Background Sex differences in the management of cardiovascular disease have been reported in secondary care. We conducted a systematic review with meta-analysis of systematically investigated sex ...differences in cardiovascular medication prescription among patients at high risk or with established cardiovascular disease in primary care. Methods and Results PubMed and Embase were searched between 2000 and 2019 for observational studies reporting on the sex-specific prevalence of aspirin, statins, and antihypertensive medication prescription, including beta blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and diuretics, in primary care. Random effects meta-analysis was used to obtain pooled women-to-men prevalence ratios for each cardiovascular medication prescription. Metaregression models assessed the impact of age and year on the findings. A total of 43 studies were included, involving 2 264 600 participants (28% women) worldwide. Participants' mean age ranged from 51 to 76 years. The pooled prevalence of cardiovascular medication prescription for women was 41% for aspirin, 60% for statins, and 68% for any antihypertensive medications. Corresponding rates for men were 56%, 63%, and 69% respectively. The pooled women-to-men prevalence ratios were 0.81 (95% CI, 0.72-0.92) for aspirin, 0.90 (95% CI, 0.85-0.95) for statins, and 1.01 (95% CI, 0.95-1.08) for any antihypertensive medications. Women were less likely to be prescribed angiotensin-converting enzyme inhibitors (0.85; 95% CI, 0.81-0.89) but more likely with diuretics (1.27; 95% CI, 1.17-1.37). Mean age, mean age difference between the sexes, and year of study had no significant impact on findings. Conclusions Sex differences in the prescription of cardiovascular medication exist among patients at high risk or with established cardiovascular disease in primary care, with a lower prevalence of aspirin, statins, and angiotensin-converting enzyme inhibitors prescription in women and a lower prevalence of diuretics prescription in men.
Aim
To determine the association between structured diabetes self‐management education (DSME) and glycaemic control in persons living with diabetes (PLD) in low‐ and middle‐income countries (LMICs).
...Methods
PubMed, Embase and Cochrane databases were searched up to June 2020 for intervention studies on the effect of structured DSME on glycaemic control in PLD in LMICs (PROSPERO registration CRD42020164857). The primary outcome was reduction in glycated haemoglobin. Included studies were assessed for risk of bias (RoB) with the Cochrane RoB tool for randomised trials. Findings were summarized in a narrative synthesis.
Results
Out of 154 s retrieved and screened for eligibility, nine studies with a total of 1389 participants were included in the review. The structured DSME interventions were culturally tailored and were delivered in‐person. They were associated with reductions in glycated haemoglobin in all studies: mean/median reduction ranged between 0.5% and 2.6% relative to baseline.
Conclusions
There is a dearth of literature on the association between structured DSME and glycaemic control among PLD in LMICs. The evidence available suggests that in LMICs; particularly in sub‐Saharan Africa, structured DSME is associated with reduction in glycated haemoglobin. We recommend further intervention studies on the effects of structured DSME in LMICs.
Background
The extent to which psychosocial stress relates to type 2 diabetes among sub‐Saharan Africans is not well understood. We assessed associations of psychosocial stresses with type 2 diabetes ...status and glycaemic control among Ghanaians.
Methods
We used data from Research on Obesity and Diabetes among African Migrants (RODAM) study. We performed logistic and linear regression models to assess association of psychosocial stresses with type 2 diabetes and HbA1c respectively with adjustments for age, sex, education and other stresses. We also assessed moderation effects of migration status (migrant Ghanaians vs. non‐migrant Ghanaians), age, sex and education by adding interaction terms in models.
Results
Four thousand eight hundred and forty one Ghanaians were included with 44% resident in Ghana, 62% women, mean age of 46 years and 10% having type 2 diabetes. Psychosocial stress at home and at work were not associated with type 2 diabetes or HbA1c levels. Negative life events in past 12 months were negatively associated with type 2 diabetes (adjusted odds ratio = 0.93, 95% CI 0.87–0.99). Perceived discrimination was positively associated with type 2 diabetes (aOR = 1.01, 95% CI 1.004–1.03). Both associations were more pronounced in men. Perceived discrimination was also positively associated with HbA1c levels, especially among those with type 2 diabetes (adjusted β = 0.01, 95% CI 0.007–0.02).
