Remote Symptom Monitoring to Enhance the Delivery of Palliative Cancer Care in Low-Resource Settings: Emerging Approaches from Africa.

This paper brings together researchers, clinicians, technology developers and digital innovators to outline current applications of remote symptom monitoring being developed for palliative cancer care delivery in Africa. We outline three remote symptom monitoring approaches from three countries, highlighting their models of delivery and intended outcomes, and draw on their experiences of implementation to guide further developments and evaluations of this approach for palliative cancer care in the region. Through highlighting these experiences and priority areas for future research, we hope to steer efforts to develop and optimise remote symptom monitoring for palliative cancer care in Africa.

Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria.

BACKGROUND: The low demand for maternal and child health services is a significant factor in Nigeria's high maternal death rate. This paper explores demand and supply-side determinants at the primary healthcare level, highlighting factors affecting provision and utilization. METHODS: This qualitative study was undertaken in Anambra state, southeast Nigeria. Anambra state was purposively chosen because a maternal and child health programme had just been implemented in the state. The three-delay model was used to analyze supply and demand factors that affect MCH services and improve access to care for pregnant women/mothers and newborns/infants. RESULT: The findings show that there were problems with both the demand and supply aspects of the programme and both were interlinked. For service users, their delays were connected to the constraints on the supply side. On the demand side, the delays include poor conditions of the facilities, the roads to the facilities are inaccessible, and equipment were lacking in the facilities. These delayed the utilisation of facilities. On the supply side, the delays include the absence of security (fence, security guard), poor citing of the facilities, inadequate accommodation, no emergency transport for referrals, and lack of trained staff to man equipment. These delayed the provision of services. CONCLUSION: Our findings show that there were problems with both the demand and supply aspects of the programme, and both were interlinked. For service users, their delays were connected to the constraints on the supply side.

Physical activity service provision in hospice care: A national mixed-methods study.

BACKGROUND: Physical activity (PA) interventions help people with advanced incurable diseases to manage symptoms and improve their quality of life. However, little is known about the extent to which PA is currently delivered in hospice care in England. OBJECTIVES: To determine the extent of and intervention features of PA service provision in hospice care in England alongside barriers and facilitators to their delivery. METHODS: An embedded mixed-methods design using (1) a nationwide online survey of 70 adult hospices in England and (2) focus groups and individual interviews with health professionals from 18 hospices. Analysis of the data involved applying descriptive statistics to the numeric items and thematic analysis to the open-ended questions. Quantitative and qualitative data were collected and analyzed separately. RESULTS: The majority of responding hospices (n = 47/70, 67%) promoted PA in routine care. Sessions were most often delivered by a physiotherapist (n = 40/47, 85%) using a personalized approach (n = 41/47, 87%) and included resistance/thera bands, Tai Chi/Chi Qong, circuit exercises, and yoga. The following qualitative findings were revealed: (1) variation among hospices in their capacity to deliver PA, (2) a desire to embed a hospice culture of PA, and (3) a need for an organizational commitment to PA service provision. SIGNIFICANCE OF RESULTS: While many hospices in England deliver PA, there is considerable variation in its delivery across sites. Funding and policy action may be needed to support hospices to initiate or scale up services and address inequity in access to high-quality interventions.

Places Nigerians visited during COVID-19 government stay-home policy: evidence from secondary analysis of data collected during the lockdown.

