Estimating the prevalence and predictors of musculoskeletal disorders in Tanzania: a cross-sectional pilot study.

Introduction: musculoskeletal (MSK) disorders account for approximately 20% of all years lived with disability worldwide however studies of MSK disorders in Africa are scarce. This pilot study aimed to estimate the community-based prevalence of MSK disorders, identify predictors, and assess the associated disability in a Tanzanian population. Methods: a cross-sectional study was conducted in one village in the Kilimanjaro region from March to June 2019. The Gait, Arms, Legs, Spine (GALS) or paediatric GALS (pGALS) examinations were used during household and school visits. Individuals positive in GALS/pGALS screening were assessed by the regional examination of the musculoskeletal system (REMS) and Modified Health Assessment Questionnaire (MHAQ). Results: among the 1,172 individuals enrolled in households, 95 (8.1%, 95% CI: 6.6 - 9.8) showed signs of MSK disorders using the GALS/pGALS examination and 37 (3.2%, 95% CI: 2.2 - 4.3) using the REMS. Among 682 schools enrolled children, seven showed signs of MSK disorders using the GALS/pGALS examination (1.0%, 95% CI: 0.4 - 2.1) and three using the REMS (0.4%, 95% CI: 0.0 - 1.3). In the household-enrolled adult population, female gender and increasing age were associated with GALS and REMS-positive findings. Among GALS-positive adults, increasing age was associated with REMS-positive status and increasing MHAQ score. Conclusion: this Tanzanian study demonstrates a prevalence of MSK disorders and identifies predictors of MSK disorders comparable to those seen globally. These findings can inform the development of rheumatology services and interventions in Tanzania and the design of future investigations of the determinants of MSK disorders, and their impacts on health, livelihoods, and well-being.

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.

Rapid ethnographic appraisal of community concepts of and responses to joint pain in Kilimanjaro, Tanzania.

INTRODUCTION: Musculoskeletal disorders, experienced as joint pain, are a significant global health problem, but little is known about how joint pain is categorised and understood in Tanzania. Understanding existing conceptualisations of and responses to joint pain is important to ensure both research and interventions are equitable and avoid biomedical imposition. METHODS: Rapid ethnographic appraisal was conducted in a periurban and rural community in Kilimanjaro, documenting language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts pain has and how people respond to it. We conducted 66 interviews with community leaders, traditional healers, community members and pharmacists.Photographs were taken and included in fieldnotes to supplement the interview data and develop thick descriptions. Data were analysed by constant comparison using QDA Miner software. RESULTS: Across the sample, dominant concepts of joint pain were named ugonjwa wa baridi, cold disease; ugonjwa wa uzee, old age disease; rimatizim, disease of the joints; and gauti, gout. Causes mentioned included exposure to the cold, old age, alcohol and red meat consumption, witchcraft, demons and injuries/falls. Age, gender and occupation were seen as important factors for developing joint pain. Perceived impacts of joint pain included loss of mobility, economic and family problems, developing new health conditions, death, reduction in sexual functioning and negative self-perceptions. Responses to joint pain blended biomedical treatments, herbal remedies, consultations with traditional healers and religious rituals. CONCLUSIONS: Conceptualisations of and responses to joint pain in the two communities were syncretic, mixing folk and biomedical practices. Narratives about who is affected by joint pain mirror emerging epidemiological findings, suggesting a strong 'lay epidemiology' in these communities. Anthropological methods can support the decolonisation of global health by decentring the imposition of English language biomedicine and pursuing synthetic, dignified languages of care.

Maternal mental health research in Malawi: Community and healthcare provider perspectives on acceptability and ethicality.

