Global landscape of locally produced alcohol-based handrub in health care settings: a scoping review.

Objectives To determine the barriers and facilitators to using real world data (RWD) in healthcare settings in low-and middle-income countries (LMICs). Method We conducted a systematic review through searching MEDLINE, EMBASE, Global Health Database and CINAHL. We searched for qualitative studies that address the use of RWD, barriers and facilitators, and its applications in LMICs. Study participants included healthcare settings/organizations in LMICs which collect and use RWD. Primary outcomes are the roles of using RWD, and barriers/facilitators affecting the applications of RWD in healthcare settings in LMICs. Data extraction included contextual and methodological data. Quality of review will be assessed using the CASP Qualitative checklist, and we will follow the ENTREQ checklist for synthesis of qualitative research. Risk of bias will be assessed using GRADE-CERQual to determine the level of confidence from qualitative evidence synthesis. Qualitative data synthesis will be done as narrative/descriptive synthesis of the roles of using RWD in healthcare settings in LMICs; thematic synthesis and conceptual framework of the barriers/facilitators of using RWD and its applications. Results The review addressed the use of real-world data in healthcare settings in LMICs, according to World Bank classification including 137 countries as per World Bank country classification. Initial search across the four databases showed a total of 2,245 search results. The results were separated into three sets; systematic reviews (n = 27) from 2012 until 2018; primary studies (n = 2,048) from 1988 until 2019; and conference abstracts (n = 170) from 2004 until 2018. Preliminary searches are completed, and piloting of the study selection process was done. Formal screening of results against eligibility criteria is underway and will be presented in conference. Conclusions The use of RWD in healthcare settings in LMICs is important to make evidence-based improvements in care delivery and health outcomes. Results from this systematic review will address the gap in evidence about what real world data is used in LMICs and the barriers and facilitators to its use. This review will generate qualitative evidence about the roles, barriers and facilitators and real-world applications of using RWD in healthcare settings in LMICs.

BackgroundDigital technology is a means to uphold or violate human rights in various domains, including business, military, and health. Given the pervasiveness of mobile technology in low- and middle-income countries (LMICs), mobile health (mHealth) interventions present an opportunity to reach remote populations and enable them to exercise civil and political rights and economic, social, and cultural rights, such as the right to health and education. Simultaneously, the ubiquity of mobile phones involves processing sensitive data which can threaten rights, including the right to privacy and nondiscrimination. Digital health is often promoted as advancing human rights and health equity; however, digital rights are underexplored in the literature on mHealth in LMICs. As such, creating an understanding of the digital rights topics covered in the 2022 literature is important to avoid exacerbating existing inequities relating to digital health design, use, implementation, and access.ObjectiveThis scoping review aims to identify digital rights topics in the 2022 peer-reviewed literature on mHealth in LMICs.MethodsThe Arksey and O’Malley framework for scoping reviews guides this review. Searches were performed across 7 electronic databases (Web of Science, Scopus, Ovid, ACM Digital Library, IEEE Xplore, ProQuest, and PubMed). The screening processes were guided by the research question “What digital rights topics have been explored in the 2022 literature on mHealth in LMICs?” Only papers addressing mHealth in LMICs and digital rights topics were included. Data extraction will include publication title, year, and type; first author’s affiliation country; LMICs implicated; infrastructure challenges; study aims, design, limitations, and future work; health area; mHealth technology, functions, purpose or application, and target end users; human or digital right terms used; explicit rights topics cited; and implied rights topics. The results will be reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist.ResultsThis scoping review was registered in Open Science Framework (December 22, 2022). Title and abstract screening and full-text paper screening were completed in 2023. This resulted in 56 papers being included in the study. The target date for completing data extraction and publishing a case study of the initial findings is the end of 2023. The full scoping review findings are expected to be disseminated through various pathways benefiting academia, practice, and policy making by the end of 2024. These include journal papers, conference presentations, publicly available toolkits for research and practice, public webinars, and policy briefs with evidence-based policy recommendations emerging from this review.ConclusionsThe planned scoping review will identify digital rights topics in the 2022 literature at the intersection of mHealth and LMICs. Furthermore, it will highlight the importance of patient empowerment, data protection, and inclusion in mHealth research and related policies in LMICs.Trial RegistrationOpen Science Framework osf.io/7mz24; https://osf.io/7mz24International Registered Report Identifier (IRRID)DERR1-10.2196/49150