Introduction: Compliance with the Government's lockdown policy is required to curtail community transmission of Covid-19 infection. The objective of this research was to identify places Nigerians visited during the lockdown to help prepare for a response towards future infectious diseases of public health importance similar to Covid-19. Methods: This was a secondary analysis of unconventional data collected using Google Forms and online social media platforms during the COVID-19 lockdown between April and June 2020 in Nigeria. Two datasets from: i) partnership for evidencebased response to COVID-19 (PERC) wave-1 and ii) College of Medicine, University of Lagos perception of and compliance with physical distancing survey (PCSH) were used. Data on places that people visited during the lockdown were extracted and compared with the sociodemographic characteristics of the respondents. Descriptive statistics were calculated for all independent variables and focused on frequencies and percentages. Chi-squared test was used to determine the significance between sociodemographic variables and places visited during the lockdown. Statistical significance was determined by P<0.05. All statistical analyses were carried out using SPSS version 22. Results: There were 1304 and 879 participants in the PERC wave-1 and PCSH datasets, respectively. The mean age of PERC wave-1 and PCSH survey respondents was 31.8 [standard deviation (SD)=8.5] and 33.1 (SD=8.3) years, respectively.In the PCSH survey, 55.9% and 44.1% of respondents lived in locations with partial and complete covid-19 lockdowns, respectively. Irrespective of the type of lockdown, the most common place visited during the lockdown was the market (shopping); reported by 73% of respondents in states with partial lockdown and by 68% of respondents in states with the complete lockdown. Visits to families and friends happened more in states with complete (16.1%) than in states with partial (8.4%) lockdowns. Conclusions: Markets (shopping) were the main places visited during the lockdown compared to visiting friends/family, places of worship, gyms, and workplaces. It is important in the future for the Government to plan how citizens can safely access markets and get other household items during lockdowns for better adherence to stay-at-home directives for future infectious disease epidemics.

A qualitative study on stigma experienced by young adults living with sickle cell disease in Accra, Ghana.

BACKGROUND: Sickle cell disease (SCD) describes a group of multisystem, genetic and stigmatising blood conditions that are prevalent in sub-Saharan Africa. Health-related stigma is a negative experience or adverse social judgement about a group based on an enduring feature conferred by a particular health problem. Literature shows that stigmatisation is experienced by people with SCD with negative implications on their lives. This study investigated self-reported views and lived experiences of young adults in Accra, Ghana, regarding SCD-related stigma and its impact on their lives. METHODS: Data were collected from 19 males and females with SCD using semi-structured individual interviews and focus group discussions. Transcripts were analysed using Braun and Clark's framework for thematic analysis. RESULTS: Five themes were identified: exclusion; status loss; SCD misconceptions; internalised stigma; and stigma and health outcomes. Overall, interpersonal and institutional levels of stigma were evident throughout the data with a lack of public education, limited specialist care and religion acting as determinants of SCD-related stigma. CONCLUSIONS: Stigma has detrimental consequences for young adults with SCD. Multilevel stigmatisation of SCD at interpersonal and institutional levels should be addressed through multipronged approaches including increased public education, investment in specialist healthcare and collaboration with socioreligious institutions. Further research is needed to investigate the experiences of young adults in rural Ghana.

The use of and need for data and information by health professionals supporting the delivery of palliative cancer care services in sub-Saharan Africa: A qualitative study.

PURPOSE: The ability to develop and evaluate approaches to the management of advanced cancer in sub-Saharan Africa is limited by the lack of local, reliable and valid data to ensure that practice is evidence-based, replicable and reflects the needs of the population served. METHODS: A secondary qualitative analysis of in-depth interviews with 59 health professionals delivering palliative cancer care in Nigeria, Uganda and Zimbabwe were conducted to determine the use and needs for data and information for patient care and service delivery. Framework analysis was used, informed by a conceptual model for data use in low and middle-income countries. RESULTS: Three meta-themes include: (1) Current practice in data gathering and use; (2) Gaps for capturing, storing information and supporting communication, and; (3) Needs and opportunities for data use. Deficits in current data access and use were identified, alongside targets for improving the quality, accessibility and utility of data to inform the development of palliative cancer care. CONCLUSIONS: The availability and use of relevant and reliable data relating to the current provision of palliative cancer care are requisite for the contextually appropriate and effective development of health services. The requirements and constraints articulated by participants can guide future development and optimisation of digital health approaches for palliative cancer care in the participating countries, with relevance to the wider sub-Saharan Africa region.

Role of digital health insurance management systems in scaling health insurance coverage in low- and Middle-Income Countries: A case study from Nigeria.

