Inequities in postnatal care in low- and middle-income countries: a systematic review and meta-analysis

Objective

To assess the socioeconomic, geographical and demographic inequities in the use of postnatal health-care services in low- and middle-income countries.

Methods

We searched Medline, Embase and Cochrane Central databases and grey literature for experimental, quasi-experimental and observational studies that had been conducted in low- and middle-income countries. We summarized the relevant studies qualitatively and performed meta-analyses of the use of postnatal care services according to selected indicators of socioeconomic status and residence in an urban or rural setting.

Findings

A total of 36 studies were included in the narrative synthesis and 10 of them were used for the meta-analyses. Compared with women in the lowest quintile of socioeconomic status, the pooled odds ratios for use of postnatal care by women in the second, third, fourth and fifth quintiles were: 1.14 (95% confidence interval, CI : 0.96–1.34), 1.32 (95% CI: 1.12–1.55), 1.60 (95% CI: 1.30–1.98) and 2.27 (95% CI: 1.75–2.93) respectively. Compared to women living in rural settings, the pooled odds ratio for the use of postnatal care by women living in urban settings was 1.36 (95% CI: 1.01–1.81). A qualitative assessment of the relevant published data also indicated that use of postnatal care services increased with increasing level of education.

Conclusion

In low- and middle-income countries, use of postnatal care services remains highly inequitable and varies markedly with socioeconomic status and between urban and rural residents.     

Telemedicine to deliver diabetes care in low- and middle-income countries: a systematic review and meta-analysis

ObjectiveTo determine the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries.MethodsWe searched seven databases up to July 2020 for randomized controlled trials investigating the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries. We extracted data on the study characteristics, primary end-points and effect sizes of outcomes. Using random effects analyses, we ran a series of meta-analyses for both biochemical outcomes and related patient properties.FindingsWe included 31 interventions in our meta-analysis. We observed significant standardized mean differences of −0.38 for glycated haemoglobin (95% confidence interval, CI: −0.52 to −0.23; I² = 86.70%), −0.20 for fasting blood sugar (95% CI: −0.32 to −0.08; I² = 64.28%), 0.81 for adherence to treatment (95% CI: 0.19 to 1.42; I² = 93.75%), 0.55 for diabetes knowledge (95% CI: −0.10 to 1.20; I² = 92.65%) and 1.68 for self-efficacy (95% CI: 1.06 to 2.30; I² = 97.15%). We observed no significant treatment effects for other outcomes, with standardized mean differences of −0.04 for body mass index (95% CI: −0.13 to 0.05; I² = 35.94%), −0.06 for total cholesterol (95% CI: −0.16 to 0.04; I² = 59.93%) and −0.02 for triglycerides (95% CI: −0.12 to 0.09; I² = 0%). Interventions via telephone and short message service yielded the highest treatment effects compared with services based on telemetry and smartphone applications.ConclusionAlthough we determined that telemedicine is effective in improving several diabetes-related outcomes, the certainty of evidence was very low due to substantial heterogeneity and risk of bias.     

Chronic hepatitis C treatment outcomes in low- and middle-income countries: a systematic review and meta-analysis

Objective

To assess the effectiveness of treatment for hepatitis C virus (HCV) infection in low- and middle-income countries and identify factors associated with successful outcomes.

Methods

We performed a systematic review and meta-analysis of studies of HCV treatment programmes in low- and middle-income countries. The primary outcome was a sustained virological response (SVR). Factors associated with treatment outcomes were identified by random-effects meta-regression analysis.

Findings

The analysis involved data on 12 213 patients included in 93 studies from 17 countries. The overall SVR rate was 52% (95% confidence interval, CI: 48–56). For studies in which patients were predominantly infected with genotype 1 or 4 HCV, the pooled SVR rate was 49% (95% CI: 43–55). This was significantly lower than the rate of 59% (95% CI: 54–64) found in studies in which patients were predominantly infected with other genotypes (P = 0.012). Factors associated with successful outcomes included treatment with pegylated interferon and ribavirin, infection with an HCV genotype other than genotype 1 or 4 and the absence of liver damage or human immunodeficiency virus infection at baseline. No significant difference in the SVR rate was observed between weight-adjusted and fixed-dose ribavirin treatment. Overall, 17% (95% CI: 13–23) of adverse events resulted in treatment interruption or dose modification, but only 4% (95% CI: 3–5) resulted in treatment discontinuation.

Conclusion

The outcomes of treatment for HCV infection in low- and middle-income countries were similar to those reported in high-income countries.     

