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The social determinants of tuberculosis: a case-control study characterising pathways to equitable intervention in Peru.
Get PDFBACKGROUND: Despite being key components of global tuberculosis policy, poverty reduction and social protection interventions have been inconsistently implemented. We aimed to characterise how poverty and interrelated personal risk factors increase tuberculosis risk in Peru to inform the design of locally appropriate, person-centred, equity-oriented interventions. METHODS: We undertook a case-control study among people aged 15 years and over in 32 communities in Peru between 2016 and 2019. Cases (n = 2337) were people diagnosed with any form of tuberculosis. Controls (n = 981) were people living in randomly selected households in the same communities. We derived measures of household poverty from three dimensions (physical, human, and financial capital) and investigated the associations between these; personal risk factors more specifically linked to health (e.g. smoking); and tuberculosis. We used logistic regression to calculate adjusted odds ratios (aOR), 95% confidence intervals (95% CI), and population attributable fractions (PAF). A directed acyclic graph was used to inform the analytical approach. RESULTS: Household poverty was strongly associated with tuberculosis (aOR = 3.1; 95% CI: 2.3-4.2 for people from the 'poorer' versus 'less poor' half of households). There was a non-linear social gradient across deciles of household poverty, with odds of tuberculosis increasing exponentially as poverty deepened (aOR = 12.6; 95% CI: 6.8-23.2 for the 'poorest' decile versus the 'least poor' decile). Overall, tuberculosis burden could be halved by reducing poverty in the 'poorer' half of households to the level of the 'less poor' half (PAF = 47%; 95% CI: 40-54). For key personal risk factors, we estimated PAF for alcohol excess (PAF = 12.3%, 95% CI: 7.2-17.2); underweight (PAF = 10.3%, 95% CI: 8.7-11.8); smoking (PAF = 8.8%, 95% CI: 3.8-13.5); HIV (PAF = 5.7%, 95% CI: 4.6-6.7); and diabetes (PAF = 4.6%, 95% CI: 3.3-6.0). We also identified other important risk factors including previous tuberculosis (PAF = 14.8%, 95% CI: 11.6-17.9); incarceration (PAF = 9.5%, 95% CI: 6.8-12.1); and lower social capital (PAF = 4.1%, 95% CI: 2.6-5.6). Most personal risk factors, particularly education and substance misuse, tuberculosis exposures (e.g. incarceration and homelessness), and undernutrition, exhibited a social gradient across quintiles of household poverty and were more prevalent in people living in poorer households (Cochran-Armitage test for linear trend P < 0.001 for variables showing these social gradients). CONCLUSIONS: Interventions addressing multidimensional household poverty and interrelated personal risk factors could substantially reduce tuberculosis burden. Our results provide an evidence base for designing person-centred, equity-oriented interventions; and support more effective implementation of poverty reduction and social protection within the global tuberculosis response
Spatial variation in time to diagnosis of visceral leishmaniasis in Bihar, India.
