The Institute for Global Health and Development
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Item Contextual constraints and dilemmas influencing health providers’ prescription practices in a conflict-affected area: Qualitative insights from Mopti, Mali(Public Library of Science, 2025-10-16) Coulibaly, Issa; Diarra, Yacouba; Ahmed, Mohamed Ali Ag; Ravinetto, Raffaella; Doumbi, Seydou; Kielmann, KarinaArmed conflicts present complex, multidimensional challenges that severely compromise both access to and the quality of healthcare, including the adequate prescription of essential medicines. This study aimed to identify and understand the factors underlying the irrational prescribing of medicine in areas affected by armed conflict in the Mopti region in Mali. An exploratory qualitative study was conducted using a semi-structured interview guide to collect data from 30 participants, including health professionals from three health districts, representatives of the regional health directorate, members of community health associations, and staff from non-governmental organisations (NGOs) working in health sector. Interviews were recorded, transcribed, and subjected to thematic content analysis, using NVIVO 14 (2023 version) to support coding and data retrieval. Study participants reported a range of health system- and patient-related factors contributing to irrational prescribing practices in these conflict-affected areas. Health systems factors included: an imbalance between workload and the availability of qualified staff; limited access to professional training and training resources; poor adherence to prescription guidelines and procedures -often a consequence of contextual constraints; and coercion from armed terrorist groups. Administrative and political challenges were also highlighted, including weak monitoring and supervision mechanisms within the local health system; a lack of oversight by health and regulatory authorities in blockaded areas; the development of an informal pharmaceutical sector to compensate for deficiencies in the formal system; and overprescription of medicines linked to insurance schemes. Patient-related factors included delayed care-seeking linked to regional insecurity and contributing to increased morbidity and worsened health outcomes. Our results show that the multiple contextual factors influencing prescribing of medicines are deeply inter-linked. Efforts to improve the quality of prescribing in conflict zones must recognise that practices often deemed ‘irrational’ are shaped by complex contextual constraints. A coordinated and comprehensive approach involving all health systems stakeholders is required.Item Integrating healthcare financing for refugees into national health systems: findings from a rapid review of the literature(Elsevier, 2025-10-16) Bertone, Maria Paola; Palmer, Natasha; Witter, SophieAs the number of refugees increases and displacement becomes protracted, providing equitable healthcare in sustainable ways is increasingly challenging. The Global Compact for Refugees calls for greater inclusion of refugees in national health systems. However, evidence is limited on the most suitable approaches to achieve integration, including from a health financing perspective. This study reviewed normative and empirical literatures on health financing for refugees, reflecting on existing arrangements, and their level of integration with national health systems. A total of 52 documents were reviewed following a purposeful search of grey and published literature. Data were analysed according to core health financing sub-functions as defined by the WHO, specifically reflecting on pathways and approaches to integration for each. The analysis found that challenges remains in relation to funding for refugee healthcare, and areas of focus concern fair burden-sharing and engagement of development funders. Fund pooling proves to be a potential entry point for integration to reduce fragmentation in health financing through use of existing mechanisms (budgets or social health insurance schemes), despite challenges highlighted in the empirical literature. Fewer documents look at purchasing and benefit packages, and they highlight the importance of tailoring those to the specific needs of refugees. In relation to equity and efficiency, integration is often assumed to lead to improvements, but evidence is limited and issues related to the underlying weaknesses of the national health system might hamper the benefits of integration. Overall, the review findings support the development of hypotheses as to how best support health financing integration