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Rare diseases (RD) pose significant challenges for healthcare systems globally, necessitating the establishment of disease registries to facilitate research, diagnosis, and treatment. This article explores the development of a comprehensive national RD registry for India, informed by insights gained through interactions with experts from India and the Asia-Pacific Economic Cooperation (APEC) region. The social and technological challenges involved in creating and maintaining a national RDs registry are highlighted. Moreover, the roles and responsibilities of different stakeholders are discussed. Additionally, the RD-RAP (Registry and Analytics Platform) framework is also discussed, which is an analytics-based RD registry model with multi-stakeholder end-user utility. Although developed for the APEC region, the RD-RAP framework holds promise in the Indian context. This article discusses the key features of the RD-RAP framework that are relevant and applicable to the Indian setting. By leveraging these insights, this research aimed to provide valuable guidance for the development and operation of a comprehensive national RD registry in India. [ABSTRACT FROM AUTHOR]

• Several obstacles exist limiting research within emergency care from low- and middle-income countries (LMICs) therefore research effort must be targeted towards addressing priorities. • Measures to increase research addressing priority questions within LMICs are needed as evidence derived from vastly different high-income country settings is not directly applicable to LMIC populations. • Establishing research priorities can ensure the limited studies carried out in LMICs are targeted towards existing emergency care knowledge gaps and result in efficient coordinated work. Low- and middle-income countries (LMICs) are disproportionally affected by conditions requiring emergency care but there are limited contextually appropriate studies performed within these settings involving the patient population and healthcare systems they aim to benefit. Over the past five years, researchers in the Western Cape of South Africa have produced approximately 20 % of all emergency care publications from Africa, yet no agreed list of research priorities exists. Establishing research priorities, via recognised consensus methods, can ensure that efforts and resources in LMICs are more appropriately targeted to the need. Using a modified Delphi study, we invited a range of public and private representatives from different professional emergency care cadres within the Western Cape to identify current evidence gaps and consensus research priorities across the four areas of the WHO Emergency Care Systems framework: scene care, prehospital care, facility-based care, and the emergency care system itself. We then purposively selected eleven experts holding key academic and management positions to form a panel and perform a nominal group technique process to discuss these identified research priorities and establish a final list of priority research questions. Forty of the sixty-six (61 %) emergency care professionals invited contributed to the Delphi phase of the study, with representation from all professional cadres. After deduplication, 154 research topics were identified in the first round. In the second round, 94 (61 %) topics were considered research priorities by at least 80 % of participants. Following the nominal group technique discussion, 26 questions were established as consensus research priorities having been ranked as a top ten priority by over 50 % of panellists. We were able to successfully collate expert opinion and identify existing emergency care knowledge gaps within the Western Cape province of South Africa. Key topics identified for future work included questions on current health-seeking behaviour, dispatch, interfacility transfer, and staff burnout. [ABSTRACT FROM AUTHOR]

Plastic waste management is a complicated challenge that in recent years has gained attention as a global policy priority. In low- and middle-income countries (LMIC), waste management is heterogeneous and context-specific and many organizations provide needed waste management services, including entrepreneurs. Sustainable entrepreneurs are uniquely positioned to provide these services; however, they face challenges such as limited support system and lack of capacity. The goal of this paper is to understand critical characteristics of successful plastic waste management ventures in LMIC and operationalize those insights into a strategic tool. A wide variety of successful ventures from diverse LMIC contexts are systematically analyzed to identify which factors contribute to their business viability and ability to deliver services. The identified success factors were built into a tool, the Plastic Venture Builder (PVB), based on the multi-criteria analysis methodology. This is validated using empirical cases, tested on projects currently in development and discussed with experts in the field. The results show that political, economic, financial, technological, operational, social, team and legal factors contribute to success; however pathways to success are diverse. We identify a strong team as the most critical factor, whereas financial, political and social factors have the least impact. The PVB can be used by entrepreneurs who want to set up or improve plastic waste management ventures by identifying weak spots or avenues for improvement. The assessment framework can also be used by policy makers, development agencies and financing organizations who want to support or assess waste management initiatives by prioritizing their resources to match the identified critical factors. [ABSTRACT FROM AUTHOR]

Background: Low and middle-income countries like India anticipate rapid population aging and increases in dementia burden. In India, dementia screening scales originally developed in other contexts need to be assessed for feasibility and validity, given the number of different languages and varying levels of literacy and education. Method: Using data from the Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (N = 4,028), we characterize the performance of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We described patterns and correlates of missingness, evaluated the psychometric properties of the scale, and assessed criterion validity against the Hindi Mental State Examination (HMSE) using linear regression. Results: Several IQCODE items had high levels of missingness, which was associated with urbanicity, respondent's gender, and informant's generation (same vs. younger generation). Full IQCODE scores showed strong criterion validity against the HMSE; each 1-point increase in IQCODE score was associated with a 3.03-point lower score on the HMSE, controlling for age, gender, and urbanicity. The statistically significant association between IQCODE and HMSE was stronger in urban than rural settings (p-value for interaction = 0.04). Associations between IQCODE and HMSE remained unchanged after removing the three items with the highest levels of differential missingness (remembering addresses and telephone numbers, ability to work with familiar machines, ability to learn to use new gadget or machine). Conclusion: Findings raise questions about the value of including items with high proportions of missingness, which may signal cultural irrelevance, while removing them did not affect criterion validity. [ABSTRACT FROM AUTHOR]

Abstract\nIMPLICATIONS FOR REHABILITATIONObjective: Access to assistive products (APs) is essential to maximising function, participation, and inclusion of persons with disabilities. Challenges to AP access in low- and middle-income countries include stigma, costs, supply, and rehabilitation capacity gaps. This study aimed to examine AT access in the context of a low-resource setting in rural South India. Objectives were to examine rehabilitation professionals’ perceptions of AP needs, barriers and facilitators of AP provision, and AT knowledge.Methods: A descriptive study design with a 2-part online survey methodology was utilized. This study was conducted in April-September 2020 at a non-governmental organization (NGO) serving children and adults with disabilities in 3 districts of rural South India. Purposive sampling of NGO’s multidisciplinary rehabilitation professionals (N=62) was used. The survey was developed based on WHO’s Assistive Products List (APL). Barriers and facilitators were classified according to the principles of AT access. Analyses revealed acceptability, affordability, and availability as the top three barrier themes across disciplines, including poor acceptance by clients/families due to stigma, high AP costs, and a long waitlist for government-provided devices. Acceptability, affordability, and accessibility were the top three facilitator themes, including community awareness, availability of AP funding, client/family education, and AT service provision training.Impact: Our study identified key enabling strategies for AT access, aimed at reducing reported barriers. Enabling AP provision was determined to be multi-factorial, aimed at users/ families, service providers, organizations, communities, and policymakers. Local stakeholder groups are crucial to understanding challenges and opportunities to AP provision within a low-resource context.Identified barriers to assistive product (AP) provision in rural South India include poor acceptance by clients/families due to stigma, high AP costs, limited AP availability, and rehabilitation capacity gaps.Suggested facilitators to AP provision in rural South India include improving AP acceptability, affordability, and accessibility through community awareness, client/family education, AP funding and supply, and assistive technology (AT) service provision capacity building.An organisational-level survey based on the WHO’s Priority Assistive Products List and the Principles of AT Access can identify local needs, barriers and facilitators.An AT access strategies in resource-limited areas may be developed based on barriers and facilitators identified by local/regional rehabilitation professionals.Identified barriers to assistive product (AP) provision in rural South India include poor acceptance by clients/families due to stigma, high AP costs, limited AP availability, and rehabilitation capacity gaps.Suggested facilitators to AP provision in rural South India include improving AP acceptability, affordability, and accessibility through community awareness, client/family education, AP funding and supply, and assistive technology (AT) service provision capacity building.An organisational-level survey based on the WHO’s Priority Assistive Products List and the Principles of AT Access can identify local needs, barriers and facilitators.An AT access strategies in resource-limited areas may be developed based on barriers and facilitators identified by local/regional rehabilitation professionals. [ABSTRACT FROM AUTHOR]

