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School feeding programs can support children's nutrition, health, and education in emergencies. This study assessed the feasibility, trade-offs, cost efficiency, and perceived benefits of school feeding modalities operating in urban Yemen. It draws on primary data from a qualitative evaluation with 21 school feeding implementers and 88 beneficiaries conducted in Feb-Mar 2023, and secondary data from a desk review of published and program literature on school feeding operations. Results showed that school feeding provided students with on average 18%, 40%, and 66% of daily energy, protein, and micronutrient requirements, respectively. Models including fortified snacks were 3-11 times more cost-efficient in terms of nutrient delivery. The most prominent strength of the models examined were the perceived benefits on child, family, and financial outcomes. Among the main weaknesses was the poor nutritional quality of the meal, which in turn emerged as a primary opportunity to improve school feeding through hybrid models providing a combination of fortified snacks and healthy meals. Other weaknesses such as poor water, sanitation, and hygiene infrastructure, and desired improvements such as the school kitchen and canteen, require considerable investments. Hybrid models are cost-efficient, acceptable, and feasible in Yemen and can serve the diet and nutrition needs of school-aged children.

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Not receiving a DPT-containing vaccine in early childhood indicates an absence of routine immunization, which puts children at an elevated risk of mortality, morbidity, and worse human development over the life course. We estimated the percentage of children 12-35 months who did not receive a dose of DPT-containing vaccine (termed zero-dose children) using household surveys from 81 low- and middle-income countries conducted between 2014 and 2023. For 68 countries with more than one survey (with the earlier survey conducted 2000-2013), we estimated the average annual percentage point change in prevalence of zero-dose children between the earliest and latest surveys. We also explored the association of zero-dose prevalence with postneonatal and child mortality, health expenditure, and Gavi-eligibility. Overall, 16% of children in our pooled sample had not received a dose of DPT-containing vaccine. There was a 0.8% point decline in zero-dose prevalence per year on average across the period studied. A single percentage point average annual decline in zero-dose prevalence was associated with an average annual decrease of 1.4 deaths in the postneonatal and childhood period per 1000 live births. Gavi-eligible countries had a much faster decline in zero-dose prevalence than other countries. Large gains have been made in reducing the percentage of children who did not receive a DPT-containing vaccine. Efforts to reduce the number of zero-dose children should focus on countries with high prevalence to achieve the Immunization Agenda 2030. Healthcare spending could be prioritized so that the prevalence of zero-dose children is reduced.

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Studies of the human microbiome are progressing rapidly but have largely focused on populations living in high-income countries. With increasing evidence that the microbiome contributes to the pathogenesis of diseases that affect infants, children, and adults in low- and middle-income countries (LMICs), and with profound and rapid ongoing changes occurring in our lifestyles and biosphere, understanding the origins of and developing microbiome-directed therapeutics for treating a number of global health challenges requires the development of programs for studying human microbial ecology in LMICs. Here, we discuss how the establishment of long-term human microbial observatory programs in selected LMICs could provide one timely approach.

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This article critically explores the complex realities faced by street-working children (SWC) in Latin America, highlighting historical and structural inequalities-such as coloniality, heteropatriarchy, and neoliberal capitalism-that perpetuate their marginalisation. Hegemonic public policies tend to focus narrowly on control, normalisation, and short-term relief, often neglecting the deeper systemic issues that sustain these vulnerabilities. This study calls for a shift towards alternative frameworks of public policy analysis that permit addressing the socio-political and cultural specificities of Latin America from a decolonial perspective. By incorporating affective, semiotic, and material dimensions, the Affective Interstice Theory provides analytical tools to understand how policy discourses not only shape the emotional and material experiences of those involved but also reinforce existing power structures. These insights reveal critical opportunities for resistance and transformative change, urging the development of policies that do more than address immediate needs-policies that actively dismantle the structural dynamics underpinning the marginalisation of SWC. The article underscores the need for contextualised approaches that engage with the complexity of local realities, offering a path towards more equitable and just policy outcomes across the region.

