Middle-income Countries Research Articles

Immunotherapeutic Strategies as Potential Treatment Options for Cutaneous Leishmaniasis.

Cutaneous leishmaniasis (CL), caused by protozoan parasites of the Leishmania genus, is prevalent in tropical and subtropical regions, with important morbidity, particularly in low- to middle-income countries. Current systemic treatments, including pentavalent antimonials and miltefosine, are associated with significant toxicity, reduced efficacy, and are frequently ineffective in cases of severe or chronic CL. Immunotherapies leverage the immune system to combat microbial infection and offer a promising adjunct or alternative approach to the current standard of care for CL. However, the heterogeneous clinical presentation of CL, which is dependent on parasite species and host immunity, may require informed clinical intervention with immunotherapies. This review explores the clinical and immunological characteristics of CL, emphasising the current landscape of immunotherapies in in vivo models and clinical studies. Such immune-based interventions aim to modulate immune responses against Leishmania, with additive therapeutic effects enabling the efficacy of lower drug doses and decreasing the associated toxicity. Understanding the mechanisms that underlie immunotherapy for CL provides critical insights into developing safer and more effective treatments for this neglected tropical disease. Identifying suitable therapeutic candidates and establishing their safety and efficacy are essential steps in this process. However, the feasibility and utility of these treatments in resource-limited settings must also be considered, taking into account factors such as cost of production, temperature stability, and overall patient access.

Meaning of Work Participation After Spinal Cord Injury in Bangladesh: A Qualitative Study in a Low- and Middle-Income Country Context.

This study aimed to explore the meaning of work participation for people with spinal cord injury (SCI) in Bangladesh. Narrative inquiry methodological framework was used to explore the meaning of work participation after SCI. Face-to-face interviews with twenty adults with SCI, who were either living in the community or in-patients at a rehabilitation center. The Worker Role Interview questionnaire was used as an interview guide. Participants were descriptively analyzed in two groups, rehabilitation participants and community participants. Their transcripts were analyzed using individual narrative analysis to understand the meaning of their experience at an individual level and then the findings from the individual narrative analyses were summarized using thematic analysis to identify themes that collectively represented the meaning of work after SCI in Bangladesh. Five themes were identified from the interviews: "work life before injury"; "current life in relation to work"; "framing future prospects of work participation"; "motives for working"; and "enablers of work participation." The meaning of work is subjective and is influenced by the participants' pre-existing experiences and other factors related to their work life, such as work preferences, habits, and daily routines. Therefore, creating opportunities to better understand the meaning of work for each individual and incorporating these factors into rehabilitation are keys to sustainable rehabilitation outcomes.

Childhood Adversity and Life Satisfaction in Adults with Alternative Care Experience in 12 Low- and Middle-Income Nations: The Mediating Roles of Individual and Relational Protective Factors and Resilience

Adults with care experience have elevated rates of adverse childhood experiences (ACEs) and a greater likelihood of poor outcomes. Some research has examined how protective factors and resilience impact outcomes among care leavers, but few studies include those from low- and middle-income countries (LMICs). Further, little work has examined the interactive impact of protective factors and resilience in this population. We investigated (a) the prevalence of ACEs among care leavers from LMICs, the mediating roles of (b) resilience and (c) individual and relational protective factors on the relationship between ACEs and life satisfaction, and (d) whether mediation was occurring both in parallel and sequentially. Five hundred forty-two care leavers from twelve LMICs completed an online survey. Participants completed the Brief Resilience Scale, ACEs Questionnaire, and open-ended questions regarding care experiences. Open-ended questions were coded for protective factors. There was a high prevalence of ACEs among care leavers. The relationship between ACEs and life satisfaction was partially mediated by resilience. Individual and relational protective factors partially mediated the relationship between ACEs and life satisfaction. Finally, resilience and protective factors partially mediated the relationship between ACEs and life satisfaction in both parallel and sequential mediation among care leavers from LMICs. Protective factors operate interactively to influence resilience, increasing life satisfaction among care leavers from LMICs.

Heterogenous impact of energy security and environmental regulations on energy transition: Exploring the disparity between high-income and middle-income countries

This study investigates the impact of energy security, environmental regulation, economic complexity, globalization, and geopolitical risk on the process of energy transition. To this end Methods of Moment Quantile regression is employed on panel data of twenty-one high-income countries and nine middle-income countries from 1996 to 2018. Findings indicate that energy insecurity and environmental regulation have positive impact on energy transition in both high income and middle-income countries. However, high geopolitical risk significantly reduces the positive effects of energy insecurity on energy transition. Further, the quantile regression reveals the heterogenous impact of these factors across the energy transition distribution. In view of such findings, the policy implications suggest that the governments in high-income countries should take advantage of the favorable aspects of energy insecurity and geopolitical risk to transform their energy structure, enforce stringent environmental policies and manage the negative implications of economic complexity on energy transition. Governments in middle-income countries should try to use effectively the energy insecurity and the globalization process. There is a need to control the negative influence of geopolitical risk on energy transformation.

