The objective of this study is to assess the impact of financial inclusion on the performance of Micro, Small and Medium Enterprises (MSMEs) in Gombe state, Nigeria. The population of the study is 1745 registered MSMEs in Gombe state out of which the sample of 324 were computed using Taro Yamane formula and selected using convenience sampling technique. Accordingly, the study collects data using primary method with self-administered questionnaire and analyzed with Partial Least Square Structural Equation Modeling via SmartPLS software. The finding revealed that digital financing and financial literacy have significant positive effect on MSMEs’ performance in Gombe state of Nigeria. In view of the obtained result, it is recommended that governments at different levels players should invest in infrastructural development such as internet connectivity and mobile network services especially in rural and underserved area. Also, financial institutions and fintech companies should develop and offer digital financial products specifically tailored to the need of MSMEs. Lastly, there is need for financial institutions to establish mechanisms for ongoing financial education such as regular workshops, seminars and online course to ensure that MSMEs owners continue to build their financial literacy as their business grow.

Introduction: Post-stroke motor rehabilitation typically involves in-person therapy sessions in which clinicians prescribe tailored exercises for patients. However, access to in-person therapy is often limited, particularly for individuals in underserved and rural areas. While digital rehabilitation tools exist to bridge this gap, they frequently lack sufficient personalization considering the patient’s home environment and individual needs. To address this issue, we evaluated the feasibility of a novel AI-enabled augmented reality (AR) system that translates natural language into software using large language model (LLM) code generation at the point of care, allowing therapists to 1) design personalized, home-based exercises and 2) monitor exercise completion by patients in detail. Methods: In a prospective, single-arm proof-of-concept study, 20 therapists conducted simulated remote therapy sessions with a standardized patient with right upper extremity weakness using the AI-enabled AR system. Therapists prescribed personalized exercises with voice recordings and manual typings, which the LLM translated into software in the Scenic programming language. By using a commercial AR headset, the software provided instructions to the patient and independently monitored the completion of each exercise step, offering to therapists information to guide future exercise prescriptions. Results: The system successfully delivered 99.8% (95% CI: 98.6-100%) of the 398 instructions prescribed without errors or hallucinations. The accuracy of monitoring exercise completion was 88.4% (95% CI: 84.9-91.9%) when compared to the gold-standard evaluation by therapists. Therapists reported excellent usability (mean Likert 5-point score: 4.5 ± 0.5) and 75% indicated they would like to use the technology in clinical practice. For 90% of the therapists, the system did not have an added risk of injury compared to the current usual care with paper worksheets. Conclusions: In conclusion, our AR system can enable therapists to remotely create and deliver personalized rehabilitation exercises for stroke and other neurological conditions while monitoring completion. To our knowledge, this is the first study evaluating LLMs for real-time code generation to support clinicians in prescribing interventions in rehabilitation. This approach has the potential to expand access to individualized stroke rehabilitation beyond traditional in-person care.

Surgery and public health: Case studies of surgeons working at the intersection of research and advocacy.

Using the Low-Income Housing Tax Credit to Fund Assisted Living: Mapping the Current Environment.

Dermatological disorders affect millions of people worldwide, but effective and timely diagnosis continues to be a challenge, particularly in underserved or rural areas with limited access to a dermatologist. Using deep learning techniques this study demonstrates an AI-enabled tool that will assist effective and timely diagnosis of skin conditions and will assist health care providers in making initial assessments. The tool analyzes images of skin ailments and provides the user a preliminary assessment. This skin assessment system will assist health professionals to make quicker and better decisions regarding diagnosing skin disorders and treating dermatological diseases. The purpose of the AI tool for dermatology is to increase efficiency of care, decrease time to treatment, and ultimately improve care for dermatopathy patients. The system will be improved by developing semi-automated location-based services to assist users in finding nearby hospitals or clinics. It will also make it more relevant and easier to use in the real-world contexts.