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OBJECTIVES: There is a large treatment gap for mental health conditions in sub-Saharan Africa where most patients who receive any care do so from lay primary health care workers (PHCW). We sought to examine the experiences of PHCW who provide care for older people with depression in Nigerian primary health care (PHC) settings. METHODS: Qualitative study design. A total of 24 PHCW participated. Using in-depth key informant interviews (KIIs), we explored the views of 15 PHCW selected from 10 rural and urban PHCs in South-Western Nigeria. An additional focus group discussion comprising nine participants was also conducted to discuss emerging themes from KIIs. Data were analysed using thematic analysis. RESULTS: Three overall themes were identified: views about depression, treatment options, and community outreach implications. Participants perceived depression in older people as being characterised by a range of mood, behavioural, and cognitive symptoms which made clinical assessments particularly challenging. Common treatment options used by PHCW included general advice and counselling, as well as frequent need to prescribe mild analgesics, vitamins and occasional sedatives in line with patients' expectations. Antidepressants were rarely used even though PHCW are authorised. While home visits are part of their expected work schedule, PHCW rarely implemented these due to non-availability of transport facilities. Mobile technology was identified as a possible way of overcoming this constraint to providing community based mental healthcare for older people. CONCLUSION: PHCWs perceived that patients' poor cognitive performance, expectations to prescribe sedatives, analgesics and vitamins, as well as non-existence of community-based services were existing barriers to providing evidenced based continued care for older people with depression in the study settings.

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BACKGROUND: Health systems responsiveness (HSR) is the ability of systems to respond to legitimate non-health expectations of the population. The concept of HSR by the World Health Organization (WHO) includes respect for dignity, individual autonomy, confidentiality, prompt attention to care, availability of basic amenities, choice of provider, access to social support networks, and clarity of communication. The WHO tool is applied globally to assess HSR in low, middle, and high-income countries. OBJECTIVE: We have revised the conceptual framework of HSR following a rigorous systematic review and made it specific for low- and middle-income countries (L&MICs). This study is designed to (1) run the Delphi technique to validate the upgraded conceptual framework of HSR, (2) modify and upgrade the WHO measurement tool for assessing HSR in the context of L&MICs, and (3) determine the validity of the upgraded HSR measurement tool by pilot testing it in Pakistan. METHODS: The Delphi technique will be run by inviting global public health experts to provide suggestions on the domains and subdomains of HSR specific to L&MICs. Cronbach ɑ will be calculated to determine internal consistency among the participants. The upgraded HSR conceptual framework will serve as a beacon to modify the measurement tool by the research team, which will be reviewed by subject experts for refinement. The modified tool will be pilot-tested by administering it to 1128 participants from primary, secondary, and tertiary care hospitals in Rawalpindi district, Pakistan. Additionally, an "observation checklist" of HSR domains and subdomains will be completed to objectively measure the state of HSR across health care facilities. HSR assessment will be further strengthened by incorporating the perspective of hospital managers, service providers, and policy makers (ie, the supply side) as well as community leaders and representatives (ie, the demand side) through qualitative interviews. RESULTS: The study was started in January 2024 and will continue until February 2025. A multidimensional approach will yield significant quantifiable information on HSR from the demand and supply sides of L&MICs. CONCLUSIONS: This study will provide a conceptual understanding of HSR and a corresponding measurement tool specific to L&MICs. It will contribute to global public health literature and provide a snapshot of HSR in Rawalpindi district, Pakistan, with concrete action points for policy makers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/59836.

