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Socio-economic and geographic equity in maternal health services utilization in Ethiopia: a community-based cross-sectional study.
Get PDFBACKGROUND: Addressing disparities in reproductive, maternal, newborn, and child health services is crucial in achieving the Sustainable Development Goal of universal health coverage. The persistence of social and geographic disparities in maternal health service coverage and utilization poses significant challenges. Ensuring equity in health service access and utilization as part of universal health coverage requires evidence whether these inequities exist. This study aimed to measure socio-economic and geographic equity in coverage and effective coverage of both antenatal care and skilled birth attendance. METHODS: We conducted a secondary analysis of data collected from the Performance Monitoring for Action Ethiopia from 2019 to 2020, including 2714 postpartum women at around six weeks and service delivery point assessment data from 462 health facilities. We measured inequities in the utilization of four or more antenatal care visits and skilled birth attendance using equiplots and concentration index. Moran's I, Getis-Ord Gi statistics and Kriging interpolations were employed to analyze geographic variations of maternal health service utilization. RESULTS: In this study, 40% (95%CI: 36, 45) utilized four or more ANC visits, and 12% (95%CI: 11, 14) received quality antenatal care. Over half (54%, 95%CI: 48, 59) of women utilized skilled birth attendance, but only 7% (95%CI: 4, 8) received quality delivery care. The absolute equity gap between the least poor and the poorest women was 43 percentage points for ANC visits and 65 percentage points for skilled birth attendance. A higher proportion of women in Central and Northern parts of Ethiopia had four or more ANC visits and utilized skilled birth attendance, while most parts of the Eastern part of the country and most areas in the South had low levels of utilization. CONCLUSION: The coverage of four or more antenatal care visits and skilled birth attendance was low and inequitable, with the poorest women receiving fewer services. The coverage varied across different parts of the country. Interventions that target groups of women and geographic areas with low coverage of services are crucial for reaching the goal of universal health coverage
Economic costing methodologies for drug-resistant bacterial infections in humans in low-and middle-income countries: a systematic review.
Get PDFBACKGROUND: This review examined methodologies used to cost the impact of antimicrobial resistance (AMR) infections in humans from household and health system perspectives. Although extensive research has been conducted on the clinical AMR burden in low- and middle-income countries (LMICs) in terms of prevalence and other drivers of antimicrobial resistance, there is increased misuse and overuse of antibiotics which increases the risk of AMR infections compared to high-income countries. Lack of comprehensive estimates on economic costs of AMR in LMICs due to lack of standard methodologies that incorporate time biases and inference for instance, may negatively affect accuracy and robustness of results needed for reliable and actionable policies. METHODS: We conducted a systematic review of studies searched in PubMed and other electronic databases. Only studies from LMICs were included. Data were extracted via a modified Covidence template and a Joanna Briggs Institute (JBI) assessment tool for economic evaluations to assess the quality of the papers. RESULTS: Using PRISMA, 2542 papers were screened at the title and abstract levels, of which 148 were retrieved for full-text review. Of these, 62 articles met the inclusion criteria. The articles had a quality assessment score averaging 85%, ranging from 63 to 100%. Most studies, 13, were from China (21%), followed by 8 from South Africa (13%). Tuberculosis (TB), general bacterial, and nosocomial infection costs are the most studied, accounting for 40%, 39%, and 6%, respectively with TB common in South Africa than the rest of the countries. The majority of the papers used a microcosting approach (71%), followed by gross costing (27%), while the remainder used both. Most studies analyzed costs descriptively (61%), followed by studies using regression-based techniques (17%) and propensity score matching (5%), among others. CONCLUSION: Overall, the use of descriptive statistics without justification, limited consideration for potential data challenges, including confounders, and short-term horizons suggest that the full AMR cost burden in humans in LMICs has not been well accounted for. Given the limited data available for these studies, the use of a combination of methodologies may help triangulate more accurate and policy-relevant estimates. While the resources to conduct such cost studies are limited, the use of modeling costs via regression techniques while adjusting for cofounding could help maximize robustness and better estimate the vast and varied burden derived directly and indirectly from AMR
The epidemiology and burden of cardiovascular diseases in countries of the Association of Southeast Asian Nations (ASEAN), 1990-2021: findings from the Global Burden of Disease Study 2021.
