Studies In Low- And Middle-income Countries Research Articles

The prevalence and pattern of comorbid long-term conditions with low back pain and osteoarthritis in low- and middle-income countries: a systematic review and meta-analysis

ABSTRACT Chronic musculoskeletal (MSK) pain, specifically low back pain (LBP) and osteoarthritis (OA), are a major cause of global disability, reduced quality of life and high socioeconomic burden. Research in high income countries suggests MSK pain is often comorbid with other long-term conditions / non-communicable diseases (NCDs) including diabetes, hypertension, and cardiovascular disease. However, the epidemiology of comorbid NCDs and MSK pain in low- and middle-income countries (LMICs) is unclear. This systematic review aims to describe the prevalence and pattern of comorbid NCDs in adults with MSK pain in LMICs. Nine databases were searched for epidemiological studies in LMICs (World Bank categories). Paired researchers independently identified studies, extracted data, and completed critical appraisal using Hoy risk of bias tool. Random-effect meta-analysis was used to estimate prevalence of NCDs comorbid with MSK pain. From 2112 citations; 14 studies (n=6093 adults with MSK pain, mean age=46.9years) were included. Overall prevalence of MSK pain with comorbid NCDs was 46.1% (95%CI 32.3 - 59.9). Systemic hypertension had the highest comorbid prevalence with MSK pain (42.6%, 95%CI 25.6-59.6), followed by diabetes (26.7%, 95%CI 16.1-37.3) and mental health conditions (anxiety/depression; 24.9% 95%CI 11.5-38.4). A high proportion of patients with MSK pain in LMICs experience comorbid NCDs. Variable data/population samples, and under-reporting limit accurate capture of prevalence estimates. Understanding the true burden of MSK pain (specifically lower back pain and hip/knee osteoarthritis) and comorbid NCDs is critical to informing effective treatment strategies. The health systems implications of these findings are imperative towards person-centred care, organisation of care and efficient resource utilisation in LMICs.

Embedding research capacity strengthening in multi-country studies in low-and middle-income countries: learnings from sexual and reproductive health research

ABSTRACT Research capacity strengthening (RCS) can empower individuals, institutions, networks, or countries to define and prioritize problems systematically; develop and scientifically evaluate appropriate solutions; and reinforce or improve capacities to translate knowledge into policy and practice. However, how to embed RCS into multi-country studies focusing on sexual and reproductive health and rights (SRHR) is largely undocumented. We used findings from a qualitative study, from a review of the literature, and from a validation exercise from a panel of experts from research institutions that work on SRHR RCS. We provide a framework for embedded RCS; suggest a set of seven concrete actions that research project planners, designers, implementers, and funders can utilise to guide embedded RCS activities in low- and middle-income countries; and present a practical checklist for planning and assessing embedded RCS in research projects.

"There is nothing that can prevent me from supporting her:" men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya.

Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies. Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description. Thirty-nine male participants meeting the eligibility criteria participated in five FGDs. The mean age of participants was 42.5 years. Most participants, 79.5%, had a female partner with a history of cervical precancer treatment, 5.1% did not, and 15.4% were unsure of their female partner's prior precancer treatment history. The study aimed to assess men's support of their female partners' use of topical therapies for treating cervical precancer. We find that male participants strongly express acceptance and willingness to support their wives or partners in using such therapies, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support. The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.

Incidence of Sudden Cardiac Death in Low- and Middle-Income Countries: A Systematic Review of Cohort Studies.

Sudden cardiac death (SCD) is a leading cause of mortality worldwide and, in recent years, has become an urgent public health concern in low- and middle-income countries (LMICs). Data from LMICs, however, remains limited. As such, the aim of this article is to systematically review the current literature on the incidence of SCD in LMICs to inform policymakers and identify potential research gaps. A search of PubMed and Embase was utilized to capture the targeted condition, outcome, and setting. Only peer-reviewed cohort studies in LMICs reporting SCD incidence estimates in the general population of individuals aged ≥1 year were eligible for selection. Papers providing incidence data for specific types of SCD, including sudden coronary death or death from sudden cardiac arrest, were also included. After deduplication, 1941 citations were identified and screened. Seven studies representing four countries-Cameroon, China, India, and Iran-met the criteria for inclusion and were considered in our analysis. The crude incidence rate for SCD ranged from 19.9 to 190 cases per 100,000 person-years, while age-adjusted rates ranged from 33.6 to 230 cases per 100,000 person-years. There was notable variability in methods utilized to ascertain SCD cases. These findings suggest that the incidence of all-cause SCD in LMICs and may exceed that of high-income countries; however, observed disparities may be partly attributable to differences in case ascertainment methods. Additional research is needed to better understand the true incidence of SCD in developing countries. It is crucial that future studies across regions utilize standard diagnostic criteria and methodology for identifying SCD, which would provide a framework by which to compare outcomes between settings.

