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Implementing intravenous iron for maternal anemia in Nigeria: A qualitative study of healthcare provider experiences using the normalization process theory.
Full text linkBACKGROUND: Maternal anemia remains a significant public health challenge in Nigeria, affecting approximately 25-46% of pregnant women and contributing to adverse maternal and neonatal outcomes. Intravenous (IV) iron provides a promising alternative to conventional oral iron supplementation for managing moderate to severe maternal anemia; however, its implementation in resource-limited settings faces numerous challenges. This study aimed to understand how the implementation of IV iron became embedded in everyday practice, including factors influencing skilled healthcare providers' (SHPs) engagement, workflow integration processes, and sustainability.
METHODS: This was a qualitative study embedded within the Implementation Research for Intravenous Iron Use in Pregnant and Postpartum Women in Nigeria (IVON-IS) project across six healthcare facilities in Lagos, Nigeria. Eighteen key informant interviews were conducted with purposively sampled SHPs across the six IVON-IS facilities. The data were analyzed deductively based on the Normalization Process Theory (NPT) constructs (coherence, cognitive participation, collective action, and reflexive monitoring), and inductively to identify themes related to each of these constructs.
RESULTS: Our study revealed strong coherence among SHPs regarding the purpose and benefits of IV iron compared to traditional treatments. Cognitive participation varied across facilities, with leadership support and patient-centred motivation emerging as critical facilitators. Collective action was faced with challenges, including workflow disruptions, staffing constraints, and space limitations, despite adequate resource provision. Reflexive monitoring processes were robust, with providers continuously evaluating effectiveness through clinical outcomes and patient feedback while expressing concerns about long-term sustainability.
CONCLUSION: The implementation of IV iron for maternal anemia in Nigeria demonstrated variability across NPT constructs, with strong coherence and reflexive monitoring but challenges in cognitive participation and collective action. Critical success factors included strong leadership support, adequate resource provision, continuous quality improvement processes, and proactive sustainability planning. The findings from this study provide valuable guidance for scaling up IV iron use as part of comprehensive maternal health services in Nigeria and similar resource-constrained settings
Beta-blockers after myocardial infarction: effects according to sex in the REBOOT trial.
Full text linkBACKGROUND AND AIMS: Recent trials have challenged the guideline recommendation of beta-blockers for post-myocardial infarction (MI) patients without reduced left ventricular ejection fraction (LVEF). Whether these recent findings apply equally to women and men remains unknown.
METHODS: Using data from REBOOT (tREatment with Beta-blockers after myOcardial infarction withOut reduced ejection fracTion), the largest randomized trial evaluating the effect of beta-blockers after acute MI with LVEF > 40%, a pre-specified sex-specific subgroup analysis was performed. A total of 8438 out of the 8505 randomized patients comprised the intention-to-treat population.
RESULTS: Among 8438 patients, 1627 were women, who were older, had more comorbidities, and received fewer guideline-based therapies than men. Over a median follow-up of 3.7 years, women had overall higher rates of the primary composite outcome (death, MI, or heart failure hospitalization) than men. The incidence rate of the primary endpoint in women was 30.4 and 21.0/1000 patient-years in the beta-blocker group and no beta-blocker group, respectively (hazard ratio 1.45, 95% confidence interval 1.04-2.03). No significant differences were observed in men (hazard ratio .94, 95% confidence interval .79-1.13; P for interaction = .026). The excess risk in women was mainly driven by increased mortality and was most evident among those with preserved LVEF (P for interaction = .030) and those receiving higher beta-blocker doses (P for interaction = .045).
