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Environmental and socio-economic determinants of malaria transmission in West Africa: a systematic review.
Get PDFBACKGROUND: Malaria remains one of the greatest issues in sub-Saharan Africa. METHODS: This study aimed to identify the socio-economic and environmental determinants influencing the transmission of malaria and its incidence in West Africa. A systematic review was conducted using articles published from January 1989 to April 2025, within PubMed and Directory of Open Access Journals (DOAJ) databases. A total of 1145 articles related to our topic were found in the PubMed database, and 125 articles were identified in the DOAJ database. After inclusion and exclusion criteria, 68 articles were selected from both databases. RESULTS: The results indicate that among the environmental determinants, air temperature, rainfall, relative humidity, and vegetation are the most common environmental factors that predict malaria transmission. Moreover, education level, place of residence, housing structure, poverty, and quality of information are the key socio-economic determinants to consider in the prediction of malaria. CONCLUSION: These factors can be indicators for target programmes for the elimination and prevention of the infection of malaria in West Africa
Decentralising DR-TB care: the trade-off between quality of care and service coverage in the early phase of implementation.
Get PDFBACKGROUND: A policy of decentralised care for drug-resistant TB (DR-TB) was introduced in South Africa in 2011. We describe a trade-off between increasing coverage of services and poor quality of care, in the early phase of policy implementation. METHODS: This was a mixed methods case study, comparing implementation in KwaZulu-Natal and Western Cape provinces; with interviews and quantitative analysis of routine DR-TB programme data. We analysed qualitative data, thematically organizing findings into inputs, processes, and outputs to explore how decentralisation influenced quality of DR-TB care. RESULTS: Decentralisation of DR-TB care expanded access across provinces but there was wide variation in pace, planning and structural readiness. Where rapid scale-up outpaced capacity-building, weaknesses in resourcing, workforce, and clinical governance compromised quality of care. Two illustrative examples highlight that decentralisation to inadequately resourced sites resulted in morbidity to patients who did not receive effective monitoring for adverse events; and decentralising services to inadequately capacitated clinicians resulted in incorrect initiation in more complex cases and late referral of clinical complications. CONCLUSIONS: Attempts to decentralise DR-TB treatment in the context of complex treatment algorithms and limited health system capacity resulted in trade-offs of care quality. We argue that quality of care should be an essential consideration in early implementation of health programmes
Ecological drivers of malaria vector habitat and transmission over 1 year of long-lasting insecticidal net intervention in Côte d’Ivoire
Get PDFBackground:
Malaria is a mosquito-borne parasitic disease that causes significant morbidity and mortality in at-risk populations, especially in children in sub-Saharan Africa. Despite reductions in malaria burden owing to the scale-up of effective interventions, there are concerns that long-lasting insecticidal net (LLIN) effects may not be sustained owing to widespread insecticide resistance and differential impacts of LLIN on vector species. In this study, we aimed to test the effect of different LLIN products and other environmental factors on the ecological niche of three mosquito vector species using state-of-the-art ecological niche modelling approaches.
Methods:
This study used data from a cluster randomized control trial that took place in Tiébissou, in Central Côte d’Ivoire. Anopheles mosquito density and Plasmodium falciparum vector infection data were available across 33 clusters. We used satellite remote sensing related to land cover, climate, topography and population density across the study area alongside vector species occurrence data to construct ecological niche models for An. coluzzi, An. gambiae s.s. and An. funestus s.s., and for P. falciparum-infected vectors, at baseline and 1-year post-LLIN intervention. We compared the projected habitat and habitat determinants for each species, and assessed the respective contributions of each intervention arm and environmental factors on the probability of species occurrence.
Results:
Minimal to considerable overall reductions in suitable habitat across the study area were observed for the three mosquito vector species (less than 1% to more than 60%), and considerable overall reduction was observed for P. falciparum-infected vectors (more than 50%). We did not detect an effect of intervention arm on the probability of occurrence of any vector species, while we found strong significant effects of a combination of land cover, climate, topography and/or population density variables on each of the three mosquito vector species and malaria-infected vectors. Our results suggest environmental factors may have facilitated or restricted changes in the probability of occurrence of vector species and infected vectors in the context of vector control interventions.
