BMJ Global Health最新文献

Introduction: Elevated blood pressure (BP) is the major contributor to mortality and disease burden worldwide. May Measurement Month (MMM) is a global BP screening campaign, which aims to raise awareness of BP measurement and provide evidence to inform and influence related health policy.

Methods: This cross-sectional survey included individuals aged≥18 years recruited through opportunistic sampling at sites in 60 countries during MMM 2022. Each participant had three sitting BP measurements and a questionnaire was completed including demographics, comorbidities and lifestyle factors. Hypertension was defined as a systolic BP≥140 mm Hg and/or a diastolic BP≥90 mm Hg (average of the second and third readings) or taking antihypertensive medication. Multiple imputation was used to estimate BP readings where any participant's BP readings were missing. Linear mixed effects models were used to identify associations between participant characteristics and systolic or diastolic BP.

Results: Of the 715 518 participants surveyed (excluding 50 200 self-measured home BP screenees recruited via the ZOE Health Study app), 257 421 (36.0%) were identified as hypertensive, of whom 57.6% were aware and 49.3% were on antihypertensive medication. Of all participants with hypertension, 26.1% were controlled to <140/90 mm Hg and 12.0% to <130/80 mm Hg. Of those taking antihypertensive medication, 52.7% were taking only one drug class, 52.9% were controlled to <140/90 mm Hg and 24.4% to 130/80 mm Hg. In total, 190 314 (26.6% of total surveyed, 73.9% of hypertensives) participants screened were found to have untreated or inadequately treated hypertension. Only 27.6% of treated hypertensive participants were taking a statin. Substantial coexistence of diabetes, overweight and hypertension was apparent among participants.

Conclusions: MMM confirms a high global burden of hypertension with low rates of awareness, treatment and control. In the absence of systematic BP screening in many countries, the results from MMM underscore the continued need for BP screening to detect and thereby control raised BP.

Introduction: In high tuberculosis (TB) burden countries, the private sector manages a large proportion of initial visits by presumptive patients with TB. In Indonesia, the second largest contributor of TB cases globally, private practitioners (PPs) often do not adhere to national TB guidelines. A district public-private mix programme to mitigate this issue was started in 2019, yet engagement remains low. This study examines what affects the decisions of Indonesian PPs regarding TB management.

Methods: We performed semistructured in-depth interviews and focus group discussions (FGDs) with 24 PPs and 6 relevant stakeholders. Data collection and analysis were based on Flottorp's comprehensive and generic checklist on determinants of healthcare professional practice, including seven domains: guideline factors; individual professional barriers; patient factors; professional interactions; incentives and resources; organisational changes capacity and social, legal and political factors. The interviews and FGDs were recorded and transcribed verbatim. Coding and analysis were conducted by using NVivo software.

Results: Barriers that influenced PPs adherence to following the national TB guideline were found in all seven domains, including incoherence between national and international TB management guidelines, the complex referral and financing system, limited access to appropriate diagnostics tools and drugs, and patient preferences. This was further exacerbated by perceived lack of trust between PPs and local governmental stakeholders. In this study, in addition to seventh Flottorp's domain, we also found the complex nature of TB disease, which also complicates the decision-making process of PPs in TB management.

Conclusion: PPs face several challenges in complying with TB guidelines to enable optimal clinical decision-making.

Introduction: The relationship between food insecurity and access to healthcare in low-resource settings remains unclear. Some studies find that food insecurity is a barrier to accessing care, while others report that food insecurity is associated with a greater need for care, leading to more care utilisation. We use data from the Harambee study in western Kenya to assess the association between food insecurity and difficulty accessing care among people living with HIV (PLWH) with or without comorbid non-communicable diseases (NCDs).

Methods: The Harambee study is a cluster randomised trial that tested the effectiveness of delivering integrated HIV and NCD care for PLWH. In this cross-sectional analysis, we examined baseline data from Harambee participants to investigate the relationship between household food insecurity and difficulty accessing care, using multivariable logistic regression models, controlling for sociodemographic factors and care satisfaction. We tested for effect measure modification by gender and household wealth and stratified analyses by NCD status.

Results: Among 1039 participants, 11.1% reported difficulty accessing care, and 18.9% and 51.9% of participants had moderate and severe food insecurity, respectively. Among those with difficulty accessing care, 73.9% cited transportation issues as the major barrier. Difficulty accessing care was greater with higher levels of food insecurity: among participants with low, moderate and severe food insecurity, 5.9%, 9.7% and 14.4% reported difficulty accessing care, respectively. After adjusting for confounders, severe food insecurity was independently associated with difficulty accessing care (adjusted OR=2.5, 95% CI 1.4 to 4.4). There was no statistical evidence for effect measure modification by gender or wealth.

Conclusions: We found that greater food insecurity was associated with greater difficulty accessing care among PLWH with or without NCDs in rural western Kenya. These findings suggest that addressing social determinants of health may be necessary when implementing integrated HIV and NCD care programmes.

