Lessons from the COVID-19 pandemic to strengthen NCD care and policy in humanitarian settings: a mixed methods study exploring humanitarian actors' experiences.

BACKGROUND: The COVID-19 pandemic and response severely impacted people living with non-communicable diseases (PLWNCDs) globally. It exacerbated pre-existing health inequalities, severely disrupted access to care, and worsened clinical outcomes for PLWNCDs, who were at higher risk of morbidity and mortality from the virus. The pandemic's effects were likely magnified in humanitarian settings, where there were pre-existing gaps in continuity of care for non-communicable diseases (NCDs). We sought to explore factors affecting implementation of NCD care in crisis settings during the COVID-19 pandemic and the adaptations made to support implementation. METHODS: Guided by the Consolidated Framework for Implementation Research, we undertook an online survey of 98 humanitarian actors from multiple regions and organization types (March-July 2021), followed by in-depth interviews with 13 purposively selected survey respondents (October-December 2021). Survey data were analysed using descriptive statistics, while interview data were analysed thematically, using both deductive and inductive approaches. RESULTS: Initially, humanitarian actors faced challenges influenced by external actors' priorities, such as de-prioritisation of NCD care by governments, travel restrictions and supply chain interruptions. With each infection wave and lockdown, humanitarian actors were better able to adapt and maintain NCD services. The availability of COVID-19 vaccines was a positive turning point, especially for the risk management of people with NCDs and protection of health workers. Key findings include that, despite pre-existing challenges, humanitarian actors largely continued NCD services during the crisis. Enabling factors that supported continuity of NCD services included the ability to quickly pivot to remote means of communication with PLWNCDs, flexibility in medicine dispensing, and successful advocacy to prioritize NCD management within health systems. Key lessons learned included the importance of partnerships and cooperation with other health actors, and the mobilisation or repurposing of community health workers/volunteer networks. CONCLUSIONS: The COVID-19 experience should prompt national and global health stakeholders to strengthen inclusion of NCDs in emergency preparedness, response, and resilience planning. Key lessons were learned around remote care provision, including adapting to NCD severity, integrating community health workers, providing context-adapted patient information, combating misinformation, and strengthening cross-sectoral partnerships.

An intervention package for supporting the mental well-being of community health workers in low, and middle-income countries during the COVID-19 pandemic.

BACKGROUND: As the COVID-19 pandemic continues, there is an increasing reliance on community health workers (CHWs) to achieve its control especially in low, and middle-income countries (LMICs). An increase in the demand for their services and the challenges they already face make them prone to mental health illness. Therefore, there is a need to further support the mental health and well-being of CHWs during the COVID-19 pandemic. METHODS: We organised a workshop on Zoom to deliberate on relevant components of an intervention package for supporting the mental health of CHWs in LMICs during the COVID-19 pandemic. We used a thematic analysis approach to summarise deliberations from this workshop. OUTCOMES: Participants identified the need for a hub for coordinating CHW activities, a care coordination team to manage their health, training programs aimed at improving their work performance and taking control of their health, a communication system that keeps them in touch with colleagues, family, and the communities they serve. They cautioned against confidentiality breaches while handling personal health information and favoured tailoring interventions to the unique needs of CHWs. Participants also advised on the need to ensure job security for CHWs and draw on available resources in the community. To measure the impact of such an intervention package, participants encouraged the use of mixed methods and a co-designed approach. INTERPRETATION: As CHWs contribute to the pandemic response in LMICs, their mental health and well-being need to be protected. Such protection can be provided by using an intervention package that harnesses inputs from members of the broader health system, their families, and communities.

Development of a core outcome set for multimorbidity trials in low/middle-income countries (COSMOS): study protocol.