processes, and highlight areas for further research.Item Lived experience must be properly recognised [Letter](BMJ Publishing Group, 2025-10-09) Gautam, Araya; Johnson, SanathItem Navigating power in policy adoption: the political economy of noncommunicable diseases in Sierra Leone(Elsevier, 2025-10-06) Loffreda, Giulia; Senesi, Reynold; Diaconu, Karin; Idriss, Ayesha; Witter, SophieNon-communicable diseases (NCDs) represent a rising health burden globally, yet low- and middle-income countries (LMICs), particularly fragile states, face persistent barriers to NCD prevention and control policy adoption and implementation. This qualitative case study examines the factors influencing NCD policy adoption in Sierra Leone, a country that, in recent years, has focused on tackling these conditions. Drawing on 20 key informant interviews and 39 policy documents and media analysis, the study highlights the interplay of global health norms, commercial determinants, and local capacities. Findings reveal how international frameworks like WHO’s ‘best buys’ provide essential guidance but often fail to accommodate local socio-political realities. The analysis underscores how multisectoral coalitions, power dynamics, and commercial interests shape outcomes of policy adoption, while chronic underfunding and donor-driven priorities further complicate governance. Recommendations emphasize the importance of context-sensitive strategies that integrate local knowledge systems, strengthen leadership, and embed implementation research. Ultimately, fostering adaptive, accountable, and well-resourced health systems, supported by global solidarity and coordinated governance reforms, is essential to achieving sustainable NCD responses, particularly in an era marked by fractured multilateralism and weakened collective action, where strengthening local capacities and political commitment becomes even more critical.Item Facilitators to strengthening vaccine uptake post-pandemic amongst underserved populations considering social norms and health beliefs: a global systematic review(Elsevier, 2025-09-27) Chaudhry, T.; Tum, P.; Morrow, F.; Hargreaves, S.; Kielmann, Karina; Kunst, H.; Griffiths, C.; Campbell. N.J.C.; Zenner, D.Reasons for low vaccine uptake include personal, physical, and societal barriers, which are not well understood for specific underserved communities, particularly ethnic minority and migrant groups. We reviewed gaps to understanding low vaccination uptake in underserved populations globally and summarise key determinants associated with vaccination uptake considering social norms and health beliefs. Methods Published literature was searched using PubMed, MEDLINE, EMBASE; PSYCHINFO and Web of Science from 2020 to 2024 for primary research, with no restrictions on language; to understand uptake of COVID-19 and other vaccinations considering social norms and health beliefs in underserved groups. 55, 925 papers were screened, and 37 studies included from regions including Europe, USA, UK, African, South-Asian, and South-East Asian regions. Findings A total of 37 studies were included. Four themes pertinent to behavioural outcomes were identified in relation to vaccine uptake across ethnic groups, ethnic minority, and underserved groups, including: Influences of Health Belief Systems, Behaviours and Vaccine Uptake; Role of Social and Cultural norms, and Vaccine Uptake; Provision of Information and Vaccine Uptake; and Trust and Vaccine Uptake. We found vaccine uptake was linked with socio-demographic factors, particularly age, gender and ethnicity. There were similarities between first generation migrants and ethnic minority groups from USA or UK, and those from other regions. Younger, male and individuals from rural regions from their own native countries were also less likely to take up vaccination. Societal influences and norms were found to be significant predictors of vaccine uptake. Discussion We reviewed, how social norms and health beliefs interplay with vaccine uptake in underserved groups and report facilitators to overcome vaccine hesitancy across these population groups. There is a need to provide adequate, tailored information to combat misinformation, through trusted messengers or gatekeepers to overcome the misconceptions around vaccine, by gaining the trust of underserved groups. Discussion This review provides an overview of how social norms and health beliefs interplay with vaccine uptake in underserved and ethnic groups. It reports facilitators to overcome the barriers associated with vaccine hesitancy across these population groups. There is a need to provide and spread