Use In Low- And Middle-income Countries Research Articles

Validation of postnatal growth and retinopathy of prematurity (G-ROP) screening guidelines in a tertiary care hospital of Pakistan: A report from low-middle income country.

Retinopathy of Prematurity (ROP) significantly contributes to childhood blindness globally, with a disproportionately high burden in low- and middle-income countries (LMICs) due to improved neonatal care alongside inadequate ROP screening and treatment facilities. This study aims to validate the performance of Postnatal Growth and Retinopathy of Prematurity (G-ROP) screening criteria in a cohort of premature infants presenting at a tertiary care setting in Pakistan. This cross-sectional study utilized retrospective chart review of neonates admitted to the neonatal intensive care unit (NICU) at The Aga Khan University Hospital, Pakistan from January 2018 to February 2022. The complete G-ROP criteria were applied as prediction tool for infants with type 1 ROP, type 2 ROP, and no ROP outcomes. Out of the 166 cases, 125 cases were included in the final analysis, and remaining cases were excluded due to incomplete data. ROP of any stage developed in 83 infants (66.4%), of whom 55 (44%) developed type 1 ROP, 28 (22.4%) developed type 2 ROP, and 19 (15.2%) were treated for ROP. The median BW was 1060 gm (IQR = 910 to 1240 gm) and the median gestational age was 29 wk (IQR = 27 to 30 wk). The G-ROP criteria demonstrated a sensitivity of 98.18% (95% CI: 90.28-99.95%) for triggering an alarm for type 1 ROP. The G-ROP criteria achieved 100% sensitivity (95% CI: 87.66 to 100%) for type 2 ROP. The overall sensitivity of G-ROP criteria to trigger an alarm for any type of ROP was 98.8% (95% CI: 93.47 to 99.97%). Thus, the G-ROP screening model is highly sensitive in detecting at-risk infants for ROP in a Pakistani tertiary care setting, supporting its use in LMICs where standard screening criteria may not suffice.

Mapping awareness-raising and capacity-building materials on developmental disabilities for non-specialists: a review of the academic and grey literature.

Most children with developmental disabilities (DD), such as intellectual disabilities and autism, live in low- and middle-income countries (LMICs), where services are usually limited. Various governmental, non-governmental and research organisations in LMICs have developed awareness-raising campaigns and training and education resources on DD in childhood relevant to LMICs. This study aimed to comprehensively search and review freely available materials in the academic and grey literature, aimed at awareness raising, training and education on DD among non-specialist professionals and community members in LMICs. We consulted 183 experts, conducted key-word searches in five academic databases, four grey-literature databases and seventeen customised Google search engines. Following initial screening, we manually searched relevant systematic reviewsand lists of resources and conducted forwards and backwards citation checks of included articles. We identified 7327 articles and resources after deduplication. We then used a rigorous multi-step screening process to select 78 training resources on DD relevant to LMICs, of which 43 aimed at informing and/or raising awareness DD, 16 highlighted specific strategies for staff in health settings and 19 in education settings. Our mapping analysis revealed that a wealth of materials is available for both global and local use, including comics, children's books, flyers, posters, fact sheets, blogs, videos, websites pages, social media channels, handbooks and self-education guides, and training programmes or sessions. Twelve resources were developed for cross-continental or global use in LMICs, 19 were developed for and/or used in Africa, 23 in Asia, 24 in Latin America. Most resources were developed within the context where they were intended to be used. Identified gaps included a limited range of resources on intellectual disabilities, manuals for actively delivering training to staff in education settings and resources targeted at eastern European LMICs: future intervention development and adaptation efforts should address such gaps, to ensure capacity building materials exist for a sufficient variety of DD, settings and geographical areas. Beyond identifying these gaps, the value of the review lies in the compilation of summary tables of information on all freely available resources found, to support their selection and use in wider contexts. Information on the resource content, country of original development and copyright is provided to facilitate resource sharing and uptake.

