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"If we lose it, we are worried": Individual and provider level perceptions towards weight change among people living with HIV who undergo TB screening in routine health care settings in Gauteng Province, South Africa.
Get PDFBACKGROUND: HIV weakens the immune system, increasing the risk of tuberculosis (TB) in people with living HIV (PLHIV). People living with HIV and on antiretroviral treatment (ART) often experience physical body size changes. Studies have found a significant discrepancy between PLHIV's self-reported weight loss and their measured weight loss when being screened for TB using the WHO tool. To understand this inconsistency, a qualitative sub-study was conducted to explore perceptions and attitudes towards weight change among adults attending HIV care, as well as health care workers in public clinics in Gauteng, South Africa. METHODS: Our qualitative study was nested within the XPHACTOR study. A total of seven focus group discussions were conducted, five with adult participants attending for HIV care and two with health care workers and research staff in clinics around Gauteng. Inductive thematic analysis was used to analyse the data. FINDINGS: The majority of PLHIV preferred to gain weight due to fear of stigma associated with weight loss. Weight loss is associated with HIV/AIDS, suggesting that people attending HIV care may underreport weight loss in the context of a TB symptoms screening tool because they fear stigma. Participants reported that weight changes impacted their daily lives and had psychological effects on them. Some PLHIV described lipodystrophy as disproportional weight gain. Culture and media have an influence on the perception of ideal body size and shape for both men and women. CONCLUSIONS: Underreporting weight loss might result in poor sensitivity of the WHO TB screening tool and suggests that we need either alternative ways to determine weight loss or screening tools for TB that are less dependent on reported symptoms
Institutional Legitimacy and Health System Resilience in Contexts of Perpetual Crisis: Insights from Lebanon
Get PDF1. Governance is understood as an important influence on health system resilience, but
empirical investigation of this has been limited including in humanitarian settings.
2. This chapter draws together insights from governance of childhood vaccination delivery
in Lebanon in the context of multiple, systemic shocks.
3. Long-term path dependencies are important in explaining limitations to the perceived
legitimacy of key institutions in vaccination delivery in Lebanon until recently.
4. Successive shocks helped create opportunities for transformative change as power relations
between key domestic and international actors were reconfigured.
5. There are important links between governance and financing that are important for longterm system resilience that should be a focus for future research work
Vaccine confidence and potential implications for new tuberculosis vaccines.
Get PDFBACKGROUND: A lack of general vaccine confidence has been identified as a potential barrier to the introduction of new tuberculosis (TB) vaccines. In the absence of TB-specific vaccine confidence surveys, analysis of general national vaccine confidence data can provide a useful proxy to determine where demand generation strategies may need to be focused ahead of future TB vaccine introductions. METHODS: We analysed 2023 Vaccine Confidence Index (VCI) data from 18 of the 49 countries present on at least one of the three World Health Organisation (WHO) high TB burden lists, and together containing 65% of the global TB burden, to explore overall confidence in vaccines in high TB burden countries. Based on collected answers to three different statements, we categorised responses 1-2 as 'positive' (vaccine confident) and 3-4 as 'negative' (vaccine hesitant) and calculated a total vaccine confidence score using the mean proportion of positive responses across the three statements. RESULTS: In 2023, over 80% of respondents in 14 of the 18 countries analysed, and over 60% of respondents in all 18 countries, believed that 'vaccines are important for people of all ages'. India, accounting for around 30% of global TB cases, demonstrated confidence levels exceeding 90%, as did Vietnam, Ethiopia and Sierra Leone. South Africa, the country with the seventh highest TB burden (280,000 incident cases in 2023), Russia and Cameroon exhibited a relatively low vaccine confidence score of 75.5% or lower, signalling a potential area for concern. These countries may require focused awareness-raising and advocacy efforts prior to the rollout of new TB vaccines, though additional research on TB-specific confidence indicators is needed. CONCLUSIONS: This analysis underscores the importance of monitoring vaccine confidence levels to address emerging challenges to maintaining or bolstering the public's trust in vaccination. Our findings could help determine which countries to prioritise for social mobilisation and demand generation efforts to boost vaccine confidence, and thus improve readiness for new TB vaccines
Generalized framework for identifying meaningful heterogenous treatment effects in observational studies: A parametric data-adaptive G-computation approach.
