BMJ Global Health最新文献

Background: The likelihood of HIV acquisition is increased following forced vaginal sex. This relates in part to epidemiological and behavioural factors; however, the biological effects of forced vaginal sex, including impacts on immune parameters linked to HIV susceptibility, are poorly understood. Here, we examine biological mediators of HIV susceptibility among female sex workers (FSWs) in Nairobi, Kenya, who recently experienced forced vaginal sex.

Methods: The Maisha Fiti study was a longitudinal cohort study of FSWs from Nairobi, Kenya. At up to three visits, HIV-uninfected participants completed a detailed sociodemographic survey in which they were asked if they had experienced forced vaginal sex in the past 7 days. Proinflammatory cytokines and soluble E-cadherin (sE-cad), a biomarker of epithelial barrier disruption, were quantified in cervico-vaginal secretions by multiplex immunoassay. Associations between recent forced sex and genital inflammation were assessed longitudinally in a mixed-effects regression model adjusted for potential confounders and within-participant correlation.

Results: Of the 746 participants, 44 (6%) reported forced vaginal sex in the past 7 days at baseline, with strong evidence of associations with adverse childhood experiences (p<0.001), mental health issues (p<0.001) and poverty (p=0.02). Recent forced sex was associated with increased genital inflammation (adjusted OR (aOR)=2.74; 95% CI 1.33 to 5.68; p<0.01) independent of previously defined confounders but was not associated with altered levels of sE-cad (p=0.56). Neither recent consensual sex (aOR=0.94, 95% CI 0.63 to 1.40, p=0.76) nor forced sex within the past 6 months, excluding the past 7 days (aOR=0.93, 95% CI 1.21 to 5.42, p=0.70), was associated with genital inflammation.

Conclusions: Cervicovaginal inflammation is increased in FSWs for at least a week after forced vaginal sex. This has important implications for HIV prevention programmes that provide care to women experiencing gender-based violence. Further studies are needed to understand the specific timing of proinflammatory cytokine release following forced vaginal sex.

Background: Although medical education regulation is widely practised and given substantial resource and priority by policymakers and leaders, there is little empirical evidence to support it or guide regulation practices at an international level. In recent years, international and cross-border accreditation systems have gained prominence, often linked to migratory opportunities for graduating physicians. Given the high-stakes nature of regulation in medical education, there is a pressing need for research in this area, including the development of a framework to guide how to prioritise the different areas of scholarly inquiry that need to be addressed to best inform and elevate accreditation practices.

Methods: This article reports a nominal group technique consensus exercise on global medical education regulation conducted in August 2023 in London, UK. Participants were invited based on their research and leadership roles in medical education regulation around the world. Working in three groups using the nominal group technique, participants examined issues associated with medical education regulation globally that required research and evaluation.

Results: 18 participants from 11 countries took part. There was remarkable consistency across the three groups. Each group identified over 15 areas of inquiry summarised in seven overall research domains: Purpose, Quality and Sustainability, Economics, Governance, Colonialism, Process and Outcomes.

Discussion: Regulation is ubiquitous in medical education, and a panel of international scholars and leaders identified a pressing set of global issues that require exploration to inform future practices. This research agenda can help policymakers and researchers understand and embrace the complexity that underlies this topic and use it to prioritise research efforts in the years ahead.

Background: Global warming poses a significant threat to human mental health, with disproportionate effects on vulnerable and highly exposed populations, such as women from low-income and middle-income countries (LMICs). This scoping review mapped available evidence on associations between high ambient temperature and psychiatric, neurologic and neurocognitive outcomes in women from LMICs.

Methods: A systematic literature search was conducted in the electronic databases MEDLINE, Embase, Web of Science, Global Health, CINAHL and Global Index Medicus in December 2024, and updated in September 2025, without date restriction. Controlled vocabulary terms were used to identify relevant studies in the domains of ambient heat exposure, mental disorders/mental health, emotional regulation, sleep, pain and LMICs. 70 studies were included based on a priori defined eligibility criteria. A qualitative, narrative synthesis was conducted.

Results: We found evidence suggesting positive associations between exposure to high ambient temperature and adverse psychiatric, neurologic and neurocognitive outcomes among women from LMICs. Associations of heat with psychiatric outcomes seem to be non-specific. Studies were heavily concentrated in China, with notable underrepresentation from Latin America, Africa and Southeast Asia, and many used overlapping data sources. Most studies analysed female subgroups within mixed-sex samples, rather than focusing exclusively on female samples.

Conclusions: A critical research gap remains concerning women from LMICs. Comprehensive, methodologically rigorous research is essential to understand regional differences and the temporal pathways through which heat exposure affects women, particularly those from Africa and Latin America. Understanding the severe health consequences of global warming is imperative as populations with the least resources are the most affected.

