High-income Countries Research Articles

National early warning systems for emerging AMR in high-income countries: a systematic review

Abstract Background An urgent need of implementing national surveillance systems for timely detection and reporting of emerging antimicrobial resistance (AMR) was recently advocated by the World Health Organization (WHO). However, public information on existing national early warning systems (EWSs) is often incomplete. Furthermore, when findings are available, understanding these systems is challenging due to different approaches used for data collection, reporting and definitions, with a comprehensive overview on this topic currently lacking. The aim of this study was to map existing EWSs for emerging AMR, focusing on high-income countries, and describe their main characteristics. Methods A systematic review was performed on bibliographic databases, and a targeted search was conducted on national websites. Any article, report or webpage describing national EWSs in high-income countries was eligible for inclusion. EWSs were identified considering the emerging AMR reporting WHO framework. Results We identified seven national EWSs in 72 high-income countries: two (Australia, Japan) in the East Asia and Pacific Region, three (France, Sweden, United Kingdom) in Europe and Central Asia, and two (United States, Canada) in North America. The systems were established quite recently; in most cases they covered both community and hospital settings, but their main characteristics varied widely across countries in terms of organization and microorganisms under surveillance, with also different definitions of emerging AMR and alert functioning. A formal system assessment was available only in Australia. Conclusions A broader implementation and investment of national surveillance systems that allow early detection of emerging AMR is still needed to establish EWSs in countries and regions lacking such capabilities. A more standardized data collection and reporting is also advisable to improve cooperation on a global scale. Key messages • This study provides a synthesis of publicly available information on national EWSs for emerging AMR in high-income countries, highlighting the urgent need for a broader implementation of such systems. • Main characteristics of EWSs have been outlined, varying widely across countries. Findings could help stakeholders in strengthening current standard national AMR surveillance systems.

The state of primary health care systems in ten high-income countries

Abstract Primary care systems in high-income countries perform comparatively better than the U.S. system in large part due to decades of investment, an adequate workforce supply, and universal healthcare. This research identifies successes and areas of improvement of 10 high-performing primary care systems in four areas of care: 1) access, 2) continuity, 3) comprehensiveness, 4) and coordination. Cross-national comparisons using primary data from the 2022 CMWF International Health Policy Survey of Primary Care Physicians (N ranged from 321-2,092) and the 2023 CMWF International Health Policy Survey on the General Population (N ranged from 750-4,820). Countries included: Australia, Canada, France, Germany, Netherlands, New Zealand, Sweden, Switzerland, the U.K., and the U.S. • More than 90% of adults in all surveyed countries reported having a regular primary care doctor except Sweden, the U.S., and Canada. • Less than 5% of physicians reported high telehealth use in their patient encounters, except for in the U.K. and New Zealand where over 10% reported high use. • Over a quarter of physicians in the U.S., Germany, and France report screening patients for social needs, compared to just 8% in the Netherlands. • Care coordination with social services was a major challenge in all surveyed countries, with over 75% of physicians in the U.K., Australia, and France reporting major challenges. Primary care systems in 10 other high-income countries outperform the U.S. system, particularly when it comes to access to care and care continuity. Policy options to consider for U.S. policymakers include narrowing the wage gap between generalist and specialist physicians and rewarding and holding providers accountable for continuity of care. On the other hand, countries like Sweden and the Netherlands can learn from the U.S. on how to adequately coordinate care between primary care physicians, specialists, and hospitals. Key messages • Investment in primary care yields better health outcomes, greater equity and lower costs. • Many high-income countries in Europe have high performing primary care systems, something the U.S. system can learn from.

Is chronic kidney disease predictive of coronary artery bypass grafting after acute coronary syndrome? A systematic review and meta-analysis