Background: Populations are ageing globally and Low- and Middle-Income Countries (LMICs) are experiencing the fastest rates of demographic change. Few studies have explored the burden of frailty amongst older people in hospital in LMICs, where healthcare services are having to rapidly adapt to align with the needs of older people. This study aimed to measure the prevalence of frailty amongst older people admitted to hospital in Tanzania and to explore their demographic and clinical characteristics. Methods: This study had a prospective observational design. Over a six-month period, all adults ≥ 60 years old admitted to medical wards in four hospitals in northern Tanzania were invited to participate. They were screened for frailty using the Clinical Frailty Scale (CFS) and the Frailty Phenotype (FP). Demographic and clinical characteristics of interest were recorded in a structured questionnaire. These included the Barthel Index, the Identification of Elderly Africans Instrumental Activities of Daily Living (IADEA-IADL) and Cognitive (IDEA-Cog) screens, the EURO-D depression scale and Confusion Assessment Method. Results: 540 adults aged ≥ 60 were admitted, and 308 completed assessment. Frailty was present in 66.6% using the CFS and participants with frailty were significantly older, with lower levels of education and literacy, greater disability, greater comorbidity, poorer cognition and higher levels of delirium. Using the FP, 57.0% of participants were classed as frail though a majority of participants (n = 159, 51.6%) could not be classified due to a high proportion of missing data. Conclusions: This study indicates that the prevalence of frailty on medical wards in northern Tanzania is high according to the CFS. However, the challenges in operationalising the FP in this setting highlight the need for future work to adapt frailty screening tools for an African context. Future investigations should also seek to correlate frailty status with long-term clinical outcomes after admission in this setting. [ABSTRACT FROM AUTHOR]

Traumatic tension pneumocephalus is a rare and life-threatening complication of traumatic brain injury necessitating prompt diagnosis and neurosurgical treatment. Nevertheless, various possibilities for impedance in timely management, including patient-related barriers are commonly experienced in low-and middle-income countries setting. Here we presented a delay of management in traumatic tension pneumocephalus case due to initial refusal for emergency surgery. A 59-year-old male presented to the emergency department following a motorcycle accident fully alert with no neurological deficit. He acknowledged clear nasal discharge within 1 h after the initial trauma, but no rhinorrhea or otorrhea was present during physical examination. Head CT revealed extensive pneumocephalus with "Mount Fuji sign," anterior skull base fracture, and frontal sinus fracture. The patient initially refused immediate surgical intervention due to excellent clinical condition and financial scare. Acute decrease of consciousness occurred 40 h post-trauma: GCS of 6 with slight dilatation of both pupils (4 mm) and sluggish pupillary reflex. Emergency bifrontal craniotomy, subdural air drainage, and dura mater tear repair were performed afterwards. Postoperative care was uneventful, with rapid improvement of consciousness and follow-up head CT showing minimal subdural fluid collection and absence of remaining pneumocephalus. The patient was discharged from the hospital after 7 days with GCS of 15 and GOS of 5, proving the importance of overcoming barriers for delay in delivering neurotrauma care in low-and middle-income countries. [ABSTRACT FROM AUTHOR]

Introduction: Trauma burden is one of the leading causes of young human life and economic loss in low- and middle-income countries. Improved emergency and trauma care systems may save up to 2 million lives in these countries. Method: This is a comprehensive expert opinion participated by 4 experts analyzing 6 Asian countries compiling the most pressing trauma care issues in Asia as well as goal directed solutions for uplifting of trauma care in these countries. Result: Lack of legislation, stable funding under a dedicated lead agency is a major deterrent to development and sustainment of trauma systems in most Asian countries. While advocating trauma, critical care as a specialty is a key event in the system establishment, Trauma specialized training is challenging in low resource settings and can be circumvented by regional cooperation in creating trauma specialized academic centers of excellence. Trauma quality improvement process is integral to the system maturity but acquisition and analysis of quality data through trauma specific registries is the least developed in the Asian setting. [ABSTRACT FROM AUTHOR]

Introduction: Craniopharyngioma constitutes approximately 10% of primary brain tumors in children. It can cause considerable morbidity and mortality due to the local aggressiveness of the tumor itself or its management affecting the hypothalamus-pituitary axis and optic pathway involvement. There is very scarce data available from LMIC which makes the management controversial where multidisciplinary teams are already not available in most of the centers. This is a single-center cross-sectional retrospective review of 20-year record of 49 patients with craniopharyngioma treated between 2001 and 2020 at Aga Khan University Hospital, a tertiary care center in Karachi, Pakistan. Methods: We have assessed the epidemiological data of children presenting with the diagnosis of craniopharyngioma, treatment modalities used, and neurological, endocrine, and hypothalamic complications in these patients. The assessment involved a retrospective review of medical records and medical follow-up. Results: Out of a total of 49 patients, 26 (53%) were male, and 23 (46.9%) were female. The mean age was 9.5 years (SD ± 4.5 years). Most common symptoms at initial presentation were headache 41 (83.6%), visual deficit 40 (81.6%), nausea and vomiting 26 (53%), and endocrine abnormalities 16 (32%). Treatment modalities used at our center include gross total resection 11 (22%) and subtotal resection 38 (77%) out of total, while 6 (12.2%) patients received intracystic interferon. Histopathologic findings of the majority of patients (40 (81%)) revealed an adamantinomatous type of tumor. Only 23 (46.9%) children followed in clinic post-op. Median follow-up after craniopharyngioma presentation was 5 years (± 2.1 SD, range: 2–10 years). Pituitary hormone deficiencies (98%) and visual disturbances (75%) were the most common long-term health conditions observed. Conclusions: Since pituitary hormone deficiencies and visual disturbance were the most common long-term health conditions observed in our study, these patients require a multidisciplinary team follow-up to improve their quality of life. [ABSTRACT FROM AUTHOR]

Objective: Mental health disorders affect many children in South Africa, where vulnerability is high, and treatment is limited. We sought to determine the feasibility and acceptability of a universally delivered classroom‐based programme for the promotion of mental health in young adolescents. Method: We pilot tested an 8 session, cognitive‐behavioural therapy‐based programme, 4 Steps To My Future (4STMF) in two schools. Participants were grade 5 learners (n = 222; Meanage = 10.62 (Standard deviation = 0.69)). 4STMF was delivered in class time by trained psychology postgraduates. Feasibility (rates of parental opt‐out, child assent, assessment completion at baseline and follow‐up, programme completion, session attendance and programme fidelity), acceptability (teacher feedback and focus groups with learners), as well as demographic data and data on a battery of a psychological measures were collected at baseline, postintervention and at one‐month follow‐up. Results: Most eligible learners at both schools agreed to participate (85% – school 1; 91% – school 2) with more than 80% completing postintervention measures. Learner session attendance and programme fidelity were high. Teachers rated facilitators highly on confidence, preparedness, enthusiasm and classroom management and observed children to be enjoying the programme. Focus group data suggest that learners liked the programme, could recall the content and had shared some of the content with their family. An exploratory analysis of outcomes showed significant pre–post differences on self‐esteem at school 1 and on emotion regulation at school 1 and school 2, maintained at follow‐up. Conclusions: This pilot study has shown that 4STMF can acceptably and feasibly be delivered, at classroom level, as a universal school‐based prevention programme to young adolescent learners in South African primary schools. The programme could fit in with school context, could be delivered by nonspecialists, showed significant improvements on self‐esteem and emotion regulation and was liked by the learners. [ABSTRACT FROM AUTHOR]

Background: The co‐occurrence of depression among tuberculosis (TB) patients is a critical issue, contributing to poor treatment outcomes, prolonged hospitalisations and increased healthcare expenses. Objective: The objective of this study was to assess the feasibility of delivering a co‐designed depression care pathway within TB services in Pakistan. Design: Mixed‐method study. Setting and Participants: Routine depression screening for TB patients was conducted at three TB facilities in Peshawar, Pakistan, encompassing primary, secondary and tertiary care settings. All patients aged 18 or above (male and female) attending the three TB facilities between November 2021 and February 2022 were included in the study using the consecutive sampling technique. Results: A total of 301 people with confirmed TB, within the past 4 weeks, visited the three TB care facilities; 191/301 patients were screened for depression. Approximately 35% of the 191 TB patients screened positive for depression, with varying severity levels. Qualitative findings highlighted the acceptability of integrated depression care, emphasising the importance of open communication and empathetic attitudes. Barriers to integration include stigma, logistical challenges, patient noncompliance and cost burdens. Facilitators included the empathetic attitude of healthcare providers and the availability of mental health services within the same facility. Conclusion: There is a high burden of depression in patients with TB, highlighting the pressing need for mental health support in this population. Acceptability of integrated care was evident, with factors such as co‐located mental health services, training healthcare providers and provider empathetic attitudes playing a crucial role. Further research is required to evaluate the effectiveness of the integrated TB‐depression screening systems towards improved health outcomes, implementation, scalability and impact on the broader healthcare system. Patient and Public Contribution: To create a more inclusive and comprehensive TB and depression care pathway, we gathered input from both service providers and service users (TB patients, their carers). Reflective meetings with community leaders, social activists and health professionals from various sectors were also conducted during pathway delivery to get their insights. Power, gender and age imbalances were addressed by encouraging participation of patients and carers across gender and age groups. This approach ensured that the perspectives of all stakeholders were considered in the development of the care pathway. [ABSTRACT FROM AUTHOR]

