Low- To Middle-income Countries Research Articles

The current state of primary healthcare in Pakistan: a way forward for low-to-middle income countries.

Primary healthcare (PHC) plays a crucial role in improving health outcomes and reducing healthcare burden, especially in low-to-middle-income countries (LMICs). However, PHC has not received adequate attention in Pakistan despite its recognized importance. This study aims to examine the current state of PHC in Pakistan, identifying factors compromising its quality and effectiveness. To find relevant data, the authors conducted a thorough literature search on PubMed, Google Scholar, and Cochrane Library from inception till 2 July 2022, without any language restriction. The following keywords were employed during the literature search, separated by Boolean operators AND, OR: "Primary Healthcare", "PHC", "Healthcare primary", "Primary Health", and "Pakistan". Pakistan's PHC infrastructure shows promise, with a considerable number of healthcare facilities in place. However, various factors hinder its effectiveness and compromise the quality of care provided. Insufficient investment, resource constraints, inadequate training of healthcare providers, lack of oversight, and limited access to essential medicines and equipment are some of the key challenges observed. Improving PHC in Pakistan is vital for addressing the population's healthcare needs, particularly in rural areas. Adequate investment, enhanced training programs, improved oversight mechanisms, and increased availability of essential resources are necessary to strengthen the PHC system. By prioritizing PHC and addressing the identified challenges, Pakistan can enhance healthcare access, reduce healthcare burden, and improve overall health outcomes for its population. It is high time LMICs like Pakistan recognize PHC as the most economically feasible pathway toward accomplishing healthcare targets and adopt adequate measures to elevate its standards.

The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa

BackgroundThe incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre. MethodsThis qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation. ResultsSaturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers (“Poor Communication”; “Lack of Support”; “Caller Hesitance or Uncertainty;” “Emotionality”; and “Practical Barriers”) and three facilitators (“Caller Willingness”; “Support” and “CPR in Progress”) were extracted. ConclusionNumerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.

Enhancing Quality of Congenital Heart Care Within Resource-Limited Settings.

Over 90% of the world's children with congenital heart disease (CHD) are born in the resources poor settings of low- to middle-income countries (LMICs). The shortfall in human and material resources and dysfunctional health systems leads to poor quality of care (QoC) which contributes substantially to suboptimal outcomes of patients with CHD in LMICs. Notwithstanding these challenges, it is possible to develop a quality improvement (QI) framework that can have a significant impact on outcomes and prevent a number of deaths. In this review, we examine the common barriers to implementing effective QI processes in LMICs. Using examples of successful QI initiatives in LMIC, we propose a broad framework that focuses on simple, yet effective measures involving cohesive efforts of all key participants guided and nurtured by a leadership that strongly values QoC.

Translation of preclinical ethnomedicine data in LMICs: the example of rooibos.

All disease, but especially non-communicable diseases, are related to dysfunction of one or more regulatory systems. In developing countries, long-term management of patients with chronic diseases has many challenges and is generally not financially viable, but Africa in particular, which is rich in diverse ethnomedicines presents a more feasible long-term therapeutic approach in this niche. However, despite comprehensive preclinical investigations on numerous plant-derived candidate medicines, only a small portion of these reach the patient as recognised medicines. In this review, we use the example of rooibos (Aspalathus linearis (Burm.f.) R. Dahlgren)-which is globally consumed as aromatic, caffeine-free tea-to illustrate the hurdles that need to be overcome in the low-to middle-income countries, before progression of ethnomedicines to official treatment regimens can be achieved. In terms of methodology, regulatory system focused rooibos papers indexed on PubMed for the past three decades (n = 112) were accessed. Papers reporting duplication of previous results were excluded, as well as review papers. Topics covered includes the high standard of ethnomedicine drug discovery and efficacy testing research performed in Africa (and South Africa in particular in the case of rooibos), the potential bias in terms of preclinical research focus, ethnomedicine ownership and the requirement for independent clinical trial coordination and/or management.

Prophylaxis of Patent Ductus Arteriosus with Paracetamol in Extremely Low Gestational Age Newborns (ELGANs): A Single-Institution Observational Study in Vietnam.