Background: Increasing global commitment to Universal Health Coverage (UHC) in the past decade has triggered UHC-inspired reforms and investments to expand health service coverage in many Low- and Middle-Income Countries (LMICs). UHC aims to ensure that all people can access quality health services, safeguard them from public health risks and impoverishment from out-of-pocket payments for healthcare when household members are sick. Aim: This paper reviews the role of health insurance as a policy tool to address health financing as a contributory mechanism for accelerating the achievement of UHC in LMICs. We focus on Nigeria's legal framework for health insurance coverage for its whole population and the role of technology in facilitating enrollment to health insurance schemes. Methods: From May to July 2022, we adopted a cross-sectional case study design combining: (i) a literature review of the effects of UHC with (ii) document analysis of health insurance systems in Nigeria, and (iii) secondary analysis of health insurance datasets to understand experiences of deploying MedStrat, a locally-developed digital health insurance management system, and its features that support the administration of health insurance schemes in multiple states of Nigeria. We drew on contemporary technology adoption models to triangulate diverse data analyzed from literature and documents reviews and from health insurance datasets to identify: (i) enablers of adoption of digital insurance schemes, (ii) the contribution of digital technology to expanding access to health insurance, and (iii) further scalability of digital insurance intervention. Results: Preliminary findings suggests that digital insurance management systems can help to increase the number of enrollees for insurance especially among poor households. Three contextual enablers of adoption of digital insurance schemes were a favourable policy environment, public-private-partnerships, and sustained stakeholder engagement and training. Discussion and conclusion: Key elements for successful scaling of digital health insurance schemes across Nigeria and similar contexts include: (i) ease of use, (ii) existing digital infrastructure to support electronic insurance systems, and (iii) trust manifested via data encryption, maintaining audit trails for all data, and in-built fraud prevention processes. Our findings affirm that digital health technology can play a role in the attainment of UHC in LMICs.

Applications of Probiotic-Based Multi-Components to Human, Animal and Ecosystem Health: Concepts, Methodologies, and Action Mechanisms.

Probiotics and related preparations, including synbiotics and postbiotics, are living and non-living microbial-based multi-components, which are now among the most popular bioactive agents. Such interests mainly arise from the wide range and numerous beneficial effects of their use for various hosts. The current minireview article attempts to provide an overview and discuss in a holistic way the concepts, methodologies, action mechanisms, and applications of probiotic-based multi-components in human, animal, plant, soil, and environment health. Probiotic-based multi-component preparations refer to a mixture of bioactive agents, containing probiotics or postbiotics as main functional ingredients, and prebiotics, protectants, stabilizers, encapsulating agents, and other compounds as additional constituents. Analyzing, characterizing, and monitoring over time the traceability, performance, and stability of such multi-component ingredients require relevant and sensitive analytical tools and methodologies. Two innovative profiling and monitoring methods, the thermophysical fingerprinting thermogravimetry-differential scanning calorimetry technique (TGA-DSC) of the whole multi-component powder preparations, and the Advanced Testing for Genetic Composition (ATGC) strain analysis up to the subspecies level, are presented, illustrated, and discussed in this review to respond to those requirements. Finally, the paper deals with some selected applications of probiotic-based multi-components to human, animal, plant, soil and environment health, while mentioning their possible action mechanisms.

Impact of sustained health policy and population-level interventions on reducing the prevalence of obesity in the Caribbean region: A qualitative study from The Bahamas.

Background: The 2020 Global Nutrition Report highlights that despite improvements in select nutrition indicators, progress is too slow to meet the 2025 Global Nutrition Targets. While the Latin America and the Caribbean (LAC) region has achieved the greatest global reduction in undernutrition (stunting, underweight, and wasting) in the past decade, it also has the highest prevalence of people with overweight worldwide. Since the early 2000s, the region has mounted increasingly comprehensive and multi-sectoral policy interventions to address nutritional health outcomes. The Bahamas is one such LAC country that has used consistent policy responses to address evolving nutritional challenges in its population. After addressing the initial problems of undernutrition in the 1970s and 80s, however, overconsumption of unhealthy foods has led to a rising prevalence of obesity which The Bahamas has grappled with since the early 2000s. Objective: This study develops a timeline of obesity-related health policy responses and explores the macrosocial factors and conditions which facilitated or constrained public health policy responses to obesity in The Bahamas over a 20-year period. Methods: This multi-method case study was conducted between 2019 and 2021. A document review of health policies was combined with secondary analysis of a range of other documents and semi-structured interviews with key actors (policymakers, health workers, scholars, and members of the public). Data sources for secondary data analysis included policy documents, national survey data on obesity, national and regional newspaper websites, and the Digital Library of the Caribbean database. An adapted framework approach was used for the analysis of semi-structured interviews. Results: Between 2000 and 2019, a series of national policies and community-level interventions were enacted to address the prevalence of obesity. Building on previous interventions, obtaining multi-sectoral collaboration, and community buy-in for policy action contributed to reducing obesity prevalence from 49.2 to 43.7% between 2012 and 2019. There are, however, constraining factors, such as political and multi-sectoral challenges and gaps in legislative mandates and financing. Conclusion: Sustained multilevel interventions are effective in addressing the prevalence of obesity. To maintain progress, there is a need to implement gender-specific responses while ensuring accessibility, availability, and affordability of nutritious food for all.

