BMJ Global Health最新文献

INTRODUCTION : International public health deployments are frequently used to support outbreak response, but there is limited evidence of their long-term impact on national response systems. This study assessed the extent to which deployments contribute to long-term, sustained impacts on the national outbreak response capacities of African Union Member States. METHODS : We used an exploratory sequential mixed-methods design for this study. We conducted 83 key informant interviews across ten countries, carried out two in-depth country case studies and administered an online survey among 304 stakeholders involved in international deployments from 28 African Union Member States. Qualitative data were analysed thematically. Adjusted ORs (aORs) and 95% CIs identified factors associated with perceived long-term, sustained impact of deployments using multivariable logistic regression. RESULTS: International deployments contributed to long-term impacts in national outbreak response across three domains: (1) strengthened systems and protocols; (2) continued use of infrastructure and equipment introduced during deployments and (3) enhanced confidence, knowledge and leadership among national stakeholders. Case studies further illustrated how adaptive, context-aware, collaborative deployments fostered national ownership and institutional memory. Deployments that were timely (aOR 4.4, CI 1.3 to 15.2), supported by deploying agencies (aOR 9.1, CI 2.1 to 39.9) and involved flexible and adaptive deployees (aOR 12.1, CI 1.9 to 77.1) were more likely to make substantial impact on national outbreak response. CONCLUSION : International deployments contribute to the sustained impact of outbreak response, particularly when they are country-led and align with local priorities. The findings suggest that international deployments should be viewed not only as emergency surge mechanisms, but also as strategic opportunities for contributing to longer-term impacts on national systems. Future deployment models should prioritise developing soft skills of deployees, ensure deployments are timely, context-appropriate and supported with additional resources to maximise their enduring value.

Introduction: Large socioeconomic disparities in healthcare utilisation and health outcomes have been well-documented in Latin American countries. However, little is known about disparities in mortality rates. We estimate socioeconomic gradients in mortality in the Latin American region and discuss their patterns.

Methods: We use death certificate data from the national vital statistics systems and population data from national censuses in Argentina, Brazil, Chile, Colombia, Ecuador, Mexico and Peru (2010-2023) to calculate mortality rates by age, sex and educational attainment. We also calculate mortality rates by cause of death. Data are harmonised to ensure comparability across countries and between death certificates and census data within countries. To analyse socioeconomic disparities, we compute the ratio between the mortality rate for individuals with a lower level of education (secondary incomplete or less) and the mortality rate for individuals with a higher level of education (secondary complete or more) by age and sex. The socioeconomic analysis is limited to adults aged 20 years or older.

Results: Mortality rates for individuals with lower education are generally higher at any age group than for individuals with higher education, with larger disparities observed in younger age groups. Differences across countries in these inequalities are also more pronounced in younger cohorts. Particularly, in the 20-29 age group, individuals with lower education show much greater dispersion in mortality rates across countries compared with those with higher education. Lower education is associated with higher mortality rates from violent causes, particularly before age 50. Among non-violent causes, mortality due to non-communicable diseases exhibits larger socioeconomic gradients than mortality due to communicable diseases in older age groups, while for younger age groups, it depends on sex and the specific age group. Among non-communicable causes, deaths from diabetes and cardiovascular diseases exhibit more socioeconomic inequality than those from neoplasms.

Conclusion: Despite overall improvements in average health indicators in the region, which are concomitant to a fall in income inequality and expansion of universal health coverage, significant challenges remain in addressing disparities in mortality rates, particularly for younger populations and women.

Introduction: The Women First (WF) Preconception Maternal Nutrition trial found greater benefits of small-quantity lipid-based nutrient supplements (SQ-LNS) for intrauterine growth among anaemic versus non-anaemic women at preconception. We investigated whether the benefits of SQ-LNS in improving markers of intrauterine growth occurred evenly across the mild to moderate spectrum of pre-pregnancy anaemia.

Methods: We analysed WF data (n=2443 maternal-newborn dyads) from Pakistan, India, Guatemala and the Democratic Republic of Congo. Women received SQ-LNS either ≥3 months preconception through pregnancy (Arm 1); starting in the late first trimester (Arm 2); or not at all (Arm 3: control), with all supplementations discontinued at delivery. The outcomes were infant weight, length and head circumference measured within 48 hours of birth, expressed as Z-scores. For each site, adjusted mean differences in the Z-scores were computed across six pre-pregnancy haemoglobin (Hb) categories (80-89, 90-99, 100-109, 110-119, 120-129, and ≥130 g/L) and pooled using meta-analysis.

