Middle-income Countries Research Articles

Shooting a moving target: Evaluating targeting tools for social programs when income fluctuates

A key challenge for policymakers in low- and middle-income countries is to design a method to select beneficiaries of social programs when income is unobservable and volatile. We use a unique panel dataset of a random sample of households in Colombia’s social registry that contains information before, during, and after the 2020 economic crisis to evaluate a traditional static proxy-means test (PMT) and three policy-relevant alternatives. We consider targeting metrics and social welfare under different curvatures of governments’ social welfare function, aggregate economic environments, and budgetary and political constraints. Updating the PMT data does not improve social welfare relative to the static PMT. Relaxing the eligibility threshold reduces the exclusion error, increases the inclusion error, and increases social welfare. A dynamic method that uses data on shocks to estimate a variable component of income reduces exclusion errors and limits the expansion in coverage, increasing social welfare during the economic crisis.

Leveraging single-dose human papillomavirus vaccination dose-efficiency to attain cervical cancer elimination in resource-constrained settings.

In low- and middle-income countries, resource constraints remain a critical factor limiting access to cervical cancer preventive measures. The option of single-dose immunization could help improve access to human papillomavirus vaccination and attain cervical cancer elimination. With simulation models adapted to country-specific data and scenarios for single-dose protection derived from International Agency for Research on Cancer India vaccine trial data, we estimated the expected impact of single-dose vaccination in India, Rwanda, and Brazil, three countries with varying profiles of cervical cancer risk and vaccination timelines. In combination with single-dose vaccination, we explored different resource reallocation strategies based on dose efficiency, elimination attainment, and cervical cancer cases prevented, with the existing 2-dose program as a comparator. Assuming lifelong single-dose protection, switching from 2-dose to 1-dose vaccination and reallocating resources to female catch-up could prevent 467-1336, 94-194, and 15-207 additional cervical cancer cases (per 100 000 women born) in cohorts aged 11-30 years in India, Rwanda, and Brazil, respectively. Resource reallocation to improve the current routine coverage could help eliminate cervical cancer in India and across all Brazilian states but not in Rwanda. For each country, we found a dose-efficient reallocation strategy (or a combination of strategies) together with 1-dose vaccination that could prevent more cervical cancers vs 2-dose vaccination, even in the worst-case scenario of single-dose protection. Adopting single-dose vaccination with resource reallocation is a resource-efficient approach to enhance progress toward cervical cancer elimination. The overall impact of vaccination can be maximized by fine-tuning resource reallocation to a country's needs.

Transition towards cancer mortality predominance over cardiovascular disease mortality in Brazil, 2000–2019: a population-based study

Cardiovascular disease (CVD) and cancer are the first and second leading causes of death in Brazil and worldwide. However, an ongoing epidemiological transition in which cancer surpasses CVD has been observed in many high and middle-income countries. In this study, we provided a nationwide analysis of the transition towards cancer mortality predominance over CVD mortality in Brazil. We leveraged data from 5570 municipalities using the Mortality Information System and classified the causes of death using ICD-10 codes. Age-standardized CVD and cancer mortality rates were calculated annually between 2000 and 2019. Mortality rate ratios (MRRs=CVD rates divided by cancer rates) described the predominance of cancer or CVD mortality across municipalities and states. Choropleth maps displayed state-specific MRRs and the transition in the predominant cause of death over time. From 2000 to 2019, CVD mortality rates declined in 25 out of 27 states, whereas cancer mortality increased in 15 states, indicating a shift towards cancer predominance. While in 2000 cancer mortality was lower than CVD in all states and only exceeded the latter in 7% of the municipalities, by 2019 the gap narrowed considerably, with 13% of municipalities displaying higher cancer mortality rates vs CVD mortality rates. Additionally, higher household income correlated with higher mortality from cancer vs CVD. An ongoing epidemiological transition in which cancer mortality surpasses CVD mortality is occurring in Brazil, particularly in municipalities with higher household incomes. Our findings may provide important information for policymakers and public health practitioners in Brazil. National Council for Scientific and Technological Development (CNPq).

