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Assessing and measuring community health system resilience – an updated scoping review of approaches
No full textBackground: A previous 2020 review on resilience in community health systems identified a small body of conceptual and empirical evidence but pointed to important limitations concerning the operationalisation of resilience assessment and measurement for these systems, and lack of consideration to measures of equity. In light of substantial research interest in health system resilience over recent years, the objective of this study was to revisit the literature for new insights concerning community health system resilience assessment and measurement in general, and in relation to climate-related hazards in particular.
Methods: Scoping review of published, peer-reviewed literature drawing on studies identified via keyword-structured searches of PubMed and Google Scholar covering the period 2019–2024. Following screening in duplicate, we included studies from all income settings that provided definition(s) of community health system resilience. Data were extracted in duplicate and narratively synthesised drawing on a conceptual framework from Disaster Risk Management to identify putative approaches to resilience assessment and/or measurement – including candidate metrics.
Results: 12 studies were included, of which 5 explicitly focused on natural and/or climatic hazards. Definitions of community resilience were diverse, spanning process and attribute-based conceptualisations among others. Included studies yielded a total of 73 resilience indicators in addition to those 20 identified through the original scoping review. A large majority of indicators (n = 51) spanning both reviews covered background factors relating to community resilience such as markers of community social capital and local health system capacity. Other indicators considered, in order of frequency, community preparedness, event response and post-event recovery – although this last category included by far the fewest indicators. Equity considerations were often implicit rather than explicit within these – commonly focusing on equity in health service access at community level, and degree of participation in governance processes.
Conclusions: There is a continuing need to develop – and particularly to empirically test – indicators of community health system resilience to better understand utility for policy and practice. While some promising areas are identifiable for development of indicators relating to equity, these remain early stage and there is a need to better conceptualise links between these and established health system outcome measures
Burden of 375 diseases and injuries, risk-attributable burden of 88 risk factors, and healthy life expectancy in 204 countries and territories, including 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023.
Get PDFBACKGROUND: For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. METHODS: The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. FINDINGS: Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). INTERPRETATION: Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. FUNDING: Gates Foundation and Bloomberg Philanthropies
Identification of age-group reservoirs for persistent vaccine-type pneumococcal carriage in rural Gambia.
Get PDFBACKGROUND: Although pneumococcal conjugate vaccines (PCVs) have been used widely in many low and middle-income countries, residual vaccine-type (VT) carriage persists in these settings. We examined the role of specific age groups in transmission and as reservoirs of VT pneumococcal infection in The Gambia. METHODS: Between January and November 2022, we conducted a nested, population-based, cross-sectional social contact and pneumococcal carriage survey in the Central and Upper River Regions of The Gambia. Participants completed questionnaires on carriage risk factors and social contacts. Nasopharyngeal swabs were collected from selected household members across all age groups. Streptococcus pneumoniae was isolated and serotyped using standard methods. We analysed matched contact and pneumococcal carriage data and estimated the proportions of VT carriage attributable to contact with different age groups. RESULTS: A total of 1638 participants were enrolled, of which 67% were children aged 0-14 years. Pneumococcal carriage prevalence was 59.6% (95% CI: 53.9 - 65.1%) in 0-4 year-olds and 36.1% (95% CI: 29.6 - 43.1%) in 5-14 year-olds. PCV13 VT carriage prevalence was not significantly different (10-13%) between these age groups. Among pneumococcal carriers, the proportion of VT carriage was significantly higher in 5- 14-year-olds [35.7% (95% CI: 25.9 - 46.9%)] compared to 0-4-year-olds [17.8% (95% CI: 13.9 - 22.6%, p-value < 0.001)]. The odds of VT carriage were 10% higher [AOR = 1.10, 95% CI: 1.01-1.20] for each additional physical contact with a child aged 10-14 years. We estimated that children aged 5-14 years contributed about 63% to the overall risk of exposure to VT pneumococci in the population. CONCLUSIONS: In rural Gambia, school-aged children, particularly those aged 5-9 years, are the main drivers of VT pneumococcal transmission. In the context of high coverage of routine PCV vaccination in infants, this suggests waning PCV protection by school entry. A booster dose for children at school entry may support better control of VT circulation in the population
Safety and coverage of Pneumosil pneumococcal polysaccharide conjugate vaccine (10-valent PCV) in a camp for internally displaced persons in Somaliland.
