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Abstract Background Ethiopia’s health system is overwhelmed by the growing burden of non-communicable diseases (NCDs). In this study, we assessed the availability of and readiness for NCD services and the interaction of NCD services with other essential and non-NCD services. Methods The analysis focused on four main NCD services: diabetes mellitus, cardiovascular diseases, chronic respiratory diseases, and cancer screening. We used data from the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey. As defined by the World Health Organization, readiness, both general and service-specific, was measured based on the mean percentage availability of the tracer indicators, such as trained staff and guidelines, equipment, diagnostic capacity, and essential medicines and commodities needed for delivering essential health services and NCD-specific services, respectively. The survey comprised 632 nationally representative healthcare facilities, and we applied mixed-effects linear and ordered logit models to identify factors affecting NCD service availability and readiness. Results Only 8% of facilities provided all four NCD services. Availability varied for specific services, with cervical cancer screening being the least available service in the country: less than 10% of facilities, primarily higher-level hospitals, provided cervical cancer screening. General service readiness was a strong predictor of NCD service availability. Differences in NCD service availability and readiness between regions and facility types were significant. Increased readiness for specific NCD services was significantly associated with increased readiness for communicable disease services and interacted with the readiness for other NCD services. Conclusion NCD service availability has considerable regional variation and is positively associated with general and communicable disease services readiness. Readiness for specific NCD services interacted with one another. The findings suggest an integrated approach to service delivery, focussing holistically on all disease services, is needed. There also needs to be increased attention to reducing resource allocation variation between facility types and locations.

Abstract Background Validated and comprehensive tools to measure treatment burden are needed for healthcare professionals to understand the treatment burden of patients in China. The study aimed to translate and validate the Chinese version of Patient Experience with Treatment and Self-management (PETS vs. 2.0) in patients with multimorbidity in primary care. Methodology The translation process of the 60-item PETS vs. 2.0 followed the Functional Assessment of Chronic Illness Therapy (FACIT) Translation, Formatting, and Testing Guidelines. Computer-assisted assessments were conducted in adult primary care patients with multimorbidity from three general out-patient clinics in Hong Kong. A sample of 502 patients completed the assessments from July to December 2023. Internal reliability was examined using Cronbach’s alphas for each domain of the PETS vs. 2.0. Concurrent validity was assessed through the correlations between different domains of PETS vs. 2.0 with established measures including quality of life, frailty, and depression. Confirmatory Factor Analysis (CFA) with maximum likelihood method was carried out to assess the construct validity. Results The mean age of participants was 64.9 years old and 56.2% were female. Internal consistency reliability was acceptable (alpha ≥ 0.70) for most domains. Higher scores of PETS domains were significantly correlated with worse quality of life, higher level of frailty, and more depressive symptoms (p

Abstract Background The prevalence of type 2 diabetes (T2DM) in China is over 10%, affecting around 114 million people. Despite the inclusion of T2DM in the National Basic Public Health Service Program (NBPHSP), most people with T2DM experience challenges in achieving optimal management targets. This study aimed to identify barriers and facilitators of diabetes management from the perspectives of primary health care (PHC) service providers and recipients. Methods This mixed-methods study was conducted in Shijiazhuang City, Hebei Province, China. A quantitative PHC facility assessment survey was conducted in all administrative districts and qualitative in-depth interviews were conducted in one district to government officials, medical staff, patients with T2DM, and their family members. Interviews were thematically analyzed, and all findings were synthesized using Michie’s COM-B theory. Results A total of 197 village/community level PHC facilities and 66 township/street level PHC facilities answered the survey, and 42 in-depth interviews were conducted. The key facilitators stemmed from the NBPHSP policy, which standardized the basic infrastructure, medical equipment, and medication for the PHC facilities, provided training on NCD prevention and control, and compensated the PHC workers. However, we identified a detrimental cycle among PHC providers characterized by inadequate capacity, overwhelming workloads, insufficient income, limited career development opportunities, and challenges in attracting young talents. Although patients were covered by the national medical insurance schemes, they experienced capability constraints primarily driven by low education levels, advanced age, low health literacy, and a proliferation of misinformation. These factors influenced patients’ motivation to be actively engaged in care and contributed to inertia to intensify treatment and achieve their clinical management goals. Conclusion This study identifies several major facilitators and barriers from the perspectives of both PHC providers and patients with T2DM. Our findings suggest there are substantial opportunities to strengthen the NBPHSP, including improving the capacity and the income level of the PHC providers, attracting and retaining skilled health workers in rural areas, supporting patients to improve their health literacy and take a more active role in their health care, and improving access to high-quality care through digital health approaches. Trial registration ClinicalTrials.gov (record NCT02726100, 03/22/2016).

Abstract Background Adolescents are vulnerable to stressors because of the rapid physical and mental changes that they go through during this life period. Young people residing in slum communities experience additional stressors due to living conditions, financial stress, and limited access to healthcare and social support services. The Adolescents’ Resilience and Treatment nEeds for Mental Health in Indian Slums (ARTEMIS) study, is testing an intervention intended to improve mental health outcomes for adolescents living in urban slums in India combining an anti-stigma campaign with a digital health intervention to identify and manage depression, self-harm/suicide risk or other significant emotional complaints. Methods In the formative phase, we developed tools and processes for the ARTEMIS intervention. The two intervention components (anti-stigma and digital health) were implemented in purposively selected slums from the two study sites of New Delhi and Vijayawada. A mixed methods formative evaluation was undertaken to improve the understanding of site-specific context, assess feasibility and acceptability of the two components and identify required improvements to be made in the intervention. In-depth interviews and focus groups with key stakeholders (adolescents, parents, community health workers, doctors, and peer leaders), along with quantitative data from the digital health platform, were analysed. Results The anti-stigma campaign methods and materials were found to be acceptable and received overall positive feedback from adolescents. A total of 2752 adolescents were screened using the PHQ9 embedded into a digital application, 133 (4.8%) of whom were identified as at high-risk of depression and/or suicide. 57% (n = 75) of those at high risk were diagnosed and treated by primary health care (PHC) doctors, who were guided by an electronic decision support tool based on WHO’s mhGAP algorithm, built into the digital health application. Conclusion The formative evaluation of the intervention strategy led to enhanced understanding of the context, acceptability, and feasibility of the intervention. Feedback from stakeholders helped to identify key areas for improvement in the intervention; strategies to improve implementation included engaging with parents, organising health camps in the sites and formation of peer groups. Trial Registration The trial has been registered in the Clinical Trial Registry India, which is included in the WHO list of Registries, Reference number: CTRI/2022/02/040307. Registered 18 February 2022.

Introduction There are around 250 million adolescents (10–19 years) in India. The prevalence of mental health-related morbidity among adolescents in India is approximately 7.3%. Vulnerable subpopulations among adolescents such as those living in slum communities are particularly at risk due to poor living conditions, financial difficulty and limited access to support services. Adolescents’ Resilience and Treatment nEeds for Mental Health in Indian Slums (ARTEMIS) is a cluster randomised controlled trial of an intervention that intends to improve the mental health of adolescents living in slum communities in India. The aim of this paper is to describe the process evaluation protocol for ARTEMIS trial. The process evaluation will help to explain the intervention outcomes and understand how and why the intervention worked or did not work. It will identify contextual factors, intervention barriers and facilitators and the adaptations required for optimising implementation.Methods Case study method will be used and the data will include a mix of quantitative metrics and qualitative data. The UK Medical Research Council’s guidance on evaluating complex interventions, the Reach, Efficacy, Adoption, Implementation and Maintenance Framework and the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Safety/Side Effects and, Equity criteria will be used to develop a conceptual framework and a priori codes for qualitative data analysis. Quantitative data will be analysed using descriptive statistics. Implementation fidelity will also be measured.Discussion The process evaluation will provide an understanding of outcomes and causal mechanisms that influenced any change in trial outcomes.Ethics and dissemination Ethics Committee of the George Institute for Global Health India (project number 17/2020) and the Research Governance and Integrity Team, Imperial College, London (ICREC reference number: 22IC7718) have provided ethics approval. The Health Ministry’s Screening Committee has approved to the study (ID 2020-9770).Trial registration number CTRI/2022/02/040307.

