BACKGROUND:Health workers in many low- and middle-income countries are not adequately trained to provide quality antenatal and intrapartum care. The freely available Safe Delivery App (the App) provides health care professionals with direct and instant access to evidence-based, up-to-date clinical guidelines equipping them with an on-the-job reference guide, even in the most remote areas. In this paper we describe the uptake and acceptability and the process to align the App in Papua New Guinea (PNG). METHODS:Between June 2022 and December 2024, quantitative and qualitative methods were used to explore the usage and acceptability of the App among health care workers in PNG, re-designing images and aligning clinical content with PNG national clinical guidelines. Dissemination of the App took place through formal and informal networks, including a training of trainers' program in one province. RESULTS:The App was seen as an acceptable and useful tool among midwives and nurses working clinically, particularly those in remote areas and midwifery educators. There was an increase in the use of the App, from 354 registered users in 2022 to 1304 in 2024. The majority of users were midwives and nurses, working in primary health care facilities and nursing and midwifery establishments. Participants reported that the App has led to changes in practice, supporting and encouraging staff to follow evidence-based guidelines, improving their clinical management. CONCLUSION:The Safe Delivery App is seen as a useful tool, supporting clinical practice, knowledge and skills, providing users with more confidence in their ability to provide quality maternal and newborn health care. Wider implementation of the App across PNG may be a potential way to support health care workers in the remote settings, providing up to date evidence based clinical guidance in the absence of skilled midwives and doctors.

OBJECTIVE:We prospectively determined incident cardiovascular events and their association with risk factors in rural India. METHODS:We followed up with 7935 adults from the Rishi Valley Prospective Cohort Study to identify incident cardiovascular events. Using Cox proportional hazards regression, we estimated hazard ratios (HRs) with 95% confidence intervals (95% CI) for associations between potential risk factors and cardiovascular events. Population attributable fractions (PAFs) for risk factors were estimated using R ('averisk' package). RESULTS:Of the 4809 participants without prior cardiovascular disease, 57.7% were women and baseline mean age was 45.3 years. At follow-up (median of 4.9 years, 23,180 person-years [PYs]), 202 participants developed cardiovascular events, equating to an incidence of 8.7 cardiovascular events/1000 PYs. Incidence was greater in those with hypertension (hazard ratio [HR] [95% CI] 1.73 [1.21-2.49], adjusted PAF 18%), diabetes (1.96 [1.15-3.36], 4%) or central obesity (1.77 [1.23, 2.54], 9%) which together accounted for 31% of the PAF. Non-traditional risk factors such as night sleeping hours and number of children accounted for 16% of the PAF. CONCLUSIONS:Both traditional and non-traditional cardiovascular risk factors are important contributors to incident cardiovascular events in rural India. Interventions targeted to these factors could assist in reducing the incidence of cardiovascular events.

Curable sexually transmitted infections (STIs) are neglected in public health policy, services and society at large. Effective interventions are available for some STI but seem not to be prioritised at global, regional or local levels. Zambia and Papua New Guinea (PNG) have a high burden of STIs among pregnant women but little is known about the prioritisation of STI treatment and care among this group. We undertook a qualitative study to explore how STIs are prioritised among pregnant women in local health systems in Zambia and PNG. Semi-structured interviews were conducted with 19 key informants—health care workers providing antenatal care, and policy and programme advisers across the two countries. Audio recordings were transcribed and translated into English and stored, managed, and coded in NVivo v12. Analysis used deductive and inductive thematic analysis. Findings were coded against the World Health Organization health system building blocks. Participants spoke about the stigma of STIs at the community level. They described a broad understanding of morbidity associated with undiagnosed and untreated STIs in pregnant women. The importance of testing and treating STIs in pregnancy was well recognised but many spoke of constraints in providing these services due to stock outs of test kits for HIV and syphilis and antibiotics. In both settings, syndromic management remains the mainstay for treating curable STIs. Clinical practice and treatment were not in alignment with current STI guidelines in either country, with participants recognising the need for mentorship and in-service training, as well as the availability of commodities to support their clinical practice. Local disruptions to screening and management of syphilis, HIV and other curable STIs were widely reported in both countries. There is a need to galvanise priority at national and regional levels to ensure ongoing access to supplies needed to undertake STI testing and treatment.