Risk factors for burn contractures in a lower income country: Four illustrative cases.

Burns are most prevalent in low- and middle-income countries but the risk factors for burn contractures in these settings are poorly understood. There is some evidence from low- and middle-income country studies to suggest that non-medical factors such as socio-economic and health system issues may be as, or possibly more, important than biomedical factors in the development of post-burn contractures. Four cases are presented to illustrate the impact of non-biomedical factors on contracture outcomes in a low-income setting. The cases were drawn from participants in a cross-sectional study which examined risk factors for contracture in Bangladesh. The two cases had similar burns but different standards of care for socio-economic reasons, leading to very different contracture outcomes The two cases both had access to specialist care but had very different contracture outcomes for non-medical reasons. The risk factors and contracture outcomes in each case are documented and compared. The impact of non-biomedical factors in contracture development after burns in low- and middle-income countries is highlighted and discussed. Burns are common in low- and middle-income countries (LMICs) but the risk factors for burn contractures in these settings are poorly understood. Burn contractures are formed when scarring from a burn injury is near or over a joint and results in limited movement. There is some evidence from LMIC studies which suggests that non-medical factors such as socio-economic (e.g., household income, level of education) and health system issues (e.g., whether specialist burn care could be accessed) may be as, or possibly more, important than non-medical factors (such as the type and depth of burn and the treatments received) in the development of contractures following burn injuries.Four cases are presented to illustrate the impact of non-biomedical factors on contracture outcomes in a low-income setting. The cases were drawn from participants in a larger study which examined risk factors for contracture in Bangladesh. Two cases had similar burns but different standards of care and different outcomes. Two cases had similar access to specialist care but very different outcomes for non-medical reasons. The risk factors present and contractures outcomes in each case are documented and compared.The importance of non-biomedical factors in contracture development after burns in LMICs is highlighted and discussed.

Device-measured movement behaviours in over 20,000 China Kadoorie Biobank participants

BackgroundMovement behaviours, including physical activity, sedentary behaviour, and sleep have been shown to be associated with several chronic diseases. However, they have not been objectively measured in large-scale prospective cohort studies in low-and middle-income countries. We aim to describe the patterns of device-measured movement behaviours collected in the China Kadoorie Biobank (CKB) study.MethodsDuring 2020 and 2021, a random subset of 25,087 surviving CKB individuals participated in the 3rd resurvey of the CKB. Among them, 22,511 (89.7%) agreed to wear an Axivity AX3 wrist-worn triaxial accelerometer for seven consecutive days to assess their habitual movement behaviours. We developed a machine-learning model to infer time spent in four movement behaviours [i.e. sleep, sedentary behaviour, light intensity physical activity (LIPA), and moderate-to-vigorous physical activity (MVPA)]. Descriptive analyses were performed for wear-time compliance and patterns of movement behaviours by different participant characteristics.ResultsData from 21,897 participants (aged 65.4 ± 9.1 years; 35.4% men) were received for demographic and wear-time analysis, with a median wear-time of 6.9 days (IQR: 6.1–7.0). Among them, 20,370 eligible participants were included in movement behavior analyses. On average, they had 31.1 mg/day (total acceleration) overall activity level, accumulated 7.7 h/day (32.3%) of sleep time, 8.8 h/day (36.6%) sedentary, 5.7 h/day (23.9%) in light physical activity, and 104.4 min/day (7.2%) in moderate-to-vigorous physical activity. There was an inverse relationship between age and overall acceleration with an observed decline of 5.4 mg/day (17.4%) per additional decade. Women showed a higher activity level than men (32.3 vs 28.8 mg/day) and there was a marked geographical disparity in the overall activity level and time allocation.ConclusionsThis is the first large-scale accelerometer data collected among Chinese adults, which provides rich and comprehensive information about device-measured movement behaviour patterns. This resource will enhance our knowledge about the potential relevance of different movement behaviours for chronic disease in Chinese adults.