Results: The effect of SQ-LNS on birth weight, length and head circumference varied by pre-pregnancy Hb categories. No significant differences in pooled mean Z-scores were observed for any Hb category >110 g/L, and no differences were found for Arm 1 vs Arm 2 across any Hb categories. For women with Hb 90-99 g/L pooled mean differences (95% CI) in the Z-scores for length (0.60 (0.03 to 1.23)), weight (0.50 (0.11 to 0.89)) and head circumference (0.26 (0.02 to 0.51)) were greatest for Arm 1 versus Arm 3. For women with Hb 100-109 g/L in Arm 1 versus Arm 3, pooled mean difference (95% CI) in birth weight Z-scores was significantly greater (0.33 (0.24 to 0.42)). Arm 2 vs Arm 3 women with Hb 90-99 g/L had greater birth weight Z-scores (0.14 (0.05 to 0.22)).

Conclusion: The findings highlight the importance of identifying women preconception for whom nutrition interventions may have the greatest impact on fetal growth.

Introduction: Disability is linked to poor health outcomes and increased mortality, yet evidence on this relationship in sub-Saharan Africa is limited. This study investigated the association between disability and all-cause and cause-specific mortality among older adults in Uganda.

Methods: The analysis was based on longitudinal data from the Wellbeing of Older People Study, an open cohort of individuals aged at least 50 years and followed over five data collection waves from 2009 to 2022. Disability was assessed using the WHO Disability Assessment Schedule 2.0. Mortality data were collected, supplemented by verbal autopsies. Gompertz regression models examined the association between disability severity and mortality, adjusting for sociodemographic, socioeconomic, health access and health risk factors.

Results: Among 938 participants followed up for a median of 8.0 years (interquartile range (IQR): 3.2-11.5), 153 deaths were recorded (mortality rate: 2.4 per 100 person-years). The age-sex-adjusted analyses showed that the hazard ratio (HR) was 3.88-fold higher (95% confidence interval (CI) 2.50 to 6.02; p value <0.001) among people with severe disability compared with none/mild disability. Adjusting for sociodemographic, economic, social support and health factors (health status, access and risk factors) somewhat attenuated the association (adjusted HR (aHR) 3.08, 95% CI 1.92 to 4.93; p value <0.001). This excess risk persisted across broadly categorised causes of death: HIV (aHR 8.96, 95% CI 2.52 to 31.83), communicable diseases excluding HIV (aHR 2.24, 95% CI 0.80 to 6.25), non-communicable diseases (aHR 2.29, 95% CI: 1.20 to 4.37) and indeterminate causes of death (aHR 6.89, 95% CI 1.63 to 29.1). Additionally, disability was associated with sociodemographic disadvantages, poor healthcare access and higher prevalence of health risk factors.

Conclusions: Severe disability was strongly associated with elevated mortality risk among older Ugandans, underscoring the need for targeted interventions to improve health equity. Reducing mortality disparities might require addressing barriers to healthcare access, stronger social support and integrating disability-inclusive policies in achieving global health targets, including Universal Health Coverage.

Background: Although 90% of youth live in low- and middle-income countries, only 10% of child mental health research is conducted in these settings. We sought to shed light on the mental health of Ghanaian children by estimating the prevalence of socioemotional difficulties and examining associations with psychosocial risk and protective factors.

Methods: Data come from the cross-sectional Mental Health in Ghana study. Mothers and fathers reported their depressive symptoms, positive mental health, parenting practices and sociodemographic and household characteristics. Mothers reported child (ages 6-60 months) characteristics, including mental health according to the Ages and Stages Questionnaire Social-Emotional (ASQ:SE-2) (administered for all children), Caregiver Reported Early Development Instruments (CREDI) (6-36 months old) and the Strength and Difficulties Questionnaire (SDQ) (37-60 months old). Receiver operating characteristic analysis was used to determine CREDI and SDQ cut-offs, with the ASQ;SE-2 as the gold standard. Multivariate linear regression analyses were used to examine associations with correlates.