Conclusions:
Our study highlights wide ecological differences across malaria vector species and supports the need to consider malaria vector species composition when deploying malaria vector control interventions in endemic settings
Systems Thinking in Public Health; Comment on "Using System Dynamics to Understand Transnational Corporate Power in Diet-Related Non-Communicable Disease Prevention Policy-Making: A Case Study of South Africa"
Get PDFMilson and colleagues illustrate the value of a systems approach to nutrition policy in South Africa. We respond to their call to use systems approaches, and especially, causal loop diagrams, more widely in public health. We begin with examples of how systems approaches have provided valuable perspectives on health-related problems and continue with an example of where this approach could have been used but was not, England’s response to the COVID-19 pandemic. We show how an effective response would have required integrated health, economic, and social policies, yet the British government adopted a siloed approach. We conclude by noting that examples of how systems thinking, and specifically causal loop diagrams, have been used to support pandemic responses. We conclude by emphasising the need to embed systems thinking in public health policy-making to enhance resilience and preparedness for future crises
Practical inference for a complier average causal effect in cluster randomised trials with a binary outcome.
Get PDFBACKGROUND: Individual non-compliance with an intervention in cluster randomised trials can occur and estimating an intervention effect according to intention-to-treat ignores non-compliance and underestimates efficacy. The effect of the intervention among compliers (the complier average causal effect) provides an unbiased estimate of efficacy but inference can be complex in cluster randomised trials. METHODS: We evaluated the performance of a pragmatic bootstrapping approach accounting for clustering to obtain a 95% confidence interval (CI) for a CACE for cluster randomised trials with monotonicity and one-sided non-compliance. We investigated a variety of scenarios for correlated cluster-level prevalence of a binary outcome and non-compliance (5%, 10%, 20%, 30%, 40%). Cluster randomised trials were simulated with the minimum number of clusters to provide at least 80% and at least 90% power, to detect an ITT odds ratio (OR) of 0.5 with 100 individuals per cluster. RESULTS: Under all non-compliance scenarios (5%-40%), there was negligible bias for the CACE. In the worst-case of bias, a true OR of 0.18 was estimated as 0.15 for the rarest outcome (5%) and highest non-compliance (40%). There was no under-coverage of bootstrap CIs. CIs were the correct width for an outcome prevalence of 20%-40% but too wide for a less common outcome. Loss of power for a CACE bootstrap analysis versus ITT regression analysis increased as the prevalence of the outcome decreased across all non-compliance scenarios, particularly for an outcome prevalence of less than 20%. CONCLUSIONS: Our bootstrapping approach provides an accessible and computationally simple method to evaluate efficacy in support of ITT analyses in cluster randomised trials
Duration of viral persistence in human semen after acute viral infection: a systematic review.
Get PDFThe persistence of viruses in human semen following acute infection can contribute to the ongoing transmission of a disease or cause resurgence after an outbreak has been declared ended. Viral persistence in semen affects embryonic development and male fertility, and the development of drugs and vaccines. We conducted a systematic review of viral persistence in semen in accordance with PRISMA guidelines. 373 original studies were included in this Review after screening 29 739 articles from five databases. Evidence was found of detection of 22 viruses in human semen following acute infection, including pathogens with pandemic potential. In addition to collating the largest evidence base to date on viral detection in semen following acute infection, this Review reports the maximal and median viral persistence (in days) after the onset of illness and evidence for sexual transmission and viability of the viruses in semen. Finally, the Review presents research gaps that need to be prioritised to guide further study of the dynamics of viral persistence in semen
Cost-Effectiveness of Linkage Case Management for Hospitalized People With HIV.
