Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Effectiveness of Linkage to Care and Prevention Interventions Following HIV Self-Testing: A Global Systematic Review and Meta-analysis

Over 38.4 million people were living with HIV globally in 2021. The HIV continuum includes HIV testing, diagnosis, linkage to combined antiretroviral therapy (cART), and retention in care. An important innovation in the HIV care continuum is HIV self-testing. There is a paucity of evidence regarding the effectiveness of interventions aimed at linking self-testers to care and prevention, including pre-exposure prophylaxis (PrEP). To bridge this gap, we carried out a global systematic review and meta-analysis to ascertain the effectiveness of interventions post-HIV self-testing regarding: (1) linkage to care or ART, (2) linkage to PrEP, and (3) the impact of HIV self-test (HIVST) interventions on sexual behaviors. We searched PubMed, Web of Science, SCOPUS, Cochrane Library, CINAHL Plus (EBSCO), MEDLINE (Ovid), Google Scholar, and ResearchGate. We included only published randomized controlled trials (RCTs) and quasi-experiment that compared HIVST to the standard of care (SoC). Studies with sufficient data were aggregated using meta-analysis on RevMan 5.4 at a 95% confidence interval. Cochrane's Q test was used to assess heterogeneity between the studies, while Higgins and Thompson's I2 was used to quantify heterogeneity. Subgroup analyses were conducted to identify the source of heterogeneity. Of the 2669 articles obtained from the databases, only 15 studies were eligible for this review, and eight were included in the final meta-analysis. Overall, linkage to care was similar between the HIVST arm and SoC (effect size: 0.92 [0.45-1.86]; I2: 51%; p: 0.04). In the population subgroup analysis, female sex workers (FSWs) in the HIVST arm were significantly linked to care compared to the SoC arm (effect size: 0.53 [0.30-0.94]; I2: 0%; p: 0.41). HIVST interventions did not significantly improve ART initiation in the HIVST arm compared to the SoC arm (effect size: 0.90 [0.45-1.79]; I2: 74%; p: < 0.001). We found that more male partners of women living with HIV in the SoC arm initiated PrEP compared to partners in the HIVST arm. The meta-analysis showed no difference between the HIVST and SoC arm regarding the number of clients (effect size: - 0.66 [1.35-0.02]; I2: 64%; p: 0.09) and non-clients FSWs see per night (effect size: - 1.45 [- 1.45 to 1.38]; I2: 93%; p: < 0.001). HIVST did not reduce the use of condoms during insertive or receptive condomless anal intercourse among MSM. HIVST does not improve linkage to care in the general population but does among FSWs. HIVST intervention does not improve linkage to ART nor significantly stimulate healthy sexual behaviors among priority groups. The only RCT that linked HIVST to PrEP found that PrEP uptake was higher among partners of women living with HIV in the SoC arm than in the HIVST arm. More RCTs among priority groups are needed, and the influence of HIVST on PrEP uptake should be further investigated.

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

Exploring therapeutic communication in managing chronic non-communicable diseases: a mixed-method study in Ghana

BACKGROUND

Globally, the burden of chronic non-communicable diseases is increasing rapidly and approximately one in three of all adults suffer from multiple chronic conditions. Therapeutic communication plays a crucial role in achieving curative, preventive, and promotive goals regarding chronic disease management. We examined therapeutic communication between health professionals and patients with chronic non-communicable diseases at the Ho Teaching Hospital.

METHODS

We adopted a concurrent mixed-methods approach. The quantitative aspect of the study was descriptive while the qualitative was explanatory. The quantitative study was conducted among 250 patients. The qualitative data was collected among eight health professionals. A stratified sampling and simple random sampling methods were used to recruit patients for the quantitative survey while purposive and convenient sampling was used for the qualitative aspect of the study. The quantitative data was collected using a semi-structured questionnaire while the qualitative data was collected using an in-depth interview guide. The quantitative data were analyzed using STATA v17 and the qualitative data were analyzed thematically using Atlas ti. The major themes that emerged were, therapeutic communication practices, barriers to therapeutic communication and possible solutions to good therapeutic communication.

RESULTS

We found that 37% patients were 60 years and above with 53.2% being females. It was noted that 36.4% of patients have had tertiary-level education. We found that 59.2% of patients reported having good therapeutic communication with health professionals. We, however, noted that male participants were 92% less likely to practice good therapeutic communication compared with females (aOR = 0.92,95% Cl = 0.46-1.84). Health professionals' activities to ensure good therapeutic practices included their capacity to listen, build rapport with their patients, and clarify information. We found that the major facilitators of good therapeutic communication included trust in the health professionals (90.4%), conducive environment (93.2%), using simple and plain language by health professionals (92.0%) We found that there are myriad of barriers that impede communication process. This included language, health professionals' inability to break terminologies, and the unconscious state of patients.

CONCLUSIONS

The study revealed that there was good therapeutic communication between health professionals and patients with CNCDs. Nevertheless, it was also identified that ineffective therapeutic communication between health professionals and their patients due to barriers like language could lead to dissatisfaction with care, misdiagnosis, and noncompliance to treatment regimen. For Ghana as a country to achieve SDG target 3.4 by reducing mortality due to NCDs and improve wellbeing of patients by 2030, it will be imperative on Ghana Health Service to design communication strategy training for health professionals that could help improve therapeutic communication between patients and health professionals.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Health-related quality of life among adults living with chronic non-communicable diseases in the Ho Municipality of Ghana: a health facility-based cross-sectional study

BACKGROUND

Morbidity and mortality rates from chronic non-communicable diseases (CNCDs) are increasing globally. In Ghana, CNCDs account for 43% of all deaths. We examined the Health-Related Quality of Life (HRQoL) and associated factors among adults living with CNCDs in the Ho Municipality.

METHODS

This was a health facility-based descriptive cross-sectional study among 432 adults living with cancer, diabetes, chronic kidney disease (CKD), stroke, and hypertension in the Ho Municipality of Ghana. The study adopted the EQ-5D-5L instrument and the Ugandan value set to compute respondents' HRQoL index. Quantile regression models were used in analysing the data with STATA v17.0 at 95% Confidence Intervals, and statistical significance set at p < 0.05.

RESULTS

63.7% of our respondents reported having a problem across the five dimensions of the EQ-5D-5L. The most problems were reported in the dimensions "Anxiety/Depression" (94.4%) and "Pain/Discomfort" (91.4%). Divorced/separated respondents (aOR=-0.52, 95% CI=-0.71, -0.33) and those living with comorbidities (aOR=-0.95, 95% CI=-0.15, -0.04,) were less likely to report high index for HRQoL. However, respondents diagnosed with CKD (aOR = 0.26, 95% CI = 0.10, 0.42), diabetes (aOR = 0.28, 95% CI = 0.11, 0.45), hypertension (aOR = 0.35, 95% CI = 0.19, 0.50) and stroke (aOR = 0.26, 95% CI = 0.11, 0.40) were more likely to report higher index than those diagnosed with cancer.

CONCLUSION

Our study revealed elevated proportions of reported problems in the "Anxiety/Depression" and "Pain/Discomfort" dimensions, indicating noteworthy concerns in these areas of HRQoL. The prevalent issues reported across HRQoL dimensions are cause for concern, posing potential exacerbation of health conditions. We advocate for collaborative efforts from the Ministry of Health, Ghana Health Service, and relevant stakeholders to scrutinize and implement interventions targeting social and psychological factors. These efforts should specifically address contributors to diminished health-related quality of life, particularly among less educated, divorced, and comorbid individuals.

Prevalence and correlates of tetanus toxoid uptake among women in sub-Saharan Africa: Multilevel analysis of demographic and health survey data

BACKGROUND

Tetanus toxoid vaccination is one of the most effective and protective measures against tetanus deaths among mothers and their newborns. We examined the prevalence and correlates of tetanus toxoid uptake among women in sub-Saharan African (SSA).

