Middle-income Countries Research Articles

Advancing acute MI care in densely populated low- and middle-income countries (LMICs): innovative stand-alone chest pain units for expedited triage and timely management

The incidence of myocardial infarction (MI) and its adverse effects on health and mortality remain high in densely populated low- and middle-income countries (LMICs). To address the issue of densely populated areas and timely access to primary PCI, chest pain units (CPUs) were deployed at strategic locations in Karachi, with a populace of over 23 million people. This study describes the results of this initiative in expediting MI care. Between 2017 and 2023, 18 CPUs, each with a cardiologist, technician, ECG machine, crash cart and an ambulance were placed in high density areas. A total of 915,564 patients were seen at 18 CPUs over the study period. 692,444 (75.6%) were categorized as non-cardiac and subsequently discharged. 223,120 (24.6%) patients were directed for additional care. Of these, 9% had ST elevation myocardial infarction (STEMI) (19, 580), 29% NSTE ACS/Unstable angina, and 31% with various other cardiac conditions. Additionally, 31% were referred for medical outpatient evaluation. CPU inception led to a significant annual growth (16-20%) in primary PCI procedures at NICVD, totaling 20,000 by 2022-2023. The median first medical contact to device time was 100min (IQR 80-135), while total ischemic was 232min (IQR: 172-315; 5th-95th %le: 50-920). The overall in-hospital mortality rate for patients undergoing primary PCI was 5.58%, with a range between 5.1% and 6.9% through the study period. Novel standalone chest pain units, operational from 2017 in Karachi, Pakistan, have expedited triage and enhanced the timely management of AMI. This initiative's transformative impact presents a model that resonates beyond borders, serving as a role model for global healthcare systems. The CPU and primary PCI program is fully funded by the government of Sindh. No specific funding was allocated for this study.

The WHO surgical safety checklist for cesarean section in an Ethiopian teaching hospital: a prospective cross-sectional study

Background: Implementing the World Health Organization (WHO) Surgical Safety Checklist is crucial for preventing post-surgical complications, including surgical site infections, in low-resource settings such as Ethiopia. The country has the lowest measured rate of safe surgery worldwide, with a significant unmet need for safe and affordable surgical care. The WHO checklist can improve maternal health equity by enhancing surgical and obstetric care safety, ultimately improving maternal outcomes in low- and middle-income countries (LMICs). Objective: This study aimed to assess the compliance, completeness, and determinants of using the WHO’s Surgical Safety Checklist during cesarean section (CS). Methods: This prospective study was conducted in the Obstetrics and Gynecology Department of a large tertiary hospital in Addis Ababa, Ethiopia. Primary data were collected from observations of clinical interactions in the obstetrics operating room (OR) during CSs. The rates of performing the checklist and completing each section were analyzed. Results: Of 250 observed CSs, 26.4% were elective, and 73.6% were emergency procedures. Patient ages ranged from 18 to 45 years, with a median age of 28. The overall compliance rate for the WHO surgical safety checklist was 98%, with 100% compliance for elective procedures and 97.2% for emergency procedures. The completeness rates for sign-in, time-out, and sign-out were 80.1%, 66.4%, and 45.3%, respectively. Conclusion: The study revealed high compliance but low completeness rates for the surgical safety checklist during CS. A noticeable distinction was observed, with elective procedures exhibiting superior compliance and completeness rates compared to emergency procedures. This could be attributed to the sense of urgency and limitations in available time.

