delivery. They also highlighted the importance of sociocultural factors. Based on the findings, we developed recommendations for intervention design which included (but were not limited to): (a) a focus on a bottom-up approach to intervention design, (b) the recruitment of skilled local volunteers, and (c) the importance of fun and simplicity.

Job satisfaction criteria to improve general practitioner recruitment: a Delphi consensus.

BACKGROUND: The clinical general practitioner (GP) workforce is decreasing. Many studies have analysed the negative aspects of the profession but, few examine the positive aspects and job satisfaction. A European collaborative group including 8 participating countries recently conducted a qualitative study to analyse the positive factors and found 31 job satisfaction factors. OBJECTIVES: To determine which of these 31 factors are important and applicable to future policies to improve family medicine attractiveness, recruitment, and retention in France. METHOD: The Delphi consensus method was chosen. Two Delphi rounds were conducted in March-April 2017 and retained satisfaction factors with at least 70% of scores ≥7. The Nominal Group Technique (NGT) was used to rank these retained factors. Participants assigned 5 points to the factor they considered most important, 3 points to the second, and 1 point to the third. Factors receiving at least 5% (10 points) of the total points (198 points) were included in the final list. The expert panel included GPs and non-GPs. RESULTS: Twenty-nine experts began the procedure and 22 completed it. Thirty factors were retained after the 2 Delphi rounds. The NGT resulted in 8 factors: (i) Engage in family medicine to take care of the patients; (ii) Care coordination, patient advocacy; (iii) Flexibility in work; (iv) Trying to be a person-centred doctor; (v) Involvement in healthcare organization; (vi) Benefiting from a well-managed practice; (vii) Being a teacher, a trainer; (viii) Efficient professional collaboration. CONCLUSION: These 8 job satisfaction factors are important to consider and apply to future policy development.

In Europe, general practitioner (GP) numbers are falling. Policies considering GP job satisfaction could be a solution. GPs with higher job satisfaction have lower levels of stress and burnout, are more interested in their job, and stay in their job for longer. Recently, a European study found 31 GP factors that influence job satisfaction. However, it is not clear which of these 31 factors policy makers could use to improve attractiveness, recruitment, and retention in family medicine in France. A panel of experts consisting of GPs and non-GPs used the Delphi consensus method to agree on which satisfaction factors were relevant and important. These factors were then ranked in order of importance. The experts agreed upon thirty satisfaction factors. From these, 8 were ranked as most important: (i) Engage in family medicine to take care of patients; (ii) Care coordination, patient advocacy; (iii) Flexibility in work; (iv) Trying to be a person-centred doctor; (v) Involvement in the healthcare organization; (vi) Benefiting from a well-managed practice; (vii) Being a teacher, a trainer; (viii) Efficient professional collaboration. These should be considered and applied to future policy development.

Level of cardiovascular disease knowledge, risk perception and intention towards healthy lifestyle and socioeconomic disparities among adults in vulnerable communities of Belgium and England.

