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Health system governance cooperation with unrecognised health authorities: a political economy analysis in Afghanistan and Northwest Syria
Get PDFBackground: The government is normally the leading actor in health system governance, yet in some conflict-affected contexts, government or equivalent health authorities are not formally recognised by the international partners who co-finance the health system. This study considers what has inhibited or facilitated cooperation between two types of non-recognised health authorities and international partners in Afghanistan from 2021 to 24 and Northwest Syria from 2013 to 19. Methods: A literature review was combined with 14 semi-structured key informant interviews, mostly with representatives (often health advisers) of donors or UN agencies. A political economy analysis (PEA) analytical framework was used, focusing on the capacities, incentives, beliefs, institutional and structural factors that influenced the behaviour of the key health system actors. Results: Although widely cited as a critical barrier, the lack of formal recognition was not the main constraint on cooperation. The in/stability of the conflict context, the likelihood of survival of de facto health authorities, the extent to which there were clashing norms between actors, and the incentives and ‘ways of doing things’ of both unrecognised authorities and international actors also played key roles. For example, in Afghanistan, the Taliban’s approach to women’s rights and education was identified as the major barrier to cooperation. In Northwest Syria, on the other hand, establishing health governance bodies that were strongly technical in focus and claimed functional independence from sanctioned ruling militias significantly boosted cooperation and protected the health system. Most interviewees felt there was more room for international actors to work with unrecognised health authorities within the “red lines” of international law and organisational mandates, using promising entry points such as supporting Human Resources for Health. There was significant agreement between authorities and international partners on the core health system strategies and priorities in these contexts. But health authorities wanted – and aid cuts suggested they should take – more control over financing and management, and they were naturally more focused than international actors on the holistic needs of the health system, beyond ‘emergency’ assistance. Conclusions: International partners and de facto authorities can both take action to use more of the operational space for cooperation
Retrovirus-based pseudotyped virus neutralisation assays overestimate neutralising activity in sera from participants receiving integrase inhibitors.
Get PDFRetroviral pseudotype-based virus neutralisation assays are widely used to estimate functional immunity, but may be unsuitable for testing human immunodeficiency virus (HIV)-infected individuals receiving integrase inhibitor treatment. We evaluated these assays for measuring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and hepatitis C virus (HCV) neutralisation in people living with HIV. SARS-CoV-2 neutralisation was assessed using HIV-based SARS-CoV-2 pseudoviruses in sera from a longitudinal Malawian cohort (n = 1,876), detecting neutralisation across timepoints in 10.5-54.5% of HIV-uninfected vs. 85.5-93.9% of HIV-infected participants (n = 96). HIV-infected sera were re-tested using vesicular stomatitis virus (VSV)-based SARS-CoV-2 pseudoviruses, estimating seroprevalence at 5.6-65.2%, suggesting HIV-based assays overestimate neutralisation. HIV-based VSV-glycoprotein(G) pseudoviruses confirmed non-specific inhibition in 75.0-87.9% of HIV-infected participants. HCV neutralisation was assessed in UK-based HCV patients (n = 100, n = 90 HIV-infected) using murine leukaemia virus (MLV)-based HCV pseudoviruses. Non-HCV-specific inhibition was detected in integrase inhibitor recipients. Median neutralisation of MLV(HCV) pseudoviruses was higher in integrase inhibitor recipients (71.8% vs. 21.3%). Testing HIV(SARS-CoV-2) and MLV(HCV) pseudoviruses against antiretroviral drugs showed interference by integrase inhibitors (specifically, dolutegravir). Isolating IgG from serum removed the interference by residual drugs. Retrovirus-based assays are therefore unsuitable for testing individuals receiving integrase inhibitors. Protective immunity to viruses has likely been over-reported in HIV prevalent populations
Walking a tightrope: Social support in early adulthood in resource-constrained South Africa.
Get PDFSupportive social relations are crucial to wellbeing as young adults transition to independence, especially when these transitions are impeded by limited employment and educational opportunities, leading to lengthy 'waithoods'. Yet, there is limited empirical evidence on what young adults' support networks look like in highly resource-constrained settings. We therefore analysed the core support networks of 929 16-29 year-old rural South Africans to explore their social support landscape, using descriptive statistics and multilevel regression models. We found that these youth have small but intense support networks, with contacts often providing multiple types of support on a daily basis. While kin and parents are important support sources when present, parents are also frequently missing from these networks. Women received more intense support than men with more kin ties; men's networks contained more friends. While non-kin ties (friends and romantic partners) provide substantial support, they may also be unstable: for young men through dissolution following conflict and for young women due to the transactional nature of romantic relations. These findings imply that where work opportunities are scarce, young people's support networks are smaller and less parentally focused than elsewhere, potentially increasing their fragility and raising the risk of isolation
Morbidity and health seeking behavior among children and adolescents (0-19 years): a household survey assessment in Northwestern Tanzania.
