Low- And Middle-income Research Articles

P-275. Risk Factors for Community Colonization with Extended-Spectrum Cephalosporin-Resistant Enterobacterales (ESCrE) among People with HIV in Botswana

Abstract Background Extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) are a major global threat, and there is a significant gap in research on the burden and associated risk factors for ESCrE in low-and middle income countries(LMICs). This is particularly true for people with HIV (PWH), who make up a significant proportion of the population in sub-Saharan Africa. In Botswana, 20% of individuals aged 15-49 are PWH. The risk factors associated with ESCrE colonization, typically a precursor to infection, are important to understand as such infections can result in increased healthcare costs as well as high morbidity and mortality. Methods Within a larger regional surveillance study, 546 adults with HIV were recruited from clinics and communities in 3 districts and underwent interviews and rectal sampling. ESCrE was defined as Enterobacterales demonstrating non-susceptibility to ceftriaxone or ceftazidime. Results 27% of participants screened positive for ESCrE colonization. The mean CD4 count was 635 cells/mm3 (SD± 267). Table 1 describes the demographics of the participants with and without ESCrE colonization. Escherichia coli was the most commonly isolated ESCrE (146/174; 84%). Bivariate and multivariate analysis was used to determine risk factors associated with ESCrE colonization (Table 2). Recent hospitalization and certain geographic locations were independent risk factors for ESCrE colonization. Recent antibiotic use had an elevated OR for ESCrE colonization that did not achieve statistical significance in adjusted analysis. Conclusion These results add to the limited data on risk factors associated with ESCrE colonization in PWH. Hospitalization is an independent risk factor for colonization despite controlling for antibiotic use, which suggests the need for further investigation into hospital-specific factors that contribute to ESCrE colonization. Further research is needed to understand the geographic differences in ESCrE colonization in this setting. As LMICs with high HIV burdens build capacity for antimicrobial stewardship and infection prevention infrastructure in healthcare, research on unique potential mechanisms that result in multi-drug resistant colonization in PWH may impact strategies and priorities to combat antimicrobial resistance. Disclosures Robert Gross, MD, MSCE, Pfizer Inc: DSMB member for drug unrelated to study

Early intervention in psychosis programs in Africa, Asia and Latin America; challenges and recommendations.

While early intervention in psychosis (EIP) programs have been increasingly implemented across the globe, many initiatives from Africa, Asia and Latin America are not widely known. The aims of the current review are (a) to describe population-based and small-scale, single-site EIP programs in Africa, Asia and Latin America, (b) to examine the variability between programs located in low-and-middle income (LMIC) and high-income countries in similar regions and (c) to outline some of the challenges and provide recommendations to overcome existing obstacles. EIP programs in Africa, Asia and Latin America were identified through experts from the different target regions. We performed a systematic search in Medline, Embase, APA PsycInfo, Web of Science and Scopus up to February 6, 2024. Most EIP programs in these continents are small-scale, single-site programs that serve a limited section of the population. Population-based programs with widespread coverage and programs integrated into primary health care are rare. In Africa, EIP programs are virtually absent. Mainland China is one of the only LMICs that has begun to take steps toward developing a population-based EIP program. High-income Asian countries (e.g. Hong Kong and Singapore) have well-developed, comprehensive programs for individuals with early psychosis, while others with similar economies (e.g. South Korea and Japan) do not. In Latin America, Chile is the only country in the process of providing population-based EIP care. Financial resources and integration in mental health care, as well as the availability of epidemiological data on psychosis, impact the implementation of EIP programs. Given the major treatment gap of early psychosis in Africa, Latin America and large parts of Asia, publicly funded, locally-led and accessible community-based EIP care provision is urgently needed.

