Cervical cancer prevention and control in women living with human immunodeficiency virus.

Despite being highly preventable, cervical cancer is the fourth most common cancer and cause of cancer death in women globally. In low-income countries, cervical cancer is often the leading cause of cancer-related morbidity and mortality. Women living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome are at a particularly high risk of cervical cancer because of an impaired immune response to human papillomavirus, the obligate cause of virtually all cervical cancers. Globally, approximately 1 in 20 cervical cancers is attributable to HIV; in sub-Saharan Africa, approximately 1 in 5 cervical cancers is due to HIV. Here, the authors provide a critical appraisal of the evidence to date on the impact of HIV disease on cervical cancer risk, describe key methodologic issues, and frame the key outstanding research questions, especially as they apply to ongoing global efforts for prevention and control of cervical cancer. Expanded efforts to integrate HIV care with cervical cancer prevention and control, and vice versa, could assist the global effort to eliminate cervical cancer as a public health problem.

Household Air Pollution Interventions to Improve Health in Low- and Middle-Income Countries: An Official American Thoracic Society Research Statement.

Background: An estimated 3 billion people, largely in low- and middle-income countries, rely on unclean fuels for cooking, heating, and lighting to meet household energy needs. The resulting exposure to household air pollution (HAP) is a leading cause of pneumonia, chronic lung disease, and other adverse health effects. In the last decade, randomized controlled trials of clean cooking interventions to reduce HAP have been conducted. We aim to provide guidance on how to interpret the findings of these trials and how they should inform policy makers and practitioners.Methods: We assembled a multidisciplinary working group of international researchers, public health practitioners, and policymakers with expertise in household air pollution from within academia, the American Thoracic Society, funders, nongovernmental organizations, and global organizations, including the World Bank and the World Health Organization. We performed a literature search, convened four sessions via web conference, and developed consensus conclusions and recommendations via the Delphi method.Results: The committee reached consensus on 14 conclusions and recommendations. Although some trials using cleaner-burning biomass stoves or cleaner-cooking fuels have reduced HAP exposure, the committee was divided (with 55% saying no and 45% saying yes) on whether the studied interventions improved measured health outcomes.Conclusions: HAP is associated with adverse health effects in observational studies. However, it remains unclear which household energy interventions reduce exposure, improve health, can be scaled, and are sustainable. Researchers should engage with policy makers and practitioners working to scale cleaner energy solutions to understand and address their information needs.

Navigating the economic challenges in childhood cancer control in low- and middle-income countries: Insights from the CC-BRIDGE tool and the global initiative for childhood cancer.

The increasing incidence of childhood cancer in low- and middle-income countries (LMICs) presents significant economic and logistical challenges, affecting health care provision and equitable treatment access. This editorial explores the economic barriers to pediatric oncology care in LMICs, highlighting resource scarcity, socioeconomic inequities, and health care complexities. It emphasizes the need for detailed cost analysis within health systems complicated by inadequate data and variable treatment protocols. Central to the discussion is the "Childhood Cancers Budgeting Rapidly to Incorporate Disadvantaged Groups for Equity (CC-BRIDGE) Tool" from the manuscript by Nancy Bolous et al., who proposed an innovative method to estimate the cost of integrating childhood cancer services into National Cancer Control Plans. This tool aligns with the World Health Organization's Global Initiative for Childhood Cancer to enhance survival rates and advocate for universal health coverage in pediatric oncology. The CC-BRIDGE tool's methodological rigor provides a structured framework for cost analysis. Yet, it is recognized as an initial step requiring further enhancements for comprehensive economic forecasting and societal cost assessments. In conclusion, the editorial highlights the tool's critical role in incorporating childhood cancer care into national strategies in LMICs, contributing to the broader fight against cancer and advocating for comprehensive, equitable health care. It signifies a vital stride toward addressing pediatric oncology's economic challenges and supporting universal health coverage for childhood cancer care.

Financial Toxicity: Unveiling the Burden of Cancer Care on Patients in Rwanda.

