The Ghana heart initiative - a health system strengthening approach as index intervention model to solving Ghana's cardiovascular disease burden.

Cardiovascular diseases (CVD) are the leading cause of death worldwide, with 80% of these deaths occurring in low-middle income countries (LMICs). In Ghana and across Africa, CVDs have emerged as the leading causes of death primarily due to undetected and under treated hypertension, yet less than 5% of resources allocated to health in these resource-poor countries go into non-communicable diseases (NCD) including CVD prevention and management. Consequently, most countries in Africa do not have contextually appropriate and sustainable health system framework to prevent, detect and manage CVD to achieve Universal Health Coverage (UHC) in CVD care through improved Primary Health Care (PHC) with the aim of achieving Sustainable Development Goals (SDG) in CVD/NCD. In view of this, the Ghana Heart Initiative (GHI) was envisaged as a national strategy to address the identified gaps using a health system and a population-based approach to reduce the national burden of CVDs. The GHI intervention includes the development of guidelines and training manuals; training, equipment support, establishment of a national call/support center, and improvement in the national data capturing system for CVDs and NCD, management of Hypertension, Deep Vein Thrombosis (DVT) and Heart Failure (HF). Following the implementation of the GHI concept, a national CVD Management Guideline was developed and 300-health facilities across the different levels of care including one teaching hospital, was also supported with basic life-saving equipment. In addition, more than 1,500 healthcare workers also reported improvement in their knowledge and skills in the management and treatment of CVD-related cases in their health facilities. These are key contributions to strengthening the health system for CVD care and learning lessons for scale up.

Interventions to improve the mental health or mental well-being of migrants and ethnic minority groups in Europe: A scoping review.

In Europe, migrants and ethnic minority groups are at greater risk for mental disorders compared to the general population. However, little is known about which interventions improve their mental health and well-being and about their underlying mechanisms that reduce existing mental health inequities. To fill this gap, the aim of this scoping review was to synthesise the available evidence on health promotion, prevention, and non-medical treatment interventions targeting migrants and ethnic minority populations. By mapping and synthesising the findings, including facilitators and barriers for intervention uptake, this scoping review provides valuable insights for developing future interventions. We used the PICo strategy and PRISMA guidelines to select peer-reviewed articles assessing studies on interventions. In total, we included 27 studies and synthesised the results based on the type of intervention, intervention mechanisms and outcomes, and barriers and facilitators to intervention uptake. We found that the selected studies implemented tailored interventions to reach these specific populations who are at risk due to structural inequities such as discrimination and racism, stigma associated with mental health, language barriers, and problems in accessing health care. The majority of interventions showed a positive effect on participants' mental health, indicating the importance of using a tailored approach. We identified three main successful mechanisms for intervention development and implementation: a sound theory-base, systematic adaption to make interventions culturally sensitive and participatory approaches. Moreover, this review indicates the need to holistically address social determinants of health through intersectoral programming to promote and improve mental health among migrants and ethnic minority populations. We identified current shortcomings and knowledge gaps within this field: rigorous intervention studies were scarce, there was a large diversity regarding migrant population groups and few studies evaluated the interventions' (cost-)effectiveness.

A multilevel and multicenter assessment of health care system capacity to manage cardiovascular diseases in Africa: a baseline study of the Ghana Heart Initiative.

