Andmiddle-income Countries Research Articles

HAYMAN COMPRESSION SUTURES : AN UNDERUTILIZED TOOL FOR MANAGEMENT OF UTERINE ATONY AND POSTPARTUM HAEMORRHAGE.

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low- andmiddle-income countries. Uterine atony accounts for 70–80% of PPH cases. Management of PPH isusually based on a cascade beginning with the use of uterotonics and eventually hysterectomy in casesof refractory PPH. Different compression suture techniques have been described and used for themanagement of uterine atony where medical management is insufficient and preservation of fertility isdesired.Case presentation: This is a series of four patients who presented to our facility and consequentlydeveloped uterine atony that was unresponsive to medical management during cesarean delivery despitethe use of multiple uterotonics. All four patients had established risk factors for uterine atony, includinginduction of labor, augmentation of labor, chorioamnionitis, or fetal macrosomia. Hayman compressionsutures were performed in all four patients with success. Estimated blood loss in the series ranged from400 to 1200 mls. All patients recovered well with no complications reported during the postpartum period.Conclusion: Hayman compression sutures offer an alternative to the more ubiquitous B-Lynch suturewith several advantages, including ease of placement and no need for a hysterotomy in PPH post vaginalbirth or placement post repair of hysterotomy in cesarean cases. Thus, the may be easier to perform forjunior health care professionals as well as in stressful situations.

A landscape evaluation of caffeine citrate availability and use in newborn care across five low- and middle-income countries.

Apnoea of prematurity (AOP) is a common complication among preterm infants (< 37 weeks gestation), globally. However, access to caffeine citrate (CC) that is a proven safe and effective treatment in high-income countries is largely unavailable in low- and-middle income countries, where most preterm infants are born. Therefore, the overall aim of this study was to describe the demand, policies, and supply factors affecting the availability and clinical use of CC in LMICs. A mixed methods approach was used to collect data from diverse settings in LMICs including Ethiopia, Kenya, Nigeria, South Africa, and India. Qualitative semi-structured interviews and focus group discussions were conducted with 107 different health care providers, and 21 policymakers and other stakeholders from industry. Additional data was collected using standard questionnaires. A thematic framework approach was used to analyze the qualitative data and descriptive statistics were used to summarize the quantitative data. The findings indicate that there is variation in in-country policies on the use of CC in the prevention and treatment of AOP and its availability across the LMICs. As a result, the knowledge and experience of using CC also varied with clinicians in Ethiopia having no experience of using it while those in India have greater knowledge and experience of using it. This, in turn, influenced the demand, and our findings show that only 29% of eligible preterm infants are receiving CC in these countries. There is an urgent need to address the multilevel barriers to accessing CC for managing AOP in Africa. These include cost, lack of national policies, and, therefore, lack of demand stemming from its clinical equivalency with aminophylline. Practical ways to reduce the cost of CC in LMICs could potentially increase its availability and use.

Health technologies as innovative tools to prevent cervical cancer in low -and-middle income countries

Introduction: Cervical cancer's mortality and morbidity, as well as the prospect of effective screening-based prevention, make it a critical area of intervention attention. By engaging social support groups in health education, participation in cervical c cancer screening and early diagnosis of the illness in the community is enhanced. In the continuous efforts to enhance cervical cancer prevention, control, and management, technology, and digital health will play a significant role. As a result of mHealth educational activities in this region, knowledge of cervical cancer risk factors, warning signs and symptoms, and information on HPV vaccination improved. By boosting screening rates, raising awareness, and encouraging early diagnosis, mHealth methods can help reduce the symptoms of cervical cancer. These initiatives use mobile technology to give targeted and individualized information, reminders, and support, allowing individuals to be proactive in cervical cancer prevention and screening. Objective: This study shows that e-health interventions can improve cervical cancer screening awareness, intention, and uptake. It indicates that electronics may be used to reach out to poor and medium-income countries as well as minority populations all around the world. Conclusion: The mobile health age has shown promising promise for more efficient health care delivery throughout the world. The term "mobile" connotes the freedom and flexibility to complete any work, anywhere and at any time, as it may be utilized to prevent cervical cancer in women by raising public awareness about Pap smear screening. It is critical to stress that the use of health technology in cervical cancer screening programs should be accompanied by suitable infrastructure, training, and supporting policies to enable long-term sustainability and equal access to services.