Prevalence of Human Papillomavirus‐Associated Head and Neck Cancer in Rwanda: A 10‐Year Review

ABSTRACTIntroductionHead and neck cancer (HNC) is a significant global health burden, with late presentation leading to complex treatment. While human papillomavirus (HPV) infection has been implicated in HNC, data from low‐ and middle‐income countries (LMICs) are limited. In this study, we investigated the prevalence and role of HPV in head and neck cancers diagnosed in Rwanda.MethodsA retrospective cross‐sectional study was conducted using Rwanda Cancer Registry from January 2011 through December 2020. p16 immunohistochemistry as a surrogate for HPV was performed on a randomly selected case. p16‐positive cases were genotyped.ResultsA total of 1001 patients with HNC were identified; 82% (n = 819) had squamous cell carcinoma. The mean age at diagnosis was 51.1 years, with a majority being males (58%). Oral cavity and lip (27%) were the most common primary cancer sites. Stage was unknown in most cases (75%, n = 747). HIV status was known in 33% (n = 334) of patients with 10% (n = 33) HIV‐positive; 22% of 202 randomly selected cases were p16‐positive; 34% of the p16‐positive cases were oropharynx. PCR analysis of p16‐positive cases showed 19% HPV positivity, and HPV16 was the most common high‐risk HPV strain, and 55.5% were recorded HPV‐positive by PCR.ConclusionsHNC cases in Rwanda have been increasing from 2011 to 2020, with a significant portion being HPV‐positive. Strategies to implement routine testing for p16, especially in oropharynx cancer patients, improved preservation of tissue samples, collection of comprehensive information including cancer risk factors, staging, and treatment are needed in Rwanda.

Exploring the Impact of Ocean Acidification Information on Consumers'Preference for Seafood

We conducted a discrete choice experiment to explore whether providing information about a lesser-known issue related to climate change, as it is ocean acidification (OA), affects consumers’ preferences for seafood products in a middle-income country in the southern hemisphere. Our objective was to determine whether OA information affects consumer preferences for seafood using stated preference (SP) techniques. Seafood attributes include shell size and appearance, meat color, texture, taste, nutritional composition, product assortments, and price. We applied a split-sample approach to test for information effects, with one sample receiving information about OA while the other did not. We analyze the differences between samples using visual instruments and statistical tests. The results demonstrate that although the statistical test does not identify a difference between models, we did find that OA information increases the precision of ’consumers’ responses. Moreover, using visual instruments, we found differences in specific parameters – not detected in the statistical analysis - which can lead to substantial differences in the willingness to pay for seafood attributes. The article is relevant as understanding these matters is essential when generating more effective communicational strategies regarding the impacts of climate change.

Creation of a Unique Centrally Monitored and Operated Neonatal Transport Network in a Lower and Middle-Income Country: A First of its Kind Initiative

Creation of a Unique Centrally Monitored and Operated Neonatal Transport Network in a Lower and Middle-Income Country: A First of its Kind Initiative

Feasibility and acceptability of the Problem Management for Moms programme for improving maternal mental health in Zambia: an open-label trial