This practice paper reflects on an ongoing Participatory Action Research project that combines community-engaged methods, national data analysis and advocacy to support community-based emergency response to extreme weather events in 16 Indigenous communities in Alta Verapaz province, Guatemala. Our work points to a worrying predicament experienced in climate-affected areas, where some populations face a dangerous confluence of climate vulnerability, social exclusion and state abandonment that imperils human health. Indigenous communities in Alta Verapaz are often particularly vulnerable to health impacts from climate-driven extreme weather events, a reality compounded by the historical and contemporary ways the state marginalises them. We share work from our project activities to shed light on these interconnected problems and how Indigenous communities in Alta Verapaz, especially Maya Q'eqchi' communities, are using creative strategies to confront them. Technical solutions are important but insufficient responses. Community-led activism to push for state support to address extreme weather events, as has been practised in struggles for health rights, can provide vital tools for addressing the increasing challenges these populations face in the context of the climate crisis.

Introduction: Trials of GLP-1 (glucagon-like peptide-1) medicines have changed the paradigm of obesity treatment. Diversity in trial participation is imperative considering that obesity disproportionately impacts marginalised populations worldwide. We performed a systematic review and meta-analyses to evaluate the representation of racialised and ethnically diverse populations in randomised controlled trials (RCTs) of GLP-1 medicines for obesity.

Methods: We searched PubMed/Embase/ClinicalTrials.gov. Prevalence of each racial/ethnic group was compared in relation to the USA, Canada, the UK, Brazil and South Africa. The geographical locations of the trial sites were extracted.

Results: 27 RCTs were identified (n=21 547 participants). Meta-analyses of prevalence demonstrated the vast predominance of white/Caucasians (79%) with smaller proportion of blacks (9%), Asians (13%), Indigenous (2%) and Hispanics (22%). The gaps in representation were evidenced by the significantly under-represented proportion of non-white individuals in these RCTs as compared with the prevalence of non-white individuals in the general population of the USA (-23%, p=0.002) and Canada (-34%, p<0.0001), reaching an alarming gap of -58% in relation to Brazil and striking under-representation of -68% as compared with South Africa. Similar discrepancies in proportions of blacks, Asians and Indigenous peoples as compared with reference nations were found. Moreover, the trial sites (n=1859) were predominately located in high-income countries (84.2%), in sharp contrast to the global prevalence of obesity that is predominantly in low-income and middle-income countries.

Conclusion: There are discrepancies in representation of racialised and ethnically diverse populations in obesity trials as compared with multiethnic populations worldwide. These data highlight the need for broader reform in the research process in order to ultimately address health inequities.

Introduction: Gypsies, Roma and Travellers (GRT) frequently experience poorer health outcomes than the general population and represent the most socially and economically disadvantaged individuals in many countries. In general, GRT in OECD (Organisation for Economic Co-operation and Development) countries have lower rates of literacy than the general population. Although 'health literacy' has been examined before, the link between low functional literacy and its effects on health has not yet been explored.

Methods: Searches were conducted on five large English-language databases for research papers since 2008. Grey literature was included as the number of eligible papers was small. This was complimented by citation 'chaining'. Study findings of qualitative papers were extracted, codes were devised and then analysed thematically. A narrative synthesis was reported, supplemented by the quantitative findings.

Results: 15 studies (and two substudies) were analysed. Four strongly overlapping themes were developed: (1) The context of culturally inadequate healthcare systems, (2) psychological impact and disempowerment, (3) intersectional, contextual factors and the unique needs of GRT and (4) considerations for health information resources for GRT patients with low literacy.

Conclusion: Although low literacy in GRT groups is a well-recognised issue, this is the first systematic review to analyse the link between low literacy and its effects on health outcomes for GRT. The wide range of socioeconomic and cultural factors present in GRT communities, combined with low literacy, act synergistically to worsen the physical and mental health of GRT groups in different ways than that seen in members of the general population with similar low literacy levels. National intervention is required to improve the literacy of GRT children and adults. There is a clear need to develop policies and processes that facilitate a better understanding of literacy levels and how they interact with other social determinants of GRT health among healthcare professionals.

Registration number: CRD42023468449.

Background: Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC) was developed to protect public health policies from tobacco industry interference. The guiding principles of Article 5.3 emphasise a fundamental conflict between the tobacco industry's interests and public health interests (principle 1) and recommend that the government be accountable and transparent (principle 2), demand accountability and transparency from the industry (principle 3), and refrain from providing incentives to the industry (principle 4). This study quantitatively explored attitudes towards Article 5.3's guiding principles and recommendations among Thai tobacco control stakeholders and whether they were associated with awareness of tobacco industry tactics.

Methods: We conducted an online survey of 703 individuals involved in tobacco control in Thailand . We employed multivariable ordinal logistic regression analysis to explore factors associated with attitudes towards Article 5.3's guiding principles and recommendations.

