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IntroductionDetermining whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions. In low-income and middle-income countries (LMICs), where misdiagnoses are frequent, this is challenging. Additionally, such details are often unavailable for prescription audits. Recent studies using standardised patients (SPs) offer a unique opportunity to generate unbiased prevalence estimates of antibiotic overuse, as the research design involves patients with predefined conditions.MethodsSecondary analyses of data from nine SP studies were performed to estimate the proportion of SP–provider interactions resulting in inappropriate antibiotic prescribing across primary care settings in three LMICs (China, India and Kenya). In all studies, SPs portrayed conditions for which antibiotics are unnecessary (watery diarrhoea, presumptive tuberculosis (TB), angina and asthma). We conducted descriptive analyses reporting overall prevalence of antibiotic overprescribing by healthcare sector, location, provider qualification and case. The WHO Access–Watch–Reserve framework was used to categorise antibiotics based on their potential for selecting resistance. As richer data were available from India, we examined factors associated with antibiotic overuse in that country through hierarchical Poisson models.ResultsAcross health facilities, antibiotics were given inappropriately in 2392/4798 (49.9%, 95% CI 40.8% to 54.5%) interactions in India, 83/166 (50.0%, 95% CI 42.2% to 57.8%) in Kenya and 259/899 (28.8%, 95% CI 17.8% to 50.8%) in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas (adjusted prevalence ratio (aPR) 0.70, 95% CI 0.52 to 0.96) and higher for qualified versus non-qualified providers (aPR 1.55, 95% CI 1.42 to 1.70), and for presumptive TB cases versus other conditions (aPR 1.19, 95% CI 1.07 to 1.33). Access antibiotics were predominantly used in Kenya (85%), but Watch antibiotics (mainly quinolones and cephalosporins) were highly prescribed in India (47.6%) and China (32.9%).ConclusionGood-quality SP data indicate alarmingly high levels of antibiotic overprescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China.

Many have called for greater inclusion of researchers from low- and middle-income countries (LMICs) in the conduct of global health research, yet the extent to which this occurs is unclear. Prior studies are journal-, subject-, or region-specific, largely rely on manual review, and yield varying estimates not amenable to broad evaluation of the literature. We conducted a large-scale investigation of the contribution of LMIC-affiliated researchers to published global health research and examined whether this contribution differed over time. We searched titles, abstracts, and keywords for the names of countries ever classified as low-, lower middle-, or upper middle-income by the World Bank, and limited our search to items published from 2000 to 2017 in health science-related journals. Publication metadata were obtained from Elsevier/Scopus and analysed in statistical software. We calculated proportions of publications with any, first, and last authors affiliated with any LMIC as well as the same LMIC(s) identified in the title/abstract/keywords, and stratified analyses by year, country, and countries’ most common income status. We analysed 786 779 publications and found that 86.0% included at least one LMIC-affiliated author, while 77.2% and 71.2% had an LMIC-affiliated first or last author, respectively; however, analagous proportions were only 58.7%, 36.8%, and 29.1% among 100 687 publications about low-income countries. Proportions of publications with LMIC-affiliated authors increased over time, yet this observation was driven by high research activity and representation among upper middle-income countries. Between-country variation in representation was observed, even within income status categories. We invite comment regarding these findings, particularly from voices underrepresented in this field.

IntroductionThe COVID-19 pandemic caused a healthcare crisis in China and continues to wreak havoc across the world. This paper evaluated COVID-19’s impact on national and regional healthcare service utilisation and expenditure in China.MethodsUsing a big data approach, we collected data from 300 million bank card transactions to measure individual healthcare expenditure and utilisation in mainland China. Since the outbreak coincided with the 2020 Chinese Spring Festival holiday, a difference-in-difference (DID) method was employed to compare changes in healthcare utilisation before, during and after the Spring Festival in 2020 and 2019. We also tracked healthcare utilisation before, during and after the outbreak.ResultsHealthcare utilisation declined overall, especially during the post-festival period in 2020. Total healthcare expenditure and utilisation declined by 37.8% and 40.8%, respectively, while per capita expenditure increased by 3.3%. In a subgroup analysis, we found that the outbreak had a greater impact on healthcare utilisation in cities at higher risk of COVID-19, with stricter lockdown measures and those located in the western region. The DID results suggest that, compared with low-risk cities, the pandemic induced a 14.8%, 26.4% and 27.5% reduction in total healthcare expenditure in medium-risk and high-risk cities, and in cities located in Hubei province during the post-festival period in 2020 relative to 2019, an 8.6%, 15.9% and 24.4% reduction in utilisation services; and a 7.3% and 18.4% reduction in per capita expenditure in medium-risk and high-risk cities, respectively. By the last week of April 2020, as the outbreak came under control, healthcare utilisation gradually recovered, but only to 79.9%–89.3% of its pre-outbreak levels.ConclusionThe COVID-19 pandemic had a significantly negative effect on healthcare utilisation in China, evident by a dramatic decline in healthcare expenditure. While the utilisation level has gradually increased post-outbreak, it has yet to return to normal levels.

