Low- And Lower-middle-income Countries Research Articles

Socioeconomic status and alcohol use in low- and lower-middle income countries: A systematic review.

Harmful use of alcohol is a major cause of global morbidity and mortality. The role of alcohol as a driver of the unfolding non-communicable disease crisis has led to high-profile calls for better epidemiological data. Despite causing a disproportionate amount of harm in low-income groups, there is a critical dearth of evidence on the intra-national socioeconomic patterning of alcohol use in low- and lower-middle income countries (LLMICs). This review aims to fill the gap, providing evidence on the association between socioeconomic status (SES) and alcohol use in these low-income settings. We conducted a comprehensive literature search for primary research published between January 1, 1990 and June 30, 2015 using 13 electronic databases, including Embase and Medline. We also hand-searched references and reviewed 'gray literature' - studies that have not been published in peer-reviewed journals. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and alcohol use. No age or language restrictions were applied. Due to high heterogeneity, we used a narrative approach for data synthesis. After reviewing 4242 records and 247 full-text articles, 23 studies met our inclusion criteria, reporting data on 861,295 individuals aged >10 years from 10 countries. Alcohol use was found to be more prevalent in lower socioeconomic groups in the majority of Southeast Asian studies. The association was mixed for African studies, although these tended to have smaller sample sizes and weaker methods. Studies that measured multiple domains of SES found good agreement between different indicators. Definitions of alcohol use and abuse varied widely between studies, as did socioeconomic groupings. The lack of consistency between studies and the abject lack of data from the majority of LLMICs present a major barrier to policymakers tasked with reducing alcohol-related harm in these settings. Adherence to standardized definitions, the publication of WHO survey data on alcohol and SES, and enhanced surveillance is needed to build an accurate picture of the socioeconomic patterning of alcohol use in developing countries.

Sorption of active pharmaceutical ingredients in untreated wastewater effluent and effect of dilution in freshwater: Implications for an “impact zone” environmental risk assessment approach

Evidence of ecotoxicological effects of active pharmaceuticals ingredients (APIs) has increased research into their environmental fate. In low and low-middle income countries (LLMICs) the main source of APIs to surface waters is from discharge of untreated wastewater. Consequently, concentrations of APIs can be relatively high in the “impact zone” downstream of a discharge point. Little is known about the fate of APIs in these impact zones. In this laboratory scale investigation, the effect of successive dilution of synthetic untreated wastewater (dilution factor 1 to 10) on the distribution of APIs was studied. The sorption was consistent with the chemical properties of each compound: charge, lipophilicity, and structure. Dilution increased desorption of the basic and neutral APIs (up to 27.7%) and correlated with their lipophilicity (R2>0.980); the positive charge was of secondary importance. Anions did not significantly desorb (<10% loss). Increased concentrations of dissolved organic matter at dilutions of 8 and 10 times that of untreated wastewater coincided with lower dissolved API concentrations. The data showed a clear trend in the desorption process of APIs that may lead to higher exposure risk than anticipated. Therefore, it is suggested that these aspects should be accounted for in the development of dedicated environmental risk assessment approach for APIs in riverine impact zones of LLMICs countries.

Wheelchair service provision education and training in low and lower middle income countries: a scoping review

Purpose: Improving access to education and training for those providing wheelchair and seating assistive technology to meet personal posture and mobility requirements, as a basic human right, is a priority. This review considers education and training available to personnel within low and lower middle income countries (LLMIC), to ascertain where gaps in knowledge exist and identify human resource education priorities.Method: A scoping review, mapping out existing scientific and grey literature within the field between 1993 and 2017 was conducted. The search strategy included use of online databases, manual analogue searches and key stakeholder informant advice. A content analysis process was applied to organize the literature retrieved and extract key themes.Results: Education and training in LLMIC appears ad hoc and limited, however, there is growing recognition as to its importance, notably by the World Health Organization and nongovernmental organizations, delivering education initiatives to a number of countries, along with the development of a credentialing test. Inconsistency exists regarding personnel responsible for wheelchair provision, with no specific professional clearly recognized to oversee the system within many LLMIC.Conclusions: Education and training is required for all stakeholders involved in wheelchair provision. Advocating for programme development to enhance personnel skills, build capacity and ensure best practice is a priority. Pilot sites, delivering and credentialing appropriate wheelchair provision education and training within context should be considered. Measuring outcomes and transferable skills should be part of education programme delivery structures. Considering a new discipline responsible for oversight of wheelchair provision should be investigated.Implications for rehabilitationEducation and training is an essential step in the wheelchair provision process in the bid to obtain an appropriate wheelchair via appropriate provision services. However, it is more than education and training; its a human rights issue.Mandatory education and training needs to be a requirement for all stakeholders involved in wheelchair provision.Key wheelchair personnel need to establish their central role in this arena.The study raises awareness as to the importance of working with governments to commit to building sustainable wheelchair provision infrastructures.