Maternal mental health (MMH) is recognised as globally significant. The prevalence of depression and factors associated with its onset among perinatal women in Malawi has been previously reported, and the need for further research in this domain is underscored. Yet, there is little published scholarship regarding the acceptability and ethicality of MMH research to women and community representatives. The study reported here sought to address this in Malawi by engaging with communities and healthcare providers in the districts where MMH research was being planned. Qualitative data was collected in Lilongwe and Karonga districts through 20 focus group discussions and 40 in-depth interviews with community representatives and healthcare providers from January through April 2021. All focus groups and interviews were audio recorded, transcribed verbatim (in local languages Chichewa and Tumbuka), translated into English, and examined through thematic content analysis. Participants' accounts suggest that biopsychosocial MMH research could be broadly acceptable within the communities sampled, with acceptability framed in part through prior encounters with biomedical and public health research and care in these regions, alongside broader understandings of the import of MMH. Willingness and consent to participate do not depend on specifically biomedical understandings of MMH, but rather on familiarity with individuals regarded as living with mental ill-health. However, the data further suggest some 'therapeutic misconceptions' about MMH research, with implications for how investigations in this area are presented by researchers when recruiting and working with participants. Further studies are needed to explore whether accounts of the acceptability and ethicality of MMH research shift and change during and following research encounters. Such studies will enhance the production of granular recommendations for further augmenting the ethicality of biomedical and public health research and researchers' responsibilities to participants and communities.

Multi-country collaborative citizen science projects to co-design cardiovascular disease prevention strategies and advocacy: findings from Ethiopia, Malawi, Rwanda, and South Africa.

BACKGROUND: Cardiovascular diseases (CVD) were responsible for 20.5 million annual deaths globally in 2021, with a disproportionally high burden in sub-Saharan Africa (SSA). There is growing evidence of the use of citizen science and co-design approaches in developing interventions in different fields, but less so in the context of CVD prevention interventions in SSA. This paper reports on the collaborative multi-country project that employed citizen science and a co-design approach to (i) explore CVD risk perceptions, (ii) develop tailored prevention strategies, and (iii) support advocacy in different low-income settings in SSA. METHODS: This is a participatory citizen science study with a co-design component. Data was collected from 205 participants aged 18 to 75 years in rural and urban communities in Malawi, Ethiopia and Rwanda, and urban South Africa. Fifty-one trained citizen scientists used a mobile app-based (EpiCollect) semi-structured survey questionnaire to collect data on CVD risk perceptions from participants purposively selected from two communities per country. Data collected per community included 100-150 photographs and 150-240 voice recordings on CVD risk perceptions, communication and health-seeking intentions. Thematic and comparative analysis were undertaken with the citizen scientists and the results were used to support citizen scientists-led stakeholder advocacy workshops. Findings are presented using bubble graphs based on weighted proportions of key risk factors indicated. RESULTS: Nearly three in every five of the participants interviewed reported having a relative with CVD. The main perceived causes of CVD in all communities were substance use, food-related factors, and litter, followed by physical inactivity, emotional factors, poverty, crime, and violence. The perceived positive factors for cardiovascular health were nutrition, physical activity, green space, and clean/peaceful communities. Multi-level stakeholders (45-84 persons/country) including key decision makers participated in advocacy workshops and supported the identification and prioritization of community-specific CVD prevention strategies and implementation actions. Citizen science-informed CVD risk screening and referral to care interventions were piloted in six communities in three countries with about 4795 adults screened and those at risk referred for care. Health sector stakeholders indicated their support for utilising a citizen-engaged approach in national NCDs prevention programmes. The citizen scientists were excited by the opportunity to lead research and advocacy. CONCLUSION: The collaborative engagement, participatory learning, and co-designing activities enhanced active engagement between citizen scientists, researchers, and stakeholders. This, in turn, provided context-specific insights on CVD prevention in the different SSA settings.

How European Fans in Training (EuroFIT), a lifestyle change program for men delivered in football clubs, achieved its effect: a mixed methods process evaluation embedded in a randomised controlled trial.

