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Competing Interests: Declaration of competing interest None.

Background: Although healthcare personnel (HCP) are targeted for influenza vaccination they typically underutilize vaccines especially in low- and middle-income countries. We explored knowledge, attitudes, and practices of HCP about seasonal influenza vaccines (SIV) to identify factors associated with and modifiable barriers to SIV uptake., Methods: We pooled individual-level data from cross-sectional surveys about SIV conducted among health workers in 12 low- and middle- income countries during 2018-2020 (i.e., Albania, Armenia, Cote d'Ivoire, Kenya, Kyrgyzstan, Lao PDR, Lebanon, Morocco, North Macedonia, Tunisia, Tajikistan, and Uganda). Eleven countries used a standard protocol and questionnaire based on the Health Belief Model to measure perceptions of susceptibility and severity of influenza disease, benefits of, barriers to, and motivators for vaccination. We analyzed attitudes and perceptions among HCP, including acceptance of vaccine for themselves and willingness to recommend vaccines to patients, grouped by the presence/absence of a national influenza vaccination program. Models were adjusted for geographic region., Results: Our analysis included 10,281 HCP from 12 countries representing four of the six World Health Organization regions: African, Eastern Mediterranean, European, and Western Pacific. The sample was distributed across low income (LIC) (3,183, 31 %), lower-middle (LMIC) (4,744, 46 %), and upper-middle income (UMIC) (2,354, 23 %) countries. Half (50 %) of the countries included in the analysis reported SIV use among HCP in both the year of and the year preceding data collection while the remainder had no influenza vaccination program for HCP. Seventy-four percent (6,341) of HCP reported that they would be willing to be vaccinated if the vaccine was provided free of charge. HCP in LICs were willing to pay prices for SIV representing a higher percentage of their country's annual health expenditure per capita (6.26 % [interquartile range, IQR: 3.13-12.52]) compared to HCP in LMICs and UMICs. HCP in countries with no SIV program were also willing to pay a higher percentage for SIV (5.01 % [IQR: 2.24-8.34]) compared to HCP in countries with SIV programs.. Most (85 %) HCP in our analysis would recommend vaccines to their patients, and those who would accept vaccines for themselves were 3 times more likely to recommend vaccines to their patients (OR 3.1 [95 % CI 1·8, 5·2])., Conclusion: Increasing uptake of SIV among HCP can amplify positive impacts of vaccination by increasing the likelihood that HCP recommend vaccines to their patients. Successful strategies to achieve increased uptake of vaccines include clear guidance from health authorities, interventions based on behavior change models, and access to vaccine free-of-charge., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: This research investigates the fundamental factors which may stymie or simplify the adoption of m-learning by medical college educators in Sudan. We made use of the Extended Unified Theory of Acceptance and Use Technology (UTAUT) with COVID-19 fear (CF) and social isolation (SIS) as exogenous components., Objective: This research aims to find out factors impacting medical students' behavioural intention to use mobile learning., Methods: Data was gathered from 499 undergraduate learners from different universities in Sudan. Partial Least Square (PLS) and structural equation modeling (SEM) were used to examine the data., The Results: Showed that expected performance, effort expectancy (EE), social influence (SI), facilitation condition (FC), COVID-19 fear, and social isolation (SIS) are predictors of behavioural intentions (BI). In addition, our findings show that COVID-19 fear and social isolation increase student adoption of mobile learning during the COVID-19 epidemics in developing countries., Conclusions: The study unveiled that the suggested framework, derived from UTAUT, effectively discerns the factors impacting students' intentions in mobile learning during pandemics. Sudanese medical students' can strategize and execute effective classroom environments based on these findings., (© 2024. The Author(s).)

The World Health Organization (WHO) has published new hemoglobin cutoff points for defining anemia and its measurement. This change could impact the prevalence of anemia, particularly in countries with populations living in high-altitude areas. This study estimates the national prevalences of anemia in children aged 6-59 months using Centers for Disease Control and Prevention (CDC) 1989 and WHO 2024 criteria. Data from 406,106 children in 48 countries (45 Demographic and Health Surveys [DHS Program] and 3 Andean [Ecuador, Bolivia, and Peru]) were analyzed. The pooled prevalence of anemia was 61.4% according to the WHO 2024 criteria. Three countries showed changes in anemia prevalence, with shifts of 10 or more percentage points (Uganda, Rwanda, and Jordan). Across all the studied countries, the prevalence of anemia was higher at greater altitudes, rural areas, and children from households of low wealth quintiles, regardless of the criteria used. Moreover, changes in anemia prevalence were identified when stratified by altitude of residence, showing differences in the levels of public health significance across various political-administrative regions in Andean countries. Overall, these findings provide valuable insights into the epidemiology of anemia and highlight the need for continued surveillance and targeted interventions to effectively address this global health challenge., (© 2024 The New York Academy of Sciences.)

The aim of this research is to investigate the role of servicescape on re-patronage and recommended intention through pleasure feeling and satisfaction in healthcare settings that put substantial contribution in the process of healthcare service delivery. Data were collected through cross-sectional convenience sampling via a self-administered survey questionnaire from 431 clinical outpatients who revisit the same hospital of metropolitan areas of Punjab, Pakistan. Structural Equation Modeling (SEM) was carried out for path analysis through AMOS (24.0 V), while statistical measures were analyzed using SPSS (25.0 V). The present study results revealed that patients' intention optimistically triggered through partial mediation and affirm the direct and indirect association with servicescape. It also revealed that patient-recommended and re-patronage intentions to visit the clinic were statistically substantial and positively influenced by intervening constructs of pleasure feeling and satisfaction. Additionally, it is found that servicescape and pleasure feeling contributed to 30% change in satisfaction. Moreover, pleasure feeling, and satisfaction contributed to 50% change in re-patronage and 31% change in recommendation intention of the patients. The current study findings contribute significantly to servicescape literature from a theatrical perspective and reevaluate the patterns and operations in healthcare. It also helps managers and administrators of private hospitals to make strategies to increase patient satisfaction., Competing Interests: NO authors have competing interests., (Copyright: © 2024 Rauf et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Spending on preventive care in low- and middle-income countries (LMICs), including Indonesia, is much lower than spending on curative care. There has been a pressing need to develop a clear pathway to increase spending on preventive care. This study aimed to assess the current financing landscape for health promotion and disease prevention in Indonesia and, subsequently, to develop a framework and recommendations for future health promotion financing in the country., Methods: We adopted a mixed-method approach to gather information from all relevant stakeholders from December 2022 to June 2023. For the qualitative approach, we conducted (a) in-depth interviews (IDIs) and (b) focus group discussions (FGDs) with government officials at national and district levels, academics, professional organizations, healthcare workers in primary healthcare centres (PHCs), community health volunteers, non governmental organizations and private companies. For the quantitative approach, we applied a national online survey to healthcare workers involved in health promotion in PHCs. IDIs and FGDs were conducted with purposefully selected resource persons at the national level, five selected districts across Indonesia, and within 15 primary health offices and their communities. All qualitative data were recorded, transcribed, coded, interpreted, and then triangulated with national survey findings to develop the financing framework., Results: We identified gaps between the theory and practice of health promotion and disease prevention. These included the limited scope of health promotion initiatives, lack of direction and coordination between ministries, agencies and government levels, limited availability and capacity of health promoters, various yet uncoordinated funding resources and inflexibility in using the funds. To bridge the gap, the framework we developed suggests strengthening the legal and regulatory basis, strategically prioritizing financing arrangements, promoting evidence-based health promotion activities, developing the capacity of health promoters, enhancing the health financing information system and improving monitoring and evaluation., Conclusions: Identified gaps and challenges in health promotion and disease prevention initiatives inform the development of our framework for future health promotion financing. This framework assists the national government in organizing national health promotion financing strategies and potentially serves as a valuable model for other LMICs., (© 2024. The Author(s).)

