Low- And Middle-income Countries Settings Research Articles

Diagnostic accuracy of digital technologies compared with 12-lead ECG in the diagnosis of atrial fibrillation in adults: A protocol for a systematic review.

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in the world. AF increases the risk of stroke 5-fold, though the risk can be reduced with appropriate treatment. Therefore, early diagnosis is imperative but remains a global challenge. In low-and middle-income countries (LMICs), a lack of diagnostic equipment and under-resourced healthcare systems generate further barriers. The rapid development of digital technologies that are capable of diagnosing AF remotely and cost-effectively could prove beneficial for LMICs. However, evidence is lacking on what digital technologies exist and how they compare in regards to diagnostic accuracy. We aim to systematically review the diagnostic accuracy of all digital technologies capable of AF diagnosis. MEDLINE, Embase and Web of Science will be searched for eligible studies. Free text terms will be combined with corresponding index terms where available and searches will not be limited by language nor time of publication. Cohort or cross-sectional studies comprising adult (≥18 years) participants will be included. Only studies that use a 12-lead ECG as the reference test (comparator) and report outcomes of sensitivity, specificity, the diagnostic odds ratio (DOR) or the positive and negative predictive value (PPV and NPV) will be included (or if they provide sufficient data to calculate these outcomes). Two reviewers will independently assess articles for inclusion, extract data using a piloted tool and assess risk of bias using the QUADAS-2 tool. The feasibility of a meta-analysis will be determined by assessing heterogeneity across the studies, grouped by index device, diagnostic threshold and setting. If a meta-analysis is feasible for any index device, pooled sensitivity and specificity will be calculated using a random effect model and presented in forest plots. The findings of our review will provide a comprehensive synthesis of the diagnostic accuracy of available digital technologies capable for diagnosing AF. Thus, this review will aid in the identification of which devices could be further trialed and implemented, particularly in a LMIC setting, to improve the early diagnosis of AF. Systematic review registration: PROSPERO registration number is CRD42021290542. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021290542.

Advanced Practice Pediatric Oncology Nursing as Imagined or In Place in Four Lower- and Upper-Middle-Income Countries

The implementation of pediatric oncology advanced practice nurse (s) roles in low- and middle-income countries (LMICs) presents opportunities and challenges. The authors explore the implications of pediatric oncology advanced practice nursing roles in Pakistan, Cameroon, Turkey, and Mexico. Potential benefits and drawbacks of advanced practice nursing roles, impacts on nursing care, and strategies for advanced practice nursing role development in LMIC settings are considered. Information from scholarly articles, policy documents, and four LMIC pediatric oncology nurse expert perspectives on existing and imagined advanced practice nursing roles in pediatric oncology in LMIC were synthesized. Current literature and policies point to efforts across LMICs to establish a wide variety of advanced nursing practices, not necessarily aligned with internationally accepted advanced practice nursing standards of practice or education. The LMIC nurses describe a wide range of national general nurse education and government advanced practice nurse recognition/licensing. Challenges to achieving or strengthening advanced practice nursing roles include, for example, healthcare professional resistance, government unwillingness to recognize/license advanced practice nurses, and lack of advanced practice nursing faculty. To promote a pediatric oncology advanced practice nursing role in LMICs requires navigating the national nursing scope of practice and nursing culture. The strategic introduction of pediatric oncology advanced practice nursing roles in LMICs has the potential to significantly enhance patient care by, for example, addressing healthcare workforce shortages and facilitating timely care delivery. However, challenges related to role complexity, resistance from traditional healthcare structures, and role overlap must be considered. Tailoring these roles to local contexts and fostering stakeholder collaboration are essential for successful implementation. The adoption of advanced practice nursing roles can lead to improved quality of care for pediatric oncology patients and their families in LMICs, where cancer care is challenging. The positive impact of pediatric oncology advanced practice nurses on patient outcomes and healthcare delivery cannot be discounted but must align with local nursing and healthcare culture and expectations.

