Emmanuel Peprah

Emmanuel Peprah
Emmanuel Peprah

Director of Implementation Science for Global Health

Assistant Professor of Global Health

Professional overview

Dr. Emmanuel Peprah’s research interests lie at the confluence of understanding what, why, and how some evidence-based interventions work in some populations and not others. The programattic focus of his research is understanding the contextual factors that influence the burden of co-morbidity in people living with HIV/AIDS (PLWH), with a particular focus on cardiovascular disease risk factors and mental health. As the burden of non-communicable diseases (NCDs) continues to increase, there is an opportunity to integrate NCD management into HIV care with implemention strategies that leverage the global infrasturcture designed to improve care delivery for PLWH. Dr. Peprah has built collaborations with multidisciplinary teams of investigators, both nationally and internationally, to address the high burden of comorbidity in PLWH globally.  He is also the founder of the Baakoye Foundation, a nonprofit philanthropic organization dedicated to serving people in sub-Saharan Africa, and co-founder of the Washington Leaders Index (WLI), which aims to empower the next generation of emerging leaders through active, innovative, and inclusive leadership programs. Both nonprofit organizations serve the needs of children and people globally within the domains of education and health.

Before joining GPH, Dr. Peprah was a senior program official at the National Institutes of Health (NIH), where he worked with senior leadership to oversee strategic planning, initiative development, and implementation of research priorities in the areas of translational research, implementation science, and global health. He led and managed HIV/AIDS programs and a $10 million portfolio as part of the National Heart, Lung, and Blood Institute’s Trans-Omics for Precision Medicine Program. He was instrumental in launching the Human, Heredity, and Health in Africa (H3Africa) Initiative, a multimillion trans-NIH program, and served on its executive board. Dr. Peprah has received several awards for strategic planning, management, and implementation of large-scale NIH programs.

Education

BS, Biology, Texas A&M University, Commerce, TX
PhD, Molecular Biology & Biomedical Science, Meharry Medical College, Nashville, TN

Honors and awards

NIH Director’s Award for Leadership H3Africa Stage II Team: For exceptional leadership and dedication in implementing Stage II of the Human Heredity and Health in Africa program (2018)
NHLBI’s Director's for Outstanding Service (2018)
NHLBI’s Director's for Outstanding Service Partnership/Collaboration Award for bringing multiple disciplines together to understand HIV-related co-morbidities and prepare for the challenges presented by the complex conditions of the new HIV era (2018)
NHLBI’s Director's for Outstanding Translational Science Award for demonstrating exemplary leadership and service in advancing translation research (2017)
Federal Service Career Promotion (2016)
NHLBI’s Director's for Outstanding Translational Science Award as part of the Center for Translational Research and Implementation Science (CTRIS) Leadership Team for demonstrating exemplary leadership and service in advancing CTRIS’s translation (2016)
NHLBI’s Director's for Breath of Fresh Air (Innovation) award for exemplary work evaluating NHLBI’s support for multi-project research grants and proposing creative and innovative enhancements to the NHLBI’s program project grants (PPG) (2016)
NHLBI’s Director's for Learning Environment Award for fostering a learning environment through effective administration, knowledge sharing, and thoughtful implementation of the NHLBI R35 Program (2016)
NHLBI’s Director's for Partnership/Collaboration in recognition of outstanding collaborative efforts in developing a conceptual framework for the NHLBI R35 program to provide greater funding stability and flexibility to investigators (2015)
NIH Director's Common Fund Leadership Award for the NIH Common Fund Early Independence Award Program (2013)
NIH Director's Award as a member of the Common Fund Global Health Leadership Team for outstanding service in the coordination of the Common Fund Global Health Initiatives (2012)
Certificate of Appreciation for Invited Presenter, NIH Seminar Series, STEM Careers (2012)
Certificate of Appreciation for Invited Presenter, Washington Mathematics Science Technology Public Charter High School, Washington, DC (2012)
Leadership Award, Postdoctoral Fellows Research Symposium Committee, Emory University, Atlanta, GA (2008)

Areas of research and study

Dissemination and Implementation of Evidence-based Programs
HIV/AIDS
Implementation science
Inter-organizational Networks
Translational science

Publications

Publications

Barriers to Therapeutic Use of Hydroxyurea for Sickle Cell Disease in Nigeria: A Cross-Sectional Survey

Okocha, E. C., Gyamfi, J., Ryan, N., Babalola, O., Etuk, E. A., Chianumba, R., Nwegbu, M., Isa, H., Madu, A. J., Adegoke, S., Nnebe-Agumandu, U., Brown, B., Peprah, E., & Nnodu, O. E.

Publication year

2022

Journal title

Frontiers in Genetics

Volume

12
Abstract
Abstract
Background: Sickle cell disease, the inherited blood disorder characterized by anemia, severe pain and other vaso-occlusive complications, acute chest syndrome, disproportionate hospitalization, and early mortality, has significant financial, social, and psychosocial impacts and drains individuals, families, and health systems globally. Hydroxyurea could improve the health of the 300,000 individuals born each year with sickle cell disease in sub-Saharan Africa; however, challenges to adoption and adherence persist. This study assessed the barriers to therapeutic use of hydroxyurea for sickle cell disease within the Nigerian healthcare system, specifically from the level of the patient, provider, and health system. Methods: We used purposive sampling to recruit participants from 13 regions in Nigeria. A cross-sectional survey was administered to physicians (n = 70), nurses or counselors (n = 17), and patients or their caregivers (n = 33) at 13 health centers. Findings were mapped onto the appropriate Consolidated Framework for Implementation Research (CFIR) domains. Results: This study was able to identify factors that mapped onto the inner setting, outer setting, and characteristics of individuals domains of CFIR. The majority of physicians (74.3%) prescribe hydroxyurea, and half stated hydroxyurea is the standard of care. Among clinicians, barriers included limited knowledge of the drug, as well as low self-efficacy to prescribe among physicians and to counsel among nurses; perceived side effects; perceived patient preference for traditional medicine; cost for patient and expense of accompanying laboratory monitoring; and limited availability of the drug and equipment for laboratory monitoring. Among patients and caregivers, barriers included lack of knowledge; perceived side effects; cost; religious beliefs of disease causation; and lack of pediatric formulation. Conclusions: Findings suggest that patient, provider, and health systems-level interventions are needed to improve hydroxyurea uptake among providers and adherence among patients with sickle cell disease in Nigeria. Interventions such as patient education, provider training, and policy change could address the disproportionate burden of sickle cell disease in sub-Saharan Africa and thus improve health equity.

HIV, Tuberculosis, and Food Insecurity in Africa—A Syndemics-Based Scoping Review

Ojo, T., Ruan, C., Hameed, T., Malburg, C., Thunga, S., Smith, J., Vieira, D., Snyder, A., Tampubolon, S. J., Gyamfi, J., Ryan, N., Lim, S., Santacatterina, M., & Peprah, E.