Background: Low- and middle-income countries (LMICs) face high burden of common mental disorders (CMDs). Most of the evidence for the Collaborative Care (CC) model effectiveness comes from high-income countries (HICs) and may not generalise to LMICs. A systematic review was conducted to assess effectiveness of CC for CMDs in LMICs., Methods: We searched eight-databases, two trial registries (2011-November 2023). Randomised controlled trials (RCTs) of adults (≥18 years) with depression/anxiety diagnosis, reporting remission/change in symptom severity were eligible. Random effects meta-analyses were conducted for: short-(0-6 months), medium-(7-12 months), long-(13-24 months), and very long-term (≥25 months) follow-up. Quality was assessed with Cochrane RoB2 tool. PROSPERO registration: CRD42022380407., Results: Searches identified 7494 studies, 12 trials involving 13,531 participants were included; nine had low-risk of bias. CC was more effective than usual care for depression: dichotomous outcomes (short-term, 7 studies, relative risk (RR) 1.39, 95%CI 1.31, 1.48; medium-term, 6 studies, RR 1.35, 95%CI 1.28, 1.43); and continuous outcomes (short-term, 8 studies, standardised mean difference (SMD) -0.51, 95%CI -0.80, -0.23; medium-term, 8 studies, SMD -0.59, 95%CI -1.00, -0.17). CC was found to be effective at long-term (one study), but not at very long-term. Improvement in anxiety outcomes with CC (2 studies, 340 participants) reported up to 12-months; improvements in quality-of-life were not statistically significant (3 studies, 796 participants, SMD 0.62, 95%CI -0.10, 1.34)., Limitations: Pooled estimates showed high heterogeneity., Conclusions: In LMICs, CC was more effective than usual care for improving depression outcomes at short and medium-term follow-up. A similar improvement was found for anxiety outcomes, but evidence is limited., Competing Interests: Declaration of competing interest The authors declare that they have no known competing interests that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

The ambitious sustainable development goal (SDG) 6 of the United Nations, which aims to achieve universal access to safe water and sanitation by 2030, remains elusive for many developing countries like Ethiopia. This is often due to a multitude of intricate factors, including the escalating degradation of water quality. Here, we present a comprehensive nationwide and regional analysis of heavy metal pollution in drinking water sources and the associated human health risks in Ethiopia based on a dataset of 11 heavy metal concentrations (n = 975) collated from available studies. Results indicate significant variations in heavy metal pollution in drinking water sources in Ethiopia, with 44 % of the total concentration exceeding maximum permissible limits. The mean concentrations were ranked as follows: Pb (1.92 mg/L) > Zn (1.25 mg/L) > Fe (0.56 mg/L) > Mn (0.43 mg/L) > Cu (0.40 mg/L) > Co (0.30 mg/L) > As (0.12 mg/L) > Ni (0.12 mg/L) > Cr (0.10 mg/L) > Cd (0.06 mg/L) > Hg (0.04 mg/L). We found that children are more vulnerable to non-carcinogenic health risks than adults, with the highest hazard quotient (HQ) exceedances of up to a factor of 1823 and 762, respectively. Furthermore, a Monte Carlo-based probabilistic risk assessment highlighted significant concerns regarding co-exposure to multiple heavy metals. The measured concentrations, ingestion rates, and exposure frequencies were identified as sensitive parameters. Overall, a higher risk was attributed to Pb and As, with river drinking water sources and the Tigray region requiring immediate mitigation measures. In conclusion, the findings emphasize the urgent need to test and purify water before consumption and to implement effective public health interventions. Furthermore, a multifaceted approach including regular monitoring, source protection, and proper waste management is recommended to expedite the achievement of SDGs and promote water sustainability in resource-limited Ethiopia and sub-Saharan Africa., Competing Interests: Declaration of competing interest All authors declare no financial or non-financial competing interests., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The Maternal Death Surveillance and Response (MDSR) system is designed to continuously identify and review all maternal deaths. It aims to help countries understand the scale and distribution of maternal deaths, identify their causes, and inform corrective measures to address the challenge. Despite the growing adoption of the MDSR by numerous low- or middle-income countries, its implementation faces various challenges, including legal ones. This scoping review was conducted to map legal issues and challenges that arise during the implementation of the MDSR. It adapted the Bain and Kongnyuy framework, categorizing legal issues into data, people, use of findings, and legal regulation. Literature was retrieved from seven databases, complemented by additional online searches. We included studies published in English between 2010 and November 2022 that report on legal issues arising during the implementation of MDSR. Out of 1174 studies screened, 31 were selected for review. The review highlighted the limited attention given to the legal dimension of the MDSR by the research community. It also documented the lack of adequate legal framework essential for the system's effective implementation. Inadequate safeguards for informational privacy and the lack of confidentiality reinforce a prevalent sense of being blamed, mainly among health workers. Consequently, widespread under-reporting and intentional misattribution of causes of maternal death, defensive referrals, and disengagement from the MDSR process were reported. We recommend that implementing countries regulate the gathering and use of MDSR data through appropriate laws and legally ensure that the MDSR data are only used for the intended purpose. Appropriate complaint-handling mechanisms are needed in health systems to prevent the misuse of the MDSR. Future studies on MDSR implementation would benefit from involving legal experts, considering the multifaceted legal dimensions of the MDSR., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: The private healthcare sector has become an essential component of healthcare systems globally. This interest has increased with the universal health coverage agenda. However, in most low- and middle-income countries, few classificatory studies of the private hospital sector were carried out., Methods: This study describes the private hospital sector in a developing country setup and propose a typology that could facilitate the identification of its categories and the understanding of its organizational and strategic characteristics., Results: All private hospitals in Morocco as of December 31, 2021 including 397 facilities are included. Most hospitals are for-profit, poly-disciplinary, independent, commercial societies, have fewer than 30 beds or between 30 and 99 beds and are located in urban areas. Private hospitals have a median turnover of 9.8 million MAD and a median capital value of 2 million MAD. The clustering method identifies three main categories of private hospitals: for-profit hospitals with medium size and turnover, spread across the country but with a high concentration in large regions; not-for-profit hospitals, with medium to large size, high turnover, located in large regions and including university hospitals; and small for-profit hospitals with low turnover, independent ownership and wide distribution over the country. Three criteria have the most significant discriminatory power: ownership, size (beds, turnover) and mode of governance., Conclusions: Private hospitals in Morocco are organized into three types according to three similarity criteria including ownership, size and governance. These criteria might be used as the basis for a common typology of private hospitals in Morocco and possibly in other low- and middle-income countries with similar contexts., (© 2024. The Author(s).)

Background: Although mobile health (mHealth) interventions have shown promise in improving health outcomes, most of them rarely translate to scale. Prevailing mHealth studies are largely small-sized, short-term and donor-funded pilot studies with limited evidence on their effectiveness. To facilitate scale-up, several frameworks have been proposed to enhance the generic implementation of health interventions. However, there is a lack of a specific focus on the implementation and integration of mHealth interventions in routine care in low-resource settings. Our scoping review aimed to synthesize and develop a framework that could guide the implementation and integration of mHealth interventions., Methods: We searched the PubMed, Google Scholar, and ScienceDirect databases for published theories, models, and frameworks related to the implementation and integration of clinical interventions from 1st January 2000 to 31st December 2023. The data processing was guided by a scoping review methodology proposed by Arksey and O'Malley. Studies were included if they were i) peer-reviewed and published between 2000 and 2023, ii) explicitly described a framework for clinical intervention implementation and integration, or iii) available in full text and published in English. We integrated different domains and constructs from the reviewed frameworks to develop a new framework for implementing and integrating mHealth interventions., Results: We identified eight eligible papers with eight frameworks composed of 102 implementation domains. None of the identified frameworks were specific to the integration of mHealth interventions in low-resource settings. Two constructs (skill impartation and intervention awareness) related to the training domain, four constructs (technical and logistical support, identifying committed staff, supervision, and redesigning) from the restructuring domain, two constructs (monetary incentives and nonmonetary incentives) from the incentivize domain, two constructs (organizational mandates and government mandates) from the mandate domain and two constructs (collaboration and routine workflows) from the integrate domain. Therefore, a new framework that outlines five main domains-train, restructure, incentivize, mandate, and integrate (TRIMI)-in relation to the integration and implementation of mHealth interventions in low-resource settings emerged., Conclusion: The TRIMI framework presents a realistic and realizable solution for the implementation and integration deficits of mHealth interventions in low-resource settings., (© 2024. The Author(s).)

