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One-year follow-up of survival and health-related quality of life in patients with medical conditions admitted acutely to hospital in Malawi and Tanzania
Get PDFMultimorbidity, defined as the coexistence of two or more long-term conditions, is a major public health issue. In southern and eastern Africa, limited access to primary care frequently results in delayed diagnosis and chronic disease decompensation with the need for acute hospital admission [1]. This report details 1-year survival and health-related quality of life (HRQoL) data in patients admitted acutely to hospitals in Malawi and Tanzania and follows on from our study that detailed the high prevalence of hypertension (44%); HIV (31%); and diabetes mellitus (27%) in patients admitted to hospital [2].We conducted this study in line with our published protocol [3] and with statistical methodology replicated from our multicentre cohort study [2]. Patients were categorised based on the number (none, one and two or more) of long-term conditions. The 1-year follow-up for all patients was completed in December 2024. We evaluated 1-year survival and HRQoL (where a score of 1 represents perfect health and a score of 0 represents death) in survivors using EQ5D-5l. We have provided an open access link to our database hosted at: https://publications.mlw.mw. The 1-year survival analysis for this study was performed in R (4.4.1; R Studio for Statistical Computing, Vienna, Austria) using the survival, survminer and ggplot2 packages and HRQoL analysis was conducted in Stata MP 18.0 (StataCorp, College Station, TX, USA)
Spatiotemporal changes in prevalence of Sodalis glossinidius, Spiroplasma spp. and trypanosome species in wild Glossina tachinoides from Sora-Mboum animal African trypanosomiasis focus in northern Cameroon
Get PDFSterile Insect Technique (SIT) has proven effective to reduce tsetse population density in large infected areas where animal African trypanosomosis (AAT) and human African trypanosomiasis (HAT) elimination was difficult to achieve. However, the decrease in mass production of insectary-reared tsetse and the limited but incomplete knowledge on symbiont–trypanosome interaction over time, impede large-scale use of SIT. We investigated the spatiotemporal changes in symbiont prevalence and symbiont–trypanosome interactions in wild tsetse of Sora-Mboum AAT focus in northern Cameroon, collected in 2019 and 2020, to provide insights into the mass production of refractory tsetse. Spiroplasma spp., Sodalis glossinidius and trypanosomes were screened with PCR. G. tachinoides was the most abundant Glossina species found in Sora-Mboum focus. Symbiont prevalences in G. tachinoides were higher in 2019 compared to 2020, from 67.6% to 53.5% for Spiroplasma spp. and from 28.8% to 8.1% for S. glossinidius. These symbionts were also found at higher prevalence in flies from Mouhoun HAT focus in Burkina Faso. Four trypanosome taxa (Trypanosoma congolense forest type, T. congolense savannah type, T. brucei s.l., and T. vivax) were found in Sora-Mboum focus and Mouhoun focus, though at lower prevalence in Mouhoun. The presence of Spiroplasma spp. in adult tsetse was negatively associated with that of trypanosomes. Our study highlights the potential of Spiroplasma spp. as a good paratransgenesis candidate to enhance SIT application. This symbiont is naturally found in high proportions of tsetse and could prevent factory flies from acquiring and transmitting trypanosomes during their lifespan when released for population density control.</p
Inequities in diabetes prevention and control in fragile, conflict-affected and vulnerable settings: a mixed-methods study from the WHO Eastern Mediterranean Region
Get PDFObjectives To evaluate progress in the implementation of the WHO Eastern Mediterranean Regional Office (EMRO) Regional Framework for Action on Diabetes Prevention and Control, identify implementation barriers and facilitators, and provide recommendations for accelerating progress, with a particular focus on fragile, conflict-affected and vulnerable settings (FCVs). Design: Mixed-methods study combining secondary analysis of quantitative data from WHO datasets with qualitative synthesis of inputs from WHO consultative meetings with EMR member states. Setting 22 countries of the WHO EMR, including 10 classified as FCV and 12 as non-FCV according to World Bank and WHO classifications. Participants: Quantitative data were drawn from the 2021 WHO Country Capacity Survey targeting all EMR countries and other WHO sources. Qualitative data were based on insights from 16 country representatives during a regional WHO EMRO webinar, including non-communicable diseases programme managers, policy leads and WHO country office staff. Results: Among the 22 countries analysed, only 10% (1/10) of FCVs had a national diabetes action plan compared with 67% (8/12) of non-FCVs. A sugar-sweetened beverage tax was