Socio-economic and geographical inequalities in neonatal mortality rates in Sierra Leone, 2008-2019.

Sierra Leone has reduced neonatal mortality rates(NMR) in recent years. Despite this progress, disparities in newborn survival persist across socio-economic and geographic areas. This study examined the inequalities in neonatal mortality rates in Sierra Leone between 2008 and 2019. We utilized data from the Sierra Leone Demographic Health Survey rounds conducted in 2008, 2013, and 2019. We used the World Health Organisation Health Equity Assessment Toolkit to calculate simple measures of inequality (Difference, and Ratio), and complex measures of inequality (Population Attributable Risk, and Population Attributable Fraction). Inequality in neonatal mortality rate was calculated on six stratifiers: maternal age, maternal economic status, maternal level of education, place of residence, sex of the child, and sub-national province. Neonatal mortality rate decreased in Sierra Loene from 48.6 deaths per 1,000 live births in 2008 to 29.6 deaths per 1,000 live births in 2019. There was an increase in age-related inequality from a Difference of 0.7 deaths per 1,000 live births in 2008 to 4.3 deaths per 1,000 live births in 2019. Economic inequality decreased from a Difference of 26.8 deaths per 1,000 live births in 2008 to -3.4 deaths per 1,000 live births in 2019. Inequality in education decreased from a Difference of 4.6 deaths per 1,000 live births in 2008 to -4.2 deaths per 1,000 live births in 2019. Inequality increased from a Difference of - 0.5 deaths per 1,000 live births in 2008 to -4.2 deaths per 1,000 live births in 2019 for place of residence. For the child's sex, the inequality increased from a Difference of - 7.9 deaths per 1,000 live births in 2008 to -11.1 deaths per 1,000 live births in 2019. Provincial inequality increased slightly from a Difference of 14.0 deaths per 1,000 live births in 2008 to 14.4 deaths per 1,000 live births in 2019. The findings show a decline in the national neonatal mortality rate from 2008 to 2019, indicating improvements in healthcare and maternal support. While economic and educational inequalities have decreased, especially in education, sustaining these gains is essential for equitable healthcare access. Despite this progress, inequalities based on age, residence, child's sex, and province still exist, and have increased between 2008 and 2019. Policymakers should focus on targeted programs for vulnerable age groups and sexes, and develop geographical strategies to ensure uniform improvements in neonatal health.

Osborne A ，Bai-Sesay AU ，Bangura C ，Rogers H ，Ahinkorah BO ... -  《BMC Pediatrics》

Trends and inequalities in BCG immunisation coverage among one-year-olds in Sierra Leone, 2008-2019.

Bacillus Calmette-Guérin (BCG) vaccination is a cornerstone of childhood immunisation programs, protecting against tuberculosis (TB), a major public health concern. Sierra Leone, a West African nation, faces challenges in achieving equitable and high BCG immunisation coverage. This study delves into the trends and inequalities in BCG coverage among one-year-old children in Sierra Leone between 2008 and 2019. Three rounds of data from the Sierra Leone Demographic and Health Surveys (2008, 2013, and 2019) were used to analysed to examine the inequalities in BCG coverage. Simple measures of inequality [Difference (D) and Ratio (R)] and complex measures of inequality [Population Attributable Ratio (PAR) and Fraction (PAF)] were calculated in the World Health Organization's Health Equity Assessment Toolkit (WHO's HEAT) software. The measures were calculated separately for each of the three surveys for age groups of women, level of education, economic status, residential areas, gender, and sub-national provinces, and their estimates were compared. The findings revealed that BCG immunisation coverage in Sierra Leone has increased significantly from 2008 (82.0%) to 2019 (96.3%). Age-related inequalities between children of older mothers (20-49) and younger mothers (15-19) increased from a Difference of -4.7 percentage points in 2008 to 4.8 percentage points in 2019. The PAF increased from zero in 2008 to 0.4% in 2019. This means that in the absence of age-related inequalities, the national average of BCG immunisation coverage would have increased by 0.4%. Economic-related inequalities between children of mothers in Quintile 5 (richest) and Quintile 1 (poorest) decreased from a Difference of 9.2 percentage points in 2008 to 1.2 percentage points in 2019. Educational-related inequalities between children of mothers with secondary/higher education and no education decreased from a Difference of 14.1 percentage points in 2008 to 0.4 percentage points in 2019. The PAF decreased from 13.3% in 2008 to 0.2% in 2019, indicating that without educational-related inequalities the setting average of BCG immunisation coverage would have increased by 0.2%. Place of residence-related inequalities between children of mothers living in urban areas and rural areas decreased from a Difference of 9.3 percentage points in 2008 to 0.7 percentage points in 2019. The PAF decreased from 8.5% in 2008 to 0.5% in 2019 indicating that the national average of BCG immunisation coverage would have increased by 0.5% without place of residence-related inequalities. The sex of the child-related inequalities between male and female children decreased from a Difference of 5.4 percentage points in 2008 to 0.7 percentage points in 2019. The PAF decreased from 3.3% in 2008 to 0.4% in 2019 indicating that the national average of BCG immunisation coverage would have increased by 0.4% without sex of the child-related inequalities. Provincial inequalities decreased from a Difference of 18.5 percentage points in 2008 to 2.3 percentage points in 2019. The PAF decreased from 14.3% in 2008 to 1.1% in 2019 indicating that the national average of BCG immunisation coverage would have increased by 1.1% without provincial inequalities. The findings indicate a substantial improvement in BCG immunisation coverage in Sierra Leone among one-year-olds, reflecting successful public health initiatives. However, age-related inequalities have worsened, with coverage among children of younger mothers declining relative to those of older mothers, suggesting a need for targeted interventions for this population. In contrast, economic, educational, sex, and place of residence-related inequalities have notably decreased, indicating progress in equitable access to immunisation across different socioeconomic strata. Additionally, provincial inequalities have decreased significantly, yet a difference of 2.3 percentage points remains, highlighting the need for continued efforts to ensure that all provinces, receive adequate healthcare resources and outreach. The absence of economic-related inequality by 2019 is particularly encouraging, as it suggests that economic barriers to immunisation have been effectively addressed. Furthermore, the reduction in educational and provincial inequalities highlights the effectiveness of strategies aimed at improving access and awareness in underserved areas.