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BACKGROUND: The importance of evidence-informed health policymaking is widely recognized. However, many low- and middle-income countries lack evidence-informed mental health policies due to insufficient data, stigma or lack of resources. Various policies address adolescent mental health in India, but published knowledge on their evidence-informed nature is limited. In this paper, we report results of our analysis of the role of evidence in adolescent mental health policymaking in India. METHODS: This paper reports findings from the document analysis of key policy documentation (n = 10) and in-depth interviews with policy actors including policymakers, researchers, practitioners and intermediaries (n = 13). Framework analysis was used, informed by the components of a conceptual framework adapted from the literature: actors, policy and evidence processes, nature of evidence itself and contextual influences. RESULTS: Results show that adolescent mental health policies in India were generally evidence-informed, with more key evidence becoming generally available from 2010 onwards. Both formal and informal evidence informed mental health policies, particularly agenda-setting and policy development. Mental health policymaking in India is deemed important yet relatively neglected due to competing policy priorities and structural barriers such as stigma. Use of evidence in mental health policymaking reflected differing values, interests, relative powers and ideologies of policy actors. Involvement of government officials in evidence generation often resulted in successful evidence uptake in policy decisions. Policy actors often favoured formal and quantitative evidence, with a tendency to accept global evidence that aligns with personal values. CONCLUSIONS: There is a need to ensure a balanced and complementary combination of formal and informal evidence for policy decisions. Evidence generation, dissemination and use for policy processes should recognize evidence preferences by key stakeholders, while prioritizing locally available evidence where possible. To help this, a balanced involvement of policy actors can ensure complementary perspectives in evidence production and policy agendas. This continued generation and promotion of evidence can also help reduce societal stigma around mental health and promote mental health as a key policy priority.

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Background and Objectives: Prior investigations have not considered whether poor vision biases cognitive testing. However, such research is vital given increasing evidence that vision impairment (VI) may be an important modifiable risk factor for dementia, particularly in low- and middle-income settings where the prevalence of VI is high. Research Design and Methods: This study employed data from 3 784 participants in Wave 1 of the Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (LASI-DAD) who underwent both visual acuity and cognitive function testing. We used multiple indicators and multiple causes models to assess differential item functioning (DIF; eg, bias) in cognitive testing by objectively measured distance and near VI. Multivariable linear regression was used to model the association between VI and cognitive factor scores before and after DIF adjustment. Analyses were performed for general cognition and separate cognitive domains, corresponding to memory, language/fluency, executive functioning, and visuospatial performance. Models were adjusted for demographic, health, and socioeconomic covariates. Results: Participants in our sample were 60 and older. Most participants with VI were 60-69 years old (59.6%) and 50.8% were female. Individuals experiencing both distance and near VI tended to be older, have lower educational attainment, be married, reside in rural settings, and belong to lower consumption and BMI categories. Both distance and near VI were associated with poorer cognition before and after DIF-adjustment. Differences between DIF-unadjusted and -adjusted scores were small compared to the standard error of measurement, indicating no evidence of meaningful measurement differences by VI. Discussion and Implications: In well-conducted large-scale surveys, bias in cognitive testing due to VI is likely minimal. Findings strengthen previous evidence on the association between VI and dementia by showing that such associations are unlikely to be attributable to vision-related measurement error in the assessment of cognitive functioning.

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Background: The significant increase in Alzheimer's disease and related dementia prevalence is a global health crisis, acutely impacting low- and lower-middle and upper-middle-income countries (LLMICs/UMICs). Objective: The objective of this study is to identify key barriers and gaps in dementia care and research in LLMICs and UMICs. Methods: We conducted an international, cross-sectional survey among clinicians and healthcare professionals (n = 249 in 34 countries) across LLMICs and UMICs, exploring patient demographics, use of clinical diagnosis, dementia evaluation, screening/evaluation tools, and care and treatment. Results: Significant disparities were found in diagnostic practices, access to assessments, and access to care. On average, clinicians in LLMICs saw more patients, had less time for evaluations, lower use of formal screening and tools, and less access to biomarkers. They were also under-resourced compared to UMICs. Conclusions: The findings provide insights for policymakers, healthcare organizations, and researchers to address the complex challenges associated with dementia care in diverse settings. Addressing these challenges requires a multipronged approach involving local, national, and international stakeholders.

