Care In Resource-limited Settings Research Articles

The global surgery blood drought: frontline provider data on barriers and solutions in Bihar, India

ABSTRACTBackground: Limited access to safe, timely banked blood is a critical barrier to providing basic surgical care in resource-limited settings globally. Contextual, locally driven data are required to elucidate country needs, develop effective interventions, and guide policy decisions.Objective: We employ qualitative methodology to describe barriers faced and solutions proposed by front-line obstetric providers in Bihar – a poor, populous Indian state where maternal mortality exceeds the national average. We aim to make locally driven recommendations for ongoing policy work in India to strengthen the country’s blood transfusion system.Methods: From February to May 2016, two researchers conducted semi-structured interviews with 19 obstetric providers across Bihar. Snowball sampling was employed until thematic saturation was reached. Following immersion into de-identified texts and dual codebook development, a primary analyst completed topical coding, and a secondary analyst confirmed reproducibility.Results: Providers report that pervasive banked blood shortages force hospitals to require replacement donation, but patients’ families often cannot or will not donate. Providers wait one to six hours for blood, depending on availability of staff and supplies, blood bank proximity, and the ability of the patient being treated to navigate the system. Providers feel forced to refer their patients, often to distant, poorly equipped centers. Providers identify donor education, improved infrastructure, and improved local coordination as focus areas for intervention.Conclusions: A multi-stakeholder approach that aims to increase blood donation through community education, mitigate limited infrastructure through short-term workarounds, and improve local-level coordination through state support and policy change is required in Bihar. This study generates data to guide policy and future research aimed at generating affordable, contextually appropriate interventions to the blood drought.

Approaches to Improve the Surveillance, Monitoring, and Management of Noncommunicable Diseases in HIV-Infected Persons: Viewpoint.

Low-income and middle-income countries (LMICs) are undergoing an epidemiological transition, in which the burden of noncommunicable diseases (NCDs) is rising and mortality will shift from infectious diseases to NCDs. Specifically, cardiovascular disease, diabetes, renal diseases, chronic respiratory diseases, and cancer are becoming more prevalent. In some regions, particularly sub-Saharan Africa, the dual HIV and NCD epidemics will pose challenges because their joint burden will have adverse effects on the quality of life and will likely increase global inequities. Given the austere clinical infrastructure in many LMICs, innovative models of care delivery are needed to provide comprehensive care in resource-limited settings. Improved data collection and surveillance of NCDs among HIV-infected persons in LMICs are necessary to inform integrated NCD-HIV prevention, care, and treatment models that are effective across a range of geographic settings. These efforts will preserve the considerable investments that have been made to prevent the number of lives lost to HIV, promote healthy aging of persons living with HIV, and contribute to meeting United Nations Sustainable Development Goals.

International Radiotherapy Referrals From Rural Rwanda: Implementation Processes and Early Clinical Outcomes

PurposeLow- and middle-income countries disproportionately comprise 65% of cancer deaths. Cancer care delivery in resource-limited settings, especially low-income countries in sub-Saharan Africa, is exceedingly complex, requiring multiple modalities of diagnosis and treatment. Given the vast human, technical, and financial resources required, access to radiotherapy remains limited in sub-Saharan Africa. Through 2017, Rwanda has not had in-country radiotherapy services. The aim of this study was to describe the implementation and early outcomes of the radiotherapy referral program at the Butaro Cancer Centre of Excellence and to identify both successful pathways and barriers to care.MethodsButaro District Hospital is located in a rural area of the Northern Province and is home to the Butaro Cancer Centre of Excellence. We performed a retrospective study from routinely collected data of all patients with a diagnosis of cervical, head and neck, or rectal cancer between July 2012 and June 2015.ResultsBetween 2012 and 2015, 580 patients were identified with these diagnoses and were potential candidates for radiation. Two hundred eight (36%) were referred for radiotherapy treatment in Uganda. Of those referred, 160 (77%) had cervical cancer, 31 (15%) had head and neck cancer, and 17 (8%) had rectal cancer. At the time of data collection, 101 radiotherapy patients (49%) were alive and had completed treatment with no evidence of recurrence, 11 (5%) were alive and continuing treatment, and 12 (6%) were alive and had completed treatment with evidence of recurrence.ConclusionThis study demonstrates the feasibility of a rural cancer facility to successfully conduct out-of-country radiotherapy referrals with promising early outcomes. The results of this study also highlight the many challenges and lessons learned in providing comprehensive cancer care in resource-limited settings.

