BMJ Global Health最新文献

Background: Migrants in Europe often face barriers to healthcare, contributing to poorer health outcomes. While healthcare utilisation has been studied within Beveridge systems (eg, the UK) and Bismarck systems (eg, Germany), less is known about healthcare use by migrants within the Netherlands' hybrid model. The Dutch model combines a Bismarckian base with Beveridge-like supplements. We investigated the use of general practitioner (GP) services, specialist care, allied health services and complementary medicine among major migrant groups in Amsterdam (South Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin) compared with the Dutch-origin population.

Methods: We used pre-pandemic Healthy Life in an Urban Setting data (2015; n=21 614) to avoid biases from intra-COVID-19 and post-COVID-19 healthcare disruptions/alterations. Structured questionnaires assessed healthcare use and reasons for seeking care. Poisson regression with a log link and robust (sandwich) standard errors examined associations between migration background and healthcare utilisation, adjusting for demographics, acculturation, health literacy, lifestyle and chronic conditions. Sensitivity analyses explored motivations for care use and overall health status.

Results: All migrant groups reported higher or similar use of GP services compared with the Dutch-origin population. Most migrant groups (except Ghanaians) also reported higher or similar use of specialist and allied health services. Conversely, use of complementary medicine was higher among Dutch-origin participants than among migrants.

Conclusion: Many migrant groups in Amsterdam show higher use of mainstream healthcare services compared with previous reports from other European settings. Further studies should examine and dissect these patterns to inform improvements in other European settings.

Background: Approximately 70% of deaths in Tanzania occur outside health facilities and are often unreported or lack cause of death (COD) information. Consequently, health planning relies on data representing only 10%-15% of the population. To address this gap, Tanzania integrated verbal autopsy (VA) into its civil registration and vital statistics (CRVS) to generate more comprehensive COD data for mortality reporting. This manuscript shares Tanzania's VA implementation experience from 2017 to 2020, focusing on its integration into the CRVS system, and assesses its capacity to generate accurate and representative mortality data to guide health policies and planning.

Methods: VA implementation followed a phased approach: (1) a pilot and pretest phase covering 10 wards (urban-to-rural ratio 1:3) and achieving 38.3% data completeness, (2) a demonstration phase covering 106 wards (urban-to-rural ratio 1:3), with data completeness at 22.7% and (3) a national scale-up phase, which is currently underway. Data were collected using a standardised WHO VA questionnaire administered via tablets. CODs were determined using physician- and computer-coded methods.

Results: The concordance (R-squared) between physician-coded and computer-coded VA (PCVA and CCVA) for cause specific-mortality fraction was 0.83 for InsilicoVA, 0.70 for InterVA5 and 0.47 for Tariff. Communicable diseases accounted for 45.6% of deaths, with a higher burden in rural areas, whereas non-communicable diseases (40.2%) were more prevalent in urban areas. The leading CODs were HIV/AIDS, cardiac diseases, malaria, tuberculosis and diabetes.

Conclusions: VA plays a pivotal role in generating comprehensive mortality statistics, particularly in low-resource settings. Its integration into CRVS systems with support from CCVA provides a scalable and sustainable solution to address critical data gaps and improve public health interventions, thus better enabling evidence-based health policies and planning in Tanzania.

Reliance on purely face-to-face in-service training for primary healthcare workers in low- and middle-income countries is increasingly unsustainable. The COVID-19 pandemic accelerated the transition of the University of Cape Town Knowledge Translation Unit's Practical Approach to Care Kit programme from a facility-based cascade model to online and blended learning formats.This paper analyses the implementation of this transition across 29 courses between 2020 and 2023 in South Africa. Using the Health System Process Goals framework, we reflect on the challenges and enablers of e-learning, shifting the focus from digital training as a standalone technical solution to a systemic enabler of health system strengthening.While e-learning expanded access and standardised content, successful implementation relied on addressing systemic barriers. Key learnings include the necessity of subsidised ('reverse-billed') data to ensure equitable access; the superiority of a 'blended' pedagogical model that combines digital content with peer interaction and in-person technical support and the value of automated reporting for workforce management. The systemic barriers included the lack of protected time for learners, which risks placing an inequitable burden on the workforce and reliance on donor funding, challenging long-term institutionalisation.For e-learning to effectively strengthen the health system, it must be integrated into administrative workflows and budget lines. We provide actionable recommendations for Ministries of Health, funders and implementers, advocating for a transition to government-owned platforms, accredited blended learning models and policy that mandates protected time for capacity development.