BACKGROUND: The burden of cardiovascular diseases (CVDs) greatly varies between and within countries. Low- and middle-income countries (LMICs) and vulnerable communities of high-income countries (HIC) share disproportionately higher burden. Evidence is limited on the level of CVD knowledge and risk perception in vulnerable communities. Hence, in this study, we assessed the level of CVD knowledge, risk perception and change intention towards physical activity and healthy diet among vulnerable communities in Antwerp, Belgium and Nottingham, England. Furthermore, we investigated the socioeconomic disparities particularly in the Antwerp setting. METHOD: A cross-sectional study was performed among 1,424 adults (958 in Antwerp and 466 in Nottingham) aged 18 or older among selected vulnerable communities. Districts or counties were selected based on socioeconomic and multiple deprivation index. A stratified random sampling was used in Antwerp, and purposive sampling in Nottingham. We determined the level of CVD knowledge, risk perception and intention towards a healthy lifestyle in Antwerp and Nottingham using a percentage score out of 100. To identify independent socioeconomic determinants in CVD knowledge, risk perception, intention to PA and healthy diet, we performed multilevel multivariable modeling using the Antwerp dataset. RESULTS: The mean knowledge percent score was 75.4 in Antwerp and 69.4 in Nottingham, and only 36.5% and 21.1% of participants respectively, had good CVD knowledge (scored 80% or above). In the multivariable analysis using the Antwerp dataset, level of education was significantly associated with (1) CVD knowledge score (Adjusted ß = 0.11, 95%CI: 0.03, 0.18), (2) risk perception (0.23, 95%CI: 0.04, 0.41), (3) intention to physical activity (PA) (0.51, 95%CI: 0.35, 0.66), and (4) healthy diet intention (0.54, 95%CI: 0.32, 0.75). Furthermore, those individuals with a higher household income had a better healthy diet intention (0.44, 95%CI: 0.23, 0.65). In contrast, those who were of non-European origin scored lower on intention to have a healthy diet (-1.34, 95%CI:-2.07, -0.62) as compared to their European counterparts. On average, intention to PA was significantly higher among males (-0.43, 95%CI:-0.82, -0.03), whereas females scored better on healthy diet intention (2.02, 95%CI: 1.46, 2.57). CONCLUSIONS: Knowledge towards CVD risks and prevention is low in vulnerable communities. Males have a higher intention towards PA while females towards a healthy diet and it also greatly varies across level of education. Moreover, those born outside Europe and with low household income have lower healthy diet intention than their respective counterparts. Hence, CVD preventive interventions should be participatory and based on a better understanding of the individuals' socioeconomic status and cultural beliefs through active individual and community engagement.

Implementation of a malaria prevention education intervention in Southern Ethiopia: a qualitative evaluation.

BACKGROUND: Though school-aged children (SAC) are at high risk of malaria, they are the ones that benefit the least from malaria prevention measures. A cluster randomized controlled trial was conducted to evaluate the effect of malaria prevention education (MPE) on insecticide-treated bed net (ITN) utilization and prompt diagnosis, reported incidence and treatment (PDAT) of malaria. Qualitative evaluation of the implementation of such interventions is vital to explain its effectiveness and will serve as guidance for future interventions. Therefore, this study aimed to evaluate the implementation of the MPE in southern Ethiopia.  METHODS: The trial was registered in Pan African Clinical Trials Registry (PACTR202001837195738) on 21/01/2020. A descriptive qualitative study using semi-structured interview with participants of the MPE was conducted in January 2020 and January 2021. The collected data were transcribed verbatim and analyzed thematically. The analysis of the data was supported by NVivo. RESULTS: The four themes identified after evaluation of MPE training were the setup of the training, challenges for the success of the training, anticipated challenges for practice as per the protocol and experienced immediate influences of the training. Participants appreciated the training: content covered, way of delivery and the mix of the participants. The context specific facilitators to bed net use were the collateral benefits of ITN and perceived at high risk of malaria while its barriers were quality and quantity of the bed nets, bed net associated discomforts, malaria health literacy and housing condition. Severeness of malaria symptoms and malaria health literacy were reported as both barriers and facilitators of the PDAT of malaria. The identified facilitators of PDAT of malaria were health professionals' attitude and exposure to MPE while its barriers were poverty, use of traditional medicine, health facility problems and Coronavirus Disease 2019 (COVID-19) pandemic. CONCLUSION: Low attendance of parents in the training was the major challenge for the success of MPE. National malaria program should ensure the access to malaria prevention measures; and future studies using increased frequency of the intervention embedded with monitoring adherence to the intervention protocol shall be conducted to improve the gains from existing malaria interventions.

Prevalence and associated risk factors of asymptomatic malaria and anaemia among school-aged children in Dara Mallo and Uba Debretsehay districts: results from baseline cluster randomized trial.