Prophylactic paracetamol for extremely low gestation age neonates (ELGAN, <27 weeks' gestation) with symptomatic patent ductus arteriosus (sPDA) in high-income countries (HIC) reduces medical and surgical interventions. Its effectiveness in low-to-middle-income countries (LMIC) remains uncertain. This study assesses prophylactic paracetamol's impact on sPDA interventions in ELGANs in an LMIC. This is a retrospective cohort study that compared a historical cohort of ELGANs that were treated with oral ibuprofen or intravenous paracetamol after diagnosis of sPDA (n = 104) with infants (n = 76) treated with prophylactic paracetamol (20 mg/kg loading, 7.5 mg/kg qid for 4 days), in a tertiary neonatal intensive care unit (NICU) in Vietnam. Oral ibuprofen or intravenous therapeutic paracetamol were administered if prophylactic paracetamol failed to close sPDA. Surgical ligation was conducted if targeted medical intervention failed, or the infant deteriorated from conditions attributable to sPDA. In the historical cohort, 57 (55%) infants died within 7 days of life compared to 18 (24%) from the prophylactic cohort (p < 0.01). Of the survivors, 21 (45%) of the historical and 23 (39.7%) of the prophylactic cohort required surgical ligation (p = 0.6). Duration of hospitalization for survivors was lower in the prophylactic cohort (mean 74 vs. 97 days, p = 0.01). In the prophylactic cohort, 24 (41%) infants did not need further treatment while 34 (59%) required further treatment including ibuprofen and/or paracetamol 28 (48%) and surgical ligation 22 (38%). Prophylactic paracetamol for ELGAN in LMIC does not reduce the need for surgical ligation, sPDA rates, and other PDA-related morbidities in infants who survive beyond 7 days of age. It may reduce the risk of death and the duration of hospitalization but further study into the reasons behind this need to be determined with larger studies.

Patient Satisfaction With, and Outcomes of, Ultrasound-Guided Regional Anesthesia at a Referral Hospital in Tanzania: A Cross-Sectional Study.

Regional anesthesia techniques are increasingly used in high-income countries (HICs) for both surgical anesthesia and postoperative analgesia. However, regional anesthesia has not been utilized to the same degree in low- to middle-income countries (LMICs) due to a lack of resources and trained personnel. This study evaluates patient satisfaction with, and outcomes of, ultrasound-guided regional anesthesia for extremity surgery at Kilimanjaro Christian Medical Center (KCMC) in the Northeastern zone of Tanzania. Study patients were ≥18 years of age; American Society of Anesthesiologists (ASA) physical status I, II, or III; and underwent extremity surgery under peripheral nerve block with ultrasound guidance at KCMC. After placement, blocks were assessed for effectiveness intraoperatively, as demonstrated by the need for supplemental analgesic or sedative medication or conversion to a general anesthetic. Postoperatively, patients were assessed for satisfaction with their nerve block and pain at 12 and 24 hours. Adverse events related to regional anesthesia were assessed immediately, 45 minutes after block placement, and at 12 and 24 hours postoperatively. The primary outcome was patient satisfaction at 12 hours. Secondary outcomes were block success rate and analgesia at 12 and 24 hours postoperatively. A convenience sample of 170 patients was included in the study, of whom 156 (95% confidence interval [CI], 87-95) were either satisfied or very satisfied with their block. Block placement was highly successful with only 8 of 170 participants (95% CI, 2.4-8.3), requiring conversion to a general anesthetic. Analgesia continued in the postoperative period, with 164 of 170 (95% CI, 93-98) patients and 145 of 170 (95% CI, 80-90) patients reporting acceptable analgesia at 12 and 24 hours, respectively. No major adverse events, such as local anesthetic toxicity, infection, bleeding, nerve injury, or pneumothorax, were observed. Our study found that ultrasound-guided regional anesthesia in a resource-constrained setting was effective for extremity surgery and resulted in high patient satisfaction. No complications occurred. The use of ultrasound-guided regional anesthesia shows promise for the safe and effective care of patients undergoing extremity surgery in LMICs.

The use of emergency medical services for palliative situations in Western Cape Province, South Africa: A retrospective, descriptive analysis of patient records.