P.4.a.005 - Chronic social defeat stress: impact on sleep in susceptible mice

The possibility of pulse oximetry screening (POS) for congenital heart defects was first described over 20 years ago. Since then, an accumulation of research evidence and clinical practice experience has established POS as an important test to detect critical congenital heart defects (CCHDs). POS meets the criteria for universal screening and professional bodies around the globe have recommended universal POS. Many countries have already adopted POS while several others are working towards its implementation. In low and low-middle-income countries (LLMIC), POS has the additional potential for reducing morbidity and mortality from neonatal sepsis. This review summarises the evidence for POS and looks at current global uptake and different approaches to the implementation of POS.

Psychiatric disorders among people with cancer in low- and lower-middle-income countries: study protocol for a systematic review and meta-analysis

IntroductionCancer is a rapidly growing public health problem in low- and lower-middle-income countries (LLMICs). There is evidence from upper-income countries that comorbid mental illness is common and can adversely impact...

Progress in HPV vaccination in low- and lower-middle-income countries.

The past 10years have seen remarkable progress in the global scale-up of human papillomavirus (HPV) vaccinations. Forty-three low- and lower-middle-income countries (LLMICs) have gained experience in delivering this vaccine to young adolescent girls through pilot programs, demonstration programs, and national introductions and most of these have occurred in the last 4years. The experience of Senegal is summarized as an illustrative country case study. Publication of numerous delivery experiences and lessons learned has demonstrated the acceptability and feasibility of HPV vaccinations in LLMICs. Four areas require dedicated action to overcome remaining challenges to national scaling-up: maintaining momentum politically, planning successfully, securing financing, and fostering sustainability. Advances in policy, programming, and science may help accelerate reaching 30 million girls in LLMICs with HPV vaccine by 2020.

Scaling up proven innovative cervical cancer screening strategies: Challenges and opportunities in implementation at the population level in low- and lower-middle-income countries.

The problem of cervical cancer in low- and lower-middle-income countries (LLMICs) is both urgent and important, and calls for governments to move beyond pilot testing to population-based screening approaches as quickly as possible. Experiences from Zambia, Bangladesh, Guatemala, Honduras, and Nicaragua, where scale-up of evidence-based screening strategies is taking place, may help other countries plan for large-scale implementation. These countries selected screening modalities recommended by the WHO that are within budgetary constraints, improve access for women, and reduce health system bottlenecks. In addition, some common elements such as political will and government investment have facilitated action in these diverse settings. There are several challenges for continued scale-up in these countries, including maintaining trained personnel, overcoming limited follow-up and treatment capacity, and implementing quality assurance measures. Countries considering scale-up should assess their readiness and conduct careful planning, taking into consideration potential obstacles. International organizations can catalyze action by helping governments overcome initial barriers to scale-up.

"Why screen if we cannot follow-up and manage?" Challenges for gestational diabetes screening and management in low and lower-middle income countries: results of a cross-sectional survey.