The barriers and facilitators family caregivers experience when participating in resource-limited hospital care: a qualitative systematic review

BackgroundIn many resource-limited settings, understaffed hospitals rely on patients’ families to provide care during admission. These care tasks are often performed informally, untrained and unsupported. The WHO has called for...

The impact of temperature on non-typhoidal Salmonella and Campylobacter infections: an updated systematic review and meta-analysis of epidemiological evidence

As temperatures rise, the transmission and incidence of enteric infections such as those caused by Salmonella and Campylobacter increase. This study aimed to review and synthesise the available evidence on the effects of exposure to ambient temperatures on non-typhoidal Salmonella and Campylobacter infections. A systematic search was conducted for peer-reviewed epidemiological studies published between January 1990 and March 2024, in PubMed, Scopus, Embase, and Web of Science databases. Original observational studies using ecological time-series, case-crossover or case-series study designs reporting the association between ambient temperature and non-typhoidal Salmonella and Campylobacter infections in the general population were included. A random-effects meta-analysis was performed to pool the relative risks (RRs) per 1°C temperature increase, and further meta regression, and subgroup analyses by climate zone, temperature metrics, temporal resolution, lag period, and continent were conducted. The Navigation Guide systematic review methodology framework was used to assess the quality and strength of evidence. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). Out of 3472 results, 44 studies were included in this systematic review encompassing over one million cases each of Salmonella and Campylobacter infections. Geographically, the 44 studies covered 27 countries across five continents and most of the studies were from high income countries. The meta-analysis incorporated 23 Salmonella studies (65 effect estimates) and 15 Campylobacter studies (24 effect estimates). For each 1°C rise in temperature, the risk of non-typhoidal Salmonella and Campylobacter infections increased by 5% (RR: 1.05, 95% CI: 1.04-1.06), and 5% (RR: 1.05, 95% CI: 1.04-1.07%), respectively, with varying risks across different climate zones. The overall evidence was evaluated as being of "high" quality, and the strength of the evidence was determined to be "sufficient" for both infections. These findings emphasise the relationship between temperature and the incidence of Salmonella and Campylobacter infections. It is crucial to exercise caution when generalising these findings, given the limited number of studies conducted in low and middle-income countries. Nevertheless, the results demonstrate the importance of implementing focused interventions and adaptive measures, such as the establishment of localised early warning systems and preventive strategies that account for climatic fluctuations. Furthermore, our research emphasises the ongoing need for surveillance and research efforts to monitor and understand the changing dynamics of temperature-related enteric infections in the context of climate change. Australian Research Council Discovery Projects grant (ARC DP200102571) Program.

Scrutinizing the load capacity curve for a global perspective: The role of Fintech, government effectiveness and renewable energy

With the evolving world order, countries are using financial technologies (Fintech) to access financial resources more effectively, and Fintech can have an impact on the environment. This study aims to investigate the influence of Fintech on ecological sustainability, focusing on the contribution of renewable energy (RE) and government effectiveness (GE) under the Load Capacity Curve (LCC). This research analyzes data from 69 middle-income economies between 2006 and 2022 using the dynamic panel threshold model (DPTR). The outcomes document that GDP reduces the LCF below a certain threshold, but a positive impact above this threshold. Specifically, the model yielded a threshold value of $US 5222.234, which is higher than the average GDP of $US 4276.802. This finding suggests a U-shaped relationship between GDP and LCF, which supports the LCC hypothesis. The outcome also reports that Fintech plays a crucial role in improving ecological sustainability, while government effectiveness has a negative effect. The study emphasizes that middle-income countries should support Fintech and renewable energy along development with economic progress to improve ecological quality.

Mothers’ health-seeking practices and associated factors towards neonatal danger signs in Ethiopia: a systematic review and meta-analysis

BackgroundA decrease in obtaining quality healthcare is a major cause of maternal and newborn deaths in low-income and middle-income countries. Ethiopia has one of the highest neonatal mortality rates. Increasing...

