IntroductionWhile antiretroviral therapy (ART) has significantly improved HIV outcomes, viral load remains unsuppressed for 6% of the people on ART globally in 2024. In South Africa, 5.7 million people are on ART, and viral load non-suppression was reported in 8% of them in 2022. Viral load non-suppression during ART is associated with health decline and HIV transmission. Weight is also a vital component for the management of HIV. High body mass index (BMI) increases the risk of non-communicable diseases, increasing the risk of multimorbidity in people living with HIV. Both ART effectiveness and obesity have been shown to be affected by socioeconomic, psychological and health related factors, but their interrelationships in South Africans living with HIV are not well known. This study aims to investigate the effects of socioeconomic and health related factors at enrolment, and their changes over time in viral load non-suppression and BMI among people receiving ART who have depression symptoms.MethodsThis was a secondary analysis of data from a randomised controlled trial of depression management in 2002 adults receiving ART. We investigated the effects of sociodemographic characteristics, comorbidities, depression symptoms (Patient Health Questionnaire-9 (PHQ-9)), functional disability (WHODAS-2.0), AIDS-related stigma and ART adherence - all measured at baseline - on viral load non-suppression (viral load ≥1000 copies/ml) and on body mass index (BMI), at baseline and on changes 12 months later, using longitudinal mixed effect logistic and linear regression models. A P-value of 0.05 or less was considered statistically significant. Potentially confounding covariates were selected and adjusted for using least absolute shrinkage and selection operator (LASSO) inference as a sensitivity analysis.ResultsPeople with viral load non-suppression at baseline were more likely to be male, younger and to earn lower income. Health characteristics associated with viral load non-suppression at baseline were previous tuberculosis, having been on ART for less than 6 months or more than 10 years, and self-reported non-adherence to ART. Higher disability score and ART duration <6 months or >10 years at baseline were associated with an increasing likelihood of viral load non-suppression 12 months later. Higher BMI at baseline was associated with being female, being married, earning higher income and hypertension, no history of tuberculosis and not having viral load non-suppression. BMI increased from baseline to follow-up, and women and younger people had greater increases in BMI 12 months later. Depression symptom scores and stigma scores were not associated with viral load non-suppression or BMI.ConclusionsThis study identified sociodemographic risk factors associated with viral non-suppression in PLWH, but most of them were not associated with further changes over time. Functional disability, however, was a risk factor with long-term implications. Younger people and women were at greater risk of BMI increasing over time. This suggests a need for ART programs to integrate long-term support services like frequent adherence assessment, mental health, rehabilitation and weight management strategies tailored to high-risk groups. ClinicalTrials.gov (NCT02407691), Pan African Clinical Trials Registry (201504001078347), South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048, NHREC 4048).

Objectives Local public health organisations require information about local variations in healthy life expectancy (HLE) and associated risks to inform decisions about how and where to intervene to improve HLE, a key indicator of population health. We aimed to estimate both HLE and levels of risk in small areas and quantify associations between them.Design Cross-sectional population-based study.Setting Norfolk and Waveney Integrated Care System.Population 128 Middle Layer Super Output Areas and eight Lower Tier Local Authority Areas.Outcome measures HLE (estimated using self-reported health status from the 2021 UK Census) in each Middle layer Super Output Area and levels of 10 risk factors (selected based on existing evidence of association with lower life expectancy or self-reported health and availability of local risk information): index of multiple deprivation; weekly net income; urban area; diet not meeting five portions of fruit and vegetables on a usual day; physical inactivity; older person living alone; falls admissions rate; alcohol mortality rate; road casualties and air pollution.Main results HLE in 2021 was 66.5 years for men (range 52–73) and 67.5 years for women (range 56–74). The difference between areas was 21 years for men and 18 years for women. Higher income was strongly associated with all healthy life expectancies: £100 higher weekly income was associated with 4.4 (95% confidence limits 3.5 to 5.2) and 4.6 (3.8 to 5.4) years greater HLE at birth in males and females respectively and with 1.7 (1.3 to 2.2) and 2.0 (1.5 to 2.5) greater HLE at age 65. Higher percentage of older adults living alone was associated with lower HLE at birth in males and females. Physical inactivity was associated with lower HLE at 65 in males and at birth in females.Conclusions This approach uses standard methods and publicly available data to estimate both HLE and risk exposures in small areas to find areas with low life expectancy and high risks, where local organisations may prioritise the implementation of cost-effective interventions. It could be replicated in other areas to target interventions and inequalities. More accurate data on risk exposures in small areas would allow a broader range of risk factors, including smoking, to be considered.