BACKGROUND: A randomised trial of European Fans in Training (EuroFIT), a 12-week healthy lifestyle program delivered in 15 professional football clubs in the Netherlands, Norway, Portugal, and the United Kingdom, successfully increased physical activity and improved diet but did not reduce sedentary time. To guide future implementation, this paper investigates how those effects were achieved. We ask: 1) how was EuroFIT implemented? 2) what were the processes through which outcomes were achieved? METHODS: We analysed qualitative data implementation notes, observations of 29 of 180 weekly EuroFIT deliveries, semi-structured interviews with 16 coaches and 15 club representatives, and 30 focus group discussions with participants (15 post-program and 15 after 12 months). We descriptively analysed quantitative data on recruitment, attendance at sessions and logs of use of the technologies and survey data on the views of participants at baseline, post program and after 12 months. We used a triangulation protocol to investigate agreement between data from difference sources, organised around meeting 15 objectives within the two research questions. RESULTS: We successfully recruited clubs, coaches and men to EuroFIT though the draw of the football club seemed stronger in the UK and Portugal. Advertising that emphasized getting fitter, club-based deliveries, and not 'standing out' worked and attendance and fidelity were good, so that coaches in all countries were able to deliver EuroFIT flexibly as intended. Coaches in all 15 clubs facilitated the use of behaviour change techniques and interaction between men, which together enhanced motivation. Participants found it harder to change sedentary time than physical activity and diet. Fitting changes into daily routines, planning for setbacks and recognising the personal benefit of behaviour change were important to maintain changes. Bespoke technologies were valued, but technological hitches frustrated participants. CONCLUSION: EuroFIT was delivered as planned by trained club coaches working flexibly in all countries. It worked as expected to attract men and support initiation and maintenance of changes in physical activity and diet but the use of bespoke, unstable, technologies was frustrating. Future deliveries should eliminate the focus on sedentary time and should use only proven technologies to support self-monitoring and social interaction. TRIAL REGISTRATION: ISRCTN81935608, registered 16/06/2015.

Factors influencing the implementation of the EuroFIT lifestyle change program in professional football clubs in Europe: a qualitative study in four European countries.

This paper investigated facilitators and barriers to implementing the European Football Fans in Training program (EuroFIT) in professional sports clubs in England, the Netherlands, Norway, and Portugal. We analyzed qualitative data collected at clubs that delivered EuroFIT, based on semi-structured interviews with coordinating staff (n = 15), coaches (n = 16), and focus group interviews with participants (n = 108), as well as data from clubs that considered delivering EuroFIT in the future, based on interviews with staff (n = 7) and stakeholders (n = 8). Facilitators for implementation related to the content and structure of the program, its evidence-base, and the context for delivery in the football stadia. Financial and human resources were both facilitators and barriers. Further barriers were mostly practical, relating to human resources and infrastructure. Major differences between countries related to experience and commitment to running community projects, and differences in infrastructure, financing, and human resources. Professional football clubs' ability to support health promotion efforts depended on their ethos and the financial and human resources available to them. Overall, the EuroFIT program was well received by clubs, coaches, participants, and stakeholders, which was reflected by the many facilitators supporting sustained implementation. For sustainable implementation, it is crucial that clubs and their stakeholders engage fully with the EuroFIT program and understand that for an adequate program delivery their views (ethos) and ways of working influence the implementation and thereby the effectiveness of EuroFIT. An important prerequisite for future roll out of EuroFIT would be a strong EuroFIT delivery partner organization to ensure financial and human resources while overseeing and guiding the quality of delivery in clubs.

The European Football Fans in Training program (EuroFIT) led to health improvements in male football fans delivered through professional sports clubs in England, the Netherlands, Norway, and Portugal. This study looked at what factors influenced the implementation of the program. Facilitators for implementation related to the content and structure of the program, its evidence-base, and the context for delivery in the football stadia. Financial and human resources were both facilitators and barriers. Further barriers were mostly practical, relating to human resources and infrastructure. Major differences between countries related to experience and commitment to running community projects, and differences in infrastructure, financing, and human resources. Professional football clubs' ability to support health promotion efforts depended on their ethos and financial and human resources available to them. Overall, the EuroFIT program was well received by clubs, coaches, participants, and stakeholders, which was reflected by the many facilitators supporting sustained implementation. Yet, an important prerequisite for the future roll out of EuroFIT would be a strong EuroFIT delivery partner organization to ensure financial and human resources, while overseeing and guiding the quality of delivery in clubs.

Qualitative study of practices and attitudes towards physical activity among prediabetic men and women in urban and rural Malawi.

