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"Resilience amidst challenges": Healthcare users' experiences of access and utilisation of primary healthcare services during the COVID-19 pandemic in southwestern Uganda.
Get PDFPrimary healthcare (PHC) systems are the first point of contact for healthcare users and are critical for disease prevention and early treatment. The COVID-19 pandemic overwhelmed PHC systems globally, including in sub-Saharan Africa, significantly impacting access to essential services. We describe the experiences of community PHC users' accessing and utilizing health services at 15 purposively selected health centers during the COVID-19 pandemic in Masaka district, southwestern Uganda. A qualitative study (13th-August-2021-4th-November-2021) was embedded with in a large investigation evaluating the impact of COVID-19 on PHC services across three African regions. We conducted 28 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) among adult (females and males) healthcare users (aged ≥18 years). Data was analyzed by themes and charted against the Andersen's Behavioral Model for healthcare utilization. The analysis revealed that structural adjustments to enforce COVID-19 protocols, such as handwashing stations and reduced waiting times, were viewed positively. Facilitators of healthcare access included community sensitization, positive attitudes of health workers, and users' determination despite movement restrictions. However, barriers included fear of infection, medication shortages, reduced clinic hours, and the prioritization of COVID-19 care over other services. Participants adapted by obtaining travel permission letters and using herbal remedies when conventional care was inaccessible. Our key finding is that despite significant disruptions to PHC services during the COVID-19 pandemic, healthcare users demonstrated resilience in accessing care. However, systemic challenges, such as workforce shortages and limited essential medical supplies, highlighted vulnerabilities within the PHC system. Addressing these structural barriers and investing in more resilient and adaptive healthcare systems is crucial for ensuring equitable access to essential health services during future public health crises
Trends over 48 years in a one-number index of survival for all cancers combined, England and Wales (1971-2018): a population-based registry study.
Get PDFBACKGROUND: Trends in cancer survival are a key indicator of progress in the effectiveness of the health system in managing cancer. We aimed to provide long-term trends in a one-number index of survival for all cancers combined, to support national cancer policy. METHODS: We examined long-term trends in a one-number index of net survival (Cancer Survival Index) for all cancers combined in adults in England and Wales. Net survival includes all cancer patients, regardless of whether cancer was the cause of their death. We estimated net survival up to 10 years after diagnosis for 10,769,854 adults diagnosed with a first, primary, invasive cancer during 1971-2018 and followed up to 2019, using anonymised individual records from the National Disease Registration Service for England and the Welsh Cancer Intelligence and Surveillance Unit. We examined trends in the Cancer Survival Index (CSI) at one, five, seven and 10 years after diagnosis, using the entire data set. We present results for selected periods: 1971-72, 1980-81, 1990-91, 2000-01, 2005-06, 2010-11 and 2018. FINDINGS: During the 48 years 1971-2018, the CSI for England and Wales rose substantially, at all intervals up to 10 years after diagnosis. For patients diagnosed in 1971-72, the CSI was 46.5% at 1 year after diagnosis. For patients diagnosed in 2018, the index is 49.8% at 10 years after diagnosis. The CSI has remained about 10% higher for women than men since the early 1970s. The speed of improvement has slowed down: between 2000-01 and 2005-06, the 10-year CSI rose by 4.0%. Ten years later, the increase between 2010-11 and 2015-16 was only 1.4%. INTERPRETATION: The slow-down since 2010 of long-term trends in the CSI for all cancers combined in England and Wales is likely to be at least partly explained by longer waits for diagnosis and treatment. A long-term national cancer plan to bring cancer survival trends back towards the best in the world is essential. FUNDING: Cancer Research UK
Two-dimensional modeling of nitrate transport in canola field under Moistube irrigation using HYDRUS 2D/3D
Get PDFIntroduction: Understanding nitrate distribution and leaching under various irrigation strategies is critical for optimizing nitrogen use efficiency and minimizing environmental losses. While previous studies have explored wetting patterns under Moistube Irrigation (MTI) and discussed qualitative nitrate retention, few have quantitatively simulated nitrate transport through variably saturated zones with fine temporal-spatial resolution.
