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Competing Interests: TB is an overseas development institute fellow at the Ministry of Health in Sierra Leone; honorary global health lecturer at King's College London; and a visiting lecturer at Njala University. LCC is on part-time secondment as Chief Scientific Adviser to the Department of Health and Social Care, UK and Chief Executive Officer at the National Institute for Health and Care Research. LDO declares no competing interests.

Vaccination against hepatitis B virus (HBV) is effective at preventing vertical transmission. Sierra Leone, Liberia, and Guinea are hyperendemic West African countries; yet, childhood vaccination coverage is suboptimal, and the determinants of incomplete vaccination are poorly understood. We analyzed national survey data (2018-2020) of children aged 4-35 months to assess complete HBV vaccination (receiving 3 doses of the pentavalent vaccine) and incomplete vaccination (receiving <3 doses). Statistical analysis was conducted using the complex sample command in SPSS (version 28). Multivariate logistic regression was used to identify determinants of incomplete immunization. Overall, 11,181 mothers were analyzed (4,846 from Sierra Leone, 2,788 from Liberia, and 3,547 from Guinea). Sierra Leone had the highest HBV childhood vaccination coverage (70.3%), followed by Liberia (64.6%) and Guinea (39.3%). Within countries, HBV vaccination coverage varied by socioeconomic characteristics and healthcare access. In multivariate regression analysis, factors that were significantly associated with incomplete vaccination in at least one country included sex of the child, Muslim mothers, lower household wealth index, <4 antenatal visits, home delivery, and distance to health facility vaccination (all p  < 0.05). Understanding and addressing modifiable determinants of incomplete vaccination will be essential to help achieve the 2030 viral hepatitis elimination goals.

Introduction: Access to care for cardiovascular disease risk factors (CVDRFs) in low- and middle-income countries is limited. We aimed to describe the need and access to care for people with CVDRF and the preparedness of the health system to treat these in Bo, Sierra Leone., Methods: Data from a 2018 household survey conducted in Bo, Sierra Leone, was analysed. Demographic, anthropometric and clinical data on CVDRF (hypertension, diabetes mellitus or dyslipidaemia) from randomly sampled individuals 40 years of age and above were collected. Future risk of CVD was calculated using the World Health Organisation-International Society of Hypertension (WHO-ISH) calculator with high risk defined as >20% risk over 10 years. Requirement for treatment was based on WHO package of essential non-communicable (PEN) disease guidelines (which use a risk-based approach) or requiring treatment for individual CVDRF; whether participants were on treatment was used to determine whether care needs were met. Multivariable regression was used to test associations between individual characteristics and outcomes. Data from the most recent WHO Service Availability and Readiness Assessment (SARA) were used to create a score reflecting health system preparedness to treat CVDRF, and compared to that for HIV., Results: 2071 individual participants were included. Most participants (n = 1715 [94.0%]) had low CVD risk; 423 (20.6%) and 431 (52.3%) required treatment based upon WHO PEN guidelines or individual CVDRF, respectively. Sixty-eight (15.8%) had met-need for treatment determined by WHO guidelines, whilst 84 (19.3%) for individual CVDRF. Living in urban areas, having education, being older, single/widowed/divorced, or wealthy were independently associated with met need. Overall facility readiness scores for CVD/CVDRF care for all facilities in Bo district was 16.8%, compared to 41% for HIV., Conclusion: The number of people who require treatment for CVDRF in Sierra Leone is substantially lower based on WHO guidelines compared to CVDRF. CVDRF care needs are not met equitably, and facility readiness to provide care is low., Competing Interests: The authors have declared that no competing interests exist.

