Low- And Middle-income Countries Context Research Articles

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.

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...

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.

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.

What Is the Likely Impact of Alternative Proteins on Diet Quality, Health, and the Environment in Low- and Middle-Income Countries

Alternative protein (AP) foods are proposed to support a global protein transition. Whereas AP food innovation has been a strategy to promote consumption of protein sources with low environmental impact in high-income countries (HICs) diets, their relation to sustainable, high-quality diets in low- and middle-income countries (LMICs) remains to be established. AP foods vary in nutrient profile, processing requirements, costs, and environmental impact. Current literature regarding AP suitability in LMIC contexts is limited. This perspective examined environmental and nutritional metrics that can assess the sustainability of AP in LMICs. Current research areas needed to accurately assess environmental impacts while considering nutritional density were identified. An overview of the usability of relevant AP in both high- and low-resource settings was also explored. Metrics addressing diverse contextual synergies in LMICs, unifying nutritional, environmental, and socioeconomic considerations, were found necessary to guide the integration of AP into LMIC diets.

Implementation of Universal Design for Learning in Low- and Middle-Income Countries: ‘I Thought These Principles Could Have Been Written by Me’

UNESCO’s Global Education Monitoring Report (2020) strongly recommends the adoption of Universal Design for Learning (UDL) at the government level so that it becomes an integral part of countries’ inclusive education policies. However, UDL has largely been developed in high-income countries with technology as a central theme. The question is whether the purported benefits of the UDL approach can translate into low and middle-income country (LMIC) contexts. This study explores the relevance and fit of UDL to LMIC contexts by use of interviews (either individual or group) with 12 representatives of international agencies, non-governmental organizations (NGOs), and UDL experts who have experience in providing inclusive education services in LMICs. Three themes are reported: understanding of UDL, UDL supporting inclusive education, and UDL in teacher-training initiatives and capacity building. The concept of UDL is not new in LMICs, although the name may be. The potential for UDL to support inclusive education in LMICs is recognized. UDL needs to be mainstreamed in teacher training programs, and its implementation should be adapted to respond to the contextual realities of LMICs. The encounter between UDL proponents from high-income countries and education stakeholders in LMICs should be mutually enriching rather than imposing the approach from high-income countries on those in LMICs.

Developing an infection prevention and control intervention to reduce hospital-acquired infections in Cambodia and Lao People's Democratic Republic: the HAI-PC study protocol.

Hospital-acquired infections (HAIs) are significant public health issues, especially in low-and middle-income countries (LMICs). Hand hygiene and low-level disinfection of equipment practices among healthcare workers are some of the essential measures to reduce HAIs. Various infection prevention and control (IPC) interventions to reduce HAI incidence have been developed. However, effective interventions have not been well developed in the LMICs context. Therefore, this protocol aims to develop, pilot, and assess the feasibility and acceptability of an IPC intervention in Cambodia and the Lao People's Democratic Republic. This study will consist of four phases guided by the Medical Research Council (MRC) Framework. Three hospitals will be purposely selected - each from the district, provincial, and national levels - in each country. The gap analysis will be conducted in Phase 1 to explore IPC practices among healthcare workers at each hospital through desk reviews, direct observation of hand hygiene and low-level disinfection of equipment practices, in-depth interviews with healthcare workers, and key informant interviews with stakeholders. In Phase 2, an IPC intervention will be developed based on the results of Phase 1 and interventions selected from a systematic literature review of IPC interventions in LMICs. In Phase 3, the developed intervention will be piloted in the hospitals chosen in Phase 1. In Phase 4, the feasibility and acceptability of the developed intervention will be assessed among healthcare workers and representatives at the selected hospitals. National consultative workshops in both countries will be conducted to validate the developed intervention with the national technical working groups. The MRC Framework will be employed to develop and evaluate an intervention to reduce HAIs in two LMICs. This theoretical framework will be used to explore the factors influencing hand hygiene compliance among healthcare workers. The gap analysis results will allow us to develop a comprehensive IPC intervention to reduce HAI incidence in Cambodia and Lao People's Democratic Republic. Findings from this protocol will feed into promising IPC interventions to reduce HAI incidence in other resource-limited settings. ClinicalTrial.Gov, identifier NCT05547373.

