Association between breastfeeding duration and educational attainment in rural Southwest Uganda: a population-based cohort study.

BACKGROUND: Breastfeeding is important for early childhood nutrition and health. The positive effects on educational outcomes may be attributed to socioeconomic factors. Socioeconomic status is not a strong predictor of breastfeeding in sub-Saharan African countries. Yet, few studies have investigated the association between breastfeeding and educational outcomes in these countries. OBJECTIVE: This study investigated the association between breastfeeding duration and children's educational attainment in rural Southwest Uganda. METHODS: We analysed longitudinal data on 3018 children who had information on breastfeeding and were followed for at least 5 years, with at least one primary school grade recorded by 2005. Data on breastfeeding duration were collected from mothers. The highest school grade was recorded repeatedly between ages 6 and 12 years. We calculated age-for-grade based on whether a child was on, over, or under the official age for a grade. Generalised estimating equations and binary logistic regression estimated the effect of breastfeeding duration on being 2 years, 3 or more years, or any years over-age for grade in primary school, adjusting for socioeconomic status and maternal-child characteristics. RESULTS: Most mothers breastfed for more than a year. Just over one-third breastfed for 18-23 months, and 30% breastfed for longer. By age eight, 42% of the children were two years over-age for their grade. Three or more years over-age for grade increased from 19% at age nine to 56% at age 12. Both adjusted and unadjusted estimates were consistent in showing reduced odds for children being 2 years, 3 or more years, or any years over-age for grade among children breastfed for 7-12, 13-17, 18-23, and > 23 months compared to those breastfed for 0-6 months. There was no evidence to support an overall association between breastfeeding duration and being over-age for grade. There was no evidence of association in the sex and age sub-group analyses. CONCLUSION: Although we found no association between breastfeeding duration and educational attainment, breastfeeding remains important for children's health and nutrition, and mothers should be encouraged and supported to breastfeed for the recommended duration.

Main findings: We found no clear evidence of an association between breastfeeding duration and educational attainment in rural Uganda.Added knowledge: The findings of this study contribute to a better understanding of the relationship between breastfeeding and educational outcomes in sub-Saharan African countries, where evidence on this topic is limited.Global health impact for policy and action: Our findings should not discourage breastfeeding, as it is essential for infant health and nutrition.

Policies for type 2 diabetes and non-communicable disease management during the COVID-19 pandemic in Kenya and Tanzania: a desk review and views of decision-makers.

BACKGROUND: The COVID-19 pandemic caused disruptions in care that adversely affected the management of non-communicable diseases (NCDs) globally. Countries have responded in various ways to support people with NCDs during the pandemic. This study aimed to identify policy gaps, if any, in the management of NCDs, particularly diabetes, during COVID-19 in Kenya and Tanzania to inform recommendations for priority actions for NCD management during any future similar crises. METHODS: We undertook a desk review of pre-existing and newly developed national frameworks, policy models and guidelines for addressing NCDs including type 2 diabetes. This was followed by 13 key informant interviews with stakeholders involved in NCD decision-making: six in Kenya and seven in Tanzania. Thematic analysis was used to analyse the documents. RESULTS: Seventeen guidance documents were identified (Kenya=10; Tanzania=7). These included pre-existing and/or updated policies/strategic plans, guidelines, a letter, a policy brief and a report. Neither country had comprehensive policies/guidelines to ensure continuity of NCD care before the COVID-19 pandemic. However, efforts were made to update pre-existing documents and several more were developed during the pandemic to guide NCD care. Some measures were put in place during the COVID-19 period to ensure continuity of care for patients with NCDs such as longer supply of medicines. Inadequate attention was given to monitoring and evaluation and implementation issues. CONCLUSION: Kenya and Tanzania developed and updated some policies/guidelines to include continuity of care in emergencies. However, there were gaps in the documents and between policy/guideline documents and practice. Health systems need to establish disaster preparedness plans that integrate attention to NCD care to enable them to better handle severe disruptions caused by emergencies such as pandemics. Such guidance needs to include contingency planning to enable adequate resources for NCD care and must also address evaluation of implementation effectiveness.

Utilizing a multi-stage transition model for analysing child stunting in two urban slum settlements of Nairobi: A longitudinal analysis, 2011-2014.