Get PDFBACKGROUND: Information on morbidity and health-seeking behavior beyond early childhood is crucial for planning evidence-based interventions. Currently, data is limited to children under five. This study introduces a method for estimating morbidity and health-seeking behavior in older children and adolescents (5-19 years) using women's birth histories from a household survey in northwestern Tanzania, comparing it with data on children under five. METHODS: We conducted a household survey among women 15-49 years as part of the Magu Health and Demographic Surveillance from October 2020 to November 2021, including 16,896 children aged 0-19 living with their mothers. The study outcomes were the prevalence of reported illness in the last four weeks and health-seeking behavior, defined as visiting a health facility for recent illness. Modified Poisson regression analysis was performed, accounting for mothers as clusters and adjusting for child and mother characteristics. We compared the prevalence of recent illness and health-seeking behavior among older children and adolescents (5-19 years) with children under five within the same population. RESULTS: Morbidity presented as the prevalence of any illness decreased with age, from 26.1% in children under-five to 10.4% among adolescents aged 15-19. Health seeking behavior also decreased with age, from 48.2% in children under-five to nearly 30% among adolescents aged 15-19. Types of illnesses reported were similar across age groups, with Fever/Malaria accounting more than two-thirds, followed by respiratory tract illnesses. Higher illness prevalence was noted in rural areas for both age groups. Health seeking behavior was higher among mothers with secondary education and above for both children under-fives (APR:1.22;95% CI: 1.02, 1.47) and 5-19-year-olds (APR: 1.31; 95% CI:1.01, 1.70). Additionally, those with health insurance also reported higher health seeking behavior (APR: 1.38; 95% CI:1.07, 1.78), while lower for children in rural households (APR: 0.72; 95% CI:0.61, 0.83), for 5-19-year-olds. CONCLUSIONS: Our findings on morbidity and health-seeking behavior demonstrate the importance of extending health monitoring beyond early childhood. The inequalities identified point to gaps in programming and health service delivery that require attention
Resilient health systems in action: How actor relationships and organizational adaptation shaped the health sector's response to the 2015–2018 Western Cape drought
Get PDFAbstract
Climate change is making droughts more frequent and severe, creating serious challenges for health systems and vulnerable communities worldwide. From 2015 to 2018, the Western Cape Province, South Africa, faced an extreme drought that nearly led to “Day Zero”—a point when water supplies would run out. Despite this crisis, documentation of the drought overlooks the health sectors response. To understand how health decision-makers managed this drought, in-depth interviews with 31 people from the health sector and other related fields were conducted. Transcripts were anonymized, transcribed, and deductively and inductively coded. A thematic analysis grouped the findings into four large themes with sub-themes of enabling factors. The study revealed that the health sector played a vital role by ensuring hospitals and clinics had water, reducing water use in facilities, and working closely with other sectors to protect community health. Interestingly, the most critical factors in managing the crisis were not just physical resources like procuring water tanks or fixing pipes in hospitals but the “software” of the health system: strong relationships, good communication, and shared values among health workers and decision-makers. These elements, albeit complex, enabled quick and effective action during the drought, and remained responsive to population needs that allowed for an effective health system response. The findings provide important lessons for making health systems more resilient to future droughts and other climate-related challenges
Targeted sequencing of Enterobacterales bacteria using CRISPR-Cas9 enrichment and Oxford Nanopore Technologies.