Food handling practices and sanitary conditions of charitable food assistance programs in eThekwini District, KwaZulu-Natal, South Africa

Unsafe food handling practices by food handlers have dire health and financial implications worldwide. Each year, approximately 600 million people, or about 1 in 10 people, are said to become ill from eating contaminated food, and 420,000 people inadvertently die. According to the 2019 World Bank report on the economic burden of foodborne diseases, the annual cost of treating foodborne illnesses is estimated to be US$ 15 billion, and the total productivity loss caused by foodborne diseases in low- and middle-income countries is estimated to be US$ 95.2 billion annually. The purpose of this study was to assess the food handling practices and sanitary conditions of the charitable food assistance programs (CFAPs) in the eThekwini District of KwaZulu-Natal, South Africa. A descriptive cross-sectional study was conducted among 196 CFAPs in eight study settings across five municipal planning regions (MPRs) of the eThekwini District between January 2021 and May 2021. Data were collected using a standardized 37-item observational checklist and analysed through Stata Statistical Software (TX: StataCorp. 2021 LLC.: Release 17. College Station). Compliance levels were calculated using the compliance score (C-score), whereby 0.0–0.20 (0–20%), 0.21–0.40 (21–40%), 0.41–0.60 (41–60%), 0.61–0.80 (61–80%), and 0.81–1.00 (81–100%) were determined as very poor, poor, average, good, and very good, respectively. Statistically significant associations were declared at p < 0.05. Compliance with food hygiene, storage, and packaging was very poor (C-score = 0.003), as were personal hygiene and staff facilities (C-score = 0.147), as well as product information/labelling (C-score = 0.003). Similarly, waste management and pest control systems (C-score = 0.203), compliance with health and hygiene education/training (C-score = 0.335), as well as use and maintenance of transport (C-score = 0.333), all scored ‘poor’. Only the design of premises and facilities had an average compliance score (C-score = 0.43). Given CFAPs’ role in mitigating the impact of poverty, their strict compliance with hygiene protocols is of utmost importance. Systems for identifying and correcting common noncompliance in CFAPs are required.

Multimodal intervention on perception and quality of life of geriatric clients regarding health promotional outcomes at a selected hospitals, Kolar, Karnataka, India

ABSTRACT Background of Study: Old age is a privilege for a second childhood and a new stage of opportunity and strength. Older adults are the most rapidly growing segment of the population. By 2050, 80% of all older people will live in low- and middle-income countries. Purpose: To evaluate the effectiveness of multimodal intervention on perception and quality of life among geriatric clients. Methods: Quantitative approach quasi-experimental interventional controlled study with pre-test, post-test design and follow-up for two months, adopted by using purposive sampling technique among 120 geriatric clients who gave consent for participation in the study at two different settings of hospitals from July 2022 to January 2023, Kolar. After obtaining Central Ethics Committee approval, data was obtained using the structured perception questionnaire and WHO Quality of Life questionnaire, and the Multimodal Intervention package consisting of a snake and ladder health promotion strategies game, educational video, and informational pamphlet distributed to the experimental group, whereas routine care was given to the control group followed by post-test group on the 30th and 60th day. Reinforcement was carried out by the investigator on a fortnightly basis reminders through messages. Data were analyzed by using descriptive and inferential statistics such as repeated measures of ANOVA, independent ‘t’- test, paired ‘t-test, and Chi-square. Results: A perception significant effect was demonstrated in the experimental group with enhanced mean, standard deviation from pre-test to post-test I and Post-test II found to be 35.1 ± 7.9, 46.3 ± 6.1, and 48.3 ± 4.7, respectively, without significant changes in the control group. Concerning quality of life, important variations were demonstrated in the experimental group with enhanced mean, SD from pre-test to post-test I and Post-test II found to be 54.76 ± 10.39, 74.15 ± 6.75 and 77.71 ± 4.99, respectively, without any significant changes in the control group. Conclusion: Geriatric population was the biggest beneficiary, multimodal intervention was proven to be effective and can be implemented in hospitals and community settings in improving the perception and quality of life of senior clients to foster healthy aging. CTRI Trial Reg no: CTRI/2021/07/034632.

Participatory development of training videos for respiratory equipment.

