BMJ Global Health最新文献

Background: Suicide is one of the most common causes of death in correctional settings. This study aimed to analyse prison suicide prevention policies and procedures across Latin America.

Methods: For this multiple case study, we collected data on prison suicide prevention in policies (laws), programmes (institutional framework) and protocols (procedures) from 17 Latin American countries, from (1) the public domain and (2) archival records held by prison administrations. The search was conducted using Google, through hand search on prison administration websites and requests to public information departments and prison administrations. Theory-driven thematic analysis was conducted based on 11 key components of suicide prevention in prison. Presence and quality of policies, programmes and protocols were assessed using tailored instruments. Between-country comparisons were made by cross-case analysis.

Results: Data were retrieved from 17 Latin American jurisdictions. Nine cases had a policy or law, 6 had an institutional plan or programme and 13 had suicide prevention protocols. In 6 of the 17 cases (Argentina, Chile, Colombia, Ecuador, Mexico and Panama), the three elements were present. Among the 13 cases with protocols, 7 (Argentina, Brazil, Chile, Colombia, Mexico, Paraguay and Uruguay) had high, 2 had medium and 4 cases had low quantity and quality of key components. In the composite quality assessment of policies, programmes and protocols, three cases (Argentina, Colombia and Mexico) had high quality, four cases had medium quality and the other seven cases had low quality of suicide prevention in place.

Conclusion: Many Latin American countries still need to draft policies and develop institutional frameworks for suicide prevention in prison. Most countries may review their suicide prevention protocols in prisons to cover all key components with clear procedures. Prison administrations in Latin America should publish internal plans and protocols for prison suicide prevention to facilitate cross-country policy evaluations and research.

Study objective: Promoting healthy lifespan equity is a pivotal challenge in the global wave of population ageing, aiming to enable the majority of people in today's long-lived societies to reach a similar age in good health. This study aims to develop a systematic analytical framework to identify age-specific priority diseases and injuries for intervention, thereby comprehensively improving healthy lifespan equity measured by health-adjusted life expectancy (HALE, the average number of years a person can expect to live in full health).

Methods: First, we quantify the contribution of reducing the disease burden at each age to changes in overall HALE and healthy lifespan equity. Then, we decompose these contributions into portions attributable to mortality versus disability, ensuring no residual. Finally, we combine these weights with measures of the stability and relative importance of various causes to produce a list of priority causes for intervention across the entire life course.

Results: Globally, the age-specific leading causes where mortality prevention shall be a priority to achieve healthy lifespan equity are enlisted as follows: neonatal disorders (0 years), malaria (1-4 years), drowning (5-9 years), road injuries (10-24 years), HIV/AIDS (25-44 years) and ischaemic heart disease (45-84 years and over 85 years). The age-specific leading causes of disability in need of prioritisation regarding health lifespan equity are as follows: dietary iron deficiency (0-9 years), headache disorders (10-34 years), low back pain (35-69 years), age-related and other hearing loss (70-84 years) and Alzheimer's disease and other dementias (over 85 years). Notably, the specific ranking and relative importance of these causes varied substantially by region and sex, underscoring the need for context-specific strategies.

Discussion: Our comprehensive framework can inform policy-makers of whether resources need to be reallocated to meet the healthy lifespan equity challenges in an ageing era.

Background: Medical specialists are integral to the medical workforce and play a pivotal role in referral systems. However, in low-income and middle-income countries (LMICs), there is a perception that specialists often fail to align with local health needs, system capacities and Universal Health Coverage (UHC) objectives.

Methods: A systematic review was conducted in 2024 using a best-fit framework to assess the contributions of specialists to health systems and population health in LMICs. Searches covered eight databases and specialist journals, guided by an expert-validated 'a priori' framework for data extraction and analysis. We used the Johanna Briggs Institute critical appraisal tools to assess the quality of the evidence, and the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to report the findings. The study protocol was registered in the PROSPERO database (CRD42024572877).

Findings: We found and reviewed 89 studies, focusing on the stock of specialists in LMICs and highlighting a critical shortage of specialists, particularly surgeons, anaesthetists and psychiatrists. Evidence linked specialists' availability to improved health outcomes such as lives saved through expanded surgical capacity, though broader health system contributions were less clear. Specialists were reported to play key roles in referrals, hospital management, mentoring and research. Governance of their professions was found to be rather uneven across LMICs, with wide differences in specialty types, training curricula, accreditation systems and regulation of private-sector involvement. Reports frequently documented specialists' engagement with private health markets, revealing blurred boundaries between public and private care. A dynamic market for specialists was also observed, driven by a sustained global demand for their services. However, few policies were found addressing shortages and improving governance of specialties, with existing strategies focusing on task-shifting, clinical training and sharing responsibilities.

