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Patterns and temporal trends in childhood cancer incidence in northern Ghana: evidence from medical records, 2016 to 2023.
Get PDFBACKGROUND: Childhood cancers contribute significantly to child morbidity and mortality worldwide, with an even greater burden in resource-limited settings. However, there is limited research documenting the incidence and patterns of childhood cancers in Ghana. AIM: We aimed to examine the trends and patterns of childhood cancers in Northern Ghana over an eight-year period.
METHODS: We conducted a retrospective descriptive analysis of medical records from the pediatric oncology unit at Tamale Teaching Hospital in Northern Ghana. The study included children diagnosed with cancer and admitted to the oncology unit between January 2016 and December 2023. We classified cancers based on the International Classification of Childhood Cancer and quantified the number of cases of each type, both overall and stratified by time and child characteristics. SAS JMP Professional Software (version 17.1) was used to analyze the data.
RESULTS: A total of 216 child medical records were analyzed. Most (62.5%) children were male, with 48.1% aged 0 to 3 years. The number of children admitted with cancer increased progressively over time, from 15 cases in 2016/2017 to 82 in 2022/2023. Males and those 0 to 7 years were more likely to be admitted with cancer. Ten cancer types were identified, with retinoblastoma being the most commonly diagnosed cancer (30.1%), followed by lymphomas (23.1%) and renal tumors (15.7%). Of the 184 children with admission outcome data, 56.5% (n = 104) died. Cancer-related deaths were highest among those diagnosed with lymphomas and reticuloendothelial neoplasms (31 out of 104 cases; 29.8%) and retinoblastoma (30 out of 104 cases; 28.8%), as well as those aged 0-3 years (47 out of 104 cases; 45.2%) and among males (70 out of 104 cases; 67.3%). Overall, cancer deaths declined steadily from 71.4% in 2016/2017 to 44.4% in 2022/2023.
CONCLUSION: Our findings indicate a high burden of childhood cancers in Northern Ghana, with a greater proportion of cases occurring among male children. The observed increase in the number of childhood cancer admissions to the oncology unit may reflect improved case detection, greater awareness among caregivers, and increased referrals to specialized care, rather than a definitive rise in cancer incidence. These findings highlight the urgent need for population-based cancer registries and further research to accurately track and understand childhood cancer trends in the region
Community engagement in maternal and perinatal death surveillance and response: a realist review.
Get PDFBackground: Community engagement in maternal and perinatal death surveillance and response (MPDSR) could support health systems in providing people-centred care and ensure accountability for the prevention of maternal and perinatal deaths. Although community engagement activities in MPDSR have been described, the literature does not adequately explain which community engagement in MPDSR strategies succeed, the contexts in which they work, the outcomes they produce, and for whom.
Methods: We conducted a realist review, which involved the identification and refinement of programme theories. An initial literature search identified four initial programme theories (IPTs) that explain how community engagement works in the different parts of the MPDSR cycle.
Six databases (Medline, Embase, Scopus, Global Health, CINAHL Plus and Web of Science) and Google were searched for papers and grey literature published between 2004 and August 2022. We used retroductive analysis on included articles to support the identification of generative causation using the heuristic of ‘context-mechanism-outcome configuration’ (CMOCs), which explained what mechanisms were triggered in different contexts and the outcomes that were produced. The findings were then used to refine the IPTs and produce final programme theories.
Results
Forty-five articles from 40 studies reported some form of community engagement in MPDSR. We identified 20 CMO configurations that were synthesised into five programme theories:
(1) Fear of blame demotivates community members and health professionals from engaging in MPDSR.
(2) Dialogue between health professionals and community members improves collaboration and empowers community members to propose innovative solutions.
(3) Trusted social connections between bereaved families and community volunteers enables them to identify and report deaths.
(4) Financial and non-financial incentives motivate community members and health professionals to engage in MPDSR.
(5) Community engagement is more sustainable when it is routinised and integrated into the health system.
Conclusion:
Implementing community engagement in MPDSR requires a systems approach that addresses the five Programme Theories collectively, rather than implementing community engagement in specific parts of the MPDSR cycle as our initial programme theories had suggested. Establishing conducive participatory spaces that promote dialogue, trust and minimise blame culture is critical for the success of community engagement in MPDSR programmes. Community members can be engaged in MPDSR processes in health facilities and community settings and high- and low-income countries
Who is at the table and who has the power? Case study analysis of decision-making processes for the Global Financing Facility in Tanzania.
