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Projected shortfall of 10 million healthcare workers by 2030: implications for low- and middle-income countries and the way forward 预计到2030年将短缺1 000万卫生保健工作者:对低收入和中等收入国家的影响及前进道路
Pub Date : 2023-08-11 DOI: 10.4081/hls.2023.11359
B. Gulumbe, N. Usman
NA  
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引用次数: 0
Clinical manifestation and microbial profiling of recurrent MDR microorganisms associated with head and neck infection- a retrospective study 与头颈部感染相关的复发性耐多药微生物的临床表现和微生物谱——一项回顾性研究
Pub Date : 2023-08-11 DOI: 10.4081/hls.2023.11527
S. Lenka, Debasmita Dubey, Shakti Rath, Somadatta Das, S. Swain
Head and neck infection (HNI) can lead to life-threatening complications, including death. The purpose of this study is to look at the entire clinico-demographic profile of patients with HNI as well as the microbiologic profile of recurring bacterial infection cases with a variety of symptoms. A retrospective cross-sectional study was conducted on 1080 HNI patients in a tertiary care hospital in Bhubaneswar, Odisha, India, from January 2018 to December 2022. Of the 1080 cases, 771 (71.39%) were males, 309 (28.61%) were females, and 603 (55.83%) were from rural areas reporting to a tertiary care hospital. 62% of the cases were between the ages of 31 and 60. Neck abscesses account for 570 (52.78%) of all cases, with parotid abscesses accounting for 233 (21.57%), peritonsillar abscesses accounting for 170 (15.74%), otitis media 32 (2.96%), and oral cavity infection accounting for 26 (2.41%). In 854 (79.07%) cases, the etiology was odontogenic, followed by sinus in 188 (17.41%) and otogenic in 38 (3.52%). The most common presenting features were neck swelling in 537 (49.72%) cases and face swelling in 238 (22.04%) cases, followed by jaw pain in 26 (2.41%) cases and others. Patients were hospitalized for an average of 11.824.38 days. Treatment and recurrence had a strong significant relationship (p 0.001). Microbiologic investigation of recurrent patients revealed 12 microorganisms, including bacteria and fungus, mainly multidrug-resistant in given ascending order Staphylococcus aureus (26.74%), Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli, Candida albicans (4.65%), Aspergillus fumigatus, A. flavus, A. niger, C. tropicalis, C. glabrata, C. krusei. Apart from colistin, almost all antibiotics were highly resistant to gram-negative bacteria, whereas against S. aureus, benzylpenicillin, and oxacillin showed 100% resistance, followed by erythromycin (91.3%), levofloxacin (86.96%), and ciprofloxacin (82.61%). This exploratory study would aid in determining the HNI burden and epidemiology, as well as their treatment status.
头颈部感染(HNI)可导致危及生命的并发症,包括死亡。本研究的目的是观察HNI患者的整个临床人口学特征,以及具有各种症状的复发性细菌感染病例的微生物学特征。2018年1月至2022年12月,对印度奥里萨邦布巴内斯瓦尔一家三级护理医院的1080名HNI患者进行了一项回顾性横断面研究。在1080例病例中,771例(71.39%)为男性,309例(28.61%)为女性,603例(55.83%)来自农村地区,向三级护理医院报告。62%的病例年龄在31岁至60岁之间。颈部脓肿570例(52.78%),腮腺脓肿233例(21.57%),扁桃体周围脓肿170例(15.74%),中耳炎32例(2.96%),口腔感染26例(2.41%),其次是鼻窦188例(17.41%)和耳源性38例(3.52%)。最常见的表现为颈部肿胀537例(49.72%)和面部肿胀238例(22.04%),其次是颌骨疼痛26例(2.41%)和其他。患者平均住院11.8243.38天。治疗与复发有着极强的显著关系(p 0.001)。对复发患者的微生物学调查显示,12种微生物,包括细菌和真菌,主要耐多药,按升序排列为金黄色葡萄球菌(26.74%)、肺炎克雷伯菌、绿脓杆菌、鲍曼不动杆菌、大肠杆菌、白色念珠菌(4.65%),烟曲霉、黄曲霉、黑曲霉、热带曲霉、光滑曲霉、克鲁塞曲霉。除粘菌素外,几乎所有抗生素对革兰氏阴性菌都具有高度耐药性,而对金黄色葡萄球菌、苄青霉素和苯唑西林的耐药性为100%,其次是红霉素(91.3%)、左氧氟沙星(86.96%)和环丙沙星(82.61%)。这项探索性研究将有助于确定HNI负担、流行病学及其治疗状况。
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引用次数: 0
Exploring healthcare system adaptive techniques and challenges in caring for people living with HIV and AIDS during the COVID-19 lockdown period in Harare, Zimbabwe 在津巴布韦哈拉雷新冠肺炎封锁期间,探索医疗保健系统在照顾艾滋病毒和艾滋病患者方面的适应性技术和挑战
Pub Date : 2023-08-07 DOI: 10.4081/hls.2023.11424
Tendai Makwara, Rumbidzai Chireshe, M. Nyashanu