Local alcohol-based hand rub (ABHR) production systems in low-resource settings, such as in health care facilities (HCFs) in low- and middle-income countries, frequently reuse containers for storing and dispensing ABHR. Cleaning/disinfection (C/D) of ABHR containers is necessary to safely reuse them and is an integral part of the WHO's guidelines on local ABHR production. However, HCFs may not be aware of the need for C/D; combined with suboptimal implementation, this poses a risk of contamination of ABHR. As part of district-led ABHR production in HCFs in five rural districts in Uganda, we developed a standard operating procedure (SOP) for C/D of reused ABHR containers and provided on-site training for infection prevention and control personnel. Using in-person surveys, we assessed the availability of C/D supplies and equipment and the self-reported C/D practices before and after the training. At baseline, almost all (n = 90/91) HCFs reported reusing ABHR containers; 8% and 12% of HCFs routinely had all of the key C/D materials needed for adequately cleaning and disinfecting containers using chlorine and thermal disinfection methods, respectively. HCFs that reported adequately cleaning containers per the SOP increased from 3% (n = 2) at baseline to 18% (n = 16) after the training, whereas adequate disinfection increased from 0% (n = 0) to 5% (n = 5). All HCFs that performed disinfection reported using chlorine, and none reported using thermal disinfection. Improving access to C/D supplies, providing routine mentorship, and monitoring ABHR container C/D are needed to further improve C/D practices.

Help or hindrance? Is current infection control advice applicable in low- and middle-income countries? A review of the literature

Background:The growth of antimicrobial resistance worldwide has led to increased focus on antimicrobial stewardship (AMS) and infection prevention and control (IPC) measures, although primarily in high-income countries (HIC). We aimed to compare pediatric AMS and IPC resources/activities between low- and middle-income countries (LMIC) and HIC and to determine the barriers and priorities for AMS and IPC in LMIC as assessed by clinicians in those settings.Methods:An online questionnaire was distributed to clinicians working in HIC and LMIC healthcare facilities in 2020.Results:Participants were from 135 healthcare settings in 39 LMIC and 27 HIC. Formal AMS and IPC programs were less frequent in LMIC than HIC settings (AMS 42% versus 76% and IPC 58% versus 89%). Only 47% of LMIC facilities conducted audits of antibiotic use for pediatric patients, with less reliable availability of World Health Organization Access list antibiotics (29% of LMIC facilities). Hand hygiene promotion was the most common IPC intervention in both LMIC and HIC settings (82% versus 91%), although LMIC hospitals had more limited access to reliable water supply for handwashing and antiseptic hand rub. The greatest perceived barrier to pediatric AMS and IPC in both LMIC and HIC was lack of education: only 17% of LMIC settings had regular/required education on antimicrobial prescribing and only 25% on IPC.Conclusions:Marked differences exist in availability of AMS and IPC resources in LMIC as compared with HIC. A collaborative international approach is urgently needed to combat antimicrobial resistance, using targeted strategies that address the imbalance in global AMS and IPC resource availability and activities.

Radiation-Induced Vaginal Stenosis in Patients With Cervical Cancer in Low- and Middle-Income Countries: A Scoping Review.