adequate and tailored information to combat misinformation, through trusted messengers or gatekeepers, which in turn could overcome misconceptions around vaccination, by gaining the trust of underserved groups, through support programmes facilitating vaccine uptake.Item Without retention, the NHS’s 10 Year Plan will fail [Letter](BMJ Publishing Group, 2025-08-28) Gautam, Araya; Johnson, SanathItem Care as Resistance, Care as Agency, Care as a Burden: A Relational Exploration of the Impact of Giving and Receiving Care on Refugees’ Lives(Oxford University Press, 2025-09-23) Baillot, Helen; Vera Espinoza, Marcia; Yurdakul, G.; Beaman, J.; Mügge, L.; Scuzzarello, S.; Sunanta, S.This chapter discusses the multidimensionality and multidirectionality of care and its impact upon refugees’ pathways toward inclusion. Drawing on qualitative data collected during workshops and interviews with 55 recently recognized refugees in Scotland, the chapter explores how care in multiple forms is experienced, given, and negotiated. The chapter draws from ideas around care that conceptualize it as a means to resist restrictive government policies, as an expression of agency within familial and social contexts, and as a burden that affects people differentially as they seek to rebuild lives in new country contexts. In exploring the multiple dimensions and directions of care and the ways it intersects with gender and immigration status, among other social locations, we highlight conceptual and empirical parallels between care and integration. One, the text suggests, should not be understood without full consideration of the other. The chapter concludes by calling for care to be accorded a greater importance in explorations of refugees’ integration experiences, in ways that fully encompass care’s potentialities and limitations for the people who provide and receive it.Item Risks and Resilience Amongst Rural Honduran Children(Springer, 2025-09-20) Viola, Lorian VThis study utilized a socioecological systems framework to examine the interplay of risk and resilience factors among children in middle childhood residing in a rural community in Honduras. In such contexts marked by structural disadvantage, a nuanced understanding of resilience is essential for mitigating the effects of adversity and fostering children’s potential. Utilizing an exploratory mixed-methods design, the research was conducted in three sequential phases. In the first phase (focus groups, N = 4), participants identified 12 context-specific childhood adversities and six associated signs of vulnerability. The second phase (risk screening, N = 175) found that children frequently encountered multiple, co-occurring risks, such as prolonged parental absence. In the third phase (survey, N = 84), resilience was assessed using the Child and Youth Resilience Measure (CYRM-28), revealing that among children experiencing co-occurring risks, resilience was primarily relational in nature, with social networks providing essential protective resources. Logistic regression analyses identified four key protective factors within children’s social ecologies: three at the household level (consistent adult presence in the home and the regular availability of time and resources for academic tasks) and one at the community level (perceived safety during school commutes). Although the study’s relatively small sample size limits the generalizability of the findings, the results highlight the critical role of multisystemic influences in fostering positive outcomes for children exposed to high levels of adversity.Item Refugee integration in national health systems of low- and middle-income countries (LMICs): evidence synthesis and future research agenda(Elsevier, 2025-09-12) Olabi, Amina; Palmer, Natasha; Bertone, Maria Paola; Loffreda, Giulia; Bou-Orm, Ibrahim; Sempé, Lucas; Vera Espinoza, Marcia; Dakessian, Arek; Kadetz, Paul; Ager, Alastair; Witter, SophieThis paper reviews evidence on healthcare responses for refugees, documenting the different approaches and their effectiveness and impact in particular in relation to supporting integrating refugees into national health systems. The review adopted a purposeful, iterative approach, utilizing electronic databases, grey literature, and reference lists from relevant studies. A total of 167 studies, primarily from low- and middle-income countries (LMICs), focusing on refugees and forcibly displaced persons with empirical data, were included. The review highlights a substantial literature on refugee health and healthcare access, with well-covered areas including delivery models, access barriers, gaps in coverage, and