Coping strategies among conflict-affected adults in low- and middle-income countries: A systematic literature review

Mental health is recognised as a key issue for populations affected by conflict. The aim of this systematic literature review is to examine coping strategies among conflict-affected civilians in low- and middle-income countries. The objectives were to examine (1) the types of coping strategies used by conflict-affected civilians; (2) factors influencing coping strategies; (3) relationships between coping strategies and mental health outcomes. A database search was conducted on May 13, 2014. Qualitative and quantitative studies that report on coping strategies used by adult conflict-affected civilians in LMICs were included, yielding 50 articles. Coping strategies were organised into a typology of problem-solving, support seeking, escape-avoidance, distraction, and positive cognitive restructuring domains. Support-seeking, positive cognitive restructuring, and problem-solving domains were the most frequently reported coping domains across the articles. Significant factors influencing coping included gender and exposure to trauma. The relationship between coping and mental health outcomes was nuanced. The diverse findings reported across the studies reflect the variety of contexts from which the samples are drawn, the range of coping typologies, and differing methodological approaches to exploring coping and mental health. Context-specific studies are needed in order to capture the social and cultural influences on coping and mental health.     

Quality of stroke guidelines in low- and middle-income countries: a systematic review

ObjectiveTo identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.MethodsWe systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.FindingsWe reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.ConclusionGuidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.     

溺水流行特征与预防控制研究进展

  目的  了解1990年与2015年湖北省人群溺水的疾病负担及变化情况,为溺水的预防和控制工作提供参考依据。  方法  利用2015年全球疾病负担（GBD）研究结果,采用患病率、死亡率、伤残损失寿命年（YLD）、过早死亡损失寿命年（YLL）、伤残调整寿命年（DALY）等指标对1990年和2015年湖北省人群溺水的疾病负担状况进行描述;应用2015年GBD的标准人口对各指标进行标化,描述其疾病负担的变化情况。  结果  2015年与1990年比较,湖北省人群溺水患病数由1990年的7.86万例降至2015年的5.00万例（下降36.39 %）,标化患病率由1990年的175.43/10万降至2015年的79.90/10万（下降54.45 %）;死亡数由1990年的1.36万例降至2015年的0.38万例（下降72.06 %）,标化死亡率由1990年的24.23/10万降至2015年的7.96/10万（下降67.15 %）;湖北省人群溺水的YLD由1990年的0.57万人年降至2015年的0.22万人年（下降61.40 %）,标化YLD率由1990年的12.33/10万降至2015年的3.55/10万（下降71.21 %）;YLL由1990年的96.54万人年降至2015年的17.88万人年（下降81.48 %）,标化YLL率由1990年的1 598.76/10万降至2015年的425.41/10万（下降73.39 %）;DALY由1990年的97.11万人年降至2015年的18.10万人年（下降81.36 %）,标化DALY率由1990年的1 611.09/10万降至2015年的428.96/10万（下降73.37 %）。不同年龄组人群中,1990年与2015年溺水患病率均以 ≥ 70岁老年人为最高（505.73/10万和331.62/10万）;溺水死亡率1990年以 < 5岁儿童为最高（88.94/10万）,2015年以 ≥ 70岁老年人为最高（21.39/10万）;1990年和2015年YLL率、DALY率均以 < 5岁儿童为最高（7 526.43/10万和1 109.36/10万、7 528.24/10万和1 109.64/10万）,YLD率均以 ≥ 70岁老年人为最高（28.99/10万和14.29/10万）;2015年与1990年比较,2015年溺水患病率、死亡率、YLD率、YLL率和DALY率在各年龄段均有下降,其下降幅度随年龄增长而减少,其中 < 5岁儿童的下降幅度均最大。  结论  2015年较1990年湖北省人群溺水的疾病负担有所下降,溺水的疾病负担主要由早死所致,儿童、青少年和老年人仍是溺水关注的重点人群。     

Adult vaccination uptake strategies in low- and middle-income countries: A systematic review

