The role of constraints and information gaps in driving risky medicine purchasing practices in four African countries.

Substandard and falsified (SF) medical products pose a major threat to public health and socioeconomic development, particularly in low- and middle-income countries. In response, public education campaigns have been developed to alert consumers about the risks of SF medicines and provide guidance on 'safer' practices, along with other demand- and supply-side measures. However, little is currently known about the potential effectiveness of such campaigns while structural constraints to accessing quality-assured medicines persist. This paper analyses survey data on medicine purchasing practices, information and constraints from four African countries (Ghana, Nigeria, Sierra Leone and Uganda; n > 1000 per country). Using multivariate regression and structural equation modelling, we present what we believe to be the first attempt to tease apart, statistically, the effects of an information gap vs structural constraints in driving potential public exposure to SF medicines. The analysis confirms that less privileged groups (including, variously, those in rural settlements, with low levels of formal education, not in paid employment, often women and households with a disability or long-term sickness) are disproportionately potentially exposed to SF medicines; these same demographic groups also tend to have lower levels of awareness and experience greater levels of constraint. Despite the constraints, our models suggest that public health education may have an important role to play in modifying some (but not all) risky practices. Appropriately targeted public messaging can thus be a useful part of the toolbox in the fight against SF medicines, but it can only work effectively in combination with wider-reaching reforms to address higher-level vulnerabilities in pharmaceutical supply chains in Africa and expand access to quality-assured public-sector health services.

Can a Smartphone Application Help Address Barriers to Reporting Substandard/Falsified Medical Products? A Pilot Study in Tanzania and Indonesia.

INTRODUCTION: Reporting is an essential component of efforts to combat the distribution and circulation of substandard and falsified (SF) medical products worldwide. However, little is known about why health care professionals (HCPs) do not report suspect products to the national medicine regulatory authority (NMRA) and what measures might address this. This pilot study aimed to assess the utility of a smartphone application for reporting SF medical products in Tanzania and Indonesia. METHODS: At baseline, in 2017, HCPs completed a survey describing perceived barriers to reporting and received training in the identification of SF products and received use of the smartphone reporting application (N=309). The application reporting system was piloted for 6 months. Evaluations took place with HCPs and NMRA staff at the midpoint and endline of the pilot study (2018). RESULTS: At baseline, HCPs surveyed (n=254) identified the following key barriers to reporting: difficulties identifying SF products, frustrations with existing reporting systems, and fears that reporting may have personal or reputational repercussions. During the pilot period, HCPs submitted a total of 36 reports of 27 products to the NMRAs in their respective countries; of these, 8 products were determined to be SF and 2 were unregistered. In all 10 cases, appropriate regulatory action was taken. Feedback from HCPs and NMRA staff was positive in both countries, suggesting that the application addressed several barriers to reporting as it was convenient and, importantly, opened a line of communication between HCPs and the NMRA. However, the application did not address all barriers to reporting, such as concerns of repercussions. CONCLUSION: The findings suggest that this smartphone application may be useful for improving HCPs' reporting of suspected SF products. Developing and piloting similar reporting applications in other countries and contexts is required.

Socioeconomic correlates of sedentary time during pregnancy among women at risk of gestational diabetes in the UK.

Little is known about the relationship between socioeconomic position (SEP) and duration and patterning of objectively measured sedentary time (ST) among adults, especially adults at high risk of diabetes. The aim of this study was to examine cross-sectional associations of SEP with ST (total, prolonged ST, breaks in ST) and self-reported TV time among pregnant women at risk of gestational diabetes in the UK. At 20 weeks' gestation, pregnant women (n=174) wore an activPAL accelerometer and reported their usual TV time. Generalized linear mixed models were used to test associations of education, household income and area-level deprivation (separately and with mutual adjustment) with total ST, prolonged ST and breaks in ST. Logistic regression models were used to test associations between SEP indicators and high (≥2h/day) TV time. Those with the lowest education, lowest household income and highest area-level deprivation had the lowest ST and lowest prolonged ST. After mutual adjustment, area-level deprivation remained associated with total ST (ß=0.10 [0.01, 0.20]). There was an inverse association between area-level deprivation and breaks in sedentary time (exp(b)=1.11 [1.01, 1.22]). Education was the only SEP correlate of high TV time, with more of those with least education reporting high TV time; this association persisted after adjustment for household income and area-level deprivation. The association between SEP and total and prolonged ST (positive) was the opposite of the association between education and high TV time (negative) in this sample of high-risk pregnant women. These findings should inform interventions to reduce sedentary time.

