Pub Date : 2024-06-27DOI: 10.1136/bmjgh-2023-014840
Zakia Arfeen, Brett Diaz, Cynthia Ruth Whitehead, Mohammed Ahmed Rashid
Introduction: Following India and Pakistan gaining independence from British colonial rule, many doctors from these countries migrated to the UK and supported its fledgling National Health Service (NHS). Although this contribution is now widely celebrated, these doctors often faced hardship and hostility at the time and continue to face discrimination and racism in UK medical education. This study sought to examine discursive framings about Indian and Pakistani International Medical Graduates (IPIMGs) in the early period of their migration to the UK, between 1960 and 1980.
Methods: We assembled a textual archive of publications relating to IPIMGs in the UK during this time period in The BMJ. We employed critical discourse analysis to examine knowledge and power relations in these texts, drawing on postcolonialism through the contrapuntal approach developed by Edward Said.
Results: The dominant discourse in this archive was one of opportunity. This included the opportunity for training, which was not available to IPIMGs in an equitable way, the missed opportunity to frame IPIMGs as saviours of the NHS rather than 'cheap labour', and the opportunity these doctors were framed to be held by being in the 'superior' British system, for which they should be grateful. Notably, there was also an opportunity to oppose, as IPIMGs challenged notions of incompetence directed at them.
Conclusion: As IPIMGs in the UK continue to face discrimination, we shed light on how their cultural positioning has been historically founded and engrained in the imagination of the British medical profession by examining discursive trends to uncover historical tensions and contradictions.
{"title":"An opportunity to be grateful for? Exploring discourses about international medical graduates from India and Pakistan to the UK between 1960 and 1980.","authors":"Zakia Arfeen, Brett Diaz, Cynthia Ruth Whitehead, Mohammed Ahmed Rashid","doi":"10.1136/bmjgh-2023-014840","DOIUrl":"10.1136/bmjgh-2023-014840","url":null,"abstract":"<p><strong>Introduction: </strong>Following India and Pakistan gaining independence from British colonial rule, many doctors from these countries migrated to the UK and supported its fledgling National Health Service (NHS). Although this contribution is now widely celebrated, these doctors often faced hardship and hostility at the time and continue to face discrimination and racism in UK medical education. This study sought to examine discursive framings about Indian and Pakistani International Medical Graduates (IPIMGs) in the early period of their migration to the UK, between 1960 and 1980.</p><p><strong>Methods: </strong>We assembled a textual archive of publications relating to IPIMGs in the UK during this time period in <i>The BMJ</i>. We employed critical discourse analysis to examine knowledge and power relations in these texts, drawing on postcolonialism through the contrapuntal approach developed by Edward Said.</p><p><strong>Results: </strong>The dominant discourse in this archive was one of opportunity. This included the opportunity for training, which was not available to IPIMGs in an equitable way, the missed opportunity to frame IPIMGs as saviours of the NHS rather than 'cheap labour', and the opportunity these doctors were framed to be held by being in the 'superior' British system, for which they should be grateful. Notably, there was also an opportunity to oppose, as IPIMGs challenged notions of incompetence directed at them.</p><p><strong>Conclusion: </strong>As IPIMGs in the UK continue to face discrimination, we shed light on how their cultural positioning has been historically founded and engrained in the imagination of the British medical profession by examining discursive trends to uncover historical tensions and contradictions.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11216068/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141466188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-25DOI: 10.1136/bmjgh-2024-015580
Jorge Ricardo Ledesma, Christopher Isaac, Scott F Dowell, David L Blazes, Gabrielle V Essix, Katherine Budeski, Jessica Bell, Jennifer B Nuzzo
{"title":"Authors' reply to 'assessments of the performance of pandemic preparedness measures must properly account for national income'.","authors":"Jorge Ricardo Ledesma, Christopher Isaac, Scott F Dowell, David L Blazes, Gabrielle V Essix, Katherine Budeski, Jessica Bell, Jennifer B Nuzzo","doi":"10.1136/bmjgh-2024-015580","DOIUrl":"10.1136/bmjgh-2024-015580","url":null,"abstract":"","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11202660/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141455339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-25DOI: 10.1136/bmjgh-2023-014821
Ursula Gazeley, Marvine Caren Ochieng, Onesmus Wanje, Angela Koech Etyang, Grace Mwashigadi, Nathan Barreh, Alice Mnyazi Kombo, Mwanajuma Bakari, Grace Maitha, Sergio A Silverio, Marleen Temmerman, Laura Magee, Peter von Dadelszen, Veronique Filippi
Introduction: The burden of severe maternal morbidity is highest in sub-Saharan Africa, and its relative contribution to maternal (ill) health may increase as maternal mortality continues to fall. Women's perspective of their long-term recovery following severe morbidity beyond the standard 42-day postpartum period remains largely unexplored.
