Digital Commons Network^™

Maternal Mortality In Zambia: Associations With Health Services Utilization, Birth Spacing, And Province, Selina Mubwanga

Walden Dissertations and Doctoral Studies

Maternal mortality remains one of the leading public health issues in Zambia characterized by elevated maternal mortality rates among women of reproductive age. This research study investigated the effect of birth spacing, province type and location, and maternal health services utilization on maternal deaths among women in the Lusaka, Eastern, Central, and North-Western provinces of Zambia. The theoretical underpinning of this investigation drew upon the social-ecological systems framework. Using secondary data from the 2018 Zambia Demographic and Health Survey (ZDHS) of 1,868 women aged 15–49 years, the study adopted a quantitative, descriptive, cross-sectional research design. Binary logistic regression analysis revealed …

Dynamic Mutational Profiling Of Binding Interactions And Allosteric Networks In Conformational Ensembles Of The Sars-Cov-2 Spike Protein Complexes With Classes Of Antibodies Targeting Cryptic Binding Sites: Confluence Of Binding And Allostery Determines Molecular Mechanisms And Hotspots Of Immune Escape, Mohammed Alshahrani, Vedant Parikh, Brandon Foley, Gennady M. Verkhivker

Mathematics, Physics, and Computer Science Faculty Articles and Research

The ongoing evolution of SARS-CoV-2 variants has underscored the need to understand not only the structural basis of antibody recognition but also the dynamic and allosteric mechanisms that could underlie complexity of broad and escape-resistant neutralization. In this study, we employed a multi-scale approach integrating structural analysis, hierarchical molecular simulations, mutational scanning and network-based allosteric modeling to dissect how Class 4 antibodies (represented by S2X35, 25F9, and SA55) and Class 5 antibodies (represented by S2H97, WRAIR-2063 and WRAIR-2134) can modulate conformational behavior, binding energetics, allosteric interactions and immune escape patterns of the SARS-CoV-2 spike protein. Using hierarchical simulations of the …

Associations Between Social Drivers Of Health And Breast Cancer Stage At Diagnosis Among U.S. Black Women, Mollie Barnard, Bo Qin, Marc Emerson, Etienne Holder, Matthew Dunn, Shromona Sarkar, Nuo Xu, Yutong Li, Christine Ambrosone, Elisa Bandera, Julie Palmer, Melissa Troester, Terry Hyslop

Department of Pharmacology, Physiology, and Cancer Biology Faculty Papers

U.S. Black women have disproportionately high breast cancer mortality, partly due to later-stage diagnoses. We examined how social drivers of health (SDOH) relate to stage at diagnosis by analyzing data from 4,995 breast cancer survivors in the Black Women's Health Study, Carolina Breast Cancer Study, and Women's Circle of Health Studies. SDOH were self-reported and stage was ascertained from medical records. We used polytomous logistic regression to estimate odds ratios (ORs) for diagnosis at stages III/IV or II versus stage I (referent), adjusting for age, insurance status, and income. Meta-analyzed results indicated that underutilization of screening mammography (OR = 3.21, …

Sulfated Dietary Fiber Protects Gut Microbiota From Antibiotics, Fuqing Wu, Xiaoqian Annie Yu, David Angeles-Albores, Susan E Erdman, Eric J Alm

Faculty, Staff and Student Publications

Background: Antibiotics, while essential for combating pathogens, also disrupt commensal bacteria, leading to gut microbiota imbalance and associated diseases. However, strategies to mitigate such collateral damage remain largely underexplored.

