The burden of type-2 diabetes (T2D) and hypertension (HTN) in Cambodia is a major concern. The government and donors have introduced several interventions, yet human resource shortages hamper their implementation. Community health workers (CHWs) can be a valuable additional resource for health in T2D and HTN management. The current study aimed to assess (1) CHWs' knowledge, attitude, and practices (KAP) in T2D and HTN management and (2) the potential health system barriers for incorporating CHWs in T2D and HTN management. This mixed-method study comprised a survey among 153 active CHWs to assess their KAP towards T2D and HTN, and semi-structured interviews with key informants were conducted to understand the challenges of the health system and propose solutions in incorporating CHWs in T2D and HTN management. Approximately 90% of CHWs correctly answered general knowledge questions on NCDs, risk factors, and prevention; however, only around 20-40% correctly answered questions on family history or tobacco use as risk factors. Most respondents appeared to have positive attitudes and have been practicing some activities related to T2D and HTN. Both financial and non-financial resource constraints were cited as challenges of the health system; therefore, re-structuring the definition of CHWs' roles and responsibilities, and assessing the need and workload have been proposed as ways forward to effectively incorporate CHWs in T2D and HTN care. CHWs in Cambodia have shown their potential in T2D and HTN management; however, a well-designed strategy, including technical training, clearly defined roles and responsibilities, and strong support structure, is important to maximize their potential in the health system.

Diabetes is a major health issue that is increasingly prevalent in Europe. Providing high-quality care is crucial, as failing to do so can lead to various complications. This study employed a cascade-of-care approach and data from 11 European countries to identify the points at which patients disengage from the diabetes care continuum, and explored the relationship with social capital variables, sociodemographic factors, and health indicators. Using cross-country data from Wave 6 and its related dried blood spot sample of the Survey of Health, Ageing and Retirement in Europe, multilevel logistic regression models were constructed using a stepwise approach. The stages of the cascade of care were outcome variables: prevalence of diabetes, receiving a diabetes diagnosis, and achieving glycaemic control based on HbA1c levels. Higher levels of bridging social capital are associated with lower diabetes prevalence, partly mediated by sociodemographic factors and health indicators. Diabetes is more commonly diagnosed in older individuals (although this link weakens in the oldest age groups), men, and those in poorer health. Better HbA1c control is associated with having a partner in the household, lower BMI, and being a woman. This study highlights that social capital is associated with diabetes care among older adults in Europe. Bridging social capital can reduce prevalence, and having a partner can enhance diabetes control. Social capital also appears to be indirectly related to receiving a diagnosis. This reinforces the need for a combined medical and social approach to diabetes care.

The COVID-19 crisis gave rise to measures such as physical distancing, sheltering in place, and social bubbles that impacted sexual lives profoundly. One group particularly badly impacted by COVID-19 containment, and at risk of sexual and mental health consequences as a result, comprised gay, bisexual and other men who have sex with men -- many of whom were more likely to live alone, to have had multiple partners before the epidemic, and some of whom were lacking in peer support for their mental health. This study investigated how members of this group living in Flanders (Belgium) experienced sex and sexuality during the COVID-19 epidemic. We conducted 29 in-depth interviews with gay, bisexual and other men who have sex with men who practised consensual nonmonogamy and/or sociosexuality, and used reflexive thematic analysis to analyse the data. Interviewees provided a nuanced and emotionally resonant account of sex as a pathway to intimacy, rather than just a physical act. In their descriptions, Intimacy was framed as a protective factor against the mental health challenges exacerbated by pandemic isolation.