Early exposure to science, technology, engineering, and mathematics (STEM) can inspire children from medically underserved areas and populations (MUA/P) to pursue health and biomedical careers, helping reduce long-term cancer disparities. The Georgetown University Lombardi Comprehensive Cancer Center and KID Museum co-developed the Young Scholars Program (YSP) to engage elementary students from Title I schools in the Washington, DC region, in hands-on learning about cancer biology and prevention through a maker education approach. This study evaluated the YSP's impact on students' inventive learning, sense of belonging in STEM, and STEM interest using mixed methods. During the 2024-2025 school year, N = 432 students from four Title I schools participated. Most identified as Black (35%) or Latine (53%), and 49% were female. Among program attendees, N = 306 completed exit tickets, N = 224 returned evaluation surveys, and N = 184 had exit tickets matched to surveys. Post-program, nearly all students reported practicing as a scientist (99%) or engineer (98%). Knowledge of cancer biology and prevention was high, with 88-96% answering key questions correctly. Students endorsed strong inventive learning (90%), belonging in STEM (92%), and STEM interest (81%). Among students with matched data, those who reported practicing as scientists or engineers showed significantly greater inventive learning (F = 16.19, p < 0.001), belonging (F = 9.65, p = 0.002), and STEM interest (F = 4.75, p = 0.03). Qualitative reflections (N = 284 responses) most frequently described initiative (48%), followed by skill building (19%), teamwork (17%), perspective-taking (11%), and exploration (5%). The YSP strengthened students' STEM identity, comprehension of cancer concepts, and engagement in maker learning. Hands-on, culturally relevant instruction fostered initiative, collaboration, and belonging. Community-based STEM programs like the YSP show promise for advancing early STEM engagement and diversifying the future biomedical workforce.

Introduction: One of the leading causes of cardiovascular death is hypertensive heart disease (HHD), especially in people who also have behavioral and mental disorders (BMDs). Cardiovascular risk is increased in this population by lifestyle factors, drug side effects, and inflammatory pathways. National data on HHD mortality trends for impacted subgroups in the USA are still scarce, despite the growing burden of both BMDs and HHD. Methods: Using the CDC WONDER Multiple Cause of Death database, we examined death records from 1999 to 2020 in the USA. ICD-10 codes for BMDs (F01–F99) and hypertensive cardiac disease (I11.0–I11.9) were used to identify cases. Regional and demographic-specific age-adjusted mortality rates (AAMRs) were computed. Annual percent changes (APCs) and trends were assessed using joinpoint regression, with significance set at P &lt; 0.05. Results: About 284 797 people died from HHD with accompanying mental illnesses between 1999 and 2020. From 1.15 to 13.69 per 100 000, the AAMR increased (AAPC: 11.65%; P &lt; 0.0001). AAMRs peaked among Black adults and were consistently higher in men. Regional load was largest in the South, and final fatality rates were higher in urban than rural areas. Disparities at the state level varied from 1.40 in Nebraska to 15.71 in Washington, DC. The greatest increases in HHD-related mortality were linked to male sex, substance-related mental illnesses, and living in underserved areas. Conclusion: Men, Black adults, and Southern regions were disproportionately affected by the more than 10-fold increase in mortality from HHD and mental disorders between 1999 and 2020. Urban areas saw the largest increases, underscoring the urgent regional and demographic disparities that require focused interventions.