Background: Access to essential diagnostics is crucial for primary healthcare (PHC) in low-and-middle income countries (LMICs). Many LMICs have invested in equipping PHC with point-of-care (PoC) diagnostics for infectious diseases, however there has been no similar investment to improve PHC capacities for clinical chemistry. The biochemistry gap is among the deterrents to universal health coverage., Methods: A social sciences project was conducted with the aim to understand the key PHC stakeholders' insights on the pertinence of PoC biochemistry for PHC in LMICs. Data generation was conducted between July-November 2023 in Mongolia, Nigeria and Peru. Decision-makers in healthcare delivery, healthcare professionals, and patient and community advocates were engaged using a combination of sampling techniques. Unstructured individual and group conversations, and non-participant observation were conducted. Analysis involved an inductive line-by-line coding on printed transcripts, followed by a deductive coding and theme-by-theme analysis on digitized transcripts., Results: Fifteen, 51 and 20 informants from Mongolia, Nigeria and Peru, respectively, participated. Fifty-five of the 94 informants were female. Most informants considered that PoC biochemistry in PHC would be pertinent, from a clinical and a resources-saving perspective. Those households that currently bear the burden of referrals (i.e., the poor, the bedridden, the older adults) would benefit the most from the deployment of PoC biochemistry for essential biochemistry parameters. Improved access to PoC glycated hemoglobin (HbA1c), lipid, liver and kidney profile was perceived as helpful to inform clinicians' decision-taking. The value of PoC biochemistry for the management of noncommunicable diseases (diabetes, hypertension) and infectious conditions (dengue, malaria, tuberculosis), to improve child health outcomes (severe dehydration in children with diarrhea and/or malnutrition) and to reduce preventable causes of death (dengue-related renal failure) was highlighted., Conclusions: PoC biochemistry holds potential to revert the impact that the biochemistry gap has for patient care in some LMICs' PHC settings. PoC equipment for parameters such as HbA1c, urea, creatinine or electrolytes could enhance community-level management of preventable causes of mortality, improve service delivery for patients affected by locally-prevalent infectious conditions, and improve the psychosocial and economic wellbeing of patients facing the burden of referrals to remote biochemistry-equipped centers., Trial Registration: Not applicable., (© 2024. The Author(s).)

Objective: To examine robotic interventions for upper limb rehabilitation post-stroke, focusing on geographical distribution, stroke chronicity, outcome measures, outcomes of robotic interventions, and publication trends in Low- and Middle-Income Countries (LMICs) compared to High-Income Countries (HICs)., Data Sources: Using JBI methodology and PRISMA-ScR guidelines, PubMed, CENTRAL, Embase, CINAHL, and PEDro databases were searched for studies on upper extremity rehabilitation with robotics post-stroke., Study Selection: This review focused on randomized controlled trials (RCTs) published between 2012 and 2024 that examined rehabilitation robots for upper-limb impairments caused by stroke. The studies included adults aged 18 and older in the acute, subacute, or chronic recovery phases. Eligible trials involved using robotic devices, independently or combined with other interventions. Only RCTs with two or more arms were considered, and all included studies were published in English., Data Extraction: Reviewers independently extracted data on study characteristics, stroke chronicity, outcome measures, outcomes of robotic interventions, and temporal trends., Data Synthesis: Of 129 articles meeting the criteria, 107 were from HICs, and 22 were from LMICs. Major contributors from HICs included Italy, Taiwan, and the USA, while China was a significant contributor among LMICs. Most studies focused on chronic stroke patients, with varying assessment tools, the most common being the Fugl-Meyer Upper Extremity Evaluation. Positive outcomes were reported across studies, and recent research activity has increased in both settings., Conclusions: This review underscores the expanding research on robotic therapy for upper limb rehabilitation in stroke patients, primarily from high-income countries with limited input from low- and middle-income nations. While positive outcomes were frequently observed, disparities between high-income and low-and middle-income countries were clear. The growing research indicates rising interest and advancements in this domain., Competing Interests: Declaration of competing interest All authors were salaried by the Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore., (Copyright © 2024. Published by Elsevier Inc.)

Background: For a variety of reasons related to biology, behaviour, and environment, a subset of a population known as female sex workers (FSWs) or female transactional sex workers is at increased risk of health, depression, social stigma and access to timely and quality healthcare when needed. In low- and middle-income countries (LMICs), there was lack of understanding regarding the experiences and healthcare utilisation and behaviours, the health burden among them, their experiences, and how they access health care. Using Anderson's behavioural model of health service utilisation as a framework, this review aimed to explore the experiences of, and healthcare seeking behaviours of female sex workers in low-and middle-income countries., Methods: Six relevant databases such as PubMed, Embase, Global Health, Scopus, Web of Science, and Google Scholar were searched for peer-reviewed research articles published between January 1990 and December 2023 that discussed female transactional sex work in low- and middle-income countries. Subject terms such as: low-and middle- incomes, sex workers (female and male), sexually transmitted infections (STIs) in the sex work industry, prostitution, commercial sex, and health-seeking behaviour were used for the databases search. Out of 6,135 articles that were retrieved for the study, 26 met the inclusion criteria. Of the total number of studies, four were reviews, eight were quantitative studies, six were qualitative studies, and two utilised mixed methods., Findings: Results from a thematic analysis of studies that combined quantitative and qualitative methods yielded six overarching themes.The study found that women engaged in sex work for different reasons - to fend for themselves (i.e., livelihood), self-employment and others do it for pleasure. However, force sex or unprotected which can lead to sexually transmitted infections, sexual abuse, job insecurity, were critical risks factors in engaging in sex work. These factors make them vulnerable to predators and health risks. It was found that sex workers were aware of the importance of seeking healthcare, and do make the efforts, however, crucial factors such as difficulty accessing healthcare and maltreatment by healthcare providers and social stigma disincentivises FSW health-seeking behaviours. Sexual workers reported discomfort disclosing their occupations because of the stigma and discrimination which further affects their regular health examinations and obtaining medically approved condoms from healthcare facilities., Conclusion: Complex challenges rooted in economic vulnerability, social marginalisation, and limited access to healthcare afflict female sex workers in LMICs. The maltreatment and stigma can potentially affect LMICs from achieving using health facility care, with potential implications on achieving the universal health coverage goals. Comprehensive, rights-based strategies that address structural injustices and empower these women to live healthier, more secure lives are necessary to address their special needs., (© 2024. The Author(s).)

This systematic review examines the impact of the COVID-19 pandemic on global neurosurgical education, with a focus on the disparities between low- and middle-income countries (LMICs) and high-income countries (HICs). The study analyzes 26 articles, highlighting significant disruptions in neurosurgical training, including reduced surgical exposure and a transition to online learning. LMICs faced greater challenges, including limited access to virtual education and increased financial insecurities for trainees. Despite these setbacks, advancements in virtual technology provided new educational opportunities. The review underscores the need for continued innovation, particularly in cost-effective, immersive technologies, to bridge the gap in surgical training and enhance resilience for future crises., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