Do WHO criteria for gestational diabetes fit a rural population in Tanzania? – A follow-up study assessing mother and child health six years after a pregnancy diagnosed with gestational diabetes

Aims and MethodsIn low- and middle- income countries (LMICs) consequences of gestational diabetes (GDM) is understudied. Using a prospective cohort of mothers (n = 197)and children (n = 251), from rural north-eastern Tanzania, we assessed prediabetes and type 2 diabetes (T2D) prevalence six years after a pregnancy with/without GDM. ResultsThe prevalence of prediabetes (49.4 % vs. 46.4 %) orT2D (20.0 % vs. 16.1 %), p ≥ 0.36, based on fasting plasma glucose (FPG) or HbA1clevels (prediabetes: 16.9 % vs. 13.8 % and T2D 1.2 % vs. 0 %, p = 0.47), andcardio-metabolic health parameters,weresimilar between women with/without previous GDM. These results were supported by similar perinatal outcomes and child health at follow-up.The overall prevalence ofprediabetes/T2D was high, but no differences in other cardio-metabolic risk markers were observed in women with prediabetes/T2D compared to women with normal glucose tolerance. ConclusionsDespite high prevalence of GDM amongTanzanian women, the diagnosis was not associated with adverse pregnancy outcomes, nor with increased risk of prediabetes or T2D at follow-up. FPG and HbA1c may be poor markers for diabetes in this population, and further follow-up studies with longer time intervals are warranted to evaluate which GDM diagnostic criteria are most optimal for women in rural Tanzania and similar LMIC settings.

273 A Direct Domparative Analysis of Pediatric Traumatic Brain Injury Presentation and Outcomes in the United States and Uganda

INTRODUCTION: Pediatric traumatic brain injury (pTBI) is the leading cause of death and disability among children globally. However, few studies have explored pTBI in low- and middle-income countries (LMICs) compared to high-income countries (HICs). METHODS: Patient records were extracted from the Duke University Hospital subset of the National Trauma Data Bank (NTDB, n = 866) and a dataset at the Mbarara Regional Referral Hospital in Uganda (MRRH, n = 571). Descriptive statistics were performed to compare across settings. Logistic regression was used to quantify the odds of mortality in each setting given ICU utilization, admission GCS, and other factors. RESULTS: In-hospital mortality was higher in the LMIC versus the HIC (9.4% vs 2.9%, p < 0.001), while ICU utilization was lower in the LMIC (9.0% vs 33.4%, p < 0.001). Rates of surgical management did not differ significantly (15.8% vs 17.0%). More patients presented with moderate (27.8% vs 4.3%) and severe TBI (16.5% vs 11.8%) in the LMIC (p < 0.001). No deaths were reported among patients presenting with moderate or mild TBI in the HIC setting, whereas LMIC pTBI patients died in every TBI severity category. Over 50% of LMIC ICU patients died, versus 8.1% of HIC ICU patients. In a multivariate regression model of mortality, ICU placement was associated with mortality (OR: 6.7, 95% CI: 2.1-20.9), an association not seen in the HIC setting. CONCLUSIONS: Pediatric TBI mortality is greater in the LMIC vs the HIC setting. The LMIC setting also had a high prevalence of moderate/severe TBI and low ICU availability and effectiveness. Future work should involve the implementation and evaluation of interventions to assess these gaps in the LMIC setting.

Efficacy and Feasibility of Short-Stretch Compression Therapy for Filarial Lymphedema in Sri Lanka.

The WHO-recommended essential package of care (EPC) for filarial limb lymphedema consists of daily limb washing, entry lesion management, limb protection, exercises, and elevation. Decongestive therapy (DT) with compression bandaging by trained lymphedema therapists adds additional benefit but is unavailable for most in low- and middle-income countries (LMICs). To determine whether DT using self-adjustable, short-stretch compression garments (SSCG), prefitted using portable, three-dimensional infrared imaging (3DII), would be effective and feasible in LMIC settings, we conducted a pilot 6-week, interventional, single-group, open-label pilot study in Galle, Sri Lanka. Ten participants with Dreyer stage 3 lymphedema used SSCG for 2 weeks after a 4-week lead-in EPC period. Effect of EPC and compression on quality of life was assessed using the 12-item WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Median participant age was 73 years (range: 32-85 years). Median percent limb volume reduction due to compression was 11.3% (range: 1.1-27.2%). WHODAS 2.0 scores did not change significantly between enrollment and study end. Garment acceptability was high throughout the study. These results provide proof of concept for 3DII-enabled SSCG in LMICs where trained therapists for filarial lymphedema may not be available.