During the coronavirus disease 2019 (COVID-19) pandemic, medical oxygen therapy was urgently needed for patients with hypoxaemia. Many low- and middle-income countries lacked the medical devices for oxygen therapy and experience in their use. In addition to providing medical devices for oxygen therapy for countries in need, the World Health Organization (WHO) and partners developed training videos to help local health workers select, use and maintain this equipment. Diverse health professionals, including engineers and clinicians from resource-constrained countries, collaborated in developing draft videos in their local settings. A production team refined these drafts and delivered the training videos through the platform OpenWHO. OpenWHO is WHO's free open-access platform providing courses for health workers and others. The courses, based on WHO's scientific and operational guidance, can be easily adapted, contextualized and translated. The production team refined the drafts into 32 training videos. More than 17 505 health workers participated in the OpenWHO course on COVID-19 respiratory equipment between 28 February 2022 and 30 November 2023. Participants were from 189 countries and 38% (6027/16 047) were from low- and lower-middle-income countries. Involving volunteer biomedical engineers and clinicians from low- and middle-income countries helped provide an appropriate training resource. WHO should continue to develop such training tools and offer them through OpenWHO, especially for emergencies.

Cross national patterns in educational inequalities in functional limitations among middle aged and older adults at two time points

IntroductionIn recent decades, the global population has aged rapidly while socioeconomic inequalities in health have widened, with older adults who are most disadvantaged experiencing the poorest health. Functional limitations are key predictors of disability and quality of life and are therefore considered an important measure of how well individuals and populations are aging. We determine if educational inequalities in functioning have widened over time and across countries. MethodsWe used data from five nationally representative surveys of aging, covering 14 high- and middle-income countries, with harmonized measures of functional limitations. We examined change over time in the number of functional limitations among adults aged 50-64 and 65 and older in each country as well as changes in educational inequality in functional limitations over time for both age groups. ResultsIn most high-income countries, the number of functional limitations decreased over time, but they increased in China and Mexico, with the largest increases occurring among adults 65 and older. Educational inequality in functional limitations among those aged 65 and older widened for several countries in our study, but for different reasons. In some countries, it widened due to increased limitations among the least-educated, while in others it widened due to declines in limitations among the most-educated. ConclusionGrowing educational inequality in functional limitations for older adults in several high- and middle-income countries suggests that, despite improvements in health and mortality, socioeconomic differences in functional health among older adults are widening.

Genotypic Antimicrobial Resistance Profiles of Diarrheagenic Escherichia coli and Nontyphoidal Salmonella Strains Isolated from Children with Diarrhea and Their Exposure Environments in Ethiopia.

Antimicrobial resistance (AMR) poses a significant global threat, particularly in low- and middle-income countries, such as Ethiopia, where surveillance is limited. This study aimed to predict and characterize the AMR profiles of diarrheagenic Escherichia coli (DEC) and nontyphoidal Salmonella (NTS) strains isolated from human, animal, food, and environmental samples using whole genome sequencing. A total of 57 NTS and 50 DEC isolates were sequenced on an Illumina NextSeq 550. The ResFinder and PointFinder tools were employed to identify antimicrobial resistance genes (ARGs) and point mutations. Salmonella serotypes were determined using SeqSero. The analysis identified at least one ARG in every NTS sample and 78% of the DEC isolates, with 22 distinct ARGs in the NTS samples and 40 in the DEC samples. The most prevalent ARGs were aac(6')-Iaa and aph(3')-Ib, which predict aminoglycoside resistance in 100% of NTS and 54% of DEC isolates, respectively. Other commonly identified ARGs include sul2, aph(6)-Id, blaTEM-1B , and tet(A), which confer resistance to folate inhibitors, aminoglycosides, β-lactams, and tetracycline. Some ARGs predicted phenotypic multidrug resistance in both DEC and NTS isolates. All identified β-lactam ARGs, except for blaTEM -1D, conferred resistance to more than three antibiotics. Interestingly, blaCTX- M-15 was found to confer resistance to nine antibiotics, including third-generation cephalosporins, in 18% of DEC and 3.5% of NTS isolates. DEC isolates from children exhibited the highest ARG diversity. Notably, genes such as aph(3″)-Ib, aph(6)-Id, sul2, and tet(A) were detected across all sample types, including water sources, although some ARGs were exclusive to specific sample types. Point mutations mediating AMR were detected in several genes, with mutations associated with nucleotide substitution being the most frequent. This genotypic AMR profiling revealed the presence of widespread drug-resistant NTS and DEC strains in Ethiopia. Robust and sustained AMR surveillance is essential for monitoring the emergence and spread of these resistant pathogens.

