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BackgroundExpanding access to shorter regimens for tuberculosis (TB) prevention, such as once-weekly isoniazid and rifapentine taken for 3 months (3HP), is critical for reducing global TB burden among people living with HIV (PLHIV). Our coprimary hypotheses were that high levels of acceptance and completion of 3HP could be achieved with delivery strategies optimized to overcome well-contextualized barriers and that 3HP acceptance and completion would be highest when PLHIV were provided an informed choice between delivery strategies.Methods and findingsIn a pragmatic, single-center, 3-arm, parallel-group randomized trial, PLHIV receiving care at a large urban HIV clinic in Kampala, Uganda, were randomly assigned (1:1:1) to receive 3HP by facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), or informed choice between facilitated DOT and facilitated SAT using a shared decision-making aid. We assessed the primary outcome of acceptance and completion (≥11 of 12 doses of 3HP) within 16 weeks of treatment initiation using proportions with exact binomial confidence intervals (CIs). We compared proportions between arms using Fisher's exact test (two-sided α = 0.025). Trial investigators were blinded to primary and secondary outcomes by study arm. Between July 13, 2020, and July 8, 2022, 1,656 PLHIV underwent randomization, with equal numbers allocated to each study arm. One participant was erroneously enrolled a second time and was excluded in the primary intention-to-treat analysis. Among the remaining 1,655 participants, the proportion who accepted and completed 3HP exceeded the prespecified 80% target in the DOT (0.94; 97.5% CI [0.91, 0.96] p < 0.001), SAT (0.92; 97.5% CI [0.89, 0.94] p < 0.001), and Choice (0.93; 97.5% CI [0.91, 0.96] p < 0.001) arms. There was no difference in acceptance and completion between any 2 arms overall or in prespecified subgroup analyses based on sex, age, time on antiretroviral therapy, and history of prior treatment for TB or TB infection. Only 14 (0.8%) participants experienced an adverse event prompting discontinuation of 3HP. The main limitation of the study is that it was conducted in a single center. Multicenter studies are now needed to confirm the feasibility and generalizability of the facilitated 3HP delivery strategies in other settings.ConclusionsShort-course TB preventive treatment was widely accepted by PLHIV in Uganda, and very high levels of treatment completion were achieved in a programmatic setting with delivery strategies tailored to address known barriers.Trial registrationClinicalTrials.gov NCT03934931.

BACKGROUND: Tuberculosis(TB) is among the leading causes of infectious death worldwide. Contact investigation is an evidence-based, World Health Organisation-endorsed intervention for timely TB diagnosis, treatment, and prevention but has not been widely and effectively implemented. METHODS: We are conducting a stepped-wedge, cluster-randomised, hybrid Type III implementation-effectiveness trial comparing a user-centred to a standard strategy for implementing TB contact investigation in 12 healthcare facilities in Uganda. The user-centred strategy consists of several client-focused components including (1) a TB-education booklet, (2) a contact-identification algorithm, (3) an instructional sputum-collection video, and (4) a community-health-rider service to transport clients, CHWs, and sputum samples, along with several healthcare-worker-focused components, including (1) collaborative improvement meetings, (2) regular audit-and-feedback reports, and (3) a digital group-chat application designed to develop a community of practice. Sites will cross-over from the standard to the user-centred strategy in six, eight-week transition steps following a randomly determined site-pairing scheme and timeline. The primary implementation outcome is the proportion of symptomatic close contacts completing TB evaluation within 60 days of TB treatment initiation by the index person with TB. The primary clinical effectiveness outcomes are the proportion of contacts diagnosed with and initiating active TB disease treatment and the proportion initiating TB preventative therapy within 60 days. We will assess outcomes from routine source documents using intention-to-treat analyses. We will also conduct nested mixed-methods studies of implementation fidelity and context and perform cost-effectiveness and impact modelling. The Makerere School of Public Health IRB(#554), the Uganda National Council for Science and Technology(#HS1720ES), and the Yale Institutional Review Board(#2000023199) approved the study and waived informed consent for the main trial implementation-effectiveness outcomes. We will submit results for publication in peer-reviewed journals and disseminate findings to local policymakers and representatives of affected communities. DISCUSSION: This pragmatic, quasi-experimental implementation trial will inform efforts to find and prevent undiagnosed persons with TB in high-burden settings using contact investigation. It will also help assess the suitability of human-centred design and communities of practice for tailoring implementation strategies and sustaining evidence-based interventions in low-and-middle-income countries. TRIAL REGISTRATION: The trial was registered(ClinicalTrials.gov Identifier NCT05640648) on 16 November 2022, after the trial launch on 7 March 2022.