MATERIALS AND METHODS

We analysed pooled data from the Demographic and Health Surveys (DHS) of 32 countries in SSA conducted from 2010 to 2020. We included 223,594 women with a history of childbirth before the survey. Percentages were used to present the prevalence of tetanus toxoid vaccine uptake among the women. We examined the correlates of tetanus toxoid uptake using a multilevel binary logistic regression.

RESULTS

The overall prevalence of tetanus toxoid uptake was 51.5%, which ranged from 27.5% in Zambia to 79.2% in Liberia. Women age, education level, current working status, parity, antenatal care visits, mass media exposure, wealth index, and place of residence were the factors associated with the uptake of tetanus toxoid among the women.

CONCLUSION

Uptake of tetanus toxoid vaccination among the women in SSA was low. Maternal age, education, current working status, parity, antenatal care visits, exposure to mass media, and wealth status influence tetanus toxoid uptake among women. Our findings suggest that health sector stakeholders in SSA must implement interventions that encourage pregnant women to have at least four antenatal care visits. Also, health policymakers in SSA could ensure that the tetanus toxoid vaccine is free or covered under national health insurance to make it easier for women from poorer households to have access to it when necessary.

Ethical considerations in using a smartphone-based GPS app to understand linkages between mobility patterns and health outcomes: The example of HIV risk among mobile youth in rural South Africa

Smartphones with Global Positioning System (GPS) apps offer simple and accurate tools to collect data on human mobility. However, their associated ethical challenges remain to be assessed. We used the Emanuel framework to assess the ethical concerns of using smartphone GPS to record mobility patterns of young adults in rural South Africa for a larger study on mobility and HIV risk (Sesikhona). We conducted four focus groups (FGDs) with individuals eligible for the Sesikhona study. FGD data were coded using the Emanuel framework. Participants perceived use of smartphone GPS to study human mobility and HIV risk as valuable. They raised concerns about invasion of privacy and confidentiality. Also mentioned were risk/benefit ratio, informed consent and ongoing respect. Concerns expressed provided a useful evidence-base for the development of a guide to inform future participants about ethical issues arising in the use of GPS technology to track mobility and health-related issues.

Improving investment in chronic disease care in Sub-Saharan Africa is crucial for the achievement of SDG 3.4: application of the chronic care model

Over 41 million people die of chronic non-communicable diseases (CNCDs) each year, accounting for 71% of all global deaths. The burden of CNCD is specifically a problem in sub-Saharan Africa (SSA) since CNCDs are largely a leading major cause of mortality in the sub-region. While the disease burden and mortality from chronic non-communicable diseases (CNCDs) have reached an epidemic threshold in sub-Saharan Africa (SSA), health systems, policy-makers and individuals still consider CNCDs to be uncommon and, therefore, do not give its management the required attention. In sub-Saharan Africa (SSA), effectively addressing the growing burden of CNCDs will require comprehensive measures that incorporate both curative and preventive interventions, towards achieving the Sustainable Development Goal (SDG) 3.4 target of reducing by one-third premature mortality from CNCDs through prevention and treatment and the promotion of mental health and well-being by the year 2030. In this commentary, we adopt the Chronic Care Model (CCM) to discuss how improved investment in Chronic Disease Care is crucial in achieving the SDG target in SSA. At the health systems level of the CCM, we propose that countries in SSA should increase the proportion of their annual budgets allocated to health in line with the Abuja Declaration of 2001. Social health insurance should also be adopted by all countries and effectively implemented. At the community level, we propose intensified community-based health education, the formation of peer support groups and the implementation of community-based policies that promote healthy eating and physical activity.

Task shifting and task sharing in the health sector in sub-Saharan Africa: evidence, success indicators, challenges, and opportunities

This review explores task shifting and task sharing in sub-Saharan African healthcare to address workforce shortages and cost-effectiveness. Task shifting allocates tasks logically, while task sharing involves more workers taking on specific duties. Challenges include supply chain issues, pay inadequacy, and weak supervision. Guidelines and success measures are lacking. Initiating these practices requires evaluating factors and ensuring sustainability. Task shifting saves costs but needs training and support. Task sharing boosts efficiency, enabling skilled clinicians to contribute effectively. To advance task shifting and sharing in the region, further research is needed to scale up effective initiatives. Clear success indicators, monitoring, evaluation, and learning plans, along with exploration of sustainability and appropriateness dimensions, are crucial elements to consider.

Does adherence to antiretroviral therapy differ by place of residence in Nigeria? A systematic review and meta-analysis protocol

INTRODUCTION

Retention in care is still a significant challenge in the HIV treatment cascade and varies extensively across regions, leading to poor adherence to antiretroviral therapy (ART). Several factors across different socioecological levels, such as health and community-level factors, inhibit ART adherence among people living with HIV (PLWH) in Nigeria. This review seeks to ask whether adherence to ART differs by place of residence in Nigeria.

METHOD AND ANALYSIS

This systematic review and meta-analysis will follow the updated Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search PubMed, SCOPUS, CINAHL, Web of Science, MEDLINE (Ovid) and Google Scholar from onset to 30 April 2023. We will include only quantitative observational studies or mixed-method studies that measured the association between place of residence (urban and rural) and adherence to ART among PLWH aged ≥15 years. Title and abstract screening, full-text screening, data extraction and quality assessment will be done by two reviewers independently. A third reviewer will resolve disagreements. We will extract the author's name and year of publication, study aim(s), participant's characteristics, sample size, sampling method, region and state, adherence definition and adherence level in urban and rural areas. Data will be analysed with Review Manager V.5.4. The Q statistical test will be used to assess between-study heterogeneity, while Higgins and Thompson's I² will be used to quantify the heterogeneity level. Several subgroups and sensitivity analyses will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not warranted for this study since primary published data will be utilised. The findings of this review will be published in a high-impact peer-reviewed journal and presented at a conference.

PROSPERO REGISTRATION NUMBER

CRD42022371965.

Shared correlates of maternal and childhood overweight in Cameroon: a cross-sectional analysis of demographic and health survey data

BACKGROUND

Overweight parents are likelier to bear overweight babies, who are likelier to grow into overweight adults. Understanding the shared risks of being overweight between the mother-child dyad is essential for targeted life course interventions. In this study, we aimed to identify such risk factors in Cameroon.

METHODS

We conducted secondary data analysis using Cameroon's 2018 Demographic and Health Surveys. We used weighted multilevel binary logistic regressions to examine individual, household, and community correlates of maternal (15-49 years) and child (under five years) overweight.

RESULTS

We retained 4511 complete records for childhood and 4644 for maternal analysis. We found that 37% [95%CI:36-38%] of mothers and 12% [95%CI:11-13%] of children were overweight or obese. Many environmental and sociodemographic factors were positively associated with maternal overweight, namely urban residence, wealthier households, higher education, parity and being a Christian. Childhood overweight was positively associated with a child being older and a mother being overweight, a worker, or a Christian. Therefore, only religion affected both mothers overweight (aOR: 0.71[95%CI:0.56-0.91]) and childhood overweight (aOR 0.67[95%CI: 0.5-0.91]). Most of the potentially shared factors only indirectly affected childhood overweight through maternal overweight.

CONCLUSION

Besides religion, which affects both mothers and childhood overweight (with the Muslim faith being protective), much of childhood overweight is not directly explained by many of the observed determinants of maternal overweight. These determinants are likely to influence childhood overweight indirectly through maternal overweight. Extending this analysis to include unobserved correlates such as physical activity, dietary, and genetic characteristics would produce a more comprehensive picture of shared mother-child overweight correlates.

Management of chronic non-communicable diseases in Ghana: a qualitative study of patients' coping strategies and the role of caregivers

BACKGROUND

Chronic Non-Communicable Diseases (CNCDs) has become a major cause of mortality and disability globally. We explored the coping strategies adopted by CNCD patients and the roles of caregivers in the management of CNCDs in Ghana.