INTRODUCTION: Stunting is common among children in many low and middle income countries, particularly in rural and urban slum settings. Few studies have described child stunting transitions and the associated factors in urban slum settlements. We describe transitions between stunting states and associated factors among children living in Nairobi slum settlements. METHODS: This study used data collected between 2010 and 2014 from the Nairobi Urban and Demographic Surveillance System (NUHDSS) and a vaccination study nested within the surveillance system. A subset of 692 children aged 0 to 3 years, with complete anthropometric data, and household socio-demographic data was used for the analysis. Height-for-age Z-scores (HAZ) was used to define stunting: normal (HAZ ≥ 1), marginally stunted (-2 ≤ HAZ < -1), moderately stunted (-3 ≤ HAZ < -2), and severely stunted (HAZ < -3). Transitions from one stunting level to another and in the reverse direction were computed. The associations between explanatory factors and the transitions between four child stunting states were modeled using a continuous-time multi-state model. RESULTS: We observed that 48%, 39%, 41%, and 52% of children remained in the normal, marginally stunted, moderately stunted, and severely stunted states, respectively. About 29% transitioned from normal to marginally stunted state, 15% to the moderately stunted state, and 8% to the severely stunted state. Also, 8%, 12%, and 29% back transitioned from severely stunted, moderately stunted, and marginally stunted states, to the normal state, respectively. The shared common factors associated with all transitions to a more severe state include: male gender, ethnicity (only for mild and severe transition states), child's age, and household food insecurity. In Korogocho, children whose parents were married and those whose mothers had attained primary or post-primary education were associated with a transition from a mild state into a moderately stunted state. Children who were breastfed exclusively were less likely to transition from moderate to severe stunting state. CONCLUSION: These findings reveal a high burden of stunting and transitions in urban slums. Context-specific interventions targeting the groups of children identified by the socio-demographic factors are needed. Improving food security and exclusive breastfeeding could potentially reduce stunting in the slums.

Genetic Association and Transferability for Urinary Albumin-Creatinine Ratio as a Marker of Kidney Disease in four Sub-Saharan African Populations and non-continental Individuals of African Ancestry.

BACKGROUND: Genome-wide association studies (GWAS) have predominantly focused on populations of European and Asian ancestry, limiting our understanding of genetic factors influencing kidney disease in Sub-Saharan African (SSA) populations. This study presents the largest GWAS for urinary albumin-to-creatinine ratio (UACR) in SSA individuals, including 8,970 participants living in different African regions and an additional 9,705 non-resident individuals of African ancestry from the UK Biobank and African American cohorts. METHODS: Urine biomarkers and genotype data were obtained from two SSA cohorts (AWI-Gen and ARK), and two non-resident African-ancestry studies (UK Biobank and CKD-Gen Consortium). Association testing and meta-analyses were conducted, with subsequent fine-mapping, conditional analyses, and replication studies. Polygenic scores (PGS) were assessed for transferability across populations. RESULTS: Two genome-wide significant (P<5x10-8) UACR-associated loci were identified, one in the BMP6 region on chromosome 6, in the meta-analysis of resident African individuals, and another in the HBB region on chromosome 11 in the meta-analysis of non-resident SSA individuals, as well as the combined meta-analysis of all studies. Replication of previous significant results confirmed associations in known UACR-associated regions, including THB53, GATM, and ARL15. PGS estimated using previous studies from European ancestry, African ancestry, and multi-ancestry cohorts exhibited limited transferability of PGS across populations, with less than 1% of observed variance explained. CONCLUSION: This study contributes novel insights into the genetic architecture of kidney disease in SSA populations, emphasizing the need for conducting genetic research in diverse cohorts. The identified loci provide a foundation for future investigations into the genetic susceptibility to chronic kidney disease in underrepresented African populations Additionally, there is a need to develop integrated scores using multi-omics data and risk factors specific to the African context to improve the accuracy of predicting disease outcomes. METHODS: Urine biomarkers and genotype data were obtained from two SSA cohorts (AWI-Gen and ARK), and two non-resident African-ancestry studies (UK Biobank and CKD-Gen Consortium). Association testing and meta-analyses were conducted, with subsequent fine-mapping, conditional analyses, and replication studies. Polygenic scores (PGS) were assessed for transferability across populations. RESULTS: Two genome-wide significant (P<5x10-8) UACR-associated loci were identified, one in the BMP6 region on chromosome 6, in the meta-analysis of resident African individuals, and another in the HBB region on chromosome 11 in the meta-analysis of non-resident SSA individuals, as well as the combined meta-analysis of all studies. Replication of previous significant results confirmed associations in known UACR-associated regions, including THB53, GATM, and ARL15. PGS estimated using previous studies from European ancestry, African ancestry, and multi-ancestry cohorts exhibited limited transferability of PGS across populations, with less than 1% of observed variance explained. CONCLUSION: This study contributes novel insights into the genetic architecture of kidney function in SSA populations, emphasizing the need for conducting genetic research in diverse cohorts. The identified loci provide a foundation for future investigations into the genetic susceptibility to chronic kidney disease in underrepresented African populations.

