Mid-income Countries Research Articles

650-P: Safety and Effectiveness of Recombinant Human Insulin Insugen in Real-World Clinical Setting

Background: As the burden of diabetes is increasing dramatically, the demand of insulin is also on rise, affordable access to insulin remains a challenge, particularly in Low and Mid income countries. For that reason, recombinant human insulin (rHI) formulations are considered to be effective alternatives to insulin analogues in countries with limited healthcare systems and resources. Continuing patient education and support programmes with rHI are critical role players in improving the access and overall disease management. Objective: This is a non-interventional study to observe the safety and effectiveness of Recombinant Human insulin in a real world population with type 2 (T2DM) diabetes mellitus from Indian perspective. Methodology: Out of 10426 diabetes patients who were enrolled in patient support program i.e “Insulin Therapy Assistance Program (iTAP)”, 5691 patients were initiated with various formulations of rHI (Insugen R, N, 30/70 and 50/50). Insulin therapy was initiated in T2DM patients with A1C > 7%. HbA1c, FPG and PPG values were recorded at baseline and follow up of 3, 6 and 9 months. Results: The Figure 1, 2, 3 depict the baseline and follow up of FBG, PPG and HbA1c respectively. Figure 1. Change in FPG (*p<0.05). Figure 2. Change in PPG (*p<0.05). Figure 3. Change in HbA1c (*p<0.05). Conclusion: In the current study, various formulations of rHI were well tolerated and resulted in significant reduction of HbA1c, FPG and PPG when aided with patient support program. Considering the economic impact of diabetes patients in taking insulins, human insulin become an alternative option in comparison to analogues which are expensive. Early initiation of insulin therapy can prevent or delay diabetes complications. Access to affordable insulin therapy is the key success factor while considering Insulin Therapy. Disclosure P. Raj: Employee; Self; Biocon. P. J: None. D.C. Mathew: None. C. Biswas: None. S. Nethra: None.

How Far Can Telehealth Help Patients in Social Distancing due to Covid-19 in Low- and Mid-Income Countries? (Preprint)

How Far Can Telehealth Help Patients in Social Distancing due to Covid-19 in Low- and Mid-Income Countries? (Preprint)

Identification of developmental disorders including autism spectrum disorder using salivary miRNAs in children from Bosnia and Herzegovina.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by major social, communication and behavioural challenges. The cause of ASD is still unclear and it is assumed that environmental, genetic and epigenetic factors influence the risk of ASD occurrence. MicroRNAs (miRNAs) are short 21-25 nucleotide long RNA molecules which post-transcriptionally regulate gene expression. MiRNAs play an important role in central nervous system development; therefore, dysregulation of miRNAs is connected to changes in behaviour and cognition observed in many disorders including ASD. Based on previously published work, on diagnosing ASD using miRNAs, we hypothesized that miRNAs can be used as biomarkers in children with suspected developmental disorders (DD) including ASD within Bosnian-Herzegovinian (B&H) population. 14 selected miRNAs were tested on saliva of children with suspected developmental disorders including ASD. The method of choice was qRT-PCR as a relatively cheap method available in most diagnostic laboratories in low to mid-income countries (LMIC). Out of 14 analysed miRNAs, 6 were differentially expressed between typically developing children and children with some type of developmental disorder including autism spectrum disorder. Using the most optimal logistic regression, we were able to distinguish between ASD and typically developing (TD) children. We have found 5 miRNAs as potential biomarkers. From those, 3 were differentially expressed within the ASD cohort. All 5 miRNAs had shown good chi-square statistics within the logistic regression performed on all 14 analysed miRNAs. The accuracy of 5-miRNAs model training set was 90.2%, while the validation set had a 90% accuracy. This study has shown that miRNAs may be considered as biomarkers for ASD detection and may be used to identify children with ASD along with standard developmental screening tests. By combining these methods we may be able to reach a reliable and accessible diagnostic model for children with ASD in LMIC such as B&H.