implemented in 75% (9/12) of non-FCVs but in just 10% (1/10) of FCVs. For diabetes management, detailed national guidelines were available in 30% (3/10) of FCVs compared with 83% (10/12) of non-FCVs; insulin was available in primary care in 50% (5/10) of FCVs compared with 83% (10/12) of non-FCVs. Surveillance systems were less robust in FCVs: while 70% (7/10) collected data on diabetes status, only 30% (3/10) had a national diabetes registry, compared with 83% (10/12) of non-FCVs. Conclusions Addressing diabetes in the EMR requires strategic collaboration and tailored approaches for FCVs, including strengthened governance, preparedness, integrated care, medication access and surveillance. Prioritising primary healthcare and embedding diabetes prevention and control in universal health coverage and emergency response frameworks is critical to reducing inequities and improving health outcomes in fragile contexts.</p
Feasibility and acceptability of peer-led assessment of HIV risk among female sex workers in Zimbabwe
Get PDFIntroduction Female sex workers (FSWs) in sub-Saharan Africa are at higher risk of HIV acquisition and transmission. However, FSWs’ life experiences are heterogeneous and are important to characterise in order to tailor responses to individual needs. Peer microplanners are FSWs trained to engage other FSWs and offer each individual a tailored package of support. We sought to assess the feasibility, acceptability and fidelity of implementing peer-led assessments of risk. Methods: Between December 2020 and August 2021, we conducted a qualitative process evaluation study of the Adapted Microplanning: Eliminating Transmissible HIV In Sex Transactions (AMETHIST) trial’s peer-led assessment of FSWs’ risk of HIV acquisition and transmission. We enrolled 60 participants (30 FSW and 30 peer microplanners) for semistructured in-depth interviews at 3 of 11 intervention sites. Interview guides and analysis were underpinned by three elements adapted from the UK Medical Research Council’s process evaluation framework: (1) feasibility, (2) acceptability and (3) fidelity. Using a framework analytic approach, data were familiarised, coded with NVivo V.12 software, charted, interpreted and then deductively mapped to these three elements. Results Peer microplanners used the risk scores to tailor their support to FSW with good fidelity. Some experienced difficulties completing assessments during the initial period of implementation. However, it was feasible for peer microplanners to establish strong relationships, and they used observational and conversational skills to elicit sensitive information from FSW to support their assessment. The assessments and tailored support offered by peer microplanners were acceptable to FSWs, although some did not appear to know they were being assessed. Conclusions Our findings show that peer microplanners feasibly and acceptably assessed FSW for certain risk factors through a scoring tool and focused their support accordingly. This approach could be integrated into other peer-led interventions to improve prioritisation of HIV programmes.</p
Economic evaluations of community health worker programs focussed on neglected tropical diseases in low- and middle-income countries (2015–2024): A scoping literature review
Get PDFNeglected tropical diseases (NTDs) are a diverse group of more than twenty diseases caused by parasitic, bacterial, and viral infections, affecting more than one billion individuals worldwide. Economic evidence can help guide the investment in Community Health Workers (CHWs) who can help expand access to preventive and curative NTD services in low- and middle-income countries (LMICs). A scoping review was conducted across ten databases and grey literature, covering studies published between August 2015 and July 2024. Search terms related to “Community Health Workers” and “Economic Evaluations” were used. Studies were screened via Covidence software based on inclusion and exclusion criteria. Data on study methodology, costs, and outcomes were extracted, tabulated in Microsoft Excel, and analysed. Of the 29 included scenarios (n = 10 studies), 7 were about community mass drug administration and 22 focused on other topics - such as disease-specific prevention and treatment (e.g., dengue). Across scenarios, the most commonly reported outcomes were cost per service delivered (ranging from 5.33) and cost per capita (ranging from 21.09). Five scenarios reported on cost-effectiveness, with varied results (40–50% of scenarios were reported as cost effective). One study found that interventions were more likely to be cost-effective when they leveraged integrated care as opposed to vertical approaches. The evidence base for economic evaluations regarding CHW involvement in NTD programs is highly limited. From the 10 studies identified there was no clear conclusion with regards to cost-effectiveness or affordability of CHWs in NTD programs in LMICs. To better understand the critical role CHWs can play in both prevention- and treatment-focused NTD programs, further evidence of the cost-effectiveness and affordability of such interventions is needed.</p