Methods: This woman-centred, grounded theory study was nested within the Pregnancy Care Integrating Translational Science Everywhere (PRECISE) study in Kilifi, Kenya. Purposive and theoretical sampling was used to recruit 20 women who experienced either a maternal near-miss event (n=11), potentially life-threatening condition (n=6) or no severe morbidity (n=3). Women were purposively selected between 6 and 36 months post partum at the time of interview to compare recovery trajectories. Using a constant comparative approach of line-by-line open codes, focused codes, super-categories and themes, we developed testable hypotheses of women's postpartum recovery trajectories after severe maternal morbidity.
Results: Grounded in women's accounts of their lived experience, we identify three phases of recovery following severe maternal morbidity: 'loss', 'transition' and 'adaptation to a new normal'. These themes are supported by multiple, overlapping super-categories: loss of understanding of own health, functioning and autonomy; transition in women's identity and relationships; and adaptation to a new physical, psychosocial and economic state. This recovery process is multidimensional, potentially cyclical and extends far beyond the standard 42-day postpartum period.
Conclusion: Women's complex needs following severe maternal morbidity require a reconceptualisation of postpartum recovery as extending far beyond the standard 42-day postpartum period. Women's accounts expose major deficiencies in the provision of postpartum and mental healthcare. Improved postpartum care provision at the primary healthcare level, with reach extended through community health workers, is essential to identify and treat chronic mental or physical health problems following severe maternal morbidity.
{"title":"Postpartum recovery after severe maternal morbidity in Kilifi, Kenya: a grounded theory of recovery trajectories beyond 42 days.","authors":"Ursula Gazeley, Marvine Caren Ochieng, Onesmus Wanje, Angela Koech Etyang, Grace Mwashigadi, Nathan Barreh, Alice Mnyazi Kombo, Mwanajuma Bakari, Grace Maitha, Sergio A Silverio, Marleen Temmerman, Laura Magee, Peter von Dadelszen, Veronique Filippi","doi":"10.1136/bmjgh-2023-014821","DOIUrl":"10.1136/bmjgh-2023-014821","url":null,"abstract":"<p><strong>Introduction: </strong>The burden of severe maternal morbidity is highest in sub-Saharan Africa, and its relative contribution to maternal (ill) health may increase as maternal mortality continues to fall. Women's perspective of their long-term recovery following severe morbidity beyond the standard 42-day postpartum period remains largely unexplored.</p><p><strong>Methods: </strong>This woman-centred, grounded theory study was nested within the Pregnancy Care Integrating Translational Science Everywhere (PRECISE) study in Kilifi, Kenya. Purposive and theoretical sampling was used to recruit 20 women who experienced either a maternal near-miss event (n=11), potentially life-threatening condition (n=6) or no severe morbidity (n=3). Women were purposively selected between 6 and 36 months post partum at the time of interview to compare recovery trajectories. Using a constant comparative approach of line-by-line open codes, focused codes, super-categories and themes, we developed testable hypotheses of women's postpartum recovery trajectories after severe maternal morbidity.</p><p><strong>Results: </strong>Grounded in women's accounts of their lived experience, we identify three phases of recovery following severe maternal morbidity: 'loss', 'transition' and 'adaptation to a new normal'. These themes are supported by multiple, overlapping super-categories: loss of understanding of own health, functioning and autonomy; transition in women's identity and relationships; and adaptation to a new physical, psychosocial and economic state. This recovery process is multidimensional, potentially cyclical and extends far beyond the standard 42-day postpartum period.</p><p><strong>Conclusion: </strong>Women's complex needs following severe maternal morbidity require a reconceptualisation of postpartum recovery as extending far beyond the standard 42-day postpartum period. Women's accounts expose major deficiencies in the provision of postpartum and mental healthcare. Improved postpartum care provision at the primary healthcare level, with reach extended through community health workers, is essential to identify and treat chronic mental or physical health problems following severe maternal morbidity.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11202725/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141455341","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-25DOI: 10.1136/bmjgh-2023-014904
Ala Alwan, Wilhemina Jallah, Rob Baltussen, Manuel Carballo, Ernest Gonyon, Ina Gudumac, Hassan Haghparast-Bidgoli, George Jacobs, Gerard Joseph Abou Jaoude, Francis Nah Kateh, Gorbee Logan, Jolene Skordis