Background: Little is known about modifiable dietary and physical activity risk factors for cardiovascular diseases (CVDs) in Sierra Leone. This information is critical to the development of health improvement interventions to reduce the prevalence of these diseases. This cross-sectional study investigated the prevalence and socio-demographic correlates of dietary and physical activity risk behaviours amongst adults in Bo District, Sierra Leone., Methods: Adults aged 40+ were recruited from 10 urban and 30 rural sub-districts in Bo. We examined risk factors including: ≤150 min of moderate or vigorous-intensity physical activity (MVPA) weekly, physical inactivity for ≥3 h daily, ≤5 daily portions of fruit and vegetables, and salt consumption (during cooking, at the table, and in salty snacks). We used logistic regression to investigate the relationship between these outcomes and participants' socio-demographic characteristics., Results: 1978 eligible participants (39.1% urban, 55.6% female) were included in the study. The prevalence of behavioural risk factors was 83.6% for ≤5 daily portions of fruit and vegetables; 41.4 and 91.6% for adding salt at the table or during cooking, respectively and 31.1% for eating salty snacks; 26.1% for MVPA ≤150 min weekly, and 45.6% for being physically inactive ≥3 h daily. Most MVPA was accrued at work (nearly 24 h weekly). Multivariable analysis showed that urban individuals were more likely than rural individuals to consume ≤5 daily portions of fruit and vegetables (Odds Ratio (OR) 1.09, 95% Confidence Interval (1.04-1.15)), add salt at the Table (OR 1.88 (1.82-1.94)), eat salty snacks (OR 2.00 (1.94-2.07)), and do MVPA ≤150 min weekly (OR 1.16 (1.12-1.21)). Male individuals were more likely to add salt at the Table (OR 1.23 (1.20-1.27)) or consume salty snacks (OR 1.35 (1.31-1.40)) than female individuals but were less likely to report the other behavioural risk-factors examined. Generally, people in lower wealth quintiles had lower odds of each risk factor than those in the higher wealth quintiles., Conclusion: Dietary risk factors for CVD are highly prevalent, particularly among urban residents, of Bo District, Sierra Leone. Our findings highlight that forthcoming policies in Sierra Leone need to consider modifiable risk factors for CVD in the context of urbanisation., (© 2021. The Author(s).)

Context: The dietary choices people make affect personal health and have consequences for the environment, both of which have serious implications for the 2030 Sustainable Development Agenda. In global reviews, the literature on meat, fruit, and vegetable consumption in sub-Saharan Africa (SSA) is limited., Objective: This systematic review set out to quantify meat, fruit, and vegetable consumption in SSA populations and to answer the following question: How much meat, fruit, and/or vegetables are being consumed daily by which individuals in SSA over the years?, Data Sources: Following the PRISMA guidelines, the authors systematically searched the MEDLINE, EMBASE, ASSIA CINAHL, Web of Science, POPLINE, and Google Scholar databases to identify 47 (out of 5922 search results) studies reporting meat, fruit, and/or vegetable consumption in SSA populations., Data Extraction: Three independent investigators extracted data on year of data collection, study country, study population and geographical context, and population intake of meat, fruit, and/or vegetables., Data Analysis: Using STATA SE version 15 software, random-effects meta-regression analyses were used to test the effect of year of data collection and method of data collection on population meat, fruit, and vegetable consumption. The analyses also tested any association between age, sex, rural/urban residence, or a country's economic development and population intake of meat, fruits, and/or vegetables. The review was started in 2017 and completed in 2019., Results: Richer SSA countries were likely to consume more meat (ß = 36.76, P = 0.04) and vegetables (ß =43.49, P  = 0.00) than poorer countries. Vegetable intake has increased dramatically over the last 3 decades from ≈10 g to ≈110 g (ß = 4.43, P  = 0.00). Vegetable (ß= -25.48, P  = 0.00) consumption was higher in rural than in urban residents. Although the trend of meat consumption has risen (≈25 g to ≈75 g), the trend is nonsignificant (ß = 0.63, N.S.). Daily average per capita meat consumption was 98 g - above the 70 g recommendation - while fruit and vegetable intake (268 g) remain below the World Health Organization's recommendation (400 g)., Conclusions: Given the low intake of plant-based foods, it is likely that SSA populations may be deficient in high-quality protein and micronutrients as suggested by the EAT-Lancet Commission. There is a need to promote both an adequate supply and demand of plant-based protein and micronutrients, including fruit, vegetables, nuts, seeds, and