An estimated 56.8 million people require palliative care annually, while only 14% receive such care. This imbalance is particularly acute in low-to middle-income countries (LMICs), where up to 80% of patients requiring palliative care reside. To correct this imbalance, integration between palliative services and other disciplines has been recommended. While improved palliative care integration is a priority in the South African (SA) LMIC context, emergency medical services (EMS) and palliative care remain non-integrated. This has resulted in poor palliative situation management by EMS and a lack of research concerning their intersection. To examine EMS use for palliative situations in the Western Cape (WC) Province of SA by describing frequency of intersection, patient characteristics and outcomes. An observational, descriptive, retrospective patient record review was employed at two hospitals with palliative care services in the WC. All patient records of those who arrived at the hospitals between 1 January 2020 and 31 December 2020 via EMS conveyance leading to palliative care provision were included in the study. In total, 1 207 unique patients received palliative care services at both hospitals during the study period. Of these, 395 (33%) made use of EMS for hospital conveyance on 494 occasions. The median (range) patient age was 60 (20 - 93) years, and most transports involved male patients (54%, n=265). Family members were the primary caregivers in most instances (89%, n=440), dyspnoea was the chief complaint (36%, n=178) and cancer was the most frequent diagnosis (32%, n=159). The median length of hospital stay was 6 days, with most patients discharged home (60%, n=295). EMS in SA frequently encounter palliative situations for symptoms that may be managed within their scope of practice. Consequently, it appears that EMS have an important role to fulfil in the care of patients with palliative needs. Integrating EMS and palliative care may result in improved palliative care provision and, therefore, EMS and palliative care integration would be beneficial in SA.

Ghana 3D Telemedicine International MDT: A proof-of-concept study

A real-time 3D Telemedicine system - leveraging Microsoft’s HoloportationTM communication technology – enabled an international multidisciplinary team meeting (MDT) to consult with complex reconstructive patients prior, during, and after an overseas surgical collaboration. MethodsA proof-of-concept international 3D MDT clinic took place in November 2022, between Canniesburn Plastic Surgery Unit, UK and the National Reconstructive Plastic Surgery and Burns Centre, Korle Bu Teaching Hospital, Ghana. The 3D system was utilised 1) pre-visit to assess patients and enable logistical planning, 2) on-site in Ghana to further allow patients to see themselves and proposed operations in 3D, and 3) post-visit to debrief team and patients. Results4 Ghana patients were followed through their patient journey (mandibular ameloblastoma, sarcoma thigh, maxillary tumour, sarcoma back). 13 participants (4 patients, 4 Ghana clinicians, 5 UK clinicians) completed feedback on the 3D MDT. Outcome measures were rated highly with satisfaction 84.31/100, perceived benefit 4.54/5, overall quality 127.3/ 147 (Telehealth Usability Questionnaire), and usability 83.2/100 (System Usability Scale). These data show close alignment with that previously published on high income countries. ConclusionsThis novel technology has potential to enhance delivery of overseas surgical visits to low-to-middle income countries (LMIC), by improving planning, informed discussion with patients, expert consensus on complex cases, and fostering engagement with professionals who may be thousands of miles away. This is the first demonstration that real-time 3D Telemedicine can both work, and enhance care within an International MDT clinic, and may thus enable change in the approach to overseas surgical collaborations.

An Approach to Hemequity: Identifying the Barriers and Enablers of Iron Deficiency Reduction Strategies in Low-to-Middle-Income Countries

