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IntroductionUpon the onset of the COVID-19 pandemic, the Public Health Laboratory Support Unit (ZIG4) at the Robert Koch Institute (RKI), the German National Public Health Institute, developed and delivered an online training on SARS-CoV-2 qPCR diagnostics to 17 partner countries in low- and middle-income countries (LMIC). This article analyses the usefulness and cost savings of this training.MethodsThe authors performed a concurrent mixed-methodology study based on key informant interviews, interviewer-administered questionnaires, and document reviews. Economic costs were estimated from the perspective of RKI.ResultsResponding participants indicated that the course provided good and comprehensive information on up-to-date scientific knowledge and laboratory practice in PCR diagnostics. Respondents appreciated how the technical content of the training enhanced their ability to apply diagnostic methods in their daily work. Interviewees highlighted that the fast implementation and the low threshold of attending an online training had allowed them to quickly build skills that were crucial during, and beyond, the COVID-19 crisis. The total estimated cost of the online SARS-CoV-2 qPCR training was 61,644 euros. The total estimated cost of the equivalent face-to-face training was estimated at 267,592 euros. Programme weaknesses identified included the top-down approaches taken, lack of interactive components and opportunities to directly engage with other course participants and with teachers.ConclusionsAn online training was developed and implemented to support RKI partner countries in SARS-CoV-2 qPCR diagnostics during the COVID-19 pandemic, thereby strengthening pandemic response and health system resilience. The training incurred in important cost savings compared to the equivalent face-to-face training. Post-pandemic studies could usefully build on these research findings and explore ways to enhance end user involvement and improve interactive features to build stronger communities of learners and facilitate exchange of information and mutual learning.

IntroductionNon-communicable diseases (NCDs), the leading cause of death globally, are estimated to overtake communicable diseases in sub-Sahara Africa, where healthcare workers (HCWs) play a crucial role in prevention and treatment, but are in extreme shortage, thereby increasing the burden of NCDs among this specific population. To provide evidence for policy-making, we assessed the NCD burden, associated factors and treatment among HCWs in four sub-Saharan African countries.Materials and methodsWe conducted a cross-sectional study across four sub-Saharan African countries [Côte d'Ivoire (CIV), Democratic Republic of the Congo (DRC), Madagascar (MDG), and Nigeria (NIG)] between February and December 2022. In a standardized questionnaire, sociodemographic, chronic disease and treatment data were self-reported. We estimated the prevalence of (1) at least one chronic disease, (2) hypertension, and used backward elimination logistic regression model to identify risk factors.ResultsWe recruited a total of 6,848 HCWs. The prevalence of at least one chronic disease ranged between 9.7% in NIG and 20.6% in MDG, the prevalence of hypertension between 5.4% in CIV and 11.3% in MDG. At most, reported treatment rates reached 36.5%. The odds of each of both outcomes increased with age (at least one chronic disease adjusted odds ratio: CIV: 1.04; DRC: 1.09; MDG: 1.06; NIG: 1.10; hypertension: CIV: 1.10; DRC: 1.31; MDG: 1.11; NIG: 1.11) and with BMI (at least one chronic disease: CIV: 1.10; DRC: 1.07; MDG: 1.06; NIG: 1.08; hypertension: CIV: 1.10; DRC: 1.66; MDG: 1.13; NIG: 1.07). Odds of both outcomes were lower among males, except in CIV. In NIG, the odds of both outcomes were higher among medical doctors and odds of hypertension were higher among those working in secondary care. In MDG, working in secondary care increased and working as auxiliary staff decreased the odds of at least one chronic disease.ConclusionThe prevalence of self-reported chronic disease varied across the four sub-Saharan countries with potentially very low treatment rates. We identified several individual (age, sex, and BMI) and occupational (profession, level of healthcare) factors that influence the odds of NCDs. These factors should be taken into account when developing interventions addressing the burden and management of NCDs among HCWs.