BACKGROUND: Despite the growing evidence that malaria and anaemia are two interlinked health problems of school-aged children (SAC) in developing countries, there is scarce information about malaria among SAC in Ethiopia. Moreover, anaemia-related studies were more concentrated in easily accessible areas. This study aimed to assess the prevalence of malaria and anaemia and corresponding risk factors among SAC in Dara Mallo and Uba Debretshay districts, in hard to reach areas, so as to inform appropriate integrated interventions for both diseases. METHODS: This study was part of baseline data collected for a cluster-randomized trial registered in Pan African Clinical Trials Registry (PACTR202001837195738). Data were collected from 2167 SAC and their households through face-to-face interview; malaria was diagnosed by using rapid diagnostic test (RDT); haemoglobin concentration was determined using hemoCue hb 301 and adjusted for altitude to determine anaemic status; helminth infections were determined by using kato-katz, and anthropometric measurements were made to determine nutritional status of children. Generalized mixed effects logistic regression model was used to assess the association between predictor variables and malaria and anaemia using school as a random variable. RESULTS: The overall prevalence of malaria was 1.62% (95% CI 1.15-2.27%) (35/2167). Of the 35 children positive for malaria, 20 (57.14%), 3 (8.57%) and 12 (34.29%) were due to Plasmodium falciparum, Plasmodium vivax and mixed infections of P. falciparum and P. vivax, respectively. Malaria was significantly lower among children from literate household head (Adjusted OR = 0.38; 95% CI 0.15-0.95) and residence house located at an altitude range above 1100 masl (AOR = 0.40; 95% CI 0.17-0.94). The prevalence of anaemia was 22.00% (95% CI 20.3-23.8%) (477/2167) and was significantly reduced by eating legumes, nuts or seed group of food in their 24-h dietary diversity recall (AOR = 0.64; 95% CI 0.41-0.99). CONCLUSIONS: The prevalence of malaria was low and unevenly distributed per school while the overall prevalence of anaemia was moderate. It is important to implement integrated interventions targeting both malaria and anaemia, with special emphasis given to children from illiterate households and living at an altitude below 1100 masl. The micronutrient content of locally grown legumes should be further investigated to recommend specific interventions to overcome anaemia.

Effectiveness of community-based cardiovascular disease prevention interventions to improve physical activity: A systematic review and meta-regression.

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality globally. Despite preventive community-based interventions (CBIs) seem efficacious in reducing CVD risks, a comprehensive up-to-date synthesis on the effectiveness of such interventions in improving physical activity (PA) is lacking. We performed a systematic review and meta-analysis of community-based CVD preventive interventions aimed at improving PA level. MEDLINE, EMBASE, CINAHL, Cochrane register and PSYCINFO databases were searched in October 2019 for studies reported between January 2000 and June 2019. We assessed the methodological quality of included studies using the Cochrane risk of bias tools. We performed a random-effects meta-analysis and meta-regression to pool estimates of various effect measures. Results are reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline. Our study protocol was registered in the PROSPERO database (CRD42019119885). A total of 44 randomized and 20 non-randomized controlled studies involving 98,919 participants were included. Meta-analyses found that CBIs improved the odds of attaining the recommended PA level (at least 150 min of moderate and vigorous PA (MVPA)/week) at 12 month (OR: 1.62; 95%CI: 1.25-2.11) and 18 to 24 months of follow-up (OR: 1.46; 95%CI: 1.12-1.91). Furthermore, interventions were effective in improving metabolic equivalents of task at 12 month (standardized mean difference (SMD): 0.28; 95% CI: 0.03-0.53), MVPA time at 12 to 18 months (SMD: 0.34; 95%CI: 0.05-0.64), steps per day (SMD: 0.32; 95%CI: 0.08-0.55), and sitting time (SMD: -0.25; 95%CI: -0.34 to -0.17). Subgroup analyses found that interventions in low- and middle-income countries showed a greater positive effect on attainment of recommended PA level (OR: 1.40; 95%CI: 1.02-1.92) than those in high-income countries (OR: 1.31; 95%CI: 0.96-1.78). Moreover, interventions targeting high-risk groups showed greater effectiveness than those targeting the general population (OR: 1.76; 95%CI: 1.30-2.39 vs. 1.17; 95%CI: 0.89-1.55). In conclusion, community-based CVD preventive interventions have a positive impact on improving the PA level, albeit that relevant studies in lower-middle and low-income countries are limited. With the rising burden of CVDs, rolling out CBIs targeting the general population and high-risk groups are needed to control the growing CVD-burden.