Introduction: Armed conflict severely impacts health, with indirect deaths often exceeding direct casualties two to four times, disproportionately affecting women and children. Although the magnitude of these effects is well-documented, the mechanisms driving them remain insufficiently understood. This study shifts the focus from supply-side factors, such as the destruction of infrastructure, to demand-side processes, particularly healthcare-seeking behaviour and from broader conflict exposure to individual-level violent victimisation.

Methods: Data come from a representative survey (n=3006) of caregivers of young children in northeastern Nigeria, a region heavily affected by armed insurgency. Unlike previous studies, our survey included dedicated measures of victimisation, health-seeking outcomes and potential mediating factors within a single instrument, enabling precise measurement and analysis. To compare maternal and child healthcare-seeking behaviour between victimised and non-victimised caregivers, we employed a quasi-experimental observational design using propensity-score matching on demographic and contextual characteristics. Causal mediation analysis was then used to identify the mechanisms linking victimisation to health behaviours.

Results: Victimisation was widespread, with 21% of respondents (n=651) having experienced a severe form of violence in the past 3 years. While maternal healthcare-seeking behaviour appeared unaffected, victimisation significantly reduced healthcare-seeking for child health. Children of victimised caregivers were markedly less likely to be fully immunised (OR 0.43, p<0.001) and to receive care at government health facilities (OR 0.23, p<0.001). This decline was primarily driven by increased distrust in the health system (proportion mediated: 0.42-0.70, p<0.05), stemming from negative experiences during the conflict, particularly health worker absenteeism and victimisation by state security forces.

Conclusion: Addressing fear and mistrust is key to improving healthcare-seeking in conflict-affected populations. Efforts should focus on providing security for government-run health facilities, reducing violence against civilians by state security forces and restoring trust in healthcare and state institutions. Future research should explore effective strategies for achieving these objectives.

Introduction: Global health originated from colonial and tropical medicine, which served the interests of colonial powers. Despite efforts to address this legacy, the field still faces challenges in unequal partnerships between high-income (HICs) and low-income and middle-income (LMICs) countries. Activists push for paradigm shifts emphasising health equity, decolonisation and partnerships based on solidarity and justice. The Geisel School of Medicine at Dartmouth aligns with these movements, focusing its global health programmes on equity.

Methods: This study, employing ethnographic methods to centre the perspectives of learners at one of its partner institutions, the University Teaching Hospital of Kigali, identified key themes to enhance equity in global health medical education.

Results: These themes yielded concrete actions at the student, curricular and institutional levels that should be undertaken to promote equity and justice in academic global health partnerships.

Conclusion: The findings offer a tailored framework for fostering equitable and justice-oriented practices in future exchanges with potential applications to academic global health exchanges between HICs and LMICs more broadly.

Background: Evaluating progress towards WHO End Tuberculosis Strategy goals is crucial for high burden countries like the Republic of Congo. This study analysed trends in tuberculosis (TB) incidence, treatment, care quality and operational research activities from 2016 to 2023 to assess the country's control efforts.

Methods: An 8-year retrospective study of TB incidence/mortality trends was performed using a Joint Point Analysis V.5.2.0. We extracted annual national and WHO TB programme data for the period under review.

Results: From 2016 to 2023, the TB incidence rate decreased by 2.6% (annual percentage change (APC)=-0.33, 95% CI- 0.5 to -0.005; p<0.05). The proportion of bacteriologically confirmed cases significantly increased (APC=4.2, 95% CI 0.9 to 7.7; p<0.001), while treatment coverage rose by 22% (APC=2.81, 95% CI 1.1 to 4.5; p<0.05). The proportion of notified patients with TB tested for HIV significantly increased (APC=25, 95% CI 2.6 to 52.63; p<0.05), but the rate of patients with TB testing HIV positive decreased significantly (APC=-13.9, 95% CI -23.9 to -2.6; p<0.05). The proportion of unsuccessful treatment outcomes showed a non-significant decline, with an APC of 4.90% (95% CI -11.7% to 2.3%; p=0.1), while TB-related deaths increased non-significantly, with an APC of 3.76% (95% CI -1.3% to 9.2%; p=0.12). Patients with TB/HIV on ART increased by 51% (APC=6.4, 95% CI -23.9 to -2.6; p<0.05). No operational research activity has been carried out throughout the review period.

Conclusion: The observed progress was insufficient, as the Republic of Congo failed to meet the 20% TB incidence reduction target for 2020 and is unlikely to achieve the 50% reduction goal for 2025. More investment in case detection, diagnosis, treatment quality and the implementation of operational research activities is needed to achieve global goals.