Summary: Background: China’s National Essential Public Health Service Package (NEPHSP) aims to promote health for all at the primary health care level and includes a focus on hypertension and type-2 diabetes mellitus (T2DM). However, there are limited contemporary data to quantify the care cascades of hypertension and T2DM in primary health care. Methods: This cross-sectional study involved individual level linkage of routinely collected data from the NEPHSP, health insurance claims and hospital electronic health records, from four diverse regions in China, including Xiling District (central China), Wenchuan County (western), Acheng District and Jiao District (northern). We first compared numbers of people aged ≥35 with a recorded diagnosis of hypertension and T2DM against expected numbers derived from epidemiological data. We then constructed care cascades to assess the percentages (1) enrolled in the NEPHSP, (2) adherent to the follow-up care of NEPHSP, (3) receiving medication treatment, and (4) having hypertension and/or T2DM controlled. Findings: In the four regions, the total numbers of people aged ≥35 diagnosed of hypertension and T2DM from any data source were 149,176 and 50,828, respectively. This was estimated to be 46.0% (95% confidence interval [CI]: 45.8%–46.2%) and 45.6% (95% CI: 45.3%–45.9%) of the expected totals for hypertension and T2DM, respectively. Among those diagnosed, 65.4% (95% CI: 65.1%–65.6%) with hypertension and 66.1% (95% CI: 65.7%–66.5%) with T2DM were enrolled in the NEPHSP, respectively, in which 54.8% (95% CI: 54.5%–55.2%) with hypertension and 64.7% (95% CI: 64.1%–65.2%) with T2DM were adherent to the required services. Among those enrolled, the overall treatment rates were 70.8% (95% CI: 70.6%–71.1%) for hypertension and 82.2% (95% CI: 81.8%–82.6%) for T2DM. Among those treated, a further 80.9% (95% CI: 80.6%–81.2%) with hypertension and 73.9% (95% CI: 73.3%–74.4%) with T2DM achieved control. These results varied considerably across regions, with the northern sites showing relatively higher enrolment rates while the central site had higher control rates. Interpretation: Detection and control rates for hypertension and T2DM are suboptimal in these four regions of China. Further strategies are needed to improve people’s enrolment in and adherence to the NEPHSP and strengthen care delivery processes. Of note, our estimations of the diagnosis rates for each region are based on national level large epidemiological data. The interpretation of these data needs caution due to potential bias caused by regional variations. Funding: This study is funded by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Diseases funding (APP1169757), and National Natural Science Foundation of China (72074065).

Summary: Fragmented care delivery is a barrier to improving health system performance worldwide. Investment in meso-level organisations is a potential strategy to improve health system integration, however, its effectiveness remains unclear. In this paper, we provide an overview of key international and Australian integrated care policies. We then describe Collaborative Commissioning - a novel health reform policy to integrate primary and hospital care sectors in New South Wales (NSW), Australia and provide a case study of a model focussed on older person's care. The policy is theorised to achieve greater integration through improved governance (local stakeholders identifying as part of one health system), service delivery (communities perceive new services as preferable to status quo) and incentives (efficiency gains are reinvested locally with progressively higher value care achieved). If effectively implemented at scale, Collaborative Commissioning has potential to improve health system performance in Australia and will be of relevance to similar reform initiatives in other countries.

BackgroundRecent years have witnessed an increase in the use of technology-enabled interventions for delivering mental health care in different settings. Technological solutions have been advocated to increase access to care, especially in primary health care settings in low- and middle-income countries, to facilitate task-sharing given the lack of trained mental health professionals. ObjectiveThis report describes the experiences and challenges faced during the development and implementation of technology-enabled interventions for mental health among adults and adolescents in rural and urban settings of India. MethodsA detailed overview of the technological frameworks used in various studies, including the Systematic Medical Appraisal and Referral Treatment (SMART) Mental Health pilot study, SMART Mental Health cluster randomized controlled trial, and Adolescents’ Resilience and Treatment Needs for Mental Health in Indian Slums (ARTEMIS) study, is provided. This includes the mobile apps that were used to collect data and the use of the database to store the data that were collected. Based on the experiences faced, the technological enhancements and adaptations made at the mobile app and database levels are described in detail. Implementation (Results)Development of descriptive analytics at the database level; enabling offline and online data storage modalities; customizing the Open Medical Record System platform to suit the study requirements; modifying the encryption settings, thereby making the system more secure; and merging different apps for simultaneous data collection were some of the enhancements made across different projects. ConclusionsTechnology-enabled interventions prove to be a useful solution to cater to large populations in low-resource settings. The development of mobile apps is subject to the context and the area where they would be implemented. This paper outlines the need for careful testing using an iterative process that may support future research using similar technology. Trial RegistrationSMART Mental Health trial: Clinical Trial Registry India CTRI/2018/08/015355; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MjMyNTQ=&Enc=&userName=CTRI/2018/08/015355. ARTEMIS trial: Clinical Trial Registry India CTRI/2022/02/040307; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDcxMTE=&Enc=&userName=CTRI/2022/02/040307

Summary: Background: Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk of kidney failure and death in patients with chronic kidney disease (CKD) but are underused. We evaluated the number of patients with CKD in Australia that would be eligible for treatment and estimated the number of cardiorenal and kidney failure events that could be averted with improved uptake of SGLT2 inhibitors. Methods: This cross-sectional observational study leveraged nationally representative primary care data from 392 Australian general practices (MedicineInsight) between 1 January 2020 and 31 December 2021. We identified patients that would have met inclusion criteria of key SGLT2 inhibitor trials and applied these data to age and sex-stratified estimates of CKD prevalence for the Australian population (using national census data), estimating the number of preventable events using trial event rates. Key outcomes included cardiorenal events (CKD progression, kidney failure, or death due to cardiovascular or kidney disease) and kidney failure. Findings: In MedicineInsight, 44.2% of adults with CKD would have met CKD eligibility criteria for an SGLT2 inhibitor; baseline use was 4.1%. Applying these data to the Australian population, 230,246 patients with CKD would have been eligible for treatment with an SGLT2 inhibitor. Optimal implementation of SGLT2 inhibitors (75% uptake) could reduce cardiorenal and kidney failure events annually in Australia by 3644 (95% CI 3526–3764) and 1312 (95% CI 1242–1385), respectively. Interpretation: Improved uptake of SGLT2 inhibitors for patients with CKD in Australia has the potential to prevent large numbers of patients experiencing CKD progression or dying due to cardiovascular or kidney disease. Identifying strategies to increase the uptake of SGLT2 inhibitors is critical to realising the population-level benefits of this drug class. Funding: University of New South Wales Scientia Program and Boehringer Ingelheim Eli Lilly Alliance.

