Communities In Low- And Middle-income Countries Research Articles

Colorectal Cancer Outcomes: A Comparative Review of Resource-Limited Settings in Low- and Middle-Income Countries and Rural America.

Background/Objectives: Colorectal cancer remains a significant global health challenge, particularly in resource-limited settings where patient-centered outcomes following surgery are often suboptimal. Although more prevalent in low- and middle-income countries (LMICs), segments of the United States have similarly limited healthcare resources, resulting in stark inequities even within close geographic proximity. Methods: This review compares and contrasts colorectal cancer outcomes in LMICs with those in resource-constrained communities in rural America, utilizing an established implementation science framework to identify key determinants of practice for delivering high-quality colorectal cancer care. Results: Barriers and innovative, community-based strategies aimed at improving patient-centered outcomes for colorectal cancer patients in low resource settings are identified. We explore innovative approaches and community-based strategies aimed at improving patient-centered outcomes, highlighting the newly developed colorectal surgery fellowship in Sub-Saharan Africa as a model of innovation in this field. Conclusions: By exploring these diverse contexts, this paper proposes actionable solutions and strategies to enhance surgical care of colorectal cancer and patient outcomes, ultimately aiming to inform global health practices, inspire collaboration between LMIC and rural communities, and improve care delivery across various resource settings.

Access to maternal health services for Indigenous women in low- and middle-income countries: an updated integrative review of the literature from 2018 to 2023.

Ninety-seven per cent of Indigenous Peoples live in low-and middle-income countries (LMICs). A previous systematic integrative review of articles published between 2000 and 2017 identified numerous barriers for Indigenous women in LMICs in accessing maternal healthcare services. It is timely given the aim of achieving Universal Health Coverage in six years' time, by 2030, to undertake another review. This article updates the previous review exploring the recent available literature on Indigenous women's access to maternal health services in LMICs identifying barriers to services. An integrative review of literature published between 2018 and 2023 was undertaken. This review followed a systematic process using Whittemore and Knafl's five-step framework for integrative reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 944 articles were identified from six databases: Academic Search Premier, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycInfo, CINAHL Plus with Full Text and APA PsycArticles (through EBSCOhost). The search was undertaken on 16 January 2023. After screening of the title/abstract and the full text using inclusion and exclusion criteria 26 articles were identified. Critical appraisal resulted in 24 articles being included in the review. Data were extracted using a matrix informed by Penchansky and Thomas's taxonomy, extended by Saurman, which focused on six dimensions of access to health care: affordability, accessibility, availability, accommodation, acceptability and awareness. Ten studies took place in Asia, 10 studies were from the Americas and four studies took place in the African region. Seventeen articles were qualitative, two were quantitative and five were mixed methods. The methods for the integrative review were prespecified in a protocol, registered at Open Science Framework. Barriers identified included affordability; community awareness of services including poor communication between providers and women; the availability of services, with staff often missing from the facilities; poor quality services, which did not consider the cultural and spiritual needs of Indigenous Peoples; an overreliance on the biomedical model; a lack of facilities to enable appropriate maternal care; services that did not accommodate the everyday needs of women, including work and family responsibilities; lack of understanding of Indigenous cultures from health professionals; and evidence of obstetric violence and mistreatment of Indigenous women. Barriers to Indigenous women's access to maternal health services are underpinned by the social exclusion and marginalisation of Indigenous Peoples. Empowerment of Indigenous women and communities in LMICs is required as well as initiatives to challenge the stigmatisation and marginalisation that they face. The importance of community involvement in design and interventions that support the political and human rights of Indigenous Peoples are required. Limitations of this review include the possibility of missing articles as it was sometimes unclear from the articles whether a particular group was from an Indigenous community. More research on access to services in the postnatal period is still needed, as well as quality quantitative research. There is also a lack of research on Indigenous groups in North Africa, and in sub-Saharan Africa - especially hunter-gatherer groups - as well as the impact of COVID-19 on access to services.

Widening the lens of population-based health research to climate change impacts and adaptation: the climate change and health evaluation and response system (CHEERS).

