Lessons learnt from the MAGNET Malawian-German Hospital Partnership: the German perspective on contributions to patient care and capacity development

Background: Malawi is a low-income country with one of the highest HIV prevalence rates worldwide (Kendig et al., Trop Med Health 41:163–170, 2013). The health system depends largely on external funding. Official German development aid has supported health care in Malawi for many years (German Embassy Lilongwe, The German Development Cooperation in Malawi), including placing medical doctors in various departments of the Kamuzu Central Hospital (KCH) in Lilongwe. In 2008, a hospital partnership called MAGNET (Malawi German Networking for Capacity Building in Treatment, Training and Research at KCH) evolved as part of the German ESTHER network. The partnership was abruptly terminated in 2015. Methods: We reviewed 35 partnership documents and conducted an online survey of partnership stakeholders to retrospectively assess the hospital partnership based on the Capacity WORKS model of the German Corporation for International Cooperation (GIZ). This model evaluates systems’ management and implementation to understand and support the functioning of cooperation within societies. Based on this model, we considered the five success factors for cooperation management: (1) strategy, (2) cooperation, (3) steering, (4) processes, and (5) learning and innovation. In an online survey, we used an adapted version of the partnership evaluation tool by the Centers for Disease Control and Prevention (CDC). Results: From 2008 to 2015, the MAGNET partnership contributed to capacity building and improved patient care in the KCH Medical Department through clinical care, technical support, teaching and trainings, and operations research based on mutually agreed upon objectives. The MAGNET partnership was implemented in three phases during which there were changes in leadership in the Medical Department and the hospital, contractual policies, funder priorities and the competing influences of other actors. Communication and follow up among partners worked best during phases when a German doctor was onsite. The partnership was judged as a positive driver for change and support within the Medical Department, but eventually failed to implement self-sustainable, robust processes within the partnership to cope with multiple changes and challenges. Conclusion: The MAGNET partnership made a considerable contribution to patient care, continuous medical education and operations research at KCH, despite its abrupt termination. Changes in the institutional infrastructure, donor policy and interpersonal relations contributed to the loss of shared expectations and the end of the project. Institutional-hospital partnerships, like MAGNET, can make a valuable contribution to health care provision and hence a wider health agenda, provided there is a flexible, mutually agreed upon strategy, personal commitment, continuous communication and robust processes. However, partnership projects remain vulnerable to the influences of external actors and structures. Ministries of Health and donor agencies should appreciate the particular strength of hospital partnerships

Lessons learned on teaching a global audience with massive open online courses (MOOCs) on health impacts of climate change: a commentary

Background: The adverse health impacts of climate change are increasing on a global level. However, knowledge about climate change and health is still unavailable to many global citizens, in particular on adaptation measures and co-benefits of health mitigation. Educational technologies, such as massive open online courses (MOOCs), may have a high potential for providing access to information about climate change links to health for a global audience. \ud Main body: We developed three MOOCs addressing the link between climate change and health to take advantage of the methodology’s broad reach and accelerate knowledge dissemination on the nexus of climate change and health. The primary objective was to translate an existing face-to-face short course that only reached a few participants on climate change and health into globally accessible learning opportunities. In the following, we share and comment on our lessons learned with the three MOOCs, with a focus on global teaching in the realm of climate change and health. Conclusions: Overall, the three MOOCs attracted a global audience with diverse educational backgrounds, and a large number of participants from low-income countries. Our experience highlights that MOOCs may play a part in global capacity building, potentially for other health-related topics as well, as we have found that our MOOCs have attracted participants within low-resource contexts. MOOCs may be an effective method for teaching and training global students on health topics, in this case on the complex links and dynamics between climate change and health and may further act as an enabler for equitable access to quality education

Widening the lens of population-based health research to climate change impacts and adaptation: the climate change and health evaluation and response system (CHEERS)