Psychological distress is common among mothers in low-income and middle-income countries, limiting their capacity to care for themselves and their children. This study aimed to test the feasibility and acceptability of an adapted psychosocial intervention for distressed mothers in low-resource settings. In this open-label trial, we enrolled women living in Lusaka, Zambia, with high mental distress (>7 score on the 20-item Self-Reporting Questionnaire [SRQ-20]) and children younger than 2 years, who had previously enrolled in the ZamCharts early childhood nutrition trial. We randomly assigned participants (1:1) to the intervention or control group using a random number draw. The intervention was a newly developed Problem Management for Moms (PM4M) programme: a ten-session treatment adapted from Problem Management Plus, which was offered by phone or in person. After randomisation, participants in the intervention group underwent pre-intervention screening, a post-intervention assessment, and a final follow-up assessment 9 months after treatment initiation (ie, final follow-up visit). The control group was assessed at the baseline of ZamCharts and at the final follow-up assessment, and these participants did not receive any intervention. The primary study outcomes were feasibility, acceptability, and participant mental distress measured using the SRQ-20. All primary and secondary outcomes were estimated in the intention-to-treat population, which included all participants who were randomised to the intervention group and attended the final follow-up assessment. Data on ethnicity were not collected. The trial is registered at ClinicalTrials.gov, NCT05627206, and has been completed. Women with lived experience of mental health symptoms were involved in this study. Between April 26, and July 14, 2021, 790 women were interviewed in the ZamCharts trial, of whom 265 had high mental distress and were randomly assigned to treatment groups in this trial (134 to the intervention group and 131 to the control group). Of the 134 women in the intervention group, 61 (46%) received the PM4M intervention and 73 (55%) were excluded; 103 in the intervention group and 106 in the control group were successfully interviewed at the final follow-up assessment. The mean age of participants was 27·6 years (SD 7·6) at ZamCharts baseline. PM4M sessions were conducted between Dec 16, 2022, and May 6, 2023. The 61 participants deemed eligible after pre-intervention screening who started the intervention completed a mean of 7·9 (SD 2·9) of ten sessions. 55 (77%) of these 61 participants were somewhat or very satisfied with the intervention. In adjusted intention-to-treat models, the intervention reduced mean SRQ-20 scores by 2·11 points (95% CI -3·50 to -0·63) at the final follow-up, and the adjusted odds ratio of having an SRQ-20 of more than 7 was 0·50 (95% CI 0·27 to 0·93). No serious adverse events were reported. The results presented here suggest that the PM4M mental health intervention is feasible and has high rates of acceptability. Further research is needed to assess the long-term efficacy of this intervention on women and their children, and its suitability for integration into routine care. The Eckenstein-Geigy Professorship.

Strengthening Capacity in Radiotherapy Skills to Deliver High-Quality Treatments in Low- and Middle-Income Countries: A Qualitative Study

Strengthening Capacity in Radiotherapy Skills to Deliver High-Quality Treatments in Low- and Middle-Income Countries: A Qualitative Study

Development and validation of a nomogram model for predicting the risk of hypertension in Bangladesh

Background and objectivesHypertension (HTN) is a leading cause of non-communicable disease in low- and middle-income countries, including Bangladesh. Thus, the objectives of this study were to investigate the associated risk factors for HTN and develop with validate a monogram model for predicting an individual's risk of HTN in Bangladesh. Materials and methodsThis study exploited the latest nationally representative cross-sectional BDHS, 2017–18 data, which consisted of 6569 participants. LASSO and logistic regression (LR) analysis were performed to reduce dimensionality of data, identify the associated risk factors, and develop a nomogram model for predicting HTN risk in the training cohort. The discrimination ability, calibration, and clinical effectiveness of the developed model were evaluated using validation cohort in terms of area under the curve (AUC), calibration plot, decision curve analysis, and clinical impact curve analysis. ResultsThe combined results of the LASSO and LR analysis demonstrated that age, sex, division, physical activity, family member, smoking, body mass index, and diabetes were the associated risk factors of HTN. The nomogram model achieved good discrimination ability with AUC of 0.729 (95 % CI: 0.685–0.741) for training and AUC of 0.715 (95 % CI: 0.681–0.729)] for validation cohort and showed strong calibration effects, with good agreement between the actual and predicted probabilities (p-value = 0.231). ConclusionThe proposed nomogram provided a good predictive performance and can be effectively utilized in clinical settings to accurately diagnose hypertensive patients who are at risk of developing severe HTN at an early stage in Bangladesh.

Shooting a moving target: Evaluating targeting tools for social programs when income fluctuates

A key challenge for policymakers in low- and middle-income countries is to design a method to select beneficiaries of social programs when income is unobservable and volatile. We use a unique panel dataset of a random sample of households in Colombia’s social registry that contains information before, during, and after the 2020 economic crisis to evaluate a traditional static proxy-means test (PMT) and three policy-relevant alternatives. We consider targeting metrics and social welfare under different curvatures of governments’ social welfare function, aggregate economic environments, and budgetary and political constraints. Updating the PMT data does not improve social welfare relative to the static PMT. Relaxing the eligibility threshold reduces the exclusion error, increases the inclusion error, and increases social welfare. A dynamic method that uses data on shocks to estimate a variable component of income reduces exclusion errors and limits the expansion in coverage, increasing social welfare during the economic crisis.