Get PDFIMPORTANCE: The Daraja randomized clinical trial was a linkage case management intervention designed to improve HIV care engagement. Understanding the economic value of this type of case management intervention is essential to decision-makers in resource-constrained settings seeking to minimize HIV-related morbidity and mortality. OBJECTIVE: To evaluate the cost-effectiveness of Daraja compared with enhanced standard care from the Tanzania Ministry of Health and societal perspectives. DESIGN, SETTING, AND PARTICIPANTS: This prospective economic evaluation was conducted alongside the Daraja randomized clinical trial at 20 hospitals in Northwestern Tanzania from March 2019 to May 2023. Participants were patients hospitalized with HIV randomly assigned 1:1 to receive either the Daraja intervention or enhanced standard care and were followed up for 12 months through March 2023. Data were analyzed from May 2024 to March 2025. EXPOSURE: The Daraja intervention group received up to 5 sessions conducted by a social worker at the hospital, in the home, and in the HIV clinic over a 3-month period. The enhanced standard care group received predischarge HIV counseling and assistance in scheduling an HIV clinic appointment. MAIN OUTCOMES AND MEASURES: The primary outcome was the cost per disability-adjusted life-year (DALY) averted for Daraja vs standard care, assessed from Ministry of Health and societal perspectives at 3 months (intervention) and 12 months (intervention plus follow-up). RESULTS: Among 500 participants, the mean (SD) age was 37 [12] years, and 384 participants (77%) were female. Participants in the intervention group incurred more costs from the Tanzanian Ministry of Health perspective over the 3-month intervention period (24.0; difference, 9.2 to 101.6 vs 23.4 [95% CI, 38.9]). From the societal perspective, Daraja incurred more costs than standard care at 3 months (47.4; difference, 2.0 to 182.7 vs 22.2 [95% CI, -$16.4 to 60.8]). DALYs were lower for Daraja participants at both the 3-month (1.2 [95% CI, 1.1 to 1.2] DALYs averted, annualized) and 12-month (1.1 [95% CI, 1.3 to 3.7] DALYs averted) time points. CONCLUSIONS AND RELEVANCE: In this economic evaluation of the Daraja intervention, Daraja was more costly than standard care from both the Tanzanian Ministry of Health and societal perspectives; however, it was associated with improvements in DALYs. These findings suggest that Daraja has a high probability of being considered cost-effective from both economic perspectives
Development of a handwashing with soap intervention in low-income settlements of Mombasa, Kenya
Get PDFIntroduction
Interventions to improve handwashing with soap have shown mixed effects on behaviour which may be due to contextual differences in different settings. Low-income settings have complex socio-economic conditions which requires local contextual adaptation to support intervention adoption. Detailing the development of an intervention can inform other researchers and practitioners on best practices, and it enables replicability and scalability.
Methods
This study adopted the Trials of Improved Practices (TIPs) approach and incorporated co-creation and co-design of interventions with stakeholders. A total of 56 participants were randomly selected and an initial survey was conducted. The development process entailed stakeholder engagements and educational activities. Educational activities were delivered through household-level visits and community dialogue sessions. Qualitative data were collected throughout the process using in-depth interviews. A survey was conducted after the educational activities to assess availability of handwashing facilities and handwashing with soap practices. Logistic regression was used to estimate the effect of independent variables on availability of handwashing facilities and on handwashing with soap, and McNemar’s test was used to evaluate if the interventions improved handwashing practices. Qualitative data were analysed thematically, and the findings explained the process and the effect of the interventions.
Results
Initial survey results showed that 59% of handwashing facilities were not at a fixed location, and only 21% of respondents reported handwashing with soap. Households with a fixed handwashing facility had 5.3 times higher odds of handwashing with soap compared to households with mobile handwashing facilities (
P
= 0.02 CI 1.32–21.23). Participating households made improvements by designating handwashing facilities at the compound level and separate handwashing facilities at the household level. Access to fixed handwashing facilities increased from 10 to 77%, and reported handwashing with soap among respondents significantly increased from 21 to 64% after the education activities (McNemar's
X
2
(1) = 12.46;
P
= 0.00). This improvement in handwashing was attributed to the educational visits and practical demonstrations and was motivated by improved hygiene conditions in the households.