Abstract Background Coronary artery bypass grafting (CABG) provides superior long-term outcomes to percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease. People with chronic kidney disease (CKD) are at increased risk of multi-vessel coronary artery disease, and experience greater morbidity and mortality following acute coronary syndrome (ACS). Purpose To determine whether CKD affects choice of revascularisation strategy after ACS. Methods We searched EMBASE, MEDLINE, SCOPUS, CENTRAL and the NIHR’s website of funded studies to identify articles referring to ACS and invasive coronary management in high-income countries over the past 12 years until 29th September 2023. Full text articles were included if data on rates of CABG were reported in people with and without CKD who were revascularised following ACS. CKD was defined as one or more recording of an estimated glomerular filtration rate (eGFR) <60mls/min/1.73m2, however proxies for this were accepted. Risk of bias was assessed via ROBINS-E. Random effect meta-analyses estimated the odds ratios for CKD and CABG, stratified by ACS type and receipt of dialysis. Certainty of evidence was assessed according to GRADE. Results Initial searches generated 15,138 articles, of which 13 observational studies were included in this review (8,021,743 participants). Amongst people revascularised following ACS, those with CKD were more likely to receive CABG than those without kidney disease (OR for the average exposure effect 1.47 (95% CI 1.30-1.66)). The likelihood of CABG in people with CKD receiving dialysis and those with CKD not receiving dialysis were similar as the 95% confidence intervals demonstrate (ORs 1.25 (95% CI 1.00-1.57) and 1.41 (1.19-1.67) respectively). The effect of CKD on increased likelihood of CABG appeared greater following ST-elevation myocardial infarction (STEMI) than non-ST elevation ACS (NSTE-ACS) (OR 1.53 (95% CI 1.27-1.83) versus 1.10 (0.98-1.25) respectively, p=0.003). Certainty of the evidence was low for receipt of CABG in people with CKD not receiving dialysis, and moderate for all other outcomes. Conclusion In high-income countries, CKD is associated with increased receipt of CABG amongst people revascularised following ACS. This finding is likely explained by the greater prevalence of multi-vessel coronary artery disease in this population. It is however unclear why the association between CKD and receipt of CABG is stronger in those with STEMI compared to NSTE-ACS, and whether this accurately reflects differential need between the two groups.Figure 1Figure 2

Gender disparities and infective endocarditis burden in the United States and European Union: a comparative analysis

Abstract Background Despite improvement in diagnostics and treatment options, infective endocarditis (IE) remains a significant burden for healthcare systems. While high-income countries have improved diagnosis of IE, the progress in interventional cardiology with a rise in cardiac devices associated infections, and people migrations offset some of these gains. Purpose To the best of our knowledge, there is a lack of comparative data between high-income countries, including the United States (US) and European Union (EU). Methods We collected the age-standardized rates of incidence (ASIR), deaths (ASDR), and disability-adjusted life years (ASDALYs) in the US and EU from 1993 to 2019 with the Global Health Data Exchange query tool. The Bayesian geospatial regression analysis and estimated annual percentage change (EAPC) to quantify the trends in age-standardized rates (ASR) were used. The data were stratified based on the gender, year, and location. Results Males in the US had an overall ASIR of 17.2/100k with an increasing trend between 1993 and 2019, and an annual average rate of change of 0.8 % (EAPC of 0.8%). A similar trend and higher rates were noted in males in the EU, with ASIR of 20.9/100k and EAPC of 2.0%. For the same period, females in the US had lower ASIR than females in the EU (11.9/100k vs. 13.6/100k) , and lower annual percent change (1% vs. 1.3%). In the US, ASDR was higher in males than females (1.6/100k vs. 1.28/100k), but females had higher annual percentage change (EAPC of 2.7% in males and 3.3% in females). Compared to US, males and females in the EU had lower ASDR in 2019 (1.2/100k in males, and 1.0/100k in females) with lower annual percentage changes of 2.5% and 1.7%, respectively. The ASDALY was significantly higher in the US, for both males (34.6/100k) and females (25.5/100k), with a greater increase in an annual average rate of change of 2.7% in females than in males (2.2%). EU males had ASDALY of 24.9/100k with an EAPC of 1.8%, while females had 16.7/100K with an annual average increase of 1.2%. Figure 1, Table 1 Conclusion ASIR of IE appears to be higher in the EU for both males and females. Conversely, ASDR and ASDALY manifest higher rates in the US across both genders, with females notably demonstrating a higher annual percentage increase for these metrics. Further studies are needed to assess the nature of these differences and to inform health policies.The age-standardized rates in US and EUThe differences in the EAPC

Interventions to prevent Neonatal Healthcare-associated Infection: a systematic review of RCT

Abstract Background Healthcare-acquired infections (HAI) in neonatal intensive care unit (NICU) specifically refer to infections that occur in newborn infants within the healthcare environment. Preterm infants, often more vulnerable to infections, in the NICU may be exposed to various medical interventions, devices, and environments that can increase the risk of infections. This systematic review aims to evaluate the effectiveness of interventions proposed to prevent neonatal healthcare-associated infections. Methods PubMed, Scopus and Web of Science databases were searched to identify any RCT study coming from high income countries, published from 2004, that investigated the efficacy of any intervention to prevent HAI in NICU. All type of HAI were considered. Results A total of seven studies were included (2 from USA, 5 from UE). Three studies focused on: administration of donor milk; probiotic Bifidobacterium breve; intravenous Staphylococcus aureus immune globulin; all failed to demonstrate any protective action. Of the four remaining studies that investigate different aspect of the vascular catheterization process only two lead a a statistical significant reduction of HAI. Garland et al. demonstrate in 85 neonates how vancomycin-heparin lock solution is capable to reduce catheter related blood stream infection (CRBSI) 8/43 neonates (18.6%) in the control group vs 0/42 in the vancomycin-heparin-lock group (P = 0.006). Bertini et al. demonstrate in 86 preterm infants how utilization of AgION catheter in Umbelical vein catheterization (UVC) lead to CRBSI rate reduction (2 vs. 22%; p = 0.005), shorter hospital stay (p = 0.04), lower case fatality rate due to Blood stream infection (p = 0.01). Conclusions Among the proposed methodology only the one acting on the catheterization process provide a statistical significant reduction of HAI onset. Widespread observation of proposed protocol may results in reduction of HAI in NICU. Key messages • Modfiication on the catheterization process provide a statistical significant reduction of HAI onset. • Knowing these measures assure reduction of HAI.

