Low Resource Settings

Every November 12th, the global health community hosts World Pneumonia Day, and in 2020, on the 11th iteration, we find ourselves once more facing the fact that pneumonia is the leading global cause of infectious mortality amongst children under-5 years old. Many regions are not within sight of the Sustainable Development Goal 3.2 target. And yet, this situation may be less surprising given we are-11 years later-still discussing the basic question of how we define (and count) a child's single breath. The cornerstone of paediatric pneumonia diagnosis in most low-and middle-income country (LMIC) settings, and particularly in primary care, is the evaluation of respiratory rate (RR), as part of the clinical algorithms that constitute the Integrated Management of Childhood Illness (IMCI). The introduction of this standardized syndromic approach through the WHO case management guidelines has resulted in significant pneumonia mortality reductions . The current standard of determining RR is visually counting the number of breaths a child takes over an uninterrupted 60-second period, using a stopwatch or RR counting timer. However, this can be unreliable (especially amongst younger and/ or uncooperative children), challenging in timelimited high-volume settings and often not routinely done by healthcare workers. Additionally, timers are often unavailable . Therefore, the lack of lowcost, accurate and easy-to-use RR tools limits

Introduction:
Cardiovascular-related diseases, with hypertension as a key precursor, have increased in recent years. Effective management of hypertension improves life expectancy, yet poor medication adherence remains a challenge, contributing to adverse health outcomes and increased healthcare costs.

Objectives:
This study aimed to determine the association between knowledge and medication adherence, as well as identify factors associated with non-adherence to antihypertensive therapy among adult male patients attending Ashaiman Polyclinic.

Methods:
A facility-based cross-sectional study using a quantitative approach was conducted among 206 adult male clients. Participants were selected through a consecutive sampling technique. Data were collected using a structured questionnaire and analyzed with Stata version 16. Descriptive statistics (frequencies, percentages, means, standard deviations, and 95% confidence intervals) were computed. Chi-square and Fisher’s exact tests were used for bivariate analysis. Variables significant at p < 0.05 were further analyzed using multiple logistic regression to determine adjusted odds ratios (AOR).

Results:
An estimated 64.6% of respondents had adequate knowledge of hypertension, while 41.3% had adequate knowledge of antihypertensive medications. However, knowledge did not significantly translate into medication adherence (p < 0.05). Factors significantly associated with non-adherence included age (AOR = 1.72; 95% CI: 1.194–6.181; p = 0.042), educational level (AOR = 1.84; 95% CI: 1.019–5.089; p = 0.028), duration since diagnosis (AOR = 1.48; 95% CI: 1.118–7.863; p = 0.019), and history of experiencing medication side effects (AOR = 0.72; 95% CI: 0.278–0.822; p = 0.027).

Conclusion:
The study found relatively low levels of adequate knowledge regarding hypertension and antihypertensive medications among adult male patients. This knowledge did not significantly influence medication adherence. Key factors influencing adherence included age, educational level, duration of diagnosis, and past experiences with side effects. The study highlights the importance of strengthening social support systems through caregiver and community education to promote medication adherence among hypertensive patients.

This study investigates the effectiveness of structured antenatal education (SAE) programs in enhancing maternal health literacy and birth preparedness among primigravida women in low-resource settings. Despite numerous efforts to reduce maternal and neonatal morbidity, first-time mothers in underserved regions often lack the knowledge required to recognize pregnancy complications and prepare adequately for delivery. The study uses a quasi-experimental design to compare outcomes between an intervention group receiving structured education and a control group receiving standard antenatal care. Findings suggest that SAE significantly improves knowledge of danger signs, nutrition, hygiene, and delivery preparedness indicators, such as saving money, arranging transport, and identifying skilled birth attendants.

Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Nonexposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy.

A rapid test to identify patients with sickle cell disease could have important benefits in lowresource settings. Sickle cell anemia (SCA) affects about 300,000 newborns each year, the majority of whom are born in sub-Saharan Africa. Low-cost therapies are available to treat SCA, but most countries in sub-Saharan Africa lack robust neonatal screening programs needed to identify patients in need of treatment. To address this need, we developed and evaluated a competitive lateral flow assay that identifies patients with SCA (genotype HbSS) in 15 minutes using undiluted whole blood. A small volume of blood (0.5 μL-3 μL) is mixed with antibody-coated blue latex beads in a tube and applied to the strip. Strips are then placed in a well of running buffer and allowed to run for 10 minutes. Laboratory evaluation with samples containing different proportions of hemoglobin A (HbA) and hemoglobin S (HbS) indicated that the test should enable identification of SCA patients but not persons with sickle cell trait (SCT). We evaluated the test using 41 samples from individuals with SCA, SCT, and normal blood. With visual inspection or quantitative analysis, we found a 98% accuracy when differentiating SCA from normal and SCT samples as a group (90% sensitivity and 100% specificity for identifying SCA). This work demonstrates important steps towards making a lateral flow test for hemoglobinopathies more appropriate for point-of-care use; further work is needed before the test is appropriate for clinical use.