Facilitators and barriers in prevention of cardiovascular disease in Limpopo, South Africa: a qualitative study conducted with primary health care managers.

BACKGROUND: In the Southern African countries, cardiovascular disease burden is increasing and the second most prevalent cause of death after infectious diseases. The sustainable primary prevention of cardiovascular disease is associated with the engagement of facilitators that support it and hindered by barriers that undermine the support of a healthy lifestyle at the community level. The purpose of the study was to investigate facilitators and barriers at the level of primary health care facilities, on prevention of cardiovascular disease in Limpopo Province of South Africa. METHODS: This study is an exploratory and descriptive qualitative design, where open-ended key informant interviews were conducted among 20 primary health care managers conveniently sampled in their respective health care facilities. Coding and analysis were done using the thematic analysis method with the assistance of Atlas ti qualitative software. RESULTS: Various facilitators for the prevention of CVD were identified in this study. One of such facilitators is the availability and adherence to CVD treatment guidelines in the district. Other facilitators included top-down health education programme; collaboration with schools, traditional and religious leaders; the use of modern technology; and a structured healthcare system. Barriers were also identified as poor infrastructural development; shortage of medical supplies and equipment; lack of health promotion activities; shortage of nurses and other health care personnel; and poor accessibility to primary health care services. CONCLUSION: This study has identified barriers and facilitators that may be harnessed to improve cardiovascular disease prevention, care, and management in a rural setting in South Africa. The facilitators should be strengthened, and barriers identified redressed. TRIAL REGISTRATION NUMBER: REC-0310111-031.

Early detection of cervical cancer in western Kenya: determinants of healthcare providers performing a gynaecological examination for abnormal vaginal discharge or bleeding.

BACKGROUND: In western Kenya, women often present with late-stage cervical cancer despite prior contact with the health care system. The aim of this study was to predict primary health care providers' behaviour in examining women who present with abnormal discharge or bleeding. METHODS: This was a cross-sectional survey using the theory of planned behaviour (TPB). A sample of primary health care practitioners in western Kenya completed a 59-item questionnaire. Structural equation modelling was used to identify the determinants of providers' intention to perform a gynaecological examination. Bivariate analysis was conducted to investigate the relationship between the external variables and intention. RESULTS: Direct measures of subjective norms (DMSN), direct measures of perceived behavioural control (DMPBC), and indirect measures of attitude predicted the intention to examine patients. Negative attitudes toward examining women had a suppressor effect on the prediction of health workers' intentions. However, the predictors of intention with the highest coefficients were the external variables being a nurse (ß = 0.32) as opposed to a clinical officer and workload of attending less than 50 patients per day (ß = 0.56). In bivariate analysis with intention to perform a gynaecological examination, there was no evidence that working experience, being female, having a lower workload, or being a private practitioner were associated with a higher intention to conduct vaginal examinations. Clinical officers and nurses were equally likely to examine women. CONCLUSIONS: The TPB is a suitable theoretical basis to predict the intention to perform a gynaecological examination. Overall, the model predicted 47% of the variation in health care providers' intention to examine women who present with recurrent vaginal bleeding or discharge. Direct subjective norms (health provider's conformity with what their colleagues do or expect them to do), PBC (providers need to feel competent and confident in performing examinations in women), and negative attitudes toward conducting vaginal examination accounted for the most variance. External variables in this study also contributed to the overall variance. As the model in this study could not explain 53% of the variance, investigating other external variables that influence the intention to examine women should be undertaken.

Long-lasting insecticide-treated bed net ownership, utilization and associated factors among school-age children in Dara Mallo and Uba Debretsehay districts, Southern Ethiopia.