Background: Hand hygiene (HH) remains arguably the most effective way to prevent healthcare-associated infections (HAIs) and ultimately improve the prospect of patient safety. Studies have shown that as many as 50%–70% of infections are transmitted through hands due to poor HH practices. HH with use of alcohol-based hand rub (ABHR) is preferred over handwashing with soap and water because of its wide microbial efficacy, time efficiency, and improved skin tolerance. It is also well known that ABHR can be used as an effective prevention measure during disease outbreaks. Before and during the COVID-19 pandemic, health facilities in Sierra Leone have been challenged with HH infrastructural problems such as lack of sinks with constant running water. Before Sierra Leone recorded its first case of COVID-19 in March 2020, the consumption of ABHR in the health facilities was estimated to be 24,000 L per year, which doubled during the COVID-19 pandemic. The demand for commercially available ABHR increased, leading to acute shortages. The estimated cost of the locally produced ABHR ~$2–3 per 500 mL, although it may cost up to $10 for 500 mL when buying imported ABHR products from the local market. Methods: All ingredients were procured locally, and ABHR production was based on WHO formula 1. The production was set for 12 months to cover the estimated annual consumption of ABHR, with periodic monitoring to ensure effective distribution and availability at the point of care. Analysis of assessment results in 12 hospitals from the pre-COVID-19 era (2019) to the COVID-19 era (2021) was performed based on the WHO IPC Assessment Framework (IPCAF) indicator. Results: With an average monthly production of 3,482 L, a total of 41,780 L ABHR was produced and packaged in branded 500-mL containers for distribution to healthcare facilities. This quantity exceeded the estimated demand for ABHR during the COVID-19 pandemic. The data show a considerable increase (from 25% to 44%) in the number of available and functioning HH stations with mainly locally produced ABHR. Results from the monitoring of 575 peripheral health units (PHUs) in 2021 also showed that >67% of PHUs had HH facilities in all clinical areas and that the locally produced ABHR was used in 79% of these HH stations. Conclusions: Locally produced ABHR has shown to be a cost-effective and evidence-based intervention to optimize HH at the point of care. Therefore, localities are encouraged to undertake this realistic and sustainable approach to address issues of acute shortage of ABHR, especially during a global pandemic.Funding: NoneDisclosures: None

Cancer deaths in low- and middle-income countries (LMICs) will nearly double by 2040. Available evidence-based interventions (EBIs) for cancer prevention and early detection can reduce cancer-related mortality, yet there is a lack of evidence on effectively scaling these EBIs in LMIC settings. We conducted a scoping review to identify published literature from six databases between 2012 and 2022 that described efforts for scaling cancer prevention and early detection EBIs in LMICs. Included studies met one of two definitions of scale-up: (1) deliberate efforts to increase the impact of effective intervention to benefit more people or (2) an intervention shown to be efficacious on a small scale expanded under real-world conditions to reach a greater proportion of eligible population. Study characteristics, including EBIs, implementation strategies, and outcomes used, were summarized using frameworks from the field of implementation science. This search yielded 3,076 abstracts, with 24 studies eligible for inclusion. Included studies focused on a number of cancer sites including cervical (67%), breast (13%), breast and cervical (13%), liver (4%), and colon (4%). Commonly reported scale-up strategies included developing stakeholder inter-relationships, training and education, and changing infrastructure. Barriers to scale-up were reported at individual, health facility, and community levels. Few studies reported applying conceptual frameworks to guide strategy selection and evaluation. Although there were relatively few published reports, this scoping review offers insight into the approaches used by LMICs to scale up cancer EBIs, including common strategies and barriers. More importantly, it illustrates the urgent need to fill gaps in research to guide best practices for bringing the implementation of cancer EBIs to scale in LMICs.

Updating the PRISMA reporting guideline for scoping reviews: a scoping review.