Get PDFBACKGROUND: Visceral leishmaniasis (VL) is a debilitating and-without treatment-fatal parasitic disease which burdens the most impoverished communities in northeastern India. Control and ultimately, elimination of VL depends heavily on prompt case detection. However, a proportion of VL cases remain undiagnosed many months after symptom onset. Delay to diagnosis increases the chance of onward transmission, and poses a risk of resurgence in populations with waning immunity. We analysed the spatial variation of delayed diagnosis of VL in Bihar, India and aimed to understand the potential driving factors of these delays. METHODS: The spatial distribution of time to diagnosis was explored using a Bayesian hierarchical model fit to 4270 geo-located cases notified between January 2018 and July 2019 through routine surveillance. Days between symptoms meeting clinical criteria (14-day fever) and diagnosis were assumed to be Poisson-distributed, adjusting for individual- and village-level characteristics. Residual variance was modelled with an explicit spatial structure. Cumulative delays were estimated under different scenarios of active case detection coverage. RESULTS: The 4270 cases analysed were found to be prone to excessive delays in areas outside existing endemic 'hot spots'. After accounting for differences associated with age, HIV status and mode of detection (active versus passive surveillance), cases diagnosed within recently affected (≥ 1 case reported in the previous year) blocks and villages experienced shorter delays on average (by 13% [2.9-21.7%] (95% credible interval) and 7% [1.3-13.1%], respectively) than those in non-recently-affected areas. CONCLUSIONS: Delays to VL diagnosis when incidence is low could influence whether transmission of the disease could be interrupted or resurges. Prioritising and narrowing surveillance to high-burden areas may increase the likelihood of excessive delays in diagnosis in peripheral areas. Active surveillance driven by observed incidence may lead to missing the risk posed by as-yet-undiagnosed cases in low-endemic areas, and such surveillance could be insufficient for achieving and sustaining elimination
Impact and Mental Health Mediation of Intimate Partner Violence on Child Behavior in Trinidad and Tobago
Get PDFIntimate partner violence (IPV) is known to have detrimental effects on persons who directly experience this form of abuse. Emerging research also indicates that a parent’s experience of IPV may influence their children’s well-being through various intermediary pathways. However, there is still no established model to explain these mechanisms. This study is among the few that assess maternal mental health symptoms as potential mediators of the association between maternal IPV and child behavior. Using secondary data from a population-based, cross-sectional survey, we performed logistic regression analyses to assess the impact of lifetime maternal IPV exposure on child behavioral problems (withdrawal or aggression). We then applied generalized structural equation modeling to examine the mediating effects of both maternal depression and anxiety symptoms on this association. Over half (55%; 95% CI [48.3, 60.8]) of mothers had experienced IPV at some point, and 12.5% (95% CI [8.0, 19.1]) of children exhibited behavioral problems. Mothers exposed to IPV were almost three times as likely to report behavioral problems in their children compared to mothers with no history of IPV (
OR
= 2.81; 95% CI [1.08, 7.33]). Furthermore, we found that both maternal depressive and anxiety symptoms partially mediated the relationship between maternal IPV exposure and child behavioral problems. These findings suggest that the impact of maternal IPV on child behavioral problems is partially explained by maternal mental health. Reducing IPV and improving maternal mental health through enhanced screening and community-based mental health initiatives may contribute to lowering the prevalence of child behavior problems in Trinidad and Tobago
Ration or compassion? Stakeholder perspectives on the introduction of bedaquiline in South Africa.
Get PDFAntimicrobial resistance (AMR) is a global health emergency that poses a significant challenge to disease control efforts that rely on antibiotics. Drug-resistant tuberculosis (DR-TB) is a major contributor to global AMR, but its management has historically often remained confined to TB-specific discussions. The emergence of bedaquiline (BDQ), the first novel TB drug in decades, is a moment of potential confluence between AMR and DR-TB. By examining the period between 2012 and 2018, when BDQ was made available for DR-TB in South Africa, this study explores how the introduction of this novel drug foregrounded tensions between antimicrobial access and stewardship in resource-constrained settings. Through qualitative interviews with doctors, policymakers, patients, and activists in the context of DR-TB policy, programming, and care delivery, we explore how these stakeholders balanced the imperative to expand access to this critical new antibiotic and the imperative to ensure its longevity. South Africa, we show, adopted a liberal approach to access to BDQ, grounded in a compassionate care approach that represented a significant shift from the country's traditional drug rationing aimed at mitigating the spread of DR-TB. We document the numerous obstacles that were faced in enabling compassionate use, as well as the broader implications of South Africa's liberal BDQ policy both for TB management in South Africa and for global AMR strategies. The BDQ experience suggests that integrating compassionate care into stewardship models can yield positive public health outcomes, challenging some of the foundational assumptions underlying stewardship. In the process, it suggests that a third, balanced strategy is available that explicitly integrates equitable access with robust stewardship to fulfil both immediate and long-term public health goals
Determinants of access to basic handwashing facilities and handwashing with soap in low-income areas of four Kenyan cities.