Get PDFBACKGROUND: The Association of Southeast Asian Nations (ASEAN) has undergone substantial epidemiological changes over the past three decades, characterised by a growing burden of cardiovascular disease. This study provides an epidemiological overview of cardiovascular diseases across ASEAN. METHODS: As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2021, we assessed the prevalence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) of 12 cardiovascular diseases, stratified by age, sex, and location, for ten ASEAN member states (Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Viet Nam) from 1990 to 2021. We examined the contribution of major risk factors associated with cardiovascular disease. Diverse data sources and meta-analytical modelling techniques were used to synthesise data and generate consistent estimates for each metric. FINDINGS: In 2021, there were 36·8 million (95% uncertainty interval 34·4-38·8) prevalent cases of cardiovascular disease and 1·66 million (1·51-1·80) cardiovascular disease deaths across ASEAN. The total number of DALYs was 42·4 million (38·4-46·2), making cardiovascular disease the leading cause of disease burden in the region. Compared with 1990, the number of individuals with cardiovascular disease has increased by 148·1% (144·0-152·5), whereas the age-standardised prevalence rate rose by 2·5% (1·4-3·6). The highest age-standardised prevalence rate was in Malaysia, followed by Indonesia. The top three leading cardiovascular diseases with the highest age-standardised prevalence rates were ischaemic heart disease (2070·6 [1831·3-2358·2] per 100 000 people), lower extremity peripheral arterial disease (1380·8 [1189·8-1598·7] per 100 000 people), and stroke (1300·6 [1230·5-1375·4] per 100 000 people). The age-standardised mortality rate was highest in Laos (410·9 deaths [337·2-485·9] per 100 000 people). Most cardiovascular disease burden was attributed to high systolic blood pressure, dietary risks, air pollution, high low-density lipoprotein cholesterol, and tobacco use, with high BMI and high fasting plasma glucose rapidly rising as attributive factors. INTERPRETATION: Cardiovascular disease remained the leading cause of mortality and morbidity in ASEAN in 2021. The number of individuals with cardiovascular disease is expected to rise with an ageing population and socioeconomic advancement. Given the disparities across ASEAN, interventions must be tailored at all levels to address the needs in prevention, treatment, and management. FUNDING: The Gates Foundation
Quantitative bias analysis for mismeasured variables in health research: a review of software tools.
Get PDFBACKGROUND: Measurement error and misclassification can cause bias or loss of power in epidemiological studies. Software performing quantitative bias analysis (QBA) to assess the sensitivity of results to mismeasurement are available. However, QBA is still not commonly used in practice, partly due to a lack of knowledge of these software implementations. The features and particular use cases of these tools have not been systematically evaluated. METHODS: We reviewed and summarised the latest available software tools for QBA in relation to mismeasured variables in health research. We searched the electronic database Web of Science for studies published between [Formula: see text] January 2014 and [Formula: see text] May 2024 (inclusive). We included epidemiological studies that described the use of software tools for QBA in relation to mismeasurement. We also searched for tools catalogued on the CRAN archive, in Stata manuals, and via Stata's net command, available from within Stata or from the IDEAS/RePEc database. Tools were included if they were purpose-built, had documentation, and were applicable to epidemiological research. Data on the tools' features and use cases were then extracted from the full article texts and software documentation. RESULTS: 17 publicly available software tools for QBA were identified, accessible via R, Stata, and online web tools. The tools cover various types of analysis, including regression, contingency tables, mediation analysis, longitudinal analysis, survival analysis and instrumental variable analysis. However, there is a lack of software tools performing QBA for misclassification of categorical variables and measurement error outside of the classical model. Additionally, the existing tools often require specialist knowledge. CONCLUSIONS: Despite the availability of several software tools, there are still gaps in the existing collection of tools that need to be addressed to enable wider usage of QBA in epidemiological studies. Efforts should be made to create new tools to assess multiple mismeasurement scenarios simultaneously, and also to increase the clarity of documentation for existing tools, and provide tutorials and examples for their usage. By doing so, the uptake of QBA techniques in epidemiology can be improved, leading to more accurate and reliable research findings
Eculizumab withdrawal and monitoring in atypical haemolytic uraemic syndrome (SETS aHUS): a multicentre, open label, prospective, single arm trial.