Abstract Background Medical complications during pregnancy, including anaemia, gestational diabetes mellitus and hypertensive disorders of pregnancy place women are at higher risk of long-term complications. Scalable and low-cost strategies to integrate non-communicable disease screening into pregnancy care are needed. We aim to determine the effectiveness and implementation components of a community-based, digitally enabled approach, “SMARThealth Pregnancy,” to improve health during pregnancy and the first year after birth. Methods A pragmatic, parallel-group, cluster randomised, type 2 hybrid effectiveness-implementation trial of a community-based, complex intervention in rural India to decrease anaemia (primary outcome, defined as haemoglobin 1 medical officer and > 2 community health workers; and (2) capability to administer intravenous iron sucrose. Thirty PHCs in Telangana and Haryana will be randomised 1:1 using a matched-pair design accounting for cluster size and distance from the regional centre. The intervention comprises (i) an education programme for community health workers and PHC doctors; (ii) the SMARThealth Pregnancy app for health workers to support community-based screening, referral and follow-up of high-risk cases; (iii) a dashboard for PHC doctors to monitor high-risk women in the community; (iv) supply chain monitoring for consumables and medications and (v) stakeholder engagement to co-develop implementation and sustainability pathways. The comparator is usual care with additional health worker education. Secondary outcomes include implementation outcomes assessed by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), clinical endpoints (anaemia, diabetes, hypertension), clinical service delivery indicators (quality of care score), mental health and lactation practice (PHQ9, GAD7, EuroQoL-5D, WHO IYCF questionnaire). Discussion Engaging women with screening after a high-risk pregnancy is a challenge and has been highlighted as a missed opportunity for the prevention of non-communicable diseases. The SMARThealth Pregnancy trial is powered for the primary outcome and will address gaps in the evidence around how pregnancy can be used as an opportunity to improve women’s lifelong health. If successful, this approach could improve the health of women living in resource-limited settings around the world. Trial registration ClinicalTrials.gov NCT05752955. Date of registration 3 March 2023.

Background: Gaps exist between prevalence and treatment options for mental disorders in India. Limited awareness, poor help-seeking, scarcity of trained mental health professionals, limited mental health services and stigma are few examples of reasons contributing to treatment gap. Aims: This paper highlights findings from formative research of a primary mental healthcare model comprising of a preliminary feasibility testing of the Electronic Decision Support System (EDSS) to provide care using mobile based applications, perceptions of the community towards mental health and incorporating cultural adaptations for pre-existing anti-stigma campaign materials. Methods: A cross-sectional mixed methods approach tested the user acceptability of the electronic decision support system EDSS for accredited social health activists (ASHAs) and Primary Health Centre (PHC) doctors using tablets in two villages and two PHCs in rural Haryana (Northern India). Five focus groups and six in-depth interviews along with non-participant observations were used to ascertain community perceptions about various aspects related to mental health. Findings of the study were analyzed and interpreted against the key themes of Andersen's model. Results: Out of a total of 553 individuals screened for common mental disorders, 51 (9.2%) were screened positive and 32 visited PHC doctors for treatment. There was limited knowledge about common mental disorders amongst community; need to train primary health workers to identify and treat mental disorders; and incorporate cultural adaptation of anti-stigma awareness materials. Conclusions: The EDSS was found to be acceptable and feasible by primary and community health workers. The findings guided refining of the intervention prior to implementation of a large-scale cluster randomized controlled trial.

Background As a fundamental human right, the right to health (RTH) can influence state actors’ behaviour towards health inequities. Human rights advocates have invoked the RTH in a collective demand for improved access to essential medicines in low- and middle-income countries (LMICs). Similarly, scholars have used the RTH as a framework for analysing health problems. However, its utility for addressing skilled health worker (SHW) shortages in LMICs has been understudied. Realising that SHW shortages occur due to existing push-and-pull factors within and between LMICs and high-income countries (HICs), we sought to answer the question: “how, why, and under what circumstance does the RTH offer utility for addressing SHW shortages in LMICs?”Methods We conducted a realist synthesis of evidence identified through a systematic search of peer-reviewed articles in Embase, Global Health, Medline (Ovid), ProQuest – Health & Medical databases, Scopus (Elsevier), Web of Science (Clarivate), CINAHL (EBSCO), APAIS-Health, Health Systems Evidence and PDQ-EVIDENCE; as well as grey literature from Google Scholar.Results We found that the RTH offers utility for addressing SHW shortages in LMICs through HIC state actors’ concerns for their countries’ reputational risk, recognition of their obligation to support health workforce strengthening in LMICs, and concerns for the cost implication. State actors in LMICs will respond to adopt programs inspired by the RTH when they are convinced that it offers tangible national benefits and are not overly burdened with ensuring its success. The socio-economic and institutional factors that constrain state actors’ response include financial cost and sustainability of rights’-based options.Conclusion State and non-state actors can use the RTH as a resource for promoting collective action towards addressing SHW shortages in LMICs. It can also inform negotiations between state actors in LMICs and their HIC counterparts.

Abstract Background Availability of mental health services in low- and middle-income countries is largely concentrated in tertiary care with limited resources and scarcity of trained professionals at the primary care level. SMART Mental Health is a strategy that combines a community anti-stigma campaign with a primary health care workforce strengthening initiative, using electronic decision support with the goal of better identifying and supporting people with common mental disorders in India. Methods We describe the challenges faced and lessons learnt during the pre-intervention phase of SMART Mental Health cluster Randomised Controlled Trial. Pre-intervention phase includes preliminary activities for setting-up the trial and research activities prior to delivery of the intervention. Field notes from project site visit, project team meetings and detailed follow-up discussions with members of the project team were used to document operational challenges and strategies adopted to overcome them. The socio-ecological model was used as the analytical framework to organise the findings. Results Key challenges included delays in government approvals, addressing community health worker needs, and building trust in the community. These were addressed through continuous communication, leveraging support of relevant stakeholders, and addressing concerns of community health workers and community. Issues related to use of digital platform for data collection were addressed by a dedicated technical support team. The COVID-19 pandemic and political unrest led to significant and unexpected challenges requiring important adaptations to successfully implement the project. Conclusion Setting up of this trial has posed challenges at a combination of community, health system and broader socio-political levels. Successful mitigating strategies to overcome these challenges must be innovative, timely and flexibly delivered according to local context. Systematic ongoing documentation of field-level challenges and subsequent adaptations can help optimise implementation processes and support high quality trials. Trial registration: The trial is registered with Clinical Trials Registry India (CTRI/2018/08/015355). Registered on 16th August 2018. http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=23254&EncHid=&userName=CTRI/2018/08/015355

Abstract Background There are around 250 million adolescents in India. Adolescents are vulnerable to common mental disorders with depression and self-harm accounting for a major share of the burden of death and disability in this age group. Around 20% of children and adolescents are diagnosed with/ or live with a disabling mental illness. A national survey has found that suicide is the third leading cause of death among adolescents in India. The authors hypothesise that an intervention involving an anti-stigma campaign co-created by adolescents themselves, and a mobile technology-based electronic decision support system will help reduce stigma, depression, and suicide risk and improve mental health for high-risk adolescents living in urban slums in India. Methods The intervention will be implemented as a cluster randomised control trial in 30 slum clusters in each of the cities of Vijayawada and New Delhi in India. Adolescents aged 10 to 19 years will be screened for depression and suicide ideation using the Patient Health Questionnaire (PHQ-9). Two evaluation cohorts will be derived—a high-risk cohort with an elevated PHQ-9 score ≥ 10 and/or a positive response (score ≥ 2) to the suicide risk question on the PHQ-9, and a non-high-risk cohort comprising an equal number of adolescents not at elevated risk based on these scores. Discussion The key elements that ARTEMIS will focus on are increasing awareness among adolescents and the slum community on these mental health conditions as well as strengthening the skills of existing primary healthcare workers and promoting task sharing. The findings from this study will provide evidence to governments about strategies with potential for addressing the gaps in providing care for adolescents living in urban slums and experiencing depression, other significant emotional or medically unexplained complaints or increased suicide risk/self-harm and should have relevance not only for India but also for other low- and middle-income countries. Trial status Protocol version – V7, 20 Dec 2021 Recruitment start date: tentatively after 15th July 2022 Recruitment end date: tentatively 14th July 2023 (1 year after the trial start date) Trial registration The trial has been registered in the Clinical Trial Registry India, which is included in the WHO list of Registries ( https://www.who.int/clinical-trials-registry-platform/network/primary-registries ) Reference No. CTRI/2022/02/040307 . Registered on 18 February 2022. The tentative start date of participant recruitment for the trial will begin after 15th July 2022.

