Browsing by Subject "Low- and middle-income countries"
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Item A type III effectiveness-implementation hybrid evaluation of a multicomponent patient navigation strategy for advanced-stage Kaposi’s sarcoma: protocol(Springer, 2022-05-13) Collier, Sigrid; Semeere, Aggrey; Byakwaga, Helen; Laker-Oketta, Miriam; Chemtai, Linda; Wagner, Anjuli D.; Bassett, Ingrid V.; Wools-Kaloustian, Kara; Maurer, Toby; Martin, Jeffrey; Kiprono, Samson; Freeman, Esther E.; Medicine, School of MedicineBackground: For people with advanced-stage Kaposi’s sarcoma (KS), a common HIV-associated malignancy in sub-Saharan Africa, mortality is estimated to be 45% within 2 years after KS diagnosis, despite increasingly wide-spread availability of antiretroviral therapy and chemotherapy. For advanced-stage KS, chemotherapy in addition to antiretroviral therapy improves outcomes and saves lives, but currently, only ~50% of people with KS in western Kenya who have an indication for chemotherapy actually receive it. This protocol describes the evaluation of a multicomponent patient navigation strategy that addresses common barriers to service penetration of and fidelity to evidence-based chemotherapy among people with advanced-stage KS in Kenya. Methods: This is a hybrid type III effectiveness-implementation study using a non-randomized, pre- post-design nested within a longitudinal cohort. We will compare the delivery of evidence-based chemotherapy for advanced stage KS during the period before (2016–2020) to the period after (2021–2024), the rollout of a multicomponent patient navigation strategy. The multicomponent patient navigation strategy was developed in a systematic process to address key determinants of service penetration of and fidelity to chemotherapy in western Kenya and includes (1) physical navigation and care coordination, (2) video-based education, (3) travel stipend, (4) health insurance enrollment assistance, (5) health insurance stipend, and (6) peer mentorship. We will compare the pre-navigation period to the post-navigation period to assess the impact of this multicomponent patient navigation strategy on (1) implementation outcomes: service penetration (chemotherapy initiation) and fidelity (chemotherapy completion) and (2) service and client outcomes: timeliness of cancer care, mortality, quality of life, stigma, and social support. We will also describe the implementation process and the determinants of implementation success for the multicomponent patient navigation strategy. Discussion: This study addresses an urgent need for effective implementation strategies to improve the initiation and completion of evidence-based chemotherapy in advanced-stage KS. By using a clearly specified, theory-based implementation strategy and validated frameworks, this study will contribute to a more comprehensive understanding of how to improve cancer treatment in advanced-stage KS.Item Association of hemoglobin levels in the first trimester and at 26 to 30 weeks with fetal and neonatal outcomes: A secondary analyses of the Global Network for Women’s and Children’s Health’s ASPIRIN Trial(Wiley, 2021) Jessani, Saleem; Saleem, Sarah; Hoffman, Matthew K.; Goudar, Shivaprasad S.; Derman, Richard J.; Moore, Janet L.; Garces, Ana; Figueroa, Lester; Krebs, Nancy F.; Okitawutshu, Jean; Tshefu, Antoinette; Bose, Carl L.; Mwenechanya, Musaku; Chomba, Elwyn; Carlo, Waldemar A.; Das, Prabir Kumar; Patel, Archana; Hibberd, Patricia L.; Esamai, Fabian; Liechty, Edward A.; Bucher, Sherri; Nolen, Tracy L.; Koso-Thomas, Marion; Miodovnik, Menachem; McClure, Elizabeth M.; Goldenberg, Robert L.; Social and Behavioral Sciences, School of Public HealthObjective: Limited data are available from low- and middle-income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes. Design: ASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6+0 -13+6 weeks and 26+0 -30+0 weeks of gestation with fetal and neonatal outcomes. Setting: Obstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala. Population: A total of 11 976 pregnant women. Methods: Generalised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes. Main outcome measures: Preterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g. Results: The mean haemoglobin levels at 6+0 -13+6 weeks and at 26-30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6+0 -13+6 weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70-89 g/l compared with haemoglobin of 110-129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26-30 weeks of gestation. Conclusions: Both lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6+0 -13+6 weeks and at 26-30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger.Item Caesarean birth by maternal request: a poorly understood phenomenon in low- and middle-income countries(Oxford University Press, 2021-01-14) Harrison, Margo