Validation of the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in low- and middle-income countries: A multicentre observational study.

Early recognition of children at risk of serious illness is essential in preventing morbidity and mortality, particularly in low- and middle-income countries (LMICs). This study aimed to validate the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in acute care settings in LMICs. This observational study is based on previously collected clinical data from consecutive children attending four diverse settings in LMICs. Inclusion criteria and study periods (2010-2021) varied. We simulated the ED-PEWS, consisting of patient age, consciousness, work of breathing, respiratory rate, oxygen saturation, heart rate, and capillary refill time, based on the first available parameters. Discrimination was assessed by the area under the curve (AUC), sensitivity and specificity (previously defined cut-offs < 6 and ≥ 15). The outcome measure was for each setting a composite marker of high urgency. 41,917 visits from Gambia rural, 501 visits from Gambia urban, 2,608 visits from Suriname, and 1,682 visits from Tanzania were included. The proportion of high urgency was variable (range 4.6% to 24.9%). Performance ranged from AUC 0.80 (95%CI 0.70-0.89) in Gambia urban to 0.62 (95%CI 0.55-0.67) in Tanzania. The low-urgency cut-off showed a high sensitivity in all settings ranging from 0.83 (95%CI 0.81-0.84) to 1.00 (95%CI 0.97-1.00). The high-urgency cut-off showed a specificity ranging from 0.71 (95%CI 0.66-0.75) to 0.97 (95%CI 0.97-0.97). The ED-PEWS has a moderate to good performance for the recognition of high urgency children in these LMIC settings. The performance appears to have potential in improving the identification of high urgency children in LMICs.

Experiences of informal caregivers of people with dementia in low- and middle-income countries: a systematic review protocol.

This review aims to synthesize the experiences of informal caregivers of people with dementia in low- and middle-income countries (LMICs). Globally, the burden of dementia is increasing disproportionately in LMICs. Informal caregivers play a vital role and face multiple challenges in LMICs. Caregivers often lack awareness and skills to provide adequate care for people living with dementia. Many LMICs have limited resources and caregivers lack support services. Understanding their experiences and perceptions may improve interventions, helping caregivers to better support those living with dementia. Studies from all settings in LMICs will be considered. Qualitative data from qualitative or mixed methods studies that explore caregivers' experiences and perceptions will be included in this review. Participants are informal caregivers of people diagnosed with dementia at any stage, regardless of age, gender, or their relationship with people living with dementia. This review will follow the JBI methodology for a qualitative systematic reviews, with meta-aggregation as the synthesis method. The review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A 3-step search strategy will be used to locate published and unpublished studies in MEDLINE, CINAHL, Embase, PsycINFO, AgeLine, LILACS, African Index Medicus, ProQuest Dissertations and Theses, Open Dissertations, Web of Science Core Collection, and Google Scholar. There will be no date or language limitations. All studies will be screened against the inclusion criteria and data will be extracted and critically appraised for methodological quality by 2 independent reviewers using JBI tools. Confidence in the final synthesized findings will be assessed using the ConQual approach. PROSPERO CRD42023453814.

Evaluating caregiver-child interactions in low- and middle-income countries: a systematic review of tools and methods.

