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Are facility service delivery models meeting the sexual and reproductive health needs of adolescents in Sub-Saharan Africa? A qualitative evidence synthesis.
Get PDFBACKGROUND: Adolescents in Sub-Saharan Africa (SSA) face significant health and social challenges related to sexual and reproductive health (SRH), including unwanted pregnancies, unsafe abortions, and sexually transmitted infections (STI). Barriers to information and services are compounded by lack of access to appropriate information, fear of being judged, health provider attitudes and contextual factors such as culture, religion, poverty, and illiteracy. Facility-based service delivery models for adolescents offer a structured environment and provide an opportunity to deliver such information and services. The review critically examined how well these models meet the SRH needs of adolescents in SSA. METHODS: A systematic search was conducted using five databases: Web of Science, MEDLINE, Scopus, PubMed, and Google Scholar. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to maintain transparency and completeness. Covidence software was used for screening and data extraction, and NVIVO 12 PRO was used to manage the analysis. A narrative synthesis using Thomas and Harden's thematic analysis was used to identify themes. RESULTS: The search yielded 14,415 articles, and 20 papers met the inclusion criteria and were included in this review. From the findings, adolescents expressed the need for comprehensive SRH information, adolescent-friendly facilities, parental and male involvement, and respectful healthcare providers. Three facility-based adolescent-friendly SRH delivery models are used in SSA: Stand-alone clinics, Youth-friendly corners, and Integrated/mainstreamed models. Adolescent-friendly interventions, friendly staff, and accessibility were reported as facilitators to services meeting the needs of adolescents and promoting positive experiences. However, several barriers were identified: negative attitudes of health workers, financial constraints, transportation challenges, waiting time, intimidating environments, and lack of confidentiality pose a challenge to the effectiveness of the model. CONCLUSION: Facility-based SRH service delivery models can improve access to information and services when complemented with community-based interventions, adolescent-friendly providers, and assurance of service accessibility. However, significant gaps, such as healthcare providers' negative attitudes and behaviours, concerns about privacy and confidentiality, financial constraints, and transportation challenges, limit their effectiveness. These findings call for expanding out-of-facility services, adopting mHealth solutions, enhancing provider training, strengthening confidentiality, and reducing financial barriers to ensure equitable and effective access to services
The imperative for actions to protect and promote human health within Earth-system boundaries.
Get PDFImproved limit of detection for zoonotic Plasmodium knowlesi and P. cynomolgi surveillance using reverse transcription for total nucleic acid preserved samples or dried blood spots.
Get PDFBACKGROUND: Zoonotic P. knowlesi and P. cynomolgi symptomatic and asymptomatic infections occur across endemic areas of Southeast Asia. Most infections are low-parasitemia, with an unknown proportion below routine microscopy detection thresholds. Molecular surveillance tools optimizing the limit of detection (LOD) would allow more accurate estimates of zoonotic malaria prevalence. METHODOLOGY/PRINCIPAL FINDINGS: An established ultra-sensitive Plasmodium genus quantitative-PCR (qPCR) assay targeting the 18S rRNA gene underwent LOD evaluation with and without reverse transcription (RT) for P. knowlesi, P. cynomolgi and P. vivax using total nucleic acid preserved (DNA/RNA Shield) isolates and archived dried blood spots (DBS). LODs for selected P. knowlesi-specific assays, and reference P. vivax- and P. cynomolgi-specific assays were determined with reverse transcription (RT). Assay specificities were assessed using clinical malaria samples and malaria-negative controls. The use of reverse transcription improved Plasmodium species detection by up to 10,000-fold (Plasmodium genus), 2759-fold (P. knowlesi) and 1000-fold (P. vivax and P. cynomolgi). The Kamau et al. Plasmodium genus RT-qPCR assay was highly sensitive for P. knowlesi detection with a median LOD of ≤0.0002 parasites/μL compared to 0.002 parasites/μL for P. cynomolgi and P. vivax. The LODs with RT for P. knowlesi-specific PCRs were enhanced for the Imwong et al. 18S rRNA (0.0007 parasites/μL) and Divis et al. real-time 18S rRNA (0.0002 parasites/μL) assays, but not for the Lubis et al. hemi-nested SICAvar (1.1 parasites/μL) and Lee et al. nested 18S rRNA (11 parasites/μL). The LOD for P. vivax- and P. cynomolgi-specific assays with RT were moderately improved at 0.02 and 0.002 parasites/μL, respectively (1000-fold change). For DBS P. knowlesi samples the use of RT also markedly improved the Plasmodium genus qPCR LOD from 19.89 to 0.08 parasites/μL (249-fold change); no LOD improvement was demonstrated in DBS archived beyond 6 years. The Plasmodium genus and P. knowlesi-assays were 100% specific for Plasmodium species and P. knowlesi detection, respectively, from 190 clinical infections and 48 healthy controls. Reference P. vivax-specific primers demonstrated known cross-reactivity with P. cynomolgi. CONCLUSIONS/SIGNIFICANCE: Our findings support the use of an 18S rRNA Plasmodium genus qPCR and species-specific nested PCR protocol with RT for highly-sensitive surveillance of zoonotic and human Plasmodium species infections
Exploring the impact of COVID-19 hard lockdown on service provision for survivors of violence against women in South Africa: a qualitative study.
