Populations In Low- And Middle-income Countries Research Articles

Global Health Informatics: the state of research and lessons learned.

The Journal of the American Medical Informatics Association (JAMIA) focus issue on Global Health Informatics (GHI) examines how health informatics can address global health issues. The selected papers discuss how informatics can improve health outcomes, especially in low- and middle-income countries (LMICs). The articles in this issue come from a broad range of researchers, practitioners, and policymakers, provide an overview of GHI initiatives and encourage researchers and practitioners to share ideas and best practices. GHI aims to harness digital health and informatics knowledge and tools to improve the care of individuals and populations in LMIC through achieving these 5 aims: effectiveness, efficiencies, patient satisfaction, provider well-being, and equity. A central consideration is the global north-south divide and the sociotechnical determinants of and impacts on the digital health maturity of LMIC. This issue seeks to document and understand how health informatics approaches have been undertaken in multiple LMIC scenarios and environments and how they can demonstrate the scientific impact of informatics-based best practices applied to COVID-19 and beyond.

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews

BackgroundInequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs.MethodsWe searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization’s (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107).ResultsIn a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed.ConclusionThe generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

High throughput analysis of MHC class I and class II diversity of Zambian indigenous cattle populations.

The classical MHC class I and class II molecules play key roles in determining the antigenic-specificity of CD8+ and CD4+ T-cell responses-as such characterisation of the repertoire of MHCI and MHCII allelic diversity is fundamental to our ability to understand, and potentially, exploit how genetic diversity influences the outcome of immune responses. Cattle remain one of the most economically livestock species, with particular importance to many small-holder farmers in low-and-middle income countries (LMICs). However, our knowledge of MHC (BoLA) diversity in the indigenous breeds that form the mainstay of cattle populations in many LMICs remains very limited. In this study we develop a MiSeq-based platform to enable the rapid analysis of BoLA-DQA and BoLA-DQB, and combine this with similar platforms to analyse BoLA-I and BoLA-DRB repertoires, to study a large cohort of cattle (~800 animals) representing the 3 major indigenous breeds (Angoni, Barotse, Tonga) in Zambia. The data presented confirms the capacity of this high-throughput and high-resolution approach to provide a full characterisation of the MHCI-MHCII genotypes of cattle for which little previous MHC sequence data has been obtained. The cattle in Zambia were found to express a diverse range of MHCI, MHCII and extended MHCI-MHCII haplotypes. The combined MHCI-MHCII genotyping now possible opens new opportunities to rapidly expand our knowledge of MHC diversity in cattle that could find applications in a related translational disciplines such as vaccine development.

When Moving Is the Only Option: The Role of Necessity Versus Choice for Understanding and Promoting Physical Activity in Low- and Middle-Income Countries.

Given its origins in high-income countries, the field of physical activity and public health research and promotion has broadly followed a choice-based model. However, a substantial amount of the physical activity occurring routinely in many settings, particularly in low- and middle-income countries (LMICs), is the result of economic necessity and is not due to true, free choices. We propose the "necessity- versus choice-based physical activity models" framework as a conceptual tool to ground physical activity and public health research and promotion efforts in LMICs, helping ensurethat these efforts are relevant, ethical, responsive, and respectful to local contexts. Identifying ways to ensure that LMIC populations can maintain high levels of active transport while increasing opportunities for active leisure must be prioritized. To promote equity, physical activity research, programs, and policies in LMICs must focus on improving the conditions under which necessity-driven physical activity occurs for a vast majority of the population.

Using wearable devices to generate real-world, individual-level data in rural, low-resource contexts in Burkina Faso, Africa: A case study.

