BMJ Global Health最新文献

Background: Training primary care doctors and nurses to use Practical Approach to Care Kit (PACK) improved management of asthma and chronic obstructive pulmonary disease (COPD) in a previous randomised trial. The present study examined the training effects including a second year of follow-up with expanded coverage of repeated training sessions.

Methods: Using a stepped-wedge cluster randomised trial design, 48 clinics were randomly allocated either to sequence A: (1) no intervention, (2) no intervention, (3) intervention or sequence B: (1) no intervention, (2) intervention, (3) intervention, during three 12-month periods. Primary outcomes were change in treatment and spirometry ordering. Effects of any exposure to the training, and of exposure to the first and second years of training, were estimated with mixed effect logistic regression models.

Results: Any exposure to training was associated with increased changes in treatment (OR adjusted for calendar time (OR) 1.29, 95% CI 1.02 to 1.64) and more spirometry ordering (OR 1.55, (95% CI 1.22 to 1.97)) in asthma patients, and with more spirometry ordering (OR 1.50 (95% CI 1.15 to 1.96)) in patients with COPD. Change in asthma treatment was more likely during the first and second year of exposure to training compared with no exposure (ORs 1.43 (95% CI 1.09 to 1.87); 1.91 (95% CI 1.21 to 3.02)), respectively. Spirometry was more likely during the first and second year of exposure in asthma patients (ORs 1.76 (95% CI 1.34 to 2.30); 2.05 (95% CI 1.32 to 3.19)) and in patients with COPD (ORs 1.57 (95% CI 1.18 to 2.10)); 1.71 (95% CI 1.08 to 2.70)).

Conclusion: Extended follow-up suggested that PACK training continued to be effective in improving chronic respiratory care and that effective intervention delivery was sustainable for 2 years.

Trial registration number: NCT02786030.

Progress in addressing systematic health inequities, both between and within countries, has been slow. However, there are examples of actions taken on social determinants of health and policy changes aimed at shaping the underlying sociopolitical context that drives these inequities.Using case study methodology, this article identifies five countries (Ethiopia, Jordan, Spain, Sri Lanka and Vietnam) that made progress on health equity during 2011-2021 and three countries (Afghanistan, Nigeria and the USA) that had not made the same gains. The case studies revealed social, cultural and political conditions that appeared to be prerequisites for enhancing health equity.Data related to population health outcomes, human development, poverty, universal healthcare, gender equity, sociocultural narratives, political stability and leadership, governance, peace, democracy, willingness to collaborate, social protection and the Sustainable Development Goals were interrogated revealing four key factors that help advance health equity. These were (1) action directed at structural determinants of health inequities, for example, sociopolitical conditions that determine the distribution of resources and opportunities based on gender, race, ethnicity and geographical location; (2) leadership and good governance, for example, the degree of freedom, and the absence of violence and terrorism; (3) a health equity lens for policy development, for example, facilitating the uptake of a health equity agenda through cross-sector policies and (4) taking action to level the social gradient in health through a combination of universal and targeted approaches.Reducing health inequities is a complex and challenging task. The countries in this study do not reveal guaranteed recipes for progressing health equity; however, the efforts should be recognised, as well as lessons learnt from countries struggling to make progress.

The European Alps, home to a blend of permanent residents and millions of annual tourists, are found to be particularly sensitive to climate change. This article employs the impact chain concept to explore the interplay between climate change and health in Alpine areas, offering an interdisciplinary assessment of current and future health consequences and potential adaptation strategies.Rising temperatures, shifting precipitation patterns and increasing extreme weather events have profound implications for the Alpine regions. Temperatures have risen significantly over the past century, with projections indicating further increases and more frequent heatwaves. These trends increase the risk of heat-related health issues especially for vulnerable groups, including the elderly, frail individuals, children and recreationists. Furthermore, changing precipitation patterns, glacier retreat and permafrost melting adversely impact slope stability increasing the risk of gravity-driven natural hazards like landslides, avalanches and rockfalls. This poses direct threats, elevates the risk of multi-casualty incidents and strains search and rescue teams.The environmental changes also impact Alpine flora and fauna, altering the distribution and transmission of vector-borne diseases. Such events directly impact healthcare administration and management programmes, which are already challenged by surges in tourism and ensuring access to care.In conclusion, Alpine regions must proactively address these climate change-related health risks through an interdisciplinary approach, considering both preventive and responsive adaptation strategies, which we describe in this article.

Paediatric cardiovascular diseases have been referred to as diseases of injustice as access to care is inequitable globally. For example, Africa only has 78 cardiac centres, with 22 located in Sub-Saharan Africa. Most of these centres rely on visiting surgical teams to provide clinical care. While visiting surgical teams provide essential care, building a sustainable and locally run cardiac workforce in Africa is critical to addressing these inequities in access to care. This paper considers the role of south-to-south partnerships in building sustainable surgical programmes using Rwanda's paediatric cardiac surgery programme as an example.

