Global Health Interventions Research Articles

"I wanted to be a bride, not a wife": Accounts of child marriage in the Bedouin community in Israel.

This article presents a qualitative study of the experience of child marriage among Bedouin in Israel. We conducted semi-structured interviews with a convenience sample of 17 young Bedouin women, aged 17-21, who were married between the ages of 12-17. The interviewees' descriptions indicate that child marriage is a powerful cultural practice that has evolved into a "natural" and "obvious" tool for supervising girls and women. All the interviewees reported domestic violence, despair, and reported suicide attempts as a response to their existential suffering in their marriage and as an act of daily resistance to a powerful and oppressive cultural practice. These findings raise challenges in the case of global mental health interventions since these interventions not only require cultural sensitivity to avoid the constraint of Western psychiatric diagnoses and classifications, but also more critical thinking about the interactions between global and local, universalist and culturalist perspectives.

Gender, caring work, and the embodiment of kufungisisa: Findings from a global health intervention in Shurugwi District, Zimbabwe.

This paper analyses the findings from qualitative interviews conducted as part of a cross-disciplinary pilot study into the efficacy of the Friendship Bench for promoting mental health amongst rural women living in Shurugwi District, Zimbabwe. Informed by UNICEF's nurturing care framework, the pilot study hypothesised that women's caring capabilities would be enhanced if a cost-effective intervention could be found for those suffering from common mental disorders (CMD), locally referred to as kufungisisa. Focusing on the women's accounts of their embodiment of kufungisisa, the paper further highlights the important role that gender plays in women's experience of common mental health disorders. More critically, it identifies the ways in which patriarchal social relations may be reinforced through the spaces of global health interventions such as the one reported on here. The paper concludes with a moment of self-reflection. Specifically, it poses the question that our paper, and the global health intervention it reports upon, would look very different if the women's experiences of kufungisisa were considered not only as they appear in the present but at the intersection of social and spatial relations that have much longer histories.

Resource use, availability and cost in the provision of critical care in Tanzania: a systematic review

ObjectivesCritical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need...

Engaging and supporting national public health institutes as key climate actors

Abstract The International Association of National Public Health Institutes (IANPHI) collectively builds public health capacity by connecting, developing and strengthening national public health institutes worldwide. IANPHI recognizes climate action as a critical global public health intervention and acknowledges that public health interventions on environmental and socio-economic determinants of health are essential drivers of climate adaptation and mitigation. Recovery from the COVID-19 pandemic also provides a unique opportunity to reset business as usual and strengthen actions on climate change, biodiversity and health, while reducing social and health inequities in the long term. However, effective contributions of National Public Health Institutes (NPHIs) to adaptation plans and mitigation strategies for climate change have remained limited, with a primary focus on health surveillance to date. In this context, IANPHI developed a roadmap to support and reinforce the role of NPHIs in climate change mitigation and adaptation policies. Five priority actions were identified: 1. Advocate for strengthening NPHIs capacities to contribute effectively to climate and biodiversity research, policies, and action 2. Enhance capacity, competence and training through peer-to-peer support and knowledge sharing between NPHIs 3. Increase collaboration with international and regional organizations active in the fields of public health and climate change 4. Support the greening of public health services 5. Monitor progress in the NPHIs’ involvement in climate change policies through key indicators In addition to discussing the roadmap, the presentation will focus on actions that IANPHI's Climate Change and Health committee initiated to reinforce the role of NPHIs in climate change mitigation and adaptation policies. This presentation will also provide information on how IANPHI can engage and support national public health institutes as key actors in the fight against climate change.

Achieving and Sustaining Change Through Capacity Building Train-the-Trainer Health Initiatives in Low- and Middle-Income Countries: A Systematic Review.

