Poor Health System Research Articles

Identifying gaps in health system governance to eliminate informal patient payments

Abstract Background Informal patient payments continue to exist in many European countries. These payments might take various forms but can be broadly defined as any payments in addition to formal fees determined by the terms of entitlement. Poor health system governance is considered one of the main factors contributing to their presence, although different aspects of governance might be relevant in each country. The aim of this study was to develop an assessment instrument to help identify gaps in health system governance that contribute to informal patient payments. Methods The study has been performed in 2022-2023 in three stages. In the first step, relying on the TAPIC framework and available literature on informal patient payments, we developed a list of questions for each domain of governance: Transparency, Accountability, Participation, Integrity, Capacity. In the second step, the questionnaire was assessed by external experts to ensure it covers the full range of relevant aspects. We then applied the instrument to three European countries, i.e. Denmark, Greece, and Poland, where informal payments differ in scale. Results The developed instrument includes 22 questions in the five TAPIC domains. They particularly refer to the role of governance in eliminating underlying reasons for informal patient payments (poor quality of health care) and effective penalization of these payments. The application of the instrument showed that in two countries where informal payments are more common, i.e. Greece and Poland, quality and waiting time guarantees are poorly defined, monitored, and incentivized, while existing mechanisms only penalize payments proven to be bribes. Conclusions There is a broad range of health system governance aspects that can be directly or indirectly linked to informal patient payments. The proposed instrument can facilitate the development of long- and short-term policies to eliminate informal payments in European countries. Key messages • Policy makers need to take greater account of the role of governance in ensuring health care quality to eliminate informal patient payments. • The lack of mechanisms to penalize all types of informal payments may contribute to the commonness of these payments in Europe.

Regional variation in incidence and mortality due to hypertension in Sao Tome and Principe

Abstract Background The analysis of incidence and mortality due to hypertension (HT) provides statistical data for addressing public health programs, particularly in low-income countries where poor health systems impose constraints to address non-communicable diseases (NCDs). This study aims to assess the geographic pattern of incidence and mortality due to HT in Sao Tome and Principe (STP). Methods This is a descriptive ecological study. Aggregated data on new cases of and deaths due to HT by gender, age-group and district (2022-2023) were extracted from the Health National Database (STP Ministry of Health). Age-standardized incidence and mortality rates (ASIR and ASMR) and respective 95% confidence interval (95%CI) were obtained. Mortality-to-incidence ratio (MIR) was computed by district (lower values indicate better quality of care). Comparison between districts was done through standardized incidence ratios (SIR) and respective p-value. Analyses were stratified by gender. Results ASIR and ASMR per 100,000 were, respectively, 1168.9 (95%CI:1103.3-1237.6) and 76.8 (95%CI:62.0-96.2) among men and 2460.6 (95%CI:2365.0-2559.0) and 99.7 (95%CI:81.4-121.6) among women. Incidence of HT was significantly higher than expected (p < 0.001) in Agua Grande, Caue and Lemba with SIR varying from 122.8% (Agua Grande) to 201.1% (Caue) in men and from 125.1% (Lemba) to 224.1% (Caue) in women. Instead, Mé-Zochi presented much lower incidence than expected for both, men (SIR=43.1%;p<0.001) and women (SIR=38.4%;p<0.001). Large differences between districts were observed in MIR, varying from 0% (Caue and Lobata) to 84% (Mé-Zochi) in men and from 0% (Lobata) to 57% (Mé-Zochi) in women. Conclusions According to our findings there is, not only, a high incidence rate of HT, but also regional variation in this rate, deserving particular attention from policy-makers. Regional variation in hypertension incidence could be partially explained by differences in the quality of healthcare services. Key messages • Awareness should be given to the high incidence of hypertension demanding preventive strategies in the field of public health. • Public health strategies should address the quality of care in regards to the prevention, diagnosis and monitoring of hypertension.