Implementing text-messaging to support and enhance delivery of health behavior change interventions in low- to middle-income countries: case study of the Lifestyle Africa intervention

The prevalence of non-communicable diseases, such as diabetes and cardiovascular disease, is rising in low- and middle-income countries (LMICs). Health behavior change (HBC) interventions such as the widely used Diabetes Prevention Program (DPP) are effective at reducing chronic disease risk, but have not been adapted for LMICs. Leveraging mobile health (mHealth) technology such as text messaging (SMS) to enhance reach and participant engagement with these interventions has great promise, yet we lack evidence-informed approaches to guide the integration of SMS specifically to support HBC interventions in LMIC contexts. To address this gap, we integrated guidance from the mHealth literature with expertise and first-hand experience to establish specific development steps for building and implementing SMS systems to support HBC programming in LMICs. Specifically, we provide real-world examples of each development step by describing our experience in designing and delivering an SMS system to support a culturally-adapted DPP designed for delivery in South Africa. We outline eight key SMS development steps, including: 1) determining if SMS is appropriate; 2) developing system architecture and programming; 3) developing theory-based messages; 4) developing SMS technology; 5) addressing international SMS delivery; 6) testing; 7) system training and technical support; and 8) cost considerations. We discuss lessons learned and extractable principles that may be of use to other mHealth and HBC researchers working in similar LMIC contexts.Trial registration Clinicaltrials.gov, NCT03342274. Registered 10 November 2017.

Consensus study on factors influencing the academic entrepreneur in a middle-income country’s university enterprise

PurposeThis study aims to ascertain the personal characteristics of a group of successful academic entrepreneurs in a South African university enterprise and the prevalent barriers and enablers to their entrepreneurial endeavour.Design/methodology/approachThe authors used a Delphi process to identify and rank the characteristics, enablers, barriers and behaviours of entrepreneurial academics, with a Nominal Group Technique applied to establish challenges they encounter managing their enterprise and to propose solutions.FindingsPerseverance, resilience and innovation are critical personal characteristics, while collaborative networks, efficient research infrastructure and established research competence are essential for success. The university’s support for entrepreneurship is a significant enabler, with unnecessary bureaucracy and poor access to project and general enterprise funding an impediment. Successful academic entrepreneurs have strong leadership, and effective management and communication skills.Research limitations/implicationsThe main limitation is the small study participant group drawn from a single university enterprise, which complicates generalisability. The study supported the use of Krueger’s (2009) entrepreneurial intentions model for low- and middle-income country (LMIC) academic entrepreneur investigation but proposed the inclusion of mitigators to entrepreneurial activation to recognise contextual deficiencies and challenges.Practical implicationsSkills-deficient LMIC universities should extensively and directly support their entrepreneurial academics to overcome their contextual deficiencies and challenging environment.Originality/valueThis study contributes to addressing the paucity of academic entrepreneur research in LMIC contexts by identifying LMIC-specific factors that inhibit the entrepreneur’s movement from entrepreneurial intention to entrepreneurial action.

COVID-19 and adolescent girls’ mental health in Uganda: A panel data analysis

The COVID-19 pandemic and associated mitigating measures are expected to aggravate the mental health challenges of adolescents. Poor mental health among young people is of concern in itself but is also known to affect long-term outcomes. Given the global burden of the pandemic, it is particularly concerning that limited empirical evidence currently exists for young women, especially in low- and middle-income countries (LMICs), where the pandemic serves as an additional psychosocial stressor for the already challenging lives that most young women in low-resource contexts experience. This article adds to the existing evidence base by drawing on 3 rounds of panel data (2019–2021) to assess changes in adolescent mental health among 468 young women aged 13–19 years residing in rural to semi-urban villages in Uganda before and during the pandemic. Using fixed effects models, we find increases in symptoms of moderate-to-severe depression as measured by both the Patient Health Questionnaire-8 during the pandemic and accompanying lockdown measures. We also find that adolescent girls who faced a higher COVID-19 burden exhibit stronger declines in mental health. Our findings shed light on the impacts of the pandemic on young women’s mental health in an LMIC context, and suggest the need for age-, gender-, and vulnerability-targeted policies that ensure that the pandemic does not undo current progress toward a more gender equitable world.

Plastic Venture Builder (PVB): An empirically derived assessment tool to support plastic waste management ventures in low- and middle-income countries.