BackgroundWearable devices may generate valuable data for global health research for low- and middle-income countries (LMICs). However, wearable studies in LMICs are scarce. This study aims to investigate the use of consumer-grade wearables to generate individual-level data in vulnerable populations in LMICs, focusing on the acceptability (quality of the devices being accepted or even liked) and feasibility (the state of being workable, realizable, and practical, including aspects of data completeness and plausibility).MethodsWe utilized a mixed-methods approach within the health and demographic surveillance system (HDSS) to conduct a case study in Nouna, Burkina Faso (BF). All HDSS residents older than 6 years were eligible. N = 150 participants were randomly selected from the HDSS database to wear a wristband tracker (Withings Pulse HR) and n = 69 also a thermometer patch (Tucky thermometer) for 3 weeks. Every 4 days, a trained field worker conducted an acceptability questionnaire with participants, which included questions for the field workers as well. Descriptive and qualitative thematic analyses were used to analyze the responses of study participants and field workers.ResultsIn total, n = 148 participants were included (and n = 9 field workers). Participant's acceptability ranged from 94 to 100% throughout the questionnaire. In 95% of the cases (n = 140), participants reported no challenges with the wearable. Most participants were not affected by the wearable in their daily activities (n = 122, 83%) and even enjoyed wearing them (n = 30, 20%). Some were concerned about damage to the wearables (n = 7, 5%). Total data coverage (i.e., the proportion of the whole 3-week study duration covered by data) was 43% for accelerometer (activity), 3% for heart rate, and 4% for body shell temperature. Field workers reported technical issues like faulty synchronization (n = 6, 1%). On average, participants slept 7 h (SD 3.2 h) and walked 8,000 steps per day (SD 5573.6 steps). Acceptability and data completeness were comparable across sex, age, and study arms.ConclusionWearable devices were well-accepted and were able to produce continuous measurements, highlighting the potential for wearables to generate large datasets in LMICs. Challenges constituted data missingness mainly of technical nature. To our knowledge, this is the first study to use consumer-focused wearables to generate objective datasets in rural BF.

The effectiveness of lifestyle interventions on type 2 diabetes and gestational diabetes incidence and cardiometabolic outcomes: A systematic review and meta-analysis of evidence from low- and middle-income countries.

SummaryBackgroundAs lifestyle modification offers a unique strategy to prevent diabetes, we evaluated the effectiveness of lifestyle interventions in the prevention of type 2 diabetes and gestational diabetes in low- and middle-income countries (LMICs).MethodsWe did a systematic literature review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and Cochrane Library for randomised controlled trials published in English, Spanish, French, and Portuguese between 1 January 2000 and 15 June 2022, evaluating multi-target and multi-component lifestyle interventions in at-risk populations conducted in LMICs. The main outcomes were incidence of type 2 diabetes and gestational diabetes, and indicators of glycaemic control. We assessed the methodological quality of the studies using the Cochrane risk of bias tool. Inverse-variance random-effects meta-analyses estimated the overall effect sizes. Sources of heterogeneity and study bias were evaluated. The study protocol was registered in PROSPERO (CRD42021279174).FindingsFrom 14 330 abstracts, 48 (0·3%) studies with 50 interventions were eligible of which 56% were conducted in lower-middle-income countries, 44% in upper-middle, and none in low-income. 54% of the studies were assessed as moderate risk of bias and 14% as high risk. A median of 246 (IQR 137-511) individuals participated in the interventions with a median duration of 6 (3-12) months. Lifestyle interventions decreased the incidence risk ratio of type 2 diabetes by 25% (0·75 [95% CI 0·61 to 0·91]), and reduced the levels of HbA1c by 0·15% [−0·25 to −0·05], fasting plasma glucose by 3·44 mg/dL [−4·72 to −2·17], and 2-hr glucose tolerance by 4·18 mg/dL [−7·35 to −1·02]. No publication bias was suggested for these outcomes. High levels of heterogeneity (I²≥ 81%) were found in most meta-analyses. Exploration using meta-regressions could not identify any explanatory variable, except for fasting glucose for which the quality score of the articles seems to be an effect modifier decreasing slightly the heterogeneity (72%) in the low risk of bias pooled estimate. The effect on gestational diabetes could not be evaluated due to the scarcity of available studies.InterpretationComprehensive lifestyle interventions are effective strategies to prevent type 2 diabetes among at-risk populations in LMICs. The heterogeneity identified in our results should be considered when using these interventions to address the onset of type 2 diabetes.FundingNone.

