Epistemic injustice in academic global health

Bibliometric Analysis of Authorship of Publications About Sub-Saharan Africa Published in the Journal Sexually Transmitted Diseases , 2011 to 2020

BACKGROUND

As a potential indicator of equity in research partnerships, we conducted a bibliometric analysis of author affiliations and author order in publications about sub-Saharan Africa published in the journal Sexually Transmitted Diseases .

METHODS

We identified articles in the journal Sexually Transmitted Diseases that were about sub-Saharan Africa and published from 2011 to 2020. Medical Subject Heading terms in PubMed were used to identity articles about sub-Saharan Africa. Authors with at least 1 affiliation in sub-Saharan Africa were characterized as sub-Saharan Africa-affiliated authors.

RESULTS

Of the 1439 articles that were published in Sexually Transmitted Diseases from 2011 to 2020, 148 (10%) had a Medical Subject Heading term for a sub-Saharan African country. Of the 604 authors of these 148 articles, 53 (36%) of the first authors, 493 (53%) of the middle authors, and 58 (40%) of the last authors had a sub-Saharan African affiliation; 13 (8.8%) of the articles had no authors with a sub-Saharan African affiliation. The proportions of sub-Saharan African-affiliated authors in first and last authorship positions did not change significantly from 2011-2015 (77 articles) to 2016-2020 (71 articles).

CONCLUSIONS

The underrepresentation of Africans in first and last authorship positions suggests power imbalances in global scientific partnerships. Funders, researchers, editors, publishers, and grant and manuscript reviewers each have roles in promoting equity in global health research. This study may serve as an example for journals to establish benchmarks and monitor progress toward a more equitable research environment.

Hidden in plain sight: A systematic review of coercion and Long-Acting Reversible Contraceptive methods (LARC)

In recent years there has been extensive promotion of long-acting reversible contraceptives (LARC) globally to increase access to what is widely considered a highly effective contraceptive method. Yet, despite these efforts, evidence points towards the worrying propensity for LARCS to be associated with coercion. Hence, we undertook a meta-narrative review across nine databases to draw together the heterogeneous and complex evidence on the coercive practices associated with LARC programs. A total of 92 papers were grouped into three metanarratives: (1) law, (2) public health and medicine, and (3) the social sciences. Across disciplines, the evidence supports the conclusion that coercive practices surrounding LARC programs always target marginalized, disadvantaged and excluded population(s). Looking at coercion across disciplines reveals its many forms, and we present a continuum of coercive practices associated with LARC programming. We found that each discipline provides only a partial picture of coercion, and this fragmentation is a knowledge practice that prevents us from collecting accurate information on this subject and may contribute to the perpetuation of these suspect practices. We present this review to address longstanding silences around coercion and LARCs, and to encourage the development of clinical and programmatic guidance to actively safeguard against coercion and uphold reproductive rights and justice.

How and why snakebite became a global health priority: a policy analysis

BACKGROUND

Snakebite was added to the WHO neglected tropical disease (NTD) list in 2017, followed by a World Health Assembly resolution in 2018, and an explicit global target being set to reduce the burden in 2019. We aimed to understand how and why snakebite became a global health priority.

METHODS

We conducted a policy case study, using in-depth interviews, and documents (peer-reviewed and grey literature) as data sources. We drew on Shiffman et al's framework on global health network to guide the analysis.

RESULTS

We conducted 20 interviews and examined 91 documents. The prioritisation of snakebite occurred in four phases: pre-crescendo, crescendo, de-crescendo and re-crescendo. The core snakebite network consisted of academics, which expanded during the re-crescendo phase to include civil society organisations and state actors. The involvement of diverse stakeholders led to better understanding of WHO processes. The use of intersecting and layered issue framing, framing solutions around snake antivenoms, in a background of cross-cultural fascination and fear of snakes enabled prioritisation in the re-crescendo phase. Ebbs and flows in legitimacy of the network and reluctant acceptance of snakebite within the NTD community are challenges.

CONCLUSION

Our analyses imply a fragile placement of snakebite in the global agenda. We identify two challenges, which needs to be overcome. The study highlights the need to review the WHO criteria for classifying diseases as NTD. We propose that future prioritisation analysis should consider identifying temporal patterns, as well as integrating legitimacy dimensions, as in our study.

Seeking maternal health care in rural Nigeria: through the lens of negofeminism

BACKGROUND

Feminist scholarship is acutely aware that health is not dependent on behavioural choices alone but on interlocking social determinants that affect people's capacity to lead healthy lives. Women are situated within social structures that impact their health. but there is limited engagement with interpretive tools such as feminist theories that centre the realities of African women, particularly in the context of maternal health. It is imperative that women's control over their reproductive health and autonomy in seeking care, particularly skilled maternal healthcare are understood within this context. This study seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. Feminist scholarship acknowledges that women are situated within social structures that impact their health. Therefore, this paper seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism.

METHOD

This is a cross-sectional qualitative study of a total of 64 participants: 39 women and 25 men in Ewato and Okpekpe communities, two Local Government Areas of Edo State in southern Nigeria. The study presents findings from eight sex-and-age desegregated focus group discussions. This study reports on emergent data related to women's decision-making in accessing skilled maternal care. Data were transcribed and translated to English. Using the NVivo 1.6 software, data were coded and analyzed using a conventional approach to content analysis.

RESULTS

Findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism's concepts of alliance, community and connectedness were highlighted through men's constructive involvement in maternal health. Furthermore, women were shown to maneuver patriarchal norms to gain control of their healthcare decisions.

CONCLUSION

This study offers a different narrative from the dominant view of non-Western women, specifically African women, as oppressed passive victims who are ineffectual in taking charge of their health. From the perspective of negofeminism, women navigate patriarchal environments to yield the best possible maternal health outcomes. The current study can be useful in informing policy and programming that acknowledges women's social embeddedness.