Leveraging single-dose human papillomavirus vaccination dose-efficiency to attain cervical cancer elimination in resource-constrained settings

Abstract Background In low- and middle-income countries, resource constraints remain a critical factor limiting access to cervical cancer preventive measures. The option of single-dose immunization could help improve access to human papillomavirus vaccination and attain cervical cancer elimination. Methods With simulation models adapted to country-specific data and scenarios for single-dose protection derived from International Agency for Research on Cancer India vaccine trial data, we estimated the expected impact of single-dose vaccination in India, Rwanda, and Brazil, three countries with varying profiles of cervical cancer risk and vaccination timelines. In combination with single-dose vaccination, we explored different resource reallocation strategies based on dose efficiency, elimination attainment, and cervical cancer cases prevented, with the existing 2-dose program as a comparator. Results Assuming lifelong single-dose protection, switching from 2-dose to 1-dose vaccination and reallocating resources to female catch-up could prevent 467-1336, 94-194, and 15-207 additional cervical cancer cases (per 100 000 women born) in cohorts aged 11-30 years in India, Rwanda, and Brazil, respectively. Resource reallocation to improve the current routine coverage could help eliminate cervical cancer in India and across all Brazilian states but not in Rwanda. For each country, we found a dose-efficient reallocation strategy (or a combination of strategies) together with 1-dose vaccination that could prevent more cervical cancers vs 2-dose vaccination, even in the worst-case scenario of single-dose protection. Conclusion Adopting single-dose vaccination with resource reallocation is a resource-efficient approach to enhance progress toward cervical cancer elimination. The overall impact of vaccination can be maximized by fine-tuning resource reallocation to a country’s needs.

Transition towards cancer mortality predominance over cardiovascular disease mortality in Brazil, 2000–2019: a population-based study

Cardiovascular disease (CVD) and cancer are the first and second leading causes of death in Brazil and worldwide. However, an ongoing epidemiological transition in which cancer surpasses CVD has been observed in many high and middle-income countries. In this study, we provided a nationwide analysis of the transition towards cancer mortality predominance over CVD mortality in Brazil. We leveraged data from 5570 municipalities using the Mortality Information System and classified the causes of death using ICD-10 codes. Age-standardized CVD and cancer mortality rates were calculated annually between 2000 and 2019. Mortality rate ratios (MRRs=CVD rates divided by cancer rates) described the predominance of cancer or CVD mortality across municipalities and states. Choropleth maps displayed state-specific MRRs and the transition in the predominant cause of death over time. From 2000 to 2019, CVD mortality rates declined in 25 out of 27 states, whereas cancer mortality increased in 15 states, indicating a shift towards cancer predominance. While in 2000 cancer mortality was lower than CVD in all states and only exceeded the latter in 7% of the municipalities, by 2019 the gap narrowed considerably, with 13% of municipalities displaying higher cancer mortality rates vs CVD mortality rates. Additionally, higher household income correlated with higher mortality from cancer vs CVD. An ongoing epidemiological transition in which cancer mortality surpasses CVD mortality is occurring in Brazil, particularly in municipalities with higher household incomes. Our findings may provide important information for policymakers and public health practitioners in Brazil. National Council for Scientific and Technological Development (CNPq).