Bitter effect of a Sweet Disease‐ Exploring Cognitive dysfunction in Prediabetes from an Aging cohort

AbstractBackgroundIndia is unfortunately the “Diabetes Capital” of the world with estimated 101 million and 136 million patients suffering from diabetes and prediabetes respectively. Prediabetes is a transition state between euglycemia and diabetes. Although diabetes is associated with cognitive decline, studies that link prediabetes and cognition have been scarce and inconclusive especially from the Low and Middle Income (LMIC) countries. Therefore, the current study attempts to explore the relationship between prediabetes and cognition.Methods531 participants aged ≥ 45 years, recruited by CBR‐TLSA (Tata Longitudinal Study of Ageing) were included in this study. Glycosylated Haemoglobin (HbA1c) levels was utilized to categorise the participants into healthy, prediabetes and diabetes based on the American Diabetes Association (ADA), 2017 criteria. Among these participants, 65 were healthy and 234 were prediabetic. The remaining 232 participants with Diabetes were excluded and directed towards appropriate care pathways. The COGNITO (Computerized Assessment of Adult Information Processing) neuropsychological test battery was utilized to assess the cognitive functioning. Generalized Linear Model (GLM) was performed between prediabetes status and cognition after adjusting for confounding variables.ResultsThe estimated prevalence of prediabetes in our elderly cohort is 44%. After adjusting for ApoE status, GLM analysis revealed that healthy participants performed better in semantic association (B = 0.314, 95% CI (0.047, 0.582), p = 0.021) and name‐face recognition (B = 1.644, 95% CI (0.516, 2.77), p = 0.004) tasks when compared to prediabetics. Subsequently, after adjusting for age, gender, years of education and ApoE status, it was observed that the scores of semantic association (B = 0.290, 95% CI (0.025, 0.556), p = 0.032) and name‐face recognition (B = 1.390, 95% CI (0.260, 2.520), p = 0.016) tasks were higher among healthy participants.ConclusionThis study emphasizes the deleterious effect of a potentially modifiable risk factor like prediabetes. Participants with prediabetes performed poorer in memory and language related cognitive tasks. If diagnosed early, interventions aimed at improving prediabetes could potentially prevent or delay the progression to both minor and major neurocognitive disorders.

The divergent association of diet intake, parental education, and nutrition policy with childhood overweight and obesity from low- to high-income countries: A meta-analysis.

It is unclear whether the effects of dietary intake, parental education, and nutrition policy on childhood overweight and obesity is consistent between high-income (HICs) and low- and middle-income (LMICs) countries. The objective of this meta-analysis was to investigate the association of diet, parental education and nutrition policy with childhood overweight and obesity when the economic levels were controlled. PubMed, Web of Science, Embase and Scopus were searched for observational studies published from January 1980 to October 2023 that examined the association of diet, parental education and nutrition policy with childhood overweight and obesity. Meta random effects model stratified by gross national income per capita was used to assess whether the associations were varied by economic levels. From 18 191 identified studies, 154 met the inclusion criteria. Meta-analysis revealed that higher sugar-sweetened beverage intake was a risk factor for childhood overweight and obesity in both HICs and LMICs countries/regions, whereas higher intake of fruit and/or vegetable was a protective factor only in LMICs countries/regions (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.69-0.85). Moreover, lower parental education level increased the risk (OR = 1.46; 95% CI = 1.32-1.61) and nutrition policy implementation decreased the risk (OR = 0.96; 95% CI = 0.91-0.99) of childhood overweight and obesity only in HICs. Fruit and/or vegetable intake, parental education and nutritional policy exert different influences on childhood overweight and obesity in countries with varied economic levels. These findings will enhance the understanding of the complex interplay between these factors and their impact on childhood health.