Background Approximately half a billion women of reproductive age worldwide are anemic, and iron deficiency is the most common cause. Iron deficiency anemia (IDA) is cyclical and compounding with intergenerational transfer of poor iron status, where antenatal and perinatal IDA predisposes to IDA in infancy. While IDA is correctable, it remains under-addressed globally and particularly in low-to-middle-income countries (LMICs), with 85% of cases occurring in LMICs of Africa and Asia. IDA is associated with significant morbidity and mortality. In fact, pre-existing anemia and lack of access to blood components and products are the main drivers of maternal deaths in LMICs. Despite abundant evidence that iron supplementation is an effective and life-saving intervention, there is little understanding of how to deliver it effectively in LMICs and its diverse health systems. Objective The primary objective of this study is to identify the enablers and barriers to effective implementation of IDA reduction strategies in LMICs in the published literature to date. Methods A scoping review was conducted using a comprehensive search of MEDLINE, Embase, Scopus, and grey literature from inception to March 2023. Two reviewers independently screened and performed data extraction. We included studies examining iron supplementation and its implementation amongst women of reproductive age who reside in LMICs, as defined by the World Bank. Behavioral, clinical, patient-oriented and process outcomes were also included. We were guided by the intersectionality-enhanced versions of the Theoretical Domains Framework and Consolidated Framework for Implementation Research in our data synthesis to understand the factors influencing health behaviors. Results Of the 9959 articles screened, 50 studies - primarily randomized control trials (6/50), cohort (19/50), cross-sectional (15/50) and other qualitative study designs (5/50) - were included. 50% of the studies were implemented in Africa, 42% in Asia, 6% in South America and 2% in the Middle East. Barriers and enablers of IDA reduction strategies are summarized in Figure 1. Barriers: Contextual barriers included the gross underestimation and deprioritization of IDA risk in women of reproductive age; gender norms and disparities with women's health ranking as the last priority in family dynamics; and intergenerational influences from mothers-in-law who are unfamiliar with iron supplements. Interestingly, the concept of “pill stigma” emerged as a salient theme where women were fearful that taking iron supplements could be mistaken for taking antiretrovirals, suggesting additive stigma from the HIV/AIDS epidemic. Poverty at the individual, government and stakeholder levels also led to supply chain barriers, further exacerbated by conflict, war and natural disasters undermining food security and community initiatives. Forgetfulness was cited as the most common barrier to individual iron supplement uptake. Enablers: Enablers at the individual level included knowledge of anemia and iron supplements, partner support, early access to care, high socioeconomic status, and maternal literacy. Successful interventions utilized existing infrastructures, such as schools and antenatal clinics, to facilitate delivery of supplements and community initiatives. Moreover, education initiatives that included women and their greater communities increased IDA knowledge and empowered women in community decision making. Community mobilization and the degree of community ownership also determined success and sustainability of IDA reduction strategies. Finally, adherence partners, already part of the woman's social network, helped address social and cultural constraints tailored to her individual context. Conclusion We identified numerous barriers and enablers of IDA reduction strategies at different levels of the socio-ecological model and its interaction with individual-level factors. IDA is not only a medical problem, but one that is rooted in the sociocultural and political context. Both contextual and individual factors contribute to overt and subclinical manifestations of IDA, leading to further iron debt and gender inequity in LMICs. Future interventions must recognize the resilience of LMIC communities and acknowledge the importance of knowledge translation and exchange rooted in local context with community ownership and empowerment.

93 Acceptability and Usability of Tablet-Based Neuropsychological Tests among South African and Ugandan Adolescents With and Without HIV