Protein inadequacy is a major contributor to nutritional deficiencies and adverse health outcomes of populations in low- and middle-income countries (LMICs). People in LMICs often consume a diet predominantly based on staple crops, such as cereals or starches, and derive most of their daily protein intakes from these sources. However, plant-based sources of protein often contain low levels of indispensable amino acids (IAAs). Inadequate intake of IAA in comparison with daily requirements is a limiting factor that results in protein deficiency, consequently in the long-term stunting and wasting. In addition, plant-based sources contain factors such as antinutrients that can diminish protein digestion and absorption. This review describes factors that affect protein quality, reviews dietary patterns of populations in LMICs and discusses traditional and novel small- and large-scale techniques that can improve the quality of plant protein sources for enhanced protein bioavailability and digestibility as an approach to tackle malnutrition in LMICs. The more accessible small-scale food-processing techniques that can be implemented at home in LMICs include soaking, cooking, and germination, whereas many large-scale techniques must be implemented on an industrial level such as autoclaving and extrusion. Limitations and considerations to implement those techniques locally in LMICs are discussed. For instance, at-home processing techniques can cause loss of nutrients and contamination, whereas limitations with larger scale techniques include high energy requirements, costs, and safety considerations. This review suggests that combining these smalland large-scale approaches could improve the quality of local sources of proteins, and thereby address adverse health outcomes, particularly in vulnerable population groups such as children, adolescents, elderly, and pregnant and lactating women. [ABSTRACT FROM AUTHOR]

Populations in low- and middle-income countries (LMIC) typically consume less than the recommended daily amount of protein. Alternative protein (AP) sources could help combat malnutrition, but this requires careful consideration of elements needed to further establish AP products in LMIC. Key considerations include technological, nutritional, safety, social, and economic challenges. This perspective analyzes these considerations in achieving dietary diversity in LMIC, using a combination of traditional and novel protein sources with high nutritional value, namely, soy, mycoprotein, and cultivated meat. Technological approaches to modulate the technofunctionality and bitter off-tastes of plant-sourced proteins facilitate processing and ensure consumer acceptance. Economic considerations for inputs, infrastructure for production, and transportation represent key elements to scale up AP. Dietary diversification is indispensable and LMIC cannot rely on plant proteins alone to provide adequate protein intake sustainably. Investments in infrastructure and innovation are urgently needed to offer diverse sources of protein in LMIC. [ABSTRACT FROM AUTHOR]

Financial toxicity (FT) describes either objective or perceived excess financial strain due to a cancer diagnosis on the well-being of patients, families, and society. The consequences of FT have been shown to span countries of varied economic tiers and diverse healthcare models. This study attempts to describe FT and its effects in a lower- to middle-income country delivering predominantly public nonfee-levying healthcare. This was a cross-sectional study involving 210 patients with breast cancer of any stage (I to IV), interviewed between 6 and 18 months from the date of diagnosis. Financial toxicity was highly prevalent with 81% reporting 3 or more on a scale of 1 to 5. Costs incurred for travelling (94%), out-of-hospital investigations (87%), and consultation fees outside the public system (81%) were the most common contributors to FT. Daily compromises for food and education were made by 30% and 20%, respectively, with loss of work seen in over one-third. Greater FT was seen with advanced cancer stage and increasing distance to the nearest radiotherapy unit (P  = .008 and.01, respectively). Family and relatives were the most common form of financial support (77.6%). In conclusion, FT is substantial in our group, with many having to make daily compromises for basic needs. Many opt to visit the fee-levying private sector for at least some part of their care, despite the availability of an established public nonfee-levying healthcare. [ABSTRACT FROM AUTHOR]

Road collision types repeat themselves, especially in low- and middle-income countries (LMICs), where countermeasures are often improvised and implemented with little planning. At the Shahbag intersection in Dhaka, Bangladesh, speed bumps were quickly constructed at the exit of the intersection as an improvised road safety measure following the occurrence of a fatal collision, which eventually contributed to another collision between a truck and a car. The events influencing the improvisation decision, and that action's consequences, have been analysed using the Impromap methodology, a variation of the Accimap approach that focusses specifically on improvisation. The applicability of the Impromap as a systems-based approach to the road safety domain is assessed using the predictions described in Rasmussen's risk management framework, and corresponding countermeasures are proposed. The analysis shows that improvisation in the road safety domain is undesirable irrespective of the economic setting as it is likely to eventually contribute to secondary collisions. Practitioner summary: In this paper, the events influencing the improvisation decision following a road crash, and that action's consequences, have been analysed using the Impromap methodology. The applicability of Impromap as a systems-based approach in road safety domain is assessed using the Rasmussen's risk management framework-based predictions, and corresponding countermeasures are proposed. [ABSTRACT FROM AUTHOR]

Hypertension is the leading preventable cause of death worldwide. Two-thirds of people with hypertension live in Low- and Middle-Income Countries (LMIC). However, epidemiological data necessary to address the growing burden of hypertension and other Non-Communicable Diseases (NCDs) in LMICs are severely lacking. Electronic Health Records (EHRs) are an emerging source of epidemiological data for LMICs, but have been underutilized for NCD monitoring. The objective of this study was to estimate the prevalence of hypertension in a rural Indigenous community in Guatemala using EHR data, describe hypertension risk factors and current treatment in this population, and demonstrate the feasibility of using EHR data for epidemiological surveillance of NCDs in LMIC. We conducted a cross-sectional analysis of 3646 adult clinic visits. We calculated hypertension prevalence using physician diagnosis, antihypertensive treatment, or Blood Pressure (BP) ≥140/90 mmHg. We noted antihypertensives prescribed and BP control (defined as BP

IntroductionApproximately 70% of diarrheal cases in Kenya are attributed to ingestion of contaminated food and water and costs an estimated $ 1 billion USD due to morbidity and cost of treatment. This study aimed to assess the levels of microbiological contamination of meat sold in selected butcheries in Nairobi and the handling practices of butcher shop attendants.MethodsA cross-sectional study design was used during which 200 meat samples were collected, and meat handling practices were observed. Total coliforms and Escherichia coli were enumerated using 3M™ Petrifilm® count plates. Additionally, quantification of tetracycline- and cefotaxime-resistant Enterobacteriaceae was done on agar plates containing the respective antibiotics. Bacterial species were confirmed by Matrix-Assisted Laser Desorption/Ionization-Time of Flight mass spectrometry.Results and discussionSeventy two percent and 84% of the samples had E. coli and total coliforms respectively above the acceptable regulatory limits (i.e. E. coli >100 CFU/g, Total coliforms >361 CFU/g,) respectively as per the Kenya Bureau of Standards South African microbiological standards the European Union. Enterobacteriaceae resistant to tetracycline and cefotaxime were detected in 35% and 9.5% of the samples respectively. Eighty-five percent of the butcher shop attendants neither washed their hands before nor after handling the meat, 91% handled money while selling meat concurrently, and 99% did not wear gloves while handling meat. These poor meat handling practices coupled with the presence of microbial loads above the regulatory acceptable limits imply an increased risk of foodborne illness to consumers. Therefore, there is an urgent need for education of butcher shop attendants on appropriate handling of meat, highlighting the importance of good hygienic practices and their relationship to food safety, and provision of incentives for behavior change. This study is important and serves to inform policymakers in the identification of key control points for designing meat safety intervention(s).