Community-acquired sepsis in the medical intensive care unit – an experience from a lower-middle-income country

Objective: To determine microbiological pathogens and in-hospital mortality in patients admitted with community-acquired sepsis to the intensive care unit in a tertiary-care setting in a low- and middle-income country. Methods: The retrospective, observational study was conducted at the medical intensive care unit of a large tertiary care hospital in Karachi, and comprised data from January 1 to December 31, 2019, and comprised data of patients with community-acquired sepsis who were assessed using the Sepsis-3 criteria. Data was compared between survivors and non-survivors, and independent factors associated with escalation to a higher level of care were identified. Data was analysed using SPSS 23. Results: Of the 135 patients with mean age 49.8±18.0 years, 91(67.4%) were males and 44(32.6%) were females. The most common primary site of infection was the respiratory tract 63(46.7%). In-hospital mortality was noted in 52(38.5%) cases, while there were 83(61.5%) survivors. Serum levels of lactate and bicarbonate as well as urine output, fungal pathogens, septic shock and sequential organ failure were significantly associated with mortality (p<0.05). Conclusions: Clinical and microbiological spectrum of community-acquired sepsis in a low- and middle-income country was found to be different from other regions of the world. Clinicians should keep these differences in mind while managing these critically ill patients. Key Words: Sepsis, Septic shock, Critical care, Drug resistance, Fungi.

Caring in crisis: addressing patient safety, burnout, and long hours in healthcare

Madam, The World Health Organization defines patient safety as preventing errors and adverse effects to patients associated with health care and “to do no harm to patients”. Specifically, in low and middle-income countries (LMICs), about 134 million adverse events occur each year due to unsafe care in hospitals, resulting in 2.6 million deaths annually. [1] Along with other determining factors, professional well-being, long hours, and burnout syndromes also influence patient care. [2] Burnout is a condition directly linked to workplace environment, stemming from occupational stress and extended working hours. Garcia, C.L. et al., through meta-analysis, found a relationship between the development of burnout and patient safety actions, with a probability of superiority of 66.4%. High levels of burnout and worsening patient safety are related to external factors such as high workload, long working hours, lack of a secure environment, and interpersonal relationships. [3] These findings raise concerns, particularly in a country like Pakistan, where the extent of understaffing and high workload can be inferred from the following statistics: The doctor-to-population ratio in Pakistan was 1:1000 in 2018 [4]. In contrast, the doctor-to-population ratio in Malaysia was 2.2:1000 in 2018 [5]. As a result of this shortage, the current workforce in Pakistan is negatively affected. In a study by Kasi PM et al. on postgraduate trainees in Pakistan, individuals under stress were more likely to report longer working hours. This increased workload made them prone to medical errors, which ultimately undermines the patient safety culture. A study conducted at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC) compared the benchmarks from hospitals in the USA and discovered that high staff workload is a significant concern among staff [6] In Pakistan, where healthcare resources are limited, fostering a culture of effective work-hour management and breaks is essential for creating a healthier and safer environment for health professionals and patients. Ensuring adequate staffing levels to distribute the workload and prevent overburdening is essential. Providing designated areas for relaxation, offering mental health resources and mindfulness programmes like yoga or meditation can help doctors to cope with stress. Furthermore, promoting a culture of multidisciplinary teamwork, a mentorship program, and effective handover protocols during shift changes can ensure continuity of care. Medical institutes should invest in technology that can streamline administrative tasks and reduce paperwork burden. ---Continue

Institutional trust, conspiracy beliefs and Covid-19 vaccine uptake and hesitancy among adults in Ghana.