Factor structure of the alcohol expectancies questionnaire among adolescents in rural Ghana.

Children's early experiences with alcohol inform the development of alcohol-related beliefs which are known to predict alcohol consumption during the critical stage of adolescence. Yet, there has been considerably less research into these alcohol-related cognitions in low- and middle-income countries (LMIC) and existing measures of these beliefs are highly reflective of Western contexts, which may not be fully appropriate for use in LMICs. The aim is to ascertain the construct validity of the Alcohol Expectancies Questionnaire (AEQ) in a non-Western sample. A cross-sectional diagnostic accuracy study involving 500 adolescents aged 10 to 18 years randomly selected from the database of the Navrongo Health and Demographic Surveillance System. Participants were administered the locally back translated version of the 34-item AEQ. Confirmatory factor analysis using the lavaan package in R was conducted to generate indices for the factor structure of the AEQ. Confirmatory factor analyses showed that while groupings of positive and negative expectancies were similar to those observed when expectancies have been assessed previously in Western studies, these formed a single 'alcohol expectancy' factor. Questions relating to positive tension reduction and negative physical expectancies showed inconsistent responses in this study. Commonly used tools for the assessment of alcohol expectancies may not be suitable for use in Ghana, possibly owing to their development and validation in Western contexts. These findings have implications for the assessment of alcohol-related beliefs in LMIC settings and begin to map out a research agenda to develop more contextually and culturally attune alcohol assessments.

Tackling inappropriate antibiotic use in low-and middle-income countries.

Tackling inappropriate antibiotic use in low-and middle-income countries.

Exploring the Efficacy and Feasibility of Outpatient Blinatumomab Short Cycles in Pediatric Patients with Relapsed/Refractory B-ALL in LMIC: Preliminary Results

CONCLUSIONS In low- and middle-income countries (LMIC) like Mexico, the treatment of patients with refractory or relapsed acute lymphoblastic leukemia (r/r ALL) represents a significant challenge due to limited access to immunotherapy and hematopoietic stem cell transplantation (HSCT). As a result, the one-year survival rate is reported to be less than 20%. The use of intensive chemotherapy has not improved survival in this group due to its high toxicity. Blinatumomab uses the patient's own cytotoxic T-cells to induce lysis of the leukemia cells expressing CD19 and has been established as a bridge therapy for transplant in patients with r/r B-ALL. The usual pattern of administration is a dose scaled up to complete a total of 28 days of infusion. According to various studies, it is considered appropriate to use repeated cycles of this antibody to achieve the desired response. However, there are also reports of patients achieving complete responses within the first 15 days of the cycle. The high costs of Blinatumomab's administration present a significant barrier to its use in LMIC. As a consequence, the application of prolonged or multiple cycles of the drug becomes unaffordable for a substantial portion of the global population. Demonstrate the safety and efficacy of utilizing short cycles of Blinatumomab (21 days) as a bridge therapy to HSCT in pediatric patients with r/r ALL to explore the potential cost-reduction benefits and increased access to this therapy in resource-limited settings. A pilot clinical trial was conducted. Pediatric patients (<16 y) diagnosed with r/r B- ALL between the years 2020-2022 were included. The usual Blinatumomab dosing regimen was adopted, but the total duration of the cycle was reduced. Continuous infusion was initiated at a dose of 5 mcg/m2/day for the first 7 days, followed by an increase to 15 mcg/m2/day for 14 days (21-day total treatment duration). To mitigate cytokine release syndrome (CRS) a single dose of dexamethasone was administered at the start of the infusion and after the dose escalation. The entire regimen was administered on an outpatient basis, with an infusion pump at home. Caregivers were instructed on the operation of the pump and detection of any signs of toxicity, with 24/7 contact with the medical team and the option to hospitalize if necessary. A total of 7 patients were included, and all of them received Blinatumomab in a single 21-day cycle. The median age was 5 years (15 mo- 13 y). The majority of patients were stratified as high-risk at the time of diagnosis (85.7%). Among the patients, 4 had relapsed ALL, while 3 had refractory disease. The median time from the initial diagnosis to the use of Blinatumomab was 16 months (ranging 7-29 mo), and the median number of treatment lines before Blinatumomab administration was 3 (ranging 2-4). The highest level of minimal residual disease (MRD) detected before the Blinatumomab treatment was 4.2% (by flow cytometry). Remarkably, all patients (100%, n=7) achieved a complete response, with MRD being negative for flow cytometry after the 21-day cycle of Blinatumomab. In 5 out of 7 patients, the administration of the drug was completely ambulatory. Only 2 patients experienced grade I CRS which was successfully managed with steroids. No adverse effects greater than grade 2 were reported, and no patient required support with transfusion therapy during or after the infusion. There were no reports of profound neutropenia, and no treatment-related deaths occurred. HSCT was conducted in all patients to consolidate the response, with 6 patients undergoing haploidentical and 1 patient undergoing identical allogeneic HSCT. At present, 5 out of 7 patients are alive and in complete remission. One patient died on day +51 post-HSCT due to pulmonary thromboembolism, and the second patient experienced relapse on day +395 post-HSCT and subsequently died on day +640 due to disease progression. The median overall survival at 3 years was 66.7%, with a median follow-up period of 21 months (4 -30mo). An alternative outpatient, low-toxicity and cost-effective treatment approach was implemented. The findings from this study could shed light on a promising strategy to improve the outcomes for patients with ALL patients with limited therapeutic options, particularly in the context of resource-constrained settings.