Abstract Background Government-subsidised general practice management plans (GPMPs) facilitate chronic disease management; however, impact on cardiovascular disease (CVD) is unknown. We aimed to determine utilisation and impact of GPMPs for people with or at elevated risk of CVD. Methods Secondary analysis of baseline data from the CONNECT randomised controlled trial linked to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) claims. Multivariate regression examining the association of GPMP receipt and review with: (1) ≥ 1 MBS-subsidised allied health visit in the previous 24 months; (2) adherence to dual cardioprotective medication (≥ 80% of days covered with a dispensed PBS prescription); and (3) meeting recommended LDL-cholesterol and blood pressure (BP) targets concurrently. Results Overall, 905 trial participants from 24 primary health care services consented to data linkage. Participants with a GPMP (46.6%, 422/905) were older (69.4 vs 66.0 years), had lower education (32.3% vs 24.7% high school or lower), lower household income (27.5% vs 17.0% in lowest bracket), and more comorbidities, particularly diabetes (42.2% vs 17.6%) compared to those without a GPMP. After adjustment, a GPMP was strongly associated with allied health visits (odds ratio (OR) 14.80, 95% CI: 9.08–24.11) but not higher medication adherence rates (OR 0.82, 95% CI: 0.52–1.29) nor meeting combined LDL and BP targets (OR 1.31, 95% CI: 0.72–2.38). Minor differences in significant covariates were noted in models using GPMP review versus GPMP initiation. Conclusions In people with or at elevated risk of CVD, GPMPs are under-utilised overall. They are targeting high-needs populations and facilitate allied health access, but are not associated with improved CVD risk management, which represents an opportunity for enhancing their value in supporting guideline-recommended care.

The growing trends for skilled health worker (SHW) migration in Nigeria has led to increased concerns about achieving universal health coverage in the country. While a lot is known about drivers of SHW migration, including national/sub-national government's inability to address them, not enough is known about its governance. Underpinning good governance systems is a commitment to human rights norms, that is, principles that enshrine non-discrimination, participation, accountability, and transparency. Hence, this study was aimed at deriving a conceptual framework that captures the scope of SHW migration governance in Nigeria and the extent to which it is human rights based. To describe the scope of SHW migration governance, we conducted an exploratory factor analysis and mapped our findings to themes derived from a qualitative analysis. We also did a multivariate analysis, examining how governance items are related to migration intentions of SHWs. The scope of SHW migration governance in Nigeria can be described across three levels: Constitutional-where policies about the economy and the health workforce are made and often poorly implemented; Collective-which responds to the governance vacuum at the constitutional level by promoting SHW migration or trying to mitigate its impact; Operational-individual SHWs who navigate the tension between the right to health, their right to fair remuneration, living/working conditions, and free movement. Examining these levels revealed opportunities for collaboration through stronger commitment to human right norms. In recognising their role as rights holders and duty bearers at various levels, citizens, health advocates, health workers, community groups and policy makers can work collaboratively towards addressing factors related to SHW migration. Further evidence is needed on how human rights norms can play a visible role in Nigeria's governance system for SHW migration.

IntroductionNigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial.MethodsWe conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders.ResultsOverall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community.DiscussionWhile these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.

Abstract Objective: To quantify the prevalence of known health‐related risk factors for severe COVID‐19 illness among Aboriginal and Torres Strait Islander adults, and their relationship with social determinants. Methods: Weighted cross‐sectional analysis of the 2018‐19 National Aboriginal and Torres Strait Islander Health Survey; Odds Ratios for cumulative risk count category (0, 1, or ≥2 health‐related risk factors) by social factors calculated using ordered logistic regression. Results: Of the adult population, 42.9%(95%CI:40.6,45.2) had none of the examined health‐related risk factors; 38.9%(36.6,41.1) had 1, and 18.2%(16.7,19.7) had ≥2. Adults experiencing relative advantage across social indicators had significantly lower cumulative risk counts, with 30‐70% lower odds of being in a higher risk category. Conclusions: Aboriginal and Torres Strait Islander peoples must continue to be recognised as a priority population in all stages of pandemic preparedness and response as they have disproportionate exposure to social factors associated with risk of severe COVID‐19 illness. Indigeneity itself is not a ‘risk’ factor and must be viewed in the wider context of inequities that impact health Implications for public health: Multi‐sectoral responses are required to improve health during and after the COVID‐19 pandemic that: enable self‐determination; improve incomes, safety, food security and culturally‐safe healthcare; and address discrimination and trauma.

Abstract Objectives: To explore the acceptability of a novel, outreached‐based approach to improve primary and primordial prevention of Strep A skin sores, sore throats and acute rheumatic fever in remote Aboriginal communities. Methods: A comprehensive prevention program delivered by trained Aboriginal Community Workers was evaluated using approximately fortnightly household surveys about health and housing and clinical records. Results: Twenty‐seven primary participants from three remote Aboriginal communities in the Northern Territory consented, providing 37.8 years of retrospective baseline data and 18.5 years of prospective data during the study period. Household members were considered to be secondary participants. Five Aboriginal Community Workers were trained and employed, delivering a range of supports to households affected by acute rheumatic fever including environmental health support and education. Clinical record audit and household self‐report of Strep A infections were compared. No association between clinical‐ and self‐report was identified. Conclusions: Ongoing participation suggests this outreach‐based prevention program was acceptable and associated with improved reporting of household maintenance issues and awareness of prevention opportunities for Strep A infections. Implications for public health: Biomedical, clinic‐based approaches to the management of Strep A infections in remote communities can be usefully augmented by outreach‐based supports delivered by Aboriginal Community Workers responding to community needs.

Background Governments worldwide participate in skilled health worker (SHW) migration agreements to protect access to health services in their countries. Previous studies have described the value offered by these agreements in separate source and destination country perspectives. Objective We sought to identify and summarise existing literature on shared value creation for both source and destination countries. Method We conducted a systematic scoping review of health databases and grey literature. Using Mark Moore and Colin Talbot frameworks, we summarised the public value propositions in migration agreements and how state actors addressed competing priorities. Results Most articles (34/63, 53.9%) reported transnational SHW mobility as the public value proposition for source and destination countries. Fewer articles, 14 (22.2%) and 9 (14.3%) articles, respectively, referred to achieving health workforce sustainability and building capacity for SHW migration governance as shared public values. The most identified competing public value (CPV) was an overriding focus on addressing SHW shortages in destination countries (20/63, 37.7%). Efforts to address this CPV include mitigation of the adverse effects of migration (43/63, 68.3%) and promoting health workforce development in source countries (15, 23.8%). At the same time, state actors retained regulatory discretion for protecting their country’s public health interest (34, 54%). Most articles reported the lack of funds (15/63, 23.8%) and implementation mechanisms (19/63, 30.2%) as constraints on the authorising environment and the operational capacity of SHW migration governance systems. Conclusion Regarding SHW migration governance, the literature reports shared public value propositions for source and destination countries. It also shows how the value-creating process in the management of SHW migration favours destination countries. Future studies will need to explore shared value creation models that ensure equity in the governance of SHW migration.

Introduction Community health workers (CHWs) constitute the majority of primary healthcare (PHC) workers in Nigeria, yet little is understood about their motivations or the most effective interventions to meet their needs to ensure quality health coverage across the country. We aimed to identify factors that would motivate CHWs for quality service delivery.Methods A discrete-choice experiment was conducted among 300 CHWs across 44 PHC facilities in the Federal Capital Territory, Abuja Nigeria. Based on the literature review and qualitative research, five attributes, namely: salary, educational opportunities, career progression and in-service training, housing and transportation, were included in the experiment. CHWs were presented with 12 unlabelled choice sets, using tablet devices, and asked to choose which of two hypothetical jobs they would accept if offered to them, or whether they would take neither job. Mixed multinomial logistic models were used to estimate stated preferences for the attributes and the likely uptake of jobs under different policy packages was simulated.Results About 70% of the respondents were women and 39% worked as volunteers. Jobs that offered career progression were the strongest motivators among the formally employed CHWs (β=0.33) while the ‘opportunity to convert from CHW to another cadre of health workers, such as nursing’ was the most important motivator among the volunteers’ CHWs (β=0.53). CHWs also strongly preferred jobs that would offer educational opportunities, including scholarship (β=0.31) and provision of transport allowances (β=0.26). Policy scenario modelling predicted combined educational opportunities, career progression opportunities and an additional 10% of salary as incentives was the employment package that would be most appealing to CHWs.Conclusion CHWs are motivated by a mix of non-financial and financial incentives. Policy interventions that would improve motivation should be adequate to address various contexts facing different CHWs and be flexible enough to meet their differing needs.