BackgroundThe evaluation of existing resources and services is key to identify gaps and prioritize interventions to expand care capacity for children with central nervous system (CNS) tumors. We sought to evaluate the resources for pediatric neuro-oncology (PNO) in Mexico.MethodsA cross-sectional online survey with 35 questions was designed to assess PNO resources and services, covering aspects including number of patients, infrastructure, human resources, and diagnostic and treatment time intervals. The survey was distributed to the members of the Mexican Association of Pediatric Oncology and Hematology (AMOHP) who belong to the nation’s many different health systems.ResultsResponses were obtained from 33 institutions, distributed throughout the country and part of the many health systems that exist in Mexico. Twenty-one (64%) institutions had less than 10 new cases of pediatric CNS tumors per year. Although 30 (91%) institutions saw pediatric patients up to the age of 18 years, 2 (6%) had a cutoff of 15 years. Twenty-four (73%) institutions had between 1 and 3 pediatric oncologists providing care for children with CNS tumors. Six (18%) institutions did not have a neurosurgeon, while 19 (57%) institutions had a pediatric neurosurgeon. All centers had a pathology department, but 13 (39%) institutions only had access to basic histopathology. Eleven (33%) institutions reported histopathological diagnoses within one week, but 3 (9%) took more than 4 weeks. Radiotherapy for pediatric CNS tumors was referred to outside centers at 18 (55%) institutions. All centers had access to conventional cytotoxic chemotherapy, but only 6 (18%) had access to targeted therapy. Eighteen (55%) respondents estimated a survival rate of less than 60%. Fifteen (45%) centers attributed the main cause of mortality to non-tumor related factors, including infection and post-surgical complications.ConclusionsThis is the first national assessment of the resources available in Mexico for the treatment of CNS tumors. It shows disparities in resource capacity and a lack of the specific and efficient diagnoses that allow timely initiation of treatment. These data will enable the prioritization of collaborative interventions in the future.

Livestock associated antimicrobial resistance (AMR) can reduce productivity and cause economic losses, threatening the livelihoods of poor farming communities in low-income settings. We investigated the practices and risk factors for increased antibiotic use, and AMR in Escherichia coli including resistance to human critically important antibiotics like cefotaxime and colistin in semi-intensive and free-range poultry farms in Uganda. Samples and farm management data were collected from 402 poultry farms in two districts between October 2021 to March 2022. Samples were processed to isolate E. coli and to quantify cefotaxime (CTX) and colistin (COL) resistant coliforms. The identification of presumptive E. coli isolated on MacConkey agar without antibiotics, was confirmed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry and subjected to antimicrobial susceptibility testing by disk diffusion using EUCAST guidelines. Our models indicated that antibiotic use was associated with production intensity, and type of feed used. Moreover, semi-intensive farmers had better knowledge on antibiotic use compared to farmers in the free-range system. In semi-intensive farms, 52% harbored COLR and 57% CTXR coliforms. In free-range farms, 54% had COLR and 67% CTXR coliforms. Resistance to tetracycline, ampicillin and enrofloxacin were more frequent in semi-intensive farms compared to the free-range farms. Multi-drug resistant E. coli were identified in both poultry production systems despite different management and antibiotic use practices. There was no significant relationship between antibiotic use and resistance for the six antibiotics tested.

Risk stratification and molecular targeting have been key to increasing cure rates for pediatric cancers in high-income countries. In contrast, precise diagnosis in low-resource settings is hindered by insufficient pathology infrastructure. The Global HOPE program aims to improve outcomes for pediatric cancer in Sub-Saharan Africa (SSA) by building local clinical care and diagnostic capacity. This study aimed to assess the feasibility of implementing molecular assays to improve leukemia diagnoses in SSA. Custom NanoString nCounter gene fusion assays, previously validated in the US, were used to test samples from suspected leukemia patients. The NanoString platform was chosen due to relatively low cost, minimal technical and bioinformatics expertise required, ability to test sub-optimal RNA, and rapid turnaround time. Fusion results were analyzed blindly, then compared to morphology and flow cytometry results. Of 117 leukemia samples, 74 were fusion-positive, 30 were negative, 7 were not interpretable, and 6 failed RNA quality. Nine additional samples were negative for leukemia by flow cytometry and negative for gene fusions. All 74 gene fusions aligned with the immunophenotype determined by flow cytometry. Fourteen samples had additional information available to further confirm the accuracy of the gene fusion results. The testing provided a more precise diagnosis in >60% of cases, and 9 cases were identified that could be treated with an available tyrosine kinase inhibitor, if detected at diagnosis. As risk-stratified and targeted therapies become more available in SSA, implementing this testing in real-time will enable the treatment of pediatric cancer to move toward incorporating risk stratification for optimized therapy.

Background: Breast cancer (BC) is the most incident tumor and, consequently, any new intervention can potentially promote a considerable budget impact if incorporated. Cost-effectiveness (CE) studies assist in the decision-making process but may be influenced by the country's perspective of analysis and pharmaceutical industry funding. Methods: A systematic review of Medline, Scopus, and Web of Science from January 1st, 2012 to July 8th, 2022 was conducted to identify CE studies of tumor-targeted systemic-therapies for advanced BC. Articles without incremental cost-effectiveness ratio calculations were excluded. We extracted information on the country and class of drug studied, comparator type, authors’ conflicts of interest (COI), pharmaceutical industry funding, and authors' conclusions. Results: 71 studies comprising 204 CE assessments were included. The majority of studies were from the United States and Canada (44%), Asia (32%) and Europe (20%). Only 8% were from Latin America and none from Africa. 31% had pharmaceutical industry funding. The most studied drug classes were cyclin-dependent-kinase inhibitors (29%), anti-HER2 therapy (23%), anti-PD(L)1 (11%) and hormone therapy (11%). Overall, 34% of CE assessments had favorable conclusions. Pharmaceutical industry-funded articles had a higher proportion of at least one favorable conclusion (82% vs. 24%, p-value

BackgroundPublished literature documents tremendous gender inequities in the social, economic and health effects of the COVID-19 pandemic, but less evidence has come from low- and middle-income countries (LMICs) and even less from LMIC-based authors. We examine whether a) COVID-19 burden and b) LMIC-based authorship were associated with academic publications related to COVID-19 and women's well-being in LMICs.MethodsWe reviewed academic articles on COVID-19 and women's well-being in LMICs published between February 2020 and May 2021 (n=1076 articles), using six electronic databases (PubMed, Web of Science, PsycInfo, EconLit, RePeC, NBER). Multilevel, mixed effects linear regressions assessed the relationships between each of our independent variables - a) COVID-19 burden (cases/100 population, deaths/100 population, deaths/cases) and b) author's country of primary affiliation, with publications related to COVID-19 and women's well-being, both overall and stratified by country income group.FindingsEight-eight percent of articles had lead and/or senior authors affiliated with in-country institutions. Linear mixed effect models indicate that COVID-19 cases and case fatality ratios in a country were significantly and positively associated with the number of publications related to COVID-19 and women's well-being, though these relationships were significant only in upper-middle income group countries in stratified analyses. LMIC lead and senior authorship were also significantly and positively associated with our outcome, after adjusting for COVID-19 burden.InterpretationWhile the majority of COVID-19 research examining women's well-being in LMICs in the first year and a half of the pandemic included country-affiliated author leadership, there were important gaps in representation. Findings highlight the importance of LMIC-based scholars to build local and gendered research in crises.FundingBill and Melinda Gates Foundation (INV-018007).