Osborne A ，Wongnaah FG ，Bangura C ，Ahinkorah BO ... -  《BMC PUBLIC HEALTH》

Antioxidants for female subfertility.

M.G. Showell, R. Mackenzie‐Proctor, V. Jordan, and R.J. Hart, “Antioxidants for Female Subfertility,” Cochrane Database of Systematic Reviews, no. 8 (2020): CD007807, https://doi.org/10.1002/14651858.CD007807.pub4 This Editorial Note is for the above article, published online on August 27, 2020, in Cochrane Library (cochranelibrary.com), and has been issued by the Publisher, John Wiley & Sons Ltd, in agreement with Cochrane. The Editorial note has been agreed due to concerns discovered by the Cochrane managing editor regarding the retraction of six studies in the Review (Badawy et al. 2006, 10.1016/j.fertnstert.2006.02.097; El Refaeey et al. 2014, 10.1016/j.rbmo.2014.03.011; El Sharkwy & Abd El Aziz 2019a, https://doi.org/10.1002/ijgo.12902; Gerli et al. 2007, https://doi.org/10.26355/eurrev_202309_33752, full text: https://europepmc.org/article/MED/18074942; Ismail et al. 2014, http://dx.doi.org/10.1016/j.ejogrb.2014.06.008; Hashemi et al. 2017, https://doi.org/10.1080/14767058.2017.1372413). In addition, expressions of concern have been published for two studies (Jamilian et al. 2018, https://doi.org/10.1007/s12011-017-1236-3; Zadeh Modarres 2018, https://doi.org/10.1007/s12011-017-1148-2). The retracted studies will be moved to the Excluded Studies table, and their impact on the review findings will be investigated and acted on accordingly in a future update. Initial checks indicate that removal of the six retracted studies did not make an appreciable difference to the results. Likewise, the studies for which Expressions of Concern were issued will be moved to the Awaiting classification table; they did not report any review outcomes, so removal will have no impact on the review findings. A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. This may affect up to a quarter of all couples planning a child. It is estimated that for 40% to 50% of couples, subfertility may result from factors affecting women. Antioxidants are thought to reduce the oxidative stress brought on by these conditions. Currently, limited evidence suggests that antioxidants improve fertility, and trials have explored this area with varied results. This review assesses the evidence for the effectiveness of different antioxidants in female subfertility. To determine whether supplementary oral antioxidants compared with placebo, no treatment/standard treatment or another antioxidant improve fertility outcomes for subfertile women. We searched the following databases (from their inception to September 2019), with no language or date restriction: Cochrane Gynaecology and Fertility Group (CGFG) specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and AMED. We checked reference lists of relevant studies and searched the trial registers. We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment or treatment with another antioxidant, among women attending a reproductive clinic. We excluded trials comparing antioxidants with fertility drugs alone and trials that only included fertile women attending a fertility clinic because of male partner infertility. We used standard methodological procedures expected by Cochrane. The primary review outcome was live birth; secondary outcomes included clinical pregnancy rates and adverse events. We included 63 trials involving 7760 women. Investigators compared oral antioxidants, including: combinations of antioxidants, N-acetylcysteine, melatonin, L-arginine, myo-inositol, carnitine, selenium, vitamin E, vitamin B complex, vitamin C, vitamin D+calcium, CoQ10, and omega-3-polyunsaturated fatty acids versus placebo, no treatment/standard treatment or another antioxidant. Only 27 of the 63 included trials reported funding sources. Due to the very low-quality of the evidence we are uncertain whether antioxidants improve live birth rate compared with placebo or no treatment/standard treatment (odds ratio (OR) 1.81, 95% confidence interval (CI) 