BMJ Global Health最新文献

Background: Failure to possess or renew legal residency permits increases the burden on a vulnerable refugee population. It risks detention or deportation, and hinders access to basic services including healthcare. This study aimed to examine the association between legal residency status and health of Syrian refugees living in Lebanon.

Methods: Data were from two independent nested cross-sectional studies collected in 2022 through telephone surveys. In the first study, all Syrian refugees aged 50 years or older from households that received humanitarian assistance were invited to participate. The second included all adult Syrian refugees residing in a suburb of Beirut. The exposure was self-reported possession of a legal residency permit in Lebanon. The self-reported health outcomes were mental health status, COVID-19 vaccine uptake, and access to needed healthcare services. Separate logistic regression models examined the association between lacking a legal residency permit and each health outcome, adjusted for age, length of stay in Lebanon, education, employment, wealth index and receipt of assistance.

Results: The first sample included 3357 participants (median age 58 years (IQR: 54-64), 47% female), of whom 85% reported lacking a legal residency permit. The second sample included 730 participants (median age 34 years (IQR: 26-42), 49% female), of whom 79% lacked a legal residency permit. In both studies, lacking a legal residency permit increased the odds of having poor mental health (adjusted odds ratio (aOR): 1.46 (95% CI: 1.07 to 1.99); aOR: 1.62 (95% CI: 1.01 to 2.60)) and decreased the odds of COVID-19 vaccine uptake (aOR: 0.66 (95% CI: 0.54 to 0.80); aOR: 0.51 (95% CI: 0.32 to 0.81)). In the subsample who needed primary healthcare, lacking a legal residency permit decreased the odds of access to primary healthcare, which was statistically significant in the second study (aOR: 0.37 (95% CI: 0.17 to 0.84)).

Conclusions: The majority of Syrian refugees from these two samples reported lacking a legal residency permit in Lebanon. This was associated with poor mental health and lower uptake of COVID-19 vaccination, potentially originating from fear of detention or deportation. These findings call for urgent action to support access to legal documentation for refugees in Lebanon.

Introduction: An estimated 800 000 children (<15 years) globally living with HIV remain undiagnosed. To reach these children with timely HIV testing services during infancy, we implemented a community-based differentiated care model using mobile point-of-care (POC) technology for early infant diagnosis (EID) of HIV, and assessed its effects on EID positivity, antiretroviral therapy (ART) initiation and 3-month retention in care.

Methods: Between 1 June 2019 and 31 May 2020 at six health facilities in Lusaka, Zambia, we enrolled mother-infant pairs (MIPs) at high risk for vertical transmission of HIV based on missing or late infant EID testing or other maternal risk factors. We offered these MIPs community POC EID testing (post-intervention), and compared their outcomes to historical high-risk controls at the same sites (1 June 2017-31 May 2018; pre-intervention). We used propensity score matched weighting and mixed effects regression modelling to estimate outcome differences pre-intervention and post-intervention, and to identify MIP characteristics predictive of vertical transmission of HIV.

Results: 2577 MIPs were included in the analysis: 1763 and 814 high-risk MIPs from the pre-intervention and post-intervention periods, respectively. Infant HIV positivity was significantly higher in the post-intervention (2.2%) vs pre-intervention (1.1%) period (p=0.038), however this difference was attenuated (0.83%, 95% CI: -0.50%, 2.15%) after adjusting for differences in maternal age, maternal antenatal care visits, infant birth month and facility. During the post-intervention period, MIPs where the mother disengaged from care were 12.97 (95% CI: 2.41, 69.98) times as likely to have an infant diagnosed with HIV vs those in which the infant received late EID testing without maternal care disengagement. Among 18 infants diagnosed with HIV by the intervention, 16 (88.9%) initiated same-day ART and all continued ART at 3-month follow-up.

Conclusion: Community-based differentiated care employing POC EID technology increased testing positivity in unadjusted analyses, and resulted in high ART initiation and early care retention, suggesting it may be a promising approach for reaching infants and young children living with HIV being missed by current facility-based approaches.

