Rationale, Design and Baseline Characteristics of a Randomized Controlled Trial of a Cardiovascular Quality Improvement Strategy in India: The C-QIP Trial.

BACKGROUND: Quality of chronic care for cardiovascular disease (CVD) remains suboptimal worldwide. The Collaborative Quality ImProvement (C-QIP) trial aims to develop and test the feasibility and clinical effect of a multicomponent strategy among patients with prevalent CVD in India. METHODS: The C-QIP is a clinic-based, open randomized trial of a multicomponent intervention versus usual care that was locally developed and adapted for use in Indian settings through rigorous formative research guided by Consolidated Framework for Implementation Research (CFIR). The C-QIP intervention consisted of 5 components: 1) electronic health records and decision support system for clinicians, 2) trained non-physician health workers (NPHW), 3) text-message based lifestyle reminders, 4) patient education materials, 5) quarterly audit and feedback reports. Patients with CVD (ischemic heart disease, ischemic stroke, or heart failure) attending outpatient CVD clinics were recruited from September 2022 to September 2023 and were randomized to the intervention or usual care arm for at least 12 months follow-up. The co-primary outcomes are implementation feasibility, fidelity (i.e., dose delivered and dose received), acceptability, adoption and appropriateness, measured at multiple levels: patient, provider and clinic site-level, The secondary outcomes include prescription of guideline directed medical therapy (GDMT) (provider-level), and adherence to prescribed therapy, change in mean blood pressure (BP) and LDL-cholesterol between the intervention and control groups (patient-level). In addition, a trial-based process and economic evaluations will be performed using standard guidelines. RESULTS: We recruited 410 socio-demographically diverse patients with CVD from four hospitals in India. Mean (SD) age was 57.5 (11.7) years, and 73.0% were males. Self-reported history of hypertension (48.5%) and diabetes (41.5%) was common. At baseline, mean (SD) BP was 127.9 (18.2) /76.2 (11.6) mm Hg, mean (SD) LDLc: 80.3 (37.3) mg/dl and mean (SD) HbA1c: 6.8% (1.6%). At baseline, the GDMT varied from 62.4% for patients with ischemic heart disease, 48.6% for ischemic stroke and 36.1% for heart failure. CONCLUSION: This study will establish the feasibility of delivering contextually relevant, and evidence-based C-QIP strategy and assess whether it is acceptable to the target populations. The study results will inform a larger scale confirmatory trial of a comprehensive CVD care model in low-resource settings. TRIAL REGISTRATION: Clinical Trials Registry India: CTRI/2022/04/041847; Clinicaltrials.gov number: NCT05196659.

Patients as knowledge partners in the context of complex chronic conditions.

This article conveys how taking patient knowledge seriously can improve patient experience and further medical science. In clinical contexts related to infection-associated chronic conditions and other complex chronic illnesses, patient knowledge is often undervalued, even when clinicians have limited training in diagnosing and treating a particular condition. Despite growing acknowledgement of the importance of patients as 'stakeholders', clinicians and medical researchers have yet to fully develop ways to evaluate and, when appropriate, meaningfully incorporate patient knowledge-experiential, scientific, social scientific, historical or otherwise-into clinical practice and research. We argue that there are opportunities for clinicians and researchers to collaborate with patients and colleagues from the social sciences and humanities. We use two examples to demonstrate why patient knowledge should inform medical engagement with chronic and complex conditions. The first comes from a disability studies scholar who describes the social biases that can sideline patient expertise, and the second is from an anthropologist whose reading in medical humanities led to an effective treatment for her recovery. Rather than merely acknowledging 'lived experience', clinical and research teams should include patients with complex chronic conditions as 'knowledge partners'. These patients occupy unique and valuable epistemological positions, and their knowledge should be considered with as much openness and rigour as other forms of medical knowledge. As more medical schools, residency programmes and hospitals emphasise the need for 'deep listening' and patient input, we encourage meaningful engagement with patients whose insights can provide crucial knowledge for clinical and scientific advancement.

