Factors inhibiting and enabling performance-based financing in health care delivery across low and middle-income countries: a scoping review

Background: Emerging financing strategies in the health sector have been developed to improve the impact of investments and enhance healthcare outcomes. One promising approach is Results-based Financing, which establishes a connection between financial incentives and pre-established performance targets. This innovative approach holds the potential to strengthenhealthcare delivery and strengthen overall healthcare systems.Aim:The scoping review endeavored to systematically delineate the body of evidence pertaining tofacilitators and barriers to the implementation of performance-based financing within the realm of healthcare provision in low-and middle-income nations.Methods:The review used Preferred Reporting Items for Systematic Reviews and a Meta-Analysis extension for Scoping Reviews checklist to select, appraise, and report the findings. We searched PubMed, Web of Science, and Google Scholar databases and grey literature published between January 2000 and March 2022. We conducted the abstract screening with two independent reviewers. We also performed full-article screening. We used the six methodological frameworks proposed by Arksey and O'Malley. The results were thematically analyzed.Results:Of the 1071 searched studies, 34 met the eligibility criteria. 41% of the studies were descriptive, 26% cross-sectional, 18% trial, and 15% cohort studies. The enabling and inhibiting factors of performance-based financing in healthcaredelivery have been identified. Moreover, the review revealed that performance-based financing's influence on service delivery is context-specific.Conclusion:The facilitators and impediments to the effectiveness of performance-based financing in enhancing service delivery are contingent upon a holistic comprehension of the contextual factors, meticulous design, and efficient execution. Factors such as the level of care facilities, presence of community-based initiatives, stakeholder involvement, and participatory design emerge as key facilitators. Conversely, barriers such as communication obstacles, inadequacies in the PBF models, and deficiencies in the healthcare workforce are recognized as inhibitors. By harnessing the insights derived from a multitude of evidence incorporated in this scrutiny, stakeholders can deftly navigate the intricacies of performance-based financing, while also considering the prospective areas for further exploration and research

Sociodemographic determinants and mortality of premature newborns in a medium and low-income population in Colombia, 2017-2019 / Factores determinantes sociodemográficos y de mortalidad en recién nacidos prematuros en población de medianos y bajos ingresos en Colombia, 2017-2019

Introduction. The birth of premature babies is a public health problem with a high impact on infant morbidity and mortality. About 40% of mortality in children under five years occurs in the first month of life. Objective. To identify the association between maternal sociodemographic factors, premature birth, and mortality in newborns under 37 weeks in Santiago de Cali, 2017-2019. Materials and methods. We conducted a descriptive, cross-sectional study. We evaluated the records of Cali's Municipal Public Health Office. We calculated the crude and adjusted odd ratios and confidence intervals (95%) using the logistic regression model, data processing in Stata 16, and georeferencing the cases in the QGIS software. Results. From 2017 to 2019, premature babies in Cali corresponded to 11% of births. Poor prenatal care increased 3.13 times the risk of being born before 32 weeks (adjusted OR = 3.13; 95% CI = 2.75 - 3.56) and 1.27 times among mothers from outside the city (adjusted OR = 1.27; 95% CI = 1.15-1.41). Mortality was 4.29 per 1,000 live births. The mortality risk in newborns weighing less than 1,000 g increased 3.42 times (OR = 3.42; 95% CI = 2.85-4.12), delivery by cesarean section in 1.46 (OR = 1.46; CI 95% = 1.14-1.87) and an Apgar score - five minutes after birth- lower than seven in 1.55 times (OR = 1.55; CI 95% = 1.23-1.96). Conclusions. We found that less than three prenatal controls, mothers living outside Cali, afro-ethnicity, and cesarean birth were associated with prematurity of less than 32 weeks. We obtained higher mortality in newborns weighing less than 1,000 g.

Introducción. El nacimiento de bebés prematuros es un problema de salud pública con gran impacto en la morbimortalidad infantil: cerca del 40 % de las muertes de niños menores de cinco años sucede en el primer mes de vida. Objetivo. Identificar la asociación entre los factores sociodemográficos maternos, el parto prematuro y la mortalidad en recién nacidos menores de 37 semanas en Santiago de Cali, 2017-2019. Materiales y métodos. Se hizo un estudio descriptivo transversal. Se evaluaron los registros de la Secretaría de Salud Pública Municipal de Cali. Se calcularon las razones de probabilidad y los intervalos de confianza (95 %) crudos y ajustados mediante el modelo de regresión logística, en tanto que los datos se procesaron en Stata 16 y los casos se georreferenciaron con el programa QGIS. Resultados. Entre el 2017 y el 2019, los nacimientos de bebés prematuros en Cali correspondieron al 11 %. El control prenatal deficiente aumentó 3,13 veces el riesgo de nacer con menos de 32 semanas (OR ajustado = 3,13; IC95% = 2,75-3,56) y, en madres de municipios fuera de la ciudad, 1,27 veces (OR ajustado = 1,27; IC95% = 1,15-1,41). La mortalidad fue de 4,29 por 1.000 nacidos vivos. Nacer con un peso menor de 1.000 g aumentó el riesgo de mortalidad en 3,42 veces (OR = 3,42; IC95% = 2,85-4,12) y, un puntaje Apgar menor de siete a los cinco minutos del nacimiento, en 1,55 veces (OR=1,55; IC95% = 1,23-1,96). Conclusiones. Se encontró que tener menos de tres controles prenatales, la procedencia de la madre fuera de Cali, ser afrodescendiente y el parto por cesárea, estaban asociados significativamente con la prematuridad de menos de 32 semanas. Hubo mayor mortalidad en los recién nacidos con menos de 1.000 gramos al nacer.

