Aims and method: This systematic review examines the effectiveness and cost-effectiveness of behavioural health integration into primary healthcare in the management of depression and unhealthy alcohol use in low- and middle-income countries. Following PRISMA guidelines, this review included research that studied patients aged ≥18 years with unhealthy alcohol use and/or depression of any clinical severity. An exploration of the models of integration was used to characterise a typology of behavioural health integration specific for low- and middle-income countries.Results: Fifty-eight articles met inclusion criteria. Studies evidenced increased effectiveness of integrated care over treatment as usual for both conditions. The economic evaluations found increased direct health costs but cost-effective estimates. The included studies used six distinct behavioural health integration models.Clinical implications: Behavioural health integration may yield improved health outcomes, although it may require additional resources. The proposed typology can assist decision-makers to advance the implementation of integrated models.

Background Urbanisation is an important contributor to the prevalence of asthma worldwide, and the burden of this effect in low-income and middle-income countries undergoing rapid industrialisation appears to be growing. We sought to characterise adult asthma prevalence across four geographically diverse settings in Peru and identify both individual and environmental risk factors associated with adult asthma. Methods We collected sociodemographics, clinical history and spirometry in adults aged ≥35 years. We defined asthma as meeting one of the three criteria: physician diagnosis, self-report of wheezing attack or use of asthma medications. We used multivariable logistic regression to assess individual and environmental factors associated with adult asthma. Results We analysed data from 2953 participants (mean age 55 years; 49% male). Overall asthma prevalence was 7.1%, which varied with urbanisation: highest in Lima (14.5%), followed by urban Puno (4.0%), semiurban Tumbes (3.8%) and rural Puno (1.8%). In multivariable analysis, being male (OR=0.60, 95% CI 0.39 to 0.93) and living at high altitude (OR=0.26, 95% CI 0.16 to 0.42) were associated with lower odds of having asthma, whereas living in an urban setting (OR=4.72, 95% CI 3.15 to 7.23) and family history of asthma (OR=1.83, 95% CI 1.19 to 2.73) were associated with higher odds. Current daily exposure to biomass fuel smoke (OR=1.18, 95% CI 0.70 to 1.91) and smoking (OR=0.99, 95% CI 0.73 to 1.22) were not associated with asthma. Conclusions These findings confirm that urbanisation is an environmental risk factor of asthma, questions biomass fuel smoke exposure as an important risk factor and proposes high altitude as possibly protective against the development of asthma.

Objectives Brick kiln workers in Nepal are a neglected population who are exposed to high respirable silica concentrations, and few use interventions to reduce exposure. We aimed to characterise the prevalence of respiratory personal protective equipment (PPE) use, understand knowledge and attitudes towards kiln dust and respiratory PPE and identify factors associated with respiratory PPE use. Methods We conducted a cross-sectional study in Bhaktapur, Nepal. We used simple random selection to identify 10 out of 64 total kilns and stratified random sampling of 30 households to enrol workers aged ≥14 years within selected kilns. Field workers surveyed participants using structured questionnaires. Our primary outcome was to characterise the prevalence of current respiratory PPE use and secondary outcomes were summaries of knowledge, attitudes and practice of PPE use. Results We surveyed 83 workers (mean age 30.8 years, 77.1% male). Of these, 28.9% reported current respiratory PPE use at work, 3.6% heard of silicosis prior to the survey and 24.1% correctly identified the best respiratory PPE (N95, compared with surgical masks and barrier face coverings) for reducing dust exposure. Respiratory PPE users had higher income (mean monthly household income US$206 vs US$145; p=0.04) and education levels (25% vs 5.1% completed more than primary school; p=0.02) compared with non-users. Conclusions Respiratory PPE use was low. Workers had poor knowledge of kiln dust health effects and proper respiratory PPE. We highlight important barriers to PPE use, particularly knowledge gaps, which can guide future investigations to reduce the silicosis burden among brick kiln workers.

Objectives: Brick kiln workers in Nepal face high exposure to respirable silica but are not required to use personal protective equipment (PPE). We sought to understand factors influencing PPE use, design and pilot a PPE training and distribution intervention and assess its feasibility. Methods: We used a human-centred design approach guided by the Discover, Design, Build, Test framework and conducted four pre-intervention workshops (36 participants), a 21-day randomised controlled trial (RCT) and three post-intervention workshops (19 participants) at a kiln in Bhaktapur, Nepal. Workers and leadership aged ≥18 years were purposively sampled for workshops and randomly selected for the RCT (20 intervention, 20 control). Intervention participants received PPE training, weekly reminders and free N95 respirators and eyewear. Control participants received counselling and information on where to purchase PPE. Results: Pre-intervention workshops revealed barriers to PPE use, including cost, discomfort and work efficiency concerns. Workers preferred expert-led, hands-on PPE training. We identified high feasibility (mean Feasibility of Intervention Measure, 4.6±0.5 points) among workers; leadership rated feasibility lower due to cost concerns. Observed N95 use was higher in the intervention group (78.9%, 71/90 visits) compared with none in the control group (0%, 0/93 visits; p<0.001). Post-intervention feedback showed workers felt N95s reduced dust exposure and respiratory symptoms without impacting efficiency, but eyewear needed adaptation for sustained use. Conclusions: With worker-centred training, N95 respirators are feasible to reduce silica exposure in this setting. However, broader adoption may depend on improving the affordability and accessibility of PPE through advocacy and policy changes. Trial registration number: NCT06090370 .