INTRODUCTION: Cancer is a major public health problem in Rwanda and other low- and middle-income countries (LMICs). While there have been some improvements in access to cancer treatment, the cost of care has increased, leading to financial toxicity and treatment barriers for many patients. This study explores the financial toxicity of cancer care in Rwanda. METHODS: This prospective cross-sectional study was conducted at 3 referral hospitals in Rwanda, which deliver most of the country's cancer care. Data were collected over 6 months from June 1 to December 1, 2022 by trained research assistants (RAs) using a modified validated data collection tool. RAs interviewed consecutive eligible patients with breast cancer, cervical cancer, colorectal cancer, Hodgkin's and non-Hodgkin's lymphoma who were on active systemic therapy. The study aimed to identify sources of financial burden. Data were analyzed using descriptive statistics. RESULTS: 239 patients were included; 75% (n = 180/239) were female and mean age was 51 years. Breast, cervix, and colorectal cancers were the most common diagnoses (42%, 100/239; 24%, 58/239; and 24%, 57/239, respectively) and 54% (n = 129/239) were diagnosed with advanced stage (stages III-IV). Financial burden was high; 44% (n = 106/239) of respondents sold property, 29% (n = 70/239) asked for charity from public, family, or friends, and 16% (n = 37/239) took loans with interest to fund cancer treatment. CONCLUSION: Despite health insurance which covers many elements of cancer care, a substantial proportion of patients on anti-cancer treatment in Rwanda experience major financial toxicity. Novel health financing solutions are needed to ensure accessible and affordable cancer care.

The impact of in-house pathology services on downstaging cervical cancer in Tanzania over an 18-year period.

PURPOSE: Reducing time between cancer screening, diagnosis, and initiation of treatment is best achieved when services are available in the same hospital. Yet, comprehensive cancer centers are typically unavailable in low- and middle-income countries (LMICs), where resources are limited and services scattered. This study explored the impact of establishing an in-house pathology laboratory at the largest public cancer hospital in Tanzania on the downstaging of cervical cancer. METHODS: We examined clinical datasets of 8,322 cervical cancer patients treated at the Ocean Road Cancer Institute (ORCI). The first period included patients treated from 2002 to 2016, before establishment of the pathology laboratory at ORCI; the second period (post-pathology establishment) included data from 2017 to 2020. Logistic regression analysis evaluated the impact of the pathology laboratory on stage of cervical cancer diagnosis. RESULTS: Patients treated during the post-pathology period were more likely to be clinically diagnosed at earlier disease stages compared to patients in the pre-pathology period (pre-pathology population diagnosed at early disease stage: 44.08%; post-pathology population diagnosed at early disease stage: 59.38%, p < 0.001). After adjustment for age, region of residence, and place of biopsy, regression results showed patients diagnosed during the post-pathology period had higher odds of early stage cervical cancer diagnosis than patients in the pre-pathology period (OR 1.35, 95% CI (1.16, 1.57), p < 0.001). CONCLUSIONS: Integrated and comprehensive cancer centers can overcome challenges in delivering expedited cervical cancer diagnosis and treatment. In-house pathology laboratories play an important role in facilitating timely diagnosis and rapid treatment of cervical and possibly other cancers in LMICs.

A culturally adapted unified protocol for transdiagnostic treatment of anxiety disorders in adolescents (UP-A): a randomized waitlist-controlled trial.

BACKGROUND: Anxiety disorders are highly prevalent and debilitating conditions that show high comorbidity rates in adolescence. The present article illustrates how Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) was adapted for Iranian adolescents with anxiety disorders. METHODS: A total of 54 adolescents with comorbid anxiety disorders participated in a randomized, waitlist-controlled trial of group weekly sessions of either UP-A or waitlist control (WLC). Primary and process of change outcomes were assessed at baseline, posttreatment, and 1-month follow-up. RESULTS: Significant changes were observed over time on major DSM-5 anxiety disorder symptoms (F(2, 51) = 117.09, p < 0.001), phobia type symptoms (F(2, 51) = 100.67, p < 0.001), and overall anxiety symptoms (F(2, 51) = 196.29, p < 0.001), as well as on emotion regulation strategies of reappraisal (F(2, 51) = 17.03, p < 0.001), and suppression (F(2, 51) = 21.13, p < 0.001), as well as on intolerance of uncertainty dimensions including prospective (F(2, 51) = 74.49, p < 0.001), inhibitory (F(2, 51) = 45.94, p < 0.001), and total intolerance of uncertainty (F(2, 51) = 84.42, p < 0.001), in favor of UP-A over WLC. CONCLUSION: Overall, results provide a cultural application of the UP-A and support the protocol as useful for improving anxiety disorders as well as modifying of emotion regulation strategies and intolerance of uncertainty dimensions in Iranian adolescents. Future directions and study limitations are discussed.