BackgroundClimate change significantly impacts health in low-and middle-income countries (LMICs), exacerbating vulnerabilities. Comprehensive data for evidence-based research and decision-making is crucial but scarce. Health and Demographic Surveillance Sites (HDSSs) in Africa and Asia provide a robust infrastructure with longitudinal population cohort data, yet they lack climate-health specific data. Acquiring this information is essential for understanding the burden of climate-sensitive diseases on populations and guiding targeted policies and interventions in LMICs to enhance mitigation and adaptation capacities.ObjectiveThe objective of this research is to develop and implement the Change and Health Evaluation and Response System (CHEERS) as a methodological framework, designed to facilitate the generation and ongoing monitoring of climate change and health-related data within existing Health and Demographic Surveillance Sites (HDSSs) and comparable research infrastructures.MethodsCHEERS uses a multi-tiered approach to assess health and environmental exposures at the individual, household, and community levels, utilizing digital tools such as wearable devices, indoor temperature and humidity measurements, remotely sensed satellite data, and 3D-printed weather stations. The CHEERS framework utilizes a graph database to efficiently manage and analyze diverse data types, leveraging graph algorithms to understand the complex interplay between health and environmental exposures.ResultsThe Nouna CHEERS site, established in 2022, has yielded significant preliminary findings. By using remotely-sensed data, the site has been able to predict crop yield at a household level in Nouna and explore the relationships between yield, socioeconomic factors, and health outcomes. The feasibility and acceptability of wearable technology have been confirmed in rural Burkina Faso for obtaining individual-level data, despite the presence of technical challenges. The use of wearables to study the impact of extreme weather on health has shown significant effects of heat exposure on sleep and daily activity, highlighting the urgent need for interventions to mitigate adverse health consequences.ConclusionImplementing the CHEERS in research infrastructures can advance climate change and health research, as large and longitudinal datasets have been scarce for LMICs. This data can inform health priorities, guide resource allocation to address climate change and health exposures, and protect vulnerable communities in LMICs from these exposures

The unfinished agenda of communicable diseases among children and adolescents before the COVID-19 pandemic, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND: Communicable disease control has long been a focus of global health policy. There have been substantial reductions in the burden and mortality of communicable diseases among children younger than 5 years, but we know less about this burden in older children and adolescents, and it is unclear whether current programmes and policies remain aligned with targets for intervention. This knowledge is especially important for policy and programmes in the context of the COVID-19 pandemic. We aimed to use the Global Burden of Disease (GBD) Study 2019 to systematically characterise the burden of communicable diseases across childhood and adolescence. METHODS: In this systematic analysis of the GBD study from 1990 to 2019, all communicable diseases and their manifestations as modelled within GBD 2019 were included, categorised as 16 subgroups of common diseases or presentations. Data were reported for absolute count, prevalence, and incidence across measures of cause-specific mortality (deaths and years of life lost), disability (years lived with disability [YLDs]), and disease burden (disability-adjusted life-years [DALYs]) for children and adolescents aged 0-24 years. Data were reported across the Socio-demographic Index (SDI) and across time (1990-2019), and for 204 countries and territories. For HIV, we reported the mortality-to-incidence ratio (MIR) as a measure of health system performance. FINDINGS: In 2019, there were 3·0 million deaths and 30·0 million years of healthy life lost to disability (as measured by YLDs), corresponding to 288·4 million DALYs from communicable diseases among children and adolescents globally (57·3% of total communicable disease burden across all ages). Over time, there has been a shift in communicable disease burden from young children to older children and adolescents (largely driven by the considerable reductions in children younger than 5 years and slower progress elsewhere), although children younger than 5 years still accounted for most of the communicable disease burden in 2019. Disease burden and mortality were predominantly in low-SDI settings, with high and high-middle SDI settings also having an appreciable burden of communicable disease morbidity (4·0 million YLDs in 2019 alone). Three cause groups (enteric infections, lower-respiratory-tract infections, and malaria) accounted for 59·8% of the global communicable disease burden in children and adolescents, with tuberculosis and HIV both emerging as important causes during adolescence. HIV was the only cause for which disease burden increased over time, particularly in children and adolescents older than 5 years, and especially in females. Excess MIRs for HIV were observed for males aged 15-19 years in low-SDI settings. INTERPRETATION: Our analysis supports continued policy focus on enteric infections and lower-respiratory-tract infections, with orientation to children younger than 5 years in settings of low socioeconomic development. However, efforts should also be targeted to other conditions, particularly HIV, given its increased burden in older children and adolescents. Older children and adolescents also experience a large burden of communicable disease, further highlighting the need for efforts to extend beyond the first 5 years of life. Our analysis also identified substantial morbidity caused by communicable diseases affecting child and adolescent health across the world. FUNDING: The Australian National Health and Medical Research Council Centre for Research Excellence for Driving Investment in Global Adolescent Health and the Bill & Melinda Gates Foundation

Burden of non-communicable diseases among adolescents aged 10–24 years in the EU, 1990–2019: a systematic analysis of the Global Burden of Diseases Study 2019