Implementation as the acid test: International lessons from Universal Health Coverage reforms around the world

Abstract Introduction Health systems around the world are moving towards Universal Health Coverage, which is included in the Sustainable Development Goals. However, the journey towards UHC began decades ago, with countries in Europe introducing national health services following World War II. This was mirrored in Canada and, more recently, countries in Latin America introduced health reforms as part of broader social movements. Since the millennium, reforms have also taken place in Low and Middle Income Countries as well as High Incomes Countries. However, because the introduction of UHC often necessitates far-reaching reforms, countries face significant challenges along the path of policy implementation. Methods A realist review explored international experiences of introducing and implementing UHC. Embase, Medline and Web of Science were searched. Descriptive, inductive and deductive realist analysis aided the development of Context, Mechanism, Outcome Configurations, alongside stakeholder engagement. Findings How countries go about establishing UHC depends on their social, political, cultural and economic contexts. For reforms to be facilitated, there must be cohesion and commitment across all systems, as well as the functions of financing, governance and service delivery. This includes political support, often underpinned by legislation framing healthcare as a human right, as well as communication between stakeholders and the development of a strong primary care sector. Conversely, fragmentation across these systems and functions pose significant barriers to reform. Conclusions Examining international experiences of UHC reforms supports learning around the factors that facilitate or challenge implementation. These learnings empower policy makers and health system leaders by providing roadmaps for reform implementation. Finally, this research provides insights into health inequities that are rebalanced through the implementation of UHC reforms.

Differences in cardiovascular risk in the general population of low and high altitude residents in Peru. HIGH Altitude CArdiovascular REsearch Latin America Population Study (HIGHCARE-LAPS)

Abstract Introduction Living at high altitude (HA) is associated with profound changes in cardiovascular physiology, mostly caused by chronic hypoxia. Available data from high income countries (Switzerland, Austria) suggest beneficial effects of moderate altitude residence in terms of cardiovascular risk. Little is known, however, about cardiovascular risk profile in long-term residents of higher altitudes from low-income countries. Aim To compare cardiovascular risk estimated with validated score in population-based samples of permanent residents of low and high-altitude communities in Peru. Methods Study participants (adults permanently residing at either low or high altitude) were recruited by sex- and age-stratified random multistage cluster sampling from the general population of urban areas at different altitudes in Peru (lowlanders: <500 m above sea level, highlanders: cities at 3287 m, 3824 m and 4330 m). For all participants questionnaire-based information, conventional blood pressure (BP; 3 seated measurements with a validated oscillometric device) and laboratory variables were obtained. Based on the collected data atherosclerotic cardiovascular disease (ASCVD) risk was estimated according to Pooled Cohort Equations (PCE, previously calibrated in South American population). Participants below 40 years of age, with ASVCD history, with LDL-C≥190 mg/dL or on LDL-C lowering therapy were excluded from this analysis. Results The analysis included 146 lowlanders and 373 highlanders, most of whom had low 10-year ASVCD risk, with the median estimated risk being significantly higher among lowlanders. Comparisons between the groups in terms of principal variables of interest are reported in the Table. The highlanders were slightly younger, had lower BMI, conventional BP, HDL cholesterol, lower prevalence of antihypertensive medication and of diabetes, and higher heart rate. In a multivariable model the difference in ASCVD risk between lowlanders and highlanders was significant (p=0.0009) after adjusting for BMI and socio-economic variables but not after systolic BP was included in the model (p=0.800). Conclusions Residence at HA is associated with a lower estimated ASCVD risk in the general population of Peru, mainly because of lower BP levels. Considering that the prognostic value of cardiovascular risk estimates in highland populations is unknown, longitudinal cohort studies would be required to assess whether this finding is associated with a lower rate of cardiovascular events.