Biomarkers and Risk Assessment of Alzheimer's Disease in Low- and Middle-Income Countries.

Dementia is a chronic syndrome which is common among the elderly and is associated with significant morbidity and mortality for patients and their caregivers. Alzheimer's disease (AD), the most common form of clinical dementia, is biologically characterized by the deposition of amyloid-β plaques and neurofibrillary tangles in the brain. The onset of AD begins decades before manifestation of symptoms and clinical diagnosis, underlining the need to shift from clinical diagnosis of AD to a more objective diagnosis using biomarkers. Having performed a literature search of original articles and reviews on PubMed and Google Scholar, we present this review detailing the existing biomarkers and risk assessment tools for AD. The prevalence of dementia in low- and middle-income countries (LMICs) is predicted to increase over the next couple of years. Thus, we aimed to identify potential biomarkers that may be appropriate for use in LMICs, considering the following factors: sensitivity, specificity, invasiveness, and affordability of the biomarkers. We also explored risk assessment tools and the potential use of artificial intelligence/machine learning solutions for diagnosing, assessing risks, and monitoring the progression of AD in low-resource settings. Routine use of AD biomarkers has yet to gain sufficient ground in clinical settings. Therefore, clinical diagnosis of AD will remain the mainstay in LMICs for the foreseeable future. Efforts should be made towards the development of low-cost, easily administered risk assessment tools to identify individuals who are at risk of AD in the population. We recommend that stakeholders invest in education, research and development targeted towards effective risk assessment and management.

Healthcare provider-targeted mobile applications to diagnose, screen, or monitor communicable diseases of public health importance in low- and middle-income countries: A systematic review.