Given the anticipated health challenges, forecasted deficiencies in the global health workforce, and steady demands to work through resource constraints, effective and efficient training approaches to build capacity are direly needed. Although train-the-trainer (T3) is not a new approach, there has been considerable interest in using it to develop and sustain capacity, particularly in low- and middle-income countries. This systematic review aimed to better understand the factors to achieve and sustain change across multiple countries and levels through T3 approaches. A literature search was conducted of six scholarly, peer-reviewed, and gray literature databases. Data were extracted for the study method, design, characteristics, and implicit or explicit factors related to maximizing the likelihood of achieving and sustaining change. An existing conceptual framework for T3 interventions in global health guided the thematic analysis. The framework consisted of five factors pertinent to capacity building T3 initiatives: Talent, Resources, Alignment, Implementation, and Nurture and Development. Twenty-two studies met the inclusion criteria. The T3 training spanned all geographical regions, but interventions were most prevalent in sub-Saharan Africa (46%). Nearly all studies (68%) quantitatively examined change at the individual level (95%), but some studies also explored change at the organizational (77%) and institutional (23%) levels. Implementation and Nurture/Development were the two most salient factors in achieving and sustaining change. The greatest hindrances involved Resources and Context , an additional theme that the data identified. The findings and recommendations from this first systematic review exploring antecedents influencing change through health-related T3 interventions can inform training and capacity-building investments, improve existing T3 initiatives, and steer planning for future approaches.

Reflecting on our good intentions: A critical discourse analysis of women’s health and empowerment discourses in sexual and gender-based violence policies relevant to southern Africa

ABSTRACT Decades of ‘feminist’ sexual- and gender-based violence (SGBV) policies have produced limited change in southern African SGBV rates. Recent critiques highlight ongoing colonial legacies in such policymaking, arguing that these legacies limit the potential for liberatory change. Further, reflecting on such discourses can highlight reasons behind global public health intervention failure. To promote reflexivity among public health actors who create, reproduce, and implement SGBV policies, this paper presents a critical discourse analysis of how women’s empowerment is constructed in foundational global and national health and development policies bearing on SGBV in Zambia. The analysis identifies neoliberal feminist discourses of empowerment: (i) the protection of women, which perpetuates a saviour complex; (ii) the promotion of equality to men, which excludes those deemed unworthy; (iii) the eradication of harmful cultural norms, which challenge the preservation of African values; and (iv) (neoliberal) empowerment through women’s attained employment and capital, which empowers women within unequal economic relations rather than liberating women from those relations. The author critiques such neoliberal empowerment discourses for failing to structurally transform the conditions for women’s liberation. This paper offers a first step to the dismantling of colonial structures in SGBV policies by unpacking and promoting reflexivity about such discourses.

Development of a Mobile Application for Detection of Adolescent Mental Health Problems and Feasibility Assessment with Primary Health Care Workers

Introduction: There has been a sharp increase in the use of digital health interventions in global health, particularly mobile health applications, in recent years. The extreme shortage of health care providers trained in mental health screening and intervention in low- and middle-income countries raises questions about the applicability of mobile applications to deliver these services due to their accessibility and availability. This exploratory paper describes the development and feasibility assessment of a mobile screening application for the detection of mental disorders among adolescents in Zambia and South Africa. Methods: Eighty-two health care workers (HCW) working in primary care evaluated the acceptability and practicality of the mobile screening application after receiving brief training. The evaluation included questions from the Mobile Application Rating Scale (MARS) as well as open-ended questions. Results: The acceptability of the screening app was high and study participants were positive about using the app in routine care. Problems with internet connectivity, and time and staff constraints were perceived as the main barriers to regular use. Conclusion: HCW in primary care were able and willing to use a mobile screening app for the detection of mental health problems among treatment-seeking adolescents. Implementation in clinical practice needs to be further evaluated.

Introduction to the special section: Histories of Global Health in Africa.

Global health is a multidisciplinary field, yet rarely productively incorporates historical knowledge. Local historical processes, interactions with past biomedical campaigns, and dynamic ecological narratives shape how disease outbreaks, health crises, and international interventions are received and remembered. The residues and afterlives of past interactions influence contemporary understandings. We argue for a broadening of the types of knowledge that are integrated into global health research, interventions, and policymaking by paying attention to project afterlives and better integrating forms of vernacular knowledge. Recognizing, understanding, respecting, and incorporating this knowledge is critical to the efficacy of global health-related interventions and the resulting outcomes.