Background Driven by the increasing life expectancy, China and India, the two most populous countries in the world are experiencing a rising burden of multimorbidity. This study aims to explore community prevalence and dyad patterns of multimorbidity in China and India.Methods We conducted a systematic review of five English and Chinese electronic databases. Studies involving adults 18 years or older at a community level, which reported multimorbidity prevalence and/or patterns were included. A modified Newcastle-Ottawa Scale was used for quality assessment. Despite large heterogeneity among reported studies, a systematic synthesis of the results was conducted to report the findings.Results From 13 996 studies retrieved, 59 studies met the inclusion criteria (46 in China, 9 in India and 4 in both). The median prevalence of multimorbidity was 30.7% (IQR 17.1, 49.4), ranging from 1.5% to 90.5%. There was a large difference in multimorbidity prevalence between China and India, with median prevalence being 36.1% (IQR 19.6, 48.8) and 28.3% (IQR 8.9, 56.8), respectively. Among 27 studies that reported age-specific prevalence, 19 studies found multimorbidity prevalence increased with age, while 8 studies observed a paradoxical reduction in the oldest age group. Of the 34 studies that reported sex-specific prevalence, 86% (n=32) observed a higher prevalence in females. The most common multimorbidity patterns from 14 studies included hypertensive diseases combined with diabetes mellitus, arthropathies, heart diseases and metabolic disorders. All included studies were rated as fair or poor quality.Conclusion Multimorbidity is highly prevalent in China and India with hypertensive diseases and other comorbidities being the most observed patterns. The overall quality of the studies was low and there was a lack of representative samples in most studies. Large epidemiology studies, using a common definition of multimorbidity and national representative samples, with sex disaggregation are needed in both countries.PROSPERO registration number CRD42020176774.

Summary: Background: There is increasing evidence that the COVID-19 pandemic has impacted adversely on the provision of essential health services. The South East Asia region (SEAR) has experienced extremely high rates of COVID-19 infection, and continues to bear a significant proportion of communicable disease burden worldwide. Methods: We conducted a systematic literature review of quantitative evidence to estimate the impact of COVID-19 on the provision of essential prevention, detection, treatment, and management services for five high-burden infectious diseases across the SEAR. Findings: A total of 2338 studies were reviewed, and 12 studies were included in our analysis, covering six countries across the SEAR (Bhutan, Sri Lanka, Nepal, Myanmar, Thailand, and India) for three conditions of interest (HIV, TB, dengue fever). We identified significant disruption to TB testing (range=25% to 77.9%) and diagnoses (range=50% to 58%) in India, Nepal, and Indonesia; and similar disruptions were observed for screening, new diagnoses and commencing HIV treatment in India and Thailand. There was also drastically reduced case detection for dengue fever (range=75% to 90% disrupted) in Bhutan and Sri Lanka. No studies were identified for malaria nor hepatitis in any country, and nor for any service in the remaining six SEAR countries. Interpretation: We identified evidence of significant disruption to the prevention, diagnoses, treatment, and management of TB, HIV, and dengue fever due to the COVID-19 pandemic across multiple SEAR country settings. This has the potential to set back hard-fought gains in infectious disease control across the region. The lack of evidence for the impact of the pandemic on malaria and hepatitis services, and in the remaining six SEAR countries, is an important evidence gap that should be addressed in order to inform future policy for service protection and pandemic preparedness. Funding: This work was supported by the WHO Sri Lanka Country office.

Summary: Background: COVID-19 has had a profound impact on the health systems of the 11 countries of the WHO South East Asia Region. We conducted a systematic review of studies that used quantitative and comparative approaches to assess the impact of the pandemic on the service provision of four noncommunicable diseases (NCDs) (cancer, cardiovascular disease, chronic respiratory diseases, and diabetes) in the region. Methods: A systematic search was conducted in PubMed, Embase, MedRxiv, and WHO COVID-19 databases in December 2021. The quality of studies was evaluated using the Joanna Briggs Institute Critical Appraisal Checklist and the ROBINS-I risk of bias tool. A narrative synthesis was conducted following the ‘synthesis without meta-analysis’ reporting guidelines. Findings: Two review authors independently screened 5,397 records with 31 studies included, 26 which were cross-sectional studies. Most studies (n=24, 77%) were conducted in India and 19 (61%) were single-site studies. Compared to a pre-pandemic period, 10/17 cancer studies found a >40% reduction in outpatient services, 9/14 cardiovascular disease found a reduction of 30% or greater in inpatient admissions and 2 studies found diagnoses and interventions for respiratory diseases reduced up to 78.9% and 83.0%, respectively. No eligible studies on the impact of COVID-19 on diabetes services were found. Interpretation: COVID-19 has substantially disrupted the provision of essential health services for NCDs in the WHO South East Asia Region, particularly cancer and cardiovascular disease. This is likely to have serious and potentially long-term downstream impacts on health and mortality of those living with or at risk of NCDs in the region. Funding: This work was supported by the WHO Sri Lanka Country Office.

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Digital health refers to the use of novel information com­munication technologies in healthcare. The use of these technologies could positively impact public health and health outcomes of populations by generating timely data, and facili­tating the process of data collection, analysis, and knowledge translation. Using selected case studies, we aim to describe the opportunities and barriers in the use of technology applied to health-related research. We focus on three areas: strategies to generate new data using novel data collection methods, strategies to use and analyze existing data, and using digital health for health-related interventions. Exemplars from seven countries are provided to illustrate activity across these areas. Although the use of health-related technologies is increasing, challenges remain to support their adoption and scale-up –especially for under-served populations. Research using digital health approaches should take a user-centered design, actively working with the population of interest to maximize their uptake and effectiveness.

The accelerating environmental degradation as a result of modernisation and climate change is an urgent threat to human health. Environment change can impact kidney health in a variety of ways such as water scarcity, global heating and changing biodiversity. Ever increasing industrialization of health care has a large carbon footprint, with dialysis being a major contributor. There have been calls for all stakeholders to adopt a ‘one health approach’ and develop mitigation and adaptation strategies to combat this challenge. Because of its exquisite sensitivity to various elements of environment change, kidney health can be a risk marker and a therapeutic target for such interventions. In this narrative review, we discuss the various mechanisms through which environmental change is linked to kidney health and the ways that the global kidney health communities can respond to environmental change.

Abstract Background Around 1 in 7 people in India are impacted by mental illness. The treatment gap for people with mental disorders is as high as 75–95%. Health care systems, especially in rural regions in India, face substantial challenges to address these gaps in care, and innovative strategies are needed. Methods We hypothesise that an intervention involving an anti-stigma campaign and a mobile-technology-based electronic decision support system will result in reduced stigma and improved mental health for adults at high risk of common mental disorders. It will be implemented as a parallel-group cluster randomised, controlled trial in 44 primary health centre clusters servicing 133 villages in rural Andhra Pradesh and Haryana. Adults aged ≥ 18 years will be screened for depression, anxiety and suicide based on Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorders (GAD-7) scores. Two evaluation cohorts will be derived—a high-risk cohort with elevated PHQ-9, GAD-7 or suicide risk and a non-high-risk cohort comprising an equal number of people not at elevated risk based on these scores. Outcome analyses will be conducted blinded to intervention allocation. Expected outcomes The primary study outcome is the difference in mean behaviour scores at 12 months in the combined ‘high-risk’ and ‘non-high-risk’ cohort and the mean difference in PHQ-9 scores at 12 months in the ‘high-risk’ cohort. Secondary outcomes include depression and anxiety remission rates in the high-risk cohort at 6 and 12 months, the proportion of high-risk individuals who have visited a doctor at least once in the previous 12 months, and change from baseline in mean stigma, mental health knowledge and attitude scores in the combined non-high-risk and high-risk cohort. Trial outcomes will be accompanied by detailed economic and process evaluations. Significance The findings are likely to inform policy on a low-cost scalable solution to destigmatise common mental disorders and reduce the treatment gap for under-served populations in low-and middle-income country settings. Trial registration Clinical Trial Registry India CTRI/2018/08/015355 . Registered on 16 August 2018.