Communicable diseases remain a leading cause of death and disability in low- and middle-income countries (LMICs). mHealth technologies carry considerable promise for managing these disorders within resource-poor settings, but many existing applications exclusively represent digital versions of existing guidelines or clinical calculators, communication facilitators, or patient self-management tools. We thus systematically searched PubMed, Web of Science, and Cochrane Central for studies published between January 2007 and October 2019 involving technologies that were mobile phone- or tablet-based; able to screen for, diagnose, or monitor a communicable disease of importance in LMICs; and targeted health professionals as primary users. We excluded technologies that digitized existing paper-based tools or facilitated communication (i.e., knowledge-based algorithms). Extracted data included disease category, pathogen type, diagnostic method, intervention purpose, study/target population, sample size, study methodology, development stage, accessory requirement, country of development, operating system, and cost. Given the search timeline, studies involving COVID-19 were not included in the analysis. Of 13,262 studies identified by the screen, 33 met inclusion criteria. 12% were randomized clinical trials (RCTs), with 58% of publications representing technical descriptions. 62% of studies had 100 or fewer subjects. All studied technologies involved diagnosis or screening steps; none addressed the monitoring of infections. 52% focused on priority diseases (HIV, malaria, tuberculosis), but only 12% addressed a neglected tropical disease. Although most reported studies were priced under 20USD at time of publication, two thirds of the records did not yet specify a cost for the study technology. We conclude that there are only a small number of mHealth technologies focusing on innovative methods of screening and diagnosing communicable diseases potentially of use in LMICs. Rigorous RCTs, analyses with large sample size, and technologies assisting in the monitoring of diseases are needed.

Training the healthcare workforce to support task-shifting and viral hepatitis elimination: a global review of English language online trainings and in-person workshops for management of hepatitis B and C infection

BackgroundAchieving World Health Organization (WHO) targets for viral hepatitis elimination will require simplification and decentralisation of care, supported through task-shifting and training of non-specialist frontline healthcare workers. To inform development of national health worker trainings in viral hepatitis, we review and summarise available online and workshop trainings for management of hepatitis B virus (HBV) and hepatitis C virus (HCV).MethodsWe performed a systematic search of PubMed, Embase, Web of Science, conference abstracts, and grey literature using Google to identify online and in-person workshop trainings for health workers focused on HBV and/or HCV. Additional trainings were identified through a WHO regional network. We included online trainings written in English and in-person workshops developed for low-and-middle-income countries (LMICs). Available curricula are summarised together with key operational features (e.g. training length, year developed/updated, developing institution) and programmatic features (e.g. content, mechanism for self-assessment, use of clinical case studies).ResultsA total of 30 trainings met our inclusion criteria (10 online trainings; 20 in-person workshops). 50% covered both HBV and HCV, 13% HBV alone and 37% HCV alone. Among online trainings, only 2 (20%) were specifically developed or adapted for LMICs; 70% covered all aspects of hepatitis care, including prevention, assessment, and treatment; 9 (90%) included guidance on when to refer to specialists, and 6 (60%) included modules on management in specific populations (e.g., people who inject drugs [PWID], prisoners, and children). Online trainings used different formats including text-based modules, narrated slide-sets, and interactive web-based modules. Most workshops (95%) were targeted towards non-specialty providers, and 50% were an integral part of a national strategy for viral hepatitis elimination. Workshop length ranged from several hours to multiple sessions over the course of months, and many were part of a blended educational model, which included other opportunities for ongoing learning (e.g., telementorship).ConclusionThis compendium of online and in-person workshop trainings for HBV and HCV is a useful resource for national hepatitis programmes developing training curricula for non-specialists. Additional online training curricula are needed for use in LMICs, and additional materials are needed to address management challenges in key populations, such as PWID.

Towards a safe system in low- and middle-income countries: vehicles that guide drivers on self-explaining roads