Stepwise options for preparing therapeutic plasma proteins from domestic plasma in low- and middle-income countries.

Industrial plasma fractionation, a complex and highly regulated technology, remains largely inaccessible to many low- and middle-income countries (LMICs). This, combined with the limited availability and high cost of plasma-derived medicinal products (PDMPs), creates deficiency of access to adequate treatment for patients in resource-limited countries, and leads to their suffering. Meanwhile, an increasing number of LMICs produce surplus plasma, as a by-product of red blood cell preparation from whole blood, that is discarded because of the lack of suitability for fractionation. This article reviews pragmatic technological options for processing plasma collected from LMICs into therapies and supports a realistic stepwise approach aligned with recent World Health Organization guidance and initiatives launched by the Working Party for Global Blood Safety of the International Society of Blood Transfusion. When industrial options based on contract or toll plasma fractionation programme and, even more, domestic fractionation facilities require larger volumes of quality plasma than is produced, alternative methods should be considered. In-bag minipool or small-scale production procedures implementable in blood establishments or national service centres are the only realistic options available to gradually reduce plasma wastage, provide safer treatments for patients currently treated with non-pathogen-reduced blood products and concurrently improve Good Manufacturing Practice (GMP) levels with minimum capital investment. As a next step, when the available volume of quality-assured plasma reaches the necessary thresholds, LMICs could consider engaging with an established fractionator in a fractionation agreement or a contract in support of a domestic fractionation facility to improve the domestic PDMP supply and patients' treatment.

Antibiotic prescribing practices and antibiotic use quality indicators in Luang Prabang, Lao PDR: a point prevalence survey in a tertiary care hospital.

CONTEXT: The increase and global dissemination of antibiotic resistance limit the use of antibiotics to prevent and treat infections. Implementing antibiotic stewardship programs guided by local data on prescription profiles is a useful strategy to reduce the burden of antibiotic resistance. The aim was to determine the prevalence of antibiotic use and guideline compliance at Luang Prabang provincial hospital, Lao PDR. METHODS: A point prevalence survey of antibiotics was conducted among hospitalized patients admitted to Luang Prabang hospital (204 beds) in Lao PDR on May 25, 2023. All patients presenting at 8:00 AM were eligible. Sociodemographic data, indications for antibiotic use, and antibiotic prescriptions were collected from medical records using a paper-based questionnaire and entered into an electronic platform following WHO methodology. The prevalence of antibiotic use was determined. RESULTS: Out of the 102 patients included, 60(58.8%) were undergoing antibiotic treatment, of which 33(55.0%) received combination therapy, and 7(10.5%) had two indications for antibiotic use. The highest prevalence was in the surgical ward (14/15, 93%) followed by general paediatrics (18/27, 67%). Out of the 100 antibiotic prescriptions, 47(47%) were for community-acquired infections, 26(26%) for surgical prophylaxis, 13(13%) for hospital-acquired infections and 5(5%) for medical prophylaxis. Twenty(20%) antibiotics were prescribed for obstetrics and gynaecology prophylaxis, 17(17%) for intra-abdominal infections, and 10(10.0%) for pneumonia treatment as well as bone, and joint infections. The main antibiotics prescribed were ceftriaxone 36(34.6%), metronidazole 18(17.3%), ampicillin 8(7.7%), and gentamicin 8(7.7%). Only 2(3%) samples were sent to the laboratory, one of which showed a positive culture for Escherichia coli Extended Spectrum ß-Lactamase. According to the WHO Access Watch and Reserve classification, 55(52.9%) molecules belonged to the Access category, 47(49.1%) to the Watch category, and none to the Reserve category. Only 14.9% of antibiotic prescriptions were fully compliant with current guidelines. CONCLUSION: This study indicated a significant prevalence of antibiotic use and a very low compliance with guidelines at Luang Prabang provincial hospital, Lao PDR. This highlights an urgent need for comprehensive strategies at all levels to optimize antibiotic use in hospitals, emphasizing diagnostic improvements, and continued research to address the factors driving this excessive antibiotic usage and improve adherence to guidelines.