Bodies in peril: Healthcare workers on the frontlines of global maternal health interventions

ABSTRACT Drawing on long-term ethnographic fieldwork in maternity settings in Tanzania and Pakistan, we argue that ‘bodywork’ condenses all politically and practically at stake for maternal healthcare providers. Our research confronts how global health programmes expect paramedical providers working on the frontlines of obstetrics to implement interventions without also attending to violent everyday realities of providing care amidst structural constraint and precarity. We demonstrate this approach's dire aftermaths. Healthcare workers’ bodies evidence risks and injuries not only attendant on care in lower-resource settings, but which unfold specifically from their efforts to meet the onerous demands of global health systems. Toxic hospital environments represent a paradox of care – medicine exposes patients and providers to greater risks than if medicine were not involved – but this inherent riskiness barely registers. Elisions of healthcare providers’ experiences of harm are telling; they reveal global health’s neglect of occupational risk and a racialised under-attention and under-valuing of the risks carried by bodies of colour, and women especially. We trace and corroborate providers’ experiences of threats to their wellbeing while enacting global health agendas. We conclude with a provocation that social scientists’ bedside witnessing must result in actionable evidence if a more sustainable global health is to prevail.

Does the internet help governments contain the COVID-19 pandemic? Multi-country evidence from online human behaviour

The effectiveness of social distancing and other public health interventions for containing the COVID-19 pandemic has been demonstrated. However, whether and how Internet use behaviours can lead to enhanced self-protection and reduced transmission when considered in conjunction with behavioural interventions remains unclear. This study investigated the strength of effective Internet behaviours and its interaction with global public health interventions for controlling the COVID-19 pandemic. We conducted an econometric analysis of multisource infection and policy information, Internet behaviour, and meteorological information from worldwide in a 3-month period. People's Internet behaviours may contribute crucially to pandemic containment. Furthermore, they may help enhance the effects of public health interventions, particularly behavioural interventions. We discussed plausible mechanisms through which Internet behaviours reduce epidemic spread independently or in tandem with behavioural interventions. Further investigation into the heterogeneity of the interventions demonstrates Internet behaviour's significance in heightening the effects of difficult-to-implement, primitive crisis orientation, and specific objectives of interventions. Governments should recognise the importance of the Internet and leverage it in managing social crises. Our findings serve as a reference for the formulation of global public health policy. Specifically, the insights provided herein can facilitate the implementation of strategies for containing ongoing secondary outbreaks of COVID-19 or outbreaks of other emergent infectious diseases.

Provincializing bioethics

ABSTRACTSince the 1980s, anthropologists have criticized a US‐centric view of bioethics that presents individual autonomy as a universal principle without acknowledging its embeddedness in time and place. A recent turn in this critique points out how this view has gained dominance across the world, traveling alongside clinical trials and global health interventions. Here, centering a competing bioethical vision disrupts this division between the Global North as a site of ethical conceptualization and the South as the recipient of its diffusion. Indian legal bioethics—concerned with protecting the critically ill body in intensive care—rejects the primacy of autonomy, instead empowering courts to override the choices of patients, families, and doctors. This competing bioethics commits its own harms, misrepresenting vulnerability as a problem of sociomoral underdevelopment rather than as the outcome of increasing inflows of global capital, new patterns of land acquisition, and a growing public‐private health care divide. [bioethics, end of life, norms, ethics, medicine, law, intensive care, Delhi, India]

Quantitative decision making for investment in global health intervention trials: Case study of the NEWBORN study on emollient therapy in preterm infants in Kenya.