Impact of prehabilitation on objectively measured physical activity levels in elective surgery patients: a systematic review.

OBJECTIVE: To systematically review the impact of prehabilitation on objectively measured physical activity (PA) levels in elective surgery patients. DATA SOURCES: Articles published in Web of Science Core Collections, PubMed, Embase (Ovid), CINAHL (EBSCOHost), PsycInfo (EBSCOHost) and CENTRAL through August 2020. STUDY SELECTION: Studies that met the following criteria: (1) written in English, (2) quantitatively described the effect(s) of a PA intervention among elective surgery patients prior to surgery and (3) used and reported objective measures of PA in the study. DATA EXTRACTION AND SYNTHESIS: Participant characteristics, intervention details, PA measurement, and clinical and health-related outcomes were extracted. Risk of bias was assessed following the revised Cochrane risk of bias tool. Meta-analysis was not possible due to heterogeneity, therefore narrative synthesis was used. RESULTS: 6533 unique articles were identified in the search; 21 articles (based on 15 trials) were included in the review. There was little evidence to suggest that prehabilitation is associated with increases in objectively measured PA, but this may be due to insufficient statistical power as most (n=8) trials included in the review were small feasibility/pilot studies. Where studies tested associations between objectively measured PA during the intervention period and health-related outcomes, significant beneficial associations were reported. Limitations in the evidence base precluded any assessment via meta-regression of the association between objectively measured PA and clinical or health-related outcomes. CONCLUSIONS: Additional large-scale studies are needed, with clear and consistent reporting of objective measures including accelerometry variables and outcome variables, to improve our understanding of the impact of changes in PA prior to surgery on surgical and health-related outcomes. PROSPERO REGISTRATION NUMBER: CRD42019151475.

How is television time linked to cardiometabolic health in adults? A critical systematic review of the evidence for an effect of watching television on eating, movement, affect and sleep.

OBJECTIVE: To improve our understanding of how television (TV) time is linked to cardiometabolic health among adults by systematically and critically evaluating the evidence that watching TV is associated with increased food consumption, lack of movement or negative affect or affects subsequent sleep. DESIGN: Systematic review. DATA SOURCES: Web of Science and PubMed. ELIGIBILITY CRITERIA: Studies that provided quantitative evidence on short-term associations of watching TV with dietary intake, characteristics of sitting, affect and sleep among samples of healthy adults (≥18 years old). DATA EXTRACTION AND SYNTHESIS: Study quality was assessed using the National Heart, Lung, and Blood Institute Quality Assessment Tools; studies deemed to be of low quality were excluded from the review. Due to heterogeneity of study designs and measurements, the findings were synthesised using narrative summary accompanied by custom plots. RESULTS: We identified 31 studies that met the inclusion criteria. Most of the associations reported by the studies included in this review were weak or inconsistent. There was no strong evidence to suggest that food consumption is higher while watching TV than in other contexts or that TV is a particularly 'sedentary' behaviour. Affect was less likely to be positive while watching TV than in other contexts but was not more likely to be negative. Two small studies suggest that TV may impact sleep via suppressing melatonin and delaying bedtime. CONCLUSION: There is currently no strong evidence to suggest that TV might impact cardiometabolic health via increasing food consumption, being linked with prolonged/inactive sitting, affect or subsequent sleep. Additional research is required to understand how TV fits within everyday lives and relates to eating, sitting, affect and sleep to improve our understanding of how it might impact cardiometabolic health.

Effectiveness of diet and physical activity interventions among Chinese-origin populations living in high income countries: a systematic review.