Global health and the elite capture of decolonization: On reformism and the possibilities of alternate paths

Global Health is experiencing a moment of reckoning over the field's legacy and current structuring in a world facing multiple, intersecting challenges to health. While "decolonization" has emerged as the dominant frame to imagine change in the field, what the concept refers to and entails has become increasingly unclear. Despite warnings, the concept is now being used by elite Global North institutions and organization to imagine their reformation. In this article, I attempt to provide clarity to the issue of conceptualizing change in Global Health. By first outlining a brief history of decolonial thought and then exploring the current state of the decolonizing global health literature, I show a profound disjuncture between popularized calls for decolonization in Global Health and other theorizations of the term. I then argue that the diluting of "decolonization" into a depoliticized vision of reforming the inherently colonial and capitalistic institutions and organizations of Global Health is an example of "elite capture"-the coopting and reconfiguration of radical, liberatory theories and concepts then used by elites for their own gain. Showing how this elite capture has facilitated harm within the field and beyond, I conclude by calling for resistance to elite capture in all its forms.

COVID-19 and unintended steps towards further equity in global health research

There was, and possibly still is, potential for COVID-19 to disrupt power inequities and contribute to positive transformation in global health research that increases equity. While there is consensus about the need to decolonise by transforming global health, and a roadmap outlining how we could approach it, there are few examples of steps that could be taken to transform the mechanics of global health research. This paper contributes lessons learnt from experiences and reflections of our diverse multinational team of researchers involved in a multicountry research project. We demonstrate the positive impact on our research project of making further steps towards improving equity within our research practices. Some of the approaches adopted include redistributing power to researchers from the countries of interest at various stages in their career, by involving the whole team in decisions about the research; meaningfully involving the whole team in research data analysis; and providing opportunities for all researchers from the countries of interest to voice their perspectives as first authors in publications. Although this approach is consistent with how research guidance suggests research should be run, in reality it does not often happen in this way. The authors of this paper hope that by sharing our experience, we can contribute towards discussions about the processes required to continue developing a global health sector that is equitable and inclusive.

The Dynamics of Power Flow From the Global Health Financing Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process"

This article agrees with Lassa et al that biomedical paradigms and medical professionals are a dominating force within the policy dynamics of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and that there needs to be greater community involvement in how global health initiatives (GHIs) are adopted, designed, implemented and evaluated. However, we argue that many of the conditions identified are entrenched and perpetuated by how GHIs are financed and the financing modalities employed in Development Aid for Health (DAH), particularly in low resource settings. As a result, the dynamics of power not only flow from traditionally entrenched epistemic authorities but are disproportionally sustained by global health financing modalities that favour particular GHIs over others. As we argue, these DAH modalities can exert forms of power with problematic effects on policy-making.

Exploring HIV/AIDS investigator perceptions of equity within research partnerships between low-and middle-income and high-income countries: a pilot survey

BACKGROUND

Recommendations for research partnerships between low- and middle-income countries (LMICs) and high-income countries (HICs) stress the importance of equity within the collaboration. However, there is limited knowledge of the practical challenges and successes involved in establishing equitable research practices. This study describes the results of a pilot survey assessing key issues on LMIC/HIC partnership equity within HIV/AIDS research collaborations and compares perspectives of these issues between LMIC- and HIC-based investigators.

METHODS

Survey participants were selected using clustered, random sampling and snowball sampling. Responses were compared between LMIC and HIC respondents using standard descriptive statistics. Qualitative respondent feedback was analyzed using a combination of exploratory and confirmatory thematic analysis.

RESULTS

The majority of categories within four themes (research interests and resources; leadership, trust, and communication; cultural and ethical competence; representation and benefits) demonstrated relative consensus between LMIC and HIC respondents except for 'lack of trust within the partnership' which was rated as a more pronounced challenge by LMIC respondents. However, subcategories within some of the themes had significant differences between respondent groups including: equitable setting of the research agenda, compromise within a partnership, the role of regulatory bodies in monitoring partnerships for equity, and post-study access to research technology.

CONCLUSIONS

These efforts serve as a proof-of-concept survey characterizing contemporary issues around international research partnership equity. The frequency and severity of specific equity issues can be assessed, highlighting similarities versus differences in experiences between LMIC and HIC partners as potential targets for further discussion and evaluation.

Where is knowledge from the global South? An account of epistemic justice for a global bioethics

The silencing of the epistemologies, theories, principles, values, concepts and experiences of the global South constitutes a particularly egregious epistemic injustice in bioethics. Our shared responsibility to rectify that injustice should be at the top of the ethics agenda. That it is not, or only is in part, is deeply problematic and endangers the credibility of the entire field. As a first step towards reorienting the field, this paper offers a comprehensive account of epistemic justice for global health ethics. We first introduce several different conceptions of justice and decolonisation in relation to knowledge, purposefully drawing on work emanating from the global South as well as the global North. We then apply those conceptions to the global health ethics context to generate a tripartite account of the layers of epistemic justice in the field: who is producing ethics knowledge; what theories and concepts are being applied to produce ethics knowledge; and whose voices are sought, recorded and used to generate ethics knowledge. These layers reflect that the field spans conceptual and empirical research. We conclude by proposing that, going forward, three avenues are key to achieve greater epistemic justice at each layer and to help decolonise global health ethics: namely, understanding the problem, dialogue and structural change.

Conceptualizing Indigenous strengths-based health and wellness research using group concept mapping

BACKGROUND

In recent years public health research has shifted to more strengths or asset-based approaches to health research but there is little understanding of what this concept means to Indigenous researchers. Therefore our purpose was to define an Indigenous strengths-based approach to health and well-being research.

METHODS

Using Group Concept Mapping, Indigenous health researchers (N = 27) participated in three-phases. Phase 1: Participants provided 218 unique responses to the focus prompt "Indigenous Strengths-Based Health and Wellness Research…" Redundancies and irrelevant statements were removed using content analysis, resulting in a final set of 94 statements. Phase 2: Participants sorted statements into groupings and named these groupings. Participants rated each statement based on importance using a 4-point scale. Hierarchical cluster analysis was used to create clusters based on how statements were grouped by participants. Phase 3: Two virtual meetings were held to share and invite researchers to collaboratively interpret results.