In 2023, an estimated 39.9 million people globally were living with HIV, including 7.7 million in South Africa. Adherence to antiretroviral therapy (ART) is crucial for health outcomes, yet remains challenging. Households may shape health behaviours, including ART adherence. This study evaluated a household-level intervention to improve ART adherence in Cape Town, South Africa, which aimed to promote HIV competency for participants and their households. Baseline data were collected from 316 participants in 12 clinics (May 2021 - May 2022), with endline data from 198 participants (December 2021 - July 2022). Cluster-level analysis and mixed-effects models, with multiple imputation and complete case approaches, were utilised. At endline, there was evidence of a difference between control and intervention arms for following the ART schedule (aOR: 3.88, t = 2.62, p = 0.009), and taking ART on time (aOR: 2.28, t = 2.54, p = 0.01). Household-based interventions may have an impact on ART adherence, and should be considered in future adherence research, programming, and interventions. Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

South Africa has the largest ART programme in the world. ART is provided within the context of the universal test and treat strategy. Sustained high levels of ART adherence are required to ensure viral suppression and prevent ART-drug resistance. However, poor ART adherence remains a challenge in South Africa. While much research has focused on individual - and community-level factors influencing adherence, household-level factors remain under-researched. This study sought to qualitatively examine the role of household-related factors in ART adherence among 15 newly initiated people living with HIV (PLWH) in Cape Town, South Africa. The information-motivation and behavioural skills model and the concept of the HIV competent household provided the conceptual frameworks for the study. Emotional and instrumental support from household members and in particular mothers facilitated adherence. Open HIV dialogue fostered positive health behaviours and ART adherence. Household food insecurity, multimorbidity and busy work schedules both in the absence of household social support hindered ART adherence. Given the significant role of household support, particularly from mothers, in facilitating ART adherence, health facility programmes should aim to involve household members in the treatment of PLWH. This could be facilitated through training community health workers to foster and support HIV competent households.

Infant regulatory problems (RP), such as sleeping disturbances, feeding difficulties and excessive crying, affect a significant number of families and can persist beyond typical developmental stages, leading to distress for both the child and parents. These challenges disrupt the co-regulatory bond between parent and infant, often resulting in mutual dysregulation, parental burnout, and strained family relationships. Sociocultural values in Western societies, combined with conflicting role expectations, can contribute to heightened parental stress. Despite growing recognition of infant mental health (IMH), families’ lived experiences dealing with persistent and severe RP remain underexplored. This study addresses the existing gap by employing an Interpretative Phenomenological Approach (IPA), specifically the Multi Family Member Interview Analysis (MFMIA), to explore the nuanced and shared experiences of families in crisis. Interviews were conducted with six father–mother dyads who had received specialised tertiary IMH treatment due to persistent and severe RP in their child. Analysis revealed four phenomenological themes. First, families experienced more than stress or fatigue; RP represented an existential rupture that dismantled the predictability of everyday life (Disrupted lives). Second, traditional gender roles shaped coping strategies: fathers often sought refuge in work while mothers remained confined to relentless caregiving, creating a painful asymmetry that intensified exhaustion (A gendered struggle for balance). Third, social isolation emerged through external minimisation and internal reluctance to show vulnerability, leaving families increasingly disconnected (Alone on an island: trapped in a vicious cycle of isolation). Finally, the crisis extended beyond its acute phase, with participants describing a prolonged period characterised by significant differences between families, where persistent vulnerability intertwined with varying degrees of resilience (The past shapes the present). These results reveal a bidirectional dynamic, i.e., a spiralling mutual influence, operating between the infant and the parents, as well as within the co-parenting dyad. In this cycle, the challenges of raising a child with RP and the disruptions within the parent–child and parenting subsystems mutually reinforce each other, eroding identity, straining relationships, and fostering isolation. This study highlights the critical importance of societal recognition, accessible social support, and responsive government policies for families facing infant RP.

This study utilizes the illness identity framework to investigate the incorporation of HIV into a sense of self and how varying degrees of integration influence key patient-reported outcomes. Using baseline data from the SINAKO Cluster Randomised Controlled Trial, we analysed responses from 316 adults living with HIV (PLHIV) attending 12 healthcare facilities in the Cape metropole, South Africa. Respondents completed assessments on four illness identity dimensions (rejection, acceptance, engulfment, and enrichment) alongside measures for depression and anxiety symptoms, stigma, medication adherence, and self-management. Regression analyses with robust standard errors assessed associations between illness identity and patient-reported outcomes, controlling for gender, age, and illness duration. Longer illness duration was associated with acceptance and enrichment. There was no evidence of an association between gender or education level and illness identity, while age showed a weak positive association with acceptance. Higher engulfment scores correlated with greater depression and anxiety symptoms, increased stigma, and poorer treatment adherence and self-management. Higher enrichment scores were associated with better self-management and lower stigma. Higher rejection scores were associated with heightened negative self-image. Acceptance did not show unique associations with any outcome. This study highlights the vital role of illness integration in shaping health outcomes among PLHIV in resource-limited, high-prevalence settings. Strategies that rapidly identify those in an engulfment state early in the illness trajectory and foster adaptive illness integration, specifically enrichment, could improve outcomes for PLHIV.

