BMJ Global Health最新文献

Introduction: Economic shocks, that is, events that cause a sudden loss of income for households, are common in low-income and middle-income countries (LMICs), yet their impact on mental health remains understudied. While such shocks may contribute to depression and anxiety, evidence remains limited, particularly in resource-poor settings where mental health disorders are underdiagnosed and undertreated. This study examines the causal impact of economic shocks on depression and anxiety in a low-income context.

Methods: We used nationally representative panel data over two waves from Bangladesh, applying individual fixed effects to estimate the impact of economic shocks on mental health outcomes. Economic shocks were defined as adverse events negatively affecting income, assets or production. Depression and anxiety were assessed using the validated Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7 scales.

Results: In a two-round sample of 7090 observations, 16.3% (N=1155) experienced depression, 6.5% (N=459) experienced anxiety and 5.1% (N=361) experienced both depression and anxiety. Economic shocks significantly increased depression and anxiety. Individuals experiencing multiple types of shocks had nearly double the risk of reporting either mental health disorder compared with those facing a single shock. These impacts persisted for 6-12 months postshock. Adverse mental health effects were concentrated among individuals without coping mechanisms, such as use of savings, credit or support from friends and family, while those with access to such mechanisms showed no significant adverse outcomes. Education appeared protective, with individuals who had at least primary education exhibiting lower vulnerability to mental health issues in the face of shocks.

Conclusions: Economic shocks have a substantial and lasting mental health impact, with compounding effects for those experiencing multiple shocks. Education and coping mechanisms may serve as a buffer against adverse outcomes. These findings highlight the need for targeted interventions to mitigate the mental health consequences of economic disruptions in LMICs.

Introduction: Like many countries globally, childhood immunisation coverage is below government targets in the Philippines and has worsened during the COVID-19 pandemic, leading to outbreaks of vaccine-preventable diseases. This study aimed to identify the social and behavioural drivers of routine childhood immunisation and preferred caregiver information sources to improve uptake in the Philippines.

Methods: A quantitative, cross-sectional study, as part of a larger mixed-methods study, was undertaken in three regions in the Philippines with low immunisation coverage in 2023. Data on Behavioural and Social Drivers (BeSD) of immunisation, preferred information sources and vaccination status of children under 5 years were collected, analysed and reported according to the WHO BeSD framework.

Results: The study included 653 caregivers and 950 children, with 65% of children fully immunised, 31.8% partially immunised and 2.5% being zero-dose or having received no vaccines. Key reasons for complete vaccination included the protection vaccines offer, healthcare worker recommendations and vaccines being free of charge. For partial vaccination, top reasons were intercurrent illness, inaccessible vaccination sites and parental belief that the child was too young to receive vaccines. The most common reason for non-vaccination was also intercurrent illness. The predictors of complete vaccination were older age of caregivers (46-59 years) (prevalence ratio (PR)=1.29; 95% CI 1.12 to 1.48) and low concerns about vaccine safety (PR=1.13; 95% CI 1.03 to 1.25). Other Christian denominations, compared with Catholics, were less likely to have fully immunised children (PR 0.82; 95% CI 0.69 to 0.97). Preferred vaccine information sources included the Department of Health, healthcare workers and mass media.

Conclusions: We found that only 65% of children were fully immunised in 2023, with both access and acceptance factors impacting uptake of routine childhood vaccines. Improving service accessibility and education of healthcare workers on vaccine safety and effectiveness and more targeted messaging from health authorities and mass media about the benefits of vaccination could increase uptake in the Philippines, with learnings from this study applicable globally.

Introduction: While a large proportion of buccal mucosa cancer (BMC) is attributed to tobacco use, the contribution of alcohol is little-known. In India, alcohols include internationally-recognised (IRL) and locally-brewed liquor (LBL) types, which might contribute differently to the risk of BMC. We conducted an observational study to evaluate the association of local and foreign alcoholic beverage use on the risk of developing BMC.

Methods: Data from 1803 BMC cases and 1903 visitor controls from a multicentric case-control study was analysed for 11 IRLs and 30 LBLs. Healthy visitor controls were randomly sampled from the source population of the study centres which enrolled the cases. Quantitative data on the amount, the number of times consumed per day or week, and the lifetime duration of consumption for each of the alcoholic beverages were collected using an interviewer administered standardised questionnaire, which was then used to estimate the grams per day consumption of alcohol. Odds ratios (OR) and 95% CI were estimated after adjustment for potential confounders, including tobacco use. The joint effect of tobacco and alcohol on BMC risk, the attributable fraction (AF) of cases and state-wise population attributable fraction (PAF) were estimated.

Results: An increased risk of 1.68 (95% CI=1.44-1.97), 1.72 (95% CI=1.46-2.04), and 1.87 (95% CI=1.46-2.39) was observed for ever-users of any alcohol, IRLs and LBLs, respectively for BMC. The findings show 9 grams/day of alcohol increased the risk of BMC by approximately 50%, and 62% of cases could be attributed to alcohol drinking and chewing tobacco, with an overall PAF of 11.3% for India.

Conclusion: This study shows that alcohol, even in low quantities, increases the risk for BMC. Prevention of consumption of tobacco and alcohol together could substantially reduce the incidence of BMC.