D-PRISM: a global survey-based study to assess diagnostic and treatment approaches in pneumonia managed in intensive care

BackgroundPneumonia remains a significant global health concern, particularly among those requiring admission to the intensive care unit (ICU). Despite the availability of international guidelines, there remains heterogeneity in clinical management. The D-PRISM study aimed to develop a global overview of how pneumonias (i.e., community-acquired (CAP), hospital-acquired (HAP), and Ventilator-associated pneumonia (VAP)) are diagnosed and treated in the ICU and compare differences in clinical practice worldwide.MethodsThe D-PRISM study was a multinational, survey-based investigation to assess the diagnosis and treatment of pneumonia in the ICU. A self-administered online questionnaire was distributed to intensive care clinicians from 72 countries between September to November 2022. The questionnaire included sections on professional profiles, current clinical practice in diagnosing and managing CAP, HAP, and VAP, and the availability of microbiology diagnostic tests. Multivariable analysis using multiple regression analysis was used to assess the relationship between reported antibiotic duration and organisational variables collected in the study.ResultsA total of 1296 valid responses were collected from ICU clinicians, spread between low-and-middle income (LMIC) and high-income countries (HIC), with LMIC respondents comprising 51% of respondents. There is heterogeneity across the diagnostic processes, including clinical assessment, where 30% (389) did not consider radiological evidence essential to diagnose pneumonia, variable collection of microbiological samples, and use and practice in bronchoscopy. Microbiological diagnostics were least frequently available in low and lower-middle-income nation settings. Modal intended antibiotic treatment duration was 5–7 days for all types of pneumonia. Shorter durations of antibiotic treatment were associated with antimicrobial stewardship (AMS) programs, high national income status, and formal intensive care training.ConclusionsThis study highlighted variations in clinical practice and diagnostic capabilities for pneumonia, particularly issues with access to diagnostic tools in LMICs were identified. There is a clear need for improved adherence to existing guidelines and standardized approaches to diagnosing and treating pneumonia in the ICU.Trial registration As a survey of current practice, this study was not registered. It was reviewed and endorsed by the European Society of Intensive Care Medicine.Graphical abstract

Commentary: Strengthening System Readiness for Health Interventions: Lessons for Implementing Interventions and Implementation Support in Low-And Middle-Income Countries.

In low- and middle-income countries (LMICs), barriers such as low system readiness, contextual mismatches, and resource limitations impede effective implementation of evidence-based interventions. This commentary offers insights into overcoming these challenges with a case study of the PRISM project, designed to reduce behavioral and psychological symptoms of dementia in older adults living in Thailand. The case highlights how combining two evidence-based models - the Reducing Disability in Alzheimer's Disease clinical intervention and the Getting To Outcomes implementation science process enhances program success. Using interviews with stakeholders across various health system levels, we identify factors critical to successful program implementation: (1) integrating interventions into policy frameworks, (2) empowering local implementers, (3) fostering collaborative learning, and (4) adapting interventions to local contexts. The case demonstrates that building system readiness through local engagement and ownership is central to scaling up health programs in LMICs. This commentary's contribution lies in its emphasis on the role of implementation science as a vehicle for translating research into practice. It presents a practical, adaptive model for embedding interventions into routine health systems, thereby offering a pathway for successfully scaling up evidence-based programs in LMICs. Such findings provide lessons for overcoming barriers to implementation in resource-limited environments.

Assessment of cancer predisposition syndromes in children with leukemia and solid tumors: germline-genomic profiling and clinical features in a series of cases

Cancer predisposition syndromes (CPS) are a group of genetic disorders that increase the risk of various cancers. Identifying CPS has a significant impact on the treatment plan, screening and follow-up strategy, and genetic counseling of the family. However, in children, it goes underdiagnosed in most clinical setups, especially in low- and middle-income (LMIC) countries. In the present study, we screened 60 pediatric oncology patients for a possible CPS based on pre-defined selection criteria. Six patients met the criteria, three of whom had hematological malignancy, while the remaining three had sarcoma. Whole exome sequencing was performed in the selected patients to confirm the diagnosis. Germline mutation in CPS-related genes was discovered in five of six cases, including novel mutations discovered in two. An adverse outcome was observed in all five patients with underlying cancer predisposition syndrome, with three having relapsed and two having progressive disease. Our study reflects a prevalence of 10% underlying CPS in a limited cohort of patient based on the phenotype-genotype approach in our cohort. Using pre-defined clinical selection criteria, screening can be directed to a high-risk patient cohort with high-pick up rate for CPS. The selection criteria could be utilized in any LMIC-based clinical setup for pediatric cancer patients who may benefit from modification of treatment as well as genetic counseling.