BACKGROUND:Increasing Watch-group antibiotic use might be contributing to antimicrobial resistance burden in sub-Saharan Africa. We evaluated the effects of a community-based, co-created intervention bundle targeting all community-level health-care providers and the communities they serve on Watch-group antibiotic use and patient management. METHODS:In a cluster-randomised, controlled trial in Nanoro, Burkina Faso, and Kimpese, DR Congo, villages or neighbourhoods with at least 500 inhabitants and at least one community-level or primary-care provider functioning as the main medicine dispenser for the population were randomly allocated (1:1) to intervention or control groups, using the RAND function in Excel. Over 9 months, three intervention rounds consisted of community health education campaigns and educational and feedback sessions with providers, introducing WHO AWaRe (Access, Watch, Reserve) Antibiotic Book guidance for infections with highest antibiotic use. We measured baseline-to-post-intervention changes in Watch-group antibiotic use through repeated patient surveys (100 per provider per village), cluster-adjusted and offset for health-care utilisation (primary outcome), and patient management scores for five common, well defined infections through simulated patient visits (secondary outcome). Providers with fewer than 20 completed surveys at baseline or post-intervention were excluded. Field workers conducting patient surveys and simulated patient visits were masked to group assignment. CABU-EICO was registered on ClinicalTrials.gov (NCT05378880). FINDINGS:44 villages or neighbourhoods (22 each in Nanoro and Kimpese) were enrolled and randomly assigned to intervention (11 each in Nanoro and Kimpese) or control (11 each in Nanoro and Kimpese) groups. At baseline (Oct 26, 2022, to March 13, 2023), 5532 patients were surveyed (3558 in Nanoro and 1974 in Kimpese). Post-intervention (Nov 6, 2023, to April 3, 2024), 4898 patients (3180 in Nanoro and 1718 in Kimpese) were surveyed. Patients were surveyed at 32 health centres (18 intervention and 14 control), 31 private clinics (15 intervention and 16 control), 45 pharmacies (25 intervention and 20 control), and 41 informal vendors (22 intervention and 19 control). A total of 1092 simulated patient visits were completed across both periods. The weighted prevalence of Watch-group antibiotic use decreased from 26·8% (95% CI 8·8-44·8) to 17·1% (7·7-26·5) in the intervention group and increased from 13·4% (4·8-22·0) to 21·2% (8·9-33·5) in the control group; the adjusted prevalence ratio for use of Watch-group antibiotics was 0·33 (95% CI 0·14-0·78). Changes in patient management scores were minimal. INTERPRETATION:The behavioural intervention bundle was associated with a substantial reduction in Watch-group antibiotic use and no negative effect on patient management, highlighting the potential of antibiotic use improvements across health-care providers. Reduced community-level use of broad-spectrum antibiotics could help slow community-acquired pathogens' increasing resistance to clinically important antibiotics. FUNDING:The Joint Programming Initiative on Antimicrobial Resistance Research and Research Foundation-Flanders. TRANSLATIONS:For the French translation of the abstract see Supplementary Materials section.