METHODS

This was a qualitative study that adopted an exploratory design. The study was carried out at the Volta Regional Hospital. Purposive convenience sampling procedures were used to sample patients and caregivers. Data for the study were collected using in-depth interview guides. Data were collected among 25 CNCDs patients and 8 caregivers and analysed thematically using ATLAS.ti.

RESULTS

Patients adopted a variety of strategies to cope with their condition. These strategies were emotion-oriented coping, task-oriented coping, and avoidance-oriented coping. Family members were the main caregivers, who provided social and financial support for patients. Financial challenges, inadequate family support, poor attitudes of health workers, delays at the health facility, unavailability of drugs at the facility, and patients' non-adherence to the medical advice were major challenges that militated against caregivers' efforts in supporting patients in the management of their CNCDs.

CONCLUSION

We found that patients adopted various strategies to cope with their conditions. The roles of the caregivers in supporting patients in the management practices were identified as very important as they contribute immensely to the financial and social support for the patients in their management of CNCDs. It is crucial that health professionals actively involve caregivers in every aspect of the day-to-day management of CNCDs as these caregivers spend more time with these patients and understand them better.

Increased investment in Universal Health Coverage in Sub-Saharan Africa is crucial to attain the Sustainable Development Goal 3 targets on maternal and child health

Universal Health Coverage (UHC) is considered a strategic component of the Sustainable Development Goals specifically for goal 3 which seeks to ensure healthy lives and promote well-being for all, where all individuals and communities have equal access to key promotive, preventive, curative, and rehabilitative health interventions without financial constraints. Despite Sub-Saharan Africa (SSA) accelerated gains on the UHC effective coverage of 2.6% between 2010 to 2019, many countries in the sub-region show lagging performance. The major challenges faced in attaining the UHC in many countries include inadequate capital investment for health and their equitable distribution, fiscal space to finance UHC policies and programs. This paper discusses how increased investment in Universal Health Coverage in SSA is crucial to attain the Sustainable Development Goal 3 targets on maternal and child health. The Universal Health Monitoring Framework (UHMF) is adopted in this paper as the underpinning framework. The delivery of essential maternal and child health services to achieve UHC in SSA requires strategic actions such as policies, plans and programs with focus on maternal and child health. We report findings from recently published papers that clearly highlighted the strong connection between health insurance coverage and maternal health care utilization. Strategic actions such as implementing national health insurance scheme (NHIS) that directly incorporates free maternal and child health care could strengthen maternal health services and transform health systems in order to achieve UHC in SSA. We argue that achieving the SDG 3 on maternal and child health will only be possible if significant progress in made in increasing UHC. This is key to ensure optimal maternal health care utilization, and consequently reducing maternal and child deaths.

Towards achievement of Sustainable Development Goal 3: multilevel analyses of demographic and health survey data on health insurance coverage and maternal healthcare utilisation in sub-Saharan Africa

BACKGROUND

Improving maternal health and achieving universal health coverage (UHC) are important expectations in the global Sustainable Development Goals (SDGs) agenda. While health insurance has been shown as effective in the utilisation of maternal healthcare, there is a paucity of literature on this relationship in sub-Saharan Africa (SSA). We examined the relationship between health insurance coverage and maternal healthcare utilisation using demographic and health survey data.

METHODS

This was a cross-sectional study of 195 651 women aged 15-49 y from 28 countries in SSA. We adopted bivariable and multivariable analyses comprising χ2 test and multilevel binary logistic regression in analysing the data.

RESULTS

The prevalence of maternal healthcare utilisation was 58, 70.6 and 40.7% for antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC), respectively. The prevalence of health insurance coverage was 6.4%. Women covered by health insurance were more likely to utilise ANC (adjusted OR [aOR]=1.48, 95% CI 1.41 to 1.54), SBA (aOR=1.37, 95% CI 1.30 to 1.45) and PNC (aOR=1.42, 95% CI 1.37 to 1.48).

CONCLUSION

Health insurance coverage was an important predictor of maternal healthcare utilisation in our study. To accelerate progress towards the achievement of SDG 3 targets related to the reduction of maternal mortality and achievement of UHC, countries should adopt interventions to increase maternal insurance coverage, which may lead to higher maternal healthcare access and utilisation during pregnancy.

The SPIN framework to control and prevent the Marburg virus disease outbreak in Equatorial Guinea

A full grasp of the epidemiological factors promoting transmission is necessary for responding to highly infectious diseases, which involves their control and prevention. With the recent outbreak of Marburg Virus Disease (MVD) in Equatorial Guinea, we saw the need to re-shed some technical light based on our field experiences and published literature. We reviewed 15 previous MVD outbreaks globally. Coupled with core One-Health approaches, we highlighted the SPIN (socio-environmental context, possible transmission routes, informing and guiding public health action, needs in terms of control measures) framework as a guiding tool for response teams to appropriately approach this highly contagious infectious disease outbreak for collective and stronger global health security. The Central African Regional Collaborating Centre (RCC) of the Africa Centres for Disease Control and Prevention (Africa CDC) has a big lead role to play, most especially in coordinating the community engagement and risk communication packages of the response, which is highly needed at this point. We reiterate that this framework remains relevant, if not timely, in rethinking pandemic preparedness and response in resource-limited settings.

Prevalence and factors associated with adolescent pregnancies in Zambia: a systematic review from 2000-2022

BACKGROUND

Adolescent pregnancy increases risk of short- and long-term adverse social and health outcomes for the adolescent mother and child. Zambia has high prevalence rates of adolescent pregnancy. However, the risk factors are varied and in need of further review and research. The study accordingly reviewed the prevalence and factors associated with adolescent pregnancy in Zambia.

METHODS

This systematic review was conducted following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The review included original peer-reviewed research articles published from 2000 onwards in English, retrieved from Medline, EMBASE, CINAHL, and African Journals Online databases. Thematic synthesis was used in the analysis of the data extracted from the included studies.

RESULTS

Six research studies carried out in Zambia (two quantitative, two qualitative, and two mixed methods) were reviewed and included. Prevalence of adolescent pregnancy in Zambia ranged from 29 to 48%. Additionally, it was found that 29.1% of the country's adolescents, nationally, had given birth as of 2018. Factors at an individual's level such as early or child marriage, exposure to media, knowledge about sexual and reproductive health (SRH) and contraception, contraceptive use, as well as risky sexual behaviours were found to be significantly associated with adolescent pregnancy. Peer pressure, educational attainment, household wealth, and the power dynamics of the household head were identified as the major socio-economic factors alongside socio-cultural, gender and sexual norms amongst other environmental and contextual factors. Policy level factors identified were lack and limited access to SRH information and services by adolescents, including an enabling legal environment.

CONCLUSION

From the review, it was abundantly clear that a combination of individual, interpersonal, environmental, and an enabling legal/policy level factors significantly contribute to the high levels of adolescent pregnancy. There is a paucity of empirical research on the prevalence and determinants of adolescent pregnancy, which suggests an imperative need for large multi-site mixed methods studies to properly explore these and other determinants on a national scale, as well as the long-term implications of these pregnancies on adolescent mothers and babies. Multifaceted and multisectoral interventions which include improved access to education, economic empowerment, addressing gender and socio-cultural norms, should be implemented having due regard to the socio-cultural context which should ride on strong political will, failing which adolescent girls in Zambia will definitely be left behind.

Community engagement in research in sub-Saharan Africa: current practices, barriers, facilitators, ethical considerations and the role of gender - a systematic review

Introduction

meaningful community engagement is increasingly being considered the major determinant of successful research, innovation and intervention uptake. Even though there is available literature recommending community engagement in health research, there are still knowledge gaps in how communities might be best engaged in Sub-Saharan Africa. We, therefore, synthesized the existing literature on the current practices, barriers and facilitators, ethical considerations, and gender mainstreaming in the engagement of communities in research in sub-Saharan Africa.