Get PDFSequencing DNA directly from patient samples enables faster pathogen characterization compared to traditional culture-based approaches, but often yields insufficient sequence data for effective downstream analysis. CRISPR-Cas9 enrichment is designed to improve the yield of low abundance sequences but has not been thoroughly explored with Oxford Nanopore Technologies (ONT) for use in clinical bacterial epidemiology. We designed CRISPR-Cas9 guide RNAs to enrich the human pathogen Klebsiella pneumoniae, by targeting multi-locus sequence type (MLST) and transfer RNA (tRNA) genes, as well as common antimicrobial resistance (AMR) genes and the resistance-associated integron gene intI1. We validated enrichment performance in 20 K. pneumoniae isolates, finding that guides generated successful enrichment across all conserved sites except for one AMR gene in two isolates. Enrichment of MLST genes led to a correct allele call in all seven loci for 8 out of 10 isolates that had depth of 30× or more in these regions. We then compared enriched and unenriched sequencing of three human fecal samples spiked with K. pneumoniae at varying abundance. Enriched sequencing generated 56× and 11.3× the number of AMR and MLST reads, respectively, compared to unenriched sequencing, and required approximately one-third of the computational storage space. Targeting the intI1 gene often led to detection of 10-20 proximal resistance genes due to the long reads produced by ONT sequencing. We demonstrated that CRISPR-Cas9 enrichment combined with ONT sequencing enabled improved genomic characterization outcomes over unenriched sequencing of patient samples. This method could be used to inform infection control strategies by identifying patients colonized with high-risk strains. IMPORTANCE: Understanding bacteria in complex samples can be challenging due to their low abundance, which often results in insufficient data for analysis. To improve the detection of harmful bacteria, we implemented a technique aimed at increasing the amount of data from target pathogens when combined with modern DNA sequencing technologies. Our technique uses CRISPR-Cas9 to target specific gene sequences in the bacterial pathogen Klebsiella pneumoniae and improve recovery from human stool samples. We found our enrichment method to significantly outperform traditional methods, generating far more data originating from our target genes. Additionally, we developed new computational techniques to further enhance the analysis, providing a thorough method for characterizing pathogens from complex biological samples
Effect of mass drug administration on malaria incidence in southeast Senegal during 2020-22: a two-arm, open-label, cluster-randomised controlled trial.
Get PDFBACKGROUND: In Africa, the scale-up of malaria-control interventions has reduced malaria burden, but progress towards elimination has stalled. Mass drug administration (MDA) is promising as a transmission-reducing strategy, but evidence from low-to-moderate transmission settings is needed. We aimed to assess the safety, coverage, and effect of three cycles of MDA with dihydroartemisinin-piperaquine plus single, low-dose primaquine on Plasmodium falciparum incidence and prevalence in southeast Senegal. METHODS: We conducted a two-arm, open-label, cluster-randomised controlled trial in villages in the Tambacounda health district of southeast Senegal. Eligible villages had a population size of 200-800, were within a health-post catchment area with an annual malaria incidence of 60-160 cases per 1000 people, and had an established or planned Prise en Charge à Domicile Plus model. We randomly assigned villages (1:1) using a stratified, constrained randomisation approach to receive either three cycles of MDA with oral dihydroartemisinin-piperaquine plus single, low-dose primaquine administered at 6-week intervals (intervention) or to standard of care, which included three cycles of seasonal malaria chemoprevention (SMC) with oral sulfadoxine-pyrimethamine plus amodiaquine administered at 4-week intervals (control). Participants, the field team, and all investigators, including those who assessed outcomes and analysed data, were unmasked to allocation assignment. Laboratory technicians were masked to intervention assignment. The primary outcome was village-level, P falciparum-confirmed malaria incidence in the post-intervention year (ie, July to December, 2022). Secondary outcomes included malaria incidence during the intervention year (ie, July to December, 2021), coverage and safety of MDA, and adverse events. We conducted analyses using an intention-to-treat approach. The trial is registered with ClinicalTrials.gov (NCT04864444) and is completed. FINDINGS: Between Sept 1 and Oct 25, 2020, 523 villages were geolocated and screened for eligibility; 111 met the inclusion criteria. Of these, 60 villages were randomly selected and assigned to the intervention arm or control arm. Distribution coverage of all three doses of dihydroartemisinin-piperaquine was 6057 (73·6%) of 8229 participants in the first cycle, 6836 (78·8%) of 8673 participants in the second cycle, and 7065 (81·3%) of 8690 participants in the third cycle. Distribution coverage of single, low-dose primaquine was 6286 (78·6%) of 7999 participants in the first cycle, 6949 (82·1%) of 8462 participants in the second cycle, and 7199 (84·0%) of 8575 participants in the third cycle. Distribution coverage of all three doses of SMC was 3187 (92·2%) of 3457 children aged 3-120 months in the first cycle, 3158 (91·8%) of 3442 children aged 3-120 months in the second cycle, and 3139 (91·4%) of 3434 children aged 3-120 months in the third cycle. In the intervention year (ie, July to December, 2021), the adjusted effect of MDA was 55% (95% CI 28 to 71). In the post-intervention year (ie, July to December 2022), the adjusted MDA effect was 26% (-17 to 53). Malaria incidence during the transmission season of the post-intervention year was 126 cases per 1000 population in the intervention arm and 146 cases per 1000 population in the control arm. No serious adverse events were reported. INTERPRETATION: In southeast Senegal, a low-to-moderate transmission setting where malaria-control measures have been scaled up, three cycles of MDA with dihydroartemisinin-piperaquine plus single, low-dose primaquine was safe and reduced malaria burden during the intervention year. However, its sustained effect was weak and continuation of MDA or another transmission-reducing strategy could be required. FUNDING: US President's Malaria Initiative
Understanding mental health among university students in Kenya: what role do family support and age play?