Road crashes cause a huge problem of public health in low- and middle-income countries (LMICs). The Safe System approach is generally considered as the leading concept on the way to road safety. Based on the fundamental premise that humans make mistakes, the overall traffic system should be ‘forgiving’. Sustainable safe road design is one of the key elements of the Safe System approach. Road design and speed control should help prevent crashes with a high level of kinetic energy. However, the road design principles behind the Safe System approach are certainly not leading in today’s infrastructure developments in most LMICs. Cities are getting larger with increasing motorization and expanding road networks. Existing through-roads in local communities are upgraded, resulting in heavy traffic loads and high speeds on places, that are absolutely not suited for this kind of traffic. Furthermore, a Safe System would require that functional design properties of vehicles and roads would be conceptually integrated, which is not the case at all. Although advanced driver assistance systems are on their way of development for quite a long period, their potential role in the Safe System concept is mostly unclear and at least strongly underexposed. The vision on future cars is dominated by the faraway concept of automation. This paper argues that the way to self-driving cars should take a route via the concept of guidance, i.e. vehicles that guide drivers, both on self-explaining roads and on more or less unsafe roads. Such an in-vehicle guidance system may help drivers to choose safe transport mode, a safe route and a safe speed, based on criteria related to safety and sustainability. It is suggested to develop driver assistance systems using relatively simple and cheap technologies, particularly for the purpose of use in LMICs. Such a guide may make roads self-explaining—not only by their physical design characteristics—but also by providing in-car guidance for drivers. In the future, the functional characteristics of both cars and roads may be conceptualized into one integrated Safe System, in which the user plays the central role. Such a guidance system may serve as the conceptual bridge between the roadway, the vehicle and the driver, and thus be considered as an indispensable component of the Safe System approach. It is argued that such a development is necessary to bring a breakthrough in road safety developments in LMICs and also give an acceleration towards zero fatalities in high-income countries.

Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries.

Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries.

Drivers of inappropriate antibiotic use in low- and middle-income countries.

Antimicrobial resistance (AMR) is a global security threat that accounts for about 700 000 deaths annually. Studies have shown that antimicrobial resistance could result in a 2% to 3.5% reduction in global Gross Domestic Product by 2050 and a loss of between 60 and 100 trillion US dollars, worth of economic output resulting in significant and widespread human suffering. Low- and middle-income countries (LMICs) will be worse hit by an unchecked rise of AMR. For example, it is predicted that AMR could kill about 4.1 million people in Africa by 2050 if it is not curbed. Similarly rising rates of AMR will lead to increased treatment costs and an inability to attain universal health coverage, in LMICs with fragile health systems. Sadly, AMR is driven by the inappropriate use of antimicrobials, especially antibiotics. Inappropriate antibiotic use is a pertinent problem in LMICs where regulatory frame works are weak. Inappropriate antibiotic use in LMICs is a multifaceted problem that cuts across clinical and veterinary medicine and agriculture. Therefore, efforts geared at curbing inappropriate antibiotic use in LMICs must identify the factors that drive this problem (i.e. inappropriate antibiotic use) in these countries. A clear knowledge of these factors will guide effective policy and decision making to curb inappropriate antibiotic use and ultimately AMR. The focus of this review is to discuss the factors that drive inappropriate antibiotic use in LMICs.

Association Between Antimicrobial Stewardship Programs and Antibiotic Use Globally

Antimicrobial resistance continues to spread rapidly at a global scale. Little evidence exists on the association of antimicrobial stewardship programs (ASPs) with the consumption of antibiotics across health care and income settings. To synthesize current evidence regarding the association between antimicrobial stewardship programs and the consumption of antibiotics globally. PubMed, Web of Science, and Scopus databases were searched from August 1, 2010, to Aug 1, 2020. Additional studies from the bibliography sections of previous systematic reviews were included. Original studies of the association of ASPs with antimicrobial consumption across health care and income settings. Animal and environmental studies were excluded. Following the Preferred Reporting Items in Systematic Reviews and Meta-Analyses guideline, the pooled association of targeted ASPs with antimicrobial consumption was measured using multilevel random-effects models. The Effective Public Health Practice Project quality assessment tool was used to assess study quality. The main outcome measures were proportion of patients receiving an antibiotic prescription and defined daily doses per 100 patient-days. Overall, 52 studies (with 1 794 889 participants) measured the association between ASPs and antimicrobial consumption and were included, with 40 studies conducted in high-income countries and 12 in low- and middle-income countries (LMICs). ASPs were associated with a 10% (95% CI, 4%-15%) reduction in antibiotic prescriptions and a 28% reduction in antibiotic consumption (rate ratio, 0.72; 95% CI, 0.56-0.92). ASPs were also associated with a 21% (95% CI, 5%-36%) reduction in antibiotic consumption in pediatric hospitals and a 28% reduction in World Health Organization watch groups antibiotics (rate ratio, 0.72; 95% CI, 0.56-0.92). In this systematic review and meta-analysis, ASPs appeared to be effective in reducing antibiotic consumption in both hospital and nonhospital settings. Impact assessment of ASPs in resource-limited settings remains scarce; further research is needed on how to best achieve reductions in antibiotic use in LMICs.

