Low- And Middle-income Countries Context Research Articles

Methods for estimating beneficiary populations targeted by health and nutrition interventions for women, pregnant women, infants, and young children

Abstract Utilization of maternal and child interventions is typically tracked in low- and middle-income countries (LMICs) using coverage estimates from population representative surveys. These estimates cannot be directly applied to assess resource gaps in intervention delivery for which data on the population eligible is required. Moreover, coverage improvements may not necessarily reflect an expansion in utilization because of a decline in the population eligible. We develop a method to estimate the populations eligible for interventions across the continuum of care. The method uses data from the World Population Prospects and the Demographic Health Survey, data sources which are available for most LMICs. Additionally, we develop a method to estimate the eligible population covered by each intervention. Using the illustration of India, we estimate populations eligible for, and covered by interventions during preconception, pregnancy, delivery, lactation, and childhood. We find that between 2015 and 2020, the eligible population declined for all beneficiary groups. Additionally, coverage expansion was not entirely driven by an increase in the population accessing an intervention, but rather also by a decline in the eligible population. Our illustration highlights the importance of including population estimates alongside coverage for interventions, particularly in LMIC contexts due to changing fertility dynamics.

Physical activity and anxiety during the COVID-19 pandemic in Tanzania: insights for public health policy in low-income contexts

BackgroundThe COVID-19 pandemic heightened anxiety levels globally, disproportionately affecting low-and middle-income countries (LMICs). Physical activity (PA) has shown potential to alleviate mental health challenges, including anxiety. This study explores the relationship between PA and anxiety among Tanzanian adults during the pandemic, examining whether self-reported health status moderates this relationship and identifying demographic variations.MethodsData from 213 adults were collected using the International Physical Activity Questionnaire-Short Form (IPAQ-SF) and Generalized Anxiety Disorder-7 (GAD-7) scale. Self-reported health was also reported.ResultsVigorous physical activity was significantly associated with lower anxiety, while moderate physical activity showed weaker effects. Walking and sedentary behavior were not significantly associated with anxiety. Health status did not moderate these relationships, but subgroup analyses indicated stronger effects of vigorous physical activity among men and younger adults.ConclusionThese findings highlight the relevance of PA, particularly vigorous and moderate physical activity, in supporting mental health in LMIC contexts such as Tanzania. The findings further underscore the importance of targeted, culturally relevant physical activity interventions in LMICs to mitigate anxiety and enhance mental health resilience.

AI-Driven Smart Auditory Health Systems: Bridging Audiology and Public Health in Low- and Middle-Income Countries

Hearing loss is a critical global health issue that affects over 1.5 billion people worldwide, with a disproportionate burden in Low- and Middle-Income Countries (LMICs). These regions face significant challenges, including limited access to audiological services, a shortage of healthcare professionals, and a lack of affordable hearing solutions. These barriers lead to delayed diagnoses, inadequate management, and a significant negative impact on individuals' quality of life, education, and employment opportunities. The advent of Artificial Intelligence (AI) and advanced technologies offers innovative pathways to address these longstanding challenges. This review introduces the AI-driven smart Auditory Health Systems (SAHS) concept. This holistic approach integrates AI, wearable devices, Internet of Things (IoT) technology, and big data analytics to enhance the prevention, diagnosis, and management of auditory disorders. SAHS systems can provide real-time monitoring, early detection of hearing loss, and personalized care solutions tailored to individual and population needs. These systems offer community-level interventions, including noise pollution monitoring and data-driven public health strategies. Focusing on the LMIC context, this review explores the technological framework, applications, ethical considerations, and logistical challenges of implementing SAHS. By leveraging these advanced technologies, SAHS has the potential to bridge gaps in healthcare access, improve health outcomes, and transform auditory healthcare delivery in resource-constrained settings. This review underscores the importance of collaborative efforts in research, policy development, and capacity building to ensure equitable adoption of SAHS, thereby addressing hearing health disparities globally.

Engaging stakeholders in Non-communicable diseases (NCDs) Implementation Research in low- and middle-income countries (LMICs): a scoping review protocol

IntroductionNon-communicable diseases (NCDs) present a significant health challenge globally, especially in low- and middle-income countries (LMICs). Effective Implementation Research (IR) is vital in addressing this challenge, with stakeholder engagement playing...