The self-collection of vaginal swabs and point-of-care testing and treatment of sexually transmitted infections (STIs) is reported from several low-and middle-income countries. However, the reporting on women's experiences of self-collection and same-day testing and treatment of STIs is less well described. In this paper, we present the acceptability of self-collected vaginal swabs and point-of-care testing and treatment among pregnant women enrolled in a clinical trial (Women and Newborn Trial of Antenatal Intervention and Management - WANTAIM) in Papua New Guinea. Semi-structured interviews were conducted among 54 women enrolled into WANTAIM to identify the acceptability of the test and treat approach. Analysis of qualitative data used deductive and inductive thematic analysis applying Sekhon, Cartwright and Francis' acceptability theoretical framework. Most women reported that they understood that the vaginal swab was to identify infections that may affect their unborn baby; however, some were unsure about the specific infections they were being tested for. Among women who tested positive for an STI, some were unsure what they had been treated for. Overall, the self-collection of vaginal swabs for STI testing during pregnancy was highly acceptable.

Aims We compared the performance of cardiovascular risk prediction tools in rural India. Methods and results We applied the World Health Organization Risk Score (WHO-RS) tools, Australian Risk Score (ARS), and Global risk (Globorisk) prediction tools to participants aged 40-74 years, without prior cardiovascular disease, in the Rishi Valley Prospective Cohort Study, Andhra Pradesh, India. Cardiovascular events during the 5-year follow-up period were identified by verbal autopsy (fatal events) or self-report (non-fatal events). The predictive performance of each tool was assessed by discrimination and calibration. Sensitivity and specificity of each tool for identifying high-risk individuals were assessed using a risk score cut-off of 10% alone or this 10% cut-off plus clinical risk criteria of diabetes in those aged >60 years, high blood pressure, or high cholesterol. Among 2333 participants (10 731 person-years of follow-up), 102 participants developed a cardiovascular event. The 5-year observed risk was 4.4% (95% confidence interval: 3.6-5.3). The WHO-RS tools underestimated cardiovascular risk but the ARS overestimated risk, particularly in men. Both the laboratory-based (C-statistic: 0.68 and chi(2): 26.5, P = 0.003) and non-laboratory-based (C-statistic: 0.69 and chi(2): 20.29, P = 0.003) Globorisk tools showed relatively good discrimination and agreement. Addition of clinical criteria to a 10% risk score cut-off improved the diagnostic accuracy of all tools. Conclusion Cardiovascular risk prediction tools performed disparately in a setting of disadvantage in rural India, with the Globorisk performing best. Addition of clinical criteria to a 10% risk score cut-off aids assessment of risk of a cardiovascular event in rural India.

