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"We carried her in a wheelbarrow to the clinic": process evaluation of the AMETHIST intervention combining microplanning with self-help groups to improve HIV prevention and treatment among female sex workers in Zimbabwe
No full textCoping with extreme heat in primary maternity care: An ethnography of frontline health workers in rural Zimbabwe
Get PDFChallenging gender norms through participatory action research: A cross-country study of women close-to-community healthcare providers in fragile settings
No full textBackgroundDespite their critical role in delivering health services in fragile settings, women close-to-community (CTC) health providers, often face marginalisation due to deep-rooted gender norms. This study explores how participatory action research (PAR) can support these women in addressing gendered power relations and enhancing their agency in two fragile contexts.MethodsThrough a PAR study with women CTC providers in Nepal and Lebanon, a community advocacy film was co-produced and disseminated in Nepal, and a grassroots “Working Women” support group was established in Lebanon. Thematic analysis was conducted to examine the PAR process and its outcomes using the community-based participatory research (CBPR) framework.FindingsWomen CTC providers in both countries shared experiences of being undervalued, limited agency, and gendered constraints. The PAR process enabled reflection on these challenges, build solidarity, and develop context-specific interventions. In Nepal, the film-making process enhanced their visibility, allowing them to challenge community perceptions and advocate for recognition. In Lebanon, the support group created peer networks of 200 refugee women and established childcare systems. Outcomes included increased confidence, community engagement, and policy dialogue. Barriers like legal insecurity, limited resources, and safeguarding risks limited transformative changes.ConclusionPAR can act as a powerful tool to challenge and address gender norms and enhance agency among marginalised women health workers in fragile contexts. However, without structural reforms, including legal recognition, fair remuneration, and institutional integration, such approaches limit change. This study contributes to feminist global health literature by showing both the potential and limits of PAR in promoting gender-responsive approaches within health systems and its potential transformative change
Adapting health systems to men’s realities: An intersectional exploration of men’s barriers to TB care in Nigeria’s peri-urban communities
Get PDFAlthough men bear the brunt of TB morbidity and mortality globally and in Nigeria, understanding of men’s barriers to TB care is limited, including in peri-urban settlements where the risk of TB exposure is high. This research explored how masculinities combine with layers of disadvantage among men in peri-urban communities to limit their access to TB services. We conducted 20 in-depth interviews among 12 men and 8 women with presumptive or confirmed TB, 3 focus group discussions among 24 men in their workplaces, and interviews with 12 key informants exploring experiences of TB symptoms and care seeking. Audio recordings were transcribed and analysed using a reflexive thematic approach. Findings suggest many men in peri-urban settlements could not afford to show TB symptoms due to strict masculine gender expectations and norms (Theme 1), while official TB information was not tailored to reach them (Theme 2). When developing symptoms presumptive of TB, men negotiated the least disruptive way to wellbeing (Theme 3). After TB diagnosis, female healthcare workers used strategies such as baiting and negotiating to engage and retain men in care (Theme 4). In conclusion, health systems need to address the compounded barriers facing different groups of men in high-burden peri-urban settlements in Nigeria highlighted by this study and leverage existing community resources to create scalable adaptations to care that make services more responsive to their realities
Household determinants of healthcare utilisation in three informal settlements in Freetown, Sierra Leone a cross-sectional survey
Get PDFOBJECTIVE: Healthcare utilisation (HU) is key to improving the health of residents in urban informal settlements. This study aimed to explore household-level factors influencing HU among informal settlement households in Freetown, Sierra Leone. DESIGN: Cross-sectional survey. SETTING: Three informal settlements (Cockle Bay, Dwarzark and Moyiba) in Freetown, Sierra Leone. PARTICIPANTS: Primary data from 4871 households were collected during the Health and Wellbeing survey conducted between April and May 2023, targeting households with adults aged 18 years and older. PRIMARY OUTCOME MEASURES: The primary outcomes were households HU both within and outside informal settlements. Household-level predisposing and enabling explanatory variables were derived from Andersen's Behavioural Model of HU. RESULTS: Disability in households increases HU within settlements (especially in Dwarzark, 13% and Moyiba, 10%) but is less likely outside. Households engaged in income-generating activities are more likely to seek healthcare within settlements, but 12% less likely