BackgroundEvidence-based strategies can maximize vaccination intent and uptake among adults. This systematic review summarizes the existing literature on strategies to improve vaccination intent and uptake among adults in low- and middle-income countries (LMICs) to inform future implementation in various populations and contexts.MethodsEligible studies were identified through a systematic search in Medline, Embase, Cochrane Libraries, as well as grey literature databases published between January 2010 and March 2021. The search was limited to studies in LMICs that evaluated adult vaccination interventions. Data were extracted from the included studies and evaluated against the World Health Organization’s Behavioral and Social Drivers of Vaccination Framework. The National Institutes of Health study quality assessment tools were used to evaluate study quality.ResultsThe initial literature review identified 2,854 records, 22 of which met the inclusion criteria. The majority (n = 19 or 86%) of studies were from middle-income countries, with the remaining studies (n = 3 or 13%) set in low-income countries. The majority (15/22, 68%) of interventions were multi-component. 82% (18/22) of studies addressed thoughts and feelings, 59% (13/22) addressed social processes, and 73% (16/22) addressed practical issues. Five studies reported primary outcomes of vaccination intent, and the remaining 17 reported vaccine uptake. 36% (8/22) of the studies cited statistically significant positive intervention effects on vaccination intent or uptake. Few of the included studies (6/22, 27%) were RTCs, and most studies (15/22, 68%) were of poor study quality. The studies reporting the highest increase in vaccination intent and uptake were multi-component interventions that addressed all three determinants of vaccination.DiscussionThe results of this review highlight levers that can be used to encourage vaccine intent and uptake in the ongoing rollout of COVID-19 vaccines, as well as the deployment of other vaccines to adult populations in LMICs. Of the included studies, multicomponent interventions were most effective, mainly when targeting multiple determinants of vaccination. However, poor study quality indicates the need for additional research to validate these findings.     

Strategies to increase the demand for childhood vaccination in low- and middle-income countries: a systematic review and meta-analysis

ObjectiveTo investigate which strategies to increase demand for vaccination are effective in increasing child vaccine coverage in low- and middle-income countries.MethodsWe searched MEDLINE, EMBASE, Cochrane library, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science and Scopus databases for relevant studies, published in English, French, German, Hindi, Portuguese and Spanish up to 25 March 2014. We included studies of interventions intended to increase demand for routine childhood vaccination. Studies were eligible if conducted in low- and middle-income countries and employing a randomized controlled trial, non-randomized controlled trial, controlled before-and-after or interrupted time series design. We estimated risk of bias using Cochrane collaboration guidelines and performed random-effects meta-analysis.FindingsWe identified 11 studies comprising four randomized controlled trials, six cluster randomized controlled trials and one controlled before-and-after study published in English between 1996 and 2013. Participants were generally parents of young children exposed to an eligible intervention. Six studies demonstrated low risk of bias and five studies had moderate to high risk of bias. We conducted a pooled analysis considering all 11 studies, with data from 11 512 participants. Demand-side interventions were associated with significantly higher receipt of vaccines, relative risk (RR): 1.30, (95% confidence interval, CI: 1.17–1.44). Subgroup analyses also demonstrated significant effects of seven education and knowledge translation studies, RR: 1.40 (95% CI: 1.20–1.63) and of four studies which used incentives, RR: 1.28 (95% CI: 1.12–1.45).ConclusionDemand-side interventions lead to significant gains in child vaccination coverage in low- and middle-income countries. Educational approaches and use of incentives were both effective strategies.     

Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review

Background

Current WHO guidelines on the management and treatment of diarrhea in children strongly recommend continued feeding alongside the administration of oral rehydration solution and zinc therapy, but there remains some debate regarding the optimal diet or dietary ingredients for feeding children with diarrhea.

Methods

We conducted a systematic search for all published randomized controlled trials evaluating food-based interventions among children under five years old with diarrhea in low- and middle-income countries. We classified 29 eligible studies into one or more comparisons: reduced versus regular lactose liquid feeds, lactose-free versus lactose-containing liquid feeds, lactose-free liquid feeds versus lactose-containing mixed diets, and commercial/specialized ingredients versus home-available ingredients. We used all available outcome data to conduct random-effects meta-analyses to estimate the average effect of each intervention on diarrhea duration, stool output, weight gain and treatment failure risk for studies on acute and persistent diarrhea separately.

Results

Evidence of low-to-moderate quality suggests that among children with acute diarrhea, diluting or fermenting lactose-containing liquid feeds does not affect any outcome when compared with an ordinary lactose-containing liquid feeds. In contrast, moderate quality evidence suggests that lactose-free liquid feeds reduce duration and the risk of treatment failure compared to lactose-containing liquid feeds in acute diarrhea. Only limited evidence of low quality was available to assess either of these two approaches in persistent diarrhea, or to assess lactose-free liquid feeds compared to lactose-containing mixed diets in either acute or persistent diarrhea. For commercially prepared or specialized ingredients compared to home-available ingredients, we found low-to-moderate quality evidence of no effect on any outcome in either acute or persistent diarrhea, though when we restricted these analyses to studies where both intervention and control diets were lactose-free, weight gain in children with acute diarrhea was shown to be greater among those fed with a home-available diet.