BackgroundPartners from an NGO, academia, industry and government applied a tool originating in the private sector – Quantitative Decision Making (QDM) – to rigorously assess whether to invest in testing a global health intervention. The proposed NEWBORN study was designed to assess whether topical emollient therapy with sunflower seed oil in infants with very low birthweight <1500 g in Kenya would result in a significant reduction in neonatal mortality compared to standard of care.MethodsThe QDM process consisted of prior elicitation, modelling of prior distributions, and simulations to assess Probability of Success (PoS) via assurance calculations. Expert opinion was elicited on the probability that emollient therapy with sunflower seed oil will have any measurable benefit on neonatal mortality based on available evidence. The distribution of effect sizes was modelled and trial data simulated using Statistical Analysis System to obtain the overall assurance which represents the PoS for the planned study. A decision-making framework was then applied to characterise the ability of the study to meet pre-selected decision-making endpoints.ResultsThere was a 47% chance of a positive outcome (defined as a significant relative reduction in mortality of ≥15%), a 45% chance of a negative outcome (defined as a significant relative reduction in mortality <10%), and an 8% chance of ending in the consider zone (ie, a mortality reduction of 10 to <15%) for infants <1500 g.ConclusionsQDM is a novel tool from industry which has utility for prioritisation of investments in global health, complementing existing tools [eg, Child Health and Nutrition Research Initiative]. Results from application of QDM to the NEWBORN study suggests that it has a high probability of producing clear results. Findings encourage future formation of public-private partnerships for health.

Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study

In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health.

The post-colonialist condition, suspicion, and social resistance during the West African Ebola epidemic: The importance of Frantz Fanon for global health

The scholarship of Frantz Fanon has been recognized across numerous disciplines as a unique and necessary intervention for critical analyses of the (post)colonial condition. Yet, thus far, his oeuvre has largely been ignored in global health research. In this article we introduce and demonstrate the relevance of Fanon's work for the field of global health. To illustrate, we draw from Fanon's conceptual framework and observations to analyze the 2014–16 Ebola Virus Disease outbreak response in West Africa. During this Ebola epidemic, although not necessarily as widespread as Western media made it seem, numerous instances of “resistance”—sometimes violent—were levied by members of the community toward foreign outbreak response teams. In this article, we argue that the keen insights proffered by Fanon more than half a century ago help facilitate a deeper understanding of some of the reactions of community members and public health officials during the Ebola response. In calling attention to colonial histories and structural relations of power, poverty, and violence, Fanon's work can help us to effectively move towards “decolonizing” global health interventions, thus providing a framework with which to better understand and more humanely intervene in future epidemic outbreaks in the Global South.

Celebrating scientific excellence and global health impact: The 2022 Canada Gairdner Awards

From mRNA vaccines to community interventions in global child health, the 2022 Canada Gairdner awards demonstrate the importance of fundamental science and its translation into improved human health and well-being.

Cost-effectiveness analysis of human-centred design for global health interventions: a quantitative framework.

IntroductionHuman-centred design (HCD) is a problem-solving approach that is increasingly used to develop new global health interventions. However, there is often a large initial cost associated with HCD, and global health decision-makers would benefit from an improved understanding of the cost-effectiveness of HCD, particularly the trade-offs between the up-front costs of design and the long-term costs of delivering health interventions.MethodsWe developed a quantitative framework from a health systems perspective to illustrate the conditions under which HCD-informed interventions are likely to be cost-effective, taking into consideration five elements: cost of HCD, per-client intervention cost, anticipated number of clients reached, anticipated incremental per-client health benefit (ie, disability-adjusted life years (DALYs) averted) and willingness-to-pay. We evaluated several combinations of fixed and implementation cost scenarios based on the estimated costs of an HCD-informed approach to tuberculosis (TB) contact investigation in Uganda over a 2-year period to illustrate the use of this framework.ResultsThe cost-effectiveness of HCD-informed TB contact investigation in Uganda was estimated to vary from US$8400 (2400 clients reached, lower HCD cost estimate) to US$306 000 per DALY averted (120 clients reached, baseline HCD cost estimate). In our model, cost-effectiveness was improved further when the interventions were expected to have wider reach or higher per-client health benefits.ConclusionHCD can be cost-effective when used to inform interventions that are anticipated to reach a large number of clients, or in which the cost of HCD is smaller relative to the cost of delivering the intervention itself.