Liberia developed an evidence-informed package of health services for Universal Health Coverage (UHC) based on the Disease Control Priorities 3 evidence. This paper describes the policy decisions, methods and processes adopted for prioritisation, key features of the package and lessons learnt, with special emphasis on feasibility of implementation. Package design was led by the Ministry of Health. Prioritisation of essential services was based on evidence on disease burden, cost-effectiveness, financial risk, equity, budget impact, and feasibility of implementation. Fiscal space analysis was used to assess package affordability and options for expanding the budget envelope. The final adopted package focuses on primary healthcare and comprises a core subpackage of 78 publicly financed interventions and a complementary subpackage of 50 interventions funded through cost-sharing. The estimated per capita cost to the government is US$12.28, averting around 1.2 million DALYs. Key lessons learnt are described: (1) priority setting is essential for designing affordable packages of essential services; (2) the most realistic and affordable option when domestic resources are critically limited is to focus on basic, high-impact primary health services; (3) Liberia and many other countries will continue to rely on donor funding to expand the range of essential services until more domestic resources become available; (4) national leadership and effective engagement of key stakeholders are critical for a successful package design; (5) effective implementation is less likely unless the package cost is affordable and the health system gaps are assessed and addressed. A framework of action was employed to assess the consistency with the prerequisites for an appropriate package design. Based on the framework, Liberia developed a transparent and affordable package for UHC, but the challenges to implementation require further action by the government.
{"title":"Designing an evidence-informed package of essential health services for Universal Health Coverage: lessons learnt and challenges to implementation in Liberia.","authors":"Ala Alwan, Wilhemina Jallah, Rob Baltussen, Manuel Carballo, Ernest Gonyon, Ina Gudumac, Hassan Haghparast-Bidgoli, George Jacobs, Gerard Joseph Abou Jaoude, Francis Nah Kateh, Gorbee Logan, Jolene Skordis","doi":"10.1136/bmjgh-2023-014904","DOIUrl":"10.1136/bmjgh-2023-014904","url":null,"abstract":"<p><p>Liberia developed an evidence-informed package of health services for Universal Health Coverage (UHC) based on the Disease Control Priorities 3 evidence. This paper describes the policy decisions, methods and processes adopted for prioritisation, key features of the package and lessons learnt, with special emphasis on feasibility of implementation. Package design was led by the Ministry of Health. Prioritisation of essential services was based on evidence on disease burden, cost-effectiveness, financial risk, equity, budget impact, and feasibility of implementation. Fiscal space analysis was used to assess package affordability and options for expanding the budget envelope. The final adopted package focuses on primary healthcare and comprises a core subpackage of 78 publicly financed interventions and a complementary subpackage of 50 interventions funded through cost-sharing. The estimated per capita cost to the government is US$12.28, averting around 1.2 million DALYs. Key lessons learnt are described: (1) priority setting is essential for designing affordable packages of essential services; (2) the most realistic and affordable option when domestic resources are critically limited is to focus on basic, high-impact primary health services; (3) Liberia and many other countries will continue to rely on donor funding to expand the range of essential services until more domestic resources become available; (4) national leadership and effective engagement of key stakeholders are critical for a successful package design; (5) effective implementation is less likely unless the package cost is affordable and the health system gaps are assessed and addressed. A framework of action was employed to assess the consistency with the prerequisites for an appropriate package design. Based on the framework, Liberia developed a transparent and affordable package for UHC, but the challenges to implementation require further action by the government.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11202745/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141455340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-18DOI: 10.1136/bmjgh-2023-014602
Rana Islamiah Zahroh, Alya Hazfiarini, Moya Ad Martiningtyas, Fitriana Murriya Ekawati, Ova Emilia, Marc Cheong, Ana Pilar Betran, Caroline Se Homer, Meghan A Bohren
Introduction: Caesarean section (CS) rates in Indonesia are increasing rapidly. Understanding women's preferences about mode of birth is important to help contextualise these rising rates and can help develop interventions to optimise CS. This study aimed to explore Indonesian women's preferences and decision-making about mode of birth, and how their preferences may change throughout pregnancy and birth.
Methods: We conducted a longitudinal qualitative study using in-depth interviews with 28 women accessing private and public health facilities in Jakarta, the region with the highest CS rates. Interviews were conducted two times: during the woman's third trimester of pregnancy and in the postpartum period, between October 2022 and March 2023. We used a reflexive thematic approach for analysis.
