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Photovoice methodology centralizes the voices of marginalised populations within health systems using photography and critical dialogue to record, reflect and communicate community health issues. This paper presents findings from applying photovoice to explore and document the lived experiences of groups of marginalised populations in six low- and middle-income countries: Cambodia, Ghana, Nepal, Sierra Leone, Uganda and Zambia. The strengths of using photovoice included: creating safe spaces for communication; community solidarity and stakeholder engagement; community ownership of actions and advocacy; developing new soft skills and confidence; capturing hidden community challenges; and taking collective action. Suggestions for use in future photovoice studies include: providing space for the exploration of contextual factors before implementation; developing a capacity strengthening plan to ensure participants have the competencies required to effectively take part in research and dissemination; considering the use of non-visual methods alongside photovoice when needed; and having in place partnership structures between researchers and participants that facilitate power sharing, agency, empowerment and joint decision making. Lastly, we present recommendations that have the potential to strengthen the value and use of photovoice as more than a participatory method but also a vehicle for individual, relational and health systems improvements.

The diminishing effectiveness of antimicrobials raises serious concerns for\ud human health. While policy makers grapple to reduce the overuse of\ud antimicrobial medicines to stem the rise of antimicrobial resistance,\ud insufficient attention has been paid to how this applies to low-resource\ud contexts. We provide an in-depth portrayal of antimicrobial prescribing\ud at primary health care level in rural Chikwawa District, Malawi.\ud Ethnographic fieldwork took place over 18 months (2018–2020). We\ud surveyed 22 health facilities in the district, observed 1348 health\ud worker-patient consultations, and carried out 49 in-depth interviews\ud with staff and patients. Care was centred around provision of an\ud antimicrobial. Amid chronic lack of essential medicines and other\ud resources, clinic interactions were tightly scripted, providing patients\ud little time to question or negotiate their treatment. We develop the\ud concept of ‘antibiotic vulnerabilities’ to reveal multiple ways in which\ud provision of antimicrobials in rural Malawi impacts care in conditions of\ud extreme scarcity. Antibiotics are central and essential to primary care.\ud As targets for optimal antimicrobial prescribing take a more central role\ud in global policy, close attention is required of the ramifications for the\ud delivery of care to ensure that efforts to stem resistance do not\ud undermine the goal of improved health for all.

Background Ratios of bacteriologically positive tuberculosis (TB) prevalence to notification rates are used to characterise typical durations of TB disease. However, this ignores the clinical spectrum of tuberculosis disease and potentially long infectious periods with minimal or no symptoms prior to care-seeking. Methods We developed novel statistical models to estimate progression from initial bacteriological positivity including smear conversion, symptom onset and initial care-seeking. Case-detection ratios, TB incidence, durations, and other parameters were estimated by fitting the model to tuberculosis prevalence survey and notification data (one subnational and 11 national datasets) within a Bayesian framework using Markov chain Monte Carlo methods. Results Analysis across 11 national datasets found asymptomatic tuberculosis durations in the range 4–8 months for African countries; three countries in Asia (Cambodia, Lao PDR, and Philippines) showed longer durations of > 1 year. For the six countries with relevant data, care-seeking typically began half-way between symptom onset and notification. For Kenya and Blantyre, Malawi, individual-level data were available. The sex-specific durations of asymptomatic bacteriologically-positive tuberculosis were 9.0 months (95% credible interval [CrI]: 7.2–11.2) for men and 8.1 months (95% CrI: 6.2–10.3) for women in Kenya, and 4.9 months (95% CrI: 2.6–7.9) for men and 3.5 months (95% CrI: 1.3–6.2) for women in Blantyre. Age-stratified analysis of data for Kenya showed no strong age-dependence in durations. For Blantyre, HIV-stratified analysis estimated an asymptomatic duration of 1.3 months (95% CrI: 0.3–3.0) for HIV-positive people, shorter than the 8.5 months (95% CrI: 5.0–12.7) for HIV-negative people. Additionally, case-detection ratios were higher for people living with HIV than HIV-negative people (93% vs 71%). Conclusion Asymptomatic TB disease typically lasts around 6 months. We found no evidence of age-dependence, but much shorter durations among people living with HIV, and longer durations in some Asian settings. To eradicate TB transmission, greater gains may be achieved by proactively screening people without symptoms through active case finding interventions

This publication addresses the limited use of qualitative methods in neglected tropical disease (NTD) programmes. It describes a scoping literature review conducted to inform the development of a guide to inform the use of rapid qualitative assessments to strengthen NTD mass drug administration (MDA) programmes. The review assessed how qualitative methods are currently used by NTD programmes and identified qualitative approaches from other health and development programmes with the potential to strengthen the design of MDA interventions. Systematic review articles were reviewed and searched using key terms conducted on Google Scholar and PubMed. Results show that methods used by NTD programmes rely heavily on focus group discussions and in-depth interviews, often with time-consuming analysis and limited information on how results are applied. Results from other fields offered insight into a wider range of methods, including participatory approaches, and on how to increase programmatic uptake of findings. Recommendations on how to apply these findings to NTD control are made. The topic of human resources for qualitative investigations is explored and a guide to improve MDAs using qualitative methods is introduced. This guide has direct applicability across the spectrum of NTDs as well as other public health programmes.

Five years of sustained indoor residual spraying (IRS) of insecticide from 2014 to 2019, first using a carbamate followed by an organophosphate, was associated with a marked reduction in the incidence of malaria in five districts of Uganda. We assessed changes in malaria incidence over an additional 21 months, corresponding to a change in IRS formulations using clothianidin with and without deltamethrin. Using enhanced health facility surveillance data, our objectives were to 1) estimate the impact of IRS on monthly malaria case counts at five surveillance sites over a 6.75 year period, and 2) compare monthly case counts at five facilities receiving IRS to ten facilities in neighboring districts not receiving IRS. For both objectives, we specified mixed effects negative binomial regression models with random intercepts for surveillance site adjusting for rainfall, season, care-seeking, and malaria diagnostic. Following the implementation of IRS, cases were 84% lower in years 4–5 (adjusted incidence rate ratio [aIRR] = 0.16, 95% CI 0.12–0.22), 43% lower in year 6 (aIRR = 0.57, 95% CI 0.44–0.74), and 39% higher in the first 9 months of year 7 (aIRR = 1.39, 95% CI 0.97–1.97) compared to pre-IRS levels. Cases were 67% lower in IRS sites than non-IRS sites in year 6 (aIRR = 0.33, 95% CI 0.17–0.63) but 38% higher in the first 9 months of year 7 (aIRR = 1.38, 95% CI 0.90–2.11). We observed a resurgence in malaria to pre-IRS levels despite sustained IRS. The timing of this resurgence corresponded to a change of active ingredient. Further research is needed to determine causality.

Introduction\ud Understanding human mixing patterns relevant to infectious diseases spread through close contact is vital for modelling transmission dynamics and optimisation of disease control strategies. Mixing patterns in low-income countries like Malawi are not well known.\ud \ud Methodology\ud We conducted a social mixing survey in urban Blantyre, Malawi between April and July 2021 (between the 2nd and 3rd wave of COVID-19 infections). Participants living in densely-populated neighbourhoods were randomly sampled and, if they consented, reported their physical and non-physical contacts within and outside homes lasting at least 5 min during the previous day. Age-specific mixing rates were calculated, and a negative binomial mixed effects model was used to estimate determinants of contact behaviour.\ud \ud Results\ud Of 1201 individuals enroled, 702 (58.5%) were female, the median age was 15 years (interquartile range [IQR] 5–32) and 127 (10.6%) were HIV-positive. On average, participants reported 10.3 contacts per day (range: 1–25). Mixing patterns were highly age-assortative, particularly those within the community and with skin-to-skin contact. Adults aged 20–49 y reported the most contacts (median:11, IQR: 8–15) of all age groups; 38% (95%CI: 16–63) more than infants (median: 8, IQR: 5–10), who had the least contacts. Household contact frequency increased by 3% (95%CI: 2–5) per additional household member. Unemployed participants had 15% (95%CI: 9–21) fewer contacts than other adults. Among long range (>30 m away from home) contacts, secondary school children had the largest median contact distance from home (257 m, IQR 78–761). HIV-positive status in adults >=18 years-old was not associated with changed contact patterns (rate ratio: 1.01, 95%CI: (0.91–1.12)). During this period of relatively low COVID-19 incidence in Malawi, 301 (25.1%) individuals stated that they had limited their contact with others due to COVID-19 precautions; however, their reported contacts were 8% (95%CI: 1–13) higher.\ud \ud Conclusion\ud In urban Malawi, contact rates, are high and age-assortative, with little reported behavioural change due to either HIV-status or COVID-19 circulation. This highlights the limits of contact-restriction-based mitigation strategies in such settings and the need for pandemic preparedness to better understand how contact reductions can be enabled and motivated.