As the burden of chronic disease and multiple long-term conditions is increasing globally, disproportionally affecting those in low-resourced settings, there is an increasing call to action to scale effective models of care that can assist in mitigating the impact of chronic disease on functioning, activity, societal participation, and health-related quality of life. The aim of this paper is to unpack the contextual factors that have been implicitly and explicitly voiced by researchers reporting on rehabilitation interventions used to manage chronic disease in low-resourced settings. We systematically engaged the literature and applied a reflexive qualitative and systems thinking lens to unpack the contextual factors and their interplay. A total of 40 different contextual factors were derived through an iterative analysis of 144 eligible articles. The identified factors could be packaged into nine system elements or subsystems relevant to the scale-up of rehabilitation for people with chronic disease. The complexity identified encourages a focus on innovative and intersectoral approaches to address the rehabilitation needs in low-resourced settings., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Objectives: This study investigates the prevalence of the use of reusable menstrual materials in LMICs, examines differences in prevalence between countries and areas, and identifies individual and country-level factors associated with their use., Methods: Data from Multiple Indicator Cluster surveys conducted between 2017 and 2020 in LMICs were used. Prevalence estimates and 95% CIs were calculated for overall, rural, and urban areas. Multivariable logistic regression was used to identify individual and country-level factors associated with the use of reusable menstrual materials., Results: The study included 42 surveys from LMICs, with 1653850 weighted women and girls aged 15-49 years. The overall prevalence of the use of reusable menstrual materials was 12.1% (95% CI 12.1-12.2), with significant variation between and within countries, ranging from 0.5% (0.3-0.8) in Serbia to 97.2% (96.5-97.9) in Sao Tome and Principe. The prevalence was higher in rural areas (23.9% [23.8-24.0]) than in urban areas (6.2% [6.2-6.2]), with significant differences between most countries. Use of reusable menstrual materials was associated with lower education levels, being married, low economic status, living in Asia and Africa, living in countries with lower GDP, living in rural areas, and limited availability of private places to wash menstrual materials. The prevalence of the use of reusable menstrual materials had an inverse linear relationship with the country's GDP., Conclusions: The study found that the use of reusable menstrual materials is more prevalent among women and girls in rural areas, those with lower education levels, lower economic status, and those living in countries with lower GDP. Given these disparities, policies and initiatives targeted at improving menstrual health in LMICs should focus on socioeconomically disadvantaged groups to ensure they have access to safe and appropriate menstrual materials., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Roy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

WHO recently announced a process to review and potentially update the procedures for selecting essential medicines. This announcement presents an opportunity to reflect on the evolution of the WHO Model Lists of Essential Medicines (EML), including the composition of the stakeholders that shape priorities. We contextualised our findings within the broader history of the WHO EML to support future reforms to improve access to essential medicines. The current system allows individuals to propose a medicine for the WHO EML. This makes the EML reactive to applicant priorities. Almost all medicines (687/700; 98·1%) proposed to the WHO EML between 2003 and 2023 came from applicants in high-income countries. Most applications (210/700; 30·0%) were submitted by universities and research institutions, followed by non-governmental organisations (159/700; 22·7%), the UN system (158/700; 22·6%), professional associations (98/700; 14·0%), and the pharmaceutical industry (75/700; 10·7%). Between 1977 and 2023, over half of the Expert Committee members were from low-income and middle-income countries, with an increasing proportion in recent EML updates. Mainly, UN agencies acted as observers between 1977 and 2023. One central question emerges when evaluating whether applicants' geographical distribution translates to the WHO EML's intended purpose: for whom is the EML intended? Over the years, the geographical applicability has blurred. Defining a strategic vision for the WHO EML, including articulating a target audience and structured selection process, would strengthen decision-making processes by providing additional clarity, including to those implementing the guidance, mostly in low-income and middle-income countries., Competing Interests: Declaration of interests KNV received grants from the Swiss National Science Foundation and the Swiss Cancer Research Foundation. She has also received honoraria for presentations at the Swiss Academy of Multidisciplinary Oncology and Swiss Society for Endocrinology and Diabetes. KJ declares a former role with WHO as a consultant supporting activities of the WHO Model List of Essential Medicines. CEGG declares no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: The impact of rapid urbanization taking place across the world is posing variegated challenges. Especially in terms of communicable disease, the risk is more concentrated in urban poor areas where basic amenities are inadequate. This systematic review synthesizes evidence on the effective community-based interventions (CBIs) aimed at preventing and controlling infectious diseases among the urban poor in low- and middle-income countries (LMICs)., Methods: This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. A comprehensive search across five major databases was conducted to capture literature on CBIs published between 2011 and 2021. Scientific articles of any design that reported any type of CBIs effective in preventing and controlling infectious diseases (tuberculosis, diarrhea, typhoid, dengue, hepatitis B and C, influenza, and COVID-19) were included. Screening and selection of studies were done by two pairs of independent researchers using the predefined eligibility criteria. The risk of bias in included studies was assessed using the modified checklist outlined in the Cochrane Handbook for Systematic Reviews of Interventions and Effective Public Health Practice Project (EPHPP). Analysis of effective CBIs was guided by the conceptual framework for integrated CBIs for neglected tropical diseases (NTDs), and narrative synthesis was carried out. Geographical restrictions were limited to LMICs and papers published in English., Results: Out of 18,260 identified papers, 20 studies met the eligibility criteria and were included in this review. Community-based screening and socio-economic support, community-based vector control, behavior change communication, capacity building of the community health workers (CHWs), health education, and e- and m-health interventions were found as effective CBIs. Diversified CBIs were found to be effective for specific diseases, including tuberculosis (TB), diarrhea, dengue, influenza and ARI, and hepatitis B and C. Bundling of interventions were found to be effective against specific diseases. However, it was difficult to isolate the effectiveness of individual interventions within the bundle. The socio-cultural context was considered while designing and implementing these CBIs., Conclusion: The effectiveness of an intervention is inextricably linked to social context, stakeholder dimensions, and broader societal issues. System approach is recommended, emphasizing context-specific, multi-component interventions that address social determinants of health. Integrating these interventions with public health strategies and community involvement is crucial for sustainable outcomes. These findings can guide the design of future interventions for better prevention and control of communicable diseases in urban poor areas., Systematic Review Registration: PROSPERO CRD42021278689., (© 2024. The Author(s).)

Despite some progress, universal access to safe water, sanitation and hygiene (WASH) by 2030-a remit of Sustainable Development Goal 6-remains a distant prospect in many countries. Policy-makers and implementers of the WASH sector are challenged to track a new path. This research aimed to identify core orienting themes of the sector, as legacies of past processes, which can provide insights for its future. We reviewed global policy, science and programmatic documents and carried out 19 expert interviews to track the evolution of the global WASH sector over seven decades. We situated this evolution in relation to wider trends in global health and development over the same time period.With transnational flows of concern, expertise and resources from high-income to lower-income countries, the WASH sector evolved over decades of international institutionalisation of health and development with (1) a focus on technologies (technicalisation), (2) a search for generalised solutions (universalisation), (3) attempts to make recipients responsible for environmental health (responsibilisation) and (4) the shaping of programmes around quantifiable outcomes (metricisation). The emergent commitment of the WASH sector to these core themes reflects a pragmatic response in health and development to depoliticise poverty and social inequalities in order to enable action. This leads to questions about what potential solutions have been obscured, a recognition which might be understood as 'uncomfortable knowledge'-the knowns that have had to be unknown, which resonate with concerns about deep inequalities, shrinking budgets and the gap between what could and has been achieved., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Places of worship serve as a venue for both mass and routine gathering around the world, and therefore are associated with risk of large-scale SARS-CoV-2 transmission. However, such routine gatherings also offer an opportunity to distribute self-tests to members of the community to potentially help mitigate transmission and reduce broader community spread of SARS-CoV-2. Over the past four years, self-testing strategies have been an impactful tool for countries' response to the COVID-19 pandemic, especially early on to mitigate the spread when vaccination and treatment options were limited. We used an agent-based mathematical model to estimate the impact of various strategies of symptomatic and asymptomatic self-testing for a fixed percentage of weekly routine gatherings at places of worship on community transmission of SARS-CoV-2 in Brazil, Georgia, and Zambia. Testing strategies assessed included weekly and bi-weekly self-testing across varying levels of vaccine effectiveness, vaccine coverage, and reproductive numbers to simulate developing stages of the COVID-19 pandemic. Self-testing symptomatic people attending routine gatherings can cost-effectively reduce the spread of SARS-CoV-2 within places of worship and the community, resulting in incremental cost-effectiveness ratios of $69-$303 USD. This trend is especially true in contexts where population level attendance at such gatherings is high, demonstrating that a distribution approach is more impactful when a greater proportion of the population is reached. Asymptomatic self-testing of attendees at 100% of places of worship in a country results in the greatest percent of infections averted and is consistently cost-effective but remains costly. Budgetary needs for asymptomatic testing are expensive and likely unaffordable for lower-middle income countries (520-1550x greater than that of symptomatic testing alone), promoting that strategies to strengthen symptomatic testing should remain a higher priority., Competing Interests: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. The views expressed in this manuscript are those of the authors and do not necessarily represent the official position of the WHO., (Copyright: © 2024 Hansen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The inadequacy of intensive care medicine in low-resource settings (LRS) has become significantly more visible after the COVID-19 pandemic. Recommendations for establishing medical critical care are scarce and rarely include expert clinicians from LRS., Methods: In December 2023, the National Association of Intensivists from Bosnia and Herzegovina organized a hybrid international conference on the topic of organizational structure of medical critical care in LRS. The conference proceedings and literature review informed expert statements across several domains. Following the conference, the statements were distributed via an online survey to conference participants and their wider professional network using a modified Delphi methodology. An agreement of ≥ 80% was required to reach a consensus on a statement., Results: Out of the 48 invited clinicians, 43 agreed to participate. The study participants came from 20 countries and included clinician representatives from different base specialties and health authorities. After the two rounds, consensus was reached for 13 out of 16 statements across 3 domains: organizational structure, staffing, and education. The participants favored multispecialty medical intensive care units run by a medical team with formal intensive care training. Recognition and support by health care authorities was deemed critical and the panel underscored the important roles of professional organizations, clinician educators trained in high-income countries, and novel technologies such as tele-medicine and tele-education., Conclusion: Delphi process identified a set of consensus-based statements on how to create a sustainable patient-centered medical intensive care in LRS., (© 2024. The Author(s).)