Background Disability and mortality burden of non-communicable diseases (NCDs) have risen worldwide; however, the NCD burden among adolescents remains poorly described in the EU. Methods Estimates were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Causes of NCDs were analysed at three different levels of the GBD 2019 hierarchy, for which mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) were extracted. Estimates, with the 95% uncertainty intervals (UI), were retrieved for EU Member States from 1990 to 2019, three age subgroups (10–14 years, 15–19 years, and 20–24 years), and by sex. Spearman's correlation was conducted between DALY rates for NCDs and the Socio-demographic Index (SDI) of each EU Member State. Findings In 2019, NCDs accounted for 86·4% (95% uncertainty interval 83·5–88·8) of all YLDs and 38·8% (37·4–39·8) of total deaths in adolescents aged 10–24 years. For NCDs in this age group, neoplasms were the leading causes of both mortality (4·01 [95% uncertainty interval 3·62–4·25] per 100 000 population) and YLLs (281·78 [254·25–298·92] per 100 000 population), whereas mental disorders were the leading cause for YLDs (2039·36 [1432·56–2773·47] per 100 000 population) and DALYs (2040·59 [1433·96–2774·62] per 100 000 population) in all EU Member States, and in all studied age groups. In 2019, among adolescents aged 10–24 years, males had a higher mortality rate per 100 000 population due to NCDs than females (11·66 [11·04–12·28] vs 7·89 [7·53–8·23]), whereas females presented a higher DALY rate per 100 000 population due to NCDs (8003·25 [5812·78–10 701·59] vs 6083·91 [4576·63–7857·92]). From 1990 to 2019, mortality rate due to NCDs in adolescents aged 10–24 years substantially decreased (–40·41% [–43·00 to –37·61), and also the YLL rate considerably decreased (–40·56% [–43·16 to –37·74]), except for mental disorders (which increased by 32·18% [1·67 to 66·49]), whereas the YLD rate increased slightly (1·44% [0·09 to 2·79]). Positive correlations were observed between DALY rates and SDIs for substance use disorders (rs=0·58, p=0·0012) and skin and subcutaneous diseases (rs=0·45, p=0·017), whereas negative correlations were found between DALY rates and SDIs for cardiovascular diseases (rs=–0·46, p=0·015), neoplasms (rs=–0·57, p=0·0015), and sense organ diseases (rs=–0·61, p=0·0005)

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Artificial intelligence for strengthening healthcare systems in low- and middle-income countries: a systematic scoping review.

In low- and middle-income countries (LMICs), AI has been promoted as a potential means of strengthening healthcare systems by a growing number of publications. We aimed to evaluate the scope and nature of AI technologies in the specific context of LMICs. In this systematic scoping review, we used a broad variety of AI and healthcare search terms. Our literature search included records published between 1st January 2009 and 30th September 2021 from the Scopus, EMBASE, MEDLINE, Global Health and APA PsycInfo databases, and grey literature from a Google Scholar search. We included studies that reported a quantitative and/or qualitative evaluation of a real-world application of AI in an LMIC health context. A total of 10 references evaluating the application of AI in an LMIC were included. Applications varied widely, including: clinical decision support systems, treatment planning and triage assistants and health chatbots. Only half of the papers reported which algorithms and datasets were used in order to train the AI. A number of challenges of using AI tools were reported, including issues with reliability, mixed impacts on workflows, poor user friendliness and lack of adeptness with local contexts. Many barriers exists that prevent the successful development and adoption of well-performing, context-specific AI tools, such as limited data availability, trust and evidence of cost-effectiveness in LMICs. Additional evaluations of the use of AI in healthcare in LMICs are needed in order to identify their effectiveness and reliability in real-world settings and to generate understanding for best practices for future implementations

A Scoping Analysis of Cathelicidin in Response to Organic Dust Exposure and Related Chronic Lung Illnesses