Leveraging Social Networks to Integrate Depression Treatment into Primary Health and Tuberculosis Care in Brazil.

Tuberculosis (TB) and depression are highly comorbid and linked to higher rates of death and disability. Several evidence-based treatments for depression have been successfully implemented in low- and middle-income countries, but more knowledge is needed on how to bring these innovations to scale within complex 'real world' public health systems. To explore whether the principles of social network analysis could be used to enhance receptivity to integrating depression treatment into primary care for individuals with and without TB in Brazil. We used existing scales to identify settings and providers with high receptivity and connectivity within the primary care network. We trained and supervised existing staff in three primary care sites to deliver a brief evidence-based intervention over one year, coupled with active dissemination activities. Afterwards, we reassessed receptivity among individuals involved, and not involved, in the pilot. Highly significant changes were observed in mental health literacy, attitudes towards evidence-based practices, work self-efficacy, and implementation leadership supporting our hypothesis. Limited social connections between primary care clinics precluded the examination of the hypothesis that targeting settings with high connectivity could capitalize on the information flow between and transcend the decentralized structure of the network, but leveraging the centralized nature of the TB program to integrate mental health services emerged as a promising alternative. The findings of this study strongly suggest that social networks may be leveraged to change individual providers' attitudes, thereby contributing to the enhanced dissemination of evidence-based interventions.

Comparative Education in the Health Professions

As the academe in health professions institutions pursue educational reforms that anchors on the systems approach to healthcare, collaborative efforts are essential to establish more responsive and dynamic professional education systems. This paper highlights comparative education as a tool to strengthen health professions education around the world by reviewing previous and the most recent studies done, and showcase how this can improve the current pedagogical landscape. Through comparative education, a holistic approach to health professions education ensures that the learner’s training is not only comprehensive but also responsive to the dynamic needs of the country, the region, and the rest of the world by the sharing of best practices, challenges, and opportunities for collaboration. The opportunities that international comparative education provide to the health professions education include the sharing of best practices and difficulties encountered, and the enhanced viewpoint from considering different perspectives. On the other hand, the main challenges include ethnocentrism and the limited resources that majority of institutions face globally especially those from the low- and middle-income countries. Truly, once the lessons learned from comparative educational engagements are integrated into the philosophical and educational foundations in our medical schools, then we are one step closer to becoming responsive to the call for a more holistic and systems – centered health professions education.

Assessing global access to continuing professional development for rehabilitation professionals: a mixed methods study of current practices and perceived needs

ObjectivesThis study aimed to understand the current state of continuing professional development (CPD) for rehabilitation professionals globally and identify perceived requirements to enhance education to guide efforts to develop internationally...

Mobile health teleconsultation and telemedicine in operating outpatient departments during COVID-19 pandemic at a hospital in Eastern Nepal