Solution-focused approach towards improved access to assistive mobility technology and devices in low and middle-income countries: A narrative review

BACKGROUND@#The article focuses on the main challenges for low and middle-income countries (LMICs) and approaches that need to be implemented to achieve assistive mobility devices for all. World Health Organization (WHO) estimates that about one billion (15%) of the world’s population lives with some form of disability, with projections for the same to double by 2050, a significant proportion (approx.840 million) of them residing in low- and middle-income countries. As per WHO, it is estimated that only 5-15% of the people requiring assistive technology have access to it. In low and middle-income countries, the rate of accessibility is expected to be worse due to the high cost of the products, diminished awareness, lack of trained personnel, inadequate availability, and ineffective policy implementation due to lack of funds. The current developments in assistive mobility technologies and devices available at a high cost for consumers in high-income countries have neglected the requirement of persons with disabilities in low and middle-income countries. The improved rehabilitation methods of assistive mobility devices may deliver economic and health benefits to individuals and lessen the financial burden on governments in the future. Therefore, multidisciplinary research is greatly needed to measure and prove the effectiveness of rehabilitation treatment methods and to develop an evidence-based sustainable treatment, particularly in LMICs. Also, a detailed service model assessment can identify the lack of current service provision. The online databases were searched to find relevant articles for the purpose.

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study

ABSTRACT OBJECTIVE To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country. METHODS The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10. RESULTS After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women. CONCLUSIONS The study's findings were consistent, but not fully similar, to the international literature.

Sentimentos e percepções do luto de sobreviventes ao suicídio de jovens / Feelings and perceptions of grief among survivors of youth suicide / Sentimientos y percepciones de duelo entre sobrevivientes de suicidio de jóvenes

Sobreviventes ao suicídio são pessoas que têm suas vidas profundamente afetadas e apresentam sofrimento psicológico, físico ou social após serem expostas a esse fato. O objetivo deste estudo foi analisar a experiência de sobreviventes ao suicídio de jovens, a partir do luto. Participaram sete sobreviventes entre familiares, amigos e parceiros amorosos de jovens que cometeram suicídio. A análise de conteúdo de entrevistas narrativas apontou que os participantes utilizam explicações racionalizadas ou dissociadas, criando uma distância entre o evento e eles mesmos. Como formas de lidar com o sofrimento podem buscar o isolamento, apoio entre amigos, prática religiosa e/ou a dedicação ao trabalho. Reafirma-se a dimensão do luto diante dessa experiência, além da importância da prevenção ao suicídio e da posvenção aos sobreviventes.(AU)

Suicide survivors are people who have their lives deeply affected; they experience psychological, physical, and social suffering following the occurrence. The aim of this study is to analyze the experience of survivors of youth suicide attempts, based on grief. Seven survivors participated among family, friends, and romantic partners of young people who committed suicide. The content analysis of narrative interviews showed that the participants use rationalized or dissociated explanations, creating a distance between the event and themselves. As ways to deal with suffering, they seek isolation, support among friends, religious practice, and/or dedication to work. The dimension of grief in the face of this experience is reaffirmed, as well as the importance of suicide prevention and postvention for survivors.(AU)

Este artículo tiene como objetivo presentar la construcción metodológica desarrollada en una investigación de maestría, en la que sostenemos la escritura de escenas como método de investigación de la escucha clínica. Las escenas del trabajo en cuestión se recogieron a lo largo del tiempo desde la experiencia en un proyecto de extensión universitario de atención a la niñez y adolescencia en situación de vulnerabilidad social aplicado en una comunidad periférica. En este texto, presentamos los interrogantes que se elaboraron en torno a la elección por el trabajo con escenas y compartimos el rescate histórico de las mismas como un método de escribir la clínica y la reanudación del análisis a partir de la tradición psicoanalítica. Amparadas en el psicoanálisis y en lecturas y contribuciones del filósofo francés Jacques Derrida, nos basaremos en la noción de que la escena se constituye como un lugar de producción, engendrando la configuración particular de elementos significantes en los procesos de subjetivación y de construcción social. La escena no es aquí una representación de lo que pasa en la clínica, sino un modo de producir escucha y sus procesos de investigación.(AU)

Desafios do HIV/AIDS em país de baixa renda: sobrevida e retenção de pacientes em TARV nos cuidados de HIV na 'Era' de "Testar e Iniciar" o tratamento no Município de Maputo, Moçambique / HIV/AIDS challenges in low-income country: survival and retention of patients on ART in the 'Era' of "Test and Treat" treatment in Maputo Municipality, Mozambique