Prevention of dementia using mobile phone applications (PRODEMOS): a multinational randomised controlled effectiveness-implementation trial

Abstract Background The expected increase of dementia prevalence in the coming decades will mainly be within low-and middle-income countries and those with low socioeconomic status (SES) in high income countries. Forty percent of dementia is associated with modifiable, lifestyle-related cardiovascular risk factors. Mobile health interventions with remote coaching can help reach underserved high-risk populations globally. Methods This open label, blinded endpoint, hybrid effectiveness-implementation randomised controlled trial (RCT) investigated whether a coach-supported mHealth intervention can reduce dementia risk in persons aged 55-75 years of low SES in UK or from the general population in China with at least two dementia risk factors. The primary effectiveness outcome was change in CAIDE dementia risk score (including age, education, sex, systolic blood pressure, total cholesterol, BMI, physical exercise) after 12-18 months of intervention. Main implementation outcomes were coverage, acceptability, appropriateness, adoption, feasibility, sustainability, fidelity, and costs using a mixed methods approach. Findings Between 15th January 2021 and 18th April 2023, 1,488 persons were included and randomised (734 intervention, 754 control), with 1,229 (82·6%) available for analysis of the primary effectiveness outcome. After a mean follow-up of 16 months, the mean CAIDE score improved by 0·16 points in the intervention group vs. 0·01 in the control group (Mean Difference (MD) 0·16, 95% Confidence Interval (CI) 0·03-0·29). The effect was larger in those who adhered to the intervention (MD 0·27, 95%CI 0·12-0·44) and those planning to change lifestyle (MD 0·33, 95%CI 0·10-0·57). Ten percent of those invited participated; of these, 81% adopted the intervention and 50% continued active participation throughout the study. For the individual components of the CAIDE score, there were no statistically significant differences for systolic blood pressure, total cholesterol and BMI, but in the intervention group physical inactivity was reduced more than in the control group (MD 6·7%, 95%CI 2·1 to 11·2) and more participants quit smoking (MD -3·1%, 95%CI -4·8 to -1·5). Interpretation A coach-supported mHealth intervention to improve lifestyle is modestly effective in reducing dementia risk factors in those with low SES in the UK and any SES in China. Implementation is challenging in these populations, but those reached actively participated. Whether this will result in less cognitive decline and dementia requires a larger RCT with long follow-up.

Food insecurity and fruit and vegetable consumption in Belgium

Abstract Background Food insecurity is a substantial and growing concern in many high-income countries. Yet, representative data on the extent of the issue in the general Belgian population is lacking. This study aims to assess the extent of food insecurity in Belgium, identify those at risk of food insecurity, and explore the relationship between food insecurity and fruit and vegetable consumption. Methods We used data from the Belgian National Food Consumption Survey 2022-2023, a representative sample of the Belgian population aged 3 years and older (n = 2,800). Food insecurity was assessed using the 3 screening questions derived from the USDA Household Food Security Survey Module. Frequencies of fruit and vegetable consumption were obtained from a food propensity questionnaire. Prevalence of food insecurity was estimated using post-stratification weights. Logistic regression models were used to determine the association between frequency of fruit and vegetable consumption and food insecurity, adjusting for gender, household composition, educational attainment, and income. Results Preliminary results indicate that 12.6% of population experienced some form of food insecurity. Those who experienced food insecurity consumed fruit and vegetables less frequently than others, after adjustment for other socio-economic variables (ORs>4.00, p-values>0.05). Conclusions This study confirms that food insecurity is a substantial concern in Belgium. Food insecurity should be routinely monitored at the national level. Experiencing food insecurity appears to be negatively associated with the consumption of healthy foods such as fruits and vegetables and thus with the overall quality of the diet. Further research should be supported to identify effective strategies to reduce food insecurity in Belgium. Policy attention should be given to ensure financial accessibility to healthy foods and their attractiveness, especially for people experiencing food insecurity. Key messages • Food insecurity is an major concern in Belgium and should be routinely monitored. • Financial accessibility to healthy foods should be improved, especially for those facing food insecurity.

Predictors of adolescent well-being around the globe: are students from Confucian East Asia different?

PurposeUsing rich data from nearly 400,000 15-year-olds across 70 middle- and high-income countries and economies participating in PISA 2018, this study investigates (1) global predictors of adolescent subjective well-being (SWB), and (2) differences in adolescent life satisfaction, its predictors and endowments with predictors across world regions and cultures. A particular focus lies on comparing Confucian East Asia (CEA) with other world regions.MethodsData were analyzed using multiple linear regressions and Blinder-Oaxaca decomposition. As measures of adolescent well-being, this study employs life satisfaction, affective well-being, and meaning in life.ResultsGlobally, adolescent well-being outcomes are found to be most strongly linked to gender, personality, relative SES, relationship quality, peer SWB, autonomy and the learning environment, as well as local cultural factors. Estimations by world region reveal several culture-specific explanations for interregional well-being gaps. In particular, notoriously low levels of life satisfaction among students from CEA countries are found to be associated with low self-efficacy, low peer well-being, as well as with high emotional interdependence compared to other world regions. Emotional interdependence is more strongly experienced among CEA adolescents compared to adolescents from any other world region. Moreover, it is found to be more strongly associated with life satisfaction in the CEA region than in any other region. In line with the former, CEA students show stronger links between other relational factors (parents’ emotional support; sense of belonging at school) and life satisfaction compared to most other regions.ImplicationsThis study suggests that among the environmental factors that shape the experience of adolescent lives, relationship and cultural factors play key roles and are closely intertwined. Parents, educators and policymakers around the world should focus on creating a positive school environment that promotes well-being, student self-efficacy, a sense of belonging, and a safe space in which failure is accepted as part of the learning process. This is particularly needed in Confucian East Asian countries.

