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Dementia is a global public health priority which cost global societies $818 billion in 2015 and is disproportionately impacting low and middle-income countries (LMICs). With limited availability of disease modifying drugs to treat Alzheimer's disease (AD), researchers have increasingly focused on preventative strategies which may promote healthy cognitive aging and mitigate the risk of cognitive impairment in aging. Lifelong bilingualism has been presented as both a highly debated and promising cognitive reserve factor which has been associated with better cognitive outcomes in aging. A recent metanalysis has suggested that bilingual individuals present on average 4.05 years later with the clinical features of AD than monolinguals. Bilinguals are also diagnosed with AD ~2.0 years later than monolingual counterparts. In this perspective piece we critically evaluate the findings of this metanalysis and consider the specific implications of these findings to LMICs. Furthermore, we appraise the major epidemiological studies conducted globally on bilingualism and the onset of dementia. We consider how both impactful and robust studies of bilingualism and cognition in older age may be conducted in LMICs. Given the limited expenditure and resources available in LMICs and minimal successes of clinical trials of disease modifying drugs we propose that bilingualism should be positioned as an important and specific public health strategy for maintaining healthy cognitive aging in LMICs. Finally, we reflect upon the scope of implementing bilingualism within the education systems of LMICs and the promotion of bilingualism as a healthy cognitive aging initiative within government policy.

This study adapted and tested the efficacy of the Red-Light Purple-Light (RLPL) games for improving executive function (EF) skills in preprimary classrooms in Nairobi, Kenya. A cluster randomized controlled trial was used to evaluate the efficacy of the adapted RLPL intervention. Specifically, 24 centers (including 48 classrooms) were randomized to the RLPL or a wait-list control condition. Consistent with previous studies, participating classrooms delivered 16 lessons across an 8-week intervention period. A total of 479 children were recruited into the study. After exclusions based on child age and data quality, 451 and 404 children (90% retention) had completed computerized assessments of EF skills at pre- and posttest assessments, respectively. Children in the RLPL centers did not demonstrate any improvements in EF skills relative to their peers in the wait-list control condition (Cohen’s ds = −0.14 to 0.03, all ps > 0.20). Exploratory tests of moderators (language of assessment, grade, school type, baseline ability) were also all null. Results are discussed with respect to measurement limitations and contextual factors that may explain the null results of RLPL on EF skills in young children in Kenya.

Background: Launched in 2018, Time to Change Global is a new anti-stigma programme to tackle stigma and discrimination towards people with mental health problems in low- and middle-income countries. Our aim was to evaluate pre-post changes in stigma within the target populations for the social marketing campaigns ran in Ghana and Kenya carried out as components of the wider Time to Change Global programme.Methods: Using data collected before and after each campaign in Accra and Nairobi, we investigated pre-post differences in stigma-related outcome measures: mental health-related knowledge (MAKS), mental health-related attitudes (CAMI), and desire for social distance (RIBS), with regression analyses. Other covariates were included in the models to control for differences in participant demographics.Results: A significant positive change in a stigma related outcome was found at each site. Reported in standard deviation units, desire for social distance from people with mental health problems in Accra was lower after the launch of the campaign, measured as an increase in intended contact (β = 0.29, 95% CI = 0.14 to 0.43, p < 0.001). In Nairobi, the stigma related knowledge score was higher in the post campaign sample (β = 0.21, 95% CI = 0.07 to 0.34, p = 0.003).Conclusion: The increase in intended contact in the absence of other changes seen in Ghana, is consistent with the early results for Time to Change England. The estimate for the magnitude of this change is the same as Time to Change England for the general population between 2009 and 19, a very promising result for a short term public mental health campaign. The different results observed between sites may be due to campaign as well as population differences. [ABSTRACT FROM AUTHOR]

Objective: Longitudinal measurement invariance analyses are an important way to assess a test's ability to estimate the underlying construct over time, ensuring that cognitive scores across visits represent a similar underlying construct, and that changes in test performance are attributable to individual change in cognitive abilities. We aimed to evaluate longitudinal measurement invariance in a large, social and culturally diverse sample over time. Methods: A total of 5,949 participants from the Brazilian Longitudinal Study of Adult Health (ELSA- Brasil) were included, whose cognition was reassessed after four years. Longitudinal measurement invariance analysis was performed by comparing a nested series of multiple-group confirmatory factor analysis models (for memory and executive function factors). Results: Configural, metric, scalar and strict invariance were tested and supported over time. Conclusion: Cognitive temporal changes in this sample are more likely to be due to normal and/or pathological aging. Testing longitudinal measurement invariance is essential for diverse samples at high risk of dementia, such as in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

The role of pharmacists in healthcare is undergoing transformation throughout the world. The continuing professional development (CPD) model has motivated pharmacists in developed countries to adopt lifelong learning. This is vital to improve competence and to optimize patient care. This study aimed to explore the existence and understanding of CPD in Ghana, Pakistan, and Trinidad and Tobago, the barriers faced in development of a CPD model, and probable policies needed to build/improve such a model. Audiotaped qualitative in-depth interviews were conducted, transcribed, and coded with pharmacy stakeholders, including academics, community pharmacists, and regulatory professionals. A thematic analysis of the transcribed data led to the extraction of the main themes. The findings showed a process of establishment of CPD for pharmacists in Ghana, whereas in Pakistan, Trinidad, and Tobago there was no CPD model. These findings indicate the need for a realistic, relevant, and mandatory program of CPD in these countries. [ABSTRACT FROM AUTHOR]

Dementia is a global public health priority which cost global societies $818 billion in 2015 and is disproportionately impacting low and middle-income countries (LMICs). With limited availability of disease modifying drugs to treat Alzheimer's disease (AD), researchers have increasingly focused on preventative strategies which may promote healthy cognitive aging and mitigate the risk of cognitive impairment in aging. Lifelong bilingualism has been presented as both a highly debated and promising cognitive reserve factor which has been associated with better cognitive outcomes in aging. A recent metanalysis has suggested that bilingual individuals present on average 4.05 years later with the clinical features of AD than monolinguals. Bilinguals are also diagnosed with AD ~2.0 years later than monolingual counterparts. In this perspective piece we critically evaluate the findings of this metanalysis and consider the specific implications of these findings to LMICs. Furthermore, we appraise the major epidemiological studies conducted globally on bilingualism and the onset of dementia. We consider how both impactful and robust studies of bilingualism and cognition in older age may be conducted in LMICs. Given the limited expenditure and resources available in LMICs and minimal successes of clinical trials of disease modifying drugs we propose that bilingualism should be positioned as an important and specific public health strategy for maintaining healthy cognitive aging in LMICs. Finally, we reflect upon the scope of implementing bilingualism within the education systems of LMICs and the promotion of bilingualism as a healthy cognitive aging initiative within government policy. [ABSTRACT FROM AUTHOR]