Feasibility and acceptability of using biometric fingerprinting to track migrations and support retention in HIV prevention research in fishing population in East Africa.

INTRODUCTION: Fishing populations constitute a suitable key population amongst which to conduct HIV prevention trials due to very high HIV prevalence and incidence, however, these are highly mobile populations. We determined the feasibility and acceptability of using fingerprinting and geographical positioning systems to describe mobility patterns and retention among fisherfolks on the shoreline of Lake Victoria in South-western Uganda. METHODS: Between August 2015 and January 2017, two serial cross-sectional surveys were conducted during which fingerprinting of all residents aged 18-30 years on the shoreline of Lake Victoria was done. A mapper moving ahead of the survey team, produced village maps and took coordinates of every household. These were accessed by the survey team that assigned household and individual unique identifiers (ID) and collected demographic data. Using the assigned IDs, individuals were enrolled and their fingerprints scanned. The fingerprinting was repeated 6 months later in order to determine the participant's current household. If it was different from that at baseline, a new household ID was assigned which was used to map migrations both within and between villages. RESULTS: At both rounds, over 99% accepted to be fingerprinted. No fingerprinting faults were recorded at baseline and the level was under 1% at round two. Over 80% of the participants were seen at round two and of these, 16.3%, had moved to a new location whilst the majority, 85%, stayed within the same village. Movements between villages were mainly observed for those resident in large villages. Those who did not consider a fishing village to be their permanent home were less likely to be migrants than permanent residents (adjusted odds ratio = 0.37, 95%CI:0.15-0.94). CONCLUSION: Use of fingerprinting in fishing populations is feasible and acceptable. It is possible to track this mobile population for clinical trials or health services using this technology since most movements could be traced within and between villages.

Multimorbidity in African ancestry populations: a scoping review.

OBJECTIVES: Multimorbidity (MM) is a growing concern linked to poor outcomes and higher healthcare costs. While most MM research targets European ancestry populations, the prevalence and patterns in African ancestry groups remain underexplored. This study aimed to identify and summarise the available literature on MM in populations with African ancestry, on the continent, and in the diaspora. DESIGN: A scoping review was conducted in five databases (PubMed, Web of Science, Scopus, Science Direct and JSTOR) in July 2022. Studies were selected based on predefined criteria, with data extraction focusing on methodology and findings. Descriptive statistics summarised the data, and a narrative synthesis highlighted key themes. RESULTS: Of the 232 publications on MM in African-ancestry groups from 2010 to June 2022-113 examined continental African populations, 100 the diaspora and 19 both. Findings revealed diverse MM patterns within and beyond continental Africa. Cardiovascular and metabolic diseases are predominant in both groups (80% continental and 70% diaspora). Infectious diseases featured more in continental studies (58% continental and 16% diaspora). Although many papers did not specifically address these features, as in previous studies, older age, being women and having a lower socioeconomic status were associated with a higher prevalence of MM, with important exceptions. Research gaps identified included limited data on African-ancestry individuals, inadequate representation, under-represented disease groups, non-standardised methodologies, the need for innovative data strategies, and insufficient translational research. CONCLUSION: The growing global MM prevalence is mirrored in African-ancestry populations. Recognising the unique contexts of African-ancestry populations is essential when addressing the burden of MM. This review emphasises the need for additional research to guide and enhance healthcare approaches for African-ancestry populations, regardless of their geographic location.

Factors associated with COVID-19 vaccine uptake among people with type 2 diabetes in Kenya and Tanzania: a mixed-methods study.

