BMJ Global Health最新文献

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.

Introduction: More than 75% of the global population resides in low- and middle-income countries (LMICs), where healthcare-associated infection rates are notably higher than in high-income countries. Little is known about the professional experiences, perceptions and needs of infection prevention and healthcare epidemiology professionals (IPHEP) practising in these countries.

Methods: A voluntary and anonymous online survey of IPHEP in LMICs was conducted via open invitations on social media and email from October 2022 to January 2023. The survey covered five domains: (1) Survey Responders, Practice Setting and Programme Characteristics; (2) Job Responsibilities, Training and Professional Development; (3) Workload and Work Environment; (4) COVID-19 Response; and (5) Priorities and Needs. Descriptive statistics were generated for the total sample and each World Bank region.

Results: The number of survey respondents was 148, who represented 28/138 (20.3%) LMICs. They reported receiving formal training in infection prevention (80/94, 85.1%), antimicrobial stewardship (44/94, 46.8%), quality improvement and patient safety tools (55/94, 58.5%) and leadership (37/94, 39.4%). Importantly, 48.8% (42/86) reported job burnout. During the COVID-19 pandemic, 55/102 (53.9%) respondents reported their programme as effective or extremely effective, and 58/102 (56.9%) reported moderate or extreme financial hardship for their facility. Hand hygiene, improving antibiotic use and preventing multidrug-resistant organisms were ranked as top three priorities to be addressed, with specific resource needs identified for each programme by 89.0%, 95.0% and 93.8% of the survey respondents, respectively.

Conclusion: This survey provides crucial insights into the realities faced by IPHEP in LMICs, emphasising the critical need for developing and strengthening workforce, supporting their organisational environments, allocating resources strategically for infection prevention and control initiatives, as well as improving their connectivity with other IPHEP colleagues across the world to foster greater collaboration and support.

Background: Sustainable Development Goal (SDG) 3.2, which aims to reduce under-five mortality rate (UFMR) below 25 deaths per 1000 live births by 2030, is still a crucial target for improved child survival in sub-Saharan Africa because UFMRs are still high and progress has stalled in recent years.

Objective: This study aimed to model the possibility of reaching the SDG 3.2 target by 2030 and evaluate trends in under-five mortality in Kenya.

Method: Three models: autoregressive integrated moving average (ARIMA), autoregressive fractionally integrated moving average (ARFIMA) and hybrid were fitted to annual national under-five mortality data from 1995 to 2022. Automated model selection showed ARIMA (0,2,1) as the best fitting model from information criteria, predictive accuracy and residual diagnostics. The model was tested with mean absolute error, root mean square error, mean absolute percentage error and tested against the 80/20 train-test split.

Results: Kenya's UFMR has been slightly declining over the course of the study, but the ARIMA projection indicates that the rate of fall is slowing. By 2030, the UFMR is expected to be 27.8 deaths per 1000 live births (95% prediction interval (PI) 25.2 to 30.3), over the SDG 3.2 goal level (signifying an increase in predicted uncertainty). The upper bound of humanity's real 95% PI still far exceeds the aim, even as the lower bound has started to move closer. Kenya would require an accelerated annual decline in roughly 2.43 fatalities per 1000 starting in 2023 much higher than trends seen in the recent past to meet SDG 3.2.

Conclusion: Kenya's UFMR has significantly decreased; however, the SDG 3.2 target might not be met by 2030 without more initiatives. To accelerate progress, it will be essential to improve mother and child health services, increase community-level interventions, address social injustices and employ more focused county-specific strategies. Using additional high-quality data and improved modelling tools could enhance child mortality monitoring and prediction in the future.

Disparity in access to trustworthy health information between high-income and low-income settings remains stark and contributes to global health inequity. The volume of new clinical practice guidelines a healthcare provider needs to digest to deliver up-to-date, evidence-based care is overwhelming, particularly in primary care, where the scope is comprehensive. However, many low- and middle-income countries (LMICs) lack the resources to tailor guidance for their realities. International standards for adaptation or adoption of existing guidelines tend to focus on a single clinical topic and still require considerable evidence synthesis expertise, slowing provision of up-to-date, relevant protocols for the primary care provider.The Practical Approach to Care Kit (PACK) guide covers most conditions managed in primary care. It has been introduced to South Africa, Ethiopia, Brazil, Nigeria, Botswana and Indonesia to support primary care reforms. This paper describes the reference repository and updating mechanisms underpinning the PACK Global guide (that forms a template for local adaptation) so that it reflects latest international evidence and WHO guidance. The referencing and updating mechanism to curate its 3689 recommendations drew on the established evidence synthesis processes of the British Medical Journal's Best Practice and the WHO. The challenges of maintaining this content set were largely funding and resource constraints in our small team. We are exploring how advances in generative artificial intelligence might expedite review of the large clinical guidelines and policies required for PACK updates as well as address limitations of current database software as a content management system, to facilitate editorial and publication processes.Leveraging existing evidence synthesis processes appears to be a feasible approach to maintaining a comprehensive LMIC primary care clinical content set and may go some way to improving access to up-to-date health information, thus addressing global health inequities.

Background: Evidence on food environment obesogenicity has largely focused on the formal sector in high-income countries, overlooking informal food retail environments in low- and middle-income countries (LMICs).

Aim: To synthesise current evidence on the obesogenicity of foods in informal food retail environments in LMICs.

Methods: A systematic literature search across four academic databases: Scopus, Web of Science, EBSCOhost (Global Health) and EMBASE, using predefined inclusion and exclusion criteria.

Results: Thirty studies met the inclusion criteria and were included in the synthesis. Findings indicate the pervasive availability of unhealthy or more obesogenic alternatives at informal food outlets located at transport stops, public markets, schools and neighbourhoods. The results also highlight the hybrid nature of informal food environments in LMICs, where both healthier and obesogenic options. For example, at transport stops, both fresh produce and high-calorie snacks are readily available. These findings illustrate the complex interplay between food availability, customer preferences and dietary outcomes.

Conclusion: This review highlights gaps in understanding the informal food environment and the need for further research to address its complexity. The hybrid nature of this environment calls for strategies that incentivise food outlets to improve the healthfulness of their offerings. Policymakers and public health practitioners should consider tailored interventions to support healthier food choices within informal food retail settings.