Immunisation is a high priority for improving health outcomes. Yet, in many low-income and middle-income countries, achieving coverage targets independently is hindered by lack of domestic resources and reliance on partners' support. Both the 2001 Abuja Declaration and 2016 Addis Declaration were key political commitments to improving immunisation coverage; however, many signatories have yet to meet international targets. Despite signing the Global Vaccine Action Plan and Addis Declaration, the Democratic Republic of the Congo (DRC) was unable to fully disburse its portion of allocated funds to cover vaccines without support from Gavi, the Vaccine Alliance and the World Bank between 2017 and 2019. Additionally, during the same time, vaccine coverage outcomes indicated negative trends, with over 750 000 children considered 'zero-dose' in 2018. In 2019, a primary focus of the then newly elected President's agenda was universal healthcare. In collaboration with development partners and stakeholders, the first Presidential Forum was held as a public commitment to increasing childhood immunisation and ensuring the country remains polio-free. This article seeks to highlight the key outcomes of the Forum such as the signing of the Kinshasa Declaration, which formally set targets and specified national, provincial and community-level commitments to vaccination and polio eradication. As of 2023, three Forums have been conducted to reiterate political commitment to routine immunisation in the DRC. This type of high-level commitment could serve as a template for other countries struggling to have high engagement as targets for polio eradication and strengthened routine immunisation are set for 2025-2030.

The COVID-19 pandemic presented a significant challenge to health systems worldwide, requiring resources to be directed to the pandemic response while also maintaining essential health services. Those with non-communicable diseases (NCDs) are particularly vulnerable to COVID-19, and interrupted care resulting from the pandemic has the potential to worsen morbidity and mortality.We used narrative literature review and key informant interviews between August 2021 and June 2022 to identify how NCD services were impacted during the pandemic and which good practices helped support uninterrupted care.On the background of an existing strong healthcare system, Thailand exhibited strong central coordination of the response, minimised funding interruptions and leveraged existing infrastructure to make efficient use of limited resources, such as through mobilising healthcare workforce. A key intervention has been redesigning NCD systems such as through the 'New Normal Medical Services' initiative. This has promoted digital innovations, including remote self-monitoring, patient risk stratification and alternative medication dispensing. Emphasis has been placed on multidisciplinary, patient-centred and community-centred care.NCD service utilisation has been disrupted during the COVID-19 pandemic; however, newly adapted efforts on top of existing robust systems have been critical to mitigating disruptions. Yet challenges remain, including ensuring ongoing evaluation, adaptation and sustainability of redesign initiatives. This learning offers the potential to further positive health systems change on a wider scale, through sharing knowledge, international collaboration and further refinement of the 'new normal' model.

Introduction: Snakebite envenoming (SBE) results in over 500 000 deaths or disabling injuries annually. Varespladib methyl, an oral inhibitor of secretory phospholipase A2, is a nearly ubiquitous component of snake venoms. We conducted a phase II clinical trial to assess efficacy and safety of oral varespladib methyl in patients bitten by venomous snakes.

Methods: This double-blind, randomised, placebo-controlled trial enrolled patients in emergency departments in India and the USA. Patients with SBE were randomly assigned (1:1) to receive varespladib methyl or placebo two times per day for 1 week. All patients received standard of care, including antivenom. The primary outcome was change in the composite Snakebite Severity Score (SSS) measuring the severity of envenoming, from baseline to the average composite SSS at 6 and 9 hours.

Results: Among 95 patients randomised August 2021 through November 2022, the most common snakebites were from Russell's vipers (n=29), copperheads (n=18) and rattlesnakes (n=14). The SSS improved from baseline to the average at 6 and 9 hours by 1.1 (95% CI, 0.7 to 1.6) in the varespladib group versus 1.5 (95% CI, 1.0 to 2.0) in the placebo group (difference -0.4, 95% CI, -0.8 to 0.1, p=0.13). While key secondary outcomes were not statistically different by treatment group, benefit was seen in the prespecified subgroup initiating study drug within 5 hours of bite (n=37). For this early treatment group, clinically important differences were observed for illness severity over the first week, patient-reported function on days 3 and 7 and complete recovery. No death or treatment emergent serious adverse event occurred.

Conclusion: For emergency department treatment of snakebites, the addition of varespladib to antivenom did not find evidence of difference for the primary outcome based on the SSS. A potentially promising signal of benefit was observed in patients initiating treatment within 5 hours of snakebite.

Background: Despite worldwide efforts to eradicate malaria over the past century, the disease remains a significant challenge in the Democratic Republic of the Congo (DRC) today. Climate change is even anticipated to worsen the situation in areas with higher altitudes and vulnerable populations. This study in Haut-Katanga, a highland region, aims to evaluate the effectiveness of past control measures and to explore the impact of climate change on the region's distinct seasonal malaria pattern throughout the last century.

