Defining a screening tool for post-traumatic stress disorder in East Africa: a penalized regression approach.

Background: Scalable PTSD screening strategies must be brief, accurate and capable of administration by a non-specialized workforce. Methods: We used PTSD as determined by the structured clinical interview as our gold standard and considered predictors sets of (a) Posttraumatic Stress Checklist-5 (PCL-5), (b) Primary Care PTSD Screen for the DSM-5 (PC-PTSD) and, (c) PCL-5 and PC-PTSD questions to identify the optimal items for PTSD screening for public sector settings in Kenya. A logistic regression model using LASSO was fit by minimizing the average squared error in the validation data. Area under the receiver operating characteristic curve (AUROC) measured discrimination performance. Results: Penalized regression analysis suggested a screening tool that sums the Likert scale values of two PCL-5 questions-intrusive thoughts of the stressful experience (#1) and insomnia (#21). This had an AUROC of 0.85 (using hold-out test data) for predicting PTSD as evaluated by the MINI, which outperformed the PC-PTSD. The AUROC was similar in subgroups defined by age, sex, and number of categories of trauma experienced (all AUROCs>0.83) except those with no trauma history- AUROC was 0.78. Conclusion: In some East African settings, a 2-item PTSD screening tool may outperform longer screeners and is easily scaled by a non-specialist workforce.

COVID-19 pandemic effects on neonatal inpatient admissions and mortality: interrupted time series analysis of facilities implementing NEST360 in Kenya, Malawi, Nigeria, and Tanzania.

BACKGROUND: The emergence of COVID-19 precipitated containment policies (e.g., lockdowns, school closures, etc.). These policies disrupted healthcare, potentially eroding gains for Sustainable Development Goals including for neonatal mortality. Our analysis aimed to evaluate indirect effects of COVID-19 containment policies on neonatal admissions and mortality in 67 neonatal units across Kenya, Malawi, Nigeria, and Tanzania between January 2019 and December 2021. METHODS: The Oxford Stringency Index was applied to quantify COVID-19 policy stringency over time for Kenya, Malawi, Nigeria, and Tanzania. Stringency increased markedly between March and April 2020 for these four countries (although less so in Tanzania), therefore defining the point of interruption. We used March as the primary interruption month, with April for sensitivity analysis. Additional sensitivity analysis excluded data for March and April 2020, modelled the index as a continuous exposure, and examined models for each country. To evaluate changes in neonatal admissions and mortality based on this interruption period, a mixed effects segmented regression was applied. The unit of analysis was the neonatal unit (n = 67), with a total of 266,741 neonatal admissions (January 2019 to December 2021). RESULTS: Admission to neonatal units decreased by 15% overall from February to March 2020, with half of the 67 neonatal units showing a decline in admissions. Of the 34 neonatal units with a decline in admissions, 19 (28%) had a significant decrease of ≥ 20%. The month-to-month decrease in admissions was approximately 2% on average from March 2020 to December 2021. Despite the decline in admissions, we found no significant changes in overall inpatient neonatal mortality. The three sensitivity analyses provided consistent findings. CONCLUSION: COVID-19 containment measures had an impact on neonatal admissions, but no significant change in overall inpatient neonatal mortality was detected. Additional qualitative research in these facilities has explored possible reasons. Strengthening healthcare systems to endure unexpected events, such as pandemics, is critical in continuing progress towards achieving Sustainable Development Goals, including reducing neonatal deaths to less than 12 per 1000 live births by 2030.

Epidemiology and Clinical Outcomes of Bacterial Meningitis in Children and Adults in Low- and Middle-Income Countries.