Combining bottleneck analysis and quality improvement as a novel methodology to improve the quality of neonatal care in a northeastern state of India: a feasibility study.

BackgroundThe State of Meghalaya, India, has some of the worst newborn health outcomes in the country. State health authorities commissioned an assessment of newborn service delivery to improve services. This study proposes bottleneck analysis (BNA) and quality improvement (QI) methods as a combined method to improve compliance with evidence-based neonatal interventions in newborn health facilities.MethodsAn adapted Every Newborn BNA tool was applied to collect data on barriers to providing quality care in five district hospitals. Subsequently, health workers were coached to use QI methodology to overcome identified bottlenecks. Data from QI projects were analysed using run charts.ResultsBNA revealed that interventions directed toward basic newborn care and special newborn care facilities needed attention. Facilities that undertook QI projects showed an improvement in neonates having early initiation of breastfeeding within the first hour of birth, from 64% to a peak of 94% in one facility and from 75% to 91% in another. Skin-to-skin contact increased from 49% to a peak of 78% and is sustained at 58%. Improved performance has been sustained in some facilities.ConclusionsThe combination of BNA and QI is a successful method for identifying and overcoming bottlenecks in newborn care in resource-limited settings.

Pediatric oncology-hematology outreach: Evaluation of patient consultations by teleconferences between Indonesian and Dutch academic hospitals

BackgroundImproving the quality of care in resource limited settings through an outreach program is challenging. Teleconferencing is increasingly being used and considered a breakthrough in medical education. We evaluated adherence with childhood oncology-hematology teleconferences between two academic hospitals in Indonesia and Netherlands. MethodsTeleconferences held during 12 months between an Indonesian and a Dutch academic hospital were evaluated using a standardized form. Both adherence with diagnostic and treatment advices for individual patients were explored in medical records. ResultsDuring 38 teleconferences, difficult cases of 53 children were discussed by Dutch pediatric oncologists and Indonesian residents. Dutch oncologists advised diagnostic adjustments in 41 cases (77%). Most common diagnostic advices were: laboratory tests (68%), imaging (54%), physical examination (41%). Diagnostic advices were not adhered to in 12 children (30%). Common reasons for non-adherence were: not applicable in middle-income setting (25%), disagreement with Dutch advice (17%), CT scan is out of order (17%), patient died (17%). Dutch oncologists advised treatment adjustments in 40 cases (75%). Most common treatment advices were: change of protocol (38%), nutritional support (30%), prevention of tumor lysis syndrome (20%). Treatment advices were not adhered to in 9 children (22%). Common reasons for non-adherence were: poor condition of child (44%), not applicable in middle-income setting (22%), patient died (22%), disagreement with Dutch advice (11%). Twenty-four children (45%) died after teleconference was held. Twenty-nine children (55%) were alive. These children abandoned (38%), completed (31%) or were still under treatment (31%). ConclusionThrough teleconferencing, knowledge between high and low or middle-income countries can be shared to improve patient care. Locally applicable advices are required. Active participation by pediatric oncologists at both partner sites is recommended.

The Influence of a Home-Based Education Intervention on Family Caregivers’ Knowledge and Self-Efficacy for Cancer Pain Management in Adult Patients Within a Resource-Limited Setting

Cancer-related pain is prevalent and has debilitating effects on patients and their family. The effects of cancer pain can be curtailed if the family members caring for the patient receive essential support to enhance their capabilities for cancer pain management. Little has been done to study the available support to family caregivers (FCGs) towards pain management in adult cancer patients (ACPs) living in resource-limited countries where the burden of cancer is on the rise. This study evaluated the influence of an education intervention delivered in the home setting on FCGs' knowledge and self-efficacy (SE) for pain management in ACPs. One-group pre-/post-test design was used in a sample of 54 FCGs who had been caring for ACPs suffering from pain for at least 1month. Data were collected using the Family Pain Questionnaire and Caregiver Pain Management SE Scale. The FCGs' mean knowledge score post-intervention (26.69 ± 10) was higher than the baseline (45 ± 12.9), and the difference was statistically significant (t = 10.382, p = 0.000, CI = 17.12-25.43). Additionally, the FCGs' mean SE score post-intervention (1003.30 ± 191) was higher than the baseline (648.3 ± 273.4), and the difference was statistically significant (t = - 8.52, p = 0.000, CI = - 438.6-- 271.4). The home-based education intervention significantly and positively influenced the FCGs' knowledge and SE for pain management while at home. Cancer pain management educational interventions delivered at home should be considered as one of the strategies for enhancing cancer care in resource limited settings.