Background: Engagement with diverse stakeholders, including policy makers, care providers and service users and communities, is essential for successful implementation of global mental health interventions. Despite being a fundamental factor in the implementation process, evidence about challenges and drivers to stakeholder engagement is limited in the global mental health literature. Methods: We conducted semi-structured qualitative interviews with 29 recipients of Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of projects. We used framework analysis to identify key themes related to implementation barriers and drivers. This paper reports on barriers and drivers to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this journal. Results: Barriers and drivers to stakeholder engagement were identified across four themes: (1) Contextual Considerations, (2) Resources, (3) Participation, Uptake and Empowerment, and (4) Stigma. While complex contextual challenges create barriers, mechanisms such as formative research can facilitate a deeper contextual understanding that supports effective implementation planning. Limited financial and human resources and competing priorities can lead to substantial challenges. Investing in and leveraging existing local resources and expertise can help to mitigate these barriers. The challenge of achieving active participation from stakeholders and diverging expectations about the nature of participation were identified as barriers, while providing opportunities for meaningful participation and empowerment acted as drivers. Stigma at the institutional, community and individual level was also identified as a substantial barrier to engagement. Conclusion: The findings of this study are relevant to implementers in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement by investing in high-quality formative research, supporting capacity building for policy engagement, investing in longer-term funding schemes to support sustainable partnerships and scale-up, thus fostering successful engagement and supporting effective implementation of global mental health innovations. [ABSTRACT FROM AUTHOR]

Background: Health-related quality of life is recognized as a key outcome in chronic disease management, including kidney disease. With no national healthcare coverage for hemodialysis, Ugandan patients struggle to pay for their care, driving families and communities into poverty. Studies in developed countries show that patients on hemodialysis may prioritize quality of life over survival time, but there is a dearth of information on this in developing countries. We therefore measured the quality of life (QOL) and associated factors in end stage renal disease (ESRD) patients in a major tertiary care hospital in Uganda. Methods: Baseline QOL measurement in a longitudinal cohort study was undertaken using the Kidney Disease Quality of Life Short Form Ver 1.3. Patients were recruited from the adult nephrology unit if aged > 18 years with an estimated glomerular filtration rate ≤ 15mls/min/1,73m2. Clinical, demographic and micro-financial information was collected to determine factors associated with QOL scores. Results: Three hundred sixty-four patients (364) were recruited, of whom 124 were on hemodialysis (HD) and 240 on non-hemodialysis (non-HD) management. Overall, 94.3% of participants scored less than 50 (maximum 100). Mean QOL scores were low across all three principal domains: physical health (HD: 33.14, non-HD: 34.23), mental health (HD: 38.01, non-HD: 38.02), and kidney disease (HD: 35.16, non-HD: 34.00). No statistically significant difference was found between the overall quality of life scores of the two management groups. Breadwinner status (p < 0.001), source of income (p0.026) and hemodialysis management type (p0.032) were the only factors significantly associated with QOL scores, and this was observed in the physical health and kidney disease principal domains only. No factors were significantly associated with scores for the mental health principal domain and/or overall QOL score. Conclusion: The quality of life of Ugandan patients with ESRD has been found to be lower across all three domains of the Kidney Disease Quality of Life Short Form than reported anywhere in the world, with no difference observed between the non-HD and HD management groups. Interventions targeting all domains of QOL are needed among patients with ESRD in Uganda and, potentially, in other resource limited settings. [ABSTRACT FROM AUTHOR]

Background: Recognising the significant extent of poor-quality care and human rights issues in mental health, the World Health Organization launched the QualityRights initiative in 2013 as a practical tool for implementing human rights standards including the United Nations Convention on Rights of Persons with Disabilities (CRPD) at the ground level.AimsTo describe the first large-scale implementation and evaluation of QualityRights as a scalable human rights-based approach in public mental health services in Gujarat, India.Method: This is a pragmatic trial involving implementation of QualityRights at six public mental health services chosen by the Government of Gujarat. For comparison, we identified three other public mental health services in Gujarat that did not receive the QualityRights intervention.Results: Over a 12-month period, the quality of services provided by those services receiving the QualityRights intervention improved significantly. Staff in these services showed substantially improved attitudes towards service users (effect sizes 0.50-0.17), and service users reported feeling significantly more empowered (effect size 0.07) and satisfied with the services offered (effect size 0.09). Caregivers at the intervention services also reported a moderately reduced burden of care (effect size 0.15).Conclusions: To date, some countries are hesitant to reforming mental health services in line with the CRPD, which is partially attributable to a lack of knowledge and understanding about how this can be achieved. This evaluation shows that QualityRights can be effectively implemented even in resource-constrained settings and has a significant impact on the quality of mental health services.Declaration of interestNone. [ABSTRACT FROM AUTHOR]

This study adapted and tested the efficacy of the Red-Light Purple-Light (RLPL) games for improving executive function (EF) skills in preprimary classrooms in Nairobi, Kenya. A cluster randomized controlled trial was used to evaluate the efficacy of the adapted RLPL intervention. Specifically, 24 centers (including 48 classrooms) were randomized to the RLPL or a wait-list control condition. Consistent with previous studies, participating classrooms delivered 16 lessons across an 8-week intervention period. A total of 479 children were recruited into the study. After exclusions based on child age and data quality, 451 and 404 children (90% retention) had completed computerized assessments of EF skills at pre- and posttest assessments, respectively. Children in the RLPL centers did not demonstrate any improvements in EF skills relative to their peers in the wait-list control condition (Cohen's ds = −0.14 to 0.03, all p s > 0.20). Exploratory tests of moderators (language of assessment, grade, school type, baseline ability) were also all null. Results are discussed with respect to measurement limitations and contextual factors that may explain the null results of RLPL on EF skills in young children in Kenya. [ABSTRACT FROM AUTHOR]

The Indian health care system lacks the infrastructure to meet the health care demands of the country. Physician and nurse availability is 30 and 50% below WHO recommendations, respectively, and has led to a steep imbalance between the demand for health care and the infrastructure available to support it. Among other concerns, India still struggles with challenges like undernutrition, with 38% of children under the age of five being underweight. Despite these challenges, technological advancements, mobile phone ubiquity and rising patient awareness offers a huge opportunity for artificial intelligence to enable efficient healthcare delivery, by improved targeting of constrained resources. The Saathealth mobile app provides low-middle income parents of young children nflwith interactive children’s health, nutrition and development content in the form of an entertaining video series, a gamified quiz journey and targeted notifications. The app iteratively evolves the user journey based on dynamic data and predictive algorithms, empowering a shift from reactive to proactive care. Saathealth users have registered over 500,000 sessions and over 200 million seconds on-app engagement over a year, comparing favorably with engagement on other digital health interventions in underserved communities. We have used valuable app analytics data and insights from our 45,000 users to build scalable, predictive models that were validated for specific use cases. Using the Random Forest model with heterogeneous data allowed us to predict user churn with a 93% accuracy. Predicting user lifetimes on the mobile app for preliminary insights gave us an RMSE of 25.09 days and an R2 value of 0.91, reflecting closely correlated predictions. These predictive algorithms allow us to incentivize users with optimized offers and omni-channel nudges, to increase engagement with content as well as other targeted online and offline behaviors. The algorithms also optimize the effectiveness of our intervention by augmenting personalized experiences and directing limited health resources toward populations that are most resistant to digital first interventions. These and similar AI powered algorithms will allow us to lengthen and deepen the lifetime relationship with our health consumers, making more of them effective, proactive participants in improving children’s health, nutrition and early cognitive development.

