Middle-income Countries Research Articles

The Subject-to-Tax Rule in East Africa: Is It Worth It?

The two-pillar approach focusses on BEPS issues in developing countries to a greater extent than preceding OECD agreements. In particular, the Subject-to-Tax Rule (STTR) is intended to address BEPS risks in low-income countries’ tax treaties. BEPS is undoubtedly a critical issue in East Africa since corporate income tax is an unusually important source of tax revenue in Africa. This article analyses the STTR alongside treaties and domestic law to understand the likely impact of the rule in the region. It also considers the diverse domestic policy landscapes to explore whether the STTR is an attractive measure for countries in East Africa. The author believes that implementation of the rule will be complex, challenging already stretched tax administrations. Furthermore, some low-income countries may prefer not to engage with reforms that increase source taxation. The analysis concludes that any hopes that the STTR will mark a major step in addressing BEPS in this part of the world are likely to be disappointed, but it could form part of a portfolio of measures for some specific countries.

Household Consumption of Adequately Iodized Salt: A Multi-Country Analysis of Socioeconomic Disparities.

Despite global efforts to promote universal salt iodization, iodine deficiency remains a public health issue in developing countries. This study assessed the proportion and sociodemographic characteristics of households consuming adequately iodized salt in 49 low- and middle-income countries. Data from DHS surveys of 49 low- and middle-income countries (2005-2021) were used to analyze household iodized salt prevalence. R version 4.0 was employed for statistical analyses. A random-effects meta-analysis was conducted to estimate overall and regional prevalence. We found that 83.4% of households consume adequately iodized salt, although with high heterogeneity (I2 = 100.0%). The East Asia and Pacific and the Europe and Central Asia regions showed high consumption rates of 87.6% and 87.7%, respectively, while Latin America and the Caribbean presented a significantly lower proportion of 30.8%. The study highlights the need for enhanced public health strategies to increase iodized salt consumption, especially in low-income and rural households. Addressing disparities in access, education, and affordability is crucial for improving iodine intake and preventing deficiency disorders, particularly among vulnerable populations like children and pregnant women.

Periodontal diseases in Africa.

Periodontal diseases, a group of complex conditions marked by an excessive immune response and periodontal tissue destruction, are a global health concern. Since 1990, the incidence of these diseases has doubled, with Western sub-Saharan Africa experiencing the highest burden. Accurate diagnosis and case identification are crucial for understanding the etiology, features of disease, research, treatment and prevention. Modern perspectives on periodontal disease classification are based on commonality among those affected. However, current literature is often plagued by methodological inconsistencies and focused on disease mechanisms in European populations. Health inequalities in low- and middle-income countries (LMICs) are exacerbated by these challenges, with sub-Saharan Africa, and Nigeria specifically, facing unique difficulties such as clinical personnel shortages and limited research infrastructure. This review explored disparities in periodontal disease research, care and outcomes in African populations. We highlighted these disparities and identified the factors contributing to inequities in periodontal health outcomes. We further demonstrated the critical need for inclusive and equitable healthcare and research practices tailored to the unique challenges faced by diverse populations and regions with limited resources. Addressing these disparities is essential for ensuring that advancements in healthcare are accessible to all, thereby improving global oral health and general health.

Enhanced Recovery After Craniotomy: Global Practices, Challenges, and Perspectives.

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

Epilepsy in CHAD: Realities, constraints, and prospects.

Epilepsy is a significant public health problem. More than 50 million people worldwide live with epilepsy, and over three-quarters of them are in low- and middle-income countries. The situation in Chad regarding people with epilepsy is challenging to assess, starting from the shortage of scientific data, the inadequacy of technical facilities, the lack of human resources, and the inadequacy of government action. The Ministry of Health and Chadian Society of Neurology are looking forward to prioritizing epilepsy as well as improving the living conditions of persons with this disease. The epilepsy treatment issue is also problematic. Most of the patients are either off treatment or under-medicated. Few antiseizure medications (ASMs) are available, notably carbamazepine, phenobarbital, and valproic acid. Epilepsy remains little-known and does not seem to be a priority for decision-makers. We describe the current situation in Chad, to improve the conditions under which epilepsy is treated. PLAIN LANGUAGE SUMMARY: Epilepsies is a chronic brain problem that is common in poorer settings. The daily lives of people with epilepsy are chaotic in Chad. The challenges are numerous, particularly those related to health infrastructures, due to the lack of adequate diagnostic means and the lack of neurologists. The cultural and language challenges, especially since epilepsy is still considered the devil's disease and the name differs according to the dialects. Stigmatization is also frequent and is often responsible for school dropout, refusal, or dismissal from work. Care and prevention are daily challenges that require government action. Social coverage is insufficient and almost absent in rural areas. It is urgent to prioritize epilepsy in future action plans and also to increase awareness of the conditions to overcome these challenges.

