Annals of Global Health最新文献

Background: Women constitute almost two thirds of the health and social workforce. Yet, the proportion of women in decision-making positions remains significantly low leading to gender inequities in access to and appropriateness of healthcare. Several barriers which limit women's advancement to leadership positions have been documented and they generally constitute of gender stereotypes, discrimination and inhibiting systems; these hinderances are compounded by intersection with other social identities. Amelioration of the barriers has the potential to enhance women's participation in leadership and strengthen the existing health systems.

Objective: This protocol describes a proposed study aimed at addressing the organisational and individual barriers to the advancement of women to leadership positions in the Tanzanian health sector, and to evaluate the influence on leadership competencies and career advancement actions of the female health workforce.

Method: The study utilises a gender transformative approach, co-design and implementation science in the development and integration of a leadership and mentorship intervention for women in the Tanzanian health context. The key steps in this research include quantifying the gender ratio in healthcare leadership; identifying the individual and organisational barriers to women's leadership; reviewing existing leadership, mentorship and career advancement interventions for women; recruiting programme participants for a leadership and mentorship programme; running a co-design workshop with programme participants and stakeholders; implementing a leadership and mentorship programme; and conducting a collaborative evaluation and lessons learnt.

Conclusions: This research underscores the notion that progression towards gender equality in healthcare leadership is attained by fashioning a system that supports the advancement of women. We also argue that one of the pivotal indicators of progress towards the gender equality sustainable development goal is the number of women in senior and middle management positions, which we hope to further through this research.

Background: A better understanding of refugee mobility is needed to optimize HIV care in refugee settlements.

Objectives: We aimed to characterize mobility patterns among people living with HIV in refugee settlements in Uganda and evaluate the association between mobility and retention in HIV care.

Methods: Refugees and Ugandan nationals accessing HIV services at seven health centers in refugee settlements across Uganda, with access to a phone, were recruited and followed for six months. Participants received an intake survey and monthly phone surveys on mobility and HIV. Clinic visit and viral suppression data were extracted from clinic registers. Mobility and HIV data were presented descriptively, and an alluvial plot was generated characterizing mobility for participants' most recent trip. Bivariate Poisson regression models were used to describe the associations between long-term mobility (≥1 continuous month away in the past year) and demographic characteristics, retention (≥1 clinic visit/6 months) and long-term mobility, and retention and general mobility (during any follow-up month: ≥2 trips, travel outside the district or further, or spending >1-2 weeks (8-14 nights) away).

Findings: Mobility data were provided by 479 participants. At baseline, 67 participants (14%) were considered long-term mobile. Male sex was associated with an increased probability of long-term mobility (RR 2.02; 95%CI: 1.30-3.14, p < 0.01). In follow-up, 185 participants (60% of respondents) were considered generally mobile. Reasons for travel included obtaining food or supporting farming activities (45% of trips) and work or trade (33% of trips). Retention in HIV care was found for 417 (87%) participants. Long-term mobility was associated with a 14% (RR 0.86; 95%CI: 0.75-0.98) lower likelihood of retention (p = 0.03).

Conclusions: Refugees and Ugandan nationals accessing HIV care in refugee settlements frequently travel to support their survival needs. Mobility is associated with inferior retention and should be considered in interventions to optimize HIV care.

Background: Mathematical modeling of infectious diseases is an important decision-making tool for outbreak control. However, in Africa, limited expertise reduces the use and impact of these tools on policy. Therefore, there is a need to build capacity in Africa for the use of mathematical modeling to inform policy. Here we describe our experience implementing a mathematical modeling training program for public health professionals in East Africa.

Methods: We used a deliverable-driven and learning-by-doing model to introduce trainees to the mathematical modeling of infectious diseases. The training comprised two two-week in-person sessions and a practicum where trainees received intensive mentorship. Trainees evaluated the content and structure of the course at the end of each week, and this feedback informed the strategy for subsequent weeks.

Findings: Out of 875 applications from 38 countries, we selected ten trainees from three countries - Rwanda (6), Kenya (2), and Uganda (2) - with guidance from an advisory committee. Nine trainees were based at government institutions and one at an academic organization. Participants gained skills in developing models to answer questions of interest and critically appraising modeling studies. At the end of the training, trainees prepared policy briefs summarizing their modeling study findings. These were presented at a dissemination event to policymakers, researchers, and program managers. All trainees indicated they would recommend the course to colleagues and rated the quality of the training with a median score of 9/10.

Conclusions: Mathematical modeling training programs for public health professionals in Africa can be an effective tool for research capacity building and policy support to mitigate infectious disease burden and forecast resources. Overall, the course was successful, owing to a combination of factors, including institutional support, trainees' commitment, intensive mentorship, a diverse trainee pool, and regular evaluations.

Background: Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa.

Objectives: Co-design a quality improvement intervention for AMI care tailored to local contextual factors.