This study explores the perceived influence of climate change on the health of Hamer pastoralists and their livestock in south-western Ethiopia. A combination of focus group discussions and key informant interviews were conducted with Hamer communities as well as local health workers, animal health workers and non-governmental organisation (NGO) staff. Thematic framework analysis was used to analyse the data. Reductions in rangeland, erratic rainfall, recurrent droughts and loss of seasonality were perceived to be the biggest climate challenges influencing the health and livelihoods of the Hamer. Communities were travelling greater distances to access sufficient grazing lands, and this was leading to livestock deaths and increases in ethnic violence. Reductions in suitable rangeland were also precipitating disease outbreaks in animals due to increased mixing of different herds. Negative health impacts in the community stemmed indirectly from decreases in livestock production, uncertain crop harvests and increased water scarcity. The remoteness of grazing lands has resulted in decreased availability of animal milk, contributing to malnutrition in vulnerable groups, including children. Water scarcity in the region has led to utilisation of unsafe water sources resulting in diarrhoeal illnesses. Further, seasonal shifts in climate-sensitive diseases such as malaria were also acknowledged. Poorly resourced healthcare facilities with limited accessibility combined with an absence of health education has amplified the community’s vulnerability to health challenges. The resilience and ambition for livelihood diversification amongst the Hamer was evident. The introduction of camels, increase in permanent settlements and new commercial ideas were transforming their livelihood strategies. However, the Hamer lack a voice to express their perspectives, challenges and ambitions. There needs to be collaborative dynamic dialogue between pastoral communities and the policy-makers to drive sustainable development in the area without compromising the values, traditions and knowledge of the pastoralists.

Anopheles stephensi mosquitoes are urban malaria vectors in Asia that have recently invaded the Horn of Africa. We detected emergence of An. stephensi mosquitoes in 2 noncontiguous states of eastern Sudan. Results of mitochondrial DNA sequencing suggest the possibility of distinct invasions, potentially from a neighboring country.

Introduction\ud The beta EQ-5D-Y-5L is a new patient-reported outcome measure (PROM) for children aged 8–15 years that is currently under development by the EuroQol Group. The EQ-5D-Y-5L is similar to the EQ-5D-Y but has five levels of severity per dimension rather than three. The increased number of levels increases the granularity of the responses but possibly has also increased the difficulty of distinguishing between levels. The EuroQoL’s Version Management Committee (VMC) required a robust method to determine how well children distinguish between the five EQ-5D-Y-5L ordinal severity qualifiers (i.e. ‘no problems’ through to ‘extreme problems’), which are a critical aspect of both health measurement and the valuation of health states.\ud \ud Objective\ud This paper describes the development, testing, selection, and piloting of such a method.\ud \ud Methods\ud Following a literature review and consultation with the wider VMC and a Language Support Services agency, a range of exercises were developed to assess the ordering and comprehension of the five severity qualifiers. Three exercises were pre-tested with children in Spain and New Zealand. One exercise, preferred and understood by children, was then piloted.\ud \ud Results\ud Five children in Spain and 11 in New Zealand tested the three exercises. In both countries, all children found the three exercises easy to understand and complete. Of the 12 children who expressed a preference, nine said they preferred the card ranking. Card ranking also allowed the interviewer to observe difficult choices being made as the children physically rearranged the card order until they settled on their final order. Following rigorous assessment of translatability and cultural portability by an independent Language Support Service, card ranking was piloted in South Africa (n = 9) and in Indonesia (n = 10), where it highlighted severity qualifier order inversions that would otherwise not have been detected.\ud \ud Conclusion\ud The card ranking exercise was found to be a preferred and acceptable means of testing the ordering of translations of severity qualifiers among children. Additional formal testing of the exercise in other countries and languages is now underway. The approach developed and tested by the VMC for cognitive debriefing of beta EQ-5D-Y-5L language/country versions may also be useful in determining the adequacy of translated qualifiers in debriefing of adult EQ-5D-5L versions and other PROMs.

Background\ud \ud Rapid diagnostic tests (RDTs) developed for point of care detection of SARS-CoV-2 antigen are recommended by WHO to use trained health care workers to collect samples. We hypothesised that self-taken samples are non-inferior for use with RDTs to diagnose COVID-19. We designed a prospective diagnostic evaluation comparing self-taken and healthcare worker (HCW)-taken throat/nasal swabs to perform RDTs for SARS-CoV-2, and how these compare to RT-PCR.\ud \ud Methods\ud \ud Eligible participants 18 years or older with symptoms of COVID-19. 250 participants recruited at the NHS Test and Trace drive-through community PCR testing site (Liverpool, UK); one withdrew before analysis. Self-administered throat/nasal swab for the Covios® RDT, a trained HCW taken throat/nasal sample for PCR and HCW comparison throat/nasal swab for RDT were collected. RDT results were compared to RT-PCR, as the reference standard, to calculate sensitivity and specificity.\ud \ud Findings\ud \ud Seventy-five participants (75/249, 30.1%) were positive by RT-PCR. RDTs with self-taken swabs had a sensitivity of 90.5% (67/74, 95% CI: 83.9–97.2), compared to 78.4% (58/74, 95% CI: 69.0–87.8) for HCW-taken swabs (absolute difference 12.2%, 95% CI: 4.7–19.6, p = 0.003). Specificity for self-taken swabs was 99.4% (173/174, 95% CI: 98.3–100.0), versus 98.9% (172/174, 95% CI: 97.3–100.0) for HCW-taken swabs (absolute difference 0.6%, 95% CI: 0.5–1.7, p = 0.317). The PPV of self-taken RDTs (98.5%, 67/68, 95% CI: 95.7–100.0) and HCW-taken RDTs (96.7%, 58/60, 95% CI 92.1–100.0) were not significantly different (p = 0.262). However, the NPV of self-taken swab RDTs was significantly higher (96.1%, 173/180, 95% CI: 93.2–98.9) than HCW-taken RDTs (91.5%, 172/188, 95% CI 87.5–95.5, p = 0.003).\ud \ud Interpretation\ud \ud In conclusion, self-taken swabs for COVID-19 testing offer an accurate alternative to healthcare worker taken swabs for use with RDTs. Our results demonstrate that, with no training, self-taken throat/nasal samples can be used by lay individuals as part of rapid testing programmes for symptomatic adults. This is especially important where the lack of trained healthcare workers restricts access to testing.

Despite the functioning of the Bologna Declaration, the knowledge and skills of graduates educated in different countries may differ significantly. Therefore, this article aims to present the differences in results of the final exam in pharmacy among Polish pharmacy students. This exam was modeled on the British national exam supervised by the General Pharmaceutical Council. The exam was conducted in three cities in Poland, among a total of 175 final-year students (a full sample of those eligible was 451 with 276 refusals (38.58% response rate)). Taking the exam was voluntary and anonymous. The results indicate that none of the Polish students achieved the 70% mark required to pass the Great Britain exam. Significant differences in test results were noticed between cities. Students achieved the best average exam result in Bydgoszcz (46.35%), then in Warsaw (38.81%) and Łódź (38.35%). The pharmaceutical education system in Poland requires complete changes that will prepare future pharmacists for clinical work.

