BMJ Global Health最新文献

Introduction: With declining HIV-related mortality, over 20% of people with HIV (PWH) in South Africa are now over age 50 years, and tobacco-related non-communicable disease burden is increasing. We quantified the impact of smoking and smoking cessation on lung cancer and stroke incidence among PWH in South Africa.

Methods: Using a microsimulation model, we simulated 18 cohorts of initially virologically suppressed PWH over their lifetime, categorised by sex, initial age (35 years/45 years/55 years) and smoking status (current/former/never). Smoking status remains constant throughout the simulation; individuals with former smoking status quit at model start. PWH can disengage from HIV care and experience virological rebound. We modelled the relative risk of lung cancer for females (males) with current versus never smoking status as 16.69 (15.83), and for females (males) with former versus never smoking status as 1.99-8.80 (1.90-6.18), depending on age at cessation. Corresponding modelled relative risks of stroke were 1.79 (1.54) for current versus never smoking, and 1.00-1.29 (1.00-1.12) for former versus never smoking. We varied HIV-related and smoking-related parameters in sensitivity analyses.

Results: Modelled female (male) PWH who stop smoking at age 45 years experience 61.3% (70.9%) and 35.6% (18.6%) lower cumulative lung cancer and stroke incidence over 25 years compared with people who continue smoking. The proportion alive and lung cancer-free or alive and stroke-free over 25 years would increase by 10.4 (9.5) or 10.5 (8.5) percentage points. In sensitivity analysis, smoking and smoking cessation have a greater impact on lung cancer and stroke cumulative incidence if competing HIV-related mortality risks are lower or if PWH experience higher lung cancer and stroke risk compared with people without HIV apart from smoking.

Conclusion: Smoking cessation could substantially reduce lung cancer and stroke risk among PWH in South Africa. To reduce the rising non-communicable disease burden among PWH, smoking cessation should become part of routine care of PWH.

The decolonise global health movement has critically reassessed the field's historical and political underpinnings, urging researchers to recognise biases and power imbalances through reflexivity and action. Genuine change is seen as the outcome of the researcher's self-awareness, often leaving the underlying structures of global health-and global mental health (GMH)-in the background. Here, we problematise how expectations around agency and change have been mobilised in discussions around decolonisation, highlighting the gradual and contingent nature of international collaboration in GMH.We present three international research initiatives based in or focused on South America: RedeAmericas, the Platform for Social Research on Mental Health in Latin America and the HEalthcaRe wOrkErS project. Instead of comparing the three initiatives directly we identify and discuss common elements among them that challenge and redefine the boundaries of GMH by leveraging local leadership, creating hybrid expert profiles and implementing principles of equity and epistemic justice. Particular attention is given to the fragmentary translation of these principles into the project's concrete activities.The interplay of agency and the structural confines of GMH is examined in each initiative, expanding the notion of 'boundaries' in the field beyond geographical or institutional demarcations. Using the notion of milieu, we call for a more nuanced understanding of the field as simultaneously shaping and being shaped by the tentative collaborative infrastructures developed by researchers. We advocate for a reconceptualisation of GMH that is as diverse and complex as the issues it seeks to address.

Background: There has been much critical reflection among global health researchers about how power imbalances between high-income countries and low- and middle-income country collaborators are perpetuated through research programmes. Research capacity strengthening (RCS) is considered both a mechanism through which to redress structural power imbalances in global health research and a vehicle for their perpetuation. This paper examines the RCS programme of a multi-county study on violence against women, focussing on how it addressed power imbalances between countries and the challenges involved in doing so. It provides specific examples and lessons learnt.

Methods: 18 semi-structured interviews were conducted online with group members from all five countries involved in the collaboration between April and June 2020. Reflexive thematic analysis, with inductive and deductive approaches was adopted.

Findings: Participants articulated their understandings of RCS as an opportunity for (1) mutual learning, understanding and collaboration and (2) personal and team career development. Participants perceived the RCS programme activities to simultaneously reinforce and challenge power asymmetries within global health research. Power dynamics within the RCS programme operated across three levels; the global health research environment, the research group level and within individual country teams. Participants described structural barriers at all three levels, but felt there were more opportunities to challenge power imbalances at the research group level.

Conclusion: Despite a strong commitment to addressing power imbalances through the RCS programme, progress was often hampered by the fact that these inequalities reflected broader structural issues in global health, as seen within Healthcare Responding to Violence and Abuse. The programme faced tensions between enhancing researchers' careers while building capacity under the current model, which sometimes conflicted with creating social value or challenging epistemic and normative structures. Participants clearly expressed concerns about power imbalances within the partnership and were keen to address them through the RCS programme. This led to a steep learning curve and significant adaptations within the RCS programme to navigate these issues within existing structural limitations.