Background: Studies relating childhood cognitive development to poor linear growth seldom take adequate account of social conditions related to both, leading to a focus on nutrition interventions. We aimed to assess the roles of both biological and social conditions in determining early childhood cognition, mediated by birthweight and early linear growth. Methods: After exploratory structural equation modelling to identify determining factors, we tested direct and indirect paths to cognitive performance through birthweight and child height-for-age at 2 years, assessed between 4 and 8.5 years of age among 2448 children in four birth cohort studies in low-and-middle-income countries (Brazil, Guatemala, Philippines and South Africa). Determinants were compared across the cohorts. Findings: Three factors yielded excellent fit, comprising birth endowment (primarily maternal age and birth order), household resources (crowding, dependency) and parental capacity (parental education). We estimated their strength together with maternal height in determining cognitive performance. Percentage shares of total effects of the four determinants show a marked transition from mainly biological determinants of birth weight (birth endowment 34%) and maternal height (30%) compared to household resources (25%) and parental capacity (11%), through largely economic determinants of height at 2 years (household resources (60%) to cognitive performance being predominantly determined by parental capacity (64%) followed by household resources (29%). The largely biological factor, birth endowment (maternal age and birth order) contributed only 7% to childhood cognitive performance and maternal height was insignificant. In summary, the combined share of social total effects (household resources and parental capacity) rises from 36∙2% on birth weight, to 78∙2% on height for age at 24 m, and 93∙4% on cognitive functioning. Interpretation: Across four low- and middle-income contexts, cognition in childhood is influenced more by the parental capacity of families and their economic resources than by birth weight and early linear growth. Improving children's cognitive functioning requires multi-sectoral interventions to improve parental education and enhance their economic wellbeing, interventions that are known to improve also early childhood growth.

Background As in many Sub-Saharan African countries, the health system in Somalia is not operating at the capacity needed to lift childhood vaccination coverage to ninety percent or above, as recommended by United Nations Children’s Fund. Current national estimates of coverage for the six major vaccine preventable childhood diseases range from thirty to sixty percent. Infectious disease outbreaks continue to pose significant challenges for the country’s health authorities. Objective This important qualitative study, conducted in Galkayo District, Somalia, investigates limiting factors associated with childhood vaccination uptake from the perspective of both communities and health care workers. Methods Qualitative information was collected through six focus group discussions with parents (n = 48) and five one-to-one interviews with health workers (n = 15) between March and May 2017, in three settings in the Galkayo District – Galkayo city, Bayra and Bacadwayn. Results From a health system perspective, the factors are: awareness raising, hard to reach areas, negative attitudes and perceived knowledge of health workers, inadequate supplies and infrastructure, and missed vaccination opportunities. From the perspective of individuals and communities the factors are: low trust in vaccines, misinterpretation of religious beliefs, vaccine refusals, Somalia’s patriarchal system and rumours and misinformation. Parents mostly received immunization information from social mobilizers and health facilities. Fathers, who are typically family decision-makers, were poorly informed. The findings highlight the need for in-service training to enable health workers to improve communication with parents, particularly fathers, peripheral communities and local religious leaders. Conclusions Enhancing knowledge and awareness of vaccination among parents is crucial. Fathers’ involvement is lacking. This may be boosted by highlighting fathers’ obligation to protect their children’s health through vaccination. It is also important that men engage with the wider community in decision-making and advance towards the global vaccination targets.

• Novel cost-effective compensator to deliver IMRT in low-and-middle income countries. • A reusable bead-based compensator provides dose distribution similar to a solid compensator with low cost. • The system can be used with cobalt-60 unit or linear accelerator. • Beam profiles show no significant signature of the beads relative to a solid compensator. We propose a novel cost-effective compensator that can be used to facilitate access to IMRT in low-and-middle income countries. The compensator has the advantages of simplicity, less downtime, increased reliability and less impact on treatment quality from patient motion during treatment. Moreover, the system can be used with either a cobalt-60 unit or linear accelerator. In this Monte Carlo study, the dosimetric properties of the new compensator design have been evaluated. Results were obtained for different field sizes of cobalt teletherapy machine, and the dose was scored at 0.5 cm depth in a water phantom. The effects of compensator thickness, filling material type and shape, and field size were identified. Furthermore, the percentage depth dose and beam profiles for various field sizes and at different depths were obtained. Beam profiles show no significant signature of the beads relative to a solid compensator; in addition, they exhibit a better flatness while preserving symmetry for all field sizes. A reusable bead-based compensator appears to be feasible, and provides dose distribution similar to a solid compensator with low cost and no hazards. Our results avail the ongoing efforts to expand the reach to IMRT in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the association between visual impairment (VI) and depression in low‐ and middle‐income countries (LMICs) and the mediating role of disability and social participation. Methods/Design: The World Health Organization Study on global AGEing and adult health (SAGE) provided data on objective and subjective visual function, depression, disability (WHODAS‐12), and social participation for nationally representative samples of adults 50 years and older in China, India, Ghana, Mexico, Russia, and South Africa. Multivariable logistic and linear models were used to test the association between VI and depression and the indirect pathways through disability and social participation. Analyses were adjusted for sociodemographics, medical comorbidities, and complex survey design features. Results: Visual acuity was worse in respondents with depression compared to those without depression in China (0.32 vs 0.23 logMAR; P <.001), Ghana (0.26 vs 0.18 logMAR; P <.001), and India (0.36 vs 0.30 logMAR; P <.001); self‐reported vision was also significantly worse in these three countries, but not in Mexico, Russia, or South Africa. Greater disability significantly mediated the association of both objective and self‐reported VI with depression in China and India. Social participation significantly mediated the association between subjective vision and depression in Ghana. Conclusions: There is variability in the association between VI and depression across LMICs and in the mediating role of disability and social participation. Culture‐specific instruments may be needed to better characterize the association between VI and depression and further research is needed to assess causality. [ABSTRACT FROM AUTHOR]

Background: Available studies on the prevalence of infertility have proved to have certain limitations, with a scarcity of population-based studies and inconsistent reporting from surveys in countries at all income levels. We wanted to test the applicability of the current duration approach to data from the important Demographic and Health Surveys (DHS) program, funded by USAID since its inception in 1985, https://dhsprogram.com/.Methods: The current duration approach assumes that there is a well-defined time of initiation of attempts to get pregnant and defines the current duration of a still ongoing pregnancy attempt as the time interval from initiation to interview. The DHS interviews do not have an explicit question about initiation. We focused on nullipari and substituted date of "establishment of relationship with current partner" for initiation. Our study used the current duration approach on 15 datasets from DHS during 2002-2016 in eight different countries from sub-Saharan Africa, Asia, and Latin America.Results: Well-established statistical techniques for current duration data yielded results that for some countries postulated surprisingly long median times to pregnancy and surprisingly high estimates of infertility prevalence. Further study of the data structures revealed serious deviations from expected patterns, in contrast to our earlier experience from surveys in France and the United States where participants were asked explicitly about time of initiation of attempts to become pregnant.Conclusions: Using cohabitation as a proxy for the initiation of attempts to get pregnant is too crude. Using the current duration approach with DHS data will require more explicit questions during the DHS interviews about initiation of pregnancy attempt. [ABSTRACT FROM AUTHOR]