Understanding communication incommunity engagement formaternal andnewborn health programmes inlow- andmiddle-income countries: a realist review.

As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.

CLRM-05 ADAPTATION OF NEW CLASSIFICATION OF ASTROCYTOMA IN LOW AND MIDDLE INCOME COUNTRY- HOW SMOOTH IS THE ROAD AHEAD?

Abstract BACKGROUND The 2021 WHO CNS 5 classification made major changes with integration of immunohistochemistry, molecular profiling and sequencing in addition to histopathology to classify brain tumors. IDH mutation is mainstay for diagnosis of low grade glioma and 1p/19q testing required only to confirm oligodendroglioma but not in all cases. This integrated approach has favored prognosis, and diagnosis of disease as well as prediction of response to therapy. METHODS A retrospective study was conducted to analyze the molecular alterations in patients diagnosed with astrocytoma in 2021 in Kathmandu Cancer Center, Nepal. The demographic data were collected from the patients’ archived files from the medical record department. The patients were categorized as IDH: mutant and wild, and ATRX: retained and lost. RESULTS This study demonstrated IDH and ATRX mutation with 30.3% and 24.23% respectively. In our study, among grade 2 and 3 patients, 8 out of 11 (72.7%) were IDH mutant types. 2 patients of this group were IDH wild type, who ideally required further testing for correct classification but couldn’t be done due to financial constraints. IDH status of one patient in this group was unknown. 72.7% of the Grade 4 gliomas were IDH wild type and classified as Glioblastoma Multiforme. In 6 of the patients IDH status was unknown. Among 8 grade 2 and 3 tumors with IDH mutant, 2 had loss of ATRX and 6 had ATRX retained. Among these 6 patients only one had 1p/19q co-deletion done which was positive. Rests 5 were not properly classified. CONCLUSION In conclusion, higher percentage of IDH wild type was seen in Grade 4 gliomas. Similarly, the IDH mutant type predominated in Grade 2 and 3 gliomas. More pronounced investigations are still not feasible in low- and-middle income countries because of limited resources.

Using intersectionality to study gender andantimicrobial resistance inlow- andmiddle-income countries.

Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.

Using evidence inmental health policy agenda-setting inlow- andmiddle-income countries: a conceptual meta-framework from a scoping umbrella review.

The purpose of this article is to close the gap in frameworks for the use of evidence in the mental health policy agenda-setting in low- and middle-income countries (LMICs). Agenda-setting is important because mental health remains a culturally sensitive and neglected issue in LMICs. Moreover, effective evidence-informed agenda-setting can help achieve, and sustain, the status of mental health as a policy priority in these low-resource contexts. A scoping 'review of reviews' of evidence-to-policy frameworks was conducted, which followed preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Nineteen reviews met the inclusion criteria. A meta-framework was developed from analysis and narrative synthesis of these 19 reviews, which integrates the key elements identified across studies. It comprises the concepts of evidence, actors, process, context and approach, which are linked via the cross-cutting dimensions of beliefs, values and interests; capacity; power and politics; and trust and relationships. Five accompanying questions act as a guide for applying the meta-framework with relevance to mental health agenda-setting in LMICs. This is a novel and integrative meta-framework for mental health policy agenda-setting in LMICs and, as such, an important contribution to this under-researched area. Two major recommendations are identified from the development of the framework to enhance its implementation. First, given the paucity of formal evidence on mental health in LMICs, informal evidence based on stakeholder experience could be better utilized in these contexts. Second, the use of evidence in mental health agenda-setting in LMICs would be enhanced by involving a broader range of stakeholders in generating, communicating and promoting relevant information.