The prevalence of hypertension (HTN) of adults aged ≥ 40 years in Cambodia was high (35.2

Scaling up is a complex process. As a multi-dimensional concept, it requires efforts to (1) increase population coverage (coverage), (2) expand or diversify what is included in the health service package (expansion), and/or (3) institutionalise a health innovation or new practice into health system services (institutionalisation). In this paper, we provide the theoretical basis for the model joining linear as well as complex pathways – stemming from implementation and complexity science – towards three-dimensional scaling. Our scale-up model positions expansion as the backbone for scale-up, and proposes multiple back-and-forth waves between institutionalisation and coverage. This allows an incrementalist approach, going step-by-step from one to the other scale-up dimension, as well as a multi-player complexity approach, emphasising the interactions between scale-up dimensions and actors involved, to achieving population health. By offering a dual incrementalist-complexity focus, we acknowledge that there is a starting point to scale-up, and thus path dependency, in addition to highly contextual cultural, historical, socio-political, and economic forces that underpin population health and any attempt at scaling up access and integration of health services, thereby pointing at their fragmented and incomplete nature. The visualisation and underlying hypotheses offer speculation on potential pathways for scale-up, which are key processes to understand and untangle in future research.

Background Widening health inequities in Belgium highlight the need for proactive, outreach-oriented primary care models. Large-scale community health worker programmes in low- and middle-income countries have demonstrated effectiveness in bridging healthcare access gaps and are increasingly recognised as potential reciprocal innovations for high-income countries. However, little is known about how such models can be successfully transferred across contexts, as these processes are rarely reported in sufficient detail, limiting replication and cumulative learning. Aim This study addresses these gaps by detailing the development of the Community Health Workers for Primary Healthcare Access (COMPASS) intervention-a CHW-based model adapted from Brazil and South Africa for the Belgian health system. Methods The COMPASS intervention was developed through a multi-phase, iterative process informed by the ADAPT guidance (Moore et al., 2021) and the Six Steps in Quality Intervention Development (6SQuID) (Wight et al., 2016). Three phases structured the process: (i) problem identification and exploration of potential solutions through qualitative fieldwork in Belgium and South Africa as well as field visits to Brazil and the UK; (ii) participatory adaptation and intervention design via co-creation workshops with stakeholders in Belgium; and (iii) pilot testing to refine the model and prepare for evaluation. Results Phase 1 fieldwork in Antwerp identified key access barriers in Belgium; complementary fieldwork in South Africa, and field visits to Brazil and the UK, highlighted mechanisms through which CHWs address such barriers: mechanisms included sustained, structured, and culturally sensitive support embedded in both communities and the health system. Phase 2 co-creation workshops determined which elements of the Brazilian and South African CHW models could be retained as core components and which required adaptation to align with Belgian primary care structures and local needs. Phase 3 pilot testing confirmed feasibility and led to final refinements, resulting in a COMPASS intervention that is both contextually appropriate and ready for evaluation. Conclusions By providing a detailed account of the COMPASS intervention's adaptation and development, this study illustrates how established frameworks can be applied in practice to guide the design and transferability of complex health interventions. It offers practical guidance for adapting health service innovations across contexts in a transparent, systematic and context-sensitive manner.

This study explored factors influencing the experiences of HIV testing among men. The qualitative study was conducted between February and May 2024 in Cape Town, South Africa. Fifteen men, five healthcare workers, four community health workers and six community leaders took part in individual interviews. Men, women, and mixed groups of men and women took part in focus group discussions (n = 6) (5-7 participants per group). Participants were purposively selected. Thematic analysis, guided by the conceptual framework of access to healthcare, was applied. Testing was influenced by (a) healthcare workers initiating HIV testing, which men generally accepted, (b) the availability of male-friendly and men's clinics, which were limited, but approachable and preferred over general facilities, and (c) men's engagement in sexual behaviours that increased their exposure to HIV, which motivated testing after self-reflection. While men would access services, they nonetheless experienced emotional distress, including anxiety and fear. However, support services to cope with these emotions were unavailable. The findings highlight the need to integrate psychological support services with HIV testing and treatment and to stimulate and encourage social support to help men manage testing-related anxiety, cope with HIV-positive diagnoses, and improve linkage to care.

TRIAL REGISTRATION:Pan African Clinical Trial Registry identifier: PACTR201906476052236.