RESULTS

A six-cluster map representing the meaning of Indigenous strengths-based health and wellness research was created. Results of mean rating analysis showed all six clusters were rated on average as moderately important.

CONCLUSIONS

The definition of Indigenous strengths-based health research, created through collaboration with leading AI/AN health researchers, centers Indigenous knowledges and cultures while shifting the research narrative from one of illness to one of flourishing and relationality. This framework offers actionable steps to researchers, public health practitioners, funders, and institutions to promote relational, strengths-based research that has the potential to promote Indigenous health and wellness at individual, family, community, and population levels.

State of the Art of Participatory and User-led Research in Mental Health in Brazil: A Scoping Review

Background

Participatory research denotes the engagement and meaningful involvement of the community of interest across multiple stages of investigation, from design to data collection, analysis, and publication. Traditionally, people with first-hand experience of psychiatric diagnoses, services users and those living with a psychosocial disability have been seen objects rather than agents of research and knowledge production. This, despite the ethical and practical benefits of their involvement. The state of the art of knowledge about participatory research in mental health Brazil is poorly understood outside of its local context. The purpose of this article was to conduct a scoping review of participatory and user-led research in mental health in Brazil.

Findings

We identified 20 articles that met eligibility criteria. Participation in research was not treated as separate from participation in shaping mental health policy, driving care, or the broader right to fully participate in societal life and enjoy social and civil rights. Studies identified several obstacles to full participation, including the biomedical model, primacy of academic and scientific knowledge, and systemic barriers. Our extraction, charting, and synthesis yielded four themes: power, knowledge, autonomy, and empowerment.

Implications of the work

Participation in this context must address the intersecting vulnerabilities experienced by those who are both Brazilian and labeled as having a mental illness. Participatory research and Global South leadership must foreground local epistemologies that can contribute to the global debate about participation and mental health research.

Educational approaches to teach students to address colonialism in global health: a scoping review

INTRODUCTION

The enduring legacy of colonisation on global health education, research and practice is receiving increased attention and has led to calls for the 'decolonisation of global health'. There is little evidence on effective educational approaches to teach students to critically examine and dismantle structures that perpetuate colonial legacies and neocolonialist control that influence in global health.

METHODS

We conducted a scoping review of the published literature to provide a synthesis of guidelines for, and evaluations of educational approaches focused on anticolonial education in global health. We searched five databases using terms generated to capture three concepts, 'global health', 'education' and 'colonialism'. Pairs of study team members conducted each step of the review, following Preferred Reporting Items for Systematic reviews and Meta-Analyse guidelines; any conflicts were resolved by a third reviewer.

RESULTS

This search retrieved 1153 unique references; 28 articles were included in the final analysis. The articles centred North American students; their training, their evaluations of educational experiences, their individual awareness and their experiential learning. Few references discussed pedagogical approaches or education theory in guidelines and descriptions of educational approaches. There was limited emphasis on alternative ways of knowing, prioritisation of partners' experiences, and affecting systemic change.

CONCLUSION

Explicit incorporation of anticolonial curricula in global health education, informed by antioppressive pedagogy and meaningful collaboration with Indigenous and low-income and middle-income country partners, is needed in both classroom and global health learning experiences.

Principles for increasing equity in WASH research: understanding barriers faced by LMIC WASH researchers

INTRODUCTION

There have long been critiques of colonial legacies influencing global health. With growing public awareness of unjust systems in recent years, a new wave of calls for antiracist and decolonisation initiatives has emerged within the sector. This study examined research inequities in the water, sanitation and hygiene (WASH) sector, centring the perspectives of researchers from low-income and middle-income countries (LMICs), to identify barriers faced by WASH researchers in order to support more equitable changes in this subsector of global health.

METHODS

Nineteen semistructured interviews were conducted with researchers of different backgrounds regarding nationality, gender and research experience. Researchers from eight countries were asked about their experiences and direct observations of discrimination across various stages of the research process. Five interviews were conducted with key WASH research funders to assess perceptions of obstacles faced by LMIC researchers, successes achieved and challenges faced by these organisations when working towards more equitable research processes within the WASH sector.

RESULTS

The results were analysed using an emergent framework that categorised experiences based on power differentials and abuse of power; structural barriers due to organisational policies; institutional and individual indifference; othering speech, action and practices; and context-specific discrimination. The social-ecological model was combined with this framework to identify the types of actors and the level of co-ordination needed to address these issues. Researchers who worked in both LMICs and high-income countries at different career stages were particularly aware of discrimination. Ensuring pro-equity authorship and funding practices were identified as two significant actions to catalyse change within the sector.

CONCLUSION

Sector-wide efforts must centre LMIC voices when identifying research questions, conducting research, and in dissemination. Individuals, organisations and the entire WASH sector must examine how they participate in upholding inequitable systems of power to begin to dismantle the system through the intentional yielding of power and resources.

"And when will you install the new water pump?": disconcerted reflections on how to be a 'good' Global Health scholar

BACKGROUND

While critique on Global Health is not new, recent years show a surge of criticism on the field's colonial legacy and practices specifically. Such accounts argue that despite Global Health's strive for universality and equity in health, its activities regularly produce the opposite. The epistemic privileging of Northern academics and scientific method, further augmented by how Global Health funding is arranged, paints a picture of a fragmented field in which 'doing good' has become a normatively laden and controversial term. It is specifically this controversy that we seek to unpack in this paper: what does it take to be a 'good' Global Health scholar?

RESULTS

We used Helen Verran's notion of 'disconcertment' to analyse three auto-ethnographic vignettes of Robert's Global Health 'fieldwork'. We illustrate that disconcertment, a bodily and personalised experience of unease and conflicting feelings, may serve as an important diagnostic of conflicting imperatives in Global Health. Robert's fieldwork was entangled with incongruous imperatives which he constantly had to navigate through and that repeatedly produced disconcertment. The contribution that we seek to make here is that such disconcertment is not something to defuse or ignore, but to take seriously and stay with instead.