Conclusions: This review offers an evidence-based framework for understanding specialists' roles and health system engagement in LMICs. We discuss the need to reconsider specialists' deployment, prioritise alignment with UHC goals and enhance governance to optimise their contributions to health systems.

Introduction: We aimed to determine the association between paternal labour migration and the growth of the left-behind children in Dhanusha district, Nepal, where child stunting and international labour migration are highly prevalent.

Methods: We used growth data at birth, 6 months, 1 year and 2 years from a birth cohort study conducted 2012-2014, and growth data at age 6 years collected in 2018. We collected household migration history data to determine the children's exposure to paternal migration. The primary outcome was child length/height-for-age z-score (HAZ). Children's body circumferences, skinfold thicknesses, body composition, tibia length and grip strength were secondary outcomes measured at 6 years. We tested (i) the overall association between paternal international migration and the growth of the left-behind child; the roles of (ii) the duration of migration (≤12 mvs >12 m) and (iii) child age (≤6 mvs 12-72 m) as moderating factors; (iv) the association between receipt of remittances from the migrant father and child growth outcomes; and (v) stratified the main analyses by child gender. We fitted mixed-effects linear regression models for longitudinal data and linear regression models for cross-sectional data, adjusted for potential confounders.

Results: Analysing across all time points, daughters of labour migrants had lower HAZ than daughters of non-migrants (-0.13, 95% CI -0.24 to -0.03), but no overall association was found in boys. The negative associations were largest at <6 m (girls: -0.23, 95% CI -0.41 to -0.05), but in boys only if the father had recently (≤12 m) migrated (-0.26, 95% CI -0.51 to 0.00). Children of migrants showed a tendency towards smaller body sizes compared with children of non-migrants. We found no association between remittances and any measure of child growth.

Conclusions: Interventions should target support for pregnant women and mothers with young infants to provide gender-equitable childcare, especially if their husband just left for work overseas.

Persistent high maternal and neonatal mortality rates in low- and middle-income countries (LMICs) call for system-level improvements in healthcare services. However, implementing such health system strengthening interventions presents challenges due to the complex, context-specific interactions inherent in these settings.This paper presents implementation pathways of a service delivery redesign (SDR) model in Kakamega County, Kenya, offering insights into how complex health systems strengthening interventions can improve maternal and neonatal health (MNH) outcomes at scale in an LMIC setting. Drawing on a theory-of-change approach, key factors influencing the supply and demand of MNH services were identified and organised into a conceptual framework. Causal relationships were mapped through a participatory group model-building workshop into causal loop diagrams, and strategies were proposed to address barriers and facilitators to the SDR implementation process.Several critical factors were identified along causal pathways as essential to implementation success. At the community level, building trust for expectant mothers in the health system reinforces use of quality services. Across facilities, having a well-functioning and efficient referral system ensures timely, coordinated multilevel care that improves patient outcomes. Between the facility and policy level, a delicate balance between meeting increased demand for services with available resources and available resources with supportive financial policies needs to be maintained. Across these system functions, trust emerges as a key factor initiating and reinforcing positive patterns. Prioritising efforts that encourage co-creation, ongoing coordination and engagement among relevant actors to build trust bolsters individual strategies (to increase demand, improve referral, build service readiness) and is key to improving MNH outcomes.

Background: The global surge in ultra-processed food (UPF) consumption is a major public health challenge, particularly among adolescents. UPFs, characterised by high energy density, added sugars, fats and sodium, and low essential nutrients, are linked to poor diet quality and heightened risks of obesity, diabetes and all-cause mortality. Despite growing concerns, there is limited evidence on school-based interventions targeting UPF reduction in low- and middle-income countries (LMICs) like India.

Methods: A cluster-randomised controlled trial was conducted across 12 public schools in Chandigarh, India, targeting Grade 8 adolescents and their parents. The intervention was structured around the PRECEDE-PROCEED (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) Model and comprised 11 sessions for adolescents delivered over 6 months. Additionally, a single educational session was conducted for parents to enhance their awareness of reducing UPF consumption and encouraging healthier dietary behaviours. Dietary intake data were collected at baseline and endline using two non-consecutive 24-hour dietary recalls. Foods were categorised into four groups based on the extent and purpose of industrial processing using NOVA food classification. Energy levels were estimated using Prospective Urban Rural Epidemiology (PURE) study data. The intervention's effectiveness was evaluated using a difference-in-difference (DiD) analytical approach.

Findings: The intervention significantly reduced UPF energy intake among adolescents by 1062 Kcal/day (95% CI -2100 to -67) and processed food by 274 Kcal/day (95% CI -526 to -23). However, no significant changes were observed in minimally processed food consumption. Among parents, the intervention had no significant impact on energy intake for any of the NOVA classified food categories. Process evaluation highlighted high participant engagement and feasibility of the intervention in school settings.