Costs and cost-effectiveness of community health worker programmes focussed on non-communicable diseases in low- and middle-income countries (2015–2024): a scoping literature review
Get PDFBackground Non-communicable diseases (NCDs) are the leading cause of death and morbidity worldwide, responsible for 7 out of 10 deaths, 86% occurring in low- and middle-income countries (LMICs). As the NCD burden on health systems increases, community health workers (CHWs) have become increasingly involved in NCD care provision and management. This study updates a 2015 review to synthesise and critically analyse the recent evidence base on the cost-effectiveness and affordability of CHW programmes addressing NCDs in LMICs. Methods A scoping review searched 10 databases and the grey literature for original studies published between August 2015 and July 2024. Recognised search terms related to ‘Community Health Workers’ and ‘Economic Evaluation(s)’ in LMICs were used. Covidence software was employed to screen studies based on inclusion and exclusion criteria. Data on study methodology, costs and cost-related outcomes were then extracted, tabulated in a data-extraction form and analysed using Microsoft Excel. Results We identified 20 studies with 52 different scenarios covering five areas: cardiovascular disease including hypertension (n=22 scenarios); human papillomavirus and cervical cancer screening (n=13); diabetes (n=12); mental health (n=4); and behavioural risk factors (n=1). Of the 44 scenarios assessing cost-effectiveness, 35 scenarios suggest that CHW programmes are cost-effective. 11 studies compared CHW programmes against an alternative (usual care) to generate an incremental cost-effectiveness ratio, evaluated against the country’s gross domestic product per capita. Methodological heterogeneity across studies and inconsistencies or data gaps in reporting (most importantly the lack of CHW salary information) limits the usefulness of the data. Few studies assessed affordability, despite being equally relevant to decision-making. Conclusions More studies including economic evaluations (particularly for NCDs not found in our review), along with more robust and consistent reporting are needed.</p
Evaluation of large language models within GenAI in qualitative research
Get PDFLarge language models (LLMs) perform tasks such as summarizing information and analyzing sentiment to generate meaningful and natural responses. The application of GenAI incorporating LLMs raises potential utilities for conducting qualitative research. Using a qualitative study that assessed the impact of the COVID-19 pandemic on the sexual and reproductive health of adolescent girls and young women (AGYW) in rural western Kenya: our objective was to compare thematic analyses conducted by GenAI using LLM to qualitative analysis conducted by humans, with regards to major themes identified, selection of supportive quotes, and quality of quotes; and secondarily to explore quantitative and qualitative sentiment analysis conducted by the GenAI. We interfaced with GPT-4o through google colaboratory. After inputting the transcripts and pre-processing, we constructed a standardized task prompt. Two investigators independently reviewed the GenAI product using a rubric based on qualitative research standards. When compared to human-derived themes, we did not find disagreement with the sub-themes raised by GenAI, but did not consider some to rise to level of a theme. Performance was low and variable with regards to selection of quotes that were consistent with and strongly supportive of thematic and sentiment analysis. Hallucinations ranged from a single word or phrase change to truncation or combinations of text that led to modified meaning. GenAI identified numerous and relevant biases, primarily related to the underlying training data and its lack of cultural understanding. Few prior studies have directly compared LLM-driven thematic coding with human coding in qualitative analysis, and our study - grounded in qualitative study rigor - allowed for a thorough evaluation. GenAI implemented in GPT-4o was unable to provide a thematic analysis that is indistinguishable from a human analysis. We recommend that it can currently be used as an aid in identifying themes, keywords, and basic narrative, and potentially as a check for human error or bias. However, until it can eliminate hallucinations, provide better contextual understanding of quotes and undertake a deeper scrutiny of data, it is not reliable or sophisticated enough to undertake a rigorous thematic analysis equal in quality to experienced qualitative researchers.</p
Association between triglyceride glucose index trajectory and risk of hypertension in rural residents: a prospective cohort study.