Get PDFHandwashing with soap is an effective public health measure against infectious disease and is enabled by availability of handwashing facilities, soap and sufficient water. However, access to handwashing facilities in low-income urban areas is often low, which hinders effective handwashing with soap. We assessed access to basic handwashing facilities and handwashing with soap practices in low-income areas across four cities in Kenya. A cross-sectional survey was conducted and observations made at household level to assess availability of basic handwashing facilities. Respondents demonstrated how they usually washed hands and observations were made on whether hands were washed with soap or not. Multivariable logistic regression models were used to assess determinants of access to basic handwashing facilities and of handwashing with soap across the cities. Results show that most handwashing facilities were basins (77%) and customised containers (4.6%). Less than half of respondents (40%) reported always using soap during handwashing and 59% reported sometimes using soap. Those with secondary education had higher odds of having basic handwashing facilities (Adjusted Odds Ratio (AOR)-1.92, P = 0.02, CI 1.14- 3.24) while those without any compound enclosure had lower odds of having handwashing facilities (AOR = 0.42, P = 0.00, CI 0.28-0.62). Respondents with a handwashing facility (AOR = 69.52, P = 0.00, CI 42.88-112.73) and those with a water point in their compound (AOR 2.4, P = 0.00 CI: 1.43-3.98) had higher odds of handwashing with soap. Across the cities, residents from Mombasa had lower odds of having handwashing facilities (AOR = 0.47, P = 0.01 CI 0.28-0.80) and of handwashing with soap (AOR-0.19; P = 0.00; CI 0.08-0.42) compared to those from Nairobi. These results buttress the important role played by water and the presence of a handwashing facility in promoting handwashing with soap. Interventions in low-income areas should focus on increasing access to conditions such as consistent supply of water to promote adequate and sustained handwashing with soap
Integration of a vertical voluntary medical male circumcision program into routine health services in Zimbabwe: A solution for sustainable HIV prevention.
Get PDFThe global health community has recognized the importance of integrating and sustaining health programs within national health systems rather than managing stand-alone 'vertical' interventions. Corresponding with these objectives, international aid donors are embracing the principle of localization. Voluntary Medical Male Circumcision (VMMC) in Zimbabwe is a large vertical HIV prevention program that was primarily funded through development assistance for health. Program stakeholders want to sustainably integrate VMMC into routine health services so that the program will continue to be a cost-effective HIV prevention strategy. The research team studied the effectiveness of a district-level intervention to empower local stakeholders in this integration effort. To evaluate this intervention, the research team conducted a document review of district-level work plans, combined with a survey administered to district teams assessing sustainability capacity of the program. Over a two-year period, Task Teams in all five intervention districts successfully integrated the VMMC program by reducing barriers and leveraging opportunities in other parts of the health system. Key outcomes impacted all WHO health system building blocks, including enhanced leadership and governance, improved service delivery through better access and acceptability, an expanded health workforce through training, more efficient use of medical technologies, improved data quality, and the mobilization of local funds to support program financing and sustainability. The sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. By institutionalizing participatory work planning, fostering local ownership, and mobilizing resources, the project demonstrated a successful model for integrating, scaling, and sustaining VMMC services. Other health programs in low- and middle-income countries seeking to integrate and sustain health services at subnational levels should consider this diagonal, bottom-up model to promote local leadership development and health system strengthening
Implementing community-based interventions for the management of chronic conditions in low- and middle-income countries: A scoping review of qualitative evidence.
Get PDFThe rising prevalence of chronic diseases in low- and middle-income countries (LMICs) poses significant challenges to already overburdened health systems. Community-based interventions are recognised as effective strategies for managing these conditions. However, implementing such interventions faces barriers that can hinder their effectiveness. This scoping review aims to assess qualitative studies examining barriers and facilitators to implementing community-based interventions for chronic disease management in LMICs. We searched six databases for studies published between 2013-2024. Eligible studies were those with a qualitative design that explored implementation challenges and facilitators of community-based interventions. Data were thematically analysed and interpreted using the Socio-Ecological Model (SEM) to capture multi-level influences on implementation. Eighteen studies were included, covering interventions in 13 LMICs. We identified four levels of influencing the implementation of chronic condition management interventions: individual (service users and providers), community, health system/policy, and interpersonal. Barriers at the individual level included privacy concerns, misconceptions about CHW roles, and a preference for traditional medicine. Facilitators included strong CHW motivation, often driven by personal experiences with the conditions they managed. Community-level support, particularly from local leaders and sensitization events, enhanced intervention acceptance. At the health system level, training quality and role recognition of CHWs were critical, while barriers included excessive workload and insufficient infrastructure. Interpersonal relationships, especially gender dynamics and attitudes of facility-based workers towards CHWs, also influenced implementation outcomes. The quality of qualitative evidence varied, with many studies lacking clear objectives and data collection or analysis frameworks. Effective implementation of community-based interventions for chronic disease management in LMICs requires addressing both systemic and interpersonal barriers. Future interventions should emphasise structured community engagement, comprehensive training, and better integration with healthcare systems. Additionally, improving the methodological rigor of qualitative research is essential for gaining deeper insights into the complex factors that influence the success and sustainability of these interventions
Antibiotic use for common illnesses in children living with disability: a multi-country study across 42 low- and middle-income countries.