Get PDFThere has been a renewed interest in identifying heterogenous treatment effects (HTEs) to guide personalized medicine. The objective was to illustrate the use of a step-by-step transparent parametric data-adaptive approach (the generalized HTE approach) based on the G-computation algorithm to detect heterogenous subgroups and estimate meaningful conditional average treatment effects (CATE). The following seven steps implement the generalized HTE approach: Step 1: Select variables that satisfy the backdoor criterion and potential effect modifiers; Step 2: Specify a flexible saturated model including potential confounders and effect modifiers; Step 3: Apply a selection method to reduce overfitting; Step 4: Predict potential outcomes under treatment and no treatment; Step 5: Contrast the potential outcomes for each individual; Step 6: Fit cluster modeling to identify potential effect modifiers; Step 7: Estimate subgroup CATEs. We illustrated the use of this approach using simulated and real data. Our generalized HTE approach successfully identified HTEs and subgroups defined by all effect modifiers using simulated and real data. Our study illustrates that it is feasible to use a step-by-step parametric and transparent data-adaptive approach to detect effect modifiers and identify meaningful HTEs in an observational setting. This approach should be more appealing to epidemiologists interested in explanation
gigs: A package for standardizing fetal, neonatal, and child growth assessment with extensions to egen
Get PDFIn this article, we describe gigs, the Guidance for International Growth Standards package for Stata. gigs contains multiple egen functions for converting between fetal biometry or anthropometric measurements and z scores or centiles in both the World Health Organization child growth standards and the INTERGROWTH-21st standards. We also describe an additional Stata command that wraps these functions to provide growth outcome classification for newborns and infants up to five years of age using a suite of international growth standards. Clear and consistent commands with the functionality described in this article have not been available to Stata users prior to the release of this article. These features will be instrumental for standardizing methods for growth assessment in fetal, newborn, and child health research, as well as implementation, clinical practice, and population-level comparisons
Genomic diversity and antimicrobial resistance of Vibrio cholerae isolates from Africa: a PulseNet Africa initiative using nanopore sequencing to enhance genomic surveillance.
Get PDFObjectives. Vibrio cholerae remains a significant public health threat in Africa, with antimicrobial resistance (AMR) complicating treatment. This study leverages whole-genome sequencing (WGS) of V. cholerae isolates from Côte d'Ivoire, Ghana, Zambia and South Africa to assess genomic diversity, AMR profiles and virulence, demonstrating the utility of WGS for enhanced surveillance within the PulseNet Africa network.
Methods. We analysed Vibrio isolates from clinical and environmental sources (2010-2024) using Oxford Nanopore sequencing and hybracter assembly. Phylogenetic analysis, MLST, virulence and AMR gene detection were performed using Terra, Pathogenwatch and Cloud Infrastructure for Microbial Bioinformatics platforms, with comparisons against 118 global reference genomes for broader genomic context.
Results. Of 79 high-quality assemblies, 67 were confirmed as V. cholerae, with serogroup O1 accounting for the majority (43 out of 67, 67%). ST69 accounted for 60% (40 out of 67) of isolates, with 8 sequence types identified overall. Thirty-seven isolates formed distinct sub-clades within AFR12 and AFR15 O1 lineages, suggesting local clonal expansions. AMR gene analysis revealed genes associated with resistance to trimethoprim in 96% of isolates and genes associated with resistance to quinolones in 83%, while genes associated with resistance to azithromycin, rifampicin and tetracycline remained low (≤7%). A significant proportion of the serogroup O1 isolates (41 out of 43, 95%) harboured resistance genes in at least 3 antibiotic classes.
Conclusions. This study highlights significant genetic diversity and AMR prevalence in African V. cholerae isolates, with expanding AFR12 and AFR15 clades in the region. The widespread presence of genes associated with resistance to trimethoprim and quinolones raises concerns for treatment efficacy, although azithromycin and tetracycline remain viable options. WGS enables precise identification of species and genotyping, reinforcing PulseNet Africa's pivotal role in advancing genomic surveillance and enabling timely public health responses to cholera outbreaks
Functionalities of electronic routine health information systems related to newborn data: findings of the IMPULSE study in Uganda, Ethiopia, Tanzania, and the Central African Republic.
Get PDFBACKGROUND: Adequate functionality of electronic routine health information systems (eRHISs) is crucial for data use, yet few studies explored it in relation to newborn and stillbirth data in Africa.