Methods: A field experiment was conducted in a 20 m × 8 m naturally ventilated greenhouse using three irrigation regimes: (i) full irrigation (100% ETc), (ii) optimal deficit irrigation (75% ETc), and (iii) extreme deficit irrigation (55% ETc). Each regime was replicated across four 2 m × 1 m plots, physically and hydrologically separated by 1 m buffers. Fertilizer was applied at 210 ppm in two split applications. Soil samples were collected both adjacent to and 15 cm away from MTI laterals at multiple depths before and at 2 h, 4 h, 24 h, 48 h, and 72 h post-fertigation. HYDRUS 2D/3D was used to simulate solute transport, while nitrogen use efficiency was evaluated using the partial factor productivity of applied nitrogen (PFPN).
Results: The 55% ETc regime showed the highest nitrate leaching, followed by the 75% ETc regime. Full and optimal deficit irrigation regimes achieved yields ≥ 1.15 ton.ha−1 and PFPN values of 1.72 kg.kg−1 and 1.29 kg.kg−1, respectively. HYDRUS 2D/3D accurately simulated solute transport for full and optimal DI regimes with performance metrics [nRMSE ≤ 0.24, EF ≤ 0.54, PBIAS ≤ −7.41%], but performed poorly under the extreme deficit irrigation.
Discussion: The findings suggest that optimal deficit irrigation under MTI enables effective fertigation with minimal yield penalties, offering a balance between water savings and nutrient retention. MTI, combined with precise fertigation scheduling, shows promise as a climate-smart agriculture solution, particularly in nitrate-sensitive zones. The study confirms the feasibility of using MTI beyond laboratory settings, with implications for sustainable intensification in semi-arid regions
The occurrence of cross-host species soil-transmitted helminth infections in humans and domestic/livestock animals: A systematic review.
Get PDFZoonotic soil-transmitted helminths (STH), including Ancylostoma ceylanicum, Ancylostoma caninum, Ancylostoma braziliense, Trichuris vulpis, Trichuris suis, and Ascaris suum, are increasingly recognised as potential sources of human infection. Additionally, animals can act as carriers or reservoirs for human STH species. However, the extent of cross-host infection remains poorly understood, primarily due to reliance on morphological diagnostics. This review compiles data on the occurrence of cross-host STH infections, highlighting zoonotic STH in humans and human STH species in domestic and livestock animals. Following PRISMA guidelines, PubMed, Medline, and Web of Science were systematically searched without restriction on publication date, covering records available from inception to December 2024, with the earliest retrieved study published in 1942. Inclusion criteria encompassed studies on cross-host STH infections confirmed by molecular methods. Exclusion criteria included experimental infection studies, studies involving wildlife, and those that did not find cross-host infection. Two independent reviewers assessed bias using Appraisal tool for Cross-sectional studies (AXIS) and Joanna Briggs Institute appraisal tools. The protocol is registered with PROSPERO (CRD42024519067). The review screened 4197 titles and abstracts and included 51 studies. Ancylostoma ceylanicum was the commonest zoonotic STH reported, predominantly in Southeast Asia. Human STH species (Ancylostoma duodenale, Necator americanus, Trichuris trichiura and Ascaris lumbricoides) were found in dogs, cats, and pigs. Studies examining both humans and animals together in shared environments showed STH presence in both populations. Case studies revealed gastrointestinal and dermatological effects in humans particularly infected with zoonotic hookworms. This systematic review highlights STH cross-host species infections underscoring the need for further One health epidemiological investigations of humans and domestic/livestock animals in sympatric environments to better understand the burden and explore the transmission dynamics of cross-host STH infections
'They went for the test together but came back separately': a constructivist grounded theory perspective on male engagement in antenatal HIV testing in Bamenda, Cameroon.
Get PDFINTRODUCTION: Male engagement in HIV testing during pregnancy significantly contributes towards the prevention of maternal seroconversion and paediatric HIV acquisition. Despite this, men especially the male partners of pregnant women have been consistently missing in the HIV prevention cascade. The factors accounting for sub-optimal levels in male engagement intersect but reasons for this are poorly understood. Using the combined perspectives of pregnant women and their partners, this study aims to expand the evidence on the forces that influence prenatal HIV testing behaviours among couples in Bamenda, Cameroon.