Findings: Out of 750 households, 748 with data on child mental health were included in analyses. According to the CREDI and ASQ:SE-2, 35.9% (95% CI 31.4% to 40.4%) of 6-36 months old were at risk of experiencing socioemotional difficulties. Prevalence rates in 37-60 months old were slightly lower at 26.3% (95% CI 21.2% to 31.4%). The prevalence of socioemotional difficulties in the whole sample was 47.1% (95% CI 43.5% to 50.6%), with higher rates in male (51.6% (95% CI 46.5% to 56.7%)) compared with female (42.5% (95% CI 37.5% to 47.6%)) children. Maternal and paternal positive mental health and maternal use of positive disciplinary strategies were significantly associated with fewer socioemotional difficulties in female children. Only maternal positive mental health was a significant protective factor for male children's mental health.

Conclusion: A high burden of socioemotional difficulties exists among young Ghanaian children. Parental positive mental health is a key protective factor, highlighting the importance of considering the full spectrum of parental mental health and its associations with child mental health.

Introduction: Digital clinical decision support tools are increasingly used in primary-level health facilities to improve maternal and child healthcare. These tools guide health workers to input patient records digitally, providing a critical opportunity to strengthen routine health information systems with real-time data and improve quality of care. However, often, these service-level data are not always effectively integrated into existing data systems, reducing their downstream impact on data quality and data-driven decision-making. Our study evaluated the impact of a digital job aid tool (Registre Electronique de Consultations-Maternite, REC-Maternity tool), used by healthcare workers in rural primary healthcare facilities in Burkina Faso, on routine data quality at the district level.

Methods: First, we conducted an analysis comparing REC-Maternity data (n=79 895 visits) with District Health Information System 2 (DHIS2) data from 34 facilities to assess agreement in service delivery records. Next, in a quasi-experimental study design, we used DHIS2 data in Toma intervention and Gourcy comparison districts to conduct a difference-in-difference analysis with 13 months preintervention and postintervention time horizon. We assessed the impact of the intervention on three DHIS2 data quality outcomes: completeness, timeliness and internal consistency.

Results: The validation analysis revealed limited data agreement between REC-Maternity and DHIS2, particularly for postnatal care (ratio: 1.56) and family planning (ratio: 3.05). These discrepancies suggest parallel data flows from paper-based and electronic forms, indicating limited integration of the digital tool into routine reporting. The results also suggested the potential for digital records to help distinguish true zero-reporting from missing values in DHIS2. The difference-in-difference analysis indicated a significant decrease in timely reporting in the intervention district compared with the comparison district (-66.5% of facilities (95% CI -73.0% to -60.1%)).

Discussion: While digital tools offer a potential data revolution in resource-limited settings, they should not be presumed to be more efficient and replace paper-based data collection without continuous monitoring and quality improvement strategies.

Background: Foodborne diseases are an important cause of global morbidity and mortality, particularly among children who often experience diarrhoeal illnesses linked to foodborne enteric infections. Evidence on the effectiveness of interventions to reduce diarrhoea remains limited. This review synthesised evidence on the effectiveness of domestic food hygiene interventions on microbiological quality of child food and diarrhoea in children under five.

Methods and findings: Nine databases were searched, with screening and reviewing conducted independently by two reviewers. Eligible study designs included randomised and non-randomised controlled trials that clearly described a food hygiene intervention and included a concurrent control. Primary outcomes were the microbiological quality of child food and childhood diarrhoea. Risk of bias was assessed using an adapted Newcastle-Ottawa scale, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. Of the 15 586 records identified, 11 were included. Three of four studies that assessed food contamination outcomes reported evidence of reduction in Escherichia coli, faecal coliforms or other bacteria. Eight studies (10 comparisons) reported diarrhoea outcomes, with a pooled 24% reduction in diarrhoea prevalence or incidence (risk ratio, RR 0.76, 95% CI 0.57 to 1.01). Standalone food hygiene interventions (n=2) reduced childhood diarrhoea by 51% (RR 0.49, 95% CI 0.36 to 0.65), whereas combined food hygiene interventions with water, sanitation and hygiene (WASH), nutrition and childhood development (n=8) showed no evidence of an effect (RR 0.88, 95% CI 0.68 to 1.15). Three studies had high risk of bias. Certainty of evidence was moderate for food contamination outcomes and low for diarrhoea outcomes.

Conclusions: Results suggest that standalone domestic food hygiene interventions can improve microbial food quality and reduce childhood diarrhoea. However, these interventions were not effective when integrated into broader packages with WASH, nutrition or childhood development. These findings underscore the importance of dedicated food hygiene interventions for improving child health outcomes.

