Management of autoimmune haemolytic anaemia in low-to-middle income countries: current challenges and the way forward

Autoimmune haemolytic anaemia (AIHA) is a common term for several disorders that differ from one another in terms of aetiology, pathogenesis, clinical features, and treatment. Therapy is becoming increasingly differentiated and evidence-based, and several new established and investigational therapeutic approaches have appeared during recent years. While this development has resulted in therapeutic improvements, it also carries increased medical and financial requirements for optimal diagnosis, subgrouping, and individualization of therapy, including the use of more advanced laboratory tests and expensive drugs. In this brief Viewpoint review, we first summarize the diagnostic workup of AIHA subgroups and the respective therapies that are currently considered optimal. We then compare these principles with real-world data from India, the world's largest nation by population and a typical low-to-middle income country. We identify major deficiencies and limitations in general and laboratory resources, real-life diagnostic procedures, and therapeutic practices. Incomplete diagnostic workup, overuse of corticosteroids, lack of access to more specific treatments, and poor follow-up of patients are the rule more than exceptions. Although it may not seem realistic to resolve all challenges, we try to outline some ways towards an improved management of patients with AIHA.

Results from the Philippines' 2022 report card on physical activity for children and adolescents

Background/Objective

The 2022 Philippine Report Card on Physical Activity for Children and Adolescents provides a comprehensive assessment of physical activity and other related behaviors, including the various factors and settings that influence these behaviors. It serves as an advocacy tool to increase awareness of the physical activity situation among children and young people in the country. This article describes the development and results of the first Philippine Report Card on Physical Activity for Children and Adolescents.

Methods

Following a systematic process provided by the Active Healthy Kids Global Alliance, a team consisting of 25 sports and physical activity specialists identified and reviewed the best available nationally representative data related to physical activity indicators. These data were then used to inform the grades of the ten (10) physical activity indicators.

Results

Sufficient data were identified to assign grades to five (5) indicators: Overall Physical Activity (F), Active Transportation (D), Sedentary Behavior (B), School (C-), and Government (B). Insufficient data existed to assign grades to the remaining five (5) indicators: Organized Sport and Physical Activity, Active Play, Physical Fitness, Family and Peers, and Community and Environment.

Conclusion

Despite government policies related to physical activity in the country, the majority of children and adolescents in the Philippines do not meet the recommended amount of physical activity for health. More work is needed to improve the translation of these policies into measurable programs, highlighting the need to create better physical activity opportunities and develop national surveillance mechanisms.

A systematic review of validated screening tools for anxiety disorders and PTSD in low to middle income countries

BACKGROUND

Anxiety and post-traumatic stress disorder (PTSD) contribute significantly to disability adjusted life years in low- to middle-income countries (LMICs). Screening has been proposed to improve identification and management of these disorders, but little is known about the validity of screening tools for these disorders. We conducted a systematic review of validated screening tools for detecting anxiety and PTSD in LMICs.

METHODS

MEDLINE, EMBASE, Global Health and PsychINFO were searched (inception-April 22, 2020). Eligible studies (1) screened for anxiety disorders and/or PTSD; (2) reported sensitivity and specificity for a given cut-off value; (3) were conducted in LMICs; and (4) compared screening results to diagnostic classifications based on a reference standard. Screening tool, cut-off, disorder, region, country, and clinical population were extracted for each study, and we assessed study quality. Accuracy results were organized based on screening tool, cut-off, and specific disorder. Accuracy estimates for the same cut-off for the same screening tool and disorder were combined via meta-analysis.

RESULTS

Of 6322 unique citations identified, 58 articles including 77 screening tools were included. There were 46, 19 and 12 validations for anxiety, PTSD, and combined depression and anxiety, respectively. Continentally, Asia had the most validations (35). Regionally, South Asia (11) had the most validations, followed by South Africa (10) and West Asia (9). The Kessler-10 (7) and the Generalized Anxiety Disorder-7 item scale (GAD-7) (6) were the most commonly validated tools for anxiety disorders, while the Harvard Trauma Questionnaire (3) and Posttraumatic Diagnostic Scale (3) were the most commonly validated tools for PTSD. Most studies (29) had the lowest quality rating (unblinded). Due to incomplete reporting, we could meta-analyze results from only two studies, which involved the GAD-7 (cut-off ≥10, pooled sensitivity = 76%, pooled specificity = 64%).

CONCLUSION

Use of brief screening instruments can bring much needed attention and research opportunities to various at-risk LMIC populations. However, many have been validated in inadequately designed studies, precluding any general recommendation for specific tools in LMICs. Locally validated screening tools for anxiety and PTSD need further evaluation in well-designed studies to assess whether they can improve the detection and management of these common disorders.

TRIAL REGISTRATION

PROSPERO registry number CRD42019121794 .