ABSTRACT Background: Telemedicine provides a means to deliver healthcare across distances, enhancing efficiency and accessibility, especially in low- and middle-income countries. The COVID-19 pandemic highlighted its importance by reducing the risk of virus transmission while maintaining healthcare delivery. This study evaluates the telemedicine program implemented at B.P. Koirala Institute of Health Sciences (BPKIHS), Nepal, which provided specialist services to remote districts via teleconsultation during the 2020 lockdown. The objectives were to identify the number of patients, the major complaints, and the follow-up departments during teleconsultation. Methods: A retrospective analysis was conducted on teleconsultation data from March 1 to August 31, 2020, across various outpatient departments at BPKIHS. Data from 10,901 patients were reviewed, with variables including age, gender, residence, and consultation medium. Descriptive statistics were calculated using SPSS (version 22). Results: Most of the patients (55.46%) were female, and the majority (30.84%) aged 21–30 years. Most consultations were from the Sunsari district (54.8%) and Koshi state (88.9%). Voice calls were the primary medium (39.62%), followed by WhatsApp video calls (30.08%). Obstetrics and gynecology had the highest consultation rate (16.15%), followed by dermatology (14.4%) and psychiatry (10.37%). Nearly half of the patients (45.0%) had follow-up consultations, primarily for dermatological issues (17.85%). Conclusion: The findings underscore telemedicine’s role in facilitating healthcare access, particularly for women and residents of remote areas, by reducing travel and exposure risks. This study highlights the need for further integration of telehealth technologies to enhance healthcare delivery, suggesting that teleconsultation can efficiently meet healthcare demands in resource-limited settings during and beyond pandemics.

Effectiveness of individualized counseling in reducing leave against medical advice among neurosurgical patients in the emergency department

Objective: Leave against medical advice (LAMA) in the emergency department (ED) is a significant challenge in low- and middle-income countries, often leading to higher rates of readmission, increased mortality, and disrupted continuity of care. This study aimed to evaluate the effectiveness of individualized counseling in reducing LAMA incidents among neurosurgical patients in the ED. Materials and Methods: This quality improvement study employed a prospective case-control design to compare LAMA rates between patients who received individualized counseling and those who did not. A “nursing-coordinator program” was introduced, focusing on patient communication and engagement. Trained staff followed a standardized checklist to address the concerns of patients and their caregivers, providing “individualized counseling.” Data collected after the intervention were compared with retrospective pre-intervention data, and the results were analyzed. Results: A total of 554 patients, ranging from 1 to 94 years of age, were included in the study, with 60.5% being male. Among the 353 patients who received the “individualized counseling” intervention, 60 opted for LAMA (study group), compared to 49 LAMA cases out of 201 patients who did not receive counseling (control group). The LAMA rate significantly decreased from 24.4% to 16.9% post-intervention (P = 0.035). The “individualized counseling” intervention effectively reduced LAMA due to factors such as misinformation about disease severity (P = 0.009), economic constraints (P &lt; 0.001), and poor prognosis (P &lt; 0.001). However, it was less effective for reasons like proximity to home (P = 0.007), inadvisable transfers for personal reasons (P = 0.023), and family problems (P = 0.293). Conclusions: This study demonstrates that individualized counseling is an effective intervention for reducing LAMA among neurosurgical patients in the ED. By addressing non-medical factors often overlooked due to inadequate counseling, this quality improvement strategy can help prevent vulnerable patients from prematurely terminating their treatment.

A systematic review and meta-analysis of the association between neglected tropical diseases and malnutrition: more research needed on diseases other than intestinal parasites, leishmaniasis and leprosy.

Background. According to the World Health Organization, neglected tropical diseases (NTDs) affect over two billion people worldwide. While the links between nutrition and many diseases have become clear over recent decades, NTDs have lagged behind and the linkage with nutrition is largely unknown. We conducted this systematic review with meta-analysis to determine the current knowledge on the association between NTDs and malnutrition. Methodology. PubMed, Embase, Scopus and African Journals Online databases were searched using predefined search terms. We included all original articles with a case-control design and at least one NTD. The studies had to compare nutritional parameters between infected cases and control participants. Articles that did not report original data were excluded. The quality of the studies was assessed using the Newcastle-Ottawa scale. Pooled estimates were conducted using the random effect model. The publication bias of the studies was determined by funnel plots. Q and I 2 statistics were used to assess the heterogeneity of the studies. Results. After screening 1294 articles, only 16 qualified for the systematic review and 12 for meta-analysis. These predominately had a focus on soil-transmitted helminthiasis (ascariasis, hookworm diseases and trichuriasis) and schistosomiasis, with a minority concerning leishmaniasis and leprosy. Pooled estimates showed an association between intestinal parasites and stunting in children [odds ratio (OR) = 1.38, 95% confidence interval (CI): 1.14-1.66, I 2 = 0%, tau2 = 0]. We also identified a moderate association established between serum iron deficiency (OR = 4.67, 95% CI: 1.91-11.44, tau2 = 0) and intestinal parasites. Conclusions/significance. Of the 20 NTDs, the links between diet and disease have been explored for only 4. There is a paucity of data from low- and middle-income countries and least-developed countries where the NTD burden is high. Therefore, more research into the role of malnutrition in NTDs other than intestinal parasites, leishmaniasis and leprosy is needed.