The COVID-19 pandemic caused unprecedented challenges for healthcare systems worldwide, affecting the provision of ongoing care for people living with HIV and AIDS (PLWHA). This study aimed to explore the adaptive techniques employed by healthcare systems in providing care for PLWHA during the pandemic and the challenges encountered. An exploratory qualitative study (EQS) methodology was employed, underpinned by the resourcefulness framework. The Silences Framework Analysis Phases were used during data analysis. Fifteen participants were interviewed, and the data were thematically analyzed. The healthcare system employed several adaptive techniques to cater to PLWHA during the pandemic, including developing new standard service protocols, implementing preventative measures to limit COVID- 19 infections during hospital visits, and improving communication. The study identified two significant challenges: a lack of health insurance and a shortage of personal protective equipment (PPEs). The findings highlight the need for adapting to changing circumstances and provide ongoing care for PLWHA during the pandemic. The results show that developing new protocols and preventative measures can effectively ensure the continuity of care in pandemic situations. Moreover, the provision of PPEs and health insurance for healthcare staff should be prioritized to create a safe working environment. In conclusion, this study underlined the importance of resourcefulness in developing healthcare resilience to sustain care and support for PLWHA during the COVID-19 pandemic.
2019冠状病毒病大流行给全球卫生保健系统带来了前所未有的挑战,影响了向艾滋病毒/艾滋病感染者提供持续护理。本研究旨在探讨卫生保健系统在大流行期间为艾滋病患者提供护理时采用的适应性技术及其面临的挑战。采用探索性定性研究(EQS)方法,以足智多谋框架为基础。在数据分析期间使用了Silences框架分析阶段。对15名参与者进行了访谈,并对数据进行了主题分析。在大流行期间,卫生保健系统采用了几种适应性技术来满足艾滋病患者的需求,包括制定新的标准服务协议,实施预防措施以限制医院就诊期间的COVID- 19感染,以及改善沟通。该研究确定了两项重大挑战:缺乏医疗保险和个人防护装备短缺。调查结果强调需要适应不断变化的环境,并在大流行期间为艾滋病感染者提供持续护理。结果表明,制定新的方案和预防措施可以有效地确保大流行情况下护理的连续性。此外,应优先为保健工作人员提供个人装备和健康保险,以创造安全的工作环境。总之,本研究强调了在2019冠状病毒病大流行期间,在发展卫生保健复原力以维持对艾滋病感染者的护理和支持方面,足智多谋的重要性。
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引用次数: 0
Evidence from systematic reviews on policy approaches to improving access to medicines 对改善药品获取的政策方法进行系统审查的证据
Pub Date : 2023-07-19 DOI: 10.4081/hls.2023.11143
Celestino Kuchena, A. Qutieshat
The prevailing frameworks on access to medicines advise global procurement as a solution by assuming the presence of medicines on the global market. Yet access to medicines remains challenging, especially in developing countries. This is a global worry because the UN considers limited access to essential medicines as one of the five indicators of securing the right to health. To fill a research gap in health system studies and inform policymaking, we synthesized evidence from systematic reviews of how government policies affect low- and middle-income country (LMIC) medicine access. We chose a rapid review approach to reduce timelines and avoid missing policy “windows of opportunity.” To include only studies published after the start of COVID-19, we chose systematic reviews published between 2019 and November 2nd, 2022. This was also in line with recommendations in the literature to look at recent systematic reviews. The themes were grouped using a thematic and textual narrative approach. This review included 32 studies that examined access to medicine from various perspectives. Both supply- and demand-side policies are needed to improve medical access. LMICs cannot afford medicines, and supply never meets demand. LMICs will continue to struggle with pharmaceutical pricing due to their limited bargaining power. The urban bias in health facilities and policy changes reduce medicine availability and use. Leaders must make policy decisions to sustain domestic funds. Policymakers should consider that organizations may act against policy goals. Instead of copying developed nations, LMIC governments must develop multipronged strategies to address their unique challenges.