Prospero registration number: CRD42022336954.

Strengthening systems of emergency healthcare is crucial to achieving global and national health goals. One of the key challenges in improving emergency care systems is the insufficient attention given to human resources for health (HRH) tasked with delivering this care. The intersection of emergency care policy and systems, human resources and health equity is an underdeveloped area of research and practice. In this project, we used HRH frameworks to conduct an exploratory and comparative mapping of emergency healthcare workforce policy and systems in four countries-Canada, Australia, Rwanda and South Africa-and to explore its intersection with health equity. We conducted a mapping exercise drawing on published peer-reviewed and grey literature (n=209), supplemented by expert consultations (n=8) in Rwanda given limited published literature in that context. We analysed these data using conceptual frameworks on HRH, particularly one framework that focused on HRH and health equity. Our findings suggest persistent limitations in the translation of equity principles into actionable HRH strategies for emergency care across all four contexts. Governance fragmentation for emergency care workforces was common, with responsibilities for workforce training, distribution, regulation and retention split among multiple governmental and non-governmental actors, typically without any high-level oversight of equity-related outcomes. The comparative nature of this project facilitated an exploration of labour market interdependencies across the countries, such as the impact of burnout and attrition in fuelling international migration of emergency care workers. Further research, analysis and policy attention is needed to understand the intersection of emergency care, workforce policy and systems, and health equity, and that comparative research has an important role to play in surfacing key learnings at the national and global level.

This study uses Population-based HIV Impact Assessments survey data to examine factors associated with gender disparities in HIV outcomes. The analysis examined the share of adult males and females living with HIV who are aware of their status, are on treatment and have achieved viral load suppression across 13 African countries. The study then used the Blinder-Oaxaca statistical method to decompose these gaps into three core elements: (1) the part caused by observed differences in characteristics between the two groups, (2) the part caused by unobservable differences between the groups, often attributed to structural barriers and (3) the unexplained portion of the gap. The study then compares how these gaps and decompositions have changed over time. The model confirms that males have poorer outcomes than females across all three indicators. Factors contributing to these gender disparities include individual-level characteristics such as age, education and wealth, as well as structural barriers such as stigma, restrictive gender norms and lower health service utilisation among men. Although males generally possess more protective individual-level characteristics, these structural barriers offset their advantages, resulting in poorer outcomes across all indicators. The gap in service outcomes between men and women has decreased over time, with structural or cultural barriers showing the greatest improvement. Additional investment in and evaluation of male-friendly services is essential to understand what interventions have contributed to decreasing this gap. This knowledge should be used to inform future investments to support individual-level treatment outcomes and prevent new infections.

Introduction: There is consensus that global health needs a new power and incentive structure and academia must benefit society more directly. However, there are few metrics to help academic global health partnerships enact these changes.This study evaluates the impact of the Botswana - University of Pennsylvania Partnership (BUP) between July 2018 and June 2023, through the lenses of academic productivity, global health decolonisation and social accountability.

Methods: The data were organised based on BUP's five strategic goals. Alignment with Botswana's burden of disease was calculated through the ratio between the percentage of BUP's funding or activities devoted to 22 Sustainable Development Goals (SDGs) targets and the percentage of total disability-adjusted life years (DALYs) for the same targets.

Results: BUP employed 67 full-time personnel, hosted 263 international personnel and raised US$22.6 million.BUP supported service delivery in public facilities across multiple specialties and trained hundreds of local health workers and 81 local investigators.Research output was 28 publications/year, 30% featuring a local investigator as first/last author.80% of grant funding went to research. Funding and activities were distributed primarily to Gaborone (75% and 69%) and hospitals (60% and 57%). Funding and activities were less for other geographic areas (25% and 31%) and health system levels (40% and 43%).BUP's DALYs alignment was strong for 7/22 SDG targets (ratio ≥80%), intermediate for 7/22 (ratio 40-79%) and weak for 8/22 (ratio <40%). Non-communicable diseases other than cancer, essential health services and determinants of health had weak or intermediate alignment.

Conclusions: BUP had a significant impact in Botswana but also gaps in its portfolio and deliverables (including local first/last authorship and primary healthcare). The study's results can help tailor programming more consistent with local needs. This approach might inform evaluation of and strategic planning for other academic global health partnerships.