Digital adherence technologies (DATs) have emerged as an alternative to directly observed therapy (DOT) for supervisions of tuberculosis (TB) treatment. We conducted a meta-analysis of implementation feedback obtained from people with TB and health care workers (HCWs) involved in TB REACH Wave 6-funded DAT evaluation projects. Projects administered standardized post-implementation surveys based on the Capability, Opportunity, Motivation, Behavior (COM-B) model to people with TB and their health care workers. The surveys included questions on demographics and technology use, Likert scale questions to assess capability, opportunity, and motivation to use DAT and open-ended feedback. We summarized demographic and technology use data descriptively, generated pooled estimates of responses to Likert scale questions within each COM-B category for people with TB and health care workers using random effects models, and performed qualitative analysis of open-ended feedback using a modified framework analysis approach. The analysis included surveys administered to 1290 people with TB and 90 HCWs across 6 TB REACH-funded projects. People with TB and HCWs had an overall positive impression of DATs with pooled estimates between 4·0 to 4·8 out of 5 across COM-B categories. However, 44% of people with TB reported taking TB medications without reporting dosing via DATs and 23% reported missing a dose of medication. Common reasons included problems with electricity, network coverage, and technical issues with the DAT platform. DATs were overall perceived to reduce visits to clinics, decrease cost, increase social support, and decrease workload of HCWs. DATs were acceptable in a wide variety of settings. However, there were challenges related to the feasibility of using current DAT platforms. Implementation efforts should concentrate on ensuring access, anticipating, and addressing technical challenges, and minimizing additional cost to people with TB.

Abstract Background Differentiation of the subclinical phases of myxomatous mitral valve disease (MMVD) in dogs relies heavily on echocardiography. Focused cardiac ultrasonography (FCU) is a point‐of‐care technique that can assess heart size. Hypothesis/Objectives Veterinary students trained in FCU can differentiate dogs with subclinical MMVD based on left ventricular (LV) and left atrial (LA) dimensions. Animals Forty‐eight dogs with subclinical MMVD. Methods Veterinary students were trained to measure LV dimension and LA‐to‐aortic root dimension ratio (LA : Ao) using FCU. Dogs were categorized into 2 cohorts based on whether or not the LV normalized internal diastolic dimension was ≥1.7 and LA : Ao was ≥1.6. Agreement between FCU and echocardiographic studies performed by cardiologists was evaluated. Results One‐hundred and forty‐six FCU examinations were performed by 58 veterinary students on 48 dogs. Overall agreement between students and cardiologists was moderate (Fleiss' kappa, 0.54; 95% confidence interval [CI], 0.39‐0.69; P

BACKGROUND: Implementation science offers a systematic approach to adapting innovations and delivery strategies to new contexts but has yet to be widely applied in low- and middle-income countries. The Fogarty Center for Global Health Studies is sponsoring a special series, Global Implementation Science Case Studies, to address this gap. METHODS: We developed a case study for this series describing our approach and lessons learned while conducting a prospective, multi-modal study to design, implement, and evaluate an implementation strategy for TB contact investigation in Kampala, Uganda. The study included formative, evaluative, and summative phases that allowed us to develop and test an adapted contact investigation intervention involving home-based sample collection for TB and HIV testing. We concurrently developed a multi-component mHealth implementation strategy involving fingerprint scanning, electronic decision support, and automated reporting of test results via text message. We then conducted a household-randomized, hybrid implementation-effectiveness trial comparing the adapted intervention and implementation strategy to usual care. Our assessment included nested quantitative and qualitative studies to understand the strategys acceptability, appropriateness, feasibility, fidelity, and costs. Reflecting on this process with a multi-disciplinary team of implementing researchers and local public health partners, we provide commentary on the previously published studies and how the results influenced the adaptation of international TB contact investigation guidelines to fit the local context. RESULTS: While the trial did not show improvements in contact investigation delivery or public health outcomes, our multi-modal evaluation strategy helped us identify which elements of home-based, mHealth-facilitated contact investigation were feasible, acceptable, and appropriate and which elements reduced its fidelity and sustainability, including high costs. We identified a need for better tools for measuring implementation that are simple, quantitative, and repeatable and for greater attention to ethical issues in implementation science. CONCLUSIONS: Overall, a theory-informed, community-engaged approach to implementation offered many learnings and actionable insights for delivering TB contact investigation and using implementation science in low-income countries. Future implementation trials, especially those incorporating mHealth strategies, should apply the learnings from this case study to enhance the rigor, equity, and impact of implementation research in global health settings.