Vaccine hesitancy is considered one of the ten threats to global health. In the context of the COVID-19 pandemic, vaccine hesitancy may undermine efforts toward controlling or preventing the disease. Nevertheless, limited research has examined vaccine hesitance, particularly in low- and middle-income countries (LMICs). It is thus imperative to examine how institutional trust and conspiracy belief in tandem influence the uptake of COVID-19 vaccines. Using data (n = 2059) from a cross-sectional study in Ghana, this study examines the association between institutional trust, conspiracy beliefs, and vaccine uptake among adults in Ghana using logistics regression. The regression model (model 3) adjusted for variables such as marital status, age, gender, employment, income, and political affiliations. The results show that individuals were significantly less likely to be vaccinated if they did not trust institutions (OR = .421, CI = .232-.531). Similarly, we found that individuals who believed in conspiracy theories surrounding the COVID-19 vaccine were less likely to be vaccinated (OR = .734, CI = .436-.867). We also found that not having a COVID-19-related symptom is associated with vaccine refusal (OR = .069, CI = .008-.618). Similarly, compared to those with a vaccine history, those without a vaccine history are less likely to accept the COVID-19 vaccine (OR = .286, CI = .108-.756). In conclusion, our results demonstrate the need for enhanced education to tackle conspiracy beliefs about the disease and enhance vaccine uptake. Given the role of trust in effecting attitudinal change, building trust and credibility among the institutions responsible for vaccinations ought to be prioritized.

High-Throughput Luminescence-Based Serum Bactericidal Assay Optimization and Characterization to Assess Human Sera Functionality Against Multiple Shigella flexneri Serotypes

Shigellosis represents a significant global health concern particularly affecting children under 5 years in low- and middle-income countries (LMICs) and is associated with stunting and antimicrobial resistance. There is a critical need for an effective vaccine offering broad protection against the different Shigella serotypes. A correlate of protection has not yet been established but there is a general consensus about the relevant role of anti-O-Antigen-specific IgG and its functionality evaluated by the Serum Bactericidal Assay (SBA). This study aims to characterize a high-throughput luminescence-based SBA (L-SBA) against seven widespread Shigella serotypes. The assay was previously developed and characterized for S. sonnei and S. flexneri 1b, 2a, and 3a and has now been refined and extended to an additional five serotypes (S. flexneri 4a, 5b, 6, X, and Y). The characterization of the assay with human sera confirmed the repeatability, intermediate precision, and linearity of the assays; both homologous and heterologous specificity were verified as well; finally, limit of detection and quantification were established for all assays. Moreover, different sources of baby rabbit complement showed to have no impact on L-SBA output. The results obtained confirm the possibility of extending the L-SBA to multiple Shigella serotypes, thus enabling analysis of the functional response induced by natural exposure to Shigella in epidemiological studies and the ability of candidate vaccines to elicit cross-functional antibodies able to kill a broad panel of prevalent Shigella serotypes in a complement-mediated fashion.

Are we ready for robotics in neurosurgery in low-and middle-income countries?

Are we ready for robotics in neurosurgery in low-and middle-income countries?

Genitourinary Cancer Care in Low- and Middle-Income Countries: Disparities in Incidence and Access to Care

Genitourinary Cancer Care in Low- and Middle-Income Countries: Disparities in Incidence and Access to Care

Burden of Benign Prostatic Hyperplasia (BPH) in Low- and Middle-Income Countries in Sub-Saharan Africa (SSA)

Burden of Benign Prostatic Hyperplasia (BPH) in Low- and Middle-Income Countries in Sub-Saharan Africa (SSA)

Post-Graduate Urology Training in Low- and Middle-Income Countries

Post-Graduate Urology Training in Low- and Middle-Income Countries

Beyond Dialysis: Reshaping CKD Paradigms in Developing Nations

Dear Sir / Madam, Respected Editor, I am writing to bring attention to the critical need for increased research on conservative kidney management (CKM) in the context of patients with advanced chronic kidney disease (CKD). The recent advancements in developed nations have demonstrated that CKM is a novel and effective approach to caring for CKD patients, particularly those who choose not to pursue maintenance dialysis. Historically, medical care for individuals with CKD has adhered to a paternalistic model, where clinicians make treatment decisions independent of patient preferences. JS Scherer et al observed that a provider's assessment of a patient's frailty and response exerted a more substantial influence on the treatment provided than the patient’s comorbidities, functional status, and stated preferences. 2 Furthermore, another study showed that some individuals exhibited a preference for conservative care after shared-decision making, irrespective of the potential survival benefits offered by dialysis if it entailed frequent hospital visits or travel restrictions. 3 This underscores the significance of patient autonomy, where the pursuit of freedom can sometimes outweigh the emphasis on clinical outcomes. However, contemporary CKD management in the 21st century emphasizes shared decision-making and patient empowerment. While research suggests CKM can improve quality of life, reduce hospitalizations, and minimize invasive procedures, offering a valuable alternative to dialysis, its impact on survival becomes less clear for patients over 80 or those with multiple comorbidities.4 Additionally, the inclusion of patients and their families in collaborative decision-making processes has proven advantageous, supported by specialized decision aids that promote well-informed discussions regarding CKM with healthcare providers.5 Nephrologists face significant challenges in implementing effective conservative kidney management (CKM) due to a lack of clinical guidelines, training, evidence, and system-level infrastructure. This has resulted in limited awareness and discussion of CKM among patients and healthcare providers, hindering its adoption. With the global burden of chronic kidney disease (CKD) increasing significantly over the past three decades, particularly affecting low- and middle-income countries, there is a pressing need for innovative, cost-effective solutions. CKM emerges as a viable alternative where dialysis is often inaccessible or unaffordable, with the potential to significantly impact CKD management, especially in resource-limited settings such as Pakistan. I urge the scientific community and policymakers to recognize the importance of supporting and conducting research on conservative kidney management. ---Continue