The Global Network Socioeconomic Status Index as a predictor of stillbirths, perinatal mortality, and neonatal mortality in rural communities in low and lower middle income country sites of the Global Network for Women's and Children's Health Research.

BackgroundGlobally, socioeconomic status (SES) is an important health determinant across a range of health conditions and diseases. However, measuring SES within low- and middle-income countries (LMICs) can be particularly challenging given the variation and diversity of LMIC populations.ObjectiveThe current study investigates whether maternal SES as assessed by the newly developed Global Network-SES Index is associated with pregnancy outcomes (stillbirths, perinatal mortality, and neonatal mortality) in six LMICs: Democratic Republic of the Congo, Guatemala, India, Kenya, Pakistan, and Zambia.MethodsThe analysis included data from 87,923 women enrolled in the Maternal and Newborn Health Registry of the NICHD-funded Global Network for Women’s and Children’s Health Research. Generalized estimating equations models were computed for each outcome by SES level (high, moderate, or low) and controlling for site, maternal age, parity, years of schooling, body mass index, and facility birth, including sampling cluster as a random effect.ResultsWomen with low SES had significantly higher risks for stillbirth (p < 0.001), perinatal mortality (p = 0.001), and neonatal mortality (p = 0.005) than women with high SES. In addition, those with moderate SES had significantly higher risks of stillbirth (p = 0.003) and perinatal mortality (p = 0.008) in comparison to those with high SES.ConclusionThe SES categories were associated with pregnancy outcomes, supporting the validity of the index as a non–income-based measure of SES for use in studies of pregnancy outcomes in LMICs.

An adapted behavioural activation intervention (DiaDeM) for people with diabetes and depression in South Asia: A feasibility study protocol

Background: The burden of depression is a rapidly growing problem worldwide. Its prevalence is particularly high among individuals with chronic physical conditions such as Type 2 Diabetes (T2DM), precipitating poorer health outcomes. There is a lack of evidence around treatments that can work among such groups, particularly in Low and Middle-Income Countries (LMICs). This study aims to test the feasibility and acceptability of a culturally adapted Behavioural Activation (BA) intervention (DiaDeM) for people with T2DM and depression in two LMICs in South Asia. Methods: A multicentre, randomised-controlled feasibility trial will be conducted from March 2022 to February 2023. We will recruit 128 adults from health facilities in Bangladesh and Pakistan with a diagnosis of T2DM and depression. Using a 1:1 allocation ratio, consenting individuals will be randomised to either optimised usual care or the DiaDeM intervention. The latter will involve six face-to-face or remotely delivered BA sessions conducted by non-mental health facilitators over six to twelve weeks. Participants will be followed up at three and six months post-randomisation. Feasibility outcomes include the feasibility and acceptability of recruitment and retention, the feasibility of intervention delivery and the feasibility of data collection at baseline and follow-up (including economic data). An embedded mixed-methods process evaluation will also be carried out to inform the main trial. Conclusions: BA is a low resource intervention for depression treatment that can be optimised for delivery in LMIC settings such as South Asia. The planned feasibility trial will directly inform a larger trial to assess the effectiveness and cost-effectiveness of such an intervention in people with T2DM and depression. It will also contribute to the wider evidence base around BA in patients with chronic physical illnesses, with particular relevance to South Asian, as well as wider LMIC regions and populations. Trial registration: ISRCTN 75501608

Outlines to Initiate Epilepsy Surgery in Low- and Middle-Income Countries.

