BMJ Global Health最新文献

Objectives: This paper examines the differential impact of responsive parenting and nutrition interventions on early child development in stunted versus never-stunted children at 24 months of age in rural India.

Methods: We conducted a secondary analysis of data from Stepping Stones-a cluster randomised controlled trial involving 21 subcentres/clusters allocated to intervention or control group. The intervention comprised home visits, group sessions and community workshops, focusing on responsive parenting and nutrition. Developmental outcomes, cognitive, motor, language and socio-emotional, were assessed at 24 months using validated tools. A mixed-effects regression model with an interaction term was used to estimate effect sizes for stunted and never-stunted children.

Results: Among 588 children analysed, 35.9% were stunted at 24 months, and 35 (5.95%) of them exhibited 'early-onset persistent stunting'. The intervention improved cognitive (β=0.22), motor (β=0.23), language (β=0.17) and socio-emotional development (β=0.23) in never-stunted children compared with those who have not received intervention. For stunted children who have not received the intervention, a development score was lower for all development domains compared with never-stunted children, but not statistically significant (p>0.05). Although the effects differed between stunted and never-stunted children, the interaction effects between intervention and stunting were not statistically significant across all domains (p>0.05), indicating that the intervention's benefits did not significantly differ by stunting status.

Conclusion: Integrated parenting and nutrition interventions improved developmental outcomes across all domains, regardless of the child's stunting status. These findings support universal application of such programmes, highlighting the need to integrate them into existing child development and nutrition programmes.

Background: Azithromycin mass drug administration (MDA) to ages 1-59 months can reduce childhood mortality; however, more evidence is needed to support targeting a narrower age range of 1-11 months. This trial assesses the efficacy of azithromycin MDA to 1-11-month-old children in reducing mortality in a real-world setting with integration of vitamin A delivery within the established Child Health Days platform in Burkina Faso.

Methods: Mortalite Infantile Reduite par l'Administration de Masse de l'Azithromycine is a double-masked, cluster-randomised, placebo-controlled trial in Child Health Days communities in Burkina Faso. Primary healthcare centre catchment areas (Centres de Santé et de Promotion Sociale (CSPS)) were randomised 2:1 to deliver biannual azithromycin or placebo for 1-11-month-old children. Birth history data at the study endpoint were used to calculate mortality rates and compare between groups.

Findings: From September 2021 to January 2024, 201 709 children in 303 CSPS received azithromycin and 100 959 children in 158 CSPS received placebo, with an overall treatment coverage of 85%. Mortality rates were 2.6 (95% CI 2.1 to 3.1) deaths per 1000 person-years in the azithromycin arm and 2.5 (95% CI 1.8 to 3.2) per 1000 person-years in the placebo arm. There was no significant difference in the mortality rates by arm (incidence rate ratio: 1.04; 95% CI 0.75 to 1.46; p value 0.80). There were 16 non-serious adverse events and no serious adverse events recorded during the trial.

Interpretation: This trial demonstrates that azithromycin MDA for child survival can be scaled up and integrated into existing child health programmes but was unable to demonstrate an effect of azithromycin distribution on infant mortality. These findings indicate future policy decisions should consider treatment delivery to the larger age group of children up to 5 years old.

Funding: The trial was funded by the Bill and Melinda Gates Foundation (INV-005395).

Trial registration number: NCT04716712.

Background: To improve uptake of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP), a cluster-randomised implementation trial of 'integrated IPTp-SP delivery' through seasonal malaria chemoprevention (SMC) alongside antenatal care (ANC) was conducted in Mali and Burkina Faso. This nested study assessed ANC provider acceptability and feasibility of the integrated strategy and whether the training they received as part of the intervention ('enhanced facilities') improved IPTp-SP delivery effectiveness.

Methods: A cross-sectional survey was conducted in 20 trial facilities in each country (10 intervention/10 control) from November 2023 to January 2024, involving ANC exit interviews with pregnant women, facility audits and structured interviews with ANC providers. The primary outcome was the proportion of eligible pregnant women receiving IPTp-SP by directly observed therapy (DOT). Predictors of receiving IPTp-SP by DOT were estimated using mixed model logistic regression. ANC provider attitudes towards the integrated strategy were assessed using Likert scales.

Results: In Mali, 240 and 297 of 703 women interviewed were eligible for SP in the intervention and control facilities, respectively, and 323 and 334 of 709 women, respectively, interviewed in Burkina Faso. Delivery effectiveness of IPTp-SP was higher in the enhanced facilities in both Mali (79.2% (95% CI 74.0% to 84.3%) vs 68.7% (95% CI 63.4% to 73.9%), p=0.006) and Burkina Faso (52.3% (95% CI 46.9% to 57.8%) vs 28.7% (95% CI 23.9% to 33.6%), p<0.0001). Predictors of receiving IPTp-SP by DOT included attending a routine ANC visit in Mali, and gestational age, multiparity and a routine ANC visit in Burkina Faso. ANC providers interviewed in Mali (44) and Burkina Faso (41) thought that IPTp-SP delivery through SMC increased ANC attendance and reduced malaria cases, and that it was feasible and acceptable.

Conclusions: ANC provider training improved IPTp-SP delivery effectiveness, showing greater impact in Mali than in Burkina Faso. ANC providers found the integrated IPTp-SP strategy through ANC and SMC acceptable and feasible.

Introduction: The 2021 military coup and the accompanying armed conflicts in Myanmar have disrupted the country's health systems, particularly in conflict-affected rural areas. Anti-junta healthcare providers innovated alternative systems to address the needs. This study aims to provide insights into the experiences and perspectives of the anti-junta healthcare providers and community members regarding the prevailing health issues in conflict settings of Sagaing Region, how the anti-junta healthcare providers have established alternative care systems in the region, and the challenges the providers and community members encounter in healthcare provision and access.