BACKGROUND: People with type 2 diabetes (T2D) are at increased risk of poor outcomes from COVID-19. Vaccination can improve outcomes, but vaccine hesitancy remains a major challenge. We examined factors influencing COVID-19 vaccine uptake among people with T2D in two sub-Saharan Africa countries that adopted different national approaches to combat COVID-19, Kenya and Tanzania. METHODS: A mixed-methods study was conducted in February-March 2022, involving a survey of 1000 adults with T2D (500 Kenya; 500 Tanzania) and 51 in-depth interviews (21 Kenya; 30 Tanzania). Determinants of COVID-19 vaccine uptake were identified using a multivariate logistic regression model, while thematic content analysis explored barriers and facilitators. RESULTS: COVID-19 vaccine uptake was lower in Tanzania (26%) than in Kenya (75%), which may reflect an initial political hesitancy about vaccines in Tanzania. People with college/university education were four times more likely to be vaccinated than those with no education (Kenya AOR=4.25 (95% CI 1.00 to 18.03), Tanzania AOR=4.07 (1.03 to 16.12)); and people with health insurance were almost twice as likely to be vaccinated than those without health insurance (Kenya AOR=1.70 (1.07 to 2.70), Tanzania AOR=1.81 (1.04 to 3.13)). Vaccine uptake was higher in older people in Kenya, and among those with more comorbidities and higher socioeconomic status in Tanzania. Interviewees reported that wanting protection from severe illness promoted vaccine uptake, while conflicting information, misinformation and fear of side-effects limited uptake. CONCLUSION: COVID-19 vaccine uptake among people with T2D was suboptimal, particularly in Tanzania, where initial political hesitancy had a negative impact. Policy-makers must develop strategies to reduce fear and misconceptions, especially among those who are less educated, uninsured and younger.

Epstein-Barr virus (EBV) antibody changes over time in a general population cohort in rural Uganda, 1992-2008.

BACKGROUND: Epstein-Barr virus (EBV) infection is ubiquitous and in sub-Saharan Africa, occurs early in life. In a population-based rural African cohort, we leveraged historical samples from the General Population Cohort (GPC) in Uganda to examine the epidemiology of infection with EBV over time, in the era of HIV. METHODS: We used 9024 serum samples collected from the GPC in 1992, 2000, 2008, from 7576 participants across the age range (0-99 years of age) and tested for anti-EBV immunoglobulin G (IgG) antibodies to EAd, VCA, and EBNA-1 using a multiplex bead-based assay. The related gammaherpesvirus, Kaposi's sarcoma-associated herpesvirus (KSHV) seropositivity was also determined by detection of anti-KSHV IgG antibodies to K8.1 or ORF73 measured by recombinant protein enzyme-linked immunosorbent assay. Data on sex, age, and HIV serostatus were also collected. EBV seropositivity was modeled with age (excluding those under one year, who may have had maternal antibodies), sex, HIV serostatus, and KSHV serostatus using generalized linear mixed effects models to produce beta estimates. RESULTS: More than 93% of children were EBV seropositive by one year of age. EBV seropositivity was significantly associated with KSHV seropositivity. Anti-EBNA-1 antibody levels decreased with increasing age and were lower on average in people living with HIV. In general, anti-EAd antibody levels increased with age, were higher in males and KSHV seropositive persons, but decreased over calendar time. Anti-VCA antibody levels increased with age and with calendar time and were higher in KSHV seropositive persons but lower in males. CONCLUSIONS: This is the first study to identify factors associated with EBV antibodies across the entire life-course in rural sub-Saharan Africa. Consistent with other studies, EBV was near ubiquitous in the population by age one year. Patterns of antibodies show changes by age, sex and calendar time, but no association with HIV was evident, suggesting no relationship between EBV sero-epidemiology and the spread of HIV in the population over time in Uganda.

Cardiometabolic multimorbidity and associated patterns of healthcare utilization and quality of life: Results from the Study on Global AGEing and Adult Health (SAGE) Wave 2 in Ghana.