Half of all pregnancies at risk of malaria worldwide occur in the Asia–Pacific region, where Plasmodium falciparum and Plasmodium vivax co-exist. Despite substantial reductions in transmission, malaria remains an important cause of adverse health outcomes for mothers and offspring, including pre-eclampsia. Malaria transmission is heterogeneous, and infections are commonly subpatent and asymptomatic. High-grade antimalarial resistance poses a formidable challenge to malaria control in pregnancy in the region. Intermittent preventive treatment in pregnancy
reduces infection risk in meso-endemic New Guinea, whereas screen-and-treat strategies will require more sensitive point-of-care tests to control malaria in pregnancy. In the first trimester, artemether–lumefantrine is approved, and safety data are accumulating for other artemisinin-based combinations. Safety of novel antimalarials to treat artemisinin-resistant P. falciparum during pregnancy, and of 8-aminoquinolines during lactation, needs to be established. A more systematic approach to the prevention of malaria in pregnancy in the Asia-Pacific is required.

Many low-income countries continue to have high fertility levels and unmet need for family planning (FP) despite progress in increasing access to modern contraceptive methods and in reducing the total fertility rate (TFR). Health facilities in sub-Saharan Africa (SSA) and South Asia (SA) are thought to be unable to adequately deal with the burden of high unmet FP demands due to their weaker health systems. As a result, determining the readiness of health facilities that offer FP services is critical for identifying weaknesses and opportunities for continued development of FP health systems in those regions. Service Provision Assessment (SPA) tools-which break down health systems into measurable, trackable components-are one useful way to assess service readiness and the ability of health institutions to deliver FP services. Using data from nationally representative SPA surveys, we conducted a study that aimed to: (1) evaluate healthcare facilities' readiness to provide FP services; and (2) identify the factors that affect FP service readiness. Using a cross-sectional survey design, we used data from SPA surveys conducted in 10 low-resource SA and SSA countries: Afghanistan,

Public-Private Partnerships (PPPs) are increasingly recognized as vital mechanisms for improving healthcare supply chains in low-resource settings. These partnerships bring together the strengths of the public sector—such as policy oversight and equity goals—with the private sector’s efficiency, innovation, and logistical expertise. Healthcare supply chains in many low- and middle-income countries suffer from persistent challenges including inadequate infrastructure, fragmented delivery systems, funding shortfalls, and limited accountability. Through a structured literature review, this paper explores how PPPs can be leveraged to address these issues, with a focus on vaccine logistics and last-mile delivery. The paper discusses conceptual frameworks underpinning PPP models, identifies key operational strategies, and highlights examples from Nigeria, India, Kenya, Rwanda, and Senegal. These cases illustrate the impact of service contracts, digital tracking platforms, drone delivery systems, and informed push models in enhancing logistics performance. In addition to presenting the benefits of PPPs—including improved efficiency, accountability, and innovation—the paper also explores significant challenges such as regulatory gaps, donor dependency, and power asymmetries. Policy recommendations include the establishment of enabling legal frameworks, sustainable financing, stakeholder engagement, and robust monitoring systems. Overall, the findings support a strategic and evidence-based approach to PPPs as a pathway for strengthening healthcare logistics, particularly in environments constrained by resources and capacity limitations.

AimsSince its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19.Methods and resultsA narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19.ConclusionThis comprehensive review is not a formal guideline but rather a ...

The stepped care model (SCM) is a healthcare approach in which patients and providers collaborate to select interventions and adjust the level of care over time based on outcomes. The approach is widely used in primary healthcare and becoming increasingly prevalent in busy mental health settings such as community clinics and university counseling centers. This manuscript provides a brief overview of SCM, its utility in counseling, and some core features of the approach including an emphasis on client readiness for change, common factors in counseling outcomes, an integrative or eclectic approach to treatment, and a transdiagnostic understanding of mental health disorders. Two case examples are presented to illustrate the utility of SCM in one setting.

Generative transformer-based models have reached cutting-edge performance in long document summarization. Nevertheless, this task is witnessing a paradigm shift in developing ever-increasingly computationally-hungry solutions, focusing on effectiveness while ignoring the economic, environmental, and social costs of yielding such results. Accordingly, such extensive resources impact climate change and raise barriers to small and medium organizations distinguished by low-resource regimes of hardware and data. As a result, this unsustainable trend has lifted many concerns in the community, which directs the primary efforts on the proposal of tools to monitor models&#39; energy costs. Despite their importance, no evaluation measure considering models&#39; eco-sustainability exists yet. In this work, we propose Carburacy, the first carbon-aware accuracy measure that captures both model effectiveness and eco-sustainability. We perform a comprehensive benchmark for long document summarizat...