Introdução: Considerando as evidências segundo as quais o início precoce do TARV, independentemente da contagem do CD4 ou do estágio clínico da OMS, aumenta a sobrevida e a retenção de pacientes em TARV; diminui a morbidade e mortalidade; e reduz a incidência do HIV, a OMS propôs a ETI para países de baixa renda fortemente afetados por HIV/AIDS, no entanto, estudos que avaliam o seu efeito sobre indicadores clínicos e programáticos ainda são escassos em Moçambique. Objetivos: (i) Estimar taxas de mortalidade e de perda no seguimento clínico e psicossocial nas coortes de pacientes submetidos à ETI (DTI) e não submetidos à estratégia (ATI), respectivamente, e compará-las; (ii) Estimar as medianas do tempo e as probabilidades de sobrevida e de retenção nos cuidados de HIV nas duas coortes (ATI e DTI) e compará-las; (iii) Analisar a influência da ETI na sobrevida e na retenção de pacientes em TARV nos cuidados de HIV, após ajuste para potenciais confundidores. Método: Estudo de coorte retrospectivo de pacientes em TARV, com idades entre 15 e 49 anos, inscritos nos serviços públicos de saúde do município de Maputo, Moçambique. As variáveis estudadas foram sociodemográficas (sexo, idade, escolaridade, região de residência); clínicas (data do diagnóstico de HIV; óbito; estádio clínico da OMS; contagem de CD4; carga viral; data de início do TARV; perda no seguimento; regime de tratamento; co-infecção HIV/TB; indice de massa corporal); programáticas (serviço de diagnóstico/testagem de HIV; participação nos grupos de apoio para a adesão comunitária; exposição à ETI) e os desfechos de interesse foram óbito e perda no seguimento clínico e psicossocial. Utilizou-se o estimador produto limite de Kaplan-Meier, o modelo de riscos proporcionais de Cox e as estimativas das razões de "Hazard" (HR), com respectivos intervalos de confiança a 95%. Estimou-se a FAP para a exposição à ETI, como medida de impacto da estratégia na população. Resultados: A taxa média de mortalidade na coorte ATI foi de 28,1/1000 pessoas-ano, enquanto na coorte DTI foi de 24,5/1000 pessoas-ano. A taxa média de perdas no seguimento clínico e psicossocial na coorte ATI foi de 17,3/1000 pessoas-ano e na coorte DTI de 15,0/1000 pessoas-ano. A MTS na coorte ATI foi de 43,1 meses e na coorte DTI de 50,6 meses. A MTR na coorte ATI foi de 39,8 meses e na coorte DTI de 49,0 meses. Mostraram-se associadas ao tempo de sobrevida, independentemente das demais covariáveis: pertencer à faixa etária de 25-39 (HR=1,52; IC 95% 1,37 - 1,69) e 40-49 (HR=2,16; IC 95% 1,94 - 2,41); ser residente de região suburbana (HR=1,45; IC 95% 1,36 - 1,54); ser do sexo masculino (HR=1,41; IC 95% 1,33 - 1,49); estar em TARV com a II linha (HR=1,19; IC 95% 1,13 - 1,26); estar co-infectado HIV/TB (HR=1,16; IC 95% 1,10 - 1,23); pertencer ao estágio clínico IV da OMS (HR=1,93; IC 95% 1,70 - 2,17), ter IMC <18,5 Kg/m2 (HR=1,18; IC 95% 1,07 - 1,29); não estar exposto à ETI (HR=1,16; IC 95% 1,10 - 1,22). Mostraram-se associadas ao tempo de retenção nos cuidados, independentemente das outras covariáveis: estar em regime de TARV da II linha (HR = 1,48; IC 95% 1,40 - 1,56); pertencer ao estágio III (HR = 1,28; IC 95% 1,19 - 1,36) e IV (HR = 3,51; IC 95% 3,17 - 3,88) da OMS; não estar exposto à ETI (HR = 1,75; IC 95% 1,65 - 1,85); estar co-infectado HIV/TB (HR = 1,18; IC 95% 11,11 - 1,24); ser do sexo masculino (HR = 1,17; IC 95% 1,11 - 1,24); pertencer aos GAAC (HR = 1,21; IC 95% 1,12 - 1,30). A fração atribuível na população para o grupo exposto à ETI (DTI) foi de 6,4% em relação à sobrevida e 20,0% para a retenção nos cuidados de HIV. Conclusões: No contexto de um país de baixa renda fortemente afetado por HIV/AIDS e situado na região Austral de África, a ETI mostrou impacto relevante no aumento da sobrevida e a retenção de pacientes em TARV nos cuidados de HIV, bem como na redução da mortalidade e das perdas no seguimento clínico e psicossocial. O estudo também confirmou o papel de fatores associados aos dois desfechos, também identificados em outras regiões da África Subsaariana e do mundo. Estes resultados fortalecem a importância da ETI para países de baixa e média renda fortemente afetados pelo HIV, para acelerar a resposta local e global do HIV/AIDS por via de intervenções nacionais.