Trial registration number: This trial is registered under the following Clinicaltrials.gov Identifier: NCT03133728.

The Immunization Agenda 2030 emphasises the need for a motivated, skilled and knowledgeable workforce equipped to plan, manage, implement and monitor immunisation programmes at all levels. The rapid introduction of COVID-19 vaccines during the pandemic highlighted the adaptability of the health workforce but also exposed gaps in professional development and learning.This practice paper describes the implementation of an immunisation training programme in the Kingdom of Cambodia and the Lao People's Democratic Republic. The programme was developed and delivered by the project team in partnership with local stakeholders and technical experts. A country-centric approach ensured that training programmes met each country's needs, while input from technical experts ensured an evidence-based programme that aligned with international standards. There were 445 training participants from professional groups across various levels and sectors of the health system. Training curricula included a range of differentiated training modules which aimed to build knowledge and skills to drive increased vaccine demand, improve service delivery and optimise monitoring and evaluation of programmes.The Gavi Learning and Performance Management framework supported a structured reflection of programme strengths, limitations and opportunities. Strengths were the country-centric and learner-centric approach and the high technical quality of the programme. The pandemic context necessitated agility and adaptation to meet changing country needs and priorities, however, this introduced some limitations. Future training programmes should undertake an enhanced assessment of training needs, workforce and digital capabilities and learning and performance management systems, alongside the development of country-driven immunisation workforce training roadmaps to ensure optimal impact and sustainability.

Background: This study systematically analysed global and regional adherence to mask-wearing and its impact on the incidence and deaths of viral respiratory infectious diseases (VRIDs).

Methods: Relevant studies were sourced from PubMed, Web of Science, Embase and Scopus. We included observational studies with available raw data on mask-wearing adherence (rates of acceptability of mask-wearing, mask-wearing in public settings and correct mask-wearing) during VRID pandemics/epidemics. The COVID-19-related incidence and deaths were sourced from Global Burden of Diseases 2021. The quality of each study was assessed using the Agency for Healthcare Research and Quality Scale. Pooled rates and effects of mask-wearing were calculated using random effects models and generalised linear models.

Results: We included 448 studies from 70 countries/regions. During the VRID pandemics/epidemics, global pooled rates for the acceptability of mask-wearing, mask-wearing in public settings and correct mask-wearing were 65.27% (95% CI 60.34% to 70.05%), 74.67% (95% CI 69.17% to 79.8%) and 63.63% (95% CI 59.28% to 67.87%), respectively. In individuals with chronic diseases/elderly/pregnant women, the rates of acceptability (42.54%) and correct mask-wearing (60.56%) were both low. Among the general population, the rates of mask-wearing in public settings (68.2%) and correct mask-wearing (57.45%) were the lowest. During the COVID-19 pandemic, countries with a requirement for mask-wearing exhibited a higher rate in public settings (76.10% vs 58.32%), especially in regions with more stringent containment and health measures (β=0.86, p=0.008). The mask-wearing in public settings has been found to significantly reduce the COVID-19 incidence (β=-265.26, p=0.004), COVID-19 deaths (β=-2.04, p<0.001) and other COVID-19 pandemic-related deaths (β=-0.83, p<0.001).

Conclusion: During the VRID pandemics/epidemics, adherence to mask-wearing was relatively low. Implementing policies requiring mask-wearing during the pandemic could enhance the mask-wearing rate, potentially leading to a significant reduction in VRID-related incidence and deaths.

Trial registration number: CRD42024496464.

Background: The COVID-19 pandemic has revealed significant disparities in global vaccine accessibility, particularly affecting low and middle-income countries (LMICs). However, current research on COVID-19 vaccine accessibility primarily focuses on individual countries or high-income countries (HIC). We aimed to evaluate geographic accessibility to COVID-19 vaccination on a multicountry scale, covering comparisons across LMICs and HICs. Additionally, we explored the potential economic factors related to accessibility and their impacts on health outcomes.