关于药品获取的现行框架建议将全球采购作为一种解决方案,假设药品在全球市场上存在。然而,获得药品仍然具有挑战性,尤其是在发展中国家。这是一个全球性的担忧,因为联合国认为获得基本药物的机会有限是确保健康权的五个指标之一。为了填补卫生系统研究的研究空白并为决策提供信息,我们综合了政府政策如何影响中低收入国家(LMIC)药品获取的系统审查证据。我们选择了快速审查方法来缩短时间,避免错过政策“机会之窗”。为了只包括新冠肺炎开始后发表的研究,我们选择了2019年至2022年11月2日发表的系统审查。这也符合文献中关于查看最近系统综述的建议。这些主题采用主题和文本叙述方法进行分组。这篇综述包括32项研究,这些研究从不同的角度考察了获得药物的途径。需要同时采取供给和需求两方面的政策来改善医疗服务。LMIC负担不起药品,而且供应永远无法满足需求。LMIC由于议价能力有限,将继续与药品定价作斗争。卫生设施中的城市偏见和政策变化减少了药品的供应和使用。各国领导人必须做出维持国内资金的政策决定。政策制定者应该考虑到组织可能会违背政策目标。LMIC政府必须制定多管齐下的战略来应对其独特的挑战,而不是照搬发达国家的做法。
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引用次数: 0
Compliant strategies to contain coronaviruses amidst the inconveniency of social distancing 在社交距离不便的情况下遏制冠状病毒的合规策略
Pub Date : 2023-07-06 DOI: 10.4081/hls.2023.11204
T. T. Desta, Tewodros Mulugeta
Social distance is the most promising technique for containing respiratory disorders such as coronaviruses. However, social separation is impractical in some situations where physical proximity is unavoidable. This research proposes alternative and complementary preventive and suppressive social distancing measures. This study explored the literature, produced critical ideas, and synthesized personal insights to develop realistic respiratory syndrome containment measures. Client-initiated congestion is common in enterprises and institutions that supply critical goods and services, according to experience. When overcrowding is unavoidable, containment methods such as using face masks, practicing proper cleanliness, improving the health of living and working environments, expanding access to critical supplies and services, and boosting social wellness must be implemented. Additionally, using (locally available) antiseptics, avoiding risky behaviors such as aggression, loneliness, smoking, drug abuse, and excessive alcohol consumption, eating greens, getting enough rest, receiving psychological treatment, and forming social ties could all help to reduce the negative effects of respiratory syndromes. Snipping hot liquids, preferably with honey, providing special attention to the elderly and individuals with comorbid diseases, seeing on-time healthcare workers and following their advise, and decreasing stress-inducing lifestyle factors all help to regulate respiratory syndromes. To control the transmission of contagions that cause respiratory syndromes, cost-effective and simple-to-implement measures should be used. Ignoring impoverished and marginalized communities in pandemic cases allows contagions to flourish unchecked, increasing the recurrence and circulation of pathologically important respiratory disorders.