Methods: An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context.

Findings: The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education.

Conclusion: MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.

Objective: To map ophthalmologist locations and surgical practices as they vary sub-nationally within Honduras to maximize the impact of efforts to develop cataract surgical capacity.

Methods: An anonymous survey was sent to all Honduran ophthalmologists with questions on surgical volume, department-level location, type of facility in which they work, surgical methods, and age. Surgical volume, population, and poverty data sourced through the Oxford Poverty Human Development Initiative were mapped at the department level, and cataract surgical rates (CSR; surgeries per million population per year) were calculated and mapped.

Results: Sixty-one of the 102 Honduran ophthalmologists contacted responded. Of those, 85% perform cataract surgery, and 49% work at least part time in a non-profit or governmental facility. Honduras has fewer surgical ophthalmologists per million than the global average, and though national CSR appears to be increasing, it varies significantly between departments. The correlation between CSR and poverty is complex, and outliers provide valuable insights.

Conclusion: Mapping ophthalmological surgical practices as they relate to population and poverty at a sub-national level provides important insights into geographic trends in the need for and access to eye care. Such insights can be used to guide efficient and effective development of cataract surgical capacity.

Background: Evidence-based medicine (EBM), as originally conceived, used all types of peer-reviewed evidence to guide medical practice and decision-making. During the SARS-CoV-2 Coronavirus disease (COVID-19) pandemic, the standard usage of EBM, modeled by the Evidence-Based Medicine Pyramid, undermined EBM by incorrectly using pyramid levels to assign relative quality. The resulting pyramid-based thinking is biased against reports both in levels beneath randomized control trials (RCTs) and those omitted from the pyramid entirely. Thus, much of the evidence was ignored. Our desire for a more encompassing and effective medical decision-making process to apply to repurposed drugs led us to develop an alternative to the EBM Pyramid for EBM. Herein, we propose the totality of evidence (T-EBM) wheel.

Objectives: To create an easily understood graphic that models EBM by incorporating all peer-reviewed evidence that applies to both new and repurposed medicines, and to demonstrate its potential utility using ivermectin as a case study.

Methods: The graphics were produced using Microsoft Office Visio Professional 2003 except for part of the T-EBM wheel sunburst chart, which was produced using Microsoft 365 Excel. For the case study, PubMed® was used by searching for peer-reviewed reports containing "ivermectin" and either "covid" or "sars" in the title. Reports were filtered for those using ivermectin-based protocols in the treatment of COVID-19. The resulting 265 reports were evaluated for their study design types and treatment outcomes. The three-ringed graphical T-EBM wheel was composed of two inner rings showing all types of reports and an outer ring showing outcomes for each type.

Findings-conclusions: The T-EBM wheel avoids the biases of the EBM Pyramid and includes all types of reports in the pyramid along with reports such as population and mechanistic studies. In both early and late stages of medical emergencies, pyramid-based thinking may overlook indications of efficacy in regions of the T-EBM wheel beyond RCTs. This is especially true when searching for ways to prevent and treat a novel disease with repurposed therapeutics before RCTs, safety assessments, and mechanisms of action of novel therapeutics are established. As such, T-EBM Wheels should replace the EBM Pyramids in medical decision-making and education. T-EBM Wheels can be expanded upon by implementing multiple outer rings, one for each different kind of outcome (efficacy, safety, etc.). A T-EBM Wheel can be created for any proprietary or generic medicine. The ivermectin (IVM) T-EBM Wheel displays the efficacy of IVM-based treatments of COVID-19 in a color-coded graphic, visualizing each type of evidence and the proportions of each of their outcomes (positive, inconclusive, negative).

Despite the commendable progress made in addressing global health challenges and threats such as child mortality, HIV/AIDS, and Tuberculosis, many global health organizations still exhibit a Global North supremacy attitude, evidenced by their choice of leaders and executors of global health initiatives in low- and middle-income countries (LMICs). While efforts by the Global North to support global health practice in LMICs have led to economic development and advancement in locally led research, current global health practices tend to focus solely on intervention outcomes, often neglecting important systemic factors such as intellectual property ownership, sustainability, diversification of leadership roles, and national capacity development. This has resulted in the implementation of practices and systems informed by high-income countries (HICs) to the detriment of knowledge systems in LMICs, as they are deprived of the opportunity to generate local solutions for local problems. From their unique position as international global health fellows located in different African countries and receiving graduate education from a HIC institution, the authors of this viewpoint article assess how HIC institutions can better support LMICs. The authors propose several strategies for achieving equitable global health practices; 1) allocating funding to improve academic and research infrastructures in LMICs; 2) encouraging effective partnerships and collaborations with Global South scientists who have lived experiences in LMICs; 3) reviewing the trade-related aspects of intellectual property Rights (TRIPS) agreement; and 4) achieving equity in global health funding and education resources.