BMJ Global Health最新文献

Introduction: Health workers (HWs) set an example for vaccine recipients, convey vaccine benefits and risks and interface with patients at increased risk for complications in pandemic settings. We explored HWs' acceptance of and recommendation for COVID-19 vaccine with and without previous receipt of seasonal influenza vaccine (SIV) in nine countries.

Methods: In 2023-2024, cross-sectional surveys among HW were conducted in Bangladesh, Cote d'Ivoire, Ghana, Laos, Lebanon, Morocco, Philippines, Thailand and Tunisia. Country researchers used a standard protocol and questionnaire to assess beliefs, perceptions and acceptance around SIV and COVID-19 vaccine and likelihood of recommending these vaccines to patients. Pooled findings were stratified by the presence or absence of a national HW SIV recommendation. Generalised mixed effects models were used to characterise the relationship between receipt of SIV and COVID-19 vaccine acceptance and recommendation, adjusting for WHO region, sex and duration of employment.

Results: Our analysis included 12 296 HWs from nine countries representing four WHO regions: African, Eastern Mediterranean, Southeast Asian and Western Pacific. Five countries had a national HW SIV recommendation (61% of HWs surveyed) prior to COVID-19 vaccine introduction. More than 90% of HWs reported completing the COVID-19 vaccination series, whereas intention to continue receiving annual COVID-19 vaccine was lower (61%). HWs who received SIV in the last season compared with those who did not were more likely to have received one or more COVID-19 booster doses (adjusted OR (aOR) 2.63, 95% CI 2.27 to 3.04) and to have recommended COVID-19 vaccine to patients (aOR 1.53, 95% CI 1.29 to 1.82).

Conclusions: Prior experience with SIV was associated with HW behaviour and recommendations regarding COVID-19 vaccination. Intention to continue receiving COVID-19 vaccines remains a challenge; ongoing training and education for vaccination staff could be beneficial. HWs play a critical role in the successful delivery of new and existing vaccines, particularly in a pandemic setting.

Background: Community-based health insurance (CBHI) is crucial for strengthening primary healthcare (PHC) and progressing towards universal health coverage (UHC), especially in resource-constrained, war-affected settings. While previous studies have explored CBHI in various contexts, this study uniquely investigates household willingness to join (WTJ) CBHI and its determinants in post-war Tigray, Ethiopia, offering valuable insights into the specific challenges and opportunities in this under-researched setting.

Methods: We conducted a multistage community-based survey across 15 districts within 6 accessible administrative zones, 1 year after the cessation of hostilities, sampling 2289 households in 30 clusters. The primary outcome variable-household WTJ CBHI-was analysed in relation to sociodemographic factors, a wealth index, type of frequently accessed healthcare facility, knowledge on CBHI benefits and prior experience with CBHI. Weighted logistic regression identified significant predictors of WTJ with p<0.05.

Results: 2270 households participated (99.17% response rate). Respondents were 60.31% female, and median age 42.50 years (IQR 33-55). Pre-war CBHI enrolment of households was approximately 62.40% (95% CI 60.11% to 64.63%), while post-war WTJ reached about 87.57% (95% CI 85.99% to 88.99%) of households. Key WTJ predictors included younger age, marital status, host community status, farming occupation, belonging to the 'less poor' wealth quintile, hospital access, knowledge of CBHI benefits and previous CBHI membership.

Conclusions: This study reveals substantial interest in CBHI among households in post-war Tigray, highlighting its potential to strengthen the healthcare system. To ensure equitable access and achieve UHC-particularly in rural and war affected areas-revitalising CBHI and rebuilding PHC are essential. While longitudinal research is warranted to understand how war-driven contextual changes affect CBHI demand over time, policies should prioritise affordability, enhance awareness and strengthen hospital linkages. This supports the prioritisation of CBHI investment as a crucial strategy in this context and potentially in similar under-resourced and war-torn settings.