"From the Time You Start With them Until the Lord Calls You": A Qualitative Study on the Experiences and Expectations of People Living with Advanced Cancer Interacting With Palliative Care Services in Uganda, Nigeria and Zimbabwe.

CONTEXT: A challenge facing the provision of palliative care in sub-Saharan Africa is a means of increasing coverage of services whilst maintaining quality. Developing an evidence base that reflects patients' experiences and expectations of palliative care services, the context within which services are provided, and the approaches adopted by services in caring for patients, could facilitate and inform the planning and development of patient-centered and responsive services. OBJECTIVES: To explore the experiences and expectations of palliative care for people living with advanced cancer in Nigeria, Uganda, and Zimbabwe. METHODS: A secondary qualitative analysis of in-depth interviews with 62 people with advanced cancer in Nigeria, Uganda, and Zimbabwe. Framework approach to thematic analysis of transcripts was adopted, focusing on patients' experiences and expectations when interacting with palliative care services, aligning reporting with the COnsolidated criteria for REporting Qualitative research (COREQ). RESULTS: Four main themes were generated from the analysis: 1) Condition and community as drivers of a multidimensional burden when living with advanced cancer; 2) The expectations and endeavors of palliative care to ameliorate the impact of cancer on physical, psychological and basic needs; 3) Processes and preferences for interacting and communicating with palliative care services, and; 4) Restoration of hope in the context of limited resources. CONCLUSION: Wide-ranging physical, psychological, social and financial impacts on participants were outlined. These concerns were largely met with compassionate and responsive care in the context of constrained resources. Study findings can inform evolving notions of patient-centred care for serious illnesses in the participating countries.

Leveraging big data for improving the estimation of close to reality travel time to obstetric emergency services in urban low- and middle-income settings.

Maternal and perinatal mortality remain huge challenges globally, particularly in low- and middle-income countries (LMICs) where >98% of these deaths occur. Emergency obstetric care (EmOC) provided by skilled health personnel is an evidence-based package of interventions effective in reducing these deaths associated with pregnancy and childbirth. Until recently, pregnant women residing in urban areas have been considered to have good access to care, including EmOC. However, emerging evidence shows that due to rapid urbanization, this so called "urban advantage" is shrinking and in some LMIC settings, it is almost non-existent. This poses a complex challenge for structuring an effective health service delivery system, which tend to have poor spatial planning especially in LMIC settings. To optimize access to EmOC and ultimately reduce preventable maternal deaths within the context of urbanization, it is imperative to accurately locate areas and population groups that are geographically marginalized. Underpinning such assessments is accurately estimating travel time to health facilities that provide EmOC. In this perspective, we discuss strengths and weaknesses of approaches commonly used to estimate travel times to EmOC in LMICs, broadly grouped as reported and modeled approaches, while contextualizing our discussion in urban areas. We then introduce the novel OnTIME project, which seeks to address some of the key limitations in these commonly used approaches by leveraging big data. The perspective concludes with a discussion on anticipated outcomes and potential policy applications of the OnTIME project.

Repercussions of overturning Roe v. Wade for women across systems and beyond borders.