Conclusions
Perceived discrimination and negative life events are associated with type 2 diabetes and glycaemic control among Ghanaians, especially in men. Further studies are needed to identify context‐specific mechanisms underlying these associations.
Objective
We aimed to determine the prevalence of abnormal umbilical artery (UA), uterine artery (UtA), middle cerebral artery (MCA) and cerebroplacental ratio (CPR) Doppler, and their relationship ...with adverse perinatal outcomes in women undergoing routine antenatal care in the third trimester.
Design
Prospective cohort.
Setting
Kagadi Hospital, Uganda.
Population
Non‐anomalous singleton pregnancies.
Methods
Women underwent an early dating ultrasound and a third‐trimester Doppler scan between 32 and 40 weeks of gestation, from 2018 to 2020. We handled missing data using multiple imputation and analysed the data using descriptive methods and a binary logistic regression model.
Main outcome measures
Composite adverse perinatal outcome (CAPO), perinatal death and stillbirth.
Results
We included 995 women. The mean gestational age at Doppler scan was 36.9 weeks (SD 1.02 weeks) and 88.9% of the women gave birth in a health facility. About 4.4% and 5.6% of the UA pulsatility index (PI) and UtA PI were above the 95th percentile, whereas 16.4% and 10.4% of the MCA PI and CPR were below the fifth percentile, respectively. Low CPR was strongly associated with stillbirth (OR 4.82, 95% CI 1.09–21.30). CPR and MCA PI below the fifth percentile were independently associated with CAPO; the association with MCA PI was stronger in small‐for‐gestational‐age neonates (OR 3.75, 95% CI 1.18–11.88).
Conclusion
In late gestation, abnormal UA PI was rare. Fetuses with cerebral blood flow redistribution were at increased risk of stillbirth and perinatal complications. Further studies examining the predictive accuracy and effectiveness of antenatal Doppler ultrasound screening in reducing the risk of perinatal deaths in low‐ and middle‐income countries are warranted.
Tweetable
Blood flow redistribution to the fetal brain is strongly associated with stillbirths in low‐resource settings.
Tweetable
Blood flow redistribution to the fetal brain is strongly associated with stillbirths in low‐resource settings.
This article includes Author Insights, a video available at https://vimeo.com/bjogs/authorinsights17115.
Objective
There is insufficient evidence on the role of self‐financing patient support groups in the control of blood pressure (BP) and/or diabetes in low‐ and middle‐income countries (LMICs). We ...conducted a systematic review to investigate the effectiveness of these groups in BP and glycaemic control.
Methods
We searched PubMed, Embase, SCOPUS, Web of Science, Global Health, African Journals Online, CINAHL and African Index Medicus for published peer‐reviewed articles from inception up to November 2021. Grey literature was obtained from OpenGrey. Studies on patient support groups for hypertension and/or diabetes with a component of pooling financial resources, conducted in LMICs, were included. Narrative reviews, commentaries, editorials and articles published in languages other than English and French were excluded. Study quality and risk of bias were assessed using the National Institutes of Health Quality assessment tool and the revised Cochrane risk‐of‐bias tool. Results are reported according to PRISMA guidelines.
Results
Of 724 records screened, three studies met the criteria: two trials conducted in Kenya and a retrospective cohort study conducted in Cambodia. All studies reported improvement in BP control after 12 months follow‐up with reductions in systolic BP of 23, 14.8, and 16.9 mmHg, respectively. Two studies reported diabetes parameters. The first reported improvement in HbA1c (reduction from baseline 10.8%, to 10.6% at 6 months) and random blood sugar (baseline 8.9 mmol/L, to 8.5 mmol/L at 6 months) but these changes did not achieve statistical significance. The second reported a reduction in fasting blood glucose (baseline—216 mg/dl, 12 months—159 mg/dl) in diabetic patients on medication.
Conclusion
Self‐financing patient support groups for diabetes and hypertension are potentially effective in the control of BP and diabetes in LMICs. More studies are needed to add to the scarce evidence base on the role of self‐financing patient support groups.
Objectives
To systematically review reasons for the willingness to participate in biomedical human subjects research in low‐ and middle‐income countries (LMICs).