99DOTS is a low-cost digital adherence technology that allows people with tuberculosis (TB) to self-report treatment adherence. There are limited data on its implementation, feasibility, and acceptability from sub-Saharan Africa. We conducted a longitudinal analysis and cross-sectional surveys nested within a stepped-wedge randomized trial at 18 health facilities in Uganda between December 2018 and January 2020. The longitudinal analysis assessed implementation of key components of a 99DOTS-based intervention, including self-reporting of TB medication adherence via toll-free phone calls, automated text message reminders and support actions by health workers monitoring adherence data. Cross-sectional surveys administered to a subset of people with TB and health workers assessed 99DOTS feasibility and acceptability. Composite scores for capability, opportunity, and motivation to use 99DOTS were estimated as mean Likert scale responses. Among 462 people with pulmonary TB enrolled on 99DOTS, median adherence was 58.4% (inter-quartile range [IQR] 38.7-75.6) as confirmed by self-reporting dosing via phone calls and 99.4% (IQR 96.4-100) when also including doses confirmed by health workers. Phone call-confirmed adherence declined over the treatment period and was lower among people with HIV (median 50.6% vs. 63.7%, p3 consecutive doses. Surveys were completed by 83 people with TB and 22 health workers. Composite scores for capability, opportunity, and motivation were high; among people with TB, composite scores did not differ by gender or HIV status. Barriers to using 99DOTS included technical issues (phone access, charging, and network connection) and concerns regarding disclosure. 99DOTS was feasible to implement and highly acceptable to people with TB and their health workers. National TB Programs should offer 99DOTS as an option for TB treatment supervision.

BackgroundMitigating financial barriers to tuberculosis (TB) diagnosis and treatment is a core priority of the global TB agenda. We evaluated the impact of a cash transfer intervention on completion of TB testing and treatment initiation in Uganda.MethodsWe conducted a pragmatic complete stepped wedge randomised trial of a one-time unconditional cash transfer at 10 health centres between September 2019 and March 2020. People referred for sputum-based TB testing were enrolled to receive UGX 20 000 (∼USD 5.39) upon sputum submission. The primary outcome was the number initiating treatment for micro-bacteriologically confirmed TB within 2 weeks of initial evaluation. The primary analysis included cluster-level intent-to-treat and per-protocol analyses using negative binomial regression.Results4288 people were eligible. The number diagnosed with TB initiating treatment was higher in the intervention period versus the pre-intervention period (adjusted rate ratio (aRR)=1.34) with a 95% CI of 0.62-2.91 (p=0.46), indicating a wide range of plausible true intervention effects. More were referred for TB testing (aRR=2.60, 95% CI 1.86-3.62; p

BackgroundPreventing childhood obesity and associated comorbidities is often hampered by disproportionate disparity in healthcare provision in minority ethnic populations. This study contextualized factors influencing childhood obesity and related comorbidity from the perspectives and experiences of parents of ethnic minority populations.MethodsFollowing ethical approval, families (n = 180) from ethnic minority populations in the Northeast of England were contacted through flyers, community social groups and online forum. Of the 180 families contacted, 22 expressed interests, of whom 12 parents were eligible to participate in the study, and one family dropped out due to time constraints. Therefore 11 parents from ethnic minority communities living with at least one child with obesity were interviewed. Each family was separately visited at home and took part in a semi-structured interview based on the study’s qualitative, descriptive phenomenological design. Nine of the families had one child who was diagnosed with an obesity-related comorbidity (non-alcoholic fatty liver disease, musculoskeletal problems or respiratory disorder). Semi-structured interviews were standardized around parents’ perspective and experience on how their children were impacted by obesity and comorbidities, healthcare preventative interventions including lifestyle physical activity and nutrition, and views on tackling obesity impact on their lives. All interviews were analyzed using qualitative thematic analysis.ResultsParents’ perspectives revealed 11 themes centered around experience of living with a child with obesity, risks, and impact of obesity related Non-Communicable Diseases; and access to support, and barriers unique to minority ethnic groups. Parents revealed social disadvantages, fear of victimization by social services, perceptions on their cultural and religious traditions, and racial stigmatization related to their child’s weight. Parents reported closer bonding with their children to protect them from the untoward consequences of overweight, and little awareness of healthcare obesity prevention programs. Work pressure, lack of time, absence of guidance from professionals were seen as barriers to healthy lifestyle, while support from friends and closer family bond in adopting healthy lifestyle behaviors were facilitators. However, there was little awareness or access to current healthcare obesity preventive offerings.ConclusionMinority ethnic communities’ perspective on childhood obesity prevention does not match the healthcare system preventative offerings. Community and family-oriented obesity preventative approaches, especially lifestyle interventions are needed beyond those administered by the primary healthcare system.