Understanding the patterns of multimorbidity, defined as the co-occurrence of more than one chronic condition, is important for planning health system capacity and response. This study assessed the association of different cardiometabolic multimorbidity combinations with healthcare utilization and quality of life (QoL). Data were from the World Health Organization (WHO) study on global AGEing and adult health Wave 2 (2015) conducted in Ghana. We analysed the clustering of cardiometabolic diseases including angina, stroke, type 2 diabetes, and hypertension with unrelated conditions such as asthma, chronic lung disease, arthritis, cataract and depression. The clusters of adults with cardiometabolic multimorbidity were identified using latent class analysis and agglomerative hierarchical clustering algorithms. We used negative binomial regression to determine the association of multimorbidity combinations with outpatient visits. The association of multimorbidity clusters with hospitalization and QoL were assessed using multivariable logistic and linear regressions. Data from 3,128 adults aged over 50 years were analysed. We identified four distinct classes of multimorbidity: relatively "healthy class" with no multimorbidity (47.9%): abdominal obesity only (40.7%): cardiometabolic and arthritis class comprising participants with hypertension, type 2 diabetes, stroke, abdominal and general obesity, arthritis and cataract (5.7%); and cardiopulmonary and depression class including participants with angina, chronic lung disease, asthma, and depression (5.7%). Relative to the class with no multimorbidity, the cardiopulmonary and depression class was associated with a higher frequency of outpatient visits [ß = 0.3; 95% CI 0.1 to 0.6] and higher odds of hospitalization [aOR = 1.9; 95% CI 1.0 to 3.7]. However, cardiometabolic and arthritis class was associated with a higher frequency of outpatient visits [ß = 0.8; 95% CI 0.3 to 1.2] and not hospitalization [aOR = 1.1; 95% CI 0.5 to 2.9]. The mean QoL scores was lowest among participants in the cardiopulmonary and depression class [ß = -4.8; 95% CI -7.3 to -2.3] followed by the cardiometabolic and arthritis class [ß = -3.9; 95% CI -6.4 to -1.4]. Our findings show that cardiometabolic multimorbidity among older persons in Ghana cluster together in distinct patterns that differ in healthcare utilization. This evidence may be used in healthcare planning to optimize treatment and care.

Perceived health system facilitators and barriers to integrated management of hypertension and type 2 diabetes in Kenya: a qualitative study.

OBJECTIVE: Understanding the facilitators and barriers to managing hypertension and type 2 diabetes (T2D) will inform the design of a contextually appropriate integrated chronic care model in Kenya. We explored the perceived facilitators and barriers to the integrated management of hypertension and T2D in Kenya using the Rainbow Model of Integrated Care. DESIGN: This was a qualitative study using data from a larger mixed-methods study on the health system response to chronic disease management in Kenya, conducted between July 2019 and February 2020. Data were collected through 44 key informant interviews (KIIs) and eight focus group discussions (FGDs). SETTING: Multistage sampling procedures were used to select a random sample of 12 study counties in Kenya. PARTICIPANTS: The participants for the KIIs comprised purposively selected healthcare providers, county health managers, policy experts and representatives from non-state organisations. The participants for the FGDs included patients with hypertension and T2D. OUTCOME MEASURES: Patients' and providers' perspectives of the health system facilitators and barriers to the integrated management of hypertension and T2D in Kenya. RESULTS: The clinical integration facilitators included patient peer support groups for hypertension and T2D. The major professional integration facilitators included task shifting, continuous medical education and integration of community resource persons. The national referral system, hospital insurance fund and health management information system emerged as the major facilitators for organisational and functional integration. The system integration facilitators included decentralisation of services and multisectoral partnerships. The major barriers comprised vertical healthcare services characterised by service unavailability, unresponsiveness and unaffordability. Others included a shortage of skilled personnel, a lack of interoperable e-health platforms and care integration policy implementation gaps. CONCLUSIONS: Our study identified barriers and facilitators that may be harnessed to improve the integrated management of hypertension and T2D. The facilitators should be strengthened, and barriers to care integration redressed.

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.

Mobility limitations and emotional dysfunction in old age: The moderating effects of physical activity and social ties.