Objective:Neuropsychological (NP) tests are increasingly computerized, which automates testing, scoring, and administration. These innovations are well-suited for use in resource-limited settings, such as low- to middle- income countries (LMICs), which often lack specialized testing resources (e.g., trained staff, forms, norms, equipment). Despite this, there is a dearth of research on their acceptability and usability which could affect performance, particularly in LMICs with varying levels of access to computer technology. NeuroScreen is a tablet-based battery of tests assessing learning, memory, working memory, processing speed, executive functions, and motor speed. This study evaluated the acceptability and usability of NeuroScreen among two groups of LMIC adolescents with and without HIV from Cape Town, South Africa and Kampala, Uganda.Participants and Methods:Adolescents in Cape Town (n=131) and Kampala (n=80) completed NeuroScreen and questions about their use and ownership of, as well as comfort with computer technology and their experiences completing NeuroScreen. Participants rated their technology use -comfort with and ease-of-use of computers, tablets, smartphones, and NeuroScreen on a Likert-type scale: (1) Very Easy/Very Comfortable to (6) Very Difficult/Very Uncomfortable. For analyses, responses of Somewhat Easy/Comfortable to Very Easy/Comfortable were collapsed to codify comfort and ease. Descriptive statistics assessed technology use and experiences of using the NeuroScreen tool. A qualitative question asked how participants would feel receiving NeuroScreen routinely in the future; responses were coded as positive, negative, or neutral (e.g., “I would enjoy it”). Chi-squares assessed for group differences.Results:South African adolescents were 15.42 years on average, 50.3% male, and 49% were HIV-positive. Ugandan adolescents were 15.64 years on average, 50.6% male, and 54% HIVpositive. South African participants were more likely than Ugandan participants to have ever used a computer (71% vs. 49%; p&lt;.005), or tablet (58% vs. 40%; p&lt;.05), whereas smartphone use was similar (94% vs 87%). South African participants reported higher rates of comfort using a computer (86% vs. 46%; p&lt;.001) and smartphone (96% vs. 88%; p&lt;.05) compared to Ugandan participants. Ugandan adolescents rated using NeuroScreen as easier than South African adolescents (96% vs. 87%; p&lt;.05).). Regarding within-sample differences by HIV status, Ugandan participants with HIV were less likely to have used a computer than participants without HIV (70% vs. 57%; p&lt;.05, respectively).The Finger Tapping test was rated as the easiest by both South African (73%) and Ugandan (64%) participants. Trail Making was rated as the most difficult test among Ugandan participants (37%); 75% of South African participants reported no tasks as difficult followed by Finger Tapping as most difficult (8%). When asked about completing NeuroScreen at routine doctor’s visits, most South Africans (85%) and Ugandans (72%) responded positively.Conclusions:This study found that even with low prior tablet use and varying levels of comfort in using technology, South African and Ugandan adolescents rated NeuroScreen with high acceptability and usability. These data suggest that scaling up NeuroScreen in LMICs, where technology use might be limited, may be appropriate for adolescent populations. Further research should examine prior experience and comfort with tablets as predictors NeuroScreen test performance.

PAEDIATRIC-15 MANAGEMENT OF PEDIATRIC CENTRAL NERVOUS SYSTEM TUMORS BY A NEURO-ONCOLOGY MULTIDISCIPLINARY TEAM : OUR EXPERIENCE

Abstract The outcome of pediatric central nervous system tumors has improved over the past decades due to advances in diagnostic testing, treatment and increased understanding of the disease biology. Nevertheless, the probability of survival of this tumors remains much lower in low-to middle-income countries. The gaps that prevent optimal clinical management of brain tumors are multifactorial and mostly related to underdiagnosis; a lack of specialized and dedicated radiologic, histopathologic, neurosurgical, radiotherapeutic, and oncology services, and a deficiency of coordinated multidisciplinary care in many centers. The aim of this report was to evaluate the impact of multidisciplinary team meetings on the clinical management of pediatric central nervous system tumors in Abidjan (Côte d'Ivoire). We retrospectively reviewed the clinical data of pediatric patients (aged &amp;lt;15 years) with central nervous system tumors diagnosed and treated in the Neurosurgery Department and National Center of Radiotherapy between 2019 (the year a neuro-oncological multidisciplinary staff was established) and 2023. Data on patient demographics, clinical notes, imaging studies, tumor characteristics and multidisciplinary team decision were collected from the multidisciplinary team database. During the multidisciplinary team meetings era, 40 pediatric central nervous system tumors were diagnosed and treated. The median age at diagnosis was 8.5 years. The mostly histological types were high grade and low grade gliomas. Decision-making was largely consistent with available guidelines. Therapeutic were surgery, external beam radiation treatment with concurrent and adjuvant chemotherapy. Benefits of neuro-oncology multidisciplinary team include coordination, direction for complicated cases, education, and a forum for communication, and clinical trials.

Psychometric properties of End Stage Renal Disease-Adherence Questionnaire-Sinhalese version among patients receiving haemodialysis.