Result: In this study, we found that fucoidan, a marine polysaccharide derived from brown seaweed, provides broad-spectrum growth protection against multiple classes of antibiotics for human gut microbial isolates in vitro and for fecal communities ex vivo. This protective effect is dependent on the structural integrity, molecular weight, and sulfur content of the polysaccharide. Transcriptomic analysis showed that while fucoidan had minimal impact on baseline gene expression, it counteracted about 60% …

Development Of A Customizable Web-Based Dashboard For Remote Blood Pressure Monitoring: Feasibility And Usability Implementation Study, Joshua Wollen, Thuy Nguyen, Charles Coton, Gina Dewildt, Gabretta Cooksey, Audrey Cohen, Nicholas Hoang, Munachi Okpala, Michael Gonzalez, Mengxi Wang, Chigozirim Izeogu, Elmer Bernstam, Charles Green, Sean Savitz, Jose-Miguel Yamal, Anjail Sharrief

Faculty, Staff and Student Publications

Background: Effective blood pressure (BP) management is essential for several disease states, including secondary stroke prevention. Remote BP monitoring used in combination with an electronic data capture (EDC) system offers potential for improved BP control for patients. While such systems currently exist, there are many patient-, provider-, and system-specific challenges these systems currently do not address. In addition, such systems are rarely described transparently and comprehensively in the literature with enough detail to be reproduced by other clinicians.

Objective: This study aims to describe the development and design of a web-based EDC system tailored for remote BP monitoring and management …

The Impact Of Culturally Grounded Breastfeeding Programs On Black Maternal And Infant Outcomes: A Scoping Review, Kelsey B. Green

Master's Projects and Capstones

Abstract

Background: The lack of culturally grounded breastfeeding programs and understanding of their impact on Black breastfeeding initiation, duration, and health outcomes hinders improving Black breastfeeding rates in the U.S.

Research aim: This scoping review examines the impact of culturally grounded breastfeeding programs on Black mothers' and infants' health, and factors contributing to their success.

Methods: A scoping review of the literature was conducted using the CINAHL and SCOPUS databases. In the end, 34 scholarly articles were chosen for this review because they examined the impact of culturally grounded breastfeeding programs on Black breastfeeding rates and health outcomes.

Results: Culturally …

The Exploration Of Self-Management Support Programs For African American Adults Ages 18 To 75 In Harnett County, North Carolina, Moya Camille Henny

Doctoral Dissertations and Projects

This phenomenological study explored the health needs and self-management experiences of African American adults ages 18 to 75 living with type 2 diabetes and hypertension in Harnett County, North Carolina. The study aimed to understand how self-management support programs could be better tailored to meet the cultural, social, and behavioral needs of this population, who face a disproportionate burden of these chronic conditions. Guided by Critical Care Theory, Chronic Care Model, and Social Cognitive Theory, the research examined how systemic inequalities, community resources, and personal beliefs shaped participants’ ability to manage their health. Data were collected through in-depth, semi-structured interviews …

Changing Hearts And Minds: Educating Medical Students To Transform Knowledge And Attitudes Toward Organ Donation, Matilin G. Rigsby

Doctoral Dissertations and Projects

The national organ shortage is exacerbated by physicians who, contrary to federal mandates, do not refer patients with organ donation potential in a timely fashion. Whereas United States medical school curricula widely omit organ donation-related topics, literature demonstrates that educating future physicians significantly improves those students’ ability to understand and positively perceive donation, influencing their willingness to refer donor candidates. Therefore, the purpose of this study is to determine if an educational module among fourth-year medical students at Texas A&M University College of Medicine Dallas Campus affects those students’ perceived knowledge and attitudes toward organ donation. The researcher administered a …

Drug Development Studies Supporting Zileuton As A Parenteral Adjuvant To Attenuate Antibiotic-Associated Nephrotoxicity, Cole S Hudson, James E Smith, Linh T Vuong, Nicholas S Teran, Nazanin Pouya, David Sheikh-Hamad, Xinli Liu, Shama Kajiji, Vincent H Tam