Background: Considering the evidence that early initiation of ART, regardless of CD4 count or WHO clinical stage, increases survival and retention of patients on ART, decreases morbidity and mortality, and reduces HIV incidence, WHO proposed the test-and-treat strategy for low-income countries with a high burden of HIV/AIDS, however, studies evaluating the effect of this strategy on survival and retention of patients on ART are still scarce in Mozambique. Objectives: (i) Estimate the mean rates of mortality and loss in clinical and psychosocial follow-up among the cohorts, respectively, of patients submitted to the strategy (DTI) and not submitted to the strategy (ATI) and compare them; (ii) Estimate the median time and probabilities of survival and retention in HIV care in the two cohorts (ATI and DTI) and compare them; (iii) Analyze the influence of the test-and-start strategy on survival and retention of patients on ART in HIV care, after adjusting for potential confounders. Method: Retrospective cohort study of patients on ART, aged between 15 and 49 years old, enrolled in public health services of Maputo municipality. Variables studied were: sociodemographic (gender, age, education, region of residence); clinical (date of HIV diagnosis; death; WHO clinical stage; CD4 count; viral load; ART initiation date; loss to follow-up; treatment regimen; HIV/TB co-infection; body mass index); programmatic (HIV diagnosis/testing service; participation in support groups for community adherence; exposure to the "test and treat" strategy) and the outcomes of interest were death and loss of clinical and psychosocial follow-up. Kaplan-Meier estimator, Cox proportional hazards model and Hazard ratio (HR) estimates were used, with 95% confidence intervals. Attributable fraction in the population for the exposure to the "test and treat" strategy was estimated as a measure of the strategy's impact on the population. Results: Mean mortality rate in ATI cohort was 28.1/1000 person-years, while in DTI cohort it was 24.5/1000 person-years. Mean rate of loss to clinical and psychosocial follow-up in ATI cohort was 17.3/1000 person-years and in DTI cohort was 15.0/1000 person-years. Median survival time (MTS) in ATI cohort was 43.1 months and in DTI cohort was 50.6 months. Median retention time (MTR) in ATI cohort was 39.8 months and in DTI cohort was 49.0 months. Regardless of the other covariates, the predictors of death were the following: belonging to the age group 25-39 (HR=1.52; CI 95% 1.37 - 1.69) and 40-49 (HR=2.16; CI 95% 1.94 - 2.41); be resident of a suburban region (HR=1.45; 95%CI 1.36 - 1.54); be male (HR=1.41; 95% CI 1.33 - 1.49); be on second-line ART regime (HR=1.19; 95% CI 1.13 - 1.26); be co-infected HIV/TB (HR=1.16; 95% CI 1.10 - 1.23); belonging to WHO clinical stage IV (HR=1.93; 95% CI 1.70 - 2.17), having a BMI <18.5 Kg/m2 (HR=1.18; 95% CI 1.07 - 1 ,29); not being exposed to the test-and-treat strategy (HR=1.16; 95% CI 1.10 - 1.22). Regardless of the other covariates, the predictors of the loss in clinical and psychosocial follow-up were: be on second-line ART regime (HR = 1.48; 95% CI 1.40 - 1.56); belonging to WHO stage III (HR = 1.28; 95% CI 1.19 - 1.36) and IV (HR = 3.51; 95% CI 3.17 - 3.88); not being exposed to the test-and-start strategy (HR = 1.75; 95% CI 1.65 - 1.85); be co-infected with HIV/TB (HR = 1.18; 95% CI 11.11 - 1.24); be male (HR = 1.17; 95% CI 1.11 - 1.24); belonging to the GAAC (HR = 1.21; 95% CI 1.12 - 1.30). Population attributable fraction for the group exposed to the test-and-treat (DTI) strategy was 6.4% for survival and 20.0% for retention in HIV care. Conclusions: In the context of a low-income country strongly affected by HIV/AIDS and located at southern Africa region, the test-and-treat strategy showed a relevant impact on increasing survival and retention time of patients on ART in HIV care, as well as on reducing of mortality and losses in clinical and psychosocial follow-up. The study confirmed, as well, the role of factors associated with the two studied outcomes, also identified in other regions of sub-Saharan Africa and worldwide. These results strengthen the importance of the test-and-treat strategy for low- and middle-income countries heavily affected by HIV, to accelerate local and global HIV/AIDS response through national interventions.

Psicologia, Conselho Federal de Psicologia e covid-19: enfrentamento às desigualdades psicossociais no Brasil / Psychology, FCP, and covid-19: facing the psychosocial inequalities in Brazil / Psicología, Consejo Federal de Psicología y covid-19: enfrentando las desigualdades psicosociales en Brasil

A pandemia da covid-19 impôs transformações no cotidiano mundial, em âmbito micro e macroestrutural. Seu impacto psicológico desestabiliza e evidencia desigualdades e vulnerabilidades psicossociais brasileiras. Configura-se como um estudo de perspectiva crítica, com base na Psicologia Sócio-histórica, com o objetivo de mapear os posicionamentos da Psicologia, vindos de diferentes campos, diante das ações de saúde mental. Para tanto, utiliza-se o site do Conselho Federal de Psicologia para a análise de 62 documentos, que resultaram em dois eixos de produção crítica: 1) a relação da Psicologia com o Conselho Federal de Psicologia; e 2) da Psicologia com a sociedade. Revela-se o abismo social entre segmentos da sociedade brasileira; formas de exclusão da população carcerária; violência doméstica contra as mulheres e as crianças; dificuldades de acesso a estratégias sociais, na educação e na saúde, e de superação dos impasses acirrados com a infecção global pelo novo coronavírus. Conclui-se que a diversidade de públicos, temáticas, áreas de atuação e referenciais teóricos materializa um compromisso crítico e científico da Psicologia.(AU)

The COVID-19 pandemic imposed transformations in the world daily life, at the micro and macrostructural levels. Its psychological impact destabilizes and highlights Brazilian inequalities and psychosocial vulnerabilities. This is a critical perspective study, based in socio-historical Psychology, aiming to map the positions of Psychology, from different fields, in the face of mental health actions. To this end, the Federal Council of Psychology website is utilized to analyze 62 documents, which resulted in two axes of critical production: 1) the relation between Psychology and the Federal Council of Psychology; and 2) Psychology with society. They reveal the social gap between segments of Brazilian society; ways of excluding prison po7pulation; domestic violence against women and children; and difficulties in accessing social strategies, in education and health, and in overcoming impasses aggravated by the global infection by the new coronavirus. In conclusion, the diversity of public, themes, areas of professional performance, and theoretical references materialize Psychology's critical and scientific commitment.(AU)

La pandemia del COVID-19 provocó transformaciones globales en lo cotidiano a nivel micro y macroestructural. Su impacto psicológico desestabiliza y destaca las desigualdades y vulnerabilidades psicosociales en Brasil. Esta es una investigación en la perspectiva crítica, basada en la psicología sociohistórica, con el objetivo de mapear las posiciones de la Psicología, procedentes de diferentes campos, frente a las acciones de salud mental. Para este fin, se utiliza el sitio web del Consejo Federal de Psicología para el análisis de 62 documentos, lo que resultó en dos ejes de producción crítica: 1) la relación de la Psicología con el Consejo Federal de Psicología; y 2) de la Psicología con la sociedad. Se revelan la brecha social entre los segmentos de la sociedad brasileña; las formas de exclusión de la población carcelaria; la violencia doméstica contra las mujeres y los niños; y las dificultades para acceder a las estrategias sociales, en la educación y la salud, para superar los impasses agravados por la infección global por el nuevo coronavirus. Se concluye que la diversidad de públicos, temáticas, áreas de actividad y referentes teóricos materializa un compromiso crítico y científico de la Psicología.(AU)