The Spatial Patterns and Local Economic Determinant of Industrial Agglomeration in Semarang District, Indonesia

Urbanization creates opportunities for Indonesia, potentially to boost economic growth and create vibrant cities (metropolitan). Urbanization and agglomeration economies should be an important element in Indonesia‘s development as a mid-income country. Manufacturing industry becomes a dominant economic sector in metropolitan area such as Semarang that shows urbanization-industrialization relationship. Industrial agglomeration potentially induces socio-economic changes in the region. To prepare these changes, it is important to understand the spatial dynamics of agglomeration and predict its determinants locally. This paper aims to answer questions related to the spatial patterns and determinants of industrial agglomeration in Semarang Regency, a periphery of Semarang metropolitan. Nearest Neighbor Analysis is used to identify spatial patterns, followed by Ellison and Glaeser Index to measure agglomeration strength, and Specialization Index to measure industrial specialization. Geographically Weighted Regression is used to identify determinants of agglomeration. Analysis uses geographical database of Large and Medium Industries in 2016 and related sub-district based data. Result shows 11 of 21 sub-sectors of industries geographically form clustered (agglomerated) pattern. Six of them are strongly agglomerated (most localized). High specializations in these six sub-sectors occur in 14 sub-districts. Result obtains a significant spatial regression model explains the effect of independent variables simultaneously occurring in three sub-sectors: beverages; wearing apparel; wood and products of wood and cork, except furniture, articles of straw and plaiting materials. Partially, industrial agglomeration by three sub-sector’s specializations in sub-district level is determined by variables: industrial employment; vocational school; Gross Regional Domestic Product; population; arterial road; agricultural land availability; and agricultural households.

Residential green space, air pollution, socioeconomic deprivation and cardiovascular medication sales in Belgium: A nationwide ecological study

Green space may improve cardiovascular (CV) health, for example by promoting physical activity and by reducing air pollution, noise and heat. Socioeconomic and environmental factors may modify the health effects of green space. We examined the association between residential green space and reimbursed CV medication sales in Belgium between 2006 and 2014, adjusting for socioeconomic deprivation and air pollution. We analyzed data for 11,575 census tracts using structural equation models for the entire country and for the administrative regions. Latent variables for green space, air pollution and socioeconomic deprivation were used as predictors of CV medication sales and were estimated from the number of patches of forest, census tract relative forest cover and relative forest cover within a 600 m buffer around the census tract; annual mean concentrations of PM2.5, BC and NO2; and percentages of inhabitants that were foreign-born from lower- and mid-income countries, unemployed or had no higher education. A direct association between socioeconomic deprivation and CV medication sales [parameter estimate (95% CI): 0.26 (0.25; 0.28)] and inverse associations between CV medication sales and green space [−0.71 (−0.80; −0.61)] and air pollution [−1.62 (−1.69; −0.61)] were observed. In the regional models, the association between green space and CV medication sales was stronger in the region with relatively low green space cover (Flemish Region, standardized estimate −0.16) than in the region with high green space cover (Walloon Region, −0.10). In the highly urbanized Brussels Capital Region the association tended towards the null. In all regions, the associations between CV medication sales and socioeconomic deprivation were direct and more prominent. Our results suggest that there may be an inverse association between green space and CV medication sales, but socioeconomic deprivation was always the strongest predictor of CV medication sales.

A Distributed Gamified System Based on Automatic Assessment of Physical Exercises to Promote Remote Physical Rehabilitation