Feasibility of SMS booster for alcohol reduction in injury patients in Tanzania.

Alcohol use is associated with 3 million annual deaths globally. Harmful alcohol use, which is associated with a high burden of disease in low- and middle-income countries (LMICs), often increases the probability of traumatic injury. Treatments for harmful alcohol use in LMICs, such as Tanzania, lack trained personnel and adequate infrastructure. The aim of this study was to assess the feasibility of using SMS boosters to augment a hospital based brief negotiational intervention (BNI) in this low resourced setting. We conducted a three stage, four arm feasibility trial of a culturally adapted BNI for injury patients with harmful and hazardous drinking admitted to Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. Post hospital discharge, two of the four arms included patients receiving either a standard or personalized short message service (SMS) booster to enhance and or perpetuate the effect of the in-hospital BNI. Text messages were sent weekly throughout a 3-month follow-up period. SMS feasibility was assessed according to the TIDier checklist evaluating what, when, how much, tailoring processes, modifications and how well (intervention fidelity). Data was collected with SMS logs and short answer surveys to participants. A total of 41 study participants were assigned to each receive 12 SMS over a three-month period; 38 received messages correctly, 3 did not receive intended messages, and 1 received a message who was not intended to. Of the 258 attempted texts, 73% were successfully sent through the messaging system. Of the messages that failed delivery, the majority were not able to be sent due to participants traveling out of cellular service range or turning off their phones. Participants interviewed in both booster arms reported that messages were appropriate, and that they would appreciate the continuation of such reminders. At 6-month follow-up, 100% (n = 11) of participants interviewed believed that the boosters had a positive impact on their behavior, with 90% reporting a large impact. This study demonstrated feasibility and acceptability of the integration of SMS mobile health technology to supplement this type of nurse-led BNI. SMS booster is a practical tool that can potentially prolong the impact of a brief hospital based intervention to enact behavioral change in injury patients with AUD.

Structural Interventions to Enable Adolescent Contraceptive Use in LMICs: A Mid-Range Theory to Support Intervention Development and Evaluation.

Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or 'upstream' determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were 'likely effective' or 'likely ineffective' due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents' life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios.

Tobacco product menthol and flavour bans: their utility for LMIC and lessons from the EU ban

Abstract Background Flavoured tobacco products increase smoking uptake and create dependence. By June 2020 all cigarettes with a characterising flavour, including menthol were banned across the EU, UK and Moldova but many low and middle income countries (LMIC) are yet to develop and implement bans despite high smoking prevalence. This paper has two objectives: to establish whether (1) flavoured tobacco products are present and marketed in LMIC and (2) the experience of bans in Europe can guide development of legislation elsewhere. Methods Research involved analysis of menthol/flavour market data, review of academic and commercial literature and online media. Results The median menthol/capsule market share of the cigarette market grew significantly in middle income countries (p < 0.05) between 2005 and 2019, both in lower and upper middle-income countries [lower: 2.5% (IQR: 0.5-4.0) to 6.5% (IQR: 3.6-15.9); and upper: 4.0% (IQR: 0.8-9.8) to 12.3% (IQR: 3.5-24.3)]. No market data were available on low-income countries, but the academic literature suggested high prevalence of menthol use in Zambia. Tobacco industry strategies underpinning growth of menthol/flavoured tobacco use in LMICs included in-store marketing and display, colourful packs and non-conventional flavour names. Tobacco industry attempts to circumvent the EU ban included introducing new flavoured tobacco products and accessories not included in the ban and exploiting the ban on characterising flavour (as opposed to an ingredient ban) by introducing cigarettes with lower levels of menthol. Conclusions Banning flavoured and menthol cigarettes in LMIC would impact a growing proportion of smokers in these countries. From the European experience, menthol and flavour bans that include all tobacco products and accessories and ban flavour as an ingredient rather than a characterising flavour is recommended. Currently, lack of marketing bans and standardised packaging in LMICs exacerbate the impact of flavours. Key messages