A Scoping Review of Parenting Programs for Preventing Violence Against Children in Low- and Middle-Income Countries.

Violence against children affects their well-being globally, with a greater burden in low-and middle-income countries (LMICs). This scoping review aimed to summarize the available evidence on parenting programs for reducing violence against children in LMICs and identify knowledge gaps in this area. Six English databases and gray literature were systematically searched to identify studies in LMICs that examined the efficacy of parenting programs to prevent violence against children, before April 15, 2023. A total of 4,183 independent studies were identified, of which 31 met the inclusion criteria. The majority were conducted in Africa and Asia, delivered by trained local community/childcare workers and lay workers, and targeted younger children aged <10 years. Although the core modules varied in terms of number of group sessions and age of the children, the majority emphasized the importance of building a positive relationship with children and nonviolent discipline strategies. The vast majority demonstrated intervention efficacy in reducing general maltreatment and physical and emotional abuse, and improving positive parenting. Ineffective programs for violence tended to be characterized by self-designed programs, small sample sizes, and low corporal punishment levels in the baseline assessment. In conclusion, parenting programs are promising for preventing and reducing the risk factors for violence in LMICs. Future intervention studies should expand to low-income countries outside Eastern Africa with more trials targeting older children, utilizing direct observational assessments, designing core modules relevant to child neglect, involving more male caregivers, and conducting long-term follow-up assessments.

Tracheostomy care quality improvement in low- and middle-income countries: A scoping review

Tracheostomy is a lifesaving, essential procedure performed for airway obstruction in the case of head and neck cancers, prolonged ventilator use, and for long-term pulmonary care. While successful quality improvement interventions in high-income countries such as through the Global Tracheostomy Collaborative significantly reduced length of hospital stay and decreased levels of anxiety among patients, limited literature exists regarding tracheostomy care and practices in low and middle-income countries (LMIC), where most of the world resides. Given limited literature, this scoping review aims to summarize published tracheostomy studies in LMICs and highlight areas in need of quality improvement and clinical research efforts. Based on the PRISMA guidelines, a scoping review of the literature was performed through MEDLINE/PubMed and Embase using terms related to tracheostomy, educational and quality improvement interventions, and LMICs. Publications from 2000–2022 in English were included. Eighteen publications representing 10 countries were included in the final analysis. Seven studies described baseline needs assessments, 3 development of training programs for caregivers, 6 trialed home-based or hospital-based interventions, and finally 2 articles discussed development of standardized protocols. Overall, studies highlighted the unique challenges to tracheostomy care in LMICs including language, literacy barriers, resource availability (running water and electricity in patient homes), and health system access (financial costs of travel and follow-up). There is currently limited published literature on tracheostomy quality improvement and care in LMICs. Opportunities to improve quality of care include increased efforts to measure complications and outcomes, implementing evidence-based interventions tailored to LMIC settings, and using an implementation science framework to study tracheostomy care in LMICs.

Establishing vaccine pregnancy registries and active surveillance studies in low-and middle-income countries: Experience from an observational cohort surveillance project in The Gambia

Establishing vaccine pregnancy registries and active surveillance studies in low-and middle-income countries: Experience from an observational cohort surveillance project in The Gambia

Effects of short birth interval on different forms of child mortality in Bangladesh: Application of propensity score matching technique with inverse probability of treatment weighting.

