BMJ Global Health最新文献

Background: Indigenous knowledge and responses were implemented during the COVID-19 pandemic to protect health, showcasing how Indigenous communities participation in health systems could be a pathway to increase resilience to emergent hazards like climate change. This study aimed to inform efforts to enhance climate change resilience in a health context by: (1) examining if and how adaptation to climate change is taking place within health systems in the Peruvian Amazon, (2) understanding how Indigenous communities and leaders' responses to climatic hazards are being articulated within the official health system and (3) to provide recommendations to increase the climate change resilience of Amazon health systems.

Methods: This study was conducted among two Peruvian Amazon healthcare networks in Junin and Loreto regions. A mixed methodology design was performed using a cross-sectional survey (13 healthcare facilities), semistructured interviews (27 official health system participants and 17 Indigenous participants) and two in-person workshops to validate and select key priorities (32 participants). We used a climate-resilient health system framework linked to the WHO health systems building blocks.

Results: Indigenous and official health systems in the Peruvian Amazon are adapting to climate change. Indigenous responses included the use of Indigenous knowledge on weather variability, vegetal medicine to manage health risks and networks to share food and resources. Official health responses included strategies for climate change and response platforms that acted mainly after the occurrence of climate hazards. Key pathways to articulate Indigenous and official health systems encompass incorporating Indigenous representations in climate and health governance, training the health work force, improving service delivery and access, strengthening the evidence to support Indigenous responses and increasing the budget for climate emergency responses.

Conclusions: Key resilience pathways call for a broader paradigm shift in health systems that recognises Indigenous resilience as valuable for health adaptation, moves towards a more participatory health system and broadens the vision of health as a dimension inherently tied to the environment.

Introduction: The COVID-19 pandemic triggered one of the largest global health and economic crises in recent history. COVID-19 vaccination (CV) has been the central tool for global health and macroeconomic recovery, yet estimates of CV's global health and macroeconomic value remain scarce.

Methods: We used regression analyses to measure the impact of CV on gross domestic product (GDP), infections and deaths. We combined regression estimates of vaccine-averted infections and deaths with estimates of quality-adjusted life years (QALY) losses, and direct and indirect costs, to estimate three broad value components: (i) QALY gains, (ii) direct and indirect costs averted and (iii) GDP impacts. The global value is the sum of components over 148 countries between January 2020 and December 2021 for CV generally and for Pfizer-BioNTech specifically.

Results: CV's global value was US$5.2 (95% CI US$4.1 to US$6.2) trillion, with Pfizer-BioNTech's vaccines contributing over US$1.9 (95% CI US$1.5 to US$2.3) trillion. Varying key parameters results in values 10%-20% higher or lower than the base-case value. The largest value component was GDP impacts, followed by QALY gains, then direct and indirect costs averted. CV provided US$740 of value per dose, while Pfizer-BioNTech specifically provided >US$1600 per dose. We estimated conservative benefit-cost ratios of 13.9 and 30.8 for CV and Pfizer-BioNTech, respectively.

Conclusions: We provide the first estimates of the broad value of CV incorporating GDP, QALY and direct and indirect cost impacts. Through December 2021, CV produced significant health and economic value, represented strong value for money and produced significant macroeconomic benefits that should be considered in vaccine evaluation.

Background: Malaria mortality is influenced by several factors including climatic and environmental factors, interventions, socioeconomic status (SES) and access to health systems. Here, we investigated the joint effects of climatic and non-climatic factors on under-five malaria mortality at different spatial scales using data from a Health and Demographic Surveillance System (HDSS) in western Kenya.

Methods: We fitted Bayesian spatiotemporal (zero-inflated) negative binomial models to monthly mortality data aggregated at the village scale and over the catchment areas of the health facilities within the HDSS, between 2008 and 2019. First order autoregressive temporal and conditional autoregressive spatial processes were included as random effects to account for temporal and spatial variation. Remotely sensed climatic and environmental variables, bed net use, SES, travel time to health facilities, proximity from water bodies/streams and altitude were included in the models to assess their association with malaria mortality.

Results: Increase in rainfall (mortality rate ratio (MRR)=1.12, 95% Bayesian credible interval (BCI): 1.04-1.20), Normalized Difference Vegetation Index (MRR=1.16, 95% BCI: 1.06-1.28), crop cover (MRR=1.17, 95% BCI: 1.11-1.24) and travel time to the hospital (MRR=1.09, 95% BCI: 1.04-1.13) were associated with increased mortality, whereas increase in bed net use (MRR=0.84, 95% BCI: 0.70-1.00), distance to the nearest streams (MRR=0.89, 95% BCI: 0.83-0.96), SES (MRR=0.95, 95% BCI: 0.91-1.00) and altitude (MRR=0.86, 95% BCI: 0.81-0.90) were associated with lower mortality. The effects of travel time and SES were no longer significant when data was aggregated at the health facility catchment level.

Conclusion: Despite the relatively small size of the HDSS, there was spatial variation in malaria mortality that peaked every May-June. The rapid decline in malaria mortality was associated with bed nets, and finer spatial scale analysis identified additional important variables. Time and spatially targeted control interventions may be helpful, and fine spatial scales should be considered when data are available.

Effective community entry processes influence community participation and acceptance of public health interventions. Though there is a growing body of literature on the importance of community partnerships, there is a lack of pragmatic and practical documentation of the experiences involved in the community entry process as it relates to culturally sensitive topics such as child marriage which can help to support researchers working in this field. This article highlights key themes related to knowledge of the community, effective communication, cultural sensitivity, coproduction and giving feedback which help to build trust between the community members and the research team. Institutional representation, not managing expectations, and lack of clarity, along with personal opinions of community gatekeepers can create challenges for the fostering of trustworthy relationships with the community. These realities must be actively addressed right at the onset of the process between the research team and community stakeholders. Researchers can develop trust, form connections and engage different communities by working with local groups and leaders, using culturally appropriate methods, and addressing community concerns. Future projects working with communities on child marriage in Nigeria and other countries would benefit from the reflections presented in this paper.

Background: Adolescents comprise one-sixth of the world's population, yet there is no clear understanding of the features that promote adolescent-friendly services (AFS). The lack of clarity and consistency around a definition presents a gap in health services.

Methods: The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a scoping review of peer-reviewed empirical studies to explore AFS in low-income and middle-income countries (LMICs) published between January 2000 and December 2022. The databases searched were CAB Direct (n=11), CINAHL (n=50), Cochrane Databases (n=1103), Embase (n=1164), Global Health Medicus (n=3636) and PsycINFO (n=156). The title, abstract and full text were double screened by three independent reviewers. Three independent reviewers assessed the study's quality using the Joanna Briggs Initiative Quality Appraisal and Cochrane Risk of Bias 2 tools.

Results: We identified the key components, barriers and facilitators of AFS. The following emerged from our review: a non-judgmental environment, culturally appropriate and responsive interventions and a focus on supporting marginalised communities often living in high-poverty settings. Using these components, we have extended guidance around a possible framework and tool assessing quality of AFS.

Interpretation: As LMICs are heterogeneous and unique, it was assumed that the operational definition of 'adolescent-friendly' might vary depending on different contexts, but there must be core components that remain consistent. Possible limitations of our review include a lack of grey literature. Potential future implications include training healthcare providers, testing these attributes for service improvement and future development and localisation of policy guidelines.

Key highlights: Our review has mapped the research framing of AFS and provided a comprehensive review of barriers and facilitators to implementing a holistic outlook of AFS set-up in a tightly controlled research and real-world context. Our paper is one of the few efforts to synthesise behavioural and mental health elements underpinning AFS.