METHODS: We conducted this cross-sectional study between November 2022 and July 2024 in data offices at central and subnational levels in 12 regions and 4 city administrations in the Central African Republic (CAR), Ethiopia, Tanzania, and Uganda. Except for end-user perspectives (collected via interviews), we collected data related to eRHIS functionalities by direct observation following standard operating procedures as for the Every Newborn-Measurement Improvement for Newborn & Stillbirth Indicators (EN-MINI) Tool 3.1, based on the Performance of Routine Information System Management (PRISM) framework. We analysed data according to the PRISM Users' Kit.
RESULTS: We assessed 53 data offices in total. All countries used the same software application, the District Health Information Software 2 (DHIS2). Settings were heterogeneous across countries, with a tendency for DHIS2 to offer fewer functionalities to users in the CAR. Overall functionalities for generating facility annual summary reports (100% in all countries) and for calculating percentage of reports received/expected (75.0% in Ethiopia to 88.9% in Tanzania) were widely available. Data integration and data disaggregation, meanwhile, had lower availability. Functionalities for calculating coverage on specific indicators, such as respectful care, were lacking in all countries, those for quality assurance varied across countries, while those related to data visualisation were almost always available in Uganda and Tanzania, but showed specific gaps in Ethiopia (i.e. for early initiation breastfeeding), and most often lacked in the CAR. Most end-users indicated needs for eRHIS improvement (ranging from 37.5% in Ethiopia to 100% in the CAR; P = 0.001), with 17.0% reporting needs for major improvement (from 10.0% in Uganda to 28.6% in the CAR; P = 0.001). Subgroup analyses suggested high within-country heterogeneity and more eRHIS functionalities available at central vs. subnational level.
CONCLUSION: Identified strengths and gaps in existing DHIS2 functionalities can inform the design of context-specific interventions that will enhance data use for reducing neonatal mortality and stillbirth rates
Facility newborn and stillbirth data use and enabling factors at different levels of the health system: findings of the IMPULSE study across 142 sites in the Central African Republic, Ethiopia, Tanzania, and Uganda.
Get PDFBACKGROUND: Improving data quality and use is a priority identified by the World Health Organization (WHO) to reduce stillbirths and newborn deaths; however, few studies have documented newborn and stillbirth data use in the African Region. To address this gap, we conducted a cross-sectional study from November 2022 to July 2024 in 12 regions and four city administrations across the Central African Republic (CAR), Ethiopia, Tanzania, and Uganda.
METHODS: We collected data using Every Newborn - Measurement Improvement for Newborn & Stillbirth Indicators (EN-MINI) tools, through direct observation, and from routine electronic and/or paper-based forms and reports. We analysed both the overall and country-level samples following the Performance of Routine Information System Management User's Kit.
RESULTS: We assessed 142 sites, comprising 93 health facilities and 49 data offices. Enabling factors, such as electronic systems, guidelines, annual plans, and feedback mechanisms, were highly available in Ethiopia (n/N = 22/30), moderately available in Uganda and Tanzania (n/N = 15/30 and n/N = 12/30), and scarce in the CAR (n/N = 1/30), with key indicators in all countries being ≥80%. Key data-use indicators showed similar patterns across countries, but lower frequencies (Ethiopia: n/N = 15/66; Uganda: n/N = 14/66; Tanzania: n/N = 5/66; the CAR: n/N = 1/66). Decisions documented in meetings rarely focussed on healthcare quality improvement, particularly at the district level (47.1% in Tanzania vs. 44.4% in Uganda vs. 30% in Ethiopia vs. 0% in the CAR). Data dissemination to public representatives was also subpar (40.8% in facilities, 71.4% in subnational offices). Among 141 end-users, 100% of respondents in the CAR, 75-82.4% in Tanzania and Uganda expressed the need to improve the newborn and stillbirth data use compared to 16.7-21.7% in Ethiopia.
CONCLUSIONS: Newborn and stillbirth data use was low, despite variations across countries and health system levels. Evidence-based decision-making in health service delivery remains a priority action to reduce stillbirths and newborn deaths. This study identified context-specific, sustainable, and scalable interventions co-created with end-users to ensure wider newborn and stillbirth data use
Effectiveness and Cost‐Effectiveness of Ecosystem‐Based Disaster Risk Reduction Interventions in Low‐ and Middle‐Income Countries: A Rapid Systematic Review
Get PDFABSTRACT
Background:
Climate change and widespread environmental degradation have increased the risk of natural hazards in recent decades. Hydrological, meteorological, and climatological disasters have become more frequent globally (Parry et al. 2007; Cavallo and Noy 2009; CRED 2022), affecting over 3.9 billion people since 2000 and causing losses totalling USD 2.2 trillion (CRED 2020). However, the greatest consequences are felt in low and middle income countries (LMICs) where nearly 90% of deaths due to natural hazards between 2000 and 2018 (World Meteorological Organization 2021).