BackgroundThe prevalence of gestational diabetes (GDM) in low and lower middle income countries (LLMIC) is increasing. Despite its associated short and long term complications for mothers and their newborns, there is a lack of knowledge about how to detect and manage GDM. The objective of our study was to identify the challenges that first line healthcare providers in LLMIC face in screening and management of GDM.MethodsWe conducted a cross-sectional survey of key informants from 40 low and lower-middle income countries in Africa, South-Asia and Latin-America by sending out questionnaires to 182 gynecologists, endocrinologists and medical doctors. Sixty-seven respondents from 26 LLMIC provided information on the challenges they encounter. Data was thematically analyzed and revealed eight overarching themes, including guidelines; human resources; access; costs; availability of services, equipment and drugs; patient and community factors; and collaboration and communication.ResultsUnavailability of guidelines combined with lack of knowledge about GDM on the part of both providers and patients poses a substantial barrier to detection and management of GDM, leading to deficiencies in screening and counseling. Limited access to regular monitoring and follow-up care as a result of distance and costs, in particular with respect to additional expenses related to specific tests and changes in diet were identified as important challenges. Services were not available at all levels nor was adequate testing equipment. Patient factors included lack of motivation and compliance with the recommended therapy. Respondents also highlighted the lack of communication and collaboration between different specialists and treatment delays as a result of patients being seen by multiple providers.ConclusionsProviders from LLMIC face various challenges related to screening and managing GDM. Policy makers need to address these challenges by strengthening their health care system as a whole and by assuring that non-communicable diseases are better integrated into the existing packages of free or subsidized maternal health care.

Poverty and risk factors for non-communicable diseases in developing countries: a systematic review

BackgroundThe association between poverty and health is highly context-specific; in high-income countries, low socioeconomic status is associated with use of tobacco and alcohol, physical inactivity, and poor diet. We lack good quality epidemiological evidence from developing countries, especially from low and lower middle-income countries (LLMICs). This systematic review sought to fill this gap. MethodsWe conducted a comprehensive literature search for primary research published between Jan 1, 1990, and June 30, 2015, using 13 electronic databases, including Embase and Medline, as well as a grey literature review and hand searching of references. Two reviewers independently screened papers retrieved from 13 databases with a search devised by an experienced medical librarian combining MeSH terms and synonyms for non-communicable diseases, behavioural risk factors, poverty, and the 84 LLMICs defined by the World Bank. We included studies from LLMICs that presented data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. We performed narrative data synthesis. FindingsAfter review of 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals aged more than 10 years from 39 LLMICs. Most studies found that, compared with high socioeconomic groups, lower status groups had a high prevalence of tobacco and alcohol use (odds ratios up to 18·8 and 3·5, respectively). Most studies also found that lower socioeconomic groups consumed less fruit, vegetables, fish, and fibre (odds ratios negligible to 12·9, depending on context). Higher socioeconomic groups were up to 4·4 times less physically active and consumed more fats, salt, and processed food; however, these dietary studies tended to be smaller with wide confidence intervals. InterpretationDespite variation in exposure and outcome measures, there is clear evidence that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal 3.4—reducing premature mortality from non-communicable diseases by a third by 2030—should leverage their development budgets to address the poverty–health nexus in these settings. Our findings are also important for health workers serving these populations, and for policymakers tasked with preventing and controlling the rise of non-communicable diseases. FundingNone.

Poverty and development interventions that address behavioural risk factors of non-communicable diseases in low and lower middle income countries: a systematic review