Rapid range shifts in African Anopheles mosquitoes over the last century.

Facing a warming climate, many tropical species-including the arthropod vectors of several infectious diseases-will be displaced to higher latitudes and elevations. These shifts are frequently projected for the future, but rarely documented in the present day. Here, we use one of the most comprehensive datasets ever compiled by medical entomologists to track the observed range limits of African malaria mosquito vectors (Anopheles spp.) from 1898 to 2016. Using a simple regression approach, we estimate that these species' ranges gained an average of 6.5 m of elevation per year, and the southern limits of their ranges moved polewards 4.7 km per year. These shifts would be consistent with the local velocity of recent climate change, and might help explain the incursion of malaria transmission into new areas over the past few decades. Confirming that climate change underlies these shifts, and applying similar methods to other disease vectors, are important directions for future research.

Perceptions and experiences of prostate cancer patients in a public tertiary hospital in urban South Africa.

ABSTRACTProstate cancer is among the most prevalent forms of cancer worldwide and is reported to have the highest incidence, mortality, and 5-year prevalence rate of all cancers among men living in Africa. Despite this widespread burden in the African continent, little is known about the perspectives and experience of prostate cancer among African men. To further understand experiences among patients living in urban South Africa, we conducted in-depth, semi-structured qualitative interviews to examine the perceptions and experiences of 28 Black African prostate cancer patients receiving treatment at a major tertiary hospital in Johannesburg, South Africa. Our data explored four major areas of patients' experiences with prostate cancer: detection, diagnosis, treatment, and follow-up care. Our results showed that the experience of living with prostate cancer among low-income, Black South African men is a stressful and emotionally painful experience due in part to men feeling that they had insufficient knowledge about their own condition and feeling disempowered or ill-equipped to manage their cancer. These feelings were strongly associated with distrust or dissatisfaction with physicians and the health care system. Resilience factors include social support from family, friends, and religious communities, acceptance of their diagnosis, religion, and positive appraisals of their medical care.

Evaluating the mental health impacts of the COVID-19 pandemic: perceived risk of COVID-19 infection and childhood trauma predict adult depressive symptoms in urban South Africa.

BACKGROUND: South Africa's national lockdown introduced serious threats to public mental health in a society where one in three individuals develops a psychiatric disorder during their life. We aimed to evaluate the mental health impacts of the COVID-19 pandemic using a mixed-methods design. METHODS: This longitudinal study drew from a preexisting sample of 957 adults living in Soweto, a major township near Johannesburg. Psychological assessments were administered across two waves between August 2019 and March 2020 and during the first 6 weeks of the lockdown (late March-early May 2020). Interviews on COVID-19 experiences were administered in the second wave. Multiple regression models examined relationships between perceived COVID-19 risk and depression. RESULTS: Full data on perceived COVID-19 risk, depression, and covariates were available in 221 adults. In total, 14.5% of adults were at risk for depression. Higher perceived COVID-19 risk predicted greater depressive symptoms (p < 0.001), particularly among adults with histories of childhood trauma, though this effect was marginally significant (p = 0.063). Adults were about two times more likely to experience significant depressive symptoms for every one unit increase in perceived COVID-19 risk (p = 0.021; 95% CI 1.10-3.39). Qualitative data identified potent experiences of anxiety, financial insecurity, fear of infection, and rumination. CONCLUSIONS: Higher perceived risk of COVID-19 infection is associated with greater depressive symptoms during the first 6 weeks of quarantine. High rates of severe mental illness and low availability of mental healthcare amidst COVID-19 emphasize the need for immediate and accessible psychological resources.

Understanding the "Sometimes Masker": Political Orientation and Trust in the Media During the COVID-19 Pandemic.

