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Women and health workers' conceptualisations of reproductive coercion and abuse: a comparative synthesis from Brazil, Nepal, Palestine, and Sri Lanka.
Get PDFBACKGROUND: Reproductive coercion and abuse (RCA) is a hidden form of violence against women, involving controlling behaviours by a partner or family member to manipulate a woman's reproductive autonomy, either to prevent or promote pregnancy. It correlates with partner violence, unintended pregnancy, contraceptive non-adherence, and poor sexual and reproductive health. However, research often oversimplifies RCA, treating it as a uniform phenomenon and neglecting its diverse manifestations. Additionally, there is scarce evidence on RCA in low- and middle-income countries. This study examines the conceptualisation and discourse surrounding reproductive coercion among health workers and women victims/survivors in Brazil, Nepal, occupied Palestinian Territories, and Sri Lanka. The main objectives include: 1) Investigating acts of reproductive coercion reported by women and health workers. 2) Exploring how health workers approach reproductive coercion in their practice. 3) Understanding the structural, institutional, and social barriers affecting victim/survivors encounters with reproductive coercion.
METHODS: We conducted 62 qualitative interviews with health workers and domestic violence victims/survivors across the four countries, plus three focus groups with women in Nepal. Data were analysed thematically.
RESULTS: The findings reveal that reproductive coercion emerged as a form of domestic violence across all settings studied. Reported acts of coercion and violence by both women and health workers included attempts to force pregnancy against a woman's wishes and to hinder contraceptive use, driven by jealousy or the desire to promote pregnancy. Perpetrators, mainly husbands and family members (particularly in-laws in Nepal and Sri Lanka), employed various coercive behaviours such as pressure, decision-making control, threats (e.g., leaving the partner or violence), verbal harassment, and physical violence. The analysis also underscored broader structural and social challenges constraining women's reproductive choices and health workers' responses, encompassing religious beliefs surrounding contraception and abortion, cultural norms regarding son preference (notably in Nepal), and restrictive health policies concerning abortion and spousal consent for family planning (observed in Nepal and Sri Lanka).
CONCLUSIONS: The study emphasises the necessity for further research to comprehensively understand acts of reproductive coercion and abuse and guide health workers in effectively addressing this issue
Impact of Tuberculosis Preventive Treatment on Adverse Pregnancy Outcomes in women living with HIV in Uganda: A Quasi-experimental study using routine care data.
No full textBACKGROUND: The World Health Organization recommends tuberculosis preventive treatment (TPT) for people living with HIV, including pregnant women. However, data on the safety of TPT during pregnancy particularly from routine care settings in high tuberculosis (TB) burden countries remain limited. We evaluated the association between TPT exposure and adverse pregnancy outcomes among pregnant women living with HIV (WLHIV) in Uganda.
METHODS: We conducted a quasi-experimental study using routinely collected data from five public urban primary health care facilities in Kampala, Uganda. We included pregnant WLHIV on antiretroviral therapy (ART) between 2016 and 2023. The primary outcome was a composite of adverse pregnancy outcomes: miscarriage, stillbirth, low birth weight, congenital anomalies, or maternal/neonatal death. The primary exposure was 6-months isoniazid TPT (IPT) during pregnancy. Analyses used inverse probability of treatment weighting (IPTW) using logistic regression model to adjust for confounding and multiple imputation for handling missing data.
RESULTS: Analysis included 521 pregnant WLHIV, 44% were exposed to IPT during pregnancy. Overall, 10.0% experienced an adverse pregnancy outcome, with no significant difference between IPT-exposed and unexposed groups (10.3% vs. 9.6%; p = 0.81). Adjusted IPTW analysis showed no significant association between IPT exposure and adverse outcomes (pooled weighted odds ratio 1.04; 95% CI: 0.69-1.58). Sensitivity and subgroup analyses yielded consistent results.
CONCLUSION: We found no evidence that 6-month isoniazid TPT increases the risk of adverse pregnancy outcomes. However, limitations in outcome and adverse event documentation from routine care may affect these findings. Strengthening pharmacovigilance and clinical reporting is essential to safeguard maternal and neonatal health as TPT coverage expands in high TB/HIV burden settings
Seroepidemiology of maternal and childhood pathogen exposure in three European mother-child cohorts.
Get PDFOBJECTIVES: To describe the epidemiology of common pathogens and risk factors among pregnant women and their children.