Introduction: A disproportionate share of global neonatal deaths occurs in armed-conflict settings, where progress in reducing neonatal mortality remains slow. This systematic review aims to synthesise the literature on implementing essential newborn care (ENC) interventions in high-intensity armed conflict settings.

Methods: We searched PubMed, CINAHL, Embase and the grey literature from January 2014 to March 2024. Eligible original studies in English implemented at least one component of ENC in settings experiencing high-intensity armed conflict. Data were extracted on study characteristics, ENC implementation and outcomes. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) for quantitative studies and GRADE-Confidence in the Evidence from Reviews of Qualitative Research for qualitative and mixed-method studies.

Results: 32 studies were included, primarily from hospital settings (n=15, 47%) in Pakistan (n=6, 19%) and South Sudan (n=5, 16%). Interventions focused on health workforce (n=19, 59%) and service delivery (n=8, 25%), predominantly through community health worker training (n=27, 84%). Positive effects were observed for ENC coverage (8/10 studies) and health outcomes (7/12 studies), particularly for interventions promoting breastfeeding, skin-to-skin contact, chlorhexidine applications to the umbilical cord and quality improvement approaches. Neonatal resuscitation training showed variable effects. Key facilitators included local healthcare workers providing emergency supervision and the use of audio-visual or mobile technologies, while barriers included insecurity, conflict-imposed movement restrictions, violence against health facilities and workers, the inability of supervisors to access facilities and the community, population displacement and degradation of ENC quality.

Conclusion: Implementation of ENC interventions, particularly breastfeeding promotion, Kangaroo Mother Care and cord care, that do not depend on functional health facilities can improve coverage and neonatal health outcomes in high-intensity armed conflicts, but requires adaptations to context-specific challenges. Strategies to strengthen the health workforce, leverage community health workers and integrate technology may enhance the delivery of lifesaving newborn care amidst armed conflict. Our review was limited by a lack of grey and non-English literature and studies on caring for small and/or sick newborns, implementation of comprehensive care packages and effectiveness evaluations. Further research is needed on comprehensive ENC packages and innovative approaches to overcome systemic barriers.

Prospero registration number: CRD42023388617.

Almost no evidence exists on effectively delivering school violence prevention interventions at scale. The Good School Toolkit (GST), developed by Uganda-based non-governmental organisation (NGO) Raising Voices, is an effective whole-school violence prevention intervention when delivered by NGO staff. This study aimed to determine whether GST, delivered via a scalable delivery model using Regional Resource Persons (RRPs), is effective in changing teachers' attitudes towards violence and improving perceptions of school operational culture.A pre-post study was conducted in 95 schools across Uganda, randomly selected from 1000 schools implementing GST via RRPs. All schools had the opportunity to implement GST. Teachers participated in cross-sectional baseline (February-April 2022) and endline (September-October 2023) surveys. Primary outcomes were acceptance of physical discipline and markers of school operational culture. We fitted mixed-effects linear regression models to examine changes in outcomes over time and influence of GST exposure.Analyses showed that each unit increase in GST exposure was associated with an increase of 0.59 (95% CI 0.49 to 0.69, p<0.001) in teachers' perception of school operational culture, and 0.12 (95% CI 0.09 to 0.14, p<0.001) in perceptions of staff and student involvement in school operations. Although mean acceptance of physical discipline increased over time (β=0.51, 95% CI 0.27 to 0.76, p<0.001)-likely attributable to changes in schools post-COVID-19-each unit increase in GST exposure corresponded to an attenuation in acceptance by 0.06 (95% CI -0.12 to 0.00, p=0.046). Teachers reporting higher exposure to GST were also less likely to report using past year physical violence (OR=0.92, 95% CI 0.89 to 0.96, p<0.001).This study is the first in the Global South to evaluate a new delivery model for implementing an evidence-based violence prevention intervention at scale. GST delivered via RRPs mitigated an increased acceptance of physical discipline and was associated with improvements in school operational culture and reduced teacher physical violence, highlighting the promise of the RRP delivery model for implementing GST.

Introduction: Since July 2019, the WHO has recommended dolutegravir (DTG)-based regimens as preferred first-line antiretroviral therapy (ART) for adults and adolescents living with HIV (DTG-for-All), a reversal of a 2018 safety alert on use of DTG-based regimens by women of reproductive age (WRA). We examined sex and age disparities in DTG uptake before and after DTG-for-All in the International epidemiology Databases to Evaluate AIDS.