Purpose of Review: Despite the availability of effective vaccines against the three primary pathogens (Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis) that cause bacterial meningitis, this condition remains a significant cause of morbidity, neurologic sequelae, and mortality among children and adults living in low-income and middle-income countries. Recent Findings: Bacterial meningitis represents a significant public health challenge for national and global health systems. Since vaccine-preventable meningitis remains highly prevalent in low-income and middle-income countries, the World Health Organization (WHO) recently developed a global roadmap to defeating meningitis by 2030 and ameliorating its associated neurological sequelae. Summary: There is a need for a global approach to surveillance and prevention of bacterial meningitis. Increasing vaccination coverage with conjugate vaccines against pneumococcus and meningococcus with optimal immunization schedules are high-value healthcare interventions. Additionally, overcoming diagnostic challenges and the early institution of empirical antibiotic therapy and, when feasible, adjunctive steroid therapy constitutes the pillars of reducing the disease burden of bacterial meningitis in resource-limited settings.

Therapists' perspective on acceptance of robot-assisted physical rehabilitation in a middle-income country: a study from Vietnam.

Robot-assisted physical rehabilitation offers promising benefits for patients, yet its adoption among therapists remains a complex challenge. This study investigates the acceptance of robot-assisted physical rehabilitation technology among therapists in Vietnam, a middle-income country with a growing demand for rehabilitation services. Drawing on the Technology Acceptance Model 2 (TAM2) and the Theory of Planned Behaviour (TPB), an online survey and semi-structured interviews were conducted to explore therapists' attitudes and intentions towards using this technology. The results show that Vietnamese therapists recognised its potential benefits and expressed a willingness to use it. Although having similar acceptance patterns compared to developed regions, they demonstrated significantly higher levels of agreement across acceptance constructs. This may be attributed to factors such as the novelty effect, cultural perceptions of robots, and the high workload of therapists in Vietnam. Gender and location were found to influence two acceptance constructs-subjective norms and image, respectively-highlighting the need for tailored strategies in technology implementation. The study underscores the importance of considering socio-cultural factors in the adoption of technology and provides insights for enhancing the acceptance and effectiveness of robot-assisted physical rehabilitation in Vietnam. This contributes to the global understanding of therapist acceptance of technology in this field.

While robot-assisted physical rehabilitation offers promising benefits, there is limited understanding of therapist acceptance on a global scale, highlighting the need for more research in this area.This study in a middle-income country, Vietnam, reveals a generally positive view among therapists, but specific issues such as the novelty effect, cultural perceptions of robots, and high therapist workload impact acceptance levels, indicating the need for tailored strategies.Strategies for implementing robot-assisted physical rehabilitation should include addressing training needs, providing technological support, and considering sociocultural factors to enhance acceptance and effectiveness.

Enhancing Patient Outcomes Through Integrated Education and Navigation Programs at the Breast Cancer Comprehensive Center, National Cancer Institute, Cairo University.

Breast cancer remains a significant global health challenge, particularly in low- and middle-income countries where disparities in healthcare exacerbate the disease burden. The Breast Cancer Comprehensive Center at the National Cancer Institute, Cairo University, has implemented integrated patient navigation and education programs aimed at enhancing patient outcomes and healthcare quality. This study evaluated the effectiveness of these programs involving 2202 participants over 12 months. The methodology included systematic data collection, material preparation, and the application of tailored educational strategies to facilitate the patient's journey from diagnosis to treatment. The study utilized three-phased patient navigation assistance to provide comprehensive support. The programs significantly improved patient satisfaction, with over 90% of participants reporting high levels of contentment with the services received. Key improvements included enhanced understanding of breast cancer (including risk factors, symptoms, importance of seeking early care, and treatment options), reduction in patient anxiety, improved treatment adherence, and streamlined diagnostic and treatment processes. Notably, the use of audio-visual educational tools effectively bridged the literacy gap among patients. The integration of patient navigation and education systems at BCCC-NCI has proven to be a highly effective model for improving breast cancer care. This model not only enhances patient understanding and treatment compliance but also facilitates a more efficient healthcare process. The study underscores the potential for replicating this approach in similar healthcare settings globally, suggesting that such integrations can significantly improve cancer care outcomes.

Inequity in uptake of maternal health care services in developing countries: a systematic review and meta-analysis.