Get PDFINTRODUCTION: Pneumococcal conjugate vaccines (PCVs) have substantially reduced pneumococcal morbidity and mortality worldwide, but their use in crisis settings has been limited. Routine immunisation is typically not feasible during a crisis; however,mass-vaccination campaigns with wider age-targeting could effectively protect crisis-affected populations against pneumococcal disease. The 10-valent Pneumosil PCV (PCV10-SII) is currently licensed for use in children aged 6 weeks to 2 years. We conducted a nested phase II evaluation of PCV10-SII safety within a phase IV intervention study measuring the impact of a PCV campaign on pneumococcal carriage. METHODS: We vaccinated children aged 6 weeks to 59 months in a camp for internally displaced persons (IDPs) in Somaliland. Children aged <1 year received two doses of PCV10-SII; children aged 1 to 4 years received a single dose. We administered an adverse event following immunisation (AEFI) survey on the day of vaccination (to document the occurrence of background AEFI-associated symptoms over the preceding week), and seven days later. We identified severe adverse events (SAEs) using several approaches including daily follow-up with the local health facility. We assessed nutritional status using mid-upper arm circumference. We also calculated campaign coverage, and estimated population coverage. RESULTS: Of the 364 vaccinated children included in the analysis, two (<1 %) were malnourished. AEFIs occurred in 34 (11 %) children after their first dose, and in 20 (49 %) infants after their second dose. The most common AEFIs were fever (n = 36, 10 %), decreased appetite (n = 15, 4 %), and a rash at the injection site (n = 13, 4 %). We detected three SAEs. On investigation, none of the SAEs were deemed to be causally associated with vaccination. Campaign coverage was high (93.4 %), while population coverage reduced to 57.1 % over a two-year period. CONCLUSIONS: Vaccination of children PCV10-SII resulted in a small number of AEFIs. Campaign coverage suggests high acceptability of a newly introduced vaccine amongst IDPs in Somaliland. TRIAL REGISTRATION: NCT04945681
A system to rapidly develop a bunyavirus pseudotyped virus neutralisation assay for pandemic preparedness
Get PDFSeveral Bunyavirales families have been listed as being of high pandemic or epidemic risk by the WHO R&D Blueprint. To support pandemic preparedness and the 100 Days Mission, along with rapid provision of vaccines and therapeutics, the development of tools to assess the immune response is required. Pseudotyped viruses (PV) have been shown to be a suitable alternative to authentic infectious virus to measure virus-neutralising activity, a key component of the immune response. They alleviate the need to acquire and amplify viral isolates and do not require high containment facilities. Generating PV of some families within the class Bunyaviricetes is challenging because of a lack of co-localisation of viral glycoproteins at the vector budding site. Here, we describe a versatile plug-and-play system focusing on two prototype viruses for the family Phenuiviridae, Rift Valley fever virus (RVFV) and for the family Nairoviridae, Crimean-Congo haemorrhagic fever virus (CCHFV). Shared key parameters for the production of RVFV and CCHFV PV were identified and optimised on a single-cycle, recombinant vesicular stomatitis virus vector (VSV), which allowed for the successful and rapid production of PV for Dabie bandavirus and Oropouche virus. We propose that this system could be successfully applied to other high-consequence bunyaviruses, including those yet unknown, which may emerge in the future. Assessment of the novel bunyavirus PV generated here demonstrated a good correlation with traditional neutralisation assays with infectious virus. This system offers an adaptable and widely accessible platform that can be rapidly developed in response to emerging viral threats
Growth and body composition of adolescents and young adults with perinatal HIV infection: a systematic review and meta-analysis.