Ethiopian Health Extension Workers' Training Status and Perceived Competency

BACKGROUND: Training and work experience are critical inputs for delivering quality health services. However, no nationwide assessment has been conducted on the status of training and the competency of Health Extension Workers (HEWs). Therefore, this study aimed to assess HEWs' pre service training status and perceived competency in Ethiopia. METHODS: The study was conducted in all regions and all HEWs training institutions in Ethiopia. We used cross sectional study design with a mixed method approach that included 585 HEWs, 1,245 HEW trainees, 192 instructors, and 43 key informants. Descriptive statistics and thematic analysis were used to analyse quantitative and quantitative data respectively. RESULT: Twenty-six percent of the HEWs said that they were competent to deliver all the HEP activities, and 73% of the HEWs said that they could confidently deliver 75% of the HEP activities. Receiving in-service training and having level III/IV qualifications are positively associated with the competency of HEWs. Similarly, HEP trainees perceived themselves as highly competent in executing their professional work, except in using computer and mobile health technology. Both instructors and trainees rated the quality of the curriculum and course materials positively. However, basic services and facilities in most training institutions were perceived to be inadequate. Additionally, individual learning, problem-solving, case-analysis, and assessment methods such as project work and portfolios were rarely practiced. CONCLUSIONS: Although the perceived competence of HEW trainees is high, the HEWs' training is not provided as per the curriculum because of limited resources. All the necessary resources should be made available to produce competent HEWs

Ascariasis errática biliar como causa exótica de ictericia obstructiva / Erratic Biliary Ascariasis as an Exotic Cause of Obstructive Jaundice

Introducción: Áscaris lumbricoides es el helminto más frecuente en el tracto gastrointestinal humano; la mayor prevalencia se registra en países en desarrollo, tropicales y subtropicales. En Cuba constituye una causa exótica de ictericia obstructiva con pocos casos reportados. Objetivo: Describir el manejo terapéutico exitoso de un caso de un hombre con ictericia obstructiva secundaria a ascariasis coledociana. Caso clínico: Paciente de 74 años operado en el Hospital Clínico Quirúrgico "Lucía Íñiguez Landín" de la provincia Holguín por ictericia obstructiva por ascariasis coledociana, con evolución clínico-quirúrgica satisfactoria. Conclusiones: En países en desarrollo debe tomarse en cuenta la ascariasis como causa de enfermedad obstructiva biliar o pancreática. El conocimiento del cuadro clínico y sus complicaciones, además, de las diferentes opciones en el tratamiento, debe ser del dominio de todo médico. La ictericia obstructiva por áscaris lumbricoides constituye en Cuba una causa exótica de esta infestación por parásitos(AU)

Introduction: Ascaris lumbricoides is the most frequent helminthiasis in the human gastrointestinal tract; the highest prevalence is recorded in developing, tropical and subtropical countries. In Cuba, it constitutes an exotic cause of obstructive jaundice with few reported cases. Objective: To describe the successful therapeutic management of a case of a man with obstructive jaundice secondary to choledochal ascariasis. Clinical case report: We report the case of a 74-year-old patient operated on at Lucía Íñiguez Landín Surgical Clinical Hospital, in Holguín province, for obstructive jaundice due to choledochal ascariasis, with satisfactory clinical-surgical evolution. Conclusions: In developing countries, ascariasis should be taken into account as a cause of biliary or pancreatic obstructive disease. Knowledge of the clinical condition and its complications, in addition to the different treatment options, should be the domain of every physician. Obstructive jaundice due to ascaris lumbricoides constitutes an exotic cause of this parasite infestation in Cuba(AU)

Mudanças da prevalência de dentes permanentes cariados no Brasil e em países de renda média-alta nos anos 1990 e 2017 / Changes in the prevalence of decayed permanent teeth in Brazil and upper-middle income countries in the years 1990 and 2017

Resumo A distribuição da cárie é desigual e fortemente associada aos diferentes perfis socioeconômicos dos países. Objetivou-se descrever as mudanças da prevalência de dentes permanentes cariados no Brasil e em países de renda média-alta nos anos 1990 e 2017. Trata-se de um estudo descritivo realizado a partir de dados secundários extraídos do Global Burden of Disease. Foram incluídos os 53 países pertencentes ao grupo de renda média-alta. As estimativas de prevalência de cárie foram coletadas nos anos de 1990 e 2017. A variação percentual da prevalência foi calculada entre os dois anos. Também foram coletados os valores do Índice de Desenvolvimento Humano (IDH) para cada país. Os resultados evidenciam tendência de redução da prevalência de dentes permanentes cariados no Brasil e na maioria dos países de renda média-alta. A prevalência de cárie não tratada no Brasil foi de 38,17%, em 1990, e de 37,46% em 2017. O Brasil ocupa a 41ª posição no ranking de redução na prevalência de cárie entre os 53 países avaliados. Os países que alcançaram as maiores reduções na prevalência de cárie foram os que melhoraram o seu IDH. Nesse sentido, considera-se a necessidade de rever as políticas públicas de saúde bucal, bem como uma reflexão acerca do enfrentamento das iniquidades presentes nos países pesquisados.