OBJECTIVES: The COVID-19 pandemic in the United States has brought to light the problematic way partisan politics interferes with public health prevention and control measures. This study aims to investigate how Americans responded to the novel coronavirus with respect to their sociopolitical identity and masking habits. STUDY DESIGN: This mixed-methods study incorporated three ethnographic projects and surveys together, from two rural areas (in Iowa and California) and one suburban community in California. METHODS: We interviewed 156 Americans about how masking habits related to six themes: participants' perceived risk level, concern for themselves and others, support for President Trump, trust in scientific organizations, and confidence in major news outlets. We conducted content analysis of qualitative interviews and evaluated survey questions to understand how and why people masked or engaged in public health prevention practices. RESULTS: Greater perceived risk, concern for others, and trust in health and media institutions was correlated with increased masking, while support for Trump was predictive of anti-masking sentiments. Participants who diverged from these trends, specifically those who sometimes wore masks, but not always were called "sometimes maskers". These sometimes maskers often identified as politically moderate and were more likely to mask due to concern for a vulnerable person or group in their lives. CONCLUSIONS: Since one in three Americans are political moderates, understanding what promotes their adherence to public health guidelines is essential for policy makers interested in pandemic containment. Relatedly, the conservative tendency to distrust mainstream media is what separated those who reported sometimes masking from those who reported always masking.

"Thinking Too Much": A Systematic Review of the Idiom of Distress in Sub-Saharan Africa.

Idioms of distress have been employed in psychological anthropology and global mental health to solicit localized understandings of suffering. The idiom "thinking too much" is employed in cultural settings worldwide to express feelings of emotional and cognitive disquiet with psychological, physical, and social consequences on people's well-being and daily functioning. This systematic review investigates how, where, and among whom the idiom "thinking too much" within varied Sub-Saharan African contexts was investigated. We reviewed eight databases and identified 60 articles, chapters, and books discussing "thinking too much" across Sub-Saharan Africa. Across 18 Sub-Saharan African countries, literature on "thinking too much" focused on particular sub-populations, including clinical populations, including people living with HIV or non-communicable diseases, and women experiencing perinatal or postnatal depression; health workers and caregivers; and non-clinical populations, including refugees and conflict-affected communities, as well as community samples with and without depression. "Thinking too much" reflected a broad range of personal, familial, and professional concerns that lead someone to be consumed with "too many thoughts." This research demonstrates that "thinking too much" is a useful idiom for understanding rumination and psychiatric distress while providing unique insights within cultural contexts that should not be overlooked when applied in clinical settings.

Perceptions, risk and understandings of the COVID-19 pandemic in urban South Africa.

BACKGROUND: How people perceive the coronavirus disease 2019 (COVID-19) pandemic and understand their risk can influence their health, behaviours and overall livelihood. The disease's novelty and severity have elicited a range of attitudes and perspectives countrywide, which consequently influence the public's adherence to public health prevention and treatment guidelines. AIM: To investigate perceptions, experiences and knowledge on COVID-19 in a community-based cohort study. SETTING: Adults living in Soweto in South Africa's Gauteng province during the first six weeks of the national lockdown regulations (i.e. Alert Level 5 lockdown from end of March to beginning of May 2020). METHODS: Participants completed a series of surveys and answered open-ended questions through telephonic interviews (n = 391). We queried their perceptions of the origins of COVID-19, understandings of the disease, personal and communal risks and its relations with the existing disease burden. RESULTS: Findings from our sample of 391 adults show that perceptions and knowledge of COVID-19 vary across several demographic characteristics. We report moderate levels of understanding about COVID-19, prevention methods and risk, as well as exposure to major physical, psychosocial and financial stressors. Depressive symptoms, perceived infection risk and concern about COVID-19 significantly predicted COVID-19 prevention knowledge. CONCLUSION: Public health communication campaigns should focus on continuing to improve knowledge and reduce misinformation associated with the virus. Policymakers should consider the mental health- and non-health-related impact of the pandemic on their citizens in order to curb the pandemic in a manner that maximises well-being.