Get PDFINTRODUCTION: Approximately 1.3 million pregnancies are exposed to HIV perinatally each year, with transmission rates ranging from 4 to 21%, despite 85% antiretroviral therapy (ART) coverage among pregnant women. While ART has significantly reduced mother-to-child transmission, recent studies indicate an increased risk of chronic conditions among perinatally HIV-infected youth. There is a critical need for further research on the growth and health of these populations to inform effective health interventions. Therefore, the aim of this study is to critically evaluate observational research assessing the growth and body composition of perinatally HIV-infected adolescents and young adults. METHODS: We conducted a systematic review using the MEDLINE (by PubMed), Embase, Central (by Cochrane Library), Latin American and Caribbean Health Science Information (LILACS) and Web of Science databases. The initial search was conducted on November 24, 2022, and updated on June 3, 2024. We included cohort studies that evaluated perinatally HIV-infected adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). A meta-analysis was performed to estimate the prevalence of stunting (HAZ < -2) and underweight (BAZ < -2). Additionally, we conducted meta-analyses for the mean values of HAZ and BAZ in the population after the follow-up period, as well as for the mean change in HAZ and BAZ post-follow-up. RESULTS: Our search strategy retrieved 11,017 documents. After excluding duplicates, we analyzed 9,273 titles and abstracts. A full-text review of the remaining 87 records was conducted. Following the updated search, we identified 6 publications from 4 studies, resulting in a total of 14 studies and 16 publications. Nine studies focused exclusively on adolescents, while three evaluated both children and adolescents, and three included both adolescents and young adults. We estimated a prevalence of stunting at 26% (95% CI: 0.23-0.29) and underweight at 14% (95% CI: 0.12-0.17). In this population, the mean HAZ was -1.58 (95% CI: -1.90; -1.27), and the mean BAZ was -0.34 (95% CI: -0.61; -0.06). Additionally, we identified an increase of 0.55 (95% CI: 0.07; 1.03) in mean HAZ and 0.12 (95% CI: -0.56; 0.79) in mean BAZ after the follow-up period. CONCLUSIONS: Our study highlights significant growth and body composition challenges among perinatally HIV-infected adolescents and young adults, with concerning rates of stunting and underweight. Although there was a modest increase in height-for-age, persistent challenges in achieving optimal growth remain. The slight improvement in BMI is insufficient to fully address underweight concerns. The limited number of studies and their inherent limitations restrict the ability to draw consistent conclusions regarding the effects and magnitude of exposure on anthropometric outcomes. Further research is needed to better elucidate these relationships. TRIAL REGISTRATION: CRD42022372837
Depression and academic performance among youths in armed conflict areas in North Wollo, Ethiopia: Structural equation modeling.
Get PDFBACKGROUND: Adolescents living in war-affected areas are more likely to suffer from depression than adolescents living outside war-affected areas. However, there is limited evidence from Northern Ethiopia that was affected by armed conflicts. This study was conducted to assess the magnitude of depression and to identify inter-related factors with depression and academic performance in armed conflict-affected areas of North Wollo Zone, Ethiopia. METHODS: A school-based cross-sectional study was conducted among high school students in North Wollo Zone, Ethiopia. A multistage sampling method was used, and the study participants were selected using simple random sampling. The Structural Equation Model was used to verify the hypothesized relationship between various internal and external or mediating factors. The effect size was provided using standardized beta coefficients, 95% CI, and statistical significance defined as a p-value <.05. RESULTS: Out of 3,400 study participants, 48.1% (95% CI [46.5%, 49.8%]) endorsed depressive symptoms. Being female (β = .05, 95% CI [0.011, 0.087]), far from family because of education (β = .10, 95% CI [0.060, 0.134]), anxiety (β = .95, 95% CI [0.893, 1.011]), and alcohol use (β = .14, 95% CI [0.108, 0.180]) had a significant and positive association with a total direct effect on depression. Conversely, academic performance (β = -.04, 95% CI [-0.061, -0.011]) had a significant and negative association with a total direct effect on depression. CONCLUSION: This study found a much higher magnitude of depression among students in conflict-affected areas compared to non-affected areas. High school students, particularly girls in conflict-affected areas, need social support and special protection. Additional efforts are needed to ensure safety and security in high schools and establish student support systems such as student counseling and guidance services
Modeling Intraday Aedes-human exposure dynamics enhances dengue risk prediction.