Barrier analysis for continuity of palliative care from health facility to household among adult cancer patients in Addis Ababa, Ethiopia

BackgroundAnnually 57 million people across the globe require palliative care, 76% are from low- and-middle income countries. Continuity of palliative care contributes to a decline in emergency room visits., decreased hospital deaths, improved patient satisfaction, better utilization of services, and cost savings. Despite efforts made to develop the palliative care guideline in Ethiopia, the service is not yet organized and linked to primary health care. This study aimed to explore barriers to the continuum of palliative care from facility to household for cancer patients in Addis Ababa.MethodsQualitative exploratory study was conducted with face-to-face interviews with a total of 25 participants. The study population was adult cancer patients, primary caregivers, healthcare providers, volunteers, and nationwide advocates. Data were audio recorded, transcribed verbatim and finally imported to Open code version 4.02 software for coding and analysis. Thematic analysis was guided by Tanahashi’s framework.ResultsThe key barriers to continuity of palliative care included opioid scarcity and turnover and shortage of healthcare workers. A shortfall of diagnostic materials, cost of medications, lack of government backing, and home-based center’s enrollment capacity hampered accessibility. Care providers were instruments of cultural barriers in delivering appropriate end-of-life care, on the other hand, patients’ preference for conventional medicine hindered acceptability. Lack of community volunteers, failure of health extension workers to link patients, and spatial limits fraught utilization. The lack of defined roles and services at several levels and the workload on healthcare professionals affected the effectiveness of the nexus.ConclusionThe continuum of palliative care service from health facility to household in Ethiopia is yet in its infancy compromised by factors related to availability, accessibility, acceptability, utilization, and effectiveness. Further research is required to delineate the roles of various actors; the health sector should smudge out the continuum of palliation to cope with the growing need for palliative care.

Toward a New Paradigm of North-South and South-South Partnerships for Pandemic Preparedness: Lessons Learned from COVID-19 and Other Outbreaks.

COVID-19 underscores the need to reimagine North-South partnerships and redefine best practices for building public health and research capacity to address emergent health threats and pandemic preparedness in low- and-middle income countries (LMICs). Historically, outbreak and emergency responses have failed to ensure that the Global South has the autonomy and capacity to respond to public health threats in a timely and equitable manner. The COVID-19 response, however, has demonstrated that innovations and solutions in the Global South can not only fill resource and capacity gaps in LMICs but can also provide solutions to challenges globally. These innovations offer valuable lessons about strengthening local manufacturing capacity to produce essential diagnostic, treatment, and prevention tools; implementing high-quality research studies; expanding laboratory and research capacity; and promoting effective cooperation and governance. We discuss specific examples of capacity-building from Rwanda, South Africa, and Senegal. To fulfill promises made to the Global South during the COVID-19 pandemic, restore and resume health service delivery, and effectively prevent and respond to the next health threat, we need to prioritize equitable access to local manufacturing of basic health tools while building health systems capacities in the Global South.

Strengthening Health Systems for Climate Adaptation and Health Security: Key Considerations for Policy and Programming.

Strengthening Health Systems for Climate Adaptation and Health Security: Key Considerations for Policy and Programming.