OBJECTIVES: Given the decline in physical activity levels in Malawi, like other sub-Saharan African countries, and its implication for non-communicable disease (NCD) prevention, this study aimed to compare and contrast accounts of practices and attitudes towards physical activity among Malawian men and women (previously identified as having pre-diabetes) in urban and rural settings. SETTING: Two communities: one urban (Lilongwe) and one rural (Karonga). PARTICIPANTS: 14 men (urban N=6, rural N=8) and 18 women (urban N=9, rural N=9) classified as prediabetic during their participation in an NCD survey 3-5 years previously. DESIGN: A qualitative focus group study (N=4) and thematic analysis, with the ecological model used as a framework to characterise the types of physical activity people engaged in and potential ways to support them to exercise more. RESULTS: Participants reported undertaking different types of physical activity across all ecological model domains (household, occupational, transport, recreational). Rural participants reported more vigorous physical activities than urban participants, and women reported more household activities than men. Many participants recognised a need to promote physical activity in Malawi, and the health benefits of doing so, including the importance of physical activity in helping them stay strong to maintain physical functioning. Barriers to physical activity included competing priorities (especially urban men), societal expectations around wealth, use of motorised transport, lack of accessible facilities for women, ageing and ill health. CONCLUSIONS: Physical activity is declining in Malawi as working and transport practices change in response to economic development, making promotion of alternative forms of physical activity a public health priority. Multilevel interventions emphasising the personal benefits/value of physical activity for all ages, and routine and group-based exercising, as well as investment in accessible recreational facilities (including for women) and active travel infrastructure should be considered to improve physical activity levels in Malawi.

Development and optimisation of a multi-component workplace intervention to increase cycling for the Cycle Nation Project.

The Cycle Nation Project (CNP) aimed to develop, test the feasibility of and optimize a multi-component individual-/social-level workplace-based intervention to increase cycling among office staff at a multinational bank (HSBC UK). To do this, we first explored barriers to cycling in a nationally-representative survey of UK adults, then undertook focus groups with bank employees to understand any context-specific barriers and ways in which these might be overcome. These activities led to identification of 10 individual-level, two social-level, and five organizational-level modifiable factors, which were mapped to candidate intervention components previously identified in a scoping review of cycling initiatives. Interviews with HSBC UK managers then explored the practicality of implementing the candidate intervention components in bank offices. The resultant pilot CNP intervention included 32 core components across six intervention functions (education, persuasion, incentivisation, training, environmental restructuring, enablement). Participants received a loan bike for 12-weeks (or their own bike serviced), and a 9-week cycle training course (condensed to 6 weeks for those already confident in basic cycling skills), including interactive information sharing activities, behavior change techniques (e.g., weekly goal setting), bike maintenance training, practical off-road cycling skill games and on-road group rides. Sessions were delivered by trained bank staff members who were experienced cyclists. The CNP pilot intervention was delivered across three sites with 68 participants. It was completed in two sites (the third site was stopped due to COVID-19) and was feasible and acceptable to both women and men and across different ethnicities. In addition, the CNP intervention was successful (at least in the short term) in increasing cycling by 3 rides/week on average, and improving perceptions of safety, vitality, confidence, and motivation to cycle. Following minor modifications, the long-term effectiveness and cost-effectiveness of the CNP intervention should be tested in a full-scale randomized controlled trial.

Gambling in Sub-Saharan Africa: Traditional Forms and Emerging Technologies.

Purpose of Review: The gambling industry in Africa has seen substantial growth and evolution over recent years with a growing body of literature describing these shifts. Here, we provide a narrative synthesis of the extant literature on the origins, trends and consequences of the expansion and intensification of the commercial gambling industry in sub-Saharan Africa with a reference for future research on gambling as a growing public health concern. Recent Findings: The historical shift and permeation of gambling in sub-Saharan Africa is diverse with evidence of certain countries following a neo-colonial logic. Advances in technology have made gambling more accessible and created new markets in Africa. A key motive driving gambling on the continent is a lack of stable employment. While the intensification and growth of Africa's gambling industry has brought economic benefits to some African investors and individuals, this has been accompanied by a range of gambling harms. Legislation and policies designed to better regulate the gambling industry and redress these harms are needed. In this context, a small number of services and campaigns designed to mitigate gambling harms demonstrate promise, but more research is needed in this area. Summary: The gambling industry in sub-Saharan Africa has undergone a dramatic transformation. While it is true that the growth of the African gambling industry has provided an additional revenue stream to governments, it is also necessary to acknowledge the concurrent rise in gambling addiction and the health-related and social harms that it elicits. As such, designing effective regulatory measures and policy interventions that can reduce the public health burden of gambling harms is vital. However, these interventions need to take in to account the significance of cultural differences that exist among countries on the continent.

