Globally the number of people with Type 2 diabetes mellitus (T2DM) has risen significantly over the last few decades. Aligned to this is a growing use of community health workers (CHWs) to deliver T2DM self-management support with good clinical outcomes especially in High Income Countries (HIC). Evidence and lessons from these interventions can be useful for Low- and Middle-Income countries (LMICs) such as South Africa that are experiencing a marked increase in T2DM prevalence. This study aimed to examine how CHW have been utilized to support T2DM self-management globally, their preparation for and supervision to perform their functions. The review was guided by a stepwise approach outlined in the framework for scoping reviews developed by Arksey and O’Malley. Peer reviewed scientific and grey literature was searched using a string of keywords, selecting English full-text articles published between 2000 and 2015. Articles were selected using inclusion criteria, charted and content analyzed. 1008 studies were identified of which 54 full text articles were selected. Most (53) of the selected studies were in HIC and targeted mostly minority populations in low resource settings. CHWs were mostly deployed to provide education, support, and advocacy. Structured curriculum based education was the most frequently reported service provided by CHWs to support T2DM self-management. Support services included informational, emotional, appraisal and instrumental support. Models of CHW care included facility linked nurse-led CHW coordination, facility-linked CHW led coordination and standalone CHW interventions without facility interaction. CHWs play several roles in T2DM self-management, including structured education, ongoing support and health system advocacy. Preparing and coordinating CHWs for these roles is crucial and needs further research and strengthening.

Background. Long waiting times are a major source of dissatisfaction for patients attending public healthcare facilities in South Africa (SA). The National Department of Health has identified this as one of six priority areas for improvement. Health system-strengthening (HSS) interventions to improve patient waiting time are being implemented in public health facilities across SA as part of the ‘Ideal Clinic’ model. The effect of these interventions on patient waiting time needs to be assessed and evidence generated for system improvement. Objectives. To determine the effect of Ideal Clinic HSS intervention on patient waiting time in public health facilities in Amajuba District, KwaZulu-Natal Province, SA. Methods. We implemented 12 months of HSS activity, including facility reorganisation and patient appointment scheduling. The major outcome of interest was the total time spent by patients in a facility during a visit. This was calculated as the median time spent, obtained through a ‘before-and-after’ intervention survey. Univariate and multivariate factors associated with waiting time were determined. Results. A total of 1 763 patients from nine clinics were surveyed before and after the intervention (n=860 at baseline and n=903 at follow-up). The median overall waiting time after the intervention was 122 minutes (interquartile range (IQR) 81 - 204), compared with 116 minutes (IQR 66 - 168) before (p<0.05). Individual facility results after the intervention were mixed. Two facilities recorded statistically significant reductions in patient waiting time, while three recorded significant increases (p<0.05). Patient load per nurse, type of service received and time of arrival in facilities were all independently associated with waiting time. Patients’ arrival patterns, which were determined by appointment scheduling, played a significant role in the results obtained. Conclusions. Implementation of the Ideal Clinic model in the selected facilities led to changes in patient waiting time. Observed changes were positive when a clinic appointment system was successfully implemented and negative when this was unsuccessful. We recommend strengthening of the appointment system component of the Ideal Clinic model to improve patient waiting time. Assessing facility waiting time performance in terms of average time spent by patients during a clinic visit was shown to be inadequate, and we suggest the inclusion of ‘proportion of clients who spent above the national waiting time threshold during their visit’ as a sensitive measure of performance.