Background: In rural KwaZulu-Natal Province, South Africa, less than 25 % of persons with hypertension have controlled blood pressure. We conducted a formative evaluation of current clinic-based care to identify barriers and facilitators that could impact effective implementation of a community-based hypertension intervention (IMPACT-BP). Methods: We conducted individual interviews and group discussions with clinic managers, nurses, community health workers (CHWs), community leaders, and patients to identify barriers and facilitators experienced in clinic-based hypertension care, which could affect the acceptability, feasibility, and implementation of the IMPACT-BP intervention. The Conceptual Model of Implementation Research and the Theoretical Framework of Acceptability guided the design of data collection instruments and analysis. Qualitative data collection was performed by trained social science research assistants, recorded, transcribed, translated, and analyzed using thematic analysis. Results: Forty-one participants (92 % women) participated in group discussions (n = 32) or individual interviews (n = 9). Barriers to intervention acceptability and feasibility included inadequate levels of staffing, high patient volumes, distrust of CHWs’ work at clinics and in the community, and insufficient training and equipment for CHWs. Facilitators included home delivery of medications by CHWs. Conclusions: Our findings allowed us to identify specific adaptations to the intervention implementation strategy to make the proposed community-based intervention acceptable and feasible in this setting. Adaptations included employing dedicated CHWs and nurses for trial-related activities, developing an expanded CHW training module on hypertension knowledge, teaching CHWs to measure blood pressure and subsequently train patients to do the same, and training CHWs to educate patients about hypertension management.

The World Health Assembly has called for clinical trials to be strengthened, with broader demographic and geographical inclusion of populations. The objective of this paper is to highlight the importance of rigorous evidence to maximise the health gains of primary health care, and to identify strategies for strengthening clinical trials in primary care. Clinical trials should evaluate interventions of all kinds, including preventive manoeuvres, diagnostics, health service research questions, behavioural and educational interventions, vaccines, therapeutics, and policies. Single question trials can be inefficient and seldom strengthen health systems. New approaches that develop or strengthen health research infrastructure and embed research in primary care will identify effective interventions faster, how to deliver them better, and more accurately determine to whom they should be applied. When patients and community members, together with researchers, contribute to conception, design, and delivery, research will result in more useful, relevant evidence. Traditional site-based recruitment (where the participant comes to the trial) can be complemented by approaches that give people the opportunity to contribute regardless of where they live and receive their health care (taking the trials to the people). However, this cannot be done until regulation is modernised to make it easier for health-care professionals, researchers, and research participants to co-design, deliver, and implement such trials, and to develop processes to coordinate and monitor progress against goals for budget shifts, delivery, engagement, trials activity, and impact. Strengthening primary care trials is especially important in those regions where primary care is most under-resourced and is key to pandemic preparedness. Not doing so risks widening inequities further.

BACKGROUND:Poorly controlled hypertension is a common problem worldwide, particularly in low-resource settings. METHODS:We conducted an open-label, randomized, controlled trial of a home-based model of hypertension care in South Africa. Adults with hypertension were assigned to receive home-based care, which consisted of patient monitoring of blood pressure, home visits from a community health worker (CHW) for data collection and medication delivery, and remote nurse-led decision making supported by a mobile application (CHW group); enhanced home-based care, which consisted of the same intervention but with blood-pressure machines transmitting readings automatically (enhanced CHW group); or standard care with clinic-based management (standard-care group). The primary outcome was the systolic blood pressure at 6 months. Secondary outcomes were the systolic blood pressure at 12 months and hypertension control at 6 and 12 months. Safety outcomes included adverse events, deaths, and retention in care. RESULTS:A total of 774 adults underwent randomization. The mean age was 62 years; 76.0% of the participants were women, 13.6% had diabetes mellitus, and 46.5% had human immunodeficiency virus infection. The mean systolic blood pressure at 6 months was lower in the CHW group than in the standard-care group (difference, -7.9 mm Hg; 95% confidence interval [CI], -10.5 to -5.3; P<0.001) and was also lower in the enhanced CHW group than in the standard-care group (difference, -9.1 mm Hg; 95% CI, -11.7 to -6.4; P<0.001). The percentage of participants with hypertension control at 6 months was 32.5% in the standard-care group, as compared with 57.4% in the CHW group (relative risk, 1.76; 95% CI, 1.40 to 2.13) and 61.3% in the enhanced CHW group (relative risk, 1.89; 95% CI, 1.51 to 2.27). The improvements in systolic blood pressure and hypertension control with home-based care appeared to persist at 12 months. Severe adverse events and deaths occurred in 2.7% and 1.0% of the participants, respectively, and occurred in a similar percentage of participants across trial groups. Retention in care was observed in more than 95% of the participants in the CHW and enhanced CHW groups. CONCLUSIONS:In South Africa, home-based hypertension care led to a significantly lower mean systolic blood pressure at 6 months than standard, clinic-based care. (Supported by the National Institutes of Health and others; IMPACT-BP ClinicalTrials.gov number, NCT05492955; South African National Clinical Trials Register number, DOH-27-112022-4895.).