Developing research priorities for palliative care in Colombia: a priority setting partnership approach

BackgroundA recent Lancet commission called for more research on palliative care in low- and middle-income (LMIC) countries such as Colombia. A research priority setting approach has been recommended by The Global Forum for Health Research to address the huge gap in research output between LMIC and high-income countries, with influential health service bodies recommending the active involvement of non-research expert stakeholders in establishing research priorities to address service user needs.MethodPriority setting partnership (PSP) following the four stages of the James Lind Alliance methodology; establishing the partnership, identifying evidence uncertainties, refining questions and uncertainties, and prioritization. Data from MS forms were analysed using descriptive statistics.ResultsA total of 33 stakeholders attended an online PSP workshop and completed the Mentimeter exercise in Microsoft Teams. A total of 48 attended the subsequent in person prioritisation exercise in urban Bogota (n = 22) and rural Popayan (n = 25). The stakeholders were a diverse group of health professionals (physicians, medical students, nurses, dentists, physiotherapists, nutritionist, occupational and speech therapists), financial and administrative staff and patients with life-limiting illness and caregivers. Top research priorities included patient and caregiver needs, service provider education and training, and better integration of palliative care with cancer and non-cancer services. The key challenges included a lack of interest in palliative care research, along with funding, time and resource constraints. Key solutions included collaboration across disciplines and settings, highlighting benefits of palliative research to help secure adequate resources, and multicentre, mixed method research, with patient involvement from the research development stage.ConclusionThe findings of this PSP should be disseminated among palliative care associations worldwide to inform international multicentre studies, and among governmental and nongovernmental organisations that promote research in Colombia. A focus on patient and family caregiver palliative care needs in Colombia should be prioritised.

Engaging women to set the research agenda for assisted vaginal birth.

Public and patient involvement can provide crucial insights to optimise research by enhancing relevance and appropriateness of studies. The World Health Organization (WHO) engaged in an inclusive process to ensure that both technical experts and women had a voice indefining the research gaps and needs to increase or reintroduce the use of assisted vaginal birth (AVB) in settings where this intervention is needed but unavailable or underused. We describe the methods and outcomes of online workshops led by WHO to obtain women representatives' perspectives about AVB research gaps and needs. After technical experts created a list of research questions based on various evidence syntheses, WHO organised four online workshops with 31 women's representatives from 27 mostly low- and middle-income (LMIC) countries. Women rated the importance and priority of the research questions proposed by the technical experts, improving and broadening some of them, added new questions, and voiced their main concerns and views about AVB. Women helped to put the research questions into context in their communities, highlighted neglected factors/dimensions that influence practices and affect women's experience during labour and childbirth, underscored less salient consequences of AVB, and highlighted the main concerns of women about research on AVB. The consolidated vision of technical experts and women's representatives resulted in a technical brief published by WHO. The technical brief is expected to stimulate global research and action closely aligned with women's priorities. We describe a successful experience of engaging women, mostly from LMICs, in the identification of research gaps and needs to reintroduce AVB use. This process contributed to better aligning research questions with women's views, concerns, and priorities. Given the scarcity of reports about engaging women from LMICs to optimise research, this successful experience can serve as an inspiration for future work. Women representatives were involved at every stage of the workshops described in full in this manuscript.