The prevalence of Short Birth Interval (SBI) is higher in Low- and Middle-Income countries (LMICs), including Bangladesh. Previous studies in LMICs have estimated the effects of SBI on child mortality by comparing two unequal groups of mothers based on their socio-economic status. This approach may lead to overestimation or underestimation of the true effect of birth interval on child mortality, particularly when sample sizes are relatively small. We determined the effects of SBI on several forms of child mortality in Bangladesh by comparing two equal groups created by applying the propensity score matching technique. This study analyzed data from 5,941 mothers and 1,594 health facilities extracted from the 2017/18 Bangladesh Demographic and Health Survey and the 2017 Bangladesh Health Facility Survey. The exposure variable was SBI (defined as the interval between two subsequent births <33 months: yes, no), while the outcome variables were neonatal mortality (defined as mortality within 28 days of birth: yes, no), infant mortality (defined as mortality within 1 year of birth: yes, no), and under-five mortality (defined as mortality within 5 years of birth: yes, no). Multilevel Poisson regression based on inverse probability treatment weights was used to determine the association between exposure and outcome variables. The prevalence rates of neonatal, infant, and under-five mortality were 48.8, 30.8, and 23.1 per 1000 live births, respectively. Newborns of SBI mothers were found to have a 63% higher likelihood of neonatal mortality (aPR, 1.63; 95% CI, 1.08-2.46) compared to newborns of non-SBI mothers. Furthermore, the prevalence of infant mortality and under-five mortality was 1.45 times higher (aPR, 1.45; 95% CI, 1.01-2.08) and 2.82 times higher (aPR, 2.82; 95% CI, 2.16-3.70), respectively, among babies born in a short interval of their immediately preceding sibling as compared to babies born in a normal interval of their immediately preceding sibling. Findings of this study indicate that SBI is an important predictor of child mortality. Consequently, around 1 million children born in a short interval every year in Bangladesh are at risk of dying before reaching their fifth birthday. This indicates a challenge for Bangladesh to achieve the SDG 3 target to reduce neonatal and under-five mortality to 12 and 25 deaths per 1000 live births, respectively. Hence, awareness-building programs about the adverse effects of SBI and strengthening existing healthcare facilities are important.

Cost of childhood RSV management and cost-effectiveness of RSV interventions: a systematic review from a low- and middle-income country perspective

BackgroundApproximately 97% of global deaths due to RSV occur in low- and middle-income countries (LMICs). Until recently, the only licensed preventive intervention has been a shortacting monoclonal antibody (mAb), palivizumab (PVZ) that is expensive and intensive to administer, making it poorly suited for low-resource settings. Currently, new longer acting RSV mAbs and maternal vaccines are emerging from late-stage clinical development with promising clinical effectiveness. However, evidence of economic value and affordability must also be considered if these interventions are to be globally accessible. This systematic review’s objective was to summarise existing evidence on the cost-of-illness (COI) and cost-effectiveness of RSV prevention interventions in LMICs.MethodsWe conducted a systematic literature review using the Embase, MEDLINE, and Global Index Medicus databases for publications between Jan 2000 and Jan 2022. Two categories of studies in LMICs were targeted: cost-of-illness (COI) of RSV episodes and cost-effectiveness analyses (CEA) of RSV preventive interventions including maternal vaccines and long-acting mAbs. Of the 491 articles reviewed, 19 met the inclusion criteria.ResultsCOI estimates varied widely: for severe RSV, the cost per episode ranged from $92 to $4114. CEA results also varied—e.g. evaluations of long-acting mAbs found ICERs from $462/DALY averted to $2971/DALY averted. Study assumptions of input parameters varied substantially and their results often had wide confidence intervals.ConclusionsRSV represents a substantial disease burden; however, evidence of economic burden is limited. Knowledge gaps remain regarding the economic value of new technologies specifically in LMICs. Further research is needed to understand the economic burden of childhood RSV in LMICs and reduce uncertainty about the relative value of anticipated RSV prevention interventions. Most CEA studies evaluated palivizumab with fewer analyses of interventions in development that may be more accessible for LMICs.

Apparent Temperature Modifies the Effects of Air Pollution on Cardiovascular Disease Mortality in Cape Town, South Africa

Cardiovascular disease (CVD) is the top cause of mortality and a main contributor to disability globally. The evidence so far is varied on whether cold or heat modifies the CVD effects of air pollution. Weather conditions and air pollution sources and levels are different in different countries. Studies in low-and middle-income countries are lacking. Mortality data were obtained from Statistics South Africa. Air pollution and meteorological data were obtained from the South African Weather Service. A time-stratified case–crossover epidemiological design was applied. The association between air pollutants (PM10, NO2 and SO2) and CVD mortality was investigated using conditional logistic regression models. Susceptibility by sex and age groups was investigated. In total, 54,356 CVD deaths were included in the 10-year study. The daily PM10, NO2 and SO2 levels exceeded the daily WHO guidelines on 463, 421 and 8 days of the 3652 days, respectively. Higher air pollution risks were observed in this study compared to those reported in meta-analyses. In general, the elderly and females seemed to be vulnerable to air pollutants, especially at high and moderate apparent temperature levels. Harvesting effects were observed at longer lags. The results can be used to develop an early warning system for the city.

Caesarean section or vaginal delivery for low-risk pregnancy? Helping women make an informed choice in low- and middle-income countries.