Quality of Life and Road Traffic Injury: A Bibliometric Analysis

Road injury is classified as an unintentional injury resulting from road crashes with one or more vehicles or persons, and this injury may result in fatality. Among unintentional injuries, Road Traffic Injury (RTI) is the most common cause of death worldwide (Onainor, 2019). Approximately 1.3 million people are involved in road crashes, resulting in 20 to 50 million suffering from non-fatal injuries worldwide (World Health Organization, 2021). Pedestrians, cyclists, motorcyclists, and pillions are considered at-risk groups that were contributing to half of the road traffic fatalities and injuries. About 93% of these road fatalities are from low and middle-income countries, negatively impacting their countries' economic well-being. Apart from that, the condition impacts the national economic growth and the household financial burden due to the loss of productivity caused by premature death aged 5 – 29 (World Health Organization, 2021). While there are costing analyses and mathematical injury models that might project the burden of RTIs, there is another way to understand the burden: measuring the quality of life of those affected. QOL is one of the prominent tools used in RTI, which provides evidence-based patient-reported outcomes regarding individuals' well-being. QOL is also used in guiding informed decision making for future healthcare planning. The QOL measurement also is relevant when the measurement of morbidity and mortality cannot be assessed accurately (Rissanen, Berg, &amp; Hasselberg, 2017). While the health provider and policymaker are affected economically due to road crashes, the patients involved too are greatly affected by the crash aftermath. Keywords: Quality of life, Road Traffic Injury, Bibliometric Analysis, VOSviewer, Harzing's Publish or Perish

Three Growth Spurts in Global Physical Activity Policies between 2000 and 2019: A Policy Document Analysis.

Non-communicable diseases (NCDs) contribute significantly to global mortality and are of particular concern in growing urban populations of low- and-middle income countries (LMICs). Physical inactivity is a key NCD determinant and requires urgent addressing. Laudable global and regional efforts to promote physical activity are being made, but the links between physical activity (PA), NCD reduction, and integrated intersectoral approaches to reducing obesogenic environments are not consistently made. This study applied a document analysis approach to global PA and NCD policies to better understand the current global policy environment and how this may facilitate integrated PA promotion. A total of 34 global policies related to PA, from different sectors, were analyzed. PA policy in mitigation of NCDs has evolved exponentially, with a progression towards addressing structural determinants alongside individual behavior change. The global PA agenda is primarily driven by the World Health Organization. Intersectoral collaboration is importantly regarded, but the contributions of other sectors, outside of health, education, transport, and urban planning, are less clear. Improving PA among key sub-populations—women, girls, and adolescents—requires greater policy consideration. It is imperative for PA-relevant sectors at all levels to recognize the links with NCDs and work towards integrated policy and practice in mitigation of the rising NCD pandemic.

How public health crises expose systemic, day-to-day health inequalities in low- and-middle income countries: an example from East Africa

BackgroundThe current Coronavirus disease pandemic reveals political and structural inequities of the world’s poorest people who have little or no access to health care and yet the largest burdens of poor health. This is in parallel to a more persistent but silent global health crisis, antimicrobial resistance (AMR). We explore the fundamental challenges of health care in humans and animals in relation to AMR in Tanzania.MethodsWe conducted 57 individual interviews and focus groups with providers and patients in high, middle and lower tier health care facilities and communities across three regions of Tanzania between April 2019 and February 2020. We covered topics from health infrastructure and prescribing practices to health communication and patient experiences.ResultsThree interconnected themes emerged about systemic issues impacting health. First, there are challenges around infrastructure and availability of vital resources such as healthcare staff and supplies. Second, health outcomes are predicated on patient and provider access to services as well as social determinants of health. Third, health communication is critical in defining trusted sources of information, and narratives of blame emerge around health outcomes with the onus of responsibility for action falling on individuals.ConclusionEntanglements between infrastructure, access and communication exist while constraints in the health system lead to poor health outcomes even in ‘normal’ circumstances. These are likely to be relevant across the globe and highly topical for addressing pressing global health challenges. Redressing structural health inequities can better equip countries and their citizens to not only face pandemics but also day-to-day health challenges.