Fertility Preservation in Postpubertal Males Undergoing Cancer Treatment in a Middle-Income Country: Is it Possible Despite the Barriers?

Increased survival rates in childhood cancer have led to an emphasis on the importance of treatment-related infertility. Fertility preservation methods should be explained to every patient and their families (PaFs) before treatment. Establishing good communication with PaFs is crucial in this regard despite many barriers such as cultural and financial barriers. Routine feasibility of sperm preservation (SP) in adolescent males newly diagnosed with cancer was evaluated after the implementation of reimbursement for the procedure and storage by the national healthcare system. Males <18 years of age planned to undergo cancer treatment between 2021 and 2023 were included. Patient and their families were informed by the treating physician about the disease, treatment modality, side effects, the importance of SP, and the method. Information about the purpose and technique of SP was provided to the patient alone in a comfortable environment. Questions from PaFs were answered, and consent was obtained. The procedure and storage cost was covered by the social security institution. Seventeen patients (median age 15) (15 with bone/soft tissue sarcoma, 1 brain tumor, and 1 Hodgkin lymphoma) were included. There were no refusals for SP. Eleven patients were able to provide sperm samples. Of the 6 patients who could not provide sperm, 3 stated embarrassment, 2 anxiety, and 1 cancer-related pain. Increasing awareness among physicians about the importance of treatment-related infertility, allocating sufficient time to inform PaFs about fertility preservation, and providing information taking into account societal or socio-cultural factors will contribute to preventing treatment-related infertility. Establishing close communication with the Reproductive Health Center (RHC), along with the rapid and cost-free nature of the procedure, enhances success.

Effectiveness of the upscaled use of a silver–ceramic (silver ionization) technology to disinfect drinking water in tanks at schools in rural India

ABSTRACT In many low- and middle-income countries, school children consume untreated water that has been pumped into storage tanks. The water is often of poor quality and consumption can cause gastrointestinal illnesses resulting in missed school days, growth stunting, and cognitive impairment. This study deployed a silver–ceramic technology (MadiDrop) to disinfect drinking water in school storage tanks. While silver ionization is effective at the household scale, relatively little research has been conducted on its effectiveness at the community scale. To address this gap, we assessed disinfection via MadiDrop at three schools that serve vulnerable populations in rural India. Tank inflow and treated outflow samples were tested for total coliforms (TCs) and Escherichia coli (EC). TC was significantly reduced overall and in two of three intervention tanks. Compared to the baseline, reductions in TC were significant in all three tanks and overall, while EC reductions were significant overall and in two of three tanks. TC reduction was negatively correlated with silver concentration and tank residence time, and silver concentrations were maintained below the drinking water quality guideline. While the intervention could be considered successful, several barriers and caveats are provided as are study limitations and areas for future research.

Meta-Analysis: Global Prevalence of Coeliac Disease in Type 1 Diabetes.

Coeliac disease (CD) is common in patients with type 1 diabetes (T1D), but prevalence varies globally due to differing screening protocols. There have been substantial changes in screening guidelines over the past two decades. To evaluate CD prevalence in patients with T1D, focusing on screening studies using antitissue transglutaminase (anti-tTG) antibody. We searched PubMed, Web of Science, Embase and Scopus for studies published up to 11 December 2023 using keywords related to CD and diabetes. We used random-effects models for overall prevalence and all subgroups, with heterogeneity assessed using Cochran's Q test and the I2 statistic performed in STATA 18. We included 106 articles involving 65,102 T1D patients across 40 countries. The pooled CD seroprevalence and confirmed CD prevalence were 9% (95% confidence interval, CI, 8%-10%) and 6% (95% CI 5%-7%), respectively. The prevalence was higher in females and children. Denmark, Saudi Arabia and Libya exhibited the highest prevalence (11%), followed by India and Egypt (10%). Belgium, France, Germany, South Africa and the United States had the lowest prevalence (2%). High-income countries showed significantly a lower CD prevalence than middle-income countries (p = 0.03). Meta-regression based on the Human Development Index (HDI) indicated that countries with higher HDI have lower seroprevalence and confirmed CD prevalence. Approximately 1 in 16 patients globally and 1 in 12 patients in Asia and the Middle East with T1D has CD. We suggest that all patients with T1D should be screened for CD.