Burden of Child Anemia Attributable to Fine Particulate Matters Brought by Sand Dusts in Low- and Middle-Income Countries.

Addressing environmental factors has recently been recommended to curb the growing trend of anemia in low- and middle-income countries (LMICs). Fine particulate matter (PM2.5) generated by dust storms were concentrated in place with a high prevalence of anemia. In a multicounty, multicenter study, we analyzed the association between anemia and life-course averaged exposure to dust PM2.5 among children aged <5 years based on 0.65 million records from 47 LMICs. In the fully adjusted mixed effects model, each 10 µg/m3 increase in life-course averaged exposure to dust PM2.5 was associated with a 9.3% increase in the odds of anemia. The estimated exposure-response association was nonlinear, with a greater effect of dust PM2.5 exposure seen at low concentrations. Applying this association, we found that, in 2017, among all children aged <5 years in the 125 LMICs, dust PM2.5 contributed to 37.98 million cases of anemia. Results indicated that dust PM2.5 contributed a heavier burden than all of the well-identified risk factors did, except for iron deficiency. Our study revealed that long-term exposure to dust PM2.5 can be a novel risk factor, pronouncedly contributed to the burden of child anemia in LMICs, affected by land degradations or arid climate.

Advancing access to care: An assessment of the prehospital system in Senegal.

BACKGROUND: Most low- and middle-income countries do not have a mature prehospital system limiting access to definitive care. This study sought to describe the current state of the prehospital system in Senegal and offer recommendations aimed at improving system capacity and population access to definitive care. METHODS: Structured interviews were conducted with key informants in various regions throughout the country using qualitative and quantitative techniques. A standardized questionnaire was generated using needs assessment forms and system frameworks. Descriptive statistics were performed for quantitative data analysis, and qualitative data was consolidated and presented using ATLAS.ti. RESULTS: Two (20%) of the studied regions, Dakar and Saint-Louis, had a mature prehospital system in place, including dispatch centers and teams of trained personnel utilizing equipped ambulances. 80% of the studied regions lacked an established prehospital system. The vast majority of the population relied on the fire department for transport to a healthcare facility. The ambulances in rural regions were not part of a formal prehospital system, were not equipped with life-support supplies, and were limited to inter-facility transfers. CONCLUSIONS: While Dakar and Saint-Louis have mature prehospital systems, the rest of the country is served by the fire department. There are significant opportunities to further strengthen the prehospital system in rural Senegal by training the fire department in basic life support and first aid, maintaining cost efficiency, and building on existing national resources. This has the potential to significantly improve access to definitive care and outcomes of emergent illness in the Senegalese community.

Community pharmacists as antimicrobial resistance stewards: a narrative review on their contributions and challenges in low- and middle-income countries.

Antimicrobial resistance (AMR) is a global public health crisis that impedes the therapeutic effectiveness of available antimicrobial agents. Due to the high burden of infectious diseases and limited resources, especially trained healthcare professionals, low- and middle-income countries (LMICs) are particularly susceptible to the detrimental effects of AMR. Sometimes, as the first and last point of contact for patients seeking treatment for infections, community pharmacists can play a pivotal role in the stewardship required for AMR. This review aims to highlight the contributions made by community pharmacists in LMICs as AMR stewards. The review considers the challenges from the perspectives of limited resources, inadequate training, a lack of policies and regulations, and issues related to patient behavior. Community pharmacists in LMICs could optimize their advocacy contributions by focusing on One Health AMR stewardship. Transformational and actionable patient and population-centric antimicrobial stewardship (AMS) is feasible with the synergy of policymakers and other healthcare providers in the implementation of AMS policies and programs that support community pharmacists in their efforts to promote rational antimicrobial use.

Early to mid-pregnancy HbA1c levels and its association with adverse pregnancy outcomes in three low middle-income countries in Asia and Sub-Saharan Africa.