Emma R Lawrence,1 Bela J Parekh,2 Ruth Owusu-Antwi,3 Noah Newman,2 Colin B Russell,1 Titus K Beyuo,4,5 Michael Yeboah,6 Samuel A Oppong,4,5 Cheryl A Moyer1,7 1Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; 2University of Michigan Medical School, Ann Arbor, MI, USA; 3Department of Behavioural Sciences, Kwame Nkrumah University of Science and Technology/ Psychiatry Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana; 4Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana; 5Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Korle Bu, Accra, Ghana; 6Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana; 7Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USACorrespondence: Ruth Owusu-Antwi, Department of Behavioural Sciences, Kwame Nkrumah University of Science and Technology/ Psychiatry Unit, Komfo Anokye Teaching Hospital, Accra Road, Kumasi, Ashanti Region, Ghana, Tel +233244650245, Email rucha_2001@yahoo.comPurpose: Globally, the COVID-19 pandemic has brought attention to the impact of negative patient outcomes on healthcare providers. In Ghana, obstetric providers regularly face maternal and neonatal mortality, yet limited research has focused on provision of mental health support for these providers. This study sought to understand how obstetric providers viewed seeking mental health support after poor clinical outcomes, with a focus on the role of mental health stigma.Patients and Methods: Participants were 52 obstetric providers (20 obstetrician/gynecologists and 32 midwives) at two tertiary care hospitals in Ghana. Five focus groups, led by a trained facilitator and lasting approximately two hours, were conducted to explore provider experiences and perceptions of support following poor maternal and neonatal outcomes. Discussions were audiotaped and transcribed verbatim, then analyzed qualitatively using grounded theory methodology.Results: Most participants (84.3%, N=43) were finished with training, and 46.2% (N=24) had been in practice more than 10 years. Emerging themes included pervasive stigma associated with seeking mental health care after experiencing poor clinical outcomes, which was derived from two overlapping dimensions. First, societal-level stigma resulted from a cultural norm to keep emotions hidden, and the perception that psychiatry is equated with severe mental illness. Second, provider-level stigma resulted from the belief that healthcare workers should not have mental health problems, a perception that mental health care is acceptable for patients but not for providers, and a fear about lack of confidentiality. Despite many providers acknowledging negative mental health impacts following poor clinical outcomes, these additive layers of stigma limited their willingness to engage in formal mental health care.Conclusion: This study demonstrates that stigma creates significant barriers to acceptance of mental health support among obstetric providers. Interventions to support providers will need to respect provider concerns without reinforcing the stigma associated with seeking mental health care.Keywords: provider burnout, therapy, sub-Saharan Africa, LMIC

Abstract Background Adolescents are vulnerable to stressors because of the rapid physical and mental changes that they go through during this life period. Young people residing in slum communities experience additional stressors due to living conditions, financial stress, and limited access to healthcare and social support services. The Adolescents’ Resilience and Treatment nEeds for Mental Health in Indian Slums (ARTEMIS) study, is testing an intervention intended to improve mental health outcomes for adolescents living in urban slums in India combining an anti-stigma campaign with a digital health intervention to identify and manage depression, self-harm/suicide risk or other significant emotional complaints. Methods In the formative phase, we developed tools and processes for the ARTEMIS intervention. The two intervention components (anti-stigma and digital health) were implemented in purposively selected slums from the two study sites of New Delhi and Vijayawada. A mixed methods formative evaluation was undertaken to improve the understanding of site-specific context, assess feasibility and acceptability of the two components and identify required improvements to be made in the intervention. In-depth interviews and focus groups with key stakeholders (adolescents, parents, community health workers, doctors, and peer leaders), along with quantitative data from the digital health platform, were analysed. Results The anti-stigma campaign methods and materials were found to be acceptable and received overall positive feedback from adolescents. A total of 2752 adolescents were screened using the PHQ9 embedded into a digital application, 133 (4.8%) of whom were identified as at high-risk of depression and/or suicide. 57% (n = 75) of those at high risk were diagnosed and treated by primary health care (PHC) doctors, who were guided by an electronic decision support tool based on WHO’s mhGAP algorithm, built into the digital health application. Conclusion The formative evaluation of the intervention strategy led to enhanced understanding of the context, acceptability, and feasibility of the intervention. Feedback from stakeholders helped to identify key areas for improvement in the intervention; strategies to improve implementation included engaging with parents, organising health camps in the sites and formation of peer groups. Trial Registration The trial has been registered in the Clinical Trial Registry India, which is included in the WHO list of Registries, Reference number: CTRI/2022/02/040307. Registered 18 February 2022.

Abstract Context An elective placement is a core part of most United Kingdom (UK) medical degrees, and a significant proportion of students choose to pursue their elective in low- and middle-income countries (LMIC). There is a risk that students are ill-prepared for some of the ethical challenges that they will face during these placements, and that they have little appreciation for some of the negative effects that their placement can have on the host healthcare system. This study sought to address some of these negative consequences by exploring the preparation of medical students for these experiences, and the effect of including the LMIC perspective in preparation materials. Methods This qualitative study used thematic analysis to explore the attitudes of final year medical students at a Scottish medical school to international volunteering, after completing a module on global health. This module was designed and delivered in partnership with academics from Malawi, Rwanda and Zambia, thus incorporating a strong LMIC perspective. Findings This study demonstrated the ability of a global health module with a strong LMIC perspective to influence the attitudes of final year medical students in the following ways: 1) Challenging assumptions around international volunteering and, in particular, around some of the negative effects of international volunteering that had not previously been considered. 2) Changing future practice around international volunteering. Implications This study provides good evidence that having a strong LMIC voice in preparation materials for medical students embarking on LMIC electives has the ability to increase awareness of some of the potential harms, and to positively influence how they plan to have discussions around and approach such experiences in the future.

Abstract Background Fewer than 1 in 20 people on the African continent in need of palliative care receive it. Malawi is a low-income country in sub-Saharan Africa that has yet to achieve advanced palliative care integration accompanied by unrestricted access to pain and symptom relieving palliative medicines. This paper studied the impact of Malawi’s Waterloo Coalition Initiative (WCI) – a local project promoting palliative care integration through service development, staff training, and increased service access. Methods Interdisciplinary health professionals at 13 hospitals in southern Malawi were provided robust palliative care training over a 10-month period. We used a cross-sectional evaluation to measure palliative care integration based on 11 consensus-based indicators over a one-year period. Results 92% of hospitals made significant progress in all 11 indicators. Specifically, there was a 69% increase in the number of dedicated palliative care rooms/clinics, a total of 253 staff trained across all hospitals (a 220% increase in the region), substantive increases in the number of patients receiving or assessed for palliative care, and the number of hospitals that maintained access to morphine or other opioid analgesics while increasing the proportion of referrals to hospice or other palliative care programs. Conclusion Palliative care is a component of universal health coverage and Sustainable Development Goal 3. The WCI has made tremendous strides in establishing and integrating palliative care services in Malawi with notable progress across 11 project indicators, demonstrating that increased palliative care access is possible in severely resource-constrained settings through sustained models of partnership at the local level.

Abstract Background This study of nutritional patterns in relation to cancers among pediatric oncology population in Tanzania was motivated by the lack of up-to-date information about the nutritional practices, the controversy around the importance of nutritional support and the lack of consistent nutritional criteria among pediatric oncology populations. Methods A survey study in two cancer referral hospitals of children diagnosed with any cancers, aged between 1 and 17 years inclusive and being eligible for enteral feeding included 131 children. Their demographic, nutritional, feeding and cancer profiles were analyzed descriptively through mapping and other approaches as well as inferentially using multinomial regression models to understand different aspects of nutrition for children suffering from cancers. Results The majority (15% or higher) of pediatric oncology population originated from the lake zone. Between 7 and 12% of pediatric oncology population originated from the Western zone. The top-three cancers with their percentages in the brackets were: Wilms Tumor (32%), Acute Lymphoblastic Leukemia (26%) and Retinoblastoma (13%). About 69% of the pediatric oncology population ate foods that are rich in energy but poor in protein such as rice (21.5%), porridge (19.3%), banana (11.7%) and potatoes (10.2%). On the other hand, only 17.5% ate foods that are generally protein-rich such as meat (8.0%), fish (5.3%) and chicken (4.2%); and 12.7% ate milk (4.2%), beans (3.4%), vegetables (2.7%), eggs (1.9%) and fruits (1.5%). Cancers impacted food intake in about 60% of all children with cancers and affected appetite in 18.3% of them. Cancers caused vomiting in 16% and diarrhea in 6.1% of children. The majority of children with cancers (61.8%) took at least one meal while 34.4% took just snacks (p

UNESCO’s Global Education Monitoring Report (2020) strongly recommends the adoption of Universal Design for Learning (UDL) at the government level so that it becomes an integral part of countries’ inclusive education policies. However, UDL has largely been developed in high-income countries with technology as a central theme. The question is whether the purported benefits of the UDL approach can translate into low and middle-income country (LMIC) contexts. This study explores the relevance and fit of UDL to LMIC contexts by use of interviews (either individual or group) with 12 representatives of international agencies, non-governmental organizations (NGOs), and UDL experts who have experience in providing inclusive education services in LMICs. Three themes are reported: understanding of UDL, UDL supporting inclusive education, and UDL in teacher-training initiatives and capacity building. The concept of UDL is not new in LMICs, although the name may be. The potential for UDL to support inclusive education in LMICs is recognized. UDL needs to be mainstreamed in teacher training programs, and its implementation should be adapted to respond to the contextual realities of LMICs. The encounter between UDL proponents from high-income countries and education stakeholders in LMICs should be mutually enriching rather than imposing the approach from high-income countries on those in LMICs.