Results: We generated three themes: (1) preferences about the mode of birth, (2) decision-making about the mode of birth and (3) regrets about the actual mode of birth. Most women preferred vaginal birth. However, they were influenced by advertisements promoting enhanced recovery after CS (ERACS) as an 'advanced technique' of CS, promising a comfortable, painless and faster recovery birth. This messaging influenced women to perceive CS as equivalent or even superior to vaginal birth. Where women's preferences for mode of birth shifted around the time of birth, this was primarily due to the obstetricians' discretion. Women felt they did not receive adequate information from obstetricians on the benefits and risks of CS and vaginal birth and felt disappointed when their actual mode of birth was not aligned with their preferences.
Conclusion: Our study shows that despite rising CS rates, Indonesian women prefer vaginal birth. This highlights the need for better communication strategies and evidence-based information from healthcare providers. Given the rising popularity of ERACS, more work is urgently needed to standardise and regulate its use.
{"title":"Rising caesarean section rates and factors affecting women's decision-making about mode of birth in Indonesia: a longitudinal qualitative study.","authors":"Rana Islamiah Zahroh, Alya Hazfiarini, Moya Ad Martiningtyas, Fitriana Murriya Ekawati, Ova Emilia, Marc Cheong, Ana Pilar Betran, Caroline Se Homer, Meghan A Bohren","doi":"10.1136/bmjgh-2023-014602","DOIUrl":"10.1136/bmjgh-2023-014602","url":null,"abstract":"<p><strong>Introduction: </strong>Caesarean section (CS) rates in Indonesia are increasing rapidly. Understanding women's preferences about mode of birth is important to help contextualise these rising rates and can help develop interventions to optimise CS. This study aimed to explore Indonesian women's preferences and decision-making about mode of birth, and how their preferences may change throughout pregnancy and birth.</p><p><strong>Methods: </strong>We conducted a longitudinal qualitative study using in-depth interviews with 28 women accessing private and public health facilities in Jakarta, the region with the highest CS rates. Interviews were conducted two times: during the woman's third trimester of pregnancy and in the postpartum period, between October 2022 and March 2023. We used a reflexive thematic approach for analysis.</p><p><strong>Results: </strong>We generated three themes: (1) preferences about the mode of birth, (2) decision-making about the mode of birth and (3) regrets about the actual mode of birth. Most women preferred vaginal birth. However, they were influenced by advertisements promoting enhanced recovery after CS (ERACS) as an 'advanced technique' of CS, promising a comfortable, painless and faster recovery birth. This messaging influenced women to perceive CS as equivalent or even superior to vaginal birth. Where women's preferences for mode of birth shifted around the time of birth, this was primarily due to the obstetricians' discretion. Women felt they did not receive adequate information from obstetricians on the benefits and risks of CS and vaginal birth and felt disappointed when their actual mode of birth was not aligned with their preferences.</p><p><strong>Conclusion: </strong>Our study shows that despite rising CS rates, Indonesian women prefer vaginal birth. This highlights the need for better communication strategies and evidence-based information from healthcare providers. Given the rising popularity of ERACS, more work is urgently needed to standardise and regulate its use.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11191729/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141426359","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions.
Methods: A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes.
Results: Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives.
Conclusion: While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.
{"title":"Understanding the extent of economic evidence usage for informing policy decisions in the context of India's national health insurance scheme: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY).","authors":"Deepshikha Sharma, Akashdeep Singh Chauhan, Lorna Guinness, Abha Mehndiratta, Anamika Dhiman, Malkeet Singh, Shankar Prinja","doi":"10.1136/bmjgh-2024-015079","DOIUrl":"10.1136/bmjgh-2024-015079","url":null,"abstract":"<p><strong>Introduction: </strong>Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions.</p><p><strong>Methods: </strong>A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes.</p><p><strong>Results: </strong>Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives.</p><p><strong>Conclusion: </strong>While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11168173/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141299894","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-10DOI: 10.1136/bmjgh-2023-014737
Silvia Situma, Luke Nyakarahuka, Evans Omondi, Marianne Mureithi, Marshal Mutinda Mweu, Matthew Muturi, Athman Mwatondo, Jeanette Dawa, Limbaso Konongoi, Samoel Khamadi, Erin Clancey, Eric Lofgren, Eric Osoro, Isaac Ngere, Robert F Breiman, Barnabas Bakamutumaho, Allan Muruta, John Gachohi, Samuel O Oyola, M Kariuki Njenga, Deepti Singh
Background: Recent epidemiology of Rift Valley fever (RVF) disease in Africa suggests growing frequency and expanding geographic range of small disease clusters in regions that previously had not reported the disease. We investigated factors associated with the phenomenon by characterising recent RVF disease events in East Africa.