METHODS: This qualitative study purposively selected pregnant women receiving prenatal care for semi-structured interviews (n = 38); focus group discussion (n = 6) and their male partners (n = 30 for semi-structured interviews and n = 6 for focus group discussion) in Nkwen Baptist Hospital-an urban hospital in Bamenda, Cameroon. Nvivo was used for data management and subsequently we performed a grounded theory analysis through memoing and constant comparisons.
RESULTS: Maternal HIV risk perception was the prominent theme intersecting with couple communication, perceptions on HIV testing outcome, and engagement of male partners by facility staff to influence couple prenatal HIV testing behaviours. Although participants recognised the need for couple HIV testing, individual, interspousal, structural and socio-cultural factors determined uptake of male partner testing. Perceptions on HIV risk were largely inaccurate and strongly gendered. For example, normative expectations on female fidelity were perceived as a buffer against HIV acquisition but this was not the norm regarding male partner behaviour. Also, couple communication was rare or subtle-mostly initiated by women who suspected spousal infidelity. For some men, HIV testing was a conscious decision to confirm fidelity, for others this was challenged by the fear of sero-discordant results and assumptions that maternal test results were a representation of their sero-status.
CONCLUSION: Male partner involvement in prenatal HIV testing is largely influenced by gendered perceptions on HIV risk and couple testing outcomes. Given that these perceptions are moderated by spousal communication and the engagement of male partners by health facility staff, we call for gender-transformative interventions and policies that offer education on prenatal HIV risk, support couple communication and spousal disclosure
The association between indoor biofuel use for cooking and glucose metabolism in adults: A cross-sectional study in Tanzania.
Get PDFThe burden of type 2 diabetes is rapidly increasing in low- and middle-income countries (LMICs), but determinants are not well-characterized. Household air pollution (HAP) from indoor biofuel use for cooking has been associated with non-communicable diseases and could be contributing to the increasing burden of diabetes in LMICs, though data are limited. We assessed the association between indoor biofuel use for cooking and glucose metabolism in HIV-infected and HIV-uninfected Tanzanian adults. This cross-sectional analysis included Tanzanian adults with and without HIV, from whom we collected sociodemographic and non-communicable disease risk factor data. The main predictor variable was indoor biofuel use for cooking, established using self-reported cooking location (indoor or outdoor) and fuel type (electricity/gas or biomass fuel), and categorized as minimal or no exposure, moderate exposure, and high exposure. Blood glucose and insulin were measured during oral glucose tolerance tests, allowing computation of outcome variables including markers of β-cell dysfunction (homeostatic model assessment-β, insulinogenic index, oral disposition index), insulin resistance (HOMA-IR and Matsuda index), and pre-diabetes and diabetes status. Logistic regression was used to assess associations, adjusting for age, sex, physical activity, smoking, socioeconomic status, HIV status, and body mass index. Among 1,871 participants (mean age 40.6 ± 11.9 years; 59.8% female), those with moderate and high exposure to HAP had approximately two-fold higher odds of a lower insulinogenic index (adjusted odds ratio [aOR] = 2.13, 95% CI: 1.27-3.57 and aOR = 2.31, 95% CI: 1.39-3.83, respectively) compared to those with minimal or no exposure. HAP was not associated with other markers of β-cell function, insulin resistance, pre-diabetes, or diabetes. In conclusion, HAP is associated with increased risk of β-cell dysfunction among individuals using biofuel for indoor cooking. Longitudinal studies using objective HAP measurements are needed to confirm these findings
Protocol for the development and validation of a Core Set for exercise-based rehabilitation of adults with multiple long-term conditions (multimorbidity) based on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) framework.