Plastic waste management is a complicated challenge that in recent years has gained attention as a global policy priority. In low- and middle-income countries (LMIC), waste management is heterogeneous and context-specific and many organizations provide needed waste management services, including entrepreneurs. Sustainable entrepreneurs are uniquely positioned to provide these services; however, they face challenges such as limited support system and lack of capacity. The goal of this paper is to understand critical characteristics of successful plastic waste management ventures in LMIC and operationalize those insights into a strategic tool. A wide variety of successful ventures from diverse LMIC contexts are systematically analyzed to identify which factors contribute to their business viability and ability to deliver services. The identified success factors were built into a tool, the Plastic Venture Builder (PVB), based on the multi-criteria analysis methodology. This is validated using empirical cases, tested on projects currently in development and discussed with experts in the field. The results show that political, economic, financial, technological, operational, social, team and legal factors contribute to success; however pathways to success are diverse. We identify a strong team as the most critical factor, whereas financial, political and social factors have the least impact. The PVB can be used by entrepreneurs who want to set up or improve plastic waste management ventures by identifying weak spots or avenues for improvement. The assessment framework can also be used by policy makers, development agencies and financing organizations who want to support or assess waste management initiatives by prioritizing their resources to match the identified critical factors.

The Aga Khan Development Network’s (AKDN) approach to supply chain carbon foot printing for healthcare providers

Very few examples of footprints exist for lower-middle-income countries and none for low-income countries. Where footprints do exist, they suggest that healthcare in LMICs is more carbon intensive per unit of expenditure than in high-income or upper-middle-income countries. At the same time, delivery of global commitments on Universal Health Coverage implies that healthcare provision in low and middle-income countries (LMICs) must grow more rapidly than anywhere else in the word.There has been little or no access to appropriate, comprehensive but affordable support to enable operations in LMICs to calculate full Scope 1,2 and 3 footprints. Without this it has been challenging for operations in LMICs to effectively target actions to reduce their emissions.With this in mind this paper sets out to demonstrate an approach to carbon foot printing healthcare in LMICs that is sufficiently robust to support targeted action, while using tools, resources and data that are freely accessible in all countries.This paper describes and discusses a 4-tiered ‘hybrid’ approach, developed using the international Greenhouse Gas Protocol. The approach was used successfully by staff to generate carbon footprints for healthcare organisations in 8 LMICs in South and Central Asia and East Africa. The organisations covered all fall within the Aga Khan Development Network (AKDN); specifically, the Aga Khan Health Services (AKHS) and the Aga Khan Universities (AKU)The principles discussed in this paper, have been used to build a comprehensive carbon management tool in Microsoft Excel. The use of the approach and the tool has enabled AKDN healthcare providers to effectively, baseline, target and structure their carbon reduction activity.This work has had to pragmatically balance accuracy with deliverability in an LMIC context. While footprinting for Scope 1 and 2 has followed standard protocols, proxy data has been used to generate high level supply chain footprints, this has then been refined with data from suppliers.The tool and its accompanying guide are published and available, free to use, from AKDN to support other healthcare organisations in footprinting and reducing their own carbon emissions.

A Scoping Review of Footwear Worn by People With Diabetes in Low- and Middle-Income Countries: Implications for Ulcer Prevention Programs.

International guidelines advise people with diabetes to wear close-toed, thick-soled footwear to protect against foot ulceration. However, this type of footwear is incompatible with some of the cultures, climates, and socioeconomic conditions in many low- and middle-income countries (LMICs). This scoping review aims to summarize what is known about footwear used by people with diabetes in LMICs and consider whether international diabetic foot guidelines are practical and actionable in these contexts, given current practices. PubMed, CINAHL, Scopus, Embase, Web of Science, Latin American and Caribbean Health Sciences Literature, and African Journals Online were searched for articles that documented the footwear used by people with diabetes in LMICs. Twenty-five studies from 13 countries were eligible for inclusion and indicated that a large proportion of people with diabetes wear footwear that is considered inappropriate by current guidance, with sandals and flip-flops being popular choices in a majority of the studies. Reasons given for these choices include poverty, lack of awareness of and provider communication about the importance of footwear selection, comfort, and cultural norms. We recommend that LMIC health care systems relying on international guidelines critically consider whether their recommendations are sensible in their settings. Diabetic foot experts and LMIC-based health care stakeholders should collaborate to design alternative guidelines, strategies, and interventions specifically for LMIC contexts to increase preventative practice feasibility and uptake.