BMJ Global Health最新文献

Introduction: Self-sampling for cervical cancer screening is a promising strategy to improve coverage and reduce strain on health systems. First-void urine (FVU) has emerged as a non-invasive alternative to self-collected vaginal samples for detecting high-risk human papillomavirus (HPV). However, most supporting evidence is from colposcopy clinic settings and not from screening settings. This community-based study in Eastern India aimed to (1) assess agreement between HPV testing on FVU and vaginal samples, (2) compare their accuracy in detecting cervical intraepithelial neoplasia grade 2 (CIN2+) lesions and (3) evaluate feasibility and acceptability in a resource-limited setting.

Methods: At multiple rural clinics, 2500 women aged 30-60 years provided both FVU and self-collected vaginal samples. All samples were tested centrally using the Cobas4800 assay; discordant results were retested with the Allplex HR-HPV assay. HPV-positive women were referred for colposcopy and biopsy. Acceptability and preference were assessed through structured surveys with 1500 women and focus group discussions with health workers. These health workers counselled women at the clinics to provide both self-collected samples.

Results: All participants provided satisfactory samples, except for two FVU samples, which did not yield satisfactory test results on repeated analysis. Agreement between FVU and vaginal samples for HPV detection was 99.0% (κ=0.90), with high concordance for HPV 16/18 (κ=0.90). CIN2+ detection rates were 6.0 and 7.2 per 1000 women screened with FVU and vaginal samples, respectively (p=0.6), with no statistically significant difference in sensitivity. Among surveyed women, 98.1% preferred urine sampling. Health workers favoured both self-sampling methods over speculum-based clinician collection.

Conclusion: HPV testing using FVU demonstrates high agreement with vaginal self-sampling, comparable accuracy in detecting CIN2+ lesions and greater acceptability among women. This method is feasible and well-suited for cervical cancer screening in resource-limited settings.

Introduction: Humanitarian crises substantially impact the health of affected populations, and the scale of humanitarian need is at a historic high level. To more effectively support the growing number of people affected by humanitarian crises, the WHO, the Global Health Cluster and humanitarian partners undertook an initiative to define a core set of services to be delivered during a humanitarian response. This paper describes that process.

Methods: The methodology used in the development of a Package of High-Priority Health Services for Humanitarian Response (the H3 Package) was derived from an evidence-informed deliberative process and included the following steps: identifying operational assumptions, defining the burden of disease context, identifying services in relevant existing service packages, identifying priority-setting criteria, defining service delivery platforms, selecting services based on WHO's Universal Health Coverage Compendium of Health Interventions services and conducting an expert validation process.

Results: The final H3 Package is organised across six domains: foundations of care, sexual and reproductive health, violence and injury, rehabilitation and palliative care, communicable diseases, and non-communicable diseases and mental health. The full package is available online via the WHO Service Planning, Delivery and Implementation Platform. The H3 Package is intended as a reference to be contextualised, and steps for contextualisation are proposed.

Conclusion: The H3 Package sets a global standard for a core set of health services that humanitarian actors can reasonably be expected to deliver in humanitarian settings. This paper provides an overview of the H3 package, describes the methods used in its development and suggests steps for package contextualisation and implementation.

WHO's Global HEARTS is the largest worldwide effort to improve hypertension control through standardised care. HEARTS in the Americas is its regional adaptation. To address the rising burden of cardiovascular, kidney and metabolic conditions, the initiative launched HEARTS 2.0, aiming to promote integrated care, reduce fragmentation and improve quality, access and health outcomes. In phase I, an expert-led consensus identified 45 evidence-based interventions for inclusion in an expanded Clinical Pathway. This report presents findings from phase II on the readiness of 26 Latin American and Caribbean countries to implement these interventions. We used a cross-sectional design and a structured, self-administered questionnaire completed by national implementation teams. It systematically assessed the availability, feasibility, time required and key barriers for each proposed intervention. While many interventions, especially for risk assessment and non-pharmacological treatments, are considered feasible in many countries, their current availability is limited due to ongoing shortages of diagnostics, medicines and infrastructure. Over the next 3 years, 18 countries are projected to implement >30 of the 45 interventions, four countries aim to implement 20-30 and four expect to implement fewer than 20. While primary health systems in most HEARTS-implementing countries do not yet appear ready to deliver integrated cardiovascular, kidney and metabolic care, the scale-up of HEARTS 2.0 presents a strong opportunity to advance this integration. As health systems worldwide face the challenge of increasing multimorbidity in their patients and fragmented care delivery systems, this assessment offers a practical tool for planning and action.

Introduction: Healthcare delivery should be based on evidence-informed decisions in the clinical, public health, managerial and policy domains. Data are gathered at the point of care via routine health information systems (RHIS). The Paper-based Health Information Systems in Comprehensive Care (PHISICC) project shifted the paradigm from data collection to decision-making, especially decision-making at the point of care by the frontline health workers. We used a human-centred design (HCD) approach to re-design a RHIS that is responsive to the needs of frontline health workers.

Methods: The PHISICC research programme took place in Côte d'Ivoire, Mozambique and Nigeria and included the design and testing of a suite of paper-based RHIS tools. We report here the results of the HCD process. This was structured into three phases: (1) setup of co-creation group, (2) concept exploration and (3) detailed design phase.

Results: The concept exploration included a brainstorming session and produced 'quick paper mock-ups', such as ideas to follow-up patients' healthcare. The output of this 'concept workshop' was a design hypothesis of the health information system. A follow-up workshop identified the healthcare areas to prioritise. The first round of design developed a version of several tools. The second round consisted of user testing in the three countries. Several iterations were implemented, incorporating health workers' feedback. Tools were pilot-tested and then produced and distributed for use in a cluster randomised controlled trial.