Abstract Background Globally, mental health problems are a growing public health concern. Resources and services for mental disorders are disproportionately low compared to disease burden. In order to bridge treatment gaps, The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health Project was implemented across 12 villages in West Godavari district of the southern Indian state of Andhra Pradesh. This paper reports findings from a process evaluation of feasibility and acceptability of the intervention that focused on a mental health services delivery model to screen, diagnose and manage common mental disorders (CMDs). Methods A mixed methods evaluation was undertaken using quantitative service usage analytics, and qualitative data from in-depth interviews and focus group discussions were conducted with stakeholders including primary care physicians, community health workers, field staff and community members. Barriers to and facilitators of intervention implementation were identified. Andersen’s Behavioral Model for Health Services Use was the conceptual framework used to guide the process evaluation and interpretation of data. Results In all, 41 Accredited Social Health Activists (ASHAs) and 6 primary health centre (PHC) doctors were trained in mental health symptoms and its management. ASHAs followed up 98.7% of screen positive cases, and 81.2% of these were clinically diagnosed and treated by the PHC doctors. The key facilitators of implementation were adequate training and supervision of field staff, ASHAs and doctors, use of electronic decision support, incorporation of a door-to-door campaign and use of culturally tailored dramas/videos to raise awareness about CMDs, and organising health camps at the village level facilitating delivery of intervention activities. Barriers to implementation included travel distance to receive care, limited knowledge about mental health, high level of stigma related to mental health issues, and poor mobile network signals and connectivity in the villages. Lack of familiarity with and access to mobile phones, especially among women, to accessing health related messages as part of the intervention. Conclusions The evaluation not only provides a context to the interventions delivered, but also allowed an understanding of possible factors that need to be addressed to make the programme scalable and of benefit to policy makers.

Introduction: Health care demands increase over the winter period, especially for people with chronic diseases. Hospital avoidance programs have potential to address seasonal surges. Methods: An integrated care intervention was provided to patients at high risk of hospitalisation during the 2017 and 2018 winters in Northern New South Wales, Australia. Patients received increased support including general practice sick day action plans, automated admission notifications to the general practitioner, and care coordination services. Outcomes were provider and patient experience and preventable hospitalisation rates. Results: The program enrolled 1244 participating patients from 37 general practices with at least 12 months follow-up. It was associated with marked improvements in provider and patient experience. However, when compared to a propensity score matched control group there was no difference in hospital utilisation or emergency presentation rates. Discussion and Conclusion: An integrated care strategy to address chronic care needs of patients in winter was well received by practitioners and patients, but did not translate to changes in hospital utilisation or emergency presentation rates. Areas for improvement include: strengthening inter-professional engagement between hospital, specialists and primary care providers, more tailored support services for patients with complex health needs, and a more expansive set of process measures beyond hospital and emergency utilisation to assess impact.

Objective: To investigate long-term adherence to guideline-recommended cardioprotective medications following hospitalization for an acute myocardial infarction (AMI), and identify characteristics associated with adherence.Methods: An Australian population-based cohort study was used to identify participants who had their first AMI between 2006 and 2014 and were alive after 12 months. Linked routinely collected hospital, and prescription medication claims data was used to study adherence over time. Predictors and rates of adherence to both lipid-lowering medication and renin-angiotensin system blockade at 12 months post-AMI was assessed.Results: 14,200 people (mean age 69.9 years, 38.7% female) were included in our analysis. At 12 months post-AMI, 29.5% (95% CI: 28.8–30.3%) of people were adherent to both classes of medication. Individuals receiving treatment with both lipid-lowering medication and renin-angiotensin system blockade during the 6 months prior to their AMI were over 9 times more likely to be adherent to both medications at 12 months post-AMI (66.2% 95% CI: 64.8–67.5%) compared to those with no prior medication use (treatment naïve) (7.1%, 95% CI: 6.4–7.9%). Prior cardiovascular treatment was the strongest predictor of long-term adherence even after adjusting for age, sex, education and income.Conclusions: Despite efforts to improve long-term medication adherence in patients who have experienced an acute coronary event, considerable gaps remain. Of particular concern are people who are commencing guideline-recommended cardioprotective medication at the time of their AMI. The relationship between prior cardiovascular treatments and post AMI adherence offers insight into the support needs for the patient. Health care intervention strategies, strengthened by enabling policies, are needed to provide support to patients through the initial months following their AMI.

Training and supervision of health workers are critical components of any health system;thus, we assessed how they impact health extension workers' (HEWs) role in non-communicable disease (NCD) service delivery in Ethiopia's health extension program (HEP), using an in-depth qualitative study conducted in 2019.The study covered two regions-the Tigray and the South Nations, Nationalities and Peoples Region (SNNPR)-and involved the Federal Ministry of Health. We conducted twenty-seven key informant interviews with federal and regional policymakers, district health officials, health centre representatives and HEWs.Participants highlighted substantial implementation challenges with training and supervision practices delivered via the HEP. Training for NCDs lacked breadth and depth. IT was described as inconsistently delivered with variable availability within and between regions;and when available, the quality was low with scant content specific to NCDs. HEP supervision was inconsistent and, rather than being supportive, mainly focused on finding faults in HEW work practices. Supervisors themselves had skill gaps in critical areas overall, and specifically concerning NCDs. HEWs' performance appraisal encompassed too many indicators, leading to excessive complexity, which was burdensome to HEWs. This, negatively impacted HEW motivation and compromised service delivery. HEW involvement in non-HEP activities (such as promoting other government programs) often competed with their core mandates, thus affecting HEP service delivery.Efforts to address training and supervision constraints in Ethiopia's HEP should focus on improving the quality of NCD training for HEWs and supervisors, shifting from authoritative to supportive supervision, simplifying performance appraisal and reducing competing attention from other programs.

As chronic diseases, non-communicable diseases (NCDs) require sustained person-centred and community-based care. Given its direct link to communities and households, Primary Health Care (PHC) is well positioned to achieve such care. In Nigeria, the national government has prioritized PHC system strengthening as a means of achieving national NCD targets. However, strengthening PHC systems for NCDs require re-organization of PHC service delivery, based on contextual understanding of existing facilitators and barriers to PHC service delivery for NCDs. We conducted a mixed method case study to explore NCD service delivery with 13 PHC facilities serving as the cases of interest. The study was conducted in two northern and two southern states in Nigeria-and included qualitative interviews with 25 participants, 13 focus group discussion among 107 participants and direct observation at the 13 PHCs. We found that interprofessional role conflict among healthcare workers, perverse incentives to sustain the functioning of PHC facilities in the face of government under-investment, and the perception of PHC as an inferior health system were major barriers to improved organisation of NCD management. Conversely, the presence of physicians at PHC facilities and involvement of civil society organizations in aiding community linkage were key enablers. These marked differences in performance and capacity between PHC facilities in northern compared to southern states, with those in the south better organised to deliver NCD services. PHC reforms that are tailored to the socio-political and economic variations across Nigeria are needed to improve capacity to address NCDs.