To Assess the Level of Awareness on Problems of Drugs Dependence among Adolescent in Selected Area of Gautam Budh Nagar, Uttar Pradesh

Background: Globally substance abuse is a major public health and social concern. With changes in lifestyle,globalization in substance marketing, the erosion of powers of censure that have existed in traditionalsocieties, and an increased acceptance of such substances, it is clear that their use is growing in low andmiddle income countries, particularly in the children, adolescents and the youth1.Methods: It was a descriptive study. Total 100 adolescents were selected using convenient samplingtechnique. Structured questionnaire was used to collect the demographic characteristics &amp; to assess the levelof awareness on problems of drug dependence among adolescents in selected area.Results: the findings of study revealed that only 4% of adolescents had excellent awareness, 38% ofadolescents had good awareness, 44% of adolescents had average awareness, 14% of adolescents had poorawareness regarding ill effects of substance abuse.Conclusion: The study concluded that there is a need to spread awareness about the drugs dependence &amp;its possible consequences using campaigns &amp; awareness class. The findings of study reveals that most ofadolescents are having average awareness regarding problems of drug dependence.

Effectiveness and moderators of a multicomponent school-based intervention on screen time devices: the Movimente cluster-randomized controlled trial

BackgroundInterventions targeting reduce screen time in adolescents are urgently needed, mainly in low and middle-income countries because of the lack of evidence. Thus, the aims of the study were to examine the effect of a cluster-randomized controlled trial on screen time (ST) devices among Brazilian adolescents and to identify possible moderators.MethodsMovimente was a multicomponent school-based intervention that was performed in 2017 and consisted of teacher training, education curriculum, and environmental improvements. Baseline and post-intervention assessments (over one academic year) were conducted with students aged 10–16 years at baseline (baseline n = 921, [n = 538 intervention group; n = 383 control group]). A self-report questionnaire was used to measure daily minutes of device specific screen time (TV, computer, video games and smartphone) and demographic variables. Linear mixed models were used to examine intervention effects and an exploratory moderation analysis (sex, grade and socioeconomic status) was performed.ResultsThe intervention had no significant effects on TV time (β = − 6.4, 95% CI: − 6.1;13.4), game time (β = − 8.2, 95% CI: − 7.2;10.8), computer time (β = 1.1, 95% CI: − 6.3;18.5), smartphone time (β = − 10.2, 95% CI: − 32.5;12.1), screen time (β = − 12.8, 95% CI: − 50.5;24.8), meeting screen time guidelines (OR: 1.29, 95% CI: 0.65,2.57) and meeting screen time guidelines with smartphone (OR: 1.66, 95% CI: 0.37,7.40). There was a significant intervention effect on reducing TV time (β = − 37.1, 95% CI: − 73.0, − 1.3) among 8th grade students only.ConclusionsThe Movimente intervention was effective only for TV time among 8th grade students. Understanding how school-based interventions can improve adolescents’ device specific screen time across age groups is needed. Future strategies should cover all screen-based devices. Further, there is a need for more studies in low- and-middle income countries to assist in the development of effective strategies.Trial registrationClinicaltrials.gov identifier NCT02944318 (25/10/2016).

Clubfoot Correction in Walking-age Children: A Review

Children with clubfoot often present after the walking age, especially in low- and middle-income countries where approximately 80% of children with clubfoot are born. With advancing age, there is increased stiffness of the soft tissue structures and decreased remodeling potential of the bones of the foot. Not all clubfeet in older children are rigid—some are flexible and amenable to stretching and conservative treatment. Hence, the initial evaluation of the deformity must include an assessment of correctability. The treatment of clubfoot in the older child is challenging and was traditionally performed using complex soft tissue and bony surgeries, often with poor outcomes in the long term. Recent literature has focused on the role of conservative treatment utilizing Ponseti principles of serial manipulation and casting, combined with limited surgery. The purpose of this review is to report the changing trends in the management of clubfoot in the walking child, to review the current literature regarding various treatment modalities, and to recommend a practical approach to treatment based upon age, inherent flexibility of the foot, available resources, and contextual factors. <!-- named anchor --> How to cite this article Penny N, Aroojis A, Mehtani A, et al. Clubfoot Correction in Walking-age Children: A Review. J Foot Ankle Surg (Asia Pacific) 2021;8(3):102–109.