1.36 to 2.43; P < 0.001, I2 = 29%; 13 RCTs, 1227 women). This suggests that among subfertile women with an expected live birth rate of 19%, the rate among women using antioxidants would be between 24% and 36%. Low-quality evidence suggests that antioxidants may improve clinical pregnancy rate compared with placebo or no treatment/standard treatment (OR 1.65, 95% CI 1.43 to 1.89; P < 0.001, I2 = 63%; 35 RCTs, 5165 women). This suggests that among subfertile women with an expected clinical pregnancy rate of 19%, the rate among women using antioxidants would be between 25% and 30%. Heterogeneity was moderately high. Overall 28 trials reported on various adverse events in the meta-analysis. The evidence suggests that the use of antioxidants makes no difference between the groups in rates of miscarriage (OR 1.13, 95% CI 0.82 to 1.55; P = 0.46, I2 = 0%; 24 RCTs, 3229 women; low-quality evidence). There was also no evidence of a difference between the groups in rates of multiple pregnancy (OR 1.00, 95% CI 0.63 to 1.56; P = 0.99, I2 = 0%; 9 RCTs, 1886 women; low-quality evidence). There was also no evidence of a difference between the groups in rates of gastrointestinal disturbances (OR 1.55, 95% CI 0.47 to 5.10; P = 0.47, I2 = 0%; 3 RCTs, 343 women; low-quality evidence). Low-quality evidence showed that there was also no difference between the groups in rates of ectopic pregnancy (OR 1.40, 95% CI 0.27 to 7.20; P = 0.69, I2 = 0%; 4 RCTs, 404 women). In the antioxidant versus antioxidant comparison, low-quality evidence shows no difference in a lower dose of melatonin being associated with an increased live-birth rate compared with higher-dose melatonin (OR 0.94, 95% CI 0.41 to 2.15; P = 0.89, I2 = 0%; 2 RCTs, 140 women). This suggests that among subfertile women with an expected live-birth rate of 24%, the rate among women using a lower dose of melatonin compared to a higher dose would be between 12% and 40%. Similarly with clinical pregnancy, there was no evidence of a difference between the groups in rates between a lower and a higher dose of melatonin (OR 0.94, 95% CI 0.41 to 2.15; P = 0.89, I2 = 0%; 2 RCTs, 140 women). Three trials reported on miscarriage in the antioxidant versus antioxidant comparison (two used doses of melatonin and one compared N-acetylcysteine versus L-carnitine). There were no miscarriages in either melatonin trial. Multiple pregnancy and gastrointestinal disturbances were not reported, and ectopic pregnancy was reported by only one trial, with no events. The study comparing N-acetylcysteine with L-carnitine did not report live birth rate. Very low-quality evidence shows no evidence of a difference in clinical pregnancy (OR 0.81, 95% CI 0.33 to 2.00; 1 RCT, 164 women; low-quality evidence). Low quality evidence shows no difference in miscarriage (OR 1.54, 95% CI 0.42 to 5.67; 1 RCT, 164 women; low-quality evidence). The study did not report multiple pregnancy, gastrointestinal disturbances or ectopic pregnancy. The overall quality of evidence was limited by serious risk of bias associated with poor reporting of methods, imprecision and inconsistency. In this review, there was low- to very low-quality evidence to show that taking an antioxidant may benefit subfertile women. Overall, there is no evidence of increased risk of miscarriage, multiple births, gastrointestinal effects or ectopic pregnancies, but evidence was of very low quality. At this time, there is limited evidence in support of supplemental oral antioxidants for subfertile women.

Showell MG ，Mackenzie-Proctor R ，Jordan V ，Hart RJ ... -  《Cochrane Database of Systematic Reviews》

Unlocking data: Decision-maker perspectives on cross-sectoral data sharing and linkage as part of a whole-systems approach to public health policy and practice.

Tweed E ，Cimova K ，Craig P ，Allik M ，Brown D ，Campbell M ，Henderson D ，Mayor C ，Meier P ，Watson N ... -  《-》

Qualitative evidence synthesis informing our understanding of people's perceptions and experiences of targeted digital communication.