Implications
Households can improve reported handwashing with soap if they are provided with the necessary skills for making improvements. This approach could serve as a model for future public health initiatives aimed at improving hygiene practices in similar settings
Frontline staff perspectives on multi-disciplinary team working and the effectiveness of integrated service delivery: Findings from the evaluation of the Integrated Care and Support Pioneers in England.
Get PDFObjectives:
Horizontal integration of health and social care in England is frequently supported by multi-disciplinary (MDT) case management focused on high-risk older people with multiple chronic conditions living in the community. This paper analyses MDT working in two of the 25 areas participating in the Integrated Care and Support Pioneer Programme in England. The analysis aims to understand the experience of frontline staff in such MDTs of working with professionals and staff from multiple sectors, and their perceptions of their roles and the benefits of integrated working.
Methods: We conducted semi-structured interviews with a purposive sample of 54 frontline staff from a range of professional backgrounds working in 11 community-based MDTs in two Integrated Care and Support Pioneers. A largely inductively developed coding frame was used to thematically code and guide analysis of verbatim interview transcripts from audio recordings.
Findings: Staff conceptualised the team as a cohesive yet 'porous' entity, able to evolve a shared sense of purpose to deliver holistic care that helped to level traditional professional hierarchies, enable collective problem-solving and share responsibility for patient care. MDT working was seen as benefiting staff and patients. Despite strong similarities between the MDTs in members' understandings of the role and purpose of a MDT, each MDT was adapted to its context and the needs of the population served. The process of working through inter-professional tensions seemed to strengthen relationships within the team and enhance its ability to work effectively in the local health and care system. However, without performance or outcome measures, these perceptions were driven by 'soft' intelligence alone.
Conclusions: Frontline staff accounts of MDT working demonstrate their strong commitment to this way of working, as a mechanism enabling them to deliver more holistic care with perceived benefits to patients
Linkage of multiple electronic health record datasets using a "spine linkage" approach compared to all "pairwise linkages".
Get PDFObjectivesTo compare two approaches for linking multiple datasets: using all "pairwise linkages", linking each dataset to every other dataset; versus linking each dataset to a designated "spine dataset", by: considering the differences between these approaches, and illustrating using real-world data on patients undergoing emergency bowel cancer surgery.
ApproachWe linked an administrative hospital dataset (Hospital Episode Statistics; HES) capturing patients admitted to hospitals in England, and two clinical datasets comprising patients undergoing emergency bowel surgery (National Emergency Laparotomy Audit; NELA) and patients diagnosed with bowel cancer (National Bowel Cancer Audit; NBOCA), with study period from 31 October 2013 to 30 April 2018. We compared pairwise linkage to spine linkage, designating HES as the spine dataset, by considering the number of eligible patients linked by each approach, characteristics of linked patients, levels of missing data, and whether analysis results were sensitive to the approach used.
ResultsThe spine linkage approach resulted in an analysis cohort of 15,826 patients, equating to 98.3% of the 16,100 patients identified with the pairwise linkage approach. Of 274 additional patients captured in the pairwise approach, approximately two-thirds were only in the emergency surgery dataset (NELA) and one-third were only in the bowel cancer dataset (NBOCA). There were no systematic differences in patient characteristics between these analysis cohorts. Associations of patient and tumour characteristics with mortality, complications, and length of stay were not sensitive to the linkage approach. When eligibility criteria were applied before linkage, spine linkage included 14,509 patients (90.0% compared to pairwise linkage).
ConclusionSpine linkage can be an efficient alternative to pairwise linkage, if case ascertainment in the spine dataset and data quality of linkage variables are high. These aspects should be systematically evaluated in the nominated spine dataset before spine linkage. Results are sensitive to order of linkage steps