Climate change significantly impacts health in low-and middle-income countries (LMICs), exacerbating vulnerabilities. Comprehensive data for evidence-based research and decision-making is crucial but scarce. Health and Demographic Surveillance Sites (HDSSs) in Africa and Asia provide a robust infrastructure with longitudinal population cohort data, yet they lack climate-health specific data. Acquiring this information is essential for understanding the burden of climate-sensitive diseases on populations and guiding targeted policies and interventions in LMICs to enhance mitigation and adaptation capacities. The objective of this research is to develop and implement the Change and Health Evaluation and Response System (CHEERS) as a methodological framework, designed to facilitate the generation and ongoing monitoring of climate change and health-related data within existing Health and Demographic Surveillance Sites (HDSSs) and comparable research infrastructures. CHEERS uses a multi-tiered approach to assess health and environmental exposures at the individual, household, and community levels, utilizing digital tools such as wearable devices, indoor temperature and humidity measurements, remotely sensed satellite data, and 3D-printed weather stations. The CHEERS framework utilizes a graph database to efficiently manage and analyze diverse data types, leveraging graph algorithms to understand the complex interplay between health and environmental exposures. The Nouna CHEERS site, established in 2022, has yielded significant preliminary findings. By using remotely-sensed data, the site has been able to predict crop yield at a household level in Nouna and explore the relationships between yield, socioeconomic factors, and health outcomes. The feasibility and acceptability of wearable technology have been confirmed in rural Burkina Faso for obtaining individual-level data, despite the presence of technical challenges. The use of wearables to study the impact of extreme weather on health has shown significant effects of heat exposure on sleep and daily activity, highlighting the urgent need for interventions to mitigate adverse health consequences. Implementing the CHEERS in research infrastructures can advance climate change and health research, as large and longitudinal datasets have been scarce for LMICs. This data can inform health priorities, guide resource allocation to address climate change and health exposures, and protect vulnerable communities in LMICs from these exposures.

Equity in Global Health Research.

Equity in Global Health Research.

Solid Waste Management in Rural Communities of Developing Countries: An Overview of Challenges and Opportunities

Solid waste management (SWM) in rural areas of many low- and middle-income countries (LMICs) represents a critical and underrated topic. However, almost half of the world’s population still lives in rural areas and an adequate SWM is crucial in reducing environmental and health threats. A lack of knowledge and appropriate tools often leads to inappropriate practices such as waste dumping and uncontrolled burning. However, appropriate methods can transform waste into resources and even guarantee a revenue source. This manuscript provides an overview of the state of the knowledge characterising SWM in rural communities of LMICs, analysing common practices and principal issues. Different solid waste fractions are considered. Virtuous approaches are presented, taking into account recent sustainable solutions. Considering that a relevant part of the world population is still living in rural areas, the benefits associated with an appropriate SWM may be enormous. Such activities may improve local conditions from social, environmental and health perspectives; furthermore, they may have a global impact on facing climate change and environmental pollution.

Adherence to 24-hour movement guidelines among rural Brazalian preschool children: associations with parenting practices

Background:Young children residing in rural areas of low-and-middle income countries (LMICs) such as Brazil are at greater risk of obesity and related chronic health conditions. Yet, the extent to which rural preschool children from Brazil aged 3- to 6-years meet the World Health Organisation (WHO) 24-hour movement guidelines is unknown. Parents play a central role in the development of children’s movement behaviors with logistic support, co-participation, modelling, and setting rules and limits recognized as influential parenting practices. However, the bulk of parenting research has been conducted in families from high income countries (HICs) and little is known about the relationship between parenting practices and children’s movement behaviors in LMIC communities. Therefore, the aims of this study were two-fold: (1) report the proportion of preschool children from low-income families in rural Brazil meeting the WHO 24-hour movement guidelines; and (2) determine associations with theory-based parenting practices related to physical activity, screen time, and sleep.Methods:A representative sample of 324 families from a rural district in north-eastern Brazil completed a validated, culturally adapted interviewer-administered survey assessing child physical activity, screen time and sleep, and associated parenting practices. The proportion of children meeting the physical activity, screen time, and sleep recommendations and all combinations of these recommendations was calculated. Forward selection logistic regression was used to determine which parenting practices were associated with meeting the individual recommendations and the 24-hour movement guidelines.Results:Less than half of the children (47.5%) met the physical activity recommendation, 22% met the screen time recommendation, 62% met the sleep recommendation, with just over 10% meeting all three recommendations in the 24-h movement guidelines. Having fewer rules and restrictions around indoor and outdoor play, limiting, or monitoring screen time, and maintaining a consistent bedtime routine were key parenting practices associated with children´s adherence to the 24-hour movement guidelines.Conclusion:Only 1 in 10 rural Brazilian preschool children meet the 24-hour movement guidelines. These findings underscore the need for family-based interventions targeting parenting practices to support healthful movement behaviors in young children from LMICs.