Methods: We conducted qualitative, semi-structured, in-depth online interviews with 26 healthcare workers providing, managing or supporting healthcare services and six community members receiving these services from the Sagaing Region, Myanmar. We analysed the data thematically.

Results: Prevailing health issues included conflict-related injuries, infectious diseases, chronic non-communicable diseases and mental health concerns. In resistance force-controlled rural areas, junta-controlled rural health centres have stopped functioning, and anti-junta healthcare workers and local communities have established new systems to provide primary care to the local communities, although secondary care was still limited. However, limited workforce, supplies, funding and infrastructure, restricted travel and communication and safety concerns impeded their efforts. Moreover, the politicisation of healthcare, targeted attacks and interference by the junta further hindered effective responses to these challenges.

Conclusion: The post-coup conflict has severely devastated Sagaing Region's healthcare systems and health status, disproportionately affecting rural areas, demanding immediate action. Failure to address these issues promptly could worsen the region's health outcomes and deepen the humanitarian crisis. Improving healthcare in the region will require effective interventions from international stakeholders to stop junta attacks on healthcare and civilians and innovative ways to support new local healthcare initiatives technically, financially and logistically.

Background: Demand for a future HIV vaccine, similar to other vaccines, is vulnerable to misinformation. A number of studies have examined HIV vaccine acceptability and demand, but few have systematically explored the specific concerns and misinformation that shape these attitudes. This structured review and content analysis of published and grey literature identifies concerns about the HIV vaccine that might fuel misinformation about the vaccine when it is available.

Methods: A literature search was conducted across multiple publication databases and Google Scholar with a search strategy that used a combination of keywords. A web search was also conducted to identify other unpublished sources. Articles, including published and grey literature such as reports, were included if they were published in English and contained HIV vaccine concerns or misinformation. There was no defined timeline for article inclusion. HIV vaccine concerns extracted from the literature were documented in an Excel database and coded using NVivo V.12. Content analysis revealed several distinct topics.

Results: From a total of 78 articles and 9 reports, 333 concerns were extracted and included in the analysis. Seven topics emerged: (1) HIV vaccine safety, including concerns about side effects; (2) HIV vaccine causing HIV infection; (3) vaccine-related stigma and social concerns; (4) behavioural implications of the HIV vaccine, including concerns that the vaccine promotes risky behaviours; (5) conspiracy theories about the vaccine fuelled by distrust in governments and scientists; (6) concerns about partial efficacy of the vaccine and (7) HIV vaccine access, including eligibility for and availability of the vaccine.

Conclusions: This review highlights key concerns about an HIV vaccine, many of which are both influenced by misinformation and could seed future misinformation campaigns. The findings can inform targeted interventions to counter misinformation and communicate the vaccine's preventive benefits to populations at highest risk of HIV.

Ethiopia has made substantial progress in improving maternal health outcomes; however, significant disparities remain among populations whose individual, interpersonal, community and cultural factors place them at greater risk, as compared with those with better access to resources and healthcare facilities. Addressing these disparities requires initiating advanced and targeted segmentation tools to effectively identify and reach vulnerable groups.This study developed and validated a maternal vulnerability segmentation tool designed to assist community health workers to identify pregnant women who are least likely to access essential maternal care services. Key predictors of maternal health service utilisation were identified and incorporated into an initial 20-item questionnaire. Through a process of refinement and validation, these were condensed into six items for rural and four for urban-rural settings. Findings indicated that women with higher vulnerability scores were significantly less likely to attend antenatal care and more likely to deliver at home (p<0.01, for each). Based on these results, a maternal vulnerability segmentation tool was tested and implemented by community health workers to identify and support underserved pregnant women in Ethiopia.

Introduction: The China-UK-Tanzania pilot project of 1,7-malaria reactive community-based testing and response (1,7-mRCTR) approach was implemented in Tanzania between 2015 and 2018. This project targeted villages with the highest malaria incidence to conduct screening and treatment. While socioeconomic factors are known to be strongly associated with malaria burden, their specific impacts on malaria prevention behaviours during the 1,7-mRCTR implementation period remained unclear. This study aimed to construct a household wealth index and investigate its association with malaria prevention outcomes within the context of 1,7-mRCTR.

Methods: We used data from two cross-sectional household surveys conducted in 2015 (baseline) and 2018 (endline), covering 19 686 households. A 12-item wealth index was constructed using Mokken scale analysis, with weighted wealth scores calculated via multiple correspondence analysis to categorise households into wealth tertiles. Using logistic regression within a Difference-in-Differences (DID) framework, we assessed the association between household wealth and the household ownership of useful long-lasting insecticidal nets (LLINs), use of LLINs and use of antimalarial drugs.

Results: Analysis of the pooled data showed that households in the first (poorest) tertile had significantly lower odds of owing LLINs (OR=0.62, 95% CI 0.54 to 0.70, p<0.001) and using LLINs (OR=0.53, 95% CI 0.45 to 0.62, p<0.001) compared to the third (wealthiest) tertile. The DID analysis, accounting for the interaction between the intervention period (2018 vs 2015) and wealth tertile, showed a significantly greater increase in the odds of owing LLINs (OR=1.26, 95% CI 1.03 to 1.56) and using LLINs (OR=1.88, 95% CI 1.25 to 2.82) among households in the first tertile compared with the third tertile.

Conclusion: The wealth index effectively differentiated household socioeconomic status, revealing significant wealth-based disparities in malaria prevention behaviours. Importantly, the implementation of the 1,7-mRCTR approach appears to have had a disproportionately positive effect on poorer households, leading to a reduction in wealth-based inequalities related to key malaria prevention measures.