Get PDFOBJECTIVE: To explore the impact of South Africa's COVID-19 hard lockdown on the provision of services to survivors of violence against women (VAW). DESIGN: We conducted a qualitative study using semistructured interviews. Data was analysed thematically. We conducted 18 semistructured interviews (10 face-to-face and 8 online or by phone) with service providers and key informants (KIs). SETTING: The study was conducted across healthcare facilities, social services, national helplines and shelters in Gauteng province, South Africa. Data was collected between September 2022 and October 2023. PARTICIPANTS: The sample included 18 participants, purposively selected, comprising 13 frontline service providers (nurses, social workers and managers) and 5 KIs. Participants shared their experiences of delivering VAW services during the lockdown. RESULTS: The findings highlight five key themes affecting VAW service provision during COVID-19. (1) Confusion and uncertainty: initial uncertainty about whether VAW services were essential led to temporary closures and reduced availability. (2) Decreased demand for services: fear of mobility restrictions and reporting barriers reduced access, particularly in the first lockdown month. (3) Adaptations by providers: services shifted to remote counselling, while shelters paused new intakes. (4) Challenges in service provision: staff shortages, resource constraints (eg, personal protective equipment shortages) and disrupted referral systems hindered service delivery. (5) Emotional impact on frontline workers: health and helpline workers faced stress, fear of infection, social stigma and burnout, affecting their well-being and capacity to respond effectively. CONCLUSIONS: The study highlights how South Africa's COVID-19 hard lockdown disrupted essential VAW services, emphasising the need for resilient service delivery models during crises. Strengthening staffing, resources and improving referral pathways are critical for mitigating the emotional and operational challenges faced by service providers and for ensuring sustained support for survivors
Applying High-Dimensional Propensity Scores in a Study of Inhaled Corticosteroids and COVID-19 Outcomes.
Get PDFBACKGROUND: In pharmacoepidemiologic studies of COVID-19, there were concerns about bias from residual confounding. We investigated the effects of inhaled corticosteroids (ICS) on COVID-19 outcomes, applying high-dimensional propensity scores (HDPS) to adjust for unmeasured confounding. METHODS: We selected patients with chronic obstructive pulmonary disease on 01 March 2020 from Clinical Practice Research Datalink (CPRD) Aurum, comparing ICS/LABA/(+/-LAMA) and LABA/LAMA users. ICS effects on the outcomes COVID-19 hospitalisation and death were assessed through IPT-weighted and unweighted Cox regression. HDPS were estimated from primary care observations, prescriptions and hospitalisations. SNOMED-CT codes and dictionary of medicines and devices codes from CPRD Aurum were mapped to International Classification of Disease 10th revision codes and British National Formulary paragraphs, respectively. We estimated propensity scores (PS) combining prespecified and HDPS covariates, selecting the top 100, 250, 500, 750 and 1000 covariates ranked by confounding potential. RESULTS: When excluding triple therapy users, conventional PS-weighted estimates showed weak evidence of increased COVID-19 hospitalisation risk among ICS users (HR 1.19 [95% CI: 0.92-1.54]). Results varied slightly based on the number of covariates included in HDPS (HR using 100 HDPS covariates excluding triple therapy 1.01 [95% CI: 0.76-1.33], HR using 250 HDPS covariates excluding triple therapy 1.24 [95% CI: 0.83-1.87]). Conventional PS-weighted models showed weak evidence of a harmful association of ICS with COVID-19 death when excluding triple therapy users (HR 1.24 [95% CI: 0.87-1.75]). HDPS-weighting moved estimates toward the null (HR using 250 HDPS covariates excluding triple therapy 1.08 [95% CI: 0.73-1.59]). CONCLUSIONS: HDPS may have better controlled confounding for COVID-19 deaths in this case. HDPS results can be sensitive to the number of covariates included, highlighting the importance of sensitivity analyses
Estimating the magnitude and scope of disability-related direct costs: a systematised review.