Physical rehabilitation aims at improving the functional ability and quality of life of patients affected by physical impairments or disabilities. Neurological diseases represent the largest cause of disability worldwide. For many, there is no cure and physiotherapy allows symptoms to be managed. Physiotherapy is based on the daily execution of exercises, traditionally under the supervision of a therapist. However, performing these exercises requires that both the patient and the physiotherapist are together so that the physiotherapist can assist the patient while exercising. For patients with a neurological condition, rehabilitation is a long term process, lasting months or even years. Not withstanding the personal costs, the cost of care/physiotherapy is high and represents €27,711 per year in Spain. This is compounded by a shortage of qualified therapists, often cited as one reason why stroke survivors do not received the recommended amount of therapy. The challenge is even greater in low to mid-income countries where there is a lack of trained personnel as well as under-served and remote regions. Technology can be employed to alleviate these problems by remotely monitoring a rehabilitation session taking place at home or anywhere in the community. This paper presents a computer vision-based system for home-use that automatically assesses how well the patient performs the exercises and transmits the information back to the clinic. The patient and physiotherapist do not need to be co-located. Gamification methods and techniques are used to engage patients when carrying out the rehabilitation routines. To this end, we propose a distributed gamified system that automatically evaluates the performance of exercises by analyzing and comparing motion curves using the DTW (Dynamic Time Warping) algorithm.

Pediatric Cardiac Surgery in Low-and Middle-Income Countries: Present Status and Need for a Paradigm Shift.

In low and mid-income countries, there has been a 50% global decrease in the incidence of preventable deaths of children since 1990. However, the mortality from non-communicable diseases (NCD) such as congenital heart disease (CHD) has not changed. Of the estimated 1.3 million children born with CHD annually, over 90% do not have access to cardiac care. With the increasing fertility rates in sub-Saharan Africa, the health burden of CHD will increase as well. Over the last 30 years much has been achieved with short term cardiac medical missions. However, much remains to be done to provide long term solutions needed to achieve the sustainable development goal of reducing deaths of children <5 years of age. This review discusses the present status and the need for a paradigm shift to achieve long term sustainability.

Fine particulate (PM2.5) dynamics before and after China's “Reform and Opening up” policy in Shenzhen

Understanding the trade-off between urbanization and air pollution could provide important insights on urban sustainable development. Such cases in China were very rare for PM2.5 due to the recent short-term availability of the PM2.5 monitoring records. We therefore estimated the long time series PM2.5 concentration in Shenzhen during 1973–2017 under the truth that PM2.5 is the major component of PM10, and PM2.5 have a significant relationship (y = 100e−0.086x; r = 0.69, P < 0.05) with meteorological visibility in Shenzhen. We found that Shenzhen's PM2.5 concentration experienced an inversed U-shape changes with five distinct stages of slow increase, rapid increase, stay in high level, slow decrease and rapid decrease. Shenzhen's PM2.5 concentration dynamic was not fully followed the EKC's inverse U-shape but a M-shape. The results of this research would not only provide an example for the other cities in China but also suggest to other cities in low- and mid-income countries for developing through a better way of paying more attention to the trade-off between urban development and urban air pollution.

Molecular identification of Entamoeba histolytica from stool samples of Ilam, Iran.

Amoebiasis is a multifactorial, life-threatening public health issue and the third parasitic disease cause of mortality in worldwide, particularly in low- and mid-income countries. The aim of this study was to attempt to explore genetic encoding differences of CP8 (conserved gene) of Entamoeba histolytica/Entamoeba dispar in its various infectious properties isolated from Ilam located at a southwest part of Iran. A total of 2023 stool samples were collected between 2016 and 2018 from the hospital in Ilam, of which only 30 isolates were identified as E. histolytica/E. dispar. These isolates were collected from the intensive care unit, infectious disease, and surgery settings. The isolates were identified and the polymerase chain reaction (PCR) was performed to detect the CP8 gene. In all stages, Entamoeba histolytica HM1: IMSS was used as a positive control. In genotype confirmation, only two isolates had the CP8 gene found in the PCR technique. The sequencing results confirmed the mentioned gene with 99%-100% specificity. It is concluded that PCR is highly sensitive to detect E. histolytica and indicating this important role as screening tools in direct DNA extraction from stool samples and valuable technique in early detection of symptomatic and asymptomatic E. histolytica patients.