BACKGROUND: Malaria is one of the major causes of morbidity and mortality among school-age children (SAC) in sub-Saharan Africa. SAC account for more than 60% of the reservoir of malaria transmission, but they are given less emphasis in prioritizing malaria prevention interventions. This study was aimed at assessing the ownership of long-lasting insecticide treated bed nets (LLINs), its utilization and factors associated with ownership of LLINs by households and LLINs utilization among SAC in malaria-prone areas of Dara Mallo and Uba Debretsehay districts in Southern Ethiopia, October to December 2019. METHODS: This study is part of a baseline assessment in a cluster-randomized controlled trial. The data was collected through interview and observation, following a structured questionnaire, of 2261 SAC households. Univariable and multivariable multilevel logistic regressions were used to assess the association between LLINs ownership and utilization and potential predictor variables. Odds ratio (OR) and corresponding 95% confidence interval (CI) were used to determine the strength and statistical significance of association. RESULTS: The ownership of at least one LLIN by households of SAC was about 19.3% (95% CI 17.7-21.0%) but only 10.3% % (95% CI 7.7-13.7%) of these households had adequate access of bed nets to the household members. Ownership of bed net was marginally affected by living in semi-urban area (adjusted OR = 2.6; 95% CI 1.0-6.9) and occupational status of the household head being a civil servant (adjusted OR = 2.7; 95% CI 0.9-7.9). About 7.8% (95% CI 6.7-10.0%) of all SAC participated in the study and 40.4% (95% CI 57.4-66.7%) of children in households owning at least one LLIN passed the previous night under LLIN. LLIN utilization by SAC conditional to presence of at least one net in the household was significantly correlated with education level of mother above grade 6 (adjusted OR = 3.4; 95% CI 1.3-9.3) and the household size to bed net ratio less than or equal to 2 (adjusted OR = 20.7; 95% CI 4.7-132.5). CONCLUSION: Ownership of bed net was lower than universal coverage of at least one bed net for two individuals. It is important to monitor replacement needs and educate mothers with low education level with their SAC on the benefit of consistent utilization of bed nets.

Cardiovascular risk factor mapping and distribution among adults in Mukono and Buikwe districts in Uganda: small area analysis.

BACKGROUND: Sub-Saharan Africa (SSA) is experiencing an increasing burden of Cardiovascular Diseases (CVDs). Modifiable risk factors including hypertension, diabetes, obesity, central obesity, sedentary behaviours, smoking, poor diet (characterised by inadequate vegetable and fruit consumption), and psychosocial stress are attributable to the growing burden of CVDs. Small geographical area mapping and analysis of these risk factors for CVD is lacking in most of sub-Saharan Africa and yet such data has the potential to inform monitoring and exploration of patterns of morbidity, health-care use, and mortality, as well as the epidemiology of risk factors. In the current study, we map and describe the distribution of the CVD risk factors in 20 parishes in two neighbouring districts in Uganda. METHODS: A baseline survey benchmarking a type-2 hybrid stepped wedge cluster randomised trial design was conducted in December 2018 and January 2019. A sample of 4372 adults aged 25-70 years was drawn from 3689 randomly selected households across 80 villages in 20 parishes in Mukono and Buikwe districts in Uganda. Descriptive statistics and generalized linear modelling controlled for clustering were conducted for this analysis in Stata 13.0, and a visual map showing risk factor distribution developed in QGIS. RESULTS: Mapping the prevalence of selected CVD risk factors indicated substantial gender and small area geographic heterogeneity which was masked on aggregate analysis. Patterns and clustering were observed for hypertension, physical inactivity, smoking, alcohol consumption and risk factor combination. Prevalence of unhealthy diet was very high across all parishes with no significant observable differences across areas. CONCLUSION: Modifiable cardiovascular risk factors are common in this low-income context. Moreover, across small area geographic setting, it appears significant differences in distribution of risk factors exist. These differences suggest that underlying drivers such as sociocultural, environmental and economic determinants may be promoting or inhibiting the observed risk factor prevalences which should be further explored. In addition, the differences emphasize the value of small geographical area mapping and analysis to inform more targeted risk reduction interventions.