Introduction: Although an appropriate population range for caesarean section (CS) has been debated, the WHO recommends national CS rates be between 10% and 15%. Yet rates are much higher in many low-income and middle-income countries, including Bangladesh. These studies also reveal wide disparities in CS use by geographic location and sociodemographic conditions. Nevertheless, few studies have the sample size and temporal precision necessary to model convergence and divergence trends over time. We assessed trends in CS segregated by key sociodemographic factors known to affect CS.

Methods: We conducted our study using prospective pregnancy observation data from two distinct Maternal, Neonatal, and Child Health service areas: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and the government service areas in Matlab, Bangladesh. We evaluated sociodemographic variations and trends using the multivariable logistic regression model.

Findings: The proportion of CS rose from 5.9% in 2005 to 55.7% in 2019, about a ninefold increase, implying a 3.3% average annual growth rate. The CS was positively associated with residence in the icddr,b service area (vs government service area), older age, higher assets, lower parity births and, to a lesser extent, with higher levels of schooling. Among factors positively associated with CS, we observed negative time interactions for maternal age, education and place of delivery, suggesting a convergence in CS rates between high-risk and low-risk groups in these categories. However, positive time interactions for parity and asset score indicate that disparities in CS rates persist and are widening over time.

Conclusions: Transition towards near-universal CS, irrespective of sociodemographic status or service area, is likely to be the inevitable future for rural Bangladesh. If such high rates of CS are considered sub-optimal for mother-and-child health, then evidence is needed to support alternatives.

Introduction: Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, but its impact is limited by low uptake and poor continuation rates. This study investigates oral PrEP continuation among key populations (KPs) enrolled in an HIV prevention programme across seven states in Nigeria, representing one of the largest longitudinal PrEP continuation studies in Sub-Saharan Africa to date.

Methods: We analysed data from 43 788 clients who initiated daily oral PrEP between January 2020 and March 2023. The sample comprised female sex workers (20 574, 47.0%), men who have sex with men (12 946, 29.6%), people who inject drugs (9462, 21.6%) and transgender individuals (806, 1.8%). The primary outcome was 6-month PrEP continuation, defined as having a recorded PrEP refill more than 6 months after initiation. We used multivariable mixed-effects logistic regression to identify factors associated with PrEP continuation; the model included KP group, age, education, occupation, marital status and time since PrEP initiation and accounted for clustering at the facility level.

Results: Among the 43 788 clients initiating PrEP, the 6-month continuation rate was 11.5%. Female sex workers had the highest 6-month continuation rate (13.7%), while transgender individuals had the lowest (3.5%; adjusted OR (aOR) 0.37 (0.24-0.55), compared with female sex workers). The continuation rate generally increased with age; the oldest clients (≥40 years) had a significantly higher continuation rate than those aged 18-24 (12.9% vs 11.0%; aOR 1.15 (1.02-1.29)). Unemployment was also associated with a small but significant reduction in continuation, with a rate of 11.8% for unemployed clients compared with 12.1% for employed clients (aOR 0.86 (0.79-0.94)).

Conclusion: These findings highlight the need for targeted interventions to improve PrEP continuation among KPs in Nigeria, particularly for younger clients and transgender people.

Introduction: Women make up a significant portion of the global health workforce but are under-represented in leadership roles. In sub-Saharan Africa (SSA), 70% of the health workforce is women, yet only 38% hold leadership positions in health ministries. This gap can lead to gender biases in health research and policymaking, perpetuating systemic gender biases. Despite these barriers, women leaders are making an impact globally. However, evidence of their impact is lacking.

Methods: We conducted an explanatory sequential mixed-methods study to identify perceptions of women leaders' influence and impact within the fields of reproductive, maternal, child and adolescent health and nutrition and immunisation across SSA. The study included a multicountry online survey with men and women leaders and key informant interviews with a subset of women leaders. Descriptive statistics were computed with SPSS, and thematic analysis was conducted using NVivo.

Results: 408 women and men leaders completed at least one section of the survey; 34 women leaders participated in key informant interviews. Women leaders are conducting their leadership differently, using identity-derived power and the power of the collective to influence health policy and programme change. They have unique access to communities and can build trust with marginalised groups. Women leaders also prioritise women-centric and neglected health issues, demonstrating ethical responsibility through transparency, commitment to inclusion, accountability and maximising impact with limited resources.

Conclusion: The findings from this study underscore the critical role of women leaders in advancing health policy and gender equity across SSA. Women leaders' impact can be amplified and enhanced through targeted investments that strengthen enabling environments, foster allyship, champion gender integration activities implemented by women leaders and support their unique networks. Such investments will benefit women and adolescent girls and contribute to achieving broader public health goals and sustainable development.