Results: 441 participants responded to the survey (response rate 62.7%). Among the Article 5.3 guiding principles, principle 1 received the lowest agreement (83%), whereas the other three principles had an average of 93% agreement. In multivariable ordinal logistic regression, we found awareness of tobacco industry tactics was associated with Article 5.3's guiding principles: principle 1 (adjusted OR (AOR) 1.11; 95% CI 1.07 to 1.15; p<0.001), principle 2 (AOR 1.07; 95% CI 1.02 to 1.12; p=0.002), principle 3 (AOR 1.11; 95% CI 1.06 to 1.15; p<0.001) and principle 4 (AOR 1.14; 95% CI 1.09 to 1.19; p<0.001). In addition to awareness of tobacco industry tactics, age, years of experience in tobacco control, role in tobacco control and smoking by family members and friends were associated with perspectives towards Article 5.3's guidelines.

Conclusions: This study provides quantitative evidence of the association between attitudes towards WHO FCTC Article 5.3 and awareness of tobacco industry tactics in Thailand. Denormalisation of the tobacco industry is thus a vital component of successfully implementing and enforcing Article 5.3.

Introduction: An adequate health workforce is one of the cornerstones of a healthy nation. Over the last two decades, Africa has gained momentum in mitigating critical health workforce gaps, but urgent actions are still needed to accelerate progress towards universal health coverage and ensuring health security. This analysis provides an overview of the health workforce in the WHO African Region for the last decade.

Methods: Data were extracted and triangulated from the National Health Workforce Accounts (NHWA), health labour market analyses, countries' human resources for health (HRH) profiles, HRH strategic plans and annual reports. A descriptive analysis of health worker stock, training capacity and unemployment levels was undertaken. The density of health workers was calculated per 10 000 population for each country and examined by occupational groups and income levels of the countries to provide a more comprehensive understanding of the health workforce dynamics.

Results: The stock of the health workforce progressively increased from 1.6 million in 2013 to 4.3 million in 2018 and 5.1 million in 2022. The stock of doctors, nurses, midwives, dentists and pharmacists was 2.6 million in 2022, representing a threefold increase over 10 years, with an annual growth rate of 13%. The density of these five health workforce occupations grew by 1.9% per annum between 2018 and 2022, from 11.14 per 10 000 in 2013 to 26.82 per 10 000 in 2022. The health professions education capacity in the region increased by 70%, with the annual education output growing from 148 357 graduates in 2018 to over 255 000 in 2022. The comprehensiveness of the findings can be attributed to improvement in health workforce data availability and quality as more countries implement the NHWA. The improvements in the health workforce in the region are also partly attributable to increasing investments in the capacity of health professions education institutions to produce more health workers, and use of evidence in planning, decision-making and high-level advocacy at various levels to invest in health workers.

Conclusion: This study provides crucial insights for policy reforms and investments to enhance the health workforce, which is essential to achieving universal health coverage and ensuring health security. While progress is notable, countries with unique challenges need targeted analyses and continuous support to develop the necessary number and skills of health workers in the African region.

Background: Parenting programmes, including those delivered in the Global South, are effective strategies to reduce violence against children (VAC). However, there is limited evidence of their impact when implemented at scale within routine delivery systems. This study aimed to address this gap by evaluating the real-world delivery of Parenting for Lifelong Health for Teens in Tanzania.

Methods: Participating parents/caregivers and their adolescent girls were recruited by local implementing partners in 2020-2021 as part of a community-based HIV prevention initiative focused on addressing drivers of female adolescent HIV-vulnerability such as VAC, caregiver-adolescent relationships and sexual reproductive health communication. The 14-session, group-based parenting programme was delivered by trained teachers and community facilitators. Quantitative surveys administered by providers measured a variety of outcomes including child maltreatment (primary outcome) and multiple secondary outcomes linked to increased risk of VAC. Multilevel models examined pre-post effects as well as variation by attendance and baseline demographic variables.

Results: Pre-post data from 27 319 parent/caregiver-child dyads were analysed, of which 34.4% of parents/caregivers were male. Analyses showed large reductions in child maltreatment (parents/caregivers: IRR=0.55, (95% CI 0.54, 0.56); adolescents: IRR=0.57, (95% CI 0.56, 0.58)), reduced intimate partner violence experience, reduced school-based violence, increased communication about sexual health, reduced poor supervision, reduced financial insecurity, reduced parenting stress, reduced parent and adolescent depression, and reduced adolescent conduct problems. In contrast to these positive outcomes, parents/caregivers and adolescents also reported reduced parental positive involvement and support of education, with those experiencing greater adversity reporting less change than those with less adversity.

Conclusions: This study is the first to examine the large-scale implementation of an evidence-based parenting programme in the Global South. Although additional research is necessary to examine potential negative effects on positive parenting and parent support of education, findings suggest that Furaha Teens can sustain its impact on key outcomes associated with VAC when delivered at scale.