BACKGROUND:Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and bacterial vaginosis have been associated with adverse maternal and perinatal outcomes, but there is conflicting evidence on the benefits of antenatal screening and treatment for these conditions. We aimed to determine the effect of antenatal point-of-care testing and immediate treatment of C trachomatis, N gonorrhoeae, T vaginalis, and bacterial vaginosis on preterm birth, low birthweight, and other adverse maternal and perinatal outcomes compared with current standard of care, which included symptom-based treatment without laboratory confirmation. METHODS:In this pragmatic cluster randomised crossover trial, we enrolled women (aged ≥16 years) attending an antenatal clinic at 26 weeks' gestation or earlier (confirmed by obstetric ultrasound), living within approximately 1 h drive of a study clinic, and able to provide reliable contact details at ten primary health facilities and their catchment communities (clusters) in Papua New Guinea. Clusters were randomly allocated 1:1 to receive either the intervention or control (standard care) in the first phase of the trial. Following an interval (washout period) of 2-3 months at the end of the first phase, each cluster crossed over to the other group. Randomisation was stratified by province. Individual participants were informed about trial group allocation only after completing informed consent procedures. The primary outcome was a composite of preterm birth (livebirth before 37 weeks' gestation), low birthweight (<2500 g), or both, analysed according to the intention-to-treat population. This study is registered with ISRCTN Registry, ISRCTN37134032, and is completed. FINDINGS:Between July 26, 2017, and Aug 30, 2021, 4526 women were enrolled (2210 [63·3%] of 3492 women in the intervention group and 2316 [62·8%] of 3687 in the control group). Primary outcome data were available for 4297 (94·9%) newborn babies of 4526 women. The proportion of preterm birth, low birthweight, or both, in the intervention group, expressed as the mean of crude proportions across clusters, was 18·8% (SD 4·7%) compared with 17·8% in the control group (risk ratio [RR] 1·06, 95% CI 0·78-1·42; p=0·67). There were 1052 serious adverse events reported (566 in the intervention group and 486 in the control group) among 929 trial participants, and no differences by trial group. INTERPRETATION:Point-of-care testing and treatment of C trachomatis, N gonorrhoeae, T vaginalis, and bacterial vaginosis did not reduce preterm birth or low birthweight compared with standard care. Within the subgroup of women with N gonorrhoeae, there was a substantial reduction in the primary outcome. FUNDING:UK Department of Health and Social Care; UK Foreign, Commonwealth and Development Office; UK Medical Research Council; the Wellcome Trust; the Australian National Health and Medical Research Council; and Swiss National Science Foundation.

Aim: In three socioeconomically diverse regions of rural India, we determined the optimal cut-offs for definition of overweight, the prevalence of overweight, and the relationships between measures of overweight and risk of hypertension.Subjects and methods: Villages were randomly sampled within rural Trivandrum, West Godavari, and Rishi Valley. Sampling of individuals was stratified by age group and sex. Cut-offs for measures of adiposity were compared using area under the receiver operating characteristic curve. Associations between hypertension and definitions of overweight were assessed by logistic regression. Results: Of 11 657 participants (50 % male; median age 45 years), 29.8 % had hypertension. Large proportions were overweight as defined by body mass index (BMI) > 23 kg/m2 (47.7 %), waist circumference (WC) > 90 cm for men or > 80 cm for women (39.6 %), waist-hip ratio (WHR) > 0.9 for men or > 0.8 for women (65.6 %), waist-height ratio (WHtR) > 0.5 (62.5 %), or by BMI plus either WHR, WC or WHtR (45.0 %). All definitions of overweight were associated with hypertension, with optimal cut-offs being at, or close to, the World Health Organization (WHO) Asia-Pacific standards. Having overweight according to both BMI and a measure of central adiposity was associated with approximately twice the risk of hypertension than overweight defined by only one measure. Conclusions: Overweight, as assessed by both general and central measures, is prevalent in rural southern India. WHO standard cut-offs are appropriate in this setting for assessing risk of hypertension. However, combining BMI with a measure of central adiposity identifies risk of hypertension better than any single measure. The risk of hypertension is significantly greater in those centrally and generally overweight than those overweight by a single measure.

Objectives To assess the prevalence and determinants of cardiometabolic disease (CMD), and the factors associated with healthcare utilisation, among people with CMD. Methods Using a cross-sectional design, 11,657 participants were recruited from randomly selected villages in 3 regions located in Kerala and Andhra Pradesh from 2014 to 2016. Multivariable logistic regression was used to identify factors independently associated with CMD and healthcare utilisation (public or private). Results Thirty-four per cent (n = 3629) of participants reported having ≥1 CMD, including hypertension (21.6%), diabetes (11.6%), heart disease (5.0%) or chronic kidney disease (CKD) (1.6%). The prevalence of CMD was progressively greater in regions of greater socio-economic position (SEP), ranging from 19.1% to 40.9%. Among those with CMD 41% had sought any medical advice in the last month, with only 19% utilising public health facilities. Among people with CMD, those with health insurance utilised more healthcare (age-gender adjusted odds ratio (AOR) (95% confidence interval (CI)): 1.31 (1.13, 1.51)) as did those who reported accessing private rather than public health services (1.43 (1.23, 1.66)). Discussion The prevalence of CMD is high in these regions of rural India and is positively associated with indices of SEP. The utilisation of outpatient health services, particularly public services, among those with CMD is low.