Abstract Urban planners increasingly recognize the importance of improving access to nature to support human well-being, social inclusion, and urban sustainability. However, assessing accessibility to urban green spaces remains challenging, particularly in rapidly urbanizing cities of the Global South, where mobility constraints and socio-spatial inequalities shape who can effectively benefit from these spaces. Urban wetlands, despite providing multiple ecosystem services, are rarely incorporated into formal green infrastructure networks and are often excluded from accessibility assessments. This study examines how integrating urban wetlands as Nature-Based Solutions (NbS) modifies patterns of access to nature in Concepción, Chile. We combine land-use data on parks and wetlands with accessibility measures and origin–destination travel survey data to model walking accessibility under two scenarios: green spaces excluding wetlands and green spaces including wetlands. A Random Forest model is applied to capture heterogeneity across socio-demographic profiles, including age, gender, employment status, and driver’s license ownership. Results show that incorporating urban wetlands significantly increases the accessible surface of green space across the city, with particularly strong gains for groups with limited mobility options, such as women, older adults, unemployed residents, and individuals without access to private vehicles. In peripheral and underserved areas, wetlands partially compensate for deficits in formal park provision, reducing accessibility gaps. These findings provide empirical evidence that urban wetlands function as grounded NbS by redistributing access to nature and underscore the importance of formally integrating wetlands into urban planning instruments to promote more inclusive and resilient cities.

As part of an effort to boost physician supply and opportunity, several US states have recently enacted laws permitting internationally trained physicians to practice without completing an Accreditation Council for Graduate Medical Education-accredited residency or fellowship, representing a major departure from long-standing licensure norms. Little is known about how the public perceives these laws, particularly in surgical fields in which technical competency and patient trust are paramount. To assess public perceptions of state laws permitting internationally trained surgeons to practice in the US without US-based residency training. This cross-sectional study involving perspectives of US adults on state licensure of internationally trained surgeons to address surgical workforce shortages was conducted in July 2025 using an online crowdsourcing platform (Amazon Mechanical Turk; Amazon Mechanical Turk, Inc). A 21-item survey was administered through Qualtrics (Qualtrics, LLC). Quality control included definitional understanding, attention checks, and time-based screening. Primary outcomes included support for licensure laws for internationally trained surgeons, ethical concerns regarding international brain drain, perceived training equivalence, personal comfort with internationally trained surgeon care, hospital trust, and preferences for regulatory oversight. Subgroup analyses were performed by sex and self-defined political views using χ2 testing. Of 1270 initial responses, 1066 (83.9%) passed quality criteria and were analyzed. Among 1066 respondents (634 male [59.5%], median [IQR] age 33 [29-35] years), 906 (85.0%) supported state licensure laws for internationally trained surgeons. Most respondents (991; 93.0%) believed such laws would improve access and 856 (80.3%) felt diversity would improve, yet 755 (70.8%) expressed ethical concerns about international brain drain. Regarding training, a majority of respondents (787; 73.8%) did not view international training as equivalent to US training, and 831 (78.0%) reported they would be less likely to select an internationally trained surgeon for surgery. Regarding informed consent, nearly all respondents (1005; 94.3%) supported mandatory disclosure of training background. Males (575 of 634 [90.7%], P < .001) and conservatives (512 of 569 [89.9%], P < .001) were significantly more supportive of the laws, whereas liberals were more likely to express ethical concern (248 of 301 [82.4%], P < .001) and discomfort with internationally trained surgeon care (257 of 301 [85.3%], P = .02). The majority of respondents (817 [76.6%]) supported restricting internationally trained surgeon practice to underserved areas. Findings of this study suggest that the US public generally supports licensure laws for internationally trained surgeons but with important caveats, including geographic restriction of practice, strong preferences for disclosure of training background, ethical concern over brain drain, and reluctance to receive care personally from an internationally trained surgeon. Policymakers need to balance workforce expansion with safeguards for patient safety, transparency, and global equity. These findings provide an important baseline for future research as internationally trained surgeons begin entering US surgical practice.