INTRODUCTION: Cardiovascular diseases (CVD) remain the leading cause of death worldwide, with over 70% of these deaths occurring in low- and middle-income regions such as Africa. However, most countries in Africa do not have the capacity to manage CVD. The Ghana Heart Initiative has been an ongoing national program since 2018, aimed at improving CVD care and thus reducing the death rates of these diseases in Ghana. This study therefore aimed at assessing the impact of this initiative by identifying, at baseline, the gaps in the management of CVDs within the health system to develop robust measures to bolster CVD management and care in Ghana. METHODS: This study employed a cross-sectional study design and was conducted from November 2019 to March 2020 in 44 health facilities in the Greater Accra region. The assessment covered CVD management, equipment availability, knowledge of health workers in CVD and others including the CVD management support system, availability of CVD management guidelines and CVD/NCD indicators in the District Health Information Management System (DHIMS2). RESULTS: The baseline data showed a total of 85,612 outpatient attendants over the period in the study facilities, 70% were women and 364(0.4%) were newly diagnosed with hypertension. A total of 83% of the newly diagnosed hypertensives were put on treatment, 56.3% (171) continued treatment during the study period and less than 10% (5%) had their blood pressure controlled at the end of the study (in March 2020). Other gaps identified included suboptimal health worker knowledge in CVD management (mean score of 69.0 ± 13.0, p < 0.05), lack of equipment for prompt CVD emergency diagnosis, poor management and monitoring of CVD care across all levels of health care, lack of standardized protocol on CVD management, and limited number of indicators on CVD in the National Database (i.e., DHIMS2) for CVD monitoring. CONCLUSION: This study shows that there are gaps in CVD care and therefore, there is a need to address such gaps to improve the capacity of the health system to effectively manage CVDs in Ghana.

Digital health for all: How digital health could reduce inequality and increase universal health coverage.

Digital transformation in health care has a lot of opportunities to improve access and quality of care. However, in reality not all individuals and communities are benefiting equally from these innovations. People in vulnerable conditions, already in need of more care and support, are often not participating in digital health programs. Fortunately, numerous initiatives worldwide are committed to make digital health accessible to all citizens, stimulating the long-cherished global pursuit of universal health coverage. Unfortunately initiatives are not always familiar with each other and miss connection to jointly make a significant positive impact. To reach universal health coverage via digital health it is necessary to facilitate mutual knowledge exchange, both globally and locally, to link initiatives and apply academic knowledge into practice. This will support policymakers, health care providers and other stakeholders to ensure that digital innovations can increase access to care for everyone, leading towards Digital health for all.

Assessing the Readiness to Provide Integrated Management of Cardiovascular Diseases and Type 2 Diabetes in Kenya: Results from a National Survey.

Introduction: Integrated chronic disease management is the desired core function of a responsive healthcare system. However, many challenges surround its implementation in Sub-Saharan Africa. The current study assessed the readiness of healthcare facilities to provide integrated management of cardiovascular diseases (CVDs) and type 2 diabetes in Kenya. Methods: We used data from a nationally representative cross-sectional survey of 258 public and private health facilities conducted in Kenya between 2019 and 2020. Data were collected using a standardised facility assessment questionnaire and observation checklists modified from the World Health Organization Package of Essential Non-communicable Diseases. The primary outcome was the readiness to provide integrated care for CVDs and diabetes-defined as the mean availability of tracer items comprising trained staff and clinical guidelines, diagnostic equipment, essential medicines, diagnosis, treatment and follow-up. A cut-off threshold of ≥70% was used to classify facilities as 'ready'. Gardner-Altman plots and modified Poisson regression were used to examine the facility characteristics associated with care integration readiness. Results: Of the surveyed facilities, only a quarter (24.1%) were ready to provide integrated care for CVDs and type 2 diabetes. Care integration readiness was lower in public versus private facilities [aPR = 0.6; 95% CI 0.4 to 0.9], and primary healthcare facilities were less likely to be ready compared to hospitals [aPR = 0.2; 95% CI 0.1 to 0.4]. Facilities located in Central Kenya [aPR = 0.3; 95% CI 0.1 to 0.9], and the Rift Valley region [aPR = 0.4; 95% CI 0.1 to 0.9], were less likely to be ready compared to the capital Nairobi. Conclusions: There are gaps in the readiness of healthcare facilities particularly primary healthcare facilities in Kenya to provide integrated care services for CVDs and diabetes. Our findings inform the review of current supply-side interventions for integrated management of CVDs and type 2 diabetes, especially in lower-level public health facilities in Kenya.

Family participation to enhance care and tackle health worker shortages in resource-limited hospitals: A systematic review.