PSY10 Global and Regional Prevalence and Incidence of LUPUS in Low and-Middle Income Countries: A Systematic Review and Meta-Analysis

The aim of this study was to systematically summarise the prevalence and incidence of SLE in low and-middle income countries (LMICs). A systematic search of MEDLINE, CINHAL, Web of Science and Global Index Medicus was carried out using keyword search terms for SLE combined with prevalence, incidence and epidemiology. The search was to identify papers addressing SLE in LMICs and published up to September 1, 2020. The prevalence and incidence of SLE were pooled through random effect model. Pooled estimates were expressed with 95% confidence intervals. Out of 1757 papers, 16 studies were included. The mean age at diagnosis ranged from 25.5 to 45.8 years. The included studies were conducted in Argentina (n = 2), Brazil (n = 3), China (n = 2), Colombia, Greece, India, Malaysia, Pakistan, Venezuela, Zimbabwe and French Guiana. The SLE prevalence and incidence varied from 3.2 to 159 per 100,000 and 1.4 to 8.7 per 100,000 population, respectively. In the random effects meta-analysis (n = 8), the pooled prevalence of SLE was 120 (95% confidence interval [CI]:100 – 200) per 100,000. Meta-analysis of data from six incidence studies revealed an incidence of 4 cases per year (95% CI: 2 – 6) per 100,000. According WHO regions, the pooled prevalence of American and Western Pacific regions was 300 (95% CI -200 – 900) and 36 (95% CI 35 – 37) per 100,000, respectively. The pooled incidence of the American region was 10 (95% 0 – 14) per 100,000 population. Our findings provide a comprehensive and up-to-date summary of the prevalence and incidence of SLE in LMICs. As SLE is an important threat to the population, health professionals and policymakers needs to put in place appropriate programmes to reduce the burden of SLE in LMICs.

How Public Health Crises Expose Systemic, Day-to-Day Health Inequalities in Low- and-Middle Income Countries - An Example From East Africa

Background: The Coronavirus disease pandemic reveals political and structural inequities of the world’s poorest people who have little or no access to health care and with the largest burdens of poor health. This is in parallel to a more persistent but global health crisis, antimicrobial resistance (AMR). We explore the fundamental challenges of health care in humans and animals in relation to AMR in Tanzania. Methods: We conducted 57 individual interviews and focus groups with providers and patients in high, middle and lower tier health care facilities and communities across three regions of Tanzania between April 2019 and February 2020. We covered topics from health infrastructure and prescribing practices to health communication and patient experiences. Findings: Three interconnected themes emerged about systemic issues impacting health. First, there are challenges around infrastructure and availability of vital resources such as healthcare staff and supplies. Second, health outcomes are predicated on patient and provider access to services as well as social determinants of health. Third, health communication is critical in defining trusted sources of information, and narratives of blame emerge around health outcomes with the onus of responsibility for action falling on individuals. Interpretation: Entanglements between infrastructure, access and communication exist while constraints in the health system lead to poor health outcomes even in ‘normal’ circumstances. These are likely to be relevant across the globe and highly topical for addressing pressing global health challenges. Redressing structural health inequities can better equip countries and their citizens to not only face pandemics but also day-to-day health challenges. Funding Statement: This research was funded by the Antimicrobial Resistance Cross-Council Initiative through a grant from the Medical Research Council, a Council of UK Research and Innovation and the National Institute for Health Research (MRC/AMR/ MR/S004815/1). Hilton’s time was also funded by a core grant for the Medical Research Council/Chief Scientist Office (MRC/CSO) Social and Public Health Sciences Unit (MC_UU_12017/14; SPHSU14; MC_UU_12017/15; SPHSU15). This publication was supported by the University of Edinburgh and the University of Glasgow Jointly Funded PhD studentships (Loosli).Declaration of Interests: There are no conflicts of interests between the authors and/or institutions.Ethics Approval Statement: The study received approval from the Kilimanjaro Christian Medical University College Ethics Review committee with certificate n. 2408 and the Catholic University Health and Allied Sciences committee with certificate n. CREC/318/2018; National Institute for Medical Research (NIMR), Tanzania, with Reference Number NIMR/HQ/R.8a/Vol. IX/3017; Tanzanian Commission for Science and Technology (Davis, permit n. 2020-335-NA-2019-205; Lembo, permit n. 2020-333-NA-2019-205; Laurie, permit n. 2020-332-NA-2019-205; Mutua, permit n. 2020-334-NA-2019-205; Nthambi, permit n. 2020-336-NA-2019-205; Matthews, permit n. 2019-482-NA-2019-205; and Hilton, permit n.2019-476-NA-2019-205); and College of Medical Veterinary and Life Sciences ethics committee at the University of Glasgow (project application number 200180046). Permission for research in communities was obtained from relevant local and district authorities. All participants were explained study objectives and written and/or verbal informed consent was obtained. Verbal consent was utilised instead of written consent with participants who were unable to write. Informed consent forms and participant information sheets were approved by all ethics panels.