Conclusions

Among children in low- and middle-income countries, where the dual burden of diarrhea and malnutrition is greatest and where access to proprietary formulas and specialized ingredients is limited, the use of locally available age-appropriate foods should be promoted for the majority of acute diarrhea cases. Lactose intolerance is an important complication in some cases, but even among those children for whom lactose avoidance may be necessary, nutritionally complete diets comprised of locally available ingredients can be used at least as effectively as commercial preparations or specialized ingredients. These same conclusions may also apply to the dietary management of children with persistent diarrhea, but the evidence remains limited.

     

Cost-effectiveness and economic benefits of vaccines in low- and middle-income countries: A systematic review

Background

Public health interventions that prevent mortality and morbidity have greatly increased over the past decade. Immunization is one of these preventive interventions, with a potential to bring economic benefits beyond just health benefits. While vaccines are considered to be a cost-effective public health intervention, implementation has become increasingly challenging. As vaccine costs rise and competing priorities increase, economic evidence is likely to play an increasingly important role in vaccination decisions.

Methods

To assist policy decisions today and potential investments in the future, we provide a systematic review of the literature on the cost-effectiveness and economic benefits of vaccines in low- and middle-income countries from 2000 to 2010. The review identified 108 relevant articles from 51 countries spanning 23 vaccines from three major electronic databases (Pubmed, Embase and Econlit).

Results

Among the 44 articles that reported costs per disability-adjusted life year (DALY) averted, vaccines cost less than or equal to $100 per DALY averted in 23 articles (52%). Vaccines cost less than $500 per DALY averted in 34 articles (77%), and less than $1000 per DALY averted in 38 articles (86%) in one of the scenarios. 24 articles (22%) examined broad level economic benefits of vaccines such as greater future wage-earning capacity and cost savings from averting disease outbreaks. 60 articles (56%) gathered data from a primary source. There were little data on long-term and societal economic benefits such as morbidity-related productivity gains, averting catastrophic health expenditures, growth in gross domestic product (GDP), and economic implications of demographic changes resulting from vaccination.

Conclusions

This review documents the available evidence and shows that vaccination in low- and middle-income countries brings important economic benefits. The cost-effectiveness studies reviewed suggest to policy makers that vaccines are an efficient investment. This review further highlights key gaps in the available literature that would benefit from additional research, especially in the area of evaluating the broader economic benefits of vaccination in the developing world.     

Vaccine vial monitor availability and use in low- and middle-income countries: A systematic review

IntroductionThe vaccine vial monitor (VVM) registers cumulative heat exposure on vaccines over time. As low- and lower-middle-income countries transition beyond support from the Global Alliance for Vaccines and Immunization (Gavi), they will assume full responsibility for vaccine financing and procurement. It is unclear to what extent countries transitioning out of Gavi support will continue to include VVMs on their vaccines. This paper aims to systematically review evidence on VVM availability and use in low- and middle-income countries to document factors behind global access to and country demand for VVMs. Such results could help identify actions needed to ensure continued use of VVMs in countries that transition out of Gavi support.MethodsWe performed a systematic review of electronic databases, reference lists, and grey literature in English and French languages with publication dates from 2005 onwards. The studies included were analyzed for the following outcomes: (1) availability and deployment of VVM-labeled vaccines; (2) VVM practices and perceptions in the immunization system; (3) vaccine introduction and decision-making processes; (4) Gavi graduation and vaccine program sustainability.ResultsThe study found that VVM availability and use was affected by multiple sourcing of vaccines and the extent to which VVM was included in the vaccine specification in the tendering documents when procuring vaccines. Knowledge about VVM and its impact on the EPI program was found to be high among health workers as well as decision-makers. However, the study also found that weak capacity in key national institutions such as NRA and NPA might impact on demand for VVM. As countries take decisions regarding the adoption of new vaccines, factors such as disease burden and vaccine price may assume greater importance than vaccine characteristics and presentation. Finally, the study found that countries rely largely on the advice and recommendations from technical partners such as WHO and PAHO.ConclusionThe study concludes that global access to and country demand for VVM are dependent on policy statements and recommendations about VVM by key policy institutions such as WHO and UNICEF. The study also concludes that despite Gavi-eligible countries having access to VVM-labeled vaccines, inclusion is often below 100%. Weak institutional capacity in key national agencies such as NRA and NPA seems to be a contributing factor, while other factors include the procurement of clear national policies on the inclusion of VVM on vaccines, along with the capacity to enforce the policy. Finally, the study concludes that knowledge about VVM and its impact on vaccine program efficiency, safety, and cost is critical for transitioning countries’ continuous demand for VVM.     