Publication year

2022

Journal title

International journal of environmental research and public health

Volume

19

Issue

3
Abstract
Abstract
The double burden of HIV/AIDS and tuberculosis (TB), coupled with endemic and problematic food insecurity in Africa, can interact to negatively impact health outcomes, creating a syndemic. For people living with HIV/AIDS (PWH), food insecurity is a significant risk factor for acquiring TB due to the strong nutritional influences and co-occurring contextual barriers. We aim to synthesize evidence on the syndemic relationship between HIV/AIDS and TB co-infection and food insecurity in Africa. We conducted a scoping review of studies in Africa that included co-infected adults and children, with evidence of food insecurity, characterized by insufficient to lack of access to macronutrients. We sourced information from major public health databases. Qualitative, narrative analysis was used to synthesize the data. Of 1072 articles screened, 18 articles discussed the syndemic effect of HIV/AIDS and TB co-infection and food insecurity. Reporting of food insecurity was inconsistent, however, five studies estimated it using a validated scale. Food insecure co-infected adults had an average BMI of 16.5–18.5 kg/m2 . Negative outcomes include death (n = 6 studies), depression (n = 1 study), treatment non-adherence, weight loss, wasting, opportunistic infections, TB-related lung diseases, lethargy. Food insecurity was a precursor to co-infection, especially with the onset/increased incidence of TB in PWH. Economic, social, and facility-level factors influenced the negative impact of food insecurity on the health of co-infected individuals. Nutritional support, economic relief, and psychosocial support minimized the harmful effects of food insecurity in HIV–TB populations. Interventions that tackle one or more components of a syndemic interaction can have beneficial effects on health outcomes and experiences of PWH with TB in Africa.

An emerging syndemic of smoking and cardiopulmonary diseases in people living with HIV in Africa

Peprah, E., Armstrong-Hough, M., Cook, S. H., Mukasa, B., Taylor, J. Y., Xu, H., Chang, L., Gyamfi, J., Ryan, N., Ojo, T., Snyder, A., Iwelunmor, J., Ezechi, O., Iyegbe, C., O’reilly, P., & Kengne, A. P.

Publication year

2021

Journal title

International journal of environmental research and public health

Volume

18

Issue

6

Page(s)

1-12
Abstract
Abstract
Background: African countries have the highest number of people living with HIV (PWH). The continent is home to 12% of the global population, but accounts for 71% of PWH globally. Antiretroviral therapy has played an important role in the reduction of the morbidity and mortality rates for HIV, which necessitates increased surveillance of the threats from pernicious risks to which PWH who live longer remain exposed. This includes cardiopulmonary comorbidities, which pose significant public health and economic challenges. A significant contributor to the cardiopulmonary comorbidities is tobacco smoking. Indeed, globally, PWH have a 2–4-fold higher utilization of tobacco compared to the general population, leading to endothelial dysfunction and atherogenesis that result in cardiopulmonary diseases, such as chronic obstructive pulmonary disease and coronary artery disease. In the context of PWH, we discuss (1) the current trends in cigarette smoking and (2) the lack of geographically relevant data on the cardiopulmonary conditions associated with smoking; we then review (3) the current evidence on chronic inflammation induced by smoking and the potential pathways for cardiopulmonary disease and (4) the multifactorial nature of the syndemic of smoking, HIV, and cardiopulmonary diseases. This commentary calls for a major, multi-setting cohort study using a syndemics framework to assess cardiopulmonary disease outcomes among PWH who smoke. Conclusion: We call for a parallel program of implementation research to promote the adoption of evidence-based interventions, which could improve health outcomes for PWH with cardiopulmonary diseases and address the health inequities experienced by PWH in African countries.

Applying the WHO ICD-MM classification system to maternal deaths in a tertiary hospital in Nigeria: A retrospective analysis from 2014–2018

Akaba, G. O., Nnodu, O. E., Ryan, N., Peprah, E., Agida, T. E., Anumba, D. O., & Ekele, B. A.

Publication year

2021

Journal title

PloS one

Volume

16

Issue

1
Abstract
Abstract
Background Addressing the problem of maternal mortality in Nigeria requires proper identification of maternal deaths and their underlying causes in order to focus evidence-based interventions to decrease mortality and avert morbidity. Objectives The objective of the study was to classify maternal deaths that occurred at a Nigerian teaching hospital using the WHO International Classification of Diseases Maternal mortality (ICD-MM) tool. Methods This was a retrospective observational study of all maternal deaths that occurred in a tertiary Nigerian hospital from 1st January 2014 to 31st December,2018. The WHO ICD-MM classification system for maternal deaths was used to classify the type, group, and specific underlying cause of identified maternal deaths. Descriptive analysis was performed using Statistical Package for Social Sciences (SPSS). Categorical and continuous variables were summarized respectively as proportions and means (standard deviations). Results The institutional maternal mortality ratio was 831/100,000 live births. Maternal deaths occurred mainly amongst women aged 25–34 years;30(57.7%), without formal education; 22(42.3%), married;47(90.4%), unbooked;24(46.2%) and have delivered at least twice;34 (65.4%). The leading causes of maternal death were hypertensive disorders in pregnancy, childbirth, and the puerperium (36.5%), obstetric haemorrhage (30.8%), and pregnancy related infections (17.3%). Application of the WHO ICD-MM resulted in reclassification of underlying cause for 3.8% of maternal deaths. Postpartum renal failure (25.0%), postpartum coagulation defects (17.3%) and puerperal sepsis (15.4%) were the leading final causes of death. Among maternal deaths, type 1, 2, and 3 delays were seen in 30(66.7%), 22(48.9%), and 6(13.3%), respectively. Conclusion Our institutional maternal mortality ratio remains high. Hypertensive disorders during pregnancy, childbirth, and the puerperium and obstetric haemorrhage are the leading causes of maternal deaths. Implementation of evidence-based interventions both at the hospital and community levels may help in tackling the identified underlying causes of maternal mortality in Nigeria.

Evidence-based interventions implemented in low-and middle-income countries for sickle cell disease management: A systematic review of randomized controlled trials

Global, regional, and national mortality among young people aged 10–24 years, 1950–2019: a systematic analysis for the Global Burden of Disease Study 2019

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Publication year

2021

Journal title

The Lancet

Volume

398

Issue

10311

Page(s)

1593-1618
Abstract
Abstract
Background: Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10–24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods: We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10–24 years by age group (10–14 years, 15–19 years, and 20–24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10–24 years with that in children aged 0–9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10–24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017). Findings: In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39–1·59) worldwide in people aged 10–24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10–14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15–19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1–4 years (2·4%), and around a third less than in females aged 1–4 years (2·5%). The proportion of global deaths in people aged 0–24 years that occurred in people aged 10–24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%. Interpretation: Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10–24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group. Funding: Bill & Melinda Gates Foundation.