Background: Cost-effectiveness evidence is a critical tool to support resource allocation decisions. There is growing recognition that the development of benefit packages for surgical care should be guided by such evidence, particularly in resource-constraint settings., Methods: We conducted a systematic review of evidence (Medline, Embase, Global Health, EconLit and grey literature) on the cost-effectiveness of surgery across low-income and middle-income countries published between January 2013 and January 2023. We included studies with minor and major therapeutic surgeries and minimally invasive intraluminal and endovascular interventions. We computed and compared the average cost-effectiveness ratios (ACERs) for different surgical interventions to the respective national gross domestic product per capita to determine cost-effectiveness and to common traditional public health interventions., Results: We identified 87 unique studies out of 20 070 articles screened. Studies spanned 23 countries, with China (n=20), Thailand (n=12), Brazil (n=8) and Iran (n=8) accounting for about 55% of the evidence. Overall, the median ACERs across procedure groups ranged from I$17/disability-adjusted life year (DALY) for laparotomies to I$170 186/DALY for bariatric surgeries. Most of the ACER estimates were classified as cost-effective (89%) or very cost-effective (76%). Low-complexity surgical interventions compared favourably to common public health interventions., Conclusion: These findings reinforce the growing body of evidence that investments in surgery are economically smart. There remains however paucity of high-quality evidence that would allow decision-makers to assess the comparative cost-effectiveness of surgery and to determine best buys across a wide range of specialties and interventions. A concerted effort is needed to advance the generation and utilisation of economic evidence in the drive towards scale-up of surgical care across low-income and middle-income countries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of our study was to evaluate the renal response (RR) of three immunosuppressive protocols in the induction treatment of proliferative lupus nephritis (PLN) in a Tunisian population., Methods: We performed a retrospective prognostic cohort study in the Internal Medicine Department of the Habib Thameur University Hospital in Tunis from January 2000 to December 2023, and included kidney biopsy proven proliferative lupus nephritis patients. Three induction treatments were compared: High CYP regimen: glucocorticoids (GC) + IV cyclophosphamide (CYP) in monthly pulses of 0.7 g/m2 for 6 months; Low CYP regimen: GC + IV CYP in biweekly pulses of 500 mg for 3 months; and MMF regimen: GC + oral MMF 1.5 g twice daily for 6 months. The primary endpoint was the incidence of RR (complete and partial remission) at one year post-diagnosis. The additional outcomes were end-stage kidney disease (ESKD), severe adverse events (AEs) and death., Results: Our study included 78 PLN patients (High CYP: 17, Low CYP: 40, MMF: 21). The study found that 94.1% of patients receiving High CYP achieved the primary endpoint, RR, compared to 67.5% of those receiving Low CYP and 61.9% in the MMF group. For the additional outcomes, there were 3 cases of ESKD, all in the Low CYP group, 5 cases of death (4 in the Low CYP group and 1 in the MMF group), and 20 cases of severe AEs, all of which were severe infections (5 in the High CYP group, 12 in the Low CYP group, and 3 in the MMF group). Multivariate analysis showed that the High CYP regimen was more associated with RR than the MMF regimen, with an adjusted OR of 9.846 (95% CI: 1.087-98.210); p = 0.042. Multivariate analysis did not show statistically significant differences between the High CYP regimen and the Low CYP regimen in terms of RR., Conclusion: As an induction treatment for PLN, the High CYP regimen was strongly associated with a higher rate of RR than the MMF regimen. There were no statistically significant differences between the High CYP regimen and the Low CYP regimen in terms of RR., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Low- and middle-income countries (LMICs) contribute relatively little to global carbon emissions but are recognised to be among the most vulnerable parts of the world to health-related consequences of climate change. To help inform resilient health systems and health policy strategies, we sought to systematically analyse published projections of the impact of rising global temperatures and other weather-related events on human health in LMICs. A systematic search involving multiple databases was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies with modelled projections of the future impact of climate change on human health. Qualitative studies, reviews and meta-analyses were excluded. The search yielded more than 2500 articles, of which 70 studies involving 37 countries met criteria for inclusion. China, Brazil and India were the most studied countries while the sub-Saharan African region was represented in only 9% of studies. Forty specific health outcomes were grouped into eight categories. Non-disease-specific temperature-related mortality was the most studied health outcome, followed by neglected tropical infections (predominantly dengue), malaria and cardiovascular diseases. Nearly all health outcomes studied were projected to increase in burden and/or experience a geographic shift in prevalence over the next century due to climate change. Progressively severe climate change scenarios were associated with worse health outcomes. Knowledge gaps identified in this analysis included insufficient studies of various high burden diseases, asymmetric distribution of studies across LMICs and limited use of some climate parameters as independent variables. Findings from this review could be the basis for future research to help inform climate mitigation and adaptation programmes aimed at safeguarding population health in LMICs., Competing Interests: Competing interests: The views expressed in this article are those of the authors and not necessarily their affiliated institutions. PGA, GB, CB and JS are employees of Novartis., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Informal healthcare providers (IHCPs) play a big role in health systems in low-and middle-income countries (LMICs) and are often the first point of contact for healthcare in rural and underserved areas where formal healthcare infrastructure is insufficient or absent. This study was performed to systematically review the literature on interventions targeting IHCPs in improving the delivery of healthcare services in LMICs., Methods: PubMed, Embase, and Cochrane CENTRAL databases were searched for studies that assessed any type of intervention among IHCPs to improve the delivery of healthcare services in any LMIC. Outcomes included changes in knowledge, attitude, and reported practice of appropriate case diagnosis and management; improved referral services; effective contraceptive use; and medication appropriateness (PROSPERO ID: CRD42024521739)., Results: A total of 7,255 studies were screened and 38 were included. Most of the studies were conducted in Africa and Asia. The IHCPs who were trained included medicine sellers, community health workers/traditional healers, and traditional birth attendants. The main intervention used was educational programs in the form of training. The other interventions were health services, policy and guidelines, and community-based interventions. Most of the interventions were multi-faceted. The disease/service areas targeted were mainly maternal and child health, sexually transmitted diseases, common infectious diseases, medicine use/dispensing practices, and contraception. The outcomes that showed improvements were knowledge, attitude, and reported practice; diagnosis and case management; improved referral services; contraceptive uses; and medication appropriateness. Around one-fourth of the studies reported negative results. The certainty of evidence generated (GRADE criteria) was very low., Conclusion: Some multifaceted interventions coupled with training showed improvements in the delivery of healthcare services by IHCPs. However, the improvements were inconsistent. Hence, it is unclear to identify any context-specific optimum intervention to improve the delivery of healthcare services by IHCPs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Das, Khare, Eriksen, Diwan, Stålsby Lundborg and Skender.)