BACKGROUND: This review examines the effectiveness of diet and physical activity interventions to reduce cardiometabolic risk among Chinese immigrants and their descendants living in high income countries. The objective of this review is to provide information to help build future interventions aimed at improving diet and increasing physical activity levels among Chinese immigrants. METHODS: Outcomes included BMI, weight, waist circumference (WC), waist-hip ratio (WHR), cholesterol (LDL, HDL), systolic and diastolic blood pressure (SBP, DBP), hemoglobin A1c (HgbA1c), fasting blood glucose (FBG), and HOMA-IR. Six databases were systematically searched from database inception to date of search (February 2020). Meta-analyses used random effect models to estimate pooled effects of outcomes with 95% confidence intervals. The outcomes assessed were changes in mean outcomes (post-intervention versus baseline) among the intervention group versus control groups. RESULTS: Twenty-one articles were included for synthesis, and eight of these were included in the meta-analysis. Among children/adolescents, there were no significant effects of intervention for any of the outcomes having sufficient data for meta-analysis (BMI, WHR, SBP, and DBP). Among adults, the pooled effect including three studies showed significant changes in BMI (effect size = - 1.14 kg/m2; (95% CI: - 2.06, - 0.21), I2 = 31%). There were also significant effects of intervention among adults in terms of changes in SBP and DBP, as the pooled effect across three studies was - 6.08 mmHg (95% CI - 9.42, - 2.73), I2 = 0% and - 3.81 mmHg (95% CI: - 6.34, - 1.28), I2 = 0%, respectively. Among adults there were no other significant effects among the meta-analyses conducted (weight, WC, LDL, HgbA1c, and FBG). CONCLUSIONS: This review is the first to summarize the effectiveness of diet and physical activity interventions specifically designed for Chinese immigrants living in high income countries. There were clinically meaningful changes in BMI and blood pressure among adults, but evidence was weak for other cardiometabolic outcomes (weight, WC, LDL, HgbA1c, and FBG), and among children, there was no evidence of effect for any cardiometabolic outcomes. Given our mixed findings, more work is needed to support the design of successful interventions, particularly those targeting children and their families. TRIAL REGISTRATION: The systematic review protocol was registered in PROSPERO on December 17, 2018, the international prospective register of systematic reviews (registration number: CRD42018117842 ).

"Sit Yourself Down": Women's Experiences of Negotiating Physical Activity During Pregnancy.

Approaches to understanding why physical activity (PA) tends to decline during pregnancy are generally based on individualized behavioral models, examining "barriers" or "enablers." In contrast, we used a social practice approach to explore the ways in which women negotiate PA during pregnancy within the contexts and routines of their everyday lives. Semistructured interviews were conducted with 18 pregnant women who had been classed as being at risk of gestational diabetes. We found that leisure-time physical activities were valued as pleasurable and therapeutic, but women's roles as employees and carers for others often constrained their opportunities for leisure-time PA. Women encountered others' expectations that they should sit down and slow down. This surveillance was often resisted, as women relied on "listening to the body" as a way to negotiate PA. These findings have important implications for public health strategies or interventions designed to promote PA during pregnancy.

Associations Between Television Time and activPAL-Measured Duration and Pattern of Sedentary Time Among Pregnant Women at Risk of Gestational Diabetes in the UK.

BACKGROUND: Television (TV) time is associated with poor cardiometabolic health outcomes. This finding is commonly attributed to duration of sitting or patterns of sitting associated with high TV time, but there is very little evidence on this link. METHODS: Pregnant women (n = 167) at risk of gestational diabetes wore an activPAL accelerometer and self-reported their usual TV time in the second trimester. Generalized linear mixed models were used to compare objectively measured total sedentary time (ST), prolonged ST (bouts ≥30 min), and breaks in ST for all hours and evening hours (6 PM-11 PM) between those with high (≥2 h/d) and low TV time. RESULTS: Over all waking hours, those with high TV time had fewer breaks in ST than those with low TV time, exp(b) 0.92; 95% confidence interval, 0.86 to 0.998; there were no differences in total ST or prolonged ST between the 2 groups. Those with high TV time had significantly higher evening ST (b = 9.9; 95% confidence interval, 0.5 to 19.2); there were no differences in prolonged ST or breaks in ST during evening hours. CONCLUSIONS: These findings suggest that high TV time may be associated with higher evening ST and fewer breaks in ST. The link between TV time and sitting patterns requires further investigation.