Methods: Data on 100 disease events (2008-2022) from Kenya, Uganda and Tanzania were obtained from public databases and institutions, and modelled against possible geoecological risk factors of occurrence including altitude, soil type, rainfall/precipitation, temperature, normalised difference vegetation index (NDVI), livestock production system, land-use change and long-term climatic variations. Decadal climatic variations between 1980 and 2022 were evaluated for association with the changing disease pattern.
Results: Of 100 events, 91% were small RVF clusters with a median of one human (IQR, 1-3) and three livestock cases (IQR, 2-7). These clusters exhibited minimal human mortality (IQR, 0-1), and occurred primarily in highlands (67%), with 35% reported in areas that had never reported RVF disease. Multivariate regression analysis of geoecological variables showed a positive correlation between occurrence and increasing temperature and rainfall. A 1°C increase in temperature and a 1-unit increase in NDVI, one months prior were associated with increased RVF incidence rate ratios of 1.20 (95% CI 1.1, 1.2) and 1.93 (95% CI 1.01, 3.71), respectively. Long-term climatic trends showed a significant decadal increase in annual mean temperature (0.12-0.3°C/decade, p<0.05), associated with decreasing rainfall in arid and semi-arid lowlands but increasing rainfall trends in highlands (p<0.05). These hotter and wetter highlands showed increasing frequency of RVF clusters, accounting for 76% and 43% in Uganda and Kenya, respectively.
Conclusion: These findings demonstrate the changing epidemiology of RVF disease. The widening geographic range of disease is associated with climatic variations, with the likely impact of wider dispersal of virus to new areas of endemicity and future epidemics.
{"title":"Widening geographic range of Rift Valley fever disease clusters associated with climate change in East Africa.","authors":"Silvia Situma, Luke Nyakarahuka, Evans Omondi, Marianne Mureithi, Marshal Mutinda Mweu, Matthew Muturi, Athman Mwatondo, Jeanette Dawa, Limbaso Konongoi, Samoel Khamadi, Erin Clancey, Eric Lofgren, Eric Osoro, Isaac Ngere, Robert F Breiman, Barnabas Bakamutumaho, Allan Muruta, John Gachohi, Samuel O Oyola, M Kariuki Njenga, Deepti Singh","doi":"10.1136/bmjgh-2023-014737","DOIUrl":"10.1136/bmjgh-2023-014737","url":null,"abstract":"<p><strong>Background: </strong>Recent epidemiology of Rift Valley fever (RVF) disease in Africa suggests growing frequency and expanding geographic range of small disease clusters in regions that previously had not reported the disease. We investigated factors associated with the phenomenon by characterising recent RVF disease events in East Africa.</p><p><strong>Methods: </strong>Data on 100 disease events (2008-2022) from Kenya, Uganda and Tanzania were obtained from public databases and institutions, and modelled against possible geoecological risk factors of occurrence including altitude, soil type, rainfall/precipitation, temperature, normalised difference vegetation index (NDVI), livestock production system, land-use change and long-term climatic variations. Decadal climatic variations between 1980 and 2022 were evaluated for association with the changing disease pattern.</p><p><strong>Results: </strong>Of 100 events, 91% were small RVF clusters with a median of one human (IQR, 1-3) and three livestock cases (IQR, 2-7). These clusters exhibited minimal human mortality (IQR, 0-1), and occurred primarily in highlands (67%), with 35% reported in areas that had never reported RVF disease. Multivariate regression analysis of geoecological variables showed a positive correlation between occurrence and increasing temperature and rainfall. A 1°C increase in temperature and a 1-unit increase in NDVI, one months prior were associated with increased RVF incidence rate ratios of 1.20 (95% CI 1.1, 1.2) and 1.93 (95% CI 1.01, 3.71), respectively. Long-term climatic trends showed a significant decadal increase in annual mean temperature (0.12-0.3°C/decade, p<0.05), associated with decreasing rainfall in arid and semi-arid lowlands but increasing rainfall trends in highlands (p<0.05). These hotter and wetter highlands showed increasing frequency of RVF clusters, accounting for 76% and 43% in Uganda and Kenya, respectively.</p><p><strong>Conclusion: </strong>These findings demonstrate the changing epidemiology of RVF disease. The widening geographic range of disease is associated with climatic variations, with the likely impact of wider dispersal of virus to new areas of endemicity and future epidemics.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11168176/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141299896","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-10DOI: 10.1136/bmjgh-2024-015259
Gwen Lemey, Ynke Larivière, Bernard Isekah Osang'ir, Trésor Zola, Primo Kimbulu, Solange Milolo, Engbu Danoff, Yves Tchuma, Vivi Maketa, Patrick Mitashi, Raffaella Ravinetto, Pierre Van Damme, Jean-Pierre Van Geertruyden, Hypolite Muhindo-Mavoko
Introduction: Clear guidelines to implement ancillary care (AC) in clinical trials conducted in resource-constrained settings are lacking. Here, we evaluate an AC policy developed for a vaccine trial in the Democratic Republic of the Congo and formulate policy recommendations.
