BMJ Global Health最新文献

The Ethiopian Neonatal Network (ENN) represents one of the first low-income country neonatal quality improvement (QI) communities. To determine if changes in structure, process and outcome measures were associated with formation of the ENN and to learn from teams, quantitative and qualitative analyses were completed. All infants discharged during 2018-2022 from 11 hospitals with consistent data collection over the 5-year period were included in infant-level analyses. Trends by year were evaluated using Cochran-Armitage tests. Annual surveys captured facility-level data. Nurse and physician leads at ENN hospitals participated in focus groups in 2023. Inductive and deductive approaches were used to extract themes and findings. Overall, 38 049 infants were discharged. Participating sites reduced nurse-to-patient ratios, increased newborn beds and implemented continuous positive airway pressure (CPAP) with blended oxygen. There were significant increases in antenatal steroid exposure, kangaroo mother care and receipt of oxygen or CPAP among infants with respiratory distress (p<0.0001). Admission hypothermia among inborn infants decreased (p<0.0001). Overall survival decreased (p<0.0001). Mortality due to prematurity-related complications decreased (p=0.0089) while mortality due to infection increased (p=0.0016). Three themes were determined from focus groups: positive changes to data utilisation and patient care following ENN membership, data entry, technical issues and buy-in as barriers to participation and recommendations on additional support. Development of the ENN was associated with adopting a culture of data-driven improvement, positive changes in measurable quality of care and improved patient outcomes. Sustaining, spreading and evaluating multidisciplinary neonatal QI communities are important components to global efforts targeting mortality reduction.

Cancer remains a leading cause of morbidity and mortality in Kenya, with the healthcare system increasingly challenged by oncologic emergencies (OEs)-acute, life-threatening complications that require immediate intervention. Although Kenya has advanced in decentralising cancer care through regional centres and expanding access to chemotherapy, radiotherapy and palliative care, a critical gap persists in the recognition and management of OEs. Conditions such as spinal cord compression, febrile neutropenia, tumour lysis syndrome and superior vena cava obstruction are common but often underdiagnosed or inadequately managed in acute settings. Poor outcomes are largely driven by workforce shortages, weak triage systems, financial toxicity and limited provider training. This paper calls for a national strategy to integrate OEs management into cancer centres and emergency departments through standardised clinical guidelines, capacity building, improved referral networks and inclusion in health insurance coverage. Strengthening infrastructure, workforce education and longitudinal research on OEs patterns will be essential to improving outcomes. A timely, coordinated response to OEs can substantially enhance survival, reduce complications and promote equitable access to life-saving care across Kenya.

Maternal depression affects one in five women in Malawi. Integrated interventions simultaneously addressing multiple risks are a promising strategy to improve mental health. This study evaluated the impact of a nutrition-sensitive social behaviour change (SBC) intervention (agriculture and livelihoods, male engagement and Caring for the Caregiver) with or without cash transfers on maternal perinatal depression during the lean season in rural Malawi. A midline survey for a cluster-randomised controlled trial was conducted, where 156 clusters were randomly assigned to four arms (39 clusters/arm): (1) standard of care (SoC), (2) SBC, (3) SBC+low cash (US$17 per month) and (4) SBC+high cash (US$43 per month). Pregnant women and mothers of children <2 years of age (n=2677) were enrolled at baseline (May-June 2022). A subsample of 1303 women was followed-up at midline (November-December 2023). Maternal perinatal depression was assessed using the Self-Reporting Questionnaire with a score of ≥8 indicating symptoms consistent with depression. Intervention effects were estimated using linear mixed effects models. At midline, SBC+high cash reduced depression scores relative to SoC (mean difference -1.13 (95% CI -1.96 to -0.31)) but had no impact on the proportion of women with depressive symptoms. Relative to SoC, SBC+low cash and SBC alone had no impact on depression scores or the proportion of women with depressive symptoms. Relative to SBC alone, adding cash to SBC reduced depression scores and the proportion of women with depressive symptoms regardless of the size of the cash transfer. Cash transfers integrated with SBC can benefit maternal perinatal mental health in rural Malawi during the lean season. Trial registration number ISRCTN53055824.