Background. Little is known about the experience of carers of children with disabilities in Uganda, where child disability constitutes 31.4% of all disabilities. This study examined the experiences, beliefs, and attitudes of parents/ main carers of children with disabilities, and the challenges they face, in order to optimize rehabilitation strategies for the child and their family. Methods. Qualitative data were collected from ten semi - structured interviews with eight main carers children receiving rehabilitation in rural Uganda. Results. Three main themes were identified: (1) experiences, (2) beliefs, and (3) attitudes of the parents/ main carers. Carers experienced emotional stress and many life changes as the burden of care fell primarily on them. A lack of knowledge and information about disability amongst carers, resulted in alternative beliefs about treatment. Social stigma towards disability remains an issue within Ugandan society. Conclusions. Family centered rehabilitation should be incorporated into rehabilitation programmes to decrease burden of care upon the main carer. Health care practitioners are in a strong position to educate families about causation, diagnosis, and prognosis of a child’s condition, but such services should be improved through community education about disability and facilitated with the development of parental support groups. [ABSTRACT FROM AUTHOR]

Background: There exists limited agreement on the recommendations for the treatment of transitional circulatory instability (TCI) in preterm neonates OBJECTIVE: To compare the efficacy of various interventions used to treat TCI METHODS: Medline and Embase were searched from inception to 21 st July 2023. Two authors extracted the data independently. A Bayesian random effects network meta-analysis was used. Recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework., Interventions: Dopamine, dobutamine, epinephrine, hydrocortisone, vasopressin, milrinone, volume and placebo., Main Outcome Measures: Mortality, major brain injury (MBI) (intraventricular haemorrhage > grade 2 or cystic periventricular leukomalacia), necrotising enterocolitis (NEC) ≥stage 2 and treatment response (as defined by the author)., Results: 15 Randomized Controlled Trials (RCTs) were included from the 1365 titles and abstracts screened. Clinical benefit or harm could not be ruled out for the critical outcome of mortality. For the outcome of MBI, epinephrine possibly decreased the risk when compared to dobutamine and milrinone (very low certainty). Epinephrine was possibly associated with a lesser risk of NEC when compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Dopamine was possibly associated with a lesser risk of NEC when compared with dobutamine (very low certainty). Vasopressin possibly decreased the risk of NEC compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Clinical benefit or harm could not be ruled out for the outcome response to treatment., Conclusions: Epinephrine may be used as the first-line drug in preterm neonates with TCI, the evidence certainty being very low. We suggest future trials evaluating the management of TCI with an emphasis on objective criteria to define it., Competing Interests: Competing interests: None., (© 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.)

Objectives: Systematic priority setting is necessary for achieving high-quality healthcare using limited resources in low- and middle-income countries. Health technology assessment (HTA) is a tool that can be used for systematic priority setting. The objective of this study was to conduct a stakeholder and situational analysis of HTA in Zimbabwe., Methods: We identified and analyzed stakeholders using the International Decision Support Initiative checklist. The identified stakeholders were invited to an HTA workshop convened at the University of Zimbabwe. We used an existing HTA situational analysis questionnaire to ask for participants' views on the need, demand, and supply of HTA. A follow-up survey was done among representatives of stakeholder organizations that failed to attend the workshop. We reviewed two health policy documents relevant to the HTA. Qualitative data from the survey and document review were analyzed using thematic analysis., Results: Forty-eight organizations were identified as stakeholders for HTA in Zimbabwe. A total of 41 respondents from these stakeholder organizations participated in the survey. Respondents highlighted that the HTA was needed for transparent decision making. The demand for HTA-related evidence was high except for the health economic and ethics dimensions, perhaps reflecting a lack of awareness. Ministry of Health was listed as a major supplier of HTA data., Conclusions: There is no formal HTA agency in the Zimbabwe healthcare system. Various institutions make decisions on prioritization, procurement, and coverage of health services. The activities undertaken by these organizations provide context for the institutionalization of HTA in Zimbabwe.

Mental health conditions, recognised as a global crisis, were further exacerbated by the COVID-19 pandemic. Access to mental health services remains limited, particularly in low-income regions. Task-sharing interventions, exemplified by Problem Management Plus (PM+), have emerged as potential solutions to bridge this treatment gap. This study presents an evaluation of the PM+ scale-up in Sub-Saharan Africa (Ethiopia and Benin) and Eastern Europe (Croatia and Bosnia and Herzegovina) as part of a mental health and psychosocial support programming including 87 adult participants. A mixed-method approach assesses the impact of the intervention. Quantitative analyses reveal significant reductions in self-reported problems, depression, anxiety and improved functioning. Qualitative data highlight four main themes: general health, family relationships, psychosocial problems and daily activities. These thematic areas demonstrate consistent improvements across clients, irrespective of the region. The findings underscore the impact of PM+ in addressing a broad spectrum of client issues, demonstrating its potential as a valuable tool for mitigating mental health challenges in diverse settings. This study contributes to the burgeoning body of evidence supporting PM+ and highlights its promise in enhancing mental health outcomes on a global scale, particularly for vulnerable populations., Competing Interests: The authors declare none., (© The Author(s) 2024.)

Competing Interests: Competing interests: None declared.

Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Background: The prevalence of chronic kidney disease is on the rise globally and in sub-Saharan Africa. Due to its "silent" nature, many patients often present with advanced disease. At this point options for care are often limited to renal replacement therapies such as hemodialysis and kidney transplantation. In resource limited settings, these options are associated with catastrophic expenditures and increased household poverty levels. Early palliative care interventions, if shown to ensure comparable quality of life (QoL), can significantly mitigate this by focusing care on comfort, symptom control and QoL rather than primarily on prolonging survival.Methods: A mixed methods longitudinal study, recruiting patients with End Stage Renal Disease (ESRD) on hemodialysis or conservative management and following them up over 12 months. The study aims are to: 1) measure and compare the health-related quality of life (HRQoL) scores of patients with ESRD receiving hemodialysis with those receiving conservative management, 2) measure and compare the palliative care needs and outcomes of patients in the two groups, 3) explore the impact of treatment modality and demographic, socio-economic and financial factors on QoL and palliative care needs and outcomes, 4) review patient survival over 12 months and 5) explore the patients' lived experiences. The Kidney Disease Quality Of Life Short Form version 1.3 (KDQOL-SF) will be used to measure HRQoL; the African Palliative Care Association Palliative care Outcome Score (APCA POS) and the Palliative care Outcome Score for renal symptoms (POS-S Renal) will be used to assess palliative care needs and outcomes; and semi-structured in-depth interviews to explore the patients' experiences of living with ESRD. Data collection will be carried out at 0, 3, 6, 9 and 12 months.Discussion: To the best of our knowledge, no similar study has been conducted in sub-Saharan Africa. This will be an important step towards raising awareness of patients' need and preferences and the strengths and limitations of available health care services for ESRD in resource limited settings. [ABSTRACT FROM AUTHOR]