Introduction: The UN General Assembly in 2018 passed a resolution to eliminate obstetric fistula within a decade. Because the prevalence of obstetric fistula is not known, it is difficult to develop appropriate national and global health strategies to prevent, treat and eliminate the condition. We estimate the prevalence of obstetric fistula in 55 countries targeted by the UNFPA-led global Campaign to End Fistula Programme.

Methods: We used data on reported symptoms of obstetric fistula from 31 Demographic and Health Surveys conducted in 22 countries and applied a predictive model to estimate the global, regional and country-level prevalences of current obstetric fistula cases in target countries. Self-reported fistula symptoms are subject to over-reporting and misclassification biases. Using known estimates of clinically diagnostic validation from large population studies, we additionally corrected self-reported obstetric fistula estimates for misclassification errors.

Results: We estimate the global fistula prevalence of about 457 000 (95% CI 303 000 to 709 000) among women aged 15-64 and about 386 000 (95% CI 256 000 to 599 000) among women of reproductive age (15-49). The obstetric fistula prevalence rate was almost two times higher in the sub-Saharan region (71 per 100 000 women) compared with Asia (36 per 100 000 women).

Conclusion: The estimated prevalence of obstetric fistula is substantially lower than the previously cited numbers of 2 million women. The prevalence and incidence rates of obstetric fistula have likely declined over time due to a number of factors. Skilled birth attendance, access to emergency obstetric care and caesarean section deliveries have substantially increased in low- and middle-income countries with a concurrent decline in maternal mortality during the last two decades. The global Campaign to End Fistula, launched in 2003, together with other international efforts, has also targeted improving prevention and treatment of obstetric fistula during this period. This is a preventable and treatable condition, and the global community must mobilise to eliminate this devastating and tragic condition by ensuring that women have access to timely and quality emergency obstetric care, including safe surgical care for caesarean section.

Background: Evidence impact of the COVID-19 pandemic on health-related indicator in Sub-Saharan Africa is limited. We aimed to assess the indirect effect of COVID-19 on essential health service and outcomes in Guinea.

Methods: In this interrupted time series analysis, we analysed a nationally surveillance data from January 2018 to December 2022 of nine indicators of HIV, malaria, tuberculosis (TB) and childhood vaccination. We fitted a Poisson segmented regression model accounting for seasonality to estimate the immediate impact of the COVID-19 on these outcomes as well as per-pandemic trend through incidence rate ratio (IRRs) with 95% CIs.

Results: Between January 2018 and December 2022, the month-to-month (quarter-to-quarter for TB) changes before COVID-19 outbreak increased from 0.4% to 6.4% in all indicators except for TB therapeutic success rate (IRR 0.995, 95% CI 0.987 to 1.004). Overall, there was a decrease in three indicators ranging from 6% for pentavalent vaccine (IRR 0.940, 0.906 to 0.974) to 15% for TB total cases notification (IRR 0.850, 0.785 to 0.920). The pandemic COVID-19 trend significantly downward monthly for four indicators ranging from 0.8% for in-patient malaria cases (IRR 0.992, 0.986 to 0.998) to 8% for PCR test in infants (IRR 0.920, 0.902 to 0.938), and significantly increased monthly by 2.5% for TB-positive microscopy (IRR 1.025, 1.015 to 1.036) and by 0.9% for TB therapeutic success rate (IRR 1.009, 1.001 to 1.017).

Conclusion: In Guinea, during the 2020 COVID-19 pandemic, the malaria indicators were generally maintained, while the number of HIV tests in infants, childhood vaccines and TB indicators were heavily impacted. There is an urgent need for more protective and targeted strategies to improve the preparedness of the healthcare service.

Introduction: Repeated exposure to domestic violence (DV) is common among women; however, little is known about how women's experiences of DV change over time. This study explores transitions in women's experience of physical DV over a 19-year period (2001-2020) and identifies risk and protective factors for such transitions in violence using data from the MINIMat cohort study in rural Bangladesh.

Methods: Data on physical DV were collected using a modified Conflict Tactic Scale from a cohort of 1078 women, from Matlab, a rural subdistrict of Bangladesh, recruited during pregnancy and followed up 10 and 18 years after the birth of the index child. Discrete-time Markov Chain and covariate-dependent Markov models were used to identify transitions across time points and associated and risk and protective factors among women who transitioned from: (1) no lifetime violence at enrolment to victimisation at 10-year follow-up and (2) lifetime victimisation at enrolment to revictimisation at 10-year follow-up. Risk and protective factors for revictimisation at 18-year follow-up were also identified.

Results: Most women reporting lifetime physical DV at enrolment experienced revictimisation at 10-year follow-up (70%), while 30% of women without prior experience of DV reported new victimisation. Revictimisation was lower at 18-year follow-up among women victimised at both prior points (30%). Low agency in decision-making and high agency in mobility increased likelihood of physical DV at 10-year follow-up regardless of violence status at enrolment. Living with in-laws protected against revictimisation at 10-year follow-up (adjusted OR (aOR) 2.53; 95% CI 1.30 to 4.91). Higher age (aOR 0.87; 95% CI 0.80 to 0.95) and non-governmental organisation (NGO) membership (aOR 0.23; 95% CI 0.09 to 0.55) reduced risk of revictimisation at 18-year follow-up.

Conclusion: Findings highlight the complex nature of women's empowerment and its evolving relationship with DV over time. Tailored approaches to empowerment and targeting older women in NGO programmes may offer long-term protection.

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.