The United Nations Sustainable Development Goals (SDGs) has placed emphasis on improving early child development globally. This is supported through the Nurturing Care Framework which includes responsive caregiving. To evaluate responsive caregiving, tools to assess quality of caregiver-child interactions are used, however there is little information on how they are currently employed and/or adapted particularly in low- and middle-income countries (LMICs) where children have a greater risk of adverse outcomes. The aim of this review is to provide a comprehensive guide on methodologies used to evaluate caregiver-child interaction - including their feasibility and cultural adaptation. We conducted a systematic review of studies over 20years in LMICs which assessed caregiver-child interactions. Characteristics of each tool, their validity (assessed with COSMIN Risk of Bias checklist), and the quality of the study (Mixed Methods Appraisal Tool) are reported. We identified 59 studies using 34 tools across 20 different LMICs. Most tools (86.5%) employed video-recorded observations of caregiver-child interactions at home (e.g. Ainsworth's Sensitivity Scale, OMI) or in the laboratory (e.g. PICCOLO) with a few conducting direct observations in the field (e.g. OMCI, HOME); 13.5% were self-reported. Tools varied in methodology with limited or no mention of validity and reliability. Most tools are developed in Western countries and have not been culturally validated for use in LMIC settings. There are limited caregiver-child interaction measures used in LMIC settings, with only some locally validated locally. Future studies should aim to ensure better validity, applicability and feasibility of caregiver-child interaction tools for global settings.

Portfolio analysis of global tobacco control research funding at the National Cancer Institute, 2000-2019.

Research in low- and middle-income countries (LMICs), where the majority of global tobacco users reside, is critical to addressing the global tobacco epidemic. This analysis describes the global tobacco control research portfolio funded by the National Cancer Institute from fiscal years 2000 to 2019. We used the National Institutes of Health Query, View, Report database to identify extramural grants relevant to global tobacco control research. Abstracts were analyzed to describe grant characteristics, including topic areas, tobacco products, countries, and regions of focus. Bibliometric and co-authorship network analyses were performed for publications associated with relevant grants. Of the 93 relevant grants with foreign (non-US) involvement, the majority (83.9%) supported research in upper and lower middle-income countries. The majority of grants (86.0%) focused on cigarettes, with a small subset of grants addressing smokeless tobacco, waterpipe use, or other non-cigarette products. Most grants focused on at least one of the six tobacco control policy measures in the World Health Organization MPOWER package; almost half (48.4%) focused on monitoring tobacco use and around one-third (32.3%) focused on offering tobacco cessation treatment, while other MPOWER measures received less attention in the research portfolio. While most of these grants, and the funding initiatives that supported them, emphasized research in low- and middle-income countries (LMICs), only 3 of 93 grants were awarded directly to LMIC-based institutions. There is a critical need for research to develop and test strategies to adapt, implement, and scale up evidence-based interventions across diverse LMIC settings. This study identified gaps in research activity that should be addressed to strengthen global tobacco control research capacity.

Gravity-driven crossflow membrane filtration and mechanical centrifugation yield plasma with equivalent total and COVID-19-specific immunoglobulin content

While the administration of convalescent plasma is a promising therapy for coronavirus disease 2019 (COVID-19), upfront costs and technological barriers of conventional plasmapheresis have limited the collection and processing of COVID-19 convalescent plasma (CCP) in Low- and Middle-Income Countries (LMICs). We previously reported that bedside plasma separation using gravity-driven microfiltration has made CCP therapy accessible as a treatment option in Suriname. However, the question remains whether the gravity-driven microfiltration method yields similar amounts of immunoglobulins as compared to conventional plasmapheresis. Here, we compared the gravity-driven microfiltration method with conventional plasma centrifugation for the total and COVID-19-specific immunoglobulin content of the obtained CCP. Blood donations from 10 donors recovered from PCR-confirmed COVID-19 were processed using both methods. Samples were collected pre- and post-processing for analysis to allow direct comparison of both methods. There were no differences in COVID-19-specific IgG levels between convalescent plasma obtained by microfiltration and centrifugation for 4 of the 5 assays used. Anti-RBD-Omicron IgG levels were slightly higher in the plasma obtained after filtration (median 274, range 69 to 1258) than after centrifugation (median 249, range 67 to 1175), Wilcoxon P = 0.0488. No significant differences were detected between the two methods for levels of total albumin, total cholesterol, total IgA, IgM and IgG levels. These results indicate that gravity-driven microfiltration and conventional centrifugation yield CCP with equivalent amounts of total and COVID-19-specific antibodies. This makes the gravity-driven microfiltration method a viable option for the collection and treatment with CCP in the LMICs setting.