Co-designing digital mental health interventions with young people: 10 recommendations from lessons learned in low-and-middle-income countries

Background: Youth-focused co-design, involving active collaboration between researchers, designers, clinicians and end users, is essential for enhancing the acceptability, feasibility and effectiveness of digital mental health interventions (DMHIs). However, most literature on co-design comes from high-income countries and offers limited contextually relevant guidance to programme and intervention developers in low- and middle-income countries (LMICs). Aims: This paper presents 10 recommendations drawn from the co-authors’ experiences of co-designing youth-focused DMHIs as researchers, public engagement specialists and youth advisors. Methods: The recommendations emphasise key aspects of the co-design process including the use of conceptual frameworks, the involvement of diverse youth groups, contextual considerations, and the promotion of young people’s safety and well-being. Results: The recommendations highlight strategies and examples for involving young people, the importance of acknowledging young people’s contributions and evaluating experiences of co-design to improve the overall effectiveness and relevance of DMHIs in LMICs. Conclusion: By implementing these recommendations, DMHI developers can foster more effective and inclusive co-design processes that better meet the needs of young people in LMIC contexts.

Inadequate foundational decoding skills constrain global literacy goals for pupils in low- and middle-income countries.

Learning to read is the most important outcome of primary education. However, despite substantial improvements in primary school enrolment, most students in low- and middle-income countries (LMICs) fail to learn to read by age 10. We report reading assessment data from over half a million pupils from 48 LMICs tested primarily in a language of instruction and show that these pupils are failing to acquire the most basic skills that contribute to reading comprehension. Pupils in LMICs across the first three instructional years are not acquiring the ability to decode printed words fluently and, in most cases, are failing to master the names and sounds associated with letters. Moreover, performance gaps against benchmarks widen with each instructional year. Literacy goals in LMICs will be reached only by ensuring focus on decoding skills in early-grade readers. Effective literacy instruction will require rigorous systematic phonics programmes and assessments suitable for LMIC contexts.

A critical review of literature and a conceptual framework for organising and researching urban health and community health services in low- and middle-income countries.

Low- and middle-income countries (LMIC) are rapidly urbanizing, and in response to this, there is an expansion in the body of scholarship and significant policy interest in urban healthcare provision. The idea and the reality of 'urban advantage' has meant that health research in low- and middle-income countries (LMICs) has disproportionately focused on health and healthcare provision in rural contexts and is yet to sufficiently engage with urban health as actively. We contend that this research and practice can benefit from a more explicit engagement with the rich conceptual understandings that have emerged in other disciplines around the urban condition. Our critical review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We draw upon scholarship anchored in sociology to unpack the nature and features of the urban condition; we use these theoretical insights to critically review the literature on urban community health worker programs, as a case to reflect on community health practice and urban health research in LMIC contexts. Through this analysis, we delineate key features of the urban - such as heterogeneity, secondary spaces and ties, size and density, visibility and anonymity, precarious work and living conditions, crime, and insecurity, and specifically the social location of the urban CHWs and present their implications for community health practice. We propose a conceptual framework for a distinct imagination of the urban to guide health research and practice in urban health and community health programs in the LMIC context. The framework will enable researchers and practitioners to better engage with what entails a 'community' and a 'community health program' in urban contexts.

Lost in translation: key lessons from conducting dissemination and implementation science in Zambia

BackgroundAs the field of implementation science continues to grow, its key concepts are being transferred into new contexts globally, such as Low and Middle Income Countries (LMICs), and its use is constantly being reexamined and expanded. Theoretical and methodological positions commonly used in implementation research and practice have great utility in our work but in many cases are at odds with LMIC contexts. As a team of implementation scientists based in Zambia, we offer this commentary as a critical self-reflection on what has worked and what could limit us from fully utilizing the field’s promise for addressing health problems with contextual understanding.Main bodyWe used a ‘premortem,’ an approach used to generate potential alternatives from failed assumptions about a particular phenomenon, as a way to reflect on our experiences conducting implementation research and practice. By utilizing prospectively imagined hindsights, we were able to reflect on the past, present and possible future of the field in Zambia. Six key challenges identified were: (i) epistemic injustices; (ii) simplified conceptualizations of evidence-informed interventions; (iii) limited theorization of the complexity of low-resource contexts and it impacts on implementation; (iv) persistent lags in transforming research into practice; (v) limited focus on strategic dissemination of implementation science knowledge and (vi) existing training and capacity building initiatives’ failure to engage a broad range of actors including practitioners through diverse learning models.ConclusionImplementation science offers great promise in addressing many health problems in Zambia. Through this commentary, we hope to spur discussions on how implementation scientists can reimagine the future of the field by contemplating on lessons from our experiences in LMIC settings.