METHODS: In three European population-based birth cohorts, we examined 2213 mother-child pairs, contributing 5036 blood samples from pregnancy to 12 years of age. We measured serum immunoglobulin G levels against polyomaviruses (BKPyV, JCPyV, KIPyV, WUPyV, MCPyV), herpesviruses (Epstein-Barr virus [EBV], cytomegalovirus [CMV], varicella-zoster virus), adenovirus 36, Helicobacter pylori, and Toxoplasma gondii with multiplex serology.
RESULTS: Among pregnant women, seroprevalence ranged from 18.7% (H. pylori) to 95.7% (EBV); among 4-6-year-old children, seroprevalence ranged from 3.6% (H. pylori) to 88.4% (BKPyV). Although most primary infections occurred in the first 4 years of life, some children had primary infections at later ages. Seropositive mothers were more likely to have seropositive children, but an intergenerational decrease in seroprevalence was evident for herpesviruses and H. pylori. There were sizeable differences between countries for H. pylori and T. gondii. Non-western ethnicity mothers and their children were more likely to be infected. Female sex (WUPyV, MCPyV, CMV), breastfeeding (CMV), early daycare attendance (CMV, H. pylori), and obesity (JCPyV, EBV, Adv-36) were associated with child's seroprevalence.
CONCLUSIONS: European children acquire common pathogens but often experience first exposure beyond early childhood. Differences are expected between and within countries and across generations
Climate change policies reduce air pollution and increase physical activity: Benefits, costs, inequalities, and indoor exposures.
Get PDFThe burden of diseases attributable to air pollution is comparable to those of global health risks such as unhealthy diets and tobacco smoking, with many air pollution sources also emitting climate heating gases. In this UK study we estimated the co-benefits of Net Zero (NZ) climate policy on the health benefits of air pollution reduction, increased active travel, outdoor exposure inequalities and indoor air pollution changes. The study focused on two of the largest UK sources, road transport and building heating, with comparisons made between NZ and UK existing policy, referred to as Business as Usual (BAU). Particulate matter (PM2.5), Nitrogen Dioxide (NO2) and Ozone (O3) projections were made between 2019 and 2050, with emphasis placed upon the NZ co-benefits in 2030 and 2040. We compared the UK BAU scenarios with the Climate Change Committee's (CCC) Balanced Net Zero Pathway (BNZP) and Widespread Innovation (WI) pathway. Compared to BAU predictions, BNZP assumptions lead to more electric vehicles, reduced vehicle km, more low carbon building heating, and reduced emissions of NO2 and PM2.5. By 2040 under BNZP, relative to BAU, the buildings sector was predicted to be three times more effective at reducing PM2.5 than road transport. To help reduce the inequality gap the NZ building transition was tailored toward those most in need. Outdoor air pollution exposure inequalities prevailed across the socioeconomic spectrum, especially for NO2, but were less pronounced due in part to NZ policies. Core air quality health benefits for the BNZP buildings sector were £21.3 billion (16.4 to 26.2) by 2050 and £98.4 billion (75.7 to 121.1) by 2154. For the transport sector the health benefits were £9.1 billion (7.0 to 11.2) by 2050 and £36.5 billion (28.1 to 44.9) by 2154. NZ building sector operating costs did not achieve break-even via efficiency savings, but with Greenhouse Gas (GHG) (lower benefits) break-even was achieved in 2052. With additional air pollution health benefits, building-sector time to break-even improved by between 3.1 (2.5 to 4.7) and 6.3 (4.7 to 7.6) years to between 2046 and 2049. Analysis found that removing gas cooking at home, for NZ, may result in greater concentration reductions than outdoor air pollution for NO2. Net Zero health and economic co-benefits are large, as are the changes needed, requiring political leadership and public engagement. Our findings are relevant to other countries facing the NZ transition
The impact of very preterm vs very low birth weight on early and mid-adulthood preference-based HRQoL outcomes: findings from the Dutch study on preterm and small for gestational age infants.
Get PDFOBJECTIVES: Very preterm (VP, < 32 weeks gestation) birth and very low birth weight (VLBW, < 1500 g) are distinct but overlapping risk factors with different clinical implications. We aimed to investigate the separate and combined impacts of being born VP and/or VLBW on health-related quality of life in early and mid-adulthood.
METHODS: We analyzed data from the Dutch Project on Preterm and Small-for-gestational-age infants (POPS), a national prospective cohort of individuals born in 1983. Participants were categorized into three groups: (1) VP & VLBW, (2) VP-only, and (3) VLBW-only. We used the Health Utilities Index Mark 3 at ages 19 and 28, and the Short Form 6-Dimension at age 35 to assess multi-attribute utility (MAU) scores and domain-level functioning. Adjusted linear regression models were used, controlling for covariates and employing inverse probability weighting to account for attrition.