Background: Maternal health service uptake remains an important predictor of maternal outcomes including maternal mortality. This systematic review and meta-analysis aimed to summarize the available evidence on the uptake of maternal health care services in developing countries and to assess the impact of place of residence, education status, and wealth index on the uptake of these services. Methods: We examined the databases MEDLINE, Web of Science, Global Index Medicus, and Scopus until June 14, 2022. Cross-sectional studies done between 2015 and 2022 were considered. Mothers of reproductive age and all states of health were included in the study. Independently, two authors determined the eligibility of studies, extracted data, evaluated the risk of bias, and ranked the evidence's degree of certainty. To combine the data, we performed a random-effects meta-analysis. The PROSPERO registration ID is CRD42022304094. Results: We included 51 studies. Mothers living in urban areas were three times more likely to receive antenatal care (OR 2.95; 95% CI 2.23 to 3.89; 15 studies; 340,390 participants) than rural mothers. Compared with no education, those with primary education were twice as likely to utilize antenatal care (OR 2.36; 95% CI 1.80 to 3.09; 9 studies; 154,398 participants) and those with secondary and higher education were six and fourteen times more likely to utilize antenatal care, respectively. Mothers in the second wealth index were twice as likely as mothers in the lowest wealth index to utilize antenatal care (OR 1.62; 95% CI 1.36 to 1.91; 10 studies; 224,530 participants) and antenatal care utilization increased further among mothers in the higher wealth index. We observed similar relative inequalities in skilled delivery care and postnatal care utilization based on the pace of residence, education, and wealth index. Conclusion: In developing countries, the problem of inequity in utilizing maternal health care services persists and needs considerable attention.

Etiology-specific incidence and mortality of diarrheal diseases in the African region: a systematic review and meta-analysis.

BACKGROUND: Diarrheal diseases substantially affect public health impact in low- and middle-income countries (LMIC), particularly in Africa, where previous studies have indicated a lack of comprehensive data. With a growing number of primary studies on enteric infections in Africa, this study aimed to estimate the incidence and mortality of diarrheal pathogens across all ages in Africa in the year 2020. We also explored different methodological assumptions to allow comparison with other approaches. METHODS: Through a systematic review and meta-analysis of data from African LMICs, we estimated the etiology proportions for diarrheal diseases and deaths. We combined the etiology proportions with incidence data collected from a population survey in Africa from 2020 and mortality data from the Global Health Observatory of WHO. RESULTS: We estimated 1,008 billion diarrhea cases (95% UI 447 million-1,4 billion) and 515,031 diarrhea deaths (95% UI 248,983-1,007,641) in the African region in 2020. In children under five, enteroaggregative E. coli (EAEC) (44,073 cases per 100,000 people, 95% UI 18,818 - 60,922) and G. lamblia (36,116 cases per 100,000 people, 95% UI 15,245 - 49,961) were the leading causes of illness. Enteroinvasive E. coli (EIEC) (155 deaths per 100,000 people, 95% UI 106.5-252.9) and rotavirus (61.5 deaths per 100,000 people, 95% UI 42.3-100.3) were the primary causes of deaths. For children over five and adults, Salmonella spp. caused the largest number of diarrheal cases in the population of children ≥ 5 and adults (122,090 cases per 100,000 people, 95% UI 51,833 - 168,822), while rotavirus (16.4 deaths per 100,000 people, 95% UI 4.2-36.7) and enteroaggregative E. coli (EAEC) (14.6 deaths per 100,000 people, 95% UI 3.9-32.9) causing the most deaths. Geographically, the highest incidence of diarrhea was in Eastern Africa for children under five (114,389 cases per 100,000 people, 95% UI 34,771 - 172,884) and Central Africa for children over five and adults (117,820 cases per 100,000 people, 95% UI 75,111-157,584). Diarrheal mortality was highest in Western Africa for both children below five and above (children < 5: 194.5 deaths per 100,000 people, 95% UI 120-325.4; children ≥ 5 and above: 33.5 deaths per 100,000 people, 95% UI 12.9-75.1). CONCLUSION: These findings provide new information on the incidence and mortality of sixteen pathogens and highlight the need for surveillance and control of diarrheal infectious diseases in Africa. The cause-specific estimates are crucial for prioritizing diarrheal disease prevention in the region.