The age at which children enter school represents a transitional period between early childhood and adolescence that involves increasing autonomy, interaction with peers, and exposure to environments outside the home. Although mortality is generally much lower in the 5 to 9 age group compared with infancy and early childhood, there are many preventable causes of mortality, morbidity, and disability that emerge in this age group, including injuries, noncommunicable diseases, and vaccine-preventable and highly treatable infections.1 Partly because of relatively low mortality rates and less frequent contacts with the health system, school-age children and younger adolescents ages 5 to 14 have been referred to as the “missing middle,” in that there is a dearth of robust data on key health indicators, morbidity burden, and cause-specific mortality in this group.2 Many health issues that have a high burden in early childhood can persist in older children, especially in low- and middle-income countries (LMIC), resource-constrained settings, and marginalized communities worldwide. Undernutrition and infections occurring in the context of poverty remain leading causes of morbidity and mortality in school-age children living in LMIC,3 whereas those children in higher-income settings are more likely to die due to injuries or noncommunicable disease (NCD). In addition, the prevalence of overweight and obesity in children and adolescents has increased steadily over the last few decades,4 though the rate of these increases varies widely among countries.5New risk factors relating to diet, lifestyle, mental health, injuries, and NCDs also become more prominent as children approach and enter adolescence, many of which can contribute to the development of chronic NCDs over the life course. Within this period, school-age children begin to establish healthy lifestyle habits (eg, diet, physical activity, avoidance of substance use), and are learning about sexual and reproductive health and rights, as well as the measures they can take to protect themselves and others. This represents a window of opportunity for educational interventions to support good health, optimal development, and well-being. A growing body of evidence suggests that school-based and digital platforms and delivery strategies are promising tools that aid in the delivery of health interventions to older children.The methodology and reviews described herein contributed to the portion of the upcoming 2022 Lancet Optimizing Child and Adolescent Health and Development Series6 related to school-age child and adolescent health interventions. This Lancet Series is the product of an ongoing academic collaboration involving global child health researchers worldwide, including many who are authors on articles within this supplement. The aim of the specific Lancet Series article citing this supplement is to provide a comprehensive overview of systematic reviews describing the most recent evidence for effective interventions to support maternal, newborn, child, and adolescent health and development from preconception through to 20 years of age.Figure 1 provides an overview of the key child health domains, and a breakdown of the intervention review topics addressing key risk factors covered by the articles included in this journal supplement. On the basis of work done in previous comprehensive overviews of interventions for child and adolescent health (eg, Disease Control Priorities, 3rd edition7; Lancet Adolescent Health Commission8), we identified a comprehensive set of key child health domains that represented priority areas for interventions to address modifiable risks for the major causes of child mortality and morbidity. The factors that informed which domains were covered in this supplement included: conditions with a high global burden of disease, conditions with disproportionate impacts on vulnerable and marginalized populations, potential to support improved human capital development across the life course, and pragmatic considerations including whether the topic had recently been covered elsewhere. In cases where the child health domain was deemed too broad in scope for a single review (eg, infectious diseases), the subtopics for individual reviews were also chosen on the basis of these factors. The age group of specific interest for these reviews was older school-age children (ages 5–9.9), though the period of early adolescence (ages 10–14.9) was also recognized as an important area of overlap and transition. The general outcomes of interest aligned with those chosen through consensus by the Lancet Series working group. These included, but were not limited to, mortality, severe morbidity, disability, growth and development, knowledge and behavior, and indicators of improved human capital development such as academic achievement.The methodological approaches taken, and child health domains covered in this supplement of reviews, was informed by a broad initial literature-scoping and evidence-mapping process to identify key health interventions and associated evidence for their effectiveness in the form of systematic reviews. This was done across all domains, from preconception and pregnancy to ages 0 to 20 to inform the 2022 Lancet Optimizing Child and Adolescent Health and Development Series.6 This involved leveraging existing large-scale intervention overviews (eg, Disease Control Priorities 3rd edition, Lancet Series) that had already highlighted existing effective interventions and the most recent systematic reviews detailing the evidence for their effectiveness. Additional targeted searches for newer interventions and systematic reviews in each domain were also conducted. Through this evidence-mapping process, we explored coverage and extent of LMIC-specific evidence across all child health domains to identify areas where school-age evidence was lacking and determined that there were significant gaps in existing evidence for intervention effectiveness in school-age children.We funneled the reviews identified during this initial scoping process that contained studies covering school-age children and adolescents into the individual reviews for each domain of child health covered in this supplement. We elected to conduct targeted overviews of systematic reviews if there was deemed to be a large body of existing evidence syntheses. In cases where there was a lack of evidence syntheses of intervention effectiveness for a given domain of school-age child health, conventional systematic reviews of primary literature (ie, experimental studies) were conducted. The general methodology for these 2 approaches are described below. See Table 1 and Fig 1 for a summary of the review methods used for each child health domain, and Fig 2 for a breakdown of the main methodology followed in each type of review.For those child health domains that encompassed a variety of intervention types addressing a wide range of risk factors and health conditions, and for which the initial scoping process identified a variety of existing systematic reviews of intervention effectiveness, an overview of systematic reviews was undertaken. This approach was taken to ensure comprehensiveness, reduce duplication of review efforts, and make the review process feasible.In addition to incorporating those relevant reviews previously identified in the initial literature-scoping and evidence-mapping exercise, tailored searches were executed in several databases (eg, Medline, Cochrane Database of Systematic Reviews, Campbell Library) to identify literature published up until the end of 2020. Evidence derived from Cochrane reviews and other high-quality systematic reviews that synthesized evidence from randomized controlled trials and quasi-experimental studies examining the effectiveness of interventions was prioritized for inclusion. A first pass of title and abstract screening for relevance was conducted, followed by a full text screening that was done by at least 2 reviewers against inclusion criteria. Two reviewers independently filled a standardized data abstraction form to capture review characteristics, the characteristics of included studies and interventions (eg, age coverage, country representation, delivery platform), and pooled-effect estimates (eg, risk ratios, odds ratios, mean differences, 95% confidence intervals) derived from meta-analyses where they were reported. The main outcomes of interest across the reviews included measures of child morbidity, mortality, development, academic achievement, and mental and physical well-being. The extracted data were