Get PDFBACKGROUND: Approximately 240 million children worldwide are living with disabilities. Understanding the association between disability status and reported antibiotic use for common illnesses can help develop strategies to address the critical intersection of antimicrobial resistance (AMR) and disability. METHODS: Data were collected from 42 low- and middle-income countries through the UNICEF-supported Multiple Indicator Cluster Survey (2017-2023). Disability status was assessed using the Washington Group-Child Functioning Module. Reported antibiotic use was measured by whether children with disabilities received antibiotic treatment for common childhood illnesses. Logistic regression models were applied to investigate the association between disability status and the prevalence of acute respiratory infection (ARI), diarrhea, and fever in the past two weeks, as well as reported antibiotic use for these illnesses. Analyses controlled for age, sex, place of residence, mother's education, the number of children under five in the household and country. FINDINGS: The study included 301,857 children, 6.9% of whom were living with disabilities. Children with disabilities were more likely to experience common illnesses compared to those without disabilities: aOR = 1.78 (95% CI: 1.34-2.36) for ARI and aOR = 1.54 (95% CI: 1.22-1.96) for fever. The odds of antibiotic use among children with disabilities were comparable to those without disabilities: aOR = 1.13 (95% CI: 0.68-1.87) for ARI, aOR = 0.93 (95% CI: 0.64-1.36) for diarrhea, and aOR = 1.23 (95% CI: 0.81-1.86) for fever. This varied across countries, the lower-middle income countries had lower odds of reported antibiotic use for ARI and diarrhea (aOR = 0.85, 95% CI: 0.74-0.97, aOR = 0.78, 95% CI: 0.64-0.95, respectively). Lesotho, Iraq, Comoros and Honduras had higher odds of reported antibiotic use for children with disabilities, and in Pakistan where children with disabilities had lower odds of reported antibiotic use. Subgroup analyses showed that girls with disabilities were less likely to use antibiotics for diarrhea (aOR = 0.78, 95% CI: 0.63-0.96) compared to girls without disabilities. Similarly, girls with disabilities had lower odds of using antibiotics (aOR = 0.53, 95% CI: 0.29-0.98) compared to boys with disabilities. The associations also varied by impairment type, children with seeing, controlling behaviour or learning impairments are less likely to have reported antibiotic use. INTERPRETATION: Children with disabilities are at a higher risk of developing common illnesses but are not necessarily more or less likely to use antibiotics for these conditions compared to children without disabilities. However, gender, country and impairment type disparities persist. Targeted efforts are needed to address these health inequities and ensure equitable access to care. FUNDING: This research was partially supported by National Natural Science Foundation of China (grant number: 72374228, 72074234), Guangdong Basic and Applied Basic Research Foundation (grant number: 2023A1515010163), Guangzhou Basic and Applied Basic Research Program (grant number: 2025A04J5118), and Fundamental Scientific Research Funds for Central Universities, China (grant number: SYSU-25wkjc02)
Human animal contact, land use change and zoonotic disease risk: a protocol for systematic review.