BACKGROUND: Hyperglycemia during pregnancy leads to adverse maternal and fetal outcomes. Thus, strict monitoring of blood glucose levels is warranted. This study aims to determine the association of early to mid-pregnancy HbA1c levels with the development of pregnancy complications in women from three countries in South Asia and Sub-Saharan Africa. METHODS: We performed a secondary analysis of the AMANHI (Alliance for Maternal and Newborn Health Improvement) cohort, which enrolled 10,001 pregnant women between May 2014 and June 2018 across Sylhet-Bangladesh, Karachi-Pakistan, and Pemba Island-Tanzania. HbA1c assays were performed at enrollment (8 to < 20 gestational weeks), and epidemiological data were collected during 2-3 monthly household visits. The women were followed-up till the postpartum period to determine the pregnancy outcomes. Multivariable logistic regression models assessed the association between elevated HbA1c levels and adverse events while controlling for potential confounders. RESULTS: A total of 9,510 pregnant women were included in the analysis. The mean HbA1c level at enrollment was found to be the highest in Bangladesh (5.31 ± 0.37), followed by Tanzania (5.22 ± 0.49) and then Pakistan (5.07 ± 0.58). We report 339 stillbirths and 9,039 live births. Among the live births were 892 preterm births, 892 deliveries via cesarean section, and 532 LGA babies. In the multivariate pooled analysis, maternal HbA1c levels of ≥ 6.5 were associated with increased risks of stillbirths (aRR = 6.3, 95% CI = 3.4,11.6); preterm births (aRR = 3.5, 95% CI = 1.8-6.7); and Large for Gestational Age (aRR = 5.5, 95% CI = 2.9-10.6). CONCLUSION: Maternal HbA1c level is an independent risk factor for predicting adverse pregnancy outcomes such as stillbirth, preterm birth, and LGA among women in South Asia and Sub-Saharan Africa. These groups may benefit from early interventional strategies.

Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda.

BACKGROUND: Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally. METHODS: We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions. RESULTS: Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level. CONCLUSION: Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.

Conducting co-creation for public health in low and middle-income countries: a systematic review and key informant perspectives on implementation barriers and facilitators.

BACKGROUND: There has been an increase in the use of co-creation for public health because of its claimed potential to increase an intervention's impact, spark change and co-create knowledge. Still, little is reported on its use in low-and-middle-income countries (LMICs). This study offers a comprehensive overview of co-creation used in public-health-related interventions, including the interventions' characteristics, and reported implementation barriers and facilitators. METHODS: We conducted a systematic review within the Scopus and PubMed databases, a Google Scholar search, and a manual search in two grey literature databases related to participatory research. We further conducted eight interviews with first authors, randomly selected from included studies, to validate and enrich the systematic review findings. RESULTS: Through our review, we identified a total of twenty-two studies conducted in twenty-four LMIC countries. Majority of the interventions were designed directly within the LMIC setting. Aside from one, all studies were published between 2019 and 2023. Most studies adopted a co-creation approach, while some reported on the use of co-production, co-design, and co-development, combined either with community-based participatory research, participatory action research or citizen science. Among the most reported implementation barriers, we found the challenge of understanding and accounting for systemic conditions, such as the individual's socioeconomic status and concerns related to funding constraints and length of the process. Several studies described the importance of creating a safe space, relying on local resources, and involving existing stakeholders in the process from the development stage throughout, including future and potential implementors. High relevance was also given to the performance of a contextual and/or needs assessment and careful tailoring of strategies and methods. CONCLUSION: This study provides a systematic overview of previously conducted studies and of reported implementation barriers and facilitators. It identifies implementation barriers such as the setting's systemic conditions, the socioeconomic status and funding constrains along with facilitators such as the involvement of local stakeholders and future implementors throughout, the tailoring of the process to the population of interest and participants and contextual assessment. By incorporating review and interview findings, the study aims to provide practical insights and recommendations for guiding future research and policy.

Intellectual property licensing of therapeutics during the COVID-19 crisis: lessons learnt for pandemic preparedness and response.