Background Child and adolescent mental health problems are a global public mental health priority. However, there is a lack of evidence-based scalable psychological interventions for adolescents living in low resource settings. This trial was designed to evaluate the feasibility and acceptability of delivering the World Health Organization’s Early Adolescent Skills for Emotions (EASE) intervention at public schools in a rural sub-district in Rawalpindi, Pakistan. Methods A two arm, single blinded, feasibility cluster randomized controlled trial with mixed-methods evaluation was conducted with 59 adolescents and their caregivers from 8 public schools. In the 4 intervention arm schools, 6 non-specialist facilitators delivered the culturally-adapted EASE group sessions to the adolescents (n = 29) and their caregivers with desired fidelity under the supervision of in-country supervisors. Results The participation rate of adolescents in the intervention sessions was 83%. The intervention strategies were implemented by the adolescents. However, attending biweekly sessions at schools was challenging for caregivers with only 50% caregivers attending the sessions. Conclusions The results of this study support the feasibility and acceptability of delivering this culturally adapted intervention through non-specialist facilitators in school settings in Pakistan and pave the way to conduct a fully powered cluster randomized controlled trial to test the effectiveness of intervention to improve psychological outcomes in adolescents. Trial registration Trial registered with Clinicaltrials.gov prospectively; NCT04254393.

Background A cohesive and strategic governance approach is needed to improve the health workforce (HW). To achieve this, the WHO Global Strategy on Human Resources for Health (HRH) promotes mechanisms to coordinate HRH stakeholders, HRH structures and capacity within the health sector to support the development and implementation of a comprehensive HW agenda and regular reporting through WHO’s National Health Workforce Accounts (NHWA). Methods Using an adapted HRH governance framework for guidance and analysis, we explored the existence and operation of HRH coordination mechanisms and HRH structures in Malawi, Nepal, Sudan and additionally from a global perspective through 28 key informant interviews and a review of 165 documents. Results A unified approach is needed for the coordination of stakeholders who support the timely development and oversight of an appropriate costed HRH strategy subsequently implemented and monitored by an HRH unit. Multiple HRH stakeholder coordination mechanisms co-exist, but the broader, embedded mechanisms seemed more likely to support and sustain a comprehensive intersectoral HW agenda. Including all stakeholders is challenging and the private sector and civil society were noted for their absence. The credibility of coordination mechanisms increases participation. Factors contributing to credibility included: high-level leadership, organisational support and the generation and availability of timely HRH data and clear ownership by the ministry of health. HRH units were identified in two study countries and were reported to exist in many countries, but were not necessarily functional. There is a lack of specialist knowledge needed for the planning and management of the HW amongst staff in HRH units or equivalent structures, coupled with high turnover in many countries. Donor support has helped with provision of technical expertise and HRH data systems, though the benefits may not be sustained. Conclusion While is it important to monitor the existence of HRH coordination mechanisms and HRH structure through the NHWA, improved ‘health workforce literacy’ for both stakeholders and operational HRH staff and a deeper understanding of the operation of these functions is needed to strengthen their contribution to HW governance and ultimately, wider health goals.

Long-lasting insecticidal nets (LLINs) supplemented with the synergist piperonyl butoxide have been developed in response to growing pyrethroid resistance; however, their durability in the field remains poorly described. A pragmatic cluster-randomised trial was embedded into Uganda's 2017-2018 LLIN distribution to compare the durability of LLINs with and without PBO. A total of 104 clusters (health sub-districts) were included with each receiving one of four LLIN products, two with pyrethroid + PBO (Olyset Plus and PermaNet 3.0) and two pyrethroid-only (Olyset Net and PermaNet 2.0). Nets were sampled at baseline, 12 and 25 months post-distribution to assess physical condition, chemical content, and bioefficacy. Physical condition was quantified using proportionate Hole Index and chemical content measured using high-performance liquid chromatography. Bioefficacy was assessed with three-minute World Health Organisation (WHO) Cone and Wireball assays using pyrethroid-resistant Anopheles gambiae, with 1-h knockdown and 24-h mortality recorded. There was no difference in physical durability between LLIN products assessed (P = 0.644). The pyrethroid content of all products remained relatively stable across time-points but PBO content declined by 55% (P

Background\ud Cases of human monkeypox are rarely seen outside of west and central Africa. There are few data regarding viral kinetics or the duration of viral shedding and no licensed treatments. Two oral drugs, brincidofovir and tecovirimat, have been approved for treatment of smallpox and have demonstrated efficacy against monkeypox in animals. Our aim was to describe the longitudinal clinical course of monkeypox in a high-income setting, coupled with viral dynamics, and any adverse events related to novel antiviral therapies.\ud \ud Methods\ud In this retrospective observational study, we report the clinical features, longitudinal virological findings, and response to off-label antivirals in seven patients with monkeypox who were diagnosed in the UK between 2018 and 2021, identified through retrospective case-note review. This study included all patients who were managed in dedicated high consequence infectious diseases (HCID) centres in Liverpool, London, and Newcastle, coordinated via a national HCID network.\ud \ud Findings\ud We reviewed all cases since the inception of the HCID (airborne) network between Aug 15, 2018, and Sept 10, 2021, identifying seven patients. Of the seven patients, four were men and three were women. Three acquired monkeypox in the UK: one patient was a health-care worker who acquired the virus nosocomially, and one patient who acquired the virus abroad transmitted it to an adult and child within their household cluster. Notable disease features included viraemia, prolonged monkeypox virus DNA detection in upper respiratory tract swabs, reactive low mood, and one patient had a monkeypox virus PCR-positive deep tissue abscess. Five patients spent more than 3 weeks (range 22–39 days) in isolation due to prolonged PCR positivity. Three patients were treated with brincidofovir (200 mg once a week orally), all of whom developed elevated liver enzymes resulting in cessation of therapy. One patient was treated with tecovirimat (600 mg twice daily for 2 weeks orally), experienced no adverse effects, and had a shorter duration of viral shedding and illness (10 days hospitalisation) compared with the other six patients. One patient experienced a mild relapse 6 weeks after hospital discharge.\ud \ud Interpretation\ud Human monkeypox poses unique challenges, even to well resourced health-care systems with HCID networks. Prolonged upper respiratory tract viral DNA shedding after skin lesion resolution challenged current infection prevention and control guidance. There is an urgent need for prospective studies of antivirals for this disease.

Background The estimated five million snakebites per year are an important health problem that mainly affect rural poor populations. The global goal is to halve both mortality and morbidity from this neglected tropical disease by 2030. Data on snakebite morbidity are sparse and mainly obtained from hospital records. Methods This community-based study was conducted among 379 rural residents with or without a history of snakebite in the Ashanti and Upper West regions of Ghana. All participants in the snakebite group were bitten at least six months before the day of survey. The World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Buruli Ulcer Functional Limitation Score were used to obtain patient-reported measure of functioning and disability. Long-term consequences were evaluated based on the severity of the symptoms at the time of the snakebite. Findings The median (IQR) time since the snakebite was 8.0 (3.5–16.5) years. The relative risk of disability was 1.54 (95% CI, 1.17–2.03) in the snakebite group compared to the community controls. Among patients with clinical symptoms suggesting envenoming at the time of bite, 35% had mild/moderate disabilities compared to 20% in the control group. The disability domains mainly affected by snakebite envenoming were cognition level, mobility, life activities and participation in society. A combination of the severity of symptoms at the time of the bite, age, gender and region of residence most accurately predicted the odds of having functional limitations and disabilities. Conclusion The burden of snakebite in the community includes long-term disabilities of mild to moderate severity, which need to be considered when designing appropriate public health interventions. Estimating the total burden of snakebite is complicated by geographic differences in types of snakes and their clinical manifestations.