Super-resolution (SR) techniques present a suitable solution to increase the image resolution acquired using an ultrasound device characterized by a low image resolution. This can be particularly beneficial in low-resource imaging settings. This work surveys advanced SR techniques applied to enhance the resolution and quality of fetal ultrasound images, focusing Dual back-projection based internal learning (DBPISR) technique, which utilizes internal learning for blind super-resolution, as opposed to blind super-resolution generative adversarial network (BSRGAN), real-world enhanced super-resolution generative adversarial network (Real-ESRGAN), swin transformer for image restoration (SwinIR) and SwinIR-Large. The dual back-projection approach enhances SR by iteratively refining downscaling and super-resolution processes through a dual network training method, achieving high accuracy in kernel estimation and image reconstruction. Real-ESRGAN uses synthetic data to simulate complex real-world degradations, incorporating a U-shaped network (U-Net) discriminator to improve training stability and visual performance. BSRGAN addresses the limitations of traditional degradation models by introducing a realistic and comprehensive degradation process involving blur, downsampling, and noise, leading to superior real-world SR performance. Swin models (SwinIR and SwinIR_large) employ a Swin Transformer architecture for image restoration, excelling in capturing long-range dependencies and complex structures, resulting in an outstanding performance in PSNR, SSIM, NIQE, and BRISQUE metrics. The tested images, sourced from five developing countries and often of lower quality, enabled us to show that these approaches can help enhance the quality of the images. Evaluations on fetal ultrasound images reveal that these methods significantly enhance image quality, with DBPISR, Real-ESRGAN, BSRGAN, SwinIR, and SwinIR-Large showing notable improvements in PSNR and SSIM, thereby highlighting their potential for improving the resolution and diagnostic utility of fetal ultrasound images. We evaluated the five aforementioned Super-Resolution models, analyzing their impact on both image quality and classification tasks. Our findings indicate that these techniques hold great potential for enhancing the evaluation of medical images, particularly in development countries. Among the models tested, Real-ESRGAN consistently enhanced both image quality and diagnostic accuracy, even when challenged by limited and variable datasets. This finding was further supported by deploying the ConvNext-base classifier, which demonstrated improved performance when applied to the super-resolved images. Real-ESRGAN's capacity to enhance image quality, and in turn, classification accuracy, highlights its potential to address the resource constraints often encountered in these settings.

Purpose Food insecurity has been linked with maternal depression in low-income settings. Few studies have looked at factors associated with both food insecurity and maternal depression as outcomes. This study aimed to assess factors associated with food insecurity and depression in a sample of pregnant South African women. Methods We conducted a cross-sectional study at a Midwife Obstetric Unit in a low-income suburb in Cape Town. Pregnant women attending the clinic for their first antenatal visit were invited to participate. The shortened form of the US Household Food Security Survey Module was used to measure food insecurity. The Expanded Mini-International Neuropsychiatric Interview was used to diagnose depression, anxiety, alcohol and drug dependence, and assess for suicidal ideation and behaviour. Logistic regression modelling was conducted to explore factors associated with food insecurity and depression in separate models. We found that 42% of households were food insecure and that 21% of participants were depressed (N = 376). The odds of being food insecure were increased in women with suicidal behaviour (OR = 5.34; 95% CI 1.26-22.57), with depression (4.27; 1.43-12.70) and in those with three or more children (3.79; 1.25-11.55). The odds of depression was greater in women who were food insecure (5.30; 1.63-17.30), substance dependent (15.83; 1.31-191.48) or diagnosed with an anxiety disorder (5.04; 1.71-14.82). Conclusions Food insecurity and depression are strongly associated in pregnant women. The relationship between food insecurity and depression is complex and requires further investigation. Interventions that improve both food security and mental health during the perinatal period are likely to benefit the physical and mental well-being of mothers and children.

Purpose Food insecurity has been linked with maternal depression in low-income settings. Few studies have looked at factors associated with both food insecurity and maternal depression as outcomes. This study aimed to assess factors associated with food insecurity and depression in a sample of pregnant South African women. Methods We conducted a cross-sectional study at a Midwife Obstetric Unit in a low-income suburb in Cape Town. Pregnant women attending the clinic for their first antenatal visit were invited to participate. The shortened form of the US Household Food Security Survey Module was used to measure food insecurity. The Expanded Mini-International Neuropsychiatric Interview was used to diagnose depression, anxiety, alcohol and drug dependence, and assess for suicidal ideation and behaviour. Logistic regression modelling was conducted to explore factors associated with food insecurity and depression in separate models. We found that 42% of households were food insecure and that 21% of participants were depressed (N = 376). The odds of being food insecure were increased in women with suicidal behaviour (OR = 5.34; 95% CI 1.26-22.57), with depression (4.27; 1.43-12.70) and in those with three or more children (3.79; 1.25-11.55). The odds of depression was greater in women who were food insecure (5.30; 1.63-17.30), substance dependent (15.83; 1.31-191.48) or diagnosed with an anxiety disorder (5.04; 1.71-14.82). Conclusions Food insecurity and depression are strongly associated in pregnant women. The relationship between food insecurity and depression is complex and requires further investigation. Interventions that improve both food security and mental health during the perinatal period are likely to benefit the physical and mental well-being of mothers and children.

Health disparities in low-resource settings persist as a critical challenge, amplifying inequalities in access to healthcare services. Innovative financial mechanisms, including microfinance initiatives, health insurance schemes tailored for impoverished communities, and social impact bonds, have been proposed as effective strategies to mitigate these disparities. This paper explores the role of these mechanisms in reducing health inequities through a concise literature review and empirical analysis. We present evidence from successful case studies and a comparative analysis of different financial models, highlighting their impact on health outcomes in underserved populations. The findings suggest that while these financial tools show promise, their success largely depends on local governance and socioeconomic conditions. The paper concludes with policy recommendations and identifies areas for future research to optimize the impact of these financial innovations.