Cardiovascular disease prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda.

BACKGROUND: With the growing epidemic of Cardiovascular Disease (CVD) in sub-Saharan Africa, behavioural change interventions are critical in supporting populations to achieve better cardiovascular health. Population knowledge regarding CVD is an important first step for any such interventions. This study examined CVD prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda. METHODS: The study was cross-sectional in design conducted among adults aged 25 to 70 years as part of the baseline assessment by the Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa (SPICES) - project. Data were collected using pretested semi-structured questionnaires, and respondents categorized as knowledgeable if they scored at least five out of six in the knowledge questions. Data were exported into STATA version 15.0 statistical software for analysis conducted using mixed-effects Poisson regression with fixed and random effects and robust standard errors. RESULTS: Among the 4372 study respondents, only 776 (17.7%) were knowledgeable on CVD prevention. Most respondents were knowledgeable about foods high in calories 2981 (68.2%), 2892 (66.1%) low fruit and vegetable intake and high salt consumption 2752 (62.9%) as CVD risk factors. However, majority 3325 (76.1%) thought the recommended weekly moderate physical activity was 30 min and half 2262 (51.7%) disagreed or did not know that it was possible to have hypertension without any symptoms. Factors associated with high CVD knowledge were: post-primary education [APR = 1.55 (95% CI: 1.18-2.02), p = 0.002], formal employment [APR = 1.69 (95% CI: 1.40-2.06), p < 0.001] and high socio-economic index [APR = 1.35 (95% CI: 1.09-1.67), p = 0.004]. Other factors were: household ownership of a mobile phone [APR = 1.35 (95% CI: 1.07-1.70), p = 0.012] and ever receiving advice on healthy lifestyles [APR = 1.38 (95% CI: 1.15-1.67), p = 0.001]. CONCLUSIONS: This study found very low CVD knowledge with major gaps around recommended physical activity duration, diet and whether hypertension is asymptomatic. Observed knowledge gaps should inform suitable interventions and strategies to equip and empower communities with sufficient information for CVD prevention. TRIAL REGISTRATION: ISRCTN Registry ISRCTN15848572 , January 2019, retrospectively registered.

Acceptability of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: a qualitative study.

BACKGROUND: Cardiovascular diseases (CVDs) are on the rise in many low-and middle-income countries where 80% of related deaths are registered. Community CVD prevention programmes utilizing self-care approaches have shown promise in contributing to population level reduction of risk factors. However, the acceptability of these programmes, which affects their uptake and effectiveness, is unknown including in the sub-Saharan Africa context. This study used the Theoretical Framework of Acceptability to explore the prospective acceptability of a community CVD prevention programme in Mukono and Buikwe districts in Uganda. METHODS: This qualitative descriptive study was conducted in March 2019 among community health workers (CHWs), who would implement the intervention and community members, the intervention recipients, using eight focus group discussions. All discussions were audio-recorded, transcribed verbatim and analysed thematically guided by the theoretical framework. RESULTS: CHWs and community members reported high eagerness to participate in the programme. Whereas CHWs had implemented similar community programmes and cited health promotion as their role, community members looked forward to health services being brought nearer to them. Although the intervention was preventive in nature, CHWs and community members expressed high interest in treatments for risk factors and were skeptical about the health system capacity to deliver them. CHWs anticipated barriers in mobilising communities who they said sometimes may not be cooperative while community members were concerned about failing to access treatment and support services after screening for risk factors. The major cost to CHWs and community members for engaging in the intervention was time that they would have dedicated to income generating activities and social events though CHWs also had the extra burden of being exemplary. CHWs were confident in their ability to deliver the intervention as prescribed if well trained, supported and supervised, and community members felt that if provided sufficient information and supported by CHWs, they could change their behaviours. CONCLUSIONS: The community CVD prevention programme was highly acceptable among CHWs and community members in Mukono and Buikwe districts of Uganda amidst a few burdens and opportunity costs. Suggestions made by study participants to improve programme effectiveness informed programme design and implementation for impact.