CONCLUSION

Staying with the disconcertment serves as a starting point for conversations about 'doing good' in Global Health fieldwork and creates opportunity for making Global Health teaching and projects more reflexive. The paper thereby positions itself in discussions about fair collaborations between the Global North and South and our analysis offers a set of considerations that can be used by Northern scholars to critically reflect on their own role within Global Health.

Towards achieving transnational research partnership equity: lessons from implementing adaptive platform trials in low- and middle-income countries

Background: Use of adaptive clinical trials, particularly adaptive platform trials, has grown exponentially in response to the coronavirus disease (COVID-19) pandemic. Implementation of these trials in low- and middle-income countries (LMICs) has been fostered through the formation or modification of transnational research partnerships, typically between research groups from LMICs and high-income countries (HICs). While these partnerships are important to promote collaboration and overcome the structural and economic disadvantages faced by LMIC health researchers, it is critical to focus attention on the multiple dimensions of partnership equity. Methods: Based on informal literature reviews and meetings with leaders of one of the multinational COVID-19 adaptive platform trials, we describe what can be learned about research partnership equity from these experiences. Results: We organize these considerations into eight thematic categories: 1) epistemic structures, 2) funding, 3) ethics oversight, 4) regulatory oversight, 5) leadership, 6) post-trial access to interventions, data, and specimens, 7) knowledge translation, and 8) research capacity strengthening and maintenance. Within each category we review the normative claims that support its relevance to research partnership equity followed by discussion of how adaptive platform trials highlight new dimensions, considerations, or challenges. Conclusion: These observations provide insight into procedural and substantive equity-building measures within transnational global health research partnerships more broadly.

What constitutes equitable data sharing in global health research? A scoping review of the literature on low-income and middle-income country stakeholders' perspectives

INTRODUCTION

Despite growing consensus on the need for equitable data sharing, there has been very limited discussion about what this should entail in practice. As a matter of procedural fairness and epistemic justice, the perspectives of low-income and middle-income country (LMIC) stakeholders must inform concepts of equitable health research data sharing. This paper investigates published perspectives in relation to how equitable data sharing in global health research should be understood.

METHODS

We undertook a scoping review (2015 onwards) of the literature on LMIC stakeholders' experiences and perspectives of data sharing in global health research and thematically analysed the 26 articles included in the review.

RESULTS

We report LMIC stakeholders' published views on how current data sharing mandates may exacerbate inequities, what structural changes are required in order to create an environment conducive to equitable data sharing and what should comprise equitable data sharing in global health research.

CONCLUSIONS

In light of our findings, we conclude that data sharing under existing mandates to share data (with minimal restrictions) risks perpetuating a neocolonial dynamic. To achieve equitable data sharing, adopting best practices in data sharing is necessary but insufficient. Structural inequalities in global health research must also be addressed. It is thus imperative that the structural changes needed to ensure equitable data sharing are incorporated into the broader dialogue on global health research.

The importance of SDG 17 and equitable partnerships in maximising participation of persons with communication disabilities and their families

BACKGROUND

Equitable partnerships across borders, sectors and communities are integral in creating shared understanding, novel solutions and sustainable development. Sustainable development goal (SDG) 17: Partnerships for goals, focuses on strengthening global partnerships. This highlights the importance of partnership as a tool to support the achievement of all SDGs. Partnerships are particularly vital to creating sustainable and appropriate services to support people who experience communication or swallowing disability and their families, in under-served communities, where services and expert personnel may be limited and where innovative strategies are required for working with families and communities to improve service accessibility.

PURPOSE

To reflect on key principles underpinning the creation of a speech-language pathologists' (SLPs') community of practice, designed to support SLPs from high-, low- and middle-income countries to develop equitable partnerships, aimed at supporting people who experience communication or swallowing disability their families.

RESULT

We draw on the authors' experiences of building partnerships to enhance participation for people who experience communication or swallowing disability. We discuss the need for global partnerships and challenges with current funding mechanisms.

CONCLUSION

We use the principles of the speech-language pathology community of practice and concepts from the Partnership Accelerator 2030 Agenda to frame reflections and recommendations. This commentary paper focuses on partnerships for the goals (SDG 17).

Adoption and scale-up of the cardiovascular Polypill: a realist institutional analysis

Efforts to promote the adoption and scale-up of health system innovations must contend with the existing institutional context. But there are no commonly used frameworks to ensure that the insights of actors involved in such institutional efforts connect to one another. To test and modify a potential framework-the 'four-by-four' framework-we interviewed researcher-entrepreneurs involved in the unfolding story of the cardiovascular Polypill. The framework has four types/levels of institutions that affect adoption and scale-up: (1) informal institutions (L1, e.g. social norms), (2) formal institutions (L2, e.g. government policies and regulation), (3) organizational structures (L3, e.g. organizational boards and mission) and (4) everyday exchange (L4, e.g. service delivery), vis-à-vis four potential entrepreneurial strategies in response: (1) abide by existing institutions, (2) evade them, (3) alter them and/or (4) exit entrepreneurial action. Using this framework, we conducted a realist-informed analysis to understand how context (i.e. institutions) and mechanism (i.e. entrepreneurial strategies) influence each other to shape outcomes (i.e. adoption and scale-up). We found that researcher-entrepreneurs began with efforts to abide with existing institutions but encountered institutional obstacles at each level. Efforts to abide were followed by seeking to evade and/or alter unfavourable institutions, with greater success evading and/or altering lower (L3 and L4) than upper (L1 and L2) institutions. Exit considerations followed the failure of the evade or alter strategy. Shifts between strategies were propelled by 'learning'. The 'four-by-four' framework can be used as a scaffold to generate narratives of adoption or scale-up efforts, a sensitizing tool to prospectively map out contingencies and a matrix to synthesize narratives and experiences across multiple innovations or settings. Used in these ways, the 'four-by-four' framework can help to optimize the transferability and cumulation of insights on how to promote the adoption and scale-up of health system innovations.