Arousal status of patient in correlation with anaesthetic effect is the vital consideration for an anaesthesiologist. Recent anaesthesia has proposed hi-tech solutions to deal with it. This review throws a light on practical and realistic approaches prior equipping the O.T. with sophisticated depth of anaesthesia monitors. This review includes information from literature on health technology assessment, Bi-spectral Index (BIS) and anaesthesia’s current practice. It also portrays Indian and UK anaesthesiologist’s perspectives on deployment of BIS and other similar modalities .It is expected that this article will help to save significant amount of overuse of healthcare resources in low resource settings by providing insight on ethical and economical aspects on use of such technology.

For a clinical study in the European research network on better diagnosis for neglected infectious diseases (NIDIAG) project (Better Diagnosis of Neglected Infectious Diseases: www. nidiag.org), we developed Standard Operating Procedures (SOPs), which we implemented in a basically equipped laboratory in a 380-bed rural hospital ("Hôpital Général de Référence Mosango") in the Kwilu province in the Democratic Republic of the Congo (DRC). The study aimed to improve the early diagnosis of severe and treatable infections among patients with neurological disorders and took place over a 20-month period (14/09/2012-24/05/2014) (Clin-icalTrials.gov Identifier: NCT01589289). The set of 50 SOPs (S1 Appendix), all in French, include procedures related to the inclusion and clinical management of patients with neurological disorders (n = 4), diagnostic testing (n = 33), data collection and management (n = 5), and quality assurance (n = 8). In this symposium paper, we (i) review current standards and guidelines about writing and implementing laboratory SOPs, (ii) discuss best practices for writing and implementing laboratory SOPs in low-resource settings, and (iii) share some lessons learned in the NIDIAG study in the DRC. This paper targets clinical investigators of Neglected Tropical Diseases (NTDs), but also laboratory managers involved in routine patient care and policy makers developing national laboratory regulations in low-resource settings. Why are SOPs important? SOPs are written step-by-step instructions on how to carry out procedures correctly. SOPs are meant to ensure consistency, accuracy, and quality of data [1]. SOPs harmonize laboratory practices, reduce user errors, and can be used as training tools. Moreover, they help ensure compliance to the study protocol, regulations, and international standards. SOPs are the main building blocks of a laboratory quality assurance framework and are, as such, embedded in the

Background People with HIV-1 (PWH) exhibit a high fall incidence and increased fracture risk. As little is known about fall frequency and associated factors in PWH residing in lower-middle-income countries (LMIC), we investigated fall frequency, bone quality, and factors associated with fall history in a South African cohort. Methods Fifty PWH without obvious predisposing factors for mobility impairments attending 2 public primary care clinics in the Western Cape region participated. Demographic, clinical, and physical performance data were collected. Falls were assessed retrospectively over 12 months. Mobility and balance were evaluated using a physical performance battery. Bone mineral density was screened using quantitative ultrasound (QUS). Associations between variables and falls grouping were analyzed using chi-square tests, t tests, and Mann-Whitney U tests, and effect sizes (ES) were calculated. Results Thirty-four percent of PWH (median age, 36.6 years) reported falling dur...

Self-regulation is developed early in life through family and parenting interactions. There has been considerable debate on how to best conceptualize and enhance self-regulation. Many consider self-regulation as the socio-emotional competencies required for healthy and productive living, including the flexibility to regulate emotions, control anger, maintain calm under pressure, and respond adaptively to a variety of situations. Its enhancement is the focus of many child and family interventions. An important limitation of the self-regulation field is that most empirical and conceptual research comes from high-income countries (HICs). Less is known about the manifestation, measurement and role of self-regulation in many collectivistic, rural, or less-developed contexts such as low-and middle-income countries (LMICs). This position paper aims to present an initial review of the existing literature on self-regulation in LMICs, with a focus on parenting, and to describe challenges in terms of measurement and implementation of self-regulation components into existing interventions for parents, children and adolescents in these settings. We conclude by establishing steps or recommendations for conducting basic research to understand how self-regulation expresses itself in vulnerable and low-resource settings and for incorporating components of self-regulation into services in LMICs.

Generative transformer-based models have reached cutting-edge performance in long document summarization. Nevertheless, this task is witnessing a paradigm shift in developing ever-increasingly computationally-hungry solutions, focusing on effectiveness while ignoring the economic, environmental, and social costs of yielding such results. Accordingly, such extensive resources impact climate change and raise barriers to small and medium organizations distinguished by low-resource regimes of hardware and data. As a result, this unsustainable trend has lifted many concerns in the community, which directs the primary efforts on the proposal of tools to monitor models&#39; energy costs. Despite their importance, no evaluation measure considering models&#39; eco-sustainability exists yet. In this work, we propose Carburacy, the first carbon-aware accuracy measure that captures both model effectiveness and eco-sustainability. We perform a comprehensive benchmark for long document summarizat...

BackgroundInternational thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources.MethodsThyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined.ResultsUsing the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines.ConclusionsSuccessful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenario...

BackgroundInternational thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources.MethodsThyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined.ResultsUsing the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines.ConclusionsSuccessful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenario...

The Ebola virus (EBOV) causes a highly virulent and deadly disease. The 2014 Ebola outbreak in West Africa was the largest in history. The rapid spread highlighted the need for a quick and accurate diagnostic method that can be employed in resource-limited conditions. In this study, we developed a probe that can be used as an internal positive control, coupled with a reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay to accurately detect EBOV. This RT-LAMP assay is a simple one-step reaction performed at a constant temperature, and the results can be visualized by a colorimetric change from violet to sky blue. Our assay enabled detection of 10 copies of synthetic EBOV RNA within 1 hour. Compared to traditional RT-qPCR, RT-LAMP requires no sophisticated equipment, the results are easier to interpret, and they can be obtained in less time. These features make RT-LAMP an ideal method for detection of EBOV in low-resource settings.