Get PDFBACKGROUND: Atypical Haemolytic Uraemic Syndrome is a rare disease, associated with high morbidity and mortality. Eculizumab, a monoclonal complement inhibitor, is an effective treatment but the optimal way to use this high-cost medication has not been determined. The SETS aHUS trial aimed to establish the safety of eculizumab withdrawal and the effectiveness of a monitoring protocol to detect disease relapse and reintroduction of treatment if relapse occurs. METHODS: The SETS aHUS multicentre, open label, prospective, single-arm trial enrolled participants from 15 UK hospitals. Patients over two years of age with aHUS who were receiving eculizumab therapy for at least six months were eligible to withdraw from treatment, replacing it with monitoring to assess disease activity and treatment re-introduction if relapse occurred. The primary outcome measure was harm to a participant as a consequence of eculizumab withdrawal. Participants met a primary outcome if there was a permanent reduction in estimated glomerular filtration rate, requirement for kidney replacement therapy or significant extra-renal manifestation of disease. The Bayes factor single arm binary model was used to monitor and analyse the trial data, applying pre-trial stopping rules. The trial is registered with the European Union Drug Regulating Authority (EudraCT 2017-003916-37) and is closed for recruitment. FINDINGS: One of 28 participants (3.6%) who withdrew from treatment met a primary outcome. Four of the 28 participants (14.3%) relapsed. Only participants with an identified cause of complement dysregulation relapsed. It was possible, by monitoring and rapid participant access, to reintroduce eculizumab treatment. Based on the pre-trial analysis plan, withdrawal from treatment may represent no greater risk to patients. INTERPRETATION: In this single arm study, for patients fulfilling trial entry criteria, which excluded some high-risk patients, withdrawal of eculizumab treatment with monitoring of disease activity was not associated with an increased risk of harm compared to continuation of eculizumab. FUNDING: National Institute for Health and Care Research Health Technology Assessment programme
Recent Antiretroviral Therapy Initiation Is Associated With Increased Mortality Risk in Human Immunodeficiency Virus–associated Cryptococcal Meningitis: An Analysis of Clinical Trial Data From Africa
Get PDFBackground: More than half of people diagnosed with human immunodeficiency virus-associated cryptococcal meningitis are antiretroviral therapy (ART)-experienced. The impact of recent ART initiation (≤14 days) on outcomes from cryptococcal meningitis, and how to optimally manage ART in this patient population, are unknown.
Methods: We analyzed data from the recent Ambisome Therapy Induction Optimisation (AMBITION) trial to (1) examine whether patients diagnosed with cryptococcal meningitis within 14 days of ART initiation are at higher risk of mortality and (2) determine the impact of ART interruption at diagnosis of cryptococcal meningitis. Combined data from the AMBITION trial and the earlier Antifungal Combinations for Treatment of Cryptococcal Meningitis in Africa trial were analyzed to describe baseline characteristics of patients according to ART status.
Results: Among the 810 AMBITION participants, adjusted 2-week mortality risk was 20.8% (95% confidence interval [CI]: 11.5-30.2; 26/120) in those on ART for 14 days or less at presentation, 10.4% (95% CI: 3.6-17.2; 18/130) on ART for >2 weeks to 2 months, 7.1% (95% CI: 0-14.9; 7/92) on ART for >2 months to 6 months, and 13.0% (95% CI: 8.5-17.6; 50/307) in those on ART for more than 6 months compared to 12.4% (95% CI: 9.2-15.5; 111/707) among individuals not on ART. In the combined dataset, baseline fungal burdens were lower and baseline CD4 counts were higher with increasing ART duration. Among individuals on ART for ≤14 days at presentation, 2-week mortality was 35% (8/23) in those continuing ART versus 14% (7/49) in those discontinuing ART.
Conclusions: Mortality from cryptococcal meningitis was higher in recent ART initiators. ART interruption in this group may lead to improved outcomes
Identification of Anthrax as the Cause of a Cluster of Unexplained Deaths, Uganda, 2023: The Role of Metagenomic Next-Generation Sequencing and Postmortem Specimens.
Get PDFBetween April and November 2023, 27 unexplained human deaths that presented with swelling of the arms, skin sores with black centers, difficulty in breathing, obstructed swallowing, headaches, and other body aches were reported in Kyotera District, Uganda by the Public Health Emergency Operations Center. Subsequently, the death of cattle on farms and the consumption of carcass meat by some residents were also reported. Field response teams collected clinical/epidemiological data and autopsy samples to determine the cause of deaths. Metagenomic next-generation sequencing (mNGS) and target enrichment sequencing conducted on postmortem samples confirmed Bacillus anthracis, the etiological agent of anthrax disease, as the cause of the deaths. Applying mNGS to autopsy specimens is useful as a retrospective tool for identifying high-consequence pathogens during suspected outbreaks of unknown etiology
Selecting Cost-Effectiveness Methods for Health Benefits Package Design: A Systematic Approach.