Objective: To test the validity of the paediatric early warning score (PEWS) and to identify the patients with deteriorating clinical conditions who were reviewed by a rapid response team (RRT) and were advised higher level of care., Study Design: Observational study. Place and Duration of the Study: Paediatric ward and high dependency unit (HDU) of The Aga Khan University Hospital (AKUH), Karachi, Pakistan, from January 2021 to March 2022., Methodology: All children aged 1 month to 18 years, admitted with non-surgical diagnoses at AKUH and referred for an RRT consultation were identified by non-probability consecutive sampling. The bedside nurse assessed the PEWS and alerted the clinical team. The patient's further course of action was decided based on the PEWS, detailed systemic examination, and laboratory workup. This aided in deciding the level of care (General ward, HDU, Paediatric Intensive Care Unit) required by the patients. Patients with length of stay >24 hours were included and those with did not resuscitate orders were excluded., Results: Overall 10,032 patients were admitted to the ward and high dependency unit (HDU). Out of which, 323 (3.2%) patients had an RRT call and were included in the study. The median age of the study population was 3.15 years during the study period, and 30.3% were <1 year. System-wise admission diagnoses included respiratory (33.2%) and neurological diseases (16.1%). Median [interquartile range (IQR)] PEWS at RRT call was 2 (IQR, 1-2) on median admission day 2 (IQR, 1-3). The cumulative data at PEWS ≥3 demonstrated an area under the curve of 63% with a sensitivity of 90% and a specificity of 30%., Conclusion: PEWS >3 can probably identify the patients at risk of deterioration with excellent sensitivity., Key Words: Paediatrics, Rapid response team, Early warning score.

Objective: To evaluate compliance with enhanced recovery after surgery protocol of patients undergoing colorectal carcinoma surgery, and to compare its effect on outcomes., Methods: The retrospective study was conducted at the Maroof International Hospital, Islamabad, Pakistan, and comprised data from July 15, 2016, to March 20, 2022, of patients of either gender undergoing elective or emergency colorectal carcinoma surgery. Data included age, gender, tumour site, type of surgery, surgical approach, compliance with each of the 25 components of the enhanced recovery after surgery protocol, length of hospital stay, surgery duration, 30-day readmission rate and perioperative mortality. Data was analysed using SPSS 23., Results: Of the 96 patients with mean age 50.03±14.86 years (range: 20-79 years), 65(67.7%) were males, 70(72.91%) were aged at least 40 years, and 75(78.12%) underwent elective surgery. Most common tumour site was rectum and sigmoid 49(51%). Laparoscopic surgery was performed in 17(17.7%) patients. No compliance was seen with carbohydrate loading of patients or limiting use of opioids in standard anaesthesia protocol. No nutritional supplementation was started from postoperative day 1. Mean compliance with all the protocol components was 74.9%±37.652 for both elective and emergency cases. Mean duration of surgery was 192.50±75.33 minutes, while mean length of hospital stay was 5.52±1.57 days. Re-admission within 30 days was needed in 2(2.1%) cases. There was no perioperative mortality., Conclusions: Better compliance with enhanced recovery after surgery protocol resulted in better perioperative outcomes.

Background: Increasing health expenditure in low-income countries is associated with rapid gains in health status. Less attention has been paid to the possibility of diminishing marginal returns to health expenditure at high levels of spending, or to the relationship between health-care greenhouse gas emissions and outcomes. Our study aimed to investigate the existence, scale, and implications of diminishing marginal returns to health-care expenditure and emissions., Methods: Segmented (piecewise) regression analysis was used to explore the relationship between two measures of health outcome from the Global Burden of Disease project (mortality amenable to health care [MAH] and health-adjusted life expectancy [HALE]), four aggregates of health expenditure per capita from the WHO Global Health Expenditure Database, and health-care sector greenhouse gas emissions per capita derived from a 2020 study by Lenzen and colleagues. Turning point knots-points at which the elasticity or velocity of increasing returns to expenditure and emissions changed substantially-were estimated and countries in the vicinity of these knots identified., Findings: Rapidly increasing returns (improvements in population health as measured by MAH and HALE) to health expenditure were estimated in low-income and lower-middle-income countries; at levels of spending above approximately US$500 per capita, these returns start to slow. At levels of spending above those seen in high-income countries such as Italy (approximately US$3400), there is little or no evidence of further health returns to additional spending or to increasing health-care greenhouse gas emissions., Interpretation: Dramatic improvements in population health outcomes could be achieved by additional investment in health expenditure in low-income countries. Conversely, continuing growth in health expenditure in high-income countries will, by itself, be unlikely to yield rapid improvements in health outcomes. Our findings inform the emerging debate on the importance of sufficiency within planetary boundaries-low-income countries need rapid growth in health expenditure, whereas high-income countries could potentially achieve better health outcomes at substantially lower levels of resource use., Funding: None., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Little is known about how long it takes for new medicines to reach countries with different income levels. We analyzed data, sourced from IQVIA, on the timing of new drug launches in seventy-five low-, middle-, and high-income markets from 1982 to 2024. The sample captured the majority of essential medicines (as designated by the World Health Organization in the twenty-third Model List of Essential Medicines) that first came into medical use anywhere globally from 1982 onward. Kaplan-Meier estimates were used to quantify delays in launches across countries. Our analysis comprised 119 medicines with 6,871 observed launches. Nearly three-quarters (74 percent) of first launches occurred in just eight countries (in order of the most first launches, the US, the Netherlands, Sweden, Switzerland, the United Kingdom, France, Germany, and Japan). From the first launch globally, the median time to availability was 2.7 years for high-income countries, 4.5 years for upper-middle-income countries, 6.9 years for lower-middle-income countries, and 8.0 years for low-income countries. The gap between richer (high- and upper-middle-income) and poorer (lower-middle- and low-income) countries remained largely unchanged over time. Strategies to address the disparities highlighted by this analysis are urgently needed.

Researchers in the Global South (GS, developing countries) make valuable contributions to the field of comparative physiology, but face economic and scientific disparities and several unique challenges compared with colleagues in the Global North (developed countries). This Perspective highlights some of the challenges, knowledge gaps and disparities in opportunity faced by GS researchers, especially those at early-career stages. We propose collaborative solutions to help address these issues, and advocate for promoting investment and cultural and societal change for a more inclusive research community. Additionally, we highlight the role of GS researchers in contributing expert knowledge on local biodiversity and the environment; this knowledge can help to shape the future of comparative physiology, allowing us to achieve a better understanding of the evolution of physiological mechanisms and to develop innovative solutions to environmental and biomedical challenges. With this Perspective, we hope to highlight the need to foster a more diverse, equitable and inclusive research landscape in comparative physiology; one that empowers GS scientists to address the global challenges associated with biodiversity loss, climate change and environmental pollution., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2024. Published by The Company of Biologists Ltd.)

Background: Tetralogy of Fallot with an absent pulmonary valve is a very rare variant of tetralogy. It is characterized by absent valve tissue, severe pulmonary regurgitation, and secondary aneurysmal dilatation of the pulmonary arteries., Aim: In this study, we aim to investigate the clinical presentations, management strategies, and outcomes of patients with tetralogy of Fallot and absent pulmonary valve., Methodology: We retrospectively reviewed the charts of all patients who presented to the American University of Beirut Medical Center between January 2010 and December 2020 and who were diagnosed with this anomaly., Results: A total of 300 cases of tetralogy of Fallot were identified, of which 18 patients had absent pulmonary valves. They were followed up for an average of 8.2 years. Prenatal diagnoses were made in four patients, while 13 patients were identified in the neonatal period, with an average age of 4.5 days. Genetic testing confirmed DiGeorge syndrome in one patient. Five patients underwent surgical intervention in the neonatal period, while the remaining patients were operated on during their early childhood. While overall there were no surgical mortalities nor any need for reinterventions, a variety of morbidities were encountered., Conclusion: This study provides an overview of this rare anomaly and its management in a developing country., (© 2024 Wiley Periodicals LLC.)