Get PDFBACKGROUND: Core outcome sets for people with multiple long-term conditions (multimorbidity) intervention studies offer an opportunity to compare data across studies and countries. However, a key research gap remains: the development of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) Core Set for multimorbidity rehabilitation. ICF Core Sets are a selection of essential categories from the full ICF classification that are considered most relevant for describing the functioning of a person with a specific health condition or in a specific healthcare context. This study aims to develop and validate an ICF Core Set for exercise-based multimorbidity rehabilitation. Unlike system- or disease-specific rehabilitation, multimorbidity rehabilitation entails using a modified structure that accommodates all conditions that an individual with multimorbidity has. METHODS: The three-phase, multi-method process created by the WHO and ICF Research Branch will be followed. The process will involve conducting four preparatory studies (phase 1), including (i) a systematic literature review (to examine researcher perspectives), (ii) a qualitative study (to examine patient perspectives), (iii) an expert survey (to examine health professional perspectives), and (iv) an empirical study (to examine clinical perspectives). This will be followed by an international consensus conference (phase 2) where lists of ICF categories resulting from phase 1 studies will be consolidated into a first version of an ICF Core Set for multimorbidity rehabilitation, which will be validated using an international comparative data analysis (phase 3). CONCLUSION: An ICF Core Set created for multimorbidity rehabilitation will (1) benefit patients with multimorbidity who are often excluded from clinical trials of single-disease rehabilitation programs, (2) ensure precise and comprehensive assessment and documentation of functioning and disability relevant to this patient population, (3) help rehabilitation providers and their patients and/or caregivers when setting rehabilitation goals and planning rehabilitative interventions to achieve those goals, (4) help researchers in the synthesis of evidence for multimorbidity rehabilitation and facilitate the comparability of data across studies and countries, and (5) provide the scientific basis from which assessment tools can be derived for use in clinical and research settings and health care administration. TRIAL REGISTRATION: COMET database (https://www.comet-initiative.org/Studies/Details/3266)
Phenome-wide association study and functional annotation of hemoglobin A1c-associated variants in African populations.
Get PDFBACKGROUND: Glycated hemoglobin (HbA1c) measures the average blood sugar level over the past three months. As a vital biomarker of blood glucose levels, it is used to diagnose Type-2 diabetes mellitus (T2D) and monitor glycemic control. A heritability estimate of 47% to 59% suggests that about half of the variation in HbA1c levels can be attributed to genetic factors. Despite African populations being the most genetically diverse and unique for fine-mapping, there is a paucity of data on the genetic drivers of HbA1c in African individuals. In this study, we performed functional annotation and a Phenome-Wide Association Study (PheWAS) of HbA1c-associated variants in two African populations. METHOD: In this study, we utilized summary statistics of the HbA1c GWAS meta-analysis of 7,526 individuals from South Africa and Uganda to conduct a PheWAS using GWASATLAS. We also performed a functional analysis using the functional mapping and annotation (FUMA) tool. Single nucleotide polymorphisms (SNPs) were prioritized using the SNP2GENE function, while the gene expression patterns and shared molecular functions were explored in the GENE2FUNC. RESULT: Three genome-wide significant loci were identified with the lead SNPs: rs6724428, rs148228241, and rs8045544 - mapped to GULP1, HBA1, and ITFG3 genes, respectively. The minor allele frequencies of rs148228241 (0.07) and rs8045544 (0.19) are rare or non-existent in non-African populations. Both rs8045544 and rs148228241 are significantly associated with the mean corpuscular hemoglobin concentration (MCHC). A lower MCHC is associated with alpha thalassaemia, resulting from deletions in HBA1 and HBA2 genes. Such deletions are prevalent in malaria-endemic regions of Africa due to their selective survival advantage. The rs6724428 variant is associated with skeletal functions, reflecting the link between glucose metabolism and bone mineral density. DISCUSSION: Our findings highlight the interplay between glucose metabolism, erythropoiesis, and skeletal health. The significant associations of HbA1c-variants with both skeletal function and MCHC underscore the potential of these variants to impact broader physiological processes. A large-scale study of African individuals will be essential to unravel genetic variants influencing HbA1c
Extreme climate events, such as flooding in Rio Grande do Sul: the potential contribution of primary health care to building climate-resilient communities
Get PDFClimate change is increasing the frequency and intensity of extreme events such as heatwaves, floods, and droughts around the world. The recent flooding in the state of Rio Grande do Sul, Brazil, in April-May 2024 broke all previous records and had profound implications for the health and well-being of the population. Flooding can lead to an increase in deaths, infectious diseases, and injuries; it can also disrupt health care delivery and worsen noncommunicable diseases, including contributing to a rise in mental health conditions. In this article, we outline how primary health care (PHC) can reduce the health risks associated with flooding through its role in prevention, preparedness, response, and recovery. We discuss the key role of PHC in addressing the health impacts of climate change and present interventions that can help protect population health. We also emphasize the need to recognize the PHC workforce as a key actor in responding to the climate emergency
Long-term effects of azithromycin mass administration to reduce childhood mortality on Streptococcus pneumoniae antimicrobial resistance: a population-based, cross-sectional, follow-up carriage survey.