Exploring cultural competence barriers in the primary care sexual and reproductive health centres in Catalonia, Spain: perspectives from immigrant women and healthcare providers

BackgroundImmigrant populations, especially women, continue facing challenges in accessing quality healthcare, particularly sexual and reproductive health services (SRH). Poor cultural competent health systems contribute to communication challenges between immigrant women and healthcare providers perpetuating health disparities. This exploratory study describes these communication barriers from the perspective of Moroccan and Pakistani immigrant women and healthcare providers within the Catalan health system and its implications to ensure an equitable provision of SRH services.MethodsAn exploratory-descriptive qualitative study was conducted in various municipalities of Barcelona with high concentration of immigrants. Eight focus groups (N = 51) and semi-structured interviews (N = 22) with Moroccan and Pakistani immigrant women were combined with key informant interviews (N = 13) with healthcare professionals. Thematic analysis and data triangulation were performed primarily using an inductive approach.ResultsLanguage barriers and cultural differences in health needs, expectations, care-seeking behaviours and understanding of quality healthcare provision hindered the ability of immigrant women and providers to interact effectively. Limited availability of intercultural mediators and inadequate cultural competence training opportunities for health staff were also identified. Findings suggest a lack of minority representation in the Catalan health workforce and leadership roles.ConclusionThis study reinforces the evidence of persistent inequities in accessing healthcare among immigrant populations by focusing on the cultural competence barriers of the Catalan health system in the provision and access to SRH services. The regularization of adequately trained intercultural mediators, quality training in cultural competence for health staff and a commitment to increase workforce diversity would contribute to improve intercultural communication between immigrant patients and providers. An urgent call to action in this direction is needed to ensure an equitable access to SRH services among immigrant women.

Patients’ experiences with ‘sludge’ (administrative burden) in the cancer screening process and its relationship with screening completion, experience and health system distrust

Objective‘Sludge’ refers to administrative burdens or frictions that preclude people from getting what they want or need (eg, duplicative forms, complicated instructions, long waiting times). This mixed methods study evaluated...

Identifikasi Penyakit Protozoa Terhadap Manusia

Protozoa is a microscopic, one-cell organism that belongs to the protista group. Some protozoa species are pathogenic and can cause a variety of serious diseases in humans, which are often spread through water, contaminated food, or vectors such as mosquitoes and flies. Diseases caused by protozoa, such as malaria, amebiasis, giardiasis, and leishmaniasis, have a significant impact on public health, especially in developing countries with poor sanitation and limited health systems. This research uses a method (literature review) with a keyword search for articles on protozoa disease against humans in the context of articles in Indonesia. Data collection techniques using search processes in Google Scholar Research results show that increased awareness, education, and training for medical personnel are also important to ensure that protozoa infections can be diagnosed and treated effectively, thus minimizing the impact of the disease on society. Overall, the study emphasizes the importance of sanitation, personal hygiene, health education, routine screening, and vector control to reduce the prevalence of intestinal protozoa infections and improve the health of people with weakened immunity

A hospital-based survey assessing the health facility-level factors that contribute to delayed diagnosis of cervical cancer; patients views

Background In Kenya, Cervical Cancer is the 2nd commonly diagnosed type of cancer and the leading cause of cancer-related death among women. Globally, more than 50% of Cervical Cancer diagnoses are made late, with this proportion rising to 80% in developing countries. Poor Health systems can cause delays in diagnosis; thus, this study focused on determining the health facility level factors that contribute to delayed diagnosis among Cervical Cancer patients at Kenyatta National Hospital (KNH). Methods An analytical cross-sectional mixed method study was adopted to collect data on hospital and referral experiences from 139 Cervical Cancer patients systematically sampled at the KNH, using a semi-structured questionnaire. Associations between stage at diagnosis and hospital and referral experience were tested using a logistic regression model at a 95% Confidence Interval. Results 86 (61.9%) patients were diagnosed with advanced stages III and IV. The potential predictors for delayed diagnosis were a higher number of hospital referrals (p =0.000), facing referral challenges (p =0.041), longer time taken for diagnosis appointment (p =0.059), and longer time taken for diagnostic results (p =0.007) in the bivariate analysis. A higher number of hospital referrals (p =0.001) and longer time taken for diagnostic results (p =0.025) were significantly associated with delayed diagnosis of cervical cancer in the multivariate logistic regression test model. Referral challenges include misdiagnosis, cost of diagnosis, and prolonged diagnosis appointments. The study concluded that the advanced stage at presentation for most patients was due to poor health and referral systems, inadequate medical personnel, and diagnostic equipment. Conclusion This study recommends improving referral systems and encouraging partnerships to decentralize diagnostic centers and equipment and to train more experts on Cervical Cancer.