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BACKGROUND: Tele-neurorehabilitation (TNR) allows for remote delivery of rehabilitation services for those with neurological disabilities. Despite growing global interest and uptake, its adoption remains challenging in Low-and-Middle-Income-Countries (LMICs). OBJECTIVE: To explore available literature on the nature of training and education, research and practice of TNR in LMICs. METHODS: Following PRISMA-ScR guidelines and predefined selection criteria, four databases were screened. Quality assessment was performed using the Joanna Briggs Institute tools. Relevant data was extracted to using a data extraction form in Microsoft Excel and were narratively synthesised under Education/training, Research and Clinical Practice of TNR. RESULTS: We identified no formal structured training courses/programs for TNR users/providers. Sessions were mainly delivered as part of a research project. The included studies highlighted the need to engage stakeholders in TNR research and improve digital-literacy among healthcare providers/users. Development and use of clinical decision-making-tools, models of TNR suitable for varied populations and prior area-mapping were a few suggestions for clinical/research practice. CONCLUSION: There is an immense need to develop academic/structured programs for TNR to build capacity among providers/users in LMICs. Practice must adhere to principles of safety, effectiveness, and based on high quality clinical-guidelines suitable to the context to ensure optimal uptake and practice of TNR in LMICs.

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INTRODUCTION: Chronic obstructive pulmonary disease (COPD) ranks among the top three global causes of death, with 90% of fatalities concentrated in low- and middle-income countries (LMICs). The projected rise in COPD burden, especially in LMICs, emphasizes the need to address the challenges for effective control and reversal of this trend. We aimed to provide an overview, and propose potential solutions to these challenges. AREAS COVERED: We highlight the challenges faced in managing COPD in LMICs and put forward the potential approaches to mitigate the same. EXPERT OPINION: In LMICs, the effective management of COPD encounters numerous barriers. These include limited access to critical diagnostic services, inadequately trained healthcare personnel, shortages of inhaler medications, oxygen therapy, insufficient access to vaccines, and pulmonary rehabilitation programs. Compounding the above challenges is the late presentation due to misdiagnosis by health workers, and limited access to vital diagnostics. Moreover, the pharmacological armamentarium for optimal COPD therapy, notably inhaled therapies, face constraints in both access and affordability. We propose multi-level and multifaceted interventions to address the urgent need for enhanced respiratory care, human resource capacity building, relevant diagnostic approaches, increased access to medications, government, regional and global efforts to achieve optimal COPD management in LMICs.

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INTRODUCTION: Preeclampsia can elevate the likelihood of unfavorable consequences for a mother, such as severe morbidity and mortality. World Health Organization recommends low dose acetylsalicylic acid (aspirin, 75 mg per day) for the prevention of preeclampsia in women at moderate or high risk of developing the condition. The use of low dose aspirin is dependent on the knowledge of health care providers working in the antenatal care units. We found inconsistent figures regarding the knowledge level of health care providers on low dose aspirin for preeclampsia prevention around different low and middle income countries in the world. Thus, determining the pooled knowledge level of health care providers is very important. METHODS: This systematic review and meta-analysis (SRMA) was conducted on the knowledge level of among obstetric care providers towards preeclampsia prevention in low and middle income countries. We identified relevant literature in the English language only. A comprehensive search was conducted on databases such as PubMed, Google Scholar, HINARI, and Scopus. Subsequently, all datasets were exported to Mendeley reference manager and transferred to a Microsoft Excel spreadsheet to eliminate duplicate data during the review process. The extracted Microsoft Excel spreadsheet format data was imported to STATA software version 17 (STATA corporation, Texas, USA) for analysis. Then random effect model was used to estimate the pooled level of knowledge of health care providers on low dose aspirin for preeclampsia prevention in low income countries. Cochrane Q-test and I2 statistics were computed to assess heterogeneity among all the studies included in this SRMA. RESULT: A total of 1231 articles were identified through our search strategies, including Google Scholar, PubMed, Hinari and Scopus. Ultimately, six articles met the eligibility criteria for inclusion in the final SRMA. The pooled knowledge level of healthcare providers regarding the use of low-dose aspirin for preeclampsia prevention in low-income countries was found to be 16.38% (95% CI: 4.36-28.40). The Cochrane heterogeneity index, with a substantial I2 value of 98.89% and a significant P-value of 0.01, indicated significant heterogeneity among the primary studies included. CONCLUSION: the knowledge level of obstetric care providers in low and middle income countries is found very low and all the governmental and non-governmental organizations should strive to enhance the knowledge of obstetric care providers on the use of low dose aspirin for preeclampsia prevention in low and middle income countries.