specific health services such as psychosocial care, non-communicable diseases, mental health, and maternal and child health. However, less attention is given to integration models, health system responses, and their impact on system resilience and social cohesion. Few studies examine the costs, feasibility, or sustainability of integration models, and little research focuses on health system perspectives or comparative analyses. Moreover, the host health system's status, capacity, and needs are often underexplored. Some countries are particularly well-represented in studies, e.g. Turkey, Jordan, Lebanon, Bangladesh, Democratic Republic of Congo (DRC), and Uganda. There is however a paucity of data that would provide the basis for more quantitative or analytical evaluation from a systems perspective. This gap highlights the need for further research on effective integration models, their operational aspects, and their long-term impact on local health systems' resilience and sustainability. To support this research agenda, we propose a conceptual framework to provide analytic guidance for future research on healthcare responses for refugees and health system integration.Item Recent-onset atrial fibrillation: challenges and opportunities(2025-08-28) Svennberg, Emma; Freedman, Ben; Andrade, Jason G; Anselmino, Matteo; Biton, Yitschak; Boriani, Giuseppe; Brandes, Axel; Buckley, Claire M; Cameron, Alan; Clua-Espuny, J L; Crijns, Harry J G M; Diederichsen, Søren Zöga; Doehner, Wolfram; Dominguez, Helena; Duncker, David; Fauchier, Laurent; Glotzer, Taya; Guo, Yutao (Sheila); Haeusler, Karl Georg; Haim, Moti; Healey, Jeff S; Hendriks, Jeroen M; Hills, Mellanie True; Hindricks, Gerhard; Hobbs, F D Richard; Johnson, Linda S; Joung, Boyoung; Kamel, Hooman; Kirchhof, Paulus; Lane, Deirdre A; Levin, Lars-Åke; Lip, Gregory Y H; Liu, Shaowen; Lobban, Trudie; Macfarlane, Peter W; Mairesse, Georges H; Marcus, Gregory M; Noseworthy, Peter A; Ntaios, George; Orchard, Jessica J; Passman, Rod; Reidpath, Daniel; Reiffel, James A; Ribeiro, Antonio Luiz; Rivard, Lena; Sanders, Prashanthan; Sandhu, Roopinder K; Schnabel, Renate B; Siontis, Konstantinos C; Sposato, Luciano A; Stavrakis, Stavros; Steinhubl, Steven R; Svendsen, Jesper H; Teh, Andrew W; Themistoclakis, Sakis; Tieleman, Robert G; Camm, A JohnAtrial fibrillation (AF) is increasingly diagnosed early, close to its first occurrence due to: (i) increased public awareness with self-screening; (ii) health care initiatives including population screening and opportunistic case finding; and (iii) increased use and surveillance of implantable cardiac devices. At its onset, AF is often low burden, and cardiovascular co-morbidities may be absent or at an early stage. Thus, the management of recent-onset AF has become an issue of growing importance. Professional guidelines have traditionally focused on anticoagulant thromboprophylaxis, generally recommending a cautious approach to rhythm control, and priority has been given to rate control to alleviate symptoms. In recent guidelines, the importance of managing lifestyle and co-morbidities has increased. The AF-SCREEN collaboration proposes that a vigorous approach to active management of recent-onset AF may be warranted. This includes addressing co-morbidities and promoting healthy lifestyles to prevent the emergence or progression of AF and associated cardiovascular disease, as well as the initiation of active rhythm control ± anticoagulation to prevent AF-related morbidity and mortality, including stroke and heart failure (HF). Intuitively, intervention early after AF onset would be beneficial since lifestyle and co-morbidity management, plus rhythm control and anticoagulation, are important contributors to improved outcomes in patients with established AF, but robust evidence is lacking for recent-onset AF. There is a delicate balance between achieving favourable outcomes such as preventing strokes, HF and AF progression vs the complications and potential adverse effects of interventions. Given the serious long-term consequences, innovative approaches are necessary to determine the value and risks of initiating active therapy very early in the course of AF. More data are needed to guide the best management of recent-onset AF, bearing AF burden in mind. Long-term studies using large national databases linked to electronic medical records and rhythm monitoring devices offer excellent opportunities. Shorter-term studies focusing on reducing AF burden to slow AF progression and studies focusing on outcomes such as HF could be used in both randomized clinical trials and observational cohort studies.