Methods

this synthesis was developed following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). A combination of keywords and medical subject headings was used to search MEDLINE, EMBASE, Global Health Library through OVID SP, the Cochrane Library, PsychINFO, CINAHL, WHO Afro Library, WHO Global Index Medicus and the National Institute for Health Research, for all literature published between 1 January 2000 to 31 July 2021.

Results

thirty articles met our inclusion criteria. The key reported facilitators of effective community engagement in research included appropriate community entry and engagement of stakeholders. Barriers to effective community engagement in research included the availability of prohibitive cultural, historical and religious practices; geographical/spatial limitations, difficulties in planning and executing community engagement activities and communication barriers. Awareness creation and sensitization on the research through drama, social media, documentaries, and community durbars are some of the existing practices adopted in engaging communities in research. Gender mainstreaming was not considered appropriately in the engagement of communities in research, as only a few studies made provisions for gender considerations, and most of the time, interchanging gender for sex. Respect for autonomy, privacy and informed consent were the main ethical issues reported.

Conclusion

gender mainstreaming and ethical standards were reported as important, but not explored in depth. Gender as a social construct needs to be carefully integrated in the entire research cycle. Clear ethical concerns within a research project have to be co-discussed by the research team, community members and potential research participants.

There is an urgent need for a global rural health research agenda

People living in rural areas generally experience adverse health outcomes compared to their urban counterparts. They experience a greater burden of non-communicable diseases including: diabetes, hypertension, stroke, kidney disease, and chronic obstructive pulmonary disease (COPD), have limited access to healthcare services, and experience scarcity in specialized healthcare services. The disproportionately high all-cause mortality experienced by rural residents has been termed "the rural mortality penalty". With over 90% of the world's rural population living in Africa and Asia, we argue that the lack of an authoritative and respected global rural health research agenda contributes to increasing health inequalities, given that many of these people are receiving substandard care. There are differences in how rural and urban resident's experience healthcare. Living in rural settings might not be systematically connected to adverse health outcomes. It is important to clearly articulate the positive health outcomes associated with living in rural settings (e.g., the positive relationship between mental health and strong social ties/green spaces). Indeed, health policies stand the chance of unconsciously excluding the positive outcomes associated with rurality, as well as the rural experiences of health. Defining rural health remains an issue of controversy with a persistent reality regarding the lack of consensus as to what it means for a region or area to be considered as "rural". We outline the most common definitions of "rural areas" in the literature, as well as the shortcomings of these definitions. By unpacking the meaning of "rural health", we aim to foster communication among rural health professionals and researchers locally and internationally, as well as highlight the key research and policy implications that could emanate from a "good" definition of rural health. We agree that context remains key when it comes conceptualizing complex subjects like rurality. However, developing minimum criteria to foster communication among rural health researchers is needed. Systematically providing operational definitions of what authors describe as "rural" in the rural health research and policy literature is of utmost relevance.

Age-sex differences in the global burden of lower respiratory infections and risk factors, 1990-2019: results from the Global Burden of Disease Study 2019

BACKGROUND

The global burden of lower respiratory infections (LRIs) and corresponding risk factors in children older than 5 years and adults has not been studied as comprehensively as it has been in children younger than 5 years. We assessed the burden and trends of LRIs and risk factors across all age groups by sex, for 204 countries and territories.

METHODS

In this analysis of data for the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we used clinician-diagnosed pneumonia or bronchiolitis as our case definition for LRIs. We included International Classification of Diseases 9th edition codes 079.6, 466-469, 470.0, 480-482.8, 483.0-483.9, 484.1-484.2, 484.6-484.7, and 487-489 and International Classification of Diseases 10th edition codes A48.1, A70, B97.4-B97.6, J09-J15.8, J16-J16.9, J20-J21.9, J91.0, P23.0-P23.4, and U04-U04.9. We used the Cause of Death Ensemble modelling strategy to analyse 23 109 site-years of vital registration data, 825 site-years of sample vital registration data, 1766 site-years of verbal autopsy data, and 681 site-years of mortality surveillance data. We used DisMod-MR 2.1, a Bayesian meta-regression tool, to analyse age-sex-specific incidence and prevalence data identified via systematic reviews of the literature, population-based survey data, and claims and inpatient data. Additionally, we estimated age-sex-specific LRI mortality that is attributable to the independent effects of 14 risk factors.

FINDINGS

Globally, in 2019, we estimated that there were 257 million (95% uncertainty interval [UI] 240-275) LRI incident episodes in males and 232 million (217-248) in females. In the same year, LRIs accounted for 1·30 million (95% UI 1·18-1·42) male deaths and 1·20 million (1·07-1·33) female deaths. Age-standardised incidence and mortality rates were 1·17 times (95% UI 1·16-1·18) and 1·31 times (95% UI 1·23-1·41) greater in males than in females in 2019. Between 1990 and 2019, LRI incidence and mortality rates declined at different rates across age groups and an increase in LRI episodes and deaths was estimated among all adult age groups, with males aged 70 years and older having the highest increase in LRI episodes (126·0% [95% UI 121·4-131·1]) and deaths (100·0% [83·4-115·9]). During the same period, LRI episodes and deaths in children younger than 15 years were estimated to have decreased, and the greatest decline was observed for LRI deaths in males younger than 5 years (-70·7% [-77·2 to -61·8]). The leading risk factors for LRI mortality varied across age groups and sex. More than half of global LRI deaths in children younger than 5 years were attributable to child wasting (population attributable fraction [PAF] 53·0% [95% UI 37·7-61·8] in males and 56·4% [40·7-65·1] in females), and more than a quarter of LRI deaths among those aged 5-14 years were attributable to household air pollution (PAF 26·0% [95% UI 16·6-35·5] for males and PAF 25·8% [16·3-35·4] for females). PAFs of male LRI deaths attributed to smoking were 20·4% (95% UI 15·4-25·2) in those aged 15-49 years, 30·5% (24·1-36·9) in those aged 50-69 years, and 21·9% (16·8-27·3) in those aged 70 years and older. PAFs of female LRI deaths attributed to household air pollution were 21·1% (95% UI 14·5-27·9) in those aged 15-49 years and 18·2% (12·5-24·5) in those aged 50-69 years. For females aged 70 years and older, the leading risk factor, ambient particulate matter, was responsible for 11·7% (95% UI 8·2-15·8) of LRI deaths.

INTERPRETATION

The patterns and progress in reducing the burden of LRIs and key risk factors for mortality varied across age groups and sexes. The progress seen in children younger than 5 years was clearly a result of targeted interventions, such as vaccination and reduction of exposure to risk factors. Similar interventions for other age groups could contribute to the achievement of multiple Sustainable Development Goals targets, including promoting wellbeing at all ages and reducing health inequalities. Interventions, including addressing risk factors such as child wasting, smoking, ambient particulate matter pollution, and household air pollution, would prevent deaths and reduce health disparities.

FUNDING

Bill & Melinda Gates Foundation.

Provision of injectable contraceptives by community health workers in sub-Saharan Africa: a systematic review of safety, acceptability and effectiveness

BACKGROUND

Injectable contraceptives are the most popular method of contraception in sub-Saharan Africa (SSA), but their availability in clinical settings has been severely limited, despite the scarcity of health care providers and limited access to health facilities. WHO and USAID have endorsed the community-based distribution of injectable contraceptives as a promising option for improving access to family planning services and expanding the method mix for women who want to limit the number of births. Studies have shown that community health workers (CHWs) can provide women with injectable contraceptives that meet acceptable quality standards. The goal of this study is to identify, evaluate and synthesize evidence supporting the use of community-based administration of injectable contraceptives in SSA.