Evaluating a stepped care model of psychological support for adults affected by adversity: study protocol for a randomised controlled trial in Jordan

BackgroundThe burden of common mental disorders in low and middle-income countries (LMICs) is growing with little known about how to allocate limited resources to reach the greatest number of people...

Modeling the Lifetime Impact of Reconstructive Plastic Surgery Training: Implications for Building Capacity in Global Surgery.

Training local surgeons and building local surgical capacity is critical to closing the gap in unmet surgical burden in low- and middle-income country (LMIC) settings. We propose a conceptual framework to quantify the impact of a single surgeon's training across multiple generations of trainees. A literature review was conducted to identify existing models for quantifying the impact of training. A model to estimate the attributable impact of surgical training was devised, based on a surgeon's attributable impact on a trainee and the lifetime number of cases trainees would perform. A quantitative survey was sent to high-income country and LMIC-based surgeons to determine the model's inputs across eight index procedures in reconstructive plastic surgery. We found no existing models for quantifying the multigenerational impact of training in surgery, medicine, or nonmedical fields. Twenty-eight US-based academic plastic surgeons and 19 LMIC-based surgeons representing 10 countries provided responses. The lifetime impact of multigenerational surgical training ranged from 4100 attributable cases (skin graft) to 51,900 attributable cases (cleft lip repair) in high-income countries and from 18,200 attributable cases (carpal tunnel release) to 134,300 attributable cases (cleft lip repair) in LMICs. There is a sizeable impact in the first generation of training, and this impact is even greater in the second generation of training, highlighting the importance of a "multiplier effect," particularly in LMIC settings. Given the paucity of surgeons, this multiplier effect is critical in closing the surgical gap, as efforts are underway to train new cohorts of reconstructive plastic surgeons.

State of the Science of Scale-Up of Cancer Prevention and Early Detection Interventions in Low- and Middle-Income Countries: A Scoping Review.

Cancer deaths in low- and middle-income countries (LMICs) will nearly double by 2040. Available evidence-based interventions (EBIs) for cancer prevention and early detection can reduce cancer-related mortality, yet there is a lack of evidence on effectively scaling these EBIs in LMIC settings. We conducted a scoping review to identify published literature from six databases between 2012 and 2022 that described efforts for scaling cancer prevention and early detection EBIs in LMICs. Included studies met one of two definitions of scale-up: (1) deliberate efforts to increase the impact of effective intervention to benefit more people or (2) an intervention shown to be efficacious on a small scale expanded under real-world conditions to reach a greater proportion of eligible population. Study characteristics, including EBIs, implementation strategies, and outcomes used, were summarized using frameworks from the field of implementation science. This search yielded 3,076 abstracts, with 24 studies eligible for inclusion. Included studies focused on a number of cancer sites including cervical (67%), breast (13%), breast and cervical (13%), liver (4%), and colon (4%). Commonly reported scale-up strategies included developing stakeholder inter-relationships, training and education, and changing infrastructure. Barriers to scale-up were reported at individual, health facility, and community levels. Few studies reported applying conceptual frameworks to guide strategy selection and evaluation. Although there were relatively few published reports, this scoping review offers insight into the approaches used by LMICs to scale up cancer EBIs, including common strategies and barriers. More importantly, it illustrates the urgent need to fill gaps in research to guide best practices for bringing the implementation of cancer EBIs to scale in LMICs.