The Safe Delivery App is a freely available smartphone application currently used in more than 40 low-and middle-income countries. It has been shown to improve outcomes for women and newborns by providing direct access to evidence-based, locally adapted clinical guidelines on key aspects of care during pregnancy and birth, through animated instructions and videos. A key challenge for health care workers in Papua New Guinea (PNG) is poor access to reliable, up-to-date information to manage obstetric emergencies and provision of early newborn care. In 2021 the global version of the Safe Delivery App was introduced in Papua New Guinea. We used a mixed-methods approach to review usage and acceptability of the Safe Delivery App among different cadres of health care workers in PNG. We conducted individual interviews with different users of the App in PNG, reviewed and redesigned images and aligned clinical content to the PNG context. A new version of the App, specific to PNG was made available and reviewed for the acceptability and usability of the new version. Among 375 registered users of the App, 52% were midwives. Just over half (56%) had used the App within the previous 30 days of data collection. Most users had learnt about the App through in service training. Active management of third stage, manual removal of placenta and postpartum haemorrhage were the most widely viewed modules. Individual interviews revealed that the App is being used to support clinical practice and has been well accepted in PNG. There was a desire to develop the App into Tok Pisin and align content to national guidelines. We will report additional findings on the acceptability and usability of a new PNG specific version of the App. The Safe Delivery App is available, and a useful tool in this low-resource setting.

Low birth weight (LBW, <2.50 kg) and preterm birth (PTB, <37 completed weeks of gestation) are important contributors to neonatal death. Newborn foot length has been reported to identify LBW and PTB babies. The objectives of this study were to determine the diagnostic accuracy of foot length to identify LBW and PTB and to compare foot length measurements of a researcher with those of trained volunteers in Papua New Guinea. Newborn babies were enrolled prospectively with written informed consent from their mothers, who were participating in a clinical trial in Madang Province. The reference standards were birth weight, measured by electronic scales and gestational age at birth, based on ultrasound scan and last menstrual period at the first antenatal visit. Newborn foot length was measured within 72 hours of birth with a firm plastic ruler. Optimal foot length cut-off values for LBW and PTB were derived from receiver operating characteristic curve analysis. Bland-Altman analysis was used to assess inter-observer agreement. From 12 October 2019 to 6 January 2021, we enrolled 342 newborns (80% of those eligible); 21.1% (72/342) were LBW and 7.3% (25/342) were PTB. The area under the curve for LBW was 87.0% (95% confidence intervals 82.8-90.2) and for PTB 85.6% (81.5-89.2). The optimal foot length cut-off was <7.7 cm for both LBW (sensitivity 84.7%, 74.7-91.2, specificity 69.6%, 63.9-74.8) and PTB (sensitivity 88.0% (70.0-95.8), specificity 61.8% (56.4-67.0). In 123 babies with paired measurements, the mean difference between the researcher and volunteer measurements was 0.07 cm (95% limits of agreement -0.55 to +0.70) and 7.3% (9/123) of the pairs were outside the 95% limits of agreement. When birth at a health facility is not possible, foot length measurement can identify LBW and PTB in newborns but needs appropriate training for community volunteers and evaluation of its impact on healthcare outcomes.