Unpacking the Implications of SARS-CoV-2 Breakthrough Infections on COVID-19 Vaccination Programs.

Despite an array of preventive global public health interventions, SARS-CoV-2 has continued to spread significantly, infecting millions of people across the globe weekly. Newer variants of interest and concern have continued to emerge, placing the need for policymakers to rethink prevention strategies to end the pandemic. The approval of SARS-CoV-2 vaccines for public health use in December 2020 was seen as a significant development towards pandemic control and possibly ending the pandemic. However, breakthrough infections have continued to be observed among the ‘fully vaccinated’, and the duration and sustainability of vaccine-induced immunity has remained a topical public health discourse. In the absence of accurate public health communication, the breakthrough infections and waning immunity concepts have potential to further compound vaccine hesitancy. With this viewpoint, we discuss breakthrough SARS-CoV-2 infections, waning immunity, the need for COVID-19 booster shots, vaccine inequities, and the need to address vaccine hesitancy adequately to propel global vaccination programs forward.

Global health education for the post-pandemic years: parity, people, planet, priorities, and practices

Global health degree programs are now offered by institutions of higher education in most world regions. Based on our review of the curricula for many of these programs, we identified five domains that are central to current global health education. “Parity” emphasizes health equity as the ultimate goal of global health. “People” comprises the social, economic, cultural, and political contributors to health and access to medical care for individuals and communities. “Planet” encompasses various aspects of globalization and environmental health that affect population health. “Priorities” and “practices” include the values, data, and tools used to design, implement, and evaluate partnerships, policies, programs, and other global health interventions in countries of all income levels. The pandemic is likely to increase student demand for global health education from the undergraduate through the graduate and professional levels. Our “5 Ps model of global health education” provides a comprehensive framework for the core student learning objectives for global health today. Knowledge of each of these domains is essential for preparing students for meaningful experiential learning and skilled professional practice in global health.

Systems Thinking for Effective Interventions in Global Environmental Health.

Environmental health risks such as household air pollution due to burning solid fuels, inadequate water, sanitation, and hygiene, and chemical pollution disproportionately affect the poorest and most marginalized populations. While billions of dollars and countless hours of research have been applied toward addressing these issues in both development and humanitarian contexts, many interventions fail to achieve or sustain desired outcomes over time. This pattern points to the perpetuation of linear thinking, despite the complex nature of environmental health within these contexts. There is a need and an opportunity to engage in critical reflection of the dominant paradigms in the global environmental health community, including how they affect decision-making and collective learning. These paradigms should be adapted as needed toward the integration of diverse perspectives and the uptake of systems thinking. Participatory modeling, complexity-aware monitoring, and virtual simulation modeling can help achieve this. Additionally, virtual simulation modeling is relatively inexpensive and can provide a low-stakes environment for testing interventions before implementation.

Why marry early? Parental influence, agency and gendered conflict in Tanzanian marriages.

Global health interventions increasingly target the abolishment of 'child marriage' (marriage under 18 years, hereafter referred to as 'early marriage'). Guided by human behavioural ecology theory, and drawing on focus groups and in-depth interviews in an urbanising Tanzanian community where female early marriage is normative, we examine the common assumption that it is driven by the interests and coercive actions of parents and/or men. We find limited support for parent-offspring conflict. Parents often encouraged early marriages, but were motivated by the promise of social and economic security for daughters, rather than bridewealth transfers alone. Moreover, forced marriage appears rare, and adolescent girls and young women (AGYW) were active agents in the transition to marriage, sometimes marrying against parental wishes. Support for gendered conflict was stronger. AGYW were described as being lured into unstable relationships by men misrepresenting their long-term intentions. Community members voiced concerns over these marriages. Overall, early marriage appears rooted in limited options, encouraging strategic, but risky choices on the marriage market. Our results highlight plurality and context dependency in drivers of early marriage, even within a single community. We conclude that engaging with the importance of context is fundamental in forging culturally sensitive policies and programs on early marriage.