A review of the effect of iron supplementation on the gut microbiota of children in developing countries and the impact of prebiotics.

Iron is essential for many physiological functions of the body, and it is required for normal growth and development. Iron deficiency (ID) is the most common form of micronutrient malnutrition and is particularly prevalent in infants and young children in developing countries. Iron supplementation is considered the most effective strategy to combat the risk of ID and ID anaemia (IDA) in infants, although iron supplements cause a range of deleterious gut-related problems in malnourished children. The purpose of this review is to assess the available evidence on the effect of iron supplementation on the gut microbiota during childhood ID and to further assess whether prebiotics offer any benefits for iron supplementation. Prebiotics are well known to improve gut-microbial health in children, and recent reports indicate that prebiotics can mitigate the adverse gut-related effects of iron supplementation in children with ID and IDA. Thus, provision of prebiotics alongside iron supplements has the potential for an enhanced strategy for combatting ID and IDA among children in the developing world. However, further understanding is required before the benefit of such combined treatments of ID in nutritionally deprived children across populations can be fully confirmed. Such enhanced understanding is of high relevance in resource-poor countries where ID, poor sanitation and hygiene, alongside inadequate access to good drinking water and poor health systems, are serious public health concerns.

Gendered gaps to tuberculosis prevention and care in Kenya: a political economy analysis study

BackgroundTuberculosis (TB) remains a public health concern in Kenya despite the massive global efforts towards ending TB. The impediments to TB prevention and care efforts include poor health systems, resource...

Statement on Impact of Air Pollution on Human Health; Africa Region

The impacts of air pollution on human health are enormous and in African region, morbidity and mortality from air pollution causes rose since 1990. The significant sources of air pollution have been observed from human activities such as Industrialization, agricultural burning, transport and traffic, combustion of wood, coal, paraffin and animal dung for household energy needs, dusty roads and burning of household solid waste in areas without regular residential waste collection services. Africa with a poor health system faces a severe lack of air pollution detection metrics, with only 7 out of 54 countries having air quality detection monitors. Long- and short-term exposure to air pollution is associated with increasing rate of morbidity and mortality from acute and chronic respiratory diseases, cardiovascular diseases and cancers. The progression of asthma, lung cancer, cardiovascular diseases, Alzheimer's and Parkinson's diseases is linked to air pollution exposure. Measures to reduce and control air pollution in Africa Region have been suggested in this paper.

A first insight into tuberculosis transmission at the border of Ecuador and Colombia: a retrospective study of the population structure of Mycobacterium tuberculosis in Esmeraldas province.

Tuberculosis (TB) is a major public health concern in Ecuador and Colombia, considering that both countries are high-burden TB settings. Molecular epidemiology is crucial to understand the transmission dynamics of Mycobacterium tuberculosis complex (MTBC) and to identify active transmission clusters of regional importance. We studied the potential transmission of TB between Colombia and Ecuador through the analysis of the population structure of MTBC lineages circulating in the Ecuadorian province of Esmeraldas at the border with Colombia. A total of 105 MTBC strains were characterized by 24-loci MIRU-VNTR and spoligotyping. MTBC lineage 4 is only present in Esmeraldas; no MTBC strains belonging to Lineage 2-sublineage Beijing were found despite its presence in other provinces of Ecuador and, in Colombia. Genotyping results revealed a high degree of diversity for MTBC in Esmeraldas: Neither active transmission clusters within this province nor including MTBC strains from Colombia or other provinces of Ecuador were found. Our data suggest that tuberculosis dynamics in this rural and isolated area may be not related to highly transmitted strains but could be influenced by other health determinants that favor TB relapse such as poverty and poor health system access. Further studies including a larger number of MTBC strains from Esmeraldas are necessary to test this hypothesis.