June 24th, 2022, a day that will be etched in today and future generations' textbooks as a historic day, the United States of America revoked the constitutional right to seek safe abortion care. Overturning Roe v Wade allowed the divided individual states to independently decide the legal parameters regarding abortion care. A decision that disproportionately effects the reproductive lives of women residing on the land of America. Given the systemic impacts of racism, neoliberalism and white supremacy, it is the Black, racialized and poor women who suffer terrible repercussions. In this commentary the authors begin by discussing the historical biopolitical perspective, colonial systems and longstanding impacts on racialized women's bodies in America. The discussion transitions to the implications of geopolitics at play nationally and cascading impacts globally, focusing on humanitarian and emergency settings. Using a medical humanities perspective, authors highlight the collision between politics and reproductive health policy and its implications on social determinants of health, such as women's education, employment, housing, racial and gender equity and wellbeing. Long standing advocates, community leaders and healers, leading scientists, birth attendants, doctors, nurses, allied health professionals/providers and humanitarian workers - and many others - are reminded and live the weight of the continuous battle of population control, stemming from the oppressive history of control and exploitation.

Research priorities to reduce the impact of COVID-19 in low- and middle-income countries.

Background: The COVID-19 pandemic has caused disruptions to the functioning of societies and their health systems. Prior to the pandemic, health systems in low- and middle-income countries (LMIC) were particularly stretched and vulnerable. The International Society of Global Health (ISoGH) sought to systematically identify priorities for health research that would have the potential to reduce the impact of the COVID-19 pandemic in LMICs. Methods: The Child Health and Nutrition Research Initiative (CHNRI) method was used to identify COVID-19-related research priorities. All ISoGH members were invited to participate. Seventy-nine experts in clinical, translational, and population research contributed 192 research questions for consideration. Fifty-two experts then scored those questions based on five pre-defined criteria that were selected for this exercise: 1) feasibility and answerability; 2) potential for burden reduction; 3) potential for a paradigm shift; 4) potential for translation and implementation; and 5) impact on equity. Results: Among the top 10 research priorities, research questions related to vaccination were prominent: health care system access barriers to equitable uptake of COVID-19 vaccination (ranked 1st), determinants of vaccine hesitancy (4th), development and evaluation of effective interventions to decrease vaccine hesitancy (5th), and vaccination impacts on vulnerable population/s (6th). Health care delivery questions also ranked highly, including: effective strategies to manage COVID-19 globally and in LMICs (2nd) and integrating health care for COVID-19 with other essential health services in LMICs (3rd). Additionally, the assessment of COVID-19 patients' needs in rural areas of LMICs was ranked 7th, and studying the leading socioeconomic determinants and consequences of the COVID-19 pandemic in LMICs using multi-faceted approaches was ranked 8th. The remaining questions in the top 10 were: clarifying paediatric case-fatality rates (CFR) in LMICs and identifying effective strategies for community engagement against COVID-19 in different LMIC contexts. Interpretation: Health policy and systems research to inform COVID-19 vaccine uptake and equitable access to care are urgently needed, especially for rural, vulnerable, and/or marginalised populations. This research should occur in parallel with studies that will identify approaches to minimise vaccine hesitancy and effectively integrate care for COVID-19 with other essential health services in LMICs. ISoGH calls on the funders of health research in LMICs to consider the urgency and priority of this research during the COVID-19 pandemic and support studies that could make a positive difference for the populations of LMICs.

Nature-Based One Health Approaches to Urban Agriculture Can Deliver Food and Nutrition Security.

The increasing global human population is projected to reach 9.7 billion people by 2050. This population growth is currently linked to the trends of world-wide urbanization, growth of megacities and shifting dietary patterns. While humankind faces the daunting challenge of feeding and providing healthy lives for its teeming populations, urban agriculture holds promise for improving the quality of life in cities. Fortunately, policymakers and planners are accepting the need to support peri-urban farmers to increase the resilience of food systems while efficiently managing already strained natural resources. We argue that for urban agriculture to significantly increase food yields, it is crucial to adopt a One Health approach to agriculture and environmental stewardship. Here, we propose six nature-based and climate-smart approaches to accelerate the transition toward more sustainable food systems. These approaches include reducing the reliance on synthetic agricultural inputs, increasing biodiversity through producing locally adapted crops and livestock breeds, using probiotics and postbiotics, and adopting portable digital decision-support systems. Such radical approaches to transforming food production will require cross-sectoral stakeholder engagement at international, national, and community levels to protect biodiversity and the environment whilst ensuring sustainable and nutritious diets that are culturally acceptable, accessible, and affordable for all.

