BMJ Global Health最新文献

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.

Introduction: People in the Gaza Strip have been denied food and medical care through war and displacement since October 2023, introducing the risk of famine in the region. We sought to estimate the proportion of children assessed in nutritional centres with moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) in the Gaza Strip during this war.

Methods: We conducted a cross-sectional analysis of nutritional assessments for children up to 5 years old in the Gaza Strip, Palestine, from May 2024 to November 2024. We used de-identified data from humanitarian relief clinics to determine the proportion of MAM and SAM. We defined SAM as weight-for-length Z score <-3. For children above 6 months, we additionally used mid-upper arm circumference (MUAC) <11.5 cm to identify SAM. We defined MAM as weight-for-height Z-score between -2 and -3, or MUAC 11.5-12.4 cm. We used logistic regression to determine factors associated with acute malnutrition.

Results: Of 22 901 children (49.6% girls; 12.0% in North Gaza), there were 2042 (8.92%, 95% CI 8.56% to 9.28%) children diagnosed with SAM or MAM during the study period. SAM was higher in North Gaza/Gaza City than in South/Middle Gaza (15.7% vs 0.4%, p<0.001). In North Gaza/ Gaza City, SAM was associated with having a deceased father (adjusted OR 1.97, 95% CI 1.24 to 3.06) and in children <6 months (adjusted OR 1.86, 95% CI 1.15 to 2.96). The prevalence of SAM decreased in North Gaza/Gaza City during this study period.

Conclusion: A high proportion of children under 5 years old had evidence of SAM or MAM, particularly in North Gaza and Gaza City, which has been subjected to more intense bombings and restrictions in aid. Cessation of hostilities and resumption of humanitarian aid relief is urgently needed for children in Gaza.

Introduction: 4 years after the Ebola outbreak, the arrival of COVID-19 presented West Africa with a new shock. Despite widespread disruptions, malaria service continuity remained a priority in both countries. In Sierra Leone, the proportion of pregnant women receiving at least three doses of intermittent preventive treatment increased from 36% in 2018 to 50% in 2021. Similarly, insecticide-treated net ownership in Guinea rose from 44% to 63%, reflecting the ability of national programmes to sustain essential interventions despite pandemic-related constraints. Against this backdrop, this study investigates the strategies used to strengthen health system resilience in Guinea and Sierra Leone during the pandemic. Specifically, it explores how both countries responded to the pandemic's demands and mitigated potential negative effects on health service delivery, using malaria as an example of routine care.

Methods: We conducted a document review and interviewed 36 key informants (16 in Guinea and 20 in Sierra Leone) leading malaria elimination efforts and the national COVID-19 response. The review included malaria surveillance data and health performance reports to contextualise our qualitative findings. Interviews identified strategic responses by decision-makers overseeing malaria and COVID-19 efforts. This qualitative approach offers an in-depth understanding of decision-making within broader health systems.

Results: Three major themes were shared between countries: (1) 'Responding quickly and decisively to COVID-19', (2) 'Ensuring continuity of essential services during the pandemic' and (3) 'Improving health system responsiveness, despite contextual challenges'. The document review confirmed sustained malaria service delivery, with minimal declines in outpatient consultations compared to Ebola.

Conclusions: Strategies used in both countries enabled the health systems to absorb the acute shock of COVID-19, adapt to the challenges and transform aspects to improve responsiveness. Institutionalising these policies and fostering agility could enhance pandemic preparedness and contribute to stronger health systems in these and other low-income countries in the region.

Introduction: Selling sex has been associated with negative social and health outcomes, but most studies have been limited geographically and have not distinguished between selling and buying sex. This study assesses prevalence and factors associated with selling sex in the last 12 months among men who have sex with men (MSM) in 18 Latin American countries.

Methods: Data were collected in 2018 through the Latin American MSM Internet Survey, a cross-sectional online survey. Of 64 655 participants, 9585 were excluded due to data inconsistencies on age and partner status, and 1728 due to missing outcome data, yielding an analytic sample of 53 342. Multivariable logistic regression was used for analysis.