BACKGROUND:Improving Access to Psychological Therapies (IAPT), an NHS England service providing talking therapies, is meeting its target recovery rate of 50%. However, engagement in treatment, as well as recovery rates, may be lower for some groups. AIMS:To assess variation in treatment completion and recovery rates by demographic and socioeconomic group and to describe rates of further referrals for patients to IAPT and secondary mental health services. METHOD:Using 121 548 administrative records for 2019-2020 and 2022-2023 for the Norfolk and Waveney area, we estimated associations of age, gender, ethnicity and deprivation with the likelihood of treatment completion and recovery using logistic regression modelling. We also described rates of further referrals. RESULTS:Younger people and those living in deprived areas were less likely to recover or complete treatment, with those aged 16-17 years (n = 735) having the lowest adjusted odds for recovery (adjusted odds ratio = 0.5, 95% CI: 0.5-0.6) compared with those aged 36-70 years, and those aged 18-24 years (n = 23 563) having the lowest rate of completion (adjusted odds ratio = 0.5, 95% CI: 0.5-0.6). Further referrals before April 2022 were recorded for 45.4% of 6513 patients who had completed treatment and 68.8% of 9469 who had not completed treatment, and for 39.4% of 2007 recovered patients in 2019-2020 and 53.1% of 1586 who had not recovered. Non-completers had relatively more further referrals to secondary mental health services compared with completers (43.6% v. 22.8%; P < 0.01). CONCLUSIONS:Younger people and those living in deprived areas have lower recovery and completion rates. Those who have completed treatment and not recovered have higher rates of further referrals.

Introduction:Unsuppressed viral load during antiretroviral therapy (ART) is associated with health decline and HIV transmission. Being overweight or obese increases the risk of non-communicable diseases, increasing the risk of multimorbidity in people living with HIV. Both ART effectiveness and obesity have been shown to be affected by socioeconomic, psychological and health related factors, but their interrelationships in South Africans living with HIV are not well known. Methods:This was a secondary analysis of data from a randomised controlled trial of depression management in 2002 adults receiving ART. We investigated the effects of sociodemographic characteristics, comorbidities, depression symptoms (Patient Health Questionnaire-9 (PHQ-9)), functional disability (WHODAS-2.0), AIDS-related stigma and ART adherence on viral load non-suppression (viral load ≥1000 copies/ml) and on body mass index (BMI), at baseline (baseline) and on changes 12 months later, using longitudinal mixed effect logistic and linear regression models. Potentially confounding covariates were selected and adjusted for using least absolute shrinkage and selection operator (LASSO) inference. Results:People with viral load non-suppression at baseline were more likely to be male, younger and to earn lower income. Health characteristics associated with viral load non-suppression at baseline were previous tuberculosis, having been on ART for less than 6 months or more than 10 years, and self-reported non-adherence to ART. Higher disability score and ART duration <6 months or >10 years at baseline were associated with an increasing likelihood of viral load non-suppression 12 months later. Higher BMI at baseline was associated with being female, being married, earning higher income and hypertension, no history of tuberculosis and not having viral load non-suppression. BMI increased from baseline to follow-up, and younger age was associated with a greater increase in BMI 12 months later. Depression symptom scores and stigma scores were not associated with viral load non-suppression or BMI. Conclusions:Viral load non-suppression was associated with lower BMI, most likely due to its effects on HIV-related illness. Viral load non-suppression and BMI were both associated with a variety of sociodemographic factors, while viral load non-suppression was also associated with disability and ART non-adherence. These findings together indicate subgroups of people with HIV who most need improved ART access and adherence support. Neither outcome was associated with severity of depression symptoms or self-reported stigma.ClinicalTrials.gov (NCT02407691), Pan African Clinical Trials Registry (201504001078347), South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048, NHREC 4048).