社交距离是遏制冠状病毒等呼吸系统疾病最有希望的技术。然而,在某些不可避免的身体接近的情况下,社交分离是不切实际的。本研究提出了替代性和补充性的预防性和抑制性社会距离措施。本研究探讨了文献,提出了批判性的观点,并综合了个人的见解,以制定现实的呼吸综合征控制措施。根据经验,客户引发的拥堵在提供关键商品和服务的企业和机构中很常见。当过度拥挤不可避免时,必须实施诸如使用口罩、适当清洁、改善生活和工作环境卫生、扩大获得关键用品和服务的机会以及促进社会健康等遏制措施。此外,使用(当地可用的)防腐剂,避免攻击性、孤独、吸烟、滥用药物和过度饮酒等危险行为,吃蔬菜,得到足够的休息,接受心理治疗,建立社会关系,都有助于减少呼吸综合征的负面影响。剪热液体(最好是加蜂蜜的),对老年人和有合并症的人给予特别关注,按时看医护人员并听从他们的建议,减少导致压力的生活方式因素,这些都有助于调节呼吸系统综合症。为控制引起呼吸道综合征的传染病的传播,应采用成本效益高且易于实施的措施。在大流行病例中忽视贫困和边缘化社区,会使传染病不受控制地肆虐,增加在病理上重要的呼吸系统疾病的复发和传播。
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引用次数: 0
The impact of C-reactive protein testing on treatment-seeking behavior and patients' attitudes toward their care in Myanmar and Thailand. c反应蛋白检测对缅甸和泰国求诊行为和患者护理态度的影响
Pub Date : 2023-07-06 DOI: 10.4081/hls.2023.11278
Rachel C Greer, Thomas Althaus, Sabine Dittrich, Christopher C Butler, Phaik Yeong Cheah, Tri Wangrangsimakul, Frank M Smithuis, Nicolas P J Day, Yoel Lubell

C-reactive protein (CRP) point-of-care testing can reduce antibiotic prescribing in primary care patients with febrile and respiratory illness, yet little is known about its effects on treatment-seeking behavior. If patients go on to source antibiotics elsewhere, the impact of CRP testing will be limited. A randomized controlled trial assessed the impact of CRP testing on antibiotic prescriptions in Myanmar and Thai primary care patients with a febrile illness. Here we report patients' treatment-seeking behavior before and during the two-week study period. Self-reported antibiotic use is compared against urine antibacterial activity. Patients' opinions towards CRP testing were evaluated. Antibiotic use before study enrolment was reported by 5.4% while antimicrobial activity was detected in 20.8% of samples tested. During the study period, 14.8% of the patients sought additional healthcare, and 4.3% sourced their own antibiotics. Neither were affected by CRP testing. Overall, patients' satisfaction with their care and CRP testing was high. CRP testing did not affect patients' treatment-seeking behavior during the study period whilst modestly reducing antibiotic prescriptions. CRP testing appears to be acceptable to patients and their caregivers.

c反应蛋白(CRP)即时检测可以减少初级保健患者发热和呼吸系统疾病的抗生素处方,但对其对寻求治疗行为的影响知之甚少。如果患者继续在其他地方寻找抗生素,CRP检测的影响将是有限的。一项随机对照试验评估了CRP检测对缅甸和泰国发热性疾病初级保健患者抗生素处方的影响。在这里,我们报告了患者在两周研究期间之前和期间的寻求治疗行为。将自我报告的抗生素使用情况与尿液抗菌活性进行比较。评估患者对CRP检测的意见。在研究入组前使用抗生素的报告占5.4%,而在20.8%的检测样本中检测到抗菌活性。在研究期间,14.8%的患者寻求额外的医疗保健,4.3%的患者自行采购抗生素。两人均未受CRP检测影响。总体而言,患者对护理和CRP检测的满意度较高。在研究期间,CRP检测不影响患者的求医行为,同时适度减少抗生素处方。c反应蛋白检测似乎可以被患者和他们的护理人员接受。
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引用次数: 0
Evaluation of the static and dynamic balance in single and dual tasks among active smokers and non-smokers 评价主动吸烟者和非吸烟者在单任务和双任务中的静态和动态平衡
Pub Date : 2023-07-03 DOI: 10.4081/hls.2023.11159
Yuvraj Rana, H. Vaish
Chronic smoking may lead to postural imbalance and there is the risk of injuries due to instability. Balance is needed to maintain posture. Literature is scarce regarding static and dynamic balance in smokers. Hence, the study aimed to evaluate the static and dynamic balance in single and dual tasks among active smokers and age-matched non-smokers.100 smokers and 100 non-smokers aged 20-50 years were selected by purposive sampling. Static balance was assessed by a single-leg stance (SLS) test. Dynamic balance was assessed by performing the time up and go (TUG) test, and 10m walk test. All the tests were performed in single and dual tasks in both smokers and age-matched non-smokers. Kolmogorov-Smirnov test was used for assessing normality. Mann-Whitney U test was used to compare the two groups. pvalue ≤ 0.05 was considered significant. There was a significant difference in the SLS test, 10M walk test, and TUG test in single as well as dual tasks. The static and dynamic balance is impaired in chronic smokers in comparison to age-matched non-smokers and seeks further exploration in larger samples.