Pregnancy dietary intake may be associated with newborn body composition, a predictor of future obesity. In Samoa, an energy-dense diet contributes to an alarming prevalence of adult obesity. Identifying associations between pregnancy nutrition and infant body composition in this setting may guide strategies to mitigate intergenerational transmission of obesity risk. To examine dietary macro- and micronutrient intake of Samoan women during the third trimester of pregnancy and associations with infant body composition. At 34–41 weeks of gestation, we measured dietary intake from the prior month using a Food Frequency Questionnaire (FFQ). Dual-energy X-ray absorptiometry (DXA) measured infant body composition at 1–14 days. We used multivariable linear regression models accounting for confounders to identify independent effects of nutrient intake on infant body composition. After adjusting for maternal body mass index, age, gravidity, infant age, and sex, a respective 0.2 g increase and 0.2 g decrease in infant bone mass was associated with fibre and saturated fat intake. Increased protein intake was associated with 0.02 g decrease in bone mass. While maternal dietary intake was not associated with infant adiposity or lean mass, we observed an effect on bone mass whose role in regulating metabolic health is overlooked. [ABSTRACT FROM AUTHOR]

Background: Hypertension (HTN) is a major risk factor for cardiovascular diseases, and its prevalence has been rising in low- and middle-income countries. The current study describes HTN prevalence in central Mozambique, association between wealth and blood pressure (BP), and HTN monitoring and diagnosis practice among individuals with elevated BP.Methods: The study used data from a cross-sectional, representative household survey conducted in Manica and Sofala provinces, Mozambique. There were 4101 respondents, aged ≥20 years. We measured average systolic and diastolic BP (SBP and DBP) from three measurements taken in the household setting. Elevated BP was defined as having either SBP ≥140 or DBP ≥90 mmHg.Results: The mean age of the participants was 36.7 years old, 59.9% were women, and 72.5% were from rural areas. Adjusting for complex survey weights, 15.7% (95%CI: 14.0 to 17.4) of women and 16.1% (13.9 to 18.5) of men had elevated BP, and 7.5% (95% CI: 6.4 to 8.7) of the overall population had both SBP ≥140 and DBP ≥90 mmHg. Among participants with elevated BP, proportions of participants who had previous BP measurement and HTN diagnosis were both low (34.9% (95% CI: 30.0 to 40.1) and 12.2% (9.9 to 15.0) respectively). Prior BP measurement and HTN diagnosis were more commonly reported among hypertensive participants with secondary or higher education, from urban areas, and with highest relative wealth. In adjusted models, wealth was positively associated with higher SBP and DBP.Conclusions: The current study found evidence of positive association between wealth and BP. The prevalence of elevated BP was lower in Manica and Sofala provinces than the previously estimated national prevalence. Previous BP screening and HTN diagnosis were uncommon in our study population, especially among rural residents, individuals with lower education levels, and those with relatively less wealth. As the epidemiological transition advances in Mozambique, there is a need to develop and implement strategies to increase BP screening and deliver appropriate clinical services, as well as to encourage lifestyle changes among people at risk of developing hypertension in near future. [ABSTRACT FROM AUTHOR]

The global vision for primary health care (PHC) is defined by regular access to quality care for comprehensive services throughout the course of life. However, this is not what typically happens, especially in low- and middle-income countries, where many people access the formal health system only for emergent needs. Yet, even episodic care is nearly impossible to attain due to infrastructure barriers, critical shortages of health care providers, and low-quality care. Artificial intelligence and machine learning (AI/ML) can help us revolutionize the current reality of health care into the vision of continuous health care that promotes individuals to maintain a constant healthy state. AI/ML can deliver precise recommendations to the individual, transforming patients from a passive receiver of health services into an active participant of their own care. By accounting for each individual, AI/ML can also ensure equitable coverage for entire populations with an ongoing data exchange between personal health, genomic data, public health, and environmental factors. The greatest challenge to enlisting AI/ML in the quest toward the PHC vision will be instilling a sense of responsibility with global citizens to recognize health data for the global good while prioritizing protected, individually owned data sets. Only when individuals start taking a collective approach to health data, shifting the mindset toward the goal of prevention, will the potential of AI/ML for PHC be realized. Until we overcome this challenge, the paradigm shift of the global community away from our ad hoc, reactive health system culture will not be achieved.

Inclusion of early child development in the United Nations Sustainable Development Agenda raises issues of how this goal should be monitored, particularly in low resource settings. The aim of this paper was to explore the validity of the early Human Capability Index (eHCI); a population measure designed to capture the holistic development of children aged 3–5 years. Convergent, divergent, discriminant and concurrent validity were examined by exploring the associations between eHCI domains and child (sex, age, stunting status, preschool attendance) and family (maternal education, home learning environment) characteristics. Analyses were repeated using data from seven low and middle income countries: Brazil (n = 1810), China (n = 11421), Kiribati (n = 8339), Lao PDR (n = 7493), Samoa (n = 12191), Tonga (n = 6214), and Tuvalu (n = 549). Correlations and linear regressions provide evidence that within these country samples, the tool is capturing the aspects of early child development that it was designed to measure. Although the tool was intended to measure development of children aged 3–5 years, results suggest it can be validly applied to children aged 2–6 years. The eHCI is free, requires minimal implementation resources, captures development across domains and abilities, and is designed to allow cultural and contextual concepts to be included. The eHCI appears psychometrically robust in diverse country contexts and could enable evaluation of early years policies and programs, as well as monitoring of children's development to track progress towards the Sustainable Development Agenda.

BackgroundMaternal depression is a notable concern, yet little evidence exists on its economic burden in low- and middle-income countries.AimsThis study assessed societal costs and economic outcomes across pregnancy to 12 months postpartum comparing women with depression with those without depression. Trial registration: ClinicalTrials.gov: NCT01977326 (registered on 24 October 2013); Pan African Clinical Trials Registry (www.pactr.org): PACTR201403000676264 (registered on 11 October 2013).MethodParticipants were recruited during the first antenatal visit to primary care clinics in Khayelitsha, Cape Town. In total, 2187 women were screened, and 419 women who were psychologically distressed were retained in the study. Women were interviewed at baseline, 8 months gestation and at 3 and 12 months postpartum; the Hamilton Rating Scale for Depression was used to categorise women as having depression or not having depression at each interview. Collected data included sociodemographics; health service costs; user fees; opportunity costs of accessing care; and travelling expenses for the women and their child(ren). Using Markov modelling, the incremental economic burden of maternal depression was estimated across the period.ResultsAt 12 months postpartum, women with depression were significantly more likely to be unemployed, to have lower per capita household income, to incur catastrophic costs and to be in a poorer socioeconomic group than those women without depression. Costs were higher for women with depression and their child(ren) at all time points. Modelled provider costs were US$805 among women without depression versus US$1303 in women with depression.ConclusionsEconomic costs and outcomes were worse in perinatal women with depression. The development of interventions to reduce this burden is therefore of significant policy importance.

The current use of technology for medical education in low and middle income countries (LMIC) during the COVID-19 pandemic is not yet reaching its potential. We provide recommendations for LMIC that has focus on a systematic framework that considers both faculty development and developing the skills of students. An enormous challenge for all medical educators, but especially in LMIC, continues to be how to maintain clinical teaching in these extraordinary times.

BackgroundLow- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10–24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA.AimsTo use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania.MethodIn-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes.ResultsFindings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context.ConclusionsQualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.