Methods: We collected population data at a 1 km resolution and geocoded all vaccination sites across the selected countries/regions. Four measures were used to evaluate vaccine accessibility from different perspectives: population coverage with varying travel time thresholds, driving time to vaccination sites, the number of sites within a 30-min threshold and a geographic accessibility index using enhanced two-step floating catchment area method. Finally, we explored the relationships between geographic accessibility and several factors: gross domestic product per capita, vaccination uptake and mortality.

Findings: We found substantial disparities in vaccine accessibility across the selected countries/regions. In 24.07% of these countries/regions, over 95% of the population can access the nearest vaccination services within 15 min. In contrast, in countries/regions such as Manitoba (Canada), Zimbabwe and Bhutan, less than 30% of the population can reach these sites within 60 min. Underserved areas, termed 'vaccine deserts', were identified in both HICs and LMICs. We found that countries/regions with higher vaccine accessibility tend to achieve higher vaccination rates, whereas those with lower vaccine accessibility are likely to experience substantial increases in COVID-19 mortality rates.

Conclusion: LMICs require enhanced attention to improve geographic accessibility to vaccination. Additionally, there are internal disparities in accessibility within both HICs and LMICs. National public health officials and global health initiatives are suggested to prioritize 'vaccine deserts' and to ensure equitable vaccine access in future pandemics.

Introduction: There is emerging evidence that the social media industry contributes to adverse health outcomes by shaping the digital food environment for children and adolescents (aged 0-18). The aim of this scoping review was to determine the extent of research on how the social media industry, including the broader online landscape, influences the digital food environment and affects child and adolescent health.

Methods: A scoping review was conducted in the electronic databases of PubMed, Scopus and PsycINFO, along with forward and reverse citation searching for peer-reviewed articles published in English between 2000 and May 2023. A qualitative descriptive synthesis of the included articles was performed to identify trends, themes and research gaps in the current literature.

Results: The review identified 36 articles for inclusion. Most research was conducted in high-income countries and publications have increased since 2021. The review found most children and adolescents are exposed to food advertisements on social media and most advertised food is ultra-processed. Heightened by a lack of social media advertising awareness, digital food marketing influences children and youth's consumption and food behaviour. Voluntary children's food marketing regulations are ineffective for the online environment. Countering unhealthy food marketing will require media literacy and government regulation.

Conclusion: The social media industry may act as a commercial determinant of health to shape the digital food environment as an extension of the obesogenic environment. Further research should explore approaches to monitor unhealthy food marketing practices and understand social media's role in the digital food environment.

Despite seeing few cases during the 2022-2023 mpox global outbreak, reports in May-July 2024 of 22 cases among men-who-have-sex-with-men (MSM) in South Africa, including three deaths, have raised concerns about under-reported community transmission. We used a Monte Carlo simulation model to estimate the true epidemic size, considering the increased severity of mpox among MSM living with advanced HIV, documented over-representation of people living with HIV among mpox cases and HIV prevalence in South Africa. We estimate that there have been between 220 and 450 cases among MSM LHIV in South Africa, with a total of 290-560 cases among all MSM. We provide an upper bound of 750-1600 cases as a sensitivity analysis where the prevalence of HIV among mpox patients is the same as population prevalence among MSM in South Africa. Estimates in both scenarios suggest a substantial number of undetected cases, with case ascertainment rates estimated between 1% and 8%. Our findings underscore the need for enhanced surveillance, targeted public health interventions and awareness campaigns to mitigate the outbreak's impact at a population level.

Introduction: HIV prevalence disproportionately affects high-risk populations, particularly female sex workers in Africa. Women and girls engaging in transactional sex (WGTS) face similar health risks from unsafe practices, economic vulnerabilities and stigma. However, they are not recognised.