Development of Culturally Adapted Media to Increase Community Awareness of Childhood Cancer in Tanzania

PURPOSE There is low childhood cancer awareness in many low and middle income countries (LMICs), contributing to delayed hospital presentation, and treatment abandonment. In Tanzania, only 20% of the estimated 3,500 new cases per year present for treatment. While childhood cancer awareness media exist, they are not adapted for use in many LMIC communities, including Tanzania. METHODS To reach consensus on childhood cancer education content and education strategy selection, a Delphi process was completed with an expert advisory panel representing three Tanzanian referral hospitals. Focus groups discussions (FGD) were completed with rural and urban communities from each of the Mwanza, Dar Es Salaam and Kilimanjaro regions. Thematic analysis was guided by content consensus to identify community knowledge gaps. Sample education materials were reviewed to identify preferred delivery format. RESULTS A total of 14 and 72 participants formed the expert panel and community FGD respectively. Education strategies with the highest feasibility and impact included community health worker led education, a song, and social media messaging. The following key knowledge content areas were identified to have the lowest community awareness. (1) The cause of most childhood cancer is unknown: 83% felt untreated illnesses, cooking oil, witchcraft, immune system deficiency, and the environment were causes of childhood cancer; (2) Symptom recognition and hospital based studies can improve early detection: 66% reported that ill children see a traditional healer or pharmacist and only go a hospital if febrile or if symptoms do not improve; (3) Most childhood cancer can be cured with early detection: 50% felt that there is no cure. CONCLUSION This study identified key childhood cancer knowledge gaps within the Tanzanian community and culturally adapted strategies to disseminate education media. Additional studies are needed to evaluate the impact of culturally adapted media on community awareness and early hospital presentation in the region.

Developing indicators of age-friendly neighbourhood environments for urban and rural communities across 20 low-, middle-, and high-income countries

BackgroundBy 2050, the global population of adults 60 + will reach 2.1 billion, surging fastest in low- and middle-income countries (LMIC). In response, the World Health Organization (WHO) has developed indicators of age-friendly urban environments, but these criteria have been challenging to apply in rural areas and LMIC. This study fills this gap by adapting the WHO indicators to such settings and assessing variation in their availability by community-level urbanness and country-level income.MethodsWe used data from the Prospective Urban and Rural Epidemiology (PURE) study’s environmental-assessment tools, which integrated systematic social observation and ecometrics to reliably capture community-level environmental features associated with cardiovascular-disease risk factors. The results of a scoping review guided selection of 18 individual indicators across six distinct domains, with data available for 496 communities in 20 countries, including 382 communities (77%) in LMIC. Finally, we used both factor analysis of mixed data (FAMD) and multitrait-multimethod (MTMM) approaches to describe relationships between indicators and domains, as well as detailing the extent to which these relationships held true within groups defined by urbanness and income.ResultsTogether, the results of the FAMD and MTMM approaches indicated substantial variation in the relationship of individual indicators to each other and to broader domains, arguing against the development of an overall score and extending prior evidence demonstrating the need to adapt the WHO framework to the local context. Communities in high-income countries generally ranked higher across the set of indicators, but regular connections to neighbouring towns via bus (95%) and train access (76%) were most common in low-income countries. The greatest amount of variation by urbanness was seen in the number of streetscape-greenery elements (33 such elements in rural areas vs. 55 in urban), presence of traffic lights (18% vs. 67%), and home-internet availability (25% vs. 54%).ConclusionsThis study indicates the extent to which environmental supports for healthy ageing may be less readily available to older adults residing in rural areas and LMIC and augments calls to tailor WHO’s existing indicators to a broader range of communities in order to achieve a critical aspect of distributional equity in an ageing world.