Background\ud Sepsis protocols in sub-Saharan Africa (sSA) are typically extrapolated from high-income settings, yet sepsis in sSA is likely caused by distinct pathogens and may require novel treatment strategies. Data to guide such strategies are lacking. We aimed to define causes and modifiable factors associated with sepsis outcome in Blantyre, Malawi to inform design of treatment strategies tailored to sSA.\ud \ud Methods\ud We recruited 225 adults meeting a sepsis case-definition defined by fever and organ dysfunction, in an observational cohort study at a single tertiary centre. Aetiology was defined using culture, antigen detection, serology and PCR. Effect of treatments on 28-day outcomes were assessed by Bayesian logistic regression.\ud \ud Results\ud 143/213 (67%) of participants were HIV-infected. We identified a diagnosis in 145/225 (64%) participants: most commonly tuberculosis (34%) followed by invasive bacterial (17%) and arboviral infections (13%) and malaria (9%) Tuberculosis was associated with HIV infection whereas malaria and arboviruses with the absence of HIV infection. Antituberculous chemotherapy was associated with survival (aOR 28-day death 0.17 [95% CrI 0.05-0.49] for receipt of antituberculous therapy). Of those with confirmed aetiology, 83% received the broad-spectrum antibacterial ceftriaxone but it would be expected to be active in only 24%.\ud \ud Conclusions\ud Sepsis in Blantyre, Malawi, is caused by a range of pathogens; the majority are not susceptible to the broad-spectrum antibacterials that most patients receive. HIV status is a key determinant of aetiology. Novel antimicrobial strategies for sepsis tailored to sSA – including consideration of empiric antitubercular therapy in the HIV-infected - should be developed and trialed.

COVID-19 brings uncertainties and new precarities for communities and researchers, altering and amplifying relational vulnerabilities (vulnerabilities which emerge from relationships of unequal power and place those less powerful at risk of abuse and violence). Research approaches have changed too, with increasing use of remote data collection methods. These multiple changes necessitate new or adapted safeguarding responses. This practice piece shares practical learnings and resources on safeguarding from the Accountability for Informal Urban Equity hub, which uses participatory action research, aiming to catalyse change in approaches to enhancing accountability and improving the health and well-being of marginalised people living and working in informal urban spaces in Bangladesh, India, Kenya and Sierra Leone. We outline three new challenges that emerged in the context of the pandemic (1): exacerbated relational vulnerabilities and dilemmas for researchers in responding to increased reports of different forms of violence coupled with support services that were limited prior to the pandemic becoming barely functional or non-existent in some research sites, (2) the increased use of virtual and remote research methods, with implications for safeguarding and (3) new stress, anxiety and vulnerabilities experienced by researchers. We then outline our learning and recommended action points for addressing emerging challenges, linking practice to the mnemonic ‘the four Rs: recognise, respond, report, refer’. COVID-19 has intensified safeguarding risks. We stress the importance of communities, researchers and co-researchers engaging in dialogue and ongoing discussions of power and positionality, which are important to foster co-learning and co-production of safeguarding processes.

Long-lasting insecticidal nets (LLINs) are the foundation of malaria control but resistance of mosquito vectors to pyrethroids threatens their effectiveness. We embedded a cluster-randomised trial into Uganda's 2017-18 campaign to distribute LLINs. LLINs with piperonyl butoxide (PBO) reduced parasite prevalence more effectively than conventional LLINs (without PBO) for 18 months. Here, we report the final 25-month survey results.LLINEUP was a cluster-randomised trial conducted in 48 districts in eastern and western Uganda. 104 health subdistricts (clusters) without ongoing or planned indoor residual spraying with pirimiphos-methyl (Actellic, Basel, Switzerland) were eligible for inclusion in the trial. Clusters were randomly assigned to PBO LLINs (PermaNet 3.0 or Olyset Plus) and conventional LLINs (PermaNet 2.0 or Olyset Net) with proportionate randomisation using STATA version 14.2. LLINs were delivered from March 25, 2017, to March 18, 2018. Between April 23, 2019, and Sept 13, 2019, community surveys were conducted in 50 randomly selected households per cluster; ten households per cluster were randomly selected for entomology surveys. Mosquitoes were collected in the morning from indoor surfaces of households using Prokopack aspirators. Due to COVID-19 restrictions, only 90 of the 104 clusters were surveyed at 25 months. The primary outcome was parasite prevalence by microscopy in children aged 2-10 years, assessed in the as-treated population, determined using the results from the 6-month household survey on the type of LLINs received in each cluster. This trial is registered with ISRCTN, ISRCTN17516395, and is now completed.In the as-treated analysis, two clusters were excluded (no predominant LLIN received) and four were reassigned; 40 PBO LLIN clusters (30 PermaNet 3.0, ten Olyset Plus) and 48 non-PBO LLIN (36 PermaNet 2.0, 12 Olyset Net) were included. Parasite prevalence was 17·1% (506 of 2958 participants) in the PBO group and 19·8% (701 of 3534) in the non-PBO group (prevalence ratio adjusted for baseline 0·80 [95% CI 0·69-0·93], p=0·0048). Comparing within-treatment group parasite prevalence to baseline, parasite prevalence ratios were lower in the PBO groups at all timepoints, but the difference was greatest at 6 months (PBO LLINs parasite prevalence at baseline 28·8% [1001 of 3472, 95% CI 27·3-30·4] vs at 6 months 12·0% [361 of 3009, 10·9-13·2], prevalence ratio [PR] 0·43 [95% CI 0·36-0·52], p0·0001; non-PBO LLINs parasite prevalence at baseline 25·4% [1015 of 4004, 24·0-26·7] vs 6 months 14·8% [526 of 3551, 13·7-16·0], PR 0·60 [0·54-0·68], p0·0001) and 25 months (PBO LLINs parasite prevalence at 25 months 17·1% [506 of 2958, 15·8-18·5], PR 0·63 [95% CI 0·57-0·71], p0·0001; non-PBO LLINs parasite prevalence at 25 months 19·8% [701 of 3534, 18·5-21·2], PR 0·79 [0·73-0·86], p0·0001).In Uganda, PBO LLINs outperformed pyrethroid-only LLINs for 25 months. WHO concluded that PBO LLINs are more effective against malaria than non-PBO LLINs when resistance to pyrethroids is high and issued a conditional recommendation suggesting PBO LLINs should be deployed in areas of pyrethroid resistance.The Against Malaria Foundation, UK Department for International Development, Innovative Vector Control Consortium, and Bill and Melinda Gates Foundation.

Background Compensation for research participants can be provided for reasons including reimbursement of costs; compensation for time lost, discomfort or inconvenience; or expression of appreciation for participation. This compensation involves numerous ethical complexities, at times entailing competing risks. In the context of transnational research, often incorporating contexts of economic inequality, power differentials and post-colonialism, these issues extend into wider questions of ethical research conduct. Methods We describe experiences of conducting a community-based study of air pollution in southern Malawi incorporating ethnographic, participatory and air quality monitoring elements. Decisions surrounding participant compensation evolved in response to changing circumstances in the field. Results Attention to careful researcher–participant relationships and responsiveness to community perspectives allowed dynamic, contextualised decision-making around participant compensation. Despite widely cited risks, including but not restricted to undue influence of monetary compensation on participation, we learned that failure to adequately recognise and compensate participants has its own risks, notably the possibility of ‘ethics dumping’. Conclusions We recommend active engagement with research participants and communities with integration of contextual insights throughout, including participant compensation, as for all elements of research conduct. Equitable research relationships encompass four central values: fairness, care, honesty and respect.