BackgroundDecentralised molecular testing for tuberculosis could reduce missed diagnoses and losses to follow-up in high-burden settings. The aim of this study was to evaluate the cost and cost-effectiveness of the Xpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) study strategy, a multicomponent strategy including decentralised molecular testing for tuberculosis, in Uganda.MethodsWe conducted a costing and cost-effectiveness analysis nested in a pragmatic cluster-randomised trial of onsite (decentralised) versus hub-and-spoke (centralised) testing for tuberculosis with Xpert MTB/RIF Ultra (Xpert) in 20 community health centres in Uganda. We collected empirical data on the cost of the XPEL-TB strategy (decentralised Xpert testing, workflow redesign, and performance feedback) and routine tuberculosis testing (onsite smear microscopy with specimen transport for centralised Xpert testing) from the health system perspective. Time-and-motion studies were performed to estimate activity-based service costs. Cost-effectiveness was assessed as the incremental cost (2019 US$) per tuberculosis diagnosis and per 14-day treatment initiation.FindingsThe XPEL-TB study ran from Oct 22, 2018, to March 1, 2020. Effectiveness and cost-effectiveness outcomes were assessed from Dec 1, 2018, to Nov 30, 2019 and included 4867 women and 3139 men. On a per-test basis, the cost of decentralised ($20·46, range $17·85-25·72) and centralised ($18·20, range $16·58-24·25) Xpert testing was similar. However, decentralised testing resulted in more patients receiving appropriate Xpert testing, so the per-patient cost of decentralised testing was higher: $20·28 (range $17·68-25·48) versus $9·59 (range $7·62-14·34). The XPEL-TB strategy was estimated to cost $1332 (95% uncertainty range $763-5558) per incremental tuberculosis diagnosis and $687 ($501-1207) per incremental patient initiating tuberculosis treatment within 14 days. Cost-effectiveness was reduced in sites performing fewer than 150-250 tests annually.InterpretationThe XPEL-TB strategy facilitated higher rates of Xpert testing for tuberculosis at a similar per-test cost and modest incremental cost per tuberculosis diagnosis and treatment initiation. Decentralised Xpert testing, with appropriate implementation supports, should be scaled up to clinics with sufficient testing volume to support a single-module device.FundingThe National Heart, Lung, and Blood Institute.

This essay contends that emotional oscillations between subordination and emancipation are responsible for the inconclusivity and evasiveness of Le Fanu’s plots, which critics often emphasise but rarely try to explain. The parallels between, on the one hand, the dual structures that pervade Le Fanu’s works and, on the other, the binaries of latent dream thoughts and manifest dream content, the familiar and the uncanny, which Sigmund Freud employs in his explorations of the unconscious, shed significant light on the motivational forces at work in Le Fanu’s oeuvre. Le Fanu uses displacement and condensation, the major operations Freud attributes to dream work, to create an outside world, which reveals itself as an upended world within. This essay tries to demonstrate the psychological significance of central motifs in Le Fanu’s works, such as the double and the closed room. In light of later psychoanalytical insights into the influence of childhood traumatisation on the creativity of writers, Le Fanu appears absorbed by the incorporation of his innermost mortifications and yearnings into the defamiliarisations of his fiction. On the basis of Gothic patterns, he produces psychological fiction avant la lettre. He anticipates George Orwell’s dissection of mental processes in terms of manipulative social engineering, H.P. Lovecraft’s fantastic evocations of a Jungian collective unconscious, and literary interiorisation by modernist techniques, developed not long after Le Fanu’s death by the likes of James Joyce and Virginia Woolf.