Methods: To evaluate the AC policy, we performed a longitudinal cohort study, nested in an open-label, single-centre, randomised Ebola vaccine trial conducted among healthcare personnel. Participants' demographic information, residence distance to the study site and details on the financial and/or medical support provided for any (serious) adverse events ((S)AE) were combined and analysed. To assess the feasibility of the AC policy, an expenditure analysis of the costs related to AC support outcomes was performed.
Results: Enrolment in this evaluation study started on 29 November 2021. The study lasted 11 months and included 655 participants from the Ebola vaccine trial. In total, 393 participants used the AC policy, mostly for AE management (703 AE and 94 SAE) via medication provided by the study pharmacy (75.3%). Men had a 35.2% (95% CI 4.0% to 56.6%) lower likelihood of reporting AE compared with women. Likewise, this was 32.3% lower (95% CI 5.8% to 51.4%) for facility-based compared with community-based healthcare providers. The daily AE reporting was 78.8% lower during the passive vs the active trial stage, and 97.4% lower during unscheduled vs scheduled visits (p<0.001). Participants living further than 10 km from the trial site more frequently reported the travel distance as a reason for not using the policy (p<0.04). In practice, only 1.1% of the operational trial budget was used for AC policy support.
Conclusion: The trial design, study population and local health system impacted the use of the AC policy. Nonetheless, the AC policy implementation in this remote and resource-constrained setting was feasible, had negligible budgetary implications and contributed to participants' healthcare options and well-being.
导言:在资源有限的环境中开展临床试验时,缺乏明确的辅助护理(AC)实施指南。在此,我们对刚果民主共和国的一项疫苗试验制定的辅助护理政策进行了评估,并提出了政策建议:为了评估埃博拉疫苗政策,我们开展了一项纵向队列研究,该研究嵌套于一项在医护人员中开展的开放标签、单中心、随机埃博拉疫苗试验。我们综合分析了参与者的人口统计学信息、居住地与研究地点的距离以及为任何(严重)不良事件((S)AE)提供的经济和/或医疗支持的详细信息。为评估AC政策的可行性,还对AC支持结果的相关费用进行了支出分析:这项评估研究于 2021 年 11 月 29 日开始报名。研究为期 11 个月,包括 655 名埃博拉疫苗试验参与者。共有 393 名参与者使用了 AC 政策,主要是通过研究药房提供的药物(75.3%)进行 AE 管理(703 例 AE 和 94 例 SAE)。与女性相比,男性报告 AE 的可能性低 35.2%(95% CI 4.0% 至 56.6%)。同样,与社区医疗服务提供者相比,医疗机构医疗服务提供者报告 AE 的可能性低 32.3%(95% CI 5.8% 至 51.4%)。被动试验阶段与主动试验阶段相比,每日AE报告率降低了78.8%,计划外就诊与计划内就诊相比,每日AE报告率降低了97.4%(P结论:试验设计、研究人群和当地医疗系统都对 AC 政策的使用产生了影响。尽管如此,在这种偏远且资源有限的环境中实施 AC 政策是可行的,对预算的影响微乎其微,而且有助于参与者的医疗保健选择和福祉。
{"title":"An ancillary care policy in a vaccine trial conducted in a resource-constrained setting: evaluation and policy recommendations.","authors":"Gwen Lemey, Ynke Larivière, Bernard Isekah Osang'ir, Trésor Zola, Primo Kimbulu, Solange Milolo, Engbu Danoff, Yves Tchuma, Vivi Maketa, Patrick Mitashi, Raffaella Ravinetto, Pierre Van Damme, Jean-Pierre Van Geertruyden, Hypolite Muhindo-Mavoko","doi":"10.1136/bmjgh-2024-015259","DOIUrl":"10.1136/bmjgh-2024-015259","url":null,"abstract":"<p><strong>Introduction: </strong>Clear guidelines to implement ancillary care (AC) in clinical trials conducted in resource-constrained settings are lacking. Here, we evaluate an AC policy developed for a vaccine trial in the Democratic Republic of the Congo and formulate policy recommendations.</p><p><strong>Methods: </strong>To evaluate the AC policy, we performed a longitudinal cohort study, nested in an open-label, single-centre, randomised Ebola vaccine trial conducted among healthcare personnel. Participants' demographic information, residence distance to the study site and details on the financial and/or medical support provided for any (serious) adverse events ((S)AE) were combined and analysed. To assess the feasibility of the AC policy, an expenditure analysis of the costs related to AC support outcomes was performed.