Analysis of social investment in health systems reform: a case study of results-based financing in Marondera District, Zimbabwe.

suboptimal use of donor funds and poor health systems performance is rife across most developing countries; to address this, results-based financing (RBF) models were developed. However, it is imperative to explore the emic and context specific influence of results-based financing in health systems performance. This study therefore sought to explore the influence of results-based financing on health worker motivation and governance, temporal perspective, distributional principle, and policy coherence. Finally, the influence of results-based financing on interrelations across donors, technical partners, and health workers was explored. the study adopted a qualitative, exploratory, descriptive, phenomenological design using audio-recorded face-to-face semi-structured interviews to capture diverse perspectives from the remaining and available two health financing experts, two technical partner organization representatives, and six health workers who have been implementing results-based financing from 2011 to 2022 in the Marondera district of Zimbabwe. Data was transcribed and collectively analyzed using NVIVO software. improved staff motivation, better governance, health system development, equity, and policy consistency were attributable to results-based financing, notwithstanding several challenges including understaffing, increased workload, procurement red tape, financial rigidity, and delays in subsidy payments, which eroded gains of better performance. Additionally, a lack of continuum of care due to user fees faced by the poor at higher levels of care, and limited engagement between donors and healthcare facility workers were also observed. Conclusion: reinforcing pinpointed positives is vital for sustaining realized health gains; however, urgent attention is required to address the challenges to safeguard the milestones achieved thus far.

Lifetimes of Vulnerability: Childhood Adversity, Poor Adult Health, and the Criminal Legal System.

On average, incarcerated people have higher rates of poor health, mental illness, and histories of adverse childhood experiences (ACEs) than the general population. This mixed-methods analysis examines the relationship between ACEs and poor adult health among a sample of formerly incarcerated people. The quantitative analysis (N = 122) shows childhood adversity is associated with various health conditions in adulthood, although the strength of this relationship varies by the kinds of ACEs respondents encountered. The qualitative analysis of life history timelines (N = 42) reveals two pathways relating ACEs to poor health and legal system involvement: (1) violence and victimization and (2) drug use as a coping mechanism. Unaddressed mental health challenges in the aftermath of adversity emerged as an important precursor to both pathways. Prisons lack a meaningful consideration of these early life events and the social structures that result in the high rates of vulnerable people in its care.

Determining the Growing Potential of Jatropha curcas and Pongamia pinnata under Various Water Regimes

Pakistan is the among the most populated countries of the world with predominantly arid climate facing different challenges like food insecurity, energy crises, poor health system, poverty, small forest area cover, and significant effects of global warming and climate change. However, there is still a large area with scanty vegetation. Research on devising cultivation techniques for growing more economically profitable plants in these areas will not only improve the ecological environment but also the people’s living standards. Jatropha curcas (JC) and Pongamia pinnata (PP) are two economically important species (bioenergy plants) with potential to grow on dry tropical arid land. Therefore, this study was carried out to check the hypothesis “JC and PP are the suitable species to grow in the dry tropical arid land of Pakistan due to their drought tolerance ability”. The experiment was carried out at the nursery of Bahauddin Zakariya University, Multan. One year old seedlings of both plants were used in the experiment. The design involves two plants of the same species in each row, four treatments, and three replications. The levels of drought were T1 (100% water), T2 (75% water), T3 (50% water), and T4 (25% water). A generalized linear model was applied to check the variation among species and within the treatments of the same species. There is a significant difference (p ≥ 0.05) in growth among species and within the treatments of the same species. JC showed better growth as compared to PP in water stress conditions but PP grow as well. The growth parameters of JC showed a positive response in T2 (75% water) and T3 (50% water) drought levels while the growth parameters of PP showed a positive response in treatments T1 (100% water) and T2 (75% water)as compared to other drought levels. In the case of the fresh and dry weight of JC and PP, significant difference (p ≥ 0.05) was also found among species and within the treatments. Both JC and PP are recommended to grow in the dry tropical regions of Pakistan but JC is declared as the prime specie as compared to PP.