Mycoplasma genitalium is a sexually transmitted bacterium that colonises the human urogenital tract and in pregnant women has been associated with adverse pregnancy and birth outcomes. In pregnancy, the prevalence of M. genitalium is estimated to be 0.9% (95% CI 0.6% to 1.4%) in highincome settings and 12.5% in individual studies in lowand middleincomecountries. 2 Globally, M. genitalium antimicrobial resistance (AMR) continues to escalate, and despite rising rates of AMR the prevalence of macrolide and fluoroquinolone resistance in M. genitalium has not been widely studied among pregnant women. Treatment of M. genitalium during pregnancy with selected antimicrobials such as macrolides is recommended, while tetracyclines are contraindicated and caution is recommended for fluoroquinolones, highlighting the potential issues surrounding available/effective antibiotics for this pathogen during pregnancy. In Papua New Guinea (PNG), macrolides and fluoroquinolones are routinely used for treatment of STIs and hence we aimed to characterise M. genitalium AMR in pregnant women. We screened 69 M. genitaliumpositive urine samples obtained from women attending their first antenatal clinic visit at five health facilities in Madang Province (PNG) between 2018 and 2019, enrolled in the control arm of a randomised controlled trial in PNG, the Women And Newborn Trial of Antenatal Interventions and Management. Confirmatory PCR was performed to verify the presence of M. genitalium in all 69 samples. Samples with positive results were then tested for the presence of AMR using targeted PCR assays. Macrolide and fluoroquinolone resistance/susceptibility markers were determined using previously published assays (online supplemental file). Stata V.15.1 was used to calculate the proportion of samples with resistance markers, with 95% exact binomial CI calculated using the ClopperPearson method. Where there were zero events, we give the 97.5% CI as the upper limit. From the five study sites, all 69 samples that were initially reported to be positive for M. genitalium were confirmed as positive by repeat PCR testing. Of these, 58 (84.1%) samples were successfully characterised for macrolide resistance, while 54 (78.3%) were successfully characterised for fluoroquinolone susceptibility/resistance (table 1). In summary, no samples with available results harboured macrolide resistance mutations (0.0%, 975% CI 0.0% to 6.2%) or the S83I fluoroquinolone resistance mutation (0.0%, 97.5% CI 0.0% to 6.6%), and all 54 samples were characterised as fluoroquinolonesusceptible (S83 wildtype). While data on M. genitalium AMR remain limited in many regions, including in lowincome countries of the Western Pacific region, our findings indicate no evidence of macrolide or fluoroquinolone resistance in PNG. This further supports the findings of two previous studies of M. genitalium in PNG (78 pregnant women) and Solomon Islands (56 nonpregnant women) that also reported no macrolide resistance. 6 Some of the reasons behind the lack of resistance in M. genitalium in these regions may include the fact that current STI treatment guidelines in PNG do not stipulate testing and treatment of M. genitalium in symptomatic persons. Other studies have identified that incorrect screening practices leading to treatment with macrolides have contributed to M. genitalium’s increasing resistance to macrolides. Given that both macrolides and fluoroquinolones are prescription drugs in PNG, their use in treating STIs and other infections is highly regulated. These drugs are not available for use in selfmedication and so the repeated consumption/use of these drugs is not likely to be driving the selection of resistance in PNG, as has been suggested in other regions of the world. From an STI management perspective, the clinical symptoms of M. genitalium infection are not distinct nor fully understood, as M. genitalium can be found in conjunction with other STIs, including Research Letter

Papua New Guinea has among the highest rates of maternal and newborn mortality and stillbirths globally. The burden of maternal and newborn morbidity in this setting is less well described. Conducted in PNG, WANTAIM (2017- 2022) was a cluster randomised cross-over trial of testing and treatment for sexually transmitted infections among antenatal women. In line with good clinical practice, all serious adverse events among women and their newborns were classified and reported to relevant bodies. Information describing hospital admissions, maternal deaths, stillbirths, neonatal deaths, and other events was systematically collected using a study specific template ensuring standard, comprehensive information was collected for every event. We reviewed all serious adverse event reports among WANTAIM women and newborns for the duration of the study. We describe rates and causes of all events and factors associated with all stillbirths. Among 4,532 women we had 4,409 births. We report 1,006 adverse events including: 765 hospital admissions, 105 stillbirths, 56 early and 11 late neonatal deaths, 11 maternal deaths, 30 congenital abnormalities, 25 miscarriages and 3 cases of domestic violence. There were 439 maternal admissions, 16% were emergency caesarean section, 15% due to pre-eclampsia and 10% were due to malaria. Among the 326 newborn admissions 33% had neonatal sepsis, 21% were born preterm, and 13% had meconium aspiration syndrome. The stillbirth rate and perinatal mortality rates were 23.4 and 36.5 per 1,000 births, respectively. Among all stillbirths we identified 178 avoidable factors associated with the adverse outcome. We identified a high burden of perinatal deaths and maternal and newborn morbidity among a well characterised study cohort. In this cohort, potentially preventable causes and avoidable factors were identified that require health system strengthening, particularly the upskilling of primary level health staff, as well as targeted health education of women and the community.