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

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Publication year

2021

Journal title

The Lancet

Volume

398

Issue

10303

Page(s)

870-905
Abstract
Abstract
Background: Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival. Methods: We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index. Findings: Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3–74·0) in 2000 to 37·1 (33·2–41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8–29·5) in 2000 to 17·9 (16·3–19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05–10·30) in 2000 and 5·05 million (4·27–6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53–4·02]) in 2000 to 48% (2·42 million; 2·06–2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71–0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27–1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35–2·58; 37% [95% UI 32–43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier. Interpretation: Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress. Funding: Bill & Melinda Gates Foundation.

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990–2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

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Publication year

2021

Journal title

The Lancet HIV

Volume

8

Issue

10

Page(s)

e633-e651
Abstract
Abstract
Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). Findings: In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation: Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics. Funding: The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems

Cork, M. A., Henry, N. J., Watson, S., Croneberger, A. J., Baumann, M., Letourneau, I. D., Yang, M., Serfes, A. L., Abbas, J., Abbasi, N., Abbastabar, H., Abreu, L. G., Abu-Gharbieh, E., Achappa, B., Adabi, M., Adal, T. G., Adegbosin, A. E., Adekanmbi, V., Adetokunboh, O. O., Agudelo-Botero, M., Ahinkorah, B. O., Ahmadi, K., Ahmed, M. B., Alhassan, R. K., Alipour, V., Almasi-Hashiani, A., Alvis-Guzman, N., Ancuceanu, R., Andrei, T., Anvari, D., Aqeel, M., Arabloo, J., Aremu, O., Asaad, M., Atnafu, D. D., Atreya, A., Quintanilla, B. P. A., Azari, S., B., D. B., Baig, A. A., Banach, M., Bante, S. A., Barboza, M. A., Basu, S., Bedi, N., Ramirez, D. F., Bensenor, I. M., Beyene, F. H. Y., Bezabih, Y. M., Bhagavathula, A. S., Bhardwaj, N., Bhardwaj, P., Bhattacharyya, K., Bhutta, Z. A., Bijani, A., Birlik, S. M., Bitew, Z. W., Bohlouli, S., Boloor, A., Brunoni, A. R., Butt, Z. A., Cárdenas, R., Carvalho, F., Castaldelli-Maia, J. M., Casta-ñeda-orjuela, C. A., Charan, J., Chatterjee, S., Chattu, V. K., Chattu, S. K., Chowdhury, M. A. K., Christopher, D. J., Chu, D. T., Cook, A. J., Cormier, N. M., Dahlawi, S. M., Daoud, F., Dávila-Cervantes, C. A., Weaver, N. D., De La Hoz, F. P., Demeke, F. M., Denova-Gutiérrez, E., Deribe, K., Deuba, K., Dharmaratne, S. D., Dhungana, G. P., Diaz, D., Djalalinia, S., Duraes, A. R., Eagan, A. W., Earl, L., Effiong, A., Zaki, M. E. S., Tantawi, M. E., Elayedath, R., El-Jaafary, S. I., Faraon, E. J. A., Faro, A., Fattahi, N., Fauk, N. K., Fernandes, E., Filip, I., Fischer, F., Foigt, N. A., Foroutan, M., Fukumoto, T., Gad, M. M., Gebremariam, T. B., Gebremed-Hin, K. B., Gebremeskel, G. G., Gesesew, H. A., Ghadiri, K., Ghashghaee, A., Gilani, S. A., Golechha, M., Gori, U., Goulart, A. C., Goulart, B. N., Gugnani, H. C., Guimaraes, M. D., Guimarães, R. A., Guo, Y. I., Gupta, R., Haeuser, E., Haider, M. R., Haile, T. G., Haj-Mirzaian, A., Haj-Mirzaian, A., Hanif, A., Hargono, A., Hariyani, N., Hassanipour, S., Hassankhani, H., Hayat, K., Herteliu, C., Ho, H. C., Holla, R., Hosseinzadeh, M., Househ, M., Hwang, B. F., Ibeneme, C. U., Ibitoye, S. E., Ile-Sanmi, O. S., Ilic, M. D., Ilic, I. M., Iqbal, U., Jahagir-Dar, D., Jain, V., Jakovljevic, M., Jha, R. P., Johnson, K. B., Joseph, N., Joukar, F., Kalankesh, L. R., Kalhor, R. L., Kanchan, T., Matin, B. K., Karch, A., Karimi, S. E., Kassahun, G., Kayode, G. A., Karyani, A. K., Keramati, M., Khalid, N., Khan, E. A., Khan, G., Khan, M. N. N., Khatab, K., Kianipour, N., Kim, Y. J., Kisa, S., Kisa, A., Kosen, S., Laxminarayana, S. L. K., Koyanagi, A., Krishan, K., Defo, B. K., Kuchenbecker, R. S., Kulkarni, V., Kumar, N., Kumar, M., Kurmi, O. P., Kusuma, D., Vecchia, C. L., Lal, D. K., Landires, I., Lasrado, S., Lee, P. H., Legrand, K. E., Li, B., Li, S., Liu, X., Amin, H. I., Machado, D. B., Madi, D., Magis-Rodriguez, C., Malta, D. C., Mansournia, M. A., Manzar, M. D., Arnedo, C. A., Martins-Melo, F. R., Masoumi, S. Z., Mayala, B. K., Medina-Solís, C. E., Memish, Z. A., Mendoza, W., Menezes, R. G., Mestrovic, T., Mirica, A., Moazen, B., Mohammad, Y., Mezerji, N. M. G., Mohammadian-Hafshejani, A., Mohammadpourhodki, R., Mohammed, S., Mokdad, A. H., Moni, M. A., Moradi, M., Moradi, Y., Moradzadeh, R., Moraga, P., Khaneghah, A. M. S., Mustafa, G., Mwanri, L., Nagaraja, R., Nagarajan, A. J., Naim-Zada, M. D., Nascimento, B. R., Naveed, D. M., Nayak, V. C., Nazari, J., Negash, H., Negoi, I., Nepal, S., Nguefack-Tsague, G., Nguyen, C. T., Nguyen, H. L., Nikbakhsh, R., Noubiap, J. J., Nunez-Samudio, V., Oancea, B., Ogbo, F. A., Olagunju, A. T., Otstav-Nov, N., A., M. P., Padubidri, J. R., Pandi-Perumal, S. R., Pardo-Montaño, A. M., Patel, U. K., Pawar, S., Peprah, E. K., Pereira, A., Perkins, S., Pescarini, J. M., Pokhrel, K. N., Postma, M. J., Pot-Too, F. H., Prada, S. I., Preotescu, L., Pribadi, D. R., Radfar, A., Rahim, F., Rahman, M. H. U., Rahmani, A. M., Ramezanzadeh, K., Rana, J., Ranabhat, C. L., Rao, S. J., Rathi, P., Rawaf, S., Rawaf, D. L., Rawassizadeh, R., Renjith, V., Rezaei, N., Rezapour, A., Ribeiro, A. I., Roever, L., Rubagotti, E., Rumisha, S. F., Rwegerera, G. M., Sagar, R., Sajadi, S. M., Salem, M. R., Samy, A. M., Sarmiento-Suárez, R., Sathian, B., Schaeffer, L. E., Schneider, I. J., Seidu, A. A., Sha, F., Shaikh, M. A., Sharafi, K. M., Sheikh, A., Shibuya, K., Shin, J. I., Silva, D. A., Singh, J. A., Skryabin, V. Y., Skryabina, A. A., Sligar, A., Soheili, A., Steuben, K. M., Sufiyan, M. B., Tadesse, E. G., Tesema, A. K., Tesfay, F. H., Thapar, R., Thompson, R. L., Tovani-Palone, M. R., Tran, B. X., Tsegaye, G. W., Umeokonkwo, C. D., Unnikrish-Nan, B., Vasseghian, Y., Violante, F. S., Vo, B., Vu, G. T., Waheed, Y., Wang, Y. P., Wang, Y., Ward, P., Welay, F. T., Westerman, R., Wickramasinghe, N. D., Yaya, S., Yip, P., Yonemoto, N., Yu, C., Yuce, D., Yusefzadeh, H., Zamanian, M., Zastroz-Hin, M. S., Zhang, Z. J., Zhang, Y., Ziapour, A., Hay, S. I., & Dwyer-Lindgren, L.