Background: A growing global shortage of health workers is limiting access to health care, especially in resource-limited countries. Family participation in hospital care could enhance care while tackling health worker shortages. With the same resources, it might deliver additional and more personalised care. This review assessed the effect and safety of family participation interventions in the care of hospitalised adults in resource-limited settings and, ultimately, if it is a viable strategy to tackle health worker shortages. Methods: For this systematic review, Medline, Embase, CINAHL and the Global Health Library were searched from inception till April 7, 2022. Clinical studies were included if they described a family participation intervention for hospitalised adults, were performed in a low- or middle-income country and reported on a patient-related outcome. Data were collected on patient, family, staff and health service-related outcomes. Risk of bias was assessed with the ROB2 and ROBINS-I tool. Results: From 4444 studies, six were included for narrative synthesis, with a total of 1794 participants. Four studies were performed in Asia and two in Africa; all were published between 2017 and 2022. In-hospital family participation interventions aimed at medication administration and adherence, delirium prevention, and palliative cancer care were successful in significantly improving patient outcomes. Involving family in post-stroke rehabilitation interventions showed no significant effect on mortality and long-term disability. Few data were reported on participating family members' outcomes or hospital staffing issues. None of the included studies showed harm from family participation. Conclusions: The limited data suggest that family participation can be effective and safe in specific contexts. However, more research is needed to determine the effect of family participation and justify further implementation. Family participation research for enhancing care while tackling health worker shortages should be a collaborative priority of researchers, health care professionals, funding agencies and policymakers. Registration: PROSPERO registration No. CRD42020205878.

The Africa Food Environment Research Network (FERN): from concept to practice.

BACKGROUND: Africa is contending with unhealthy food environments that are, in part, driving increasing rates of overweight, obesity and diet-related non-communicable diseases, alongside persistent undernutrition. This current paradigm requires expanded efforts - both in the volume and nature of empirical research, as well as the tools and capacity of those who conduct it. High quality and context-relevant research supports the development and implementation of policies that create healthy food environments. AIM AND APPROACH: This paper sets out the concept of the Africa Food Environment Research Network (FERN) initiative recently established by the Measurement, Evaluation, Accountability, and Leadership Support for non-communicable diseases (NCDs) (MEALS4NCDs) prevention project. Central to the Africa FERN initiative are: 1) building research capacity for innovative food environment research in Africa; 2) improving South-South, South-North partnerships to stimulate robust food environment research and monitoring in Africa and 3) sustaining dialogue and focusing priorities around current and future needs for enhanced food environment research and monitoring in Africa. CONCLUSION: The FERN initiative presents an opportune platform for researchers in Africa and the global North to weave the threads of experience and expertise for research capacity building, collaboration and advocacy, to advance food environment research.

Inequalities in COVID-19 deaths by migration background during the first wave, interwave period and second wave of the COVID-19 pandemic: a closed cohort study of 17 million inhabitants of the Netherlands.

BACKGROUND: It is not known how differences in COVID-19 deaths by migration background in the Netherlands evolved throughout the pandemic, especially after introduction of COVID-19 prevention measures targeted at populations with a migration background (in the second wave). We investigated associations between migration background and COVID-19 deaths across first wave of the pandemic, interwave period and second wave in the Netherlands. METHODS: We obtained multiple registry data from Statistics Netherlands spanning from 1 March 2020 to 14 March 2021 comprising 17.4 million inhabitants. We estimated incidence rate ratios for COVID-19 deaths by migration background using Poisson regression models and adjusted for relevant sociodemographic factors. RESULTS: Populations with a migration background, especially those with Turkish, Moroccan and Surinamese background, exhibited higher risk of COVID-19 deaths than the Dutch origin population throughout the study periods. The elevated risk of COVID-19 deaths among populations with a migration background (as compared with Dutch origin population) was around 30% higher in the second wave than in the first wave. CONCLUSIONS: Differences in COVID-19 deaths by migration background persisted in the second wave despite introduction of COVID-19 prevention measures targeted at populations with a migration background in the second wave. Research on explanatory mechanisms and novel prevention measures are needed to address the ongoing differences in COVID-19 deaths by migration background.

Ethnic differences in functional limitations: a comparison of older migrants and native Dutch older population.