Objectives:
This rapid systematic review aimed to assess and synthesise the evidence on the effects and cost‐effectiveness of ecosystem disaster risk reduction (Eco‐DRR) interventions in preventing and mitigating hazards and natural disasters, and consequences for natural capital and human development outcomes.
Search Methods:
We initially screened 529 articles from a prior review (Sudmeier‐Rieux et al. 2021) on Eco‐DRR interventions using a pre‐validated tool in EPPI Reviewer to apply inclusion and exclusion criteria. We also identified project‐level evaluations from organisations such as OECD DEReC, UNDP ERC, and the UNDRR. The search was further enhanced using machine learning in Open Alex to create a citation network, using the studies identified in the initial steps as a training dataset.
Selection Criteria:
This review includes empirical primary studies measuring the impacts and cost‐effectiveness of Eco‐DRR interventions. We searched for and included studies that evaluated primary outcomes, including hazard prevention, hazard mitigation and natural capital stocks; we also included secondary human development outcomes if reported in these papers. Eligible designs included ex‐post impact evaluations using randomised assignment (randomised controlled trials [RCTs]), quasi‐experimental designs (QEDs) and qualitative impact evaluation designs, and ex‐ante impact evaluations using statistical modelling approaches. Economic and financial evaluations (cost‐effectiveness, cost‐utility and cost‐benefit analyses [CBAs]) were included to measure cost‐ effectiveness.
Data Collection and Analysis:
Two reviewers were assigned to screen the title and abstract for each study. Potentially relevant studies were then assessed at full text by two independent coders, following which data collection for the included studies was double‐coded. A third reviewer resolved all disagreements. All included studies were assessed using a pre‐validated critical appraisal tool based on the, ‘weakest link’ principle. Findings were synthesised by grouping outcomes into hazard prevention and mitigation, natural capital, and human development outcomes.
Results:
The review synthesised evidence from 58 studies, of which 28 were effectiveness studies, 20 were economic evaluations, and 10 were modelling studies. The effectiveness studies were all in green infrastructure nearly all concerned forestry and natural land use interventions, primarily protected areas although one study also evaluated geophysical hazards (public investment and early warning about urban landslides). Most evaluations were of interventions in Latin America and the Caribbean (21 studies), although there was a small number in Sub‐Saharan Africa (5 studies) and East Asia and the Pacific (16 studies); five evaluations were done at the global (LMICs) level. The effectiveness studies were assessed as being of moderate confidence (6 studies) or low confidence (21 studies). The synthesis of outcomes, using meta‐analysis of effect sizes (
g
), found beneficial effects of Eco‐DRR interventions on hazard incidence and exposure and natural capital outcomes. These included large effects on the reduction of forest fire (
g
= 0.32; 95% confidence interval (CI) = 0.23, 0.48; evidence from 4 studies), and medium‐ and small‐sized beneficial effects on forest cover (
g
= 0.12; 95% CI = 0.07, 0.18; 16 studies) and vegetation cover (
g
= 0.06; 95% CI = 0.01, 0.11; 4 studies). The synthesis of secondary human development outcomes was more limited because only a small subset (3) of papers that primarily measured hazard exposure and natural capital also reported these outcomes, which included loss of life, property damage, income, expenditure, and agricultural revenues. There were 10 modelling papers, of which half were for countries in Latin America and the Caribbean, 4 from East Asia, and 1 for South Asia. Five of the papers were concerned exclusively with flooding, two concerned storm surges (and thus also with flooding), and two more included flooding among the hazards assessed. One paper concerned landslides. Each paper used a different model and reported different outcomes. All papers used a range of different data sources, including satellite data, existing meteorological and other data sources, and primary data collection by the study team. None of the papers reported economic analysis. Two of the 10 papers were rated as high confidence in study findings, 5 at moderate confidence, and 3 at low confidence. Twenty economic evaluations assessing the cost‐effectiveness of Eco‐DRR measures were included. All the included papers were CBAs, with two papers accounting for income differences and incorporating equity weights to estimate social welfare benefits. While direct costs for structural measures were widely included, indirect costs and benefits were rarely reported. These indirect costs include the loss of productivity due to evacuations, repairs, and disruptions to economic activity. Similarly, the benefits of non‐structural measures, such as reduced flood damage and avoided societal disruptions, are often difficult to quantify and not reported. Five of the 20 papers were rated as having high confidence in the study findings, 8 were at moderate confidence and the 7 were at low confidence. Most results support the economic effectiveness of Eco‐DRR interventions. BCRs of 4 and above were regularly reported. For example, an extremely high BCR of 1800 was reported for drought risk reduction measures in Sudan for irrigation, early warning systems demonstrating exceptionally high potential financial returns (IRR of 409%). Additionally, the ecological prioritisation of engineering measures was lower compared to EbA measures, as they were primarily focused on addressing water scarcity without the same level of positive ecological impacts.