长期吸烟可能导致姿势不平衡,并且由于不稳定存在受伤的风险。保持姿势需要平衡。关于吸烟者的静态和动态平衡的文献很少。因此,本研究旨在评估活跃吸烟者和年龄匹配的非吸烟者在单任务和双任务中的静态和动态平衡。采用有目的抽样的方法,选取20 ~ 50岁吸烟者和非吸烟者各100人。静平衡通过单腿站立(SLS)测试进行评估。动态平衡通过拔腿(time up and go, TUG)测试和10m步行测试进行评估。所有的测试都在吸烟者和年龄匹配的非吸烟者中进行了单任务和双任务。采用Kolmogorov-Smirnov检验评估正态性。采用Mann-Whitney U检验对两组进行比较。p值≤0.05被认为是显著的。SLS测验、10M行走测验、TUG测验在单任务和双任务上均有显著性差异。与年龄匹配的非吸烟者相比,慢性吸烟者的静态和动态平衡受损,需要在更大的样本中进一步探索。
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引用次数: 0
Pityriasis Versicolor: host susceptibility in relation to IL-10 and IFN γ cytokine gene polymorphism 花斑糠疹:宿主易感性与IL-10和IFN γ细胞因子基因多态性有关
Pub Date : 2023-06-23 DOI: 10.4081/hls.2023.11302
Charu Jain, Shukla Das, V. Ramachandran, R. Saha, Sambit Nath Bhattacharyak, S. Dar, Nikita Birhman, N. Singh
Pityriasis Versicolor is a skin condition caused by the commensal yeast Malassezia. Little is known about the pathogenesis of why a commensal only causes symptoms in a subset of infected individuals. Understanding the susceptibility of the host to these commensal-associated diseases may be facilitated by knowledge of genetic polymorphism. The purpose was to investigate the relationship between Single Nucleotide Polymorphism in the IL10 and IFN genes of the host and susceptibility to Malassezia infection. There were 38 cases of Pityriasis Versicolor (PV) and 38 healthy controls in the sample. Blood samples were extracted for genomic DNA from all study participants. Amplification refractory mutations system- polymerase chain reaction (ARMS-PCR) with sequence-specific primers was used to genotype cytokines. In all patients and healthy controls, three SNPs (IL10-1082A/G; IL10-819/592C/T; IFN- +874A/T) in two cytokine loci were analyzed. In the PV group, we observed significant differences in allele or genotype distribution for the IL10-819/592C/T and IFN- +874A/T gene polymorphisms. In the present investigation, cytokine gene polymorphism revealed that the host was susceptible to Malassezia infection.
花斑糠疹是一种由共生酵母菌马拉色菌引起的皮肤病。为什么共生菌只在一小部分受感染个体中引起症状的发病机制尚不清楚。了解宿主对这些寄生虫相关疾病的易感性可能会通过了解遗传多态性而得到促进。目的探讨宿主il - 10和IFN基因单核苷酸多态性与马拉色菌感染易感性的关系。样本中有38例花斑糠疹(PV)和38例健康对照。提取所有研究参与者的血液样本进行基因组DNA检测。采用扩增难解突变系统-聚合酶链反应(ARMS-PCR)和序列特异性引物对细胞因子进行基因分型。在所有患者和健康对照中,有三个snp (IL10-1082A/G;IL10-819/592C / T;IFN- +874A/T)在两个细胞因子位点的表达。在PV组中,我们观察到IL10-819/592C/T和IFN- +874A/T基因多态性的等位基因或基因型分布存在显著差异。在本研究中,细胞因子基因多态性显示宿主对马拉色菌感染敏感。
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引用次数: 0
Helicobacter Pylori infection and non-alcoholic fatty liver disease. Is there a relationship? 幽门螺杆菌感染与非酒精性脂肪肝。有关系吗?