Background Illness identity is the extent to which a chronic illness is integrated into one's sense of self. It can significantly impact the health outcomes and well-being of people living with HIV (PLHIV). Because incorporating HIV into one's identity is shaped by social context, particularly the household environment, we hypothesised that household HIV competence would play an important role in shaping key dimensions of illness identity: acceptance, rejection, engulfment, and enrichment. Methods Data were drawn from the baseline phase of the SINAKO cluster randomised controlled trial. A total of 316 adults living with HIV, aged 18 to 65 years (mean age = 35.49; 83% women), completed questionnaires evaluating household HIV competence and the four illness identity dimensions. Most participants (73%) had been living with HIV for more than six months. Multiple regression analyses with robust standard errors were conducted to assess associations between household HIV competence and each illness identity dimension, controlling for gender, age, and illness duration. Results In adjusted models, there was strong evidence that household HIV competence was associated with two dimensions of illness identity: higher household HIV competence was associated with greater acceptance (β = 0.06, p = 0.04) and lower rejection (β = −0.14, p = 0.002). No evidence was found of an association with engulfment (β = −0.10, p = 0.13) or enrichment (β = 0.10, p = 0.05). Conclusions These findings build on the illness identity literature by demonstrating that household HIV competence is uniquely linked to acceptance and rejection among people living with HIV. Recognising the central role of families in shaping the illness experience is vital. Strengthening household HIV competence through targeted family support may reduce rejection and promote acceptance, with the potential to improve long-term health outcomes for those living with HIV. Trial registration: Pan African Clinical Trial Registry, PACTR201906476052236. Registered 6 June 2019. https://pactr.samrc.ac.za

Social norms around PrEP act as both barriers to and stimulants of the use of PrEP across a wide range of target populations, yet remain relatively understudied. To stimulate theoretical innovation and provide a quantitative check for qualitative findings, we integrate norm types from the Behavioral Models (BM) and the Social Norms Approach (SNA) into the socio-ecological model (SEM) and analyze their relationship with PrEP-intention. We include attitude and role belief at the individual level, injunctive norms at the interpersonal level and descriptive norms and self-comparison to peers at the community level. The data were drawn from a survey on sexual health distributed on social media by Flemish MSM community organizations from October 19th, 2022, to December 19th, 2022, resulting in a total convenience sample of 610. Structural Equation Modelling analyses, including confirmatory factor analysis of the latent variables and path analysis of the relationship between norm types and PrEP intention, were conducted on a convenience sample of 350 Belgian MSM who were not living with HIV. At the individual level, attitude towards PrEP was positively and moderately to strongly associated with intention, while role belief that ‘It is inappropriate for someone with my relationship(s) to use PrEP’ was negatively and moderately to strongly associated with intention. At the interpersonal level, injunctive norms, the expectation of a positive reaction to the respondent’s PrEP use, were positively and moderately to strongly associated with intention. At the community level, descriptive norms, thinking more peers use PrEP, were positively and weakly associated with intention. While self-comparison to peers, estimating one’s own sexual behaviour as safer than peers, was negatively and weakly associated with intention. All norm types included in the analysis, at the individual level (attitude and role belief), interpersonal level (injunctive norms), and the community level (descriptive norms and self-comparison to peers), were associated with PrEP-intention among MSM. Most PrEP interventions target cognition, while our analysis shows significant untapped potential for norm-based interventions to increase intention to use PrEP.

BACKGROUND:Family involvement (FI) in medical decision making (MDM) is increasingly recognized as a dimension of patient-centered care; however, patient preferences for FI vary across clinical and cultural contexts. In health care systems emphasizing autonomy and direct communication, less is known about how patient characteristics and illness scenarios (cancer vs depression; and mild vs severe depression) influence FI preferences. METHODS:We analyzed data from a subsample of a national online probability panel (N = 1,175) collected in 2024. In a survey experiment, respondents evaluated vignettes describing skin cancer and depression; the depression vignette was randomly assigned as mild or severe. Ordered logistic regression models assessed associations between FI preferences and sociodemographic and economic factors as well as religious affiliation. RESULTS:Preference for family-led decision making was uncommon across vignettes (skin cancer: 1.2%; severe depression: 2.7%; mild depression: 1.4%), while the majority preferred patient-led decision making (77.4%, 70.9%, and 81.0%, respectively). Making medical decisions together with family members was most often preferred in cases of severe depression (26.4%), followed by cancer (21.4%) and mild depression (17.6%). Living with a partner and having a migration background (European or non-European) were associated with a greater preference for FI. Respondents identifying as Christian (vs nonreligious/liberal) showed stronger preferences for FI in the cancer and severe depression vignette. Higher educational attainment was associated with weaker preferences for FI, particularly in the cancer vignette. CONCLUSIONS:Preferences for family-led decision making were low, with most respondents favoring autonomous decision making. FI preferences varied modestly by illness context and sociodemographic characteristics, particularly migration background, living situation, education, and religious affiliation. These findings underscore the importance of flexible MDM approaches that accommodate heterogeneity in patient preferences.