Objective: Despite rising prevalence, very limited evidence is available on the clustering of hypertension and clustering of diabetes at household level in India. This study examines the clustering of hypertension and clustering of diabetes at household level among members aged 15 years and above in India.

Methods: Clustering of hypertension is defined as two or more members of the household having hypertension. Clustering of diabetes is defined as two or more members of the household having diabetes. Clustering was examined in 636 699 households interviewed in the fifth round of the National Family Health Survey 2019-2021. The relationship dyads of clustering and awareness of the diseases within households were also examined.

Results: Two or more members suffered from hypertension in 14.9% households, which contributed to 49.8% of total hypertension cases in India. Diabetes was clustered in 7.7% of households which contributed to 39.3% of total diabetes cases in India. Among households with two diagnosed members, the most common relationship dyad was spouses (53.6% for hypertension and 53.8% diabetes), followed by parent-child (29.8% for hypertension and 28.8% for diabetes). In households with three diagnosed members, the most common dyad was parent-child (44.3% for hypertension and 42.5% for diabetes). Among households with clustering, all the members with disease were unaware in 42.5% of the households for hypertension and 55.5% for diabetes, and mixed awareness was seen in 37.9% and 31.4% households for hypertension and diabetes, respectively.

Conclusion: Given the disproportionate amount of India's total case burden of hypertension and diabetes concentrated within clustered households, our findings underscore the importance of targeting households for interventions of hypertension and diabetes management in addition to interventions targeting individuals. Our findings may equip health systems with information on patterns of concentrated pockets of undiagnosed disease burden within households and may help in designing intensified interventions for rapid progress towards Sustainable Development Goal V.3.4.

Introduction: Emerging evidence of durable immunogenicity from mono-dose human papillomavirus vaccination (HPVV) prompted the WHO to recommend a single-dose HPVV schedule in December 2022. There is, however, limited understanding of processes and considerations influencing country adoption of the updated HPVV dosing schedule recommendation.

Methods: We identified four archetypes characterising countries' progress along the HPVV introduction and single-dose adoption continua. From September 2023 to February 2024, we purposefully sampled and conducted semistructured interviews with immunisation stakeholders representing Ministries of Health, Gavi-funded technical assistance partners, civil society organisations and multilateral agencies from African and Asian low-income and middle-income countries. Using multicycle, iterative thematic analysis, we identified factors enabling the adoption of the HPVV single-dose recommendation, as well as constraints to rendering a decision on the HPVV dosing schedule.

Results: We interviewed 66 stakeholders across 19 countries with mature HPVV programmes (n=11) or forthcoming national HPVV introductions (n=8), as well as countries adopting (n=10) or undecided about (n=9) the single-dose schedule. Stakeholders conveyed enthusiasm for single-dose HPVV, citing the following anticipated benefits: higher HPVV schedule completion and coverage, especially in underimmunised populations; costs saved from operational reconfigurations and reduced vaccine procurement demands, particularly for countries transitioning out of Gavi co-financing in a vaccine supply-constrained environment; and optimised vaccine stock management capacity, importantly for countries pursuing new vaccine introductions for multiple antigens simultaneously. Factors demotivating HPVV single-dose schedule adoption or delaying decision-making included: limited localised evidence of long-term immunologic protection from single-dose HPVV; off-label product use liabilities; costs/resources required for retraining the health workforce in countries with mature HPVV programmes; and potential for widening HPVV coverage inequities, notably in countries with elevated HIV burdens.

Conclusions: Coupled with the WHO's endorsement, the perceived benefits of single-dose HPVV consistently outweighed the anticipated risks, even when these risks delayed country-level HPVV schedule-related decision-making.

Objective: To determine whether liquefied petroleum gas (LPG) can reduce perinatal mortality in a setting with high reliance on biomass fuels for cooking.

Design: Community-based two-arm parallel cluster randomised controlled trial, in Sherpur, Bangladesh.