The implementation of a longitudinal POCUS curriculum for physicians working at rural outpatient clinics in Chiapas, Mexico

BackgroundMedical care in resource limited settings is challenging, particularly with limited access to diagnostic and imaging studies. The most portable and cost effective diagnostic imaging in these areas is ultrasound. Ultrasound is a very teachable skill with a short, single intensive training course and hands-on teaching; however, there are limited data on a longitudinal point-of-care ultrasound (POCUS) curriculum in resource limited settings. The goal of this intervention is to develop an effective longitudinal POCUS curriculum for local physicians working in rural clinics in the state of Chiapas, Mexico, and evaluate its effectiveness on patient care.MethodsThis is a 12-month longitudinal ultrasound educational curriculum for local supervising physicians working in rural clinics in Chiapas, Mexico. The 10 clinics are a collaboration of the Mexican government and Compañeros En Salud with limited access to any diagnostic imaging or laboratory studies. The investigators assisted in obtaining four portable ultrasound machines for use in the clinics. Next, they organized four point-of-care ultrasound (POCUS) teaching sessions over a year, each session focusing on several distinct concepts. The sessions included lectures and hands-on teaching with both healthy volunteers and with patients in the various communities. Over the 12 months, the POCUS were logged and the majority of images saved. The logs were analyzed to determine if POCUS affected the medical management of the patients. The primary investigator reviewed 35.2% of the total ultrasounds completed, which was 52.2% of the save images, for quality assurance and feedback.ResultsOver the 12 months, there were 584 ultrasound studies documented. The most common study was a transabdominal obstetric examination (45.5%) followed by abdomen/pelvis (26.6%) and musculoskeletal (5.7%) and skin and soft tissue (5.7%). The use of POCUS changed the patient diagnosis after 194 scans (34%) and changed the clinical management for the patient encounter in 171 (30%) scans. In the 194 scans in which POCUS changed the diagnosis, the clinical management was changed, as a direct result of the scan results, in 152 (78.4%) of those patient encounters.ConclusionA longitudinal POCUS educational curriculum is an effective way to equip local physicians in resource limited countries with a tool to improve their clinical management of patients.

Global Emergency Medicine: A Review of the Literature From 2017.

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners. This year, 17,722 articles written in three languages were identified by our electronic search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. Another two reviewers searched the gray literature, yielding an additional 11 articles. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles. A total of 848 articles met our inclusion criteria and underwent full review. Sixty-three percent were categorized as emergency care in resource-limited settings, 23% as disaster and humanitarian response, and 14% as EM development. Twenty-one articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed a Cohen's kappa of 0.344. In 2017, the total number of articles identified by our search continued to increase. Studies and reviews with a focus on infectious diseases, pediatrics, and trauma represented the majority of top-scoring articles.

Short Communication: Nucleoside Reverse Transcriptase Inhibitors with Reduced Predicted Activity Do Not Impair Second-Line Therapy with Lopinavir/Ritonavir or Darunavir/Ritonavir.

Second-line therapy randomized trials with lopinavir/ritonavir question the value of resistance testing to guide nucleoside reverse transcriptase inhibitor (NRTI) selection. In this study, we investigated the association between baseline drug resistance and treatment outcome after 104 weeks of second-line therapy with NRTIs and either darunavir/ritonavir or lopinavir/ritonavir in West-central Africa. We did an observational analysis of data from 387 individuals in a randomized, open-label 2LADY trial in Burkina Faso, Cameroon, and Senegal. We modeled the association between RTI drug resistance mutations (DRMs) and virological failure (VF) (viral load [VL] <50 copies/mL) at week 104 using logistic regressions. Covariates included baseline VL and CD4+ count, demographic, and adherence data. Overall, 193 (49.9%), 150 (38.8%), and 44 (11.4%) individuals had, respectively, low/none (genotypic susceptibility score [GSS] <1), intermediate (GSS = 1), and high predicted NRTI activity (GSS >1) in their prescribed second-line regimen. The average number of DRMs by drug class, the proportion of individuals by GSS category, and the duration of first-line therapy were not associated with VF (p > .05). High VL at switch was the only consistent prognostic factor for VF after multivariate adjustment (p < .01). Suboptimal adherence, high predicted RTI activity, or low NRTI mutations were associated with VF (p < .05) when using higher end points for VF or in the intention-to-treat analysis. In conclusion, the use of RTIs with predicted reduced activity does not impair second-line protease inhibitor-based therapy. Therefore, HIV care in resource-limited settings should prioritize strategies to improve adherence and targeted VL testing over drug resistance testing for selecting NRTIs during a protease-based second-line switch.

Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned.

Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.

Rates and predictors of attrition among children on antiretroviral therapy in Ethiopia: A prospective cohort study.

IntroductionAttrition from antiretroviral therapy (ART) programmes is a critical challenge among children receiving care in resource-limited settings. Our objective was to determine the rates and predictors of attrition among children on ART in Ethiopia.MethodsBetween December 2014 and September 2016, we conducted a prospective cohort study in eight health facilities in Ethiopia. Eligibility criteria included age 3 months–14 years; being on ART for not more than a month. Outcome was attrition due to death and/or loss to follow-up. Predictor variables were child clinical and socio-demographic characteristics, and caregiver socio-demographic characteristics. We used Cox Regression analyses to examine the association between predictors and outcome.ResultsOf 309 children, 304 were included, 52% were male. Their median age was 9 years (Inter-quartile range, IQR, 6–12). At ART initiation, their median CD4 was 362 cells/mm3 (IQR 231–499); and 74.3% had WHO stage 1 or 2 disease. During 287.7 person-years of observation (PYO), 24 attritions were recorded, yielding an attrition rate of 8.3 per 100 PYO (95% CI 5.4–12.1). Of these, six children were reported dead, leading to a mortality rate of 2.1 per 100 PYO (95% CI 0.8–4.3). Eighteen were lost to follow-up (LTFU) leading to LTFU rate of 6.26 per 100 PYO (95% CI: 3.83–9.70). The majority, 14 (58%) of attrition occurred during the first six months of treatment.Age below three years [aHR] = 5.14 (95% CI: 2.07–12.96), rural residence (aHR = 3.97, 95% CI: 1.34–11.78) and baseline Hgb in g/dl < 10 g/dl [aHR] = 5.68 (95% CI: 2.03–6.23) predicted higher risk of attrition. Baseline Hgb < 10 g/dl (aHR = 16.63, 95% CI: 1.64–168.4) and WHO stage III or IV (aHR = 12.25, 95% CI: 1.26–119.05) predicted the death of the child. Higher attrition was documented among children of both biological parents alive and biologically related close family caregivers.ConclusionYounger children, those from rural areas, and children with anaemia were at higher risk of attrition, especially during the early months of treatment, and therefore should be prioritized during treatment follow-up. Further studies should examine underlying reasons for higher attrition.

Simple Mortality Predictive Models for Improving Critical Care in Resource-Limited Settings: An Insight on the Modified Early Warning Score and Rapid Emergency Medical Score.

Mortality rate among critically ill patients admitted to the Intensive Care Unit is high, particularly in low-income countries (LIC). Many scores have been developed to predict these fatal outcomes. In LIC, the applicability of scoring systems is precluded by the unavailability of resources to compile all the parameters of these scores. Herein, we highlight the advantages of two models: the Modified Early Warning Score (MEWS) and the Rapid Emergency Medical Score (REMS). The REMS and the MEWS have the advantage of being accurate, simple, inexpensive, and practical for LIC.

Detection of Plasmodium Species by High-Resolution Melt Analysis of DNA from Blood Smears Acquired in Southwestern Uganda.