: Decline in the ability to perform activities of daily living (ADL) or ‘functional decline’ is a major health concern among aging populations. With intervention, ADL decline may be delayed, prevented or reversed. The capacity to anticipate the trajectory of future functional change can enhance care planning and improve outcome for residents. Methods: This is a 36 months’ retrospective longitudinal analysis of LTC residents in five Canadian provinces. Group-based trajectory modelling (GBTM) was performed to identify distinct trajectories and resident attributes associated with membership of the trajectory groups. Results: A total of 204 036 LTC residents were included in this study. Their admission mean age was 83.7 years (SD = 8.6), and 63.3% were females. Our model identified four distinct trajectories namely: ‘Catastrophic decline’ (n = 48 441, 22.7%), ‘Rapid decline with some recovery’ (n = 27 620, 18.7%), ‘Progressive decline’ trajectory (n = 30 287, 14.4%), and the ‘No/Minimal decline’ (n = 97 688, 47.9%) Residents’ admission ADL Hierarchy score was the single, strongest predictor of functional decline trajectory that residents followed. Residents with ADLH 5–6 OR 0.03 (0.03–0.04) were least likely to follow a catastrophic decline trajectory, while those with ADLH 5–6 OR 39.05 (36/60–41.88) were most likely to follow a minimal or no decline trajectory. Conclusion: Results of this study further highlight the heterogeneity of health trajectory among residents in LTC setting, re-affirming the need for personalized care. The study shows who among residents would be most at risk for different levels of functional decline. The study findings provide useful information that would assist both immediate and advanced care planning as well as to forecast care personnel requirements into the future based on total acuity levels of residents.

Background. Cardiovascular diseases (CVDs) are a challenge to populations and health systems worldwide. It is projected that by 2020 about a third of all deaths globally will be caused by CVDs, and that they will become the single leading cause of death by 2030. Empirical evidence suggests that there is socioeconomic patterning in the distribution and prevalence of risk factors for CVD, but the exact nature of this relationship in South Africa remains unclear. Objective. To examine the association between socioeconomic status (SES) and risk factors for CVD in a cohort of adult South Africans living in rural and urban communities. Method. This was a cross-sectional analytical study of baseline data on a population-based cohort of 1 976 SA men and women aged 35 - 70 years who were part of the Cape Town arm of the Prospective Urban and Rural Epidemiology (PURE) Study. Results. We found a complex association between SES and CVD risk factors, its pattern differing between urban and rural participants. Marital status showed the most consistent association with CVD risk in both groups: widowed participants living in urban communities were more likely to be hypertensive as well as diabetic, while single participants in both locations were more likely to use alcohol and tobacco products. Level of education was the only SES variable that had no significant association with any CVD risk factor in either study group. All measured SES variables were significantly different between urban and rural participants (p<0.05), with diabetes, obesity and alcohol use significantly more prevalent in urban than in rural participants (p<0.05) while hypertension and tobacco use were not (p≥0.05). Conclusions. In this cohort of South Africans, there were significant associations between SES and CVD risk, with marked differences in these associations between rural and urban locations. These findings highlight the need to consider SES and area of residence when designing interventions for CVD prevention and control.

Objective: The demand for long-term care in community and facilitybased settings in Canada is expected to increase with population growth. The Toronto Grace Health Center piloted an intervention program that aims to support return to the community of acute hospital patients designated for LTC placement. We investigated whether this program was effective in transitioning the program patients back to their homes in the community and the factors associated with transitioning patients to different destinations. Method: We performed a competing risk multi-state analysis of 111 patients enrolled into the Harbour Light (HL) transitional unit program between January 2020 and June 2023. Results: At the time of the study, 92 enrolled patients had been discharged and of those these, 48.9% (45) were successfully transitioned back to their private home in the community. The remaining 51.1% (46) were discharged to other destinations. Being a female was the only positive predictor of transitioning back home. Higher CPS scores (HR 0.53, 95% CI 0.31-0.88), PADDRS scale of 1+, and higher ADL Hierarchy scale, strongly predicted lower odds of transitioning back to the community. Conclusion: Within the context of rising LTC bed demand and lengthy waiting time in Canada, with appropriate measures, this program successfully transitioned LTC home bound persons back to their homes. If replicable on a large scale, this could provide short and long-term solution to LTC bed demand in Canada.