Closed-Loop Biodigesters on Small-Scale Farms in Low- and Middle-Income Countries: A Review

Anaerobic digestion (AD) systems are prominent in low- and middle-income countries (LMICs), although their implementation within organic farms to enhance resource efficiency and “close the loop” has been limited. This paper thus reviewed existing literature on the potential of AD technologies as part of closed-loop rural family farming communities in LMICs. Data from eleven existing case studies matching this criterion was then collated to understand practical considerations of implementing and maintaining viable AD systems for small farmers. The case studies analyzed indicate that most, if not all, of the biogas produced in the AD process is used for household purposes such as cooking, lighting and heating. The AD systems are either based on the fixed biogas dome or the floating drum design, although the tubular flexible balloon model is mentioned as a low-cost alternative. Future research opportunities in this topic include studying the applicability of recommendations offered across different geographies, consideration of long-term sustainability and impact of biodigester technology, and sociocultural factors such as community ownership and indigenous practices.

Estimating underreporting of leprosy in Brazil using a Bayesian approach.

BackgroundLeprosy remains concentrated among the poorest communities in low-and middle-income countries and it is one of the primary infectious causes of disability. Although there have been increasing advances in leprosy surveillance worldwide, leprosy underreporting is still common and can hinder decision-making regarding the distribution of financial and health resources and thereby limit the effectiveness of interventions. In this study, we estimated the proportion of unreported cases of leprosy in Brazilian microregions.Methodology/Principal findingsUsing data collected between 2007 to 2015 from each of the 557 Brazilian microregions, we applied a Bayesian hierarchical model that used the presence of grade 2 leprosy-related physical disabilities as a direct indicator of delayed diagnosis and a proxy for the effectiveness of local leprosy surveillance program. We also analyzed some relevant factors that influence spatial variability in the observed mean incidence rate in the Brazilian microregions, highlighting the importance of socioeconomic factors and how they affect the levels of underreporting. We corrected leprosy incidence rates for each Brazilian microregion and estimated that, on average, 33,252 (9.6%) new leprosy cases went unreported in the country between 2007 to 2015, with this proportion varying from 8.4% to 14.1% across the Brazilian States.Conclusions/SignificanceThe magnitude and distribution of leprosy underreporting were adequately explained by a model using Grade 2 disability as a marker for the ability of the system to detect new missing cases. The percentage of missed cases was significant, and efforts are warranted to improve leprosy case detection. Our estimates in Brazilian microregions can be used to guide effective interventions, efficient resource allocation, and target actions to mitigate transmission.

Hearing healthcare gaps in LMICS: snapshot from a semi-urban community in Nigeria.

Low and middle-income countries (LMICs) have high prevalence of hearing loss which are mainly due to preventable causes. While urban communities in LMICs are likely to have functional hearing healthcare delivery infrastructure, rural and semi-urban communities may have different reality. This study aimed to provide: (i) a snapshot of the burden of ear diseases and (ii) a description of available hearing healthcare resources in a semi-urban Nigerian community. A cross-sectional study of households selected by multistage random sampling technique. Seventy-four participants: 39 males and 35 females with mean age of 34 years ± 5.24 were recruited and answered a structured questionnaire. In addition, the availability of hearing healthcare services in 15 health centers within the community were determined. All participants reported recent occurrence of ear complaints or gave similar history in a household member. Common complaints were ear discharge, ear pain and hearing loss. Medical intervention was sought from patent medicine stores, hospitals and traditional healers. None of the assessed hospitals within the study site was manned by an ENT surgeon or ENT trained nurse. Despite the heavy burden of ear complaints there is inadequate hearing healthcare delivery in a typical LMIC community. This highlights the need for urgent improvement of hearing healthcare.

