BMJ Global Health最新文献

Introduction: In Kenya and many other low- and middle-income countries, prehospital care systems are underdeveloped or entirely non-existent, leaving emergency departments (EDs) as the primary point of care for medical emergencies. The aim of this cross-sectional observational study was to use a geographic information system (GIS) to comprehensively analyse access to public EDs in Kenya within 1-hour and 2-hour travel times.

Methods: Using open-source GIS software, population, land cover, elevation and road network data were analysed to create maps of 1-hour and 2-hour travel time catchment areas around public EDs in Kenya. Travel time analysis was calculated using AccessMod with a combined walking and motorised transport model.

Results: Approximately 93.7% of Kenya's population has access to a public ED within 1 hour, and 98.2% within 2 hours. Of the 6.3% of the population lacking access to a public ED within 1 hour, many reside in rural areas with suboptimal road conditions. There was a significant difference in the proportions within 1-hour and 2-hour travel times across all counties (p<0.001). There was a weak association between the number of facilities in each county and the population proportion within 1 hour (ρ=0.237, p=0.109) and 2 hours (ρ=0.230, p=0.119).

Conclusions: By mapping population distribution in Kenya against the availability of public EDs, geospatial analysis provides crucial insights into emergency care access gaps, guiding policymakers in identifying areas that require infrastructure investments or prehospital service enhancements.

The recently unveiled America First Global Health Strategy represents a fundamental reorientation of US engagement in global health, framed as a 'new playbook' designed to safeguard US lives, prosperity and influence. Built around pillars of security, sovereignty and economic self-interest, the strategy emphasises bilateral agreements, co-investment and the global promotion of US health innovation. While positioned as a corrective to inefficiency and dependency in past aid programmes, this shift raises profound questions about equity, solidarity and the future of multilateralism in health governance. This analysis critically examines the implications of the US first approach through four inter-related lenses. First, the strategy's security-first framing risks privileging outbreak containment over collaboration, potentially reinforcing a fortress mentality rather than fostering collective preparedness. Second, its critique of 'dependency' obscures the documented contributions of US programmes such as the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative to health system strengthening, raising concerns that abrupt transitions could dismantle fragile gains. Third, the prioritisation of US innovation in commodity procurement highlights tensions between economic diplomacy and moral legitimacy, with the risk of crowding out local innovation ecosystems. Finally, the privileging of bilateralism over multilateralism may deliver short-term accountability but risks fragmenting global health coordination and undermining shared responsibility. At its core, global health security is indivisible; no nation can insulate itself indefinitely from cross-border threats. A strategy that prioritises national interests while relegating equity to the margins risks eroding US credibility and weakening global solidarity. We argue that only by integrating equity, reciprocity and multilateral collaboration into its 'new playbook' can the US safeguard both its own people and global health security.

Integration of non-communicable diseases (NCDs) prevention, screening and treatment into maternal, newborn and child healthcare (MNCH) services has become increasingly important as countries address the dual burden of communicable and NCDs. While global policy attention has grown, practical experiences from low- and middle-income countries on how to operationalise this integration, particularly its implications for the health workforce, remain limited.This practice paper synthesises programme learning from Kyrgyzstan, Tajikistan and Viet Nam, drawing on WHO-supported country assessments, programme reports and practitioner perspectives, with a particular focus on workforce challenges. Health workforce shortages, skills gaps, limited training capacity and uneven distribution remain major barriers to service integration in these countries. We apply Donabedian's quality improvement model, encompassing outcome, process and structure, to elaborate on these challenges. We emphasise the importance of taking a systemic perspective in addressing health workforce issues and improving the quality of care. We recognise the need for additional research in key areas that are instrumental for strengthening the health workforce, particularly for the effective integration of NCD services into MNCH and strengthening primary healthcare. Our insights aim to assist in the development of integrated programmes and to promote advancements in the research agenda for the health workforce.

Introduction: Gastroschisis mortality is disproportionately high in Africa due in part to delayed presentation and limited surgical capacity. Skilled birth attendants (SBAs) are often the first to encounter these babies and can be an important part of their stabilisation. We assessed baseline Ugandan SBA knowledge of gastroschisis and interest in a training course.

Methods: Southwestern Ugandan SBAs were surveyed regarding practice patterns, common beliefs and training course interest. Data were analysed with descriptive statistics.

Results: We recruited 121 participants (70 midwives, 51 nurses). Most had a certificate or diploma (n=117, 97%) and 85% had more than 3 years of experience (n=103). Eighty-seven (72%) SBAs had cared for babies with gastroschisis. Most reported that communities stigmatised families (n=67, 55%), saw the child as cursed (n=74, 61%), blamed the mother (n=69, 57%) and advised parents to kill (n=30, 24%) or abandon the child (n=55, 45%). Barriers to families seeking care included healthcare mistrust (n=3, 2%), hopelessness (n=37, 31%), lack of knowledge (n=51, 42%), transportation difficulties (n=54, 45%) and fear of impoverishment (n=84, 69%). Most SBAs were unsure of the cause of gastroschisis and only 6% (n=8) recognised fetal vascular interruption as the cause. While 57% (n=69) prioritised intestinal coverage, only 7% (n=9) and 5% (n=6) would place a nasogastric tube or fast the baby. Three midwives encouraged immediate breastfeeding. Antibiotics (n=22, 18%) and fluid resuscitation (n=19, 16%) were sometimes recommended. Most participants (n=119, 98%) desired a course on gastroschisis management, but 41% (n=50) reported time constraints as a barrier.