Abstract Background Malaria is a leading cause of death and reduced life span in Guinea and Sierra Leone, where plans for rolling out the malaria vaccine for children are being made. There is little evidence about caregiver acceptance rates to guide roll-out policies. To inform future vaccine implementation planning, this analysis aimed to assess potential malaria vaccine acceptance by caregivers and identify factors associated with acceptance in Guinea and Sierra Leone. Methods A cross-sectional household survey using lot quality assurance sampling was conducted in three regions per country between May 2022 and August 2022. The first survey respondent in each household provided sociodemographic information. A household member responsible for childcare shared their likelihood of accepting a malaria vaccine for their children under 5 years and details about children’s health. The prevalence of caregiver vaccine acceptance was calculated and associated factors were explored using multivariable logistic regression modelling calculating adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results Caregivers in 76% of 702 sampled households in Guinea and 81% of 575 households in Sierra Leone were accepting of a potential vaccine for their children. In both countries, acceptance was lower in remote areas than in urban areas (Guinea: aOR 0.22 [95%CI 0.09–0.50], Sierra Leone: 0.17 [0.06–0.47]). In Guinea, acceptance was lower among caregivers living in the richest households compared to the poorest households (0.10 [0.04–0.24]), among those whose children were tested for malaria when febrile (0.54 [0.34–0.85]) and in households adopting more preventative measures against malaria (0.39 [0.25–0.62]). Better knowledge of the cause of malaria infection was associated with increased acceptance (3.46 [1.01–11.87]). In Sierra Leone, vaccine acceptance was higher among caregivers living in households where the first respondent had higher levels of education as compared to lower levels (2.32 [1.05–5.11]). Conclusion In both countries, malaria vaccine acceptance seems promising for future vaccine roll-out programmes. Policy makers might consider regional differences, sociodemographic factors, and levels of knowledge about malaria for optimization of implementation strategies. Raising awareness about the benefits of comprehensive malaria control efforts, including vaccination and other preventive measures, requires attention in upcoming campaigns.

BackgroundThe question of the utility of face masks in preventing acute respiratory infections has received renewed attention during the COVID-19 pandemic. However, given the inconclusive evidence from existing randomized controlled trials, evidence based on real-world data with high external validity is missing. ObjectiveTo add real-world evidence, this study aims to examine whether mask mandates in 51 countries and mask recommendations in 10 countries increased self-reported face mask use and reduced SARS-CoV-2 reproduction numbers and COVID-19 case growth rates. MethodsWe applied an event study approach to data pooled from four sources: (1) country-level information on self-reported mask use was obtained from the COVID-19 Trends and Impact Survey, (2) data from the Oxford COVID-19 Government Response Tracker provided information on face mask mandates and recommendations and any other nonpharmacological interventions implemented, (3) mobility indicators from Google’s Community Mobility Reports were also included, and (4) SARS-CoV-2 reproduction numbers and COVID-19 case growth rates were retrieved from the Our World in Data—COVID-19 data set. ResultsMandates increased mask use by 8.81 percentage points (P=.006) on average, and SARS-CoV-2 reproduction numbers declined on average by −0.31 units (P=.008). Although no significant average effect of mask mandates was observed for growth rates of COVID-19 cases (−0.98 percentage points; P=.56), the results indicate incremental effects on days 26 (−1.76 percentage points; P=.04), 27 (−1.89 percentage points; P=.05), 29 (−1.78 percentage points; P=.04), and 30 (−2.14 percentage points; P=.02) after mandate implementation. For self-reported face mask use and reproduction numbers, incremental effects are seen 6 and 13 days after mandate implementation. Both incremental effects persist for >30 days. Furthermore, mask recommendations increased self-reported mask use on average (5.84 percentage points; P

Abstract Background During outbreaks, uncertainties experienced by affected communities can influence their compliance to government guidance on public health. Communicators and authorities are, hence, encouraged to acknowledge and address such uncertainties. However, in the midst of public health crises, it can become difficult to define and identify uncertainties that are most relevant to address. We analyzed data on COVID-19-related uncertainties from four socio-economic contexts to explore how uncertainties can influence people’s perception of, and response to Risk Communication and Community Engagement (RCCE) strategies. Results This qualitative study, which adopts an interpretative approach, is based on data from a documentary review, key informant interviews (KII), and focus group discussions (FGD) with members of the general public and people with barriers to information from Germany, Guinea, Nigeria, and Singapore. Transcripts from the KII and FGD were coded and analyzed thematically. We interviewed a total of 155 KIs and conducted 73 FGD. Our analysis uncovered a divergence between uncertainties deemed relevant by stakeholders involved in policy making and uncertainties that people reportedly had to navigate in their everyday lives and which they considered relevant during the pandemic. We identified four types of uncertainties that seemed to have influenced people’s assessment of the disease risk and their trust in the pandemic control strategies including RCCE efforts: epidemiological uncertainties (related to the nature and severity of the virus), information uncertainties (related to access to reliable information), social uncertainties (related to social behavior in times of heightened risk), and economic uncertainties (related to financial insecurities). Conclusion We suggest that in future outbreaks, communicators and policy makers could improve the way in which affected communities assess their risk, and increase the trust of these communities in response efforts by addressing non-epidemiological uncertainties in RCCE strategies.