RISK FACTORS OF CHILDHOOD OBESITY IN URBAN VS. RURAL INDIA: A SYSTEMATIC REVIEW

Background: - Childhood obesity has become a pressing global public health issue, particularly in low- and middle-income countries like India. This systematic review aims to investigate the prevalence of childhood obesity and its associated risk factors in urban and rural regions of India. Methods: - A comprehensive systematic search was conducted in PubMed, Embase, and Scopus databases to identify relevant English-language studies published within the past decade. Inclusion criteria included studies conducted in India, focusing on children and adolescents aged 0-18, and reporting either the prevalence of childhood obesity or related risk factors. Ten studies, comprising both cross-sectional and quantitative research designs, met these criteria. Results: - The findings reveal a significant disparity in childhood obesity prevalence between urban and rural areas of India. Urban regions exhibit notably higher rates, with a pooled prevalence estimated at 9.0% (95% CI: 2.0 to 17), compared to 4.0% (95% CI: 4.0 to 5.0) in rural areas. Risk factors associated with childhood obesity in urban settings include unhealthy dietary habits, limited physical activity, higher income levels, parental education, and attendance at private schools. In rural areas, gender, age, and household size emerged as potential risk factors. Discussion: - These findings underscore the urgent need for geographically tailored interventions to address the urban-rural disparities in childhood obesity. Lifestyle-oriented strategies promoting healthier dietary patterns and increased physical activity are essential. Gender-inclusive programs targeting both boys and girls are crucial. Future research should consider regional and cultural diversity to design more effective public health responses. Conclusion: - This systematic review provides valuable insights into the prevalence and risk factors of childhood obesity in India. It highlights the necessity for customized interventions and lifestyle adjustments to combat this escalating public health challenge and reduce disparities in health outcomes.

Early Rituximab versus Escalating Therapy in Neuromyelitis Optica: A Cost and Quality of Life Analysis

Introduction: Rituximab, an anti-CD20 monoclonal antibody, has shown effectiveness in reducing disease relapses and disability accrual through relapses in patients with neuromyelitis optica spectrum disorders (NMOSD). However, its higher cost compared to oral immunosuppressants raises questions about its cost-effectiveness, particularly in low and middle-income countries. This study aimed to compare the cost-effectiveness of early rituximab treatment versus escalation treatment in NMOSD patients. Methods: We conducted a retrospective study of NMOSD patients treated with rituximab in the first five years of disease at a hospital in São Paulo, Brazil, from 2015 to 2019. The Early Group consisted of NMOSD patients who received rituximab as a first-line treatment. The Escalating Therapy Group included patients who were prescribed rituximab after experiencing disease activity while on oral immunosuppressants, primarily azathioprine. An economic model based on Expanded Disability Status Score (EDSS) transitions was used to assess cost-effectiveness. Cost and utility data were derived from previous studies, and sensitivity analyses for different willingness to pay (WTP) thresholds and percentage of patients upscaling from oral immunossupressants to rituximab were performed. Results: Thirty NMOSD patients were included. In the Early Group, the proportion of patients reaching the highest EDSS states (6.5 or more) decreased over five years compared to baseline. In contrast, the Escalating Therapy Group experienced an increase in this proportion over the same period. Cost-effectiveness was achieved for willingness to pay (WTP) of €20-80,000 in our main analysis, sustained in our sensitivity analysis. Conclusion: Early treatment with rituximab has the potential to lower healthcare costs and enhance quality of life for NMOSD patients, supporting its early prescription for preventive treatment.