The barriers and facilitators family caregivers experience when participating in resource-limited hospital care: a qualitative systematic review

BackgroundIn many resource-limited settings, understaffed hospitals rely on patients’ families to provide care during admission. These care tasks are often performed informally, untrained and unsupported. The WHO has called for innovative approaches to tackle health worker shortages globally. Family participation interventions could be such an innovation, but current family participation should be understood before implementation. This review explored the barriers and facilitators family caregivers experience participating in resource-limited adult hospital care.MethodsFor this qualitative systematic review, MEDLINE, Embase, CINAHL and the Global Health Library were searched from inception to 17 February 2023. Studies were included if they described experiences of family caregivers participating in hospital-like environments, were performed in a low- or middle-income country and included qualitative data. Open coding was performed, followed by thematic analysis. The risk of bias was assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument.Results3099 studies were screened, and 16 were included, involving 466 participants. All studies were published between 2009 and 2023. Three studies were performed in Africa, three in South America and 10 in Asia. 13 main themes were identified, seven for barriers and six for facilitators, including 50 subthemes. The main barriers identified were caregiver burden, a discouraging hospital environment, economic burden, ineffective collaboration with health workers, lack of support, sacrificing personal life to care and unpreparedness for caregiving. The main facilitators identified were a caregiving mindset, competence for caregiving, effective collaboration with health workers, encouraging hospital environment, sufficient financial means and supportive caregiving systems.DiscussionThis review presents the first overview of barriers and facilitators experienced by family caregivers participating in resource-limited hospital care. Research in more contexts and among other stakeholders is necessary to comprehend family participation holistically. To improve family participation, this review suggests prioritising educational interventions.PROSPERO registration numberCRD42023384414.

The impact of temperature on non-typhoidal Salmonella and Campylobacter infections: an updated systematic review and meta-analysis of epidemiological evidence

As temperatures rise, the transmission and incidence of enteric infections such as those caused by Salmonella and Campylobacter increase. This study aimed to review and synthesise the available evidence on the effects of exposure to ambient temperatures on non-typhoidal Salmonella and Campylobacter infections. A systematic search was conducted for peer-reviewed epidemiological studies published between January 1990 and March 2024, in PubMed, Scopus, Embase, and Web of Science databases. Original observational studies using ecological time-series, case-crossover or case-series study designs reporting the association between ambient temperature and non-typhoidal Salmonella and Campylobacter infections in the general population were included. A random-effects meta-analysis was performed to pool the relative risks (RRs) per 1°C temperature increase, and further meta regression, and subgroup analyses by climate zone, temperature metrics, temporal resolution, lag period, and continent were conducted. The Navigation Guide systematic review methodology framework was used to assess the quality and strength of evidence. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). Out of 3472 results, 44 studies were included in this systematic review encompassing over one million cases each of Salmonella and Campylobacter infections. Geographically, the 44 studies covered 27 countries across five continents and most of the studies were from high income countries. The meta-analysis incorporated 23 Salmonella studies (65 effect estimates) and 15 Campylobacter studies (24 effect estimates). For each 1°C rise in temperature, the risk of non-typhoidal Salmonella and Campylobacter infections increased by 5% (RR: 1.05, 95% CI: 1.04-1.06), and 5% (RR: 1.05, 95% CI: 1.04-1.07%), respectively, with varying risks across different climate zones. The overall evidence was evaluated as being of "high" quality, and the strength of the evidence was determined to be "sufficient" for both infections. These findings emphasise the relationship between temperature and the incidence of Salmonella and Campylobacter infections. It is crucial to exercise caution when generalising these findings, given the limited number of studies conducted in low and middle-income countries. Nevertheless, the results demonstrate the importance of implementing focused interventions and adaptive measures, such as the establishment of localised early warning systems and preventive strategies that account for climatic fluctuations. Furthermore, our research emphasises the ongoing need for surveillance and research efforts to monitor and understand the changing dynamics of temperature-related enteric infections in the context of climate change. Australian Research Council Discovery Projects grant (ARC DP200102571) Program.