Mind the gap: Data availability, accessibility, transparency, and credibility during the COVID-19 pandemic, an international comparative appraisal

Data transparency has played a key role in this pandemic. The aim of this paper is to map COVID-19 data availability and accessibility, and to rate their transparency and credibility in selected countries, by the source of information. This is used to identify knowledge gaps, and to analyse policy implications. The availability of a number of COVID-19 metrics (incidence, mortality, number of people tested, test positive rate, number of patients hospitalised, number of patients discharged, the proportion of population who received at least one vaccine, the proportion of population fully vaccinated) was ascertained from selected countries for the full population, and for few of stratification variables (age, sex, ethnicity, socio-economic status) and subgroups (residents in nursing homes, inmates, students, healthcare and social workers, and residents in refugee camps). Nine countries were included: Bangladesh, Indonesia, Iran, Nigeria, Turkey, Panama, Greece, the UK, and the Netherlands. All countries reported periodically most of COVID-19 metrics on the total population. Data were more frequently broken down by age, sex, and region than by ethnic group or socio-economic status. Data on COVID-19 is partially available for special groups. This exercise highlighted the importance of a transparent and detailed reporting of COVID-19 related variables. The more data is publicly available the more transparency, accountability, and democratisation of the research process is enabled, allowing a sound evidence-based analysis of the consequences of health policies.

Physician-Suggested Innovative Methods for Health System Resilience amidst Workforce Emigration and Sociopolitical Unrest in Nigeria: A Survey-Based Study

Introduction

Physician emigration (the brain drain) and sociopolitical unrest significantly contribute to the instability of many low- and middle-income countries' healthcare systems. However, limited literature captures the locally driven and context specific suggestions to promote and sustain these health systems' resilience. Thus, the purpose of this study is to 1) understand the effects of physician emigration and sociopolitical unrest on Nigeria's healthcare system, and to 2) synthesize solutions suggested by Nigeria-trained physicians in the form of a resilience framework.

Methods

An anonymous online survey was conducted among Nigeria-trained physicians. Respondents were recruited using convenience and snowball sampling methods via a WhatsApp group for Nigeria-trained doctors. Quantitative data were analyzed using Stata 17 and qualitative themes were coded by two independent researchers.

Results

The final sample included 49 Nigeria-trained physicians-35 physicians practicing in Nigeria and 14 emigrated physicians. All of the physicians currently practicing in Nigeria have considered emigrating, with 79% of them having concrete plans to emigrate in the next five years. Among emigrated physicians, factors such as remuneration (92%) and socioeconomic state of the country (92%) contributed to their decision to emigrate. Suggestions to enhance health system resilience fell into six broad themes: 1) policy and politics, 2) funding and resources, 3) organization and structure, 4) training and education, 5) research and primary health, and 6) health for peace initiatives.

Conclusions

The healthcare system is currently unstable and vulnerable due to physician emigration and sociopolitical unrest. To develop and implement solutions to mitigate these issues, capturing the locally trained physicians' perspectives are critical. While each country's healthcare system is unique, countries with similar strains can adapt this model for resilience building. Future studies should focus on adapting the model in different countries with policy-level action points.

Striving towards true equity in global health: A checklist for bilateral research partnerships

Interest in "global health" among schools of medicine, public health, and other health disciplines in high-income countries (HIC) continues to rise. Persistent power imbalances, racism, and maintenance of colonialism/neocolonialism plague global health efforts, including global health scholarship. Scholarly projects conducted in low- and middle-income countries (LMIC) by trainees at these schools in HIC often exacerbate these problems. Drawing on published literature and shared experiences, we review key inequalities within each phase of research, from design through implementation and analysis/dissemination, and make concrete and practical recommendations to improve equity at each stage. Key problems facing global health scholarship include HIC-centric nature of global health organizations, paucity of funding directly available for LMIC investigators and trainees, misplaced emphasis on HIC selected issues rather than local solutions to local problems, the dominance of English language in the scientific literature, and exploitation of LMIC team members. Four key principles lie at the foundation of all our recommendations: 1) seek locally derived and relevant solutions to global health issues, 2) create paired collaborations between HIC and LMIC institutions at all levels of training, 3) provide funding for both HIC and LMIC team members, 4) assign clear roles and responsibilities to value, leverage, and share the strengths of all team members. When funding for global health research is predicated upon more ethical and equitable collaborations, the nature of global health collaborations will evolve to be more ethical and equitable. Therefore, we propose the Douala Equity Checklist as a 20-item tool HIC and LMIC institutions can use throughout the conduct of global health projects to ensure more equitable collaborations.

Toward global citizenship? People (de)bordering their lives during COVID-19 in Latin America and Europe

The COVID-19 pandemic highlighted global interdependencies, accompanied by widespread calls for worldwide cooperation against a virus that knows no borders, but responses were led largely separately by national governments. In this tension between aspiration and reality, people began to grapple with how their own lives were affected by the global nature of the pandemic. In this article, based on 493 qualitative interviews conducted between 2020 and 2021, we explore how people in Argentina, Austria, Bolivia, Ecuador, Ireland, Italy and Mexico experienced, coped with and navigated the global nature of the pandemic. In dialogue with debates about the parameters of the 'global' in global health, we focus on what we call people's everyday (de)bordering practices to examine how they negotiated (dis)connections between 'us' and 'them' during the pandemic. Our interviewees' reactions moved from national containment to an increasing focus on people's unequal socio-spatial situatedness. Eventually, they began to (de)border their lives beyond national lines of division and to describe a new normal: a growing awareness of global connectedness and a desire for global citizenship. This newfound sense of global interrelatedness could signal support for and encourage transnational political action in times of crises.

