Examining geographical inequalities for malaria outcomes and spending on malaria in 40 malaria-endemic countries, 2010-2020.

BACKGROUND: While substantial gains have been made in the fight against malaria over the past 20 years, malaria morbidity and mortality are marked by inequality. The equitable elimination of malaria within countries will be determined in part by greater spending on malaria interventions, and how those investments are allocated. This study aims to identify potential drivers of malaria outcome inequality and to demonstrate how spending through different mechanisms might lead to greater health equity. METHODS: Using the Gini index, subnational estimates of malaria incidence and mortality rates from 2010 to 2020 were used to quantify the degree of inequality in malaria burden within countries with incidence rates above 5000 cases per 100,000 people in 2020. Estimates of Gini indices represent within-country distributions of disease burden, with high values corresponding to inequitable distributions of malaria burden within a country. Time series analyses were used to quantify associations of malaria inequality with malaria spending, controlling for country socioeconomic and population characteristics. RESULTS: Between 2010 and 2020, varying levels of inequality in malaria burden within malaria-endemic countries was found. In 2020, values of the Gini index ranged from 0.06 to 0.73 for incidence, 0.07 to 0.73 for mortality, and 0.00 to 0.36 for case fatality. Greater total malaria spending, spending on health systems strengthening for malaria, healthcare access and quality, and national malaria incidence were associated with reductions in malaria outcomes inequality within countries. In addition, government expenditure on malaria, aggregated government and donor spending on treatment, and maternal educational attainment were also associated with changes in malaria outcome inequality among countries with the greatest malaria burden. CONCLUSIONS: The findings from this study suggest that prioritizing health systems strengthening in malaria spending and malaria spending in general especially from governments will help to reduce inequality of the malaria burden within countries. Given heterogeneity in outcomes in countries currently fighting to control malaria, and the challenges in increasing both domestic and international funding allocated to control and eliminate malaria, the efficient targeting of limited resources is critical to attain global malaria eradication goals.

Tracking development assistance for health from India to low- and middle-income countries, 2009-2020.

BACKGROUND: Development assistance for health (DAH) is an important source of financing for health for many low-income and some middle-income countries. Most DAH has predominantly been contributed by high-income countries. However, in the context of economic progress and changing global priorities, DAH contributions from countries of the Global South such as India have gained importance. In this paper, we estimate DAH contributed by India between 2009 and 2020. METHODS: We leveraged data from budgetary documents, databases, and financial reports of the Ministry of External Affairs and multilateral organizations to estimate DAH contributions. The proportions of development assistance that go towards health in major recipient countries were estimated and reported by recipient country and year. RESULTS: Between 2009 and 2020, DAH contributed by India to bilateral and multilateral partners totaled $206.0 million. South Asian countries including Bangladesh, Bhutan, Nepal, Sri Lanka, and Myanmar received the most DAH from India. DAH contributed relative to DAH received ranged from 1.42% in 2009 to 5.26% in 2018, the latest year with country-level data. Health focus areas prioritized by India included technical training and innovation, health care infrastructure support, and supply of medications and medical equipment. CONCLUSION: India is an important development partner to many countries-particularly to those in the South Asian region. India's DAH allocation strategy prioritizes contributions toward neighboring countries in the South Asia region in several health focus areas. Detailed project-level data are needed to estimate DAH contributions from India with greater precision and accuracy.

The Transitions to Long-term In Home Ventilator Engagement Study (Transitions to LIVE): study protocol for a pragmatic randomized controlled trial.