Publication year

2021

Journal title

BMC Medicine

Volume

19

Issue

1
Abstract
Abstract
Background: Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico. Methods: We performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017. Results: All countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries—apart from Ecuador—across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups—the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017. Conclusions: Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

Subnational mapping of HIV incidence and mortality among individuals aged 15–49 years in sub-Saharan Africa, 2000–18: a modelling study

Failed generating bibliography.

Publication year

2021

Journal title

The Lancet HIV

Volume

8

Issue

6

Page(s)

e363-e375
Abstract
Abstract
Background: High-resolution estimates of HIV burden across space and time provide an important tool for tracking and monitoring the progress of prevention and control efforts and assist with improving the precision and efficiency of targeting efforts. We aimed to assess HIV incidence and HIV mortality for all second-level administrative units across sub-Saharan Africa. Methods: In this modelling study, we developed a framework that used the geographically specific HIV prevalence data collected in seroprevalence surveys and antenatal care clinics to train a model that estimates HIV incidence and mortality among individuals aged 15–49 years. We used a model-based geostatistical framework to estimate HIV prevalence at the second administrative level in 44 countries in sub-Saharan Africa for 2000–18 and sought data on the number of individuals on antiretroviral therapy (ART) by second-level administrative unit. We then modified the Estimation and Projection Package (EPP) to use these HIV prevalence and treatment estimates to estimate HIV incidence and mortality by second-level administrative unit. Findings: The estimates suggest substantial variation in HIV incidence and mortality rates both between and within countries in sub-Saharan Africa, with 15 countries having a ten-times or greater difference in estimated HIV incidence between the second-level administrative units with the lowest and highest estimated incidence levels. Across all 44 countries in 2018, HIV incidence ranged from 2·8 (95% uncertainty interval 2·1–3·8) in Mauritania to 1585·9 (1369·4–1824·8) cases per 100 000 people in Lesotho and HIV mortality ranged from 0·8 (0·7–0·9) in Mauritania to 676·5 (513·6–888·0) deaths per 100 000 people in Lesotho. Variation in both incidence and mortality was substantially greater at the subnational level than at the national level and the highest estimated rates were accordingly higher. Among second-level administrative units, Guijá District, Gaza Province, Mozambique, had the highest estimated HIV incidence (4661·7 [2544·8–8120·3]) cases per 100 000 people in 2018 and Inhassunge District, Zambezia Province, Mozambique, had the highest estimated HIV mortality rate (1163·0 [679·0–1866·8]) deaths per 100 000 people. Further, the rate of reduction in HIV incidence and mortality from 2000 to 2018, as well as the ratio of new infections to the number of people living with HIV was highly variable. Although most second-level administrative units had declines in the number of new cases (3316 [81·1%] of 4087 units) and number of deaths (3325 [81·4%]), nearly all appeared well short of the targeted 75% reduction in new cases and deaths between 2010 and 2020. Interpretation: Our estimates suggest that most second-level administrative units in sub-Saharan Africa are falling short of the targeted 75% reduction in new cases and deaths by 2020, which is further compounded by substantial within-country variability. These estimates will help decision makers and programme implementers expand access to ART and better target health resources to higher burden subnational areas. Funding: Bill & Melinda Gates Foundation.

The Role of Implementation Science in Advancing Resource Generation for Health Interventions in Low- and Middle-Income Countries

Ojo, T., Kabasele, L., Boyd, B., Enechukwu, S., Ryan, N., Gyamfi, J., & Peprah, E.

Publication year

2021

Journal title

Health Services Insights

Volume

14
Abstract
Abstract
Low- and middle-income countries (LMICs) bear the brunt of communicable and non-communicable diseases and experience higher mortality and poor health outcomes compared to resource-rich countries. Chronic resource deficits in LMICs impede their ability to successfully address vexing health issues. Implementation science provides researchers with an approach to develop specific interventions that can generate and/or maximize resources to facilitate the implementation of other public health interventions, in resource-constrained LMIC settings. Resources generated from these interventions could be in the form of increased health workers’ skills, task shifting to free up higher-skilled health workers, increasing laboratory capacity, and using supply chain innovations to make medications available. Pivotal to the success of such interventions is ensuring feasibility in the LMIC context. We selected and appraised three case studies of evidence-based resource-generating health interventions based in LMICs (Zambia, Zimbabwe, and Madagascar), which generated or maximized resources to facilitate ongoing health services. We used a determinant implementation framework—Consolidated Framework for Implementation Research (CFIR) to identify and map contextual factors that are reported to influence implementation feasibility in an LMIC setting. Contextual factors influencing the feasibility of these interventions included leadership engagement, local capacity building and readiness for research and implementing evidence-based practices (EBPs), infrastructural support for multilevel scale-up, and cultural and contextual adaptations. These factors highlight the importance of utilizing implementation science frameworks to evaluate, guide, and execute feasible public health interventions and projects in resource-limited settings. Within LMICs, we recommend EBPs incorporate feasible resource-generating components in health interventions to ensure improved and sustained optimal health outcomes.