Background: Mental health services in sub-Saharan Africa, including Tanzania, are little studied and hence challenges and opportunities are not well known, leading to difficulties in improving access to, and quality of, services to those in need. Objectives: 1. To conduct a situational analysis of mental health services in Dar es Salaam region, 2. To consult with key stakeholders on mental health services delivery and planning, and 3. To develop a regional mental health services plan. Methods: This was a mixed-methods study, using the PRIME situational analysis tool, which provided a quantitative overview of mental health service needs, resources and activities. We conducted individual in-depth interviews (IDI, n = 5) with regional mental health service managers, and focus group discussions (FGD, n = 7) with 29 mental healthcare workers at primary healthcare facilities. We led a workshop with regional mental health service managers to discuss findings and to develop a regional mental healthcare services plan. Results: The situational analysis identified a large burden of mental health care needs, but also a variety of health care services and providers in the region. The IDIs and FGDs found inadequate health facilities and staff providing mental health services, ineffective implementation of mental health policy regarding user fee exemptions and cost sharing, stigma in the community, and low community awareness. The financial burdens on patients were lower if patients were covered by health insurance, but health insurance has limitations regarding medication provision. The regional mental health plan proposes strengthening mental health services by integrating them into primary health care facilities, training health providers and other workers on mental health issues, strengthening referral systems, and increasing government and social insurance funding. Conclusion: Despite barriers hindering mental health service provision in Dar es Salaam, there are positive factors that could potentially make mental health delivery more effective and sustainable. Financial and human resource constraints will limit such developments. Implementation of the regional plan will require ongoing engagement with stakeholders, but has the potential to enhance access to and improve quality of mental health care in the region.

BACKGROUND:Access to and use of urgent and emergency care in the United Kingdom's National Health Service reduced during COVID-19 related lockdowns but demand reportedly increased since then. We investigated the impact of COVID-19 on urgent and emergency health care services activity in an eastern England population of 1.1 million. METHODS:We used health care activity data from a municipal health department, recorded at the level of discrete events (such as visits to hospital or ambulance calls) to compare system activity between 2018-2020 (pre-COVID), 2020-2021 (lockdown) and 2021-2023 (post-lockdown), carrying out interrupted time series analyses to describe changes in activity. RESULTS:Daily emergency department (ED) attendances were 10% (95% confidence interval 9-12%) lower during the lockdown period, and 7% (6-8%) higher in the post-lockdown period than pre-COVID. Attendances arriving by ambulance were 13% (12-14%) lower post-lockdown than pre-COVID, while attendances of arrivals by other means were 17% (16-19%) higher. Post-lockdown, overall attendances were continually reducing. ED waiting times were 45% (44-47%) longer in the post-lockdown period compared to the pre-COVID period and continued to increase post-lockdown. There was a 15% (14-16%) reduction in daily ambulance dispatches post-lockdown versus pre-COVID. Ambulance arrivals with delayed handover to hospital care exceeding 60 minutes increased by 17% (16-18%) post-lockdown versus pre-COVID, and probability of delay showed a continuously upward trend post-lockdown of 20% (19-21%) per year. CONCLUSION:Patients are facing long waits in EDs to be admitted to hospital, discharged or transferred. This results in delays in ambulances handing over patients and attending to other calls, which may explain decreasing rates of ambulance dispatches. Potential solutions are likely to involve enhancing the flow through and discharge of patients from hospital, and a whole systems approach which considers the capacity of the local health and care infrastructure, including intermediate care and social care.

IntroductionDemand for urgent and emergency health care in England has grown over the last decade, for reasons that are not clear. Changes in population demographics may be a cause. This study investigated associations between individuals' characteristics (including socioeconomic deprivation and long term health conditions (LTC)) and the frequency of emergency department (ED) attendances, in the Norfolk and Waveney subregion of the East of England.MethodsThe study population was people who were registered with 91 of 106 Norfolk and Waveney general practices during one year from 1 April 2022 to 31 March 2023. Linked primary and secondary care and geographical data included each individual's sociodemographic characteristics, and number of ED attendances during the same year and, for some individuals, LTCs and number of general practice (GP) appointments. Associations between these factors and ED attendances were estimated using Poisson regression models.Results1,027,422 individuals were included of whom 57.4% had GP data on the presence or absence of LTC, and 43.1% had both LTC and general practitioner appointment data. In the total population ED attendances were more frequent in individuals aged under five years, (adjusted Incidence Rate Ratio (IRR) 1.25, 95% confidence interval 1.23 to 1.28) compared to 15-35 years); living in more socioeconomically deprived areas (IRR 0.61 (0.60 to 0.63)) for least deprived compared to most deprived,and living closer to the nearest ED. Among individuals with LTC data, each additional LTC was also associated with increased ED attendances (IRR 1.16 (1.15 to 1.16)). Among individuals with LTC and GP appointment data, each additional GP appointment was also associated with increased ED attendances (IRR 1.03 (1.026 to 1.027)).ConclusionsIn the Norfolk and Waveney population, ED attendance rates were higher for young children and individuals living in more deprived areas and closer to EDs. In individuals with LTC and GP appointment data, both factors were also associated with higher ED attendance.