BackgroundEmergency risk communication (ERC) is key to achieving compliance with public health measures during pandemics. Yet, the factors that facilitated ERC during COVID-19 have not been analyzed. We compare ERC in the early stages of the pandemic across four socio-economic settings to identify how risk communication can be improved in public health emergencies (PHE).MethodsTo map and assess the content, process, actors, and context of ERC in Germany, Guinea, Nigeria, and Singapore, we performed a qualitative document review, and thematically analyzed semi-structured key informant interviews with 155 stakeholders involved in ERC at national and sub-national levels. We applied Walt and Gilson's health policy triangle as a framework to structure the results.ResultsWe identified distinct ERC strategies in each of the four countries. Various actors, including governmental leads, experts, and organizations with close contact to the public, collaborated closely to implement ERC strategies. Early integration of ERC into preparedness and response plans, lessons from previous experiences, existing structures and networks, and clear leadership were identified as crucial for ensuring message clarity, consistency, relevance, and an efficient use of resources. Areas of improvement primarily included two-way communication, community engagement, and monitoring and evaluation. Countries with recurrent experiences of pandemics appeared to be more prepared and equipped to implement ERC strategies.ConclusionWe found that considerable potential exists for countries to improve communication during public health emergencies, particularly in the areas of bilateral communication and community engagement as well as monitoring and evaluation. Building adaptive structures and maintaining long-term relationships with at-risk communities reportedly facilitated suitable communication. The findings suggest considerable potential and transferable learning opportunities exist between countries in the global north and countries in the global south with experience of managing outbreaks.

Abstract The last months have left no-one in doubt that the COVID-19 pandemic is exerting enormous pressure on health systems around the world, bringing to light the sub-optimal resilience of even those classified as high-performing. This makes us re-think the extent to which we are using the appropriate metrics in evaluating health systems which, in the case of this pandemic, might have masked how unprepared some countries were. It also makes us reflect on the strength of our solidarity as a global community, as we observe that global health protection remains, as this pandemic shows, focused on protecting high income countries from public health threats originating in low and middle income countries. To change this course, and in times like this, all nations should come together under one umbrella to respond to the pandemic by sharing intellectual, human, and material resources. In order to work towards stronger and better prepared health systems, improved and resilience-relevant metrics are needed. Further, a new model of development assistance for health, one that is focused on stronger and more resilient health systems, should be the world’s top priority.

The term resilience has dominated the discourse among health systems researchers since 2014 and the onset of the Ebola outbreak in West Africa. There is wide consensus that the global community has to help build more resilient health systems. But do we really know what resilience means, and do we all have the same vision of resilience? The present paper presents a new conceptual framework on governance of resilience based on systems thinking and complexity theories. In this paper, we see resilience of a health system as its capacity to absorb, adapt and transform when exposed to a shock such as a pandemic, natural disaster or armed conflict and still retain the same control over its structure and functions.

Abstract Background A competent, enabled and efficiently deployed health workforce is crucial to the achievement of the health-related sustainable development goals (SDGs). Methods for workforce planning have tended to focus on ‘one size fits all’ benchmarks, but because populations vary in terms of their demography (e.g. fertility rates) and epidemiology (e.g. HIV prevalence), the level of need for sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workers also varies, as does the ideal composition of the workforce. In this paper, we aim to provide proof of concept for a new method of workforce planning which takes into account these variations, and allocates tasks to SRMNAH workers according to their competencies, so countries can assess not only the needed size of the SRMNAH workforce, but also its ideal composition (the ‘Dream Team’). Methods An adjusted service target model was developed, to estimate (i) the amount of health worker time needed to deliver essential SRMNAH care, and (ii) how many workers from different cadres would be required to meet this need if tasks were allocated according to competencies. The model was applied to six low- and middle-income countries, which varied in terms of current levels of need for health workers, geographical location and stage of economic development: Azerbaijan, Malawi, Myanmar, Peru, Uzbekistan and Zambia. Results Countries with high rates of fertility and/or HIV need more SRMNAH workers (e.g. Malawi and Zambia each need 44 per 10,000 women of reproductive age, compared with 20–27 in the other four countries). All six countries need between 1.7 and 1.9 midwives per 175 births, i.e. more than the established 1 per 175 births benchmark. Conclusions There is a need to move beyond universal benchmarks for SRMNAH workforce planning, by taking into account demography and epidemiology. The number and range of workers needed varies according to context. Allocation of tasks according to health worker competencies represents an efficient way to allocate resources and maximise quality of care, and therefore will be useful for countries working towards SDG targets. Midwives/nurse-midwives who are educated according to established global standards can meet 90% or more of the need, if they are part of a wider team operating within an enabled environment.