In performing the calibration of the sphygmomanometer, the officer needs to first reset the installation and pump the bulb slowly until it reaches the set point in accordance with the calibration settings where this does not provide convenience to the calibration officer. So the author wants to do research on making additional devices to support DPM calibration instruments that have been commercialized to speed up the pump process in Sphygmomanometer calibration. The purpose of this research is to make an Automatic Pump module with PID control to analyze the stability of the pressure achievement in accordance with the set point when using the smoothing program or not. This study used set points of 50, 100, 150, 200, and 250 mmHg. Data retrieval was carried out within 260 seconds at each set point at the Campus of the Department of Electrical Engineering Poltekkes Kemenkes Surabaya. The results of this study indicate that the tool testing using the smoothing program experienced small...

Single-visit “screen-and-treat” strategies using visual inspection with acetic acid (VIA) and cryotherapy (liquid nitrous oxide ablation) in low-resource settings are commonly used to detect and treat precancerous lesions for cervical cancer prevention. This study compared VIA sensitivity and specificity in rural indigenous Guatemalan communities, to that of oncogenic human papillomavirus (HPV) testing for detection of precancerous changes, using cytology as the reference standard. Between 3–8 September 2017, trained nurses examined 222 women aged 23–58 years with VIA. Specimens for liquid-based cytology and HPV testing were obtained prior to VIA with a cytobrush and transported in PreservCyt to a US clinical laboratory. VIA and HPV test sensitivities were assessed as proportions of women with abnormal cytology that had abnormal VIA or HPV results, respectively, and specificities, as proportions with normal cytology with normal VIA or negative HPV tests. Of 222 women, 18 (8.1%) had ...

There is great global disparity in the outcome of infants born with gastroschisis. Mortality approaches 100% in many low income countries. Barriers to better outcomes include lack of antenatal diagnosis, deficient pre-hospital care, ineffective neonatal resuscitation and venous access, limited intensive care facilities, poor access to the operating theatre and safe neonatal anesthesia, and lack of neonatal parenteral nutrition. However, lessons can be learned from the evolution in management of gastroschisis in high-income countries, generic efforts to improve neonatal survival in low- and middle-income countries as well as specific gastroschisis management initiatives in low-resource settings. Micro and meso-level interventions include educational outreach programs, and pre and in hospital management protocols that focus on resuscitation and include the delay or avoidance of early neonatal anesthesia by using a preformed silo or equivalent. Furthermore, multidisciplinary team training, nurse empowerment, and the intentional involvement of mothers in monitoring and care provision may contribute to improving survival. Macro level interventions include the incorporation of ultrasound into World Health Organisation antenatal care guidelines to improve antenatal detection and the establishment of the infrastructure to enable parenteral nutrition provision for neonates in low- and middle-income countries. On a global level, gastroschisis has been suggested as a bellwether condition for evaluating access to and outcomes of neonatal surgical care provision.

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, servic...

In Bangladesh, female paramedics known as Family Welfare Visitors (FWVs), conduct normal deliveries in first-level primary care facilities, or Union Health and Family Welfare Centres (UH&FWC). Utilization of partographs allow for early identification of abnormal labour and referral for advanced care to Emergency Obstetric Care (EmOC) facilities. A systematic assessment of the quality of partograph utilization in clinical-decision making will contribute to understanding the use of the tool by health workers. In 2013, the USAID supported MaMoni HSS project, led in country by Save the Children, trained FWVs on the use of partographs in five UH&FWCs in Habiganj district. As part of the follow-up after training, intrapartum case record forms, accompanying partographs, and referral registers for all obstetric cases managed in these five facilities from July 2013 to June 2014 were reviewed. Partographs were reviewed to identify abnormal labour cases based on pre-defined indications. All re...

The enforced rapid transition to online/distance education in 2020 created immeasurable disruption both for the faculty and students in HE contexts. The present study discusses whether an opportunity is born out of a globally experienced challenge for university instructors and students to develop new and transformative roles. The data for the present study were collected during the third term of distance education through a survey conducted with 112 students and 9 faculty members and semi-structured interviews with a convenient sampling of students and faculty members of an English department in Istanbul, Turkey. The findings indicated that online education enabled students to become more active and self-directed learners and faculty members to develop newer roles and strategies as course designers and mentors. The findings revealed an in-depth understanding of the experience and yielded implications for the viability of applications of distance/online/blended modes of learning and teaching.

Background Current guidelines recommend the use of the lateral flow urine lipoarabinomannan assay (LAM) in HIV-positive, ambulatory patients with signs and symptoms of tuberculosis (TB) only if they are seriously ill or have CD4 count � 100 cells/μl. We assessed the diagnostic yield of including LAM in TB diagnostic algorithms in HIV-positive, ambulatory patients with CD4 < 200 cells/μl, as well as the risk of mortality in LAM-positive patients who were not diagnosed using other diagnostic tools and not treated for TB.