Political ecology of climate change in Sundarbans, India: Understanding well‐being, social vulnerabilities, and community perception

AbstractThis study is an attempt to review the climate change phenomenon through the theoretical lens of “Political Ecology of Health.” It identifies the strategic implications of climate change policies on health and well‐being in the Sundarbans region of India and other related factors which come into play in determining the health status there. It encapsulates the existing vulnerabilities observed in this eco‐sensitive region and tries to reflect on the community's perception of the climate change crises inflicted upon them. The paper presents a comprehensive review of current conditions in the region. In addition to utilizing electronic databases, the author also reached out to experts from pertinent organizations with related expertise to gather supplementary references. Adapting to climate change is crucial to cope with the changing surroundings and elevate competency. Since Sundarbans’ adaptation strategies are intricately dependent on historical positionality, community behavior, gender roles, social capital, and ecoregion sensitivity, the well‐being and recovery in the community are very much context‐specific. Thus, it must give space to discourses of newer politics of adaptation, emerging from a rigorous ecological standpoint. Looking into the matter through the lens of “situated knowledge, political economy and socio‐ecological relationships” brought out important issues like land‐ownership conflict, fading away of the traditional knowledge system, conspicuous utilization of funds and a poor public health system.

Heterogeneity of Mycobacterium tuberculosis Strains Circulating in Panama's Western Region.

Tuberculosis remains a challenge in both rural and urban areas. Although a majority of countries display a higher burden in urban areas compared with rural areas, Panama continues to report the highest mortality rate in Central America. Urban areas, such as Panama City, report a high tuberculosis burden, whereas Panama's western region, including the provinces of Chiriquí, Bocas del Toro (both semiurban) and Ngäbe-Bugle (rural), show a lower burden. We aimed to identify highly transmitted Mycobacterium tuberculosis strains within rural and semiurban settings of Panama's western region during a 3-year period (2017, 2019, 2021). We randomly selected 87 M. tuberculosis isolates from a biobank from Panama's western region and analyzed them using allele-specific oligonucleotide polymerase chain reaction and 24-mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR). Our results show only 11.7% (10/85) of M. tuberculosis strains identified as prevalent A-Beijing, B-Haarlem, or C-LAM Strains. We found a low prevalence of A, B, and C M. tuberculosis strains in both rural and semirural settings compared with isolates collected from the Eastern Colon Province. MIRU-VNTR genotyping revealed a high degree of diversity with no clusters with single loci variation of ≥ 2 loci. These results support the notion that tuberculosis prevalence in the rural and semiurban western region of Panama are not due to previously described highly transmitted strains but is influenced instead by other health determinants, including poor health system access and a lack of systematic transmission chain monitoring. For remote rural and semiurban settings, we recommend allocating resources to reinforce efforts to prevent tuberculosis spread.

Qualitative Assessment of Challenges in Tuberculosis control in Public Health Facilities of Bule Hora Town, Ethiopia; Health Workers’ and Tuberculosis control Program Coordinators’ Perspectives, 2020

Introduction: The Millennium Development Goal target of halting and reversing TB incidence has been achieved on a global scale. Mortality from TB has fallen by 47% since 1990. Despite these gains, however, TB still remains a major worldwide health crisis. According to a recent WHO report, there where in 2018, an estimated 10 million people fell sick with tuberculosis (TB) worldwide. 5.7 million Men, 3.2 million women and 1.1 million children. Poor health systems pose many barriers to effective tuberculosis (TB) control. This study aimed at exploring health workers and TB control program coordinator’s perspectives on health systems challenges facing TB control in Bule Hora Town, Oromia Region, southern, Ethiopia. Objective: To identify challenges of health care workers and tuberculosis control program co-ordinator towards tuberculosis control at Public health facilities of Bule Hora town-2020. Method: Qualitative study was conducted at Public health facilities of Bule Hora town, Ethiopia. Four in-depth interviews with TB control program coordinators and two focus group discussions among 8 health workers were conducted. Purposive sampling was used to recruit study participants. Thematic analysis was used to identify and analyze main themes. Results: We identified that shortage of laboratory reagents, Shortages of TB diagnostic tools and intermittent supply of anti-TB drugs, shortage of trained and motivated health care staffs, Poor community TB mobilization and collaboration between health institutions were challenges facing the TB control program performance in the study area. Conclusion: Ensuring no proper supply of anti-TB drugs, laboratory reagents and Shortages of TB diagnostic tools to all health facilities is essential. Continuous updated training of health workers on standard TB care and data handling, developing and implementing a sound retention strategy to attract and motivate health professionals to work in study areas are necessary interventions to improve the TB control program performance in the study area.