Health communication is an area where changing technologies, particularly digital technologies, have a growing role to play in delivering and exchanging health information between individuals, communities, health systems, and governments.[1] Such innovation has the potential to strengthen health systems and services, with substantial investments in digital health already taking place, particularly in low‐ and middle‐income countries. Communication using mobile phones is an important way of contacting individual people and the public more generally to deliver and exchange health information. Such technologies are used increasingly in this capacity, but poor planning and short‐term projects may be limiting their potential for health improvement. The assumption that mobile devices will solve problems that other forms of communication have not is also prevalent. In this context, understanding people's views and experiences may lead to firmer knowledge on which to build better programs. A qualitative evidence synthesis by Heather Ames and colleagues on clients' perceptions and experiences of targeted digital communication focuses on a particular type of messaging – targeted messages from health services delivered to particular group(s) via mobile devices, in this case looking at communicating with pregnant women and parents of young children, and with adults and teenagers about sexual health and family planning.[2] These areas of reproductive, maternal, newborn, child, and adolescent health (RMNCAH) are where important gains have been made worldwide, but there remains room for improvement. Ames and colleagues sought to examine and understand people's perceptions and experiences of using digital targeted client communication. This might include communication in different formats and with a range of purposes related to RMNCAH – for example, receiving text message reminders to take medicines (e.g. HIV medicines) or go to appointments (such as childhood vaccination appointments), or phone calls offering information or education (such as about breastfeeding or childhood illnesses), support (e.g. providing encouragement to change behaviours) or advice (such as advising about local healthcare services). These communication strategies have the potential to improve health outcomes by communicating with people or by supporting behaviour change. However, changing people's health behaviours to a significant and meaningful degree is notoriously challenging and seldom very effective across the board. There are a multitude of systematic reviews of interventions aiming to change behaviours of both patients and providers, with the overall objective of improving health outcomes – many of which show little or no average effects across groups of people.[3] This evidence synthesis is therefore important as it may help to understand why communicating with people around their health might (or might not) change behaviours and improve consequent health outcomes. By examining the experiences and perspectives of those receiving the interventions, this qualitative evidence synthesis allows us to better understand the interventions' acceptability and usefulness, barriers to their uptake, and factors to be considered when planning implementation. The synthesis looked at 35 studies from countries around the world, focussing on communication related to RMNCAH. Of the 35 studies, 16 were from high‐income countries, mainly the United States, and 19 were from low‐ or middle‐income countries, mainly African countries. Many of the studies presented hypothetical scenarios. The findings from the synthesis are mixed and give us a more nuanced picture of the role of targeted digital communication. People receiving targeted digital communications from health services often liked and valued these contacts, feeling supported and connected by them. However, some also reported problems with the use of these technologies, which may represent barriers to their use. These included practical or technical barriers like poor network or Internet access, as well as cost, language, technical literacy, reading or issues around confidentiality, especially where personal health conditions were involved. Access to mobile phones may also be a barrier, particularly for women and adolescents who may have to share or borrow a phone or who have access controlled by others. In such situations it may be difficult to receive communications or to maintain privacy of content. The synthesis also shows that people's experiences of these interventions are influenced by factors such as the timing of messages, their frequency and content, and their trust in the sender. Identifying key features of such communications by the people who use them might therefore help to inform future choices about how and when such messaging is used. The authors used their knowledge from 25 separate findings to list ten implications for practice. This section of the review is hugely valuable, making a practical contribution to assist governments and public health agencies wishing to develop or improve their delivery of digital health. The implications serve as a list of points to consider, including issues of access (seven different aspects are considered), privacy and confidentiality, reliability, credibility and trust, and responsiveness to the needs and preferences of users. In this way, qualitative evidence is building a picture of how to better communicate with people about health. For example, an earlier 2017 Cochrane qualitative evidence synthesis by Ames, Glenton and Lewin on parents' and informal caregivers' views and experiences of communication about routine childhood vaccination provides ample evidence that may help program managers to deliver or plan communication interventions in ways that are responsive to and acceptable to parents.[4] The qualitative synthesis method, therefore, puts a spotlight on how people's experiences of health and health care in the context of their lives may lead to the design of better interventions, as well as to experimental studies which take more account of the diversity that exists in people's attitudes and decision‐making experiences.[5] In the case of this qualitative evidence synthesis by Ames and colleagues, the method pulled together a substantial body of research (35 data‐rich studies were sampled from 48 studies identified, with the high‐to‐moderate confidence in the evidence for 13 of the synthesized findings). The evidence from this review can inform the development of interventions, and the design of trials and their implementation. While waiting for such new trials or trial evidence on effects to emerge, decision‐makers can build their programs on the highly informative base developed by this review. This qualitative evidence synthesis, alongside other reviews, has informed development by the World Health Organization of its first guideline for using digital technologies for health systems strengthening,[1, 6] part of a comprehensive program of work to better understand and support implementation of such new technologies.

Ryan R ，Hill S 《Cochrane Database of Systematic Reviews》