Danai T Zhou,1 Taona E Mudhluli,1,2 Lindsay J Hall,3– 5 Justen Manasa,1,6 Shungu Munyati6 1Department of Laboratory Diagnostic and Investigative Sciences, University of Zimbabwe, Harare, Zimbabwe; 2Department of Biochemistry, Midlands State University, Gweru, Zimbabwe; 3Gut Microbes & Health, Quadram Institute Bioscience, Norwich, UK; 4Norwich Medical School, University of East Anglia, Norwich, UK; 5Intestinal Microbiome, Technical University of Munich, Freising, Germany; 6Department of Laboratory Sciences, Biomedical Research and Training Institute, Harare, ZimbabweCorrespondence: Danai T Zhou, Department of Laboratory Diagnostic and Investigative Sciences, University of Zimbabwe, Box A 178, Avondale, Harare, Zimbabwe, Email dzhou@medsch.uz.ac.zw; danaizh@yahoo.co.ukBackground: Gut microbiota play a key role in host health, with certain Bifidobacterium strains critical for immune development. The healthy gut of breastfed infants is dominated by these pioneer microbes, especially the strains that feed on human milk oligosaccharides.Objective: This is a scoping review of gut microbiome research from Zimbabwe. It focuses on distribution and dynamic changes of bifidobacteria, and milk components that promote growth of microbes in infants, together with the distribution of associated gut microbes in adults.Design: Online databases were searched for publications from 2000 to 2023.Results and Analysis: Fourteen publications on microbiota of infants and adults were included in this scoping review. Most were cross-sectional, while three were clinical trials/cohort protocols. Publications focused on pediatrics (78.5%), pregnant women (14.3%), and men (7.2%). Zimbabwe has a high burden of HIV; hence 35.7% of study populations were delineated by HIV status. The laboratory methods used included shotgun metagenomics (62%) or 16S rRNA gene amplicon sequencing. Almost 85% of the studies focused on total microbiome profiles and rarely reported the distribution of different Bifidobacterium species and variants. None of the papers studied human breast milk composition. There were reports of reduced abundance of beneficial genera in pregnant women, children, and adolescents living with HIV. Additionally, gut microbiota was reported to be poorly predictive of child growth and vaccine response, though this was not conclusive.Conclusion: There are few studies that characterize the gut microbiome by Zimbabwe-based researchers. However, studies on strain level diversity of Bifidobacterium and other key microbes, and their role in health during and beyond infancy, lag behind in Zimbabwe and other low- and middle-income countries. Such cohorts are needed to inform future mechanistic studies and downstream translational work such as next-generation probiotics and prebiotics.Keywords: Bifidobacterium, gut microbiome, human milk oligosaccharides, LMIC, prebiotics, probiotics, Zimbabwe

Background: Wilms Tumor (WT) is a highly curable cancer if treatment is appropriate and timely. The outcomes and prognostic factors in a large low- and middle-income country (LMIC) tertiary center were assessed. Materials and methods: Retrospective review of data of all patients, 0–15 years diagnosed between 2010 and 2020 with WT. Kaplan Meier curves were used for survival analysis, and the chi-square test was used for multivariate analysis. Results: Of the 40 patients enrolled (median age: 38 months) in the cohort, 10 had metastatic disease. The most common site of metastasis was lungs (6/10). Nine (22.5%) abandoned treatment. Large tumor (>500 ml) volume was found in half the patients at diagnosis. The majority of patients were treated per the SIOP approach. Out of 34 who went for surgery, 31 received neoadjuvant chemotherapy with tumor shrinkage to less than 500 ml in 26/31 (80%). Maximum tumor shrinkage was observed in the SIOP low-risk group (p

Background: Data on outcomes in children with acute lymphoblastic leukaemia (ALL) who are on Berlin-Frankfurt-Munster (BFM)-based chemotherapy protocol is scarce from India. We share experience on the survival of children with ALL treated on the modified IC BFM 2002 protocol. Methods: Children (1–18 years) diagnosed with ALL between January 1, 2011 and January 1, 2021 at BLK-MAX Super Specialty Hospital were analyzed retrospectively. Patients were treated with modified IC BFM 2002 protocol. Data on the type of leukaemia, risk status, minimal residual disease (MRD), cytogenetic, and molecular genetics were collected. Disease free survival (DFS) and overall survival (OS) were calculated. Results: Hundred (88 B-cell, 12 T-cell) patients with ALL were evaluated. The median age at presentation was 6.5 years. According to the BFM risk stratification, 35 children were standard-risk, 45 were intermediate and 20 were high-risk. Bone marrow aspiration for MRD by flow cytometry on day 33 of induction chemotherapy was performed in 61 patients. One patient died on day 50 of induction. Day 78 MRD was performed in 60 patients. Day 78 MRD positivity was used for treatment escalation. There were 18 deaths. DFS as on 1st July 2023 for standard, intermediate and high-risk patients was 89%, 85% and 55% respectively. Overall survival in all risk groups was 82%. Conclusion: Treating childhood ALL with BFM-based chemotherapy protocol is feasible in developing countries without major modifications and with results comparable to those reported in Western literature.

Introduction: Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery. Methods: In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p

Abstract Background South Africa has a complex range of historical, social, political, and economic factors that have shaped fatherhood. In the context of the Bukhali randomised controlled trial with young women in Soweto, South Africa, a qualitative study was conducted with the male partners of young women who had become pregnant during the trial. This exploratory study aimed to explore individual perceptions around relationship dynamics, their partner’s pregnancy, and fatherhood of partners of young women in Soweto, South Africa. Methods Individual, in-depth interviews were conducted with male partners (fathers, n = 19, 25–46 years old) of Bukhali participants. A thematic approach was taken to the descriptive and exploratory process of analysis, and three final themes and subthemes were identified: (1) relationship dynamics (nature of relationship, relationship challenges); (2) pregnancy (feelings about the pregnancy, effect of the pregnancy on their relationship, providing support during pregnancy; and 3) fatherhood (view of fatherhood, roles of fathers, influences on views and motivation, challenges of fatherhood). Results While most male participants were in a committed (“serious”) relationship with their female partner, less than half of them were cohabiting. Most reported that their partner’s pregnancy was not planned, and shared mixed feelings about the pregnancy (e.g., happy, excited, shocked, nervous), although their views about fatherhood were overwhelmingly positive. Many were concerned about how they would economically provide for their child and partner, particularly those who were unemployed. Participants identified both general and specific ways in which they provided support for their partner, e.g., being present, co-attending antenatal check-ups, providing material resources. For many, the most challenging aspect of fatherhood was having to provide financially. They seemed to understand the level of responsibility expected of them as a father, and that their involvement and presence related to love for and connection with their child. Participants’ responses indicated that there were some changes in the norms around fatherhood, suggesting that there is a possibility for a shift in the fatherhood narrative in their context. Conclusions These findings suggest that the complex array of factors influencing fatherhood in South Africa continue to play out in this generation, although promising changes are evident.

Abstract Background Factors influencing the health of populations are subjects of interdisciplinary study. However, datasets relevant to public health often lack interdisciplinary breath. It is difficult to combine data on health outcomes with datasets on potentially important contextual factors, like political violence or development, due to incompatible levels of geographic support; differing data formats and structures; differences in sampling procedures and wording; and the stability of temporal trends. We present a computational package to combine spatially misaligned datasets, and provide an illustrative analysis of multi-dimensional factors in health outcomes. Methods We rely on a new software toolkit, Sub-National Geospatial Data Archive (SUNGEO), to combine data across disciplinary domains and demonstrate a use case on vaccine hesitancy in Low and Middle-Income Countries (LMICs). We use data from the World Bank’s High Frequency Phone Surveys (HFPS) from Kenya, Indonesia, and Malawi. We curate and combine these surveys with data on political violence, elections, economic development, and other contextual factors, using SUNGEO. We then develop a stochastic model to analyze the integrated data and evaluate 1) the stability of vaccination preferences in all three countries over time, and 2) the association between local contextual factors and vaccination preferences. Results In all three countries, vaccine-acceptance is more persistent than vaccine-hesitancy from round to round: the long-run probability of staying vaccine-acceptant (hesitant) was 0.96 (0.65) in Indonesia, 0.89 (0.21) in Kenya, and 0.76 (0.40) in Malawi. However, vaccine acceptance was significantly less durable in areas exposed to political violence, with percentage point differences (ppd) in vaccine acceptance of -10 (Indonesia), -5 (Kenya), and -64 (Malawi). In Indonesia and Kenya, although not Malawi, vaccine acceptance was also significantly less durable in locations without competitive elections (-19 and -6 ppd, respectively) and in locations with more limited transportation infrastructure (-11 and -8 ppd). Conclusion With SUNGEO, researchers can combine spatially misaligned and incompatible datasets. As an illustrative example, we find that vaccination hesitancy is correlated with political violence, electoral uncompetitiveness and limited access to public goods, consistent with past results that vaccination hesitancy is associated with government distrust.