BACKGROUND OVERVIEW AND RATIONALE: We co-developed a multi-component virtual care solution (TtLIVE) for the home mechanical ventilation (HMV) population using the aTouchAway™ platform (Aetonix). The TtLIVE intervention includes (1) virtual home visits; (2) customizable care plans; (3) clinical workflows that incorporate reminders, completion of symptom profiles, and tele-monitoring; and (4) digitally secure communication via messaging, audio, and video calls; (5) Resource library including print and audiovisual material. OBJECTIVES AND BRIEF METHODS: Our primary objective is to evaluate the TtLIVE intervention compared to a usual care control group using an eight-center, pragmatic, parallel-group single-blind (outcome assessors) randomized controlled trial. Eligible patients are children and adults newly transitioning to HMV in Ontario, Canada. Our target sample size is 440 participants (220 each arm). Our co-primary outcomes are a number of emergency department (ED) visits in the 12 months after randomization and change in family caregiver (FC) reported Pearlin Mastery Scale score from baseline to 12 months. Secondary outcomes also measured in the 12 months post randomization include healthcare utilization measured using a hybrid Ambulatory Home Care Record (AHCR-hybrid), FC burden using the Zarit Burden Interview, and health-related quality of life using the EQ-5D. In addition, we will conduct a cost-utility analysis over a 1-year time horizon and measure process outcomes including healthcare provider time using the Care Coordination Measurement Tool. We will use qualitative interviews in a subset of study participants to understand acceptability, barriers, and facilitators to the TtLIVE intervention. We will administer the Family Experiences with Care Coordination (FECC) to interview participants. We will use Poisson regression for a number of ED visits at 12 months. We will use linear regression for the Pearlin Mastery scale score at 12 months. We will adjust for the baseline score to estimate the effect of the intervention on the primary outcomes. Analysis of secondary outcomes will employ regression, causal, and linear mixed modeling. Primary analysis will follow intention-to-treat principles. We have Research Ethics Board approval from SickKids, Children's Hospital Eastern Ontario, McMaster Children's Hospital, Children's Hospital-London Health Sciences, Sunnybrook Hospital, London Health Sciences, West Park Healthcare Centre, and Ottawa Hospital. DISCUSSION: This pragmatic randomized controlled single-blind trial will determine the effectiveness and cost-effectiveness of the TtLIVE virtual care solution compared to usual care while providing important data on patient and family experience, as well as process measures such as healthcare provider time to deliver the intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT04180722 . Registered on November 27, 2019.

Escaping the Red Queen: Health as a corporate food marketing strategy.

Public health advocates highlight the role of corporate actors and food marketing in shaping diets and health. This study analyses insider-oriented communications in food industry magazines in the UK to analyse actions and narratives related to health and nutrition, providing insights into relatively overlooked areas of marketing strategy including inter-firm dynamics. From a sample of four specialized food industry magazines covering the main industry segments we identified 319 articles (published 2007-2018) mentioning health or nutrition together with industry actions affecting the food environment. We identified health-related actions and analysed underlying strategies through content and thematic analyses. Health and nutrition have a rapidly growing role in food marketing strategy. Content analysis revealed a focus on ultra-processed foods, as well as product and nutrient-specific trends including increased health-based marketing of snacks and "protein rich" products. Health-related actions predominantly relied on consumer agency rather than invoking structural food environment changes. Thematic analysis identified proactive and defensive marketing strategies. Proactive approaches included large investments in health-related promotion of ultra-processed foods which are made highly visible to competitors, and the reliance on a "credence goods" differentiation strategies. Defensive strategies included a 'Red Queen' effect, whereby firms take health-related actions to keep up with competitors. These competitive strategies can create challenges, as well as some opportunities, for public health promotion. Challenges can include undermining efforts to support product comparison and healthier choice, and limiting firms' engagement in specific health improving actions. Systematic analysis of health-oriented marketing strategies could support more effective public health intervention.

Risk factors for death or heart transplantation in single-ventricle physiology (tricuspid atresia, pulmonary atresia, and heterotaxy): A systematic review and meta-analysis.

BACKGROUND: In this study we sought to evaluate risk factors (RFs) for death or heart transplantation (D-HT) in single-ventricle (SV) physiology due to tricuspid atresia (TA), pulmonary atresia‒intact ventricular septum (PA-IVS), and heterotaxy with SV (HX), clinical conditions for which outcome data are limited. METHODS: To conduct a systematic review, we included citations that evaluated occurrence of D-HT in SV physiology of TA, PA-IVS, and HX in English articles published between January 1998 and December 2017 based on inclusion and exclusion criteria, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The Cochrane Risk of Bias in Non-Randomized Studies-Interventions (ROBINS-I) tool for non-randomized studies was used to assess the risk of bias. Meta-analysis was performed if RF data were available in more than 3 studies. RESULTS: Of 11,629 citations reviewed, 30 met inclusion criteria. All 30 were observational, retrospective studies. In all, 1,770 patients were included, 481 died and 21 underwent HT (63 lost to follow-up); 723 patients reached Fontan completion. We found that systemic ventricular dysfunction (odds ratio [OR] 20.7, confidence interval [CI] 10.0-42.5, I2 = 0%) and atrioventricular valve regurgitation (AVR) were associated with risk of D-HT (OR 3.7, CI 1.9-6.9, I2 = 14%). RF associations with D-HT could not be derived for right ventricle‒dependent coronary circulation, pulmonary arteriovenous malformations, total anomalous pulmonary venous return, arrhythmias, and pulmonary atresia. CONCLUSIONS: This systematic review and meta-analysis has identified a high mortality rate in children born with non-HLHS SV heart disease and points to potential under-utilization of HT. Systemic ventricular dysfunction and AVR were identified as RFs for D-HT in this subset of patients SV with TA, PA-IVS, and HX.