legumes, in SSA countries. While dietary changes in SSA may offer large absolute benefits, consideration of the magnitude of dietary change, particularly increasing or reducing meat consumption, will need to occur in a way that ensures that policy and interventions support the reduction of undernutrition and micronutrient deficiencies without worsening the prevalence and environmental impacts of noncommunicable diseases. There is also the need for preventive action that ensures that SSA populations do not increase their meat consumption as disposable incomes increase and countries' economic development rises, as is seen in most countries undergoing economic transformation., Systematic Review Registration: PROSPERO registration no. CRD42018090497., (© The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Prevalence of cardiovascular disease risk factors (CVDRF) is increasing, especially in low-income countries. In Sierra Leone, there are no previous studies on the knowledge and the awareness of these conditions in the community. This study aimed to explore the knowledge and understanding of CVDRF, as well as the perceptions of the barriers and facilitators to accessing care for these conditions, among patients and community leaders in Sierra Leone., Design: Qualitative study employing semistructured interviews and focus group discussions., Setting: Urban and rural Bo District, Sierra Leone., Participants: Interviews with a purposive sample of 37 patients and two focus groups with six to nine community leaders., Results: While participants possessed general knowledge of their conditions, the level and complexity of this knowledge varied widely. There were clear gaps in knowledge regarding the coexistence of CVDRF and their consequences, as well as the link between behavioural factors and CVDRF. An overarching theme from the data was the need to create an understanding and awareness of CVDRF in the community in order to prevent and improve management of these conditions. Cost was also seen as a major barrier to accessing care for CVDRFs., Conclusions: The knowledge gaps identified in this study highlight the need to design strategies and interventions that improve knowledge and recognition of CVDRF in the community. Interventions should specifically consider how to develop and enhance awareness about CVDRF and their consequences. They should also consider how patients seek help and where they access it., Competing Interests: Competing interests: AI reports grants from the National Institute of Applied Health Research during the conduct of this study., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Prevalence of cardiovascular disease risk factors (CVDRFs) is increasing, especially in low-income countries. In Sierra Leone, there is limited empirical data on the prevalence of CVDRFs, and there are no previous studies on the access to care for these conditions., Methods: This study in rural and urban Sierra Leone collected demographic, anthropometric measurements and clinical data from randomly sampled individuals over 40 years old using a household survey. We describe the prevalence of the following risk factors: diabetes, hypertension, dyslipidaemia, overweight or obesity, smoking and having at least one of these risk factors. Cascades of care were constructed for diabetes and hypertension using % of the population with the disease who had previously been tested ('screened'), knew of their condition ('diagnosed'), were on treatment ('treated') or were controlled to target ('controlled'). Multivariable regression was used to test associations between prevalence of CVDRFs and progress through the cascade for hypertension with demographic and socioeconomic variables. In those with recognised disease who did not seek care, reasons for not accessing care were recorded., Results: Of 2071 people, 49.6% (95% CI 49.3% to 50.0%) of the population had hypertension, 3.5% (3.4% to 3.6%) had diabetes, 6.7% (6.5% to 7.0%) had dyslipidaemia, 25.6% (25.4% to 25.9%) smoked and 26.5% (26.3% to 26.8%) were overweight/obese; a total of 77.1% (76.6% to 77.5%) had at least one CVDRF. People in urban areas were more likely to have diabetes and be overweight than those living in rural areas. Moreover, being female, more educated or wealthier increased the risk of having all CVDRFs except for smoking. There is a substantial loss of patients at each step of the care cascade for both diabetes and hypertension, with less than 10% of the total population with the conditions being screened, diagnosed, treated and controlled. The most common reasons for not seeking care were lack of knowledge and cost., Conclusions: In Sierra Leone, CVDRFs are prevalent and access to care is low. Health system strengthening with a focus on increased access to quality care for CVDRFs is urgently needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)