Associations of sedentary time and self-reported television time during pregnancy with incident gestational diabetes and plasma glucose levels in women at risk of gestational diabetes in the UK.

BACKGROUND: Sedentary time is associated with increased risk of type 2 diabetes, but the association between objectively measured sedentary time and incident gestational diabetes mellitus (GDM) has not been tested. The purpose of this paper is to test associations between objectively measured sedentary time and self-reported television time during pregnancy with incident GDM and plasma glucose levels among women at high risk for GDM. METHODS: At 20 weeks' gestation, pregnant women (n = 188) in the North East of England with a risk factor for GDM wore an activPAL accelerometer and reported their usual television time. Participants underwent a standard oral glucose tolerance test at 24-28 weeks' gestation. Regression analyses were used to test for associations of total and prolonged sedentary time, breaks in sedentary time, and television time with GDM and fasting and 2-h glucose levels. Interaction terms were applied to examine whether the association between each indicator of sedentary time and glucose levels differed by GDM status. RESULTS: Total sedentary time (hours/day) was not associated with incident GDM (OR 1.00 (95%CI 1.00, 1.01)). The association between total sedentary time and glucose levels depended on GDM status: sedentary time was associated with fasting (ß = 0.16 (95%CI 0.01, 0.31)) and 2-h (ß = 0.15 (95%CI 0.01, 0.30)) glucose levels for those without GDM, while breaks in sedentary time were associated with lower fasting (ß = - 0.55 (95%CI - 0.92, - 0.17)) and 2-h (ß = - 0.40 (95%CI - 0.77, - 0.03)) glucose levels for those with GDM. Prolonged sedentary time was associated with higher fasting glucose levels regardless of GDM status (ß 0.15 (0.01, 0.30)). Television time was associated with development of GDM (OR 3.03 (95%CI 1.21, 7.96)) but not with plasma glucose levels. CONCLUSIONS: This is the first study to test associations between posture-based measures of sedentary time during pregnancy and GDM and glucose levels. The findings presented here suggest the possible importance of minimizing or breaking up sedentary time for the management of glucose levels during pregnancy, at least among women at high risk of GDM. Further research is needed to understand the different roles of total sedentary time and television time in the development of GDM.

Gender differences in walking (for leisure, transport and in total) across adult life: a systematic review.

BACKGROUND: The aim of this systematic review was to examine gender differences in walking for leisure, transport and in total in adults living in high-income countries, and to assess whether gender differences in walking practices change across the life-course. METHODS: A systematic literature search was conducted of publications dated 1995 to 2015. Papers providing quantitative data on participation in walking of both men and women aged at least 18 years in a high-income country were screened for the quality of the data on gender differences in walking. Data were extracted and results were synthesised using forest plots and narrative summary. RESULTS: Thirty-six studies were included in the review: 18 reported on walking for leisure, 16 on walking for transport (in total, or for particular purposes), and 14 on total walking. Most (33) studies provided data comparing the proportion of men and women who walked (at all or for a minimum duration) over a defined period, usually one week. There was consistent evidence that more women than men walk for leisure, although effect sizes were small. However, this effect varies by age: more younger women than younger men walk for leisure, but the gender difference diminishes with age and appears to reverse in the oldest age groups. Taking all ages together, there was no consistent gender difference in walking for transport or in total walking, although the small number of studies reporting on walking to undertake errands suggested that more women than men walk for this purpose. CONCLUSIONS: While there is little evidence that levels of total walking consistently vary by gender, our findings suggest that there are consistent gender differences in participation in walking for some purposes, including for leisure, and that there are gender differences in the impact of age on walking. We conclude that more research is needed to improve our understanding of how walking fits into the lives of women and men across the life-course, especially in relation to gender differences in the impact of aging on walking. PROSPERO REGISTRATION: PROSPERO registration number: CRD42015025961 .