Making Sense of the Complexity of Decentralised Governance Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis"

The article by Rotulo and colleagues suggests that health sector fiscal decentralisation has been bad for Italy. But given the complexity of fiscal decentralisation, this interpretation is not necessarily so. Their analysis was based on assumptions about causality that are better suited for simple interventions. Assumptions of simplicity show up as misleading artefacts in the conclusion of evaluations of complex interventions. Complex interventions work by triggering mechanisms - eg, reasoning and learning processes - that manifest differently across the units of a decentralised system, contingent on context, evolving over time. Evaluation findings can only be partial and provisional; neither summarily good nor bad. The goal of evaluating a complex intervention - such as decentralised governance - should be to understand how, under what circumstances and for whom they are good or bad - at a point in time.

With equity in mind: Evaluating an interactive hybrid global surgery course for cross-site interdisciplinary learners

There is limited understanding of the role of transcultural, cross-site educational partnerships for global surgery training between high- and low- or middle-income country (LMIC) institutions. We describe the development, delivery, and appraisal of a hybrid, synchronous, semester-long Global Surgical Care course by global health collaborators from widely different contexts, and evaluate the equity of the collaboration. The course was collaboratively modified by surgical educators and public health professionals with emphasis on collaboration ethics. Faculty from high-income and LMICs were paired to deliver lectures. To collaborate internationally, students and faculty participated either onsite or online. Perceptions and knowledge gained were quantitatively evaluated through participant and faculty cross-sectional surveys, using Likert scales, prioritization rankings, and free text responses analysed qualitatively. Equity was assessed using the Fair Trade Learning rubric and additional probes. Thirty-five learners from six institutions participated. Teams produced mock National, Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) for selected LMICs, and reported a 9% to 65% increase in self-reported global health competencies following the course. Online learners had favourable perceptions of learning, but experienced connectivity challenges. Barriers to effective group work included time differences and logistics of communication for dispersed team members. Individuals taking the course for academic credit scored significantly higher than other learners in peer assessments of participation (8.56±1.53 versus 5.03±3.14; p<0.001). Using the Fair Trade Rubric, 60% of equity indicators were ideal, and no respondents perceived neo-colonialism in the partnership. Blended, synchronous, interdisciplinary global surgery courses based on "North-South" partnerships with a focus on equity in design and delivery are feasible but require careful and deliberate planning to minimize epistemic injustice. Such programs should address surgical systems strengthening, and not create dependency. Equity in such engagements should be evaluated and monitored in an ongoing fashion to stimulate discussion and continuous improvement.

PreprintMatch: A tool for preprint to publication detection shows global inequities in scientific publication

Preprints, versions of scientific manuscripts that precede peer review, are growing in popularity. They offer an opportunity to democratize and accelerate research, as they have no publication costs or a lengthy peer review process. Preprints are often later published in peer-reviewed venues, but these publications and the original preprints are frequently not linked in any way. To this end, we developed a tool, PreprintMatch, to find matches between preprints and their corresponding published papers, if they exist. This tool outperforms existing techniques to match preprints and papers, both on matching performance and speed. PreprintMatch was applied to search for matches between preprints (from bioRxiv and medRxiv), and PubMed. The preliminary nature of preprints offers a unique perspective into scientific projects at a relatively early stage, and with better matching between preprint and paper, we explored questions related to research inequity. We found that preprints from low income countries are published as peer-reviewed papers at a lower rate than high income countries (39.6% and 61.1%, respectively), and our data is consistent with previous work that cite a lack of resources, lack of stability, and policy choices to explain this discrepancy. Preprints from low income countries were also found to be published quicker (178 vs 203 days) and with less title, abstract, and author similarity to the published version compared to high income countries. Low income countries add more authors from the preprint to the published version than high income countries (0.42 authors vs 0.32, respectively), a practice that is significantly more frequent in China compared to similar countries. Finally, we find that some publishers publish work with authors from lower income countries more frequently than others.

Dismantling and reimagining global health education

Global health emerged as a distinct public health discipline within the last two decades. With over 95% of Masters of Global Health degree programmes located in high-income countries (HICs), the area of study has been primarily pursued by White, middle and upperclass, citizens of Europe and North America. In turn, the global health workforce and leadership reflect these same demographics. In this article, we present several key arguments against the current state of global health education: (1) admissions criteria favour HIC applicants; (2) the curriculum is developed with the HIC gaze; (3) student practicums can cause unintended harms in low- and middle-income country communities. We argue that global health education in its current form must be dismantled. We conclude with suggestions for how global health education may be reimagined to shift from a space of privilege and colonial practice to a space that recognises the strengths of experiences and knowledge above and beyond those from HICs.

Health literacy development is central to the prevention and control of non-communicable diseases

The WHO's report Health literacy development for the prevention and control of non-communicable diseases (NCDs) delivers practical what-to-do how-to-do guidance for health literacy development to build, at scale, contextually-relevant public health actions to reduce inequity and the burden of NCDs on individuals, health systems and economies. The key premise for health literacy development is that people's health awareness and behaviours are linked to lifelong experiences and social practices, which may be multilayered, hidden and beyond their control. Meaningful community engagement, local ownership and locally driven actions are needed to identify health literacy strengths, challenges and preferences to build locally fit-for-purpose and implementable actions. Health literacy development needs to underpin local and national policy, laws and regulations to create enabling environments that reduce community exposures to NCD risk factors. Deficit approaches and siloed health system and policy responses need to be avoided, focusing instead on integrating community-based solutions through co-design, cognisant of people's daily experiences and social practices.

'Voice needs teeth to have bite'! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa

There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community 'voice' and initiating dialogue with the authorities, giving the voice 'teeth'. Achieving 'bite', however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative.

What influences cancer treatment service access in Ghana? A critical interpretive synthesis

OBJECTIVES

Multiple social-cultural and contextual factors influence access to and acceptance of cancer treatment in Ghana. The aim of this research was to assess existing literature on how these factors interplay and could be susceptible to local and national policy changes.