A survey of barriers and facilitators to caffeine use for apnoea of prematurity in low- and middle-income countries

ABSTRACT Background Despite its associated benefits which include better long-term pulmonary and neurodevelopmental outcome, the use of caffeine for apnoea of prematurity (AoP) has been limited in low- and middle-income countries (LMIC). Aim To better understand current caffeine use, the barriers and facilitators to its use and perceptions and practices in LMIC which have a disproportionately high burden of prematurity. Methods An anonymous online global survey was conducted, targeting healthcare providers working and training in paediatrics and/or neonatology in LMIC. Results A total of 181 respondents in 16 LMIC were included in the analysis; most were physicians working in publicly-funded urban tertiary hospitals. Most had received training in the use of caffeine for AoP (77%), reported expertise (70%) and confidence (96%) in its use, and had access to caffeine (65%). Caffeine availability was reported to be the greatest barrier (48%) and the greatest facilitator (37%). Other common barriers included cost (31%), access (7%) and policies or guidelines on caffeine use (7%); other common facilitators included policies or guidelines on caffeine use (11%), access (10%), staff/other providers’ acceptance of caffeine as an appropriate treatment (9%) and the availability of staff to administer caffeine (8%). Most (79%) noted that access to caffeine was important, 92% agreed that caffeine improves quality of care, and 95% agreed that caffeine improves patient outcome. Conclusion Improving availability and access to low-cost caffeine will be key to increasing caffeine use in LMIC. Abbreviations AoP: Apnoea of Prematurity; LMIC: low- and middle-Income countries; REDCap: Research Electronic Data Capture.

Device for Negative Pressure Wound Therapy in Low-Resource Regions: Open-Source Description and Bench Test Evaluation.

Background: Negative (vacuum) pressure therapy promotes wound healing. However, commercially available devices are unaffordable to most potential users in low- and middle-income countries (LMICs), limiting access to many patients who could benefit from this treatment. This study aimed to design and test a cheap and easy-to-build negative pressure device and provide its detailed open-source description, thereby enabling free replication. Methods: the negative pressure device was built using off-the-shelf materials available via e-commerce and was based on a small pump, a pressure transducer, and the simplest Arduino controller with a digital display (total retail cost ≤ 75 US$). The device allows the user to set any therapeutic range of intermittent negative pressure and has two independent safety mechanisms. The performance of the low-cost device was carefully tested on the bench using a phantom wound, producing a realistic exudate flow rate. Results: the device generates the pressure patterns set by the user (25–175 mmHg of vacuum pressure, 0–60 min periods) and can drain exudate flows within the clinical range (up to 1 L/h). Conclusions: a novel, low-cost, easy-to-build negative pressure device for wound healing displays excellent technical performance. The open-source hardware description provided here, which allows for free replication and use in LMICs, will facilitate the application and wider utilization of this therapy to patients.

Failure modes and downtime of radiotherapy LINACs and multileaf collimators in Indonesia.