Public risk perception and behaviours towards COVID-19 during the first and second waves in Nigeria: a secondary data analysis.

OBJECTIVES: To describe changes in public risk perception and risky behaviours during the first wave (W1) and second wave (W2) of COVID-19 in Nigeria, associated factors and observed trend of the outbreak. DESIGN: A secondary data analysis of cross-sectional telephone-based surveys conducted during the W1 and W2 of COVID-19 in Nigeria. SETTING: Nigeria. PARTICIPANTS: Data from participants randomly selected from all states in Nigeria. PRIMARY OUTCOME: Risk perception for COVID-19 infection categorised as risk perceived and risk not perceived. SECONDARY OUTCOME: Compliance to public health and social measures (PHSMs) categorised as compliant; non-compliant and indifferent. ANALYSIS: Comparison of frequencies during both waves using χ2 statistic to test for associations. Univariate and multivariate logistic regression analyses helped estimate the unadjusted and adjusted odds of risk perception of oneself contracting COVID-19. Level of statistical significance was set at p<0.05. RESULTS: Triangulated datasets had a total of 6401 respondents, majority (49.5%) aged 25-35 years. Overall, 55.4% and 56.1% perceived themselves to be at risk of COVID-19 infection during the W1 and W2, respectively. A higher proportion of males than females perceived themselves to be at risk during the W1 (60.3% vs 50.3%, p<0.001) and the W2 (58.3% vs 52.6%, p<0.05). Residing in the south-west was associated with not perceiving oneself at risk of COVID-19 infection (W1-AOdds Ratio (AOR) 0.28; 95% CI 0.20 to 0.40; W2-AOR 0.71; 95% CI 0.52 to 0.97). There was significant increase in non-compliance to PHSMs in the W2 compared with W1. Non-compliance rate was higher among individuals who perceived themselves not to be at risk of getting infected (p<0.001). CONCLUSION: Risk communication and community engagement geared towards increasing risk perception of COVID-19 should be implemented, particularly among the identified population groups. This could increase adherence to PHSMs and potentially reduce the burden of COVID-19 in Nigeria.

Sustainability of the Effects and Impacts of Using Digital Technology to Extend Maternal Health Services to Rural and Hard-to-Reach Populations: Experience From Southwest Nigeria.

BACKGROUND: Nigeria has one of the worst health and development profiles globally. A weak health system, poor infrastructure, and varied socio-cultural factors are cited as inhibitors to optimal health system performance and improved maternal and child health status. eHealth has become a major solution to closing these gaps in health care delivery in low- and middle-income countries (LMICs). This research reports the use of satellite communication (SatCom) technology and the existing 3G mobile network for providing video training (VTR) for health workers and improving the digitization of healthcare data. OBJECTIVE: To evaluate whether the expected project outcomes that were achieved at the end-line evaluation of 2019 were sustained 12 months after the project ended. METHODS: From March 2017 to March 2019, digital innovations including VTR and data digitization interventions were delivered in 62 healthcare facilities in Ondo State, southwest Nigeria, most of which lacked access to a 3G mobile network. Data collection for the evaluation combined documents' review with quantitative data extracted from health facility registers, and 24 of the most significant change stories to assess the longevity of the outcomes and impacts of digital innovation in the four domains of healthcare: use of eHealth technology for data management, utilization of health facilities by patients, the standard of care, and staff attitude. Stories of the most significant changes were audio-recorded, transcribed for analysis, and categorized by the above domains to identify the most significant changes 12 months after the project closedown. RESULTS: Findings showed that four project outcomes which were achieved at end-line evaluation were sustained 12 months after project closedown namely: staff motivation and satisfaction; increased staff confidence to perform healthcare roles; improved standard of healthcare delivery; and increased adoption of eHealth innovations beyond the health sector. Conversely, an outcome that was reversed following the discontinuation of SatCom from health facilities is the availability of accurate and reliable data for decision-making. CONCLUSION: Digital technology can have lasting impacts on health workers, patients, and the health system, through improving data management for decision-making, the standard of maternity service delivery, boosting attendance at health facilities, and utilization of services. Locally driven investment is essential for ensuring the long-term survival of eHealth projects to achieve sustainable development goals (SDGs) in LMICs.