Get PDFBACKGROUND: Zoonotic diseases pose a significant risk to human health globally. The interrelationship between humans, animals, and the environment plays a key role in the transmission of zoonotic infections. Human-animal contact (HAC) is particularly important in this relationship, where it serves as the pivotal interaction for pathogen spillover to occur from an animal reservoir to a human. In the context of disease emergence linked to land-use change, increased HAC as a result of land changes (e.g., deforestation, agricultural expansion, habitat degradation) is frequently cited as a key mechanism. We propose to conduct a systematic literature review to map and assess the quality of current evidence linking changes in HAC to zoonotic disease emergence as a result of land-use change. METHOD: We developed a search protocol to be conducted in eight (8) databases: Medline, Embase, Global Health, Web of Science, Scopus, AGRIS, Africa-Wide Info, and Global Index Medicus. The review will follow standard systematic review methods and will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The search will consist of building a search strategy, database search, and a snowballing search of references from retrieved relevant articles. The search strategy will be developed for Medline (through PubMed) and EMBASE databases. The search strategy will then be applied to all eight (8) databases. Retrieved articles will be exported to EndNote 20 where duplicates will be removed and exported to Rayyan®, to screen papers using their title and abstract. Screening will be conducted by two independent reviewers and data extraction will be performed using a data extraction form. Articles retrieved will be assessed using study quality appraisal tools (OHAT-Office for Health Assessment and Technology Risk of Bias Rating Tool for Human and Animal Studies, CCS-Case Control Studies, OCCSS-Observational Cohort and Cross-Sectional Studies, and CIS-Controlled interventional studies). Data will be analysed using descriptive statistics and a meta-analysis where data permits. DISCUSSION: The review will provide an important systematic literature aggregate of existing evidence on the role and evidence quality linking HAC to the emergence of zoonoses via land-use change. The outcome of the proposed review will produce a high-level evidence document that could inform intervention points and further research priorities. REGISTRATION: The review will be registered with PROSPERO
Novel insecticide resistance mutations associated with variable PBO synergy in Anopheles gambiae s.l. from the Democratic Republic of Congo.
Get PDFOver-reliance on pyrethroid insecticides in insecticide-treated nets (ITNs) has imposed significant selection pressure for the evolution of insecticide resistance among major malaria vector species. In the Democratic Republic of Congo (DRC), the country with the second highest malaria burden globally, pyrethroid resistance is pervasive, but there is a paucity of information regarding the molecular mechanisms driving resistance. A clear understanding of the specificity of resistance mechanisms to individual insecticides and the likelihood of selecting for cross-resistance mechanisms is crucial for the development of new vector control tools. Anopheles gambiae s.l. populations from eight study sites across the DRC were phenotyped for resistance to alpha-cypermethrin, deltamethrin and permethrin, with and without pre-exposure to the synergist piperonyl butoxide (PBO), followed by multiplex amplicon sequencing. Phenotypic pyrethroid resistance and loss of PBO synergy was confirmed in all sites across the DRC. In An. gambiae s.s. four non-synonymous SNPs which have been previously associated with insecticide resistance were detected: gste2-L119V, vgsc-L995F, vgsc-L995S and rdl-A296G, while three were novel: gste2-T154S, ace1-N246T and ace1-P265L. Nationwide geographical trends in insecticide resistance mutation distribution, prevalence and selection were evident. In the West, near fixation of vgsc-L995F and almost complete absence of vgsc-L995S was observed, alongside low-moderate frequencies of rdl-A296G and gste2-L119V. Further East, the converse was apparent. Gste2-L119V was significantly associated with resistance to deltamethrin following PBO-pre-exposure, warranting functional validation to determine its putative role in reduced PBO synergy. Furthermore, gste2-T154S was implicated in deltamethrin and permethrin resistance but susceptibility to alpha-cypermethrin after PBO pre-exposure. Study findings comprise the most comprehensive overview of the prevalence of genetic markers of Anopheles insecticide resistance across the DRC and provide an important baseline for improved malaria vector control and the design of proactive insecticide resistance management strategies. Given the significant scale up in PBO-ITNs, with more than 58% of all ITNs delivered to sub-Saharan Africa in 2023 containing PBO, there is an urgent need to identify novel molecular markers to monitor changes in PBO synergy, which may be predicative of loss of intervention operational efficacy