Abstract The distribution of caries is uneven and strongly associated with the different socioeconomic profiles of countries. The scope of this study was to describe the changes in the prevalence of decayed permanent teeth in Brazil and in upper-middle income countries for the years 1990 and 2017. It is a descriptive study based on secondary data extracted from the Global Burden of Disease. The 53 countries included in the upper-middle income group were included. Caries prevalence estimates were collected for the years 1990 and 2017. The percentage change in prevalence was calculated between the two years. The values of the Human Development Index (HDI) for each country were also collected. The results show the trend of a reduction in the prevalence of decayed permanent teeth in Brazil and in most upper-middle income countries. The prevalence of untreated caries in Brazil was 38.17% in 1990 and 37.46% in 2017. Brazil occupies the 41st position in the ranking of the reduction in the prevalence of caries among the 53 countries evaluated. The countries that achieved the greatest reductions in the prevalence of caries were those with an improvement in their HDI. In this respect, the need to review public oral health policies is revealed, as well as a reflection on addressing the inequities present in the countries surveyed.

Anemia, estado nutricional y parasitosis intestinales en niños de hogares de Guayas / Anemia, nutritional status and intestinal parasites in children from homes in Guayas

Las parasitosis intestinales afectan principalmente a países subdesarrollados, donde se presentan condiciones socioeconómicas y geográficas propicias para desarrollarse, con mayor prevalencia en la población infantil. Dichas infecciones se han asociado a desnutrición y anemia, consideradas las alteraciones nutricionales más graves a nivel global. Se realizó un estudio descriptivo en 87 niños de la provincia de Guayas, Ecuador, con edades entre 24 y 59 meses, para determinar anemia, evaluar el estado nutricional y parasitosis intestinal. Se determinaron parámetros antropométricos, valores de hemoglobina y hematocrito, y se identificó las especies parasitarias. Se obtuvo mayor proporción de infantes eutróficos para talla e IMC según el género y grupo etáreo; los niños presentaron mayor prevalencia de sobrepeso, obesidad, retardo en la talla y delgadez, respecto las niñas; además el grupo etáreo entre 4 -5 años presentó mayor retardo en crecimiento y delgadez. Asimismo, 24,14% de niños presentaron anemia y los individuos parasitados significativamente presentaron anemia, mayor retardo en la talla y delgadez, frente a los no parasitados; siendo los protozoarios Entamoeba histolytica, Entamoeba coli y Giardia intestinalis los más frecuentes, mientras que, Enterobius vermicularis y Ascaris lumbricoides fueron los helmintos predominantes. El presente estudio evidencia deficiencias nutricionales asociadas a anemia e infección por parásitos intestinales en niños menores de 5 años de la provincia de Guayas; cuya población requiere adecuados servicios de salud y saneamiento, acceso a los alimentos, apropiadas prácticas de higiene y educación sanitaria, que contribuyan a aminorar los efectos de estas patologías y sus complicaciones(AU)

Intestinal parasites mainly affect underdeveloped countries, where socioeconomic and geographical conditions are conducive to development, with a higher prevalence in the child population. These infections have been associated with malnutrition and anemia, considered the most serious nutritional disorders globally. A descriptive study was carried out in 87 children from the province of Guayas, Ecuador, aged between 24 and 59 months, to determine anemia, evaluate nutritional status and intestinal parasitosis. A higher proportion of eutrophic infants was obtained for height and BMI according to gender and age group; boys had a higher prevalence of overweight, obesity, delayed height and thinness, compared to girls; In addition, the age group between 4 -5 years presented greater retardation in growth and thinness. Likewise, 24.14% of children presented anemia and significantly parasitized individuals presented anemia, greater delay in height and thinness, compared to those without parasitization; being the protozoa Entamoeba histolytica, Entamoeba coli and Giardia intestinalis the most frequent, while Enterobius vermicularis and Ascaris lumbricoides were the predominant helminths. The present study shows nutritional deficiencies associated with anemia and infection by intestinal parasites in children under 5 years of age in the province of Guayas; whose population requires adequate health and sanitation services, access to food, appropriate hygiene practices and health education, which contribute to lessen the effects of these pathologies and their complications(AU)

Trends in non-Melanoma Skin Cancer Mortality in Brazil and its Macroregions / Tendências na Mortalidade por Câncer de Pele não Melanoma no Brasil e suas Macrorregiões / Tendencias de la Mortalidade por Cáncer de Piel no Melanoma em Brasil y sus Macrorregiones

Introduction: Non-melanoma skin cancer (NMSC) is the most common among all malignancies. Objective: To describe trends in NMSC mortality rates in Brazil and its macroregions from 2001 to 2018. Method: Adjusted mortality rates stratified by sex were estimated and presented per 100,000 person-years. An autoregressive analysis was implemented to assess temporal trends, annual percent change (APC) and 95% Confidence Intervals (95% CI). Results: There were 27,550 NMSC deaths in Brazil with higher frequency in males (58.1%) and among individuals aged ≥70 years (64.3%). The overall rates were 2.25 (males) and 1.22 (females) per 100,000 person-years. The trends followed an upward direction in Brazil for males (APC: 2.91%; 95% CI: 1.96%; 3.86%) and females (APC: 3.51%; 95% CI: 2.68%; 4.34%). The same occurred in the North Region, in males (APC: 9.75%; 95% CI: 7.68%; 11.86%) and in females (APC: 10.38; 95% CI: 5.77%; 15.21%), as well as in Northeast Region, in males (APC: 9.98%; 95% CI: 5.59%; 14.57%) and in females (APC: 8.34%; 95% CI: 3.29%; 13.64%). Conclusion: NMSC deaths are not rare in Brazil. Upward mortality trends were observed for the whole country and in the North and Northeast regions, which are the closest to the Equator line and also the least developed socioeconomically. A synergism between different types of inequalities and environmental exposure in these macroregions may be promoting an increase in the number of NMSC deaths, a type of cancer which is considered completely preventable