Artificial intelligence (AI) is revolutionizing cardiac imaging, including echocardiography. However, AI has scarce penetration in resource-limited regions. The implementation of AI-aided echocardiography (AIE) poses unique challenges and opportunities in resource-limited areas. Some obvious advantages of AIE include aiding image acquisition, interpretation, and triaging patients based on severity. The challenges AIE faces in resource-limited regions include a lack of data accessibility for model development, physician apprehension, and an outdated regulatory framework. Based on our early experience with AI, we believe AIE in resource-limited regions will enhance health equity, improve access to the technology, and lead to cost savings. However, significant efforts are needed to realize these objectives., (© 2024 Wiley Periodicals LLC.)

Background: Complications of prematurity are the leading cause of under-5 mortality globally and 80% of newborn deaths are of low birth weight (LBW) babies. Early identification of LBW and preterm infants is crucial to initiate timely interventions., Objective: To evaluate the feasibility and diagnostic accuracy of alternative neonatal anthropometric measurements in identifying LBW and preterm infants in Africa., Methods: In this systematic review and meta-analysis, we evaluated the diagnostic performance of infant foot length, mid-upper arm circumference (MUAC), head and chest circumferences against birth weight and gestational age. Pooled correlation between the index and the reference methods was estimated. Multiple anthropometric thresholds were considered in estimating the pooled sensitivity, specificity and area under receiver operating characteristic curve (AUC)., Results: 21 studies from 8 African countries met the inclusion criteria. Correlation coefficients with birth weight were 0.79 (95% CI 0.70 to 0.85) for chest circumference, 0.71 (95% CI 0.62 to 0.78) for MUAC and 0.66 (95% CI 0.59 to 0.73) for foot length. Foot length measured by rigid ruler showed a higher correlation than tape measurement. Chest circumference with 28.8 cm cut-off detects LBW babies with AUC value of 0.92 (95% CI 0.71 to 0.97). Foot length identified preterm infants, with 82% sensitivity, 89% specificity and AUC of 0.91 (95% CI 0.69 to 0.98) at a 7.2 cm optimal cut-off point. MUAC had an AUC of 0.83 (95% CI 0.47 to 0.95) for preterm detection. In identifying LBW babies, foot length and MUAC have AUC values of 0.89 (95% CI 0.70 to 0.96) and 0.91 (95% CI 0.73 to 0.97) at 7.3 cm and 9.8 cm optimal cut-off points, respectively. Foot length and MUAC are relatively simple and minimise the risk of exposing infants to cold., Conclusion: Newborn foot length, MUAC, head and chest circumferences have comparable diagnostic accuracy in identifying LBW and preterm babies. Using foot length and MUAC in low-resource settings are the most feasible proxy measures for screening where weighing scales are not available., Prospero Registration Number: CRD42023454497., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Sleep is a crucial determinant of maternal and fetal health, significantly impacting the well-being of both the mother and her developing fetus. Poor sleep quality, characterized by difficulties in falling asleep or staying asleep, can cause poor pregnancy outcome. Conversely, studies came with inconsistent result in the prevalence of poor sleep quality in different trimester of pregnancy. Therefore, this systematic review and meta-analysis study aimed to compare the prevalence of poor sleep quality in different trimesters., Method: A systematic review and meta-analysis were done on published studies. Electronic data base search was done from PubMed, Hinari, Medline and Google Scholar. Data were extracted with Excel and the analysis were done using STATA version 17. Publication bias was assessed both graphically and statistically. I-square test was used to identify heterogeneity., Result: In this meta-analysis, 38 studies that measured poor sleep quality using the Pittsburg Sleep Quality Index (PSQI ≥ 5) were included. The pooled prevalence of poor sleep quality was identified as 37.46% (95% CI: 29.26, 45.67) in the first trimester, 47.62% (95% CI: 42.23, 53.02) in the second trimester, and 60.05% (95% CI: 51.32, 68.78) in the third trimester., Conclusion: This study identified a significant discrepancy in the prevalence of poor sleep quality, which increases as gestational age advances. Therefore, this discrepancy should be addressed, and additional support should be provided to pregnant women to help them achieve adequate sleep, especially as gestational age advances., (© 2024. The Author(s).)

Background: Until local healthcare infrastructure is strengthened, cardiac surgical care in low- and middle-income countries is often provided by non-governmental organizations by way of visiting healthcare teams. This is generally considered to be a cost-effective alternative to transporting patients to high income countries for surgical care, but the costs of cardiac surgery consumables under this model are poorly understood. Our objective was to identify the per-patient cost of cardiac surgery consumables used in single and double valve replacements performed by a non-governmental organization in Rwanda., Methods: Financial data from 2020 were collected from Team Heart, a non-governmental organization that supports cardiac surgical care in Rwanda. A comprehensive list of consumables was generated, including surgical, perfusion, anesthesia, and inpatient supplies and medications. Acknowledging the variability in perioperative needs, the quantities of consumables were calculated from an average of six patients who underwent single or double-valve replacement in 2020. Total costs were calculated by multiplying purchasing price by average quantity per patient. Costs absorbed by the local hospital were excluded from the calculations., Results: The total cost per patient was estimated at $9,450. Surgical supplies comprised the majority of costs ($6,140 per patient), with the most substantial cost being that of replacement valves ($3,500 per valve), followed by surgical supplies ($1,590 per patient)., Conclusions: This preliminary analysis identifies a cost of just over $9,000 per patient for consumables used in cardiac valve surgery in Rwanda, which is lower than the estimated costs of transporting patients to centers in high income countries. This work highlights the relative cost effectiveness of cardiac surgical care in low- and middle- income countries under this model and will be instrumental in guiding the allocation of local and international resources in the future., (© 2024. The Author(s).)

Background and Objectives: Hypertensive disorders of pregnancy (HDPs) remain one of the leading causes of maternal mortality globally, especially in Low- and middle-income countries (LMICs). To reduce the burden of associated morbidity and mortality, standardized prompt recognition, evaluation, and treatment have been proposed. Health disparities, barriers to access to healthcare, and shortage of resources influence these conditions. We aimed to synthesize the literature evidence for the management of HDPs in LMICs., Methods: A scoping review was conducted in five databases (PubMed, Web of Science, Epistemonikos, Clinical Key and, Scielo) using MeSh terms, keywords, and Boolean connectors. We summarized the included studies according to the following categories: study design, objectives, settings, participant characteristics, eligibility criteria, interventions, assessed outcomes, and general findings., Results: Six hundred fifty-one articles were retrieved from the literature search in five databases. Following the selection process, 65 articles met the predefined eligibility criteria. After performing a full-text analysis, 27 articles were included. Three themes were identified from the articles reviewed: prevention of HDPs, management of HDPs (antihypertensive and non-hypertensive management) and pregnancy monitoring and follow-up. The topics were approached from the perspective of LMICs., Conclusions: LMICs face substantial limitations and obstacles in the comprehensive management of HDPs. While management recommendations in most LMICs align with international guidelines, several factors, including limited access to crucial medications, unavailability of diagnostic tests, deficiencies in high-quality healthcare infrastructure, restrictions on continuing professional development, a shortage of trained personnel, community perceptions of preeclampsia, and outdated local clinical practice guidelines, impede the comprehensive management of patients. The development and implementation of protocols, standardized guides and intervention packages are a priority., (© 2024. The Author(s).)

