BackgroundContracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are particularly constrained. Afghanistan, the longest-running example of Basic Package of Health Services (BPHS) contracting in a conflict-affected setting, enables study of how implementation of a national intervention influences access to prioritised health services. This study explores stakeholder perspectives of sexual and reproductive health (SRH) services delivered through the BPHS in Afghanistan, using Bamyan Province as a case study.MethodsTwenty-six in-depth interviews were conducted with health-system practitioners (e.g. policy/regulatory, middle management, frontline providers) and four focus groups with service-users. Inductive thematic coding used the WHO Health System Framework categories (i.e. service delivery, workforce, medicines, information, financing, stewardship), while allowing for emergent themes.ResultsImprovements were noted by respondents in all health-system components discussed, with significant improvements identified in service coverage and workforce, particularly improved gender balance, numbers, training, and standardisation. Despite improvements, remaining weaknesses included service access and usage - especially in remote areas, staff retention, workload, and community accountability.ConclusionsBy including perspectives on SRH service provision and BPHS contracting across health-system components and levels, this study contributes to broader debates on the effects of contracting on perceptions and experiences among practitioners and service-users in conflict-affected countries.

Background: Older adults with Type 2 diabetes (T2D) are more likely to be frail, which increases the risk for disability and mortality. Objectives: To determine the feasibility of a behavioral lifestyle intervention, enhanced with mobile health technology for self-monitoring of diet and activity, to improve frailty in overweight/obese older adults (≥65 years) diagnosed with T2D. Design, Setting, and Participants: Single arm, 6-month study of a behavioral lifestyle intervention in 20 overweight/obese (BMI>25) older adults (≥ 65 years) with self-reported T2D diagnosis who owned a smartphone. A Fitbit tracker was provided to all participants for self-monitoring of diet and physical activity. Our primary outcome of feasibility was measured by session attendance, adherence to Fitbit usage to self-monitor diet and physical activity, and study retention. Secondary outcomes included the preliminary efficacy of the intervention on frailty, physical function, quality of life, and T2D-related outcomes. Results: Eighteen participants completed the study. The mean age was 71.5 (SD ± 5.3) years, 56% were female, and half were Hispanic. At baseline, 13 (72%) were pre-frail, 4 (22%) were frail, and 1 (6%) were non-frail. At follow-up, frailty scores improved significantly from 1.61 ± 1.15 to 0.94 ± 0.94 (p=0.01) and bodyweight improved from 205.66 ± 45.52 lbs. to 198.33 ± 43.6 lbs. (p=<0.001). Conclusion: This study provides evidence for the feasibility of a behavioral lifestyle intervention in overweight/obese older adults with T2D and preliminary results support its potential efficacy in improving frailty score.

Increasing facility-based delivery rates is pivotal to reach Sustainable Development Goals to improve skilled attendance at birth and reduce maternal and neonatal mortality in low- and middle-income countries (LMICs). The translation of global health initiatives into national policy and programmes has increased facility-based deliveries in LMICs, but little is known about the impact of such policies on social norms from the perspective of women who continue to deliver at home. This qualitative study explores the reasons for and experiences of home delivery among women living in rural Zimbabwe. We analysed qualitative data from 30 semi-structured interviews and 5 focus group discussions with women who had delivered at home in the previous 6 months in Mashonaland Central Province. We found evidence of strong community-level social norms in favour of facility-based delivery. However, despite their expressed intention to deliver at a facility, women described how multiple, interacting vulnerabilities resulted in delivery outside of a health facility. While identified as having delivered ‘at home’, narratives of birth experiences revealed the majority of women in our study delivered ‘on the road’, en route to the health facility. Strong norms for facility-based delivery created punishments and stigmatization for home delivery, which introduced additional risk to women at the time of delivery and in the postnatal period. These consequences for breaking social norms promoting facility-based delivery for all further increased the vulnerability of women who delivered at home or on the road. Our findings highlight that equitable public health policy and programme designs should include efforts to actively identify, mitigate and evaluate unintended consequences of social change created as a by-product of promoting positive health behaviours among those most vulnerable who are unable to comply.