The Development and Evaluation of the Mobile Obstetric Referral Emergency System (MORES) in Bong County, Liberia [ID 2683571

INTRODUCTION: Liberia and much of sub-Saharan Africa lacks a standard triage system for obstetric emergencies. Research conducted in low- and middle-income (LMICs) has shown that maternal mortality is directly related to inadequate triage systems. This study aimed to implement a novel mobile obstetric referral emergency system to improve obstetric triage in Liberia. METHODS: Ninety-seven midwives were recruited from 18 rural health facilities (RHFs) and two referral hospitals in Bong County, Liberia. The study utilized WhatsApp, an encrypted messaging platform, to enable communication between providers at RHFs and referral hospitals. Training sessions at RHFs on sending patient referral data including indication, age, gravidity/parity, gestational age, method of transportation, and delays were conducted. Midwives at referral hospitals were instructed to send messages confirming arrival and outcome. RESULTS: A total of 380 referral messages were sent, with significantly more referrals completing the referral process than not (60%). Both hypertension and hemorrhage accounted for 12% of referrals. Nonemergent obstetric causes accounted for 34%. Of women who arrived, 31% delivered via cesarean section. Significantly more women transported via ambulance arrived compared to self-transport or taxi. When money was identified as a barrier, only 45% of women arrived. CONCLUSION: This is the first study to introduce a real-time two-way mobile-phone obstetric triage platform for use in Liberia. Strengthening the obstetric triage system is critical to prevent delays in reaching care and improve obstetric outcomes. Addressing socioeconomic barriers is vital to increasing access to maternal health care. Future work includes country-wide scale-up in Liberia and assessment of the sustainability of the MORES intervention.

Lifecycle of surgical devices: Global, environmental, and regulatory considerations.

Technological advancements, improved surgical access, and heightened demand for surgery have fueled unprecedented device and supply turnover impelling wealthy hospitals to upgrade continually and sell, donate, recycle, or dispose of used, expired, antiquated, or surplus goods. This paper reviews the issues related to device and supply lifecycles and discusses the opportunities and challenges they present for sustainable surgical growth in low- and middle-income (LMICs) countries. This review found, in LMICs countries, regulatory disparities persist that limit effective harmonization secondary to highly variable national policies and a lack of prioritized enforcement. Heterogeneity in the regulatory landscape, specifically in the classification, nomenclature, and identification of medical devices, encumbers effective regulation and distribution. Once devices are sold, donated, or reused in LMICs countries, complexities arise in regulatory compliance, maintenance, and appropriate use of these technologies. At the end of the lifecycle, waste management poses significant obstacles with limited resources hindering the implementation of best practices. There are major disparities in access to quality surgical equipment and supplies around the world. Improved communication between relevant stakeholders and harmonization of manufacture and disposal regulations will be needed to ensure adequate and appropriate responses to these challenges. Not applicable.

Abstract 7290: Novel plasmid-based screening method for cervical cancer

Abstract Introduction: Alabama (AL) is tied for third-highest incidence rate and has second-highest death rate of cervical cancer as of 2020. Globally, cervical cancer has the fourth-highest incidence among cancers in women; 90% of deaths from cervical cancer in 2020 occurred in low- and middle-income (LMIC) countries. Inhibitor of differentiation/DNA binding 1 (Id1) expression correlates with tumorigenesis, clinical grade/stage, and aggressiveness of cervical cancer. Thus, Id1 expression could be exploited in novel screening approaches that aim to improve survival rates of cervical cancer in LMIC and clinically underserved settings. As a first step in developing an Id1-based screening approach, these preclinical studies utilized a plasmid that induces expression of a secreted reporter enzyme (secreted embryonic alkaline phosphatase, SEAP), controlled by the Id1 promoter sequence (pId1-SEAP). These studies examined relationships between Id1 expression and kinetics of reporter expression following plasmid transfection to detect human cervical cancer cells. Methods and Results: To confirm the relevance of Id1 as a target in cervical cancer, immunohistochemical staining for Id1 was performed on a human cervical cancer tissue microarray. Western blotting was performed to determine Id1 expression in human cervical cancer cell lines (HeLa, SiHa, CaSki). Optimal transfection conditions with pId1-SEAP were determined experimentally for each line, and then media was sampled through a 48-hour period post-transfection to quantify reporter SEAP expression. Immunohistochemical stain for Id1 showed that early stage and late stage human cervical cancer tissues expressed significantly (p < 0.05) higher levels of Id1 compared to normal tissues, with stain optical density values being 3e5±1e5 for early and late stage compared to 3e4±3e4 for normal tissues (early stage p=0.0001, late stage p=0.0002). Western blot for Id1 in HeLa, SiHa, and CaSki lines showed that all three positively expressed Id1, with Beta-actin-normalized expression values of 0.78±0.12, 1.12±0.05, and 0.76±0.08, respectively. The cell lines transfected with pId1-SEAP expressed SEAP at rates significantly higher than control cells, with the highest rates of production seen during the 36-48-hour post-transfection period. Rates of SEAP production (counts/hour) during this time period were 1e4±3e3 (p=0.0278), 8e2±1e2 (p=0.0834), and 3e2±5e1 (p=0.0683) for transfected HeLa, SiHa, and CaSki cells, respectively. Conclusions: The pId1-SEAP system enabled sensitive detection of cervical cancer cells. These preliminary data support future studies evaluating the in vivo performance of the system in preclinical models of early stage cervical cancer. Further development of this approach could enable sensitive and reliable detection of cervical cancer during early stages when treatment is most effective. Citation Format: Abbigael Eli, Yolanda Hartman, Benjamin B. Kasten, Rebecca Arend, Jason Warram. Novel plasmid-based screening method for cervical cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7290.