Get PDFBACKGROUND: Cost-effectiveness (CE) is a common prioritization criterion in health benefits package (HBP) design. However, to assess CE is a time- and data-demanding process, so most HBP exercises rely wholly or partially on global evidence. Extensive investment has been made in analyses, models, and tools to support cost-effectiveness analyses (CEAs) for HBPs. However, little attention has been paid to how national HBP assessors should both understand and select CE estimates. A structured, national process to select assessment methods is essential for ensuring the accuracy, ownership, and transparency of HBP design. This can be supported by "adaptive" health technology assessment (aHTA) principles, which focus on structured methodological choices based on the time, data, and capacity available. The objective of this paper was to apply aHTA framing to CEA methods selection for HBPs, and to make recommendations on how countries may consider systematically making these choices going forward. METHODS: We first reviewed the definitions and categorization of different aHTA methods. We then conducted a scoping review of previous HBP assessments to understand how CEA methods used in HBPs fit into the aHTA framework, and a follow-up survey of authors to fill gaps. Results of the literature review and survey were interpreted and narratively synthesized. RESULTS: We found that previous HBP assessments used four aHTA methods, sometimes simultaneously: expert opinion (n=3/20), review (n=12/20), model adaptation (n=6/20), and new model (n=2/20). The literature review and survey found that aHTA methods for HBPs take between 1-13 months; require different data sources depending on the method(s) used; and generally, require capacity in health economics, medicine, public health, and CE modelling. We supplement our report with a discussion of key considerations for methods selection. CONCLUSION: Trading off time, data, and capacity needs for different CE assessment methods can help to support structured, local design of HBP assessments
Small and sick newborn care: Changes in service readiness scoring between baseline and 2023 for 65 neonatal units implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania.
Get PDFHealth Facility Assessments (HFAs) are important for measuring and tracking service readiness for small and sick newborn care (SSNC). NEST360 Alliance aims to reduce neonatal mortality in four countries (Kenya, Malawi, Nigeria, Tanzania). NEST360 and UNICEF facilitated HFA tool design with ministries of health in four African countries and developed two complimentary approaches to summarise readiness. Using the NEST360/UNICEF HFA tool, we collected data, developed two service readiness scoring approaches for SSNC (standards-based scoring by adapted World Health Organization (WHO) health system building blocks (HSBBs) and assessing service readiness across the health system, and level-2+ scoring by WHO clinical interventions), and applied across 65 neonatal units implementing NEST360. Service readiness change was assessed between baseline (Sept 2019-March 2021) and follow-up HFA (May-July 2023). For each neonatal unit, a percentage difference score was computed between baseline and 2023 HFA scores. Scores were calculated for each neonatal unit as the unit of analysis, and disaggregated by HSBB, clinical intervention, and sub-modules. Data from 65 neonatal units were analysed, i.e., 36 in Malawi, 13 in Kenya, 7 in Tanzania, and 9 in Nigeria. Median time between baseline and 2023 HFAs was 31 months [IQR 29-34 months]. Median baseline and 2023 scores were 41% [IQR 35-52%] and 55% [IQR 46-62%] respectively with 14% median score change [IQR 4-18%] for level-2+ scores. For standards-based scores, median baseline and 2023 scores were 51% [IQR 48-58%] and 60% [IQR 54-66%] respectively with a 9% median score change [IQR 3-11%]. Hospitals in Tanzania [Median 24%, IQR 16-30%] and Nigeria [Median 28%, IQR 17-30%] showed greater improvements on average for level-2+ scores compared to hospitals in Kenya and Tanzania. Data on changes in service readiness scores can be used to track service readiness over time, benchmark between hospitals, identify gaps, and assess progress towards newborn targets
Factors Associated With Prelacteal Feeding of Commercial Milk Formula: An Analysis of Cohort Data From the BADUTA Study in Indonesia.
Get PDFIntroducing commercial milk formula (CMF) as prelacteal feeds can disturb exclusive breastfeeding and shorten breastfeeding duration. However, the prelacteal feeding of CMF has been growing alongside its increasing sales in Indonesia. This study examined predictors of the CMF feeding in the Malang and Sidoarjo districts of Indonesia. This analysis used post-delivery data collected from 676 mothers in a cohort evaluation of a cluster randomised controlled trial (Baduta study). Multivariate random effects logistic models were employed to assess factors associated with the CMF feeding. A total of 467 (69.1%) respondents reported giving CMF to their infants during the first 3 days after delivery. Mothers with low breastfeeding self-efficacy (BFSE) were at a higher risk of providing CMF within 3 days of birth compared to those with medium or high BFSE (adjusted odds ratio (aOR) 8.12; 95% confidence interval (CI) (4.26-15.48). Receiving explanations to solve breastfeeding problems from health professionals (aOR: 1.87; 97% CI: 1.12-3.11) and primipara parity (aOR: 1.71; 95% CI: 1.12-3.04) were positively associated with the CMF feeding. Early initiation of breastfeeding (EIBF) was protective against CMF feeding (aOR: 0.40; 95% CI: 0.22-0.58). There was an interaction between EIBF and BFSE. EIBF was protective among mothers with high or medium BFSE, but had no effect among those with low BFSE. CMF feeding was prevalent in Indonesia. Future strategies should focus on improving health-staff capacity to strengthen BFSE during pregnancy and provide adequate counselling for mothers with breastfeeding problems