Microscopic diagnosis of malaria using Giemsa-stained blood smears is the standard of care in resource-limited settings. These smears represent a potential source of DNA for PCR testing to confirm Plasmodium infections or for epidemiological studies of archived samples. Therefore, we assessed the use of DNA extracts from stained blood smears for the detection of Plasmodium species using real-time PCR. We extracted DNA from archived blood smears and corresponding red blood cell pellets collected from asymptomatic children in southwestern Uganda in 2010. We then performed real-time PCR followed by high-resolution melting (HRM) to identify Plasmodium species, and we compared our results to those of microscopy. We analyzed a total of 367 blood smears and corresponding red blood cell pellets, including 185 smears (50.4%) that were positive by microscopy. Compared to microscopy, PCR-HRM analysis of smear DNA had a sensitivity of 93.0% (95% confidence interval [CI], 88.2 to 96.2%) and a specificity of 96.7% (95% CI, 93.0 to 98.8%), and PCR-HRM analysis of pellet DNA had a sensitivity of 100.0% (95% CI, 98.0 to 100.0%) and a specificity of 94.0% (95% CI, 89.4 to 96.9%). Identification of positive PCR-HRM results to the species level revealed Plasmodium falciparum (92.0%), Plasmodium ovale (5.6%), and Plasmodium malariae (2.4%). PCR-HRM analysis of DNA extracts from Giemsa-stained thick blood smears or corresponding blood pellets had high sensitivity and specificity for malaria diagnosis, compared to microscopy. Therefore, blood smears can provide an adequate source of DNA for confirmation of Plasmodium species infections and can be used for retrospective genetic studies.

Graduate medical education competencies for international health electives: A qualitative study

Background: Residency programs offer international health electives (IHEs), providing multiple educational benefits. This study aimed to identify how IHEs fulfill the Accreditation Council for Graduate Medical Education (ACGME) core competencies.Methods: We conducted a thematic analysis of post-rotation reflective reports from residents who participated in IHEs through the Mayo International Health Program. We coded reports using a codebook created from the ACGME competencies. Using a constant comparative method, we identified significant themes within each competency.Results: Residents from 40 specialties participated in 377 IHEs in 56 countries from 2001 to 2014. Multiple themes were identified within each of the six ACGME core competencies: Patient Care and Procedural Skills (4), Medical Knowledge (5), Practice-Based Learning and Improvement (3), Interpersonal and Communication Skills (5), Professionalism (4), and Systems-Based Practice and Improvement (3). Themes included improving physical exam and procedural skills, providing care in resource-limited setting, gaining knowledge of tropical and non-tropical diseases, identifying socioeconomic determinants of health, engaging in the education of others, and increasing communication across cultures and multidisciplinary teams.Conclusions: Through IHEs, residents advanced their knowledge, skills, and attitudes in each of the six ACGME competencies. These data can be used for development of IHE competencies and milestones for resident assessment.

HIV Drug Resistance Testing in a Resource Limited Setting with High Viral Diversity: The First Twenty Eight Months Experience

First line antiretroviral therapy in a resource-limited setting consists of nucleotide and non-nucleotide reverse transcriptase inhibitors. Protease inhibitors are the hub of second line therapy. The decision to change antiretroviral therapy for a patient is frequently presumptive because of the lack of genotypic resistance tests in routine follow-up. We describe here the resistance profiles observed in patients with varying terms of antiretroviral therapy in Cameroon after implementation of HIV genotypic resistance testing in routine practice. HIV genotypic resistance testing was carried out on consecutive samples received between August 2013 and November 2015. Protease (Prot) and reverse transcriptase (Rt) genes of the HIV genome were amplified, sequenced and analyzed for drug resistance mutations following the algorithm set up by the French National Agency for research on HIV/AIDS and viral hepatitis. Specimens from a total of 167 patients infected with non-B HIV subtypes were received during the study period. Overall 61.7% patients had viral loads of more than 3log copies/ml, suggesting treatment failure. Among the 72 patients on first line, 56 (77.8%) were resistant to Lamivudine, 57 (79.1%) to Efavirenz and 58 (80.6%) to Nevirapine. Overall, more patients (75.0%) on first line antiretroviral therapy harbored multi-drug resistance compared to their counterparts on second line (25.8%). This study revealed that a group of patients with antiretroviral therapy failure harbored multi-drug resistance mutations related to the majority of drugs in the first line regimen. Therefore, HIV resistance testing could be a useful tool to improve HIV care in resource limited settings like Cameroon where treatment options are limited.

Global Emergency Medicine: A Review of the Literature From 2016.