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Millions of children and young people (CYP) in low- and middle-income countries (LMICs) have no access to mental health care. This huge treatment gap is primarily due to limited availability of trained mental health professionals. We propose task-sharing as a scalable strategy to expand access to child and adolescent mental health (CAMH) interventions in LMICs. Task-sharing involves using the few mental health specialists in LMICs to train and supervise nonspecialists to provided CAMH interventions. There is strong evidence of clinical and cost effectiveness of task-shared mental health interventions for adults in LMICs and promising evidence for CYP. To succeed, task-shared programmes need to be embedded in a balanced system-wide care setting that includes stakeholder involvement. The existing mental health specialists may require additional training in leadership, supervision, mentoring, service design and evaluation in order to meet the additional expectations of managing task-sharing programmes. The nonspecialists to be trained would need assurances about workload, ongoing supervision, clinical back up for cases that exceed their expertise, certification for their training and career progression. CAMH task-sharing offers good promise for increasing CYP's access to mental health interventions in LMICs. However, planners need to be aware of the important practical, ethical and contextual considerations necessary for success and sustainability.

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The WHO Surgical Safety Checklist has been instrumental in reducing surgical deaths by 47% globally since its inception in 2009. A study was conducted to assess the compliance of hospital staff with the Surgical Safety Checklist and identify potential barriers to its implementation at a large tertiary public hospital in Vietnam. The study analysed 135 surgical cases between February and September 2021 using the Pareto principle with eight error categories, including (1) patient identification, (2) equipment, (3) risk management, (4) blood loss, (5) allergy, (6) items left inside the patient, (7) surgical specimens and (8) patient safety and recovery management. Compliance with the Surgical Safety Checklist was between 77% and 93%, with five categories accounting for more than 80% of errors. Periodic monitoring and staff training can improve compliance and help reduce errors for better patient safety. Long-term solutions addressing infrastructure challenges are also crucial.

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BACKGROUND: Familial adenomatous polyposis is characterized by the presence of multiple colorectal adenomatous polyps and caused by germline mutations in the tumor suppressor gene and adenomatous polyposis coli, located on chromosome 5q21-q22. Familial adenomatous polyposis occurs in approximately 1/10,000 to 1/30,000 live births, and accounts for less than 1% of all colorectal cancers in the USA. It affects both sexes equally and has a worldwide distribution. The incidence of colon cancer in low- and middle-income countries is rising. In addition to the increasing incidence, lack of early detection and impeded access to optimal multidisciplinary treatment may worsen survival outcomes. Developing quality diagnostic services in the proper health context is crucial for early diagnosis and successful therapy of patients with colorectal cancer, and applying a resource-sensitive approach to prioritize essential treatments on the basis of effectiveness and cost-effectiveness is key to overcoming barriers in low- and middle-income countries. We report a case of familial adenomatous polyposis presenting as adenocarcinoma with multiple colorectal adenomatous polyps. The diagnosis of familial adenomatous polyposis was made by the presence of numerous colorectal adenomatous polyps and family history of colonic adenocarcinoma. Due to its rarity, we decided to report it. CASE PRESENTATION: A 22-year-old Ethiopian female patient presented to Addis Ababa University College of Health science, Addis Ababa, Ethiopia with rectal bleeding. Abdominopelvic computed tomography scan was done and showed distal rectal asymmetric anterior wall thickening in keeping with rectal tumor. Colonoscopy was done and she was diagnosed to have familial adenomatous polyposis with severe dysplasia. In the meantime, colonoscopy guided biopsy was taken and the diagnosis of adenocarcinoma with familial adenomatous polyposis was rendered. For this, total proctocolectomy was carried out. On laparotomy there was also incidental finding of left ovarian deposition for which left salpingo-oophorectomy was done, and 4 weeks after surgical resection, the patient was started on oxaliplatin, leucovorin, fluorouracil chemotherapy regimen. CONCLUSION: In the clinical evaluation of a patient with rectal bleeding, familial adenomatous polyposis must be considered as a differential diagnosis in subjects having family history of colonic adenocarcinoma for early diagnostic workup, management, family genetic counseling, and testing.