This study aims to demonstrate the contribution of census data combined with Geographic Information System (GIS) techniques to local development planning in Mali, with a particular focus on spatial accessibility to health infrastructure in a rural context. A cross-sectional study design was adopted, integrating spatial and statistical analyses of census and geospatial data. The study was conducted in the rural commune of Kroukoto, located in the cercle of Kéniéba, Kayes Region, south-western Mali, covering approximately 250 km² with an estimated population of about 12,000 inhabitants. Georeferenced census data were integrated with spatial layers representing settlements, road networks, health centers, and educational facilities within a GIS environment. Distance-based accessibility modeling was applied using commonly adopted rural planning thresholds, including 5 km for access to health centers. The results indicate that approximately 65% of the population lives within 5 km of an existing community health center, while 35% remains beyond this threshold, mainly in peripheral and poorly connected areas. Spatial analysis further shows that the existing health facility serves 4,671 people across 1 village and 43 hamlets, whereas the proposed second health center would serve 5,089 people in 5 villages and 44 hamlets, with 2,331 people benefiting from overlapping service areas. These findings reveal significant spatial disparities in service accessibility linked to settlement dispersion and road connectivity. The integration of census data with GIS provides an effective decision-support tool for identifying underserved areas, improving resource allocation, and strengthening evidence-based territorial planning in rural Mali.

BackgroundPhysician maldistribution remains a global challenge, with Japan’s rural regions facing critical health care shortages. Regional quota programs aim to attract medical students to underserved areas; however, their effectiveness in fostering long-term commitment is uncertain. Community-oriented medical education (COME) programs aim to address this issue by developing students’ understanding and dedication to rural health care.ObjectiveThis study investigated the impact of an enhanced COME program, featuring increased early clinical exposure and faculty development, on first-year regional quota medical students’ perception of community health care at Chiba University.MethodsWe conducted a cross-sectional qualitative study comparing 2 cohorts, 20 students enrolled from the existing COME course (April-December 2021) and 20 from the revised course (April-December 2022). The revised course included an additional day of community-based clinical exposure supervised by COME-trained attending physicians. Students’ written reflections were analyzed using qualitative content analysis and categorized according to the Fink Taxonomy of significant learning, comprising 6 domains, including foundational knowledge, application, integration, human dimension, caring, and learning how to learn. Reflections were synthesized into higher-order themes crosswalked to the Fink domains.ResultsDemographics were similar between the 2021 and 2022 cohorts. In 2021, 311 learning codes were identified across foundational knowledge (n=128), application (n=91), integration (n=40), human dimension (n=16), caring (n=30), and learning how to learn (n=6). In 2022, codes increased to 385, with notable growth in caring (n=58) and human dimension (n=57), alongside increases in learning how to learn (n=15) and integration (n=45). Theme-based synthesis identified four overarching themes: (1) community health care as an interconnected, resource-constrained system; (2) patient-centered relationships and trust through communication and teamwork; (3) emerging professional identity and responsibility toward community service; and (4) developing a self-directed learning orientation for community practice. Qualitative analysis revealed that students gained a deeper understanding of patient-centered care, interprofessional collaboration, and social challenges in rural health care. The consistency in the foundational knowledge domain underscored a stable conceptual foundation, while the increase in affective and reflective domains reflected greater emphasis on interpersonal, value-oriented, and reflective learning in the revised cohort.ConclusionsEnhancements of the COME program, including additional early clinical exposure and faculty development, were associated with improved students’ perceptions of community health care. The increased focus on the caring and human dimension domains underscores the role of practical experiences in fostering collaboration, communication, and patient-centered care. The theme-based synthesis further suggests that the revised program prompted more frequent reflections on professional identity formation and self-directed learning while maintaining a stable foundation of community health care concepts. Mentorship by community hospital attendings, alongside structured clinical exposure, appears crucial in shaping medical students’ understanding and commitment to rural medicine. Ongoing longitudinal evaluations are warranted to assess the sustained impact of COME programs on career trajectories in underserved areas.