BACKGROUND: This study aims to examine the association between mobility limitations and emotional dysfunction among older Ghanaians and evaluate the buffering effect of physical activity (PA) and social ties in this association. METHODS: The analysis included 1201 adults aged ≥50 from the 2016-17 Aging, Health, Psychological Well-being, and Health-seeking Behavior study. The Medical Outcomes Study Short Form-36 (MOS SF-36) assessed mobility limitations and emotional dysfunction. We measured PA using the International Physical Activity Questionnaire Short Form (IPAQ-SF). Hierarchical OLS regressions were performed to evaluate the hypothesized direct and interactive relationships. RESULTS: The mean age of the sample was 66.2 (SD = 11.9), and 63.3% were women. After full adjustment for potential confounders, OLS regressions found that mobility limitations increased the risk of emotional dysfunction (ß = 0.113, p = 0.004). Moreover, social ties (ß = -0.157, p < 0.001) and PA (ß = -0.096, p < 0.001) were independently and negatively associated with emotional dysfunction. We finally found a significant effect modification of the association of mobility limitations with emotional dysfunction by PA (ß = -0.040, p < 0.002) and social ties (ß = -0.013, p = 0.013). CONCLUSIONS: Mobility-enhancing strategies such as engagement in positive behavioral choices, focusing on regular PA, and maintaining resourceful interpersonal social networks can mitigate the impact of mobility limitations on emotional dysfunction in later life.

Effectiveness of integrated chronic care models for cardiometabolic multimorbidity in sub-Saharan Africa: a systematic review and meta-analysis.

OBJECTIVES: This review aimed at identifying the elements of integrated care models for cardiometabolic multimorbidity in sub-Saharan Africa (SSA) and their effects on clinical or mental health outcomes including systolic blood pressure (SBP), blood sugar, depression scores and other patient-reported outcomes such as quality of life and medication adherence. DESIGN: Systematic review and meta-analysis using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. DATA SOURCES: We systematically searched PubMed, Embase, Scopus, Web of Science, Global Health CINAHL, African Journals Online, Informit, PsycINFO, ClinicalTrials.gov, Pan African Clinical Trials Registry and grey literature from OpenSIGLE for studies published between 1999 and 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included randomised controlled trial studies featuring integrated care models with two or more elements of Wagner's chronic care model. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search and screen included studies. Publication bias was assessed using the Doi plot and Luis Furuya Kanamori Index. Meta-analysis was conducted using random effects models. RESULTS: In all, we included 10 randomised controlled trials from 11 publications with 4864 participants from six SSA countries (South Africa, Kenya, Nigeria, Eswatini, Ghana and Uganda). The overall quality of evidence based on GRADE criteria was moderate. A random-effects meta-analysis of six studies involving 1754 participants shows that integrated compared with standard care conferred a moderately lower mean SBP (mean difference=-4.85 mm Hg, 95% CI -7.37 to -2.34) for people with cardiometabolic multimorbidity; Hedges' g effect size (g=-0.25, (-0.39 to -0.11). However, integrated care compared with usual care showed mixed results for glycated haemoglobin, depression, medication adherence and quality of life. CONCLUSION: Integrated care improved SBP among patients living with cardiometabolic multimorbidity in SSA. More studies on integrated care are required to improve the evidence pool on chronic care models for multimorbidity in SSA. These include implementation studies and cost-effectiveness studies. PROSPERO REGISTRATION NUMBER: CRD42020187756.

Effect of Patient Support Groups for Hypertension on Blood Pressure among Patients with and Without Multimorbidity: Findings from a Cohort Study of Patients on a Home-Based Self-Management Program in Kenya.

Introduction: Patient support group interventions have been widely used to manage chronic diseases in Kenya. However, the potential benefits of these groups on patient health outcomes, and how this is influenced by multimorbidity, have not been rigorously evaluated. Objective: We assessed the effect of a patient support group intervention on blood pressure (BP) management and the potential moderating effect of multimorbidity among low- and middle-income patients with hypertension in Kenya. Methods: We analysed data from a non-randomized, quasi-experimental study of 410 patients with hypertension on a home-based self-management program conducted from September 2019 to September 2020. The program included the formation and participation in patient support groups. Using a modified STEPS questionnaire, data were collected on BP, anthropometry and other measurements at enrolment and after 12 months of follow-up. Multimorbidity was defined as the simultaneous presence of hypertension and at least one or more related conditions with similar pathophysiology (concordant multimorbidity) or unrelated chronic conditions (discordant multimorbidity). Propensity score (PS) weighting was used to adjust for baseline differences among 243 patients who participated in the support groups and 167 who did not. We estimated the effects of patient support groups and moderating effects of multimorbidity on BP management using multivariable ordinary linear regression weighted by PS. Findings: Participation in support groups significantly reduced systolic BP by 5.4 mmHg compared to non-participation in the groups [ß = -5.4; 95% CI -1.9 to -8.8]. However, among participants in the support group intervention, the mean systolic BP at follow-up assessment for those with concordant multimorbidity was 8.8 mmHg higher than those with no multimorbidity [ß = 8.8; 95% CI 0.8 to 16.8]. Conclusion: Although patient support groups are potentially important adjuncts to home-based self-care, multimorbidity attenuates their effectiveness. There is a need to tailor patient support group interventions to match the needs of the people living with multimorbidity in low- and middle-income settings in Kenya.