Introdução: O câncer de pele não melanoma (CPNM) é o mais comum entre todas as malignidades. Objetivo: Descrever as tendências da mortalidade por CPNM no Brasil e nas suas Macrorregiões, de 2001 a 2018. Método: As taxas de mortalidade ajustadas por idade e estratificadas por sexo foram apresentadas por 100 mil pessoas-ano. Uma análise autorregressiva foi implementada para avaliar tendências, Mudança Percentual Anual (MPA) e intervalos de confiança de 95% (IC 95%). Resultados: Houve 27.550 óbitos por CPNM no Brasil com maior frequência em homens (58,1%) e entre pessoas de 70 anos e mais (64,3%). As taxas globais foram de 2,25 (homens) e 1,22 (mulheres) por 100 mil pessoas-ano. As tendências seguiram em elevação no Brasil, em homens (MPA: 2,91%; IC95%: 1,96%; 3,86%) e em mulheres (MPA: 3,51%; IC95%: 2,68%; 4,34%). O mesmo ocorreu na Região Norte, em homens (MPA: 9,75%; IC95%: 7,68%; 11,86%) e em mulheres (MPA: 10,38%; IC95%: 5,77%; 15,21%), bem como na Região Nordeste, em homens (MPA: 9,98%; IC95%: 5,59%; 14,57%) e em mulheres (MPA: 8,34%; IC95%: 3,29%; 13,64%). Conclusão: Os óbitos por CPNM não são raridade no Brasil. O país e as Regiões Norte e Nordeste experimentaram taxas com tendência em elevação. Norte e Nordeste são as Regiões mais próximas da Linha do Equador e as menos desenvolvidas socioeconomicamente. Nessas Macrorregiões, um sinergismo entre diferentes tipos de desigualdades e exposições ambientais pode estar promovendo um aumento dos óbitos por esse tipo de câncer considerado totalmente evitável

Introducción: El carcinoma de piel no melanoma (CPNM) es el más común dentre todas las neoplasias malignas. Objetivo: Describir las tendencias de la mortalidad por CPNM en Brasil y sus macrorregiones, de 2001 a 2018. Método: Las tasas de mortalidad ajustadas por edad y estratificadas según sexo fueron presentadas por 100.000 personas-año. Se implementó una análisis autoregresiva para evaluar las tendencias, el porcentaje estimado de cambio anual (PECA) y sus intervalos de confianza del 95% (IC 95%). Resultados: Hubo 27.550 muertes por CPNM en Brasil con mayor frecuencia en hombres (58,1%) y entre personas de edad ≥70 años (64,3%). Las tasas generales fueron 2,25 (hombres) y 1,22 (mujeres) por 100.000 personas-año. Las tendencias continuaron aumentando en Brasil, en hombres (PECA: 2,91%; IC 95%: 1,96%; 3,86%) y en mujeres (PECA: 3,51%; IC 95%: 2,68%; 4,34%). Lo mismo ocurrió en el Norte, en hombres (PECA: 9,75%; IC 95%: 7,68%; 11,86%) y en mujeres (PECA: 10,38%; IC 95%: 5,77%; 15,21%), así como en el Nordeste, en hombres (PECA: 9,98%; IC 95%: 5,59%; 14,57%) y en mujeres (PECA: 8,34%; IC 95%: 3, 29%; 13,64%). Conclusión: Las muertes por CPNM no son una rareza en Brasil. El país y las regiones Norte y Nordeste experimentaron tasas con tendencia ascendente. Las regiones Norte y Nordeste son las más cercanas al Ecuador y también las menos desarrolladas socioeconómicamente. En estas regiones, una sinergia dentre diferentes tipos de desigualdades y exposiciones ambientales puede estar promoviendo un aumento de las muertes por este tipo de cáncer considerado totalmente prevenible. Palabras clave: neoplasias cutáneas/mortalidad

Lower dose pembrolizumab monotherapy in the treatment of brain metastases from non-small cell lung carcinoma: A report of two cases

Introduction@#Lung cancer is the leading malignancy metastatic to the central nervous system with approximately 20% to 44% of all cases developing brain metastasis. Immunotherapy using pembrolizumab, an anti-PD1monoclonal antibody, is a novel method in lung cancer treatment and has shown favorable results in patients with metastatic brain lesions from non-small cell lung carcinoma (NSCLC). However, the cost of the recommended treatment dose limits its use especially in developing countries like the Philippines. @*Case Presentation@#The authors report two patients with lung cancer with brain metastasis upon diagnosis. The first patient is a 65-year-old male, non-smoker with PD-L1 expression of 60%. He was started on pembrolizumab 100 mg IV every three (3) weeks and a repeat CT scan after 11 cycles revealed a reduction of the two brain metastatic lesions and no fluoro-D-glucose (FDG) uptake on positron emission tomography (PET) scan even after one year into treatment. The second patient is a 67-year-old female, a previous smoker with PD-L1 expression of 50% with a metastatic solitary solid nodule in the cortex of the right cerebellum. After five cycles of pembrolizumab 100 mg IV every three weeks, there was noted complete resolution of brain metastasis on PET scan even after one year of treatment. @*Conclusion@#A lower dose of pembrolizumab (100 mg given every 3 weeks) was found to be effective in the management of advanced NSCLC with brain metastasis in the two patients. Further studies are recommended to investigate lower dose pembrolizumab as monotherapy without radiation therapy or surgery in patients with NSCLC with brain metastasis especially in the setting of a resource-limited country like the Philippines.