Pub Date : 2023-06-22 DOI: 10.4081/hls.2023.11379
Neveen Rashad Mostafa, Abeer A. M. Ali, M. Alkaphoury, R. Marzo
The most prevalent infection that causes chronic gastritis, gastric ulcers, and gastric cancer is Helicobacter pylori infection. Recent research has implicated H. pylori in the pathogenesis of non-gastrointestinal diseases such as cardiovascular, autoimmune, and metabolic disorders. In addition, since H. pylori is believed to be implicated in insulin resistance, numerous studies have been conducted to determine the relationship between H. pylori infection and nonalcoholic fatty liver diseases (NAFLD), but the results have been contested. The purpose of this study is to determine the relationship between H. Pylori infection and nonalcoholic fatty liver diseases. One hundred patients were examined via urea breath test for the presence of H. pylori infection and vibration-controlled transient elastography for the diagnosis of non-alcoholic fatty liver disease. After adjusting for other variables, age, body mass index (BMI), and H. pylori infection were associated with elastography 248dB/m. Infection with H. pylori contributes to the development of NAFLD, and its eradication may influence prognosis.
引起慢性胃炎、胃溃疡和胃癌的最常见的感染是幽门螺杆菌感染。最近的研究表明幽门螺杆菌与非胃肠道疾病如心血管、自身免疫和代谢紊乱的发病机制有关。此外,由于幽门螺杆菌被认为与胰岛素抵抗有关,已经进行了大量研究来确定幽门螺杆菌感染与非酒精性脂肪性肝病(NAFLD)之间的关系,但结果一直存在争议。本研究的目的是确定幽门螺杆菌感染与非酒精性脂肪肝之间的关系。通过尿素呼吸试验检查100例患者是否存在幽门螺杆菌感染,并通过振动控制瞬时弹性成像诊断非酒精性脂肪肝。在调整其他变量后,年龄、体重指数(BMI)和幽门螺杆菌感染与弹性成像248dB/m相关。幽门螺杆菌感染有助于NAFLD的发展,其根除可能影响预后。
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引用次数: 0
The antiviral properties of edible medicinal plants: potential remedies against coronaviruses 可食用药用植物的抗病毒特性:针对冠状病毒的潜在补救措施
Pub Date : 2023-06-19 DOI: 10.4081/hls.2023.11205
T. T. Desta, Kero Jemal, Rediet Sitotaw, D. Lemessa, Melesse Maryo, Alemtshay Teka, Tewodros Mulugeta
SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) is an unparalleled challenge for the international community. Subsequently, an extraordinary effort has been made to contain SARS-CoV-2. However, this has been largely limited to behavioral changes and vaccination. To make the containment strategies effective, behavioral changes and vaccination need to be complemented with alternative prevention methods and curative treatments. This work reports the antiviral properties of some of the commonly known edible medicinal plants that can be used as potential remedies to suppress coronaviruses. A growing body of evidence substantiates that edible medicinal plants with antiviral properties that have been proven effective against sibling coronaviruses likely contain the spread of SARS-CoV-2, and they may also suppress the fatality of COVID-19 (coronavirus disease 2019). The secondary metabolites found in herbal medicines do not cause pathogens to develop drug resistance, which is a common problem in conventional medicines. The use of edible medicinal plants is much safer and causes less panic, thereby avoiding the fear associated with the use of herbal medicines. Right dosages and mixtures of edible medicinal plants need to be rigorously investigated to circumvent unanticipated side effects and chronic health risks.
SARS-CoV-2(严重急性呼吸综合征冠状病毒2)是国际社会面临的前所未有的挑战。随后,为遏制SARS-CoV-2作出了非凡的努力。然而,这在很大程度上仅限于行为改变和接种疫苗。为了使遏制战略有效,行为改变和疫苗接种需要辅以其他预防方法和治疗方法。这项工作报告了一些常见的可食用药用植物的抗病毒特性,这些植物可以用作抑制冠状病毒的潜在补救措施。越来越多的证据表明,具有抗病毒特性的可食用药用植物已被证明对兄弟冠状病毒有效,它们可能抑制了SARS-CoV-2的传播,还可能抑制COVID-19(2019冠状病毒病)的致死率。在草药中发现的次生代谢物不会导致病原体产生耐药性,这是常规药物的一个常见问题。食用药用植物更安全,引起的恐慌更少,从而避免了与使用草药相关的恐惧。需要严格调查食用药用植物的正确剂量和混合物,以避免意外的副作用和慢性健康风险。
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引用次数: 1
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Healthcare in Lowresource Settings
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