Get PDFBackground In 2015, Tanzania joined the Global Financing Facility (GFF), a global health initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). Despite its resource mobilization goals, little is known about power dynamics in GFF policy processes. This paper presents the first power analysis of Tanzania's GFF engagement.ObjectiveTo examine policy processes in developing GFF documents during its first two phases in Tanzania. Methods An exploratory qualitative case study using document reviews (*n* = 22) and key informant interviews (*n* = 21) conducted in 2022-2023. Data were thematically analyzed and interpreted using Gaventa's power cube (levels, spaces, and forms of power). Results Stakeholders praised the GFF's country-led, evidence-based approach and local autonomy. However, closed-door decision-making in phase one excluded civil society and the private sector. Invisible power imbalances in funding allocations left stillbirths and adolescent health without dedicated budgets, while vulnerable groups (e.g. people with disabilities) were overlooked. Disbursement-linked indicators emphasized measurable outcomes, reflecting visible power. Phase two showed adaptive learning, with improved inclusivity. Conclusion While government-led, global actors (e.g. World Bank, donors) heavily influenced decisions. Greater civil society engagement is needed for accountability. Future efforts must address power imbalances through meaningful citizen participation to strengthen RMNCAH-N services
Evaluating the use of red flags by online symptom checkers.
Get PDFBACKGROUND: Online Symptom Checkers (OSCs) are digital health tools providing triage, diagnostic, and self-care advice based on user reported symptoms. Amidst global trends of increasing demand and workforce shortages, OSCs have the potential to alleviate primary care workload. However, their ability to seek red flag symptoms, a critical marker of a safe consultation in primary care, remains unexplored. Using clinical vignettes, this study evaluates OSCs' performance in seeking red flag symptoms compared to Primary Care Physicians (PCPs).
METHODS: Four OSCs (Ada, Babylon, Symptomate, Healthily) were evaluated using 51 clinical vignettes. Two standard setters used guidelines to determine which vignettes required emergency triage and identified the relevant red flags symptoms for the remaining vignettes. Two laypersons entered data from vignettes into OSCs and outputs were collected following a standardised form. The same vignettes were independently assessed by PCPs to compare triage accuracy and red flag identification. Summary statistics and 95% confidence intervals were calculated using Wilson Score intervals, and Fisher's exact test was used to compare performance between OSCs and PCPs.
RESULTS: Of the 51 clinical vignettes, standard setters determined 14 to require emergency triage and the remaining 37 vignettes suitable for primary care triage. Of the primary care triaged vignettes, standard setters identified a total of 77 relevant red flag symptoms to be sought. Of the 14 emergency vignettes, PCPs correctly triaged 85.7% (95% CI: 74.3-92.6%) of cases compared to OSCs 76.9% (95% CI: 59.3-87.9%), with no statistically significant difference (p = 0.299). Specificity, the proportion of correctly triaged primary care vignettes, PCPs performed significantly better compared to OSCs, 91.9% (95%CI 78.9-97.0%) vs. 83.3% (95%CI 68.1-91.9%), p = 0.024.
CONCLUSIONS: OSCs demonstrated comparable ability to appropriately triage clinical vignettes requiring emergency triage as PCPs, however, were less specific, triaging more primary care vignettes as emergency. OSCs do not seek the majority of red flags. This raises concerns about their safety and effectiveness in primary care. OSCs developers should focus on improving OSCs' red flag coverage to ensure safe integration into primary care settings
Gender equity and sustainable development through the lens of fertility intentions among highly educated women: a systematic review and meta-analysis.