The lack of equitable access to radiotherapy (RA) linear accelerators (LINACs) is a substantial barrier to cancer care in low- and middle-income countries (LMICs). These nations are expected to bear up to 75% of cancer-related deaths globally by 2030. State-of-the-art LINACs in LMICs experience major issues in terms of robustness, with mechanical and electrical breakdowns resulting in downtimes ranging from days to months. While existing research has identified the higher failure frequency and downtimes between LMICs (Nigeria, Botswana) compared to high-income countries (HICs, the UK), there has been a need for additional data and study particularly relating to multileaf collimators (MLCs). This study presents for the first time the analysis of data gathered through a dedicated survey and workshop including participants from 14 Indonesian hospitals, representing a total of 19 LINACs. We show the pathways to failure of radiotherapy LINACs and frequency of breakdowns with a focus on the MLC subsystem. This dataset shows that LINACs throughout Indonesia are out of operation for seven times longer than HICs, and the mean time between failures of a LINAC in Indonesia is 341.58 h or about 14 days. Furthermore, of the LINACs with an MLC fitted, % of all mechanical faults are due to the MLC, and % of cases requiring a replacement component are related to the MLC. These results highlight the pressing need to improve robustness of RT technology for use in LMICs, highlighting the MLC as a particularly problematic component. This work motivates a reassessment of the current generation of RT LINACs and demonstrates the need for dedicated efforts toward a future where cancer treatment technology is robust for use in all environments where it is needed.

Long-acting injectable cabotegravir: implementation science needed to advance this additional HIV prevention choice.

Long-acting injectable cabotegravir: implementation science needed to advance this additional HIV prevention choice.

Awareness About and E-Cigarette Use Among Adults in 15 Low- and Middle-Income Countries, 2014-2018 Estimates From Global Adult Tobacco Surveys.

E-cigarette (EC) use is seldom reported from low- and middle-income countries (LMICs). We report the prevalence of "awareness" about EC, its use, and distribution of EC use by sociodemographic factors and cigarette smoking (CS) status. We analyzed Global Adult Tobacco Survey data in Bangladesh, China, Costa Rica, Ethiopia, India, Kazakhstan, Mexico, Philippines, Romania, Russia, Senegal, Ukraine, Turkey, Uruguay, and Viet Nam during 2014-2018. The weighted prevalence of "awareness" (heard about), "ever" (even once), and "current" (daily/nondaily) EC use among never, current, and former cigarette smokers and quit ratios (past smokers/ever smokers) was estimated. Association of EC use with sociodemographic, and CS, was explored by multilevel regression. Overall, prevalence of "awareness," "ever," and "current" ECs use was 19.3% (95% confidence interval [CI] 27.4, 31.1), 2.6% (95% CI 2.4, 2.8), and 0.7% (95% CI 0.6, 0.8), respectively. In most countries, "ever use" <10%, and "current use" was about 1% except Romania (4.4%) and Russia (3.5%). "Current use" was 0.1%, 2.9%, and 3.1% among never, current, and former smokers, respectively. "Current" and "ever" EC use was higher among current and former than never smokers (2.8% and 3.1% vs. 0.1%; 9.9% and 10.9% vs. 0.7%), respectively. Current EC use was associated with male sex, urban residence and younger age, higher education, and wealth. "Quit attempts" (aOR 1.3, 95% CI 1.2, 1.5) and cigarettes smoked per day (aOR 1.6, 95% CI 1.4, 1.9) were associated with "ever use." EC use was low in most countries. "Dual use" was common among current smokers and the quit ratio was higher among ECs users. EC use is increasing in high-income countries (HICs) where regulations on ECs are usually permissive. Evidence on the individual- or population-level impact of ECs on CS cessation is inconclusive. Little is known about the prevalence of EC use in LMICs where regulations are nonexistent or less restrictive. Studying the distribution of EC use rates by population subgroups, CS status, and quit ratios for CS among EC users will assist the formulation of EC regulatory policies. We provide comparable nationally representative prevalence estimates of "awareness" about and, use of ECs to serve as a benchmark for future monitoring. EC use was associated with the attempt to quit CS and smoking >10 cigarettes per day. However, "dual use" was common, and the quit ratio for CS was higher among EC users. EC use was very low relative to HICs. Nevertheless, comprehensive EC regulatory policies should be implemented to prevent the escalation of EC use by targeting population subgroups such as young adults, educated and wealthier individuals.