then matched among reviewers to check for errors and ensure consistency, and then consolidated into a single table for inclusion in the article. The AMSTAR 2 tool12 was used for review quality assessment, and was also conducted in duplicate, with any disagreements in ratings resolved by consensus or the involvement of a third reviewer.If for a given domain the initial evidence-mapping exercise revealed that the existing evidence-synthesis literature was lacking for the school-age group, we proceeded with a conventional systematic review of primary literature. All systematic reviews were reported in accordance with the reporting guidance provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.13Search strategies were developed using the population, intervention, control, and outcomes methodology, relevant medical subject headings terms, and keywords derived from the scoping search. The search terms were adapted for use in other bibliographic databases in combination with database-specific filters for controlled trials, where these were available. Searches for the individual, domain-specific reviews were conducted in a variety of databases, including but not limited to: PubMed, Embase, Medline, PsycINFO, Ovid SP, The Cochrane Library, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, and the World Health Organization regional databases. Evidence derived from LMIC was prioritized for synthesis, though evidence from high-income countries (HIC) settings was leveraged to highlight whether effective interventions exist in cases where LMIC evidence was sparse. Gray literature searches and additional hand searching were conducted in Google Scholar and reference lists of relevant articles, book chapters, and reviews.After removal of duplicate studies, a multistage screening process was performed to select studies that met the eligibility criteria. Each title and abstract was assessed by at least 1 reviewer, who excluded those that were deemed irrelevant. At the full-text review stage, at least 2 reviewers assessed all full texts. Any disagreements in inclusion decisions were resolved by discussion and, where necessary, by consulting a third reviewer. At this stage, reasons for exclusion were documented. The methods section of each individual review in this supplement describes their selection and eligibility criteria, which differed depending on the child health domain being assessed. Data from included studies were independently extracted and coded by 2 review authors using standardized, previously piloted data extraction forms, which sought general study characteristics, details of the population, intervention, comparison groups, and quantitative outcome data. Data extraction forms were matched and checked, and if necessary, a third review author was consulted in the event of any disagreements to establish consensus.Assessment of risk of bias for included studies was conducted according to criteria and tools outlined in the Cochrane Effective Practice and Organization of Care guidelines14 for randomized trials, nonrandomized trials, controlled before–after, interrupted time series, and the Cochrane Handbook for Systematic Reviews of Interventions.15 Assessments were conducted independently by 2 review authors; scores were compared, and a final risk of bias judgement was reported for the included studies of each systematic review. Randomized trials were assessed using the Cochrane Risk of Bias tool15 across the following domains: randomization process, deviations from the intended interventions (blinding of personnel, participants, and outcome assessment), missing outcome data, outcome measurement, the selection of the reported result, disclosure of funding, and conflicts of interest. Studies were assigned an overall risk of bias judgement accordingly (low risk, high risk, or some concerns/medium risk). Quasi-experimental study designs were assessed using the Risk of Bias Tool for Nonrandomized Studies of Interventions (ROBINS-I) tool.15,16 Studies were assessed according to the following domains: bias because of confounding, bias in selection of study participants, bias in classification of interventions, bias because of deviations from intended interventions, bias because of missing data, bias in measurement of outcomes, and bias in selection of the reported result. Each study was assigned an overall risk of bias judgement (low, moderate, serious, and critical risk).Meta-analyses were conducted where possible using Review Manager 5.4 software.17 Randomized controlled trials and cluster-randomized controlled trials were analyzed separately from quasi-experimental study designs. To mitigate heterogeneity within included studies, a random-effects meta-analysis was used for pooled outcomes. For those situations where meta-analysis was not possible, data on the effect of interventions from individual studies was tabulated and reported, and a narrative synthesis was conducted for each key intervention domain.Where there were a sufficient quantity of comparable studies (in both interventions and outcome), a summary of the intervention effect and a measure of quality for key outcomes were produced using the Grading of Recommendations Assessment, Development and Evaluation approach.18 The Grading of Recommendations Assessment, Development and Evaluation approach considers 5 domains (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of the body of evidence for each outcome. The evidence was downgraded from “high quality” by 1 level for serious (or by 2 levels for very serious) limitations, depending on assessments for risk of bias, indirectness of evidence, serious inconsistency, imprecision of effect estimates, or potential publication bias.The aim of the authors of this supplement of reviews is to comprehensively assess the available evidence for the effectiveness of interventions to improve health and well-being in school-age children and adolescents. The initial literature-scoping and evidence-mapping process, followed by the different review approaches taken, has helped to maximize the scope covered across this set of reviews, and has allowed us to provide the most comprehensive assessment of the state of the published literature covering interventions for school-age children and adolescents. The individual reviews in this supplement have also highlighted child health domain-specific gaps in the evidence for both primary literature in the school-age group, and gaps in existing evidence syntheses.It is important to note that, for the reviews within this supplement, the descriptions of intervention effects are meant to provide an overview of what is currently known in terms of evidence for effectiveness, and do not imply that other interventions were ineffective simply because there was an evidence gap. Given the limited space and large scope, it was only possible to provide the highlights of specific comparisons and outcomes in each of the results sections. Comprehensive tables of study characteristics, outcomes, and effect estimates are provided in both the main articles and appendices.Although we were specifically interested in focusing on LMIC research, this was only feasible for a few review topics (eg, sexual and reproductive health and rights, neglected tropical diseases) because of a dearth of literature. Instead of being used to attempt to generalize their effectiveness to LMIC settings, evidence from intervention effectiveness in HIC settings are included and described to establish that effective interventions do indeed exist and may differ in their impact between settings. This approach has previously been used in the context of adolescent health interventions.19 This evidence from HIC could act as a starting point for future research and implementation in various LMIC settings, with program components tailored to local contexts.In the case of those reviews taking the overview of systematic reviews approach, we were limited to including only those primary studies already included in systematic reviews and could not cover each subdomain in depth. Thus, we were unable to identify and include those primary studies that may not have been included in systematic reviews because of studies not being identified in review authors’ database searches, not meeting their inclusion criteria, or falling out of the time frame of the review. Furthermore, some systematic reviews of primary literature were unable to perform meta-analyses because of high heterogeneity or a lack of high-quality evidence from randomized trials, which makes synthesizing the existing evidence more difficult.