Objectives The combination of obesity with age-related loss of muscle mass and strength creates a cumulative risk to function and the physical ability of older adults to sustain daily activities. The aim was to determine whether a higher protein intake can improve function and protect lean mass in older adults following a diet and exercise obesity intervention. Methods Obese (BMI ≥30 kg/m2) older (≥60 yrs) participants (female n = 50; male n = 15; 46% black) with functional limitations (Short Physical Performance Battery (SPPB) score = 9.1 ± 1.4 out of 12) were randomized to an RDA-level protein weight loss regimen (0.8 g/kg bw/d; Control; n = 33) or a higher protein arm (1.2 g/kg bw/d, with ≥30 g high quality protein (predominantly dairy) at each meal; Protein; n = 32). Both groups followed a hypo-caloric diet and participated in 2 supervised low-intensity chair exercise sessions per wk and 1 session/wk at home. Measurements at baseline, 3 and 6 months included body weight, SPPB, 6-minute walk time, 8-foot up and go test, and body composition (BODPOD). Results Mean baseline characteristics were BMI 35.0 ± 4.9 kg/m2 and age = 69.5 ± 6.2 yrs. At 6 months, weight loss and body fat reduction were significant (P &lt; 0.001) in both Control (7.0% weight) and Protein (6.6% weight) with no group difference. The slight (&lt;−1 kg) change in lean mass was not different between groups. At 3 and 6 months, SPPB scores significantly increased in both groups (P &lt; 0.01) with no difference between groups. However, at 3 months, the Protein group had significantly greater improvements in distance walked in 6 minutes (Protein = 48.3 ± 71.7 m; Control = 3.4 ± 69.3 m; P = 0.01) and timed 8-foot up and go (Protein = −0.9 ± 1.0 s; Control = −0.3 ± 1.2 s; P = 0.04) compared to control; no difference between groups for either test at 6 months. Conclusions We found that a hypocaloric balanced, higher protein diet (predominantly low-fat dairy) improved distance walked in 6 minutes and 8-foot up and go times at the 3 month time point; this group difference was absent at 6 months, when the improvements in these tests, as well as SPPB were equal between groups. Further study is needed to assess the potential that higher protein intake accelerates function responses to a diet plus exercise intervention for obese older adults. Funding Sources The National Dairy Council and US Department of Veterans Affairs Rehabilitation Research and Development Program.

Introduction The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) collects quality of life data via Kansas City Cardiomyopathy Questionnaire (KCCQ-12) and Visual Analog Score (VAS). These data are collected pre- and post-LVAD implantation. Though previous studies have shown that overall health-related quality of life (HRQoL) improves at one year after implantation, specific factors that predict a higher quality of life have not been identified. Hypothesis Self-perceived quality of life after LVAD implant is influenced by demographics and preexisting comorbidities. Methods We identified 118 patients in the INTERMACS database who received a LVAD at our institution. Of these, 26 patients completed the KCCQ-12 questionnaire and 32 patients completed VAS at 1-year follow up. An exploratory data analysis was conducted using descriptive statistics, correlation tests, and non-parametric comparison tests such as Wilcoxon rank-sum to identify important trends and predictors for changes in HRQoL. Multiple variables (patient characteristics, clinical data) were tested independently against the KCCQ-12 and VAS scores at one year and with the absolute change in these scores over a one-year period. Due to low sample size, we were not able to perform a multivariate model. Results New York Heart Association Class IV symptoms at baseline (p=0.01) were predictive of large gains in VAS scores at one year. Frailty, although not reaching significance, may be associated with smaller magnitudes of improvement in KCCQ at one year (p=0.067). The presence of peripheral vascular disease at pre-implant predicts a lower VAS score at one year (p=0.03). Demographic factors such as age, sex, and marital status at implant did not predict higher post implant quality of life by either VAS or KCCQ. Conclusion Existing non-cardiac comorbidities should be taken into consideration when assessing the health related quality of life benefit of LVAD implantation.