Taxing animal-based food products: A qualitative framing analysis of the media debate in Germany

Abstract Background In most high-income countries, consumption of animal-based food products exceeds levels recommended for health and environmental reasons. Although taxes can reduce the consumption of animal-based products, they are politically controversial. In recent years, various tax models and motivations for these have been discussed. Our study seeks to identify key arguments and policy actors in the German media debate on the taxation of animal-based products, shedding light on emerging narrative frames surrounding tax models and motivations. Methods We conducted a qualitative analysis of German media coverage on taxes and levies influencing the price of animal-based foods. We analyzed 488 articles from 10 national newspapers and eight trade press journals published between February 2019 and July 2023. Employing an inductive approach, we identified the actors involved in the debate and common frames and arguments around various tax proposals. Results We found broad consensus on a need for change due to inadequate animal welfare conditions, while environmental and health arguments are more contested. Significant debate surrounds the suitability of taxation as the preferred policy instrument. Furthermore, doubts are raised about a tax’s effectiveness and appropriate revenue allocation. Framing of the tax often emphasizes potential negative impacts on domestic production and product affordability. Additionally, concerns about various unintended consequences and the overall unpopularity of taxation emerge as prominent themes. Conclusions The taxation of animal-based products for health and environmental reasons is still highly contested in the media debate in Germany. Many, but not all arguments commonly raised against such taxes may be considered spurious from an evidence-based public health perspective. Proponents of such taxes may seek to address existing concerns through appropriate policy design and communication strategies. Key messages • Taxation of animal-based foods may help to align consumption with levels recommended for health and environmental reasons, but adoption and implementation is hindered by political controversy. • Objections common in the public debate on such taxes could be addressed with appropriate policy design alleviating justified concerns, and with communication strategies countering spurious arguments.

Impact of Adverse Childhood Experiences on Child Development in South America: A Systematic Review

Abstract Background Adverse Childhood Experiences (ACEs) have garnered attention globally for their detrimental effects on children’s development, such as lower communication, gross and fine motor, and personal-social domains. While extensively studied in high-income countries, there remains a gap in understanding their prevalence and impact in low- and middle-income countries (LMICs). This review aimed to identify, evaluate, and summarize the findings of an association between ACEs and children’s developmental and mental health outcomes in South America Methods A systematic review was conducted to investigate the association between ACEs and childhood development in South America. Databases MEDLINE, PsycINFO, Web of Science, Applied Social Sciences Index and Abstracts, Literatura Latino Americana em Ciências da Saúde, IBECS and CINAHL were searched. Selection criteria encompassed studies from Brazil, Colombia, Argentina, Peru, Venezuela, Chile, Ecuador, Bolivia, Paraguay, Uruguay, Guyana and Suriname examining the effects of ACEs on developmental outcomes and mental health disorders in children under 18 years old. Quality assessment aligned with World Health Organization standards was employed. Results Twenty-four studies met the inclusion criteria, with most categorized as low or very low quality. While the majority demonstrated a significant association between ACEs and developmental or mental health outcomes, a few studies reported null findings. Challenges in study quality, such as small sample sizes and selection bias, were identified. Conclusions Despite limitations in study quality, findings underscore the impact of ACEs on child development and mental health in South America. Because of the low quality of the existent studies the next steps should be to grasp a greater understanding of the issue. This review also highlights the urgency for further research and targeted interventions to mitigate the long-term consequences of ACEs in this region. Key messages • ACEs profoundly affect child development and mental health in South America, necessitating urgent attention and intervention. • Addressing the impact of ACEs in South America is critical for fostering healthier developmental trajectories and enhancing public health outcomes.