Abstract Digital health applications (apps) have the potential to improve health behaviors and outcomes. We aimed to examine the effectiveness of a consumer web-based app linked to primary care electronic health records (EHRs). CONNECT was a multicenter randomized controlled trial involving patients with or at risk of cardiovascular disease (CVD) recruited from primary care (Clinical Trial registration ACTRN12613000715774). Intervention participants received an interactive app which was pre-populated and refreshed with EHR risk factor data, diagnoses and, medications. Interactive risk calculators, motivational messages and lifestyle goal tracking were also included. Control group received usual health care. Primary outcome was adherence to guideline-recommended medications (≥80% of days covered for blood pressure (BP) and statin medications). Secondary outcomes included attainment of risk factor targets and eHealth literacy. In total, 934 patients were recruited; mean age 67.6 (±8.1) years. At 12 months, the proportion with >80% days covered with recommended medicines was low overall and there was no difference between the groups (32.8% vs. 29.9%; relative risk [RR] 1.07 [95% CI, 0.88–1.20] p = 0.49). There was borderline improvement in the proportion meeting BP and LDL targets in intervention vs. control (17.1% vs. 12.1% RR 1.40 [95% CI, 0.97–2.03] p = 0.07). The intervention was associated with increased attainment of physical activity targets (87.0% intervention vs. 79.7% control, p = 0.02) and e-health literacy scores (72.6% intervention vs. 64.0% control, p = 0.02). In conclusion, a consumer app integrated with primary health care EHRs was not effective in increasing medication adherence. Borderline improvements in risk factors and modest behavior changes were observed.

Abstract Background Reduction of cardiovascular disease (CVD) is a worldwide health priority and innovative uses of technology-based interventions may assist patients with improving prevention behaviours. Targeting these interventions to recipients most likely to benefit requires understanding how contexts of use influence responsiveness to the intervention, and how this interaction favours or discourages health behaviour. Using a realist evaluation approach, the aim of this study was to examine the contextual factors influencing behaviour change within a multi-feature eHealth intervention with personalised data integration from the primary care electronic health record (EHR). Methods Realist evaluation of qualitative data from the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) randomised trial (N = 934). Thirty-six participants from the intervention group (N = 486) who had completed 12 months of study follow-up were interviewed. Coding of transcripts was structured around configurations of contexts, mechanisms, and outcomes of intervention use. Contextual narratives were derived from thematic analysis of the interviews. Results Mechanisms favouring positive health behaviour occurred when participants responded to four interactive features of the intervention. Facilitating mechanisms included greater cognitive engagement whereby participants perceived value and benefit, and felt motivated, confident and incentivised. Participants moved from being unconcerned (or unaware) to more task-oriented engagement with personal CVD risk profile and prevention. Increased personalisation occurred when modifiable CVD risk factors became relatable to lifestyle behaviour; and experiences of feeling greater agency/self-efficacy emerged. Use and non-use of the intervention were influenced by four overarching narratives within the individual’s micro-level and meso-level environments: illness experiences; receptiveness to risk and prevention information; history of the doctor-patient relationship; and relationship with technology. Conclusions Intervention-context interactions are central to understanding how change mechanisms activate within complex interventions to exert their impact on recipients. Intervention use and non-use were context-dependent, underscoring the need for further research to target eHealth innovations to those most likely to benefit.

Abstract Effective efforts to strengthen health systems need diverse, multi-stakeholder networks working together on complex or ‘wicked’ problems such as prevention and control of chronic diseases, solutions to which go beyond the role and capability of one organisation. The contextual complexities inherent in ‘wicked’ problems mean that solutions warrant a systems approach that encompasses innovation and new ways of thinking about, facilitating and implementing collective decision-making processes and change practices. Innovation platforms are a mechanism for facilitating communication and collaboration among diverse stakeholders, promoting joint action and stimulating innovation. Developmental evaluation is an approach that is increasingly being used to evaluate innovative and emergent programmes and projects, as it enables evaluators to provide real-time feedback so that evaluation findings can be used to guide development and adaptations. Developmental evaluation emphasises learning and adaptation, and aligns well with the implementation of innovation platforms that have continuous reflection, learning and adaptation as a specific design principle. Here, we outline our rationale for applying a developmental evaluation to enhance the formation, functioning and outcomes of an innovation platform aimed at accelerating and strengthening large-scale quality improvement efforts in Australian Aboriginal and Torres Strait Islander primary healthcare. We provide examples to explain how the developmental evaluation findings were used for adaptation of the innovation platform and assess to what extent our application of developmental evaluation was consistent with, and reflective of, its essential principles. Our evaluation aligned strongly with the principles of developmental evaluation, and the approach we took was well suited to situations with a developmental purpose, innovation niche and complexity such as innovation platforms. As a result, along with the increasing interest in multi-stakeholder platforms (e.g. innovation platforms) and the inherent challenges with evaluating these complex networks, we anticipate our use of this approach being of interest globally.

Abstract Background Evaluation of health technology programmes should be theoretically informed, interdisciplinary, and generate in-depth explanations. The NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework was developed to study unfolding technology programmes in real time—and in particular to identify and manage their emergent uncertainties and interdependencies. In this paper, we offer a worked example of how NASSS can also inform ex post (i.e. retrospective) evaluation. Methods We studied the TORPEDO (Treatment of Cardiovascular Risk in Primary Care using Electronic Decision Support) research programme, a multi-faceted computerised quality improvement intervention for cardiovascular disease prevention in Australian general practice. The technology (HealthTracker) had shown promise in a cluster randomised controlled trial (RCT), but its uptake and sustainability in a real-world implementation phase was patchy. To explain this variation, we used NASSS to undertake secondary analysis of the multi-modal TORPEDO dataset (results and process evaluation of the RCT, survey responses, in-depth professional interviews, videotaped consultations) as well as a sample of new, in-depth narrative interviews with TORPEDO researchers. Results Ex post analysis revealed multiple areas of complexity whose influence and interdependencies helped explain the wide variation in uptake and sustained use of the HealthTracker technology: the nature of cardiovascular risk in different populations, the material properties and functionality of the technology, how value (financial and non-financial) was distributed across stakeholders in the system, clinicians’ experiences and concerns, organisational preconditions and challenges, extra-organisational influences (e.g. policy incentives), and how interactions between all these influences unfolded over time. Conclusion The NASSS framework can be applied retrospectively to generate a rich, contextualised narrative of technology-supported change efforts and the numerous interacting influences that help explain its successes, failures, and unexpected events. A NASSS-informed ex post analysis can supplement earlier, contemporaneous evaluations to uncover factors that were not apparent or predictable at the time but dynamic and emergent.

Abstract Background To date, efforts to measure impact have largely focused on health research in high-income countries, reflecting where the majority of health research funding is spent. Nevertheless, there is a growing body of health and medical research being undertaken in low- and middle-income countries (LMICs), supported by both development aid and established research funders. The Framework to Assess the Impact of Translational health research (FAIT) combines three approaches to measuring research impact (Payback, economic assessment and case study narrative). Its aim is to strengthen the focus on translation and impact measurement in health research. FAIT has been used by several Australian research initiatives; however, it has not been used in LMICs. Our aim was to apply FAIT in an LMIC context and evaluate its utility. Methods We retrospectively applied all three FAIT methods to two LMIC studies using available data, supplemented with group discussion and further economic analyses. Results were presented in a scorecard format. Results FAIT helped clarify pathways of impact for the projects and provided new knowledge on areas of impact in several domains, including capacity-building for research, policy development and economic impact. However, there were constraints, particularly associated with calculating the return on investment in the LMIC context. The case study narrative provided a layperson’s summary of the research that helped to explain outcomes and succinctly communicate lessons learnt. Conclusion Use of FAIT to assess the impact of LMIC research was both feasible and useful. We make recommendations related to prospective use, identification of metrics to support use of the Payback framework, and simplification of the economic assessment, which may facilitate further application in LMIC environments.