BACKGROUND: Although the older migrants population in Europe is expected to grow substantially in the coming years, there is little information about their health status and particularly functional limitations. This study examined the association of ethnicity and mobility, hearing and visual limitations in comparison to the general population in the Netherlands, and whether relevant characteristics explained the potential differences between older migrants and non-migrants. METHODS: Secondary data analysis of 12 652 subjects 55 years and older who participated in the health survey in the four largest Dutch cities. To establish limitations in vision, hearing and mobility, the Organization for Economic Co-operation and Development (OECD) questionnaire was used. Logistic regression analysis was used to examine the association between limitations and ethnic background, subsequently adjusting for demographic and socio-economic characteristics and relevant health- and lifestyle-related factors. RESULTS: Older migrants had higher prevalences of functional limitations. The age- and- gender adjusted ORs were 2 to 8-fold compared with older non-migrants. After adjusting for socioeconomic status and health-and lifestyle indicators, Moroccan, Turkish and Surinamese migrants still had increased ORs for visual limitations [ORs (95% CI), respectively: 2.48 (1.49-4.14), 3.08 (1.75-5.41) and 1.97 (1.33-2.91)] compared with the Dutch. For mobility limitations, only the Turkish migrants had an OR twice as high (2.19; 1.08-4.44) as the non-migrants. No significant differences were found between Antillean/Aruban migrants and non-migrants. CONCLUSIONS: Important ethnic inequalities exist in various functional limitations, particularly in vision. These results underline the importance of tailored preventive interventions in older migrants to detect and prevent these limitations at an early stage.

Contextual factors that shape uptake of COVID-19 preventive measures by persons of Ghanaian and Eritrean origin in the Netherlands: A focus group study.

OBJECTIVES: To explore the contextual factors that shape uptake of COVID-19 preventive measures, in specific migrant and ethnic minority populations, with a focus on migration-related, sociocultural and socioeconomic conditions. DESIGN: A qualitative design, consisting of three online focus group discussions. SETTING: This study was conducted amongst smaller, albeit substantial, migrant and minority ethnic populations in the Netherlands. PARTICIPANTS: A total of 25 participants (12 male; 13 female) of Ghanaian and Eritrean origin, purposively sampled to ensure diversity within groups, with regards to sex, age, educational level, occupation, household size and length of stay in the Netherlands. Focus group discussions were held online, therefore, experience in the use of video conferencing software was a prerequisite. RESULTS: Participants' awareness and knowledge of COVID-19 and COVID-19 preventive measures was shaped by migration-related factors, such as limited Dutch proficiency, by access to understandable information and interference of misinformation. Participants' engagement by COVID-19 preventive measures was subject to COVID-19 threat appraisal and the ease with which complex behavioural messages could be translated to individual situations. Lastly, a strong social norm to keep with cultural and religious practices, and limited opportunity for preventive behaviour in the work and home context hinder the uptake of preventive behaviour following a decision to act according to measures. CONCLUSIONS: Migration-related, sociocultural, and socioeconomic factors shape uptake of COVID-19 preventive measures amongst persons of Ghanaian and Eritrean origin in The Netherlands. To ensure equitable uptake our results suggest the importance of timely spread of multilingual information tailored to literacy needs; as well as, education and modelling delivered through online platforms and by leading figures in respective communities; and, regulations to ensure continued access to financial and material resources to minimise negative spill-over effects and exacerbation of inequality.

[Distinguishing people by ethnic background in healthcare]. / Onderscheid naar etnische afkomst.

Discrimination based on ethnic background and the use of terminology like 'Negro Race' in clinical practice guidelines have been criticized, also in this journal. Typical Dutch words 'allochtonen', 'non-western', 'Creools' and 'Hindostan' are unspecific or could also offend people. Nevertheless, there are health risks related to ethnic background. Healthcare improves when health professionals would consider these, contributing to person centred cultural sensitive care. Therefore, we aimed to start a discussion about which acceptable terminologies should be used to describe ethnic differences in guidelines and research. We suggest that terminologies use to describe ethnic minority groups should be as precise as possible and should not be offensive, for instance 'migration background' instead of allochtoon, and 'African-Surinamese' instead of Creool. We invite guideline developers, researchers and people of different ethnic background, to join this discussion.

Migration, ethnicity, racism and the COVID-19 pandemic: A conference marking the launch of a new Global Society.