Acute kidney injury (AKI) requiring dialysis (AKI-D) is an important health care burden and is associated with very high in-hospital mortality. Timely initiation of dialysis in AKI is fundamental to achieve treatment goals and to provide solute clearance and removal of excess fluid while awaiting the recovery of kidney function. The primary outcome of interest of the study was recovery of sufficient kidney function to discontinue haemodialysis therapy and complete recovery of renal function. This prospective observational study has been conducted in Mymensingh Medical College Hospital, Bangladesh from September 2019 to February 2021. All adult patients with AKI-D were included in the study. All patients were followed up till death or complete recovery or for a maximum period of six month. A total of 134 patients of AKI-D were included in the study with the mean age of 42.3±15.7 years. Male (54.5%) were slightly more than female with a male to female ratio of 1.2:1. Diabetes and hypertension were present in 16 (11.9%) and 47 (35.1%) patients respectively. The causes of AKI were sepsis (35.1%), urinary tract infection (34.3%), acute watery diarrhoea (9.7%), leptospirosis (11.2%), obstetric (10.4%), malignancy (8.2%), post renal obstruction (8.2%), drugs (7.5%), surgery (18.7%), rapidly progressive glomerulonephritis (6%), COVID 19 (5.2%), rhabdomyolysis (4.5%), intestinal obstruction (3.7%), acute gastroenteritis (2.2%), wasp bite (2.2%), insecticide poisoning (1.5%), star fruit toxicity (1.5%), haemolytic uremic syndrome (0.7%) and unknown (1.5%). Mean number of dialysis requirement was 5.9±8.6 and length of hospital stay was 15.4±10.5 days. Out of 134 patients, 95(70.9%) were discharged from hospital and 39(29.1%) died in hospital. Total death of patients during the study period were 49(36.6%) including home death of 10(7.5%) patients. Complete recovery of kidney function was achieved in 70(52.2%) patients and partial recoveries of kidney function who can survive without dialysis were observed in 12(9%) patients. Three (2.2%) patients remain on dialysis and 85(63.4%) patients survived during the study period. Survival rate was significantly higher in patients with ≤40 years (72.6%) and significantly lower in patients with malignancy (18.2%) and post renal obstruction (27.3%). Outcomes of patients with AKI-D remain poor. Advanced stage of AKI, older age, late presentation, malignancy, nutritional deficiency and delay at initiation of dialysis were associated with high mortality and reduced survival.

Despite recent economic growth and reductions in child mortality in many African countries, the region has experienced a slow fertility transition. In this study, we explore whether the slow structural economic change on the continent can explain this discrepancy. We construct a unique panel dataset combining Demographic and Health Surveys and nighttime light intensity data (an indicator of industrialization) from 57 countries at the subnational region level over three decades to analyze the drivers of fertility transitions across low- and middle-income countries. Our results confirm that household wealth, reduced child mortality, and female primary education are crucial for fertility declines. However, our analysis also highlights the importance of indicators of structural economic change, including the share of labor in nonagricultural occupations, industrialization, the share of women with higher education, and the formalization of the economy. Our simulations suggest that if high-fertility countries in sub-Saharan Africa underwent structural economic transformations comparable to those of other low- and middle-income countries with low fertility rates, their fertility levels could fall by 1 to 1.6 children., (Copyright © 2024 The Authors.)

Competing Interests: Disclosures The author has no conflicts of interest to disclose.

Manufacturing industries are vital for economic development, but they cause significant environmental damages. As there are scarce research studies for this industrial sector from developing countries, this article reports a comprehensive environmental and economic analyses for cutlery manufacturing in Pakistan. SimaPro 9.5 was used as a modelling software tool, while ReCiPe 2016 methods were used to evaluate various midpoint and endpoint environmental impacts. Various economic indicators were used to evaluate the economic performance of different alternative scenarios. The results revealed that injection molding process, due to its energy-intensive nature caused the most environmental impacts as compared to other manufacturing processes. Global warming and terrestrial ecotoxicity were the most affected impact categories with values of 11.8 kg CO 2 eq and 12.0 kg 1,4-DCB, respectively. Meanwhile, at endpoint level, human health category was most damaged as compared to others. Based on technical process intervention and energy transition, four different alternative scenarios were developed. In comparison with baseline scenario, the alternative scenario with double-cavity mold resulted in a reduction of more than 30% for various impact categories. The other three alternatives were grounded on the use of solar energy (50% or 100%) and injection mold with double or single cavity. Overall, the alternative scenario with 50% solar energy and double-cavity mold was the best solution that showed more than 50% reduction in most of the impact categories, less than 3-year payback time, 2.12 million (Pakistani Rupees) net present value, and 36.3% of return on investment. This study clearly shows the importance of renewable energy resources and simple changes in process technology for improving sustainability performance. The relevant stakeholders can effectively use the results and methodology of this study as a reference and guide for future research and practical interventions, especially in developing countries., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: I declare no competing interests. I thank the Directorate of Research of Universidad Técnica de Ambato for funding project PFCIAB 39.

Studies of the human microbiome are progressing rapidly but have largely focused on populations living in high-income countries. With increasing evidence that the microbiome contributes to the pathogenesis of diseases that affect infants, children, and adults in low- and middle-income countries (LMICs), and with profound and rapid ongoing changes occurring in our lifestyles and biosphere, understanding the origins of and developing microbiome-directed therapeutics for treating a number of global health challenges requires the development of programs for studying human microbial ecology in LMICs. Here, we discuss how the establishment of long-term human microbial observatory programs in selected LMICs could provide one timely approach., (© 2024 The Author(s). Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of The New York Academy of Sciences.)

Despite the globalization of health information, collaborations between high-income countries (HICs) and low/middle-income countries (LMICs), while present, could still increase. This study builds on previous research highlighting LMIC underrepresentation in neurosurgery literature. We conducted a comprehensive bibliometric analysis using the Scopus database to investigate collaborative neurosurgical research between HIC institutions and those in low-income country (LIC)/LMICs. Articles published between 2018 and 2020 were examined. Articles were categorized into 3 groups: guidelines, conferences, and consensus statements; articles related to training and collaborations; and other articles. We categorized articles and authors by country, role, and specific subtopic. We included 238 reports from 34 neurosurgical journals for analysis. Geographic distribution indicated that India led LIC/LMIC contributions (25.21%). Among HICs, the United States had the highest contribution (47.76%). In collaborative studies, Uganda, Cameroon, Tanzania, Indonesia, and Nigeria made significant contributions. LICs and LMICs accounted for 446 authors, while HICs contributed with 592. India has presented the highest number of authors in significant positions. In HICs, significant positions are recognized in USA articles. When scoring authors' position in collaborative papers, still HICs had a clear prevalence. The highest number of collaborations between HICs and LICs/LMICs has been observed in articles related to training and collaborations. Kenya matched India's contributions in training and collaborations. Global guidelines and consensus papers can enhance patient care, but LMICs' involvement remains limited. Further attention to training and collaboration initiatives is needed. This study emphasizes the importance of promoting collaboration and training between countries with varying resources to advance neurosurgical care globally., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Congress of Neurological Surgeons.)

This study utilized liquid chromatography (LC) alongside Fourier-transform ion cyclotron resonance mass spectrometry (FT-ICR MS) to explore the dyes and chemical contaminants in Loji River, Indonesia. We tentatively identified a total of 655 contaminants at various confidence level, subsequently classifying them into 22 distinct categories. Of the 54 dyes we detected, 12 corresponded with entries in our specialized in-house database. These 12 dyes were further confirmed by reference standards, matching both retention time (RT) and MS/MS spectra. LC-FT-ICR MS data showed that dyes from printing batik and textile industries are key contributors to river pollution. Particularly noteworthy were two sample locations that displayed substantial contamination, predominantly from azoic and reactive dyes. Additionally, pharmaceuticals were identified as one of the most frequently occurring contaminants, underscoring the inadequacies in the area's sewage management. To corroborate these findings, we conducted physicochemical, phytotoxicity, and acute toxicity tests, all of which verified the harmful effects of the Loji River's water on both the local flora and human populations. Notably, water samples that tested positive for dye contamination exhibited elevated toxicity levels. To the best of our knowledge, this study is pioneering in its molecular-level investigation of dye contamination in Southeast Asian rivers. Our results accentuate the pressing need for both targeted and non-targeted screening methods to identify contaminants in the surface waters of developing nations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)