Faculty, Staff and Students Publications

Glycopeptide, polymyxin, and aminoglycoside antibiotics are among the most commonly used agents to treat drug-resistant bacterial infections; however, their clinical use is hindered by nephrotoxicity. We previously reported that zileuton has the potential to attenuate antibiotic-associated nephrotoxicity in an animal model. Here, we further report the development of a parenteral formulation and exploration of dosing strategies for zileuton. The solubility, stability, and multi-dose safety of two zileuton formulations were evaluated. Zileuton serum and renal tissue pharmacokinetics were evaluated after a single dose and compared to steady state after 10 days. Different dosing strategies of zileuton to attenuate vancomycin-, polymyxin B-, …

The Impact Of Socio-Emotional And Provider Support On Hiv Testing In Southern United States, Ijeoma Onyinyechi Nwazuruokeh

Walden Dissertations and Doctoral Studies

HIV was first diagnosed over 40 years ago in the United States; however, HIV remains an epidemic. An understanding of how socio-emotional support, social isolation, and support from an individual's provider influence HIV testing in the Southern United States can be a key to increasing testing rates and ultimately reducing the incidence and prevalence of HIV in the Southern United States. The purpose of this non-experimental quantitative study was to examine the relationship between HIV testing, socio-emotional support, and social isolation, and how these variables are further moderated by an individual having provider support in the Southern United States. The …

Real-Time Experiences Of Racism And Stress In Association With Postpartum Weight Retention: A Longitudinal Ecological Momentary Assessment Study, Dara M Méndez, Amanda L Tapia, Sarah A Sanders, Andrea D Casas, Marquita Smalls, Esa M Davis, Stephen L Rathbun, Tiffany L Gary-Webb, Lora E Burke, Serwaa S Omowale, Linda A Adodoadji, John J Gianakas, Y Lai, Maisa Feghali, Meredith L Wallace

Faculty, Staff and Student Publications

Racial inequities in postpartum weight have been documented with limited studies on the influences of racism and other forms of discrimination. In a prospective longitudinal study applying ecological momentary assessment (EMA) and ambulatory assessment of weight, we measured the association between discrimination, stress, and postpartum weight change. The Postpartum Mothers Mobile Study is a cohort of 313 pregnant and birthing individuals who were followed during their second and third trimesters through 1 year postpartum. They were recruited in clinical settings between 2017 and 2020 in a major city center in Pennsylvania. Measures of racism and gender-based discrimination were collected via …

Socioeconomic Determinants Of Depression And Anxiety Disorders In Puerto Ricans Living On The Island And The Mainland, Herman Alvarado

Walden Dissertations and Doctoral Studies

Research shows that, among Hispanics, depression and anxiety disorders are the two most prevalent mental disorders, particularly for Puerto Ricans. The socioecological model approaches mental health conditions from a perspective where multiple levels in society influence health-related behaviors. Based on this approach, this quantitative study looked at how socioeconomic factors - marital status, education, employment, and residential status were related to a diagnosis of depression or anxiety in Puerto Ricans. This study also explored whether there were differences between two groups of Puerto Ricans: those living on the island compared to those living in the 50 states. Analysis was conducted …

Development And Validation Of Venous Thromboembolism-Bidirectional Encoder Representations From Transformers (Vte-Bert) Natural Language Processing Model, Omid Jafari, Shengling Ma, Barbara D Lam, Jun Y Jiang, Emily Zhou, Mrinal Ranjan, Justine Ryu, Raka Bandyo, Arash Maghsoudi, Bo Peng, Christopher I Amos, Abiodun Oluyomi, Nathanael R Fillmore, Jennifer La, Ang Li

Faculty, Staff and Students Publications

Background: Accurate and rapid phenotyping of venous thromboembolism (VTE) in longitudinal studies is important. A natural language processing (NLP) tool externally validated in representative patients is lacking.

Objectives: To train and validate an efficient NLP model to detect incident VTE event.