Mental Health among the Elderly in Nepal: Special Emphasis on Depression

This paper discusses the impact of Depression on the aging population. It also tries to explore the psychosocial risk factors and burden associated with geriatric depression in low-and-middle-income (LAMI) countries. Nepal, a South Asian developing country, is resource-poor and research-naïve. Research, in general, and mental health studies, in particular, are the least prioritized in this country. The lack of culturally adapted psychiatric inventories is one of the possible reasons for the low number of mental health research in Nepal. However, recent studies done at the local and regional levels show a significant load of depressive symptoms among the elderly in Nepal.

Home learning environments and children's language and literacy skills: A meta-analytic review of studies conducted in low- and middle-income countries.

A robust finding from research in high-income countries is that children living in resource-poor homes are vulnerable to difficulties with language and literacy but less is known about this association in low- and middle-income (LMI) countries. We present a meta-analysis of 6,678 correlations from studies in 43 LMI countries. Overall, the results indicate a small but significant association (r = .08) between home language and literacy environment and children's language and literacy skills. After examining a range of moderators, adult literacy practices and books-at-home had a significantly larger association with children's language and literacy skills than did home tutoring. Studies using customized measures demonstrated a more marked association between home attributes and children's outcomes (r = .14) than studies using a common measure across multiple sites (r = .06). Published studies showed significantly larger associations than unpublished studies, and countries with greater income inequality showed a larger association than relatively egalitarian societies. We conclude that the small overall association should not be taken as support for the absence of, or a vanishingly small relationship between the home learning environment and children's language and literacy skills in LMI countries. Rather, an important factor in detecting this relationship is that assessments must better reflect the nature of homes in different cultures to capture true variation in the population. Such contextually situated measurement would lead to an inclusive conceptualization of home learning environments and can better inform intervention programs to enhance children's educational success, a critical target for many LMI countries. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mental health burden among females living with HIV and AIDS in sub-Saharan Africa: A systematic review.