CONCLUSIONS: In the REBOOT trial of MI patients managed according to contemporary standards, beta-blocker therapy was associated with evidence of harm in women-particularly those with preserved LVEF and receiving higher doses-an effect not observed in men
“Implementing a policy is something else”. Governance of a complex health management information system and its digitalization in Tanzania: A qualitative study
No full textIntroduction: Health management information systems are crucial for a country's health service planning and monitoring. Research findings indicate however that data produced within this system is often of low quality or not used for decision-making in low-resource settings like Tanzania. Policymaking and -implementation towards efficient data processes and use take place in an environment challenged by limited availability of human and other resources, low levels of supervision and feedback on data quality despite national and international guidance. To better understand how this complexity affects system governance, it is crucial to analyse perceptions and practices of national policymakers and subnational healthcare managers responsible for policy implementation. We therefore aimed to understand how policymakers and health care managers perceive and practice governance of health management information data systems and processes including the introduction of digital technology in Tanzania.
Methods: We conducted 16 interviews with policymakers and healthcare managers experienced in governance and use of health management information systems in two districts, two regions and at national level in Tanzania between October 2022 and January 2023. Reflexive thematic analysis grounded in constructivism was used. Themes were developed through reflexive sessions underpinned by complexity theory and Lipsky's theory of street-level bureaucracy.
Results: Health management information system governance took place in a complex environment characterized by unpredictable funding and human capacity impairing policy agenda setting and its implementation. Policymakers at national level and healthcare managers at subnational level resorted to different power practices to ensure implementation of national policies and agendas. While policymakers mainly governed data processes using institutionalized means, e.g. international tools and guidance or formal communication platforms, healthcare managers governed implementation by making discrete, contextualized choices on managing relations with other actor groups through negotiation and connection. This led to transformed agendas in some cases but also allowed for innovations to make policies work.
Conclusions: A new perspective may be needed to understand how governance of routine health information, which is central to health system strengthening, is implemented in policy environments characterized by unpredictability, where governments strive for efficient data use. Drawing on the concept of complex adaptive systems, we propose expanding the definition of Health Management Information System governance to include not only process management but also the relationship management of interdependent actor groups, especially healthcare providers, the primary data collectors
Creative Arts to Enhance Cervical Cancer Awareness Using Art-Based Messages From a Nigerian Crowdsourcing Open Call: Qualitative Thematic Analysis.
Full text linkBACKGROUND: Cervical cancer is a leading cause of cancer deaths among women in Nigeria, yet awareness is low. Historically, art has served as a medium for processing emotions and sharing experiences, which can be effective in promoting health and behavior change. OBJECTIVE: This study aimed to examine art submissions and social media engagement from a Nigerian crowdsourcing open call to inform co-designed strategies for cervical cancer prevention among women. METHODS: This study reported following the SRQR (Standard Reporting for Qualitative Research) guideline. From October to November 2023, we launched an open call for art on social media, inviting adult women to submit artwork that raises awareness about cervical cancer prevention. Participants' submissions were anonymized and reviewed by an independent panel of judges. A total of 6 finalists were selected to participate in a social media contest during Cervical Cancer Elimination Week, and 3 winners were identified based on total social media likes and comments, as well as grading rubric scores. We analyzed participants' art entries through thematic analysis in six steps: (1) familiarization, (2) creating categories, (3) identifying themes, (4) reviewing themes, (5) defining themes, and (6) discussing findings. The emerging themes included using art to express emotions, to convey health-related content, and to use art as a form of self-regulation, which were further analyzed using the Relationships and Expectations domain of the PEN-3 (perceptions, enablers, and nurturers) cultural model. RESULTS: A total of 43 entries from participants aged 18-27 (mean 22.2, SD 2.6) years were analyzed. The entries included visuals (n=14), audiovisual (n=14), text (n=14), and audio (n=1). Most entries (42/43, 97.6%) focused on cervical cancer and human papillomavirus, covering definitions, risk factors, treatment, and prevention. Using the PEN-3 cultural model's Relationships and Expectations domain for analysis, 62.8% (27/43) addressed "perceptions" of art as a means of mental and emotional expression, reflecting feelings such as humor, sadness, hope, faith, unity, and fear related to cervical cancer prevention. A majority (34/43, 79.1%) aimed to promote human papillomavirus screening and vaccination and were categorized as "enablers," viewing art as a tool for health awareness, including educational resources. Additionally, 7% (3/43) included "nurturers," representing self-regulation addressing stresses linked to having relatives with cervical cancer. Six finalist entries were shared on social media to promote cervical cancer awareness, reaching 8685 individual Instagram accounts and generating 2727 likes and 782 comments. CONCLUSIONS: This study used art to increase awareness about cervical cancer on social media. Art can serve as a tool for promoting health by incorporating visual, emotional, and contextual messages to influence the target audience's behavior
Assessing the drivers of non-communicable diseases prevention activities in primary health care facilities in Ghana: a case study of some selected districts.