Background The development of strategies to better detect and manage patients with multiple long-term conditions requires estimates of the most prevalent condition combinations. However, standard meta-analysis tools are not well suited to synthesising heterogeneous multimorbidity data.Methods We developed a statistical model to synthesise data on associations between diseases and nationally representative prevalence estimates and applied the model to South Africa. Published and unpublished data were reviewed, and meta-regression analysis was conducted to assess pairwise associations between 10 conditions: arthritis, asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, HIV, hypertension, ischaemic heart disease (IHD), stroke and tuberculosis. The national prevalence of each condition in individuals aged 15 and older was then independently estimated, and these estimates were integrated with the ORs from the meta-regressions in a statistical model, to estimate the national prevalence of each condition combination.Results The strongest disease associations in South Africa are between COPD and asthma (OR 14.6, 95% CI 10.3 to 19.9), COPD and IHD (OR 9.2, 95% CI 8.3 to 10.2) and IHD and stroke (OR 7.2, 95% CI 5.9 to 8.4). The most prevalent condition combinations in individuals aged 15+ are hypertension and arthritis (7.6%, 95% CI 5.8% to 9.5%), hypertension and diabetes (7.5%, 95% CI 6.4% to 8.6%) and hypertension and HIV (4.8%, 95% CI 3.3% to 6.6%). The average numbers of comorbidities are greatest in the case of COPD (2.3, 95% CI 2.1 to 2.6), stroke (2.1, 95% CI 1.8 to 2.4) and IHD (1.9, 95% CI 1.6 to 2.2).Conclusion South Africa has high levels of HIV, hypertension, diabetes and arthritis, by international standards, and these are reflected in the most prevalent condition combinations. However, less prevalent conditions such as COPD, stroke and IHD contribute disproportionately to the multimorbidity burden, with high rates of comorbidity. This modelling approach can be used in other settings to characterise the most important disease combinations and levels of comorbidity.

Abstract Background Reducing inequality in healthy life expectancy (HLE) is a UK government ambition and requires more detailed knowledge of interrelated morbidity and mortality risks at smaller areas than is routinely available. We assessed HLE and risk factors in small areas. Methods We used publicly available data to estimate HLE in 2011 and 2021 at birth and age 65 for males and females for 128 Middle layer Super Output Areas (MSOA) in Norfolk and Waveney, described the distribution using geospatial mapping, and analysed associations with risk factors using linear regression. Results Mean HLE at birth was 66.5 years (standard deviation 4.3; range 52.0 to 73.0) for men and 67.5 (3.9; 56.0 to 74.0) for women, and at age 65 was 10.9 years (1.8; 6.0 to 16.0) and 12.2 (1.9; 5.0 to 15.0) respectively in 2021. The range in HLE increased between 2011 and 2021 by 2.8 years for men and 1.6 years for women. HLE was usually lower and risks higher in urban and coastal areas. Lower HLE at area level was associated with lower weekly income, physical inactivity, air pollution, alcohol admissions, living alone as an older person and diet not meeting ‘5 a Day’. HLE at age 65 in 2021 increased by: 0.2 (95% CI 0.1,0.2) years for men and 0.2 (0.2,0.3) for women for each £10 rise in weekly net income after housing expenditure; 0.1 (0.1,0.2) years for men for each 10 fewer alcohol attributable hospital admissions per 100,000 admissions; 0.66 (0.31,1.00) years for men and 0.53 (0.15,0.91) years for women per 1 μg/m3 less 2.5 mm particulate matter concentration in air pollution; 0.6 (0.2,1.0) years for men and 0.6 (0.1,1.0) years for women for each 10% fewer people being physically inactive (multiple regression). Conclusions This innovative approach can be used to monitor risks and inform targeted public health interventions at a local level more relevant to local policy makers. Stronger public health surveillance systems are needed to accurately monitor a wider variety of local data on risks. Key messages • Healthy life expectancy at age 65 varies by over 10 years for men and women between different small geographic areas in an English county, alongside local variation in risk factors for poor health. • Lower HLE at area level was associated with lower weekly income, physical inactivity, air pollution, alcohol admissions, living alone as an older person and diet not meeting ‘5 a Day’.