Interventions addressing routine childhood immunization and its behavioral and social drivers.

Introduction: Despite the advances in vaccination, there are still several challenges in reaching millions of children in low- and middle-income countries (LMICs). In this review, we present an extensive summary of the various strategies used for improving routine immunization in LMICs to aid program implementers in designing vaccination interventions. Methods: Experimental and quasi-experimental impact evaluations conducted in LMICs evaluating the effectiveness of interventions in improving routine immunization of children aged 0-5 years or the intermediate outcomes were included from 3ie's review of systematic reviews. Some additional impact evaluation studies published in recent years in select LMICs with large number of unvaccinated children were also included. Studies were coded to identify interventions and the barriers in the study context using the intervention framework developed in 3ie's Evidence Gap Map and the WHO's Behavioral and Social Drivers (BeSD) of vaccination framework, respectively. Qualitative analysis of the content was conducted to analyze the intervention strategies and the vaccination barriers that they addressed. Results and conclusion: One hundred and forty-two impact evaluations were included to summarize the interventions. To address attitudinal and knowledge related barriers to vaccination and to motivate caregivers, sensitization and educational programs, media campaigns, and monetary or non-monetary incentives to caregivers, that may or may not be conditional upon certain health behaviors, have been used across contexts. To improve knowledge of vaccination, its place, time, and schedule, automated voice messages and written or pictorial messages have been used as standalone or multicomponent strategies. Interventions used to improve service quality included training and education of health workers and providing monetary or non-monetary perks to them or sending reminders to them on different aspects of provision of vaccination services. Interventions like effective planning or outreach activities, follow-up of children, tracking of children that have missed vaccinations, pay-for-performance schemes and health system strengthening have also been used to improve service access and quality. Interventions aimed at mobilizing and collaborating with the community to impact social norms, attitudes, and empower communities to make health decisions have also been widely implemented.

Urgent action needed: addressing the regulatory gap in e-cigarette trade and usage.

Tobacco use is associated with serious health problems. Global efforts, such as the World Health Organization's Framework for Tobacco Control, have reduced tobacco use, but challenges remain. Initially perceived as aids for smoking cessation, e-cigarettes have gained popularity among young people and non-smokers. Government approaches to regulating e-cigarettes range from treating them like tobacco, requiring a prescription for their use to outright bans. Although touted as a valuable alternative, evidence suggests that increased e-cigarette use carries potential direct and indirect health risks, necessitating urgent regulatory measures on a global scale. Lack of defined and uniform regulations poses substantial public health risks, compounded by marketing targeting vulnerable groups. Immediate interventions, public awareness, and research are essential to effectively control the current e-cigarette epidemic.

A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: statistical analysis plan for a pragmatic cluster randomised controlled trial.