</p><p><strong>Results: </strong>Enrolment in this evaluation study started on 29 November 2021. The study lasted 11 months and included 655 participants from the Ebola vaccine trial. In total, 393 participants used the AC policy, mostly for AE management (703 AE and 94 SAE) via medication provided by the study pharmacy (75.3%). Men had a 35.2% (95% CI 4.0% to 56.6%) lower likelihood of reporting AE compared with women. Likewise, this was 32.3% lower (95% CI 5.8% to 51.4%) for facility-based compared with community-based healthcare providers. The daily AE reporting was 78.8% lower during the passive vs the active trial stage, and 97.4% lower during unscheduled vs scheduled visits (p<0.001). Participants living further than 10 km from the trial site more frequently reported the travel distance as a reason for not using the policy (p<0.04). In practice, only 1.1% of the operational trial budget was used for AC policy support.</p><p><strong>Conclusion: </strong>The trial design, study population and local health system impacted the use of the AC policy. Nonetheless, the AC policy implementation in this remote and resource-constrained setting was feasible, had negligible budgetary implications and contributed to participants' healthcare options and well-being.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":7.1,"publicationDate":"2024-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11168174/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141299892","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-10DOI: 10.1136/bmjgh-2023-014223
Lhuri D Rahmartani, Maria A Quigley, Claire Carson
Introduction: Prelacteal feeding (PLF) is anything other than breastmilk given to newborns in the first few days of birth and/or before breastfeeding is established. PLF comes in many forms and is known as a challenge to optimal breastfeeding. Interestingly, both breastfeeding and PLF are common in Indonesia. This study investigated the association between PLF (any PLF, formula, honey, water and other milk) and breastfeeding duration.
Methods: This study used Indonesia Demographic and Health Surveys data from 2002, 2007 and 2017. Sample sizes were 5558 (2007), 6268 (2007) and 6227 (2017) mothers whose last child was aged 0-23 months. We used Cox regression survival analysis to assess the association between PLF and breastfeeding duration, estimating hazard ratios (HR) for stopping earlier.
Results: Overall PLF was prevalent (59%, 67% and 45% in 2002, 2007 and 2017, respectively), with formula being the most common (38%, 50% and 25%). No association between any PLF and breastfeeding duration in 2002 (HR 0.90 (95% CI 0.70 to 1.16)), but in 2007 and 2017, mothers who gave any PLF were more likely to stop breastfeeding earlier than those who did not (HR 1.33 (95% CI 1.11 to 1.61) and 1.47 (95% CI 1.28 to 1.69), respectively), especially in the first 6 months (HR 2.13 (95% CI 1.55 to 2.92) and 2.07 (95% CI 1.74 to 2.47), respectively). This association was more consistent for milk-based PLF. For example, HR in 2017 was 2.13 (95% CI 1.78 to 2.53) for prelacteal formula and 1.73 (95% CI 1.39 to 2.15) for other milk. The associations were inconsistent for the other PLF types. Prelacteal water showed no association while prelacteal honey showed some association with a longer breastfeeding duration in 2002 and 2007.
Conclusion: The impact of PLF on breastfeeding duration varied by type. While this study supports current recommendations to avoid PLF unless medically indicated, the potential consequences of different PLF types on breastfeeding outcomes should be clearly communicated to healthcare providers and mothers. Further research should explore the reasons for the high PLF prevalence in this setting.