RESULTS: Overall MAU scores did not consistently differ between the exposure groups and the VP & VLBW reference group at any time point. However, specific domain-level differences emerged in early adulthood. At 19 years, the VLBW-only group reported significantly better speech functioning (β = 0.11, p = 0.01). At 28 years, the VP-only group had better hearing (β = 0.05, p = 0.04), while the VLBW-only group had worse ambulation (β = - 0.12, p < 0.01). By 35 years, these inter-group differences were no longer statistically significant. Female sex was a consistent predictor of poorer outcomes in several domains by age 35. Attrition-weighted models produced nearly identical results.
CONCLUSIONS: VP and VLBW are not interchangeable risk categories. While overall HRQoL scores converged by mid-adulthood, distinct domain-specific and sex-based disparities were evident earlier in life. Our findings highlight the need for tailored interventions over a homogenous approach. Future research with consistent measures is required to confirm if this convergence persists over the life course
Global variation in patterns of care and time to initial treatment for breast, cervical, and ovarian cancer from 2015 to 2018 (VENUSCANCER): a secondary analysis of individual records for 275 792 women from 103 population-based cancer registries in 39 countries and territories.
Get PDFBACKGROUND: Cancers of the breast, cervix, and ovary are a major public health problem worldwide. Evaluating the consistency with clinical guidelines for treatment by use of individual high-resolution data from population-based cancer registries is a powerful tool to help interpretation of global inequalities in cancer survival. The VENUSCANCER project aims to assess the worldwide variation in patterns of care and time to initial treatment for women diagnosed with one of these three common cancers. METHODS: In this secondary analysis of anonymised individual records from population-based cancer registries (VENUSCANCER), 103 registries from 39 countries worldwide contributed high-resolution data for women diagnosed with cancer of the breast, cervix, or ovary for a single year of incidence during 2015-18. High-resolution data included cancer stage at diagnosis; staging procedures; tumour grade; biomarkers (ER, PR, and HER2); and the first course of each treatment modality (surgery, radiotherapy, chemotherapy, endocrine treatment, or anti-HER2 therapy) and related dates. We examined prognostic factors, key indicators of consistency with international clinical guidelines for treatment (ESMO, ASCO, and NCCN), and median time between diagnosis and treatment, by country or territory. We analysed the odds of women receiving treatment consistent with guidelines in high-income countries (HICs) and low-income and middle-income countries (LMICs), controlling for age and tumour subtype. FINDINGS: We received 275 792 anonymised individual records for women diagnosed with a cancer of the breast (214 111 [77·6%]), cervix (44 468 [16·1%], including in situ), or ovary (17 213 [6·2%]). In HICs, early-stage, node-negative cancers comprised over 40% of breast and cervical cancers, but less than 20% of ovarian cancers. By contrast, in LMICs, these proportions were generally below 20% for all three cancers, but higher in Cuba (30% for breast), and Russia (36% for cervix and 27% for ovary). Consistency with main international guidelines was highly variable, particularly for surgery and radiotherapy in early-stage breast cancer (from 13% in Georgia to 82% in France), chemotherapy in advanced cervical cancer (from 18% in Mongolia to 90% in Canada), and surgery plus chemotherapy in metastatic ovarian cancer (from 9% in Cuba to 53% in the USA). Some type of surgery was offered to 78% of women in HICs and 56% of women in LMICs, but initial treatment that is consistent with clinical guidelines for early-stage tumours was followed more uniformly for cervical and ovarian cancer than for breast cancer. Older women (aged 70-99 years) had lower odds of receiving initial treatment consistent with clinical guidelines than women aged 50-69 years in both HICs and LMICs. The median time between diagnosis and treatment for early-stage cancers was less than 1 month in several HICs, but up to 4 months for cervical cancer in Mongolia and ovarian cancer in Ecuador, and up to 1 year for breast cancer in Mongolia. INTERPRETATION: The VENUSCANCER project provides the first global picture of patterns of care for three of the most common cancers in women. These findings offer crucial real-world evidence to support the implementation and monitoring of global initiatives on cancer control such as WHO's Global Breast Cancer Initiative and Cervical Cancer Elimination Initiative. Although guideline-consistent treatment has become more accessible for women diagnosed with early-stage tumours in LMICs, the proportion of these women diagnosed early remains far too low. FUNDING: European Research Council Consolidator Grant
Kidney function trajectories before and after hospitalization for heart failure with reduced ejection fraction.