Determination of Vitamin A Total Body Stores in Children from Dried Serum Spots: Application in a Low- and Middle-Income Country Community Setting

BackgroundThe retinol isotope dilution (RID) method has been used to evaluate vitamin A (VA) status in healthy adults and children in low- and middle-income countries (LMIC) and to assess the efficacy of various VA interventions. ObjectiveThe study was designed to examine whether dried serum spots (DSS) can be applied to RID when conducting VA total body store (TBS) assessments in community settings. MethodsFour days after an oral dose of 0.4 mg [13C10]retinyl acetate was administered to Filipino children (12–18 mo), a single blood draw was divided to isolate both serum and plasma. Serum (40 μL) was spotted and dried on Whatman 903 cards and shipped at ambient temperature whereas liquid plasma (LP) was frozen at –80°C and shipped on dry ice. The VA tracer to tracee ratio from DSS and LP was quantified by LC-MS/MS. Comparisons between DSS and LP paired samples (n = 72) were made for [13C10]retinol specific activity (SAp) by Pearson’s correlation and for VA TBS by Bland–Altman analysis. ResultsThe sum of 3 coextracted DSS were required to consistently detect [13C10]retinol above the LC-MS/MS limit of quantitation (LOQ). [13C10]retinol SAp from DSS was highly correlated with SAp from LP (r = 0.945; P < 0.01). A comparison of methods for TBS determination using Bland–Altman analysis indicated agreement with an intraindividual difference of 24.7 μmol (4.6%). Mean total liver reserve (TLR) values from DSS and LP were 1.7 μmol/g (± 0.6 SD) and 1.6 μmol/g (± 0.6 SD), respectively. ConclusionsVA TBS can be determined from DSS thereby reducing the logistics and cost of maintaining a cold chain by shipping samples at ambient temperature and, thus, making the RID technique more feasible in LMIC community settings. This trial was registered at https://clinicaltrials.gov as NCT03030339.

Recognising values and engaging communities across cultures: towards developing a cultural protocol for researchers

Efforts to build research capacity and capability in low and middle income countries (LMIC) has progressed over the last three decades, yet it confronts many challenges including issues with communicating or even negotiating across different cultures. Implementing global research requires a broader understanding of community engagement and participatory research approaches. There is a considerable amount of guidance available on community engagement in clinical trials, especially for studies for HIV/AIDS, even culturally specific codes for recruiting vulnerable populations such as the San or Maori people. However, the same cannot be said for implementing research in global health. In an effort to build on this work, the Pakistan Institute of Living and Learning and University College London in the UK sought to better understand differences in beliefs, values and norms of local communities in Pakistan. In particular, they have sought to help researchers from high income countries (HIC) understand how their values are perceived and understood by the local indigenous researchers in Pakistan. To achieve this end, a group discussion was organised with indigenous researchers at Pakistan Institute of Living and Learning. The discussion will ultimately help inform the development of a cultural protocol for researchers from HIC engaging with communities in LMIC. This discussion revealed five common themes; (1) religious principles and rules, (2) differing concepts of and moral emphasis on autonomy and privacy, (3) importance of respect and trust; (4) cultural differences (etiquette); (5) custom and tradition (gift giving and hospitality). Based on the above themes, we present a preliminary cultural analysis to raise awareness and to prepare researchers from HIC conducting cross cultural research in Pakistan. This is likely to be particularly relevant in collectivistic cultures where social interconnectedness, family and community is valued above individual autonomy and the self is not considered central to moral thinking. In certain cultures, HIC ideas of individual autonomy, the notion of informed consent may be regarded as a collective family decision. In addition, there may still be acceptance of traditional professional roles such as ‘doctor knows best’, while respect and privacy may have very different meanings.

Hand-washing promotion for preventing diarrhoea.