A pandemic triad: HIV, COVID-19 and debt in low- and middle-income countries

This article assesses the impact of the HIV and COVID-19 pandemics and debt dynamics on health, HIV and pandemic preparedness and response-related financing in developing countries. Using a novel dataset, we did a cross-national systematic analysis of all data sources available for government expenditures on health, HIV, COVID-19 and debt servicing in selected developing countries. We found an inadequate multilateral response with the ensuing gaps allowing both pandemics to thrive. The G20 Debt Service Suspension Initiative and the Common Framework only covered countries with a third of the global population of people living with HIV. Rising and unsustainable debt levels are limiting the capacity of governments to protect the health of their populations. Government spending is already falling in response to high debt payments. Specifically, debt servicing is crowding out lifesaving investments. In 2020, for every USD 5 available, USD 4 was spent on debt servicing. Only USD 1 was invested in health. This is a binding constraint on countries' efforts to control COVID-19. Even with a gargantuan effort to increase health expenditure, the outlook for health financing remains negative. Fiscal consolidation, with a heavy emphasis on expenditure cuts, is expected to take place across 139 countries in the coming years. These findings suggest that fiscal policymakers should be concerned about the crowding-out and constraining effects of public debt. To this end, pragmatic recommendations are made to treat and cancel debt as a critical policy lever to accelerate the end of the HIV and COVID-19 pandemics in developing countries as a key condition to addressing the growing inequalities and to ensure debt can be a benefit, not a burden.

Effect of COVID-19 on older adults 50 years and above living with HIV in a less-developed country

Introduction: Globally, control measures have been communicated to reverse the COVID-19 pandemic. In Uganda, as soon as the first case of COVID-19 was identified, strict lockdown measures were enforced, including a ban on all public and private transport, night curfew, closure of schools, and suspension of religious and social gatherings and closure of non-essential shops and markets. These measures affected access to health services, which could have been worse for older people living with HIV (PLHIV). In this study, we explored how COVID-19 affected the health and social life of older PLHIV. Methods: We conducted a qualitative study in HIV clinics of two hospitals in Uganda. We completed 40 in-depth interviews with adults above 50 years who had lived with HIV for more than 10 years. The interviews explored the effect of COVID-19 on their health and social life during the lockdown. We analysed data thematically. Results: The overarching themes regarding the effects of COVID-19 on older adults living with HIV were fear and anxiety during the lockdown, lack of access to health care leading to missing HIV clinic appointments and not taking their ART medicines, financial burden, loss of loved ones, and effect on children's education. Some patients overcame health-related challenges by sending motorcycles to their health facilities with their identifying documents to get the medicines refilled. Some health care providers took the ART medicines to their patients' homes. Conclusion: The COVID-19 lockdown negatively affected the health and social well-being of older PLHIV. This calls for strategies to improve HIV care and treatment access during the lockdown to sustain the HIV program gains in this vulnerable population.

An audit of CT brain findings in adults with new-onset seizures in a resource restricted setting in South Africa

Background: Globally, adults presenting with seizures account for 1% ­ 2% of visits to emergency departments (EDs), of which 25% are new-onset seizures. Neuroimaging is essential as part of the initial workup. Multiple studies have demonstrated abnormal CT brain (CTB) findings in these patients. Objectives: To review the CTB findings in adults presenting with new-onset seizures in a resource restricted setting. Method: A retrospective review of 531 CTBs was conducted at a tertiary hospital in Gauteng on adults presenting to the ED with new-onset seizures. Results: The mean age of the patients was 45.6 ± 17.1 years, and the male to female ratio was 1.2:1. Generalised and focal seizure types were almost equally represented. Of the total 531 patients, 168 (31.6%) were HIV positive. The CTB findings were abnormal in 257 (48.4%) patients, albeit vascular pathology accounted for 21.9%. Infective pathology accounted for 14.1% with a statistically significant association with HIV (p = 0.003). Trauma related pathology was 2.4%, whilst neoplastic pathology was seen in 3.0%. Other causes included congenital pathology, calcifications, atrophy and gliosis. Clinical factors associated with abnormal CTB findings were age ≥ 40 years, HIV infection, hypertension, focal seizures, low Glasgow Coma Scale (GCS), raised cerebrospinal fluid (CSF) protein and presence of lymphocytes. Conclusion: A high yield of abnormal CTB findings was noted in adult patients who presented with new-onset seizures, supporting the use of urgent CTB in patients with certain clinical risk factors. Patients without these risk factors can be scanned within 24­48 h in a resource restricted setting.

Public health challenges of restorative dental practice in low resource settings during the Covid-19 pandemic

Background: COVID-19 remains a major public health threat globally, and has challenged healthcare systems and services including oral health Objective: This study examines the key public health challenges posed by the COVID-19 pandemic in low resource settings. While healthcare services are learning to cope with the COVID-19 pandemic, dental care services, in particular restorative dental practice have been adversely impacted because of the closeness of caregivers to the patient's mouth as well as the generation of aerosols during most restorative procedures. This presents a challenge for low-and-middle-income countries (LMICs) such as Nigeria where weak and poor governance structures characterize healthcare systems in addition to paucity of economic resources. Another challenge in the form of COVID-19 conspiracy theories has threatened to undermine public health efforts designed to control the pandemic. Conclusion: The implementation of optimal guidelines and safety protocols for effective COVID -19 infection prevention and control is a major challenge for restorative dental care practice in low resource settings owing to paucity of key material resources and inappropriate behaviour associated with lingering doubts about COVID-19 reality among the majority of the populace. The Safer Aerosol-Free Emergent Dentistry concept offers a viable practical approach for restorative dental practice in LMICs during and in the post COVID-19 pandemic era. There is a need to deploy all resources, human and material, in the education and enlightenment of the populace regarding the reality of COVID-19.