Get PDFBACKGROUND: Declining fertility rates have raised concerns about potential population crises in many nations. While previous studies have established the link between female education and fertility intentions, no global meta-analysis has examined the fertility intentions of highly educated women. METHODS: We searched Medline, Embase, Global Health, and APA PsycExtra for studies published between January 2000 and December 2022, without language restrictions. Eligible studies included cross-sectional, longitudinal, case-control, intervention, and qualitative studies that reported fertility intentions or influencing factors among females with at least a post-secondary education. We excluded abstracts, conference proceedings, letters, commentaries, editorials, reviews, and preprints. The pooled proportion of fertility intentions was estimated through a random-effects meta-analysis. We analyzed factors that influence fertility intentions using a data-based convergent synthesis design. RESULTS: Out of the initial 4,804 studies identified, 35 studies were eligible for inclusion. The meta-analysis of fertility intentions included 17,292 highly educated women from 19 countries. The pooled proportion of highly educated women who did not expect children in the future was 12.2% (95% CI 8.4-16.7%), with substantial variation across regions, from 5.1% (2.6-8.3%) in the European Region to 22.9% (13.6-33.7%) in the Western Pacific Region. Factors associated with fertility intentions included not only the pursuit of a career and education (individual-level), the need for stable relationships and family support (family-level), but also (un)supportive environments (community-level), labor market and childcare services (institutional-level), and social norms and national policies (structural-level). CONCLUSION: Regional disparities in fertility intentions among highly educated women reflect underlying differences in social welfare systems, labor market structures, and gender norms. Policies aimed at supporting fertility in this group should move beyond a narrow focus on individual preferences and instead address the broader contextual factors that shape reproductive decision-making. Creating a supportive environment for parenting, through equitable leave entitlements, accessible childcare, and family-friendly employment policies, may contribute to fostering informed fertility choices among highly educated women. TRIAL REGISTRATION: CRD42023404366
Weighted Hazard Ratio Estimation for Delayed and Diminishing Treatment Effect
Get PDFNonproportional hazards (NPH) have been observed in confirmatory clinical trials with time to event outcomes. Under NPH, the hazard ratio does not stay constant over time and the log rank test is no longer the most powerful test. The weighted log rank test (WLRT) has been introduced to deal with the presence of nonproportionality. We focus our attention on the WLRT and the complementary Cox model based on time varying treatment effect proposed by Lin and León. We investigate whether the proposed weighted hazard ratio (WHR) approach is unbiased in scenarios where the WLRT statistic is the most powerful test. In the diminishing treatment effect scenario where the WLRT statistic would be most optimal, the time varying treatment effect estimated by the Cox model estimates the treatment effect very close to the true one. However, when the true hazard ratio is large the proposed model overestimates the treatment effect and the treatment profile over time. In the delayed treatment scenario, the estimated treatment effect profile over time is typically close to the true profile. For both scenarios, we have demonstrated analytically that the hazard ratio functions are approximately equal under small treatment effects. When the assumed rate of how quickly the treatment effect profile is diminishing or delaying differs in the analysis from that in the true data generating mechanism, the estimated hazard ratio profile from the WHR approach is biased. Since in practice the true HR time profile may differ from that assumed in the WHR analysis, it may be preferable to use alternative approaches for effect estimation
Person-centred HIV care and prevention for youth in rural South Africa: preliminary implementation findings from Thetha Nami ngithethe nawe stepped-wedge trial of peer-navigator mobilization into mobile sexual health services.
Get PDFINTRODUCTION: Despite the efficacy of antiretroviral therapy (ART)-based prevention, population-level impact remains limited because those at high risk of HIV acquisition are not reached by conventional services. We investigated whether youth-centred and tailored HIV prevention, delivered by community-based peer navigators alongside sexual and reproductive health (SRH) services, can mobilize demand for HIV pre-exposure prophylaxis (PrEP) and ART among adolescents and young adults (AYA) in KwaZulu-Natal, South Africa.
METHODS: Thetha Nami ngithethe nawe is a cluster-randomized stepped-wedge trial (SWT) in 40 clusters within a rural health and demographic surveillance site. Clusters were randomized to receive the intervention in period 1 (early) or period 2 (delayed). Trained area-based peer navigators conducted needs assessments with youth aged 15-30 years to tailor health promotion, psychosocial support and referrals into nurse-led mobile SRH clinics that also provided HIV testing, and status-neutral ART and oral PrEP. Standard of care was PrEP delivered through primary health clinics. We report SRH service uptake from the 20 intervention clusters during the first period of the SWT (NCT05405582).
RESULTS: Between June 2022 and September 2023, peer-navigators reached 9742 (74.9%) of the 13,000 youth in the target population, 46.8% males. Among 9576 individuals with needs assessment, peer-navigators identified 141 (1.5%) with social needs, and 4138 (43.5%) had medium to high health needs. These individuals were referred to mobile clinics, with 2269 (54.8%) attending, including 959 (42.3%) males. HIV testing uptake was high (92.7%; 2103/2269), with 10.1% (212/2103) testing positive for HIV, 62 (29.2%) of whom started ART for the first time. The prevalence of HIV was higher among females compared to males (15.1% vs. 3.3%; p < 0.001). Among clinic attendees, 96.8% were screened for PrEP eligibility, with 38.5% deemed eligible and offered PrEP. Of the 1433 (63.2%) individuals tested for sexually transmitted infections (STIs), 418 (29.2%) tested positive, with females having higher STI prevalence (37.2% vs. 17.9%; p < 0.001). Of these, 385 (92.1%) received STI treatment. Among 1310 females, 769 (58.7%) reported not using any contraception at their initial visit, and 275/769 (35.8%) started contraception during the trial.