Women's fear and uncertainty about vaginal delivery and lack of empowerment in decision-making generate decision conflict and is one of the main determinants of high caesarean section rates in low- and middle-income countries (LMICs). This study aims to develop a decision analysis tool (DAT) to help pregnant women make an informed choice about the planned mode of delivery and to evaluate its acceptability in Vietnam, Thailand, Argentina, and Burkina Faso. The DAT targets low-risk pregnant women with a healthy, singleton foetus, without any medical or obstetric disorder, no previous caesarean scarring, and eligibility for labour trials. We conducted a systematic review to determine the short- and long-term maternal and offspring risks and benefits of planned caesarean section compared to planned vaginal delivery. We carried out individual interviews and focus group discussions with key informants to capture informational needs for decision-making, and to assess the acceptability of the DAT in participating hospitals. The DAT meets 20 of the 22 Patient Decision Aid Standards for decision support. It includes low- to moderate-certainty evidence-based information on the risks and benefits of both modes of birth, and helps pregnant women clarify their personal values. It has been well accepted by women and health care providers. Adaptations have been made in each country to fit the context and to facilitate its implementation in current practice, including the development of an App. DAT is a simple method to improve communication and facilitate shared decision-making for planned modes of birth. It is expected to build trust and foster more effective, satisfactory dialogue between pregnant women and providers. It can be easily adapted and updated as new evidence emerges. We encourage further studies in LMICs to assess the impact of DAT on quality decision-making for the appropriate use of caesarean section in these settings.

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.

Abstract 495: Outcomes of an expanded access program for patients with gastrointestinal stromal tumors in low- and middle-income countries

Abstract Background: Gastrointestinal Stromal Tumors (GIST) treatment was revolutionized by the introduction of the tyrosine kinase inhibitor imatinib. More recently, sunitinib, has prolonged survival in patients (pts) with metastatic disease resistant to imatinib. 10-year survival for high-risk pts treated with adjuvant imatinib is 79%. Median overall survival for pts with unresectable or metastatic GIST is 4.8 years. In order to bring access to these life-saving medications to pts in low- and middle- income countries (LMICs), The Max Foundation (TMF) developed its Max Access Solutions (MAS) program in 2017, after administering Novartis’ imatinib (Glivec) International Patient Assistance Program (GIPAP) since 2002. We analyzed the outcomes of pts enrolled in these programs from 2002-2020 for both adjuvant (n=2100) or metastatic (n=9,867) GIST across 67 countries. Methods: Demographic data and treatment indications were reported by treating physicians. The clinical status of each enrolled pt was reviewed with TMF every 3-4 months. Pts who were lost to follow-up (LTFU) (n=2282) with metastatic or unresectable disease were presumed to be deceased. Alternatively, for patients treated in the adjuvant setting an imputation based informed censoring model was used to estimate events for LTFU patients (n=477). Kaplan-Meier analysis was used to estimate the distribution of progression-free (PFS) and overall survival (OS). Results: The median age at diagnosis was 54 and 55 years in the adjuvant and metastatic groups, respectively. Males comprised 59.5% of all metastatic/unresectable cases and females 51.3% of adjuvant cases. Median OS for pts treated with imatinib for unresectable or metastatic disease was 5.8 years (CI: (5.6, 6.1)) and PFS was 3.5 years (CI: (3.5, 3.7)). Pts treated with imatinib in the adjuvant setting had a 10-year OS of 72% and PFS of 70%. Median OS of pts with metastatic disease treated with sunitinib was 2 years (CI: (1.5, 2.5)); PFS was 1.2 years (CI: (0.9, 1.6)). Multivariate analysis showed that male sex was a negative prognostic factor in both the metastatic and adjuvant setting. Other variables including World Bank Income groups and frequency of contact were not associated with increased mortality or progression in any group. Discussion: This is the largest known cohort of GIST outcomes and the first study to present outcomes from predominantly low- and middle-income countries. Additionally, studies in LMICs are challenged by high rates of lost to follow-up which can falsely prolong or shorten survival times due to censoring. Therefore, we employed an informed censoring model to better reflect survival in the adjuvant setting. We demonstrate that access to a targeted oral anti-cancer therapy results in outcomes similar to those in high resource countries and provides a model to help close the global gap in cancer outcomes. Citation Format: Edward Lloyd Briercheck, J. Michael Wrigglesworth, Philip Stevenson, Alicia A. Annamalay, Pat Garcia-Gonzalez, Michael Wagner. Outcomes of an expanded access program for patients with gastrointestinal stromal tumors in low- and middle-income countries [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 495.