Mental health problems, particularly depression and anxiety, are common in women and young girls living with HIV/ AIDS particularly in low- and middle-income (LMICs) countries where women's vulnerability to psychiatric symptoms is heightened due to the prevalent intersectional stressors such as stigma and intimate partner violence. However, no synthesized evidence exists on the mental health burden of females living with HIV/AIDS (FLWHA) in Africa. This systematic review aimed to synthesize the current evidence on the mental health burden among FLWHA in sub-Saharan Africa. A systematic literature review of articles published from 2013-2023 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Five electronic databases; PubMed, MEDLINE with full text, Scopus, Academic Search Complete, and Health Source: Nursing Academic Edition were searched for articles published in English. Nineteen articles (15 quantitative, 3 qualitative, and 1 case study) from over 7 African countries met the inclusion criteria. The majority of the studies' quality was determined to be moderate. The prevalence of depression ranged from 5.9 to 61% and anxiety from 28.9 to 61%. Mental health burden was a logical outcome of HIV diagnosis. Predictors of mental health outcomes in the context of HIV/AIDS were identified as intimate partner violence (IPV), stigma, childhood traumas, sexual abuse, poverty, unemployment, and social isolation. Social support and resilience were identified as protective factors against mental illness in FLWHA. Mental illness had a deleterious effect on viral suppression rates among FLWHA, resulting in delayed initiation of antiretroviral therapy treatment and increased mortality but had no impact on immune reconstitution in the face of ART adherence. Given the high prevalence rates of depression and anxiety and their relationship with HIV progression, it is crucial that mental health care services are integrated into routine HIV care.

Understanding health system responsiveness to public feedback at the sub-national level: Insights from Kilifi County, Kenya.

Responsiveness is one of four health system goals alongside health outcomes, equity in financing and efficiency. Many studies examining responsiveness report a composite satisfaction index or proportions of patients describing satisfaction with dimensions of responsiveness. Consequently, responsiveness is predominantly based on collation of service users' feedback and could be termed service responsiveness. We conceptualise system responsiveness more broadly, as how the health system more widely responds to concerns or needs of the public. In this paper we share a system responsiveness framework to reflect this wider conceptualisation and illustrate how we used this framework combined with Aragon's insights on organisational capacity, to explore system responsiveness practices at sub-national level in Kenya. Drawing on interviews and group discussions we specifically consider how two governance structures -Health Facility Committees (HFCs) and Sub-County Health Management Teams (SCHMTs)- found in many Low-and-Middle-Income (LMIC) health systems receive, process, and respond to public feedback. HFCs are formal structures with community representation linked to a health facility to support community participation in service provision and health outcomes. SCHMTs comprise middle-level managers with oversight over primary health care facilities and are commonly known as district health management teams in other LMICs. There were multiple feedback mechanisms through which the health system could receive public feedback, but these mechanisms had limited functionality, often worked in isolation, and inadequately represented vulnerable groups. Our analysis also revealed the organisational capacity gaps that constrain health system responsiveness. These gaps ranged from inadequate funding and staffing of feedback mechanisms (hardware), through absence of clear procedures and guidelines (tangible software), to norms, actor relationships and power dynamics (intangible software elements). Our findings are relevant to similar low-and-middle-income contexts and draw attention to the importance of integrating multiple mechanisms and forms of feedback, alongside considering system capacities and their interactions, in strengthening health system responsiveness.

Demographic Trends of Adolescent Suicidal Hanging Deaths in Sylhet

Background: The incidence of suicide has emerged as a global health problem, especially in low- and middle-income(LAMI) countries. Hanging is one of the most prevalent forms of suicide worldwide, particularly among adolescents.During conventional autopsies, suicidal hanging was found to be a leading cause among the unnatural deaths in Bangladesh. Methods: An observational study based on retrospective data was conducted to analyses the demographic trendsof suicidal hanging cases in Sylhet. Data on demographic variables were collected from all suicidal hanging casesreferred for medico-legal autopsy from January 2015 to December 2020 at the Sylhet MAG Osmani Medical Collegemortuary in Bangladesh. Results: An increasing trend of hanging was observed among ages between 14 and 19 years (88.4%), with a peakincidence in the late adolescent group (52.1%). Female adolescents outnumbered male victims and accounted for two-thirds of the total deaths (66.3%). Hanging deaths were more prevalent among the adolescents in the geographicalareas of Gowainghat (13.7%) and Airport (13.2%). Conclusion: The high suicide rates highlight the importance of identifying suicide among adolescents as a legitimateconcern in these areas, with an urgent need for preventive intervention.

Accreditation of antimicrobial stewardship programmes: addressing a global need to tackle antimicrobial resistance.