Experiences of multimorbidity in urban and rural Malawi: An interview study of burdens of treatment and lack of treatment.

Multimorbidity (presence of ≥2 long term conditions (LTCs)) is a growing global health challenge, yet we know little about the experiences of those living with multimorbidity in low- and middle-income countries (LMICs). We therefore explore: 1) experiences of men and women living with multimorbidity in urban and rural Malawi including their experiences of burden of treatment and 2) examine the utility of Normalization Process Theory (NPT) and Burden of Treatment Theory (BOTT) for structuring analytical accounts of these experiences. We conducted in depth, semi-structured interviews with 32 people in rural (n = 16) and urban settings (n = 16); 16 males, 16 females; 15 under 50 years; and 17 over 50 years. Data were analysed thematically and then conceptualised through the lens of NPT and BOTT. Key elements of burden of treatment identified included: coming to terms with and gaining an understanding of life with multimorbidity; dealing with resulting disruptions to family life; the work of seeking family and community support; navigating healthcare systems; coping with lack of continuity of care; enacting self-management advice; negotiating medical advice; appraising treatments; and importantly, dealing with the burden of lack of treatments/services. Poverty and inadequate healthcare provision constrained capacity to deal with treatment burden while supportive social and community networks were important enabling features. Greater access to health information/education would lessen treatment burden as would better resourced healthcare systems and improved standards of living. Our work demonstrates the utility of NPT and BOTT for aiding conceptualisation of treatment burden issues in LMICs but our findings highlight that 'lack' of access to treatments or services is an important additional burden which must be integrated in accounts of treatment burden in LMICs.

"I see salt everywhere": A qualitative examination of the utility of arts-based participatory workshops to study noncommunicable diseases in Tanzania and Malawi.

The burden of noncommunicable diseases (NCDs) including hypertension, diabetes, and cancer, is rising in Sub-Saharan African countries like Tanzania and Malawi. This increase reflects complex interactions between diverse social, environmental, biological, and political factors. To intervene successfully, new approaches are therefore needed to understand how local knowledges and attitudes towards common NCDs influence health behaviours. This study compares the utility of using a novel arts-based participatory method and more traditional focus groups to generate new understandings of local knowledges, attitudes, and behaviours towards NCDs and their risk factors. Single-gender arts-based participatory workshops and focus group discussions were conducted with local communities in Tanzania and Malawi. Thematic analysis compared workshop and focus group transcripts for depth of content and researcher-participant hierarchies. In addition, semiotic analysis examined the contribution of photographs of workshop activities to understanding participants' experiences and beliefs about NCD risk factors. The arts-based participatory workshops produced in-depth, vivid, emotive narratives of participants' beliefs about NCDs and their impact (e.g., "… it spreads all over your body and kills you-snake's poison is similar to diabetes poison"), while the focus groups provided more basic accounts (e.g., "diabetes is a fast killer"). The workshops also empowered participants to navigate activities with autonomy, revealing their almost overwhelmingly negative beliefs about NCDs. However, enabling participants to direct the focus of workshop activities led to challenges, including the perpetuation of stigma (e.g., comparing smells associated with diabetes symptoms with sewage). Semiotic analysis of workshop photographs provided little additional insight beyond that gained from the transcripts. Arts-based participatory workshops are promising as a novel method to inform development of culturally relevant approaches to NCD prevention in Tanzania and Malawi. Future research should incorporate more structured opportunities for participant reflection during the workshops to minimise harm from any emerging stigma.

Case Report: A gambling-related suicide in rural Malawi.