The chronic kidney disease is a leading public health concern, particularly in low-to middle-income countries, while the number of patients receiving haemodialysis is rapidly increasing. Adherence to a complex treatment regimen is vital for those patients on maintenance haemodialysis though the precise evaluation is reported inadequately. This study aimed to evaluate the psychometric properties of Sinhalese version of End Stage Renal Disease-Adherence Questionnaire (SINESRD-AQ) to assess treatment adherence behaviour among patients receiving haemodialysis in a Sri Lankan hospital. The cultural adaptation of ESRD-AQ involved forward and back translation, expert committee consolidation and pretesting among patients (n = 10). Face and content validity of the questionnaire was evaluated using a modified Delphi technique. Construct validity of the subscales of SINESRD-AQ was evaluated using confirmatory factor analysis (CFA). A descriptive cross-sectional study among a consecutive sample of 150 patients receiving haemodialysis in a selected Teaching hospital, Sri Lanka was involved in performing CFA. Reliability was confirmed with test-retest reliability. Excellent face and content validity were reported with Item level content validity index (0.83-1.0), Average Item level content validity index for whole scale (0.93), Item level content validity ratio (0.67-1.0) and modified kappa statistic coefficient (0.81-1.0). CFA of two subscales demonstrated better indices closure to the model fit with five- item two factor model for direct adherence behaviour subscale and eight-item two factor model for attitude/perception subscale. The intra class correlation coefficient of 0.837 (p<0.001) and 0.752 (p<0.001) indicated acceptable test-retest reliability of direct adherence behaviour and attitude/perception subscale respectively. The study confirmed SINESRD-AQ as a valid and reliable measure which enables periodic assessment of treatment adherence behaviour of the patients receiving haemodialysis in a Sri Lankan hospital.

Prevalence of adolescent-reported food insecurity and the determinants including coping strategies living in urban slum communities of Bangladesh during the era of COVID-19: a cross-sectional study

BackgroundAs food insecurity (FI) continues to rise worldwide especially in developing countries like Bangladesh, adolescent experience of FI have received minimal attention globally. This study aimed to identify the prevalence of adolescent-reported FI and its association with individual and socio-environmental factors as well as coping strategies amongst a sample of adolescents living in urban slum areas of Bangladesh in the times of the Coronavirus 19 (COVID-19) pandemic.MethodsA descriptive cross sectional study was conducted amongst 326 adolescents (12–18 years) living in the urban slums of Narayanganj, Dhaka from April to May, 2022. Adolescent-reported FI was assessed using a structured questionnaire adopted from Household Food Insecurity Access Scale (HFIAS). Descriptive statistics, Chi-square tests and ordinal logistic regression were used to draw inference.ResultsPrevalence of adolescent-reported FI was high (46.6% moderate and 29.8% severe). The likelihood of experiencing moderate or severe FI versus no/mild FI were 1.7 times (95% Confidence Interval (CI) [1.1, 2.5]) higher in younger adolescents and 5 times (95% CI [2.3, 12.7]) higher in unemployed youth. Socio-environmental factors determining the economic status of a household such as higher number of family members, only one earning family member, unemployed father, no household assets, food aid received by the family during pandemic and positive COVID-19 infection in family were associated with moderate and severe FI. Coping strategies such as a higher number of food seeking strategies (Adjusted Odds Ratio (AOR) 3.4, 95% CI [1.9, 5.9]), substance use (AOR 6.2, 95% CI [1.2, 31.7]) and stopping school (AOR 3.3, 95% CI [1.9, 5.7]) increased odds for moderate and severe FI. Stratified by drop-out of school status, an association between food seeking strategies and FI remained significant among those school-going, while there was no association among those dropping out of school.ConclusionThis study showed that adolescents living in urban slum communities in Bangladesh are at very high risk of FI and resort to harmful coping strategies. Our study highlights the importance of further research in adolescent reported FI and coping strategies in low to middle income countries (LMICs) and create appropriate interventions to lower FI among this group and improve their state of health and wellbeing.

Landscape review of global real-world data sources for studying medication use in pregnancy and lactation that support regulatory decision making.

Most pregnant people take at least one medication during gestation or while breastfeeding, however data are lacking on the safety of medication use in these populations. We conducted a landscape review of real-world data sources specific to medication use in pregnancy and breastfeeding populations that have met, or have potential to meet, health authorities' requirements for post-authorization safety studies. A 2-phase approach identified data sources from literature, publicly available registers of non-interventional post-authorization studies of pregnant women, existing database inventories, and emerging data sources known to the authors. Required key attributes were assessed according to current regulatory guidance, resulting in selection of 49 suitable data sources. All global regions were represented, with North America (37%) and Europe (33%) most common; 12% of the data sources included pregnancy information from low-to middle-income countries. Administrative healthcare claims (25%) and electronic healthcare records (21%) comprised the largest types of data sources. Across data sources, 53% were managed by national or regional governments, 27% by industry, and 20% by academic institutions. Maternal age, diagnoses, prenatal care, and reproductive history were available in most, whereas fewer included demographic data (e.g., race/ethnicity). Breastfeeding data were collected in 37% of the final data sources. We conducted a systematic approach to data source evaluation of pregnancy and breastfeeding to be used as a resource for investigators to consider when designing pregnancy-related research studies to satisfy regulatory requirements.