Scrutinizing the load capacity curve for a global perspective: The role of Fintech, government effectiveness and renewable energy

With the evolving world order, countries are using financial technologies (Fintech) to access financial resources more effectively, and Fintech can have an impact on the environment. This study aims to investigate the influence of Fintech on ecological sustainability, focusing on the contribution of renewable energy (RE) and government effectiveness (GE) under the Load Capacity Curve (LCC). This research analyzes data from 69 middle-income economies between 2006 and 2022 using the dynamic panel threshold model (DPTR). The outcomes document that GDP reduces the LCF below a certain threshold, but a positive impact above this threshold. Specifically, the model yielded a threshold value of $US 5222.234, which is higher than the average GDP of $US 4276.802. This finding suggests a U-shaped relationship between GDP and LCF, which supports the LCC hypothesis. The outcome also reports that Fintech plays a crucial role in improving ecological sustainability, while government effectiveness has a negative effect. The study emphasizes that middle-income countries should support Fintech and renewable energy along development with economic progress to improve ecological quality.

Mothers’ health-seeking practices and associated factors towards neonatal danger signs in Ethiopia: a systematic review and meta-analysis

BackgroundA decrease in obtaining quality healthcare is a major cause of maternal and newborn deaths in low-income and middle-income countries. Ethiopia has one of the highest neonatal mortality rates. Increasing...

Food handling practices and sanitary conditions of charitable food assistance programs in eThekwini District, KwaZulu-Natal, South Africa

Unsafe food handling practices by food handlers have dire health and financial implications worldwide. Each year, approximately 600 million people, or about 1 in 10 people, are said to become ill from eating contaminated food, and 420,000 people inadvertently die. According to the 2019 World Bank report on the economic burden of foodborne diseases, the annual cost of treating foodborne illnesses is estimated to be US$ 15 billion, and the total productivity loss caused by foodborne diseases in low- and middle-income countries is estimated to be US$ 95.2 billion annually. The purpose of this study was to assess the food handling practices and sanitary conditions of the charitable food assistance programs (CFAPs) in the eThekwini District of KwaZulu-Natal, South Africa. A descriptive cross-sectional study was conducted among 196 CFAPs in eight study settings across five municipal planning regions (MPRs) of the eThekwini District between January 2021 and May 2021. Data were collected using a standardized 37-item observational checklist and analysed through Stata Statistical Software (TX: StataCorp. 2021 LLC.: Release 17. College Station). Compliance levels were calculated using the compliance score (C-score), whereby 0.0–0.20 (0–20%), 0.21–0.40 (21–40%), 0.41–0.60 (41–60%), 0.61–0.80 (61–80%), and 0.81–1.00 (81–100%) were determined as very poor, poor, average, good, and very good, respectively. Statistically significant associations were declared at p < 0.05. Compliance with food hygiene, storage, and packaging was very poor (C-score = 0.003), as were personal hygiene and staff facilities (C-score = 0.147), as well as product information/labelling (C-score = 0.003). Similarly, waste management and pest control systems (C-score = 0.203), compliance with health and hygiene education/training (C-score = 0.335), as well as use and maintenance of transport (C-score = 0.333), all scored ‘poor’. Only the design of premises and facilities had an average compliance score (C-score = 0.43). Given CFAPs’ role in mitigating the impact of poverty, their strict compliance with hygiene protocols is of utmost importance. Systems for identifying and correcting common noncompliance in CFAPs are required.

Participatory development of training videos for respiratory equipment.

During the coronavirus disease 2019 (COVID-19) pandemic, medical oxygen therapy was urgently needed for patients with hypoxaemia. Many low- and middle-income countries lacked the medical devices for oxygen therapy and experience in their use. In addition to providing medical devices for oxygen therapy for countries in need, the World Health Organization (WHO) and partners developed training videos to help local health workers select, use and maintain this equipment. Diverse health professionals, including engineers and clinicians from resource-constrained countries, collaborated in developing draft videos in their local settings. A production team refined these drafts and delivered the training videos through the platform OpenWHO. OpenWHO is WHO's free open-access platform providing courses for health workers and others. The courses, based on WHO's scientific and operational guidance, can be easily adapted, contextualized and translated. The production team refined the drafts into 32 training videos. More than 17 505 health workers participated in the OpenWHO course on COVID-19 respiratory equipment between 28 February 2022 and 30 November 2023. Participants were from 189 countries and 38% (6027/16 047) were from low- and lower-middle-income countries. Involving volunteer biomedical engineers and clinicians from low- and middle-income countries helped provide an appropriate training resource. WHO should continue to develop such training tools and offer them through OpenWHO, especially for emergencies.