Methods
Five databases were ...systematically searched for articles published between 2000 and 2017 containing the domain of ‘human subjects research’ in ‘LMICs’ and determinant ‘reasons for (non)participation’. Reasons mentioned were extracted, ranked and results narratively described.
Results
Ninety‐four articles were included, 44 qualitative and 50 mixed‐methods studies. Altruism, personal health benefits, access to health care, monetary benefit, knowledge, social support and trust were the most important reasons for participation. Primary reasons for non‐participation were safety concerns, inconvenience, stigmatisation, lack of social support, confidentiality concerns, physical pain, efficacy concerns and distrust. Stigmatisation was a major concern in relation to HIV research. Reasons were similar across different regions, gender, non‐patient or patient participants and real or hypothetical study designs.
Conclusions
Addressing factors that affect (non‐)participation in the planning process and during the conduct of research may enhance voluntary consent to participation and reduce barriers for potential participants.
Objectifs
Analyser systématiquement les raisons de la volonté de participer à la recherche biomédicale sur les sujets humains dans les PRFI.
Méthodes
Cinq bases de données ont été systématiquement recherchées pour des articles publiés entre 2000 et 2017 contenant le domaine de la «recherche sur des sujets humains» dans les «PRFI» et les déterminantes «raisons de la (non) participation». Les raisons mentionnées ont été extraites, classées et les résultats décrits de manière narrative.
Résultats
94 articles ont été inclus, 44 études qualitatives et 51 études à méthodes mixtes. L'altruisme, les avantages pour la santé personnelle, l'accès aux soins de santé, les avantages pécuniaires, les connaissances, le soutien social et la confiance étaient les principales raisons de la participation. Les principales raisons de la non‐participation étaient les problèmes de sécurité, les inconvénients, la stigmatisation, le manque de soutien social, les soucis de confidentialité, la douleur physique, les soucis d'efficacité et la méfiance. La stigmatisation était une préoccupation majeure dans le cadre de la recherche sur le VIH. Les raisons étaient similaires dans les différentes régions, le sexe, les participants patients ou non‐patients et les modèles d’étude réels ou hypothétiques.
Conclusions
La prise en compte des facteurs qui affectent la (non) participation au processus de planification et au cours de la recherche peut renforcer le consentement volontaire à la participation et réduire les obstacles pour les participants potentiels.
Objective
To assess the care for hypertension in Sierra Leone, by the use of a cascade‐of‐care approach, to identify where the need for healthcare system interventions is greatest.
Methods
Using data ...from a nationwide household survey on surgical conditions undertaken in 1956 participants ≥18 years from October 2019 to March 2020, a cascade of care for hypertension consisting of four categories – hypertensive population, those diagnosed, those treated and those controlled – was constructed. Hypertension was defined as having a blood pressure ≥140/90 mmHg, or self‐reported use of antihypertensive medication. Logistic regression analysis was used to investigate factors associated with undiagnosed hypertension.
Results
The prevalence of hypertension was 22%. Among those with hypertension, 23% were diagnosed, 11% were treated and 5% had controlled blood pressure. The largest loss to care (77%) was between being hypertensive and receiving a diagnosis. Male sex, age and living in a rural location, were significantly associated with the odds of undiagnosed hypertension. There was no significant difference between men and women in the number of patients with controlled blood pressure. Adults aged 40 or older were observed to be better retained in care compared with those younger than 40 years of age.
Conclusion
There is a significant loss to care in the care cascade for hypertension in Sierra Leone. Our results suggest that increasing awareness of cardiovascular risk and risk factor screening for early diagnosis might have a large impact on hypertension care.
Maternal and neonatal mortality remains high in many low- and middle-income countries (LMIC). Availability and use of mobile phones is increasing rapidly with 90% of persons in developing countries ...having a mobile-cellular subscription. Mobile health (mHealth) interventions have been proposed as effective solutions to improve maternal and neonatal health. This systematic review assessed the effect of mHealth interventions that support pregnant women during the antenatal, birth and postnatal period in LMIC.