Utilization of Pneumococcal Vaccine and Penicillin Prophylaxis in Sickle Cell Disease in Three African Countries: Assessment among Healthcare Providers in SickleInAfrica

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Publication year

2021

Journal title

Hemoglobin

Volume

45

Issue

3

Page(s)

163-170
Abstract
Abstract
Sickle cell disease is a genetic disease with a predisposition to infections caused by encapsulated organisms, especially Streptococcus pneumoniae. Pneumococcal vaccines and prophylactic penicillin have reduced the rate of this infection and mortality in sickle cell disease. However, implementation of these interventions is limited in Africa. The objectives of the study were to assess health care providers’ behaviors with the implementation of pneumococcal vaccination and penicillin prophylaxis and to identify barriers to their use. A 25-item online questionnaire was administered through SickleinAfrica: a network of researchers, and healthcare providers, in Ghana, Nigeria, and Tanzania, working to improve health outcomes of sickle cell disease in Africa. Data was collected and managed using the Research Electronic Data Capture (REDCap), tools and data analysis was done using STATA version 13 and R statistical software. Eighty-two medical practitioners responded to the questionnaire. Only 54.0 and 48.7% of respondents indicated the availability of published guidelines on sickle cell disease management and pneumococcal vaccine use, respectively, at their facilities. The majority (54.0%) perceived that the vaccines are effective but over 20.0% were uncertain of their usefulness. All respondents from Ghana and Tanzania affirmed the availability of guidelines for penicillin prophylaxis in contrast to 44.1% in Nigeria. Eighty-five percent of respondents affirmed the need for penicillin prophylaxis but 15.0% had a contrary opinion for reasons including the rarity of isolation of Streptococcus pneumoniae in African studies, and therefore, the uncertainty of its benefit. Lack of published guidelines on the management of sickle cell disease and doubts about the necessity of prophylactic measures are potential barriers to the implementation of effective interventions.

Application of the Consolidated Framework for Implementation Research to examine nurses' perception of the task shifting strategy for hypertension control trial in Ghana

Gyamfi, J., Allegrante, J. P., Iwelunmor, J., Williams, O., Plange-Rhule, J., Blackstone, S., Ntim, M., Apusiga, K., Peprah, E., & Ogedegbe, G.

Publication year

2020

Journal title

BMC health services research

Volume

20

Issue

1
Abstract
Abstract
Background: The burden of hypertension in many low-and middle-income countries is alarming and requires effective evidence-based preventative strategies that is carefully appraised and accepted by key stakeholders to ensure successful implementation and sustainability. We assessed nurses' perceptions of a recently completed Task Shifting Strategy for Hypertension control (TASSH) trial in Ghana, and facilitators and challenges to TASSH implementation. Methods: Focus group sessions and in-depth interviews were conducted with 27 community health nurses from participating health centers and district hospitals involved in the TASSH trial implemented in the Ashanti Region, Ghana, West Africa from 2012 to 2017. TASSH evaluated the comparative effectiveness of the WHO-PEN program versus provision of health insurance for blood pressure reduction in hypertensive adults. Qualitative data were analyzed using open and axial coding techniques with emerging themes mapped onto the Consolidated Framework for Implementation Research (CFIR). Results: Three themes emerged following deductive analysis using CFIR, including: (1) Patient health goal setting- relative priority and positive feedback from nurses, which motivated patients to make healthy behavior changes as a result of their health being a priority; (2) Leadership engagement (i.e., medical directors) which influenced the extent to which nurses were able to successfully implement TASSH in their various facilities, with most directors being very supportive; and (3) Availability of resources making it possible to implement the TASSH protocol, with limited space and personnel time to carry out TASSH duties, limited blood pressure (BP) monitoring equipment, and transportation, listed as barriers to effective implementation. Conclusion: Assessing stakeholders' perception of the TASSH implementation process guided by CFIR is crucial as it provides a platform for the nurses to thoroughly evaluate the task shifting program, while considering the local context in which the program is implemented. The feedback from the nurses informed barriers and facilitators to implementation of TASSH within the current healthcare system, and suggested system level changes needed prior to scale-up of TASSH to other regions in Ghana with potential for long-term sustainment of the task shifting intervention. Trial registration: Trial registration for parent TASSH study: NCT01802372. Registered February 27, 2013.

Deconstructing syndemics: The many layers of clustering multi-comorbidities in people living with HIV

Peprah, E., Caler, E., Snyder, A., & Ketema, F.

Publication year

2020

Journal title

International journal of environmental research and public health

Volume

17

Issue

13

Page(s)

1-7
Abstract
Abstract
The HIV epidemic has dramatically changed over the past 30 years; there are now fewer newly infected people (especially children), fewer AIDS-related deaths, and more people with HIV (PWH) receiving treatment. However, the HIV epidemic is far from over. Despite the tremendous advances in anti-retroviral therapies (ART) and the implementation of ART regimens, HIV incidence (number of new infections over a defined period of time) and prevalence (the burden of HIV infection) in certain regions of the world and socio-economic groups are still on the rise. HIV continues to disproportionally affect highly marginalized populations that constitute higher-risk and stigmatized groups, underserved and/or neglected populations. In addition, it is not uncommon for PWH to suffer enhanced debilitating conditions resulting from the synergistic interactions of both communicable diseases (CDs) and non-communicable diseases (NCDs). While research utilizing only a comorbidities framework has advanced our understanding of the biological settings of the co-occurring conditions from a molecular and mechanistic view, harmful interactions between comorbidities are often overlooked, particularly under adverse socio-economical and behavioral circumstances, likely prompting disease clustering in PWH. Synergistic epidemics (syndemics) research aims to capture these understudied interactions: the mainly non-biological aspects that are central to interpret disease clustering in the comorbidities/multi-morbidities only framework. Connecting population-level clustering of social and health problems through syndemic interventions has proved to be a critical knowledge gap that will need to be addressed in order to improve prevention and care strategies and bring us a step closer to ending the HIV epidemic.

Five insights from the Global Burden of Disease Study 2019

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Publication year

2020

Journal title

The Lancet

Volume

396

Issue

10258

Page(s)

1135-1159
Abstract
Abstract
The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countries, from 1990 to 2019. Because GBD is highly standardised and comprehensive, spanning both fatal and non-fatal outcomes, and uses a mutually exclusive and collectively exhaustive list of hierarchical disease and injury causes, the study provides a powerful basis for detailed and broad insights on global health trends and emerging challenges. GBD 2019 incorporates data from 281 586 sources and provides more than 3·5 billion estimates of health outcome and health system measures of interest for global, national, and subnational policy dialogue. All GBD estimates are publicly available and adhere to the Guidelines on Accurate and Transparent Health Estimate Reporting. From this vast amount of information, five key insights that are important for health, social, and economic development strategies have been distilled. These insights are subject to the many limitations outlined in each of the component GBD capstone papers.