METHODS

This review's guidance was based on a previously developed protocol. Nine international electronic databases and the websites of organizations known to support community-based reproductive health initiatives in SSA were searched systemically. Experts in this area were also contacted for the identification of unpublished literature and ongoing studies. The reference lists of eligible studies were reviewed. The Effective Public Practice Project tool was used to assess the quality and risk of bias in eligible studies. Data were extracted and analysed using a custom data extraction form and a narrative synthesis.

RESULTS

The search strategy identified a total of 1358 studies with 12 studies meeting the inclusion criteria. One unpublished study was provided by an expert making a total of 13 studies. The results showed that irrespective of the study designs, well-trained CHWs can competently administer injectable contraceptives safely and community-based delivery of injectable contraceptives is acceptable in SSA. Also, the use of community health workers in the provision of depot-medroxyprogesterone acetate expanded access to inhabitants of hard-to-reach areas and led to an overall uptake of injectable contraceptives as well as family planning. Studies that compared CHWs to clinic-based providers revealed equivalent or higher levels of performance in favour of CHWs.

CONCLUSIONS

The CHWs can competently provide injectable contraceptives within SSA communities if appropriately trained and supervised. Hence, SSA policymakers should give this initiative due consideration as a way of improving access to family planning services.

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally.

METHODS

The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented.

FINDINGS

Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]).

INTERPRETATION

The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden.

FUNDING

Bill & Melinda Gates Foundation.

Improving Employee Mental Health: A Health Facility-Based Study in the United States

Background

In the US, over 52.9 million (21%) adults lived with a mental health illness in 2020, with depression, being one of the commonest of these conditions. The World Health Organization ranks depression as the most important contributor to global disability. As frontline workers who are responsible for taking care of a myriad of patients daily, health workers are usually exposed to depressive situations which eventually result in the development of the condition among them. This study, therefore, developed an intervention to reduce depression among workers at the Outpatient Mental Health Clinic in Washington District of Columbia, United States.

Methods

A pre-intervention survey was conducted among 43 employees. The survey used the already validated Patient Health Questionnaire depression scale (PHQ-9) to determine the prevalence of depression. The WHO Healthy Workplace Model was adopted in designing an instrument for the workplace determinants of depression. An mHealth intervention was then developed and implemented among the workers. After this, a post-intervention survey was conducted among the cohort. Descriptive and inferential statistics were adopted in analyzing the data with STATA.

Results

The pre-intervention survey showed a depression prevalence of 30.2% among the employees. The post-intervention survey, however, showed that the prevalence of depression among the employees reduced to 12.6%. The surveys also showed that the majority of employees who felt exposed to workplace hazards including harmful chemicals, expressed feelings of depression (pre-intervention = 53.6%; post-intervention = 80%).

Conclusion

The intervention designed for this study was effective in reducing self-reported depression among employees. Improving employee mental health in health care facilities will require awareness raising among employees, mental health friendly policies, and regular follow up of employee mental health needs. Though this intervention was on a small scale, it shows promise for using cheap mhealth solutions in improving mental health at the work place.

Burden of non-communicable diseases among adolescents aged 10-24 years in the EU, 1990-2019: a systematic analysis of the Global Burden of Diseases Study 2019

BACKGROUND

Disability and mortality burden of non-communicable diseases (NCDs) have risen worldwide; however, the NCD burden among adolescents remains poorly described in the EU.

METHODS

Estimates were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Causes of NCDs were analysed at three different levels of the GBD 2019 hierarchy, for which mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) were extracted. Estimates, with the 95% uncertainty intervals (UI), were retrieved for EU Member States from 1990 to 2019, three age subgroups (10-14 years, 15-19 years, and 20-24 years), and by sex. Spearman's correlation was conducted between DALY rates for NCDs and the Socio-demographic Index (SDI) of each EU Member State.

FINDINGS

In 2019, NCDs accounted for 86·4% (95% uncertainty interval 83·5-88·8) of all YLDs and 38·8% (37·4-39·8) of total deaths in adolescents aged 10-24 years. For NCDs in this age group, neoplasms were the leading causes of both mortality (4·01 [95% uncertainty interval 3·62-4·25] per 100 000 population) and YLLs (281·78 [254·25-298·92] per 100 000 population), whereas mental disorders were the leading cause for YLDs (2039·36 [1432·56-2773·47] per 100 000 population) and DALYs (2040·59 [1433·96-2774·62] per 100 000 population) in all EU Member States, and in all studied age groups. In 2019, among adolescents aged 10-24 years, males had a higher mortality rate per 100 000 population due to NCDs than females (11·66 [11·04-12·28] vs 7·89 [7·53-8·23]), whereas females presented a higher DALY rate per 100 000 population due to NCDs (8003·25 [5812·78-10 701·59] vs 6083·91 [4576·63-7857·92]). From 1990 to 2019, mortality rate due to NCDs in adolescents aged 10-24 years substantially decreased (-40·41% [-43·00 to -37·61), and also the YLL rate considerably decreased (-40·56% [-43·16 to -37·74]), except for mental disorders (which increased by 32·18% [1·67 to 66·49]), whereas the YLD rate increased slightly (1·44% [0·09 to 2·79]). Positive correlations were observed between DALY rates and SDIs for substance use disorders (r_s=0·58, p=0·0012) and skin and subcutaneous diseases (r_s=0·45, p=0·017), whereas negative correlations were found between DALY rates and SDIs for cardiovascular diseases (r_s=-0·46, p=0·015), neoplasms (r_s=-0·57, p=0·0015), and sense organ diseases (r_s=-0·61, p=0·0005).

INTERPRETATION

NCD-related mortality has substantially declined among adolescents in the EU between 1990 and 2019, but the rising trend of YLL attributed to mental disorders and their YLD burden are concerning. Differences by sex, age group, and across EU Member States highlight the importance of preventive interventions and scaling up adolescent-responsive health-care systems, which should prioritise specific needs by sex, age, and location.

FUNDING

Bill & Melinda Gates Foundation.

The burden of injury in Central, Eastern, and Western European sub-region: a systematic analysis from the Global Burden of Disease 2019 Study

BACKGROUND

Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries.

METHODS

We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year.

RESULTS

In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019.

CONCLUSIONS

Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.

Community engagement in research in sub-Saharan Africa: approaches, barriers, facilitators, ethical considerations and the role of gender - a systematic review protocol

INTRODUCTION

Meaningful community engagement (CE) is increasingly being considered the major determinant of successful research, innovation and intervention uptake. Community leaders, policy makers and funders have expressed the need to engage communities in research. CE in research empowers the host community to participate in addressing its own health needs and health disparities while ensuring that researchers understand community priorities. Thus, appropriate CE opens a unique way to promote coproduction, coimplementation and coevaluation, which may strengthen both the sense of inclusion, ownership and the effectiveness of the research life-cycle. The aim of this review is to synthesise available evidence on how to engage communities in research in a gender-sensitive, ethical, culture-appropriate and sustainable way in sub-Saharan Africa (SSA). This protocol has been developed following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and follows the guidance provided by the Cochrane Handbook for Systematic Reviews.

METHODS AND ANALYSIS

A combination of key text words and medical subject headings such as 'Community Engagement' or 'Community Involvement' will be used to search 009 databases for all literature published between 1 January 2000 and 31 July 2021. Citations retrieved from database searches will be exported into EndNote X9 to remove duplicate citations and imported into Rayyan QCRI for screening. Two independent reviewers will conduct the screening and data extraction process. Disagreements between review authors will be resolved through discussions, consensus a third reviewer serving as a tiebreaker. The risk of bias will be assessed using the 10-item Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The three-staged process described by Thomas and Harden will be used for the thematic and narrative synthesis of findings.

ETHICS AND DISSEMINATION

This is a systematic review which uses already collected data thus ethical approval not required. Findings will be published in an open access peer-reviewed journal and presented in relevant conferences and workshops.

PROSPERO REGISTRATION NUMBER

This protocol has been submitted for registration in PROSPERO and has been published under registration number CRD42021282503 .