Get PDFBACKGROUND: Mass drug administration (MDA) programmes with the macrolide antibiotic azithromycin to reduce childhood mortality are expanding in Africa; however, concerns remain about the long-term effects of these programmes on antimicrobial resistance (AMR). We aimed to evaluate the persistence and spread of Streptococcus pneumoniae AMR following a community-randomised MDA trial. METHODS: This population-based, cross-sectional, pneumococcal carriage survey was conducted in Mangochi, Malawi, 3·5 years after the MORDOR trial, in which communities received twice-yearly azithromycin or placebo for 2 years. Eligible participants in this carriage survey were children aged 4-9 years who lived in an azithromycin-treated or placebo-treated cluster during the MORDOR trial, and children aged 1-3 years who were resident in a cluster but born after the MORDOR trial ended. Nasopharyngeal swabs were collected from participants and analysed by whole genome sequencing; pneumococcal genomes obtained from a distant site in Malawi, in which MDA had not been conducted, were used as reference genomes. The primary outcome was the prevalence of S pneumoniae macrolide resistance, comparing placebo-treated and azithromycin-treated clusters at baseline, 6 months post-MDA, and 3·5 years post-MDA. FINDINGS: Between April 8 and May 14, 2021, 924 children aged 1-9 years were screened, of whom 19 were excluded and 905 were recruited to the follow-up carriage survey: 452 from azithromycin-treated clusters and 453 from placebo-treated clusters of the MORDOR trial. We assessed 426 isolates from these participants (190 from azithromycin-treated clusters and 236 from placebo-treated clusters), as well as samples from the baseline of the MORDOR trial (164 isolates; 83 from azithromycin-treated clusters and 81 from placebo-treated clusters) and from 6 months post-MDA (223 isolates; 119 from azithromycin-treated clusters and 104 from placebo-treated clusters). In azithromycin-treated clusters, macrolide resistance increased from 21·7% (95% CI 14·2-31·7; 18 of 83 isolates) at baseline to 31·9% (24·2-40·8; 38 of 119 isolates) 6 months post-MDA and to 32·1% (25·9-39·0; 61 of 190 isolates) 3·5 years post-MDA. In placebo-treated clusters, resistance increased from 21·0% (13·5-31·1; 17 of 81 isolates) at baseline to 25·0% (17·7-34·1; 26 of 104 isolates) 6 months post-MDA and to 30·9% (25·4-37·1; 73 of 236 isolates) 3·5 years post-MDA. No significant differences were observed in odds ratios between treatment groups across the survey timepoints: 0·97 (95% CI 0·36-2·55) at baseline, 1·46 (0·67-3·17) at 6 months post-MDA, and 1·12 (0·66-1·91) at 3·5 years post-MDA. Macrolide resistance in the non-MDA site remained stable: 16·9% (95% CI 12·8-21·8; 45 of 267 isolates) at baseline, 16·5% (13·3-20·3; 70 of 424 isolates) at 6 months, and 16·5% (12·5-21·4; 44 of 267 isolates) at 2·5 years. Among children born into azithromycin-treated clusters after MDA, macrolide resistance was 36·0% (27·7-45·1; 41 of 114 children). Multidrug resistance to at least three antibiotic classes was significantly higher in azithromycin-treated (p=0·0015) and placebo-treated (p<0·0001) clusters than in the comparator population at 3·5 years post-MDA and was associated with integrative conjugative elements. INTERPRETATION: Azithromycin MDA is associated with macrolide resistance that persists and potentially spreads to untreated populations. The co-existence of multidrug resistance and transmissible resistance on integrative conjugative elements in these populations is a public health concern. Careful monitoring of AMR is essential in areas where MDA is implemented. FUNDING: The Gates Foundation, the National Institute for Health and Care Research, and the Wellcome Trust