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Failed generating bibliography.

Publication year

2020

Journal title

The Lancet

Volume

396

Issue

10258

Page(s)

1160-1203
Abstract
Abstract
Background: Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods: 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings: The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66–2·79) in 2000 to 2·31 (2·17–2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5–137·8) in 2000 to a peak of 139·6 million (133·0–146·9) in 2016. Global livebirths then declined to 135·3 million (127·2–144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4–27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8–67·6) in 2000 to 73·5 years (72·8–74·3) in 2019. The total number of deaths increased from 50·7 million (49·5–51·9) in 2000 to 56·5 million (53·7–59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1–10·3) in 2000 to 5·0 million (4·3–6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0–6·3) in 2000 to 7·7 billion (7·5–8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1–60·8) in 2000 to 63·5 years (60·8–66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019. Interpretation: Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring. Funding: Bill & Melinda Gates Foundation.

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Global, regional, and national burden of congenital heart disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Zimmerman, M. S., Smith, A. G. C., Sable, C. A., Echko, M. M., Wilner, L. B., Olsen, H. E., Atalay, H. T., Awasthi, A., Bhutta, Z. A., Boucher, J. L. A., Castro, F., Cortesi, P. A., Dubey, M., Fischer, F., Hamidi, S., Hay, S. I., Hoang, C. L., Hugo-Hamman, C., Jenkins, K. J., Kar, A., Khalil, I. A., Kumar, R. K., Kwan, G. F., Mengistu, D. T., Mokdad, A. H., Naghavi, M., Negesa, L., Negoi, I., Negoi, R. I., Nguyen, C. T., Nguyen, H. L. T., Nguyen, L. H., Nguyen, S. H., Nguyen, T. H., Nixon, M. R., Noubiap, J. J., Patel, S., Peprah, E. K., Reiner, R. C., Roth, G. A., Temsah, M. H., Tovani-Palone, M. R., Towbin, J. A., Tran, B. X., Tran, T. T., Truong, N. T., Vos, T., Vosoughi, K., Weintraub, R. G., Weldegwergs, K. G., Zaidi, Z., Zheleva, B., Zuhlke, L., Murray, C. J., Martin, G. R., & Kassebaum, N. J.

Publication year

2020

Journal title

The Lancet Child and Adolescent Health

Volume

4

Issue

3

Page(s)

185-200
Abstract
Abstract
Background: Previous congenital heart disease estimates came from few data sources, were geographically narrow, and did not evaluate congenital heart disease throughout the life course. Completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017, this study aimed to provide comprehensive estimates of congenital heart disease mortality, prevalence, and disability by age for 195 countries and territories from 1990 to 2017. Methods: Mortality estimates were generated for aggregate congenital heart disease and non-fatal estimates for five subcategories (single ventricle and single ventricle pathway congenital heart anomalies; severe congenital heart anomalies excluding single ventricle heart defects; critical malformations of great vessels, congenital valvular heart disease, and patent ductus arteriosus; ventricular septal defect and atrial septal defect; and other congenital heart anomalies), for 1990 through to 2017. All available global data were systematically analysed to generate congenital heart disease mortality estimates (using Cause of Death Ensemble modelling) and prevalence estimates (DisMod-MR 2·1). Systematic literature reviews of all types of congenital anomalies to capture information on prevalence, associated mortality, and long-term health outcomes on congenital heart disease informed subsequent disability estimates. Findings: Congenital heart disease caused 261 247 deaths (95% uncertainty interval 216 567–308 159) globally in 2017, a 34·5% decline from 1990, with 180 624 deaths (146 825–214 178) being among infants (aged <1 years). Congenital heart disease mortality rates declined with increasing Socio-demographic Index (SDI); most deaths occurred in countries in the low and low-middle SDI quintiles. The prevalence rates of congenital heart disease at birth changed little temporally or by SDI, resulting in 11 998 283 (10 958 658–13 123 888) people living with congenital heart disease globally, an 18·7% increase from 1990 to 2017, and causing a total of 589 479 (287 200–973 359) years lived with disability. Interpretation: Congenital heart disease is a large, rapidly emerging global problem in child health. Without the ability to substantially alter the prevalence of congenital heart disease, interventions and resources must be used to improve survival and quality of life. Our findings highlight the large global inequities in congenital heart disease and can serve as a starting point for policy changes to improve screening, treatment, and data collection. Funding: Bill & Melinda Gates Foundation.

Implementation of the therapeutic use of hydroxyurea for sickle cell disease management in resource-constrained settings: A systematic review of adoption, cost and acceptability

Ryan, N., Dike, L., Ojo, T., Vieira, D., Nnodu, O., Gyamfi, J., & Peprah, E.

Publication year

2020

Journal title

BMJ open

Volume

10

Issue

11
Abstract
Abstract
Objectives: Mortality associated with sickle cell disease (SCD) is high in many low- and middle-income countries (LMICs). Hydroxyurea, a medicine to effectively manage SCD, is not widely available in resource-constrained settings. We identified and synthesised the reported implementation outcomes for the therapeutic use of hydroxyurea for SCD in these settings. Design: Systematic review. Data sources: PubMed, Embase, Cochrane, Web of Science Plus, Global Health, CINAHL, and PsycINFO were searched February through May 2019 without any restrictions on publication date. Eligibility criteria We included empirical studies of hydroxyurea for management of SCD that were carried out in LMICs and reported on implementation outcomes. Data extraction and synthesis: Two reviewers independently assessed studies for inclusion, carried out data extraction using Proctor et al.'s implementation and health service outcomes, and assessed the risk of bias using ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions). Results: Two cross-sectional surveys (n=2) and one cohort study (n=1) reported implementation of hydroxyurea for SCD management, namely regarding outcomes of adoption (n=3), cost (n=3) and acceptability (n=1). These studies were conducted exclusively among paediatric and adults populations in clinical settings in Nigeria (n=2) or Jamaica (n=1). Adoption is low, as observed through reported provider practices and patient adherence, in part shaped by misinformation and fear of side effects among patients, provider beliefs regarding affordability and organisational challenges with procuring the medicine. There was no difference in the cost of hydroxyurea therapy compared with blood transfusion in the paediatric population in urban Jamaica. Risk of bias was low or moderate across the included studies. Conclusions: This review rigorously and systematically assessed the evidence on implementation of hydroxyurea in resource-constrained settings such as LMICs. Findings suggest that knowledge regarding implementation is low. To address the know-do gap and guide clinical practice, implementation research is needed. Integrating effective interventions into existing health systems to improve hydroxyurea uptake is essential to reducing SCD-associated mortality.