Risk of long COVID and associated symptoms after acute SARS-COV-2 infection in ethnic minorities: a Danish nationwide cohort study

Abstract Background and aim Ethnic minorities living in high-income countries have been disproportionately affected by COVID-19 in terms of infection rates, hospitalisations, and deaths; however, less is known about long COVID in these populations. Our aim was to examine the risk of long COVID and associated symptoms among ethnic minorities. Methods We used Danish nationwide register-based cohort data on individuals diagnosed with COVID-19 aged ≥18 years (n = 2 334 271) between January 2020 and August 2022. We calculated the risk of long COVID diagnosis and long COVID symptoms among ethnic minorities compared with native Danes using multivariable Cox proportional hazard regression and logistic regression, respectively. Results Of the diagnosed COVID-19 cases, 1 973 998 (84.6%) were native Danes and 360 273 (15.4%) were ethnic minorities. After adjustment for age, sex, civil status, education, family income, and Charlson comorbidity index, ethnic minorities from North Africa (adjusted hazard ratio [aHR] 1.41, 95% CI [1.12,1.79]), Middle East (aHR 1.38, 95% CI [1.24,1.55]), Eastern Europe (aHR 1.35, 95% CI [1.22,1.49]), and Asia (aHR 1.23, 95% CI [1.09,1.40]), had significantly greater risk of long COVID diagnosis than native Danes. In the analysis by largest countries of origin, the greater risks of long COVID diagnosis were found in Iraqis (aHR 1.56, 95% CI [1.30,1.88]), Turks (aHR 1.42, 95% CI [1.24,1.63]), and Somalis (aHR 1.42, 95% CI [1.07,1.91]). A significant factor associated with an increased risk of long COVID diagnosis was COVID-19 hospitalisation. Conclusions Migrants and ethnic minorities had higher risk of long-COVID compared to native Danes.

Sub-Saharan Africa's contribution to clinical trials in international acute coronary syndromes and heart failure guidelines

Abstract Introduction There is a growing burden of acute coronary syndrome (ACS) and heart failure (HF) in sub-Saharan Africa (SSA), yet outcomes remain poor compared to high-income countries (HICs). Global clinical guidelines are pivotal to the delivery of evidence based cardiovascular care, however their applicability to populations in SSA remains unclear. Purpose To evaluate the extent to which populations from SSA contribute to pharmacotherapeutic randomised clinical trials informing international ACS and HF clinical guidelines. Methods We extracted details on pharmacotherapeutic randomised control trials (RCTs) contributing to Class I or II guideline recommendations from the 2023 European Society of Cardiology (ESC) guidelines for ACS and the 2021 ESC guidelines for HF. Data on RCTs contributing to these guidelines were extracted from the ClinicalTrials.gov or published articles. We analysed the proportion of RCTs which had a contribution from countries in each World Bank income group. Then we specifically assessed the contribution of SSA countries to clinical trials and analysed temporal trends. Results Of 119 RCTs from the ESC HF guidelines and the 343 pharmacotherapy RCTs from the ESC ASC guidelines 75.9% were exclusively conducted in high-income countries, 22.2% of the trials included at least one site from a middle-income country and none included sites from a low-income country (figure 1). The global distribution of HF (figure 2a) and ACS (figure 2b) pharmacotherapy guidelines is demonstrated in figure 2. The only country represented from SSA was South Africa which is an upper middle-income country. A site from South Africa was included in 17 (14.2%) HF RCTs and 28 (8.2%) ACS RCTs. There has been a significant increase in the proportion HF RCTs conducted in SSA, increasing from 2.6% between 1990 and 1999 to 50% since 2020 (OR 28.8, 95% CI 2.6 – 983.4, p-value for trend< 0.0001). For ACS RCTs, the proportion of trials conducted in SSA increased from 1.8% pre 1990 to 23.4% during 2000-2009 (OR 15.9, 95% CI 4.2 - 112.9, p value for trend = 0.003) then declined to 11.3% from 2010-2019. Conclusions There is a marked under-representation of SSA countries in ACS and HF pharmacotherapy RCTs, despite the region's escalating cardiovascular disease burden. South Africa is the sole contributor from the region, with all other SSA countries absent. This finding could potentially affect the applicability and generalisability of global guidelines to populations in SSA with distinct clinical presentations and healthcare challenges.Figure 1 Figure 2

Intergenerational persistence of poverty in five high-income countries.

Childhood poverty increases the likelihood of adult poverty. However, past research offers conflicting accounts of cross-national variation in the strength of-and mechanisms underpinning-the intergenerational persistence of poverty. Here the authors investigate differences in intergenerational poverty in the United States, Australia, Denmark, Germany and the United Kingdom using administrative- and survey-based panel datasets. Intergenerational poverty is decomposed into family background effects, mediation effects, tax and transfer insurance effects and a residual poverty penalty. The intergenerational persistence of poverty is 0.43 in the United States (95% confidence interval (CI) = 0.40-0.46; P < 0.001), compared with 0.16 in the United Kingdom (95% CI = 0.07-0.25; P < 0.001) and 0.08 in Denmark (95% CI = 0.08-0.08; P < 0.001). The US disadvantage is not channelled through family background, mediators, neighbourhood effects or racial or ethnic discrimination. Instead, the United States has comparatively weak tax and transfer insurance effects and a more severe residual poverty penalty. If the United States were to adopt the tax and transfer insurance effects of its peer countries, its intergenerational poverty persistence could decrease by more than one-third.