The impact of the first phase of the COVID-19 pandemic on referral patterns and therapeutic service provision for children and young people's psychosocial distress in a Low-or Middle-Income Country: A service evaluation of routinely collected data from a non-government organisation operating in schools in the Western Cape, South Africa.

In low- and middle-income countries (LMICs), including South Africa, there is a paucity of psychosocial support services. Therefore, services are often provided in schools by non-government organisations like Community Keepers (CK). The COVID-19 pandemic and resultant restrictions meant that children and young people's (CYP) lives changed, negatively affecting their mental health. Further, organisations like CK had to change their working processes. This project compared routinely collected data from CK from 2019 (pre-pandemic) to 2020 (pandemic) to describe the changes that occurred in referral patterns to, and service provision by, CK. Both pre-pandemic and during the pandemic, most referrals of CYP were for emotional/psychological support and behavioural difficulties. In 2020, referrals for general guidance increased, whilst referrals for peer group issues and sexuality decreased. Further, CK completed more brief check-ins, provided wellbeing workshops to increased numbers of teachers, parents and CYP, and had more consultation sessions with other service providers during the pandemic. Routinely collected data from this community-based service in a LMIC context shows differences in the way that support was provided, and to whom, during the COVID-19 pandemic. Clinical implications, including the importance of increasing access to psychosocial support via technology, are included.

Rural-urban Migration and Overweight Status in Low- and Middle-income Countries: Evidence from Longitudinal Data in Indonesia

With rapid urbanization and intensive rural-urban migration, being overweight has become an increasingly common source of health risks in low- and middle-income countries (LMICs). However, the impact of rural-urban migration on overweight status is understudied in the LMIC context. Previous studies primarily used cross-sectional data, failing to adjust for migration health selection. Furthermore, the potential gender pattern in the impact of rural-urban migration remained unclear, and the potential cumulative effect of the duration of urban residence among migrants was rarely examined with longitudinal data. Meanwhile, the mediating effects of health behavioral factors were poorly understood. Using data from the fourth and fifth waves of the Indonesia Family Life Survey (IFLS) and employing fixed-effects (FE) models (N=7267), this study provided new evidence on the impact of rural-urban migration on overweight status across time and gender. Findings suggest that rural-urban migration significantly and positively predicted being overweight, and the association was significantly stronger among women than men. The results also show that years lived in urban areas did not significantly predict overweight among migrants, and that mediating health-related behaviors did little to explain adverse weight outcomes of migrants. As the number of rural-urban migrants continues growing, LMIC governments should implement health interventions aiming for healthy weight status among migrant communities. Meanwhile, gender-specific programs targeting women should be considered. Future research should explore other potential mediators of the link between rural-urban migration and overweight.

Early Family Experiences and Neural Activity in Rural Pakistani Children: The Differential Role of Gender.

Adversity within low- and middle-income countries (LMICs) poses severe threats to neurocognitive development, which can be partially mitigated by high-quality early family experiences. Specifically, maternal scaffolding and home stimulation can buffer cognitive development in LMIC, possibly by protecting underlying neural functioning. However, the association between family experiences and neural activity remains largely unexplored in LMIC contexts. This study explored the relation of early family experiences to later cognitive skills and absolute gamma power (21-45 Hz), a neural marker linked to higher-order cognitive skills. Drawing data from the PEDS trial, a longitudinal study in rural Pakistan, we examined maternal scaffolding at 24 months and home stimulation quality at 18 months as predictors of verbal IQ, executive functions, and absolute gamma at 48 months for 105 mother-child dyads (52 girls). Maternal scaffolding interacted with gender to predict absolute gamma power, such that higher maternal scaffolding was related to higher gamma more strongly for girls. Maternal scaffolding also interacted with absolute gamma to predict executive functions, such that higher gamma was related to better executive functions only when maternal scaffolding was average to high. Individual differences in early family experiences may partially buffer the neural underpinnings of cognitive skills from adversity in LMIC.

Core outcome sets for trials of interventions to prevent and to treat multimorbidity in adults in low and middle-income countries: the COSMOS study

IntroductionThe burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. Core outcome sets (COS) appropriate for...