BACKGROUND:In sub-Saharan Africa, invasive antimicrobial-resistant infections often originate from community-level acquisition. In this study, we aimed to evaluate the effect of a cluster-level intervention on individual-level extended spectrum β-lactamase-producing Escherichia coli (ESBL-E) acquisition. We assessed whether a behavioural intervention bundle targeting suboptimal antibiotic use and hygiene practices reduced household-level acquisition of ESBL-E. METHODS:We conducted a cluster-randomised controlled trial in 22 village clusters in Nanoro district, Burkina Faso. We enrolled 12 randomly selected households per cluster to assess the intervention effect on ESBL-E household transmission. The intervention comprised three rounds delivered at 3-month intervals and combined WHO Access, Watch, Reserve-based educational and feedback sessions for formal and informal medicine providers with community health education campaigns. Consenting household members provided stool samples before, during, and after intervention rollout, alongside a pre-post household water, sanitation, and hygiene (WASH) survey. ESBL-E acquisition was defined as a transition from a negative to a positive stool sample between consecutive sampling visits, with transition hazards estimated using continuous-time Markov models. We estimated intervention effects on ESBL-E acquisition using Bayesian Markov models. Cox frailty models assessed associations between WASH exposures and acquisition. The study is registered with ClinicalTrials.gov (NCT05378880). FINDINGS:1203 individuals were enrolled between Oct 11, 2022, and Feb 19, 2024. At baseline, 346 (57%) of 604 individuals in the control household group and 291 (49%) of 599 individuals in the intervention household group tested positive for ESBL-E colonisation. Pre-intervention acquisition incidence rates were 3·8 per 100 person-days (95% credible interval [CrI] 2·0-9·9) in the intervention group and 3·5 per 100 person-days (95% CrI 1·8-9·6) in the control group. The intervention did not change the risk of ESBL-E acquisition in months 1-6 (hazard ratio [HR] 1·02 [95% CrI 0·78-1·31]) but was associated with a reduction in months 6-9 (HR 0·82 [95% CrI 0·56-1·14], probability of a reduction p[HR<1]=0·88). Acquisition risk was higher in the rainy season (peak HR 1·73 [95% CI 1·49-2·00]), whereas improved sanitation was associated with lower risk (HR 0·77 [95% CI 0·59-1·00]). INTERPRETATION:Findings, although inconclusive, were consistent with a modest intervention-related reduction in ESBL-E acquisition incidence. Higher acquisition rates associated with rainy seasons and poor sanitation highlight the need to tackle environmental drivers of antimicrobial resistance transmission in addition to antibiotic use in rural sub-Saharan Africa. FUNDING:EU Joint Programme Initiative on Antimicrobial Resistance CABU-EICO.

Diabetes mellitus is a growing public health concern across Europe, with substantial gaps in diagnosis, treatment, and glycemic control. Despite clinical guidelines, care performance varies widely, even between high-resource countries. This study aims to assess diabetes care performance across ten European countries using a cascade of care framework and to examine whether population characteristics explain cross-country differences. We analyzed data from 18,499 individuals aged 50 and older from wave 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE), including self-reported diabetes status, medication use, and HbA1c biomarkers. Diabetes was defined as either self-reported diagnosis, medication use, or HbA1c ≥ 6.5