IntroductionThe OncotypeDX test for patients with breast cancer with early-stage, hormone-receptor–positive, HER2-negative disease can predict the benefit of adjuvant chemotherapy in addition to hormone therapy. Delivering OncotypeDX results in a timely manner is important to inform treatment decisions. We implemented a strategy to reduce the turnaround time (TAT) from breast surgery to OncotypeDX report at a large urban public safety-net hospital in New York City.MethodsThe Plan-Do-Study-Act model was used to implement quality improvement changes. The goal was to improve efficiency to get treatment information for treatment decisions for patients with breast cancer and encourage teamwork with existing resources in the large public hospital. The primary measure was TAT from surgery to receiving OncotypeDX results in the electronic medical record (EMR). We compared TAT before and after the implementation of our strategy. The historical control included patients from May 2021 through March 2022, whereas the timeline after strategy implementation was from June 2023 to February 2024. The strategy involved the creation of a smartphrase in the EMR for breast surgery to identify and order OncotypeDX in eligible patients, and collaboration between breast surgery, pathology, vendor, and medical oncology.ResultsThe patient characteristics were similar both before and after implementing the strategy, including patient number (26 vs. 27) and mean age (61 vs. 59 years). Both groups were composed predominantly of ethnic minorities (64% vs. 59%). A higher percentage of patients were from medically underserved areas and populations (MUAs and MUPs) in the group after strategy implementation (35% vs. 44%, p = 0.65). Our strategy reduced the average TAT from 42 to 30 days.ConclusionWe developed a strategy to optimize the OncotypeDX workflow in a large safety net health system despite an increase in patients from MUAs and MUPs. Initiating ordering of OncotypeDX by breast surgery, along with communication with pathology, vendor, and medical oncology, significantly reduced TAT.

Spatial accessibility to healthcare services is commonly determined by three core components: demand, supply, and traffic speed. Although understanding which factors contribute to accessibility changes can help prioritize interventions to enhance accessibility in underserved areas, limited research has examined the extent of their individual contributions. To better capture the local dynamics that shape healthcare accessibility, this study decomposes spatial accessibility to primary healthcare services using the chain substitution method (CSM), which quantifies the impact of each component by substituting them one by one. By examining how the order of factor substitution affects the relative impact of each factor on spatial accessibility, we analyzed the importance of substitution order in the CSM. This study found that the order of factor substitution plays a significant role in measuring the relative contribution of each factor. To mitigate the effects of substitution order, we proposed an averaging CSM that uses the average value across all possible substitution combinations. Based on the averaging CSM, our findings offer insight for healthcare policymakers and urban planners by clarifying how demand, supply, and traffic speed interact in determining accessibility, ultimately supporting targeted interventions in underserved areas.

Background: Knee osteoarthritis (KOA) is one of the most prevalent chronic musculoskeletal disorders among the elderly in Saudi Arabia, leading to persistent pain, joint stiffness, and reduced mobility. Physiotherapy remains a cornerstone of management; however, access barriers such as limited mobility, transportation issues, and unequal distribution of rehabilitation centers have prompted the emergence of tele-rehabilitation as an alternative. Tele-rehabilitation employs digital platforms to deliver physiotherapy interventions remotely, potentially increasing accessibility and adherence while reducing healthcare burden. Objective: This systematic review aimed to compare the effectiveness of tele-rehabilitation versus traditional, in-person physiotherapy in improving pain, physical function, and quality of life among elderly Saudi patients with chronic knee osteoarthritis. Methods: A comprehensive literature search was conducted across PubMed, Scopus, Web of Science, and Saudi Digital Library databases for studies published between 2015 and 2025. Eligible studies included randomized controlled trials (RCTs), cohort studies, and quasi-experimental designs comparing tele-rehabilitation and conventional physiotherapy for knee osteoarthritis in adults aged ≥60 years. Primary outcomes were pain reduction (measured by the Visual Analogue Scale or WOMAC pain subscale), physical function (WOMAC or KOOS scores), and quality of life (SF-36 or EQ-5D). Data extraction and quality assessment followed PRISMA guidelines. Results: A total of 14 studies (n = 1,320 participants) met the inclusion criteria. Across studies, tele-rehabilitation interventions—delivered through video conferencing, mobile applications, or web-based platforms—demonstrated comparable improvements in pain reduction and physical function to traditional physiotherapy (mean difference in WOMAC pain score: −0.12, 95% CI −0.35 to 0.11, p &gt; 0.05). Several studies reported higher patient adherence and satisfaction with tele-rehabilitation, particularly due to convenience and reduced travel time. However, limitations included variations in digital literacy and inconsistent access to stable internet connections among older adults in rural Saudi regions. Conclusion: Tele-rehabilitation appears to be an effective and feasible alternative to traditional physiotherapy for elderly Saudi patients with chronic knee osteoarthritis. While both modalities yield similar outcomes in pain relief and functional improvement, tele-rehabilitation enhances accessibility and may improve adherence, particularly in underserved areas. Further large-scale, culturally adapted RCTs are recommended to optimize tele-rehabilitation protocols and assess long-term cost-effectiveness within the Saudi healthcare context.