Effects of Two Early Parenting Programmes on Child Aggression and Risk for Violence in Brazil: a Randomised Controlled Trial

Violence is a major public health problem globally, with the highest rates in low- and middle-income countries (LMICs) in the Americas and southern Africa. Parenting programmes in high-income countries can diminish risk for violence, by reducing risk factors such as child aggression and harsh parenting, and increasing protective factors such as child cognitive development and school readiness. However, there is critical need to identify low-cost programmes with replicable benefits that work in real-world LMICs contexts. A three-arm, randomised, single-blind trial evaluated effects of two low-cost, group-based parenting programmes recommended for LMICs (ACT: Raising Safe Kids; DBS: dialogic book-sharing) on child aggression (primary outcome), child development, parenting, maltreatment, and stress. Participants were 369 children with medium–high levels of aggression (mean age 3.1 years at baseline) in poor households. Interventions were implemented in city health and education services in southern Brazil. Maternal reports, filmed observations, child tasks, and hair cortisol were assessed at baseline, 1-month post-intervention, and 8-month follow-up. Intention-to-treat analyses compared each of ACT and DBS with a control group. Three hundred sixty-eight (99.7%) participants completed follow-up assessments 8 months after the interventions. There was no effect of ACT (standardised mean difference, SMD 0.11, 95% CI − 0.05, 0.27) or DBS (SMD 0.05, 95% CI − 0.11, 0.21) on the primary outcome of child aggression. ACT reduced harsh parenting behaviour post-intervention (SMD − 0.23; 95% CI − 0.46, − 0.01), but not at follow-up. DBS improved book-sharing practices at both time points (e.g., maternal sensitivity at follow-up SMD 0.33; 95% CI 0.08, 0.57). There were no benefits of either programme for other parenting, child development, or stress outcomes. Two parenting programmes in Brazil had small effects on parenting practices but did not reduce child aggression or several other important risk/protective factors for violence. Effective early interventions that reduce violence in real-world LMIC settings are highly desirable but may be challenging to achieve.

Adaptation of complex interventions for people with long-term conditions: a scoping review.

Adaptation seeks to transfer and implement healthcare interventions developed and evaluated in one context to another. The aim of this scoping review was to understand current approaches to the adaptation of complex interventions for people with long-term conditions (LTCs) and to identify issues for studies performed in low- and middle-income countries (LMICs). Bibliographic databases were searched from 2000 to October 2022. This review involved five stages: (i) definition of the research question(s); (ii) identifying relevant studies; (iii) study selection; (iv) data charting; and (v) data synthesis. Extraction included an assessment of the: rationale for adaptation; stages and levels of adaptation; use of theoretical frameworks, and quality of reporting using a checklist based on the 2021 ADAPT guidance. Twenty-five studies were included from across 21 LTCs and a range of complex interventions. The majority (16 studies) focused on macro (national or international) level interventions. The rationale for adaptation included intervention transfer across geographical settings [high-income country (HIC) to LMIC: six studies, one HIC to another: eight studies, one LMIC to another: two studies], or transfer across socio-economic/racial groups (five studies), or transfer between different health settings within a single country (one study). Overall, studies were judged to be of moderate reporting quality (median score 23, maximum 46), and typically focused on early stages of adaptation (identification and development) with limited outcome evaluation or implementation assessment of the adapted version of the intervention. Improved reporting of the adaptation for complex interventions targeted at LTCs is needed. Development of future adaptation methods guidance needs to consider the needs and priorities of the LMIC context.

Neonatal Physical Growth Predicts Electroencephalography Power in Rural South African Children.

Anthropometric measures at birth, indexing prenatal growth, are associated with later cognitive development. Children in low- and middle-income countries (LMIC) are at elevated risk for impaired prenatal and early postnatal growth and enduring cognitive deficits. However, the associations of neonatal physical growth with neural activity are not well-characterized in LMIC contexts, given the dearth of early childhood neuroimaging research in these settings. The current study examined birth length, weight, and head circumference as predictors of EEG relative power over the first three years of life in rural Limpopo Province, South Africa, controlling for postnatal growth and socioeconomic status (SES). A larger head circumference at birth predicted lower relative gamma power, lower right hemisphere relative beta power, and higher relative alpha and theta power. A greater birth length also predicted lower relative gamma power. There were interactions with timepoints such that the associations of birth head circumference and length with EEG power were most pronounced at the 7-month assessment and were attenuated at the 17- and 36-month assessments. The results identify birth head circumference and length as specific predictors of infant neural activity within an under-resourced context.