Get PDFOBJECTIVE: While mental health conditions play a significant role in the global disease burden, their determinants and predictors are still not well understood in Kenya. This study examined the prevalence of mental health conditions among university students and the factors associated with them. METHODS: This cross-sectional study evaluated 1,424 students at Pwani University in Kenya, assessing anxiety, depression, and psychosis, using validated screening tools: the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Psychosis Screening Questionnaire (PSQ). The Chi-square tests analyzed associations, while binary logistic regression identified predictors. Confounders were controlled using multivariable adjustments, with model selection based on both clinical relevance and statistical significance of the variables. RESULTS: The prevalence of mental health conditions among students was 30.9%. Those from unsupportive families exhibited the highest prevalence at 35.2% (χ 2 = 94.91, p < 0.001), while first-year students reported the highest rate among academic levels at 40.7% (χ 2 = 24.38, p < 0.001). Students aged 25-29 years were 2.6 times more likely to experience mental health conditions (OR = 2.6, 95% CI: 1.67-3.98, p < 0.001). Access to mental health services (χ 2 = 4.62, p = 0.032) and mental health insurance (χ 2 = 4.11, p = 0.043) were associated with lower odds of mental health conditions, thereby reducing the risk by 34 and 33%, respectively. CONCLUSION: The findings highlight the urgent need for age-sensitive, student-centered mental health interventions in Kenyan universities. Specifically, universities should implement targeted support programs for first-year and final-year students who face unique mental health risks due to transitional and graduation-related stressors. Additionally, integrating family engagement initiatives to strengthen family support structures can serve as a protective factor against mental health challenges. Policies aimed at expanding access to mental health insurance and services should also be prioritized. Given the use of non-probabilistic sampling, findings should be interpreted with caution. Future research should investigate longitudinal trends to establish causal relationships and inform the development of evidence-based policies
Refugees and asylum seekers in Europe need a rights-based approach to the issue of return: insights from the case of the Syrian displacement.
Get PDFThe state of global palliative care research: a bibliometric study.
Get PDFBACKGROUND: Palliative care research (PCR) plays a critical role in improving the quality of life for patients with serious illness, yet its global distribution and focus areas remain uneven. Understanding the trends and impact of PCR over the past decade can inform future research priorities and policy development. METHODS: We conducted a bibliometric analysis of publications indexed in the Web of Science related to PCR between 2013 and 2022. Articles were identified using a comprehensive filter based on title keywords and specialist journals, and were further classified by research domain, disease area and study type. RESULTS: The volume of PCR publications has grown over the past decade, increasing from 0.29% of all biomedical research outputs in 2013-14 to 0.62% in 2021-22. Countries with the highest levels of PCR output-primarily European and Anglophone nations-also ranked highly on the Economist Intelligence Unit's Quality of Death Index. Using eight different bibliometric indicators, we assessed the impact of countries' PCR outputs; while rankings varied by metric, European countries such as the Netherlands, Belgium, the United Kingdom and Ireland consistently performed strongly. Cancer emerged as the dominant disease focus, although many studies also addressed co-morbid conditions including COVID-19 in recent years. A significant proportion of PCR also examined the impact of illness on patients' families and caregivers. CONCLUSION: The findings highlight cancer as a major area of focus and need within PCR. However, research outputs remain disproportionately concentrated in high-income countries, revealing a persistent gap in low- and middle-income settings. RECOMMENDATIONS: To address the growing global burden of cancer and serious illness, palliative care should be integrated as a core component of national cancer control plans. This integration must be supported by a targeted research agenda that emphasises implementation and scaling of palliative care models, particularly in low- and middle-income countries. Policymakers and research funders should prioritise holistic, patient-centred approaches and ensure that impact measurement reflects meaningful outcomes for patients and families