Integration of nurses in general practice: A thematic synthesis of the perspectives of general practitioners, practice nurses and patients living with chronic illness.

AIMS AND OBJECTIVES: To explore the views of general practitioners, practice nurses and patients on interprofessional collaboration in general practice and to understand to what extent the nurse-doctor relationship meets their needs and expectations. BACKGROUND: To address future challenges of primary health care, there is a need for integrated interprofessional collaboration care systems with a patient-centred focus. Worldwide, there is an integration of nurses in general practice. However, in a transitioning Belgian context little is known about the perspectives of three key stakeholder groups. DESIGN: The results of four qualitative descriptive primary studies were triangulated and a secondary analysis resulted in a thematic synthesis within a pragmatic research paradigm. METHODS: Primary data were collected through individual, semi-structured interviews with 7 general practitioners, 19 practice nurses and 21 patients living with chronic illness in 26 primary care centres with different nurse integration levels. We conducted a secondary analysis for the thematic synthesis of the different stakeholders' perspectives. This study was reported in accordance with the COREQ checklist. RESULTS: Four overarching themes were found as follows: vision and mission at general practice level, patient-centred care, practice nurse role development and interprofessional collaboration. Interprofessional collaboration within general practice ensures better response to patient needs. Evolution of the practice nurse role to autonomous decision-making can be facilitated by clear vision and mission, team communication, complementarity of responsibilities and trust-based professional relationships. CONCLUSIONS: The key for patient-centred care in a well-organised practice is a clear vision and mission and well-defined task description for interprofessional collaboration. General practice is urging for systematic guidance for the sustainable integration of a practice nurse. RELEVANCE TO CLINICAL PRACTICE: Our study highlights opportunities and challenges to nurse integration in general practice from key stakeholders' perspectives, which can inform other transitioning contexts.

An implementation science study to enhance cardiovascular disease prevention in Mukono and Buikwe districts in Uganda: a stepped-wedge design.

BACKGROUND: Uganda is experiencing a shift in major causes of death with cases of stroke, heart attack, and heart failure reportedly on the rise. In a study in Mukono and Buikwe in Uganda, more than one in four adults were reportedly hypertensive. Moreover, very few (36.5%) reported to have ever had a blood pressure measurement. The rising burden of CVD is compounded by a lack of integrated primary health care for early detection and treatment of people with increased risk. Many people have less access to effective and equitable health care services which respond to their needs. Capacity gaps in human resources, equipment, and drug supply, and laboratory capabilities are evident. Prevention of risk factors for CVD and provision of effective and affordable treatment to those who require it prevent disability and death and improve quality of life. The aim of this study is to improve health profiles for people with intermediate and high risk factors for CVD at the community and health facility levels. The implementation process and effectiveness of interventions will be evaluated. METHODS: The overall study is a type 2-hybrid stepped-wedge (SW) design. The design employs mixed methods evaluations with incremental execution and adaptation. Sequential crossover take place from control to intervention until all are exposed. The study will take place in Mukono and Buikwe districts in Uganda, home to more than 1,000,000 people at the community and primary healthcare facility levels. The study evaluation will be guided by; 1) RE-AIM an evaluation framework and 2) the CFIR a determinant framework. The primary outcomes are implementation - acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, coverage, and sustainability. DISCUSSION: The study is envisioned to provide important insight into barriers and facilitators of scaling up CVD prevention in a low income context. This project is registered at the ISRCTN Registry with number ISRCTN15848572. The trial was first registered on 03/01/2019.

Talking to the people that really matter about their participation in pandemic clinical research: A qualitative study in four European countries.