Does Lengthening the School Day Increase School Value-Added? Evidence from a Mid-Income Country

abstractMany mid-income countries face a significant and challenging problem of low educational achievement. This research looks at a Full-Time Primary Schools Programme implemented in Mexico, to work out if extending the time pupils spend at school can enhance skills in language and mathematics. The results of matching plus difference-in-differences point to a positive impact on schools value-added. The effects are concentrated among poorer schools, with gains after policy adoption of 0.11 standard deviations (SD) in both subjects. However, quantile regressions show that the lowest-performance schools are not benefiting from longer school days, posing questions on programme effectiveness to improve the achievement of those who are more in need. Analysis of causal channels suggests that gains reported by the programme do not come from changes in the composition of teachers and pupils in treated schools, and that richer schools are more prone to devote the extra-time of instruction to non-core subjects, notably sports and arts.

Using social norms theory for health promotion in low-income countries.

Social norms can greatly influence people's health-related choices and behaviours. In the last few years, scholars and practitioners working in low- and mid-income countries (LMIC) have increasingly been trying to harness the influence of social norms to improve people's health globally. However, the literature informing social norm interventions in LMIC lacks a framework to understand how norms interact with other factors that sustain harmful practices and behaviours. This gap has led to short-sighted interventions that target social norms exclusively without a wider awareness of how other institutional, material, individual and social factors affect the harmful practice. Emphasizing norms to the exclusion of other factors might ultimately discredit norms-based strategies, not because they are flawed but because they alone are not sufficient to shift behaviour. In this paper, we share a framework (already adopted by some practitioners) that locates norm-based strategies within the wider array of factors that must be considered when designing prevention programmes in LMIC.

Theory and practice of social norms interventions: eight common pitfalls

BackgroundRecently, Global Health practitioners, scholars, and donors have expressed increased interest in “changing social norms” as a strategy to promote health and well-being in low and mid-income countries (LMIC). Despite this burgeoning interest, the ability of practitioners to use social norm theory to inform health interventions varies widely.Main bodyHere, we identify eight pitfalls that practitioners must avoid as they plan to integrate a social norms perspective in their interventions, as well as eight learnings. These learnings are: 1) Social norms and attitudes are different; 2) Social norms and attitudes can coincide; 3) Protective norms can offer important resources for achieving effective social improvement in people’s health-related practices; 4) Harmful practices are sustained by a matrix of factors that need to be understood in their interactions; 5) The prevalence of a norm is not necessarily a sign of its strength; 6) Social norms can exert both direct and indirect influence; 7) Publicising the prevalence of a harmful practice can make things worse; 8) People-led social norm change is both the right and the smart thing to do.ConclusionsAs the understanding of how norms evolve in LMIC advances, practitioners will develop greater understanding of what works to help people lead change in harmful norms within their contexts. Awareness of these pitfalls has helped several of them increase the effectiveness of their interventions addressing social norms in the field. We are confident that others will benefit from these reflections as well.

Sedentary behavior and body composition in children of low-and mid-income countries: a review

This study reviewed the relationship between sedentary behavior (SB) and body composition in children and adolescents from low-and-mid income countries (LMIC). A systematic review was developed through manual and electronic searches in eight databases. Were included observational studies conducted in LMIC, with children and adolescents from three to 19 years. As results, 39 original articles were found (37 cross-sectional, 1 case control study and 1 cohort), which in all presented 75 analyzes, most of them based on screen behaviors (n = 71; 94.7%). At all, 15 of 25 analyses showed risk associations between SB and unfavorable body composition. When focusing on the dose of sedentary behavior, risk associations were verified in distinct cut of points: 1h/d (3 of 3 analyses); 2h/d (9 of 16); 3h/d (2 of 5); 4h/d (4 of 5) and 5h/d (3 of 6). Television time was the SB type most frequently associated as risk in all categories. In conclusion, recognition of these associations is important both to support future studies and for its dissemination in preventive messages in the population of interest. Also, further longitudinal studies are necessary for narrowing the casual relationships between the variables.