Diabetes is now a truly global condition, with the most rapid increases in prevalence occurring in low- and middle-income countries (LMICs).1, 2 These regions face a convergence of demographic change, urbanisation, nutritional transition and constrained health systems, resulting in earlier onset of diabetes, high complication rates and substantial social and economic impact.1, 3, 4 Yet, despite bearing a growing share of the global burden, LMICs remain under-represented in the diabetes research literature.5-7 Other works have made similar observations. One such work is by Allen et al., who reported an imbalance in NCD research, often characterised by NCD publications led by authors from LMICs, published in lower-impact journals with lower citation rates than those led by authors from HICs.7 This imbalance matters not only for equity, but also for the relevance, applicability and quality of the global evidence base.1, 4, 8 Current estimates suggest that over 75% of people living with diabetes reside in LMICs, a proportion projected to increase further over the coming decades.9 The Lancet Commission on Diabetes has emphasised that transforming diabetes outcomes globally requires locally generated data that reflect diverse phenotypes, health systems and social contexts, rather than extrapolation from high-income settings alone.10 Similarly, the World Health Organization (WHO) and the International Diabetes Federation (IDF) have consistently highlighted the need for context-specific and domestic evidence to guide policy and practice in regions where health system capacity and resources differ markedly from those in HICs.1, 4 Despite this, the global diabetes evidence base remains dominated by research originating from HICs.5, 10 While such research is indispensable, over-reliance on evidence generated in well-resourced settings risks limiting the external validity of clinical guidelines, service delivery models and policy recommendations when applied in LMIC contexts.11-13 Differences in age of onset, multimorbidity patterns, workforce composition, access to diagnostics and therapies and health-care financing mechanisms all influence how diabetes is experienced and managed across settings.4, 5, 10, 14 Encouraging and supporting diabetes research in LMICs is therefore a scientific imperative, not simply a matter of representation.10, 12 Research conducted in LMICs offers unique and important insights. These include the connection between diabetes and infectious diseases, the impact of poverty, food insecurity and informal work on disease progression, and the development of new primary care and community-based models that use task shifting and the practical use of limited resources.10, 15, 16 Many of these approaches are becoming increasingly relevant to underserved populations in high-income countries (HICs), highlighting the global value of research led by LMICs and the importance of mutual learning.2, 17 Authorship is a key issue in this context. Academic recognition, research priorities, career advancement, funding opportunities and leadership roles are all influenced by authorship. Equitable authorship fosters research pertinent to local needs, interpretations informed by context and the development of enduring capabilities.18 Participation of researchers from LMICs in diabetes-related authorship remains significantly constrained, notwithstanding these challenges. These limitations encompass restricted access to financial support and allocated research time, insufficient research infrastructure, well-established and resourced libraries, and limited avenues for training in study design, statistical analysis and academic writing (Figure 1). Furthermore, language obstacles and publication expenses exacerbate these challenges.5, 6, 12 Structural inequities, inherent in international collaborations, can exacerbate the marginalisation of LMIC investigators; agenda-setting, senior authorship and corresponding authorship often reside within high-income country HIC institutions, which usually pay for the article processing costs as required by their institutions before payment can be made, even when the research is primarily conducted in LMIC settings, or led by authors from LMICs.5, 6, 12 These established patterns have been the subject of considerable investigation in international health research, potentially reinforcing knowledge creation practices that prioritise extraction over collaborative methodologies.12, 19 Significantly, rigorous peer review should prioritise scientific contribution and relevance over resource demands or adherence to high-income health system standards. Diabetic Medicine has consistently and uniquely demonstrated a dedication to publishing research that is both clinically pertinent and globally informed. As the epidemiology of diabetes continues to shift, there is both an opportunity and a responsibility to ensure that the voices shaping the evidence increasingly reflect the populations most affected. This includes early- and mid-career researchers, clinicians, nurses, patient advocates and allied health professionals working in LMIC settings, whose insights are central to real-world diabetes care but remain under-represented in the literature. If you're uncertain about the fit of your work, we encourage you to reach out to the journal early. Your insights are crucial for developing diabetes care that is both fair and effective globally. This project was not funded, but SS is supported by National Institute for Health Research Applied Research Collaboration East Midlands NIHR Global Research Centre for Multiple Long Term Conditions. The authors declare no conflicts of interest.