Surgery is an essential treatment option for patients with drug-resistant epilepsy. While most epilepsy patients worldwide live in low- and middle-income countries (LMIC), most of these countries do not have epilepsy surgery, and those that do have surgical epilepsy services lack capacities. The rapidly growing population in LMIC further widens the gap between the number of patients who can potentially benefit from surgery and those who can actually receive it. This makes the initiation of new surgical epilepsy centers in those countries an urgent issue. Epilepsy surgery is feasible in LMIC, even in resource-poor settings, but lack of local expertise is a major obstacle to the introduction of new surgical services. Importantly, expertise deficits can be compensated by collaborating with a well-established epilepsy center for knowledge transfer, skill building and mentoring. Such projects need to be organized in a multidisciplinary team, should focus on the given circumstances, and should use technologies and personnel that are reasonably available and can function sustainably. Local cultural factors and improvement of patients' quality of life are further spotlights reflected by an increasing number of studies. As a general outline for a new surgical epilepsy program in LMIC, it is recommended to initially focus on patients with mesial temporal lobe epilepsy due to hippocampal sclerosis or other well defined pathologies. These constellations have an excellent surgical outcome in terms of seizure control, can be diagnosed by non-invasive methods, and can be reliably identified even under low-resource conditions. Moreover, surgery can be performed with a highly standardized approach and at reasonable costs, and the vast majority of patients will benefit from surgical intervention. The range of services can then be gradually expanded, depending on growing expertise, local needs, prospects and constraints. Although the introduction of surgical epilepsy services in LMIC can face several challenges, none of them should be a permanent barrier for further establishments.

Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia

BackgroundIn an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce.MethodsWe obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals.ResultsA total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies.ConclusionsThe results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting.

Estimation of nutritional postharvest losses along food value chains: A case study of three key food security commodities in sub-Saharan Africa

Postharvest losses (PHLs) amplify food insecurity and reduce the amount of nutrients available to vulnerable populations, especially in the world's Low and Middle Income Countries (LMICs). However, little is known about nutrient loss at the various postharvest stages. The objective of our study was to develop a methodology and a tool to estimate nutritional postharvest losses (NPHLs) along food value chains for three distinct food commodities in sub-Saharan Africa. The study used a combination of literature, laboratory and field data to investigate NPHLs caused by both changes in quantity and quality of food material (quantitative and qualitative NPHLs, respectively). The method can be expanded to various other food value chains. A user-friendly predictive tool was developed for case studies involving maize and cowpea in Zimbabwe, and for sweet potato in Uganda. Quantitative and qualitative NPHLs were combined and converted into predicted nutrient loss and nutritional requirement lost due to postharvest losses. The number of people who may not meet their daily nutritional needs, as a result of the food and nutrient losses at country level, was estimated. The estimates consider nutritionally vulnerable groups such as children under five years and pregnant women. The nutrient density of the harvested food material, the level of food production, the postharvest stages along the food value chain, the levels of pest damage along the value chain, and the susceptibility of the nutrients to degradation e.g. during storage, are all important factors that affect NPHLs. Our modelling work suggests that reducing PHLs along food value chains could significantly improve access to nutritious food for populations in LMICs.

Out-of-pocket costs near end of life in low- and middle-income countries: A systematic review.

Globally, there is a rise in chronic disease, including cancer, major organ failure and dementias. Patients and their families in low- and middle-income countries (LMICs) pay a high proportion of medical costs out of pocket (OOP), and a diagnosis of serious illness often has catastrophic financial consequences. We therefore conducted a review of the literature to establish what is known about OOP costs near end of life in LMICs. To identify, organise and report the evidence on out-of-pocket costs in adult end-of-life populations in LMIC. A systematic search of 8 databases and a hand search of relevant systematic reviews and grey literature was performed. Two independent reviewers screened titles and abstracts, assessed papers for eligibility and extracted data. The review was registered with PROSPERO and adhered to the Preferred Reporting items for Systematic Reviews and Meta Analyses. The Mixed Methods Appraisal Tool was used to assess quality. The Wagstaff taxonomy was used to describe OOP. After deduplication, 9,343 studies were screened, of which 51 were read and rejected as full texts, and 12 were included in the final review. OOP costs increased with advanced illness and disease severity. The main drivers of OOP were medications and hospitalizations, with high but variable percentages of the affected populations reporting financial catastrophe, lost income, foregone education and other pressures. Despite a small number of included studies and heterogeneity in methodology and reporting, it is clear that OOP costs for care near end of life in LMIC represent an important source of catastrophic health expenditures and impoverishment. This suggests a role for widespread, targeted efforts to avoid poverty traps. Financial protection policies for those suffering from incurable disease and future research on the macro- and micro- economics of palliative care delivery in LMIC are greatly needed.