Comorbid Suffering: Breast Cancer Survivors in South Africa.

Cycles of chronic illness are unpredictable, especially when multiple conditions are involved, and that instability can transform "normal" everyday life for individuals and their families. This article employs a theory of "comorbid suffering" to interpret how multiple concurrent diagnoses produce webs of remarkable suffering. We collected 50 life stories from breast cancer survivors enrolled in the South Africa Breast Cancer Study. We present three women's narratives who grapple with comorbid suffering and illness-related work, which arise interpersonally when comorbid illnesses affects social interactions. We found that women strive to create a balance between living with comorbid suffering and continuously performing routine activities amid treatment. Discrimination and isolation were underpinned by women's fear of being rejected by their families or how their illnesses created social distance between family members and the wider community. This study therefore illustrates how comorbid suffering requires intensive family commitments amid and beyond illness.

What drives distress? Rethinking the roles of emotion and diagnosis among people with diabetes in Nairobi, Kenya.

Type 2 diabetes mellitus is a condition that both results from and produces social and psychological suffering. As 'diabetes' increases among low income patients in poorer nations, new challenges arise that drive, co-occur, and result from the condition. In this article, we describe how social suffering produces diabetes by way of addressing the varied social, psychological, and biological factors that drive diabetes and are reflected in diabetes experiences among patients seeking care at a public hospital in Nairobi, Kenya. We recruited a non-probability sample to participate in a cross-sectional study of 100 patients (aged 35-65 years), where half of the participants sought care from a diabetes clinic and half sought care from the primary healthcare clinic. We obtained informed consent in writing, and collected life history narratives, surveys, anthropometrics, and biomarkers. This paper evaluates survey data using frequencies and regression tables. We found that social factors as opposed to disease factors were major drivers of psychological distress among those with and without diabetes. Psychological distress was associated with female gender and feelings of financial and personal insecurity. We also found insulin resistance was common among those undiagnosed with diabetes, suggesting that many seeking primary care for other health conditions did not receive a routine diabetes test (most likely because it is an out-of-pocket cost, or other competing social factors) and therefore delayed their diagnosis and care. Thus, social and economic factors may drive not only emotional distress among people with diabetes but also delayed care seeking, testing, and self-care as a result of cost and other social challenges.

Coprevalence of type 2 diabetes mellitus and tuberculosis in low-income and middle-income countries: A systematic review.

Increasing coprevalence of diabetes mellitus (DM) and tuberculosis (TB) in low-income and middle-income countries (LMICs) indicates a rising threat to the decades of progress made against TB and requires global attention. This systematic review provides a summary of type 2 diabetes and tuberculosis coprevalence in various LMICs. We searched PubMed, Ovid Medline, Embase, and PsychINFO databases for studies that provided estimates of TB-DM coprevalence in LMICs published between 1990 and 2016. Studies that were non-English and exclusively conducted in multidrug resistant-tuberculosis or type 1 diabetes and inpatient settings were excluded. We reviewed 84 studies from 31 countries. There were huge diversity of study designs and diagnostic methods used to estimate coprevalence, and this precluded pooling of the results. Most studies (n = 78) were from small, localized settings. The DM prevalence among TB patients in various LMICs varied from 1.8% to 45%, with the majority (n = 44) between 10% and 30%. The TB prevalence among people with DM ranged from 0.1% to 6.0% with most studies (n = 9) reporting prevalences less than 2%. Coprevalence of TB-DM was higher than general population prevalence of either diseases in these countries. This study underscores the need for intervention and more focused research on TB DM bidirectional screening programs in low-income and middle-income countries as well as integrated chronic disease management.

How to Fail a Scale: Reflections on a Failed Attempt to Assess Resilience.