No full textBACKGROUND: Primary health care (PHC) is pivotal to equity and disease control in low- and middle-income countries. In Ghana, the rising burden of non-communicable diseases (NCDs) demands a shift from curative to preventive PHC. Evidence on the extent and drivers of PHC-led prevention, however, remains limited. METHODS: A cross‑sectional, facility‑based survey was conducted between November 2023 and March 2024, covering 210 primary‑health‑care facilities in 10 randomly selected districts of Greater Accra and the Eastern Region, Ghana. An adapted WHO‑SARA questionnaire was administered to facility heads or senior clinicians, capturing facility type, ownership, service‑readiness scores, and four self‑reported NCD‑prevention activities, community durbars, home visits, screening tests, and nutritional counselling. Multivariable logistic regression identified predictors of each activity, and a zero‑inflated negative‑binomial model evaluated the association between preventive engagement and NCD‑related outpatient‑department visits. RESULTS: Overall, 31% of facilities conducted Community Durbars, 63% Home Visits, 59% Screening Tests and 54% Nutritional Counselling. CHPS compounds (56% of facilities) were the most active—81% provided home visits, while only 8% of private clinics did so. CHPS status strongly predicted home visits (OR 26.89, 95% CI 1.20–604.85). Facilities offering Community Durbars (β 1.24, p < 0.01) or Nutritional Counselling (β 1.72, p < 0.01) recorded higher NCD-related OPD use. Higher district NHIS coverage was inversely associated with preventive engagement (OR 0.26, p < 0.01). CONCLUSION: NCD prevention in Ghana is led by lower-tier, government PHC facilities, yet resource gaps and treatment-centred financing limit wider uptake. Re-aligning NHIS incentives, investing in CHPS infrastructure and tailoring outreach to underserved groups especially men are critical for shifting Ghana’s PHC from reactive care to sustainable NCD prevention. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-026-14032-0
Plasma proteomic profiling reveals distinct protein signatures associated with hepatocellular carcinoma in chronic hepatitis B infection.
Full text linkBACKGROUND: Chronic hepatitis B virus (HBV) infection is a leading cause of hepatocellular carcinoma (HCC), yet reliable biomarkers for early detection and risk stratification remain limited. This study aimed to identify plasma proteins associated with disease progression from chronic HBV infection to HCC.
METHODS: Plasma proteomic profiling was conducted using high-resolution LC–MS/MS on samples from healthy controls, chronic HBV carriers, patients with cirrhosis, and individuals with HBV-associated HCC. Differentially expressed proteins were identified through bioinformatics analysis, and protein–protein interaction networks were reconstructed to assess functional relevance.
RESULTS: Eight proteins displayed distinct, stage-specific expression patterns along the disease continuum. ICAM1, TIMP1, and IGFBP7 were progressively upregulated, reflecting roles in inflammation, fibrosis, and tumorigenesis. In contrast, PF4V1 and GPLD1 were downregulated, suggesting loss of protective functions during disease progression. PFN1, TUBA1B, and MDH1 exhibited dynamic modulation linked to cytoskeletal remodeling, cell division, and metabolic reprogramming. Network analysis revealed their involvement in pathways critical for immune regulation, extracellular matrix remodeling, and angiogenesis. Random forest modeling further confirmed their strong discriminatory potential for disease staging.