Introduction: Cancer care in humanitarian settings is very challenging, and patients may face significant barriers to accessing the care they need. This study explored access to advanced diagnostic and treatment services for children with cancer in humanitarian settings, taking Gaza as a case study.

Methods: The study was based on 51 key informant interviews and two focus group discussions with close relatives of children with cancer, healthcare providers and Ministry of Health officials between November 2021 and January 2022. We also analysed referral data for paediatric oncology care outside Gaza in 2021.

Results: Among the structural barriers to cancer care are complex and lengthy referral mechanisms, along with an unclear permit system. These challenges contribute to significant delays in both diagnosis and the initiation of treatment. The referral pathway involves multiple administrative and logistical steps to secure approval for treatment outside Gaza. It begins with a physician-initiated referral, approval of the Ministry of Health Service Purchasing Unit, and concludes with exit permit requests for the child and a companion, which must be approved by the Israeli Gaza Coordination and Liaison Administration. Analysis of 2021 referral data reveals that 25% of children with cancer experienced permit delays of over 1 month, and 8% died while waiting for an exit permit.

Conclusions: The urgent need to scale up cancer care in Gaza is critical, particularly for children who face severe challenges due to ongoing conflict, the Israeli blockade since 2006 and the closure of the only paediatric oncology department. Immediate, coordinated national and global efforts are essential to overcome political, medical and financial barriers. Improving health outcomes and survival for children with cancer in Gaza requires addressing the root causes of late diagnosis, as well as the complex referral and unclear permit processes that delay timely access to specialised care.

Introduction: After the WHO prequalified the first vaccine against mpox, we aimed to identify the influence of vaccine attributes on mpox vaccination preferences among the African adults.

Methods: A discrete choice experiment was conducted among 1832 African adults across six countries. Respondents answered eight questions, each requiring them to choose between two hypothetical vaccines, with variations in distance from home to vaccination facilities, cost, effectiveness, duration of the protective effect, supply and side effects. A mixed logit model was employed to estimate vaccination preferences. Willingness to pay and changes in probability were also estimated from the regression coefficients.

Results: The strongest vaccine attribute was the higher effectiveness of vaccines (≥90% vs <60%: b=1.196, 95% CI 1.089 to 1.303), then followed by a longer duration of protective effect (lifetime vs <6 months: b=1.053, 95% CI 0.920 to 1.186), a low risk of side effects (<30% vs ≥30%: b=0.495, 95% CI 0.427 to 0.562) and sufficient vaccine supply (sufficient vs limited: b=0.417, 95% CI 0.360 to 0.475). Although compared with a walking distance of 60 min, a walking distance of 45 min was significant (b=0.402, 95% CI 0.296 to 0.508), there was no significant difference for walking distance at 15 and 30 min. Scenario prediction analysis showed that higher vaccine effectiveness (≥90%: 53.55%; 80%-89.99%: 51.41%; 60%-79.99%: 25.85%), a longer duration of protective effect (lifetime: 48.28%; 12-36 months: 25.51%; 6-11 months: 14.39%), lower vaccine costs (US$0: 28.10%; US$20: 25.42%; US$100: 14.34%), a risk of side effects of less than 30% (24.24%) and sufficient vaccine supply (20.57%) all increased the probability of vaccine uptake. Populations living with children preferred vaccines with sufficient supply and lower cost, compared with those living without children.

Interpretation: In Africa, alongside providing more reliable mpox vaccines, offering sufficient vaccine free of charge, particularly to those living with children, would encourage higher vaccine uptake.