Factors associated with hand hygiene adherence among healthcare workers in Guatemala during the COVID-19 pandemic

BackgroundGlobal populations, especially those in low- and middle-income countries (LMICs), are at an increased risk of musculoskeletal (MSK) pain, a leading cause of years lived with disability. Shared decision making (SDM) in the management of these conditions may drive improvements in healthcare outcomes and quality. This study aimed to synthesize and appraise available evidence regarding SDM in MSK pain consultations in LMICs.MethodsComprehensive literature searches were conducted in 12 databases for primary studies investigating SDM in MSK pain consultations across all healthcare and community settings in LMICs. Study eligibility screening, data extraction and quality appraisal (using the Critical Appraisals Skills Programme tool) were completed by pairs of reviewers. Findings were brought together using thematic synthesis of data from all the primary studies.ResultsSeven studies (mostly moderate quality) were included. There was low awareness of SDM among healthcare professionals (HCPs); however, this is not explicitly practised due to cultural and operational barriers. HCP training and patient empowerment through health literacy were proposed facilitators. The traditional paternalistic approach to treatment poses a key barrier to SDM, decreases adherence to prescribed treatments and raises the risk of poor clinical outcomes.ConclusionsSDM is still a relatively ‘foreign concept’ within consultations and management of MSK pain patients in LMICs. There is a dearth of research in SDM and patient-centred care. Given the socio-economic impact of MSK pain, further research into the value of SDM in LMIC healthcare settings requires further consideration.