ObjectiveThis study explored the attributes of asthma care coordination from the perspective of healthcare professionals at different levels of care in Ecuador.DesignQualitative descriptive study. The Integrated Health Networks Model was the theoretical framework of reference. Narrative analysis was used to identify significant phrases from the interviews.SettingHealthcare professionals involved in the care of patients with asthma in primary care, specialists, emergency and management in three Ecuadorian cities between 2019 and 2021.Participants25 healthcare professionals participated in semistructured in-depth interviews. Convenience sampling was used.ResultsParticipants highlighted the scarce use of institutional documents for the referral of asthma patients from the first level to specialists and vice versa, duplication of tests and medical prescriptions, and lack of appointment availability that limits access to specialised care. From the first level, they considered that specialists do not return patients and specialists stressed that the first level does not have enough training to follow asthma patients. Managers highlighted the system’s inability to assign appointments on time and failures in administrative processes for follow-up. Emergency professionals did not have access to the medical records of patients suffering from asthma attacks.ConclusionsThe lack of shared objectives and effective communication between different levels of care for the follow-up of asthma patients were attributes of asthma care coordination perceived by healthcare professionals at different levels of care in Ecuador. The Ecuadorian health system should consider these to improve its performance.

BackgroundTraining primary care doctors and nurses to use Practical Approach to Care Kit (PACK) improved management of asthma and chronic obstructive pulmonary disease (COPD) in a previous randomised trial. The present study examined the training effects including a second year of follow-up with expanded coverage of repeated training sessions.MethodsUsing a stepped-wedge cluster randomised trial design, 48 clinics were randomly allocated either to sequence A: (1) no intervention, (2) no intervention, (3) intervention or sequence B: (1) no intervention, (2) intervention, (3) intervention, during three 12-month periods. Primary outcomes were change in treatment and spirometry ordering. Effects of any exposure to the training, and of exposure to the first and second years of training, were estimated with mixed effect logistic regression models.ResultsAny exposure to training was associated with increased changes in treatment (OR adjusted for calendar time (OR) 1.29, 95% CI 1.02 to 1.64) and more spirometry ordering (OR 1.55, (95% CI 1.22 to 1.97)) in asthma patients, and with more spirometry ordering (OR 1.50 (95% CI 1.15 to 1.96)) in patients with COPD. Change in asthma treatment was more likely during the first and second year of exposure to training compared with no exposure (ORs 1.43 (95% CI 1.09 to 1.87); 1.91 (95% CI 1.21 to 3.02)), respectively. Spirometry was more likely during the first and second year of exposure in asthma patients (ORs 1.76 (95% CI 1.34 to 2.30); 2.05 (95% CI 1.32 to 3.19)) and in patients with COPD (ORs 1.57 (95% CI 1.18 to 2.10)); 1.71 (95% CI 1.08 to 2.70)).ConclusionExtended follow-up suggested that PACK training continued to be effective in improving chronic respiratory care and that effective intervention delivery was sustainable for 2 years.Trial registration numberNCT02786030.