A systematic literature review of missed opportunities for immunization in low- and middle-income countries

BackgroundMissed opportunities for immunization (MOIs) may contribute to low coverage in diverse settings, including developing countries.MethodsWe conducted a systematic literature review on MOIs among children and women of childbearing age from 1991 to the present in low- and middle-income countries. We searched multiple databases and the references of retrieved articles. Meta-analysis provided a pooled prevalence estimate and both univariate and multivariate meta-regression analysis was done to explore heterogeneity of results across studies.ResultsWe found 61 data points from 45 studies involving 41,310 participants. Of the 45 studies, 41 involved children and 10 involved women. The pooled MOI prevalence was 32.2% (95% CI: 26.8–37.7) among children – with no change during the study period – and 46.9% (95% CI: 29.7–64.0%) among women of child-bearing age. The prevalence varied by region and study methodology but these two variables together accounted for only 12% of study heterogeneity. Among 352 identified reasons for MOIs, the most common categories were health care practices, false contraindications, logistic issues related to vaccines, and organizational limitations, which did not vary by time or geographic region.ConclusionsMOI prevalence was high in low- and middle-income settings but the large number of identified reasons precludes standardized solutions.     

The cost-effectiveness of preventing mother-to-child transmission of HIV in low- and middle-income countries: systematic review

Background

Although highly effective prevention interventions exist, the epidemic of paediatric HIV continues to challenge control efforts in resource-limited settings. We reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). This article presents syntheses of evidence on the costs, effects and cost-effectiveness of HIV MTCT strategies for LMICs from the published literature and evaluates their implications for policy and future research.

Methods

Candidate studies were identified through a comprehensive database search including PubMed, Embase, Cochrane Library, and EconLit restricted by language (English or French), date (January 1st, 1994 to January 17^th, 2011) and article type (original research). Articles reporting full economic evaluations of interventions to prevent or reduce HIV MTCT were eligible for inclusion. We searched article bibliographies to identify additional studies. Two authors independently assessed eligibility and extracted data from studies retained for review. Study quality was appraised using a modified BMJ checklist for economic evaluations. Data were synthesised in narrative form.

Results

We identified 19 articles published in 9 journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings as measured against accepted international benchmarks. In concentrated epidemics where HIV prevalence in the general population is very low, MTCT strategies based on universal testing of pregnant women may not compare well against cost-effectiveness benchmarks, or may satisfy formal criteria for cost-effectiveness but offer a low relative value as compared to competing interventions to improve population health.

Conclusions and Recommendations

Interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses can help to ensure that pMTCT interventions for LMICs reach their full potential by focussing on unanswered questions in four areas: local assessment of rapidly evolving HIV MTCT options; strategies to improve coverage and reach underserved populations; evaluation of a more comprehensive set of MTCT approaches including primary HIV prevention and reproductive counselling; integration of HIV MTCT and other sexual and reproductive health services.     

Adolescent demand for contraception and family planning services in low- and middle-income countries: A systematic review

ABSTRACT

An estimated 23 million adolescent girls age 15–19 in low- and middle-income countries (LMICs) have an unmet need for contraception. Despite the recognised importance of expanding access to appropriate methods of contraceptives for adolescents in LMICs, the evidence base on their total demand for contraception is limited, and there is no consensus on how to measure this important phenomenon. The aim of this study was to review the published literature in order to better understand the level of adolescent demand for contraception in LMICs and to explore what demand-related indicators are being measured. A total of 1375 articles were identified and 18 met the inclusion criteria. Included studies reported findings from 29 LMICs, revealing high adolescent demand for contraception. The demand for contraception among adolescents and young women ranged from 22% among married adolescents in Azerbaijan to 98% in Peru. However, measures of this phenomenon were limited, with most studies only reporting current contraceptive use or unmet need. Most studies relied on cross-sectional data, and young, unmarried, and male adolescents were largely excluded. We make several recommendations for alternative approaches for a more comprehensive understanding of adolescent demand for contraception in LMICs.