BackgroundNon-communicable diseases (NCDs) disproportionately affect low and lower middle income countries (LLMICs), where 80% of global NCD deaths occur. LLMICs are the primary focus of interventions to address development and poverty indicators. We aimed to synthesise the evidence of the impact of these interventions on the four primary behavioural risk factors for NCDs—unhealthy diets, physical inactivity, tobacco use, and alcohol use. MethodsUsing a comprehensive search strategy we systematically searched four online databases (Medline, Embase, Web of Science, and Global Health) for primary research conducted in LLMICS, published between Jan 1, 1990, and Feb 15, 2016, with no language restriction. Studies involved development or poverty interventions that reported on outcomes relating to the four behavioural risk factors for NCDs. We extracted summary level data on study design, population, health outcomes, and potential confounders. The study is registered with PROSPERO, number CRD42016039030. FindingsFrom 2172 search results, 26 studies published between 1999 and 2015 met our inclusion criteria. Quality of included studies was poor and heterogeneity of outcome measures required narrative synthesis. Included studies were conducted in 24 LLMICs, with 12 from low-income African countries. One study measured physical activity, 26 measured dietary components, and none measured alcohol or tobacco use. Most papers (n=23) involved agricultural interventions. Primary outcome measures included micronutrient intake, child stunting, and dietary diversity with a focus on preventing undernutrition in women and children. Intensive agricultural interventions were associated with improved calorie, vitamin, fruit, and vegetable intake. However, the impact of interventions often relied on participants' land ownership or communicable disease status, or the study did not measure unhealthy food consumption. Only three studies measured adult obesity, two of which indicated that increased income and consequential food affordability had the potential to increase obesity. InterpretationAlthough many interventions addressing poverty and development have potential to affect NCD behavioural risk factors, most fail to measure or report these outcomes. Existing evidence suggests a positive impact of agricultural-based food security programmes on the intake of nutrients, fruits, and vegetables. However, studies investigating the effect of improved income on obesity tend to show an increased risk. Embedding an assessment of the impact of NCDs into development programmes is crucial in the context of the UN Sustainable Development Goals and the rapid epidemiological transitions facing LLMICs. FundingThis project was commissioned by WHO (2015/577190-0). KW and NT are supported by a grant from the British Heart Foundation (006/P&C/CORE/2013/OXFSTATS). The authors alone are responsible for the views expressed in this abstract and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

Polyvictimization Among Children and Adolescents in Low- and Lower-Middle-Income Countries: A Systematic Review and Meta-Analysis

Background: Most of the world’s children and adolescents live in low- and lower-middle-income countries (LALMIC), but there is limited evidence about polyvictimization (experiences of multiple forms of victimization) among them. The aims of this article were to systematically review the evidence from LALMIC about the overall prevalence of polyvictimization and to identify the associations between polyvictimization and health and well-being among children and adolescents. Method: A systematic search of the English-language peer-reviewed literature to identify empirical, quantitative studies conducted in LALMIC between 2005 and 2015, assessing at least four forms of victimization among young people aged up to 19 years. Where prevalence of any victimization and of polyvictimization were reported, meta-analyses were performed. Results: A total of 30/8,496 articles were included in the review. Evidence was available from 16/84 LALMIC and methodology and quality varied. Pooled prevalence of experiences of any victimization was 76.8% (95% confidence interval (CI) [64.8%, 88.9%]). Prevalence of polyvictimization ranged from 0.3% to 74.7% with an overall estimate of 38.1% (95% CI [18.3%, 57.8%]). None of the studies examined the associations between polyvictimization and physical or reproductive health or quality of life. Polyvictimization was associated with increased likelihood of mental health problems and involvement in health risk behaviors. Conclusions: Experiences of polyvictimization among children and adolescents in LALMIC are more prevalent than in high- and upper-middle-income countries and contribute to the burden of poor health among children and adolescents. Most LALMIC lack local data, and research is required to address this knowledge gap.

The ISN 0by25 Global Snapshot Study

The International Society of Nephrology's (ISN) 0by25 initiative aims to prevent avoidable deaths from acute kidney injury (AKI) by 2025, most of which occur in low and lower middle-income countries (LLMICs). To increase evidence about the epidemiology of AKI, especially in LLMICs, ISN conducted a ‘Global Snapshot', a multinational, cross-sectional study in which 322 physicians from 72 countries in 6 continents identified 3,664 adults and 354 children with AKI who were under their care of which 45% were from LLMICs, nevertheless low-income countries were under-represented. In LLMICs, patients with AKI were younger, and community acquired AKI was more common. Hypotension (40%) and dehydration (39%) were the most common causes of AKI. Dehydration was a more common cause in LLMIC, as were sepsis, pregnancy-related AKI and animal envenomation. Acute dialysis was performed in 23% of patients. Eight percent had a clinical indication for this but were not dialyzed. In LLMICs, lack of resources (16%) and inability to afford therapy (30%) accounted for almost half of these cases. Overall mortality at 7 days was 11% and was higher in LLMICs. Complete recovery from AKI occurred in 30% of patients and partial recovery 37%, and was more often complete in LLMICs. The 0by25 Global Snapshot provides new information about the worldwide epidemiology of AKI, helping to identify elements that would be amenable in intervention to reduce preventable deaths.

