HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies.

To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.

Challenges in the retrospective assessment of trauma: comparing a checklist approach to a single item trauma experience screening question.

BACKGROUND: Research on trauma and its impact on mental health typically relies on self-reports which can be influenced by recall bias and an individual's subjective interpretation of events. This study aims to compare responses on a checklist of life events with a trauma experience screening question, both of which assessed trauma experience retrospectively. METHODS: A community sample of adults were asked about life events from a checklist before asking them whether they ever had a trauma experience, i.e. "an event that either puts them or someone close to them at risk of serious harm or death". RESULTS: Less than half of the sample who reported at least one life event on the checklist that qualified as a trauma reported a trauma experience that they perceived put them or close others at risk of serious harm. Women responders, those reporting early life traumas, and a greater number of lifetime trauma events were more likely to report a trauma experience. Current symptoms of Common Mental Disorder did not account for differences in reporting of trauma experiences. CONCLUSIONS: Epidemiological approaches which require participants to make subjective judgement on the severity of the trauma experience will capture individual differences that we have shown are influenced by gender and previous trauma experience.

Validation of the standardised assessment of personality--abbreviated scale in a general population sample.

BACKGROUND: Personality disorder (PD) is associated with important health outcomes in the general population. However, the length of diagnostic interviews poses a significant barrier to obtaining large scale, population-based data on PD. A brief screen for the identification of people at high risk of PD in the general population could be extremely valuable for both clinicians and researchers. AIM: We set out to validate the Standardised Assessment of Personality - Abbreviated Scale (SAPAS), in a general population sample, using the Structured Clinical Interviews for DSM-IV Personality Disorders (SCID-II) as a gold standard. METHOD: One hundred and ten randomly selected, community-dwelling adults were administered the SAPAS screening interview. The SCID-II was subsequently administered by a clinical interviewer blind to the initial SAPAS score. Receiver operating characteristic analysis was used to assess the discriminatory performance of the SAPAS, relative to the SCID-II. RESULTS: Area under the curve for the SAPAS was 0.70 (95% CI = 0.60 to 0.80; p < 0.001), indicating moderate overall discriminatory accuracy. A cut point score of 4 on the SAPAS correctly classified 58% of participants. At this cut point, the sensitivity and specificity were 0.69 and 0.53 respectively. CONCLUSION: The SAPAS operates less efficiently as a screen in general population samples and is probably most usefully applied in clinical populations.

Challenges in researching migration status, health and health service use: an intersectional analysis of a South London community.

OBJECTIVES: This study aimed to investigate the associations between migration status and health-related outcomes and to examine whether and how the effect of migration status changes when it is disaggregated by length of residence, first language, reason for migration and combined with ethnicity. DESIGN: A total of 1698 adults were interviewed from 1076 randomly selected households in two South London boroughs. We described the socio-demographic and socio-economic differences between migrants and non-migrants and compared the prevalence of health-related outcomes by migration status, length of residence, first language, reason for migration and migration status within ethnic groups. Unadjusted models and models adjusted for socio-demographic and socio-economic indicators are presented. RESULTS: Migrants were disadvantaged in terms of socio-economic status but few differences were found between migrant and non-migrants regarding health or health service use indicators; migration status was associated with decreased hazardous alcohol use, functional limitations due to poor mental health and not being registered with a general practitioner. Important differences emerged when migration status was disaggregated by length of residence in the UK, first language, reason for migration and intersected with ethnicity. The association between migration status and functional limitations due to poor mental health was only seen in White migrants, migrants whose first language was not English and migrants who had moved to the UK for work or a better life or for asylum or political reasons. There was no association between migration status and self-rated health overall, but Black African migrants had decreased odds for reporting poor health compared to their non-migrant counterparts [odds ratio = 0.15 (0.05-0.48), p < 0.01]. CONCLUSIONS: Disaggregating migration status by length of residence, first language and reason for migration as well as intersecting it with ethnicity leads to better understanding of the effect migration status has on health and health service use.

Comparisons of polydrug use at national and inner city levels in England: associations with demographic and socioeconomic factors.

PURPOSE: This study compares polydrug use in national and inner city samples to (1) examine patterns of use underlying different prevalence rates and (2) identify how inner city polydrug use needs targeting in ways not suggested by national research. METHODS: Latent class analyses on indicators of illicit drug use in the last year, hazardous alcohol use, and cigarette smoking were compared between the inner city 2008-2010 South East London Community Health study (n = 1698) and the nationally representative 2007 Adult Psychiatric Morbidity Survey in England (n = 7403). Multinomial logistic regressions then examined latent class solutions with demographic and socioeconomic factors. RESULTS: Both samples revealed three notably similar classes of polydrug users: a "high-drug" group using multiple substances; a "moderate-drug" group using cannabis, alcohol, and cigarettes; and a "low-drug" group reporting minimal alcohol and cigarette use. However, South East London Community Health reported lower risks of polydrug use for ethnic minorities but not for more educated participants. CONCLUSIONS: Despite higher polydrug use prevalence in the inner city, latent classes of polydrug users were similar between samples. Some demographic and socioeconomic factors differed between the samples, suggesting the need for inner city services to use both local and national data for policy planning.

Identifying socio-demographic and socioeconomic determinants of health inequalities in a diverse London community: the South East London Community Health (SELCoH) study.

BACKGROUND: Responses to public health need require information on the distribution of mental and physical ill health by demographic and socioeconomic factors at the local community level. METHODS: The South East London Community Health (SELCoH) study is a community psychiatric and physical morbidity survey. Trained interviewers conducted face-to-face computer assisted interviews with 1698 adults aged 16 years and over, from 1076 randomly selected private households in two south London boroughs. We compared the prevalence of common mental disorders, hazardous alcohol use, long standing illness and general physical health by demographic and socioeconomic indicators. Unadjusted and models adjusted for demographic and socioeconomic indicators are presented for all logistic regression models. RESULTS: Of those in the sample, 24.2% reported common mental disorder and 44.9% reported having a long standing illness, with 15.7% reporting hazardous alcohol consumption and 19.2% rating their health as fair or poor. The pattern of indicators identifying health inequalities for common mental disorder, poor general health and having a long term illness is similar; individuals who are socioeconomically disadvantaged have poorer health and physical health worsens as age increases for all groups. The prevalence of poor health outcomes by ethnic group suggests that there are important differences between groups, particularly for common mental disorder and poor general health. Higher socioeconomic status was protective for common mental disorder, fair or poor health and long standing illness, but those with higher socioeconomic status reported higher levels of hazardous alcohol use. The proportion of participants who met the criteria for common mental disorder with co-occurring functional limitations was similar or greater to those with poor physical health. CONCLUSIONS: Health service providers and policy makers should prioritise high risk, socially defined groups in combating inequalities in individual and co-occurring poor mental and physical problems. In population terms, poor mental health has a similar or greater burden on functional impairment than long term conditions and perceived health.