ABSTRACT Although international efforts to strengthen health systems have intensified over the past two decades, the global distribution of health personnel remains deeply uneven. This study examines physician density trends across 199 countries from 2000 to 2023, using data from the WHO Global Health Workforce Statistics. Annual Theil indices are calculated, and a decomposition analysis is conducted to distinguish between‐region and within‐region disparities. The global Theil index declined from 0.42 in 2000 to 0.32 in 2023, reflecting gradual but incomplete progress. On average, 55% of the observed disparity stems from differences between regions, while 45% arises within them. To explore spatial patterns, Global Moran's I and Local Indicators of Spatial Association (LISA) analyses are applied. The results reveal persistent clusters of physician shortages in Sub‐Saharan Africa and South Asia, contrasted by sustained concentrations of physician abundance in Europe and Central Asia. These geographic imbalances highlight the limitations of relying solely on regional coordination. Achieving more equitable health workforce distribution will require country‐specific strategies that address structural disadvantages and reduce the loss of health professionals from underserved areas. Policy options include regional training partnerships, cross‐border mobility frameworks, and integrated workforce planning mechanisms responsive to local capacity and need.

Objectives To evaluate the perceived utility, challenges, and opportunities for improving a regional telehealth model for cochlear implant (CI) care. Methods This qualitative study involved a focus group with five CI audiologists at a tertiary care center. Participants discussed their experiences with a regional telehealth program that used seven satellite sites as part of an ongoing non-inferiority trial. The transcript was analyzed using inductive thematic analysis. Results Audiologists identified regional telehealth as beneficial for routine follow-ups, troubleshooting, and reducing travel burden. Visits were shorter and more convenient for patients and providers. Challenges included difficulty communicating with patients who had cognitive or auditory limitations, limited capacity for remote troubleshooting and device handling, and lack of audiometric testing. Site variability in equipment and room acoustics also affected care quality. Participants recommended improving audiovisual infrastructure, standardizing site setups, integrating interpreter and captioning services, and expanding reimbursement. While certain populations posed greater challenges, regional telehealth was viewed as beneficial for mitigating geographic access barriers without the technological requisites for home-based telehealth. Conclusion Audiologists perceived regional telehealth as a valuable adjunct to traditional CI care for improving access in underserved areas. Addressing infrastructure and workflow limitations may enhance effectiveness and support broader adoption.

Abstract Background Malaria remains a significant public health challenge in Madagascar, affecting vulnerable populations including children under five and pregnant women. Despite global progress in reducing malaria cases and deaths, Madagascar continues to experience a high burden due to inequities in access to prevention, diagnosis, and treatment. Methods A comprehensive literature review was conducted using major academic databases including PubMed, Web of Science, and Google Scholar. A comprehensive search of literature was conducted in PubMed, Web of Science, Google Scholar, and EBSCOhost. The search focused on studies published between 2015 and 2024, supplemented by online reports. The literature was assessed for quality and relevance to malaria prevention, diagnosis, treatment interventions, and socioeconomic factors in Madagascar. Results Disparities in malaria prevention and treatment between urban and rural areas are evident, with remote regions experiencing a higher disease burden. Geographic diversity leads to varied transmission patterns, necessitating region-specific interventions. Rural healthcare infrastructure is insufficient for timely diagnosis and treatment. Key interventions include insecticide-treated nets (ITNs), indoor residual spraying (IRS), and seasonal malaria chemoprevention (SMC). Case management primarily uses Artemisinin-based Combination Therapies (ACTs) and rapid diagnostic tests (RDTs). Social and behavior change communication (SBCC) has improved awareness but faces cultural barriers. SMC has shown promise, though logistical challenges remain. Drug resistance and diagnostic failures, along with socioeconomic inequalities, hinder effective malaria control. Conclusion To reduce malaria’s burden in Madagascar, strengthening healthcare systems, improving supply chains, and expanding prevention efforts in underserved areas are critical. Recommendations include targeting vulnerable groups, enhancing healthcare access, and fostering international collaboration for resource allocation and equitable intervention access. Strategies should emphasize scaling up IRS, ITNs distribution, and SBCC to effectively combat malaria.