Abstract Background The World Health Organization endorsed Truenat MTB rapid molecular assay in 2020 and recommended additional in-country evaluation studies before uptake. We evaluated the accuracy and operational feasibility of Truenat MTB assay (Truenat) in comparison with GeneXpert Ultra and culture. Methods In a cross-sectional study of 250 presumptive TB patients, participants were requested to provide a sputum sample on the day of their visit to the clinic. The sputum sample was homogenized and a portion was tested using GeneXpert Ultra as per the routine standard procedure and the other portion was tested using Truenat assay at the clinic laboratory. The second sample portion was processed for Concentrated Fluorescent smear Microscopy (CFM), LJ, and MGIT cultures. Truenat sensitivity and specificity were compared to GeneXpert Ultra and culture. Test performance characteristics and operational feasibility assessment data through interview of the study laboratory staff were also collected and summarized as proportions and percentages. Results Of the 250 participants recruited in the study, the sensitivity and specificity of Truenat was n/N (%, 95%CI); 66/82 (80.5, 70.2–88.4) and 156/159 (98.1, 94.5–99.6) when compared with Ultra, 50/64 (89.3, 66.0-87.4) and 166/180 (92.2, 87.2–95.6) when compared with LJ, 58/71 (81.7,70.7–89.8) and 131/138 (94.9, 89.8–97.9) when compared to MGIT culture and 59/73 (80.8, 69.9–89.1) and 159/169 (94.1,89.3–97.1) when compared to LJ and/or MGIT culture. The sensitivity of Truenat was lower, 14/23 (60.9, 40.6–82.8) among smear-negative compared to 45/50 (90.0, 78.1–96.6) among smear-positive participants but not different by HIV status. There were no special training needs especially among laboratory personnel with previous GeneXpert /molecular test experience, 19/242 (7.8%) error/invalid, and 12 (17,4%) uninterpretable/indeterminate results mainly for rifampicin resistance determination. However, there were 3 (3.5%) of GeneXpert Ultra indeterminate results. Conclusion Among presumptive TB patients in Uganda, the Truenat assay has high sensitivity and specificity. The Truenat assay has acceptable operational feasibility attributes when compared with the GeneXpert Assay.

The implementation of Evidence-Based Practice (EBP) in healthcare can significantly improve health outcomes and alleviate poverty, particularly in developing countries like Uganda. Despite its potential, EBP adoption remains limited due to challenges such as resource constraints and inadequate infrastructure. This study explores the barriers and facilitators of EBP implementation among lecturers at Makerere University College of Health Sciences (Mak-CHS) in Uganda, providing insights relevant to resource-limited settings. This qualitative study employed semi-structured interviews with 12 purposively sampled lecturers at Mak-CHS. Interviews were transcribed verbatim and analysed using thematic analysis to identify key themes related to EBP barriers and facilitators. Participants (n = 12) identified EBP as a relatively new concept in Uganda. Key barriers included resistance to change, lack of resources, inadequate organisational support, and insufficient locally generated research. Facilitators included strong organisational support, integration of EBP training into curricula, and the adoption of a ‘train-the-trainers’ approach. These factors are closely tied to the challenges and opportunities typical of resource-limited settings. EBP adoption in Uganda faces significant challenges, particularly within resource-limited environments. However, strong institutional support and targeted training programs, such as integrating EBP into undergraduate curricula and implementing ‘train-the-trainers’ strategies, are critical for overcoming these barriers. Implications for Practice: To enhance EBP adoption, it is essential to incorporate EBP training into healthcare curricula, develop robust ‘train-the-trainers’ programs, and ensure the availability of necessary resources. These strategies are crucial for fostering a culture of evidence-based decision-making in healthcare, particularly in resource-limited settings like Uganda.

AbstractCOVID-19 was declared a global pandemic by the World Health Organisation in March 2022, resulting in over 115,0000 deaths worldwide by October of the same year. Only 25% of adults worldwide undertake the recommended levels of Physical activity (PA) for their respective age ranges, potentially exacerbating the symptoms associated with contraction of COVID-19 and recovery. This review aims to identify specific barriers and facilitators to engagement with PA interventions that were implemented during the pandemic. This quantitative study was undertaken adhering to the Preferred Reporting Items for Systematic Reviews and Meta Analyses. A systematic search was conducted of the following databases: CINAHL, MEDLINE, AMED, Cochrane, SCOPUS and Web of Science. Quality appraisal of selected papers was conducted through the CASP tool, with data extraction by two independent reviewers thereby minimising bias. This was then followed by a meta-analysis of the resulting data; however, no eligible studies were identified. Whilst 258 papers were identified through the database searches, following removal of duplicates (n = 19), the remaining 239 were screened, of these 237 were excluded on title and abstract, with the remaining two subsequently excluded following full read due to failure to meet the inclusion criteria. This review identified research gaps in the study.