An integrated knowledge translation (iKT) approach to advancing community-based depression care in Vietnam: lessons from an ongoing research-policy collaboration

BackgroundEvidence-based mental health policies are key to supporting the expansion of community-based mental health care and are increasingly being developed in low and middle-income countries (LMICs). Despite this, research on the process of mental health policy development in LMICs is limited. Engagement between researchers and policy makers via an integrated Knowledge Translation (iKT) approach can help to facilitate the process of evidence-based policy making. This paper provides a descriptive case study of a decade-long policy and research collaboration between partners in Vietnam, Canada and Australia to advance mental health policy for community-based depression care in Vietnam.MethodsThis descriptive case study draws on qualitative data including team meeting minutes, a focus group discussion with research team leaders, and key informant interviews with two Vietnamese policy makers. Our analysis draws on Murphy et al.’s (2021) findings and recommendations related to stakeholder engagement in global mental health research.ResultsConsistent with Murphy et al.’s findings, facilitating factors across three thematic categories were identified. Related to ‘the importance of understanding context’, engagement between researchers and policy partners from the formative research stage provided a foundation for engagement that aligned with local priorities. The COVID-19 pandemic acted as a catalyst to further advance the prioritization of mental heath by the Government of Vietnam. ‘The nature of engagement’ is also important, with findings demonstrating that long-term policy engagement was facilitated by continuous funding mechanisms that have enabled trust-building and allowed the research team to respond to local priorities over time. ‘Communication and dissemination’ are also crucial, with the research team supporting mental health awareness-raising among policy makers and the community, including via capacity building initiatives.ConclusionsThis case study identifies factors influencing policy engagement for mental health system strengthening in an LMIC setting. Sustained engagement with policy leaders helps to ensure alignment with local priorities, thus facilitating uptake and scale-up. Funding agencies can play a crucial role in supporting mental health system development through longer term funding mechanisms. Increased research related to the policy engagement process in global mental health will further support policy development and improvement in mental health care in LMICs.

Service delivery approaches related to hearing aids in low- and middle-income countries or resource-limited settings: A systematic scoping review.

Hearing loss is an important global public health issue which can be alleviated through treatment with hearing aids. However, most people who would benefit from hearing aids do not receive them, in part due to challenges in accessing hearing aids and related services, which are most salient in low- and middle-income countries (LMIC) and other resource-limited settings. Innovative approaches for hearing aid service delivery can overcome many of the challenges related to access, including that of limited human resources trained to provide ear and hearing care. The purpose of this systematic scoping review is to synthesize evidence on service delivery approaches for hearing aid provision in LMIC and resource-limited settings. We searched 3 databases (PubMed, Scopus, Ovid MEDLINE) for peer-reviewed articles from 2000 to 2022 that focused on service delivery approaches related to hearing aids in LMIC or resource-limited settings. Fifteen peer-reviewed articles were included, which described hospital-based (3 studies), large-scale donation program (1 studies), community-based (7 studies), and remote (telehealth; 4 studies) service delivery approaches. Key findings are that hearing aid services can be successfully delivered in hospital- and community-based settings, and remotely, and that both qualified hearing care providers and trained non-specialists can provide quality hearing aid services. Service delivery approaches focused on community-based and remote care, and task sharing among qualified hearing care providers and trained non-specialists can likely improve access to hearing aids worldwide, thereby reducing the burden of untreated hearing loss.

Teaching Scottish medical students about global health in partnership with LMIC institutions. Does it change their views on volunteering in LMIC settings?

An elective placement is a core part of most United Kingdom (UK) medical degrees, and a significant proportion of students choose to pursue their elective in low- and middle-income countries (LMIC). There is a risk that students are ill-prepared for some of the ethical challenges that they will face during these placements, and that they have little appreciation for some of the negative effects that their placement can have on the host healthcare system. This study sought to address some of these negative consequences by exploring the preparation of medical students for these experiences, and the effect of including the LMIC perspective in preparation materials. This qualitative study used thematic analysis to explore the attitudes of final year medical students at a Scottish medical school to international volunteering, after completing a module on global health. This module was designed and delivered in partnership with academics from Malawi, Rwanda and Zambia, thus incorporating a strong LMIC perspective. This study demonstrated the ability of a global health module with a strong LMIC perspective to influence the attitudes of final year medical students in the following ways: 1) Challenging assumptions around international volunteering and, in particular, around some of the negative effects of international volunteering that had not previously been considered. 2) Changing future practice around international volunteering. This study provides good evidence that having a strong LMIC voice in preparation materials for medical students embarking on LMIC electives has the ability to increase awareness of some of the potential harms, and to positively influence how they plan to have discussions around and approach such experiences in the future.