IntroductionWith the ratification of the Sustainable Development Goals, there is an increased emphasis on early childhood development (ECD) and well-being. The WHO led Global Scales for Early Development (GSED) project aims to provide population and programmatic level measures of ECD for 0–3 years that are valid, reliable and have psychometrically stable performance across geographical, cultural and language contexts. This paper reports on the creation of two measures: (1) the GSED Short Form (GSED-SF)—a caregiver reported measure for population-evaluation—self-administered with no training required and (2) the GSED Long Form (GSED-LF)—a directly administered/observed measure for programmatic evaluation—administered by a trained professional.MethodsWe selected 807 psychometrically best-performing items using a Rasch measurement model from an ECD measurement databank which comprised 66 075 children assessed on 2211 items from 18 ECD measures in 32 countries. From 766 of these items, in-depth subject matter expert judgements were gathered to inform final item selection. Specifically collected were data on (1) conceptual matches between pairs of items originating from different measures, (2) developmental domain(s) measured by each item and (3) perceptions of feasibility of administration of each item in diverse contexts. Prototypes were finalised through a combination of psychometric performance evaluation and expert consensus to optimally identify items.ResultsWe created the GSED-SF (139 items) and GSED-LF (157 items) for tablet-based and paper-based assessments, with an optimal set of items that fit the Rasch model, met subject matter expert criteria, avoided conceptual overlap, covered multiple domains of child development and were feasible to implement across diverse settings.ConclusionsState-of-the-art quantitative and qualitative procedures were used to select of theoretically relevant and globally feasible items representing child development for children aged 0–3 years. GSED-SF and GSED-LF will be piloted and validated in children across diverse cultural, demographic, social and language contexts for global use.

BackgroundThe COVID-19 pandemic has led to an unprecedented global research effort to build a body of knowledge that can inform mitigation strategies. We carried out a bibliometric analysis to describe the COVID-19 research output in Africa in terms of setting, study design, research themes and author affiliation.MethodsWe searched for articles published between 1 December 2019 and 3 January 2021 from various databases including PubMed, African Journals Online, medRxiv, Collabovid, the WHO global research database and Google. All article types and study design were included.ResultsA total of 1296 articles were retrieved. 46.6% were primary research articles, 48.6% were editorial-type articles while 4.6% were secondary research articles. 20.3% articles used the entire continent of Africa as their study setting while South Africa (15.4%) was the most common country-focused setting. The most common research topics include ‘country preparedness and response’ (24.9%) and ‘the direct and indirect health impacts of the pandemic’ (21.6%). However, only 1.0% of articles focus on therapeutics and vaccines. 90.3% of the articles had at least one African researcher as author, 78.5% had an African researcher as first author, while 63.5% had an African researcher as last author. The University of Cape Town leads with the greatest number of first and last authors. 13% of the articles were published in medRxiv and of the studies that declared funding, the Wellcome Trust was the top funding body.ConclusionsThis study highlights Africa’s COVID-19 research and the continent’s existing capacity to carry out research that addresses local problems. However, more studies focused on vaccines and therapeutics are needed to inform local development. In addition, the uneven distribution of research productivity among African countries emphasises the need for increased investment where needed.

IntroductionIntimate partner violence (IPV) is a serious public health and human rights violation which impacts approximately one in three women worldwide. Some existing evidence suggests that women with disabilities are at higher risk of IPV, but is largely limited in geographical scope to the Global North, and comparison across settings has been hampered by inconsistent measurement of both IPV and disability.MethodsPooled analysis of baseline data from 8549 adult women participating in seven IPV prevention studies in five countries across Africa and Asia that used collaborative, comparative measurement strategies to assess both disability and IPV.ResultsAfter adjusting for age, women with disabilities were more likely to experience past 12-month physical IPV (adjusted OR (aOR)=1.79; 95% CI 1.49 to 2.17), sexual IPV (aOR=1.98; 95% CI 1.36 to 2.89), emotional IPV (aOR=1.84; 95% CI 1.49 to 2.27) and economic IPV (aOR=1.66; 95% CI 1.45 to 1.89), with an overall association between disability and past 12-month physical/sexual IPV of aOR=1.93 (95% CI 1.52 to 2.46). Compared to women without disability, women with moderate and severe disability showed a trend of increasing risk of IPV in the past 12 months for each of physical, sexual, emotional and economic IPV. Overall, both women with moderate disability (aOR=1.86, 95% CI 1.57 to 2.21) and women with severe disability (aOR=2.63; 95% CI 1.95 to 3.55) were significantly more likely to experience any form of IPV when compared with women without disability.ConclusionWomen with disabilities are at increased risk of past-year IPV compared to women without disabilities across a range of settings in the Global South, and the risk of IPV increases with increasing severity of disability. IPV prevention and response efforts in these settings must find ways to include and address the needs of women with disabilities, including increased outreach and improved accessibility of programmes.