Implementation outcomes of policy and programme innovations to prevent obstetric haemorrhage in low-and middle-income countries: A systematic review

Ryan, N., Vieira, D., Goffman, D., Bloch, E. M., Akaba, G. O., D’Mello, B. S., Egekeze, C., Snyder, A., Lyimo, M., Nnodu, O., & Peprah, E.

Publication year

2020

Journal title

Health Policy and Planning

Volume

35

Issue

9

Page(s)

1208-1227
Abstract
Abstract
Globally, obstetric haemorrhage (OH) remains the leading cause of maternal mortality. Much of the associated mortality is ascribed to challenges surrounding deployment of innovations rather than lack of availability. In low-and middle-income countries (LMICs), where the burden is highest, there is a growing interest in implementation research as a means to bridge the 'know-do' gap between proven interventions and their reliable implementation at scale. In this systematic review, we identified and synthesized qualitative and quantitative data across the implementation outcomes of OH prevention innovations in LMICs using a taxonomy developed by Proctor et al. We also identified service outcomes for the included innovations, as well as implementation strategies and implementation facilitators and barriers. Eligible studies were empirical, focused on the implementation of OH prevention programmes or policies and occurred in an LMIC. Eight databases were searched. Two authors independently assessed studies for selection and extracted data; the first author resolved discrepancies. Narrative synthesis was used to analyse and interpret the findings. Studies were predominantly focused in Africa and on primary prevention. Interventions included prophylactic use of uterotonics (n = 7), clinical provider skills training (n = 4) and provision of clinical guidelines (n = 1); some (n = 3) were also part of a multi-component quality improvement bundle. Various barriers were reported, including challenges among intervention beneficiaries, providers and within the health system; however, studies reported the development and testing of practical implementation solutions. These included training and monitoring of implementers, community and stakeholder engagement and guidance by external mentors. Some studies linked successful delivery to implementation outcomes, most commonly adoption and acceptability, but also feasibility, penetration and sustainability. Findings suggest that innovations to prevent OH can be acceptable, appropriate and feasible in LMIC settings; however, more research is needed to better evaluate these and other under-reported implementation outcomes.

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Lozano, R., Fullman, N., Mumford, J. E., Knight, M., Barthelemy, C. M., Abbafati, C., Abbastabar, H., Abd-Allah, F., Abdollahi, M., Abedi, A., Abolhassani, H., Abosetugn, A. E., Abreu, L. G., Abrigo, M. R., Abu Haimed, A. K., Abushouk, A. I., Adabi, M., Adebayo, O. M., Adekanmbi, V., Adelson, J., Adetokunboh, O. O., Adham, D., Advani, S. M., Afshin, A., Agarwal, G., Agasthi, P., Aghamir, S. M. K., Agrawal, A., Ahmad, T., Akinyemi, R. O., Alahdab, F., Al-Aly, Z., Alam, K., Albertson, S. B., Alemu, Y. M., Alhassan, R. K., Ali, M., Ali, S., Alipour, V., Aljunid, S. M., Alla, F., Almadi, M. A. H., Almasi, A., Almasi-Hashiani, A., Almasri, N. A., Al-Mekhlafi, H. M., Almulhim, A. M., Alonso, J., Al-Raddadi, R. M., Altirkawi, K. A., Alvis-Guzman, N., Alvis-Zakzuk, N. J., Amini, S., Amini-Rarani, M., Amiri, F., Amit, A. M. L., Amugsi, D. A., Ancuceanu, R., Anderlini, D., Andrei, C. L., Androudi, S., Ansari, F., Ansari-Moghaddam, A., Antonio, C. A. T., Antony, C. M., Antriyandarti, E., Anvari, D., Anwer, R., Arabloo, J., Arab-Zozani, M., Aravkin, A. Y., Aremu, O., Ärnlöv, J., Asaad, M., Asadi-Aliabadi, M., Asadi-Pooya, A. A., Athari, S. S., Atout, M. M. D., Ausloos, M., Avila-Burgos, L., Ayala Quintanilla, B. P., Ayano, G., Ayanore, M. A., Aynalem, Y. A., Aynalem, G. L., Ayza, M. A., Azari, S., Azzopardi, P. S., B., D. B., Babaee, E., Badiye, A. D., Bahrami, M. A., Baig, A. A., Bakhshaei, M. H., Bakhtiari, A., Bakkannavar, S. M., Balachandran, A., Banach, M., Banerjee, S. K., Banik, P. C., Bante, A. B., Bante, S. A., Barker-Collo, S. L., Bärnighausen, T. W., Barrero, L. H., Bassat, Q., Basu, S., Baune, B. T., Bayati, M., Baye, B. A., Bedi, N., Beghi, E., Behzadifar, M., Bekuma, T. T. T., Bell, M. L., Bensenor, I. M., Berman, A. E., Bernabe, E., Bernstein, R. S., Bhagavathula, A. S., Bhandari, D., Bhardwaj, P., Bhat, A. G., Bhattacharyya, K., Bhattarai, S., Bhutta, Z. A., Bijani, A., Bikbov, B., Bilano, V., Biondi, A., Birihane, B. M., Bockarie, M. J., Bohlouli, S., Bojia, H. A., Bolla, S. R. R., Boloor, A., Brady, O. J., Braithwaite, D., Briggs, A. M., Briko, N. I., Burugina Nagaraja, S., Busse, R., Butt, Z. A., Caetano Dos Santos, F. L., Cahuana-Hurtado, L., Cámera, L. A., Cárdenas, R., Carreras, G., Carrero, J. J., Carvalho, F., Castaldelli-Maia, J. M., Castañeda-Orjuela, C. A., Castelpietra, G., Castro, F., Catalá-López, F., Cederroth, C. R., Cerin, E., Chandan, J. S., Chang, A. Y., Charan, J., Chattu, V. K., Chaturvedi, S., Chin, K. L., Cho, D. Y., Choi, J. Y. J., Christensen, H., Chu, D. T., Chung, M. T., Ciobanu, L. G., Cirillo, M., Compton, K., Cortesi, P. A., Costa, V. M., Cousin, E., Dahlawi, S. M., Damiani, G., Dandona, L., Dandona, R., Darega Gela, J., Darwesh, A. M., Daryani, A., Dash, A. P., Davey, G., Dávila-Cervantes, C. A., Davletov, K., De Neve, J. W., Denova-Gutiérrez, E., Deribe, K., Dervenis, N., Desai, R., Dharmaratne, S. D., Dhungana, G. 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J., Kugbey, N., Kulkarni, V., Kumar, G. A., Kumar, N., Kumar, M., Kurmi, O. P., Kusuma, D., Kyu, H. H., La Vecchia, C., Lacey, B., Lal, D. K., Lalloo, R., Landires, I., Lansingh, V. C., Larsson, A. O., Lasrado, S., Lau, K. M. M., Lauriola, P., Lazarus, J. V., Ledesma, J. R., Lee, P. H., Lee, S. W. H., Leever, A. T., LeGrand, K. E., Leigh, J., Leonardi, M., Li, S., Lim, S. S., Lim, L. L., Liu, X., Logroscino, G., Lopez, A. D., Lopukhov, P. D., Lotufo, P. A., Lu, A., Ma, J., Madadin, M., Mahasha, P. W., Mahmoudi, M., Majeed, A., Malagón-Rojas, J. N., Maleki, S., Malta, D. C., Mansouri, B., Mansournia, M. A., Martini, S., Martins-Melo, F. R., Martopullo, I., Massenburg, B. B., Mastrogiacomo, C. I., Mathur, M. R., McAlinden, C., McKee, M., Medina-Solís, C. E., Meharie, B. G., Mehndiratta, M. M., Mehrabi Nasab, E., Mehri, F., Mehrotra, R., Mekonnen, T., Melese, A., Memiah, P. T., Mendoza, W., Menezes, R. G., Mensah, G. A., Meretoja, T. 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W., Oladnabi, M., Olagunju, A. T., Olusanya, J. O., Olusanya, B. O., Oluwasanu, M. M., Omar Bali, A., Omer, M. O., Ong, K. L., Onwujekwe, O. E., Ortega-Altamirano, D. V., Ortiz, A., Ostojic, S. M., Otstavnov, N., Otstavnov, S. S., Øverland, S., Owolabi, M. O., Padubidri, J. R., Pakhale, S., Palladino, R., Pana, A., Panda-Jonas, S., Pangaribuan, H. U., Pathak, M., Patton, G. C., Paudel, S., Pazoki Toroudi, H., Pease, S. A., Peden, A. E., Pennini, A., Peprah, E. K., Pereira, J., Pigott, D. M., Pilgrim, T., Pilz, T. M., Pinheiro, M., Piradov, M. A., Pirsaheb, M., Pokhrel, K. N., Postma, M. J., Pourjafar, H., Pourmalek, F., Pourmirza Kalhori, R., Pourshams, A., Prada, S. I., Pribadi, D. R. A., Pupillo, E., Quazi Syed, Z., Radfar, A., Rafiee, A., Rafiei, A., Raggi, A., Rahim, F., Rahman, M. A., Rajabpour-Sanati, A., Rana, S. M., Ranabhat, C. L., Rao, S. J., Rasella, D., Rashedi, V., Rath, G. K., Rathi, P., Rawaf, S., Rawaf, D. 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Publication year