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.

Cardiometabolic disease risk factors in pre- and postmenopausal women from four sub-Saharan African countries: A cross-sectional study.

OBJECTIVE: To compare the risk factors for cardiometabolic disease between pre- and postmenopausal women from four sub-Saharan African countries. STUDY DESIGN: This cross-sectional study included 3609 women (1740 premenopausal and 1869 postmenopausal) from sites in Ghana (Navrongo), Burkina Faso (Nanoro), Kenya (Nairobi), and South Africa (Soweto and Dikgale). Demographic, anthropometric and cardiometabolic variables were compared between pre- and postmenopausal women, within and across sites using multivariable regression analyses. The sites represent populations at different stages of the health transition, with those in Ghana and Burkina Faso being rural, whilst those in Kenya and South Africa are more urbanised. MAIN OUTCOME MEASURES: Anthropometric and cardiometabolic variables. RESULTS: The prevalence rates of risk factors for cardiometabolic disease were higher in South (Soweto and Dikgale) and East (Nairobi) Africa than in West Africa (Nanoro and Navrongo), irrespective of menopausal status. Regression models in combined West African populations demonstrated that postmenopausal women had a larger waist circumference (ß = 1.28 (95 % CI: 0.58; 1.98) cm), log subcutaneous fat (ß =0.15 (0.10; 0.19)), diastolic (ß = 3.04 (1.47; 4.62) mm Hg) and log systolic (ß = 0.04 (0.02; 0.06)) blood pressure, log carotid intima media thickness (ß = 0.03 (0.01; 0.06)), low-density lipoprotein cholesterol (ß = 0.14 (0.04; 0.23) mmol/L) and log triglyceride (ß= 0.10 (0.04; 0.16)) levels than premenopausal women. No such differences were observed in the South and East African women. CONCLUSIONS: Menopause-related differences in risk factors for cardiometabolic disease were prominent in West but not East or South African study sites. These novel findings should inform cardiometabolic disease prevention strategies in midlife women specific to rural and urban and peri-urban locations in sub-Saharan Africa.

Diabetes care cascade and associated factors in 10 700 middle-aged adults in four sub-Saharan African countries: a cross-sectional study.

OBJECTIVES: We investigated progression through the care cascade and associated factors for people with diabetes in sub-Saharan Africa to identify attrition stages that may be most appropriate for targeted intervention. DESIGN: Cross-sectional study. SETTING: Community-based study in four sub-Saharan African countries. PARTICIPANTS: 10 700 individuals, aged 40-60 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the diabetes cascade of care defined as the age-adjusted diabetes prevalence (self-report of diabetes, fasting plasma glucose (FPG) ≥7 mmol/L or random plasma glucose ≥11.1 mmol/L) and proportions of those who reported awareness of having diabetes, ever having received treatment for diabetes and those who achieved glycaemic control (FPG <7.2 mmol/L). Secondary outcome measures were factors associated with having diabetes and being aware of the diagnosis. RESULTS: Diabetes prevalence was 5.5% (95% CI 4.4% to 6.5%). Approximately half of those with diabetes were aware (54%; 95% CI 50% to 58%); 73% (95% CI 67% to 79%) of aware individuals reported ever having received treatment. However, only 38% (95% CI 30% to 46%) of those ever having received treatment were adequately controlled. Increasing age (OR 1.1; 95% CI 1.0 to 1.1), urban residence (OR 2.3; 95% CI 1.6 to 3.5), hypertension (OR 1.9; 95% CI 1.5 to 2.4), family history of diabetes (OR 3.9; 95% CI 3.0 to 5.1) and measures of central adiposity were associated with higher odds of having diabetes. Increasing age (OR 1.1; 95% CI 1.0 to 1.1), semi-rural residence (OR 2.5; 95% CI 1.1 to 5.7), secondary education (OR 2.4; 95% CI 1.2 to 4.9), hypertension (OR 1.6; 95% CI 1.0 to 2.4) and known HIV positivity (OR 2.3; 95% CI 1.2 to 4.4) were associated with greater likelihood of awareness of having diabetes. CONCLUSIONS: There is attrition at each stage of the diabetes care cascade in sub-Saharan Africa. Public health strategies should target improving diagnosis in high-risk individuals and intensifying therapy in individuals treated for diabetes.