The inaugural conference of the Global Society on Migration, Ethnicity, Race and Health COVID-19 examined the impact of the COVID-19 pandemic on migrants and ethnic minorities and the role of racism. Migrants everywhere have faced tightening immigration restrictions, more obstacles to healthcare, increased racism and worsening poverty. Higher COVID-19 mortality rates have been otbserved in ethnic/racial minorities in the United Kingdom and the United States. Structural racism has been implicated, operating, for example, through more crowded living conditions and higher-risk occupations. In Brazil, good data are lacking but a seroprevalence survey suggested higher rates of infection among ethnic minorities and slum dwellers. Considerable disruption of services for migrants at the border with Venezuela have occurred. National policy responses to protect vulnerable groups have been lacking. In Australia, with strict COVID-19 control metrtrun 0asures and inclusive policies, there have been few cases and deaths reported in Indigenous communities so far. In most countries, the lack of COVID-19 data by ethnic/racial group or migrant status should be addressed. Otherwise, racism and consequent inequalities will go undetected.

The Multifaceted Pathways Linking Populism to Ethnic Minority Health Comment on "A Scoping Review of Populist Radical Right Parties' Influence on Welfare Policy and its Implications for Population Health in Europe".

Based on a scoping review of empirical studies accompanied by interviews with experts, Rinaldi and Bekker studied the impact of populist radical right (PRR) parties on access to welfare provisions - the latter standing proxy for population health and for health inequalities in particular. We argue that populism can impact on migrant and ethnic minority health in multiple ways, in addition to the welfare mechanism specified in that review. These include institutionalised discrimination affecting individuals' positions in the social hierarchy, experiences of discrimination in interpersonal relationships, and a weakened legitimacy of health policies. Interdisciplinary teams that include public health scholars and political scientists should take up the challenge of understanding migrant and ethnic minority health from a systems perspective.

Access to oral health care for undocumented migrants: Perspectives of actors involved in a voluntary dental network in the Netherlands.

OBJECTIVE: Undocumented migrants in Europe face multiple barriers in access to oral health care. This study aimed to explore the accessibility of a voluntary dental network providing dental treatments to undocumented migrants in the Netherlands, from the perspectives of patients, dentists and staff members of nongovernmental organizations involved. METHODS: This qualitative study used semi-structured interviews (n = 21) with undocumented migrants (n = 12), dentists (n = 7) and staff members of nongovernmental organizations (n = 2) during the implementation of a voluntary dental network. Interviews were analysed using a framework analysis method. RESULTS: As a temporary answer to problems in access to oral health for undocumented migrants, the voluntary dental network targeted initial barriers to dental care. Main challenges within the network were conflicting expectations and perceived treatment outcomes by patients, dentist and NGO staff members, limited financial resources, logistic and communication barriers and an increasing administrative burden. Furthermore, feelings of compassion for and trust of the patient affected the ethics of the professional relationship and influenced treatment decisions of dentists. CONCLUSION: Through the implementation of a voluntary dental network, treatments could be provided to undocumented migrants as a temporary solution. However, the voluntary nature of dental care in the network resulted in a fragmented provision of oral health care among undocumented migrants. To reduce inequalities in oral health on the long term, systemic barriers in access to oral health care need to be addressed.

Healthcare Utilisation of Moluccans in the Netherlands: Equal Care for Equal Need after 60 Years of Residence in the Host Country?

BACKGROUND: In many countries, recent migrants have difficulties using healthcare to the same extent as host populations. It is uncertain whether these differences persist for long-settled migrants. This study examined healthcare utilisation of Moluccans in 2012, more than 60 years after they migrated from Indonesia to the Netherlands. METHODS: A survey was held among 715 Moluccans and 3417 Dutch persons. Differences in healthcare utilisation were assessed using regression analyses adjusting for age, gender, indicators of health, religious affiliation, and education. RESULTS: Moluccans had lower rates of healthcare use, including visits to the general practitioner (odds ratio (OR) = 0.67), outpatient medical specialist (OR = 0.50), dentist (OR = 0.65), and physiotherapist (OR = 0.56), as well as the use of paid housekeeping services (OR = 0.37). Among those who visited a healthcare service, no difference was found between Moluccans and Dutch in the frequency of visits, except for physiotherapist visits (rate ratio (RR) = 0.51). For the risk of hospitalisation, no difference was found; however, of those admitted to the hospital, the frequency of admission was lower among Moluccans than Dutch (RR = 0.74). CONCLUSIONS: Despite their long residence in the host country, equal utilisation of healthcare services has not been achieved for Moluccans in the Netherlands. Demand-based factors (e.g., family networks, health beliefs, and use of traditional medicine) may contribute to the persistence of such differences and require further investigation.