CONCLUSION: This study identifies a panel of plasma proteins closely associated with HBV-related HCC progression. These biomarkers may facilitate early detection, improve risk stratification in HBV-infected individuals, and provide new insights into the molecular mechanisms driving liver cancer development
Perinatal mortality in eastern Africa: A systematic review and meta-analysis.
Full text linkBACKGROUND: Every day, over 5000 stillbirths and more than 6000 newborn deaths are estimated to occur worldwide, the majority in sub-Saharan Africa and South Asia. Estimates, however, rely on data that might underestimate these deaths. Further, outside major categories such as preterm birth, infection, and complications at delivery, little is known about the causes of death for newborns and even less for stillbirths. OBJECTIVES: This systematic review and meta-analysis aimed to synthesize evidence on the incidence, causes, and risk factors for perinatal mortality in East Africa to inform public health policy. METHOD: We searched major databases: Medline, Web of Science, EMBASE, Global Health, SCOPUS, Cochrane Library, CINAHL, HINARI, African Index Medicus, African Journals Online (AJOL), DHS website, and the World Health Organization African Regional Office (AFRO) Library. The search was conducted without imposing any language restrictions. Studies published 2010-2022 reporting perinatal mortality (incidence/causes/risk factors) in East African countries were included. We included all observational studies (cross-sectional, case-control, prospective cohort, and retrospective studies) and community-based trials. We performed meta-analyses with random effects to estimate pooled perinatal mortality rates for the population and health facility settings. We investigated and reduced heterogeneity where appropriate. We summarized causes of death descriptively and synthesized risk factors narratively. RESULTS: We included 99 out of 22 889 studies. The pooled population-based perinatal mortality rate was 33.1/1000 births (95% confidence interval [CI]: 29.3-37.1, I2 = 96.9%), and for health facility settings 67.1/1000 (95% CI: 47.5, 89.7, I2 = 98.9%). The major reported causes of perinatal deaths were infections and intrapartum-related events. However, our understanding of the specific causes of death was limited by the lack of detailed information necessary for diagnosing specific causes. Risk factors for perinatal mortality were demographic (low socioeconomic status), related to care (lack of antenatal care, obstetric complications), and maternal comorbidities. Protective factors included women's empowerment and supporting access to care through maternity waiting homes. CONCLUSION: Perinatal mortality remains high in East Africa. Many deaths were preventable through addressing modifiable risk factors and strengthening health systems to provide quality antenatal and intrapartum care. Consistent use of standardized cause-of-death classification and improved data quality are needed to enhance the understanding of specific causes of death and target interventions
The effect of a 5-day course of azithromycin on Streptococcus pneumoniae carriage and antimicrobial resistance among Kenyan children discharged from hospital.
No full textBACKGROUND: Mass azithromycin distribution reduces child mortality in some settings, potentially through reductions in nasopharyngeal carriage of Streptococcus pneumoniae, but has been associated with increased antimicrobial resistance. Individual-level data are lacking on the impact of azithromycin on antimicrobial resistance over time. METHODS: We analyzed data from a double-blind, randomized placebo-controlled trial (ClinicalTrials.gov; NCT02414399) which followed 1,398 hospitalized Kenyan children to evaluate the impact of a 5-day course of oral azithromycin at discharge from hospital on pneumococcal carriage and the proportion of isolates (among a random sample) resistant to azithromycin. Randomization to azithromycin or placebo (1:1) was stratified by enrollment county (Kisii or Homa Bay). Using generalized estimating equations, we calculated prevalence ratios (PRs) and 95% confidence intervals for the intervention, adjusting for enrollment site. RESULTS: Overall, 1,253/1398 (89.6%) enrolled children received antibiotics during their hospitalization. Pneumococcal carriage at discharge was similar among children randomized to the azithromycin group (158/702 [22.5%]) compared to the placebo group (171/696 [24.6%]; p = 0.4) and did not differ at month 3 (65.6% vs 67.0%; PR:0.98[0.90, 1.06]) or month 6 (66.7% vs 66.5%; PR:1.00[0.92, 1.08]). At discharge, 15.7% of isolates were resistant to azithromycin and there was no difference between azithromycin-treated and placebo groups at month 3 (35/266 [13.2%] vs 32/256 [12.5%]; PR:1.06[0.86, 1.66]) or month 6 (41/245 [16.7%] vs 43/243 [17.6%]; PR:1.01[0.69,1.49]). CONCLUSIONS: Azithromycin treatment did not effect pneumococcal carriage or antimicrobial resistance 3- or 6-months post-randomization. High inpatient antibiotic use in this recently discharged population may have reduced any further impact of azithromycin
Exploring understandings and approaches to decolonisation in the field of violence against women and girls: Towards conceptual clarity and actionable strategies for funding, programming and research.