BACKGROUND: Globally, violence against children poses substantial health and economic challenges, with estimated costs nearing USD 7 trillion. This prompts the urgent call for effective evidence-based interventions in preventing and mitigating violence against children. ParentApp is a mobile, open-source application designed to offer a remote version of the Parenting for Lifelong Health (PLH) programme. ParentApp is the first digital parenting intervention for caregivers of adolescents aged 10-17 years to be tested in low- and middle-income settings. METHODS: This study is a pragmatic, two-arm, cluster-randomised trial in Mwanza, Tanzania's urban and peri-urban areas. Assessments are set for baseline, 1 month post-intervention, and 12 months post-intervention. We randomised 80 clusters, each with about 30 caregiver-adolescent dyads, with a 1:1 ratio stratified by urban or peri-urban location. Both arms receive an entry-level smartphone preloaded with Kiswahili apps-ParentApp for intervention and WashApp control. The primary method of analysis will be generalised linear mixed-effects models with adjustment for person-level characteristics and multiple imputation. In three-level models, measurement waves are nested within a person, nested within a sub-ward. Regressions will constrain groups to be equal at baseline and include covariates for stratification, percentage of male caregivers, and individual-level characteristics. DISCUSSIONS: Preparations for the trial began in December 2022, including community mobilisation and sensitisation. Rolling recruitment, baseline data collection, and implementation onboarding took place between April and September 2023. One-month post-test data collection began in August 2023 and thus far achieved 97% and 94% retention rates for caregivers and adolescents respectively. Final post-test data collection will begin in September 2024, anticipated to run until April 2025. This SAP was submitted to the journal before the interim analysis to preserve scientific integrity under a superiority hypothesis testing framework. TRIAL REGISTRATION: The trial was registered on the Open Science Framework on 14 March 2023: https://doi.org/10.17605/OSF.IO/T9FXZ . The trial protocol was published in Trials 25, 119 (2024): Baerecke, L., Ornellas, A., Wamoyi, J. et al. A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: study protocol for a pragmatic cluster-randomised controlled trial. Trials 25, 119 (2024). https://doi.org/10.1186/s13063-023-07893-x .

Understanding modifiable caregiver factors contributing to child development among young children in rural Malawi.

This study examined modifiable caregiver factors influencing child development in Malawi using baseline data from 1,021 mothers and their children <2 years of age participating in a cluster-randomized controlled trial implemented in rural Malawi (2022-2025). We fit an evidence-based theoretical model using structural equation modelling examining four caregiver factors: (1) diet diversity (sum of food groups consumed in the past 24 h), (2) empowerment (assessed using the project-level Women's Empowerment in Agriculture Index), (3) mental health (assessed using the Self-Reported Questionnaire, SRQ-20), and (4) stimulation (number of stimulation activities the mother engaged in the past 3 days). Child development was assessed using the Malawi Development Assessment Tool (norm-referenced aggregate Z-score). The model controlled for child, caregiver, and household socioeconomic characteristics. Results showed that caregiver dietary diversity was directly associated with higher child development scores (standardized coefficient 0.091 [95% CI 0.027, 0.153]) and lower SRQ-20 scores -0.058 (-0.111, -0.006). Empowerment was directly associated with higher child development scores (0.071 [0.007, 0.133]), higher stimulation score (0.074 [0.013, 0.140]), higher dietary diversity (0.085 [0.016, 0.145]), and lower SRQ-20 scores (-0.068 [-0.137, -0.002]). Further, higher empowerment was indirectly associated with improved child development through enhancement of caregiver dietary diversity, with an indirect effect of 0.008 (0.002, 0.018). These findings highlight the important role that caregiver diet and empowerment play in directly influencing child development and other aspects of caregiver well-being. Interventions aimed at enhancing child development should consider these factors as potential targets to improve outcomes for children and caregivers.

The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries.

The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study.

PURPOSE: Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study. MATERIAL AND METHODS: This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study. RESULTS: Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists. CONCLUSION: The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

A biopsychosocial approach to managing chronic low back pain offers a promising alternative to patients and physiotherapists in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to improve physiotherapists' thoughts and attitudes, and have a positive influence on their professional development in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to reverse patients' maladaptive beliefs, improve their understanding of their condition, improve outcomes in Ghana.

Core recommendations of effective preconception counselling services in low-and-middle-income countries - A scoping review.