“We Must Sit Like This and Discuss”: Introducing Needs Ranking as an Innovative Qualitative Methodology for Engaging Disengaged Youth

Giving a voice to youth and promoting their health and well-being is essential for successful future communities. However, millions of youth, particularly in low-to middle-income countries, are misunderstood, lack a voice, and face many challenges, which maintains their disengagement. As approaches for youth engagement evolve, this paper presents an innovative, qualitative methodology to engage vulnerable youth (NEETs – acronym for youth who are Not in Education, Employment or Training) in identifying and ranking their needs and giving them a voice to contribute to prevention programming. Drawing on principles of empowerment theory, the paper expands on the popular youth-adult partnerships’ literature by injecting a new engagement approach that focuses on (i) using a literature-based community needs assessment, (ii) engaging vulnerable youth in small group discussion to rank their needs, (iii) comparing rankings between groups, (iv) creating spaces for youth to include other pressing issues not identified in the literature, and (iv) comparing rankings across surrounding communities. The ideas presented demonstrate that the Needs Ranking activity, as an engagement and data collection tool, may be particularly relevant in gathering viewpoints and opinions of underserved youth. These youth are traditionally not well represented through the more conventional and common methods currently employed in research and community development such as local government community development board meetings and needs assessments, and research interviews. The paper also creates awareness around the Needs Ranking activity as a viable and verifiable qualitative approach in youth engagement.

Increased adherence to ACOG diagnostic guidelines for HDP following a workshop in Bolivia, a LMIC

ObjectivesHypertensive disorders of pregnancy (HDP) exert a heavy mortality burden in low- to middle-income countries (LMIC). ACOG revised HDP diagnostic guidelines to improve identifying pregnancies at greatest risk but whether they are used in LMIC is unknown. Study designWe held a workshop to review ACOG guidelines in La Paz, Bolivia (BO) and then reviewed prenatal, labor and delivery records for all HDP diagnoses and twice as many controls at its three largest delivery sites during the year before and the nine months after a workshop (n = 1376 cases, 2851 controls during the two periods). Main outcome measuresHDP diagnoses, maternal, and infant characteristics. ResultsBolivian and ACOG criteria identified similar frequencies of gestational hypertension (GH) or eclampsia, but preeclampsia with severe features (sPE) was under- and preeclampsia without severe features (PE) over-reported during both periods. Increases occurred after the workshop in testing for proteinuria and the detection of abnormal laboratory values and severe hypertension in HDP women. Any adverse maternal outcome occurred more frequently after the workshop in women with BO PE or sPE diagnoses who met ACOG sPE criteria. ConclusionsUtilization of ACOG guidelines increased following the workshop and improved identification of PE or sPE pregnancies with adverse maternal outcomes. Continued use of a CLAP perinatal form recognizing HELLP as the only kind of sPE resulted in under-reporting of sPE. FundingNIH TW010797, HD088590, HL138181.

Barriers and mechanisms to the development of palliative care in Aceh, Indonesia

The aim of this study was to identify barriers and mechanisms in the development of palliative care in the province of Aceh, North West Indonesia. Several factors, including an ageing population, have increased palliative care needs in the region; however, as with many low to middle income countries (LMICs), palliative care is not well established or integrated into mainstream health care services. Consequently, many people may experience serious health-related suffering (SHRS) at the end-of-life. Qualitative semi-structured interviews and focus groups were conducted with key stakeholders in Aceh, Indonesia and a semi-structured interview guide prompted an exploration of palliative care provision, including barriers and enablers. Interviews were digitally recorded, transcribed, and analysed using the principles of thematic analysis. Eight interviews and two focus groups were conducted with medics (n = 6), nurses (n = 7), hospital management (n = 1) and religious/cultural leaders (n = 2). The findings indicate that all participants recognise a need to reduce SHRS and a growing impetus to embed a culturally salient and sustainable model of palliative care within the Aceh healthcare system. The following four themes indicate key areas for further focus: (1) Local vision and leadership, (2) Prioritisation of palliative care policy and funding, (3) Access to palliative care in community and public services, and (4) supporting palliative care in the cultural context of Sharia law, family, and faith. Future expansion requires the identification of a culturally and socioeconomically salient package of palliative care which operates across rural community and acute care settings and is informed by further evaluation and evidence.