Methods: We included patients ≥16 years on or initiating treatment between January 2017 and July 2021 in 14 low- and middle-income countries where initial guidelines on DTG-based regimens for first-line ART either restricted use by WRA or had no such restrictions. We estimated the cumulative incidence of DTG uptake (CI-DTG) by sex and age group (aged 16-49 years vs 50+ years), stratified by patient, clinic and setting characteristics.

Results: Among 177 706 patients on ART during the study period, 51% were females aged 16-49 years, with 25% males aged 16-49 and 13% and 11%, respectively, females and males aged 50+. At the time of DTG-for-All, overall CI-DTG was 29.6% (95% CI 29.4% to 29.8%); it was lower among females aged 16-49 (16.2%; 95% CI 16.0% to 16.5%) than males (41.1%; 95% CI 40.6% to 41.5%), with no sex disparities among patients aged 50+ (females: 46.0%; males: 47.0%). While DTG uptake subsequently increased among all groups, by July 2021, it remained substantially lower among females 16-49 (66.4%; 95% CI 66.1% to 66.7%), compared with males 16-49 and older females and males (75.8% to 77.5%). Concentrated in countries where initial guidelines on DTG restricted use by WRA, disparities in DTG uptake persisted at all health system levels and in both low-income and lower-middle-income countries.

Conclusions: While sex-age differentials in DTG uptake narrowed after WHO's DTG-for-All recommendation, lingering disparities in uptake underscore the difficulty of policy de-implementation when new evidence emerges.

Introduction: The economically emerging countries contributed to over half of the global cervical cancer (CC) burden and are good examples showing how rapid economic growth and health policy change affect the trends of CC burden. This study aimed to analyse the time trends of CC burden across Brazil, Russia, India, China and South Africa (BRICS) and associations with age, period and birth cohort from 1992 to 2021.

Methods: Data on CC incident cases, deaths, age-standardised incidence rates (ASIRs) and age-standardised mortality rates (ASMRs) were sourced from the Global Burden of Disease Study 2021 to demonstrate the temporal trends of CC burden for BRICS countries from 1992 to 2021. An age-period-cohort model was used to determine the net drift, local drift, longitudinal age curves, as well as period and cohort relative risks regarding CC incidence and mortality.

Results: Between 1992 and 2021, the ASIR of CC decreased from 16.5 to 15.6 per 100 000 women (-5.5%) and the ASMR declined from 10.1 to 6.7 per 100 000 women (-33.7%) in BRICS. Brazil reported continuous decreases in both CC incidence (net drift: -1.1%, 95% CI -1.1% to -1.0%) and mortality (net drift: -1.7%, 95% CI -1.80% to -1.6%). India also had reduced CC incidence and mortality but experienced worsening period effects from 2012 onwards. Russia and China experienced decreasing trends in mortality yet increasing trends in incidence, and there were apparent unfavourable trends among young and middle-aged women in Russia. South Africa maintained the highest CC incidence (40.0 per 100 000 women, 95% CI 35.0 to 45.6) and mortality (21.3 per 100 000 women, 95% CI 18.8 to 24.1) across the BRICS and had the steepest growth of CC incidence and mortality rates with increasing age.

Conclusion: Despite an overall decreasing trend of CC burden in BRICS, substantial heterogeneity exists across nations. Identifying country-specific priority groups and tailoring interventions is essential, and the patterns observed have implications for public health strategies applicable not just to BRICS nations but also to many other emerging economies facing substantial CC burden.

Introduction: Few studies have explored the extent to which mother-newborn dyads have access to high-quality postnatal care (PNC) in low-income and middle-income countries. This study aims to measure effective (quality-adjusted) PNC coverage for newborns both before discharge and after discharge from the delivery facility, and for mothers before discharge, and to examine factors influencing access to high-quality PNC.

Methods: We conducted an explanatory sequential mixed-method study in Kakamega County (Kenya) between January 2022 and November 2023. We collected quantitative data immediately after birth up to 60 days post partum and conducted in-depth interviews with mothers within the 60 days post partum. We present descriptive statistics of the effective PNC coverage cascade before and after discharge, with data analysed using multivariable logistic regression. Qualitative evidence was synthesised using thematic analysis.

Results: Out of 611 births, 134 (22%) mothers and 468 (77%) newborns received effective PNC immediately after birth, respectively. By contrast, following discharge, only 171 (28%) newborns received effective PNC. Health systems factors, including antenatal care quality (OR 3.24, 95% CI 1.03 to 10.26), whether mothers received complete counselling (OR 2.20, 95% CI 1.29 to 3.76), and whether newborns received check-ups and immunisations before discharge (OR 2.21, 95% CI 1.01 to 4.79) were associated with effective PNC for newborns after discharge. Qualitative evidence from 36 interviews identified three main themes: quality of care for mother-newborn dyads before and after discharge; individual and interpersonal barriers and facilitators (including mothers' perceptions of PNC, poverty and financial constraints, and information from social networks); and health systems-level barriers and facilitators (including communication and information on PNC, community outreach after delivery, and experience with quality healthcare influencing PNC use).