BACKGROUND: Extensive guidelines and recommendations are available for preconception counselling service in high-income-countries. However limited comprehensive recommendations are available for preconception care and counselling in low-and-middle-income countries (LMICs), where most of maternal mortality occurs in the settings. AIM/OBJECTIVES: This review aims to identify any design, model or set of recommendations for their potential adoption to develop preconception care and counselling service for LMICs context. METHODS: A systematic literature search was conducted in five major databases to identify articles covering any designs, models or recommendations on preconception care, for or from LMICs settings published between 2013-2023. Articles on any single screening for preconception counselling, those evaluating the service without specific model or sets of recommendations were excluded. Articles satisfied the inclusion criteria were then appraised and were extracted and analysed using inductive approach of thematic analysis. FINDINGS: A total of nine articles were eligible for complete review, mostly were review papers, editorials and commission articles with moderate manuscript quality. Three themes of recommendations emerged from the analysis: Platforms, Core Principles, and Women Empowerment. The Platform contains recommendations on the settings, while Core principles provide essential recommendation of screening and management, while the theme Women Empowerment highlights the importance of empowering women to prepare and decide on their pregnancy. IMPLICATIONS: Actual model of preconception care in LMICs is deficient, results of this review will inform research on the development of appropriate preconception care in LMICs . We also propose for access equity and strategies to promote women empowerment as the key to succeed the preconception care in LMICs.

Saltwater intrusion and human health risks for coastal populations under 2050 climate scenarios.

Populations consuming saline drinking water are at greater risk of high blood pressure and potentially other adverse health outcomes. We modelled data and used available datasets to identify countries of higher vulnerability to future saltwater intrusion associated with climate change in 2050 under Representative Concentration Pathways (RCP)4.5 and RCP8.5. We developed three vulnerability criteria to capture geographies with: (1) any coastal areas with projected inland saltwater intrusion of ≥ 1 km inland, (2) > 50% of the population in coastal secondary administrative areas with reliance on groundwater for drinking water, and 3) high national average sodium urinary excretion (i.e., > 3 g/day). We identified 41 nations across all continents (except Antarctica) with ≥ 1 km of inland saltwater intrusion by 2050. Seven low- and middle-income countries of higher vulnerability were all concentrated in South/Southeast Asia. Based on these initial findings, future research should study geological nuances at the local level in higher-risk areas and co-produce with local communities contextually appropriate solutions to secure equitable access to clean drinking water.

Urgent appeal for expanded initiatives in gastric motility disorders across low and middle-income countries: illustrating the example of gastroparesis.

This paper provides a comprehensive exploration of the current state of gastroparesis management in low and middle-income countries (LMICs), emphasising recent innovations, persistent challenges, and future prospects. Gastroparesis, a condition characterised by delayed stomach emptying, presents debilitating symptoms and is notably linked to neuropathic disorders, including diabetes mellitus. Despite an apparent higher prevalence in LMICs compared to the global average, epidemiological data remains scarce. The paper highlights pioneering research in Pakistan, Brazil, and China, showcasing a transformative shift toward comprehensive studies that delve into nuanced aspects of gastroparesis epidemiology, gender-specific patterns, and innovative therapeutic approaches such as acupuncture. However, challenges impeding clinical management and research in LMICs are identified, encompassing the absence of extensive epidemiological studies, lack of treatment guidelines, and the scarcity of specialised training programs for healthcare professionals. These challenges are intertwined with broader issues such as limited healthcare infrastructure, resource disparities, and healthcare workforce shortages. The paper proposes a multifaceted approach for addressing these challenges, involving international collaboration, capacity building, and the integration of gastroparesis management into primary healthcare services. Strategies to combat brain drain, such as collaborative agreements akin to the UK-South Africa Memorandum of Understanding, are advocated.

Study protocol for a stepped-wedge implementation study investigating the intersectoral collaboration of implementering the TREAT INTERACT intervention for primary school teachers and the mhGAP for health care workers for child mental health promotion in Uganda.