outside in Cockle Bay and Dwarzark. Food insecurity decreases HU within Dwarzark (9%) and increases HU outside by 174% in Moyiba. Longer water fetching times and water shortages were associated with higher HU (between 6% and 16%) within settlements, especially in Cockle Bay and Dwarzark. Clean water sources (eg, piped dwelling, bowser, surface, bottled) were consistently associated with higher HU both within and outside settlements. Shared sanitation facilities (such as shared toilets) were positively associated with HU both within and outside settlements, particularly in Dwarzark and Moyiba. Households with income from fishing, informal salaried work and bike riding showed higher HU both within and outside settlements, especially in Dwarzark and Moyiba. CONCLUSIONS: We identified strong settlement-specific patterns of household-level factors that influence HU both within and outside Freetown's informal settlements. These findings provide a foundation for developing targeted policies such as strengthening local services, addressing affordability and accessibility barriers and supporting vulnerable occupation groups.</p
The impact of the termination of Lymphatic Filariasis mass drug administration on Soil-transmitted Helminth prevalence in school children in Malawi
Get PDFBACKGROUND: Soil-transmitted helminths (STH) have been passively targeted through the implementation of mass drug administration (MDA), with the drugs ivermectin and albendazole, against the parasitic disease, lymphatic filariasis (LF). In Malawi, LF MDA was administered to communities between 2008 and 2014. The aim of this analysis was to estimate the impact of LF MDA and its termination on STH prevalence in school aged children (SAC). METHODOLOGY: School survey data of STH prevalence in Malawi were obtained through the ESPEN website. The surveys spanned the periods before (1998-2004), during (2012-2014) and after LF MDA (2015-2019). Bayesian mixed-effects models were fitted to estimate the impact of LF MDA termination, and other STH risk factors, on the odds of infection, as well as generate predictions of nationwide STH prevalence during and after LF MDA. PRINCIPAL FINDINGS: SAC after the termination of LF MDA had 1.8 times greater odds of A. lumbricoides infection compared to SAC during the implementation of LF MDA (95% credible interval (CI): 1.03 - 3.35), despite ongoing STH preventive chemotherapy (PC) targeting SAC. Predictions indicate majority of districts increased in their probability of exceeding 2% A. lumbricoides prevalence in SAC after the termination of LF MDA, with Chitipa, Mulanje and Nsanje districts estimated to have > 80% probability of exceeding 2% prevalence. CONCLUSIONS/SIGNIFICANCE: An overall resurgence in A. lumbricoides infections after LF MDA was estimated in SAC, despite ongoing annual STH PC. This suggests STH PC could not sustain the prevalence levels achieved in SAC under community-wide LF MDA. The potential role of drug resistance in this resurgence calls for urgent investigation. Understanding how this resurgence corresponds to prevalence of moderate and heavy infections should be a priority for future research.</p
Low-dose rivaroxaban plus antiplatelet therapy for symptomatic intracranial atherosclerotic stenosis A prospective cohort study
No full textBackground: The antithrombotic strategies for symptomatic intracranial atherosclerotic stenosis (sICAS) remains challenging. Dual pathway inhibition (DPI) has demonstrated clinical benefit in coronary and peripheral artery disease. Aims: This study aimed to evaluate the efficacy of DPI with low-dose rivaroxaban plus antiplatelet therapy (APT) compared with APT alone on recurrent stroke with sICAS. Methods: This prospective cohort study included patients with sICAS identified from the Ischemic Cerebrovascular Disease Database of the First Affiliated Hospital of Zhengzhou University between January 2019 to August 2023. Low-dose rivaroxaban was prescribed off-label to patients in the DPI group. The outcomes were ischemic stroke, transient ischemic attack (TIA), acute coronary syndrome (ACS), all-cause death and cardio-cerebrovascular death within 1 year of discharge. Cox regression with inverse probability of treatment weighting (IPTW) was applied to compare outcomes between the DPI and APT groups. The win-ratio method was used to assess the major adverse cardiovascular events (MACE), prioritized in the order of all-cause death, recurrent ischemic stroke or TIA, and ACS. Results: Among the 1217 patients with sICAS, 131 (10.8%) received DPI therapy. The recurrence rate of ischemic stroke was lower in the DPI group compared to the APT group (8/131 [6.1%] vs 136/1086 [12.5%]). DPI significantly reduced the risk of ischemic stroke recurrence (HR = 0.46, 95% CI: 0.23–0.94, p = 0.034) and the incidence of MACE (HR = 0.53, 95% CI: 0.29–0.97, p = 0.041) during the 1-year follow-up, consistent with the IPTW-based cohort (HR = 0.35, 95% CI: 0.16–0.76, p = 0.008; HR = 0.43, 95% CI: 0.22–0.83, p = 0.012). The win-ratio analysis of MACE favored DPI therapy (win ratio = 2.34, 95% CI: 1.41–3.90, p = 0.001). Symptomatic intracranial hemorrhage, fatal bleeding, and hospitalization for gastrointestinal bleeding were infrequent in this cohort. Conclusions: DPI therapy may be associated with a lower risk of recurrent stroke compared with antiplatelet therapy alone in patients with sICAS. These findings warrant further investigation through large-scale randomized controlled trials.</p