ACCESS model: a step toward an empowerment model in global health education

The approaches to global health (GH) partnerships are as varied as the programs available across the globe. Few models have shared their philosophy and structure in sufficient detail to inform a full spectrum of how these collaborations are formed. Although contributions from low- to middle-income countries (LMICs) have markedly grown over the last decade, they are still few in comparison to those from high-income countries (HICs). In this article, we share the African Community Center for Social Sustainability (ACCESS) model of GH education through the lenses of grassroots implementers and their international collaborators. This model involves the identification and prioritization of the needs of the community, including but not limited to healthcare. We invite international partners to align with and participate in learning from and, when appropriate, becoming part of the solution. We share successes, challenges, and takeaways while offering recommendations for consideration when establishing community-driven GH programs.

Passive Sampler Technology for Viral Detection in Wastewater-Based Surveillance: Current State and Nanomaterial Opportunities.

Although wastewater-based surveillance (WBS) is an efficient community-wide surveillance tool, its implementation for pathogen surveillance remains limited by ineffective sample treatment procedures, as the complex composition of wastewater often interferes with biomarker recovery. Moreover, current sampling protocols based on grab samples are susceptible to fluctuant biomarker concentrations and may increase operative costs, often rendering such systems inaccessible to communities in low-to-middle-income countries (LMICs). As a response, passive samplers have emerged as a way to make wastewater sampling more efficient and obtain more reliable, consistent data. Therefore, this study aims to review recent developments in passive sampling technologies to provide researchers with the tools to develop novel passive sampling strategies. Although promising advances in the development of nanostructured passive samplers have been reported, optimization remains a significant area of opportunity for researchers in the area, as methods for flexible, robust adsorption and recovery of viral genetic materials would greatly improve the efficacy of WBS systems while making them more accessible for communities worldwide.

Assessing household fine particulate matter (PM2.5) through measurement and modeling in the Bangladesh cook stove pregnancy cohort study (CSPCS)

Biomass fuel burning is a significant contributor of household fine particulate matter (PM2.5) in the low to middle income countries (LMIC) and assessing PM2.5 levels is essential to investigate exposure-related health effects such as pregnancy outcomes and acute lower respiratory infection in infants. However, measuring household PM2.5 requires significant investments of labor, resources, and time, which limits the ability to conduct health effects studies. It is therefore imperative to leverage lower-cost measurement techniques to develop exposure models coupled with survey information about housing characteristics. Between April 2017 and March 2018, we continuously sampled PM2.5 in three seasonal waves for approximately 48-h (range 46 to 52-h) in 74 rural and semi-urban households among the participants of the Bangladesh Cook Stove Pregnancy Cohort Study (CSPCS). Measurements were taken simultaneously in the kitchen, bedroom, and open space within the household. Structured questionnaires captured household-level information related to the sources of air pollution. With data from two waves, we fit multivariate mixed effect models to estimate 24-h average, cooking time average, daytime and nighttime average PM2.5 in each of the household locations. Households using biomass cookstoves had significantly higher PM2.5 concentrations than those using electricity/liquefied petroleum gas (626 μg/m3 vs. 213 μg/m3). Exposure model performances showed 10-fold cross validated R2 ranging from 0.52 to 0.76 with excellent agreement in independent tests against measured PM2.5 from the third wave of monitoring and ambient PM2.5 from a separate satellite-based model (correlation coefficient, r = 0.82). Significant predictors of household PM2.5 included ambient PM2.5, season, and types of fuel used for cooking. This study demonstrates that we can predict household PM2.5 with moderate to high confidence using ambient PM2.5 and household characteristics. Our results present a framework for estimating household PM2.5 exposures in LMICs, which are often understudied and underrepresented due to resource limitations.