Get PDFBACKGROUND AND AIMS: Worsening kidney function is a key prognostic factor in heart failure (HF) with reduced ejection fraction (HFrEF). However, associations between kidney function trajectories and HF-related events remain unclear.
METHODS: Longitudinal changes in estimated glomerular filtration rate (eGFR) before and after a HF-related event, defined as HF hospitalization or HF death, were examined using individual patient data from two clinical trials (EPHESUS and EMPHASIS-HF) and a real-world cohort (BARCELONA).
RESULTS: HF-related events occurred in 14.1% of 8587 patients [EPHESUS/EMPHASIS-HF; median follow-up 17.1 (12.4-22.7) months] and 33.8% of 2048 patients [BARCELONA; median 47.0 (18.8-90.6) months]. In EPHESUS and EMPHASIS-HF, patients who experienced an HF-related event had a steeper decline in eGFR in the year preceding the event (average -4.83 mL/min/1.73 m²/year) compared with those who did not have an HF-related event (-1.18 mL/min/1.73 m²/year). Over the 1 year following an HF-related event, eGFR continued to decline, though at a slower rate (average -3.45 mL/min/1.73 m²/year). Similar kidney function trajectories were observed in BARCELONA (average eGFR decline -1.35 mL/min/1.73 m²/year in patients without HF event vs -5.77 mL/min/1.73 m²/year 1 year before an event and -3.04 mL/min/1.73 m²/year over the year after an event). Worsening New York Heart Association class paralleled steeper eGFR decline prior to HF events.
CONCLUSIONS: In HFrEF, kidney function decline may precede a HF hospitalization or death by up to 1 year, linking to symptomatic congestion. Monitoring eGFR slopes rather than relying solely on specific cut-off values may allow early detection of at-risk patients
Improving modelling for epidemic response: a progress update from a community of UK infectious disease modellers.
Get PDFWe reflect on the sustainability of modelling infectious disease outbreaks from the perspective of modelling as a field of practice. We formed a community of practice among UK infectious disease modellers who had contributed to the UK COVID-19 response. We previously used a participatory workshop approach to highlight issues in the infrastructure and incentives for outbreak modelling, and synthesized our experience into a set of 12 specific recommendations. Here, we track changes in the field of infectious disease modelling 1 year later, collecting the quantitative and qualitative views of change among 14 participants. We found participants continued to highlight a lack of ongoing, sufficient or appropriate action to develop outbreak modelling capacity in the UK, while positively noting collaborations among public health facing institutions. We emphasize the under-prioritization of funding for outbreak modelling outside of emergency response periods, and the continuation of unsustainable working practices. Correcting this is crucial to supporting evidence-based public health policy for outbreak preparedness and response
Blood RNA biomarkers and C-reactive protein for triage of adult patients with tuberculosis lymphadenitis and pericarditis in South Africa: a single-centre, prospective, observational, diagnostic accuracy study.
Get PDFBACKGROUND: Data on the diagnostic accuracy of blood RNA biomarker signatures for extrapulmonary tuberculosis are scarce. We aimed to address this question among people investigated for tuberculosis lymphadenitis and tuberculosis pericarditis.
METHODS: This prospective, observational, diagnostic accuracy study was done at a tertiary hospital in Cape Town, South Africa. We enrolled consecutive symptomatic adults (aged 18 years or older) with presumptive tuberculosis lymphadenitis (Jan 25, 2017, to Oct 9, 2019) or tuberculosis pericarditis (Nov 24, 2016, to Oct 28, 2019). We used microbiological testing of samples from the site of disease as the reference standard. We evaluated the diagnostic accuracy of seven previously reported blood RNA signatures by area under the receiver operating characteristic curve (AUROC) and sensitivity and specificity at prespecified thresholds using two SDs above the mean of a healthy reference control group, benchmarked against blood C-reactive protein and WHO target product profile for a tuberculosis triage test. Decision curve analysis was used to evaluate clinical utility of the best-performing blood RNA signature and C-reactive protein.