AbstractBackground and objectivesProcessOutcomesConclusionsThe rational for the Somaliland national harmonised curriculum (NHC) was driven by shared concern about the quality of medical education.The Ministry of Education and Science and the Ministry of Health Development produced a Medical Education Policy 2018. Policy objectives included the development of the NHC and accreditation for medical schools that met the standards of the World Federation for Medical Education (WFME). Two bodies were asked to oversee these aims: the National Health Professions’ Commission (NHPC) and the National Commission of Higher Education (NCHE). Between 2018 and 2020, a collaborative approach between the Somaliland government, medical school stakeholders, King’s Global Health Partnership’s (KGHP) volunteers and the Tropical Health Education Trust (THET) team was used to design the 6-years NHC. The NHC structure, content and delivery were grounded by WFME standards, health needs of the local population, student focused and active learning methods, and feasibility of implementation in medical schools.The NHC comprises details about the educational outcomes, curriculum model and framework, educational principles, instructional and learning methods, core as well as optional content, and assessment strategy.The approach used to develop the NHC ensured it is bespoken for Somaliland. Ongoing evaluation of patient and population needs, each medical school’s review of programme implementation and outcomes will inform continuous revision and renewal. [ABSTRACT FROM AUTHOR]

Background: Adolescents are vulnerable to stressors because of the rapid physical and mental changes that they go through during this life period. Young people residing in slum communities experience additional stressors due to living conditions, financial stress, and limited access to healthcare and social support services. The Adolescents' Resilience and Treatment nEeds for Mental Health in Indian Slums (ARTEMIS) study, is testing an intervention intended to improve mental health outcomes for adolescents living in urban slums in India combining an anti-stigma campaign with a digital health intervention to identify and manage depression, self-harm/suicide risk or other significant emotional complaints. Methods: In the formative phase, we developed tools and processes for the ARTEMIS intervention. The two intervention components (anti-stigma and digital health) were implemented in purposively selected slums from the two study sites of New Delhi and Vijayawada. A mixed methods formative evaluation was undertaken to improve the understanding of site-specific context, assess feasibility and acceptability of the two components and identify required improvements to be made in the intervention. In-depth interviews and focus groups with key stakeholders (adolescents, parents, community health workers, doctors, and peer leaders), along with quantitative data from the digital health platform, were analysed. Results: The anti-stigma campaign methods and materials were found to be acceptable and received overall positive feedback from adolescents. A total of 2752 adolescents were screened using the PHQ9 embedded into a digital application, 133 (4.8%) of whom were identified as at high-risk of depression and/or suicide. 57% (n = 75) of those at high risk were diagnosed and treated by primary health care (PHC) doctors, who were guided by an electronic decision support tool based on WHO's mhGAP algorithm, built into the digital health application. Conclusion: The formative evaluation of the intervention strategy led to enhanced understanding of the context, acceptability, and feasibility of the intervention. Feedback from stakeholders helped to identify key areas for improvement in the intervention; strategies to improve implementation included engaging with parents, organising health camps in the sites and formation of peer groups. Trial Registration: The trial has been registered in the Clinical Trial Registry India, which is included in the WHO list of Registries, Reference number: CTRI/2022/02/040307. Registered 18 February 2022. [ABSTRACT FROM AUTHOR]

Background: Fewer than 1 in 20 people on the African continent in need of palliative care receive it. Malawi is a low-income country in sub-Saharan Africa that has yet to achieve advanced palliative care integration accompanied by unrestricted access to pain and symptom relieving palliative medicines. This paper studied the impact of Malawi's Waterloo Coalition Initiative (WCI) – a local project promoting palliative care integration through service development, staff training, and increased service access. Methods: Interdisciplinary health professionals at 13 hospitals in southern Malawi were provided robust palliative care training over a 10-month period. We used a cross-sectional evaluation to measure palliative care integration based on 11 consensus-based indicators over a one-year period. Results: 92% of hospitals made significant progress in all 11 indicators. Specifically, there was a 69% increase in the number of dedicated palliative care rooms/clinics, a total of 253 staff trained across all hospitals (a 220% increase in the region), substantive increases in the number of patients receiving or assessed for palliative care, and the number of hospitals that maintained access to morphine or other opioid analgesics while increasing the proportion of referrals to hospice or other palliative care programs. Conclusion: Palliative care is a component of universal health coverage and Sustainable Development Goal 3. The WCI has made tremendous strides in establishing and integrating palliative care services in Malawi with notable progress across 11 project indicators, demonstrating that increased palliative care access is possible in severely resource-constrained settings through sustained models of partnership at the local level. [ABSTRACT FROM AUTHOR]

Context: An elective placement is a core part of most United Kingdom (UK) medical degrees, and a significant proportion of students choose to pursue their elective in low- and middle-income countries (LMIC). There is a risk that students are ill-prepared for some of the ethical challenges that they will face during these placements, and that they have little appreciation for some of the negative effects that their placement can have on the host healthcare system. This study sought to address some of these negative consequences by exploring the preparation of medical students for these experiences, and the effect of including the LMIC perspective in preparation materials. Methods: This qualitative study used thematic analysis to explore the attitudes of final year medical students at a Scottish medical school to international volunteering, after completing a module on global health. This module was designed and delivered in partnership with academics from Malawi, Rwanda and Zambia, thus incorporating a strong LMIC perspective. Findings: This study demonstrated the ability of a global health module with a strong LMIC perspective to influence the attitudes of final year medical students in the following ways: 1) Challenging assumptions around international volunteering and, in particular, around some of the negative effects of international volunteering that had not previously been considered. 2) Changing future practice around international volunteering. Implications: This study provides good evidence that having a strong LMIC voice in preparation materials for medical students embarking on LMIC electives has the ability to increase awareness of some of the potential harms, and to positively influence how they plan to have discussions around and approach such experiences in the future. [ABSTRACT FROM AUTHOR]

The World Health Organization recommends human papillomavirus (HPV) testing for cervical screening. Extended genotyping can identify the highest‐risk HPV‐positive women. An inexpensive, rapid, mobile isothermal amplification assay (ScreenFire HPV RS test) was recently redesigned to yield four channels ordered by cancer risk (ie, hierarchical approach): HPV16, HPV18/45, HPV31/33/35/52/58 and HPV39/51/56/59/68. Stored specimens from 2076 women (mean age 30.9) enrolled in a colposcopy clinic, with high HPV prevalence, were tested with ScreenFire. We calculated hierarchical channel positivity and non‐hierarchical channel and type positivity, according to histologic diagnosis (256 cancer, 350 cervical intraepithelial neoplasia [CIN]3, 409 CIN2, 1020 < CIN2) and known virologic reference results (Linear Array and TypeSeq). Additionally, we analyzed ScreenFire time‐to‐positive up to 60 min by channel and histology. Overall clinical sensitivity for CIN3+ was 94.7% (95% confidence interval 92.6‐96.4), similar to Linear Array (92.3, 89.7‐94.3) and TypeSeq (96.0, 93.9‐97.6). Sensitivity was high for all types and channels. The hierarchical approach was well in line with HPV typing and histologic diagnosis, prioritizing higher risk women having HPV16 and precancer. For HPV16, time‐to‐positive was shorter in women with precancer. ScreenFire showed excellent agreement with research reference typing tests and detection of CIN2+. Risk‐based type results could help guide clinical management of HPV‐positive women. Time‐to‐positive combined with genotyping might be useful. ScreenFire is rapid, mobile, relatively inexpensive and designed for implementation of HPV‐based screening and management, including in lower‐resource settings. Further validation in screening by self‐sampling and practical effectiveness merit evaluation. [ABSTRACT FROM AUTHOR]