Prevalence of mental health and suicide risk in prisons in low- and middle-income countries: a rapid review

ABSTRACT The majority of the world’s total prison population resides in low- and middle-income countries (LMIC), but most research into the prevalence of mental illness and suicide risk comes from high-income countries (HIC). The provision of mental health care varies widely across prisons in LMIC, with reported disparity between high levels of need and funding, resources and services. This rapid review aims to explore the existing evidence-base relating to suicide and mental health prevalence in prisons in LMIC. A total of 2,799 published and grey literature were identified through systematic searches, with 35 papers included in the final review. The prevalence of suicide ideation was lower among prisoners in LMIC than HIC, with common mental illness, severe mental illness, and substance misuse more prevalent among LMIC prisoners. Rates of suicide ideation and common mental illness were higher among females than males. These findings highlight the need for dedicated research using LMIC samples and consideration of resources within LMIC prisons. The results of this analysis can be used to inform next steps to tackle the high level of unmet mental health needs amongst prisoner populations in LMIC.

Brand inequity in access to COVID-19 vaccines

Brand inequity in access to COVID-19 vaccines

SmartKC

Keratoconus is a severe eye disease affecting the cornea (the clear, dome-shaped outer surface of the eye), causing it to become thin and develop a conical bulge. The diagnosis of keratoconus requires sophisticated ophthalmic devices which are non-portable and very expensive. This makes early detection of keratoconus inaccessible to large populations in low-and middle-income countries, making it a leading cause for partial/complete blindness among such populations. We propose SmartKC, a low-cost, smartphone-based keratoconus diagnosis system comprising of a 3D-printed placido's disc attachment, an LED light strip, and an intelligent smartphone app to capture the reflection of the placido rings on the cornea. An image processing pipeline analyzes the corneal image and uses the smartphone's camera parameters, the placido rings' 3D location, the pixel location of the reflected placido rings and the setup's working distance to construct the corneal surface, via the Arc-Step method and Zernike polynomials based surface fitting. In a clinical study with 101 distinct eyes, we found that SmartKC achieves a sensitivity of 87.8% and a specificity of 80.4%. Moreover, the quantitative curvature estimates (sim-K) strongly correlate with a gold-standard medical device (Pearson correlation coefficient = 0.77). Our results indicate that SmartKC has the potential to be used as a keratoconus screening tool under real-world medical settings.

Use of RWE to Inform Regulatory, Public Health Policy, and Intervention Priorities for the Developing World.

For low‐ and middle‐income countries (LMICs) to benefit from real‐world evidence (RWE)/real‐world data (RWD) in both product registration (“regulatory”) decision making and in product utilization policy (“policy”) decision making, they need to overcome several challenges. They need to deploy more electronic health records systems (EHRs), adjust for confounder variables, build trust between stakeholders, and create laws and regulations for local generation of data that are assented for secondary use. The role of procurers and their use of RWE/RWD in the LMIC context likewise is in a state of ongoing development. Procurers of health products are strong players currently in the “access” chain as LMICs continue to work on strengthening governmental health technology assessment (HTA) bodies. Procurers’ use of RWE is presently at an early stage and is mostly indirect, leveraging RWE results that are produced by researchers in high‐income countries (HICs), often under considerably different regulatory and policy objectives and constraints compared to LMICs’ epidemiology and priorities. Pending wider deployment of EHRs and other RWE sources, stakeholders must realize that populations from HIC RWE (i) can be devised to closely resemble phenotypic patterns in LMIC populations and (ii) can be analyzed to align with LMICs’ unmet needs.