The Upcoming Epidemic of Heart Failure in South Asia.

Currently, South Asia accounts for a quarter of the world population, yet it already claims ≈60% of the global burden of heart disease. Besides the epidemics of type 2 diabetes mellitus and coronary heart disease already faced by South Asian countries, recent studies suggest that South Asians may also be at an increased risk of heart failure (HF), and that it presents at earlier ages than in most other racial/ethnic groups. Although a frequently underrecognized threat, an eventual HF epidemic in the densely populated South Asian nations could have dramatic health, social and economic consequences, and urgent interventions are needed to flatten the curve of HF in South Asia. In this review, we discuss recent studies portraying these trends, and describe the mechanisms that may explain an increased risk of premature HF in South Asians compared with other groups, with a special focus on highly relevant features in South Asian populations including premature coronary heart disease, early type 2 diabetes mellitus, ubiquitous abdominal obesity, exposure to the world's highest levels of air pollution, highly prevalent pretransition forms of HF such as rheumatic heart disease, and underdevelopment of healthcare systems. Other rising lifestyle-related risk factors such as use of tobacco products, hypertension, and general obesity are also discussed. We evaluate the prognosis of HF in South Asian countries and the implications of an anticipated HF epidemic. Finally, we discuss proposed interventions aimed at curbing these adverse trends, management approaches that can improve the prognosis of prevalent HF in South Asian countries, and research gaps in this important field.

Indirect implications of COVID-19 prevention strategies on non-communicable diseases : An Opinion Paper of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk Assessment in Subjects Living in or Emigrating from Low Resource Settings.

BACKGROUND: After its outbreak in China, the novel COronaVIrus Disease 19 is spreading across the globe. It is an emergency the world has never seen before. MAIN TEXT: The attention of health systems is mainly focused on COronaVIrus Disease 19 patients and on the risk that intensive care units might be overwhelmed by the serious pulmonary complications. Different countries are also attempting to establish infection prevention and control strategies which proved effective in China where the outbreak was initially reported. We reflect on important lessons to be learnt from different countries. The effects that infection prevention and control strategies, such as social distancing or isolation, can have on the care of millions of patients with non-communicable diseases, who may be indirectly affected, have not been taken into consideration so much. CONCLUSIONS: When dealing with COronaVIrus Disease 19, policy makers and healthcare personnel should consider the indirect effects on the treatment of non-communicable diseases.

Early-life factors are associated with waist circumference and type 2 diabetes among Ghanaian adults: The RODAM Study.

Early-life experiences may fuel the emergence of obesity and type 2 diabetes among African populations. We evaluated childhood socio-economic status (SES) and childhood nutritional status as risk factors for increased waist circumference and type 2 diabetes among Ghanaian adults. In the multi-center, cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) Study, we calculated associations (adjusted for demographics and lifestyle) of parental education and anthropometric markers of childhood nutrition [leg length, leg length-to-height ratio (LHR)] with waist circumference and type 2 diabetes, respectively. Among 5,575 participants (mean age: 46.2 years; 62% female), lower education of either parent (vs. higher) was consistently associated with higher waist circumference (∆: 1.6-3.4 cm). Lower father's education tended to increase the odds of type 2 diabetes by 50% in women (95% confidence interval (CI): 1.0, 2.4). Reduced leg length and LHR were associated with higher waist circumference. But only in men, leg length was inversely related to type 2 diabetes (OR per 1 standard deviation decrease: 1.1; 95% CI: 1.0, 1.3). In this study, markers of poor childhood SES and early-life nutritional status relate to abdominal obesity in men and women and to type 2 diabetes in men. Thus, prevention efforts should start in early childhood.