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Background: Proctoring in neuroendovascular surgery is one of the potential solutions for the shortage of personnel and experience, particularly in unstable and limited-resource areas such as Iraq. Methods: The study was conducted at the Baghdad Neurovascular Center (BNC), the first Hybrid neurovascular institution in Iraq, where sequential online zoom-based meetings between the BNC team and the expert from the Kingdom of Saudi Arabia were used for teleproctoring for neurointerventional procedures. Results: A total of 28 sessions were conducted, four sessions for each case. Seven cases with various intracranial vascular lesions were operated for neuroendovascular procedures from July/2021 to March/2022. The teleproctoring for each case included four sequential sessions: (1) preoperative planning, (2) device selection and preparation, (3) intraoperative live-stream proctoring, and (4) postoperative reflection and follow-up planning. The procedures include coiling for dural arteriovenous fistula; preoperative tumor embolization; preoperative, partial, and staged embolization for arteriovenous malformation; coiling for intracranial aneurysm; and attempted Giant aneurysm flow-diversion. Major complications were avoided through teleproctoring, and all patients had good outcomes. In addition, the teleproctoring provided an effective training experience to the local neuroendovascular team that is otherwise not feasible. Conclusion: Teleproctoring is an effective and feasible tool to improve patient outcomes and provide a training experience to the local neuroendovascular teams in resource-limited regions.

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Background: Stigma is significantly impacted by cultural and contextual value systems. People with mental health conditions frequently have to deal with the condition itself and the associated stigma and discrimination. Contextual understanding is essential to design measures and interventions. Objective: This study aimed to explore the experiences and perceptions of people with mental health conditions, their families and key stakeholders. Method: A qualitative method used to understand mental health-related stigma and its local contexts. Sixteen participants, including service users, caregivers, service providers and health service administrators, were interviewed. Result: People with mental health conditions and their caregivers experienced various forms of stigmatization which is linked to attributions about the causality of the illness, overt manifestations of mental health condition leading to easy identification and functional impairments that adversely affect participation. Social contact, lived experiences sharing and training of service providers are relevant intervention strategy to address stigma. Implication: Stigma and exclusion are prominent in the experiences of people with mental health conditions and their caregivers in this rural Ethiopian setting. Measurement of stigma and the development of interventions should consider how stigma is socially constructed. Anti-stigma interventions need to be implemented alongside expanded local access to mental healthcare.

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BACKGROUND:  Childhood hearing loss is a global health concern. Despite the proven benefits of neonatal hearing screening (NHS), it is not yet mandated in South Africa. The lack of awareness of hearing loss and absence of NHS leads to delayed diagnosis and adverse developmental outcomes for affected children. AIM:  The study aimed to assess the availability of NHS services across primary healthcare (PHC) facilities in the City of Cape Town (CCT). SETTING:  Surveys were conducted with 26 PHC facilities in the CCT metropolitan areas that offer mother and child healthcare services. METHODS:  Surveys gathered data through online and telephone methods. The surveys aimed to assess the availability and nature of NHS services, care pathways and training of healthcare professionals regarding NHS. RESULTS:  None of the facilities used objective screening methods to screen hearing or have standardised care pathways for at-risk babies. Instead, they relied on parental concerns, with the use of the Road to Health book. None of the respondents reported having received hearing screening training, and the majority of participants (62%) lacked confidence in their knowledge of ear and hearing care. CONCLUSION:  The absence of NHS services highlights the need for standardised protocols and increased awareness among healthcare workers and caregivers. Implementing NHS services could facilitate earlier diagnosis and intervention of hearing loss for infants in the Western Cape.Contribution: This study's findings could guide efforts to improving access to NHS access at PHC level in Cape Town, ultimately providing early hearing screening services to infants.

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Using simulated patients to mimic 9 established noncommunicable and infectious diseases, we assessed ChatGPT's performance in treatment recommendations for common diseases in low- and middle-income countries. ChatGPT had a high level of accuracy in both correct diagnoses (20/27, 74%) and medication prescriptions (22/27, 82%) but a concerning level of unnecessary or harmful medications (23/27, 85%) even with correct diagnoses. ChatGPT performed better in managing noncommunicable diseases than infectious ones. These results highlight the need for cautious AI integration in health care systems to ensure quality and safety.

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