During the COVID-19 pandemic, intellectual property licensing through bilateral agreements and the Medicines Patent Pool were used to facilitate access to new COVID-19 therapeutics in low- and middle-income countries (LMICs). The lessons learnt from the application of the model to COVID-19 could be relevant for preparedness and response to future pandemics and other health emergencies.The speed at which affordable versions of a new product are available in LMICs is key to the realization of the potential global impact of the product. When initiated early in the research and development life cycle, licensing could facilitate rapid development of generic versions of innovative products in LMICs during a pandemic. The pre-selection of qualified manufacturers, for instance building on the existing network of generic manufacturers engaged during the COVID-19 pandemic, the sharing of know-how and the quick provision of critical inputs such as reference listed drugs (RLDs) could also result in significant time saved. It is important to find a good balance between speed and quality. Necessary quality assurance terms need to be included in licensing agreements, and the potentials of the new World Health Organization Listed Authority mechanism could be explored to promote expedited regulatory reviews and timely access to safe and quality-assured products.The number, capacity, and geographical distribution of licensed companies and the transparency of licensing agreements have implications for the sufficiency of supply, affordability, and supply security. To foster competition and support supply security, licenses should be non-exclusive. There is also a need to put modalities in place to de-risk the development of critical pandemic therapeutics, particularly where generic product development is initiated before the innovator product is proven to be effective and approved. IP licensing and technology transfer can be effective tools to improve the diversification of manufacturing and need to be explored for regional manufacturing for accelerated access at scale in in LMICs and supply security in future pandemics.

Vaccines for neglected, emerging and re-emerging diseases.

Efforts to produce vaccines against SARS and MERS were prematurely halted since their scope was perceived to be geographically restricted and they were subsequently categorized as neglected diseases. However, when a similar virus spread globally triggering the COVID-19 pandemic, we were harshly reminded that several other neglected diseases might also be waiting for the perfect opportunity to become mainstream. As climate change drives urbanization, natural selection of pathogens and their intermediate vectors and reservoirs, the risk of neglected diseases emerging within a larger susceptible pool becomes an even greater threat. Availability of a vaccine for COVID-19 is widely considered the only way to end this pandemic. Similarly, vaccines are also seen as the best tools available to control the spread of neglected (sometimes referred to as emerging or re-emerging) diseases, until the water, hygiene and sanitation infrastructure is improved in areas of their prevalence. Vaccine production is usually cost and labour intensive and thus minimal funding is directed towards controlling and eliminating neglected diseases (NDs). A customised but sustainable approach is needed to develop and deploy vaccines against NDs. While safety, efficacy and public trust are the three main success pillars for most vaccines, affordability is vital when formulating vaccines for neglected diseases.

Links across disabilities: unveiling associations between functional domains.

BACKGROUND: Persons with disabilities experience higher risks of mortality as well as poorer health as compared to the general population. The aim of this study is to estimate the correlations between functional difficulties across several domains in six countries. METHODS: National census data with questions on disability from six countries (Mauritius, Morocco, Senegal, Myanmar, Vietnam, and Uruguay) was used in this study. We performed logistic regressions to assess the extent to which having a functional difficulty in one domain is correlated with having a functional difficulty in each of the other domains and report weighted odds ratios (ORs) overall and within age-groups ('18-44' years and '45+' years). Models adjust for age, sex, and location (rural or urban). Sensitivity analyses around different choices of predictors and response variables were conducted. FINDINGS: For all countries, reporting a functional difficulty in one domain was consistently and significantly positively correlated with reporting a functional difficulty in other domains (overall) and for each of the two age-groups considered - '18-44' years and '45+' years. All ORs were greater than one. Cognition, mobility, and hearing were the domains that were the most correlated ones with other domains. The highest pairwise correlations were for i/ hearing and cognition; ii/ mobility and cognition. Results were robust to changing the severity thresholds for functional difficulties. Across countries, Uruguay, the only high-income country among the six countries under study, had the lowest correlations between functional domains. CONCLUSIONS: There are consistent positive associations in the experience of functional difficulties in various domains in the six countries under study. Such correlations may reflect barriers to social services including healthcare services and resources (e.g. assistive devices) that may lead to an avoidable deterioration of functioning across domains. Further research is needed on the trajectories of functional difficulties and on structural barriers that people with functional difficulties may experience in their communities and in healthcare settings in particular. This is important as some functional difficulties may be preventable.

Surgical treatment of pediatric low-grade glioma in developing countries.