The Impacts of Covid-19 Pandemic on Pastoral Community of Somali Region in Ethiopia

The Somali Regional State of Ethiopia has suffered the highest number of COVID-19 cases, and infections are rapidly rising. The impact of the crisis on lives and livelihoods of pastoral community is expected to be particularly severe. Coronavirus diseases 2019), had health impacts practically on every community in the world generally and particularly most of the pastoral communities inhabiting the remotest areas of the region have limited access to information on the pandemic and have poor health systems with limited reach to the most vulnerable. Pastoral communities are at a high risk of interacting with zoonotic infectious diseases, owing to their livestock management practices, which include herd mixing and transhumance and the locations they occupy especially their contact with wildlife - as well as the consumption of bush meat among some pastoral communities. In this quick Review we focused on pastoral public health initiatives to safeguard health access and mobility while addressing the direct health effects of COVID-19. In order to effectively respond to the COVID-19 pandemic and safeguard pastoral livelihoods and Health security, it is necessary to take a contextualized one health approach, taking into account how the pandemic will interact with current shocks and vulnerabilities in pastoral areas of the Somali region.

Evaluation of the in-vivo Antiplasmodial Activities of Ochna membranacea (Oliv) Ochnaceae Leaves and Stembark extracts in mice

Malaria is an infectious disease with high mortality rate in Africa. Development of resistance to antimalarial drugs in current clinical use such as chloroquine and Artemisinin; along with poor health systems and funding shortfalls have elevated the importance of continuous search for novel antimalarial agents. The lead compounds from which chloroquine and artemisinin were derived were isolated from plants. Therefore, there is high potential for the discovery of new and effective treatment from plants. Ochna membranacea (Oliv) Ochnaceae is among several plants used traditionally against infectious diseases including malaria with no scientific validation. This study investigated the antiplasmodial effect of the crude methanol leaves extract and crude methanol stembark extract of Ochna membranacea coded OMCLE and OMCSE respectively against Plasmodium berghei chloroquine-resistant strain. Acute toxicity studies were carried out using standard protocol. The prophylactic, suppressive and curative effects of the extracts were evaluated at the doses of 500, 1000 and 1500 mg/kg using Ryley and Peters’ method. Chloroquine (5 mg/kg) and artesunate (5 mg/kg) were used as standard drugs in the suppressive and curative tests, while 1.2 mg/kg pyrimethamine was used as standard in the prophylactic test. The oral median lethal dose (LD50) was estimated to be > 5000 mg/kg. All graded doses of OMCLE gave a statistically significant (P<0.05) prophylactic effect. Only the median and highest doses of OMCSE gave significant inhibition of parasitaemia. In the suppressive test, all tested doses of both extracts exhibited significant suppression of parasitaemia compared to the negative control. In conclusion, the study suggests that O. membranaceapossesses antiplasmodial activity making it a potent candidate in the search for newer antimalarials.

Training health workers in clinical breast examination for early detection of breast cancer in low- and middle-income countries.

