UCL Institute for Global Health

The prevalence of frailty and its effect on cardiovascular outcomes is increasing on a global scale. Pharmacotherapies for cardiovascular diseases in older people with frailty present unique challenges that require a comprehensive and individualized approach. In this Review, we provide a general overview of these challenges, followed by an in-depth discussion of the problems inherent in applying standard approaches to cardiovascular care in this population. Specifically, we consider blood pressure control, glucose lowering in patients with type 2 diabetes mellitus, lipid lowering, antiplatelet therapies, direct oral anticoagulants for stroke prevention in atrial fibrillation, and the treatment of heart failure. Although the reduction in cardiovascular events in older individuals with frailty is crucial, the potentially increased risk of adverse effects with the use of cardiovascular medications must be carefully considered. Treatment targets and the choice of drug for these patients should be based on their overall health status and personal goals of care. Frailty is common in older individuals, but can occur independently of advanced age, multimorbidity or disability. In this Review, Nguyen and colleagues draw on evidence from clinical guidelines and randomized controlled trials to provide an in-depth discussion of the unique challenges associated with cardiovascular pharmacotherapy in older patients with frailty.

There has been increasing interest in co-designing interventions with end users to prevent violence against women (VAW). Co-design is theorized as an ethical approach to research able to engage some of the most marginalized groups in VAW prevention. However, there is little evidence of whether co-designing interventions can reduce violence against women, or a theoretical consideration of how it might do so. This paper contributes to current discussions about co-design by examining the results of the E le Saua le Alofa (Love Shouldn't Hurt)-a pilot intervention that engaged Samoan communities in co-designing violence prevention activities. A mixed-methods evaluation of the pilot has shown promising results, and in this paper, we consider how the co-design process may have contributed to these results. The evaluation of the co-design process assessed four theorized mechanisms: (1) increased ownership of the problem of violence; (2) improved health behaviours and social norms; (3) relevance of actions taken to address VAW; (4) addressing power structures arising from coloniality. Our results show that a change in violence outcomes occurred through the pilot's ability to revisit previous conversations about violence in Samoa, prompting new activities by local leaders, and tightening village rules on violence. Yet, the activities implemented by local leaders were largely unpredictable and sometimes conflicted with global evidence. We argue that such actions should not be construed by policymakers as the "unpredictable outcomes" of an intervention, but rather understood within a broader framework of diversified knowledge systems. The need for balance in co-designing VAW interventions with communities affected by violence highlights a key challenge of decolonizing VAW practice within a co-production framework.

Abstract Women in Samoa experience a high rate of intimate partner violence (IPV) shaped in part by a history of colonisation and its influence on gender roles and lived experiences. As part of the EVE Project to improve the evidence base for preventing IPV in high-prevalence settings, we co-developed an intervention with 30 community-based researchers (CBRs) from 10 villages, drawing from evidence-based modules previously developed and evaluated in other neo-colonial contexts. We assessed the pilot intervention’s acceptability, feasibility and potential impact when delivered to groups of 15 men and 15 women in 10 participating villages, using a mixed methods before (baseline) and after (endline) study design. We collected a baseline (N = 289) and endline survey (N = 229); ‘stories of change’ interviews with participants (N = 151); in-depth interviews (N = 14) with CBRs, and intervention evaluation workbooks from CBRs (N = 18). The acceptability of the intervention was assessed through retention rates and participant interviews, while feasibility was assessed by interviews with CBRs, and observations of survey implementation. The potential impact of the intervention on IPV experience and perpetration, and on gender views was explored via the analysis of survey data. Results suggest a reduction in IPV experience and perpetration at endline compared to baseline, but associations were non-significant. Women’s belief of non-equitable norms was also lower at endline (β = − 0.54, 95% CI − 0.88 to − 0.21, p = 0.005). Attendance was high overall (although men’s acceptability was challenging in some villages). Participants shared positive feedback on the delivery by CBRs and careful adaptation to fa’a Samoa (‘the Samoan way’). Further research aligned with the Indigenous context of Samoa is required to assess its effectiveness. The study was registered retrospective to the pilot but prior to analysis as ISRCTN17319820 on 14 March 2024.

BACKGROUND:Cardiovascular risk is underassessed in women. Many women undergo screening mammography in midlife when the risk of cardiovascular disease rises. Mammographic features such as breast arterial calcification and tissue density are associated with cardiovascular risk. We developed and tested a deep learning algorithm for cardiovascular risk prediction based on routine mammography images. METHODS:Lifepool is a cohort of women with at least one screening mammogram linked to hospitalisation and death databases. A deep learning model based on DeepSurv architecture was developed to predict major cardiovascular events from mammography images. Model performance was compared against standard risk prediction models using the concordance index, comparative to the Harrells C-statistic. RESULTS:There were 49 196 women included, with a median follow-up of 8.8 years (IQR 7.7-10.6), among whom 3392 experienced a first major cardiovascular event. The DeepSurv model using mammography features and participant age had a concordance index of 0.72 (95% CI 0.71 to 0.73), with similar performance to modern models containing age and clinical variables including the New Zealand 'PREDICT' tool and the American Heart Association 'PREVENT' equations. CONCLUSIONS:A deep learning algorithm based on only mammographic features and age predicted cardiovascular risk with performance comparable to traditional cardiovascular risk equations. Risk assessments based on mammography may be a novel opportunity for improving cardiovascular risk screening in women.

Couples programming is an evidence-based strategy to prevent intimate partner violence (IPV) and strengthen relationship quality. Stepping Stones Creating Futures (SSCF) is a 21-session participatory programme for young adults (18-30 years) that integrates gender equity, communication and livelihoods skills, and has been evaluated in informal settlements in eThekwini, South Africa. Zithandani SSCF is an adaptation engaging young heterosexual couples. This paper documents findings from two rounds of qualitative interviews with 15 young women and 15 young men to inform the adaptation. Formative research examined relationship dynamics and manifestations of conflict and IPV. Participants identified relationship-level factors contributing to IPV such as jealousy, inequitable gender roles and sexual relations. These factors could erode relationship quality, further shaped by time spent together, openness of communication and conflict resolution strategies. Harsh socio-economic conditions were a frequent source of relationship tension. Findings highlight the importance of addressing relationship-level risk factors for IPV and determinants of relationship quality to strengthen couples-based interventions that promote healthier, more equitable and non-violent intimate relationships.