Background People with disabilities experience significant health inequalities. In Malawi, where most individuals live in low-income rural settings, many of these inequalities are exacerbated by restricted access to health care services. This qualitative study explores the barriers to health care access experienced by individuals with a mobility or sensory impairment, or both, living in rural villages in Dowa district, central Malawi. In addition, the impact of a chronic lung condition, alongside a mobility or sensory impairment, on health care accessibility is explored. Methods Using data from survey responses obtained through the Research for Equity And Community Health (REACH) Trust’s randomised control trial in Malawi, 12 adult participants, with scores of either 3 or 4 in the Washington Group Short Set (WGSS) questions, were recruited. The WGSS questions concern a person’s ability in core functional domains (including seeing, hearing and moving), and a score of 3 indicates ‘a lot of difficulty’ whilst 4 means ‘cannot do at all’. People with cognitive impairments were not included in this study. All who were selected for the study participated in an individual in-depth interview and full recordings of these were then transcribed and translated. Results Through thematic analysis of the transcripts, three main barriers to timely and adequate health care were identified: 1) Cost of transport, drugs and services, 2) Insufficient health care resources, and 3) Dependence on others. Attitudinal factors were explored and, whilst unfavourable health seeking behaviour was found to act as an access barrier for some participants, community and health care workers’ attitudes towards disability were not reported to influence health care accessibility in this study. Conclusions This study finds that health care access for people with disabilities in rural Malawi is hindered by closely interconnected financial, practical and social barriers. There is a clear requirement for policy makers to consider the challenges identified here, and in similar studies, and to address them through improved social security systems and health system infrastructure, including outreach services, in a drive for equitable health care access and provision.

The advent of antibiotics transformed the global public health landscape, dramatically improving health outcomes. Drawing on historical and ethnographic research on sex work in Zimbabwe, we examine the role of antibiotics in the management of sexually transmitted infections among sex workers, from punitive colonial approaches to "empowerment"-based discourses. We illustrate how programs for sex workers, while valued by these women, are narrow, exclusionary, and enact a pharmaceuticalized form of governance that hangs on the efficacy of antibiotics. With antibiotics' efficacy under threat, we consider how latent colonial logics are in danger of being reactivated to control both infections and women.

Introduction: In this paper, we aim to further understand how health research consortia may be structured to better support research capacity strengthening (RCS) outcomes. The primary research questions include: in what ways do consortium members perceive that they and their respective institutions’ research capacity is strengthened from said membership? And, drawing on member experiences, what are the common factors that enable these perceived gains in research capacity to be realised (or realised to a greater extent)? \ud \ud Methods: A qualitative study set within phase one (2016-2021) of the ‘Developing Excellence in Leadership, Training and Science’ (DELTAS) Africa initiative. Semi-structured interviews were completed with a total of 69 participants from seven institutions across six African countries belonging to three out of the eleven phase one DELTAS Africa consortia. Data were analysed thematically via a general inductive approach. \ud \ud Results: A diverse array of perceived individual and institutional benefits of RCS consortium membership were reported. Individual benefits were primarily related to greater access to training, resources and expertise as well as greater opportunities to engage in essential research and research leadership activities. Many of the reported institutional-level benefits of RCS consortium membership such as a better capacitated and/or expanded workforce were also primarily driven through investment in individuals. Four enabling factors presented as especially influential in realising these benefits or realising them to a greater extent. These included: 1) access to funding; 2) inclusive and engaging leadership; 3) a diverse array of facilitated interactions for consortium members; 4) and an efficient interface between a consortium and their respective member institutions. \ud \ud Conclusion: Many of the reported benefits of RCS consortium membership were realised through funding access, yet attention to the other three enabling factors may further amplify the advantages conferred by funding access or, when funds are insufficient, ensure worthwhile gains in RCS may still be achieved in a consortium context.

During a microbiological and genomic surveillance study conducted to investigate the molecular epidemiology of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli from community-acquired urinary tract infections (UTI) and commercial meat samples, in a Brazilian city with a high occurrence of infections by ESBL-producing bacteria, we have identified the presence of CTX-M (-2, -14, -15, -24, -27 and -55)-producing E. coli of international clones ST38, ST117, ST131 and ST354. The ST131 was more prevalent in human samples, and worryingly the high-risk ST131-C1-M27 was identified in human infections for the first time. We also detected CTX-M-55-producing E. coli ST117 from meat samples (i.e., chicken and pork) and human infections. Moreover, the clinically relevant CTX-M-24-positive E. coli ST354 clone was detected for the first time in human samples. In summary, our results highlight a potential of commercialized meat as a reservoir of high-priority E. coli lineages in the community, whereas the identification of E. coli ST131-C1-M27 indicates that novel pandemic clones have emerged in Brazil, constituting a public health issue.

Ethnographic research is characterised by in-person engagement with individuals and groups within a social setting, usually over an extended timeframe. These elements provide valuable insights which cannot be gained through other forms of research. In addition, such levels of involvement in “the field” create complex, shifting researcher-participant relationships which themselves shape the course of the project and its findings. The COVID-19 pandemic disrupted many research projects, but impacts on ethnographic research, with its emphasis on physical presence in the field and interpersonal relationships, reveals much about these key elements of our praxis.I discuss how the pandemic influenced the progress of an ethnographic research project, based in Malawi, including consideration of how, as lead for the project, my clinical/“public health” positionalities interacted with relationships in the village and the arrival of COVID-19 in Malawi. This account reveals shifting intersubjectivities of researchers and participants as the pandemic brought changes in the nature of the engagement, from ethnographic explorations into the roles of smoke in everyday life, through fieldwork suspension, and contextualised COVID-19 response. These experiences demonstrate how a basis of reflexive ethnographic engagement with communities can underpin thoughtful responses to upcoming challenges, with implications for future “global health” work, both within and beyond the pandemic context.

ObjectivesPatient and public involvement (PPI) in research priority-setting remains limited, especially for non-HIV STI. We identify and compare the top 10 patient and public STI research priorities with those of clinicians and STI stakeholders.MethodsThis two-stage study was conducted in May–August 2019. First, STI research priorities were canvassed through qualitative questionnaires issued to all patients attending a large sexual health clinic, all clinicians in region-wide mailing lists, all stakeholders identified through existing networks and the Charity Commission database, and to the Liverpool public. Raw responses were organised by theme into a shortlist of 25. In stage 2, these were ranked through priority-setting activities by telephone with patients and the public (n=8) and some clinicians (n=3), and in two workshops with clinicians (n=26) and stakeholders (n=5), respectively. The top 10 priorities were compared.ResultsOf 373 surveys submitted, 106 were analysed (83 patient and public; 23 clinician and stakeholder). Exclusions included lack of completion and responses out of scope. Among patient and public respondents, 55% (n=46) were aged 18–24 years, 51% (n=42) identified as heterosexual women and 23% (n=19) as men who have sex with men. Clinicians included all cadres; stakeholders were academics, commissioners and third sector representatives. In stage 2, 4 of 10 themes (STI education, targeted services for high-risk groups, antibiotic resistance and counselling for those with STI) were prioritised by all. Remote STI services and rapid diagnostics also ranked highly but the rationale differed between groups.ConclusionThis is the first non-HIV STI research priority-setting exercise to be reported in the UK. It identifies overlaps and differences between public and provider concerns, highlights gaps in the public understanding of STI research, and shows how PPI can promote research responsive to the concerns of both those who use and deliver services.

Several studies in Africa have reported effects of ‘rumours, misconceptions or misinformation’ on medical research participation and uptake of health interventions. As such, community engagement has sometimes been used for instrumental purposes to enhance acceptability of research or interventions and prevent ‘rumours’. This paper seeks to highlight the value of ongoing engagement with communities to understand research narratives ‘rumours’ reproduced in medical research. We demonstrate that ‘rumours’ are a form of divergent communication or local interpretation of medical research that needs critical attention, and we question the ethics of dismissing such divergent communication.This paper draws on experiences from ethnographical research, which aimed to understand community engagement in medical research projects conducted in Malawi. We observed that even though community meetings were held to improve participation, ‘rumours’ about research influenced decision making. ‘Rumours’ presented local critiques of medical research, legitimate concerns informed by historical experiences and local conceptualisation of health. Structural inequalities, negative outcomes or absence of visible benefits following research participation informed unmet expectations, discontent with research and consequently passive resistance. The sociocultural context where participating research communities often rely on social networks for information nurtured propagation of these divergent perspectives to inform lay discourse around medical research.We conclude that ongoing engagement, critical self-reflection and attempts to decode deeper meaning of ‘rumours’ throughout research implementation is necessary, to show respect and address community concerns expressed through ‘rumours’, enhance informed participation and adoption of future health interventions.