IntroductionDespite the high burden of mental disorders among adolescents and the potentially lifelong consequences of these conditions, access to mental health services remains insufficient for adolescents in low-income and middle-income countries. We conducted an economic modelling study to quantify the potential costs and benefits of mental health interventions to prevent or treat anxiety, depression, bipolar disorder, and suicide among adolescents.MethodsWe developed a Markov model that followed cohorts of adolescents (ages 10–19) from 36 countries to assess the impact of addressing anxiety, depression, bipolar disorder, and suicide during adolescence on health and non-health outcomes through their lives. We estimated the costs of interventions using an ingredients-based approach and modelled impacts on education and employment and the resulting economic, morbidity, and mortality benefits.ResultsImplementing the selected interventions offers a return on investment of 23.6 and a cost of $102.9 per disability adjusted life year (DALY) averted over 80 years. The high return on investment and low cost per DALY averted is observed across regions and country income levels, with the highest return on investment arising from treating mild depression with group-based cognitive behavioural therapy, prevention of suicide attempts among high-risk adolescents, and universal prevention of combined anxiety and depression in low-income and lower-middle income countries.ConclusionsThe high return on investment and low cost per DALY averted suggests the importance and value of addressing mental disorders among adolescents worldwide. Intervening to prevent and treat these mental disorders even only during adolescence can have lifelong health and economic benefits.

There is a need to use design when and as appropriate to complement existing knowledge and practice, and to ‘balance a concern for understanding current or past practices with a concern for envisioning alternative or future practices’.5 The need for guidelines for reporting research involving design In a previous scoping review of peer-reviewed journal articles on human-centred design and public health,9 we found that few articles included detailed methods and results, information on design expertise within teams, reflexivity/positionality or socioinstitutional dynamics. Clearer guidance for authors, journal editors, community members and peer reviewers will influence publication and the potential for stakeholders from diverse communities and disciplines to locate design-based health research.11 As the global health community increasingly seeks ways of scaling up beneficial interventions, clear and transparent reporting of approaches to achieve impact is warranted.12 Reporting guidelines add value and allow programme reports and research articles to be useful for a wider audience.13 14 Incomplete reporting makes research inaccessible, introduces bias and does not provide full transparency.15 Reporting guidelines for health research involving design may help investigation and programmatic activities to be shared and used more frequently and effectively. Description of the initial research question or health problem that the design-based work aimed to address. 3 Methods/approach Reporting of the approach, tools or processes that were used for the research; who was involved (both researchers and participants); when and where research was conducted; how data were reviewed, analysed and synthesised; and iteration. 4 Results/findings from design research and activities Summary of findings from design activities. Statement of what is known about the problem and what has been done to address it in the past, state of the art. 2.2 Rationale for design approach Explanation of design as appropriate to address the topic.

The calls for health research to be collaborative are ubiquitous—even as part of a recent World Health Assembly resolution on clinical trials—yet the arguments in support of collaborative research have been taken for granted and are absent in the literature. This article provides three arguments to justify why health research ought to be collaborative and discusses trade-offs to be considered among the ethical values guiding each argument.

BackgroundGlobal surgery has recently gained prominence as an academic discipline within global health. Authorship inequity has been a consistent feature of global health publications, with over-representation of authors from high-income countries (HICs), and disenfranchisement of researchers from low-income and middle-income countries (LMICs). In this study, we investigated authorship demographics within recently published global surgery literature.MethodsWe performed a systematic analysis of author characteristics, including gender, seniority and institutional affiliation, for global surgery studies published between 2016 and 2020 and indexed in the PubMed database. We compared the distribution of author gender and seniority across studies related to different topics; between authors affiliated with HICs and LMICs; and across studies with different authorship networks.Results1240 articles were included for analysis. Most authors were male (60%), affiliated only with HICs (51%) and of high seniority (55% were fully qualified specialist or generalist clinicians, Principal Investigators, or in senior leadership or management roles). The proportion of male authors increased with increasing seniority for last and middle authors. Studies related to Obstetrics and Gynaecology had similar numbers of male and female authors, whereas there were more male authors in studies related to surgery (69% male) and Anaesthesia and Critical care (65% male). Compared with HIC authors, LMIC authors had a lower proportion of female authors at every seniority grade. This gender gap among LMIC middle authors was reduced in studies where all authors were affiliated only with LMICs.ConclusionAuthorship disparities are evident within global surgery academia. Remedial actions to address the lack of authorship opportunities for LMIC authors and female authors are required.