Get PDFBackground: Globally, people with disabilities face a heightened risk of poverty, the extent of which is often underestimated due to a failure to account for disability-related direct costs or “extra costs”. People with disabilities spend significant proportions of their income on additional goods and services (e.g. personal assistance, assistive devices, extra healthcare, transportation): paying out-of-pocket for these items can substantially lower their standard of living, while inability to meet these costs can affect their well-being and social participation. Estimating the magnitude and sources of disability-related direct costs is key for policy and planning, as it can affect determinations of poverty and also identify where additional investment may be needed to reduce the individual burden of these costs (e.g., through social protection, designing more inclusive services). Objective: To synthesize evidence from recent studies on the magnitude and sources of extra costs amongst people with disabilities, comparing how estimates differ by methodological approaches, settings and individual characteristics.
Methods: We conducted a systematised review of studies published between 2015 and January 2023. Searches covered 10 databases and the grey literature.
Results: We retrieved 75 studies covering 67 countries, which reported substantial costs that often significantly increased the risk of poverty amongst people with disabilities. There was high heterogeneity across studies, depending on methodological approach and individual and contextual factors.
Conclusions: These findings indicate a pressing need to offset individual spending on costs, such as through more extensive social protection and through designing more inclusive services (e.g., health, education, transport). There is also a need for more consensus on best practices for measuring extra costs across methodological approaches
Characterising protective immune responses to SARS-CoV-2 in urban and rural Malawi between February 2021 and April 2022.
Get PDFSARS-CoV-2 transmission in Malawi remains unclear due to high proportions of mild/asymptomatic infections and limited diagnostics. Existing seroprevalence studies in Malawi have primarily used convenience samples and enzyme-linked immunosorbent assays (ELISAs). We assessed SARS-CoV-2 neutralisation in a longitudinal Malawian population-based cohort, assessing protective immunity post-infection and vaccination. Sera were obtained from rural (Karonga, n = 958) and urban (Lilongwe, n = 918) based participants at three-monthly intervals (February 2021-April 2022). Neutralising antibodies against SARS-CoV-2 were measured using human immunodeficiency (HIV)-based pseudotype assays in HIV-uninfected participants, and vesicular stomatitis virus-based assays in HIV-infected participants and an HIV-uninfected subset. Nucleocapsid ELISAs identified vaccinated participants also infected. SARS-CoV-2 neutralisation profiles increased in complexity over time from rising vaccination coverage and emerging variants. Neutralising antibody prevalence was higher in Lilongwe than Karonga (68.1% (CI 63.5-72.4) vs. 45.4% (CI 41.6-49.3), Survey 4). Hybrid immune and solely vaccinated participants exhibited higher titres than those solely infected. Children < 15 years had the lowest neutralising antibody titres among infected (not vaccinated) participants. People living with HIV had lower neutralising responses than those HIV-uninfected, particularly post vaccination. We therefore recommend surveillance of children and people living with HIV as low neutralisation responses increase reinfection risk. COVID-19 vaccination should be prioritised for HIV-infected individuals
[Revised] Community perspectives on drug promotion on social media during the COVID-19 pandemic in KwaZulu-Natal, South Africa [version 3; peer review: 2 approved]
Get PDFBackground: During the COVID-19 pandemic, social media and web-based platforms were widely used to promote medicinal substances. To assess community perspectives on drug promotions on social media, we conducted qualitative research using three workshops. The workshops aimed to highlight the public understanding of drug advertising focusing on community perceptions of social media drug promotions, their risks and benefits. Discussions were conducted on the importance of adhering to national drug regulation policies and the World Health Organisation ethical criteria for promotion, advertisement, and publicity of medicines. Methods Participants for the workshops were purposively sampled from local community youth groups and healthcare facilities. Two workshops included ten young adults aged 18-35, while the third workshop involved three healthcare professionals and one traditional healer. Results The study participants’ highlighted the value of honesty and trust in the drug promotions. Gaps in the ethical conduct of advertising were observed and concerns were raised about the reliability of social media information and the omission of valuable details on the drug advertisements. Conclusion Individuals have a right to informed choices that ensure their health safety. This study has highlighted the need for transparency and accountability in pharmaceutical and complementary medicine marketing on social media. Collaboration is needed between regulatory bodies, pharmaceutical companies, healthcare providers and community members, to make sure that drug advertising upholds ethical standards and public health
Changing parental perceptions to childhood immunisations during the COVID-19 pandemic in the UK: evidence from three cross-sectional surveys between 2020 and 2022.