AbstractStudies indicated that prior to the COVID-19 pandemic, the majority of adult Black, Asian and Minority Ethnic (BAME) individuals lived a sedentary lifestyle, which exacerbated their physical inactivity behaviours during the COVID-19 subsequent lockdowns. Experiences related to making healthy physical activity (PA) lifestyle choices in adult BAME individuals during the COVID-19 pandemic were mapped onto the capability, opportunity, and motivation model of behaviour (COM-B model). Twelve adult BAME participants were interviewed using one-on-one, semi-structured interviews that lasted 45–60 min, which captured participant perceptions of PA engagement during the pandemic between April and August 2022 via Microsoft Teams. Using thematic analysis, three themes were generated and successfully mapped onto the modified COM-B model. These include the influence of culture on the PA lifestyle, the capability to engage in the PA lifestyle, and the self-reflective determination model. Although existing literature has used both the COM-B and the self-determination models, these have been generalised findings that are not representative of adult BAME individuals’ lived PA participation experiences. This enabled the modification of the COM-B and self-reflective determination models to reflect the experiences of adult BAME individuals with respect to PA participation as well as improving PA culturally related policies.

AbstractThe study sought to explore the barriers and facilitators for making physical activity lifestyle choices among Black Asian Ethnic Minority (BAME) students at Teesside University during the COVID-19 pandemic. A qualitative approach was used to capture the in-depth physical activity experiences of BAME individuals. There is a paucity of primary qualitative studies focusing on BAME individuals’ activity lifestyles prior to and during the COVID-19 lockdowns between April and August 2020. BAME individuals faced exacerbated physical, psychological, social, and institutional barriers which are mapped onto the capability, opportunity, and motivation model of behaviour (COM-B). Twelve BAME participants were interviewed via Microsoft Teams using semi-structured interviews lasting 45 to 60 minutes. Using thematic analysis, we identified seven themes; the two primary ones were barriers and facilitators to being active and were successfully mapped onto the modified COM-B. Although existing literature has used the COM-B, these were primary quantitative findings that did not enable an in-depth exploration of BAME individuals lived experiences of physical activity participation during COVID-19. Thus, the COM-B model was modified to reflect this research’ qualitative approach, through which improved policies and implementation strategies may be applied specifically to BAME individuals.

AbstractPhysical activity (PA) is widely recognised as being integral to physical and mental wellbeing. The World Health Organisation recommends around 150–300 minutes of moderately intense PA per week for adults aged 18–64 years. Physical inactivity costs the UK £7.4 billion per year and is associated with one out of every six deaths that occur in the country. The review aims at exploring the barriers and facilitators to making healthy PA lifestyle choices among UK BAME adults during the COVID-19 pandemic. Database searches were conducted in CINAHL, AMED, Medline, SCOPUS, COCHRANE, EMBASE, and Web of Science. There are 53 records that were identified. After removing three duplicates, the titles and abstracts of 50 papers were screened. Of these, all but 50 studies were excluded after reviewing the title and abstracts, resulting in no studies eligible for inclusion. Data extraction using the JBI-QARI data extraction template was performed, followed by a narrative synthesis of the resulting data; however, no eligible studies were identified. This empty systematic review without meta-analysis, highlighted major research gaps and indicated the state of the evidence between 2019–2021. The review has, through the application of theoretical models (COM-B and TTM), highlighted themes that need to be addressed.

The generalized Lie symmetries of almost regular Lagrangians are studied, and their impact on the evolution of dynamical systems is determined. It is found that if the action has a generalized Lie symmetry, then the Lagrangian is necessarily singular; the converse is not true, as we show with aspecific example. It is also found that the generalized Lie symmetry of the action is a Lie subgroup of the generalized Lie symmetry of the Euler–Lagrange equations of motion. The converse is once againnot true, and there are systems for which the Euler–Lagrange equations of motion have a generalized Lie symmetry while the action does not, as we once again show through a specific example. Most  importantly, it is shown that each generalized Lie symmetry of the action contributes one arbitrary function to the evolution of the dynamical system. The number of such symmetries gives a lowerbound to the dimensionality of the family of curves emanating from any set of allowed initial data in the Lagrangian phase space. Moreover, if second- or higher-order Lagrangian constraints are introduced during the application of the Lagrangian constraint algorithm, these additional constraints could not have been due to the generalized Lie symmetry of the action.