Identifying the prevalence and correlates of multimorbidity in middle-aged men and women: a cross-sectional population-based study in four African countries.

OBJECTIVES: To determine the prevalence of multimorbidity, to identify which chronic conditions cluster together and to identify factors associated with a greater risk for multimorbidity in sub-Saharan Africa (SSA). DESIGN: Cross-sectional, multicentre, population-based study. SETTING: Six urban and rural communities in four sub-Saharan African countries. PARTICIPANTS: Men (n=4808) and women (n=5892) between the ages of 40 and 60 years from the AWI-Gen study. MEASURES: Sociodemographic and anthropometric data, and multimorbidity as defined by the presence of two or more of the following conditions: HIV infection, cardiovascular disease, chronic kidney disease, asthma, diabetes, dyslipidaemia, hypertension. RESULTS: Multimorbidity prevalence was higher in women compared with men (47.2% vs 35%), and higher in South African men and women compared with their East and West African counterparts. The most common disease combination at all sites was dyslipidaemia and hypertension, with this combination being more prevalent in South African women than any single disease (25% vs 21.6%). Age and body mass index were associated with a higher risk of multimorbidity in men and women; however, lifestyle correlates such as smoking and physical activity were different between the sexes. CONCLUSIONS: The high prevalence of multimorbidity in middle-aged adults in SSA is of concern, with women currently at higher risk. This prevalence is expected to increase in men, as well as in the East and West African region with the ongoing epidemiological transition. Identifying common disease clusters and correlates of multimorbidity is critical to providing effective interventions.

Cardiometabolic Multimorbidity Associated with Moderate and Severe Disabilities: Results from the Study on Global AGEing and Adult Health (SAGE) Wave 2 in Ghana and South Africa.

Background: Integrated management of cardiometabolic diseases is crucial in improving the quality of life of older persons. The objective of the study was to identify clusters of cardiometabolic multimorbidity associated with moderate and severe disabilities in Ghana and South Africa. Methods: Data were from the World Health Organization (WHO) study on global AGEing and adult health (SAGE) Wave-2 (2015) conducted in Ghana and South Africa. We analysed the clustering of cardiometabolic diseases including angina, stroke, diabetes, obesity, and hypertension with unrelated conditions such as asthma, chronic lung disease, arthritis, cataracts, and depression. The WHO Disability Assessment Instrument version 2.0 was used to assess functional disability. We used latent class analysis to calculate the multimorbidity classes and disability severity levels. Ordinal logistic regression was used to identify the clusters of multimorbidity associated with moderate and severe disabilities. Results: Data from 4,190 adults aged over 50 years were analysed. The prevalence of moderate and severe disabilities was 27.0% and 8.9% respectively. Four latent classes of multimorbidity were identified. These included a relatively healthy group with minimal cardiometabolic multimorbidity (63.5%), general and abdominal obesity (20.5%), hypertension, abdominal obesity, diabetes, cataracts, and arthritis (10.0%), and angina, chronic lung disease, asthma, and depression (6.0%). Compared to the participants with minimal cardiometabolic multimorbidity, the odds of moderate and severe disabilities were higher among participants with multimorbidity comprising hypertension, abdominal obesity, diabetes, cataract and arthritis [aOR = 3.0; 95% CI 1.6 to 5.6], and those with angina, chronic lung disease, asthma and depression [aOR = 2.7; 95% CI 1.6 to 4.5]. Conclusions: Cardiometabolic diseases among older persons in Ghana and South Africa cluster in distinct multimorbidity patterns that are significant predictors of functional disabilities. This evidence may be useful for defining disability prevention strategies and long-term care for older persons living with or at risk of cardiometabolic multimorbidity in sub-Saharan Africa.