S.; Garces, Ana; Figueroa, Lester; Esamai, Fabian; Bucher, Sherri; Bose, Carl; Goudar, Shivaprasad; Derman, Richard; Patel, Archana; Hibberd, Patricia L.; Chomba, Elwyn; Mwenechanya, Miusaku; Hambidge, Michael; Krebs, Nancy F.; Medicine, School of MedicineBackground: While trends in caesarean birth by maternal request in low- and middle-income countries are unclear, age, education, multiple gestation and hypertensive disease appear associated with the indication when compared with caesarean birth performed for medical indications. Methods: We performed a secondary analysis of a prospectively collected population-based study of home and facility births using descriptive statistics, bivariate comparisons and multilevel mixed-effects logistic regression. Results: Of 28 751 patients who underwent caesarean birth and had a documented primary indication for the surgery, 655 (2%) were attributed to caesarean birth by maternal request. The remaining 98% were attributed to maternal and foetal indications and prior caesarean birth. In a multilevel mixed effects logistic regression adjusted for site and cluster of birth, when compared with caesareans performed for medical indications, caesarean birth performed for maternal request had a higher odds of being performed among women ≥35 y of age, with a university or higher level of education, with multiple gestations and with pregnancies complicated by hypertension (P < 0.01). Caesarean birth by maternal request was associated with a two-times increased odds of breastfeeding within 1 h of delivery, but no adverse outcomes (when compared with women who underwent caesarean birth for medical indications; P < 0.01). Conclusion: Caesarean performed by maternal request is more common in older and more educated women and those with multifoetal gestation or hypertensive disease. It is also associated with higher rates of breastfeeding within 1 h of delivery.Item Ensuring Patient-Centered Access to Cardiovascular Disease Medicines in Low-Income and Middle-Income Countries Through Health-System Strengthening(Elsevier, 2017) Tran, Dan N.; Njuguna, Benson; Mercer, Timothy; Manji, Imran; Fischer, Lydia; Lieberman, Marya; Pastakia, Sonak; Medicine, School of MedicineCardiovascular disease (CVD) is the leading cause of global mortality and is expected to reach 23 million deaths by 2030. 80% of CVD deaths occur in low- and middle- income countries (LMICs). Although CVD prevention and treatment guidelines are available, translating these into practice is hampered in LMICs by inadequate healthcare systems which limit access to lifesaving medications. In this review article, we describe the deficiencies in the current LMIC supply chains that limit access to effective CVD medicines, and discuss existing solutions that are translatable to similar settings in order to address these deficiencies.Item Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis(Frontiers Media, 2024-06-07) Kortz, Teresa B.; Mediratta, Rishi P.; Smith, Audrey M.; Nielsen, Katie R.; Agulnik, Asya; Gordon Rivera, Stephanie; Reeves, Hailey; O'Brien, Nicole F.; Hau Lee, Jan; Abbas, Qalab; Attebery, Jonah E.; Bacha, Tigist; Bhutta, Emaan G.; Biewen, Carter J.; Camacho-Cruz, Jhon; Coronado Muñoz, Alvaro; deAlmeida, Mary L.; Owusu, Larko Domeryo; Fonseca, Yudy; Hooli, Shubhada; Wynkoop, Hunter; Leimanis-Laurens, Mara; Mally, Deogratius Nicholaus; McCarthy, Amanda M.; Mutekanga, Andrew; Pineda, Carol; Remy, Kenneth E.; Sanders, Sara C.; Tabor, Erica; Teixeira Rodrigues, Adriana; Yuee Wang, Justin Qi; Kissoon, Niranjan; Takwoingi, Yemisi; Wiens, Matthew O.; Bhutta, Adnan; Pediatrics, School of MedicineIn 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%–4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9–14)]; respiratory [9 (95% CI 5–13)]; and gastrointestinal [9 (95% CI 6–11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231–280)]; infectious [214 (95% CI 193–234)]; and gastrointestinal [166 (95% CI 143–190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.Item Impact of Maternal Viral Suppression on Growth Patterns for HIV-Exposed Uninfected Infants in Kenya(Global Health and Education Projects, 2024-04-22) Magerko, Katherine; Humphrey, John; Songok, Julia; Musick, Beverly; Alera, Joy Marsha; Kipchumba, Bett; Kosgei, Wycliffe; Mwangi, Winfred; Yang, Ziyi; Wools-Kaloustian, Kara; McHenry, Megan S.; Pediatrics, School of MedicineBackground and objective: Children born to mothers living with human immunodeficiency virus (HIV) are at risk for poor health outcomes but data characterizing these associations are limited. Our objective was to determine the impact of maternal viral suppression on growth patterns and malnutrition for infants who are HIV-exposed but uninfected (HEU). Methods: We conducted a retrospective cohort analysis of clinical data for infants who were HEU and their mothers (September 2015 - March 2019) in Kenya. Infants were stratified based on maternal viral suppression status (≥ or <1000 copies/mL); t-tests