CONCLUSIONS: Community-based and person-centred approaches delivered through trained peer-navigators can link AYA with SRH and HIV prevention/care needs with mobile SRH services
Urgent need for services to support children with and at risk of developmental disabilities in low- and middle-income countries.
Get PDFPredicting suicidality in people living with HIV in Uganda: a machine learning approach.
Get PDFBACKGROUND: People living with HIV (PLWH) are more likely to experience suicidal thoughts and exhibit suicidal behavior than the general population. However, there are currently no effective methods of predicting who is likely to experience suicidal thoughts and behavior. Machine learning (ML) approaches can be leveraged to develop models that evaluate the complex etiology of suicidal behavior, facilitating the timely identification of at-risk individuals and promoting individualized treatment allocation.
MATERIALS AND METHODS: This retrospective case-control study used longitudinal sociodemographic, psychosocial, and clinical data of 1,126 PLWH from Uganda to evaluate the potential of ML in predicting suicidality. In addition, suicidality polygenic risk scores (PRS) were calculated for a subset of 282 study participants and incorporated as an additional feature in the model to determine if including genomic information improves overall model performance. The model's performance was evaluated using the area under the receiver operating characteristic curve (AUC), positive predictive value (PPV), sensitivity, specificity, and Mathew's correlation coefficient (MCC).
RESULTS: We trained and evaluated eight different ML algorithms, including logistic regression, support vector machines, Naïve Bayes, k-nearest neighbors, decision trees, random forests, AdaBoost, and gradient-boosting classifiers. Cost-sensitive AdaBoost emerged as the best model, achieving an AUC of 0.79 (95% CI: 0.72-0.87), a sensitivity of 0.63, a specificity of 0.74, a PPV of 0.36, and an NPV of 0.89 on unseen baseline data. The model demonstrated good generalizability, predicting prevalent and incident suicidality at 12-month follow-up with an AUC of 0.75 (95% CI: 0.69-0.81) and 0.69 (95% CI: 0.62-0.76), respectively. Incorporating PRS as an additional feature in the model resulted in a 6% improvement in model sensitivity and a 9% reduction in specificity. A positive MDD diagnosis and high stress contributed the most to predicting suicidality risk.
CONCLUSION: A cost-sensitive AdaBoost model developed using the sociodemographic, psychosocial, and clinical data of PLWH in Uganda can predict suicidality risk, albeit with modest PPV. Incorporating suicidality PRS improved the overall predictive performance of the model. However, larger studies involving more diverse participants are needed to evaluate the potential of PRS in enhancing risk stratification and the clinical utility of the prediction model
Interventions to improve hand hygiene in community settings: a systematic review of theories, barriers and enablers, behaviour change techniques and hand hygiene station design features.
Get PDFINTRODUCTION: This systematic review identified and examined the theories, barriers and enablers, behaviour change techniques (BCTs), and design features of interventions that have been leveraged to improve and sustain hand hygiene in community settings. It was conducted to support the development of the WHO Guidelines for Hand Hygiene in Community Settings.
METHODS: We searched PubMed, Web of Science, EMBASE, CINAHL, Global Health, Cochrane Library, Global Index Medicus, Scopus, PAIS Index, WHO IRIS, UN Digital Library and World Bank eLibrary for studies published through 29 March 2023, and consulted experts. Eligible studies had an intervention targeting hand hygiene behaviour, quantitatively measured hand hygiene practice, were published in English after 1 January 1980 and were set in non-healthcare community settings. Studies in healthcare settings, nursing homes or long-term care facilities were excluded. Two reviewers independently extracted data from each study and appraised study quality (Mixed Method Appraisal Tool).
RESULTS: 223 eligible studies (including 247 398 participants) met inclusion criteria, 82% of which were reported to be effective at improving hand hygiene. A minority (28%) used theory to inform intervention design. Interventions did not always address identified barriers or enablers. Most interventions addressed 'action knowledge' (eg, handwashing instruction), which was not a widely reported barrier or enabler. Interventions did not extensively address the physical environment (eg, resource availability) despite its importance for hand hygiene. Interventions leveraged a variety of BCT combinations, limiting comparability. We did not conduct a meta-analysis on effectiveness due to heterogeneity across studies. 10 studies evaluated hand hygiene station design adaptation, six examined variations in frequency or intensity of intervention delivery, and four focused on people with disabilities, revealing gaps in evidence.
CONCLUSIONS: Findings are limited by inconsistent intervention reporting but more consistent identification and leveraging of barriers and enablers would improve alignment of hand hygiene interventions to local context. PROSPERO REGISTRATION NUMBER: CRD42023429145