In the context of the coronavirus disease 2019 (COVID-19) pandemic there has been an increase of the use of antigen-detection rapid diagnostic tests (Ag-RDT). The performance of Ag-RDT vary greatly between manufacturers and evaluating their analytical limit of detection (LOD) has become high priority. Here we describe a manufacturer-independent evaluation of the LOD of 19 marketed Ag-RDT using live SARS-CoV-2 spiked in different matrices: direct culture supernatant, a dry swab, and a swab in Amies. Additionally, the LOD using dry swab was investigated after 7 days’ storage at − 80 °C of the SARS-CoV-2 serial dilutions. An LOD of ≈ 5.0 × 102 pfu/ml (1.0 × 106 genome copies/ml) in culture media is defined as acceptable by the World Health Organization. Fourteen of 19 Ag-RDTs (ActiveXpress, Espline, Excalibur, Innova, Joysbio, Mologic, NowCheck, Orient, PanBio, RespiStrip, Roche, Standard-F, Standard-Q and Sure-Status) exceeded this performance criteria using direct culture supernatant applied to the Ag-RDT. Six Ag-RDT were not compatible with Amies media and a decreased sensitivity of 2 to 20-fold was observed for eleven tests on the stored dilutions at − 80 °C for 7 days. Here, we provide analytical sensitivity data to guide appropriate test and sample type selection for use and for future Ag-RDT evaluations.

Background The provision of post-discharge malaria chemoprevention (PMC) in children recently admitted with severe anemia reduces the risk of death and re-admissions in malaria endemic countries. The main objective of this trial was to identify the most effective method of delivering dihydroartemesinin-piperaquine to children recovering from severe anemia. Methods This was a 5-arm, cluster-randomized trial among under-5 children hospitalized with severe anemia at Zomba Central Hospital in Southern Malawi. Children were randomized to receive three day treatment doses of dihydroartemesinin-piperaquine monthly either; 1) in the community without a short text reminder; 2) in the community with a short message reminder; 3) in the community with a community health worker reminder; 4) at the facility without a short text reminder; or 5) at the facility with a short message reminder. The primary outcome measure was adherence to all treatment doses of dihydroartemesinin-piperaquine and this was assessed by pill-counts done by field workers during home visits. Poisson regression was utilized for analysis. Results Between March 2016 and October 2018, 1460 clusters were randomized. A total of 667 children were screened and 375 from 329 clusters were eligible and enrolled from the hospital. Adherence was higher in all three community-based compared to the two facility-based delivery (156/221 [70·6%] vs. 78/150 [52·0%], IRR = 1·24,95%CI 1·06–1·44, p = 0·006). This was observed in both the SMS group (IRR = 1·41,1·21–1·64, p Interpretation Community-based delivery of dihydroartemesinin-piperaquine for post-discharge malaria chemoprevention in children recovering from severe anemia resulted in higher adherence compared to facility-based methods. Trial registration NCT02721420; ClinicalTrials.gov.

Background With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. Methods A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. Results Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. Conclusions Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

Background Adolescent girls in sub-Saharan Africa are disproportionally vulnerable to sexual and reproductive health (SRH) harms. In western Kenya, where unprotected transactional sex is common, young females face higher rates of school dropout, often due to pregnancy, and sexually transmitted infections (STIs), including HIV. Staying in school has shown to protect girls against early marriage, teen pregnancy, and HIV infection. This study evaluates the impact of menstrual cups and cash transfer interventions on a composite of deleterious outcomes (HIV, HSV-2, and school dropout) when given to secondary schoolgirls in western Kenya, with the aim to inform evidence-based policy to improve girls’ health, school equity, and life-chances. Methods Single site, 4-arm, cluster randomised controlled superiority trial. Secondary schools are the unit of randomisation, with schoolgirls as the unit of measurement. Schools will be randomised into one of four intervention arms using a 1:1:1:1 ratio and block randomisation: (1) menstrual cup arm; (2) cash transfer arm, (3) cups and cash combined intervention arm, or (4) control arm. National and county agreement, and school level consent will be obtained prior to recruitment of schools, with parent consent and girls’ assent obtained for participant enrolment. Participants will be trained on safe use of interventions, with all arms receiving puberty and hygiene education. Annually, the state of latrines, water availability, water treatment, handwashing units and soap in schools will be measured. The primary endpoint is a composite of incident HIV, HSV-2, and all-cause school dropout, after 3 years follow-up. School dropout will be monitored each term via school registers and confirmed through home visits. HIV and HSV-2 incident infections and risk factors will be measured at baseline, mid-line and end-line. Intention to treat analysis will be conducted among all enrolled participants. Focus group discussions will provide contextual information on uptake of interventions. Monitoring for safety will occur throughout. Discussion If proved safe and effective, the interventions offer a potential contribution toward girls’ schooling, health, and equity in low- and middle-income countries. Trial registration ClinicalTrials.gov NCT03051789, 15th February 2017.

Background Rift Valley fever (RVF) is a mosquito-borne zoonosis endemic in Africa. With little known of the burden or epidemiology of RVF virus (RVFV) in Cameroon, this study aimed to determine the seroprevalence of RVFV in domestic ruminants of various origins in two markets of Yaoundé, Cameroon. Methodology/Principal findings The origin of animals randomly sampled at two livestock markets in Yaoundé were recorded and plasma samples collected for competitive and capture Enzyme-linked Immunosorbent Assay (ELISA) to determine the prevalence of Immunoglobulins G (IgG) and Immunoglobulins M (IgM) antibodies. Following ELISA IgM results, a real-time reverse transcription-polymerase chain reaction (qRT-PCR) was performed to detect RVFV RNA. In June-August 2019, February-March 2020, and March-April 2021, 756 plasma samples were collected from 441 cattle, 168 goats, and 147 sheep. RVFV IgG seroprevalence was 25.7% for all animals, 42.2% in cattle, 2.7% in sheep, and 2.4% in goats. However, IgM seroprevalence was low, at 0.9% in all animals, 1.1% in cattle, 1.4% in sheep, and 0% in goats. The seroprevalence rates varied according to the animal’s origin with the highest rate (52.6%) in cattle from Sudan. In Cameroon, IgG and IgM rates respectively were 45.1% and 2.8% in the North, 44.8% and 0% in the Adamawa, 38.6% and 1.7% in the Far-North. All IgM positive samples were from Cameroon. In cattle, 2/5 IgM positive samples were also IgG positive, but both IgM positive samples in sheep were IgG negative. Three (42.9%) IgM positive samples were positive for viral RVFV RNA using qRT-PCR but given the high ct values, no amplicon was obtained. Conclusion/Significance These findings confirm the circulation of RVFV in livestock in Cameroon with prevalence rates varying by location. Despite low IgM seroprevalence rates, RVF outbreaks can occur without being noticed. Further epidemiological studies are needed to have a broad understanding of RVFV transmission in Cameroon.

The COVID-19 pandemic is currently one of the major global health and economic challenges. An efficient method for reducing the transmission of the virus is a still unmet medical need. Existing experimental data have shown that coronavirus survival is negatively impacted by ozone, high temperature, and low humidity. Therefore, it is feasible to use area ozonation in pharmacies - the front line of the healthcare system. Nevertheless, further work is needed to evaluate the effectiveness of ozone disinfection to reduce the transmission of this virus in pharmacies, hospitals, and other public environments. Med Pr. 2021;72(5):529-34.