103. The Impact of COVID-19 restrictions on Open Fracture Emergency Fixation Procedures in eight institutions around South and Southeast Asia

Introduction: Around the time COVID-19 was declared a global pandemic, various restrictions and measures were implemented at all levels to limit disease spread and preserve healthcare capacity. Data is lacking in many low and middle-income countries on how these measures impact healthcare utilization and outcomes. This study aims to determine the impact of COVID-19 restrictions on volumes of the open fracture emergency fixation procedures in South and Southeast Asia. Methods: This was a retrospective cohort study of patients who underwent open fracture fixation from 1 January 2018 to 31 December 2021 at one of 8 institutions in Singapore, Malaysia, Indonesia, India and Vietnam. We compared the weekly volumes, baseline characteristics and outcomes of each procedure across different time periods in each institution defined by different level of COVID-19 restrictions using selected indicators from a city-level and hospital-level response index. Results: A total of 74 (AMH) to 299 (SGH) open fracture fixations were performed over the 4-year period. Weekly volumes decreased significantly at GNRC (p = 1.33 x 10-5), AMH (p = 1.68 x 10-6) and UGH. At UGH there was a drop in the proportion of males during HR1 (66.7%) and HR3 (46.7%) compared to pre-COVID (83.0%) and HR2 (82.4%) (p = 2.02 x 10-4). None of the outcomes were significantly different in any of the institutions. Conclusions: COVID-19 restrictions on the city and hospital level were associated with a decrease in surgical volumes of the open fracture fixation emergency procedures in some of the institutions. There was some suggestion of surgical capacity limitations in UGH and MH175 during periods of more stringent COVID-19 restrictions.

Trends and inequalities in the use of deworming medication during pregnancy in Sierra Leone, 2008–2019

BackgroundIntestinal worm infections are a significant public health concern for pregnant women in low- and middle-income countries. These infections can lead to anaemia, malnutrition, and adverse pregnancy outcomes, including premature birth and low birth weight. Deworming medication during pregnancy is a safe and effective strategy to prevent these complications and improve maternal and child health. This study aims to investigate the trends and inequalities in the use of deworming medication during pregnancy among women in Sierra Leone between 2008 and 2019.MethodsThe study utilised data from the Sierra Leone Demographic Health Surveys conducted in 2008, 2013, and 2019. We used the Health Equity Assessment Toolkit developed by the World Health Organisation to calculate various measures of inequality, including difference, ratio, population attributable risk, and population attributable fraction. An inequality assessment was conducted for five stratifiers: age, economic status, level of education, place of residence, and sub-national province.ResultsThe prevalence of deworming medication during pregnancy was 43.8% in 2008, 72.4% in 2013, and 83.5% in 2019 in Sierra Leone. There was a decrease in age-related inequality from a difference of 3.7% in 2008 to −0.8% in 2019. Economic-related inequality increased from a difference of −8.5% in 2008 to −8.2% in 2019. Both population attributable fraction and population attributable risk were zero in all survey years for economic status, indicating no improvement in the setting average without economic-related inequality. Inequality in education increased from a difference of -8.9% in 2008 to −8.4% in 2019 and decreased from a difference of −2.6% in 2008 to –5.5% in 2019 for place of residence. Provincial inequality decreased from a difference of 29.5% in 2008 to 11.8% in 2019. The population attributable risk for province reveals that the setting average could have been 10.5 percentage points lower in 2008, 8.2 percentage points lower in 2013, and 5.9 percentage points lower in 2019 without provincial inequality.ConclusionThe prevalence of deworming medication use during pregnancy substantially increased from 2008 to 2019 (43.8% to 83.5%) in Sierra Leone. This suggests a positive public health trend in maternal healthcare access and education. Inequalities related to economic status and education increased slightly while age-related, place of residence and provincial inequalities decreased. This indicates an inequitable distribution of this essential healthcare intervention across these stratifiers. The government and policymakers should continue efforts to raise awareness and promote the use of deworming medication during pregnancy.

Assessment of Dental Students' Knowledge and Attitudes About the Epidemiologic and Clinical Characteristics of Oral Cancer: Implications for Other Middle-income Countries.