BACKGROUND:HIV is characterised by high rates of comorbidity with mental health conditions including depression, as such, the detection and treatment of comorbid depression is critical to achieve viral load suppression. This study evaluated the effectiveness of a collaborative care intervention for depression among adults with comorbid depression symptoms receiving ART in primary health care (PHC) facilities. METHODS:We conducted a pragmatic cluster-randomised trial in 40 clinics in the North West province of South Africa. PHC clinics were stratified by sub-district and randomised in a 1:1 ratio. Participants were ≥ 18 years, receiving ART, and had depression symptoms indicated by Patient Health Questionnaire-9 (PHQ-9) score ≥ 9. Intervention clinics received: i) supplementary mental health training and clinical communication skills for PHC nurses; ii) workshops for PHC doctors on treating depression; and iii) lay counselling services. Using mixed effects regression models, we assessed co-primary outcomes of PHQ-9 response at 6 months (≥50 % reduction in baseline PHQ-9 score) and viral load suppression at 12 months (viral load<1000 copies/mL). RESULTS:The intervention had no effect in PHQ-9 response (49 % vs 57 %, risk difference (RD) = -0.08, 95 % CI = -0.19; 0.03, p = 0.184) or viral load suppression (85 % vs 84 %, RD = 0.02, 95 % CI = -0.01; 0.04, p = 0.125). Nurses referred 4298 clinic patients to counsellors, however, only 66/1008 (7 %) of intervention arm participants were referred to counsellors at any point during the study. LIMITATIONS:The highly pragmatic approach of this trial limited exposure to the counselling component of the intervention and referral to doctors for initiation of antidepressant treatment was extremely low. CONCLUSION:The trial showed no effect of a district-based intervention to strengthen collaborative care for depression. The trial revealed the extent of the treatment gap in the context of scaling up mental health services. TRIAL REGISTRATION:ClinicalTrials.gov (NCT02407691); Pan African Clinical Trials Registry (201504001078347).

BACKGROUND:Understanding the factors associated with demands for general practice care is crucial for policy decision makers to appropriately allocate healthcare resources.AIM:To investigate factors associated with the frequency of GP consultations.DESIGN & SETTING:Data on 8086 adults aged ≥16 years was obtained from cross-sectional Health Survey for England (HSE) 2019.METHOD:The primary outcome was the frequency of consultations of a GP in the last 12 months. Multivariable ordered logistic regression analysis was used to evaluate associations between GP consultations and a range of sociodemographic and health-related factors.RESULTS:Frequency of GP consultations for all reasons was higher among females (odds ratio [OR] 1.81, 95% confidence interval [CI] = 1.64 to 2.01), those aged ≥75 years (OR 1.48, 95% CI = 1.15 to 1.92), ethnic minority populations (Black: OR 1.42, 95% CI = 1.09 to 1.84; Asian: OR 1.53, 95% CI = 1.25 to 1.87), lowest household income (OR 1.53, 95% CI = 1.29 to 1.83), adults with long-lasting illnesses (OR 3.78, 95% CI = 3.38 to 4.22), former smokers (OR 1.17, 95% CI = 1.04 to 1.22), being overweight (OR 1.14, 95% CI = 1.01 to 1.29), and being obese (OR 1.32, 95% CI = 1.16 to 1.50). Predictors of consultations for physical health problems were similar to predictors of consultations for any health problems. However, younger age was associated with more consultations for mental health problems, or a combination of mental and physical health problems.CONCLUSION:The higher frequency of consultation of GPs is associated with female sex, older age, ethnic minority populations, being socioeconomically disadvantaged, existence of lasting illnesses, smoking, being overweight, and being obese. Older age is associated with increased consultations for physical health problems, but associated with reduced consultations for mental health or a combination of mental and physical health problems.

AbstractObjectivesDuring COVID‐19 the UK general population has been given strong messages to stay at home. Concurrently unprecedented changes occurred in healthcare access with moves to remote/triage systems. Data have shown that the number of people accessing healthcare services decreased and there are significant concerns that the pandemic has negatively affected help‐seeking for serious conditions, with potentially increased morbidity and mortality. An understanding of help‐seeking is urgently needed to inform public campaigns. We aimed to develop an in‐depth, theory‐based understanding of how, when and why people sought help for potentially serious symptoms (e.g., related to major cardiovascular events or cancer diagnoses) during the pandemic, and what influenced their decisions.DesignQualitative semi‐structured interviews.MethodsWe interviewed 25 adults recruited through a targeted social media campaign. Interviews were conducted via telephone or online platform. Our topic guide was informed by the Model of Pathways to Treatment and the Capability‐Opportunity‐Motivation‐Behaviour model.ResultsThe analysis identified four main themes: Delay in recognition, Holding on to concerns, Weighing it up and Long‐term impacts. Multiple societal and environmental factors influenced participants' help‐seeking and motivation, capability and opportunity to seek help, with long‐term impacts on well‐being and future help‐seeking.ConclusionsThere is a need for clear guidance about pathways to raise concerns about symptoms and gain advice while usual healthcare contacts are paused or stopped. Recommendations for future interventions to support help‐seeking during pandemics include clearer messaging, co‐produced with end‐users, on when, where and how to seek help.