Integrated community-based versus facility-based care for people with HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-COMM): an open-label, multicountry, cluster-randomised trial
No full textBackground In sub-Saharan Africa, the burden of diabetes and hypertension is high, alongside a high prevalence of HIV. Whether these conditions can be managed in an integrated way in the community is unknown. We aim to compare integrated community-based care with integrated facility-based care for people with HIV, diabetes, and hypertension in Tanzania and Uganda. Methods This open-label, multicountry, cluster-randomised trial was conducted in 14 primary care facilities across Tanzania and Uganda. Adults aged 18 years or older with a diagnosis of HIV, type 2 diabetes, or hypertension (or a combination); receiving regular care at the health facility for at least 6 months; considered clinically stable; living within the catchment area and planning to stay for at least 6 months; and willing to receive care in the community were enrolled. In each facility, patients were grouped into clusters of 8–14. Each group was randomly assigned (1:1) using an online data management system, to integrated facility care or community care. In facility care, participants shared the same registration and waiting areas, were managed by the same physicians and health-care workers, and used the same pharmacy and laboratory services. In community care, a nurse and a trained lay worker supported the groups at focal points in the community with groups meeting once per month. Follow-up was 12 months. The first coprimary endpoint was a composite of blood pressure or fasting glucose control (defined as blood pressure <140/90 mm Hg in participants with hypertension alone, fasting glucose <7·0 mmol/L in those with diabetes alone, or both indicators controlled in those with both conditions) and the second was plasma viral load suppression for participants with HIV alone (defined as <1000 copies per mL or undetectable viral load). Both endpoints were assessed in the intention-to-treat population. Generalised estimating equation models accounted for clustering. This trial was registered with the ISRCTN registry, ISRCTN15319595 (completed). Findings Between Jan 30 and Oct 6, 2023, 2940 patients with HIV, diabetes, or hypertension (or a combination of these conditions) who lived close enough together to be placed into a group were identified as having appointments to attend at the participating facilities. 765 (26·0%) patients were not screened and 2175 (74·0%) were screened for eligibility. 203 (9·3%) patients were ineligible, four (0·2%) did not consent, and 104 (4·8%) could not be grouped into viable clusters. 1864 (63·4%) patients were assigned into 124 groups, and groups were randomised (62 to community care and 62 to facility care). There were more females than males (1302 [76·6%] of 1700 vs 398 [23·4%]). Among those with diabetes or hypertension (or both), 38 (6·3%) of 602 in the community care group versus 43 (7·1%) of 609 in the facility care group were excluded, with nine (3·7%) of 242 versus ten (4·0%) of 247 excluded among participants with HIV. The composite of blood pressure or fasting glucose control did not significantly differ between the two groups in participants with hypertension or diabetes (or both; 317 [55·2%] of 574 in the community care group vs 304 [53·2%] of 571 in the facility care group; adjusted risk difference 1·80 [95% CI –4·52 to 8·12]; p=0·58), whereas most participants with HIV alone reached viral suppression (227 [99·1%] of 229 vs 229 (98·7%) of 232; adjusted risk difference 0·44 [–1·12 to 1·99]; pnon-inferiority<0·0001). There were seven deaths in each study group. Interpretation In sub-Saharan Africa, integrated community care could reach a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. Funding National Institute for Health and Care Research.</p
An Exploration of the Use of the Postload-Fasting Gap as a Tool to Predict the Risk of Developing Diabetes
No full textReflections on the first state of the map conference in Malawi
No full textState of the Map (SotM) conferences are important events that enable OpenStreetMap (OSM) contributors and users to present and discuss their work. However, when international SotM conferences are held in the Global North countries, participation by African geospatial scientists is not guaranteed due to various barriers, including travel costs and visa restrictions. Conversely, locally held SotM conferences within Africa mitigate these barriers. Such conferences have been held in different African countries. Malawi hosted its first SotM conference in 2024 at the Malawi University of Business and Applied Sciences (MUBAS), bringing together its local geospatial science community to discuss the landscape of the field in the country. In this paper, we reflect on the conference’s proceedings, positive developments, opportunities, and challenges facing Malawi’s geoscience community. The paper contributes to the broader understanding of how African countries are leveraging geoscience and identifies areas for further growth and collaboration.</p