Get PDFINTRODUCTION: Childhood immunisation rates in the UK have recently fallen to their lowest level in 14 years. However, there is limited temporal evidence on how parental attitudes have evolved during the COVID-19 pandemic, restricting our understanding of its broader impact. This study explores trends in parental confidence in childhood immunisations between 2020 and 2022 across the UK and how socio-demographic predictors of vaccine perceptions have shifted over time.
METHODS: This study draws on data from three nationally representative, cross-sectional surveys conducted in 2020, 2021 and 2022 including 14 720 adults responsible for decisions on childhood vaccination. Multiple logistic regression assesses changes in reported childhood vaccine refusal over time, by region, socio-demographic group and vaccine. Additional 2022 analysis explores how parental perceptions of childhood immunisations have changed since the start of the pandemic.
RESULTS: UK-wide refusal decreased from 17.3% (16.4 to 18.5%) in 2020 to 14.8% (13.7 to 15.7%) in 2021 before increasing to 21.1% (19.8 to 22.5%) in 2022, largely due to high refusal rates for the COVID-19 vaccine for children. Parents who had not received at least three COVID-19 vaccine doses were more likely to report declining confidence in childhood vaccines, suggesting a spillover of COVID-19 vaccine hesitancy onto routine vaccines. Refusal was higher among younger respondents, London residents, Hindus and Muslims. Interestingly, however, 18-34-year-olds, Hindus, Muslims and Black/Black British respondents reported becoming more positive towards childhood vaccines in 2022 compared with 2020.
CONCLUSIONS: Parental refusal of routine childhood immunisations decreased between 2020 and 2022 and remains low across the UK. Encouragingly, groups with historically lower confidence reported more positive attitudes in 2022. However, this has not been matched by increased uptake. Parents who received fewer than three COVID-19 doses are more likely to have become less positive over time and represent a key group for targeted outreach to rebuild confidence and support uptake
Living through the heat: How urban children and young people experience and envision healthier cities.
Get PDFClimate change is driving more frequent and intense heatwaves, posing growing risks to urban populations, particularly children and young people (CYP). This study examined how heatwaves affect the health, well-being, and daily lives of CYP across six rapidly urbanising cities: Accra, Kumasi, Ouagadougou, Port Harcourt, Manila, and Dar es Salaam. We conducted online surveys during both heatwave and non-heatwave periods, collecting 2,269 valid responses. Heatwaves were defined as periods when apparent temperatures exceeded the 90th percentile of historical monthly averages for at least three consecutive days, and, where available, confirmed by national meteorological sources. Non-heatwave periods were defined as days within the same month and city when apparent temperatures were less than or equal to the 10-year average daily mean. Participants, CYP aged 13-29 and parents of children under 18, were recruited via targeted digital advertisements on Meta and Google. Quantitative data were analysed using descriptive statistics, chi-square tests, and logistic regression to assess associations between heatwave exposure and self-reported health symptoms, well-being, and daily disruptions. Thematic analysis of open-ended responses identified community priorities for climate resilience. Heatwaves were associated with higher reports of headaches, low mood, anxiety or stress, not enough food, and increased reliance on family support. Adverse effects were more pronounced among younger and lower-income participants. Participants highlighted five priorities for climate-resilient cities: more green spaces, improved water and sanitation, cleaner environments, stronger health and education services, and greater youth participation in decision-making. The results highlight the growing burden of heat-related health symptoms and daily activity disruptions among CYP and youth-informed strategies to reduce the unequal impacts of extreme heat in urban areas