The Comparison of Stock Price Before and After Pandemic to Identify The Health of Sector Company

At the beginning of the Covid-19 outbreak in Indonesia, almost all activities in this country weredisrupted and economic activity was no exception. Indonesia's current economic growth is down2.07% in 2020 due to the Covid-19 pandemic which has caused it to be reduced to a low and middleincome country. Based on the gross domestic product (GDP), most sectors of the Indonesian economyexperienced a decline in growth in 2020. Only 5 economic sectors showed positive growth. The sectorwith the largest positive growth was the health services sector and social activities, which amountedto 11.60%. This growth affects the stock price of health sector companies. Grounded on the IDXIndustry category (IDXHEALTH) from 2018-2022, there was an increase of 41.28%. The HealthSector which continues to grow is driven by the payment of Covid- 19 incentives. This study wasconducted to identify the Difference in Stock prices of Health Sector Companies before and afterCovid- 19 with the supposition that the Covid- 19 pandemic occurred in March 2020 by observingstock price fluctuations two years before and after the Covid- 19 Pandemic. Based on the PairedSample T-test, the stock prices of 3 companies from 6 companies have significant differences in thespecified sample period, namely DVLA, PRDA, and MERK companies where the stock prices ofDVLA and PRDA have increased. In addition, PRDA's stock price has the largest stock price amongother health sector companies, meaning that PRDA companies have good performance.

Urologic Cancer Drug Costs in Low- and Middle-Income Countries

Urologic Cancer Drug Costs in Low- and Middle-Income Countries

Practical Consensus Guidelines on the Use of Cetuximab in Head and Neck Squamous Cell Carcinoma (HNSCC)

Head and neck squamous cell carcinoma (HNSCC) is the most common malignancy group in India and several other low- and middle-income countries. Currently, majority of the patients present in advanced stage where systemic therapy is standard of care. Multiple relapses are also not uncommon. Almost all HNSCC tumors have epidermal growth factor receptor (EGFR) overexpression, making an attractive target. Cetuximab is the most successful method to target EGFR in HNSCC. After decades of its use, it still is a prominent part of the current management guidelines. Since other agents have also been proven to be useful, we felt it was necessary to develop a real-world consensus guideline to help the decision-making process among the community oncologists. Our expert committee therefore put together currently available data, insights from their real-world clinical practice, and voted to arrive at a consensus. These consensus guidelines represent how cetuximab should be used today in the management of HNSCC.

The Impact of Socioeconomic Factors on Kidney Transplantation: A Systematic Review of Low- and Middle-Income Countries

The Impact of Socioeconomic Factors on Kidney Transplantation: A Systematic Review of Low- and Middle-Income Countries

Bridging the knowledge gap: educational needs of Iranian women for virtual breast cancer prevention: a qualitative study

BackgroundBreast cancer prevention is a globally significant and cost-effective public health priority, particularly in low- and middle-income countries. Empowering women through improved health literacy is a key strategy for reducing the disease burden. However, effective educational programs must be tailored to the specific cultural context and needs of the target community. This study explored the educational needs of Iranian women for a virtual breast cancer prevention program.MethodsA descriptive qualitative design was used from January to July 2022. Purposive sampling with maximum variation was utilized to recruit a sample of 28 participants. Data collection was conducted through semi-structured interviews. Following the method outlined by Graneheim and Lundman, qualitative content analysis was employed to analyze the interview data. MAXQDA 2020 software was used for data analysis. Components of trustworthiness, including credibility, dependability, confirmability, and transferability, were considered.ResultsOur findings identified three primary categories: “developing women’s scientific, practical, and attitudinal capabilities”; “features of program content”; and “principles of electronic content design”. These results offer valuable insights into the educational needs of Iranian women for virtual breast cancer prevention programs.ConclusionsTo design an effective virtual program, it is crucial to address all three domains: cognitive, emotional, and psychomotor. Program content should be organized and presented using methods that sensitize women to the importance of breast cancer prevention and motivate them to participate. Furthermore, the program’s design should be grounded in evidence-based practices and principles of electronic content design, ensuring cultural sensitivity to the needs of Iranian women.