The stage of detection of head and neck cancer and the time between detection and treatment are critical to prognosis. The importance of the dentist in primary diagnosis and treatment planning has been emphasized. The purpose of this study was to evaluate the knowledge of dental students in the prevention and early diagnosis of oral cancer. A descriptive cross-sectional study was conducted on 199 students from different institutions. A self-administered questionnaire with 34 multiple-choice questions on clinical and epidemiologic knowledge and opinions about oral cancer was used. Descriptive analysis to show means and frequencies and the binomial logistic regression test were used to perform the statistical analysis. The confidence level used was 95%. The results showed that all students in the study had heard of the existence of oral cancer, but only 24.6% knew someone with the disease. The majority reported a lack of information in the population about prevention and self-examination, as well as a lack of information campaigns in institutions. Although the majority perform clinical examinations of the oral mucosa (73.4%) and refer patients with suspicious lesions to specialists, there is low confidence in performing biopsies (73.4%) and gaps in training during graduation (84.4%). The majority have never attended continuing education courses on oral cancer but show interest (97.5%). The study identifies deficiencies in the knowledge and practices of dental students and highlights the need for improved teaching and training to promote oral cancer prevention and early detection. Further research in this area and ongoing assessment of students' skills are suggested.

Palliative Care in the Midst of Adversity: Insights from a Low-Income Country.

The integration of palliative care into conventional healthcare services has demonstrated significant benefits in alleviating serious health-related suffering (SHRS), reducing symptom burden, and lowering healthcare expenditure for patients and families. Despite Lebanon's initial steps towards palliative care development, its integration remains inadequate, particularly due to the country's socio-political and economic challenges. This paper examines the current landscape of palliative care services in Lebanon, including their geographical distribution and care models, while addressing the obstacles impeding their progress. Data on palliative care services were gathered from the presentations of stakeholders at the 2023 National Palliative Care Conference. Currently, three nonprofit organizations provide home-based palliative care primarily for end-of-life patients, while seven hospitals offer palliative care through inpatient consultation teams, three of which have specialized palliative care wards and two outpatient clinics. Hospital-based palliative care services are primarily located in the capital city Beirut and operate within private healthcare facilities. Notably, only home-based services are provided free of charge, while hospital-based care is not reimbursed, thus limiting access to palliative care for only those who can afford it. The political and economic instability, inadequate policies and insufficient reimbursement, shortage of trained expertise and essential medicines like morphine, and inconsistent health education are some of the challenges that Lebanon faces in developing palliative care. A multilevel coordinated response and advocacy are crucial to drive policy reforms, enhance education, promote public awareness, and improve clinical practice ensuring quality and equitable palliative care access to all.

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

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

Fathering Promotes Child Development in Low- and Middle-Income Countries Through Specific “Active Ingredient” Caregiving Activities

SYNOPSIS Objective. We do not know which specific paternal caregiving practices are associated with more advanced child development in understudied low- and middle-income countries (LMICs). The current investigation attempts to identify such caregiving practices. Design. Maternal reports of six specific paternal caregiving practices which may be uniquely associated with early childhood development were examined in a sample of 159,959 families with 3- to 4-year-old children from 51 LMICs. Both father caregiving practices and early childhood development scores were quantified using measures from UNICEF’s Multiple Indicator Cluster Surveys. Linear regression models examined which paternal caregiving practices were associated with early childhood development after controlling for the contributions of mothers and children’s other caregivers engaging in the same practices as well as father residence in the home and multiple aspects of the physical home environment and national context. Results. When fathers read to their children, named/counted/drew with their children, or sang to their children, their children demonstrated more advanced overall development. When fathers read, named/counted/drew, and told stories to their children, their children also demonstrated more advanced development in literacy/numeracy and approaches to learning. Some effects depended on whether fathers resided in the home. Fathers naming/counting/drawing with their children was associated with more advanced child development in approaches to learning, and fathers reading to their children was associated with more advanced child socioemotional development only if fathers resided in the child’s home. Conclusions. Fathers reading to their children, naming/counting/drawing with their children, and singing to their children appear to be specific “active ingredients” that promote child development in LMICs. Some of these ingredients only actively promote child development when fathers reside in the child’s home environment. These practices should be supported and encouraged in policy and practice. Fathers’ caregiving matters for child development across a wide swath of LMICs in the world.

Women's dietary diversity is associated with homestead production and market access: A cross-sectional study in rural Rwanda.