COVID-19 and Health Systems Functioning in Sub-Saharan Africa Using the "WHO Building Blocks": The Challenges and Responses

Sub-Saharan Africa (SSA) has made major progress in improving access to health care over the past three decades. Despite efforts made toward achieving universal health coverage, the health systems of countries in the sub-region are inundated by a myriad of challenges that have become more virulent amid the COVID-19 pandemic. This paper discusses the health systems challenges and responses in SSA amidst the COVID-19 using the World Health Organization's (WHO) building blocks of health systems functioning. Long-lasting abysmal health system financing and insufficient government investment in SSA pose major challenges to the effective health systems functioning amid the COVID-19 pandemic. This situation also makes it difficult for the health system to meet the demands of the COVID-19 pandemic and at the same time, cater for other essential health services. Countries in SSA must prioritize the reformation of their health systems through effective health system policy development and implementation, human resources development, training, service delivery, governance and regulation, and sustainable health financing.

Prevalence and determinants of maternal healthcare utilisation among young women in sub-Saharan Africa: cross-sectional analyses of demographic and health survey data

BACKGROUND

Maternal health constitutes high priority agenda for governments across the world. Despite efforts by various governments in sub-Saharan Africa (SSA), the sub-region still records very high maternal mortality cases. Meanwhile, adequate utilization of maternal healthcare (antenatal care [ANC], skilled birth attendance [SBA], and Postnatal care [PNC]) plays a vital role in achieving improved maternal health outcomes. We examined the prevalence and determinants of maternal healthcare utilization among young women in 28 sub-Saharan African countries using data from demographic and health surveys.

METHODS

This was a cross-sectional study of 43,786 young women aged 15-24 years from the most recent demographic and health surveys of 28 sub-Saharan African countries. We adopted a multilevel logistic regression analysis in examining the determinats of ANC, SBA, and PNC respectively. The results are presented as adjusted Odds Ratios (aOR) for the logistic regression analysis. Statistical significance was set at p < 0.05.

RESULTS

The prevalence of maternal healthcare utilisation among young women in SSA was 55.2%, 78.8%, and 40% for ANC, SBA, and PNC respectively with inter-country variations. The probability of utilising maternal healthcare increased with wealth status. Young women who were in the richest wealth quintile were, for instance, 2.03, 5.80, and 1.24 times respectively more likely to utilise ANC (95% CI = 1.80-2.29), SBA (95% CI = 4.67-7.20), and PNC (95% CI = 1.08-1.43) than young women in the poorest wealth quintile. Young women who indicated having a barrier to healthcare utilisation were, however, less likely to utilise maternal healthcare (ANC: aOR = 0.83, 95% CI = 0.78-0.88; SBA: aOR = 0.82, 95% CI = 0.75-0.88; PNC: aOR = 0.88, 95% CI = 0.83-0.94).

CONCLUSION

While SBA utilisation was high, we found ANC and PNC utilisation to be quite low among young women in SSA with inter-country variations. To accelerate progress towards the attainment of the Sustainable Development Goal (SDG) targets on reducing maternal mortality and achieving universal health coverage, our study recommends the adoption of interventions which have proven effective in some countries, by countries which recorded low maternal healthcare utilisation. The interventions include the implementation of free delivery services, training and integration of TBAs into orthodox maternal healthcare, improved accessibility of facilities, and consistent public health education. These interventions could particularly focus on young women in the lowest wealth quintile, those who experience barriers to maternal healthcare utilisation, uneducated women, and young women from rural areas.

Individual and contextual factors associated with maternal healthcare utilisation in Mali: a cross-sectional study using Demographic and Health Survey data

OBJECTIVE

We examined the national prevalence as well as the individual and contextual factors associated with maternal healthcare utilisation in Mali.

SETTING

The study was conducted in Mali.

PARTICIPANTS

We analysed data on 6335 women aged 15-49 years from Mali's 2018 Demographic and Health Survey.

OUTCOME VARIABLE

Maternal healthcare utilisation comprising antenatal care (ANC) attendant, skilled birth attendant (SBA), and postnatal care (PNC) attendant, was our outcome variable.

RESULTS

Prevalence of maternal healthcare utilisation was 45.6% for ANC4+, 74.7% for SBA and 25.5% for PNC. At the individual level, ANC4 + and SBA utilisation increased with increasing maternal age, level of formal education and wealth status. Higher odds of ANC4 + was found among women who are cohabiting (adjusted OR (aOR)=2.25, 95% CI 1.16 to 4.37) and delivered by caesarean section (aOR=2.53, 95% CI 1.72 to 3.73), while women who considered getting money for treatment (aOR=0.72, 95% CI 0.60 to 0.88) and distance to health facility (aOR=0.73, 95% CI 0.59 to 0.90) as a big problem had lower odds. Odds to use PNC was higher for those who were working (aOR=1.22, 95% CI 1.01 to 1.48) and those covered by health insurance (aOR=1.87, 95% CI 1.36 to 2.57). Lower odds of SBA use were associated with having two (aOR=0.48, 95% CI 0.33 to 0.71), three (aOR=0.37, 95% CI 0.24 to 0.58), and four or more (aOR=0.38, 95% CI 0.24 to 0.59) children, and residing in a rural area (aOR=0.35, 95% CI 0.17 to 1.69). Listening to the radio and watching TV were associated with increased maternal healthcare utilisation.

CONCLUSION

The government should increase availability, affordability and accessibility to healthcare facilities by investing in health infrastructure and workforce to achieve Sustainable Development Goal 3.4 of reducing maternal morality to less than 70 deaths per 100 000 live births by 2030. It is important to ascertain empirically why PNC levels are astonishingly lower relative to ANC and SBA.

Use and awareness of emergency contraceptives among women of reproductive age in sub-Saharan Africa: a scoping review

BACKGROUND

Emergency contraception (EC) is a method used to avoid pregnancy after unprotected sexual intercourse. Emergency contraceptives can reduce the risk of unintended pregnancy by up to over 95% when taken within 72 h of sexual intercourse. EC is helpful to women who have experienced method failure, incorrect use of contraceptives, raped or have consented to unplanned, and unprotected sexual intercourse. We set out to systematically review the current literature on the awareness and usage patterns of ECs among women of reproductive age in Sub-Saharan Africa.

METHOD

Eight hundred and sixty-seven (867) articles were selected from EMBASE and Google Scholar databases after a search was conducted. Sixty (60) full-text articles were checked for eligibility and 27 articles met our inclusion criteria. Manual data extraction on excel sheets was used to extract the authors' names, year of publication, country, sample size, study type, objectives, awareness levels, and the EC types.

FINDINGS

Awareness rates ranged from 10.1 to 93.5% (both reported from Ethiopia). The level of use was relatively low (ranging from 0% in DR Congo and Ethiopia to 54.1% in Nigeria). The most used types of EC were Postinor 2 (levonorgestrel), EC pills such as Norlevo (levonorgestrel only) and Nodette (levonorgestrel and estradiol), and intrauterine contraceptive device (IUCD).

CONCLUSIONS

Although variations in use and awareness do exist between countries in SSA according to the year of study, the general level of EC awareness has been on the increase. On the other hand, the level of EC use was lower compared to the level of awareness. Postinor 2 (levonorgestrel-only pills) was reported as the most type used EC. Further, studies could be done to find out the effect of culture, religion and believes on the use of contraceptive methods. It is important to understanding barriers to EC use despite high awareness rates. Emergency Contraceptive awareness and use should be promoted among women of reproductive age in SSA to reduce unwanted pregnancies and their complications.