Business Modeling and Public Policy in High-Tech Industries: Exploratory Evidences from Two Brazilian Semiconductor Support Programs

This paper adopts an exploratory analysis based on a multiple case study to investigate the interplay of Small and Medium Enterprises (SMEs) business modeling strategies and Science, Technology and Innovation (STI) policies in a mid-income country efforts to develop a national semiconductor industry. Specifically, we analyze how 22 Brazilian SMEs supported by two comprehensive federal programs designed and implemented business models and strategies in an attempt to, on the one hand, meet the scope and timing of public funding resources and, on the other hand, develop capabilities to enter the industry’s global value chain. Drawing on a wide body of literature and on the evidence collected, we identified and categorized the firms’ business models into five groups: Pure Play IP, Pure Play Design, Fabless, Fabless Plus and Captive. We then analysed the firms’ within the specificities of each group. The paper shows that, in addition to business models and strategies oriented to meet short-term survival needs, the financial benefits for firms were low and unstable, with recurrent and unresolved frictions between policy-makers, planners and firms.

Four avenues of normative influence: A research agenda for health promotion in low and mid-income countries.

Health promotion interventions in low and midincome countries (LMIC) are increasingly integrating strategies to change local social norms that sustain harmful practices. However, the literature on social norms and health in LMIC is still scarce. A well-known application of social norm theory in LMIC involves abandonment of female genital cutting (FGC) in West Africa. We argue that FGC is a special case because of its unique relationship between the norm and the practice; health promotion interventions would benefit from a wider understanding of how social norms can influence different types of health-related behaviors. We hypothesize that four factors shape the strength of a norm over a practice: (1) whether the practice is dependent or interdependent; (2) whether it is more or less detectable; (3) whether it is under the influence of distal or proximal norms; and (4) whether noncompliance is likely to result in sanctions. We look at each of these four factors in detail, and suggest that different relations between norms and a practice might require different programmatic solutions. Future findings that will confirm or contradict our hypothesis will be critical for effective health promotion interventions that aim to change harmful social norms in LMIC. (PsycINFO Database Record

Growing Urbanization and the Impact on Fine Particulate Matter (PM2.5) Dynamics

Changes in urban air quality and its relationship with growing urbanization provide an important insight into urban development strategies. Thus, we collected remotely sensed PM2.5 concentrations, as well as urban population datasets, and analyzed the scaling relationship between changes in urban population and concentrations of PM2.5. The majority of large cities in North America and Europe had PM2.5 concentrations which decreased significantly. Only 2.0% of large cities in the U.S. were found to have significant positive trends. PM2.5 concentration trends of less than 0.5 μg/m3·year were found in all large cities of Africa and Latin America. However, PM2.5 concentration trends of more than 1.0 μg/m3·year were found in 56.7% of the large cities in Asia, where only 2.3% of the cities in China were found with significant negative trends, and no cities in India were found with significant negative trends. Large cities in Asia were found with contributions of 4.12 ± 4.27 μg/m3·year per million people, particularly large cities in China (5.40 ± 4.80 μg/m3·year per million people) and India (4.07 ± 3.07 μg/m3·year per million people). Significant negative or positive relationships were obtained between PM2.5 trends and population change rates in large cities of North America (R2 = 0.9195, p &lt; 0.05) or Europe (R2 = 0.9161, p &lt; 0.05). Moreover, a significant inverse “U-type” relationship (R2 = 0.8065, p &lt; 0.05) was found between PM2.5 trends and population change rates in large cities of Asia. In addition, the positive or negative relationships between the trends in population and PM2.5 were obtained in typical low- and mid-income countries (e.g., China and India) or high-income countries (e.g., USA), respectively.

Using social norms theory for health promotion in low-income countries.

SummarySocial norms can greatly influence people’s health-related choices and behaviours. In the last few years, scholars and practitioners working in low- and mid-income countries (LMIC) have increasingly been trying to harness the influence of social norms to improve people’s health globally. However, the literature informing social norm interventions in LMIC lacks a framework to understand how norms interact with other factors that sustain harmful practices and behaviours. This gap has led to short-sighted interventions that target social norms exclusively without a wider awareness of how other institutional, material, individual and social factors affect the harmful practice. Emphasizing norms to the exclusion of other factors might ultimately discredit norms-based strategies, not because they are flawed but because they alone are not sufficient to shift behaviour. In this paper, we share a framework (already adopted by some practitioners) that locates norm-based strategies within the wider array of factors that must be considered when designing prevention programmes in LMIC.