Dietary diversity has been widely used as a proxy indicator for micronutrient adequacy. In low- and middle-income countries (LMICs), including Rwanda, women are at high risk of inadequate micronutrient intake resulting from poorly diversified diets. This study was conducted to examine the factors associated with women's dietary diversity, with emphasis on homestead production diversity and market access in the Northern Province of Rwanda. A cross-sectional design was used, involving 606 women aged 18-49 years. Linear regression analyses were performed to examine the association between various factors and women's dietary diversity. Results show that 84% of the sample households raised at least one livestock species. Seventy-one percent of the households had no agricultural land. Eighty percent of those without land had a homestead garden on which they grew food crops, mainly vegetables and fruit trees. The average crop species was 2.3. On average, women consumed 3 out of 9 food groups. The homestead production diversity score was positively associated with women's dietary diversity score (β = 0.16, p < 0.001). Women's dietary diversity score was negatively associated with distance from the household to the nearest market (β = -0.08, p = 0.027) and household food insecurity (β = -0.06, p < 0.001). Maternal education (p < 0.001), household wealth index (p < 0.05), and ownership of more than 2.5 acres compared to being without land (p < 0.05) were associated with women's dietary diversity score. The dietary diversity of women could be enhanced through interventions that promote the diversity of livestock and crop species produced through homestead production. Potential interventions to explore may include integrated farming systems that combine small livestock and crop production utilising improved livestock breeds and high-quality seeds and planting materials of high-yielding varieties of fruits and vegetables, along with rainwater harvesting to facilitate small-scale irrigation. The impact of such interventions on women's dietary diversity can be further reinforced by parallel programmes aimed at improving women's education and the socioeconomic status of households.

Nurturing Youth: Ethical Considerations in Pediatric Skincare Marketing.

In today's beauty-obsessed culture, children are increasingly targeted by skincare marketing, raising significant ethical concerns. The trend of children adopting skincare routines focused on anti-aging and skin lightening impacts their mental health and self-esteem, often imposing unattainable beauty standards. Marketing practices in the digital age frequently violate the International Chamber of Commerce (ICC) Framework for Responsible Marketing Communication. Disparities in skincare marketing particularly affect children in low- and middle-income countries. There is an urgent need for stringent regulations, enhanced media literacy education, and ethical marketing practices to safeguard young consumers and prioritize their well-being and dignity.

Factors associated with zero vegetable and fruit consumption among Tanzanian children

BackgroundProper nutrition during early childhood is essential for healthy growth and development, yet many children, particularly in low and middle-income countries, fail to meet recommended intake levels of fruits and vegetables. This study aims to assess the factors associated with zero vegetable and fruit (ZVF) consumption among children aged 6–23 months in Tanzania, using data from the 2022 Tanzania Demographic and Health Survey (DHS).MethodsA weighted sample of 4582 children aged between 6 and 23 months were included in the study. Data cleaning, coding, and analysis were performed using STATA version 17 software. To address the hierarchical nature of the DHS data and the binary outcome variable, a multilevel mixed-effect binary logistic regression model was used. The deviance value served as a guide for determining the best-fitting model. In the subsequent multivariable multilevel binary logistic regression analysis, adjusted odds ratios were computed alongside their respective 95% confidence intervals to evaluate the strength of association, with statistical significance set at a p-value below 0.05.ResultThe overall proportion of ZVF consumption among children aged 6–23 months in Tanzania was 48.34% (95% CI: 46.87, 49.81). Current breastfeeding status, maternal educational status, household wealth index, sex of the household head, and community poverty level were associated with higher odds of ZVF consumption. Meanwhile, child age, maternal employment status, father’s educational status, and media exposure were associated with lower odds of ZVF consumption.ConclusionChild age, current breastfeeding status, maternal educational status, maternal employment status, father’s educational status, household wealth index, sex of household, media exposure, and community poverty level were significantly associated with ZVF consumption. Efforts should focus on educating mothers about the early introduction of fruits and vegetables in children’s diets, alongside supporting breastfeeding. Tailored economic empowerment initiatives are needed in impoverished communities to improve access to nutritious foods.