Unplanned pregnancy presents ethically and clinically complex challenges, especially in health systems where early termination is legally or procedurally restricted. In Saudi Arabia (SA), Islamic jurisprudence permits abortion before foetal ensoulment (approximately 120 days) under specific conditions, including mental health risk and severe hardship. However, reproductive health policy and clinical practice rarely reflect these ethical allowances. This policy analysis and position paper explores the disconnect between Islamic ethical permissions and their operationalisation within the Saudi health system.Drawing on practitioner insight, conceptual reasoning and comparative policy analysis, the paper identifies six critical gaps in early termination access. These include the exclusion of psychological harm as a valid justification, the absence of policy pathways for rape-related pregnancies, inequities that allow privileged women to access abortion abroad while others remain unsupported, lack of system response to contraceptive failure, the ethical contradiction of offering anomaly screening without actionable follow-up and dilemmas in post-abortion care for unmarried women.Rather than calling for liberalisation beyond Islamic boundaries, this paper urges activation of existing ethical permissions through clearer guidelines, trauma-informed pathways and health system-wide policy reform. It proposes a culturally grounded co-design framework involving religious scholars, clinicians, policymakers and women with lived experience.By centring faith-aligned reproductive justice, this analysis contributes to global conversations on health equity, religious ethics and responsive policy in Muslim-majority contexts.

Climate change has been assumed as a key contributor to global undernutrition. One possible channel is that global warming increases air pollution exposure by causing more and more wildfires. This study examined the effect of wildfire-sourced particulate matter (PM)_2.5 exposure on anaemia in women of reproductive age (WRA), a dominating form of undernutrition across the low- and middle-income countries (LMICs). We collected haemoglobin measurements of 1 549 972 WRA from 85 Demographic and Health Surveys (DHS) in 45 LMICs between 2004 and 2021. Wildfire-sourced PM_2.5 exposure was estimated through a synthesis of ground observations, satellite remote sensing measurements and the Goddard Earth Observing System with Chemistry (GEOS-Chem) model simulations. The effects on the haemoglobin levels, as well as the odds of anaemia, were estimated by the mixed-effects regression models. Finally, population-attributable fraction or number was calculated to assess the burden of wildfire-sourced anaemia among WRA, by extrapolating the regression model result to a study domain of 125 LMICs. In the fully adjusted model, a 1 μg/m³ increase in wildfire-sourced PM_2.5 was associated with a 0.1263 g/L reduction in the haemoglobin levels of women (95% CI -0.1540 to -0.0987) and a 1.3% increase in odds of anaemia (ORs 1.013, 95% CI 1.010 to 1.016). The non-linear analysis showed a monotonically increasing exposure-response relationship, which suggested a saturated effect for an exposure concentration >5.85 μg/m³. Across the study domain of 125 LMICs, wildfire-sourced PM_2.5 contributed to WRA anaemia of 35.9 million (95% CI 30.1 to 42.1) in 2000, rising to 52.8 (95% CI 44.3 to 61.9) in 2019. The numbers accounted for 8.81% (95% CI 7.38% to 10.32%) and 9.54% (95% CI 7.99% to 11.17%) of all anaemic WRA, respectively. To meet the global 2030 target of reducing 50% WRA anaemia, warranted are climate mitigations and adaptations against wildfire smoke exposure.

Introduction: Population level screen and treat approach for anaemia reduction could be beneficial but its feasibility and impact remains to be tested.

Methods: This cluster randomised trial in rural Telangana included 14 clusters randomised (1:1) to either intervention or control arms. A cluster included all participants (6 months to 50 years) served by a frontline health worker. In the intervention arm, participants were screened for anaemia at point of care, using WHO 2011 cut-offs, followed by iron-folic acid (IFA) supplementation as per the national guidelines. The control arm participants were eligible for benefits of an ongoing national programme. The primary outcome was mean difference (MD) in haemoglobin between two arms at 6 months. The trial was registered at CTRI (CTRI/2019/01/016918).