Most women living in low- and middle-income countries (LMICs) present with advanced-stage breast cancer. Limitations of poor serviceable health systems, restricted access to treatment facilities, and lack of breast cancer screening programmes all likely contribute to the late presentation of women with breast cancer living in these countries. Women are diagnosed with advanced disease and frequently do not complete their care due to a number of factors, including financial reasons as health expenditure is largely out of pocket resulting in financial toxicity; health system failures, such as missing services or health worker lack of awareness on common signs and symptoms of cancer; and sociocultural barriers, such as stigma and use of alternative therapies. Clinical breast examination (CBE) is an inexpensive early detection technique for breast cancer in women with palpable breast masses. Training health workers from LMICs to conduct CBE has the potential to improve the quality of the technique and the ability of health workers to detect breast cancers early. To assess whether training in CBE affects the ability of health workers in LMICs to detect early breast cancer. We searched the Cochrane Breast Cancer Specialised Registry, CENTRAL, MEDLINE, Embase, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal, and ClinicalTrials.gov up to 17 July 2021. We included randomised controlled trials (RCTs) (including individual and cluster-RCTs), quasi-experimental studies and controlled before-and-after studies if they fulfilled the eligibility criteria. Two review authors independently screened studies for inclusion, and extracted data, assessed risk of bias, and assessed the certainty of the evidence using the GRADE approach. We performed statistical analysis using Review Manager software and presented the main findings of the review in a summary of findings table. We included four RCTs that screened a total population of 947,190 women for breast cancer, out of which 593 breast cancers were diagnosed. All included studies were cluster-RCTs; two were conducted in India, one in the Philippines, and one in Rwanda. Health workers trained to perform CBE in the included studies were primary health workers, nurses, midwives, and community health workers. Three of the four included studies reported on the primary outcome (breast cancer stage at the time of presentation). Amongst secondary outcomes, included studies reported CBE coverage, follow-up, accuracy of health worker-performed CBE, and breast cancer mortality. None of the included studies reported knowledge attitude practice (KAP) outcomes and cost-effectiveness. Three studies reported diagnosis of breast cancer at early stage (at stage 0+I+II), suggesting that training health workers in CBE may increase the number of women detected with breast cancer at an early stage compared to the non-training group (45% detected versus 31% detected; risk ratio (RR) 1.44, 95% confidence interval (CI) 1.01 to 2.06; three studies; 593 participants; I2 = 0%; low-certainty evidence). Three studies reported diagnosis at late stage (III+IV) suggesting that training health workers in CBE may slightly reduce the number of women detected with breast cancer at late stage compared to the non-training group (13% detected versus 42%, RR 0.58, 95% CI 0.36 to 0.94; three studies; 593 participants; I2 = 52%; low-certainty evidence). Regarding secondary outcomes, two studies reported breast cancer mortality, implying that the evidence is uncertain for the impact on breast cancer mortality (RR 0.88, 95% CI 0.24 to 3.26; two studies; 355 participants; I2 = 68%; very low-certainty evidence). Due to the study heterogeneity, we could not conduct meta-analysis for accuracy of health worker-performed CBE, CBE coverage, and completion of follow-up, and therefore reported narratively using the 'Synthesis without meta-analysis' (SWiM) guideline. Sensitivity of health worker-performed CBE was reported to be 53.2% and 51.7%; while specificity was reported to be 100% and 94.3% respectively in two included studies (very low-certainty evidence). One trial reported CBE coverage with a mean adherence of 67.07% for the first four screening rounds (low-certainty evidence). One trial reported follow-up suggesting that compliance rates for diagnostic confirmation following a positive CBE were 68.29%, 71.20%, 78.84% and 79.98% during the respective first four rounds of screening in the intervention group compared to 90.88%, 82.96%, 79.56% and 80.39% during the respective four rounds of screening in the control group. Our review findings suggest some benefit of training health workers from LMICs in CBE on early detection of breast cancer. However, the evidence regarding mortality, accuracy of health worker-performed CBE, and completion of follow up is uncertain and requires further evaluation.

SOCIAL DETERMINANTS OF INFANT AND CHILD MORTALITY

Infant and child mortality rate are significant phenomenon closely related to the healthy status of a society. They are major indicators of development. The secondary analysis methodology was adopted in this study while the major source of data was NDHS 2013 report. The ex post-facto research design was used in describing the NDHS 2013 qualitative data. The collected data is centered on Nigeria while empirical studies are not limited to Nigeria.to classify various social determinants of infant and child mortality either as individual and community factors or endogenous and exogenous factors. These social determinants were ex-rayed in relationship to their socio-economic implication. At the macro level, high rate of infant and child mortality are clear indices of poor health care facility and system, unhygienic environment, chronic poverty, enduring illiteracy and intense insecurity. At the micro level, it shows skewed income distribution, ignorance, poor exposure and food insufficiency. The study shows that social exclusion of mothers from decision making, inadequate knowledge about care for pregnancies, attitude toward accessibility of quality and affordable health care and insecurity have influence on morality growth. While there was an inverse relationship between income, residence, education, occupation, age of mothers, mother’s experience and infant and child mortality, there was a positive relationship between choice of contraceptives, male preference, mother’s non-freedom of choice, attitude toward place of delivery, inaccessibility of antenatal and post-natal care, perception toward acceptance of anti-tetanus treatment during pregnancies, incompetency of health workers and infant and child mortality. The study also shows that increase in per capital GDP is associated with decrease in infant and child mortality.