Methods: We integrated colonial medical records (1917-1983) from two major mining companies (Union Minière du Haut-Katanga and the Générale des Carrières et des Mines) with contemporary data (2003-2020) from Lubumbashi. Concurrently, we combined colonial climate records (1912-1946) with recent data from satellite images and weather stations (1940-2023). We used Generalised Additive Models to link the two data sources and to test for changing seasonal patterns in transmission.

Results: Malaria transmission in Haut-Katanga has fluctuated significantly over the past century, influenced by evolving control strategies, political conditions and a changing climate. A notable decrease in cases followed the introduction of dichlorodiphenyltrichloroethane (DDT), while a surge occurred after the civil wars ended at the beginning of the new millennium. Recently, the malaria season began 1-2 months earlier than historically observed, likely due to a 2-5°C increase in mean minimum temperatures, which facilitates the sporogonic cycle of the parasite.

Conclusion: Despite contemporary control efforts, malaria incidence in Haut-Katanga is similar to levels observed in the 1930s, possibly influenced by climate change creating optimal conditions for malaria transmission. Our historical data shows that the lowest malaria incidence occurred during periods of intensive DDT use and indoor residual spraying. Consequently, we recommend the systematic reduction of vector populations as a key component of malaria control strategies in highland regions of sub-Saharan Africa.

Despite progress in the development and evaluation of evidence-based primary mental health interventions in low-income and middle-income countries, implementation and scale-up efforts have had mixed results. Considerable gaps remain in the effective translation of research knowledge into routine health system practices, largely due to real-world contextual constraints on implementation and scale-up efforts. The Southern African Research Consortium for Mental Health Integration (S-MhINT) programme used implementation research to strengthen the implementation of an evidence-based integrated collaborative depression care model for primary healthcare (PHC) services in South Africa. To facilitate the scale-up of this model from a testing site to the whole province of KwaZulu-Natal, a capacity building programme was embedded within the Alliance for Health Policy and Systems Research (AHPSR) learning health systems (LHS) approach. The paper discusses efforts to scale up and embed case finding and referral elements of the S-MhINT package within routine PHC. Data from semistructured interviews, a focus group discussion, proceedings from participatory workshops and outputs from the application of continuous quality improvement (CQI) cycles were thematically analysed using the AHPSR LHS framework. Learning particularly occurred through information sharing at routine participatory workshops, which also offered mutual deliberation following periods of applying CQI tools to emergent problems. Individual-level, single-loop learning seemed to be particularly observable elements of the AHPSR LHS framework. Ultimately, our experience suggests that successful scale-up requires strong and sustained relationships between researchers, policy-makers and implementers, investments into learning platforms and organisational participation across all levels to ensure ownership and acceptance of learning processes.

Introduction: An adequate health workforce (HWF) is essential to achieving the targets of the Sustainable Development Goals (SDG), including universal health coverage. However, weak HWF planning and constrained fiscal space for health, among other factors in the WHO Africa Region, has consistently resulted in underinvestment in HWF development, shortages of the HWF at the frontlines of service delivery and unemployment of qualified and trained health workers. This is further compounded by the ever-evolving disease burden and reduced access to essential health services along the continuum of health promotion, disease prevention, diagnostics, curative care, rehabilitation and palliative care.

Methods: A stock and flow model based on HWF stock in 2022, age structure, graduation and migration was conducted to project the available stock by 2030. To estimate the gap between the projected stock and the need, a population needs-based modelling was conducted to forecast the HWF needs by 2030. These estimations were conducted for all 47 countries in the WHO African Region. Combining the stock projection and needs-based estimation, the modelling framework included the stock of health workers, the population's need for health services, the need for health workers and gap analysis expressed as a needs-based shortage of health workers.

Results: The needs-based requirement for health workers in Africa was estimated to be 9.75 million in 2022, with an expected 21% increase to 11.8 million by 2030. The available health workers in 2022 covered 43% of the needs-based requirements and are anticipated to improve to 49% by 2030 if the current trajectory of training and education outputs is maintained. An increase of at least 40% in the stock of health workers between 2022 and 2030 is anticipated, but this increase would still leave a needs-based shortage of 6.1 million workers by 2030. Considering only the SDG 3.c.1 tracer occupations (medical doctors, nurses, midwives, pharmacists and dentists), the projected needs-based shortage is 5.3 million by 2030. In sensitivity analysis, the needs-based shortage is most amenable to the prevalence of diseases/risk factors and professional standards for service delivery CONCLUSIONS: The WHO African Region would need to more than double its 2022 HWF stock if the growing population's health needs are to be adequately addressed. The present analysis offers new prospects to better plan HWF efforts considering country-specific HWF structure, and the burden of disease.