Participants: 4944 pregnant women were recruited, with 2472 in each group. Eligible women were pregnant between 40 and 120 days, aged 15-49 years, permanent residents and planning to give birth in their cluster of residence.

Intervention: LPG stove and fuel to birth. Controls continued with usual cooking practices.

Main outcome: Primary outcome at the individual level: perinatal mortality.

Secondary outcomes: early neonatal mortality, neonatal mortality, preterm birth and personal exposure to particulate matter 2.5 (PM2.5).

Results: The final birth outcomes included 4592 participants. The perinatal mortality rate (PMR) was 50 per 1000 births in the intervention group compared with 61 per 1000 births in the control group (relative risk (RR) 0.83; 95% CI 0.65 to 1.06). PM2.5 concentrations were 47.2 µg/m³ in the intervention versus 60.3 µg/m³ in the control; mean difference -0.133 (95% CI -0.194 to -0.072). In late pregnancy, it was 62·7 µg/m³ in the intervention versus 88·7 µg/m³ in the control, mean difference -0.149 (-0.198 to -0.101). Early neonatal mortality was 22% in the intervention compared with 30% in the control (RR 0.73; 95% CI 0.50 to 1.05). Preterm birth rates were similar. In post hoc subgroup of small versus large households (HH), the PMR was lower in the smaller HH in the intervention group (67, rate 54 per 1000 births) than in the control group (102, 71 per 1000 births, adjusted RR 0.75; 95% CI 0.56 to 1.00; p=0.047).

Conclusions: Reductions in perinatal mortality favoured the intervention but were statistically non-significant. These findings demonstrate a reduction in mortality in smaller HH when cooking needs are adequately covered by clean fuel.

Trial registration number: ACTRN12618001214224; Australian and New Zealand Clinical Trials Registry.

Background: Paediatric sepsis remains a significant cause of mortality in low- and middle-income countries (LMICs), where health systems are often resource-constrained. Global sepsis protocols, although effective in high-income settings, may not be well-suited to LMIC contexts.

Methods: We conducted a mixed-methods study in two hospitals in the Ashanti Region of Ghana: Komfo Anokye Teaching Hospital (KATH) and Presbyterian Hospital, Agogo (PreHA). Specifically, we conducted a retrospective chart review, followed by key informant interviews with clinical staff, and integrated our findings with a previously published situational analysis. Qualitative data analysis employed the Three Delays Framework and the Donabedian Model to identify locations and causes of delays in care.

Results: Seventy-one charts met the inclusion criteria for review, having a history of fever or hypothermia and complete vital signs documented (16 from PreHA, 55 from KATH). Despite KATH managing more severely ill patients with higher sepsis scores and longer stays, mortality rates were similar at both sites. The chart review highlighted gaps in documentation and inconsistent care processes. Key informant interviews revealed themes such as provider altruism, community financial support and the positive role of research collaborations, while also illustrating systemic delays linked to financial and resource constraints.

Conclusion: Paediatric sepsis care in Ghana is influenced by complex and interconnected structural, cultural and procedural factors. Our findings indicate that contextually adapted care pathways are crucial for improving sepsis outcomes in resource-constrained settings. Co-designed interventions, rather than wholly imported protocols, may offer a more sustainable approach to strengthening health systems in LMICs.

Japan's Prime Minister recently announced a strategic partnership with the World Bank to support human resource development for Universal Health Coverage (UHC) in the Global South. While this pivot from infrastructure to human capital is timely, it risks falling into the 'training trap'-producing skilled workers whom national governments cannot afford to employ. This commentary argues that in many low- and middle-income countries, the primary bottleneck to workforce expansion is not a lack of trained staff, but the 'paradoxical surplus': a coexistence of acute health needs, unemployed health workers and rigid fiscal constraints on public sector wage bills. Drawing on recent evidence from sub-Saharan Africa and beyond, we demonstrate that supply-side interventions (education) without demand-side reforms (employment) will merely fuel brain drain. We propose that the true value of the Japan-World Bank partnership lies in bridging the gap between Ministries of Health and Finance. Japan must leverage the World Bank's macroeconomic influence to expand 'fiscal space' for health, ensuring that Official Development Assistance (ODA) for education is matched by domestic capacity to absorb and retain graduates. Only by coupling training with fiscal reform can Japan's UHC pledge become a sustainable reality.