FINDINGS: The pooled cohort included 440 individuals, 374 of whom (275 with lymphadenitis and 99 with pericarditis) had at least one microbiological test from the site of disease, blood C-reactive protein, and RNA measurements available and were included in the analysis. 181 (48%) participants were female and 193 (52%) were male. The diagnostic accuracy of blood RNA signatures was similar across patients with lymphadenitis and pericarditis. In pooled analysis of both cohorts, all RNA signatures had similar discrimination, with AUROC point estimates ranging from 0·77 (95% CI 0·72-0·82) to 0·82 (0·77-0·86), and greater than that of C-reactive protein (0·61 [0·56-0·67]). The best-performing signature (Roe3) did not meet the WHO target product profile benchmark for a triage test. At the prespecified threshold, Roe3 had 78% (95% CI 72-83) sensitivity and 69% (62-75) specificity; C-reactive protein at a threshold of 10 mg/L had 83% (77-87) sensitivity and 35% (29-43) specificity. In this setting, decision curve analysis showed that Roe3 offered greater net benefit than other approaches for services aiming to reduce the number needed to investigate with confirmatory testing to fewer than four to identify each individual with tuberculosis.
INTERPRETATION: Our results suggest RNA biomarkers show better accuracy and clinical utility than C-reactive protein to trigger confirmatory tuberculosis testing in patients with tuberculosis lymphadenitis and tuberculosis pericarditis, but still fall short of the WHO target product profile for tuberculosis triage tests.
FUNDING: South African Medical Research Council, European and Developing Countries Clinical Trials Partnership 2, National Institutes of Health/National Institute of Allergy and Infectious Diseases, Wellcome Trust, National Institute for Health and Care Research, and Royal College of Physicians
P2Y12 inhibitor or aspirin after percutaneous coronary intervention: individual patient data meta-analysis of randomised clinical trials.
Get PDFOBJECTIVE: To assess the long term comparative effectiveness of P2Y12 inhibitor monotherapy compared with aspirin monotherapy in patients after percutaneous coronary intervention (PCI) and discontinuation of dual antiplatelet therapy (DAPT).
DESIGN: Individual participant data (IPD) meta-analysis of randomised clinical trials.
DATA SOURCES: PubMed/Medline, Scopus, Web of Science, and Ovid/Embase.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised trials investigating monotherapy with a P2Y12 inhibitor or aspirin for secondary prevention of ischaemic events in patients with coronary artery disease who underwent PCI.
DATA EXTRACTION AND SYNTHESIS: Anonymised IPD were extracted and transferred to the coordinating centre by dedicated electronic spreadsheets. Data were primarily combined by mixed effects models (one stage analysis) and complemented with multivariable mixed effects models and two stage analyses based on random effects models. The primary and co-primary outcomes were a composite of major adverse cardiac and cerebrovascular events (MACCE) and major bleeding, respectively. The secondary outcomes included a net composite of adverse cardiac and cerebrovascular events (NACCE), derived from the combination of the primary and co-primary outcomes, and individual ischaemic and bleeding events.
RESULTS: A total of 16 117 patients assigned to P2Y12 inhibitor or aspirin monotherapy after PCI and completion of the recommended DAPT regimen (median duration of 12 months) in five randomised trials were included. At a median follow-up of 1351 days (interquartile range 373-1791 days), P2Y12 inhibitor monotherapy was associated with a lower risk of MACCE compared with aspirin monotherapy (one stage analysis: hazard ratio 0.77 (95% confidence interval (CI) 0.67 to 0.89), P<0.001; multivariable one stage analysis: adjusted hazard ratio 0.77 (0.67 to 0.89), P<0.001; two stage analysis: hazard ratio 0.77 (0.67 to 0.89), P<0.001), yielding a number needed to treat to benefit of 45.5 (95% CI 31.4 to 93.6). No significant difference in major bleeding (one stage analysis: hazard ratio 1.26 (0.78 to 2.04), P=0.35; multivariable one stage analysis: 1.12 (0.74 to 1.70), P=0.60; two stage analysis: 1.15 (0.69 to 1.92), P=0.59) was observed. NACCE, myocardial infarction, and stroke were lower in patients assigned to a P2Y12 inhibitor compared with those assigned to aspirin. These findings were confirmed across multiple sensitivity and subgroup analyses.
CONCLUSIONS: In patients who had undergone PCI and discontinued DAPT, at a follow-up of about 5.5 years, P2Y12 inhibitor monotherapy with ticagrelor or clopidogrel was associated with lower MACCE, owing to reduced rates of myocardial infarction and stroke compared with aspirin monotherapy, without a concurrent increased risk of major bleeding.
REVIEW REGISTRATION: PROSPERO CRD42024517983