were used to compare groups. Growth indicators were evaluated with Chi-square, Fisher's exact, and area under the curve. Moderate-to-severe underweight status, stunting, and wasting were defined by weight-for-age (WFA), height-for-age (HFA), and weight-for-height (WFH), z-scores ≤2, and were used to define malnutrition. Multivariate logistic regression analyses were performed to evaluate potential associations with malnutrition indicators between WFH and HFA. Results: Among 674 infants who were HEU, 48.7% were male and 85.0% had mothers who were virally suppressed. The median age at first and last clinic visits was 1.5 and 16.4 months, respectively. WFA and HFA z-scores over time differed by sex, and WFA and HFA differed based on maternal viral suppression (P < 0.05). Male infants had higher adjusted odds for stunted status, and as children aged, they had slightly increased odds of becoming underweight or stunted. Maternal viral suppression and timing of maternal antiretroviral therapy initiation in relation to the prevention of vertical transmission (PVT) enrollment did not significantly affect malnutrition indicators. Conclusion and global health implications: Maternal viral suppression status was not associated with increased odds of more severe malnutrition indicators in children who were HEU. However, overall growth patterns over time, measured by z-scores of growth indicators, did differ based on maternal viral suppression status, and to a lesser degree, by gender.Item Impact of the COVID-19 pandemic on TB services at ART programmes in low- and middle-income countries: a multi-cohort survey(Wiley, 2022) Marti, Mariana; Zürcher, Kathrin; Enane, Leslie A.; Diero, Lameck; Marcy, Olivier; Tiendrebeogo, Thierry; Yotebieng, Marcel; Twizere, Christelle; Khusuwan, Suwimon; Yunihastuti, Evy; Reubenson, Gary; Shah, N. Sarita; Egger, Matthias; Ballif, Marie; Fenner, Lukas; IeDEA global consortium; Pediatrics, School of MedicineIntroduction: COVID-19 stretched healthcare systems to their limits, particularly in settings with a pre-existing high burden of infectious diseases, including HIV and tuberculosis (TB). We studied the impact of COVID-19 on TB services at antiretroviral therapy (ART) clinics in low- and middle-income countries. Methods: We surveyed ART clinics providing TB services in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in Africa and the Asia-Pacific until July 2021 (TB diagnoses until the end of 2021). We collected site-level data using standardized questionnaires. Results: Of 46 participating ART clinics, 32 (70%) were in Africa and 14 (30%) in the Asia-Pacific; 52% provided tertiary care. Most clinics (85%) reported disrupted routine HIV care services during the pandemic, both in Africa (84%) and the Asia-Pacific (86%). The most frequently reported impacts were on staff (52%) and resource shortages (37%; protective clothing, face masks and disinfectants). Restrictions in TB health services were observed in 12 clinics (26%), mainly reduced access to TB diagnosis and postponed follow-up visits (6/12, 50% each), and restrictions in TB laboratory services (22%). Restrictions of TB services were addressed by dispensing TB drugs for longer periods than usual (7/12, 58%), providing telehealth services (3/12, 25%) and with changes in directly observed therapy (DOT) (e.g. virtual DOT, 3/12). The number of TB diagnoses at participating clinics decreased by 21% in 2020 compared to 2019; the decline was more pronounced in tertiary than primary/secondary clinics (24% vs. 12%) and in sites from the Asia-Pacific compared to Africa (46% vs. 14%). In 2021, TB diagnoses continued to decline in Africa (-8%) but not in the Asia-Pacific (+62%) compared to 2020. During the pandemic, new infection control measures were introduced or intensified at the clinics, including wearing face masks, hand sanitation and patient triage. Conclusions: The COVID-19 pandemic led to staff shortages, reduced access to TB care and delays in follow-up visits for people with TB across IeDEA sites in Africa and the Asia-Pacific. Increased efforts are needed to restore and secure ongoing access to essential TB services in these contexts.Item Implementing a Locally Made Low-Cost Intervention for Wound and Lymphedema Care in Western Kenya(Elsevier, 2021) Chang, Aileen Y.; Mungai, Margaret; Coates, Sarah J.; Chao, Tiffany; Odhiambo, Haji Philip; Were, Phelix M.; Fletcher, Sara L.; Maurer, Toby; Karwa, Rakhi; Pastakia, Sonak D.; Dermatology, School of MedicineIn Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.Item Outcomes of pediatric acute myeloid leukemia treatment in Western Kenya(Wiley, 2022) van Weelderen, Romy E.; Njuguna, Festus; Klein, Kim; Mostert, Saskia; Langat, Sandra; Vik, Terry A.; Olbara, Gilbert; Kipng'etich, Martha; Kaspers, Gertjan J.L.; Pediatrics, School of MedicineBackground: Pediatric acute myeloid leukemia (AML) is a challenging disease to treat in low- and