Mobile Health (mHealth) in Low- and Middle-Income Countries.

This article reflects on current trends and proposes new considerations for the future of mobile technologies for health (mHealth). Our focus is predominantly on the value of and concerns with regard to the application of digital health within low- and middle-income countries (LMICs). It is in LMICs and marginalized communities that mHealth (within the wider scope of digital health) could be most useful and valuable. Peer-reviewed literature on mHealth in LMICs provides reassurance of this potential, often reflecting on the ubiquity of mobile phones and ever-increasing connectivity globally, reaching remote or otherwise disengaged populations. Efforts to adapt successful programs for LMIC contexts and populations are only just starting to reap rewards. Private-sector investment in mHealth offers value through enhanced capacity and advances in technology as well as the ability to meet increasing consumer demand for real-time, accessible, convenient, and choice-driven health care options. We examine some of the potential considerations associated with a private-sector investment, questioning whether a core of transparency, local ownership, equity, and safety is likely to be upheld in the current environment of health entrepreneurship.

Instrumental Activities of Daily Living Scales to Detect Cognitive Impairment and Dementia in Low- and Middle-Income Countries: A Systematic Review.

Background:The largest proportion of people with dementia worldwide live in low- and middle- income countries (LMICs), with dementia prevalence continuing to rise. Assessment and diagnosis of dementia involves identifying the impact of cognitive decline on function, usually measured by instrumental activities of daily living (IADLs).Objective:This review aimed to identify IADL measures which are specifically developed, validated, or adapted for use in LMICs to guide selection of such tools.Methods:A systematic search was conducted (fourteen databases) up to April 2020. Only studies reporting on development, validation, or adaptation of IADL measures for dementia or cognitive impairment among older adults (aged over 50) in LMICs were included. The QUADAS 2 was used to assess quality of diagnostic accuracy studies.Results:22 papers met inclusion criteria; identifying 19 discrete IADL tools across 11 LMICs. These were either translated from IADL measures used in high-income countries (n = 6), translated and adapted for cultural differences (n = 6), or newly developed for target LMIC populations (n = 7). Seven measures were investigated in multiple studies; overall quality of diagnostic accuracy was moderate to good.Conclusion:Reliability, validity, and accuracy of IADL measures for supporting dementia diagnosis within LMICs was reported. Key components to consider when selecting an IADL tool for such settings were highlighted, including choosing culturally appropriate, time-efficient tools that account for gender- and literacy-bias, and can be conducted by any volunteer with appropriate training. There is a need for greater technical and external validation of IADL tools across different regions, countries, populations, and cultures.

Health Coverage and Financial Protection in Uganda: A Political Economy Perspective.

As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector. We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

Community Health Workers Can Provide Psychosocial Support to the People During COVID-19 and Beyond in Low- and Middle- Income Countries.

The COVID-19 pandemic has been the most challenging public health issue which not only affected the physical health of the global population but also aggravated the mental health conditions such as stress, anxiety, fear, depression and anger. While mental health services are seriously hampered amid this COVID-19 pandemic, health services, particularly those of Low- and Middle- Income Countries (LMICs) are looking for alternatives to provide psychosocial support to the people amid this COVID-19 and beyond. Community Health Workers (CHWs) are an integral part of the health systems in many LMICs and played significant roles such as health education, contact tracing, isolation and mobilization during past emergencies and amid COVID-19 in many LMICs. However, despite their potentials in providing psychosocial support to the people amid this COVID-19 pandemic, they have been underutilized in most health systems in LMICs. The CHWs can be effectively engaged to provide psychosocial support at the community level. Engaging them can also be cost-saving as they are already in place and may cost less compared to other health professionals. However, they need training and supervision and their safety and security needs to be protected during this COVID-19. While many LMICs have mental health policies but their enactment is limited due to the fragility of health systems and limited health care resources. CHWs can contribute in this regard and help to address the psychosocial vulnerabilities of affected population in LMICs during COVID-19 and beyond.