BackgroundMost post-licensure vaccine pharmacovigilance in low- and middle-income countries (LMICs) are passive reporting systems. These have limited utility for maternal immunization pharmacovigilance in LMIC settings and need to be supplemented with active surveillance. Our study’s main objective was to identify existing perinatal data collection systems in LMICs that collect individual information on maternal and neonatal health outcomes and could be developed to inform active safety surveillance of novel vaccines for use during pregnancy.MethodsA scoping review was performed following the Arksey and O’Malley six-stage approach. We included studies describing electronic or mixed paper-electronic data collection systems in LMICs, including research networks, electronic medical records, and custom software platforms for health information systems. Medline PubMed, EMBASE, Global Health, Cochrane Library, LILACS, Bibliography of Asian Studies (BAS), and CINAHL were searched through August 2019. We also searched grey literature including through Google and websites of existing relevant perinatal data collection systems, as well as contacted authors of key studies and experts in the field to validate the information and identify additional sources of relevant unpublished information.ResultsA total of 11,817 records were identified. The full texts of 264 records describing 96 data collection systems were assessed for eligibility. Eight perinatal data collection systems met our inclusion criteria: Global Network’s Maternal Newborn Health Registry, International Network for the Demographic Evaluation of Populations and their Health; Perinatal Informatic System; Pregnancy Exposure Registry & Birth Defects Surveillance; SmartCare; Open Medical Record System; Open Smart Register Platform and District Health Information Software 2. These selected systems were qualitatively characterized according to seven different domains: governance; system design; system management; data management; data sources, outcomes and data quality.ConclusionThis review provides a list of active maternal and neonatal data collection systems in LMICs and their characteristics as well as their outreach, strengths, and limitations. Findings could potentially help further understand where to obtain population-based high-quality information on outcomes to inform the conduct of maternal immunization active vaccine safety surveillance activities and research in LMICs.

The changing health priorities of earthquake response and implications for preparedness: a scoping review