Conclusions: Southwestern Ugandan SBAs encounter gastroschisis babies, have limited training in its management and desire a training course. Engaging SBAs into a task-sharing role on delivery is a promising next step. Additional studies will be needed to determine if this can improve gastroschisis survival by reducing delays in care and improving community awareness.

Introduction: Computer-coded verbal autopsy (CCVA) algorithms are routinely used to determine individual cause of death (COD) and derive population-level estimates of cause-specific mortality fractions (CSMFs). But frequent COD misclassification leads to biased CSMF estimates. The VA-calibration framework reduces the bias by estimating misclassification rates; but it overlooks systematic patterns and cross-country variation, reducing the accuracy of CSMF estimates.

Methods: Using CHAMPS (Child Health and Mortality Prevention Surveillance) data and the framework in Pramanik et al (2025), we estimate misclassification rates of three widely used CCVA algorithms (Expert Algorithm VA, InSilicoVA and InterVA), two age groups (neonates aged 0-27 days and children aged 1-59 months), and eight countries (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, South Africa and 'other'). We then demonstrate their utility and use the Mozambique-specific rates to calibrate VA-only data from the Countrywide Mortality Surveillance for Action (COMSA) project in Mozambique.

Results: We report three key findings. First, the country-specific model better fits CHAMPS misclassification rates than the homogeneous model, reducing average absolute loss by 34%-38% for neonates and 13%-24% for children. Second, CCVA algorithms show consistent misclassification patterns, systematically overestimating or underestimating certain causes. Third, calibrating COMSA data increases neonatal CSMF for sepsis/meningitis/infection and decreases it for intrapartum-related events and prematurity; among children, CSMF increases for malaria and decreases for pneumonia.

Conclusions: We present an inventory of VA misclassification rate estimates across two age groups, three CCVA algorithms and eight countries. These publicly available estimates enable the calibration of VA-only data from any country without needing access to CHAMPS data. More generally, these analyses reveal systematic algorithmic biases and highlight opportunities to refine future CCVA algorithms. As reliance on computer-coded and AI-driven approaches to COD determination grows, our integrated VA-calibration workflow, grounded in robust statistical frameworks and open-source software (misclassification matrix modeling, VA-calibration R package on GitHub and CRAN), offers a critical step towards improving the accuracy of mortality surveillance.

Louse-borne relapsing fever (LBRF), caused by Borrelia recurrentis and transmitted by the human body louse, remains a persistent health emergency in Ethiopia, resulting in preventable mortality among young adults. Its continued endemicity reflects systemic failures and amplifies the syndromic effects of poverty, displacement and social stigma-locally termed 'Qmalam'-which deters care-seeking. Clinical management is further complicated by the potentially fatal Jarisch-Herxheimer reaction following antibiotic treatment. Despite these severe consequences, LBRF remains off the official WHO list of neglected tropical diseases (NTDs), hindering the mobilisation of essential resources and political will. LBRF unequivocally meets WHO criteria for NTD designation, a critical step necessary to catalyse the research, funding and coordinated action required for its elimination. In this viewpoint, we present an integrated framework for addressing transmission, treatment and prediction and issue an urgent call for formal WHO recognition.

Introduction: Glucose is a major determinant of fetal growth, but its relative contribution in different ethnic groups or populations is not fully understood. The Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) Study established a relationship between glucose and birth weight in multiple ethnic groups. However, the HAPO Study did not include any cohorts from sub-Saharan Africa (SSA), where 17% of the world population lives. This study aims to address this in a cohort study from Uganda.

Methods: We compared the relationship between oral glucose tolerance test measures and fetal outcomes in participants from Uganda (n=2544), Afro-Caribbean participants in HAPO (n=1224) and white participants in HAPO (n=7679). We used multivariable linear regression to assess the correlation between birth weight adjusted for gestational age and sex with maternal glucose concentration. Logistic regression was used to determine the association of large for gestational age (LGA) (defined as birthweight >90th percentile) with maternal fasting glucose.

Findings: The contribution of maternal fasting glucose to birth weight was substantially lower in Uganda than in other settings: β-coefficient (95% CI) 104 (58.6 to 149) g/mmol/L in Uganda, 203 (137 to 270) g/mmol/L HAPO-Afro-Caribbean (AFC) and 239 (214 to 265) g/mmol/L HAPO-white. Likewise, the risk of LGA with higher fasting glucose was smaller in Uganda compared with the HAPO cohorts (adjusted OR (95% CI) 1.13 (1.00 to 1.29) in Uganda, 1.38 (1.15 to 1.66) HAPO-AFC, and 1.57 (1.46 to 1.69) HAPO-white. The contribution of glycaemia was similar using 1-hour and 2-hour post-glucose load concentrations in place of fasting glucose.

