Background: Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment. Objective: We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs). Methods: We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD). Results: A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs. Conclusions: The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education.

The literature on health care seeking behaviour in sub-Saharan Africa for children suffering from malaria is quite extensive. This literature, however, is predominately quantitative and, inevitably, fails to explore how the local concepts of illness may affect people's choices. Understanding local concepts of illness and their influence on health care-seeking behaviour can complement existing knowledge and lead to the development of more effective malaria control interventions.

Health systems in Bangladesh are not fully organized to provide optimal care services to patients with mental health problems. There is both a lack of resources and a disproportional distribution of the available resources. To design an equitable health system and plan interventions to improve access to care, a better understanding of mental health care-seeking behavior and care pathways are crucial. A facility-based cross-sectional study was conducted using a mixed-method design at the National Institute of Mental Health (NIMH), in Bangladesh. A total of 40 patients (or their attendants) visiting the outpatient department of NIMH were selected by purposive sampling. As their first contact point for care services, 27.5% of the patients consulted a psychiatric care provider, 30% went to non-medical provider, and the majority, 42.5%, went to non-psychiatric medical care providers. Only 32.5% of the patients had been advised to go to NIMH by a private physician, hospital personnel or psychiatrist. Among all individual categories of providers, private psychiatrists were the most frequent caregivers (n = 12), followed by traditional healers (n = 9). A total of 70% of the patients had chosen a provider within 20 km. In three out of four of the cases, the family had decided on the first provider. From the start of the symptoms the median delay in the first contact with any provider was 6 months, and in reaching any psychiatric care provider was 1 year. The most common reasons for a delay in seeking care were a lack of knowledge about mental health problems, a lack of information about the place for appropriate care, and not considering the problem as serious enough to seek care. Each of those reasons were mentioned by one in every four respondents. The majority of the patients with mental health problems in Bangladesh access various categories of providers before reaching a psychiatric care provider, and use a diverse range of pathways and loops, which results in a delay or missing appropriate care. We hope that our findings are useful for planning interventions to improve access to mental health care in general, in Bangladesh, and improving referral policies and structures in particular.

Well-functioning surveillance systems are crucial for effective disease control programs. The Integrated Disease Surveillance and Response (IDSR) strategy was developed and adopted in 1998 for Africa as a comprehensive public health approach and subsequently, Ghana adopted the IDSR technical guidelines in 2002. Since 2012, the IDSR data is reported through the new District Health Information Management System II (DHIMS2) network. The objective was to evaluate the Integrated Disease Surveillance and Response (IDSR) system in northern Ghana. This was an observational study using mixed methods. Weekly and monthly IDSR data on selected infectious diseases were downloaded and analyzed for 2011, 2012 and 2013 (the years before, of and after DHIMS2 implementation) from the DHIMS2 databank for the Upper East Region (UER) and for two districts of UER. In addition, key informant interviews were conducted among local and regional health officers on the functioning of the IDSR. Clinically diagnosed malaria was the most prevalent disease in UER, with an annual incidence rate close to 1. Around 500 suspected HIV/AIDS cases were reported each year. The highest incidence of cholera and meningitis was reported in 2012 (257 and 392 cases respectively). Three suspected cases of polio and one suspected case of guinea worm were reported in 2013. None of the polio and guinea worm cases and only a fraction of the reported cases of the other diseases were confirmed. A major observation was the large and inconclusive difference in reported cases when comparing weekly and monthly reports. This can be explained by the different reporting practice for the sub-systems. Other challenges were low priority for surveillance, ill-equipped laboratories, rare supervision and missing feedback. The DHIMS2 has improved the availability of IDSR reports, but the quality of data reported is not sufficient. Particularly the inconsistencies between weekly and monthly data need to be addressed. Moreover, support for and communication within the IDSR system is inadequate and calls for attention.

The integrated disease surveillance and response (IDSR) strategy was adopted in Ghana over a decade ago, yet gaps still remain in its proper functioning. The objective of this study was to assess the core and support functions of the IDSR system at the periphery level of the health system in northern Ghana. A qualitative study has been conducted among 18 key informants in two districts of Upper East Region. The respondents were from 9 health facilities considered representative of the health system (public, private and mission). A semi-structured questionnaire with focus on core and support functions (e.g. case detection, confirmation, reporting, analysis, investigation, response, training, supervision and resources) of the IDSR system was administered to the respondents. The responses were recorded according to specific themes. The majority (7/9) of health facilities had designated disease surveillance officers. Some informants were of the opinion that the core and support functions of the IDSR system had improved over time. In particular, mobile phone reporting was mentioned to have made IDSR report submission easier. However, none of the health facilities had copies of the IDSR Technical Guidelines for standard case definitions, laboratories were ill-equipped, supervision was largely absent and feedback occurred rather irregular. Informants also reported, that the community perceived diagnostic testing at the health facilities to be unreliable (e.g. tuberculosis, Human Immunodeficiency Virus). In addition, disease surveillance activities were of low priority for nurses, doctors, administrators and laboratory workers. Although the IDSR system was associated with some benefits to the system such as reporting and accessibility of surveillance reports, there remain major challenges to the functioning and the quality of IDSR in Ghana. Disease surveillance needs to be much strengthened in West Africa to cope with outbreaks such as the recent Ebola epidemic.

Background: Effective and timely treatment is an essential aspect of malaria control, but remains a challenge in many parts of sub-Saharan Africa. The objective of this study was to describe young children's access to malaria treatment in Nouna Health District, Burkina Faso. Methods: In February/March 2006, a survey was conducted in a representative sample of 1,052 households. Results: Overall 149/1052 (14%) households reported the current possession of anti-malarial medicine, which was significantly associated with urban area, literacy of household head, having young children, and high socio-economic status. Out of a total of 802 children under five years, at least one malaria episode was reported for 239 (30%) within the last month. Overall 95% of children received treatment, either modern (72%), traditional (18%) or mixed (5%). Most of the medicines were provided as home treatment by the caregiver and half of children received some type of modern treatment within 24 hours of the occurrence of first symptoms. Despite a recent policy change to artemisinin-based combination therapy, modern anti-malarials consisted mainly of chloroquine (93%). Modern drugs were obtained more often from a health facility in localities with a health facility compared to those without (60% vs. 25.6%, p < 0.001). In contrast, beside informal providers, volunteer community health workers (CHW) were the main source of modern medicine in localities without a health centre (28% vs. 3%, p < 0.001). Conclusion: Access to modern health services providing quality controlled effective combination therapies against malaria needs to be strengthened in rural Africa, which should include a re-investigation of the role of CHW 30 years after Alma Ata.