Opening the 'black box' of performance-based financing in low- and lower middle-income countries: a review of the literature.

Although performance-based financing (PBF) receives increasing attention in the literature, a lot remains unknown about the exact mechanisms triggered by PBF arrangements. This article aims to summarize current knowledge on how PBF works, set out what still needs to be investigated and formulate recommendations for researchers and policymakers from donor and recipient countries alike. Drawing on an extensive systematic literature review of peer-reviewed journals, we analysed 35 relevant articles. To guide us through this variety of studies, point out relevant issues and structure findings, we use a comprehensive analytical framework based on eight dimensions. The review inter alia indicates that PBF is generally welcomed by the main actors (patients, health workers and health managers), yet what PBF actually entails is less straightforward. More research is needed on the exact mechanisms through which not only incentives but also ancillary components operate. This knowledge is essential if we really want to appreciate the effectiveness, desirability and appropriate format of PBF as one of the possible answers to the challenges in the health sector of low-and lower middle-income countries. A clear definition of the research constructs is a primordial starting point for such research.

Reliability and validity of the Edinburgh Postnatal Depression Scale (EPDS) for detecting perinatal common mental disorders (PCMDs) among women in low-and lower-middle-income countries: a systematic review.

BackgroundThe Edinburgh Postnatal Depression Scale (EPDS), originally developed in Britain, is one of the most widely used screening instruments for assessing symptoms of the Perinatal Common Mental Disorders (PCMDs) of depression and anxiety. However, its potential to detect PCMDs in culturally diverse low- and lower-middle income countries (LALMICs) is unclear. This systematic review aimed to appraise formally validated local language versions of the EPDS from these resource-constrained settings.MethodsFollowing the PRISMA protocol, we searched MEDLINE-OVID, CINAHL-Plus and PUBMED to identify studies reporting translation, cultural adaptation and formal validation of the EPDS to detect PCMDs among women in LALMICs. The quality of the studies meeting inclusion criteria was assessed using standard criteria and a new process-based criteria; which was developed specifically for this study.ResultsWe identified 1281 records among which 16 met inclusion criteria; three further papers were identified by hand-searching reference lists. The publications reported findings from 12 LALMICs in14 native languages. Most of these local language versions of the EPDS (LLV-EPDS) had lower precision for identifying true cases of PCMDs among women in the general perinatal population compared to the original English version. Only one study met all criteria for culturally sensitive translation, the others had not established the comprehensibility of the local version amongst representative groups of women in pre-testing. Many studies tested the LLV-EPDS only amongst convenience samples recruited at single health facilities. Diagnostic interviews for confirmation of mental disorders could have been influenced by the mental health professionals’ lack of blinding to the initial screening results. Additionally, even when diagnostic-interviews were carried out in the local language, questions might not have been understood as most studies followed standard diagnostic protocol which had not been culturally adapted.ConclusionsMost of the LLV-EPDS from non-English speaking low- and middle-income-countries did not meet all criteria for formal validation of a screening instrument. Psychometric properties of LLV-EPDS could be enhanced by adopting the new process-based criteria for translation, adaptation and validation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-0859-2) contains supplementary material, which is available to authorized users.

Evolving Monetary Policy Frameworks in Low-Income and Other Developing Countries

Over the past two decades, many low- and lower-middle income countries (LLMICs) have improved control over fiscal policy, liberalized and deepened financial markets, and stabilized inflation at moderate levels. Monetary policy frameworks that have helped achieve these ends are being challenged by continued financial development and increased exposure to global capital markets. Many policymakers aspire to move beyond the basics of stability to implement monetary policy frameworks that better anchor inflation and promote macroeconomic stability and growth. Many of these LLMICs are thus considering and implementing improvements to their monetary policy frameworks. The recent successes of some LLMICs and the experiences of emerging and advanced economies, both early in their policy modernization process and following the global financial crisis, are valuable in identifying desirable features of such frameworks. This paper draws on those lessons to provide guidance on key elements of effective monetary policy frameworks for LLMICs.

Volunteering in Honduras: Results and Reflections.