Fostering research integrity in sub-Saharan Africa: challenges, opportunities, and recommendations

Integrity and adherence to appropriate ethical standards are important elements of research. These standards are key to protecting research participants´ rights as well as ensuring the reliability and quality of research outputs. Although empirical evidence is scanty, several authors have alluded to the fact that violation of research integrity standards could be common in low- and middle-income countries including sub-Saharan Africa (SSA). Understanding the issues, challenges, and opportunities of research integrity and ethics in SSA is key to promoting the responsible conduct of research and the protection of research participants. This paper presents the authors´ critical views and recommendations on the current state of research integrity in SSA. We argue that understanding the current research integrity architecture in SSA has the potential to identify opportunities to promote responsible conduct of research in SSA. Such opportunities include, but are not limited to transparency, accountability, and reproducibility of research, which collectively lead to enhanced public trust in the research enterprise. We highlight the need to embrace equity, fairness, diversity, and inclusivity in the research cycle from conception (priority setting), funding, implementation, dissemination of findings, and scale up. We move on to provide a rationale for understanding the differences and similarities between research ethics and research integrity. Governments, research, and academic institutions must develop multifaceted approaches to promote compliance with principles of research integrity by developing and implementing clear research integrity policies and guidelines that foster responsible conduct of research and prioritize capacity building and empowerment of early career researchers, students, and other targeted key stakeholders.

Adopting population-based interventions towards sustaining child health services in the midst of COVID-19 in sub-Saharan Africa: application of the socio-ecological model

Child health services remain one of the most cost-effective strategies in reducing child mortality which is still disturbingly high in sub-Saharan Africa (SSA). Efforts by governments and other stakeholders in response to the COVID-19 pandemic have inadvertently disrupted the provision of other essential health services including those focusing on children. This comes at the backdrop of the World Health Organization´s guidelines for countries to sustain priority services while fighting the COVID-19 pandemic. Underpinned by the Socio-Ecological Model (SEM), we propose population-based interventions which could help in sustaining child health services in the midst of COVID-19 in SSA. At the intrapersonal and interpersonal levels, educating mothers during routine community outreach services, during child welfare clinics, and in church/mosques could be useful. Education and sensitization of male partners could also be an important intervention. At the institutional and community levels, we recommend the allocation of more funds to other essential health services including child health services. The training and deployment of more general nurses, community health nurses/officers, and public health officers is imperative. The provision and adherence to COVID-19 preventive protocols at health facilities are also recommended at these levels. At the public policy level, insurance and tax relief packages for frontline professionals providing child health services and micro-credit facilities at reduced interest rates for women could be implemented towards sustaining the utilisation of child health services.

Malaria Elimination: What Can Africa Learn from China?

For decades now, malaria has been an important public health concern in Africa, which bears the greatest burden for the disease, affecting children and adults alike. Although a few countries (Australia, Brunei, Singapore, and Algeria, among others) have previously eliminated malaria, the World Health Organization (WHO), on June 30, 2021, declared China malaria-free. This commentary seeks to explore what China did differently to eliminate malaria and what Africa can learn from China's experience. First, Africa can use innovative tools and strategies used by China to attain success. Second, Africa can create a multi-sector collaboration among Heads of States in high burden malaria-affected countries by involving all stakeholders such as ministries of health, finance, research, education, development, public security, the army, police, commerce, industry, and information technology, customs, media and tourism to jointly fight malaria in all African countries. Furthermore, African countries could adapt the genetics-based approaches used by China in the elimination of mosquito breeding grounds. Finally, Africa can also adapt a better surveillance system of reporting on malaria daily as China did in their experience.

Marburg virus disease outbreak in Guinea: a SPIN framework of its transmission and control measures for an exemplary response pattern in West Africa

Responding to highly infectious diseases relies on a thorough understanding of transmission epidemiology. With the recent outbreak of Marburg Virus Disease (MVD) in Guinea, we saw the need to shed some technical light based on published literature and our field experiences. We reviewed 14 previous MVD outbreaks globally. Coupled with core one - health approaches, we propose a Socio-environmental context, Possible transmission routes, Informing and guiding public health action, Needs in terms of control measures (SPIN) framework as a guiding tool for response teams to appropriately approach future infectious disease outbreaks.

Understanding the meaning of autonomy in adolescent pregnancy decision-making: lessons from Ghana

Introduction

adolescent pregnancy in Ghana, like in most low and middle income countries, is an issue of immense public health importance. Pregnant adolescents are faced with the stronger dilemma of either terminating the unwanted pregnancy or keeping it. This discourse which is based on findings from empirical research in Accra Ghana aims at contributing to the usefulness of understanding the meaning and scope of autonomy when it comes to providing ethically grounded, and adolescent friendly, reproductive health care services to pregnant adolescents. The aim of this work was to document the meaning and determinants of autonomous decision making among pregnant adolescents in the James Town area of Accra, Ghana.

Methods

thirty (30) semi-structured in depth interviews were conducted among adolescents who had been pregnant at least once, 23 in depth interviews among purposively selected stakeholders (parents, teachers, NGO staff working in reproductive health, community volunteers), and 8 focus group discussions among parents, teachers, adolescent students who had not been pregnant before, and adolescents who had at least one pregnancy in the past. Data were transcribed verbatim and analyzed thematically.

Results

most adolescents reported that the final decision to continue a pregnancy to term or go in for an abortion was taken by them. The partner´s willingness to take responsibility of the pregnant adolescent and baby, as well as financial considerations, were main players in deciding upon the pregnancy outcomes. Cultural desirability for children and health care provider/father paternalism (power dynamics) in the decision-making process were central considerations in the decision-making process. Unaffordable and unfriendly safe abortion services pushed adolescents to either continue pregnancies to term against their will, or opt to visit unsafe abortion care providers.

Conclusion

adolescents stand to make truly autonomous decisions if they are provided with the right information, at the right time, at the right place, by the right persons, and in the right way. Health system, economic, and cultural factors play significant roles in rendering pregnant adolescent autonomy meaningful when deciding upon their pregnancy outcomes. Continuing pregnancies to term against one´s will or being forced to go in for an abortion are ethically unjustified. Further research is required to examine the long-term consequences of forced pregnancy terminations or births.

Profile and outcomes of patients admitted with hyperglycemic emergencies in the Buea Regional Hospital in Cameroon

Introduction

hyperglycemic emergencies (diabetic ketoacidosis and hyperglycemic hyperosmolar state) are the most common serious acute metabolic complications of diabetes which result in significant morbidity and mortality. There is paucity of data on hyperglycemic emergencies in Cameroon. The objective of this study was to investigate the precipitants and outcomes of patients admitted for hyperglycemic emergencies in the Buea Regional Hospital in the South West Region of Cameroon.

Methods

in this retrospective study the medical records of patients admitted for hyperglycemic emergencies between 2013 and 2016 in the medical unit of the Buea Regional Hospital were reviewed. We extracted data on demographic characteristics, admission clinical characteristics, precipitants, and treatment outcomes. Logistic regression was used to determine predictors of mortality.

Results

data were available for 60 patients (51.7% females) admitted for hyperglycemic emergencies. The mean age was 55.2±16.3 (range 18-86). Overall there were 51 (85%) cases of hyperosmolar hyperglycemic state. Twenty six (43.3%) of the patients had hypertension. The most common precipitants of hyperglycemic emergencies were infections (41.7%), newly diagnosed diabetes (33.3%) and non-adherence to medications (33.3%). Mean admission blood glucose was 574mg/dl±70.0mg/dl. The median length of hospital stay was 6 days. Overall case fatality rate was 21.7%. Six (46.2%) deaths were related to infections. Predictors of mortality were a Glasgow coma score <13(p<0.001), a diastolic blood pressure <60 mmHg (p=0.034) and a heart rate >90(0.057) on admission.

Conclusion

admission for hyperglycemic emergencies in this semi-urban hospital is associated with abnormally high case fatality. Infections, newly diagnosed diabetes and non-adherence to medications are the commonest precipitants of hyperglycemic emergencies. Public health measures to reduce morbidity and mortality from hyperglycemic crisis are urgently needed.

