BMJ Global Health最新文献

Background: Obstetric haemorrhage is a leading global cause of maternal mortality, particularly in rural and resource-poor settings where delays in care are common. Non-pneumatic antishock garments (NASGs) have been proposed as a temporising measure to reduce blood loss and improve survival rates. Despite positive outcomes from clinical trials, the uptake of the NASG has been slow and faced various implementation challenges. This review thus aims to identify and analyse the barriers and facilitators of NASG implementation in low- and middle-income countries (LMICs) using the Consolidated Framework for Implementation Research (CFIR).

Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search strategy was developed to search for studies related to NASG use in Medline, Embase, CINAHL and the Cochrane Library from inception up to August 2024. Grey literature was also reviewed. Two independent reviewers screened identified records using Covidence, assessing relevant studies for inclusion. Data were synthesised using a narrative approach structured around the CFIR's five domains.

Results: A total of 17 studies were reviewed. Common barriers included high initial procurement costs. Inadequate training and knowledge among healthcare providers were another obstacle, resulting in low confidence in the proper use of NASG. Logistical issues, such as inconsistent supply chains and difficulties in maintaining NASG devices, were highlighted, alongside the challenges posed by under-resourced health infrastructures. Facilitators included effective training programmes, support from health authorities, advocacy by local and national champions, and successful integration into clinical protocols and health systems.

Conclusions: The implementation experience of NASG in LMICs highlights important lessons for stakeholders in the global health space, with challenges such as high initial costs and inadequate training being common obstacles in LMICs. Addressing these barriers and leveraging facilitators (eg, through comprehensive training, garnering local and international support and active sourcing for locally produced materials to reduce costs) across multilevel contexts influence implementation.

Investigating acute respiratory illnesses (ARIs) is difficult due to non-specific symptoms, varied health-seeking behaviors, and resource limitations; yet early detection is critical to global health security. Kenya's Ministry of Health (MOH) uses the Integrated Disease Surveillance strategy for public health surveillance, incorporating event-based surveillance (EBS) and indicator-based surveillance (IBS) for early warning system. MOH, supported by the US-CDC, established Influenza Sentinel Surveillance (ISS) in 2006 and later launched community EBS (CEBS) and health facility EBS (HEBS) pilots to enhance surveillance for COVID-19. On March 2, 2021, the CEBS system detected a signal of "Two or more people presenting with similar signs and symptoms in a community within a week" in a county. Investigations launched on March 4, 2021, investigations revealed unreported ARI cases which had been missed by both the ISS and IBS. A total of 176 ARI cases were line-listed with 91/176 (51.7%) aged <5-years and 46/176 (26.1%) hospitalized. RT-PCR tests confirmed 34/79 (43.0%) SARS-CoV-2 and 1/7 (14.3%) A/H3N2 cases. Of the CEBS, HEBS, IBS, and ISS systems deployed by the county to strengthen the early warning for respiratory diseases, CEBS detected a signal of unreported ARIs that facilitated further investigations and response.

Achieving global targets to end the HIV/AIDS epidemic as a public health threat by 2030 and beyond requires enhanced health system capacity for HIV prevention at national and subnational levels. Specifically, this system's capacity must enable countries to reach high-risk populations effectively, systematically engage communities to generate demand for HIV prevention services, build diverse delivery channels to meet this demand and address structural barriers that undermine prevention programmes. Integrating these capacities at the local level is especially critical to creating sustainable uptake and impact of emerging highly efficacious prevention options, such as long-acting injectable pre-exposure prophylaxis. Decentralised, locally led approaches that reflect the local context-yet are linked to national systems and policies-are needed to embed these capacities and strengthen the ability of local governments to coordinate and implement HIV prevention. Within this framework, the Government of Malawi is developing a district-based approach to enhance local institutional capacity for more effective and sustainable HIV prevention, starting in Blantyre-a large urban district noted for its high HIV incidence. This article provides the conceptual basis for, and early implementation experience of, the Blantyre Prevention Strategy (BPS), a health systems-based approach to HIV prevention that directs investments towards embedding essential functions within Blantyre City and District. The approach includes developing district-led systems and capabilities in effective disease surveillance and data-driven targeting, demand generation, quality service delivery and promoting the sustained use of HIV prevention interventions. Early learnings from BPS offer lessons for other low- and middle-income countries seeking to implement HIV prevention strategies that bolster their health system capacity and integrate with broader health responses.

Introduction: Unsafe water, sanitation and hygiene (WASH) causes millions of deaths and disability-adjusted life-years annually. Despite global progress towards universal WASH, much of WASH programming continues to fail to improve health outcomes or be sustainable in the longer term, consistently falling short of internal performance indicators and sometimes negatively impacting the well-being of local stakeholders. Although sector experts in high-income countries have often provided explanations for such failures, the opinions of those implementing WASH programming at the ground level are rarely published.

Methods: In 2020, we purposively recruited 108 front-line WASH professionals in Malawi, South Africa, Tanzania and Zimbabwe to participate in 96 in-depth interviews, explaining why they believe WASH failure persists. Through participatory analysis, including framework analysis with additional axial coding and member-checking of our findings, we determined the core reasons for WASH failure as perceived by participants.

Results: Interviewees reported poor engagement and commitment of intended users, unrealistic and idealistic expectations held by funders and implementers, and a general lack of workforce and financial capacity as significant contributors to WASH failure. Our analysis shows that these issues stem from WASH programming being implemented as time and budget-constrained projects. This projectisation has led to reduced accountability of funders and implementers to intended users and a focus on measuring inputs and outputs rather than outcomes and impacts. It has also placed high expectations on intended users to sustain WASH services and behaviour change after projects officially end.

Conclusions: Our findings imply that WASH programming needs to move away from projectisation towards long-term investments with associated accountability to local governments and longitudinal measurements of WASH access, as well as realistic considerations of the needs, abilities and priorities of intended users. Funders need to reconsider the status quo and how adjusting their systems could support sustainable WASH services.

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.