Conclusion: The design phase of PHISICC combined HCD with clinical and public health domains. RHIS should be designed by qualified designers, content experts and users who focus on aiding decision-making of frontline health workers, applying a user-centred approach, from problem identification up to solution testing, multidisciplinarity, flexibility, teamwork and trust. We call for researchers, designers, healthcare providers, healthcare authorities and funding agencies to propose and pilot quality standards for the implementation and reporting of HCD in global health.

Introduction: Unsafe abortions contribute to 10% of preventable maternal deaths in Africa, with higher rates in humanitarian settings. In Uganda, home to 1.8 million refugees, women and girls face heightened vulnerabilities, increasing their risk of unsafe abortions. This study assessed the availability and readiness of health facilities serving Uganda's refugee settlements to provide postabortion care (PAC), identifying gaps and opportunities for improvement.

Methods: This cross-sectional study, conducted in March 2023 across all refugee settlements in Uganda, used the health facility survey to assess the availability and readiness to provide basic and comprehensive PAC services through structured interviews with staff of health facilities within and outside refugee settlements. Availability was defined as the provision of the signal function in the past 6 months, while readiness referred to the provision of the service and availability of equipment on the day of data collection.

Results: A total of 102 eligible health facilities provided PAC across all the 13 refugee settlements, with 91 (89.2%) located within the settlement borders. The majority of health centres (HCs) were primary-level (HC IIs: 41.2% and HC IIIs: 50.9%) facilities. Only eight (7.8%) were referral-level facilities (defined as HC IV and above). Basic PAC signal function availability and readiness was 73.5% and 51.0% for all facilities. Comprehensive PAC signal function availability and readiness was 75.0% and 37.5% among the eight referral-level facilities. Only three out of the 13 settlements had facilities offering comprehensive PAC within their borders.

Conclusion: While the availability of basic and comprehensive PAC signal functions was high in all facilities, overall readiness to provide these services was low, largely due to insufficient equipment and consumable commodities stockouts. Refugee women and girls from 10 out of 13 settlements have limited access to comprehensive PAC, both within the settlements and at nearby referral facilities.

Background: We investigated the prevalence, temporal trends and associated factors of overweight and obesity among adults in the WHO African region.

Methods: We analysed individual-level data from 54 nationally/sub-nationally representative STEPS surveys conducted between 2003 and 2022 among adults aged 18-69 years. Prevalence estimates were weighted and age-standardised. Time trends were estimated using a Bayesian spatiotemporal modelling approach. Factors associated with body mass index (BMI) categories were identified in hierarchical multinomial mixed-effects logistic regression with random effects for country and survey year, using the normo-weighted as the reference group.

Results: The study population included 198 901 adults (50.3% women) with a mean age of 36.3 years. The mean BMI was 23.3±2.0 kg/m² (24.23±1.60 in women and 22.11±1.53 in men, p for sex difference <0.001). The prevalence of overweight and obesity was 17.8% and 9.0%, respectively, higher in women (20.8% and 13.3%) than in men (14.9% and 4.6%). There was no significant time trend in mean BMI (23.25 kg/m² (95% CI 20.1 to 26.6) in 2003 and 23.43 kg/m² (95% CI 19.3 to 27.8) in 2022, p for trend=0.75). However, obesity prevalence increased from 15.39% to 16.71% (p for trend <0.001), and underweight from 12.07% to 12.76% (p for trend <0.001), whereas overweight plateaued. In multivariate analysis, sex, older age, higher education, physical inactivity and low fruit and vegetable consumption increased the odds of overweight and obesity, whereas past and current smoking showed inverse associations. Specifically, adjusted odds ratios for overweight and obesity for females versus males were 2·07 [(95% CI: 1·83- to 2·34]) and 4.92 [(95% CI: 4·13- to 5·89]); for tertiary education versus no education, they were 2·07 [(95% CI: 1·63- to 2·63]) and 3·77 [(95% CI: 2·77- to 5·11]), respectively.

Conclusion: These findings support the urgent need to intensify preventive programmes to fight obesity in the WHO African region.

Introduction: Globally, half of all 6.2 million deaths in children are caused by acute illnesses which can be prevented if diagnosed and treated in time. We hypothesise that long elapsed travel time and delay in care can be tackled using telemedicine. The objective of this study is to determine the acceptability of linking ambulances that transport acutely ill children to a remote paediatric emergency physician using a simple audiovisual device.

Methods: We conducted a qualitative study to determine the acceptability of ambulance-based teleconsultation for the emergency care of acutely ill children informed by the Theoretical Framework of Acceptability. We developed semistructured guides using this framework and conducted five interviews with telemedicine physicians (TMPs), 18 interviews with parents of children who recently needed an ambulance and four focused groups with emergency medical technicians (EMTs) who transport children.

Results: All participants were supportive of using the telemedicine consultation during ambulance transport in the proposed trial as they felt that having access to a video-based physician would offer prompt intervention, particularly for critically ill children in crowded cities and remote regions with scarce resources. Parents believed that ambulance-based telemedicine would enhance their trust in EMTs and reduce their stress. The concerns related to the intervention included parental reluctance in using video cameras due to privacy issues, doubts about doctors' treatment reliability, risk of miscommunication and inadequate parental education. To address these challenges, the groups proposed solutions such as joint training for EMTs and TMPs, educating parents about intervention processes, improving telecommunication infrastructure and promoting public awareness.

Conclusion: Parents, EMTs and TMPs mutually agreed that the use of telemedicine during ambulance transport can be successfully implemented through proper training and is acceptable in our population. All participants agreed that this intervention holds great potential to improve the survival of critically ill children.

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.