To determine whether the onset of physical health problems/sensory impairments is associated with incident challenging behaviours.

A retrospective, population-based cohort study using longitudinal data from primary care records. HRs were estimated using Cox proportional hazards models accounting for recurrent events and time-varying exposures.

UK primary care data sourced from the Clinical Practice Research Datalink (CPRD) Aurum and Gold databases, covering over 850 000 person-years between 2009 and 2019.

166 989 individuals with recorded intellectual disabilities were included in the cohort.

Incident identification of challenging behaviours before or after a recorded incident of physical health problems/sensory impairment. Physical health problems/sensory impairments assessed included constipation, epilepsy, pain, visual impairment, hearing impairment, bowel incontinence, urinary incontinence and sleep problems.

21.21% (n=35 415) of the cohort had challenging behaviour recorded at least once in primary care records over the 11-year study period, equating to an incidence rate of 0.10 per person-year. 40.9% of episodes of challenging behaviour were associated with an incident physical health problem/sensory impairment. All eight physical health problems/sensory impairments were significantly associated with higher HRs for challenging behaviours after full adjustment for demographic and mental health covariates. These associations held across multiple sensitivity analyses. The strongest associations were found for bowel incontinence (HR=2.24; 95% CI 2.01 to 2.50), urinary incontinence (HR=1.93; 95% CI 1.77 to 2.11), constipation (HR=1.89; 95% CI 1.74 to 2.05) and sleep problems (HR=1.74; 95% CI 1.58 to 1.90).

This is the first longitudinal study to establish a temporal association between the onset of physical health problems/sensory impairments and challenging behaviours in people with intellectual disabilities. These findings highlight the need for proactive identification and management of physical health problems/sensory impairments as part of assessment processes to prevent or reduce the impact of challenging behaviours.

Policies promote patient-centred tuberculosis (TB) care in Kenya, a high-burden TB country, but implementation remains limited. This study sought to understand the experiences of TB healthcare workers in implementing patient-centred TB services in primary health facilities in Nairobi and explore how the challenges they face can be addressed.

Using collaborative research design, we recruited healthcare workers (n=29) from primary health facilities across three densely populated subcounties in Nairobi and TB stakeholders (n=24) including policymakers and managers. From March to April 2024, we collected data through three workshops with nurses (n=19) and clinical officers/doctors (n=10) and a joint workshop with stakeholders. Participants engaged in group discussions and participatory visual methods to define person-centred care, document practices, identify challenges and develop solutions. Our data analysis applied a framework approach drawing on the social–ecological, TB care cascade and health systems building blocks models.

Healthcare workers identified practices for differentiated TB care across age groups, genders, occupations and comorbidities. Implementation faced multiple challenges including structural, health system, community and patient’s individual constraints. Shortages of funding, workforce and capacity affected close-to-community TB screening (Theme 1). Insufficient testing capacity at lower-level facilities led to diagnostic delays (Theme 2). Inflexible clinic hours and medication stockouts requiring frequent facility visits undermined TB treatment and adherence among working populations (Theme 3). Weak collaboration and referral systems limited support for people facing homelessness, substance use or poverty. Healthcare workers proposed enhanced TB training, increased TB workforce, flexible medication delivery, integrated TB services and strengthened intersectoral collaboration with education, labour and social protection sectors (Theme 4).

Healthcare workers demonstrate willingness and capacity to deliver patient-centred TB care but require strengthened health systems, ongoing training and sustainable intersectoral partnerships. Scaling up identified practices and innovative tools while addressing systemic barriers could improve TB care delivery and outcomes for underserved populations.