Interpretation: The contribution of maternal glucose to birth weight and the risk of LGA at a given level of hyperglycaemia is substantially lower in SSA than in populations in the HAPO study. These data support the need for locally derived glycaemia cut-offs to identify women at risk of adverse pregnancy outcomes in SSA.

Introduction: Community-based healthcare approaches can improve outcomes and reduce costs for long-term physical and mental health conditions. To design, evaluate and implement such interventions, it is essential to explore the existing resources of community and healthcare institutions, understand stakeholder perspectives and identify potential barriers and facilitators to community-based care for non-communicable diseases. Our aim was to conduct a situation analysis to better understand and contextualise community-based care for long-term physical and mental health conditions in Bolivia, Colombia and Guatemala.

Methods: A multimethod approach was used, incorporating three data sources: (1) sociodemographic and morbidity indicators from selected regions and healthcare centres; (1) quantitative surveys completed by health centre management staff and (2) semistructured interviews with healthcare workers, patients, caregivers and community leaders. These tools helped assess the capacity of health centres, as well as barriers and facilitators for community-based care. Data were analysed using descriptive statistics and thematic framework analysis.

Results: 25 health centres across the three countries were included: 12 were of low complexity, 21 in urban areas and 20 used electronic medical records. Daily seen patients ranged from 1 to 270. Most of the centres had general practitioners and nursing staff, with 72% having psychologists, 24% psychiatrists and 50% specialists in cardiovascular or metabolic conditions. Barriers to community-based care included duration and frequency of appointments, a shortage of both administrative and clinical staff, a lack of continuity in treatment, long distances for patients to travel, inadequate facilities and mental health stigma.

Conclusion: Community interventions aim to manage long-term physical and mental health conditions; however, identified barriers may limit their implementation within the existing healthcare infrastructure and should be addressed when introducing new approaches.

Introduction: On 24 February 2022, Russia launched a full-scale invasion of Ukraine, escalating the conflict that began in April 2014 with the invasion and occupation of parts of Eastern Ukraine and Crimea by Russian forces. We conducted a scoping review of studies examining mental health problems of children and youth from the beginning of the war in 2014 until 2024. Additionally, we examined traumatic events, resilience, risk and protective factors of mental health.

Methods: We searched PubMed and PsycINFO for articles published in English and Open Ukrainian Citation Index and Ukrainian Scientific Periodical for articles published in Ukrainian. We reviewed quantitative and qualitative articles, focusing on children and adolescents aged 0-19 years. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) and the protocol was registered with the Open Science Framework.

Results: 37 articles (20 English, 17 Ukrainian) met the inclusion criteria. Most studies were cross-sectional in design or quantitative and focused on children and youth residing in Ukraine. The mental health outcomes were diverse, with prevalence rates varying across studies. Among the included studies on mental health, few studies assessed resilience among war-exposed adolescents. Forced displacement, exposure to war-related events and separation from parents were associated with mental health problems. Protective factors included perceived social support, living in a familiar environment and problem-focused coping skills.

Conclusion: Methodologically comparable studies, including prospective and mixed-methods studies, are needed to further advance our understanding of the long-term psychological effects of war and explore their perceptions and experiences of wartime adversities.

Protocol registration: Open Science Framework (https://osf.io/cuhgd/).

Sub-Saharan Africa (SSA) continues to bear a disproportionate global disease burden while also facing significant disparities in research productivity and impact. As such, strengthening the research capacity in SSA is an urgent priority, necessitating a multifaceted assessment of the current landscape, the role of international collaboration and the alignment of research efforts with health needs. In this study, we conducted a macro-level bibliometric analysis to assess research capacity, thematic alignment and structural autonomy in SSA. We found that SSA accounted for approximately 15% of the global population and 21% of the global disease burden, yet it received only 2.7% of global citations in 2021. Despite increasing the research output over time, academic impact and leadership remain limited. Higher international collaboration rates were positively associated with a higher research impact, but also with a markedly greater proportion of publications without SSA researchers in key authorship positions, indicating persistent structural dependency. Researcher autonomy in SSA was substantially lower than in other regions, though slight improvements were observed during the COVID-19 period. Meanwhile, the Burden-Adjusted Research Intensity analysis showed a disproportionate concentration of research on HIV/AIDS, tuberculosis and malaria. This focus was sustained-and even intensified-in SSA during the pandemic, while many other high-burden diseases, including neglected tropical diseases, remained severely under-researched. In conclusion, this study provides quantitative evidence of persistent academic dependency and misaligned research priorities in SSA, with our analyses revealing how structural inequities in international collaborations and externally driven research agendas limit local research leadership and potentially hinder effective responses to regional health needs. Achieving a more just global research ecosystem demands active decolonisation efforts centred on empowering Global South ownership, including genuinely equitable partnerships, the reform of funding mechanisms to prioritise locally led research, and sustained investment in developing local research and leadership capacity.