Social norms and social opportunities: a qualitative study of influences on tobacco use among urban adolescent girls in Ghana

BackgroundTobacco use is a global public health threat and a leading preventable cause of death in the world. While cigarette use among youth has been decreasing in high-income countries, low- and middle-income countries have contrastingly high rates of adolescent smoking. In Ghana, smoking prevalence is lower than in other parts of the African continent and more common among men than women; however the gender gap in tobacco use among adolescents has narrowed, with shisha use among girls recently surpassing boys. These trends toward increased relative use among adolescent girls are a cause for concern and highlight the need for interventions to prevent and/or reduce tobacco use in this population.MethodsWe conducted in-depth interviews with girls aged 13–20 (n = 148) and their parents (n = 7) in Ghana’s largest two cities – Accra and Kumasi, to explore the physical, social, and psychological context underlying smoking perceptions and behavior.ResultsWe identified 11 key insights into influences on smoking behavior, organized into the broader themes of perceptions of smoking, environmental factors, and internal factors. Findings underscore that perceptions around smoking are very much driven by girls’ social world, which is generally small and parent-centric for non-smokers at younger ages but can start to expand as girls get farther along in school or leave school entirely. After what may have been a sheltered adolescence, many older girls in Ghana look for ways to express their independence in decision-making and a few may use their developing agency to rationalize limited or infrequent tobacco use if they perceive the benefits to them outweigh the potential consequences.ConclusionsOur findings highlight strong social influences on girls’ perceptions, exposure to opportunities, and decision-making in ways that can often be protective against smoking, particularly at younger ages, but may also leave girls unprepared to manage challenging situations later in life. Understanding this context in Ghana will be important for any future programming aiming to prevent smoking initiation among adolescents.

The impact of healthcare worker migration in source countries: Colombia, Indonesia, and Jordan

Abstract Background To address domestic shortages, high-income countries are increasingly recruiting healthcare workers from low- and middle-income countries. This practice is much debated, yet empirical evidence is rare. This study fills this knowledge gap by reporting high-level stakeholders’ perspectives on health system impacts of international migration and active recruitment of HCWs in Colombia, Indonesia, and Jordan. Methods We used a multiple case study methodology, based on qualitative methods integrated with information available in the published literature. Results All respondents decried a lack of robust and detailed data as a serious challenge in ascertaining their perspectives on impacts of healthcare workersmigration. Stakeholders described current emigration levels as not substantially aggravating existing healthcare workforce availability challenges. This is due to the fact that all three countries are faced with healthcare worker unemployment grounded in unwillingness to work in rural areas and/or overproduction of certain cadres. Respondents, however, pleaded against targeting very experienced and specialised individuals. While observing little harm of healthcare worker migration at present, stakeholders also noted few benefits such as brain gain, describing how various barriers to skill enhancement, return, and reintegration into the health system hamper in practice what may be possible in theory. Conclusions Improved availability of data on healthcare workers migration, including their potential return and reintegration into their country of origin’s health system, is urgently necessary to understand and monitor costs and benefits in dynamic national and international health labour markets. Our results imply that potential benefits of migration do not come into being automatically, but need in-country supportive policy, such as favourable reintegration policies or programs targeting engagement of the diaspora.

Curricular innovations to address inequalities in global health education

Abstract Background Global Health education (GHE) has expanded dramatically, with new degrees and expanded competencies in medical curricula. Yet, Global Health (GH) is also going through significant reckoning and debate around inequalities in the field. GH degrees are predominantly based in high-income countries and inaccessible to most global majority students. Some suggest GH education itself contributes to reproducing inequalities in GH. Thus, both educators and policy-makers require evidence and tools to support more representative and authentic educational experiences which can adequately equip our future graduates. Objectives To present educational innovations which gesture towards responding to the stark inequalities in Global/Public Health education. These include a unique project that experiments with disrupting current power dynamics through co-design and co-delivery of a curriculum on Syrian healthcare by colleagues with lived experience, and a student-staff partnership to integrate self-reflexivity and positionality (SRP) in curricula at Imperial College London (UK). Results Qualitative data shows that the Syrian Curriculum has resulted in enhanced student experience, being consistently cited as a highlight of the curriculum, whilst alsoenhancing inclusivity for many students. SRP supplemented this by providing students with tools to engage in open, respectful discussions and critically reflect on personal biases that impact class dynamics. Conclusions These projects provide tools for educators and policy-makers across European universities to address current challenges in GH education. Nonetheless, these innovations should principally be seen as tools to reflect and advocate for fundamental changes towards more representative structures in GH. Key messages • Curriculum innovations offer key tools to address inequalities in GHE, enhancing student experience/inclusivity. • Yet, these remain limited without fundamental change towards a more representative sector.