Background: In India, 3.6 million pregnancies are affected by preterm birth annually, with many infants dying or surviving with disability. Currently, there is no simple test available for screening all women at risk of spontaneous PTB in low income setting, although high resource settings routinely use cervical length measurement and cervicovaginal fluid fetal fibronectin for identification and care of women at risk due to clinical history. In rural India, where the public health system has limited infrastructure, trained staff and equipment, there is a greater need to develop a low-cost screening approach for providing early referral, treatment and remedial support for pregnant women at risk of preterm birth. There is interest in the use of a salivary progesterone test as a screening tool preliminary evidence from India, Egypt and UK has shown promise for this type of test. The test requires further validation in a low resource community setting. Methods: The Promises study aims to validate and test the feasibility of introducing a low-cost salivary progesterone preterm birth prediction test in two rural districts in India with high rates of prematurity. It is a prospective study of 2000 pregnant women recruited from Panna and Satna in Madhya Pradesh over approximately 24 months. Demographic and pregnancy outcome data will be collected, and pregnancies will be dated by ultrasound sonography. Saliva progesterone will be measured by ELISA in samples obtained between 24-28 weeks of gestation. The association between salivary progesterone and preterm birth will be determined and the utility of salivary progesterone to predict preterm birth < 34, as well as < 30 and < 37 weeks assessed. Additional qualitative data will be obtained in terms of acceptability and feasibility of saliva progesterone testing and knowledge of PTB. Discussion: A validated cost-effective saliva test, which has potential for further adaptation to a 'point of care' setting will allow early identification of pregnant women at risk of preterm birth, who can be linked to an effective pathway of care and support to reduce preterm birth and associated adverse consequences. This will reduce both economic and emotional burden on the affected women and their families.

Generative transformer-based models have reached cuttingedge performance in long document summarization. Nevertheless, this task is witnessing a paradigm shift in developing ever-increasingly computationally-hungry solutions, focusing on effectiveness while ignoring the economic, environmental, and social costs of yielding such results. Accordingly, such extensive resources impact climate change and raise barriers to small and medium organizations distinguished by low-resource regimes of hardware and data. As a result, this unsustainable trend has lifted many concerns in the community, which directs the primary efforts on the proposal of tools to monitor models' energy costs. Despite their importance, no evaluation measure considering models' eco-sustainability exists yet. In this work, we propose Carburacy, the first carbon-aware accuracy measure that captures both model effectiveness and eco-sustainability. We perform a comprehensive benchmark for long document summarization, comparing multiple state-of-the-art quadratic and linear transformers on several datasets under eco-sustainable regimes. Finally, thanks to Carburacy, we found optimal combinations of hyperparameters that let models be competitive in effectiveness with significantly lower costs.

Based on clinical presentation, pathophysiology, high infectivity, high cardiovascular involvement, and therapeutic agents with cardiovascular toxicity of coronavirus disease 2019 (COVID-19), regular cardiovascular treatment is being changing greatly. Despite angiotensin-converting enzyme 2 serving as the portal for infection, the continuation of clinically indicated renin-angiotensin-aldosterone blockers is recommended according to the present evidence. Fibrinolytic therapy can be considered a reasonable option for the relatively stable ST segment elevation myocardial infarction (STEMI) patient with suspected or known COVID-19. However, primary percutaneous coronary intervention is still the standard of care in patients with definite STEMI if personal protective equipment is available and cardiac catheterization laboratory has a good infection control. In patients with elevated cardiac enzymes, it is very important to differentiate patients with Type 2 myocardial infarction or myocarditis from those with true acute coronary syndromes because invasive percutaneous intervention management in the former may be unnecessary, especially if they are hemodynamically stable. Finally, patients with baseline QT prolongation or those taking QT prolonging drugs must be cautious when treating with lopinavir/ritonavir and hydroxychloroquine for COVID-19.

Background: A timely differential diagnostic is essential to identify the etiology of central nervous system (CNS) infections in children, in order to facilitate targeted treatment, manage patients, and improve clinical outcome. Objective: The Pediatric Infection-Point-of-Care (PI-POC) trial is investigating novel methods to improve and strengthen the differential diagnostics of suspected childhood CNS infections in low-income health systems such as those in Southwestern Uganda. This will be achieved by evaluating (1) a novel DNA-based diagnostic assay for CNS infections, (2) a commercially available multiplex PCR-based meningitis/encephalitis (ME) panel for clinical use in a facility-limited laboratory setting, (3) proteomics profiling of blood from children with severe CNS infection as compared to outpatient controls with fever yet not severely ill, and (4) Myxovirus resistance protein A (MxA) as a biomarker in blood for viral CNS infection. Further changes in the etiology of childhood CNS infections after the introduction of the pneumococcal conjugate vaccine against Streptococcus pneumoniae will be investigated. In addition, the carriage and invasive rate of Neisseria meningitidis will be recorded and serotyped, and the expression of its major virulence factor (polysaccharide capsule) will be investigated. Methods: The PI-POC trial is a prospective observational study of children including newborns up to 12 years of age with clinical features of CNS infection, and age-/sex-matched outpatient controls with fever yet not severely ill. Participants are recruited at 2 Pediatric clinics in Mbarara, Uganda. Cerebrospinal fluid (for cases only), blood, and nasopharyngeal (NP) swabs (for both cases and controls) sampled at both clinics are analyzed at the Epicentre Research Laboratory through gold-standard methods for CNS infection diagnosis (microscopy, biochemistry, and culture) and a commercially available ME panel for multiplex