Results: Overall, 6.9% (10.3% among MSM aged 18-24) reported selling sex in the previous year. Higher odds of selling sex were associated with younger age, low education, being born abroad, low financial coping, substance use, potential alcohol dependency, early sexual debut with a male partner, low sexual agency and sex with women. High educational level and having a steady male partner were associated with lower odds.

Conclusions: Key factors associated with selling sex among MSM in Latin America include socioeconomic, behavioural and relational variables. Harm reduction and preventive interventions may be particularly needed among younger MSM. Codeveloping these interventions with the MSM community can ensure sustainability, relevance and strengthen providers' ability to offer individualised, respectful care. Longitudinal and qualitative studies are needed to monitor long-term health and tailor interventions to individual needs.

Introduction: The taxation of harmful commodities-including tobacco, alcohol and sugar-sweetened beverages (SSBs)-can reduce avertable health burdens while generating tax revenue to fund key government programmes. These tools are particularly useful in the current environment of constrained global fiscal space but remain underused.

Methods: We simulated the economic effects of taxing cigarettes, alcohol and SSBs over a 5-year period employing mathematical models informed by global economic and consumption data. Historical trends were used to project baseline consumption trajectories for each commodity. For countries with missing data, price, consumption and tax information were imputed using regional and income group averages, enabling global coverage. Tax-induced price increases of 20% and 50% were simulated.

Results: Taxes that raise retail prices by 20% would generate US$388.73 billion in additional global tax revenue annually, comprising US$104.20 (95% UI: US$92.70-US$115.48) billion from tobacco, US$202.67 (95% UI: US$191.68-US$213.69) billion from alcohol, and US$81.86 (95% UI: US$68.36-US$94.93) billion from SSBs. At 50%, the total additional revenue would be US$684.75 billion annually. As a proportion of health spending, lower-income countries generate more tax revenue than higher-income countries.

Conclusion: Excise tax increases on tobacco, alcohol and SSBs can raise substantial government revenues, which could enable increased public health and social spending. By providing short-term revenue projections, this study offers timely insights to inform near-term fiscal policy decisions, particularly in low- and middle-income countries facing fiscal constraints. Future research should explore the taxation of related goods, including ultraprocessed foods and e-cigarettes.

Introduction: Morocco's position at the crossroads of Africa and Europe has made it a major transit and destination country for migrants. While migrants are entitled to free emergency and primary healthcare services, some challenges persist. This study aimed to explore the experiences of migrants in accessing healthcare services and to identify recommendations for improvement.

Methods: This multisite qualitative study was conducted across five cities in Morocco between May 2023 and January 2024. Data were collected through semi-structured interviews and focus group discussions with 34 migrants, 17 migrant community leaders, 5 representatives of civil society organisations (CSOs), and 8 healthcare professionals. Migrants were recruited with the support of a Moroccan CSO, and primary healthcare professionals were recruited in health centres. Data were analysed using a hybrid thematic analysis approach, guided by Levesque's Patient-Centered Access to Care framework.

Results: We found that fear of costs, negative perceptions about the healthcare system, misconceptions about entitlement to services, cultural norms and health beliefs influenced participants' health-seeking behaviours. Most reported free and easy access to primary healthcare, but administrative barriers, language challenges and medication costs persisted despite entitlement. Some migrant participants showed limited understanding of care pathways, leading to delays in care-seeking and fear of service denial-especially in the absence of peer accompaniment. Financial and administrative barriers were greatest at higher levels of care, posing challenges for uninsured migrants who formed the majority of participants. CSOs provided important support services but faced limits due to inconsistent funding and heavy centralisation.

Conclusion: Morocco has become a global and regional champion in migrant health, through major policy and programmatic efforts. Yet, economic and sociocultural barriers still limit full service utilisation. Ongoing national reforms offer a chance to leapfrog towards universal health coverage through innovative migrant-inclusive health insurance schemes and empowered community actors.