Cross national patterns in educational inequalities in functional limitations among middle aged and older adults at two time points

IntroductionIn recent decades, the global population has aged rapidly while socioeconomic inequalities in health have widened, with older adults who are most disadvantaged experiencing the poorest health. Functional limitations are key predictors of disability and quality of life and are therefore considered an important measure of how well individuals and populations are aging. We determine if educational inequalities in functioning have widened over time and across countries. MethodsWe used data from five nationally representative surveys of aging, covering 14 high- and middle-income countries, with harmonized measures of functional limitations. We examined change over time in the number of functional limitations among adults aged 50-64 and 65 and older in each country as well as changes in educational inequality in functional limitations over time for both age groups. ResultsIn most high-income countries, the number of functional limitations decreased over time, but they increased in China and Mexico, with the largest increases occurring among adults 65 and older. Educational inequality in functional limitations among those aged 65 and older widened for several countries in our study, but for different reasons. In some countries, it widened due to increased limitations among the least-educated, while in others it widened due to declines in limitations among the most-educated. ConclusionGrowing educational inequality in functional limitations for older adults in several high- and middle-income countries suggests that, despite improvements in health and mortality, socioeconomic differences in functional health among older adults are widening.

Leveraging Social Networks to Integrate Depression Treatment into Primary Health and Tuberculosis Care in Brazil.

Tuberculosis (TB) and depression are highly comorbid and linked to higher rates of death and disability. Several evidence-based treatments for depression have been successfully implemented in low- and middle-income countries, but more knowledge is needed on how to bring these innovations to scale within complex 'real world' public health systems. To explore whether the principles of social network analysis could be used to enhance receptivity to integrating depression treatment into primary care for individuals with and without TB in Brazil. We used existing scales to identify settings and providers with high receptivity and connectivity within the primary care network. We trained and supervised existing staff in three primary care sites to deliver a brief evidence-based intervention over one year, coupled with active dissemination activities. Afterwards, we reassessed receptivity among individuals involved, and not involved, in the pilot. Highly significant changes were observed in mental health literacy, attitudes towards evidence-based practices, work self-efficacy, and implementation leadership supporting our hypothesis. Limited social connections between primary care clinics precluded the examination of the hypothesis that targeting settings with high connectivity could capitalize on the information flow between and transcend the decentralized structure of the network, but leveraging the centralized nature of the TB program to integrate mental health services emerged as a promising alternative. The findings of this study strongly suggest that social networks may be leveraged to change individual providers' attitudes, thereby contributing to the enhanced dissemination of evidence-based interventions.

Comparative Education in the Health Professions

As the academe in health professions institutions pursue educational reforms that anchors on the systems approach to healthcare, collaborative efforts are essential to establish more responsive and dynamic professional education systems. This paper highlights comparative education as a tool to strengthen health professions education around the world by reviewing previous and the most recent studies done, and showcase how this can improve the current pedagogical landscape. Through comparative education, a holistic approach to health professions education ensures that the learner’s training is not only comprehensive but also responsive to the dynamic needs of the country, the region, and the rest of the world by the sharing of best practices, challenges, and opportunities for collaboration. The opportunities that international comparative education provide to the health professions education include the sharing of best practices and difficulties encountered, and the enhanced viewpoint from considering different perspectives. On the other hand, the main challenges include ethnocentrism and the limited resources that majority of institutions face globally especially those from the low- and middle-income countries. Truly, once the lessons learned from comparative educational engagements are integrated into the philosophical and educational foundations in our medical schools, then we are one step closer to becoming responsive to the call for a more holistic and systems – centered health professions education.