Systematic reviews provide a critical summary of a body of knowledge that links research to decision making, whether to inform public health, clinical medicine, medical education, system-level changes, or advocacy. Good reviews are accessed by a wide range of audiences, including health service users, health service providers, and policy decision makers. Because the topics studied, the thinking behind the review questions, the analytical plan, and the review’s interpretation in the broader policy context are often complex, diagrams can play an important role in communicating the review to the reader. Indeed, graphic design is increasingly important for researchers to communicate their work to each other and the wider world.1 Visualizing the topic under study facilitates discussion, helps understanding by making complexity more accessible, provokes deeper thinking, and makes concepts more memorable.2 Higher impact scientific articles tend to include more diagrams, possibly because diagrams improve clarity and thereby lead to more citations or because high-impact articles tend to include novel, complex ideas that require visual explanation.3\ud Merriam-Webster’s Dictionary defines a diagram as “a graphic design that explains rather than represents, especially: a drawing that shows arrangement and relations (as of parts).”4 Established standards exist for visualizing the flow of studies through a review,5 risk of bias, and individual study and meta-analysis results in forest plots; these are not the subject of this editorial. We consider diagrams that communicate the conceptual framework underpinning reviews.\ud Diagrams include “logic models,” “framework models,” or “conceptual models”—terms that are often used interchangeably and inconsistently in the literature.6 We examine how diagrams can help review authors and readers and offer guidance for presenting information diagrammatically. We based our work on a purposive search for diagrams from the Cochrane Library and sources of reviews more likely to illustrate conceptual frameworks. Drawing on the data and our own experience, we adapted rapid appraisal methods7 for analyzing documents, taking an iterative, inductive approach to understand what enhances the clarity and utility of diagrams. We then related this learning to methodological articles of systematic reviewing and science communication (Appendix A, available as a supplement to the online version of this article at http://www.ajph.org). We built on our collective experience of diagrams in reviews and helping others to develop them.\ud We first describe diagrams’ various purposes. Then we discuss what we recognized, as systematic review readers, authors, and editors, as important steps to creating a good diagram. Next, we consider how diagrams can enhance the review process for authors. We discuss these findings in relation to methodologies that routinely integrate diagrams into structure systematic reviews: framework synthesis8 and logic models of illness or treatment pathways, where principles and agreed good practice are emerging.9 Finally, we discuss theories underpinning science communication.10

During the past 12 months chloroquine and hydroxychloroquine have been touted as miracle cures for COVID‐19 and introduced into COVID‐19 treatment protocols in Asia, Africa, and North and South America (see Figure 1). This has led to massive increases in demand such that patients with rheumatoid arthritis and lupus have been deprived of effective treatments.\ud \ud A Cochrane Review by Bhagteshwar Singh and colleagues definitively concludes that hydroxychloroquine has no clinical benefit in treating COVID‐19 in hospitalized patients.[1] The dissemination of information on these drugs in the scientific press and other media has been rapid and tumultuous with strong and polarized opinions among scientists, politicians, and the general public, building a climate of mistrust. Potential resulting harms included wasted resources (including research capacity) and drug shortages for evidence‐based indications. The false hope instilled may have also led to unsupervised use of potentially harmful medications. While most national and health system‐level guidance is evidence based, how did we get into such a chaotic and confusing situation with the assessment of chloroquine and hydroxychloroquine efficacy?

IntroductionThe emergence and rapid spread of COVID-19 have caused widespread and catastrophic public health and economic impact, requiring governments to restrict societal activity to reduce the spread of the disease. The role of household transmission in the population spread of SARS-CoV-2, and of host immunity in limiting transmission, is poorly understood. This paper describes a protocol for a prospective observational study of a cohort of households in Liverpool City Region, UK, which addresses the transmission of SARS-CoV-2 between household members and how immunological response to the infection changes over time.Methods and analysisHouseholds in the Liverpool City Region, in which members have not previously tested positive for SARS-CoV-2 with a nucleic acid amplification test, are followed up for an initial period of 12 weeks. Participants are asked to provide weekly self-throat and nasal swabs and record their activity and presence of symptoms. Incidence of infection and household secondary attack rates of COVID-19 are measured. Transmission of SARS-CoV-2 will be investigated against a range of demographic and behavioural variables. Blood and faecal samples are collected at several time points to evaluate immune responses to SARS-CoV-2 infection and prevalence and risk factors for faecal shedding of SARS-CoV-2, respectively.Ethics and disseminationThe study has received approval from the National Health Service Research Ethics Committee; REC Reference: 20/HRA/2297, IRAS Number: 283 464. Results will be disseminated through scientific conferences and peer-reviewed open access publications. A report of the findings will also be shared with participants. The study will quantify the scale and determinants of household transmission of SARS-CoV-2. Additionally, immunological responses before and during the different stages of infection will be analysed, adding to the understanding of the range of immunological response by infection severity.

ObjectiveTo assess the experience and impact of medical volunteers who facilitated training workshops for healthcare providers in maternal and newborn emergency care in 13 countries.SettingsBangladesh, Ghana, India, Kenya, Malawi, Namibia, Nigeria, Pakistan, Sierra Leone, South Africa, Tanzania, UK and Zimbabwe.ParticipantsMedical volunteers from the UK (n=162) and from low-income and middle-income countries (LMIC) (n=138).Outcome measuresExpectations, experience, views, personal and professional impact of the experience of volunteering on medical volunteers based in the UK and in LMIC.ResultsUK-based medical volunteers (n=38) were interviewed using focus group discussions (n=12) and key informant interviews (n=26). 262 volunteers (UK-based n=124 (47.3%), and LMIC-based n=138 (52.7%)) responded to the online survey (62% response rate), covering 506 volunteering episodes. UK-based medical volunteers were motivated by altruism, and perceived volunteering as a valuable opportunity to develop their skills in leadership, teaching and communication, skills reported to be transferable to their home workplace. Medical volunteers based in the UK and in LMIC (n=244) reported increased confidence (98%, n=239); improved teamwork (95%, n=232); strengthened leadership skills (90%, n=220); and reported that volunteering had a positive impact for the host country (96%, n=234) and healthcare providers trained (99%, n=241); formed sustainable partnerships (97%, n=237); promoted multidisciplinary team working (98%, n=239); and was a good use of resources (98%, n=239). Medical volunteers based in LMIC reported higher satisfaction scores than those from the UK with regards to impact on personal and professional development.ConclusionHealthcare providers from the UK and LMIC are highly motivated to volunteer to increase local healthcare providers’ knowledge and skills in low-resource settings. Further research is necessary to understand the experiences of local partners and communities regarding how the impact of international medical volunteering can be mutually beneficial and sustainable with measurable outcomes.

BackgroundWhole-school interventions represent promising approaches to promoting adolescent sexual health, but they have not been rigorously trialled in the UK and it is unclear if such interventions are feasible for delivery in English secondary schools. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff, and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools.MethodsFormative qualitative inquiry involving 75 students aged 13–15 and 23 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy-makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention.ResultsData confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people’s lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements.Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited or their input may conflict with the logic of interventions or what is practicable within the constraints of a trial.ConclusionsMulti-component, whole-school approaches to addressing sexual health that involve teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; involve careful teacher selection; limit additional burden on staff; and accurately reflect the realities of young people’s lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions, like whole-school sexual health interventions, that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the ‘depth’ of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures for incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted.Trial registrationProject Respect:ISRCTN12524938. Positive Choices:ISRCTN65324176

Summary box Biomedical interventions, such as therapeutics, vaccines and insecticides, are alone insufficient to achieve Sustainable Development Goal (SDG) 3—healthy lives and well-being for all ages. We also need development interventions to tackle the underlying determinants of ill-health by reducing deprivation and improving living conditions and the environment. This recognition formed the bedrock of early public health, from housing improvements and clean water provision in 19th century Europe and North America,1 to house screening for malaria elimination in the USA and water management for historical vector control in Italy, Sri Lanka, Panama and Zambia.2 Today, development interventions are a basic human right and ever more critical in response to rapid population growth, urbanisation and climate change. Despite their importance, many development interventions remain neglected in global health policy. For example, the World Health Organization (WHO) recognises the need for multisectoral approaches to malaria,3 but based on current evidence is unlikely to be able to make a strong …