Background: This study of nutritional patterns in relation to cancers among pediatric oncology population in Tanzania was motivated by the lack of up-to-date information about the nutritional practices, the controversy around the importance of nutritional support and the lack of consistent nutritional criteria among pediatric oncology populations. Methods: A survey study in two cancer referral hospitals of children diagnosed with any cancers, aged between 1 and 17 years inclusive and being eligible for enteral feeding included 131 children. Their demographic, nutritional, feeding and cancer profiles were analyzed descriptively through mapping and other approaches as well as inferentially using multinomial regression models to understand different aspects of nutrition for children suffering from cancers. Results: The majority (15% or higher) of pediatric oncology population originated from the lake zone. Between 7 and 12% of pediatric oncology population originated from the Western zone. The top-three cancers with their percentages in the brackets were: Wilms Tumor (32%), Acute Lymphoblastic Leukemia (26%) and Retinoblastoma (13%). About 69% of the pediatric oncology population ate foods that are rich in energy but poor in protein such as rice (21.5%), porridge (19.3%), banana (11.7%) and potatoes (10.2%). On the other hand, only 17.5% ate foods that are generally protein-rich such as meat (8.0%), fish (5.3%) and chicken (4.2%); and 12.7% ate milk (4.2%), beans (3.4%), vegetables (2.7%), eggs (1.9%) and fruits (1.5%). Cancers impacted food intake in about 60% of all children with cancers and affected appetite in 18.3% of them. Cancers caused vomiting in 16% and diarrhea in 6.1% of children. The majority of children with cancers (61.8%) took at least one meal while 34.4% took just snacks (p < 0.001). Conclusions: The majority of pediatric oncology population had erratic nutritional patterns and took foods high in energy and poor in proteins. There is a two-way interaction between cancers and nutrition in which cancers affect general nutritional intake which could affect the cancer treatment outcomes in return. Therefore, it is important to consider these interactions while managing pediatric oncology populations in this and similar settings. [ABSTRACT FROM AUTHOR]

Research capacity building is a process by which individuals and organizations develop skills and infrastructure resulting in greater ability to conduct useful research. Frequently, research quality and productivity measures focus on outcomes, such as peer-reviewed publications or grants awarded. Such distal measures are not informative when measuring initial stages of research, a common situation in low- and middle-income countries. This study used Cooke's six-principle framework to assess the progress of an autism research collaborative in northern Mexico. We established 64 criteria across the six principles and rated them as Not Started, In Progress, or Achieved, based on narratives and process documentation collected for this purpose. Ratings were established for the years 2018, 2020, and 2022, which correspond to Years 5, 7, and 9 since the beginning of the collaborative, respectively. As of 2022, Principles 2 and 3 ("Close to practice" and "Linkages, collaborations, and partnerships," respectively) had all begun; no criteria were rated as Not started. The principles with the highest Achieved rates were "Linkages, collaborations, and partnerships" (90%), and "Infrastructure" (Principle 6, 70%). Cooke's research capacity building framework is a useful way to monitor progress of research capacity building and contribute to harmonious development of relevant principles at different levels. To inform improvement of care and public policy, quality research is required. Conducting research projects requires skills and infrastructure. Research capacity building is the process by which individuals and organizations develop greater ability to conduct useful research. However, in the scientific community, research quality and productivity measures are often focused on long-term products, such as publications or grants awarded. Those measures are not helpful when measuring initial stages of research, a common situation in low- and middle-income countries. We used a six-principle framework designed by J. Cooke to assess the progress of an autism research collaborative in northern Mexico. We established 64 criteria across the six principles, and rated them as Not Started, In Progress, or Achieved, based on narratives and process documentation collected for this purpose. Ratings were established for the Years 2018, 2020, and 2022. The principles with the highest Achieved rates were "Linkages, collaborations, and partnerships" (90%), and "Infrastructure" (Principle 6, 70%). Cooke's research capacity building framework is a useful way to monitor progress of research capacity building and contribute to harmonious development of relevant principles at different levels. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Introduction: The Baylor International Pediatric AIDS Initiative (BIPAI) Network supports a network of independent nongovernmental organizations providing health care for children and families in low- and middle-income countries (LMIC). Using a community of practice (CoP) framework, a continuing professional development (CPD) program was created for health professionals to enhance knowledge and exchange best practices. Methods: An online learning platform (Moodle), videoconferencing (Zoom), instant messaging systems (Whatsapp), and email listserv facilitated learning and interaction between program participants. Target participants initially included pharmacy staff and expanded to include other health professionals. Learning modules included asynchronous assignments and review of materials, live discussion sessions, and module pretests and posttests. Evaluation included participants' activities, changes in knowledge, and assignment completion. Participants provided feedback on program quality via surveys and interviews. Results: Five of 11 participants in Year 1 earned a certificate of completion, and 17 of 45 participants earned a certificate in Year 2. Most modules showed an increase in module pretest and posttest scores. Ninety-seven percent of participants indicated that the relevance and usefulness of modules were good or outstanding. Ongoing evaluation indicated changes in Year 2 for program improvement, and notable outcomes indicated how CoP added value in developing a true community. Discussion: Using a CoP framework allowed participants to improve their personal knowledge and become part of a learning community and network of interdisciplinary health care professionals. Lessons learned included expanding program evaluation to capture potential value creation of the community of practice in addition to individual-level development; providing briefer, more focused programs to better serve busy working professionals; and optimizing use of technological platforms to improve participant engagement. [ABSTRACT FROM AUTHOR]

Introduction: Action 3 of the UN Decade of Healthy Ageing plan is to deliver integrated care to improve older adults' lives. Integrated care is vital in meeting the complex needs of people with dementia but little is known about how this is or could be delivered in low and middle income countries (LMIC). This paper provides insights into previously unknown care system structures and on the potential and reality of delivering integrated care in Central America for people with dementia. Methods: A social network analysis (SNA) methodology was adopted to engage with providers of services for older adults and families with dementia in Guatemala, El Salvador, Honduras, Costa Rica and Panama. Sixty-eight (68) semi-structured interviews were completed, 57 with organisations and 11 with families. Results: Across the five countries there was evidence of fragmentation and low integration within the dementia care systems. A variety of services and types of providers are present in all five countries, and high levels of diversified connections exist among organisations of differing disciplines. However, unawareness among network members about other members that they could potentially form active links with is a barrier on the path to integration. Conclusion: This innovative and robust study demonstrates SNA can be applied to evaluate LMIC care systems. Findings provide baselines of system structures and insights into where resources are needed to fortify integration strategies. Results suggest that Central American countries have the building blocks in place to develop integrated care systems to meet the needs of people with dementia, but the links across service providers are opportunistic rather than context based coordinated integration policies. [ABSTRACT FROM AUTHOR]

Background: Governmental and non-governmental organizations across medical, legal, and psychosocial sectors providing care to survivors of gender-based violence (GBV) and their families rapidly digitalized services during the COVID-19 pandemic. GBV prevention/ response services working with women and children who are forcibly displaced and/or living in low-and-middle income countries (LMIC) were no exception to the rapid digitalization trend. Literature is lacking a critical synthesis of best practices and lessons learned since digitalization replaced major operations involved in GBV prevention/response. Objective: This research qualitatively investigated how GBV service providers, located in a range of socio-political settings, navigated the process of digitalizing GBV prevention/ response during the COVID-19 crisis. Method: Semi-structured key informant interviews (KII) with GBV service providers in varied sectors were implemented virtually (2020–2021) in Brazil, Guatemala, Iraq, and Italy (regarding forcibly displaced women/girls for the latter). Participants were recruited using purposive and snowball sampling. Interview guides covered a range of topics: perceived changes in violence and service provision, experiences with virtual services, system coordination, and challenges. The KIIs were conducted in Portuguese, Spanish, Arabic, and Italian. Interviews were audio-recorded, transcribed, and translated into English. The research team conducted thematic analysis within and between countries using a structured codebook of data driven and theory driven codes. Results: Major themes concerned the: (1) spectrum of services that were digitalized during the COVID-19 crisis; (2) gender digital divide as a barrier to equitable, safe, and effective service digitalization; (3) digital violence as an unintended consequence of increased digitalization across social/public services. Conclusion: Digitalization is a balancing act with respect to (1) the variety of remotelydelivered services that are possible and (2) the access/safety considerations related to the gender digital divide and digital violence. [ABSTRACT FROM AUTHOR]