Introduction Left untreated, sexually transmitted and genital infections (henceforth STIs) in pregnancy can lead to serious adverse outcomes for mother and child. Papua New Guinea (PNG) has among the highest prevalence of curable STIs including syphilis, chlamydia, gonorrhoea, trichomoniasis and bacterial vaginosis, and high neonatal mortality rates. Diagnosis and treatment of these STIs in PNG rely on syndromic management. Advances in STI diagnostics through point-of-care (PoC) testing using GeneXpert technology hold promise for resource-constrained countries such as PNG. This paper describes the planned economic evaluation of a cluster-randomised cross-over trial comparing antenatal PoC testing and immediate treatment of curable STIs with standard antenatal care in two provinces in PNG. Methods and analysis Cost-effectiveness of the PoC intervention compared with standard antenatal care will be assessed prospectively over the trial period (2017–2021) from societal and provider perspectives. Incremental cost-effectiveness ratios will be calculated for the primary health outcome, a composite measure of the proportion of either preterm birth and/or low birth weight; for life years saved; for disability-adjusted life years averted; and for non-health benefits (financial risk protection and improved health equity). Scenario analyses will be conducted to identify scale-up options, and budget impact analysis will be undertaken to understand short-term financial impacts of intervention adoption on the national budget. Deterministic and probabilistic sensitivity analysis will be conducted to account for uncertainty in key model inputs. Ethics and dissemination This study has ethical approval from the Institutional Review Board of the PNG Institute of Medical Research; the Medical Research Advisory Committee of the PNG National Department of Health; the Human Research Ethics Committee of the University of New South Wales; and the Research Ethics Committee of the London School of Hygiene and Tropical Medicine. Findings will be disseminated through national stakeholder meetings, conferences, peer-reviewed publications and policy briefs. Trial registration number ISRCTN37134032.

We assessed the association of hypertension with markers of inflammation and infection in a rural and disadvantaged Indian population. In a case–control study, we age- and gender-matched 300 cases with hypertension to 300 controls without hypertension. Blood pressure was measured according to a strict protocol. We measured markers of inflammation and infection including serum high-sensitivity C-reactive protein (hs-CRP), blood lymphocyte count, serum homocysteine, tooth loss, overcrowding and exposure to fecal contamination. Multivariable conditional logistic regression was used to determine their association with hypertension. Median serum hs-CRP was 42% greater in cases than controls, while median serum homocysteine was 10% greater. In multivariable conditional logistic regression, elevated homocysteine (OR 1.75, 95% CI 1.09–2.82), greater lymphocyte count (OR 1.49, 95% CI 1.01–2.01) and exposure to fecal contamination, defined as a distance from the field used for toilet purposes to the household of ≤50 m (OR 2.38, 95% CI 1.07–5.29), were independently associated with hypertension in this rural population. In separate analyses for each gender, elevated hs-CRP (OR 2.62, 95% CI 1.04–6.58) was associated with hypertension in men, whereas edentulism (OR 4.75, 95% CI 1.62–13.96) was associated with greater odds of hypertension in women. Our findings demonstrate specific associations between hypertension and markers of inflammation and infection including hs-CRP, homocysteine, lymphocyte count, edentulism and exposure to fecal contamination. Thus, strategies aimed at reducing inflammation and infection may reduce the burden of hypertension in such settings of disadvantage in rural India.