Introduction: Digital payments are increasingly favoured over cash for remunerating healthcare workers in large-scale health campaigns due to perceived advantages in efficiency and security. However, evidence to guide their scaling and optimisation is limited. This study aimed to identify and prioritise a global research agenda for digital payments in health campaigns in sub-Saharan Africa (SSA).

Methods: We employed the Child Health and Nutrition Research Initiative methodology. In stage 1, we defined the context and criteria (answerability, feasibility, sustainability/equity, impact). In stage 2, 420 stakeholders were engaged via an online survey, generating 450 research questions, which were refined to a final pool of 35. In stage 3, these 35 questions were scored by 63 experts against the predefined criteria. Research Priority Scores (RPS) and Average Expert Agreement (AEA) were computed for ranking in stage 4.

Results: The overall RPS for the 35 questions ranged from 38.6% to 6.0% (mean 28.2%, SD 6.4%). The AEA ranged from 67.2% to 82.7% (mean 77%, SD 3.4%), indicating strong consensus. RPS and AEA showed a strong positive correlation (r=0.989, p<0.01). The top-ranked research questions were: (1) Minimum requirements for health systems to digitise payments responsibly (RPS 38.6%); (2) Optimisation of digital payments to enhance campaign effectiveness in SSA (RPS 36.8%); (3) Incentives for digital payment adoption in the healthcare sector (RPS 36.1%); (4) Cost-benefit analysis of digital payments vs cash (RPS 36.3%) and (5) Coverage of mobile money agents and its impact on uptake and satisfaction (RPS 34.0%).

Conclusions: This study provides an expert-consensus roadmap for research on digital payments in health campaigns. Addressing these priorities will generate critical evidence to develop robust, equitable and effective digital payment systems, ultimately strengthening health systems and improving health outcomes in SSA.

Background: Primary healthcare (PHC) is critical towards achieving Universal Health Coverage (UHC). In Ghana, PHC is organised at the district level and plays a key role in the country's pursuit of UHC. However, many districts face challenges not only with limited resources but also with how effectively they are used. We examined how efficiently districts in Ghana use their health resources and what factors are associated with this efficiency.

Methods: We used a two-step stochastic frontier analysis model using data from 181 districts. The output variable was a composite coverage index derived from eight PHC service indicators for 2021, primarily reflecting maternal and child health and infectious disease services. Input variables included district health expenditure for 2020/2021 and the number of health facilities and clinical staff in 2021. We then assessed the associations between efficiency scores generated by the model and health systems, socioeconomic and demographic factors, such as health facility type, insurance coverage, literacy level, Gini coefficient, poverty incidence, urbanisation and population density.

Results: On average, districts operated at 87% efficiency, with scores ranging from 65% to 99%. Two factors were associated with the efficiency. First, districts with a higher proportion of PHC facilities tended to use resources more efficiently (coeff=0.151; 95% CI=0.041 to 0.261). Second, districts with greater income inequality were less efficient, measured by the Gini coefficient (coeff=-0.858; 95% CI=-1.146 to -0.252).

Conclusion: Districts in Ghana have the potential to improve PHC outputs by about 13% on average by better use of existing resources and addressing determinants of efficiency. Findings suggest that districts with a higher proportion of PHC facilities and lower income inequality tend to be more efficient. These patterns highlight the value of strengthening PHC infrastructure and pursuing equity-focused policies as part of strategies to enhance efficiency in district health systems.