Background: Although research continues to support task-shifting as an effective model of delivering evidence-based practices (EBPs), little scholarship has focused how to scale up and sustain task-shifting in low- and middle-income countries, including how to sustainably supervise lay counselors. Ongoing supervision is critical to ensure EBPs are delivered with fidelity; however, the resources and expertise required to provide ongoing supervision may limit the potential to scale up and sustain task shifting. Opportunities may exist to leverage mobile technology to replace or supplement in-person supervision in low-resource contexts, but contextual variables, such as network connectivity and lay counselor preferences surrounding mobile technology, must be examined and considered when designing and implementing mobile technology supervision.Methods: This study builds from an existing randomized trial in Kenya, wherein teachers and community health volunteers have been trained to prov...

Background Many low-income countries continue to have high fertility levels and unmet need for family planning (FP) despite progress in increasing access to modern contraceptive methods and in reducing the total fertility rate (TFR). Health facilities in sub-Saharan Africa (SSA) and South Asia (SA) are thought to be unable to adequately deal with the burden of high unmet FP demands due to their weaker health systems. As a result, determining the readiness of health facilities that offer FP services is critical for identifying weaknesses and opportunities for continued development of FP health systems in those regions. Service Provision Assessment (SPA) tools-which break down health systems into measurable, trackable components-are one useful way to assess service readiness and the ability of health institutions to deliver FP services. Methods Using data from nationally representative SPA surveys, we conducted a study that aimed to: (1) evaluate healthcare facilities' readiness to provide FP services; and (2) identify the factors that affect FP service readiness. Using a cross-sectional survey design, we used data from SPA surveys conducted in 10 low-resource SA and SSA countries: Afghanistan,

The coronavirus disease 2019 (COVID-19) pandemic has affected educational institutions and instructors in an unprecedented way. The majority of educational establishments were forced to take their courses online within a very short period of time, and both instructors and students had to learn to navigate the digital array of courses without much training. Our study examined factors that affect students’ attitude toward online teaching and learning during the COVID-19 pandemic. It is different from other online learning studies where online courses are mostly a method of choice, with suitable support from institutions and expectation from instructors and students, rather than a contingency. Under this specific environment, we utilized an online survey to collect students’ feedback from eleven universities across Hong Kong. Using partial least squares for analysis on the 400 valid samples we received, we found that peer interactions and course design have the most salient impact on s...

Background This study examined the prevalence and factors associated with detectable viremia, as well as clinical outcomes among People with HIV (PWH) receiving antiretroviral therapy (ART) who initially achieved viral suppression in two southern states in Nigeria. Methods The retrospective cohort study used data from the electronic medical records from 96 comprehensive ART centers. PWH who achieved viral suppression [VL ≤50 copies/mL] upon starting ART based on the 1st VL test were followed up. We examined the presence of detectable viremia in follow up VL results – graded based on the absolute VL count from the 2nd and 3rd consecutive VL test into transient viremia (2nd follow-up VL: 51-999copies/ml; 3rd follow-up VL result: ≤50copies/ml), persistent viremia (2nd follow-up VL either 51-999copies/ml or ≥1000cpm copies/ml; 3rd follow up VL result &gt;50 copies/ml), and virologic failure (2nd and 3rd follow up VL results &gt;1000 copies/ml). We analysed for demographic and clinical f...

Background The majority of the five million perinatal deaths worldwide take place in low-resource settings. In contrast to high-resource settings, almost 50% of stillbirths occur intrapartum. The aim of this study was to synthesise available evidence of strategies for foetal surveillance in low-resource settings and associated neonatal and maternal outcomes, including barriers to their implementation. Methods and findings The review was registered with Prospero (CRD42016038679). Five databases were searched up to May 1 st, 2016 for studies related to intrapartum foetal monitoring strategies and neonatal outcomes in low-resource settings. Two authors extracted data and assessed the risk of bias for each study. The outcomes were narratively synthesised. Strengths, weaknesses, opportunities and threats analysis (SWOT) was conducted for each monitoring technique to analyse their implementation. There were 37 studies included: five intervention and 32 observational studies. Use of the partograph improved perinatal outcomes. Intermittent auscultation with Pinard was associated with lowest rates of caesarean sections (10-15%) but with comparable perinatal outcomes to hand-held Doppler and Cardiotocography (CTG). CTG was associated with the highest rates of caesarean sections (28-34%) without proven benefits for perinatal outcome. Several tests on admission (admission tests) and adjunctive tests including foetal stimulation tests improved the accuracy of foetal heart rate monitoring in predicting adverse perinatal outcomes.

Objective: To determine acceptable and achievable strategies of intrapartum fetal monitoring in busy low-resource settings. Methods: Three rounds of online Delphi surveys were conducted between January 1 and October 31, 2017. International experts with experience in low-resource settings scored the importance of intrapartum fetal monitoring methods. Results: 71 experts completed all three rounds (28 midwives, 43 obstetricians). Consensus was reached on (1) need for an admission test, (2) handheld Doppler for intrapartum fetal monitoring, (3) intermittent auscultation (IA) every 30 minutes for low-risk pregnancies during the first stage of labor and after every contraction for high-risk pregnancies in the second stage, (4) contraction monitoring hourly for lowrisk pregnancies in the first stage, and (5) adjunctive tests. Consensus was not reached on frequency of IA or contraction monitoring for high-risk women in the first stage or low-risk women in the second stage of labor. Conclusion: There is a gap between international recommendations and what is physically possible in many labor wards in low-resource settings. Research on how to effectively implement the consensus on fetal assessment at admission and use of handheld Doppler during labor and delivery is crucial to support staff in achieving the best possible care in low-resource settings.