Background: substantial increases in plastic production have resulted in plastics proliferating of in the environment, with subsequent seabed plastic deposition and ingestion by marine fauna. There is an urgent need to monitor mismanaged plastic waste from household consumption. Household expenditure survey analysis has quantified mismanaged plastic waste generated from household packaged (bottled or bagged) water consumption, but not from consumption of other products. Methods: to evaluate whether household expenditure surveys can quantify mismanaged waste from other widely consumed commodities, we quantify mismanaged plastic waste from the domestic consumption of cooking oil alongside packaged water in urban Greater Accra, Ghana, and all cities nationally in Kenya using two household expenditure surveys. Results: household survey-derived estimates indicate packaged water consumption generates considerably more plastic waste than oil packaging in Greater Accra, whereas oil packaging generates more plastic waste than packaged water in urban Kenya. Conclusion: by successfully transferring a survey analysis protocol from packaged water to cooking oil, we conclude that there is ample potential for expenditure surveys to be used internationally to quantify mismanaged plastic waste from households. However, uncertainties affecting mismanaged waste estimates need to be accounted for.

Abstract Healthcare challenges in low and middle income countries (LMICs) have been the focus of many digital initiatives that have aimed to improve both access to healthcare and the quality of healthcare delivery. Moving beyond the initial phase of piloting and experimentation, these initiatives are now more clearly focused on the need for effective scaling and integration to provide sustainable benefit to healthcare systems. Based on real-life case studies of scaling digital health in LMICs, five key focus areas have been identified as being critical for success. Firstly, the intrinsic characteristics of the programme or initiative must offer tangible benefits to address an unmet need, with end-user input from the outset. Secondly, all stakeholders must be engaged, trained and motivated to implement a new initiative, and thirdly, the technical profile of the initiative should be driven by simplicity, interoperability and adaptability. The fourth focus area is the policy environment in which the digital healthcare initiative is intended to function, where alignment with broader healthcare policy is essential, as is sustainable funding that will support long-term growth, including private sector funding where appropriate. Finally, the extrinsic ecosystem should be considered, including the presence of the appropriate infrastructure to support the use of digital initiatives at scale. At the global level, collaborative efforts towards a less-siloed approach to scaling and integrating digital health may provide the necessary leadership to enable innovative solutions to reach healthcare workers and patients in LMICs. This review provides insights into best practice for scaling digital health initiatives in LMICs derived from practical experience in real-life case studies, discussing how these may influence the development and implementation of health programmes in the future.

Abstract Background Even though integrating mental health into maternal and child health (MCH) is widely accepted as a means of closing the treatment gap for maternal mental health conditions in low- and middle-income countries (LMIC), there are not many studies on the quality of the currently available mental health care for mothers in these countries. This study assessed the existing organization of service for maternal mental health, the actual care delivered for perinatal depression, as well as the quality of the care received by affected women presenting to primary care clinics in Ibadan, Nigeria. Methods The Assessment of Chronic Illness Care (ACIC) tool was administered to the staff in 23 primary maternal care clinics and key informant interviews were conducted with 20 facility managers to explore organizational and administrative features relevant to the delivery of maternal mental health care in the facilities. Detection rate of perinatal depression by maternal care providers was assessed by determining the proportion of depressed antenatal women identified by the providers. The women were then followed up from the antenatal period up until 6 months after childbirth to track their experience with care received. Results All the facilities had ACIC domain scores indicating poor capacity to offer quality chronic care. Emerging themes from the interviews included severe manpower shortage and absence of administrative and clinical support for manpower training and care provision. Only 31 of the 218 depressed women had been identified by the maternal care providers as having a psychological problem throughout the follow-up period. In spite of the objective evidence of inadequate care, most of the perinatal women rated the service provided in the facilities as being of good quality (96%) and reported being satisfied with the care received (98%). Conclusion There are major inadequacies in the organisational and administrative profile of these primary maternal care facilities that militate against the provision of quality chronic care. These inadequacies translate to a large treatment gap for women with perinatal depression. Lack of awareness by service users of what constitutes good quality care, indicative of low service expectation, may hamper user-driven demand for quality improvement.

Abstract Background According to the World Health Organization (WHO), 80% of the world’s smokers live in low- and middle-income countries. Moreover, more than half of the world’s smoking-addicted population resides in the Asia-Pacific region. The reduction of tobacco consumption has thus become one of the major social policies in the region. This study investigates the effects of price increases on cigarette consumption, tobacco tax revenues and reduction in smoking-caused mortality in 22 low-income as well as middle-income countries in the Asia-Pacific region. Methods Using panel data from the 1999–2015 Euromonitor International, the World Bank and the World Health Organization, we applied fixed effects regression models of panel data to estimate the elasticity of cigarette prices and to simulate the effect of price fluctuations. Results Cigarette price elasticity was the highest for countries with a per capita Gross National Income (GNI) above US$6000 (China and Malaysia), and considerably higher for other economies in the region. The administered simulation shows that with an average annual cigarette price increase of 9.51%, the average annual cigarette consumption would decrease by 3.56%, and the average annual tobacco tax revenue would increase by 16.20%. The number of averted smoking-attributable deaths (SADs) would be the highest in China, followed by Indonesia and India. In total, over 17.96 million lives could be saved by tax increases. Conclusion Excise tax increases have a significant effect on the reduction of smoking prevalence and the number of averted smoking-attributable deaths. Middle- and upper-middle income countries would be most affected by high-taxation policies.

Evidence on influenza vaccine effectiveness from low and middle countries (LMICs) is limited due to limited institutional capacities; lack of adequate resources; and lack of interest by ministries of health for influenza vaccine introduction. There are concerns that the highest ethical standards will be compromised during trials in LMICs leading to mistrust of clinical trials. These factors pose regulatory and operational challenges to researchers in these countries. We conducted a community-based vaccine trial to assess the efficacy of live attenuated influenza vaccine and inactivated influenza vaccine in rural north India. Key regulatory challenges included obtaining regulatory approvals, reporting of adverse events, and compensating subjects for trial-related injuries; all of which were required to be completed in a timely fashion. Key operational challenges included obtaining audio-visual consent; maintaining a low attrition rate; and administering vaccines during a narrow time period before the influenza season, and under extreme heat. We overcame these challenges through advanced planning, and sustaining community engagement. We adapted the trial procedures to cope with field conditions by conducting mock vaccine camps; and planned for early morning vaccination to mitigate threats to the cold chain. These lessons may help investigators to confront similar challenges in other LMICs.

Abstract Background Global strategies recommend a continuum of care for maternal health to improve outcomes and access to care in low and middle income countries (LMICs). South Africa has already set priority interventions along the continuum of care for maternal health, and mandated their implementation at the district health level. However, the approach for monitoring access to this continuum of care has not yet been defined. This review assessed measurement approaches in continuum of care for maternal health among LMICs and their implications for the South African context. Methods We conducted a critical interpretive synthesis of quantitative and qualitative research sourced from Academic Search Complete (EBSCO), MEDLINE (Pubmed), Cambridge Journals Online, Credo Reference and Science Direct. We selected 20 out of 118 articles into the analysis, following a rigorous quality appraisal and relevance assessment. The outcomes of the synthesis were new constructs for the measurement of continuum of care for maternal health, derived from the existing knowledge gaps. Results We learned that coverage was the main approach for measuring and monitoring the continuum of care for maternal health in LMICs. The measure of effective coverage was also used to integrate quality into coverage of care. Like coverage, there was no uniform definition of effective coverage, and we observed gaps in the measurement of multiple dimensions of quality. From the evidence, we derived a new construct called adequacy that incorporated timeliness of care, coverage, and the complex nature of quality. We described the implications of adequacy to the measurement of the continuum of care for maternal health in South Africa. Conclusions Critical interpretive synthesis allowed new understandings of measurement of the continuum of care for maternal health in South Africa. The new construct of adequacy can be the basis of a new measure of access to the continuum of care for maternal health. Although adequacy conceptualizes a more holistic approach, more research is needed to derive its indicators and metrics using South African data sources.

