Protocol for a pragmatic cluster randomised controlled trial to evaluate the effectiveness of digital health interventions in improving non-communicable disease management during the pandemic in rural Pakistan.

BACKGROUND: The COVID-19 pandemic has revealed gaps in global health systems, especially in the low- and middle-income countries (LMICs). Evidence shows that patients with non-communicable diseases (NCDs) are at higher risk of contracting COVID-19 and suffering direct and indirect health consequences. Considering the future challenges such as environmental disasters and pandemics to the LMICs health systems, digital health interventions (DHI) are well poised to strengthen health care resilience. This study aims to implement and evaluate a comprehensive package of DHIs of integrated COVID-NCD care to manage NCDs in primary care facilities in rural Pakistan. METHODS: The study is designed as a pragmatic, parallel two-arm, multi-centre, mix-methods cluster randomised controlled trial. We will randomise 30 primary care facilities in three districts of Punjab, where basic hypertension and diabetes diagnosis and treatment are provided, with a ratio of 1:1 between intervention and control. In each facility, we will recruit 50 patients who have uncontrolled hypertension. The intervention arm will receive training on an integrated COVID-NCD guideline, and will use a smartphone app-based telemedicine platform where patients can communicate with health providers and peer-supporters, along with a remote training and supervision system. Usual care will be provided in the control arm. Patients will be followed up for 10 months. Our primary indicator is systolic blood pressure measured at 10 months. A process evaluation guided by implementation science frameworks will be conducted to explore implementation questions. A cost-effectiveness evaluation will be conducted to inform future scale up in Pakistan and other LMICs. DISCUSSION: Our study is one of the first randomised controlled trials to evaluate the effectiveness of DHIs to manage NCDs to strengthen health system resilience in LMICs. We will also evaluate the implementation process and cost-effectiveness to inform future scale-up in similar resource constrained settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier-NCT05699369.

Sociodemographic factors associated with concurrent stunting and wasting among children experiencing extreme poverty in the Philippines: A cross-sectional study.

Background: The coexistence of stunting and wasting in a child increases the risk of mortality and requires more intensive treatment and care. However, there is limited research on the burden of concurrent stunting and wasting among children and the socioeconomic factors that are correlated with having both conditions. Aim: To understand the prevalence and sociodemographic correlates of stunting, wasting, and concurrent stunting and wasting among a sample of children ages 6-144 months experiencing poverty in the Philippines. Methods: Cross-sectional data were drawn from nutrition screening and sociodemographic surveys conducted by International Care Ministries in 2018-2019. Descriptive statistics were calculated to determine the prevalence of stunting, wasting, and concurrent stunting and wasting. Multilevel logistic regression modelling was conducted to understand the sociodemographic factors that were associated with stunting and wasting. Results: Among the 3005 children in this sample, the prevalence of stunting, wasting, and concurrent stunting and wasting was 49.9%, 9.3%, and 4.6%, respectively. Children experiencing concurrent stunting and wasting lived in households in lower wealth index quintiles, had a household head with fewer years of education, and were more likely to experience food insecurity compared to children who were not stunted or wasted. The education of the household head, the number of household members, and the wealth of the household were correlated with stunting across age groups, while food insecurity was correlated with wasting among younger children. Conclusion: The presence of concurrent stunting and wasting among children provides the impetus to integrate both conditions into nutrition monitoring, prevention, and treatment interventions.

Factors Associated with Seasonal Food Insecurity among Small-Scale Subsistence Farming Households in Rural Honduras.

In the context of climate change, a nutritional transition, and increased pressures to migrate internally and internationally, this study examined the relationship between seasonal food insecurity and demographic, socioeconomic, and agricultural production factors among small-scale subsistence farmers in rural northern Honduras. Anchored by a partnership with the Fundación para la Investigación Participativa con Agricultores de Honduras (FIPAH) and the Yorito Municipal Health Centre, a cross-sectional household survey was administered in Yorito, Honduras, in July 2014. The study population included 1263 individuals from 248 households across 22 rural communities. A multivariate mixed effects negative binomial regression model was built to investigate the relationship between the self-reported number of months without food availability and access from subsistence agriculture in the previous year (August 2013-July 2014) and demographic, socioeconomic, and agricultural production variables. This study found a lengthier 'lean season' among surveyed household than previously documented in Honduras. Overall, 62.2% (95% confidence interval (CI): [59.52, 64.87]) of individuals experienced at least four months of insufficient food in the previous year. Individuals from poorer and larger households were more likely to experience insufficient food compared to individuals from wealthier and smaller households. Additionally, individuals from households that produced both maize and beans were less likely to have insufficient food compared to individuals from households that did not grow these staple crops (prevalence ratio (PR) = 0.83; 95% CI: [0.69, 0.99]). Receiving remittances from a migrant family member did not significantly reduce the prevalence of having insufficient food. As unpredictable crop yields linked to climate change and extreme weather events are projected to negatively influence the food security and nutrition outcomes of rural populations, it is important to understand how demographic, socioeconomic, and agricultural production factors may modify the ability of individuals and households engaged in small-scale subsistence agriculture to respond to adverse shocks.