Background: To improve the control of hypertension in low- and middle-income countries, we trialed a community-based group program co-designed with local policy makers to fit within the framework of India's health system. Trained accredited social health activists (ASHAs), delivered the program, in three economically and developmentally diverse settings in rural India. We evaluated the program's implementation and scalability.Methods: Our mixed methods process evaluation was guided by the United Kingdom Medical Research Council guidelines for complex interventions. Meeting attendance reports, as well as blood pressure and weight measures of attendees and adherence to meeting content and use of meeting tools were used to evaluate the implementation process. Thematic analysis of separate focus group discussions with participants and ASHAs as well as meeting reports and participant evaluation were used to investigate the mechanisms of impact.Results: Fifteen ASHAs led 32 community-based groups in three rural settings in the states of Kerala and Andhra Pradesh, Southern India. Overall, the fidelity of intervention delivery was high. Six meetings were delivered over a 3-month period to each of the intervention groups. The mean number of meetings attended by participants at each site varied significantly, with participants in Rishi Valley attending fewer meetings [mean (SD) = 2.83 (1.68)] than participants in West Godavari (Tukeys test, p = 0.009) and Trivandrum (Tukeys test, p < 0.001) and participants in West Godavari [mean (SD) = 3.48 (1.72)] attending significantly fewer meetings than participants in Trivandrum [mean (SD) = 4.29 (1.76), Tukeys test, p < 0.001]. Culturally appropriate intervention resources and the training of ASHAs, and supportive supervision of them during the program were critical enablers to program implementation. Although highly motivated during the implementation of the program ASHA reported historical issues with timely remuneration and lack of supportive supervision.Conclusions: Culturally appropriate community-based group programs run by trained and supported ASHAs are a successful and potentially scalable model for improving the control of hypertension in rural India. However, consideration of issues related to unreliable/insufficient remuneration for ASHAs, supportive supervision and their formal role in the wider health workforce in India will be important to address in future program scale up.Trial Registration: Clinical Trial Registry of India [CTRI/2016/02/006678, Registered prospectively].

Abstract Background Over 75% of global cardiovascular (CVD) deaths occur in low-to-middle-income countries (LMICs). In limited resource settings non-lab-based CVD risk algorithms could be as effective as lab-based algorithms in identifying high-risk groups. We aimed to compare the concordance between lab-and non-lab-based absolute CVD risk algorithms in a LMIC setting. Methods The study was conducted in the Rishi Valley, Andhra Pradesh, India. Over 8,000 participants were surveyed between 2012-2015. The 10-year absolute CVD risk score was computed and compared using lab-and-non-lab based Framingham and WHO algorithms. Results In participants aged 35-74 years, absolute CVD risk score increased with age, and was greater in men than women, for all risk assessment tools. Using the Framingham lab-based algorithm, 15.6% were categorized as high-risk while 14.5% were at high-risk using the non-lab-based algorithm. The non-lab-based Framingham risk score had close agreement and strong correlation with the lab-based Framingham risk score in women (90%, Spearman’s rho (rs)=0.81) and men (83%, rs=0.89). Similarly, the non-lab-based WHO risk score had close agreement and strong correlation with the lab-based WHO risk score in women (95%, rs=0.83) and men (92% rs=0.84). In both cases, agreement was better in women than men (P < 0.05 for a two-sample test of proportions). Conclusions The effectiveness of non-lab-based Framingham and WHO algorithms are comparable to that of lab-based algorithms in discriminating high-and low-risk groups. However, the performance of non-lab-based risk score is better among women than men. Key messages Non-lab-based CVD risk algorithms could be effective and resource-efficient in LMIC settings, particularly among women.

To undertake a retrospective perinatal death audit and assessment of avoidable factors associated with stillbirths among a cohort of women in two provinces in Papua New Guinea.