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners. This year 13,890 articles written in four languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles. A total of 716 articles met our inclusion criteria and underwent full review. Fifty-nine percent were categorized as emergency care in resource-limited settings, 17% as EM development, and 24% as disaster and humanitarian response. Nineteen articles received scores of 18.5 or higher out of a maximum score of 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed Cohen's kappa of 0.441. In 2016, the total number of articles identified by our search continued to increase. The proportion of articles in each of the three categories remained stable. Studies and reviews with a focus on infectious diseases, pediatrics, and the use of ultrasound in resource-limited settings represented the majority of articles selected for final review.

The patient-centered medical home: a reality for HIV care in Nigeria.

HIV care delivery in resource-limited settings (RLS) may serve as a paradigm for chronic disease care, but comprehensive measurement frameworks are lacking. Our objective was to adapt the patient-centered medical home (PCMH) framework for use in RLS, and evaluate the performance of HIV treatment programs within this framework. Cross-sectional survey administered within the AIDS Prevention Initiative in Nigeria (APIN) network. Medical directors at APIN clinics. We adapted the 2011 US National Committee on Quality Assurance's PCMH standard to develop a survey measuring five domains of HIV care: (i) enhancing access and continuity, (ii) identifying and managing patient populations, (iii) planning and managing care, (iv) promoting self-care and support and (v) measuring and improving performance. Thirty-three of 36 clinics completed the survey. Most were public (73%) and urban/semi-urban (64%); 52% had >500 patients in care. On a 0-100 scale, clinics scored highest in self-care and support, 91% (63-100%); managing patient populations, 80% (72-81%) and improving performance, 72% (44-78%). Clinics scored lowest with the most variability in planning/managing care, 65% (22-89%), and access and continuity, 61% (33-80%). Average score across all domains was 72% (58-81%). Our findings suggest that the modified PCMH tool is feasible, and likely has sufficient performance variation to discriminate among clinics. Consistent with extant literature, clinics showed greatest room for improvement on access and continuity, supporting the tool's face validity. The modified PCMH tool may provide a powerful framework for evaluating chronic HIV care in RLS.

Providing dermatological care in resource-limited settings: barriers and potential solutions.

Providing dermatological care in resource-limited settings: barriers and potential solutions.

Kangaroo mother care in resource-limited settings: implementation, health benefits, and cost-effectiveness

Kangaroo mother care in resource-limited settings: implementation, health benefits, and cost-effectiveness Samuel N Uwaezuoke Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku&ndash;Ozalla, Enugu, Nigeria Abstract: Kangaroo mother care (KMC) represents an intervention in low birth weight infants for resource-limited settings which aims to reduce mortality rates by thermoregulation, supporting breastfeeding, and promoting early hospital discharge. In terms of cost and impact on neonatal survival, it has comparative advantages over the conventional method of care (CMC). This paper aimed to review the evidence concerning the progress of KMC implementation, its health benefits, and its cost-effectiveness, especially in developing countries. From the synthesized evidence, KMC was shown to be a useful adjunct to CMC particularly with respect to improving neonatal survival, supporting breastfeeding, and promoting early discharge from the hospital. Substantial progress has been made in its implementation in many developing countries where facility-based KMC has been institutionalized. Despite the cost-effectiveness of KMC in neonatal care, its global implementation is bedeviled with country-specific, multifaceted challenges. In developed countries, there is an implementation gap due to easy accessibility to technology-based CMC. Nevertheless, many developing countries have initiated national policies to scale up KMC services in their domain. Given the major constraints to program implementation peculiar to these resource-limited countries, it has become imperative to boost caregiver confidence and experience using dedicated spaces in the hospital, as well as dedicated staff meant for adequate ambulatory follow-up and continuous health education. Capacity training for health professionals and provision of space infrastructure thus constitute the basic needs which could be funded by International Aid Agencies in order to scale up the program in these settings. Keywords: neonatal care, low birth weight infants, thermoregulation, breastfeeding, neonatal survival, developing countries&nbsp

Paper-Based Diagnostics: Rethinking Conventional Sickle Cell Screening to Improve Access to High-Quality Health Care in Resource-Limited Settings.

Every year, hundreds of thousands of children worldwide are born with sickle cell disease, a genetic disorder that impacts the hemoglobin molecules in blood. If left undiagnosed and untreated, most affected children will die before reaching the age of five. However, highly accurate diagnostic methods and effective treatment regimens for sickle cell disease have been known for many years, and children who receive early diagnosis and subsequent comprehensive care survive well into adulthood-as evidenced by the tremendous success of universal newborn screening programs in North America and Europe.