ALL induction outcome: Real-world data from a pediatric oncology center in an LMIC setup with rural predominance.

Acute lymphoblastic leukemia (ALL) has survival rates of greater than 90% in developed nations. However, various sociodemographic factors adversely affect outcome rates in low- and middle-income countries (LMICs). To study induction outcome of ALL and various factors affecting it. This was a prospective cohort study which enrolled 86 children up to the age of 18 years with newly diagnosed ALL registered in newly established pediatric hematology and oncology division over the duration of 3 years. Sociodemographic and clinical data was collected. Outcome was assessed using morphological remission, minimal residual disease (MRD) and mortality rate. Of the 170 children with malignancies registered, 86 were ALL. Mean age was 7.09 ± 4.07 years and the M: F ratio of 1.32:1. Sixteen (38.09%) of them had severe acute malnutrition and another 16 (38.09%) had moderate acute malnutrition. Thirty (68.18%) children over 5 years were undernourished. Seventy-four (86.05%) were B-ALL and 12 (13.95%) T-ALL. In total, 28.77% had WBC counts greater than 50 × 109/L. t (12;21) was the most common cytogenetic abnormality. Majority (60.46%) of the patients belonged to lower socioeconomic status. Seventy-one (93.42%) patients completed induction of which 100% attained morphological remission and 64 (90.14%) were MRD negative. There were five mortalities, three (60%) due to sepsis and 2 (40%) due to hemophagocytic lymphohistiocytosis. Fifty (65.78%) children had morbidities during induction, febrile neutropenia being the commonest. Successful induction outcome rates at par with high-income countries can be achieved even in resource-limited settings of LMIC with support from government and NGOs. Decentralized cancer care centers can effectively pave the way in reducing cancer mortality in children of lower socioeconomic status residing in rural areas.

Factor structure of the alcohol expectancies questionnaire among adolescents in rural Ghana.

Children's early experiences with alcohol inform the development of alcohol-related beliefs which are known to predict alcohol consumption during the critical stage of adolescence. Yet, there has been considerably less research into these alcohol-related cognitions in low- and middle-income countries (LMIC) and existing measures of these beliefs are highly reflective of Western contexts, which may not be fully appropriate for use in LMICs. The aim is to ascertain the construct validity of the Alcohol Expectancies Questionnaire (AEQ) in a non-Western sample. A cross-sectional diagnostic accuracy study involving 500 adolescents aged 10 to 18 years randomly selected from the database of the Navrongo Health and Demographic Surveillance System. Participants were administered the locally back translated version of the 34-item AEQ. Confirmatory factor analysis using the lavaan package in R was conducted to generate indices for the factor structure of the AEQ. Confirmatory factor analyses showed that while groupings of positive and negative expectancies were similar to those observed when expectancies have been assessed previously in Western studies, these formed a single 'alcohol expectancy' factor. Questions relating to positive tension reduction and negative physical expectancies showed inconsistent responses in this study. Commonly used tools for the assessment of alcohol expectancies may not be suitable for use in Ghana, possibly owing to their development and validation in Western contexts. These findings have implications for the assessment of alcohol-related beliefs in LMIC settings and begin to map out a research agenda to develop more contextually and culturally attune alcohol assessments.

Physical Realism of Simulation Training for Health Care in Low- and Middle-Income Countries-A Systematic Review.

This systematic review was conducted, according to PRISMA standards, to examine the impact of the level of physical realism of simulation training on clinical, educational, and procedural outcomes in low- and middle-income countries (LMICs) as defined by the World Bank. A search from January 1, 2011 to January 24, 2023 identified 2311 studies that met the inclusion criteria including 9 randomized (n = 627) and 2 case-controlled studies (n = 159). Due to the high risk of bias and inconsistency, the certainty of evidence was very low, and heterogeneity prevented any metaanalysis. We observed limited evidence for desirable effects in participant satisfaction and confidence, but no significant difference in skills acquisition and performance in the clinical practice environment. When considering the equivocal evidence and cost implications, we recommend the use of lower physical realism simulation training in LMIC settings. It is important to standardize outcomes and conduct more studies in lower income settings.