Introduction: Violence against women (VAW) during the COVID-19 pandemic was described as the 'shadow pandemic' with an increase in reports of VAW. As countries now focus on becoming more resilient to future pandemics, it is critical to understand what we learnt about evidence on VAW burden, prevention, and response during the COVID-19 pandemic. The WHO commissioned this scoping review to gain an understanding of the research evidence on VAW during COVID-19 and to inform future pandemic preparedness efforts.

Methods: Terms relating to VAW and COVID-19 were used to search six databases between 1 January 2020 and 11 February 2023, inclusive of all study designs. Data on thematic focus (ie, burden of violence and/or interventions/services), types of violence, study design, study setting and participant characteristics were synthesised.

Results: Of 25 080 identified records, 694 publications were reviewed in full text and 419 publications were included. The majority (>95%) of the published research was devoted to documenting the burden of VAW, while only 6.2% studied solutions (interventions/services), with even less emphasis on identifying how to prevent VAW in a pandemic context (1%). Gaps in research on VAW that existed prior to the pandemic on women who face multiple intersecting forms of disadvantage endured. Outstanding also was the gap in research on digital-mediated violence (<5%), even as reports of online facilitated violence soared. Additionally, gaps in evidence on specific types of violence such as femicide, forced marriage and acid attacks persisted.

Conclusion: That VAW will be a critical concern, and its impacts worsened during pandemics in the future is certain. The research community does not need to spend more on understanding the burden of forms of VAW but pivot to research to adapt and innovate how to deliver prevention and support services, especially to populations who are disproportionately impacted. In addition to addressing this broader gap in prevention and response during pandemics, further evidence is required on the specific area of technology-mediated violence, femicide, forced marriage and acid attacks.

Background: Digital adherence technologies (DATs) with associated differentiated care are potential tools to improve tuberculosis (TB) treatment outcomes and reduce associated costs for both patients and healthcare providers. However, the balance between epidemiological and economic benefits remains unclear. Here, we used data from the ASCENT trial to estimate the potential long-term epidemiological and economic impact of DAT interventions in Ethiopia.

Methods: We developed a compartmental transmission model for TB, calibrated to Ethiopia and parameterised with patient and provider costs. We compared the epidemiological and economic impact of two DAT interventions, a digital pillbox and medication labels, to the current standard of care, assuming each was introduced at scale in 2023. We projected long-term TB incidence, mortality and costs to 2035 and conducted a threshold analysis to identify the maximum possible epidemiological impact of a DAT intervention by assuming 100% treatment completion for patients on DAT.

Findings: We estimated small and uncertain epidemiological benefits of the pillbox intervention compared with the standard of care in Ethiopia, with a difference of -0.4% (95% uncertainty interval (UI) -1.1%; +2.0%) incident TB episodes and -0.7% (95% UI -2.2%; +3.6%) TB deaths. However, our analysis also found large total provider and patient cost savings (US$163 (95% UI US$118; US$211) and US$3 (95%UI: US$1; US$5), respectively, over 2023-2035), translating to a 50.2% (95% UI 35.9%; 65.2%) reduction in total cost of treatment. Results were similar for the medication label intervention. The maximum possible epidemiological impact a theoretical DAT intervention could achieve over the same timescale would be a 3% (95% UI 1.4%; 5.5%) reduction in incident TB and an 8.2% (95% UI 4.4%; 12.8%) reduction in TB deaths.

Interpretation: DAT interventions, while showing limited epidemiological impact, could substantially reduce TB treatment costs for both patients and the healthcare provider.

Governments and organisations must demonstrate accountability and delivery of results. Results-Oriented Monitoring (ROM) is a European Commission mechanism aiming at enhancing internal control and management. The Health System Strengthening (HSS) for Universal Health Coverage (UHC) programme provides support towards achieving UHC through policy dialogue in 115 countries.Drawing from the ROM review of the HSS for UHC programme, we examine the value of the Commission's ROM system as a tool to enhance accountability of large Global Health (GH) programmes. We present the lessons learnt and provide specific recommendations about how ROM tools can be employed to strengthen GH accountability.ROM reviews can provide critical data to inform the design, implementation and evaluation of large-scale GH programmes through a well-integrated mixed-methods approach in which quantitative and qualitative components reinforce each other. Recognising the tremendous power of measures of performance, they track available quantitative indicators from baseline to target along the results chain. Firmly grounded on qualitative tools, they also capture the complex nature of health systems, and the critical influence of contextual factors and stakeholder dynamics.Poor data quality and insufficient multistakeholder engagement are persisting but not unsurmountable challenges. As increasing support is provided to strengthen health information and management systems, the process of codeveloping Monitoring and Evaluation frameworks at country level could serve as a tool to enhance mutistakeholder engagement in policy dialogue. The political nature of both results-oriented systems and GH programmes suggests that mechanisms to assess power dynamics should be incorporated into policy dialogues and ROM review processes.