Background The majority of the five million perinatal deaths worldwide take place in low-resource settings. In contrast to high-resource settings, almost 50% of stillbirths occur intrapartum. The aim of this study was to synthesise available evidence of strategies for foetal surveillance in low-resource settings and associated neonatal and maternal outcomes, including barriers to their implementation. Methods and findings The review was registered with Prospero (CRD42016038679). Five databases were searched up to May 1 st, 2016 for studies related to intrapartum foetal monitoring strategies and neonatal outcomes in low-resource settings. Two authors extracted data and assessed the risk of bias for each study. The outcomes were narratively synthesised. Strengths, weaknesses, opportunities and threats analysis (SWOT) was conducted for each monitoring technique to analyse their implementation. There were 37 studies included: five intervention and 32 observational studies. Use of the partograph improved perinatal outcomes. Intermittent auscultation with Pinard was associated with lowest rates of caesarean sections (10-15%) but with comparable perinatal outcomes to hand-held Doppler and Cardiotocography (CTG). CTG was associated with the highest rates of caesarean sections (28-34%) without proven benefits for perinatal outcome. Several tests on admission (admission tests) and adjunctive tests including foetal stimulation tests improved the accuracy of foetal heart rate monitoring in predicting adverse perinatal outcomes.

Background The current COVID-19 pandemic is affecting all aspects of society worldwide. To combat the pandemic, measures such as face mask–wearing, hand-washing and -sanitizing, movement restrictions, and social distancing have been introduced. These measures have significantly disrupted education, particularly health professions education, which depends on student-patient contact for the development of clinical competence. The wide-ranging consequences of the pandemic are immense, and health professions education institutions in sub-Saharan Africa have not been spared. Objective This paper describes a protocol for assessing the preparedness of selected health professions education institutions in sub-Saharan Africa for remote teaching and learning during the COVID-19 pandemic. Methods A mixed-methods design with a case study approach will be used. The awareness, desire, knowledge, ability, and reinforcement model of change was selected as the conceptual framework to guide the study...

For a clinical study in the European research network on better diagnosis for neglected infectious diseases (NIDIAG) project (Better Diagnosis of Neglected Infectious Diseases: www. nidiag.org), we developed Standard Operating Procedures (SOPs), which we implemented in a basically equipped laboratory in a 380-bed rural hospital ("Hôpital Général de Référence Mosango") in the Kwilu province in the Democratic Republic of the Congo (DRC). The study aimed to improve the early diagnosis of severe and treatable infections among patients with neurological disorders and took place over a 20-month period (14/09/2012-24/05/2014) (Clin-icalTrials.gov Identifier: NCT01589289). The set of 50 SOPs (S1 Appendix), all in French, include procedures related to the inclusion and clinical management of patients with neurological disorders (n = 4), diagnostic testing (n = 33), data collection and management (n = 5), and quality assurance (n = 8). In this symposium paper, we (i) review current standards and guidelines about writing and implementing laboratory SOPs, (ii) discuss best practices for writing and implementing laboratory SOPs in low-resource settings, and (iii) share some lessons learned in the NIDIAG study in the DRC. This paper targets clinical investigators of Neglected Tropical Diseases (NTDs), but also laboratory managers involved in routine patient care and policy makers developing national laboratory regulations in low-resource settings. Why are SOPs important? SOPs are written step-by-step instructions on how to carry out procedures correctly. SOPs are meant to ensure consistency, accuracy, and quality of data [1]. SOPs harmonize laboratory practices, reduce user errors, and can be used as training tools. Moreover, they help ensure compliance to the study protocol, regulations, and international standards. SOPs are the main building blocks of a laboratory quality assurance framework and are, as such, embedded in the

Background: Using Doppler to improve detection of intrapartum fetal heart rate (FHR) abnormalities coupled with appropriate, timely intrapartum care in low-and middleincome countries (LMIC) can save lives. Objective: To review studies using Doppler to improve detection of intrapartum FHR abnormalities and intrapartum care quality in LMIC health facilities.

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, servic...

Background There is a dearth of information about “brain fog,” characterized by concentration, word-finding, or memory problems, which has been listed in the new World Health Organization provisional classification “U09.9 Post-COVID-19 Condition.” Moreover, the extent to which these symptoms may be associated with neurological, pulmonary, or psychiatric difficulties is unclear. Objective This ongoing cohort study aims to carefully assess neurocognitive function in the context of the neurological, psychiatric, and pulmonary sequelae of SARS-CoV-2 infection among patients with asymptomatic/mild and severe cases of COVID-19 after remission, including actively recruited healthy controls. Methods A total of 150 participants will be included in this pilot study. The cohort will comprise patients who tested positive for SARS-CoV-2 infection with either an asymptomatic course or a mild course defined as no symptoms except for olfactory and taste dysfunction (n=50), patients who tested posit...