Beyond counting intended pregnancies among young women to understanding their associated factors in sub-Saharan Africa

Background

In this article we report the prevalence and determinants of intended or wanted pregnancies among young women 15–24 y of age in selected sub-Saharan African countries.

Methods

This cross-sectional study used pooled data from current Demographic and Health Surveys conducted between 1 January 2010 and 31 December 2019 in 29 countries in sub-Saharan Africa (SSA). The sample size comprised 14 257 young women (15–24 y of age). Multivariable binary logistic regression models were used to present the results as adjusted odds ratios.

Results

The prevalence of intended pregnancies was 67.7%, with the highest and lowest prevalence in Gambia (89.9%) and Namibia (37.7%), respectively. Intended pregnancy was lower among young women who had knowledge of modern contraceptives, those with a secondary/higher education and those with four or more births. Lower odds of intended pregnancy were observed among young women in the richer wealth quintile and those who lived in southern Africa.

Conclusions

To reduce intended pregnancies in sub-Saharan African countries such as Gambia, Burkina Faso and Nigeria, there is a need for government and non-governmental organisations to recalibrate current and past interventions such as investment in increasing formal education for women and poverty alleviation programmes, as well as augmenting job creation, including skill-building. These interventions have to be sensitive to the cultural realities of each setting, especially with regards to early marriages and womanhood.

Prevalence and Determinants of Unintended Pregnancy in Sub -Saharan Africa: A Systematic Review

Over forty percent of pregnancies worldwide are unintended, with a quarter of these from Africa. There is a growing body of evidence regarding the adverse health, economic, societal, and developmental consequences of unintended pregnancies. The main aim of this systematic review is to report on the current prevalence and determinants of unintended pregnancies in sub-Saharan Africa. A literature search (in PubMed, Embase, PsycINFO and Scopus) was performed up to 29 May 2019. The Joanna Briggs Institute Reviewers' Manual guidelines to assess the quality of peer-reviewed quantitative articles were used to select articles that met our inclusion criteria. A total of 29 articles from 9 countries were included in the final review. The mean unintended pregnancy rate was 33.9%. The mean unwanted pregnancy rate was 11.2%, while the mean mistimed pregnancy rate was 22.1%. Mistimed pregnancies were more frequent across the 13 studies that classified unintended pregnancies into the unwanted and mistimed pregnancy sub-groups. Being an adolescent (19 years old or less), single, and having 5 children or more were consistent risk factors for unintended pregnancy. Awareness and use of modern contraception, level of education, socio-economic status, religion, and area of residence as independent variables were either protective or associated with an increased risk of reporting a pregnancy as being unintended. The unintended pregnancy rate in sub-Saharan Africa remains high, especially among singles, adolescents, and women with 5 or more children. There was no uniform tool used across studies to capture pregnancy intention. The studies did not capture pregnancy intention among women whose pregnancies ended up as stillbirths or abortions. More research is required to ascertain when it is best to capture pregnancy intention, and how exclusion or inclusion of pregnancies ending up as stillbirths or abortions impact reported unintended pregnancy rates.

Barriers and motivators of contraceptive use among young people in Sub-Saharan Africa: A systematic review of qualitative studies

Background

In sub-Saharan Africa, about 80% of young women either use a traditional method or do not use any form of contraception at all. The objectives of this review were to ascertain the barriers and motivators of contraceptive use among young people in Sub–Saharan Africa.

Materials and methods

We conducted electronic literature searches in PubMed, EMBASE, Ebsco/PsycINFO and Scopus. We identified a total of 4,457 publications and initially screened 2626 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 13 qualitative studies were retained for the final analysis based on the Joanna Briggs criteria for assessing qualitative studies. The systematic review is registered on PROSPERO with identifier CRD42018081877.

Results

Supportive social networks, respect for privacy and confidentiality, ready availability, affordability and accessibility of contraceptives, as well as the desire to prevent unintended pregnancy and sexually transmitted infections were the motivators of contraceptive use among young people in sub-Saharan Africa. Despite these motivators, myriad of personal, societal, and health systems-based barriers including myths and misconceptions, known side effects of contraceptives, prohibitive social norms, and negative attitude of health professionals were the major barriers to contraceptive use among young people.

Conclusion

Sub-Saharan African countries with widespread barriers to contraceptive use among young people may not be able to achieve the Sustainable Development Goal 3.8 target of achieving health for all by the year 2030. Interventions intended to improve contraceptive use need to be intersectoral and multi-layered, and designed to carefully integrate the personal, cultural, organizational and political dimensions of contraception.

Health knowledge and care seeking behaviour in resource-limited settings amidst the COVID-19 pandemic: A qualitative study in Ghana

BACKGROUND

The emergence of a pandemic presents challenges and opportunities for healthcare, health promotion interventions, and overall improvement in healthcare seeking behaviour. This study explored the impact of COVID-19 on health knowledge, lifestyle, and healthcare seeking behaviour among residents of a resource-limited setting in Ghana.

METHODS

This qualitative study adopted an exploratory design to collect data from 20 adult residents in the Cape Coast Metropolis using face-to-face in-depth interviews. Data collected were analysed thematically and statements from participants presented verbatim to illustrate the themes realised.

RESULTS

Health knowledge has improved due to COVID-19 in terms of access to health information and increased understanding of health issues. There were reductions in risky health-related lifestyles (alcohol intake, sharing of personal items, and consumption of junk foods) while improvements were observed in healthy lifestyles such as regular physical exercise and increased consumption of fruits and vegetables. COVID-19 also positively impacted health seeking behaviour through increased health consciousness and regular check-ups. However, reduced healthcare utilization was prevalent.

CONCLUSION

The COVID-19 pandemic has presented a positive cue to action and helped improved health knowledge, lifestyle, and care seeking behaviour although existing health system constrains and low economic status reduced healthcare utilization. To improve health systems, health-related lifestyles and healthcare seeking behaviour as well as overall health outcomes even after the pandemic wades off, COVID-19 associated conscious and unconscious reforms should be systematically harnessed.

Decision-making preferences and risk factors regarding early adolescent pregnancy in Ghana: stakeholders' and adolescents' perspectives from a vignette-based qualitative study

BACKGROUND

Worldwide, over half of the adolescent pregnancies recorded are unintended. The decision to continue the pregnancy to term or to opt for an abortion is a constant dilemma that is directly or indirectly influenced by stakeholders and also by the wider social environment. This study aimed at understanding the perceived decision-making preferences and determinants of early adolescent pregnancy in the Jamestown area of Accra in Ghana.

METHODS

A vignette-based qualitative study design was used. Eight focus group discussions were carried among various purposively selected groups of participants: parents, teachers, adolescent students who had not been pregnant before, and adolescents who had had at least one pregnancy in the past. The vignette was a hypothetical case of a 15-year-old high school student who had not experienced her menses for the past 6 weeks. The data were analyzed using a thematic analysis approach.

RESULTS

Lack of parent-daughter communication, the taboo on discussing sex-related issues in households and weak financial autonomy were considered to be the main contributing factors to the high early adolescent pregnancy rates in the community. Partner readiness to assume responsibility for the girl and the baby was a key consideration in either continuing the pregnancy to term or opting for an abortion. The father was overwhelmingly considered to be the one to take the final decision regarding the pregnancy outcome. Irrespective of the fact that the respondents were very religious, opting for an abortion was considered acceptable under special circumstances, especially if the pregnant adolescent was doing well in school.

CONCLUSION

Inadequate and inappropriate communication practices around sexuality issues, as well as weak financial autonomy are the major predictors of early adolescent pregnancy in this community. The father is perceived to be the main decision maker regarding a young adolescent's pregnancy outcome. Policy-makers should carefully evaluate the implications of this overwhelming perceived desire for the father to be the final decision-maker regarding adolescent pregnancy outcomes in this community.

Mandatory pre-abortion counseling is a barrier to accessing safe abortion services

Empirical research showcases that pre-abortion counseling scarcely reverses the woman’s decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman’s reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.