2020

Journal title

The Lancet

Volume

396

Issue

10258

Page(s)

1250-1284
Abstract
Abstract
Background: Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods: Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings: Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation: The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC. Funding: Bill & Melinda Gates Foundation.

Proactive prevention: Act now to disrupt the impending non-communicable disease crisis in low-burden populations

Njuguna, B., Fletcher, S. L., Akwanalo, C., Asante, K. P., Baumann, A., Brown, A., Davila-Roman, V. G., Dickhaus, J., Fort, M., Iwelunmor, J., Irazola, V., Mohan, S., Mutabazi, V., Newsome, B., Ogedegbe, O., Pastakia, S. D., Peprah, E. K., Plange-Rhule, J., Roth, G., Shrestha, A., Watkins, D. A., & Vedanthan, R.

Publication year

2020

Journal title

PloS one

Volume

15

Issue

12
Abstract
Abstract
Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as “proactive prevention.” This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/ low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.

Regional patterns and association between obesity and hypertension in Africa: Evidence from the H3Africa Chair study

Akpa, O. M., Made, F., Ojo, A., Ovbiagele, B., Adu, D., Motala, A. A., Mayosi, B. M., Adebamowo, S. N., Engel, M. E., Tayo, B., Rotimi, C., Salako, B., Akinyemi, R., Gebregziabher, M., Sarfo, F., Wahab, K., Agongo, G., Alberts, M., Ali, S. A., Asiki, G., Boua, R. P., Gómez-Olivé, F. X., Mashinya, F., Micklesfield, L., Mohamed, S. F., Nonterah, E. A., Norris, S. A., Sorgho, H., Tollman, S., Parekh, R. S., Chishala, C., Ekoru, K., Waddy, S. P., Peprah, E., Mensah, G. A., Wiley, K., Troyer, J., Ramsay, M., & Owolabi, M. O.

Publication year

2020

Journal title

Hypertension

Page(s)

1167-1178
Abstract
Abstract
Hypertension and obesity are the most important modifiable risk factors for cardiovascular diseases, but their association is not well characterized in Africa. We investigated regional patterns and association of obesity with hypertension among 30 044 continental Africans. We harmonized data on hypertension (defined as previous diagnosis/use of antihypertensive drugs or blood pressure [BP]≥140/90 mmHg/BP≥130/80 mmHg) and obesity from 30 044 individuals in the Cardiovascular H3Africa Innovation Resource across 13 African countries. We analyzed data from population-based controls and the Entire Harmonized Dataset. Age-adjusted and crude proportions of hypertension were compared regionally, across sex, and between hypertension definitions. Logit generalized estimating equation was used to determine the independent association of obesity with hypertension (P value <5%). Participants were 56% women; with mean age 48.5±12.0 years. Crude proportions of hypertension (at BP≥140/90 mmHg) were 47.9% (95% CI, 47.4–48.5) for Entire Harmonized Dataset and 42.0% (41.1–42.7) for population-based controls and were significantly higher for the 130/80 mm Hg threshold at 59.3% (58.7–59.9) in population-based controls. The age-adjusted proportion of hypertension at BP≥140/90 mmHg was the highest among men (33.8% [32.1–35.6]), in western Africa (34.7% [33.3–36.2]), and in obese individuals (43.6%; 40.3–47.2). Obesity was independently associated with hypertension in population-based controls (adjusted odds ratio, 2.5 [2.3–2.7]) and odds of hypertension in obesity increased with increasing age from 2.0 (1.7–2.3) in younger age to 8.8 (7.4–10.3) in older age. Hypertension is common across multiple countries in Africa with 11.9% to 51.7% having BP≥140/90 mmHg and 39.5% to 69.4% with BP≥130/80 mmHg. Obese Africans were more than twice as likely to be hypertensive and the odds increased with increasing age.

Assessing Stakeholder Engagement for Translation Research and Implementation Science in Low- and Middle-Income Countries: Lessons From Ghana, Guatemala, India, Kenya, Malawi, Nepal, Rwanda, and Vietnam

Peprah, E., Iwelunmor, J., & Price, L. S.

Publication year

2019

Journal title

Global Heart

Volume

14

Issue

2

Page(s)

99-101

Contact

ep91@nyu.edu 708 Broadway 4FL New York, NY, 10003