Results: Baseline characteristics of participants in the intervention (n=6131) and control (n=5255) arms were broadly similar. In the intervention arm, 88.6% of eligible participants were screened and intervention was delivered to 97% of participants. There was no difference in population haemoglobin (g/dL) between the arms (MD 0.03, 95% CI -0.06 to 0.12, p=0.464). However, after adjustment for relevant confounders, mean haemoglobin in the intervention arm was significantly higher (MD 0.25 g /dL, 95% CI 0.03 to 0. 48, p=0.028). Anaemia prevalence was lower in the intervention than the control arm in total sample (29.6% vs 32.5%, p=0.002) as well as in adolescent girls (40.7% vs 56.0%, p<0.001) and women of reproductive age (WRA, 52% vs 56.5%, p=0.02). Compliance to IFA (% consumption of prescribed dose) was 32% and 47.5% in those receiving therapeutic and prophylactic doses, respectively.

Conclusion: This study demonstrates the feasibility of implementing a population level screen and treat approach. The intervention reduced anaemia prevalence significantly among vulnerable groups, particularly adolescent girls and WRA. Modest improvement in population haemoglobin and anaemia reduction suggests a need for strategies to improve the compliance to IFA.

Trial registration number: CTRI/2019/01/016918.

Background: The annual births in our hospital (a regional perinatal centre for the southeastern coastal region) had increased to nearly 19 000 in 2019, straining the resources. Reduced low-risk childbirths due to the restrictions during the COVID-19 pandemic gave us an impetus to design and implement a risk-appropriate triage model referral system. We report its implementation process and examine its effect on birth rates and quality of care.

Methods: Initially, the data on childbirths (2019) and the districts where the majority belonged were analysed. We discussed the need for triaging and the implementation process with these district health administrators. In the antenatal clinic, a dedicated team triaged and referred new cases to risk-appropriate facilities near their homes. Using WhatsApp groups, information about those referred back and the critically ill transferred to our hospital was shared. The impact of model implementation was assessed by the change in the number of births, proportion of high-risk cases, quality indicators and feedback from health workers.

Results: The average number of childbirths per month decreased from 1530 in 2019 to 900 in 2023 after the implementation of triage on 15 December 2022. The quality indicators, such as stillbirth and scar rupture, declined after implementation, but caesarean deliveries rose from 20% to 30%. Better satisfaction among personnel and a change in the pattern to more high-risk pregnancies were noted; there was a reduction in bed occupancy rates, averting overcrowding.

Conclusion: A 'risk-appropriate maternity care-based triage model' could be implemented, reducing low-risk births and improving the quality of care for high-risk women in tertiary care institutes.

Background: Nutrition is a critical determinant of tuberculosis (TB), providing a protective effect at high body mass index (BMI) and incurring an increased risk of TB disease at low BMI. Global nutritional transition and interventions to end hunger could directly affect the TB epidemic in high TB burden countries.

Methods: We constructed dynamic TB transmission models for 12 high TB burden countries with low HIV prevalence. We explicitly accounted for the effects of BMI on TB disease progression and treatment outcomes using a meta-analysis of longitudinal cohort studies, incorporating the effect of BMI mediated through diabetes. The models were calibrated to historical trends in TB epidemiology and mean BMI. We estimated potential changes in TB incidence and mortality between 2015 and 2030 under different scenarios of population nutrition.

Findings: Compared with a scenario where mean BMI remained at 2015 levels, if past trends in mean BMI continued then by 2030 TB incidence and mortality would decline by a cumulative 14.7% (95% credible interval: 12.7%-16.7%) and 15.6% (12.5%-19.2%), respectively. In comparison, achieving zero hunger by 2030 would reduce incidence and mortality by 32.0% (20.0%-43.8%) and 37.3% (26.1%-49.6%), respectively. If past trends continued and zero hunger was also achieved, incidence and mortality would be reduced by 38.2% (27.0%-49.1%) and 42.4% (32.1%-53.5%), respectively, equivalent to preventing 20.6 million people developing TB disease and averting 5.4 million TB deaths over 15 years in the 12 high-burden countries.

Conclusions: Nutrition transitions and interventions to end hunger could have a major impact on the future epidemiology of TB in high-burden countries. Investment is urgently required to implement and scale up nutritional interventions.