Accreditation of healthcare services provides quality assurance of hospital practice to support safe and effective care for patients. Accreditation programmes focused on antimicrobial stewardship (AMS) have been developed in high-income countries (HIC) and recently the WHO has developed a toolkit to support AMS practice in low and middle-income (LMIC) countries. BSAC has developed their Global Antimicrobial Stewardship Accreditation Scheme(GAMSAS) for hospitals based on globally applicable standards. GAMSAS aims to support healthcare organizations to build measurable AMS programmes and to support spread of best practice. GAMSAS involves a desktop assessment by BSAC experts followed by a hospital visit to gather further insight into how a hospital's AMS programme operates. A final report of compliance with the GAMSAS standards and a recommendation about accreditation at one of three levels is formally approved at a GAMSAS panel meeting involving well-established global experts in AMS. The BSAC GAMSAS team reflect on progress during the first year and ambitions for future spread.

Social protection for refugees and migrants: Examining access to benefits and labour market interventions

AbstractThe article discusses the current practices for providing social protection to refugees and migrants, focusing primarily on low‐ and middle‐income (LMICs) destination countries. It examines formal providers of social protection, including state institutions, development agencies and humanitarian organizations. In recent years, there has been an increase in funding from multilateral donors, especially in the context of the COVID–19 pandemic, leading to the establishment of national assistance programmes in LMICs that also encompass refugees and to a lesser extent migrant workers. International agencies play a crucial role in providing humanitarian cash assistance to refugees, given their status under international protection under the 1951 Refugee Convention and related protocols. Access to social insurance remains tied to formal employment. Social insurance entitlements for migrants are often restricted and refugees are typically excluded from formal employment in LMICs. Regarding labour market interventions, refugees and migrants are often excluded from national programmes, with migrants’ residence permits being often tied to employment. For refugees, international agencies take a prominent role in providing livelihood programmes aimed at enhancing income‐generating opportunities, economic inclusion and financial independence. However, the effectiveness of these interventions remains unclear, lacking rigorous evidence, and often being short‐term with limited coverage.

The magnitude of precancerous cervical lesions and its associated factors among women screened for cervical cancer at a referral center in southern Ethiopia, 2021: a cross-sectional study.

Cervical cancer is the most prevalent gynecologic cancer in women and the second leading cause of cancer death worldwide. Africa's southern, eastern, and western regions have the highest rates of cervical cancer. Cervical cancer is treatable and curable when detected early, but it is nonetheless fatal in low- and middle-income (LMIC) nations where screening and early detection are not widely accessible. The objective of this study is to assess the magnitude of precancerous cervical lesions and their associated factor among women screened for cervical cancer at a referral center in southern Ethiopia, in 2021. A retrospective institution-based cross-sectional study was conducted from February 21 to April 14, 2022, among randomly selected 372 records of women screened for cervical cancer at Hawassa University Specialized Hospital. Data were extracted from clients' charts using a data extraction checklist. Statistical Package for Social Sciences version 26 and logistic regression analysis were applied to determine the association between dependent and independent variables, and significance was declared at p-value <0.05. The magnitude of abnormal cervical dysplasia in this study was 18.3% of which 14% were precancerous cervical lesions and 4.3% were cervical cancer. Early coitarche: Adjusted odds ratio (AOR) = 5.6 [95% (confidence interval) CI = 1.87-16.78], having more than one sexual partner: AOR = 2.6 [95% CI = 1.2-5.68], being HIV positive: AOR = 3.56 [95% CI = 1.53-8.29], and having sexually transmitted infections: AOR = 4.64 [95% CI = 2.08-10.35] were independent predictors of precancerous cervical lesions. The magnitude of precancerous cervical lesions in the study setting is 18% and the magnitude of cervical cancer is 14%, which is higher than the pooled prevalence of precancerous cervical lesions in Ethiopia. Having multiple sexual partners, being HIV positive, having sexual intercourse before 21 years, and new STI diagnosis was independently associated with abnormal precancerous cervical lesions.