Transforming women's and providers' experience of care for improved outcomes: A theory of change for group antenatal care in Kenya and Nigeria.

BackgroundGroup antenatal care (G-ANC) is a promising model for improving quality of maternal care and outcomes in low- and middle-income countries (LMICs) but little has been published examining the mechanisms by which it may contribute to those improvements. Substantial interplay can be expected between pregnant women and providers’ respective experiences of care, but most studies report findings separately. This study explores the experience and effects of G-ANC on both women and providers to inform an integrated theory of change for G-ANC in LMICs.MethodsThis paper reports on multiple secondary outcomes from a pragmatic cluster randomized controlled trial of group antenatal care in Kenya and Nigeria conducted from October 2016—November 2018 including 20 clusters per country. We collected qualitative data from providers and women providing or receiving group antenatal care via focus group discussions (19 with women; 4 with providers) and semi-structured interviews (42 with women; 4 with providers). Quantitative data were collected via surveys administered to 1) providers in the intervention arm at enrollment and after facilitating 4 cohorts and 2) women in both study arms at enrollment; 3–6 weeks postpartum; and 1 year postpartum. Through an iterative approach with framework analysis, we explored the interactions of voiced experience and perceived effects of care and placed them relationally within a theory of change. Selected variables from baseline and final surveys were analyzed to examine applicability of the theory to all study participants.ResultsFindings support seven inter-related themes. Three themes relate to the shared experience of care of women and providers: forming supportive relationships and open communication; becoming empowered partners in learning and care; and providing and receiving meaningful clinical services and information. Four themes relate to effects of that experience, which are not universally shared: self-reinforcing cycles of more and better care; linked improvements in health knowledge, confidence, and healthy behaviors; improved communication, support, and care beyond G-ANC meetings; and motivation to continue providing G-ANC. Together these themes map to a theory of change which centers the shared experience of care for women and providers among multiple pathways to improved outcomes.DiscussionThe reported experience and effects of G-ANC on women and providers are consistent with other studies in LMICs. This study is novel because it uses the themes to present a theory of change for G-ANC in low-resource settings. It is useful for G-ANC implementation to inform model development, test adaptations, and continue exploring mechanisms of action in future research.

Delivery Strategies Supporting School-Age Child Health: A Systematic Review.

School-aged children (SAC; 5-9 years) remain understudied in global efforts to examine intervention effectiveness and scale up evidence-based interventions. This review summarizes the available evidence describing the effectiveness of key strategies to deliver school-age interventions. We searched Medline, PsycINFO, Campbell Collaboration, and The Cochrane Library during November 2020. Systematic reviews and meta-analyses that: target SAC, examine effective delivery of well-established interventions, focus on low- and middle-income countries (LMICs), were published after 2010, and focus on generalizable, rather than special, populations. Two reviewers conducted title and abstract screening, full-text screening, data extraction, and quality assessments. Sixty reviews met the selection criteria, with 35 containing evidence from LMICs. The outcomes assessed and the reported effectiveness of interventions varied within and across delivery strategies. Overall, community, school, and financial strategies improved several child health outcomes. The greatest evidence was found for the use of community-based interventions to improve infectious disease outcomes, such as malaria control and prevention. School-based interventions improved child development and infectious disease-related outcomes. Financial strategies improved school enrollment, food security, and dietary diversity. Relatively few LMIC studies examined facility, digital, and self-management strategies. Additionally, we found considerable heterogeneity within and across delivery strategies and review authors reported methodological limitations within the studies. Despite limited research, available information suggests community-based strategies can be effective for the introduction of a range of interventions to support healthy growth and development in SAC. These also have the potential to reduce disparities and reach at-risk and marginalized populations.

Economic Costs of Violence Against Women and Girls in Low- and Middle-Income Countries: A Pilot Study on Management's Outlook.