Wealth-related disparities of comprehensive knowledge of HIV among reproductive-aged women in Ethiopia: a decomposition analysis

IntroductionHuman Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) remains a major global public health concern, especially in low-income countries like Ethiopia. Insufficient awareness about HIV/AIDS makes women vulnerable to infection. Notably, there is a disparity in the comprehensive HIV knowledge among reproductive-aged women in poorer and wealthier households. However, the contributing factors for wealth-related disparities in comprehensive knowledge of HIV among reproductive-aged women in Ethiopia have not been explored.MethodsWe used the women's record (IR) of the 2016 Ethiopian demographic health survey. Erreygers normalized concentration index and curve were used to analyze the percentage contribution of factors in the comprehensive knowledge of HIV difference across wealth index. The concentration index was decomposed into contributing factors for poor comprehensive knowledge among poorer households.ResultsA total of 14,599 reproductive-aged women were included in the analysis. The comprehensive knowledge of HIV was 14.75% and 29.33% in the poorest and wealthiest households, respectively. The weighted Erreygers normalized concentration index (ECI) was 0.11 with Standard error = 0.015 (P value < 0.05). Age (− 0.17%), residence (1.4%), education (26.2%), occupation (1.38%), region (0.61%), wealth index (30.8%), media exposure (13.4%), and internet access (0.67%) significantly contributed to the wealth-related inequalities.ConclusionThere was a pro-rich distribution of comprehensive knowledge of HIV among reproductive-age women in Ethiopia. Wealth, education, and media exposure were the major contributing factors to the wealth-related inequalities. Policymakers should prioritize media exposure and education, and work to improve the comprehensive knowledge of women in poorer households.

Impact of Artificial Intelligence-Based Autosegmentation of Organs at Risk in Low- and Middle-Income Countries

Radiation therapy (RT) processes require significant human resources and expertise, creating a barrier to rapid RT deployment in low- and middle-income countries (LMICs). Accurate segmentation of tumor targets and organs at risk (OARs) is crucial for optimal RT. This study assessed the impact of artificial intelligence (AI)-based autosegmentation of OARs in 2 LMICs. Ten patients, comprising 5 head and neck (HN) cancer patients and 5 prostate cancer patients, were randomly selected. Planning computed tomography images were subjected to autosegmentation using an Food and Drug Administration-approved AI software tool and manual segmentation by experienced radiation oncologists from 2 LMIC RT clinics. The control data, obtained from a large academic institution in the United States, consisted of contours obtained by an experienced radiation oncologist. The segmentation time, DICE similarity coefficient (DSC), Hausdorff distance, and mean surface distance were evaluated. AI significantly reduced segmentation time, averaging 2 minutes per patient, compared with 57 to 84 minutes for manual contouring in LMICs. Compared with the control data, the AI pelvic contours provided better agreement than did the LMIC manual contours (mean DSC of 0.834 vs 0.807 in LMIC1 and 0.844 vs 0.801 in LMIC2). For HN contours, AI provided better agreement for the majority of OAR contours than manual contours in LMIC1 (mean DSC: 0.823 vs 0.821) or LMIC2 (mean DSC: 0.792 vs 0.748). Neither the AI nor LMIC manual contours had good agreement with the control data (DSC < 0.600) for the optic nerves, chiasm, and cochlea. AI-based autosegmentation generates OAR contours of comparable quality to manual segmentation for both pelvic and HN cancer patients in LMICs, with substantial time savings.

The Burden of Plastic Surgery in Rural Kenya: The Kapsowar Hospital Experience.

Both governmental and nongovernmental training programs are expanding efforts to train the next generation of plastic surgeons who will work in low- and middle-income countries (LMICs). Sufficient training is dependent on acquiring the appropriate skillset for these contexts. Few studies have characterized the spectrum of practice of plastic surgeons in LMICs and their relative disparity. We performed a retrospective review on all patients who received plastic surgery at a single institution in rural western Kenya from 2021 to 2023. Data such as diagnoses, procedures, and home village/town of residence were collected. Patient home location was geomapped using an open-access distance matrix application programming interface to estimate travel time based on terrain and road quality, assuming patient access to a private vehicle and ideal traveling conditions. Descriptive statistics were performed. A total of 296 patients received surgery. Common procedures included treatment of cleft lip/palate (CLP), burn reconstruction, and reconstruction for benign tumors of the head and neck. The average distance to treatment was 159.2 minutes. Increased travel time was not associated with time to CLP repair (P > 0.05). Increased travel time was associated with delayed treatment for burns (P = 0.005), maxillofacial trauma (P = 0.032), and hand trauma (P = 0.016). Training programs for plastic surgeons in LMICs should ensure competency in CLP, flaps, burn reconstruction, and head and neck reconstruction. Our novel use of an application programming interface indicates that international partnerships have been more successful in decreasing treatment delays for CLP patients, but not other reconstructive procedure patients. Expanded commitment from international partners to address these reconstructive burdens in LMICs is warranted.