INTRODUCTION: 'Multimorbidity' describes the presence of two or more long-term conditions, which can include communicable, non-communicable diseases, and mental disorders. The rising global burden from multimorbidity is well documented, but trial evidence for effective interventions in low-/middle-income countries (LMICs) is limited. Selection of appropriate outcomes is fundamental to trial design to ensure cross-study comparability, but there is currently no agreement on a core outcome set (COS) to include in trials investigating multimorbidity specifically in LMICs. Our aim is to develop international consensus on two COSs for trials of interventions to prevent and treat multimorbidity in LMIC settings. METHODS AND ANALYSIS: Following methods recommended by the Core Outcome Measures in Effectiveness Trials initiative, the development of these two COSs will occur in parallel in three stages: (1) generation of a long list of potential outcomes for inclusion; (2) two-round online Delphi surveys and (3) consensus meetings. First, to generate an initial list of outcomes, we will conduct a systematic review of multimorbidity intervention and prevention trials and interviews with people living with multimorbidity and their caregivers in LMICs. Outcomes will be classified using an outcome taxonomy. Two-round Delphi surveys will be used to elicit importance scores for these outcomes from people living with multimorbidity, caregivers, healthcare professionals, policy makers and researchers in LMICs. Finally, consensus meetings including all of these stakeholders will be held to agree outcomes for inclusion in the two COSs. ETHICS AND DISSEMINATION: The study has been approved by the Research Governance Committee of the Department of Health Sciences, University of York, UK (HSRGC/2020/409/D:COSMOS). Each participating country/research group will obtain local ethics board approval. Informed consent will be obtained from all participants. We will disseminate findings through peer-reviewed open access publications, and presentations at global conferences selected to reach a wide range of LMIC stakeholders. PROSPERO REGISTATION NUMBER: CRD42020197293.

Diabetes as a risk factor for incident peripheral arterial disease in women compared to men: a systematic review and meta-analysis.

AIMS/HYPOTHESIS: Previous meta-analyses have suggested that diabetes confers a greater excess risk of coronary heart disease, stroke, vascular dementia, and heart failure in women compared to men. While the underlying mechanism that explains such greater excess risk is unknown, in the current meta-analysis we hypothesized that we would find a similar sex difference in the relationship between diabetes and peripheral arterial disease (PAD). METHODS: PubMed MEDLINE, the Cochrane Database of Systematic Reviews, and Embase were systematically searched for prospective population-based cohort studies, with no restriction on publication date, language, or country. We included studies that reported the relative risk (RR), and its variability, for incident PAD associated with diabetes in both sexes. We excluded studies that did not adjust at least for age, and in which participants had pre-existing PAD. In cases where sex-specific results were not reported, study authors were contacted. Random-effects meta-analyses with inverse variance weighting were used to obtain summary sex-specific RRs and the women: men ratio of RRs for PAD. The Newcastle-Ottawa scale was used to assess study quality. RESULTS: Data from seven cohorts, totalling 2071,260 participants (49.8% women), were included. The relative risk for incident PAD associated with diabetes compared with no diabetes was 1.96 (95% CI 1.29-2.63) in women and 1.84 (95% CI 1.29-2.86) in men, after adjusting for potential confounders. The multiple-adjusted RR ratio was 1.05 (95% CI 0.90-1.22), with virtually no heterogeneity between studies (I2 = 0%). All studies scored 6-8, on the Newcastle-Ottawa scale of 0-9, indicating good quality. Eleven of the 12 studies that met review inclusion criteria did not report sex-specific relative risk, and these data were collected through direct correspondence with the study authors. CONCLUSION/INTERPRETATION: Consistent with other studies, we found evidence that diabetes is an independent risk factor for PAD. However, in contrast to similar studies of other types of cardiovascular disease, we did not find evidence that diabetes confers a greater excess risk in women compared to men for PAD. More research is needed to explain this sex differential between PAD and other forms of CVD, in the sequelae of diabetes. In addition, we found that very few studies reported the sex-specific relative risk for the association between diabetes and PAD, adding to existing evidence for the need for improved reporting of sex-disaggregated results in cardiovascular disease research.