BackgroundDiarrhoea accounts for 1.8 million deaths in children in low‐ and middle‐income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.ObjectivesTo assess the effects of hand‐washing promotion interventions on diarrhoeal episodes in children and adults.Search methodsWe searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.Selection criteriaIndividually‐randomized controlled trials (RCTs) and cluster‐RCTs that compared the effects of hand‐washing interventions on diarrhoea episodes in children and adults with no intervention.Data collection and analysisThree review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day‐care centres or schools, community, and hospital‐based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random‐effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.Main resultsWe included 29 RCTs: 13 trials from child day‐care centres or schools in mainly high‐income countries (54,471 participants), 15 community‐based trials in LMICs (29,347 participants), and one hospital‐based trial among people with AIDS in a high‐income country (148 participants). All the trials and follow‐up assessments were of short‐term duration.Hand‐washing promotion (education activities, sometimes with provision of soap) at child day‐care facilities or schools prevent around one‐third of diarrhoea episodes in high‐income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high‐certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low‐certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand‐washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low‐certainty evidence).Hand‐washing promotion among communities in LMICs probably prevents around one‐quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate‐certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub‐Saharan Africa. In seven trials, soap was provided free alongside hand‐washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand‐hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high‐certainty evidence).Hand‐washing promotion for the one trial conducted in a hospital among a high‐risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference −1.68, 95% CI −1.93 to −1.43; 1 trial, 148 participants; moderate‐certainty evidence). Hand‐washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate‐certainty evidence).We found no trials evaluating the effects of hand‐washing promotions on diarrhoea‐related deaths or cost effectiveness.Authors' conclusionsHand‐washing promotion probably reduces diarrhoea episodes in both child day‐care centres in high‐income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long‐term impact of the interventions.

Associations between diet quality, blood pressure, and glucose levels among pregnant women in the Asian megacity of Jakarta.

BackgroundThe prevalence of gestational hypertension and diabetes in pregnancy is increasing worldwide. Diet is a modifiable factor that may influence these conditions, but few studies have examined the association between diet quality and blood pressure and glucose profiles among pregnant women. Data are especially scarce for women in low- and middle-income countries (LMICs), where 90% of global pregnancies occur, and in urban settings. We, therefore, assessed these associations among 174 pregnant women in the Asian megacity of Jakarta in a cross-sectional study of the Brain Probiotic and LC-PUFA Intervention for Optimum Early Life (BRAVE) project.MethodsTrained field-enumerators collected socio-demographic characteristics, measured Mid-Upper Arm Circumference (MUAC), and assessed diet by two 24-hour recalls, which were used to calculate the Alternate Healthy Eating Index for Pregnancy (AHEI-P). Blood pressure was measured by automated sphygmomanometer, and fasting blood glucose by capillary glucometer. General linear models were used to identify associations.ResultsThe median AHEI-P score was 47.4 (IQR 19.1–76.6). The middle tertile of the AHEI-P score (39.59–56.58) was associated with a 0.4 SD (standardized effect size, 95% CI -0.7 to -0.06; p = 0.02) lower diastolic blood pressure compared with the lowest tertile (<39.59), after adjustment for level of education, smoking status, MUAC, gestational age, history of hypertension, and family history of hypertension. However, no associations were found between the AHEI-P score and systolic blood pressure and blood glucose.ConclusionHigher diet quality was associated with lower diastolic blood pressure among pregnant women in an urban LMIC community, but not with systolic blood pressure and blood glucose. A behavioral change intervention trial would be warranted to confirm the influence of diet quality on blood pressure and glucose levels and among pregnant women, and even before pregnancy.

"Even though I am alone, I feel that we are many"- An appreciative inquiry study of asynchronous, provider-to-provider teleconsultations in Turkana, Kenya.

Non-physician clinicians (NPCs) in low and middle-income countries (LMICs) often have little physical proximity to the resources-equipment, supplies or skills-needed to deliver effective care, forcing them to refer patients to distant sites. Unlike equipment or supplies, which require dedicated supply chains, physician/specialist skills needed to support NPCs can be sourced and delivered through telecommunication technologies. In LMICs however, these skills are scarce and sparsely distributed, making it difficult to implement commonly used real-time (synchronous), hub-and-spoke telemedicine paradigms. An asynchronous teleconsultations service was implemented in Turkana County, Kenya, connecting NPCs with a volunteer network of remote physicians and specialists. In 2017-18, the service supported over 100 teleconsultations and referrals across 20 primary healthcare clinics and two hospitals. This qualitative study aimed to explore the impact of the telemedicine intervention on health system stakeholders, and perceived health-related benefits to patients. Data were collected using Appreciative Inquiry, a strengths-based, positive approach to assessing interventions and informing systems change. We highlight the impact of provider-to-provider asynchronous teleconsultations on multiple stakeholders and healthcare processes. Provider benefits include improved communication and team work, increased confidence and capacity to deliver services in remote sites, and professional satisfaction for both NPCs and remote physicians. Health system benefits include efficiency improvements through improved care coordination and avoiding unnecessary referrals, and increased equity and access to physician/specialist care by reducing geographical, financial and social barriers. Providers and health system managers recognised several non-health benefits to patients including increased trust and care seeking from NPCs, and social benefits of avoiding unnecessary referrals (reduced social disruption, displacement and costs). The findings reveal the wider impact that modern teleconsultation services enabled by mobile technologies and algorithms can have on LMIC communities and health systems. The study highlights the importance of viewing provider-to-provider teleconsultations as complex health service delivery interventions with multiple pathways and processes that can ultimately improve health outcomes.