ObjectiveDoula support improves maternal health outcomes. States have increasingly included doula services as a covered benefit under Medicaid. We evaluated the implementation of Virginia's Medicaid doula policy and identified lessons to improve access and utilization.MethodsThis mixed-methods study used administrative data (Medicaid claims data from January 2022-December 2024 and state-certified doula registry data) and qualitative interviews with 9 doula Medicaid providers to understand the barriers and facilitators to doula care among Medicaid beneficiaries in Virginia.ResultsAt the time of the study, there were 130 state-certified doula Medicaid providers in Virginia, but fewer than half billed Medicaid for services, most commonly billing for postpartum care. Additionally, utilization of doula services among beneficiaries was low (less than 1%) from 2022 to 2024. Geographic disparities showed limited doula availability in some high-need areas. Five policy lessons emerged.ConclusionState Medicaid programs can strengthen doula policy implementation, and in turn strengthen the doula workforce and expand access to doula care for Medicaid beneficiaries, by revising reimbursement rates and structure to better reflect the scope of doula services, recruiting doulas in underserved areas, providing technical assistance for enrollment and billing, expanding outreach to beneficiaries, and engaging a range of doulas in policy discussions.

As telecommunications expand into underserved and rural areas across Africa, retaining skilled talent has become a major challenge for sustainable service delivery. Although significant infrastructure investments are made to close the digital gap, there is often little focus on the difficulties of keeping skilled workers in remote areas. This article examines various factors impacting workforce stability in rural telecom regions, such as poor living conditions, low salaries, limited opportunities for career growth, and professional isolation.

Background Liver disease prevalence has increased dramatically in the UK over recent decades. It disproportionately affects people from lower socioeconomic backgrounds and is a major cause of mortality in working age people. There are significant geographic variations in liver disease and related mortality. Unfortunately, liver disease research has not been centred in areas with highest disease. To address this, we developed a regional research partnership in North West England, an area with some of the highest rates of disease in the country and historically low research activity. Aims Develop a research network growing out of the expertise developed in Manchester to Greater Manchester and Lancashire. Use national expertise in data access, and curation and decision analytics and methodology, including health economics and decision-analytic modelling, to develop an ambitious and feasible research plan. Establish links with local community organisations in underserved areas. Development of fundable and implementable research proposal to answer an unmet need in liver disease. Design A multi-stakeholder network of experts was developed to identify evidence gaps highlighted by healthcare workers in areas of high disease burden and develop methodologically robust research propositions to address them. Structured stakeholder meetings helped to understand the clinical unmet needs in caring for people with liver disease, focusing on areas of high disease burden and groups traditionally underserved. These questions were developed into research proposals and presented to all stakeholders to identify proposals with greatest importance and deliverable potential. Results Working alongside a breadth of stakeholders and methodological support this study developed detailed plans for four high-priority projects, establishing a shared understanding on the most critical research questions, targeted behaviours, and primary outcomes. It identified suitable methodologies to address these questions and to guide the development of effective interventions and research questions. Conclusion Through detailed discussions to address key evidence gaps in liver disease care our network collaboratively developed research proposals for national funding.