Get PDFCities are the hot spots for global dengue transmission. The increasing availability of human movement data obtained from mobile devices presents a substantial opportunity to address this prevailing public health challenge. Leveraging mobile phone data to guide vector control can be relevant for numerous mosquito-borne diseases, where the influence of human commuting patterns impacts not only the dissemination of pathogens but also the daytime exposure to vectors. This study utilizes hourly mobile phone records of approximately 3 million urban residents and daily dengue case counts at the address level, spanning 8 years (2015-2022), to evaluate the importance of modeling human-mosquito interactions at an hourly resolution in elucidating sub-neighborhood dengue occurrence in the municipality of Rio de Janeiro. The findings of this urban study demonstrate that integrating knowledge of Aedes biting behavior with human movement patterns can significantly improve inferences on urban dengue occurrence. The inclusion of spatial eigenvectors and vulnerability indicators such as healthcare access, urban centrality measures, and estimates for immunity as predictors, allowed a further fine-tuning of the spatial model. The proposed concept enabled the explanation of 77% of the deviance in sub-neighborhood DENV infections. The transfer of these results to optimize vector control in urban settings bears significant epidemiological implications, presumably leading to lower infection rates of Aedes-borne diseases in the future. It highlights how increasingly collected human movement patterns can be utilized to locate zones of potential DENV transmission, identified not only by mosquito abundance but also connectivity to high incidence areas considering Aedes peak biting hours. These findings hold particular significance given the ongoing projection of global dengue incidence and urban sprawl
Co-Designing Tiyanjane, a Participatory Intervention to Promote Parental Involvement in the Education of Children with Disabilities in Malawi
Get PDFThis paper describes the co-design of a participatory group intervention developed to promote and enhance parental involvement in supporting the education of children with disabilities in Malawi. The intervention was developed through participatory co-design workshops and consensus meetings involving 23 stakeholders, including parents, teachers, and community leaders. The Behaviour Change Wheel framework and the Delphi technique guided the intervention development process, ensuring theoretical robustness and contextual relevance. The proposed intervention, Tiyanjane (‘Let Us Unite’), includes facilitator and participant training and practical face-to-face sessions over 12 weeks. The intervention targets four key areas: developing family action plans, holding regular meetings, providing ongoing support at home and school, and facilitating training and information exchange. This participatory approach, involving a wide range of local stakeholders, offers valuable insights into the process and outcomes of co-developing culturally relevant and theoretically grounded interventions to address the needs of families with children with disabilities in low-resource settings. Future research should include an evaluation of the feasibility and acceptability of the intervention and examine its applicability in diverse sociocultural settings within LMICs (low- and middle-income countries)
Comparison of an Open versus List-Based Dietary Recall Method to Assess Unhealthy Feeding Practices among Infants and Young Children.
Get PDFBACKGROUND: Collecting accurate dietary data is critical for assessing infant and young child feeding practices, identifying populations at risk, and using evidence to inform policy. In 2021, World Health Organization/United Nations Children's Fund released new indicators of unhealthy food and beverage consumption and recommended that survey administrators use either an open or list-based method. OBJECTIVES: This study compared infants' and young children' unhealthy food consumption estimated using an open 24-h recall (24HR) compared with list-based 24HR among young children living in peri-urban Cambodia and explored the effect of social desirability bias on respondents' responses. METHODS: We conducted a secondary analysis of unhealthy food consumption estimated in a longitudinal cohort study implemented from June 2021 through January 2022 in the rural/peri-urban district of Khsach Kandal, Kandal Province, Cambodia (567 children aged 10-13.9 mo at baseline). Each month, for 5 mo, data were collected via an open 24HR. At the 6th month, half of the children were randomly assigned to also receive a list-based 24HR to collect data on unhealthy food consumption. RESULTS: The prevalence of sweet beverage and unhealthy food consumption and zero fruit and vegetable consumption among young children was high. We observed that the percentage of children consuming sweet foods was significantly higher when estimated using the list-based compared with an open 24HR method (61.6% compared with 43.8%; P = 0.012). An association between social desirability bias and reported consumption of salty/fried foods was also observed across both groups; however, this relationship was more pronounced among caregivers who received the list-based 24HR than the open 24HR (P = 0.004). CONCLUSIONS: Researchers must carefully consider the method used for 24HR because this may have implications for respondents' recall and memory. As more evidence is collected on the rising consumption of unhealthy food and beverages among young children, researchers should take into consideration the effects of caregiver's susceptibility to social desirability bias when analyzing these consumption patterns