BACKGROUND: Pandemics of new and emerging infectious diseases are unpredictable, recurrent events that rapidly threaten global health and security. We aimed to identify public views regarding provision of information and consent to participate in primary and critical care clinical research during a future influenza-like illness pandemic. METHODS: Descriptive-interpretive qualitative study, using focus groups (n = 10) and semi-structured interviews (n = 16), with 80 members of the public (>18 years) in Belgium, Spain, Poland and the UK. Local qualitative researchers followed a scenario-based topic guide to collect data. Data were transcribed verbatim, translated into English and subject to framework analysis. RESULTS: Public understandings of pandemics were shaped by personal factors (illness during the previous H1N1 pandemic, experience of life-threatening illness) and social factors (historical references, media, public health information). Informants appreciated safeguards provided by ethically robust research procedures, but current enrolment procedures were seen as a barrier. They proposed simplified enrolment processes for higher risk research and consent waiver for certain types of low-risk research. Decision making about research participation was influenced by contextual, research and personal factors. Informants generally either carefully weighed up various approaches to research participation or responded instinctively. They supported the principle of using routinely collected, anonymized clinical biological samples for research without explicit consent, but regarded this as less acceptable if researchers were motivated primarily by commercial gain. CONCLUSIONS: This bottom-up approach to ascertaining public views on pandemic clinical research has identified support for more proportionate research protection procedures for publically funded, low-risk studies.

Interventions for improving management of chronic non-communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa.

BACKGROUND: Chronic disease management (CDM) is an approach to health care that keeps people as healthy as possible through the prevention, early detection and management of chronic diseases. The aim of this study was to develop interventions to improve management of chronic diseases in the form of an integrated, evidence-based chronic disease management model in Dikgale, a rural area of Limpopo Province in South Africa. METHODS: A multifaceted intervention, called 'quality circles' (QCs) was developed to improve the quality and the management of chronic diseases in the Dikgale Health and Demographic Surveillance System (HDSS). These QCs used the findings from previous studies which formed part of the larger project in the study area, namely, the quantitative study using STEPwise survey and qualitative studies using focus group discussions and semi-structured interviews. RESULTS: The findings from previous studies in Dikgale HDSS revealed that an epidemiological transition is occurring. Again, the most widely reported barriers from previous studies in this rural area were: lack of knowledge of NCDs; shortages of medication and shortages of nurses in the clinics, which results in patients having long waiting-time at clinics. Lack of training of health care providers on the management of chronic diseases and the lack of supervision by the district and provincial health managers, together with poor dissemination of guidelines, were contributing factors to the lack of knowledge of non-communicable diseases (NCDs) management among nurses and community health care workers (CHWs). Consideration of all of these findings led to the development of model which focuses on integrating nursing services, CHWs and traditional health practitioners (THPs), including a well-established clinical information system for health care providers. A novel aspect of the model is the inclusion of community ambassadors who are on treatment for NCDs and are, thus, repositories of knowledge who can serve as a bridge between health care workers and community members. CONCLUSION: The model developed highlights the need for health interventions that aim to control risk factors at the population level, the need for availability of NCD-trained nurses, functional equipment and medication and a need to improve the link with traditional healers.

Living in a nursing home: a phenomenological study exploring residents' loneliness and other feelings.

BACKGROUND: Loneliness is suggested to be one of the most prominent feelings nursing home residents are struggling with, and is related to various negative health outcomes and impaired quality of life. While there has been some research on social predictors and the impact of depression and loneliness on social relationships in nursing home residents, there has been very little qualitative research in investigating their own perception of such feelings. OBJECTIVE: To explore general feelings among nursing home residents, with a specific interest in loneliness in order to develop strategies for support and relief. METHOD: This phenomenological study used an interview guide with open-ended questions to ensure focused in-depth data collection. Data were obtained through face-to-face interviews (n = 11). Interpretative phenomenological analysis was used for data analyses. RESULTS: Loneliness is more than being alone among others. The residents' unfulfilled need for meaningful relationships plays a crucial role in feelings of loneliness. Losing their self-determination due to institutionalisation was strongly related to loneliness and caused strong emotions, such as grief. CONCLUSION: It is vital that healthcare professionals are aware of these feelings and pay much attention to resident preferences while developing (individualised) interventions to prevent loneliness.