How we interpret concepts from suffering to survival has been historically debated in the field of anthropology, transcultural psychiatry, and global mental health. These debates have centered on the notion that such concepts are cross-culturally reproducible, although scholars who work the boundaries of culture, medicine, and psychiatry often triangulate methods from internationally standardized scales to various interpretive methods from participant observation to narrative. This article considers resilience, as opposed to suffering, as the subject of a reproducible entity by discussing the failure of an attempt to capture resilience via an internationally reputed scale called the "Resilience Scale for Adults" among cancer patients in urban South Africa. Our effort to utilize the internationally validated scale, and our attempt to draw on ethnographic and interview work to translate this scale to a locally relevant entity failed due to linguistic, cultural, and practical issues. In brief, the attempt failed because our resilience scale was too long, syntactically ambiguous, and culturally inappropriate. We write this article to spur a larger conversation about evaluating resilience from scale to ethnography, and how the concept and measurement of resilience might figure into fields of anthropology and medicine.

Syndemics and the biosocial conception of health.

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations.

The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.

When Diabetes Confronts HIV: Biological Sub-citizenship at a Public Hospital in Nairobi, Kenya.

This article investigates how international donor policies cultivate a form of biological sub-citizenship for those with diabetes in Kenya. We interviewed 100 patients at a public hospital clinic in Nairobi, half with a diabetes diagnosis. We focus on three vignettes that illustrate how our study participants differentially perceived and experienced living with and seeking treatment and care for diabetes compared to other conditions, with a special focus on HIV. We argue that biological sub-citizenship, where those with HIV have consistent and comprehensive free medical care and those with diabetes must pay out-of-pocket for testing and treatment, impedes diabetes testing and treatment. Once diagnosed, many are then systematically excluded from the health care system due to their own inability to pay. We argue that the systematic exclusion from international donor money creates a form of biological sub-citizenship based on neoliberal economic policies that undermine other public health protections, such as universal primary health care.

Utilization of Standardized Mental Health Assessments in Anthropological Research: Possibilities and Pitfalls.

In the past decade anthropologists working the boundary of culture, medicine, and psychiatry have drawn from ethnographic and epidemiological methods to interdigitate data and provide more depth in understanding critical health problems. But rarely do these studies incorporate psychiatric inventories with ethnographic analysis. This article shows how triangulation of research methods strengthens scholars' ability (1) to draw conclusions from smaller data sets and facilitate comparisons of what suffering means across contexts; (2) to unpack the complexities of ethnographic and narrative data by way of interdigitating narratives with standardized evaluations of psychological distress; and (3) to enhance the translatability of narrative data to interventionists and to make anthropological research more accessible to policymakers. The crux of this argument is based on two discrete case studies, one community sample of Nicaraguan grandmothers in urban Nicaragua, and another clinic-based study of Mexican immigrant women in urban United States, which represent different populations, methodologies, and instruments. Yet, both authors critically examine narrative data and then use the Center for Epidemiologic Studies Depression Scale to further unpack meaning of psychological suffering by analyzing symptomatology. Such integrative methodologies illustrate how incorporating results from standardized mental health assessments can corroborate meaning-making in anthropology while advancing anthropological contributions to mental health treatment and policy.

Beyond Comorbidity: A Critical Perspective of Syndemic Depression and Diabetes in Cross-cultural Contexts.

This article examines the comorbidity concept in medical anthropology. I argue that the dearth of articles on comorbidity in medical anthropology may result from the rise of syndemic theory. Syndemics recognize how social realities shape individual illness experiences as well as distribution of diseases across populations. I discuss synergistic interactions foundational to the syndemics construct through my research of depression and diabetes comorbidity in vulnerable populations from urban United States, India, and South Africa. I argue that social and economic factors that cluster with depression and diabetes alone and together exemplify the biosocial processes that are at the heart of syndemics. In doing so, I illustrate how social, cultural, and economic factors shape individual-level experiences of co-occurring diseases despite similar population-level trends. Finally, I discuss the relevance of syndemics for the fields of medicine and public health while cautioning what must not be lost in translation across disciplines.