Over two billion people worldwide are exposed to organic dust, which can cause respiratory disorders. The discovery of the cathelicidin peptide provides novel insights into the lung’s response to organic dust; however, its role in the lung’s response to organic dust exposure and chronic lung diseases remains limited. We conducted a scoping review to map the current evidence on the role of cathelicidin LL-37/CRAMP in response to organic dust exposure and related chronic lung diseases: hypersensitivity pneumonitis (HP), chronic obstructive pulmonary disease (COPD) and asthma. We included a total of n = 53 peer-reviewed articles in this review, following the process of (i) a preliminary screening; (ii) a systematic MEDLINE/PubMed database search; (iii) title, abstract and full-text screening; (iv) data extraction and charting. Cathelicidin levels were shown to be altered in all clinical settings investigated; its pleiotropic function was confirmed. It was found that cathelicidin contributes to maintaining homeostasis and participates in lung injury response and repair, in addition to exerting a positive effect against microbial load and infections. In addition, LL-37 was found to sustain continuous inflammation, increase mucus formation and inhibit microorganisms and corticosteroids. In addition, studies investigated cathelicidin as a treatment modality, such as cathelicidin inhalation in experimental HP, which had positive effects. However, the primary focus of the included articles was on LL-37’s antibacterial effect, leading to the conclusion that the beneficial LL-37 activity has not been adequately examined and that further research is required

Evaluating the impact of short animated videos on COVID-19 vaccine hesitancy: An online randomized controlled trial

Addressing the global challenge of vaccine hesitancy, amplified during the COVID-19 pandemic due to misinformation propagated via social media, necessitates innovative health communication strategies. This investigation scrutinizes the efficacy of Short, Animated, Story-based (SAS) videos in fostering knowledge, behavioral intent, and engagement around COVID-19 vaccination.We conducted an online three-arm parallel randomized controlled trial (RCT) involving 792 adult participants (≥18 years, English-speaking) from the United States. The intervention group viewed a SAS video on COVID-19 vaccination, the attention placebo control group watched a SAS video on hope, and the control group received no intervention. Our primary objectives were to assess the influence of SAS videos on knowledge, behavioral intent, and engagement regarding COVID-19 vaccination.Participants in the intervention group displayed significantly higher mean knowledge scores (20.6, 95 % CI: 20.3–20.9) compared to both the attention placebo control (18.8, 95 % CI: 18.5–19.1, P < .001) and control groups (18.7, 95 % CI: 18.4–19.0, P < .001). However, SAS videos did not notably affect behavioral intent. Perception of COVID-19 as a significant health threat emerged as a strong predictor for engaging with the post-trial video without further incentives (OR: 0.44; 95 % CI: 0.2–0.96). The 35–44 age group exhibited the highest post-trial engagement (P = .006), whereas right-wing political inclination negatively associated with engagement (OR: 1.98; 95 % CI: 3.9–1.01). Vaccination status correlated significantly with self-efficacy (P < .001), perceived social norms (P < .001), and perceived response efficacy of the COVID-19 vaccine (P < .001), all heightened in the intervention group.These findings suggest that while SAS videos effectively amplify COVID-19 vaccination knowledge, their impact on behavioral intent is not direct. They do, however, affect determinants of vaccination status, thereby indirectly influencing vaccination behavior. The study highlights the appeal of SAS videos among younger audiences, but underscores the need for further examination of factors impeding vaccination engagement. As SAS videos closely mirror conventional social media content, they hold significant potential as a public health communication tool on these platforms.Trial Registration: Trial was registered at drks.de with the identifier DRKS00027938, on 5 January 2022

Selbstgesteuertes medizinisches Lernen via E-Learning an einem Lehrkrankenhaus in Malawi: Aufbau, Erkenntnisse und Erfahrungen

Background: Malawi faces a severe lack of health workers. Despite initiatives to address this problem, a critical shortage of health care staff remains. This lack challenges the education and training of junior medical staff, especially medical interns in their final and crucial training year before they independently work as medical doctors.Project description: We have introduced an e-learning platform in the medical department of the Kamuzu Central Hospital (KCH) in Malawi. With the support of computer-assisted instruction, we aimed to improve the quality of medical training and education, as well as access to current medical materials, in particular for interns.Method: From March to April 2012, we conducted a qualitative evaluation to assess relevance and appropriateness of the e-learning platform. Data was collected via face-to-face interviews, a guided group discussion and a checklist based observation log. Evaluation data was recorded and coded using content analysis, interviewees were chosen via purposive sampling.Results: E-learning proved to be technically feasible in this setting. Users considered the e-learning platform to be relevant and appropriate. Concerns were raised about sustainability, accessibility and technical infrastructure, as well as limited involvement and responsibilities of Malawian partners. Interest in e-learning was high, yet, awareness of and knowledge about the e-learning platform among potential users was low. Evaluation results indicated that further adaptions to local needs are necessary to increase usage and accessibility.Conclusions: Interview results and our project experiences showed that, in the given setting, e-learning requires commitment from local stakeholders, adequate technical infrastructure, identification and assignation of responsibilities, as well as specific adaption to local needs