Methods: Using existing literature and data from the POWER randomised controlled trial, we developed a deterministic compartmental model to assess HIV dynamics among WGTS, their sugar daddies and low-risk populations. We evaluated the cost-effectiveness of a new structural intervention to prevent HIV among WGTS in urban Cameroon by reducing the financial need to engage in transactional sex in the case of illness and injury shocks to the household. The intervention provided free healthcare to WGTS and their economic dependents through a zero-cost health insurance package. We explored the cost-effectiveness of this intervention considering various population coverage levels (0%, 25%, 50%, 75% and 100%). We calculated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life-year (DALY) and HIV infections averted, employing both univariable and global sensitivity analyses. Probabilistic sensitivity analyses considered all parameters, including the insurance effect in reducing HIV, comparing simulated ICERs to willingness-to-pay thresholds. We also compared the health insurance strategy with expanding pre-exposure prophylaxis (PrEP) coverage. All costs were evaluated in 2023 UK pounds (£) using a 3% discount rate, with Cameroon's gross domestic product (GDP) per capita recorded at £1239.

Results: Implementing health insurance coverage levels of 25%, 50%, 75% and 100% yielded ICERs/DALY averted of £2795 (£2483-£2824), £2541 (£2370-£2592), £2263 (£2156-£2316) and £1952 (£1891-£1998), respectively, compared with 0% coverage. Probabilistic sensitivity analysis indicated an ICER=£2128/DALY averted at 100% coverage, with 58% of simulations showing ICERs

Conclusion: A comprehensive health insurance scheme for women in Cameroon could significantly reduce HIV infections and DALYs, promoting a more inclusive and targeted healthcare policy for women at high risk of HIV.

Introduction: In India, public sector patients purchase drugs from private pharmacies instead of obtaining them for free from public pharmacies-a phenomenon we call public patient forwarding to private pharmacies. This behaviour results in substantial financial hardship. We examine whether low public drug stocks, patient preferences for private drugs or the presence of private pharmacies nearby explain this behaviour.

Methods: We collected cross-sectional data from 7567 households, 523 health facilities and 1036 private pharmacies in Odisha, India. We linked 917 outpatient visits to facilities based on patient reports and linked public facilities to the nearest private pharmacy using Global Positioning System coordinates. We used ordinary least squares regression to assess whether the behaviour of facilities and patients was associated with drug stocks and pharmacy proximity, and whether patient satisfaction was associated with private drug purchases.

Results: Among public patients prescribed drugs, more than 70% purchased private drugs. In hospitals, for each 10% increase in drug stocks, 4.8% fewer patients purchased private drugs (p=0.047). In primary facilities, the same share of patients purchased private drugs across stock levels. Regardless of facility level, when more than 75% of drugs were in stock, 60% or more of patients still obtained drugs from the private sector. Patients were more likely to purchase private drugs when private pharmacies were near public facilities, but were not more satisfied with their visit when they obtained private drugs.

Conclusion: The results suggest that private pharmacies are both secondary and complementary suppliers of drugs for hospitals, but may act more like substitutes for primary facilities, consistent with evidence that private pharmacies provide advice and other services akin to primary care in Odisha. Improving public facility drug stocks alone is unlikely to fully address drug-driven financial hardship in India. Provider prescribing practices should be investigated to identify additional policy options.

Epidemic intelligence efforts aim to predict, timely detect and assess (re-)emerging pathogens, guide and evaluate infectious disease prevention or control. We emphasise the underused potential of integrating the monitoring of risks related to exposure, disease or death, particularly in settings where limited diagnostic capacity and access to healthcare hamper timely prevention/control measures. Monitoring One Health exposures, human behaviour, immunity, comorbidities, uptake of control measures or pathogen characteristics can complement facility-based surveillance in generating signals of imminent or ongoing outbreaks, and in targeting preventive/control interventions or epidemic preparedness to high-risk areas or subpopulations. Low-cost risk data sources include electronic medical records, existing household/patient/environmental surveys, Health and Demographic Surveillance Systems, medicine distribution and programmatic data. Public health authorities need to identify and prioritise risk data that effectively fill gaps in intelligence that facility-based surveillance can not timely or accurately answer, determine indicators to generate from the data, ensure data availability, regular analysis and dissemination.