Conclusion:
The evidence base on the effectiveness and cost‐effectiveness of Eco‐DRR is compartmentalised. Most studies of the effectiveness of implemented actions have evaluated green infrastructure interventions, particularly protected areas, whereas most of the modelling and cost‐effectiveness studies evaluated blue and hybrid infrastructure technologies. Green infrastructure interventions, such as protected areas, have generally shown large effects on increasing natural capital stocks, especially in forestry reserves, and on reducing the incidence of or exposure to hazards like fire, although fewer studies have measured the latter. In modelling studies, most of the papers concluded that the intervention being assessed should be adopted. But in the absence of economic analysis, such a conclusion cannot be drawn from the demonstrated impact alone. Economic evaluations generally supported the benefits exceeding costs (BCRs > 1) of Eco‐DRR, particularly in reducing flooding, especially structural hybrid interventions, but also capacity building, early warning systems, and mangrove restoration. However, these studies have significant limitations regarding information about distributional effects, non‐monetised values, and indirect costs and benefits. Interventions with the highest BCRs included early warning systems for floods and non‐structural interventions, such as land use planning and capacity building. Future economic evaluations should be more comprehensive, considering direct and indirect costs and benefits. Improvements in understanding different approaches to Eco‐DRR and the relative role of directly targeted versus systemic approaches to risk management are essential. We found very limited research on environmental hazards and geological and geophysical hazards, such as landslides and earthquakes, suggesting that these topics require investigation in LMICs in future primary studies of whatever type (both effectiveness and cost‐effectiveness). More studies that evaluate topics relating to equity, such as the effects on the social welfare of vulnerable populations, are needed. Studies of the effectiveness in these areas might usefully draw on established methods of qualitative impact evaluation. (Summary of findings tables: S1)
Exploring Grassroots Indicators for Pandemic Prevention, Preparedness, and Response: A Systematic Narrative Review
Get PDFBackground: The COVID-19 pandemic has revealed how conventional top-down, expert-driven indicators often fail to align with local community realities, marginalising their perspectives, concerns, knowledge, and narratives. However, the limitations of pandemic-related and global health security indicators are not unique but reflect recurring patterns across major social metrics. In response, an alternative paradigm advocates for grassroots-inclusive approaches to developing indicators. Our objective is to assess how and why grassroots-inclusive approaches complement top-down approaches to developing indicators, and to synthesise their theoretical and practical contributions to public health.
Methods: We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. We systematically searched six databases (MEDLINE, Embase, CINAHL, Web of Science, Scopus, and PsycINFO), as well as Google Scholar, to identify relevant articles published from their inception to September 1, 2024. We included peer-reviewed articles, opinion pieces, and book chapters, narratively synthesising their findings.
Results: This review included 43 studies from various disciplines. Across these studies, communities co-produced indicators through participatory workshops, interviews, and consensus exercises in areas such as environmental sustainability, disaster resilience, public health, well-being, and local development. The reported strengths included greater local relevance, community ownership, and accountability, alongside challenges in sustaining participation, integrating into top-down systems, and addressing data gaps. Notably, no study applied grassroots-inclusive indicators to health security or pandemic preparedness.
Conclusion: Despite retrieving and analysing articles from various disciplines, no study has specifically applied grassroots-inclusive indicators to health security or pandemic preparedness. However, the evidence clearly shows that it is both feasible and practical to integrate expert and non-expert perspectives when developing indicators