DESIGN

This study uses a critical interpretive synthesis approach to review qualitative and quantitative evidence about access to adult cancer treatment services in Ghana, applying the socioecological model and candidacy framework.

RESULTS

Our findings highlighted barriers to accessing cancer services within each level of the socioecological model (intrapersonal, interpersonal community, organisational and policy levels), which are dynamic and interacting, for example, community level factors influenced individual perceptions and how they managed financial barriers. Evidence was lacking in relation to determinants of treatment non-acceptance across all cancers and in the most vulnerable societal groups due to methodological limitations.

CONCLUSIONS

Future policy should prioritise multilevel approaches, for example, improving the quality and affordability of medical care while also providing collaboration with traditional and complementary care systems to refer patients. Research should seek to overcome methodological limitations to understand the determinants of accessing treatment in the most vulnerable populations.

The Electrophoretic Revolution in the 1960s: Historical Epistemology Meets the Global History of Science and Technology

This paper uses zone electrophoresis, one of the most frequently used tools in molecular biology, to explore two ideas derived from Hans-Jörg Rheinberger's reflections on experiments. First, the constraining role played by technical objects-instrumentation and material conditions-in the production of knowledge or epistemic things. Second, the production of interconnected experimental systems by such technical objects, which results in the unexpected entanglement of research fields and experimental cultures. By the beginning of the 1960s, the inception of zone electrophoresis in laboratories around the world transformed-some say, revolutionized-the study of proteins. Even today, electrophoresis continues to open research venues and questions in biomedicine, molecular biology, human genetics, and in the field of molecular evolution. In my essay, I seek to look at the interconnected lives of zone electrophoresis and address the broader social, and even global context, in which this apparently humble technique became a salient tool in the production of biological knowledge. In so doing, I aim to take the past and present of the history and historiography of experimental systems to the future, where experiments and technologies are interrogated as they are used in different geographies and contexts, including contexts of poverty.

Trends in country and gender representation on editorial boards in anaesthesia journals: a pooled cross-sectional analysis

Evidence exists that women and people from low- and middle-income countries are under-represented on the editorial boards of medical journals. This may adversely influence the journal output. We conducted a pooled, cross-sectional evaluation of the editorial board membership of anaesthesia journals. We collected data on members of editorial boards from the founding year and at 5-yearly intervals until 2020. For each editor, we recorded gender, country of affiliation, World Bank income classification (1990 onwards) and editorial role (2020 only). The composite editorial board diversity score was calculated for each editorial board. We obtained complete data for the composition of editorial boards from all 30 journals for 2020, but for only 171 out of 304 editorial boards (56%) over the time period examined. In 2020, 409 out of 1973 (21%) were women (range across the editorial boards 0-39%) and 139 out of 1982 (7%) were from low-, low-middle- and upper-middle-income countries (range across the editorial boards 0-71%). In 2020, of editorial board positions with known seniority status, 109 out of 259 (42%) of women and 306 out of 960 (32%) of men were in senior roles. In the same year, 397 out of 1115 (36%) of people from high-income countries were in senior roles, compared with 19 out of 93 (20%) of people from upper-middle-income countries and 0 out of 14 (0%) people from lower-middle-income countries. The median composite editorial board diversity score was 4 (range 2-6) in 2020 - 5 or less suggests poor diversity, while 8 or more suggests good diversity. Women and people from low- and middle-income countries are under-represented on anaesthesia journal editorial boards. The editorial boards do not reflect the anaesthesia workforce and may act as a barrier to the publication of research produced by these groups. Urgent action is required to improve diversity.

Health literacy measurement: embracing diversity in a strengths-based approach to promote health and equity, and avoid epistemic injustice

Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice.

Bibliometric analysis of sub-Saharan African and US authorship in publications about sub-Saharan Africa funded by the Fogarty International Center, 2008-2020

BACKGROUND

Authorship and author order have been used as one measure to characterise equity in research partnerships. First and last (senior) authorships often denote scientific merit as well as potential for research career advancement. A previous analysis found that only about 20%-25% of publications about Africa with coauthors from top-ranking US universities had a first or last author from the topic country. In this bibliometric analysis, we evaluated authorship of publications about sub-Saharan Africa (SSA) funded by the Fogarty International Center (FIC) of the US National Institutes of Health, an institution with a mission of training and capacity building in low-income and middle-income countries.

METHODS

We analysed publications from PubMed and Web of Science that were funded by FIC, about SSA, and published between 2008 and 2020. Relative citation ratio (RCR) data from iCite were used to compare group citation impact measures using the Wilcoxon rank sum test.

RESULTS

A total of 3446 publications met the inclusion criteria, with annual number increasing from 114 in 2008 to 352 in 2020. SSA-affiliated first authors increased from 53 (47%) in 2008 to 224 (63%) in 2020. SSA-affiliated last authors increased from 32 (28%) to 166 (47%). For both first and last authorships, the median RCR value of publications with SSA-affiliated authors was lower than for US-affiliated authors (first authors: 0.84 vs 0.95, p=0.0021; last authors: 0.88 vs 0.91, p=0.010).

CONCLUSION

The increase in first and last authorships by SSA-affiliated authors of publications about SSA suggests increasing equity in research activities funded by FIC. Further investigation and actions are needed to establish how authorship reflects other aspects of equity, the implication of the lower RCR in papers with SSA-affiliated first and last authors and what policies and practices are needed to further promote equity in global health research.

Development, Implementation, and Evaluation of a New Course on Essential Skills for Women's Leadership in Global Health

While many calls have been made to support the development of women leaders in global health, few resources have been developed and evaluated to meet this goal. We developed and evaluated a one week online short course on the essential skills for women’s leadership in global health, offered in June 2021 to 22 students from 4 countries (Australia, Ethiopia, Thailand, and the United States). The course covered the state of women’s leadership in global health and influencing factors; leadership theories models and frameworks; self-awareness and self-assessments; organizations and enabling environments; communication; and negotiation, and was designed to promote skills via practice, discussion, and debrief. Students rated the course highly and enjoyed the skills-building components, diversity of voices presented throughout the course, and embedded networking opportunities. Future iterations of the course, particularly those held in low-and middle-income countries, should contextualize materials, co-create with local instructors and amplify local voices, and consider incorporating shadowing, coaching, mentorship, and communities of practice.