Background:In low and middle-income countries (LMICs), violence against women and girls (VAWG) is rampant, primarily due to patriarchy. However, there is little understanding of its ripple effect in the workplace in LMICs. While recent studies in LMICs have attempted to understand the effects of VAWG on productivity using data collected from colleagues, survivors, or perpetrators, there is limited research on the employers’ perspective of the impact of VAWG on productivity.Methods:A survey, developed by the investigators, based on previous research in Peru and Vietnam, was administered to 74 senior management executives in Ghana, Pakistan, and South Sudan. Based on female employees’ absenteeism, tardiness, and presenteeism, this study provides the management’s perspective on the invisible costs of VAWG.Findings:The results show that 25% and 36% of senior executives have witnessed intimate partner violence and non-partner sexual violence, respectively, against their female colleagues. One (32%) in three managers also acknowledged the impact of VAWG on productivity and day-to-day operations.Conclusions:This study provides evidence that there is a need for the development of employee assistance programs (EAPs) in LMICs. Due to significant increase in employees’ productivity in the absence of VAWG, investing in occupational health services needs to be viewed as an investment, not cost. As many international companies in developed countries do business in LMICs, their occupational health departments need to be more aware of VAWG. Occupational health practitioners can assist in the needs assessment for EAPs as well as provide appropriate referrals and counseling to impacted employees.

Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review.

The burden of antimicrobial resistance (AMR) is considerable in many low- and middle-income countries (LMICs), and it is important to describe the antimicrobial stewardship program (ASP) activities found in these countries and report their impact. Importantly, as these programs target prescribing behavior, the factors influencing prescription of antimicrobials must also be taken into account. This scoping review aimed to (1) describe hospital-based ASP activities, (2) report methods used to measure the impact of ASPs, and (3) explore factors influencing antimicrobial prescribing behavior in LMICs. PubMed was searched from database inception until April 2021. Factors influencing antimicrobial prescribing behavior were canvassed using the Capability-Opportunity-Motivation and Behavior framework. Most of ASP studies in LMICs were predominantly conducted in tertiary care and university-based hospitals. Audit of antimicrobial prescriptions with feedback and restrictive-based strategies was the main reported activity. Total antimicrobial consumption was the main method used to measure the impact of ASPs. Positive outcomes were observed for both clinical and microbiological outcomes; however, these were measured from nonrandomized controlled trials. Dominant factors identified through the behavioral framework were a limited awareness of AMR as a local problem, a perception that overprescription of antimicrobials had limited consequences and was mainly driven by a motivation to help improve patient outcomes. In addition, antimicrobial prescribing practices were largely influenced by existing hierarchy among prescribers. Our scoping review suggests that LMICs need to evaluate antimicrobial appropriateness as an added measure to assess impact. Furthermore, improvements in the access of microbiology and diagnostic facilities and ensuring ASP champions are recruited from senior prescribers will positively influence antimicrobial prescribing behavior, helping improve stewardship of antimicrobials in these countries.

A systematic review of methodological approaches for evaluating real-world effectiveness of COVID-19 vaccines: Advising resource-constrained settings.

Real-world effectiveness studies are important for monitoring performance of COVID-19 vaccination programmes and informing COVID-19 prevention and control policies. We aimed to synthesise methodological approaches used in COVID-19 vaccine effectiveness studies, in order to evaluate which approaches are most appropriate to implement in low- and middle-income countries (LMICs). For this rapid systematic review, we searched PubMed and Scopus for articles published from inception to July 7, 2021, without language restrictions. We included any type of peer-reviewed observational study measuring COVID-19 vaccine effectiveness, for any population. We excluded randomised control trials and modelling studies. All data used in the analysis were extracted from included papers. We used a standardised data extraction form, modified from STrengthening the Reporting of OBservational studies in Epidemiology (STROBE). Study quality was assessed using the REal Life EVidence AssessmeNt Tool (RELEVANT) tool. This study is registered with PROSPERO, CRD42021264658. Our search identified 3,327 studies, of which 42 were eligible for analysis. Most studies (97.5%) were conducted in high-income countries and the majority assessed mRNA vaccines (78% mRNA only, 17% mRNA and viral vector, 2.5% viral vector, 2.5% inactivated vaccine). Thirty-five of the studies (83%) used a cohort study design. Across studies, short follow-up time and limited assessment and mitigation of potential confounders, including previous SARS-CoV-2 infection and healthcare seeking behaviour, were major limitations. This review summarises methodological approaches for evaluating real-world effectiveness of COVID-19 vaccines and highlights the lack of such studies in LMICs, as well as the importance of context-specific vaccine effectiveness data. Further research in LMICs will refine guidance for conducting real-world COVID-19 vaccine effectiveness studies in resource-constrained settings.