Aim To determine the causes of early neonatal death and the avoidable factors associated with these deaths among women participating in a cluster-randomised crossover trial in Papua New Guinea. Methods Early neonatal deaths were identified by retrospective chart review of the Women and Newborn Trial of Antenatal Interventions and Management study participants between July 2017 and January 2020. Causes of death and avoidable factors were identified using the Perinatal Problem Identification Program system. Results There were 35 early neonatal deaths among 2499 livebirths (14 per 1000 births). Fifty-seven percent (20/35) of deaths occurred on the first day of life. Idiopathic preterm birth was the leading obstetric cause of perinatal death (29%; 10/35). Extreme multi-organ immaturity (23%; 8/35) and hypoxic ischaemic encephalopathy (17%; 6/35) were the most common final causes of neonatal death. Forty-six avoidable factors were identified among 26 deaths, including delays in care-seeking, insufficient resources at health facilities, poor intrapartum care and immediate care of the newborn, including neonatal resuscitation. Conclusion In this study, potentially preventable causes and avoidable factors were identified in the majority of early neonatal deaths. Addressing these factors will require health system strengthening, particularly the upskilling of primary level health staff, as well as targeted health education of women and the community.

Objectives We compared the performance of laboratory-based cardiovascular risk prediction tools in a low-income and middle-income country setting, and estimated the use of antihypertensive and lipid-lowering medications in those deemed at high risk of a cardiovascular event. Design A cross-sectional study. Setting The study population comprised adult residents (aged ≥18 years) of the Rishi Valley region located in Chittoor District, south-western Andhra Pradesh, India. Participants 7935 participants were surveyed between 2012 and 2015. We computed the 10-year cardiovascular risk and undertook pair-to-pair analyses between various risk tools used to predict a fatal or non-fatal cardiovascular event (Framingham Risk Score (FRS), World Health Organization Risk Score (WHO-RS) and Australian Risk Score (ARS)), or a fatal cardiovascular event (Systematic COronary Risk Evaluation (SCORE-high and SCORE-low)). Concordance was assessed by ordinary least-products (OLP) regression (for risk score) and quadratic weighted kappa (κ w , for risk category). Results Of participants aged 35–74 years, 3.5% had prior cardiovascular disease. The relationships between risk scores were quasi-linear with good agreement between the FRS and ARS (OLP slope=0.96, κ w =0.89). However, the WHO-RS underestimated cardiovascular risk compared with all other tools. Twenty per cent of participants had ≥20% risk of an event using the ARS; 5% greater than the FRS and nearly threefold greater than the WHO-RS. Similarly, 16% of participants had a risk score ≥5% using SCORE-high which was 6% greater than for SCORE-low. Overall, absolute cardiovascular risk increased with age and was greater in men than women. Only 9%–12% of those deemed ‘high risk’ were taking lipid-lowering or antihypertensive medication. Conclusions Cardiovascular risk prediction tools perform disparately in this setting of disadvantage. Few deemed at high risk were receiving the recommended treatment.

Objective: To determine whether there is an interaction between knowledge about hypertension and awareness of hypertension on the treatment and control of hypertension in three regions of South India at different stages of epidemiological transition (see Video, Supplemental Digital Content 1, http://links.lww.com/HJH/B426). Methods: Using a cross-sectional design, we randomly selected villages within each of rural Trivandrum, West Godavari, and Chittoor. Sampling was stratified by age group and sex. We measured blood pressure and administered a questionnaire to determine knowledge and awareness of hypertension. Logistic regression was used to assess associations of awareness and knowledge about hypertension with its treatment and control in participants with hypertension, while examining for statistical interaction. Results: Among a total of 11 657 participants (50% male; median age 45 years), 3455 had hypertension. In analyses adjusted for age and sex, both knowledge score [adjusted odds ratio (aOR) 1.14 [95% confidence interval (CI) 1.12--1.17)] and awareness [aOR 104 (95% CI 82--134)] were associated with treatment for hypertension. Similarly, both knowledge score [aOR 1.10; 95% CI (1.08--1.12)] and awareness [aOR 13.4; 95% CI (10.7--16.7)], were positively associated with control of blood pressure in those with hypertension, independent of age and sex. There was an interaction between knowledge and awareness on both treatment and control of hypertension ( P of attributable proportion <0.001 for each). Conclusion: Health education to improve knowledge about hypertension and screening programs to improve awareness of hypertension may act in an additive fashion to improve management of hypertension in rural Indian populations.