Global mental health research and practice: a decolonial approach

The global health movement is having a paradigm crisis-a period characterised by a questioning of one's values, goals, and sense of identity. Despite important advances in population health worldwide, global health and global mental health often produce and reproduce power imbalances and patterns of oppression and exploitation that perpetuate the current modern world system (ie, Eurocentric, capitalist, and patriarchal) and its entangled global hierarchies (eg, gender, economic, epistemic, and linguistic). A consensus is emerging to decolonise global mental health, but it is not clear how to move from rhetoric to action. In this Personal View, we aim to share our experiences and the practices developed in the context of the COVID-19 health care workers (HEROES) Study. To do so, we present our HEROES decolonial team approach, which comprises three underlying principles: epistemic justice, pragmatic solidarity, and sovereign acts. We have developed decolonial team practices such as co-creating communication spaces to foster horizontal and equitable dialogue, locating and managing the study database in Chile, and ensuring local teams' rights and access to the data without barriers.

Exploring the translation process for multilingual implementation research studies: a collaborative autoethnography

Introduction

In an increasingly globalised and interconnected world, evidence to evaluate complex interventions may be generated in multiple languages. However, despite its influence in shaping the evidence base, there is little literature explicitly connecting the translation process to the goals and processes of implementation research. This study aims to explore the processes and experience of an international implementation research team conducting a process evaluation of a complex intervention in Tibet Autonomous Region, China.

Methods

This study uses a collaborative autoethnographic approach to explore the translation process from Chinese or Tibetan to English of key stakeholder interview transcripts. In this approach, multiple researchers and translators contributed their reflections, and conducted joint analysis through dialogue, reflection and with consideration of multiple perspectives. Seven researchers involved with the translation process contributed their perspectives through in-depth interviews or written reflections and jointly analysed the resulting data.

Results

We describe the translation process, synthesise key challenges including developing a ‘voice’ and tone as a translator, conveying the depth of idioms across languages, and distance from the study context. We further offer lessons learnt including the importance of word banks with unified translations of words and phrases created iteratively during the translation process, the need to collaborate between translators and the introspective work necessary for translators to explore their positionality and reflexivity during the work. We then offer a summary of these learnings for other implementation research teams.

Conclusion

Our findings emphasise that in order to ensure rigour in their work, implementation research teams using qualitative data should make concerted effort to consider both the translation process as well as its outcomes. Given the numerous multinational or multilingual implementation research studies using qualitative methods, there is a need for further consideration and reflection on the translation process.

Questioning the ethics of evidence-based practice for Indigenous health and social settings in Australia

Australian government planning promotes evidence-based action as the overarching goal to achieving health equality for Aboriginal and Torres Strait Islander populations. However, an inequitable distribution of power and resources in the conduct of evidence-based practice produces a policy environment counterintuitive to this goal. This context of contemporary evidence-based practice gives legitimacy to ‘expert practitioners’ located in Australian governments and universities to use Western guidelines and tools, embedded in Western methodology, to make ‘evidence’ informed policy and programming decisions about Aboriginal and Torres Strait Islander populations. This method for decision making assumes a positional superiority that can marginalise the important perspectives, experiences and knowledge of Aboriginal Community Controlled Organisations and their processes for decision making. Here we consider the four steps of an evidence review: (1) developing a review question; (2) acquiring studies; (3) appraising the evidence and (4) assessing the evidence, as components of wider evidence-based practice. We discuss some of the limitations across each step that arise from the broader context within which the evidence review is produced. We propose that an ethical and just approach to evidence-based review can be achieved through a well-resourced Aboriginal community controlled sector, where Aboriginal organisations generate their own evidence and evidence is reviewed using methods and tools that privilege Aboriginal and Torres Strait Islander ways of knowing, doing and being.

When the messenger is more important than the message: an experimental study of evidence use in francophone Africa

Background

Epistemic injustices are increasingly decried in global health. This study aims to investigate whether the source of knowledge influences the perception of that knowledge and the willingness to use it in francophone African health policy-making context.

Methods

The study followed a randomized experimental design in which participants were randomly assigned to one of seven policy briefs that were designed with the same scientific content but with different organizations presented as authors. Each organization was representative of financial, scientific or moral authority. For each type of authority, two organizations were proposed: one North American or European, and the other African.

Results

The initial models showed that there was no significant association between the type of authority or the location of the authoring organization and the two outcomes (perceived quality and reported instrumental use). Stratified analyses highlighted that policy briefs signed by the African donor organization (financial authority) were perceived to be of higher quality than policy briefs signed by the North American/European donor organization. For both perceived quality and reported instrumental use, these analyses found that policy briefs signed by the African university (scientific authority) were associated with lower scores than policy briefs signed by the North American/European university.

Conclusions

The results confirm the significant influence of sources on perceived global health knowledge and the intersectionality of sources of influence. This analysis allows us to learn more about organizations in global health leadership, and to reflect on the implications for knowledge translation practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00854-x.

Global health wars: a rhetorical review of global health critique

The critique of global health is a longstanding tradition in the global health humanities (GHH). Typically, this critique takes an expected tack: critics take a slice of global health, identify its rhetoric, expose its power, and elucidate its unanticipated consequences. Here, I subject global health critique to its own approach-conducting a 'rhetorical review' of global health critique in order to ascertain whether it has rhetoric, power and unanticipated consequences of its own. Following this review, I find that global health critique has a rhetoric, and that this rhetoric can be organised into three types: (1) 'global health as mere rhetoric', (2) 'splitting global health', and (3) 'figuring global health war.' Ultimately, I argue that the rhetoric of GHH critique, like the rhetoric of global health, is a rhetoric of consequence-and a rhetoric worth revisiting.