Global health research partnerships in the context of the Sustainable Development Goals (SDGs)

This themed issue on global health research has come at an opportune time in the middle of the ongoing global public health crisis arising from the coronavirus disease (COVID-19) pandemic which has claimed nearly 756,000 lives in 210 countries and territories around the world as of August 15, 2020. The public health crisis underscores the importance of global health research partnerships and collaborations to develop and evaluate the requisite health technologies to assist in containing COVID-19, other diseases, and health-related concerns that defy national borders. The 17 Sustainable Development Goals (SDGs), adopted by the member countries of the United Nations in September 2015, provide a framework for global development efforts including global health research. SDG3, which promotes health and well-being for the world populations across the age spectrum, highlights disease areas for special focus which can be adapted in specific global health research programs to serve local health needs. SDG17 promotes partnerships between high income (HIC) and low and middle-income countries (LMIC) for sustainable and equitable global development. However, given the wide disparities in fiscal and overall capacity for research between researchers in HIC and their counterparts in LMIC as well as the greater vulnerabilities of the LMIC communities when serving as research locations, a spotlight on the nature of such global health research partnerships in the context of the SDGs is desirable. This is to ensure that they are meaningful and mutually-beneficial partnerships which address local health concerns and promote long-term value for the communities involved.The objective of this commentary is, therefore, to provide a brief overview of the SDGs by way of context; explore the power differences at play when researchers from HIC are seeking research opportunities in LMIC; examine the social determinants of health and the disproportionate burden of global diseases carried by populations in LMIC to establish their vulnerability; discuss global research partnerships; and attempt to make a case for why community-based participatory research may be the preferred type of global health research partnership in the context of the SDGs.

Community-level interventions for improving access to food in low- and middle-income countries.

Community-level interventions for improving access to food in low- and middle-income countries.

Community-level interventions for improving access to food in low- and middle-income countries.

Community-level interventions for improving access to food in low- and middle-income countries.

Strategies used to establish palliative care in rural low- and middle-income countries: an integrative review.

Globally, 40 million people need palliative care; about 69% are people over 60 years of age. The highest proportion (78%) of adults are from low- and middle-income countries (LMICs), where palliative care still developing and is primarily limited to urban areas. This integrative review describes strategies used by LMICs to establish palliative care in rural areas. A rigorous integrative review methodology was utilized using four electronic databases (Ovid MEDLINE, Ovid Emcare, Embase classic+Embase and CINAHL). The search terms were: 'palliative care', 'hospice care', 'end of life care', 'home-based care', 'volunteer', 'rural', 'regional', 'remote' and 'developing countries' identified by the United Nations (UN) as 'Africa', 'Sub-Saharan Africa', 'low-income' and 'middle- income countries'. Thirty papers published in English from 1990 to 2019 were included. Papers were appraised for quality and extracted data subjected to analysis using a public health model (policy, drug availability, education and implementation) as a framework to describe strategies for establishing palliative care in rural areas. The methodological quality of the reviewed papers was low, with 7 of the 30 being simple programme descriptions. Despite the inclusion of palliative care in national health policy in some countries, implementation in the community was often reliant on advocacy and financial support from non-government organizations. Networking to coordinate care and medication availability near-patient homes were essential features of implementation. Training, role play, education and mentorship were strategies used to support health providers and volunteers. Home- and community-based palliative care services for rural LMICs communities may best be delivered using a networked service among health professionals, community volunteers, religious leaders and technology.