With limited vaccine coverage and in the absence of specific therapeutics, the options to curb the COVID-19 pandemic today are mostly infection prevention measures and diagnostic tests to identify infected individuals rapidly, followed by isolation and contact tracing. The past months have seen significant worldwide scale-up of testing through quantitative PCR (qPCR) detecting nucleic acid of SARS-CoV-2. However, with the current resurgence of cases in Europe and elsewhere, qPCR demand far exceeds capacity. Moreover, qPCR is expensive, requires sophisticated laboratories, well-trained staff, and extensive logistics. Capacity deficits are aggravated in LMICs (Lower and Middle-Income Countries) with rampant shortages of tests kits, qualified staff, and laboratories, compromising clinical utility. Africa CDC reports 23 countries with proxy PCR coverage of

Background Safety climate is an essential component of achieving Universal Health Coverage, with several organisational, unit or team-level, and individual health worker factors identified as influencing safety climate. Few studies however, have investigated how these factors contribute to safety climate within health care settings in low- and middle-income countries (LMICs). The current study examines the relationship between key organisational, unit and individual-level factors and safety climate across primary health care centres in Ghana, Malawi and Uganda. Methods A cross-sectional, self-administered survey was conducted across 138 primary health care facilities in nine districts across Uganda, Ghana and Malawi. In total, 760 primary health workers completed the questionnaire. The relationships between individual (sex, job satisfaction), unit (teamwork climate, supportive supervision), organisational-level (district managerial support) and safety climate were tested using structural equation modelling (SEM) procedures. Post hoc analyses were also carried out to explore these relationships within each country. Results Our model including all countries explained 55% of the variance in safety climate. In this model, safety climate was most strongly associated with teamwork (β = 0.56, p β = 0.34, p β = 0.29, p β = 0.30, p β = 0.46, p β = 0.21, p β = 0.56, p β = 0.43, p β = 0.35, p β = 0.39, p = 0.005) and supportive supervision (β = 0.27, p = 0.023) significantly and positively associated with safety climate. Discussion/conclusions Our findings highlight the importance of unit-level factors—and in specific, teamwork and supportive supervision—as particularly important contributors to perceptions of safety climate among primary health workers in LMICs. Implications for practice are discussed.

District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national- and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decision-makers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs’ decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.

Primaquine (PQ) is an antimalarial drug with the potential to reduce malaria transmission due to its capacity to clear mature Plasmodium falciparum gametocytes in the human host. However, the large-scale roll-out of PQ has to be counterbalanced by the additional risk of drug-induced hemolysis in individuals suffering from Glucose-6-phospate dehydrogenase (G6PD) deficiency, a genetic condition determined by polymorphisms on the X-linked G6PD gene. Most studies on G6PD deficiency and PQ-associated hemolysis focused on the G6PD A- variant, a combination of the two single nucleotide changes G202A (rs1050828) and A376G (rs1050829), although other polymorphisms may play a role. In this study, we tested the association of 20 G6PD single nucleotide polymorphisms (SNPs) with hemolysis measured seven days after low single dose of PQ given at the dose of 0.1 mg/kg to 0.75 mg/kg in 957 individuals from 6 previously published clinical trials investigating the safety and efficacy of this drug spanning five African countries. After adjusting for inter-study effects, age, gender, baseline hemoglobin level, PQ dose, and parasitemia at screening, our analysis showed putative association signals from the common G6PD mutation, A376G [−log10(p-value) = 2.44] and two less-known SNPs, rs2230037 [−log10(p-value] = 2.60), and rs28470352 [−log10(p-value) = 2.15]; A376G and rs2230037 were in very strong linkage disequilibrium with each other (R2 = 0.978). However, when the effects of these SNPs were included in the same regression model, the subsequent associations were in the borderline of statistical significance. In conclusion, whilst a role for the A- variant is well established, we did not observe an important additional role for other G6PD polymorphisms in determining post-treatment hemolysis in individuals treated with low single-dose PQ.

If research is to have an impact and change health outcomes for the better, the findings of the research should be translated into recommendations and actions that can influence policy and/or practice [...]

Children and pregnant women are vulnerable groups for malaria. Among children, research to date has focussed on pre-school children (aged

Background Midwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province. Methods A qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12. Results The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives’ living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges. Conclusion Midwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.

Background The public health impact of Chikungunya virus (CHIKV) is often underestimated. Usually considered a mild condition of short duration, recent outbreaks have reported greater incidence of severe illness, fatality, and longer-term disability. In 2018/19, Eastern Sudan experienced the largest epidemic of CHIKV in Africa to date, affecting an estimated 487,600 people. Known locally as Kankasha, this study examines clinical characteristics, risk factors, and phylogenetics of the epidemic in Kassala City. Methodology/Principal findings A prospective cohort of 102 adults and 40 children presenting with chikungunya-like illness were enrolled at Kassala Teaching Hospital in October 2018. Clinical information, socio-demographic data, and sera samples were analysed to confirm diagnosis, characterise illness, and identify viral strain. CHIKV infection was confirmed by real-time reverse transcription-PCR in 84.5% (120/142) of participants. Nine (7.5%) CHIKV-positive participants had concurrent Dengue virus (DENV) infection; 34/118 participants (28.8%) had a positive Rapid Diagnostic Test for Plasmodium falciparum; six (5.0%) had haemorrhagic symptoms including two children with life-threatening bleeding. One CHIKV-positive participant died with acute renal injury. Age was not associated with severity of illness although CHIKV-infected participants were younger (p = 0.003). Two to four months post-illness, 63% of adults available for follow-up (30) were still experiencing arthralgia in one or more joints, and 11% remained moderately disabled on Rapid3 assessment. Phylogenetic analysis showed all CHIKV sequences from this study belonged to a single clade within the Indian Ocean Lineage (IOL) of the East/Central/South African (ECSA) genotype. History of contact with an infected person was the only factor associated with infection (p = 0.01), and likely related to being in the same vector environment. Conclusions/Significance Vulnerability to CHIKV remains in Kassala and elsewhere in Sudan due to widespread Aedes aegypti presence and mosquito-fostering household water storage methods. This study highlights the importance of increasing awareness of the severity and impact of CHIKV outbreaks, and the need for urgent actions to reduce transmission risk in households., Author summary Chikungunya is an arboviral disease transmitted to humans by infected mosquitoes and characterised by fever and arthralgia. Although it is generally considered a short self-limiting infection, long term sequelae and severe disease are increasingly recognised. In 2018/19, Eastern Sudan experienced the largest epidemic of Chikungunya in Africa to date, affecting approximately 500,000 people. We undertook a prospective hospital-based cohort study of patients presenting with undifferentiated febrile illness in Kassala city, Sudan, supported by next-generation sequencing. We confirmed that CHIKV was the dominant pathogen, with positive CHIKV RT-PCR in 85% of patients presenting during the 7-day study period. Dengue virus was also circulating with nine CHIKV RT-PCR-positive patients co-infected, and we identified high rates of Plasmodium falciparum infection and CHIKV/P.falciparum co-infection. Genetic sequencing confirmed Indian Ocean Lineage of the East/Central/South African CHIKV genotype. A quarter of participants available for follow-up (16/60, 26.6%) reported being admitted to hospital including two children with haemorrhage, reflecting the severe phenotype linked to this genotype. Increased understanding of the health and economic burden of Chikungunya is needed, and recognition that severe and occasionally fatal infection exists. With widespread presence of Ae. aegypti and household water storage practices that encourage mosquito breeding, timely actions will be essential to prevent further large outbreaks.