Social Norms and Adolescents' Sexual Health: An Introduction for Practitioners Working in Low and Mid-income African countries.

Donors, practitioners and scholars are increasingly interested in harnessing the potential of social norms theory to improve adolescents' sexual and reproductive health outcomes. However, social norms theory is multifaceted, and its application in field interventions is complex. An introduction to social norms that will be beneficial for those who intend to integrate a social norms perspective in their work to improve adolescents' sexual health in Africa is presented. First three main schools of thought on social norms, looking at the theoretical standpoint of each, are discussed. Next, the difference between two important types of social norms (descriptive and injunctive) is explained and then the concept of a -reference group‖ is examined. The difference between social and gender norms are then considered, highlighting how this difference is motivated by existing yet contrasting approaches to norms (in social psychology and gender theory). In the last section, existing evidence on the role that social norms play in influencing adolescents' sexual and reproductive health are reviewed. Conclusions call for further research and action to understand how norms affecting adolescents' sexual and reproductive health and rights (SRHR) can be changed in sub-Saharan Africa.

Theory and Practice of Social Norms Interventions: Eight Common Pitfalls

Background: Scholars and practitioners working in health promotion and gender equality in low and mid-income countries (LMIC) are witnessing heightened interest in changing social norms to achieve greater wellbeing. Despite this burgeoning interest, the ability of practitioners to use social norm theory to inform programming, varies widely. Main Body: Here, we identify eight pitfalls that practitioners must avoid as they plan to integrate a social norms perspective in their interventions and as many learnings. The eight learnings are: 1) Social norms and attitudes are different; 2) Social norms and attitudes can be concordant; 3) Protective norms can offer important resources for achieving effective social improvement in people's gender-related health practices; 4) Harmful practices are sustained by an ecology of factors that need to be understood in their interactions; 5) The prevalence of a norm is not necessarily a sign of its strength; 6) Social norms can exert both direct and indirect influence; 7) Publicising the prevalence of a harmful practice can make things worse; 8) People-led social norm change is both the right and the smart thing to do. Conclusions: As the understanding of how norms evolve in LMIC advances, practitioners will develop greater understanding of what works to help people lead change in harmful norms within their contexts. Awareness of these pitfalls has helped several of them increase the effectiveness of their interventions addressing gender-related social norms in the field. We are confident that others will benefit from these reflections as well.

Establishing a tracking system in human resources department to improve the completeness of personnel files at a district hospital in Rwanda

Introduction: For decades, many low and mid income countries (LMIC) have invested significant effort to improve access to and quality of health care, with less attention paid to the non-clinical, administrative hospital management. Accordingly, a practical personnel filing system was designed and implemented to improve file management efficiency.Methods: Setting: The quality improvement project took place in a rural hospital in Rwanda. Design: A pre- and post-intervention study design to assess the effect of the intervention between January 2015 and February 2016. File auditing and time study were conducted. Intervention: A custom-made computer database to manage documents in a personnel file, standardized follow up process and policy were created and implemented. Measures: The pre- and post-intervention completeness of all personnel file and the average time to identify the missing items in a personnel file were measured to evaluate the effect of the project.Results: The completion rate of personnel files increased from 83% pre-intervention to 96% post-intervention. The average time to identify missing items significantly reduced from 6 minutes 30 seconds pre-intervention to 49.6 seconds (p &lt; .001).Conclusions: This project demonstrates that quality improvement principles can help address administrative issues in a resource-challenged setting. By utilizing available resources to implement an intervention that focused on creating an easy and efficient process, the personnel file completion rate has increased considerably and the time needed to identify missing items significantly decreased. The hospital should apply the same strategic problem solving methodology to conduct other quality improvement projects.