ObjectiveTo assess the main characteristics and result reporting of registered COVID-19 interventional trials of traditional Chinese medicine and traditional Indian medicine.Materials and methodsWe assessed design quality and result reporting of COVID-19 trials of traditional Chinese medicine (TCM) and traditional Indian medicine (TIM) registered before 10 February 2021, respectively, on Chinese Clinical Trial Registry (ChiCTR) and Clinical Trial Registry-India (CTRI). Comparison groups included registered COVID-19 trials of conventional medicine conducted in China (WMC), India (WMI), and in other countries (WMO). Cox regression analysis was used to assess the association between time from trial onset to result reporting and trial characteristics.ResultsThe proportion of COVID-19 trials investigating traditional medicine was 33.7% (130/386) among trials registered on ChiCTR, and 58.6% (266/454) on CTRI. Planned sample sizes were mostly small in all COVID-19 trials (median 100, IQR: 50–200). The proportion of trials that were randomized was 75.4 and 64.8%, respectively, for the TCM and TIM trials. Blinding measures were used in 6.2% of the TCM trials, and 23.6% of the TIM trials. Cox regression analysis revealed that planned COVID-19 clinical trials of traditional medicine were less likely to have results reported than trials of conventional medicine (hazard ratio 0.713, 95% confidence interval: 0.541–0.939; p = 0.0162).ConclusionThere were considerable between-country and within-country differences in design quality, target sample size, trial participants, and reporting of trial results. Registered COVID-19 clinical trials of traditional medicine were less likely to report results than trials of conventional medicine.

BackgroundSeveral long-term chronic illnesses are known to be associated with an increased risk of dementia independently, but little is known how combinations or clusters of potentially interacting chronic conditions may influence the risk of developing dementia. Methods447 888 dementia-free participants of the UK Biobank cohort at baseline (2006-2010) were followed-up until 31 May 2020 with a median follow-up duration of 11.3 years to identify incident cases of dementia. Latent class analysis (LCA) was used to identify multimorbidity patterns at baseline and covariate adjusted Cox regression was used to investigate their predictive effects on the risk of developing dementia. Potential effect moderations by C reactive protein (CRP) and Apolipoprotein E (APOE) genotype were assessed via statistical interaction. ResultsLCA identified four multimorbidity clusters representing Mental health, Cardiometabolic, Inflammatory/autoimmune and Cancer-related pathophysiology, respectively. Estimated HRs suggest that multimorbidity clusters dominated by Mental health (HR=2.12, p<0.001, 95% CI 1.88 to 2.39) and Cardiometabolic conditions (2.02, p<0.001, 1.87 to 2.19) have the highest risk of developing dementia. Risk level for the Inflammatory/autoimmune cluster was intermediate (1.56, p<0.001, 1.37 to 1.78) and that for the Cancer cluster was least pronounced (1.36, p<0.001, 1.17 to 1.57). Contrary to expectation, neither CRP nor APOE genotype was found to moderate the effects of multimorbidity clusters on the risk of dementia. ConclusionsEarly identification of older adults at higher risk of accumulating multimorbidity of specific pathophysiology and tailored interventions to prevent or delay the onset of such multimorbidity may help prevention of dementia.

AIMS:England's Diabetic Eye Disease Screening Programme offers screening to every resident over age 12 with diabetes, starting as soon as possible after diagnosis and repeated annually. People first diagnosed with diabetes at older ages have shorter life expectancy and therefore may be less likely to benefit from screening and treatment. To inform decisions about whether diabetic eye screening policy should be stratified by age, we investigated the probability of receiving treatment according to age at first screening episode.METHODS:This was a cohort study of participants in the Norfolk Diabetic Retinopathy Screening Programme from 2006 to 2017, with individuals' programme data linked to hospital treatment and death data recorded up to 2021. We estimated and compared the probability, annual incidence and screening costs of receiving retinal laser photocoagulation or intravitreal injection and of death, in age groups defined by age at first screening episode.RESULTS:The probability of death increased with increasing age at diagnosis, while the probability of receiving either treatment decreased with increasing age. The estimated cost of screening per person who received either or both treatments was £18,608 among all participants, increasing with age up to £21,721 in those aged 70-79 and £26,214 in those aged 80-89.CONCLUSIONS:Diabetic retinopathy screening is less effective and less cost-effective with increasing age at diagnosis of diabetes, because of the increasing probability of death before participants develop sight-threatening diabetic retinopathy and can benefit from treatment. Upper age limits on entry into screening programmes or risk stratification in older age groups may, therefore, be justifiable.