BACKGROUND: Mental and neuropsychological disorders make up approximately 14% of the total health burden globally, with 80% of the affected living in low- and middle-income countries (LMICs) of whom 90% cannot access mental health services. The main objective of the TREAT INTERACT study is to adapt, implement, and evaluate the impact of a novel, intersectoral approach to prevent, identify, refer, and treat mental health problems in children through a user centred task-sharing implementation of the TREAT INTERACT intervention, inspired by the World Health Organization (WHO) Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) for primary school staff in Mbale, Uganda. Health care personell will be trained in the mhGAP-IG. METHODS: This is a pragmatic mixed-methods hybrid Type II implementation-effectiveness study utilizing a co-design approach. The main study utilize a stepped-wedged trial design with six starting sequences, randomizing three schools to the intervention at each interval, while the remaining act as "controls". Other designs include a nested prospective cohort study, case control studies, cross-sectional studies, and qualitative research. Main participants' outcomes include teachers' mental health literacy, stigma, and violence towards the school children. Implementation outcomes include detection, reach, sustainability, and service delivery. Child and caregiver outcomes include mental health, mental health literacy, and help-seeking behaviour. DISCUSSION: Based on the results, we will develop sustainable and scalable implementation advice on mental health promotion and draft implementation guidelines in line with current WHO guidelines. This project will generate new knowledge on the structure, organization, delivery, and costs of mental health services in a LMIC setting, as well as new knowledge on the implementation and delivery of new health services. TRIAL REGISTRATION: ClinicalTrials, NCT06275672, 28.12.2023, retrospectively registered.

Cost-effectiveness and efficacy of scalp block for elective supratentorial craniotomy in resource-limited settings: A randomized controlled trial.

Background: Remifentanil is favored for neurosurgical pain management, but its utilization in low- and middle-income countries (LMICs) is limited. Scalp block techniques are effective in LMICs, but cost-effectiveness is uncertain. This study compares costs and perioperative outcomes of scalp block versus fentanyl infusion in patients undergoing elective supratentorial craniotomy. Methods: A prospective double-blind randomized controlled trial was conducted with 36 patients aged 18- 65 years undergoing elective supratentorial craniotomy. Patients were randomly assigned to receive either scalp block with 0.5% bupivacaine (Group S) or fentanyl infusion (Group F), with normal saline placebo administered in both groups. The primary endpoint was the anesthetic costs, with secondary endpoints including perioperative opioid consumption, intraoperative hemodynamic changes, and perioperative complications. Results: The cost of fentanyl was significantly lower than that of local anesthetics (3.31 [3.31, 3.75] vs. 4.27 [4.27, 4.27] United States dollars, P < 0.001). However, the overall anesthetic cost did not differ significantly between groups. Group F demonstrated a significant reduction in mean arterial pressure immediately and 5 min after pin insertion compared to Group S (75.8 [13.9] vs. 92.5 [16.9] mmHg, P = 0.003 and 67.7 [6.4] vs. 78.5 [10.7] mmHg, P < 0.001, respectively). Conclusion: Fentanyl infusion presents cost advantages over scalp block in LMIC settings. However, prudent opioid use is imperative. This study underscores the need for ongoing research to optimize neurosurgical pain management and evaluate long-term safety implications.

Use of artificial intelligence to address health disparities in low- and middle-income countries: a thematic analysis of ethical issues.

OBJECTIVES: Artificial intelligence (AI) is reshaping health and medicine, especially through its potential to address health disparities in low- and middle-income countries (LMICs). However, there are several issues associated with the use of AI that may reduce its impact and potentially exacerbate global health disparities. This study presents the key issues in AI deployment faced by LMICs. STUDY DESIGN: Thematic analysis. METHODS: PubMed, Scopus, Embase and the Web of Science databases were searched, from the date of their inception until September 2023, using the terms "artificial intelligence", "LMICs", "ethic∗" and "global health". Additional searches were conducted by snowballing references before and after the primary search. The final studies were chosen based on their relevance to the topic of this article. RESULTS: After reviewing 378 articles, 14 studies were included in the final analysis. A concept named the 'AI Deployment Paradox' was introduced to focus on the challenges of using AI to address health disparities in LMICs, and the following three categories were identified: (1) data poverty and contextual shifts; (2) cost-effectiveness and health equity; and (3) new technological colonisation and potential exploitation. CONCLUSIONS: The relationship between global health, AI and ethical considerations is an area that requires systematic investigation. Relying on health data inherent with structural biases and deploying AI without systematic ethical considerations may exacerbate global health inequalities. Addressing these challenges requires nuanced socio-political comprehension, localised stakeholder engagement, and well-considered ethical and regulatory frameworks.