Abstract Background Cardiovascular disease (CVD) is one of the leading causes of death worldwide. Our study aimed to investigate the prevalence of two conditions, angina and stroke, and relevant risk factors among older adults in six low- and middle- income countries(LMICs). Methods The data was from World Health Organization (WHO) Study on global AGEing and adult Health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russian Federation and South Africa. Presence of CVD was based on self-report of angina and stroke. Multivariate logistic regression was performed to examine the relationship between CVD and selected variables, including age, sex, urban/rural setting, household wealth, and risk factors such as smoking, alcohol drinking, fruit/vegetable intake, physical activity and BMI. Results The age standardized prevalence of angina ranged from 9.5 % (South Africa) to 47.5 % (Russian Federation), and for stoke from 2.0% (India) to 6.1 % (Russia). Hypertension was associated with angina in China, India and Russian Federation after adjustment for age, sex, urban/rural setting, education and marital status (OR ranging from 1.3 [1.1-1.6] in India to 3.8 [2.9-5.0] in Russian Federation), furthermore it was a risk factor of stroke in five countries except Mexico. Low or moderate physical activity were also associated with angina in China, and were also strongly associated with stroke in all countries except Ghana and India. Obesity had a stronger association with angina in Russian Federation and China(ORs were 1.5[1.1-2.0] and 1.2 [1.0-1.5] respectively), and increased the risk of stroke in China. Smoking was associated with angina in India and South Africa(ORs were 1.6[1.0-2.4] and 2.1 [1.2-3.6] respectively ), and was also a risk factor of stroke in South Africa. We observed a stronger association between frequent heavy drinking and stroke in India. Household income was associated with reduced odds of angina in China, India and Russian Federation, however higher household income was a risk factor of angina in South Africa. Conclusion While the specific mix of risk factors contribute to disease prevalence in different ways in these six countries – they should all be targeted in multi-sectoral efforts to reduce the high burden of CVD in today’s society.

Abstract Background The incidence and mortality of cardiovascular diseases (CVDs) in low and middle income countries (LMICs) have been increasing, while access to CVDs medicines is suboptimal. We assessed selection of essential medicines for the prevention and treatment of CVDs on national essential medicines lists (NEMLs) of LMICs and potential determinants for selection. Methods Only operational NEMLs were considered eligible for this study. A selection of medicines listed under “cardiovascular medicines” or “blood products and plasma substitutes” in the NEMLs were included if they were present on international guidelines for the prevention and treatment of CVDs (hyperlipidemia, hypertension, platelet inhibition, ischemic stroke, stable ischemic heart disease, acute coronary syndromes, heart failure, atrial fibrillation, peripheral arterial disease and acute limb ischemia). The number and diversity of essential medicines selected for CVDs were studied. Moreover, determinants of selection of essential medicines for CVDs at a national level were explored. Data analysis was done using univariate linear regression and non-parametric tests. Results All medicine groups listed by the international guidelines were selected by the majority of the 34 countries studied with the exception of adenosine diphosphate receptor inhibitors which appeared on less than half of the NEMLs studied (41% of countries). The total number of essential medicines for the prevention and treatment of cardiovascular diseases (median 24 (range 16–50)) differed significantly across income levels (median range: 19.5–25, p = 0.014) and across regions (median range: 20–32, p = 0.049). When recommendations of the international guidelines were considered, over 75% of the NEMLs contained essential medicines for the majority of CVDs. Conclusion The main medicine classes for the management of CVDs were represented on NEMLs. Consequently, for the majority of CVDs, evidence-based guideline-recommended treatment is possible as far as selection of essential medicines is concerned. Selection will therefore not be the limiting step in access to medicines for cardiovascular diseases.

Abstract Background Populations of low and middle-income countries are ageing rapidly; there is a need for policies that support an increase in the duration of old age lived in good health. There is growing evidence that social participation protects against morbidity and mortality, but few studies explore patterns of social participation. Analysis of baseline quantitative and qualitative data from a trial of the impact of Elders’ Clubs on health and well-being in the hill country of Sri Lanka provided an opportunity to better understand the extent of, and influences on, social participation among elders. Methods We analysed data from 1028 baseline survey respondents and from 12 focus group discussions. Participants were consenting elders, aged over 60 years, living in Tamil tea plantation communities or Sinhala villages in 40 randomly selected local government divisions. We assessed participation in organised social activities using self-reported attendance during the previous year. Multivariable regression analyses were used to explore associations with community and individual factors. The quantitative findings were complemented by thematic analysis of focus group discussion transcripts. Results Social participation in these poor, geographically isolated communities was low: 63% reported ‘no’ or ‘very low’ engagement with organised activities. Plantation community elders reported significantly less participation than village elders. Attendance at religious activities was common and valued. Individual factors with significant positive association with social participation in multivariable analyses were being younger, male, Sinhala, married, employed, and satisfied with one’s health. Domestic work and cultural constraints often prevented older women from attending organised activities. Conclusions Elders likely to benefit most from greater social contact are those most likely to face barriers, including older women, the oldest old, those living alone and those in poor health. Understanding these barriers can inform strategies to overcome them. This might include opportunities for both informal and formal social contact close to elders’ homes, consulting elders, providing childcare, improving physical access, advocating with elders’ families and religious leaders, and encouraging mutual support and inter-generational activities. Influences on social participation are interrelated and vary with the history, culture and community environment. Further study is required in other low and middle-income country contexts.

Abstract Background There is a dearth of validated tools measuring posttraumatic stress disorder (PTSD) in low and middle-income countries in sub-Saharan Africa. We validated the Shona version of the PTSD Checklist for DSM-5 (PCL-5) in a primary health care clinic in Harare, Zimbabwe. Method Adults aged 18 and above attending the clinic were enrolled over a two-week period in June 2016. After obtaining written consent, trained research assistants administered the tool to eligible participants. Study participants were then interviewed independently using the Clinician Administered PTSD Scale (CAPS-5) as the gold standard by one of five doctors with training in mental health. Result A total of 204 participants were assessed. Of these, 91 (44.6%) were HIV positive, 100 (49%) were HIV negative, while 13 (6.4%) did not know their HIV status. PTSD was diagnosed in 40 (19.6%) participants using the gold standard procedure. Using the PCL-5 cut-off of ≥33, sensitivity and specificity were 74.5% (95%CI: 60.4–85.7); 70.6% (95%CI: 62.7–77.7), respectively. The area under the ROC curve was 0.78 (95%CI: 0.72–0.83). The Shona version of the PCL-5 demonstrated good internal consistency (Cronbach’s alpha = 0.92). Conclusion The PCL-5 performed well in this population with a high prevalence of HIV. There is need to explore ways of integrating screening tools for PTSD in interventions delivered by lay health workers in low and middle-income countries (LMIC).