Mobile Health (mHealth) in the Developing World: Two Decades of Progress or Retrogression

Mobile healthcare, or mHealth, is one of the key pillars of information and communication technologies for healthcare that consists of telemedicine, telehealth, eHealth, and mHealth. In the past two decades, mobile health has become a transformative concept for healthcare delivery innovations on a global scale. The success was based on the market-driven strategies that utilised the advances in mobile communications, computing, and sensor technologies, especially in recent years. Those market-driven mobile health systems were also closely associated with the global proliferation of smartphones, and based on the correlated usage principle of the smartphone applications for healthcare and wellbeing. However, the global commercial success of the smartphone-based mHealth model was not widely translated into successful scaled-up and tangible healthcare benefits, especially in low- and-middle income countries, compared to the consumer mobile health markets. The numerous healthcare challenges in the developing world remained largely untackled by the existing mobile health systems and models. The much-hyped transformative benefits of these systems remain largely unfulfilled. For two decades since the inception of this concept, the majority of the population in resource-limited healthcare settings still remain in poorer health and live in worsened conditions, with limited if any access to basic healthcare services. The much-hyped mobile health services that promised transforming these fragile and limited healthcare conditions, did not come to wider fruition globally. The COVID-19 pandemic, with its devastating human and economic impact worsened this status. An overview of the origin and the basic principles of mobile health, its current landscape and status in the developing world is presented. The impact of the smartphone-centric model that dominated the landscape of mobile health systems in these countries is discussed, and a critical view on the limitation of this mobile health model adopted widely in these settings is provided.

Economic Shocks and Risky Sexual Behaviours: A Systematic Review of the Literature

This systematic review investigates the role of economic shocks in explaining HIV transmission through risky sexual behaviors. With natural disasters and global economic shocks becoming more prevalent and HIV disproportionately affecting young women in low- and middle-income countries, understanding the contribution of such shocks in driving risky sexual behaviors of both men and women is key in the response to HIV. The systematic review brings together a diverse literature, identifying for inclusion 35 papers containing 31 unique negative and 11 unique positive economic shocks combined with 322 risky sex and health outcomes. We find that increases in risky sexual behaviors are more sensitive to negative shocks than decreases are to positive shocks. Those already at risk of engaging in transactional or commercial sex are particularly vulnerable to temporary negative shocks increasing high risk behaviors. Persistent negative shocks consistently lead to increased risky sex in all samples. The implications for policy are that protecting against negative economic shocks will likely be effective in preventing STIs and HIV in low- and-middle income countries.