According to the GLOBOCAN 2012 data released by the International Agency for Research on Cancer, an estimated 14.1 million new cancer cases and 8.2 million cancer deaths occurred worldwide in 2012. This is an immense increase compared with 2008 statistics, which reported 12.7 and 7.6 million new cases and deaths, respectively. Lowand low-middle–income countries accounted for more than half of the new cancer cases and nearly two thirds of all cancerrelated deaths. The social and economic disparities in cancer prevention and treatment present a disproportionate burden in these low-resource settings. Honduras is a low-middle–income country with a total population of 8.3 million. Cancer accounts for 13% of deaths each year. The most common cancers reported are prostate, gastric, cervix, liver, and breast. The mortality rates from cervix and gastric cancers are among the highest globally, at 18.5 and 8.8%, respectively. There are 24 surgical, eight gynecologic, 13 medical, and four radiation oncologists in Honduras. Hospital General San Felipe (HGSF) is the only public cancer hospital in Honduras that treats underserved patients. Currently, there is only one surgical oncology training program in Honduras. During the 4-year curriculum, residents are taught to provide surgical care for men and women with a wide spectrum of malignancies. Efforts to improve the education and training of residents in surgery and oncology in countries with limited specialists have been growing in the last decade. Medical volunteerism in such countries has become an area of interest for medical students, residents, fellows, and attending physicians from outside of the affected countries, and there are a number of models for providing this assistance. Barriers to successful exchanges between volunteers and in-country physicians include time constraints of the volunteers and infrastructure deficits in low-resource settings that prohibit optimal learning environments. Increasingly, a combination of short-term, hands-on teaching sessions coupled with ongoing Internet-based instruction by volunteers at a distance has emerged as a successful model for supporting incountry physicians to provide increasingly sophisticated medical and surgical care within the limits of available resources. For example, a successful program of surgical training to perform radical hysterectomies in patients with cervical cancer has been implemented in Kenya through collaboration with the Society of Gynaecologic Oncology of Canada. The 2-week intensive program, which is staffed by one expert Canadian surgeon, included seven video didactics, a preand post-test, and seven live surgical sessions with oral and written feedback after each patient case. Short-term follow-up revealed four successful radical hysterectomies by the Kenyan surgeons after the Canadian trainer had left. Similarly, the Central America Gynecologic Oncology Education Program, an initiative that is focused on the education and training of obstetrics and gynecology residents in the prevention and treatment of gynecologic cancers, is a collaboration between the American College of Obstetrics and Gynecology and six Central American countries and includes in-country training trips with US gynecologic oncologists with ongoing distance learning and support. Another option for training physicians from low-resource settings is for these individuals to travel to high-resource settings for training. However, this approach has drawbacks. A recent report suggests that the numbers of physicians emigrating from Sub-Saharan Africa to the US is increasing and will negatively affect low-resource countries, where there is a great need for health care providers. Training of physicians in their respective countries offers the advantage of hands-on training, given that direct patient contact is not allowed during an observership in the United States. In addition, the context of care and the resources available for treatment are different in settings such as Honduras compared with the United States. Despite increasing numbers of medical missions to assist underserved countries, there is still a lack of formalized educational curricula and supervised training in these countries. In this article, we describe the Health Volunteers Overseas (HVO) Oncology Training Program in Honduras, which focuses on providing education, surgical training, and research mentorship to surgical oncology residents, nurses, and other health care providers in Tegucigalpa, Honduras.

Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries

This study systematically maps, assesses and aggregates research relating to postnatal depression (PND) and poverty in low and lower middle income countries (LLMICs). Our search of 12 databases yielded 2202 articles, of which 47 items from 17 countries were included in our mapping. We highlight mechanisms for the relationships between poverty and PND in LLMICs. The research base on the relationships between poverty and PND in LLMIC is limited, but has recently expanded. It is dominated by studies that consider whether poverty is a risk factor for PND. Income, socio-economic status and education are all inconsistent risk factors for PND. Clues to better ways of framing and capturing economic stress in PND research is found in the qualitative studies included in our mapping. Evidence focusses overwhelmingly on individual-level analyses. To understand the scale and implications of PND in LLMICs, research has to take account of neighbourhoods, communities, and localities.