Evaluating the health effects of place-based slum upgrading physical environment interventions: A systematic review (2012-2018)

Rapid urbanization in low- and middle-income countries (LMIC) is associated with increasing population living in informal settlements. Inadequate infrastructure and disenfranchisement in settlements can create environments hazardous to health. Placed-based physical environment upgrading interventions have potential to improve environmental and economic conditions linked to health outcomes. Summarizing and assessing evidence of the impact of prior interventions is critical to motivating and selecting the most effective upgrading strategies moving forward. Scientific and grey literature were systematically reviewed to identify evaluations of physical environment slum upgrading interventions in LMICs published between 2012 and 2018. Thirteen evaluations that fulfilled inclusion criteria were reviewed. Quality of evaluations was assessed using an adapted Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Findings were then pooled with those published prior to 2012. Narrative analysis was performed. Of thirteen evaluations, eight used a longitudinal study design (“primary evaluations”). All primary evaluations were based in Latin America and included two housing, two transportation, and four comprehensive intervention evaluations. Three supporting evaluations assessed housing interventions in Argentina and South Africa; two assessed a comprehensive intervention in India. Effects by intervention-type included improvements in quality of life and communicable diseases after housing interventions, possible improvements in safety after transportation and comprehensive interventions, and possible non-statistically significant effects on social capital after comprehensive interventions. Effects due to interventions may vary by regional context and intervention scope. Limited strong evidence and the diffuse nature of comprehensive interventions suggests a need for attention to measurement of intervention exposure and analytic approaches to account for confounding and selection bias in evaluation. In addition to health improvements, evaluators should consider unintended health consequences and environmental impact. Understanding and isolating the effects of place-based interventions can inform necessary policy decisions to address inadequate living conditions as rapid urban growth continues across the globe.

Preventing child sexual abuse: A systematic review of interventions and their efficacy in developing countries

BACKGROUND

Research on prevalence, risk factors, and prevention interventions for child sexual abuse has continued to focus on western and developed countries. Where country-level prevalence data or large-scale research exists, rates of child sexual abuse are consistently higher in developing and non-western countries than their western and developed counterparts.

OBJECTIVE

We systematically reviewed research on the nature of child sexual abuse interventions in developing countries, the settings and populations included to identify types of child sexual abuse prevention initiatives being implemented in developing countries and their effectiveness.

METHODS

Following PRISMA guidelines, we conducted a systematic search of six databases and identified eight studies to include in our analysis.

RESULTS

Most empirically evaluated interventions in developing countries have focused on preschool and primary school-aged children. Most have focused on interventions delivered in educational settings, with a lack of focus on population-level interventions to prevent child sexual abuse. Researchers have used outcomes measuring knowledge or skills for young people in self-protection and help-seeking, not deployment of those skills, actual reduction in prevalence of CSA, or improvements in conditions of safety in organizational contexts.

CONCLUSIONS

If the focus on school-based strategies to prevent child sexual abuse continues in developing countries, a significant gap in knowledge of the efficacy of population-level interventions outside of school contexts, and consistency across the application of interventions will remain. Evaluations are needed that address the efficacy of broader government-led or whole-of-community prevention interventions to reduce actual prevalence of child sexual abuse, or that can link increased knowledge and skill with reduced victimization.

Comorbidities between tuberculosis and common mental disorders: a scoping review of epidemiological patterns and person-centred care interventions from low-to-middle income and BRICS countries

Background

There is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders. Person-centred care holds much promise to ameliorate these comorbidities in low-to-middle income countries (LMICs) and emerging economies. Towards this end, this paper aims to review 1) the nature and extent of tuberculosis and common mental disorder comorbidity and 2) person-centred tuberculosis care in low-to-middle income countries and emerging economies.

Main text

A scoping review of 100 articles was conducted of English-language studies published from 2000 to 2019 in peer-reviewed and grey literature, using established guidelines, for each of the study objectives. Four broad tuberculosis/mental disorder comorbidities were described in the literature, namely alcohol use and tuberculosis, depression and tuberculosis, anxiety and tuberculosis, and general mental health and tuberculosis. Rates of comorbidity varied widely across countries for depression, anxiety, alcohol use and general mental health. Alcohol use and tuberculosis were significantly related, especially in the context of poverty. The initial tuberculosis diagnostic episode had substantial socio-psychological effects on service users. While men tended to report higher rates of alcohol use and treatment default, women in general had worse mental health outcomes. Older age and a history of mental illness were also associated with pronounced tuberculosis and mental disorder comorbidity. Person-centred tuberculosis care interventions were almost absent, with only one study from Nepal identified.

Conclusions

There is an emerging body of evidence describing the nature and extent of tuberculosis and mental disorders comorbidity in low-to-middle income countries. Despite the potential of person-centred interventions, evidence is limited. This review highlights a pronounced need to address psychosocial comorbidities with tuberculosis in LMICs, where models of person-centred tuberculosis care in routine care platforms may yield promising outcomes.

Adapting chronic care models for diabetes care delivery in low-and-middle-income countries: A review

A contextual review of models for chronic care was done to develop a context-adapted chronic care model-based service delivery model for chronic conditions including diabetes. The Philippines was used as the setting of a low-to-middle-income country. A context-based narrative review of existing models for chronic care was conducted. A situational analysis was done at the grassroots level, involving the leaders and members of the community, the patients, the local health system and the healthcare providers. A second analysis making use of certain organizational theories was done to explore on improving feasibility and acceptability of organizing care for chronic conditions. The analyses indicated that care for chronic conditions may be introduced, considering the needs of people with diabetes in particular and the community in general as recipients of care, and the issues and factors that may affect the healthcare workers and the health system as providers of this care. The context-adapted chronic care model-based service delivery model was constructed accordingly. Key features are: incorporation of chronic care in the health system's services; assimilation of chronic care delivery with the other responsibilities of the healthcare workers but with redistribution of certain tasks; and ensuring that the recipients of care experience the whole spectrum of basic chronic care that includes education and promotion in the general population, risk identification, screening, counseling including self-care development, and clinical management of the chronic condition and any co-morbidities, regardless of level of control of the condition. This way, low-to-middle income countries can introduce and improve care for chronic conditions without entailing much additional demand on their limited resources.