The review was registered with Prospero (CRD42014010292). Six databases were searched from June 2014-April 2015, accompanied by grey literature search using pre-defined search terms linked to pregnant women in LMIC and mHealth. Quality of articles was assessed with an adapted Cochrane Risk of Bias Tool. Because of heterogeneity in outcomes, settings and study designs a narrative synthesis of quantitative results of intervention studies on maternal outcomes, neonatal outcomes, service utilization, and healthy pregnancy education was conducted. Qualitative and quantitative results were synthesized with a strengths, weaknesses, opportunities, and threats analysis.
In total, 3777 articles were found, of which 27 studies were included: twelve intervention studies and fifteen descriptive studies. mHealth interventions targeted at pregnant women increased maternal and neonatal service utilization shown through increased antenatal care attendance, facility-service utilization, skilled attendance at birth, and vaccination rates. Few articles assessed the effect on maternal or neonatal health outcomes, with inconsistent results.
mHealth interventions may be effective solutions to improve maternal and neonatal service utilization. Further studies assessing mHealth's impact on maternal and neonatal outcomes are recommended. The emerging trend of strong experimental research designs with randomized controlled trials, combined with feasibility research, government involvement and integration of mHealth interventions into the healthcare system is encouraging and can pave the way to improved decision making on best practice implementation of mHealth interventions.
Stigma is one of the many factors hindering tuberculosis (TB) control by negatively affecting hospital delay and treatment compliance. In Zambia, the morbidity and mortality due to TB remains high, ...despite extended public health attempts to control the epidemic and to diminish stigma.
To enhance understanding of TB-related stigmatizing perceptions and to describe TB patients' experiences of stigma in order to point out recommendations to improve TB policy.
We conducted a mixed method study at Kanyama clinic and surrounding areas, in Lusaka, Zambia; structured interviews with 300 TB patients, multiple in-depth interviews with 30 TB patients and 10 biomedical health workers, 3 focus group discussions with TB patients and treatment supporters, complemented by participant observation and policy analysis of the TB control program. Predictors of stigma were identified by use of multivariate regression analyses; qualitative analysis of the in-depth interviews, focus group discussions and participant observation was used for triangulation of the study findings.
We focused on the 138/300 patients that described TB-related perceptions and attitudes, of whom 113 (82%) reported stigma. Stigma provoking TB conceptions were associated with human immunodeficiency virus (HIV)-infection, alleged immoral behaviour, (perceived) incurability, and (traditional) myths about TB aetiology. Consequences of stigma prevailed both among children and adults and included low self-esteem, insults, ridicule, discrimination, social exclusion, and isolation leading to a decreased quality of life and social status, non-disclosure, and/or difficulties with treatment compliance and adherence. Women had significantly more stigma-related problems than men.
The findings illustrate that many TB patients faced stigma-related issues, often hindering effective TB control and suggesting that current efforts to reduce stigma are not yet optimal. The content and implementation of sensitization programs should be improved and more emphasis needs to be placed on women and children.
Objectives
To document the prevalence of impaired glucose tolerance (IGT) and undiagnosed diabetes mellitus (DM) and to identify factors associated with undiagnosed DM in people living with HIV ...(PLWH).
Methods
Cross‐sectional study performed at Ndlovu Medical Center, Limpopo, South Africa including PLWH aged ≥18 years. Between August and November 2017, 356 HIV‐positive participants were included. Information was collected on socio‐demographics, DM symptoms and risk factors for DM. IGT and DM were diagnosed using random plasma glucose and/or HbA1c. Factors associated with undiagnosed DM were assessed by comparing participants with newly diagnosed DM to participants without DM.
Results
IGT was diagnosed in 172 (48.3%) participants. Twenty‐nine (8.1%) participants met the definition of DM, of whom 17 (58.6%) were newly diagnosed. Compared to participants without DM, participants with DM were on average 5 years older, were more likely to have a positive family history for DM, were less physically active and had higher systolic blood pressure, body mass index and waist circumference. Factors associated with undiagnosed DM included age ≥45 years (odds ratio OR = 3.59) and physical inactivity (OR = 3.17).
Conclusions
The prevalence of IGT and DM among PLWH is high and more than half of DM cases were undiagnosed. Regular screening for DM in PLWH is recommended, especially in an ageing population with additional cardiovascular disease risk factors.
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