Abstract Background A computerised, multifaceted quality improvement (QI) intervention for cardiovascular disease (CVD) management in Australian primary healthcare was evaluated in a cluster randomised controlled trial. The intervention was associated with improved CVD risk factor screening but there was no improvement in prescribing rates of guideline-recommended medicines. The aim of this study was to conduct a process evaluation to identify and explain the underlying mechanisms by which the intervention did and did not have an impact. Methods/design Normalisation process theory (NPT) was used to understand factors that supported or constrained normalisation of the intervention into routine practice. A case study design was used in which six of the 30 participating intervention sites were purposively sampled to obtain a mix of size, governance, structure and performance. Multiple data sources were drawn on including trial outcome data, surveys of job satisfaction and team climate (68 staff) and in-depth interviews (19 staff). Data were primarily analysed within cases and compared with quantitative findings in other trial intervention and usual care sites. Results We found a complex interaction between implementation processes and several contextual factors affecting uptake of the intervention. There was no clear association between team climate, job satisfaction and intervention outcomes. There were four spheres of influence that appeared to enhance or detract from normalisation of the intervention: organisational mission and history (e.g. strategic investment to promote a QI culture enhanced cognitive participation), leadership (e.g. ability to energise or demotivate others influenced coherence), team environment (e.g. synergistic activities of team members with different skill sets influenced collective action) and technical integrity of the intervention (e.g. tools that slowed computer systems limited reflective action). Discussion Use of NPT helped explain how certain contextual factors influence the work that is done by individuals and teams when implementing a novel intervention. Although these factors do not necessarily distil into a recipe for successful uptake, they may assist system planners, intervention developers, and health professionals to better understand the trajectory that primary health care services may take when developing and engaging with QI interventions. Trial registration ACTRN 12611000478910. Registered 08 May 2011.

Abstract Background Non-optimal blood pressure (BP) levels are a major cause of disease burden globally. We describe current BP and treatment patterns in rural India and compare different approaches to BP lowering in this setting. Methods All individuals aged ≥40 years from 54 villages in a South Indian district were invited and 62,194 individuals (84%) participated in a cross-sectional study. Individual 10-year absolute cardiovascular disease (CVD) risk was estimated using WHO/ISH charts. Using known effects of treatment, proportions of events that would be averted under different paradigms of BP lowering therapy were estimated. Results After imputation of pre-treatment BP levels for participants on existing treatment, 76·9% (95% confidence interval, 75.7–78.0%), 5·3% (4.9–5.6%), and 17·8% (16.9–18.8%) of individuals had a 10-year CVD risk defined as low ( 160/100 mmHg), respectively. Compared to the 19.6% (18.4–20.9%) of adults treated with current practice, a slightly higher or similar proportion would be treated using an intermediate (23·2% (22.0–24.3%)) or high (17·9% (16.9–18.8%) risk threshold for instituting BP lowering therapy and this would avert 87·2% (85.8–88.5%) and 62·7% (60.7–64.6%) more CVD events over ten years, respectively. These strategies were highly cost-effective relative to the current practice. Conclusion In a rural Indian community, a substantial proportion of the population has elevated CVD risk. The more efficient and cost-effective clinical approach to BP lowering is to base treatment decisions on an estimate of an individual’s short-term absolute CVD risk rather than with BP based strategy. Clinical trial registration Clinical Trials Registry of India CTRI/2013/06/003753, 14 June 2013.

BackgroundGlobal cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines.Methods and findingsWe conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis.ConclusionsThis study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.

Noncommunicable diseases (NCDs) are leading causes of death globally and in Nigeria they account for 29% of total deaths. Nigeria's health system is decentralized. Fragmentation in governance in federalised countries with decentralised health systems is a well-recognised challenge to coherent national health policymaking. The policy response to the rising NCD burden therefore requires strategic intent by national and sub-national governments. This study aimed to understand the implementation of NCD policies in Nigeria, the role of decentralisation of those policies, and to consider the implications for achieving national NCD targets. We conducted a policy analysis combined with key informant interviews to determine to what extent NCD policies and strategies align with Nigeria's decentralised health system; and the structure and process within which implementation occurs across the various tiers of government. Four inter-related findings emerged: NCD national policies are 'top down' in focus and lack attention to decentralisation to subnational and frontline care delivery levels of the health system; there are defective coordination mechanisms for NCD programmes which are underpinned by weak regional organisational structures; financing for NCDs are administratively burdensome and fragmented; and frontline NCD service delivery for NCDs are not effectively being integrated with other essential PHC services. Despite considerable progress being made with development of national NCD policies, greater attention on their implementation at subnational levels is needed to achieve more effective service delivery and progress against national NCD targets. We recommend strengthening subnational coordination mechanisms, greater accountability frameworks, increased and more efficient funding, and greater attention to integrated PHC service delivery models. The use of an effective bottom-up approach, with consideration for decentralization, should also be engaged at all stages of policy formulation.

BackgroundNon-communicable diseases (NCDs) now account for about 71% and 32% of all the deaths globally and in Ethiopia. Primary health care (PHC) is a vital instrument to address the ever-increasing burden of NCDs and is the best strategy for delivering integrated and equitable NCD care. We explored the capacity and readiness of Ethiopia's PHC system to deliver integrated, people-centred NCD services.MethodsA qualitative study was conducted in two regions and Federal Ministry of Health, Addis Ababa, Ethiopia. We carried out twenty-two key informant interviews with national and regional policymakers, officials from a partner organisation, woreda/district health office managers and coordinators, and PHC workers. Data were coded and thematically analysed using the World Health Organization (WHO) Operational Framework for PHC.ResultsAlthough the rising NCD burden is well recognised in Ethiopia, and the country has NCD-specific strategies and some interventions in place, we identified critical gaps in several levers of the WHO Operational Framework. Many compared the under-investment in NCDs contrasted with Ethiopia's successful PHC models established for maternal and child health and communicable disease programs. Insufficient political commitment and leadership required to integrate NCD services at the PHC level and weaknesses in governance structures, inter-sectoral coordination, and funding for NCDs were identified as significant barriers to strengthening PHC capacity to address NCDs. Among the operational-focussed levers, fragmented information management systems and inadequate equipment and medicines were identified as critical bottlenecks. The PHC workforce was also considered insufficiently skilled and supported to provide NCD services in PHC facilities.ConclusionStrengthening NCD prevention and control through PHC in Ethiopia requires greater political commitment and investment at all health system levels. Prior success strategies with other PHC programs could be adapted and applied to NCD policies and practice, giving due consideration for the unique nature of the NCD program.

Aims: To use linked routinely-collected health data to estimate diabetes prevalence and incidence in an Australian cohort of adults aged ≥45 years, and examine risk factors associated with incident disease. Research design and methods: The EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45) Study is a linked data study that combines baseline questionnaire responses from the population-based 45 and Up Study (2006–2009, n = 267,153) with multiple routinely-collected health databases up to December 2014. Among participants with ≥1 linked result for any laboratory test, diabetes status was determined from multiple data sources according to standard biochemical criteria, use of glucose-lowering medication or self-report, and the prevalence and incidence rate calculated. Independent risk factors of incident diabetes were examined using multivariable Cox regression. Results: Among 152,169 45 and Up Study participants with ≥1 linked laboratory result in the EXTEND45 database (mean age 63.0 years; 54.9% female), diabetes prevalence was 10.8% (95% confidence interval [CI] 10.6%–10.9%). Incident disease in those without diabetes at baseline (n = 135,810; mean age 62.5 years; 56.1% female) was 10.0 per 1,000 person-years (95% CI 9.8–10.2). In all age groups, diabetes incidence was lower in women compared to men, an association that persisted in the fully adjusted analyses. Other independent risk factors of diabetes were older age, being born outside of Australia (with the highest rate of 19.2 per 1,000 person-years observed in people born in South and Central Asia), lower education status, lower annual household income, residence in a major city, family history of diabetes, personal history of cardiovascular disease or hypertension, higher body mass index, smoking and long sleeping hours. Conclusions: Our study represents an efficient approach to assessing diabetes frequency and its risk factors in the community. The infrastructure provided by the EXTEND45 Study will be useful for diabetes surveillance and examining other important clinical and epidemiological questions.