Barriers to childhood immunization in sub-Saharan Africa: A systematic review.

BACKGROUND: Immunization to prevent infectious diseases is a core strategy to improve childhood health as well as survival. It remains a challenge for some African countries to attain the required childhood immunization coverage. We aim at identifying individual barriers confronting parents/caretakers, providers, and health systems that hinder childhood immunization coverage in Sub-Saharan Africa. METHOD: This systematic review searched PubMed/MEDLINE, Web of Science and EMBASE. We restricted to published articles in English that focused on childhood immunization barriers in sub-Saharan Africa from January 1988 to December 2019. We excluded studies if: focused on barriers to immunization for children in other regions of the world, studied adult immunization barriers; studies not available on the university library, they were editorial, reports, reviews, supplement, and bulletins. Study designs included were cross-sectional, second-hand data analysis; and case control. RESULTS: Of the 2652 items identified, 48 met inclusion criteria. Parents/caretakers were the most common subjects. Nine articles were of moderate and 39 were of high methodological quality. Nine studies analyzed secondary data; 36 used cross-sectional designs and three employed case control method. Thirty studies reported national immunization coverage of key vaccines for children under one, eighteen did not. When reported, national immunization coverage of childhood vaccines is reported to be low. Parents/caretaker' barriers included lack of knowledge of immunization, distance to access point, financial deprivation, lack of partners support, and distrust in vaccines and immunization programs. Other associated factors for low vaccine rates included the number of off-springs, lifestyle, migration, occupation and parent's forgetfulness, inconvenient time and language barrier. Barriers at health system level cited by healthcare providers included limited human resources and inadequate infrastructures to maintain the cold chain and adequate supply of vaccines. CONCLUSION: In this review we identified more thoroughly the parents/caretakers' barriers than those of providers and health systems. Factors that influenced decisions to get children vaccinated were mainly their gender, beliefs, socio-culture factors in the communities in which they live. Thus it is vital that immunization programs consider these barriers and address the people and societies in their communities across sub-Saharan Africa.

The Association Between Life Events and Incidence of Hypertension Among Government Employees in China: A Prospective Cohort Study.

Background: Hypertension (HTN) is a global public health concern. However, the association between life events (LEs) and HTN is complex. Thus, we conducted a prospective cohort study to explore this complex association. Methods: A total of 8,077 government employees without HTN were recruited through cluster sampling between 2018 and 2019 in Hunan Province, China. At baseline, information regarding sociodemographic characteristics, LEs, and behavioral factors was collected. After the 1-year follow-up, the participants were revisited to obtain the HTN diagnosis. Crude and adjusted Poisson regression models were constructed to calculate the incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Cubic regression spline models were used to visualize the trends between LEs and HTN IRRs. Interactive and subgroup analyses were also performed. Results: The 1-year HTN incidence rate among government employees in Hunan province was 4.30% (95% CI: 3.86-4.74%). LEs were associated with a higher HTN risk (IRR, 1.02; 95% CI, 1.00-1.04). When calculating positive and negative LEs scores separately, only the latter was a risk factor for HTN incidence (IRR, 1.04; 95% CI, 1.03-1.06); conversely, positive LEs reduced the risk (IRR, 0.90; 95% CI, 0.85-0.96). Compared with patients in the lowest quartile of LEs score, those in quartiles two (IRR, 1.28; 95% CI, 0.96-1.71), three (IRR, 1.43; 95% CI, 1.04-1.96), and four (IRR, 1.73; 95% CI, 1.26-2.37) were at progressively higher risk. In restricted spline curves, a non-linear association was noted between LEs and HTN risk. Regarding the subcategories of LEs, work-related LEs, personal LEs, and all subcategories of negative LEs were associated with an increased risk of HTN. However, among positive LEs, only the family-related cases were associated with a lower risk of HTN. Conclusion: LEs had a non-linear association with an increased risk of HTN. Negative LEs were risk factors for HTN incidence, whereas positive LEs reduced the risk of HTN. Thus, the importance of LEs should be highlighted in the development of HTN prevention strategies and initiatives.

Child and Adolescent Mental Health Policy in Low- and Middle-Income Countries: Challenges and Lessons for Policy Development and Implementation.

Background: Child and adolescent mental health (CAMH) policy is essential for the rational development of mental health systems for children and adolescents. However, there is a universal lack of CAMH policy, especially in low- and middle-income countries (LMICs). Therefore, this review aims to identify challenges and lessons for LMICs to develop and implement CAMH policy. Methods: PubMed (1781-), MEDLINE (1950-), EMBASE (1966-), and PsycINFO (1895-) were searched from inception to December 31, 2018, for publications on CAMH policy development and/or implementation. Abstracts and main texts of articles were double screened, and extracted data were analyzed through thematic synthesis. Results: A total of 31 publications were included through the systematic review. Six major challenges were identified for CAMH policy in LMICs: (i) poor public awareness and low political willingness; (ii) stigma against mental disorders; (iii) biased culture values toward children, adolescents and CAMH, from developmental nihilism to medicalization; (iv) the lack of CAMH data and evidence, from service statistics to program evaluation; (v) the shortage of CAMH resources, including human resources, service facilities, and funding; and (vi) unintended consequence of international support, including reducing local responsibilities, planning fragmentation, and unsustainability. Six lessons to overcome challenges were summarized: (i) rethinking the concept of CAMH, (ii) encouraging a stand-alone CAMH policy and budget, (iii) involving stakeholders, (iv) reinforcing the role of research and researchers in policy process, (v) innovating the usage of human and service resources, and (vi) maximizing the positive influence of international organizations and non-governmental organizations. Conclusion: Many LMICs are still facing various challenges for their CAMH policy development and implementation. To overcome the challenges, great and long-term efforts are needed, which include great determination of from domestic and global agents, multidisciplinary innovations, and collaboration and coordination from different sectors.