Pediatric low-grade gliomas constitute the most common brain tumors worldwide, though with some peculiarities in the presentation and surgical care in different parts of the world. The symptomatology in developing countries is likely to be over longer periods with a tendency to delayed diagnosis due to cultural, religious beliefs, manpower, and infrastructural deficits. Thus, the children present with large tumors with attendant morbidities and an increased risk of mortalities from surgery. Surgery is mainly by "general" neurosurgeons due to the paucity of trained pediatric neurosurgeons. The pre-operative imaging may be limited to anatomic MR imaging, and in some cases, CT scans, without expansive neuropsychological evaluation. The armamentarium available to the neurosurgeon may warrant large openings to access the tumor, and there may be limited possibility for intra-operative mapping of "eloquent" brain functions when this is deemed necessary. Complicating pre-operative acute hydrocephalus can result in two operations that further worsen the catastrophic spending associated with brain tumor surgeries in these climes. While these challenges appear daunting but certainly have not been enough to deter the "can do" spirit of neurosurgeons in developing countries, it is essential to strengthen the training of pediatric neurosurgeons in LMICs and provide a platform for the advocacy of better infrastructure for the surgical management of these tumors.

Engaging stakeholders to level up COPD care in LMICs: lessons learned from the "Breathe Well" programme in Brazil, China, Georgia, and North Macedonia.

BACKGROUND: Effective stakeholder engagement in health research is increasingly being recognised and promoted as an important pathway to closing the gap between knowledge production and its use in health systems. However, little is known about its process and impacts, particularly in low-and middle-income countries. This opinion piece draws on the stakeholder engagement experiences from a global health research programme on Chronic Obstructive Pulmonary Disease (COPD) led by clinician researchers in Brazil, China, Georgia and North Macedonia, and presents the process, outcomes and lessons learned. MAIN BODY: Each country team was supported with an overarching engagement protocol and mentored to develop a tailored plan. Patient involvement in research was previously limited in all countries, requiring intensive efforts through personal communication, meetings, advisory groups and social media. Accredited training programmes were effective incentives for participation from healthcare providers; and aligning research findings with competing policy priorities enabled interest and dialogue with decision-makers. The COVID-19 pandemic severely limited possibilities for planned engagement, although remote methods were used where possible. Planned and persistent engagement contributed to shared knowledge and commitment to change, including raised patient and public awareness about COPD, improved skills and practice of healthcare providers, increased interest and support from clinical leaders, and dialogue for integrating COPD services into national policy and practice. CONCLUSION: Stakeholder engagement enabled relevant local actors to produce and utilise knowledge for small wins such as improving day-to-day practice and for long-term goals of equitable access to COPD care. For it to be successful and sustained, stakeholder engagement needs to be valued and integrated throughout the research and knowledge generation process, complete with dedicated resources, contextualised and flexible planning, and commitment.

Hospital readiness for the provision of care to critically ill patients in Tanzania- an in-depth cross-sectional study.

BACKGROUND: Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and potential for reversibility. The burden of critical illness is high, especially in low- and middle-income countries. Critical care can be provided as Essential Emergency and Critical Care (EECC)- the effective, low-cost, basic care that all critically ill patients should receive in all parts of all hospitals in the world- and advanced critical care- complex, resource-intensive care usually provided in an intensive care unit. The required resources may be available in the hospital and yet not be ready in the wards for immediate use for critically ill patients. The ward readiness of these resources, although harder to evaluate, is likely more important than their availability in the hospital. This study aimed to assess the ward readiness for EECC and the hospital availability of resources for EECC and for advanced critical care in hospitals in Tanzania. METHODS: An in-depth, cross-sectional study was conducted in five purposively selected hospitals by visiting all wards to collect data on all the required 66 EECC and 161 advanced critical care resources. We defined hospital-availability as a resource present in the hospital and ward-readiness as a resource available, functioning, and present in the right place, time and amounts for critically ill patient care in the wards. Data were analyzed to calculate availability and readiness scores as proportions of the resources that were available at hospital level, and ready at ward level respectively. RESULTS: Availability of EECC resources in hospitals was 84% and readiness in the wards was 56%. District hospitals had lower readiness scores (less than 50%) than regional and tertiary hospitals. Equipment readiness was highest (65%) while that of guidelines lowest (3%). Availability of advanced critical care resources was 31%. CONCLUSION: Hospitals in Tanzania lack readiness for the provision of EECC- the low-cost, life-saving care for critically ill patients. The resources for EECC were available in hospitals, but were not ready for the immediate needs of critically ill patients in the wards. To provide effective EECC to all patients, improvements are needed around the essential, low-cost resources in hospital wards that are essential for decreasing preventable deaths.