Barriers and benefits of mHealth for community health workers in integrated community case management of childhood diseases in Banda Parish, Kampala, Uganda: a cross-sectional study

BackgroundLow-quality data presents a significant challenge for community health workers (CHWs) in low and middle-income countries (LMICs). Mobile health (mHealth) applications offer a solution by enabling CHWs to record and submit data electronically. However, the barriers and benefits of mHealth usage among CHWs in informal urban settlements remain poorly understood. This study sought to determine the barriers and benefits of mHealth among CHWs in Banda parish, Kampala.MethodsThis qualitative study involved 12 key informant interviews (KIIs) among focal persons from Kampala City Council Authority (KCCA) and NGOs involved in data collected by CHWs, and officials from the Ministry of Health (MOH) and two mixed-sex Focused Group Discussions (FGDs) of CHWs from Banda parish, Kampala district. Data analysis utilised Atlas Ti Version 7.5.7. Thematic analysis was conducted, and themes were aligned with the social-ecological model.ResultsThree themes of institutional and policy, community and interpersonal, and individual aligning to the Social ecological model highlighted the factors contributing to barriers and the benefits of mHealth among CHWs for iCCM. The key barriers to usability, acceptability and sustainability included high training costs, CHW demotivation, infrastructure limitations, data security concerns, community awareness deficits, and skill deficiencies. Conversely, mHealth offers benefits such as timely data submission, enhanced data quality, geo-mapping capabilities, improved CHW performance monitoring, community health surveillance, cost-effective reporting, and CHW empowering with technology.ConclusionDespite limited mHealth experience, CHWs expressed enthusiasm for its potential. Implementation was viewed as a solution to multiple challenges, facilitating access to health information, efficient data reporting, and administrative processes, particularly in resource-constrained settings. Successful mHealth implementation requires addressing CHWs’ demotivation, ensuring reliable power and network connectivity, and enhancing capacity for digital data ethics and management. By overcoming these barriers, mHealth can significantly enhance healthcare delivery at the community level, leveraging technology to optimize resource utilization and improve health outcomes. mHealth holds promise for transforming CHW practices, yet its effective integration necessitates targeted interventions to address systemic challenges and ensure sustainable implementation in LMIC contexts.

Implementing and evaluating group interpersonal therapy for postnatal depression in Lebanon and Kenya—individually randomised superiority trial

BackgroundDepression ranks as the foremost mental health concern among childbearing women. Within low- and middle-income countries (LMICs), between 20 and 25% of women encounter depression during pregnancy or soon after delivery. This condition impacts not only the mothers but also their offspring. Offspring of women suffering from postnatal depression (PND) exhibit suboptimal cognitive development and increased emotional and behavioural issues throughout their growth. This scenario becomes more pronounced in LMICs, where numerous adversities further jeopardise children’s developmental progress. Despite antenatal services providing a pivotal platform to address women’s mental health needs, PND treatment remains inaccessible in many LMICs. The World Health Organization advocates interpersonal psychotherapy (IPT) for treating depression. While research from high-income countries has established the efficacy of IPT and group-IPT (g-IPT) for PND, its effectiveness within the LMIC context and its potential benefits for child development remain uncharted. This study seeks to gauge the potency of g-IPT for women with PND in two LMICs.MethodsThis multi-site randomised controlled trial is a continuation of two preceding phases—conceptual mapping and a feasibility study executed in Lebanon and Kenya. Insights gleaned from these phases underpin this comprehensive RCT, which contrasts the efficacy and cost-effectiveness of high-quality standard care (HQ-SC) augmented with g-IPT against HQ-SC in isolation. The trial, characterised as an individually randomised superiority assessment, targets women with postnatal depression in Beirut, Lebanon, and Nairobi, Kenya. It aims to determine if culturally tailored g-IPT, administered within community settings in both countries, outperforms HQ-SC in influencing child developmental outcomes, maternal depression, and the quality of the mother–child bond.DiscussionThe SUMMIT trial, designed with pragmatism, possesses the magnitude to evaluate g-IPT within two LMIC frameworks. It seeks to enlighten policymakers, service commissioners, professionals, and users about g-IPT’s potential to alleviate maternal PND and bolster child developmental outcomes in LMICs. Additionally, the trial will generate valuable data on the clinical and economic merits of high-quality standard care.Trial registrationISRCTN, ISRCTN15154316. Registered on 27 September 2023, https://doi.org/10.1186/ISRCTN15154316

Consensus guidelines for the management of intracranial metastases for low- and middle-income countries.