Get PDFWith changes in lifestyle, the incidence of hypertension in rural areas is on the rise. However, previous studies have not investigated the association between TyG index trajectories and the risk of hypertension in rural populations, particularly in multi-center natural population cohorts. Our study aimed to examine the association between TyG index trajectories and hypertension risk in rural populations. The study included 9343 rural residents from the Xinjiang Multi-Ethnic Cohort. The TyG index was calculated as Ln [fasting triglycerides (mg/dL) × fasting blood glucose (mg/dL)/2], and a group-based trajectory model was adopted to identify the TyG index trajectories. Cox regression model was applied to assess the associations between the TyG index trajectories and incident hypertension. At a median follow-up period of 35 months, 1687 participants experienced hypertension. Three distinct TyG index trajectories were identified: low stable (n = 4239, 45.37%), moderate stable (n = 4561, 48.82%), and high stable (n = 543, 5.81%). Compared with the low stable group, the hazard ratio (95% CI) of hypertension was 1.41 (95% CI, 1.26–1.58) and 1.82 (95% CI, 1.50–2.21) for the moderate stable and high stable group, respectively. In subgroup analyses, the associations between a high TyG longitudinal trajectory and hypertension seemed to be stronger among participants with a high healthy lifestyle score (HLS) compared to those with a low HLS. In rural residents, elevated trajectories of the TyG index were associated with an increased risk of hypertension. This finding underscores the importance of paying attention to TyG levels, even among people with a healthy lifestyle.</p
Adolescents’ and young people’s perspectives on school-based sexuality education in low- and middle-income countries: a scoping review
Get PDFBackground: Sexuality education plays a crucial role in supporting adolescents’ and young people’s (AYP’s) health, well-being and gender equality and is increasingly recognised in global policies. In low- and middle-income countries (LMICs), research has raised concerns about the availability and sub-optimal implementation of sexuality education, yet few studies address these concerns considering AYP’s views. This limits insights for developing relevant and effective sexuality education programmes that can support AYP in their journey to adulthood. This review explores AYP’s perspectives on school-based sexuality education in LMICs. Methods: A scoping review was conducted across five academic databases and key stakeholder websites, identifying studies published between 2013 and 2024 in English. Following screening and systematic data extraction, 66 studies were included. Findings on characteristics of studies, AYP’s perspectives on needs, experiences and preferences related to sexuality education content and delivery, as well as socio-ecological influences were synthesized using a narrative approach. Results: The review found that while AYP across LMICs generally expressed high needs for school-based sexuality education, these often remain unmet. AYP consistently reported dissatisfaction with sexuality education as they wish for education that extends beyond cognitive learning about biology and negative implications of sexuality, to include more comprehensively its emotional, physical, and social aspects. Participants’ age, gender and urban or rural residence influence delivery preferences. Gaps in participatory, inclusive, and empowering education approaches reinforce gender norms, exclude diverse identities, and fail to address the specific needs of adolescent girls, young women, and marginalized youth. The review underscored the scarcity of research on AYP’s perspectives regarding age- and context-appropriateness, inclusivity of content, and regarding delivery formats. Studies from certain geographic regions and focusing on younger adolescents, youth with diverse social identity markers and those living in rural areas were especially underrepresented. Conclusions: For the first time, this article synthesizes direct AYP perspectives on school-based sexuality education, while also pointing to remaining knowledge gaps when capturing views of AYP in LMICs. Concerted efforts are needed to diversify research, calling for more rigorous, inclusive and youth-participatory research efforts to inform sexuality education policies and programmes that are responsive to AYP’s needs.</p
Sand fly saliva reprograms skin fibroblasts to enhance arbovirus infection
Get PDFArbovirus transmission by sand flies is a growing public health concern, yet the early skin events shaping infection outcomes remain undefined. We establish a mouse model of Toscana virus (TOSV) infection that incorporates sand fly salivary factors to mimic natural transmission. Saliva from two distinct sand fly genera significantly enhanced infection and promoted neurological signs and joint inflammation, recapitulating key features of human TOSV disease. In the skin, dermal macrophages and fibroblasts were the main infected cell types, but only fibroblasts generated infectious virus. Saliva reprogrammed fibroblasts into a wound-healing state permissive to viral replication, driving local viral amplification, systemic spread, and thereby clinical disease. These findings identify skin fibroblasts as central determinants of host susceptibility and reveal that sand fly saliva actively remodels the skin to exacerbate viral pathogenesis. This work redefines the skin's role in sand fly-transmitted infection and highlights new targets for therapeutic and vaccine development.</p