middle-income countries (LMICs). Literature suggests that survival in LMICs is poorer compared with survival in high-income countries (HICs). Aims: This study evaluates the outcomes of Kenyan children with AML and the impact of sociodemographic and clinical characteristics on outcome. Methods and results: A retrospective medical records study was performed at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya, between January 2010 and December 2018. Sociodemographic and clinical characteristics, and treatment outcomes were evaluated. Chemotherapy included two "3 + 7" induction courses with doxorubicin and cytarabine and two "3 + 5" consolidation courses with etoposide and cytarabine. Supportive care included antimicrobial prophylaxis with cotrimoxazole and fluconazole, and blood products, if available. Seventy-three children with AML were included. The median duration of symptoms before admission at MTRH was 1 month. The median time from admission at MTRH to diagnosis was 6 days and to the start of AML treatment 16 days. Out of the 55 children who were started on chemotherapy, 18 (33%) achieved complete remission, of whom 10 (56%) relapsed. The abandonment rate was 22% and the early death rate was 46%. The 2-year probabilities of event-free survival and overall survival were 4% and 7%, respectively. None of the sociodemographic and clinical characteristics were significantly associated with outcome. Conclusion: Survival of Kenyan children with AML is dismal and considerably lower compared with survival in HICs. Strategies to improve survival should be put in place including better supportive care, optimization of the treatment protocol, and reduction of the abandonment rate and time lag to diagnosis with sooner start of treatment.Item Perceptions of Global Health Engagements in Relation to the COVID-19 Pandemic Among Health Care Workers and Administrators in Western Kenya: Protocol for a Multistage Qualitative Study(JMIR, 2023-07-19) Amick, Erick; Naanyu, Violet; Bucher, Sherri; Henry, Beverly W.; Pediatrics, School of MedicineBackground: There has been significant interest in global health in low- and middle-income countries (LMICs) among individuals living in high-income countries (HICs) over the past 30 years. Much of the literature on global health engagements (GHEs) has been presented from the perspective of individuals from high-income countries. Local stakeholders such as health care workers and health care administrators represent critical constituencies for global health activities, yet their perspectives are underrepresented in the literature. The purpose of this study is to examine the experiences of local health care workers and administrators with GHEs in Kenya. We will explore the perceived role GHEs play in preparing the health system to address a public health crisis, as well as their role in pandemic recovery and its aftermath. Objective: The aims of this study are to (1) examine how Kenyan health care workers and administrators interpret experiences with GHEs as having advantaged or hindered them and the local health system to provide care during an acute public health crisis and (2) to explore recommendations to reimagine GHEs in a postpandemic Kenya. Methods: This study will be conducted at a large teaching and referral hospital in western Kenya with a long history of hosting GHEs in support of its tripartite mission of providing care, training, and research. This qualitative study will be conducted in 3 phases. In phase 1, in-depth interviews will be conducted to capture participants' lived experience in relation to their unique understandings of the pandemic, GHEs, and the local health system. In phase 2, group discussions using nominal group techniques will be conducted to determine potential priority areas to reimagine future GHEs. In phase 3, in-depth interviews will be conducted to explore these priority areas in greater detail to explore recommendations for potential strategies, policies, and other actions that might be used to achieve the priorities determined to be of highest importance. Results: The study activities commenced in late summer 2022, with findings to be published in 2023. It is anticipated that the findings from this study will provide insight into the role GHEs play in a local health system in Kenya and provide critical stakeholder and partner input from persons hitherto ignored in the design, implementation, and management of GHEs. Conclusions: This qualitative study will examine the perspectives of GHEs in relation to the COVID-19 pandemic among Kenyan health care workers and health care administrators in western Kenya using a multistage protocol. Using a combination of in-depth interviews and nominal group techniques, this study aims to shed light on the roles global health activities are perceived to play in preparing health care professionals and the health system to address an acute public health crisis.