This study looks at the equality challenges and opportunities for women with disabilities in low and middle income countries (LMICs) to participate and succeed in education, employment and motherhood. It is based on a systematic review of the literature from academic and non-governmental organization databases. The search of these databases yielded 24 articles, which were subsequently passed through open, axial, and selective coding. The resulting review found that women with disabilities in LMICs have severe difficulty participating and succeeding in education, employment and motherhood due to a number of interrelated factors: (i) hampered access to education, employment, intimacy and marriage, (ii) stigma and cultural practices resulting in discrimination and prejudice, and (iii) lack of support from family, teachers and institutions—all of which are exacerbated by poverty. Support from families, communities, the government, and non-governmental organizations improves women’s ability to fulfil their social roles (as students, employees and mothers), resulting in a better quality of life. Strategies that create awareness, minimize poverty and facilitate justice may improve the opportunities for women with disabilities in LMICs to participate in education, employment and motherhood, as well as their ability to succeed in these domains.

Introduction: Low and middle income countries (LMICs) bear more than 50% of the current cervical cancer burden over the last decade with linkages to lack of HPV vaccination, high levels of poverty, illiteracy and nonexistent or poor screening programs. Governments of LMICs need enough convincing evidence that HPV vaccination will be more cost-effective in reducing the scourge of cervical cancer. Area covered: A systematic review to identify suitable studies from MEDLINE(via PubMed), EMBASE and Electronic search through GOOGLE for original and review articles from 2007 to 2014 on cost-effectiveness of human papilloma virus vaccination of pre-adolescent girls in LMICs was conducted. A total of 19 full articles were finally selected and reviewed after screening out those not consistent with the inclusion and exclusion criteria. Expert commentary: Most studies on cost-effectiveness of HPV vaccine in LMICs show that lowering cost of HPV vaccination with or without Pap smear screening is cost-effective in areas with high incidence of cervical cancer.

Abstract Background The stillbirth rate is an indicator of quality of care during pregnancy and delivery. Good quality care is supported by a functional heath system. The objective of this study was to explore the risk factors for stillbirths, particularly those related to a health system. Methods This case-control study was conducted in two districts of Bihar, India. Information on cases (stillbirths) were obtained from facilities as reported by Health Management Information System; controls were consecutive live births from the same population as cases. Data were collected from 400 cases and 800 controls. The risk factors were compared using a hierarchical approach and expressed as odds ratio, attributable fractions and population attributable fractions. Results Of all the factors studied, 22 risk factors were independently associated with stillbirths. Health system-related factors were: administration of two or more doses of oxytocics to augment labour before reaching the facilities (OR 1.6; 95% CI 1.2–2.1), any complications during labour (OR 2.3;1.7–3.1), >30 min to reach a facility from home (OR 1.4;1.05–1.8), >10 min to attend to the pregnant woman after reaching the facility (OR 2.8;1.7–4.5). In the final regression model, modifiable health system-related risk factors included: >10 min taken to attend to women after they reach the facilities (AOR 3.6; 95% CI 2.5–5.1), untreated hypertension during pregnancy (AOR 2.9; 95% CI 1.5–5.6) and presence of any complication during labour, warranting treatment (AOR 1.7; 95% CI 1.2–2.4). Among mothers who reported complications during labour, time taken to reach the facility was significantly different between stillbirths and live births (2nd delay; 33.5 min v/s 25 min; p 30 min to reach the facility 0.48 (95% CI 0.31–0.60) and institution of management 10 min after reaching the facility 0.68 (95% CI 0.58–0.75). Reaching a facility within 30 min, initiation of management within 10 min of reaching the facility and timely management of complications during labour could have prevented 17%, 37% and 20% of stillbirths respectively. Conclusion A pro-active health system with accessible, timely and quality obstetric services can prevent a considerable proportion of stillbirths in low and middle income countries.

Background: Despite improvement in many aspects of acute trauma care, uncontrolled bleeding is responsible for more than 50% of all trauma related deaths within the first two days of admission. Objective: This study sought to determine the incidence of coagulopathy among major trauma patients and their associated outcome. Methods: A prospective descriptive study carried at KNH among major trauma patients. Coagulation status was determined within 30 minutes of arrival. Outcomes assessed included length of hospital stay, transfusion requirement and mortality for 30 days. Fischer’s exact test was used to analyze categorical variables and Student T test used to analyze continuous variables. Results: The majority (85.7%) of the 140 patients recruited were male and, the mean age was 29.4 years (SD=12.0). Coagulopathy was present in 52.1% of the patients. The mean ISS on admission was 23.3 (SD=4.8), patients with coagulopathy had a higher ISS 22.2 (SD=5.2, p=0.018). The patients with coagulopathy stayed longer in hospital 12 days and their mortality was higher 21 (95.5%) p

Interventions on mental health and psychosocial wellbeing have been largely implemented in low and middle income countries. In order to adapt the support offered, an increasing number of applied research projects in mental health and psychosocial support have been conducted. However, while challenges arising can be related to the specificity of the mental health and psychosocial sector, within a broader perspective they are also strongly linked to difficulties of access to beneficiaries, security and protections issues, and competence of staff. Research priorities and guidelines have the objective of providing recommendations to ensure a framework of best practice for research during emergencies. Therefore, this article presents and discusses operational and ethical challenges of research conducted during an emergency, as implemented by the international nongovernmental organisation Action Contre la Faim.

Background: Metabolic syndrome (MetS) is a clustering of cardiovascular risk factors, which is rising in the low and middle income countries (LMICs). There are various studies with inconsistent findings that are inconclusive for policy makers and program planners. Thus, this systematic review and meta-analysis aimed at estimating the pooled prevalence of MetS and its components in LMICs. Methods: Electronic searches were conducted in international databases including PubMed, Web of Science, EMBASE (Elsevier), Scopus, CINAHL (EBSCOhost), Science direct (Elsevier), Food Science and Technology Abstracts (FSTA), Global Health and Medline, and other sources (World Cat, Google Scholar, and Google). The pooled estimates were computed in the random effect model. The pooled prevalence was computed using the three diagnostic methods (IDF, ATP III and de Ferranti). Publication bias was verified using funnel plot and Egger's regression test. Subgroup and sensitivity analysis were performed to identify the possible sources of heterogeneity among the included studies. Result: In this study, 142,142 children and adolescents from 76 eligible articles were included to compute the pooled prevalence of MetS and its components in LMCIs. MeTs among overweight and obese population was computed from 20 articles with the pooled prevalence of 24.09%, 36.5%, and 56.32% in IDF, ATP III and de Ferranti criteria, respectively. Similarly, a total of 56 articles were eligible to compute the pooled prevalence of MetS in the general population of children and adolescents. Hence, Mets was found in 3.98% (IDF), 6.71% (ATP III) and 8.91% (de Ferranti) of study subjects. Regarding the components of MetS, abdominal obesity was the major component in overweight and obese population and low HDL-C was the most common component in the general population. This study also revealed that males were highly affected by MetS than females. Conclusion: This study illustrates that MetS among children and adolescents is an emerging public health challenge in LMICs, where the prevalence of obesity is on the move. Preventive strategies such as community and school based intervention need to be designed. Promoting physical activities and healthy eating behaviors could avert this problem. [ABSTRACT FROM AUTHOR]