Patients, Parents and Providers Perspectives Toward Treatment Options for Sickle Cell Disease

Introduction Sickle cell disease (SCD) is the most common hemoglobinopathies in the world. It is more prevalent in malaria endemic areas where most low-and-middle-income countries (LMIC) are found. Because of challenges in accessing care, persons with SCD (PWSCD) in these settings have a poor outcome and up to 50% die before the age of five years in some places. Those who survive early childhood develop complications at a young age causing their families significant emotional and socioeconomic distress. Effort in LMIC is being directed toward screening for SCD and early initiation of treatment which has improved overall survival and quality of life of PWSCD. However, there are concerns about adherence to treatment due to pill fatigue, persistent SCD symptoms, end organ damage despite available treatment, and side effects of medications. With improved care, SCD is evolving into a chronic illness even in LMIC and PWSCD are surviving into adulthood. These countries will soon face the challenge of handling lifestyle and health demands of an emerging adult and aging PWSCD. There have been significant advances in disease modifying (DM) and curative treatment for SCD in high-income-countries (HIC) and the two promising treatment modalities for cure are bone marrow transplant and gene therapy which can be life changing for PWSCD and their families despite treatment related adverse events. Curing SCD may help prevent long-term complications. It is therefore important to explore the perspectives of PWSCD, their parents and SCD providers toward traditional and novel therapies for SCD as the initial step in planning for improved access to SCD treatment in LMIC. Objective To explore the attitudes of PWSCD, Parents (caregivers) of PWSCD and SCD care providers toward traditional and novel therapies for SCD in a LMIC setting. Methodology This was a mixed methods study conducted at a referral facility for PWSCD in western Kenya. It included 5 focused group discussions (FGD) of 6 - 7 consented participants; 2 with patients, 2 with parents and 2 with SCD providers. FGDs were conducted by trained clinicians and lasted 2 hours. A discussion guide which included information on novel therapies was applied to direct the audio-recorded sessions conducted in local dialect. FGD and analysis were iterative with each thematic content analyzed independent of the others and key concepts arising from these sessions explored. Necessary adjustments were made to the discussion guide for subsequent sessions based on emerging themes. The recorded material was then transcribed in verbatim and translated for analysis using a qualitative analysis tool. Results and Discussion This study enrolled 13 PWSCD, 13 parents of PWSCD and 6 SCD providers (n=32). Participants had similar attitudes towards SCD barriers and novel treatments. 96.9% of participants reported using hydroxyurea and folic acid for themselves, their loved one, or their PWSCD. Over the past year, 83.1% of PWSCD reported painful crisis while 33.% had been hospitalized despite adherence to treatment (table 1). Most participants (65.4%) would consider using novel SCD treatments with hesitations being cost, treatment adverse effect, and distance to treatment location. After the educational intervention, participants were more likely to opt for gene therapy (65.4%) than stem cell transplant (19.2%) or remaining on their current regimen (15.6%) (Table 2). Only one SCD providers' FGD was conducted due to their limited availability from competing clinical duties. Some patients who reported being on recommended treatment continued to have health events and complications that made them, their parents or providers want an alternative treatment. Most participants preferred a curative treatment option for their disease despite the challenges mentioned, which highlighted their willingness to participate in clinical trials. While there are infrastructural challenges in LMIC, they have the highest number of PWSCD that would benefit from new DM and curative treatment for SCD despite being underrepresented in clinical trials. They are the most impacted by complications associated with SCD due to sub-optimal care thus need for action to reverse this. Conclusion This study highlights the importance of involving population in LMIC in efforts to find better treatment for PWSCD. There is a need to conduct a similar study involving a larger cohort in future to further explore more perspectives.