Full text linkDespite recognition that decolonisation is important, there remains a lack of conceptual clarity on what exactly decolonising might involve. Our qualitative study explores how colonialism and decolonisation are conceptualised within the field of violence against women and girls (VAWG), and identifies practical strategies to decolonise funding, programming and research. Our findings draw from 17 semi-structured interviews, eight focus group discussions (FGDs) and five feedback workshops (n = 83) with practitioners, researchers and donors supporting VAWG prevention and response. We identified participants through existing professional networks and used snowball sampling to recruit participants from all world regions. Interviews and FGDs were conducted in English, French, Portuguese and Spanish. We used a reflexive thematic approach for analysis. There was confusion and disagreement about what the term 'decolonisation' means. To address this, VAWG actors must identify the legacy and impact of colonialism for the field, and clarify the roles of Northern and Southern actors in decolonising. Our findings highlight that the area where most work is still needed is around VAWG programming, where coloniality may be embedded into programme design and implementation, requiring more concerted actions to decolonise. Funding was also identified as a key area where structural reform is needed. Research, however, was an area where there appeared to be much higher awareness and action related to decolonising, linked to momentum around dismantling research-based power hierarchies outside of the VAWG field. This research contributes to articulating the main barriers to decolonising and identifies practical actions for funding, programming and research within the VAWG field and beyond
Assessment of a Modified High-Dimensional Propensity Score Approach for UK Electronic Health Record Data: Evaluating Upper Gastrointestinal Safety of NSAIDs and COX-2 Inhibitors.
Full text linkPURPOSE: This study extends a version of the high-dimensional propensity score (HDPS) recently modified for the UK electronic health record setting, by enriching primary care data with hospital data. The performance of this modified approach is assessed via the estimation of a well-established association, the reduced risk of upper gastrointestinal bleeding (UGIB) in cyclo-oxygenase-2 inhibitor (COX-2i) users versus non-steroidal anti-inflammatory drug (NSAID) users. METHODS: We conducted an active-comparator, new-user cohort study using UK primary care data from the Clinical Practice Research Datalink GOLD database, with linkages to hospitalisation and mortality records. We included individuals with osteoarthritis initiating NSAIDs or COX-2is between 2000-2004. We used Cox proportional hazards models to estimate the hazard ratio (HR) for UGIB, adjusting for confounders using investigator-specified and HDPS-derived propensity scores. Sensitivity analyses were conducted varying the number of HDPS covariates included and the covariate assessment period. RESULTS: We identified 74 443 and 25 742 new users of NSAID and COX-2i users, respectively. The unadjusted HR for UGIB comparing COX-2i and NSAID users was 1.28 (95% CI: 0.95-1.72). Of the included HDPS covariates, 26% originated from the hospitalisation dimension, a source not considered in previous applications indicating the considerable information contained in these data on proxies of potential confounders. The modified-HDPS obtained similar results to the other studies, shifting the HR closer to the expected association (HR 0.86; 95% CI: 0.58-1.26). CONCLUSION: We demonstrate the ability of the modified-HDPS to obtain similar results to comparable pharmacoepidemiological studies and randomised trials, highlighting the potential benefit of these approaches in UK EHRs more widely and the value of adding hospital data to enrich the pool of covariates available for the HDPS algorithm