Integrating international lifestyle management of acute coronary syndrome and type 2 diabetes mellitus: a rapid review of guidelines

Abstract Background The rising prevalence of comorbidity has been described as an international health priority. There has been a dramatic increase in the levels of Type 2 Diabetes Mellitus (T2DM) among those with Acute Coronary Syndrome (ACS), with approximately 25-40% of patients admitted to hospital for ACS, also having diabetes. Comorbid ACS-T2DM provides a more complex set of symptoms for patients and clinicians to manage, and health policy makers to plan for. Those living with comorbid ACS-T2DM are at increased risk of death, another heart attack, re-hospitalisation, heart failure, reduced physical and psychological health, increased health service use and poorer quality of life. Due to shared disease determinants such as obesity, low physical activity levels and poorer dietary habits; individuals with ACS are more likely to have a comorbid T2DM. Care for patients with comorbidities is fragmented, siloed and poorly organised as it reflects a tradition of single disease management meaning comorbidity is rarely considered. Robust evidence is required to shape provision and guidance for those with comorbid ACS-T2DM and the clinicians involved in their care; with an emphasis on redesigning service provision and practice to address the needs of this growing population. Purpose To identify opportunities in existing clinical guidance to improve integrated care strategies and streamline management for those with comorbid ACS-T2DM. Methods Following Cochrane rapid review recommendations, a Population, Concept, and Context (PCC) framework guided eligibility. Guidelines for adults with ACS, T2DM, or both conditions in high-income countries were considered. Nineteen guidelines from the UK, Australia, Canada, Europe, Ireland, New Zealand, and the USA were compared, covering ACS (n = 10), T2DM (n = 6), and comorbid ACS-T2DM (n = 3). Lifestyle factors examined included diet/nutrition, physical activity, weight management, clinical and psychological aspects. Results The review identified consistent lifestyle recommendations for both ACS and T2DM, with overlaps in guidance for diet, physical activity, weight management, clinical, and psychological factors. The findings offer opportunity for integrated care strategies, potentially reducing duplicated lifestyle management efforts. The results lay the groundwork for more cohesive management of comorbid ACS-T2DM. Conclusions This research is relevant for healthcare providers, policymakers, and patients living with comorbid ACS-T2DM. Understanding the shared lifestyle factors provides valuable insights into the potential for integrated care. Recognising the overlap in existing clinical guidelines points to opportunity for a more streamlined and effective approach to managing comorbid ACS-T2DM. This knowledge can contribute to improved patient outcomes and seek to optimise healthcare resources.

Can mobile apps facilitate more sustainable and healthier diets? A systematic review

Abstract Background One third of all greenhouse gas emissions come from the food system, and current diets are insufficient to meet environmental and public health goals. Digital health apps offer promise to change behaviour, but little is known about the effects of different types of apps. This systematic review assessed the effectiveness of mobile apps in facilitating dietary changes across adults from high-income countries. Methods Seven electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Global Health, GreenFILE, Web of Science), two trial registries (Cochrane Trials and Clinicaltrials.gov), and Google were systematically searched for intervention studies aiming to facilitate dietary change. Interventions were characterised by their use of messaging (e.g., motivational statements) and personalised features (e.g., tailored nutrition advice). Outcomes for three food groups were synthesised through meta-analysis. Results Of the 5261 identified records, 21 met the eligibility criteria and were included. Interventions, recruiting 73,973 participants in total, lasted from three days to six months. Overall positive changes were observed in daily servings of fruit and vegetables (0.59, 95% CI 0.20, 0.99), legumes (0.05, 95% CI 0.01, 0.08), and meat (-0.14, 95% CI -0.23, -0.05), remaining significant after removing non-randomised controlled trials. Changes in fruit and vegetable intake were more pronounced for users of apps with messaging components (0.75, 95% CI 0.18, 1.32) and personalisation (0.67, 95% CI 0.16, 1.19), and meat intake changes were larger for messaging-based apps (-0.21, 95% CI -0.27, -0.15) than apps without these features. Conclusions Our findings suggest to practitioners and policymakers that mobile apps could be a useful and innovative way to change behaviour. Within a wider behaviour change approach, apps could help facilitate diets that meet food-based dietary guidelines, are predominantly plant-based, and are protective of environmental and human health. Key messages • Overall, the results from 21 studies showed positive dietary changes towards more fruits, vegetables, and legumes and less meat consumption following the use of mobile apps. • Apps including messaging and personalised elements appeared most effective and may be important for driving changes in fruits, vegetables, and meat consumption.