Background As in many other countries across sub-Saharan Africa, Malawi's commercial gambling sector has grown considerably in recent years. Driven by the widespread availability of internet through mobile devices, the industry has penetrated both urban and rural settings. In Malawi the model commonly implemented by gambling companies is similar to that used by mobile phone operators. Agents equipped with cellular devices connect to providers' servers to place wagers for customers and print receipts using simple printers attached to their devices. This has produced lucrative returns for providers. While increasing attention is being paid to this trend, most research focusses on sports betting and there is a deficit of papers that document gambling-related harms. Methods Here we present a narrative case report of a 16-year-old boy, 'Wati' (pseudonym), who lived in rural Malawi and took his own life after gambling and losing money that did not belong to him. As his community is part of a demographic surveillance site, a verbal autopsy was conducted, later supplemented with interviews with Wati's close friend and uncle, to whom his mother referred us. We triangulated data from these three sources to create a narrative case report of Wati's suicide and its relationship to his gambling practices. Results We found that the gambling harms leading up to Wati's suicide were recurrent, that his gambling practices were diverse (lottery, football betting, digital games and cards) and that signs of distress were apparent before his suicide. Conclusions From this case report, we learn that underage individuals participate in gambling in Malawi, can develop harmful habits and that their gambling is not confined to sports betting. We also learn that there is a lack of accessible services for people who develop harmful gambling practices. Wati could have benefited from such services and they may have saved his life.

Exploring the provision and motives behind the adoption of health-promotion programmes in professional football clubs across four European countries.

This study mapped existing health-promotion provisions targeting adults in professional football clubs across England, the Netherlands, Norway, and Portugal, and explored motives behind the clubs' adoption of the European Fans in Training (EuroFIT) programme. We surveyed top-tier football clubs in the four countries and interviewed representatives from football clubs and the clubs' charitable foundation who delivered EuroFIT. The findings showed large between-country differences, with football clubs in England reporting far greater healthy lifestyle provision than other countries. Relatively few health-promotion programmes targeted adults, particularly in the Netherlands, Portugal, and Norway. Club representatives reported that the motives for adopting the EuroFIT programme often involved adhering to both the social objectives of the football club or club's foundation and business-related objectives. They viewed the scientific evidence and evaluation underpinning EuroFIT as helpful in demonstrating the value and potential future impact of both the programme and the clubs' wider corporate social responsibility provision.

The impact of the initial Covid-19 lockdown upon regular sports bettors in Britain: Findings from a cross-sectional online study.

BACKGROUND: In Britain, unprecedented restrictions on daily life associated with the Covid-19 pandemic included the suspension of professional sports events during the initial 'lockdown'. This provides opportunities to observe changes in sports bettors' behaviour when their primary form of activity is removed and assess the impact of Covid-19 related circumstances upon gambling. METHODS: In July 2020, we conducted an online cross-sectional survey of people who bet regularly (at least monthly) on sports before Covid-19 (n = 3866). Bi-variate analyses compared changes in gambling behaviours before and during the initial lockdown. Multi-variate logistic regression models explored associations between problem gambling (men) and moderate risk or problem gambling (MRPG) (women) with changes in Covid-19 related circumstances and changing gambling behaviours during Britain's initial 'lockdown' (March-June 2020). RESULTS: 29.8% of male sports bettors and 33.4% of female sports bettors stopped gambling altogether during the initial Covid-19 lockdown, though 17.3% of men and 16.5% of women started a new form of gambling during lockdown. Among men, adjusted odds ratios of problem gambling were higher among those starting a new gambling activity during lockdown (OR = 2.50 [95% CI 1.38-4.53]). Among women, adjusted odds ratios of MRPG were higher among those whose frequency of gambling on any activity increased during lockdown (OR = 4.21 [1.99-8.92] and among those shielding for health reasons. Poorer wellbeing was associated with problem gambling for men and MRPG for women. CONCLUSIONS: Those changing gambling behaviours during the initial Covid-19 lockdown (e.g. increasing gambling frequency or starting a new gambling activity) are potentially vulnerable to gambling harms.

Community-driven citizen science approach to explore cardiovascular disease risk perception, and develop prevention advocacy strategies in sub-Saharan Africa: a programme protocol.