导言:母乳前喂养(PLF)是指在新生儿出生后的头几天和/或母乳喂养建立之前,给新生儿喂养母乳以外的任何食物。乳前喂养有多种形式,是对最佳母乳喂养的一种挑战。有趣的是,在印度尼西亚,母乳喂养和PLF都很常见。本研究调查了PLF(任何PLF、配方奶、蜂蜜、水和其他奶类)与母乳喂养持续时间之间的关系:本研究使用了印度尼西亚 2002 年、2007 年和 2017 年的人口与健康调查数据。样本量分别为 5558(2007 年)、6268(2007 年)和 6227(2017 年)名婴儿年龄为 0-23 个月的母亲。我们使用 Cox 回归生存分析法评估了 PLF 与母乳喂养持续时间之间的关系,并估算了提前停止母乳喂养的危险比 (HR):总的来说,PLF很普遍(2002年、2007年和2017年分别为59%、67%和45%),其中配方奶粉最常见(38%、50%和25%)。2002 年,任何 PLF 与母乳喂养持续时间之间没有关联(HR 0.90 (95% CI 0.70 to 1.16)),但在 2007 年和 2017 年,给予任何 PLF 的母亲比不给予 PLF 的母亲更有可能提前停止母乳喂养(HR 1.33(95% CI 1.11至1.61)和1.47(95% CI 1.28至1.69)),尤其是在前6个月(HR分别为2.13(95% CI 1.55至2.92)和2.07(95% CI 1.74至2.47))。这种关联在以牛奶为基础的PLF中更为一致。例如,2017年母乳前配方奶粉的HR为2.13(95% CI 1.78至2.53),其他奶类的HR为1.73(95% CI 1.39至2.15)。其他PLF类型的相关性并不一致。在 2002 年和 2007 年,母乳水与母乳喂养持续时间无关,而母乳蜜则与母乳喂养持续时间有关:结论:PLF 对母乳喂养时间的影响因类型而异。虽然这项研究支持目前的建议,即除非有医学指征,否则应避免使用PLF,但不同类型的PLF对母乳喂养结果的潜在影响应明确告知医疗保健提供者和母亲。进一步的研究应探讨在这种情况下PLF发生率高的原因。
{"title":"Do various types of prelacteal feeding (PLF) have different associations with breastfeeding duration in Indonesia? A cross-sectional study using Indonesia Demographic and Health Survey datasets.","authors":"Lhuri D Rahmartani, Maria A Quigley, Claire Carson","doi":"10.1136/bmjgh-2023-014223","DOIUrl":"10.1136/bmjgh-2023-014223","url":null,"abstract":"<p><strong>Introduction: </strong>Prelacteal feeding (PLF) is anything other than breastmilk given to newborns in the first few days of birth and/or before breastfeeding is established. PLF comes in many forms and is known as a challenge to optimal breastfeeding. Interestingly, both breastfeeding and PLF are common in Indonesia. This study investigated the association between PLF (any PLF, formula, honey, water and other milk) and breastfeeding duration.</p><p><strong>Methods: </strong>This study used Indonesia Demographic and Health Surveys data from 2002, 2007 and 2017. Sample sizes were 5558 (2007), 6268 (2007) and 6227 (2017) mothers whose last child was aged 0-23 months. We used Cox regression survival analysis to assess the association between PLF and breastfeeding duration, estimating hazard ratios (HR) for stopping earlier.</p><p><strong>Results: </strong>Overall PLF was prevalent (59%, 67% and 45% in 2002, 2007 and 2017, respectively), with formula being the most common (38%, 50% and 25%). No association between any PLF and breastfeeding duration in 2002 (HR 0.90 (95% CI 0.70 to 1.16)), but in 2007 and 2017, mothers who gave any PLF were more likely to stop breastfeeding earlier than those who did not (HR 1.33 (95% CI 1.11 to 1.61) and 1.47 (95% CI 1.28 to 1.69), respectively), especially in the first 6 months (HR 2.13 (95% CI 1.55 to 2.92) and 2.07 (95% CI 1.74 to 2.47), respectively). This association was more consistent for milk-based PLF. For example, HR in 2017 was 2.13 (95% CI 1.78 to 2.53) for prelacteal formula and 1.73 (95% CI 1.39 to 2.15) for other milk. The associations were inconsistent for the other PLF types. Prelacteal water showed no association while prelacteal honey showed some association with a longer breastfeeding duration in 2002 and 2007.</p><p><strong>Conclusion: </strong>The impact of PLF on breastfeeding duration varied by type. While this study supports current recommendations to avoid PLF unless medically indicated, the potential consequences of different PLF types on breastfeeding outcomes should be clearly communicated to healthcare providers and mothers. Further research should explore the reasons for the high PLF prevalence in this setting.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":null,"pages":null},"PeriodicalIF":8.1,"publicationDate":"2024-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11168184/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141299893","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}