Metastatic tumours are among the most common types of brain tumours. However, in low- and middle-income countries (LMICs), the numbers are considerably lower. This does not necessarily indicate a decreased incidence but rather points to decreased survival rates or limited access to healthcare. The challenge of achieving better outcomes, along with associated costs and resource constraints, often hinders the effective management of brain metastasis. Even in cases where localised disease can potentially be managed to improve survival, these challenges persist. The purpose of these guidelines is to address these challenges and outline a management strategy within the context of LMICs.

A framework to link climate change, food security, and migration: unpacking the agricultural pathway

Researchers have long hypothesized linkages between climate change, food security, and migration in low- and middle-income countries (LMICs). One such hypothesis is the “agricultural pathway,” which postulates that negative climate change impacts on food production harm livelihoods, which triggers rural out-migration, internally or abroad. Migration is thus an adaptation to cope with the impacts of climate change and bolster livelihoods. Recent evidence suggests that the agriculture pathway is a plausible mechanism to explain climate-related migration. But direct causal connections from climate impacts on food production to livelihood loss to rural out-migration have yet to be fully established. To guide future research on the climate-food-migration nexus, we present a conceptual framework that outlines the components and linkages underpinning the agricultural pathway in LMICs. We build on established environmental-migration conceptual frameworks that have informed empirical research and deepened our understanding of complex human-environmental systems. First, we provide an overview of the conceptual framework and its connection to the agricultural pathway hypothesis in the climate mobility literature. We then outline the primary components and linkages of the conceptual framework as they pertain to LMIC contexts, highlighting current research gaps and challenges relating to the agricultural pathway. Last, we discuss possible future research directions for the climate-food-migration nexus. By highlighting the complex, multiscale, interconnected linkages that underpin the agricultural pathway, our framework unpacks the multiple causal connections that currently lie hidden in the agricultural pathway hypothesis.

Preventing and Treating Pain and Anxiety during Needle-Based Procedures in Children with Cancer in Low- and Middle-Income Countries.

Introduction: Children with cancer experience significant pain and anxiety during needle-based procedures. Undertreated pain in children has long-lasting consequences and reduces the efficacy of subsequent analgesic efforts. A validated quality improvement (QI) intervention, known as the "Children's Comfort Promise", includes (1) topical anesthetics, (2) sucrose or breastfeeding for infants, (3) comfort positioning, and (4) distraction techniques, and has been shown to be highly effective in decreasing procedural pain and anxiety in children. However, there is limited data about the adoption, adaptation, and implementation of these interventions in low- and middle-income countries (LMICs). Methods: A QI pilot project utilizing the Model for Improvement of the "Global Comfort Promise" was implemented in four global pediatric cancer hospitals (Lima, Peru; Barretos, Brazil; Pietermaritzburg, South Africa; and Manila, Philippines). Between August 2021 and January 2023, the pilot sites identified a specific aim, co-designed the measurement strategy with St. Jude Children's Research Hospital, and adopted, adapted, and implemented the project at their individual sites. Results: A total of 2,185 different procedures were recorded in the first year of implementation. Most patients were less than 10 years old (60.5%) and solid tumors (37.9%) were the most common diagnosis. Overall, healthcare professionals (98.3%) were satisfied with the procedures. Parents and patients reported that only 33.7% of patients experienced pain during the procedure. All (100%) parents and patients felt the healthcare teams adequately addressed their child's pain. Median self-reported adherence to ≥2 interventions was 98.0%. Challenges to the implementation of the QI initiative included lack of training, turnover of the medical staff, maintaining staff enthusiasm, and access to topical anesthetics. Each site had unique change ideas to implement the initiative. Conclusions: This multi-site, multi-country QI initiative was feasible and was successfully adopted, adapted, and implemented in the LMIC context to improve procedural pain in children (Global Comfort Promise). Additionally, this intervention resulted in high satisfaction of both healthcare professionals and patients/families. Further work is needed to overcome the challenges of topical anesthetic access and education of the workforce. Additional plans include modifying the Global Comfort Promise to include high-quality communication and expanding to additional sites with further refinement of the implementation strategy.