BACKGROUND: In sub-Saharan Africa (SSA), which experiences a disproportionately high cardiovascular disease (CVD) burden, population-based screening and prevention measures are hampered by low levels of knowledge about CVD and associated risk factors, and inaccurate perceptions of severity of risk. METHODS: This protocol describes the planned processes for implementing community-driven participatory research, using a citizen science method to explore CVD risk perceptions and to develop community-specific advocacy and prevention strategies in the rural and urban SSA settings. Multi-disciplinary research teams in four selected African countries will engage with and train community members living in rural and urban communities as citizen scientists to facilitate conceptualization, co-designing of research, data gathering, and co-creation of knowledge that can lead to a shared agenda to support collaborative participation in community-engaged science. The emphasis is on robust community engagement, using mobile technology to support data gathering, participatory learning, and co-creation of knowledge and disease prevention advocacy. DISCUSSION: Contextual processes applied and lessons learned in specific settings will support redefining or disassembling boundaries in participatory science to foster effective implementation of sustainable prevention intervention programmes in Low- and Middle-income countries.

Protocol for a Mixed-Method Investigation of the Impact of the COVID-19 Pandemic and Gambling Practices, Experiences and Marketing in the UK: The "Betting and Gaming COVID-19 Impact Study".

The COVID-19 pandemic led to unprecedented restrictions on people's movements and interactions, as well as the cancellation of major sports events and social activities, directly altering the gambling landscape. There is urgent need to provide regulators, policy makers and treatment providers with evidence on the patterns and context of gambling during COVID-19 and its aftermath. This protocol describes a study addressing the following three questions: (1) How has COVID-19 changed gambling practices and the risk factors for, and experience of, gambling harms? (2) What is the effect of COVID-19 on gambling marketing? (3) How has COVID-19 changed high risk groups' gambling experiences and practices? This mixed-method study focuses on two groups, namely young adults and sports bettors. In workpackage-1, we will extend an existing longitudinal survey of gambling in young adults (aged 16-24 years) (first wave conducted June-August 2019), adding COVID-19-related questions to the second wave (July-August 2020) and extending to a third wave in 2021; and undertake a survey of sports bettors in the UK (baseline n = 4000, ~July-August 2020), with follow-ups in ~October-November 2020 and ~February-March 2021. In workpackage-2, we will examine changes in expenditure on paid-for gambling advertising from January 2019 to July 2021 and undertake a mixed-method content analysis of a random sample of paid-for gambling advertising (n ~ 200) and social media marketing (n ~ 100) during the initial COVID-19 "lockdown". Workpackage-3 will involve qualitative interviews with a purposive sample of (a) young adults (aged 18-24 years) and (b) sports bettors.

Arts-based approaches to promoting health in sub-Saharan Africa: a scoping review.

INTRODUCTION: Arts-based approaches to health promotion have been used widely across sub-Saharan Africa (SSA), particularly in public health responses to HIV/AIDS. Such approaches draw on deep-rooted historical traditions of indigenous groups in combination with imported traditions which emerged from colonial engagement. To date, no review has sought to map the locations, health issues, art forms and methods documented by researchers using arts-based approaches in SSA. METHODS: Using scoping review methodology, 11 databases spanning biomedicine, arts and humanities and social sciences were searched. Researchers screened search results for papers using predefined criteria. Papers included in the review were read and summarised using a standardised proforma. Descriptive statistics were produced to characterise the location of the studies, art forms used or discussed, and the health issues addressed, and to determine how best to summarise the literature identified. RESULTS: Searches identified a total of 59 794 records, which reduced to 119 after screening. We identified literature representing 30 (62.5%) of the 48 countries in the SSA region. The papers covered 16 health issues. The majority (84.9%) focused on HIV/AIDS-related work, with Ebola (5.0%) and malaria (3.3%) also receiving attention. Most studies used a single art form (79.0%), but a significant number deployed multiple forms (21.0%). Theatre-based approaches were most common (43.7%), followed by music and song (22.6%), visual arts (other) (9.2%), storytelling (7.6%) and film (5.0%). CONCLUSIONS: Arts-based approaches have been widely deployed in health promotion in SSA, particularly in response to HIV/AIDS. Historically and as evidenced by this review, arts-based approaches have provided a platform to facilitate enquiry, achieved significant reach and in some instances supported demonstrable health-related change. Challenges relating to content, power relations and evaluation have been reported. Future research should focus on broadening application to other conditions, such as non-communicable diseases, and on addressing challenges raised in research to date.