Conclusion: This study demonstrates the potential of school-based behavioural interventions to reduce UPF consumption among Indian adolescents, addressing a critical gap in public health research and practice in LMICs.

Trial registration number: CTRI/2019/09/021452.

Introduction: Many neonatal deaths are avoidable using existing low-cost evidence-based interventions. This study evaluated the effectiveness and cost-effectiveness of Neotree, a digital quality improvement tool combining data capture with education and clinical decision support, implemented in a Zimbabwean hospital.

Methods: Neotree was implemented in Chinhoyi Provincial Hospital (CPH) in December 2020. Using data collected for all neonates admitted to CPH from March 2020 to October 2023, a single group interrupted time series analysis was conducted to estimate the impact of Neotree implementation. Subgroup analyses explored the impact in low birth weight (1.5-2.5 kg) neonates, a key group targeted by the intervention.Activity-based costing and expenditure approaches estimated costs of developing and implementing Neotree in CPH from a provider perspective. Both total within-study costs and total costs at scale were estimated and used to derive cost per life saved, cost per life year saved and cost per healthy life year (HLY) gained.

Results: Analysis suggests reduced overall mortality in the post-implementation period, though this difference was not statistically significant (RR: 0.877, 95% CI 0.541 to 1.423, p=0.596). This was primarily driven by reduced mortality among the low birth weight subgroup (RR: 0.356, 95% CI 0.127 to 1.002, p=0.051). Cost-effectiveness analysis based on an assumed mortality impact in this subgroup suggests a within-study cost of around $28.44 per HLY gained, reducing to $6.35 per HLY gained at scale, substantially below the range of potential cost-effectiveness thresholds considered for Zimbabwe (US $17- US $855).

Conclusion: Neotree is a potentially low-cost and highly cost-effective digital quality improvement tool to improve newborn care, morbidity and survival, while also providing quality data. This study contributes to limited economic evidence of mHealth tools in low-income and middle-income settings.

High neonatal mortality remains a major health problem in Guinea (32 deaths /1,000 live births). This represents 15 000 deaths annually, without improvement over the past decade. We evaluated the impact of 2 days of neonatal resuscitation training of health professionals working in the disadvantaged outskirts of Conakry. Non-randomised interventional study with pre-and post-interventional analysis of the very early neonatal mortality with data collection over two 6-month periods, one before and one after intervention. Intervention: Theoretical and practical training given to health professionals working in private obstetric centres within a defined area. After training, all centres were equipped with basic resuscitation devices. We concentrated on the private sector, dominated by informal facilities scarcely equipped and run by often poorly trained paramedical staff. Outcome measures were very early neonatal mortality (6 hours) and the need for referral to higher equipped structures. Theoretical knowledge was assessed by a questionnaire, pre-training, post-training and 6 months later. 27 nurses, midwives and doctors participated, working in 13 health facilities. They performed 589 deliveries during the two periods analysed. The 6-hour neonatal mortality rate decreased (31.8‰ to 5.7‰, p=0.031), need for neonatal transfer dropped from 27.3% to 11.3% (p=0,19), whereas the stillbirth rate remained high and unchanged. There was a sustained improvement in theoretical knowledge (mean of correct answers: 59.3% before, 82.0% after training, (p<0.001) and 85.9% 6 months later). A 2-day training course for health workers in private facilities and provision of basic neonatal resuscitation equipment significantly improved neonatal outcome.

Objectives: This paper examines the differential impact of responsive parenting and nutrition interventions on early child development in stunted versus never-stunted children at 24 months of age in rural India.

Methods: We conducted a secondary analysis of data from Stepping Stones-a cluster randomised controlled trial involving 21 subcentres/clusters allocated to intervention or control group. The intervention comprised home visits, group sessions and community workshops, focusing on responsive parenting and nutrition. Developmental outcomes, cognitive, motor, language and socio-emotional, were assessed at 24 months using validated tools. A mixed-effects regression model with an interaction term was used to estimate effect sizes for stunted and never-stunted children.

Results: Among 588 children analysed, 35.9% were stunted at 24 months, and 35 (5.95%) of them exhibited 'early-onset persistent stunting'. The intervention improved cognitive (β=0.22), motor (β=0.23), language (β=0.17) and socio-emotional development (β=0.23) in never-stunted children compared with those who have not received intervention. For stunted children who have not received the intervention, a development score was lower for all development domains compared with never-stunted children, but not statistically significant (p>0.05). Although the effects differed between stunted and never-stunted children, the interaction effects between intervention and stunting were not statistically significant across all domains (p>0.05), indicating that the intervention's benefits did not significantly differ by stunting status.

Conclusion: Integrated parenting and nutrition interventions improved developmental outcomes across all domains, regardless of the child's stunting status. These findings support universal application of such programmes, highlighting the need to integrate them into existing child development and nutrition programmes.