Factors associated with modern contraceptive utilization among reproductive age women in Cambodia; evidenced by the recent Cambodia demographic and health survey

IntroductionCambodia is a low-income country with limited access to family planning (FP) in terms of modern contraceptive utilization. Despite several FP programs designed to make contraceptives accessible, adoption of contraceptives has been difficult in Cambodia, which has high rates of fertility and maternal mortality. This gap in essential care can put women and adolescent girls at greater risk of adverse outcomes such as stillbirth, spontaneous abortion, unwanted pregnancy, or even maternal death. One of the goals set by the government to decrease both maternal and child mortality and morbidity was increasing the modern contraceptives utilization. So, the main objective of this study was to evaluate spatial variations in modern contraceptives utilization and its contributing factors among women.MethodsData from the Cambodia 2021–22 Demographic and Health Survey datasets were used for secondary data analysis. A total of 19,496 women of reproductive age participated in the study. A spatial and multilevel mixed effects analysis was done on the factors affecting modern contraceptives utilization among Cambodian women. Finally, the percentage, odd ratio, together with their 95% confidence intervals and the results of the spatial analysis were provided.ResultThe prevalence of modern contraceptive use was 31.2% in Cambodia. Living in an urban area [AOR = 1.224; 95% CI = (1.126.1.330); P = 0.0001]; being married [AOR = 34.131; 95% CI= (12.673, 91.921); P = 0.0001]; and having a history of terminated pregnancy [AOR = 1.137; 95% CI= (1.055, 1.225); P = 0.0001] were found to be positively associated with modern contraceptive utilization. In contrast to this, being between the age range of 46–49 [AOR = 0.421; 95% CI = (0.364, 0.487); P = 0.0001]; being a female-headed household [AOR = 0.784; 95% CI = (0.723, 0.850); P = 0.0001]; and current breast feeding [AOR = 0.84; 95% CI = (0.75, 0.93); P = 0.010] were found to be negatively associated with modern contraceptive utilization. Additionally, the spatial analysis of modern contraceptive utilization showed that a higher proportion was utilized in the southern and southwest regions of Cambodia.ConclusionIn this study, living in urban area, being married and having history of terminated pregnancy were found positively associated with modern contraceptive utilization. In contrast to this, being old age, being female headed household and being currently breast-feeding women were found negatively associated with modern contraceptive utilization. In addition to this, there were geographic (spatial) variations in modern contraceptive utilization among Cambodian’s women across the country.

Multitargeted docking approach reveals droxidopa against DNA replication and repair-related protein of cervical cancer

Cervical cancer begins in the cells lining the cervix and is caused by persistent infection with certain types of human papillomavirus (HPV). Initially, it has no symptoms, and later it causes pelvic pain, abnormal vaginal bleeding, and pain during intercourse. It is the fourth-ranked cancer among women, and many women die from cervical cancer every year, particularly in low-income countries and the majority could be prevented with early detection and treatment. In this study, we have taken Cervical Cancer DNA Replication and Repair-Related Protein with the PDBID- 3H15, 5VBN, and 6NT9 and performed the multitargeted molecular docking with the FDA-approved drug library using HTVS, SP and XP docking. Then, the poses were filtered with MM\\GBSA for proper computations of free energy, identified a multitargeted inhibitor Droxidopa with docking and MM\\GBSA scores ranging from − 5.559 to − 6.835 Kcal/mol and − 26.04 to − 37.33 Kcal/mol, respectively. We also performed interaction fingerprints revealing 2VAL, 2LYS, 1ALA, 1ARG, 1ASN, 1CYS, 1GLN, 1GLU, 1ILE, 1MET, 1PHE, 1PRO, 1SER, and 1THR were most interacted residues and computed the ADMET properties with QikProp and DFT with Jaguar, which supported the study and compounds’ suitability. Moreover, we performed the 100ns MD simulation in water, showing the controlled deviation and fluctuations of the residues with many interactions, and MM\\GBSA was performed with the same trajectories, showing a better understanding of each frame’s total complex and binding-free energy. The whole study favours droxidopa as an inhibitor of cervical cancer DNA Replication and Repair-Related Proteins—however, experimental studies are needed before use.