Conclusions: PNC remains a weak point in the maternal newborn continuum of care, with low uptake and suboptimal quality. Efforts to enhance effective PNC, such as providing comprehensive counselling before discharge, are required across all levels of care.

Introduction: Training health workers is a common implementation strategy to expand evidence-based interventions. Digital training is a promising way of reaching more health workers, minimising clinical interruptions and lowering costs, but clinical outcomes are rarely evaluated in low-income settings. Clinical outcomes were evaluated in Malawi's HIV index case testing programme through the Package of Resources for Assisted Contact Tracing: Implementation, Costs, and Effectiveness study.

Methods: An unblinded cluster randomised controlled trial was conducted in 33 health facilities in two Malawian districts (2022-2023). Facilities were stratified by district and size and randomly assigned 2:1 to receive standard training or standard training plus a digital-based package. The package included asynchronous role-modelling, small-group practice, one-on-one feedback and tablet-guided quality improvement. Participants were lay health workers involved in index case testing. Index clients were people diagnosed with HIV. Contact clients were their partners, children and household members. Five coprimary outcomes, abstracted from programme registers over 1 year, were assessed at the cluster level: index client participation, contacts elicited, contacts tested, new HIV diagnoses and self-test kit provision. Impacts were estimated using negative binomial mixed-effects models (α=0.05).

Results: Clusters were randomly assigned to enhanced (n=11) or standard (n=22) arms and analysed in four 3-month increments (calendar-quarters) over a 1-year period. In each calendar quarter, clusters had a median of 281 potential index clients (IQR 220-427). Significant effects were observed for three primary outcomes: contact client elicitation (RR=1.37, 95% CI 1.10 to 1.71, p=0.006), contact client testing (RR=1.45, CI 1.10 to 1.92, p=0.01) and self-test kit provision (RR=2.29, 95% CI 1.19 to 4.40, p=0.01). Positive, but non-significant effects were observed for index client participation (RR=1.22, CI 0.93 to 1.60, p=0.1) and new HIV diagnoses (RR: 1.28, CI 0.94 to 1.76, p=0.1). No study-related adverse events occurred.

Conclusions: Enhanced digital training positively impacted meaningful clinical outcomes and could be replicated for expansion to other evidence-based interventions.

Trial registration number: NCT05343390.

Introduction: Early diagnosis and treatment of atrial fibrillation (AF) are crucial to reduce AF-related complications and associated healthcare costs. In low-resource settings, digital health technologies could help achieve this; however, costs of different screening strategies are key for policy change.

Methods: This decision-tree model representing the Sri Lankan public health system perspective used prevalence data from a community-based cross-sectional study of 10 000 individuals aged ≥50 years in Northern Province, Sri Lanka. Participants were screened for AF using AliveCor, a handheld single-lead ECG device. Three screening strategies (systematic, opportunistic and targeted) were compared against each other. The incremental cost-effectiveness ratio (ICER) is presented, representing the incremental total aggregated cost between screening strategies divided by the incremental number of new detected AF cases to generate a cost per additional new AF cases detected for a 1-year time horizon.

Results: Systematic screening detected 48 new AF cases, and the targeted screening detected 47. Systematic screening was more expensive (Sri Lankan rupees (Rs) 698 422; US$2123) for 10 000 screened individuals compared with targeted screening (Rs 492 002; US$1496) for 7780 screened individuals. Opportunistic screening was the cheapest strategy (Rs 360 617; US$1096) for screening 6556 individuals; however, only 30 new AF cases were identified. The ICER of targeted screening was lower compared with opportunistic screening (Rs 7729; US$23 per additional detected AF case) whereas the ICER of systematic screening compared with opportunistic screening was higher at Rs 18 767 (US$57) per detected AF case. When the systematic screening strategy was compared with targeted screening, the cost per additional detected AF case increased to Rs 206 420 ($628).

Conclusion: Targeted screening with AliveCor was the most cost-effective strategy. Systematic screening, while having similar effectiveness, was not cost-effective due to the high additional costs to detect just one further case. These findings support integrating targeted screening into Sri Lanka's primary care pathways.