Methods: We designed a novel NLP platform, NLPMed, to assist thrombosis researchers with data preprocessing, phenotype annotation, language model finetuning, and NLP application. Using clinical notes, discharge summaries, and radiology reports from patients with cancer at 2 healthcare institutions, we finetuned Bio_Clinical Bidirectional Encoder Representations from Transformers (BERT) to develop VTE-BERT. The new model was trained to detect acute …

Three Things We Can Do Now To Reduce The Risk Of Avian Influenza Spillovers, Kenneth B Yeh, William P Bahnfleth, Elaine Bradford, Carol Cardona, Kristen K Coleman, Peter J Hudson, Bernadeta Dadonaite, Rebecca J Hutchins, Anthony Maresso, C Raina Macintyre, Matthew Scotch

Faculty, Staff and Students Publications

No abstract provided.

Increased Fungal Burden In The Gastrointestinal Tract Of Brain-Dead Organ Donors, Erika J Nachman, Colleen K Ardis, A Kyle B Ardis, Javier Nieto, Madeline M Bresson, Clare M Robertson, Maggie N Seale, Nora M Villafuerte, Zhe Lyu, Eva C Preisner, Heather A Danhof, Sara C Di Rienzi, Yolanda T Becker, Robert A Britton

Faculty, Staff and Students Publications

Approximately 3% of organ transplant recipients will be diagnosed with an invasive fungal infection (IFI), with 10%-47% being fatal. The source of IFI is typically not known, but Candida spp. cause the majority of IFI cases. We obtained intestines from two types of organ donors, brain-dead (BD) (n = 7) and donation after circulatory death (DCD) (n = 5), to sample microbes from the mucosal surface and the lumen. BD donors were parenterally fed and treated with corticosteroids in the days before procurement, whereas DCD donors were enterally fed and not given corticosteroids. We found fungi present in …

Childhood Vaccination In Mozambique Pre- And Post-Covid-19 Pandemic, Remy Mwamba

Walden Dissertations and Doctoral Studies

In 2019, infectious diseases and other conditions claimed the lives of over 5 million children under 5. Global immunization coverage remains below prepandemic levels, leaving behind over 14 million zero-dose children in 2022, of whom 84% lived in low- and middle-income countries. This quantitative cross-sectional study aimed to examine, using two consecutive Demographic and Health Surveys, whether the most significant household characteristics and health service utilization risk factors associated with nonvaccination before the COVID-19 pandemic still hold postpandemic in Mozambique. Andersen's behavioral model of healthcare service utilization was the foundation for this investigation. The sample included N=2034 children aged 12-35 …

Factors Influencing Covid-19 Vaccine Uptake Among Vulnerable Communities In Texas: Perceptions Of 2-1-1 Helpline Callers, Lara S Savas, Paula Cuccaro, Kehe Zhang, Rodrigo Hernandez, Meghan E Haffey, Belinda Reininger, Anais Mendiola, Olivia Dominguez, Maribel Sifuentes, Cici Bauer, Maria E Fernandez

Faculty, Staff and Student Publications

Background: Vaccination effectively and safely prevents serious illness from coronavirus disease 2019 (COVID-19). This study examines the complex factors associated with vaccination uptake among economically disadvantaged adults calling the Texas/United Way 2-1-1 helpline. Results informed the development of strategies to increase COVID-19 vaccine uptake among vulnerable populations disproportionately impacted by COVID-19-related morbidity and mortality.

Material and methods: We conducted a cross-sectional survey among 2-1-1 adult callers (May 2021-September 2022). The survey examined demographic, sociocultural, healthcare access, and psychosocial factors, as well as mistrust in health agencies. We used multivariable logistic regression models to examine factors associated with vaccination uptake, and …

Socioecological Factors And Age Of Diagnosis For Autism Spectrum Disorder Among U.S. Children, Richline Wilson

Walden Dissertations and Doctoral Studies

As autism spectrum disorder (autism/ASD) diagnoses rise, understanding the influence of socioecological factors on the age of diagnosis among children in the United States is critical for timely intervention and improved quality of life. The purpose of this study was to examine how socioecological factors influence the age at which children are diagnosed with autism/ASD. The quantitative causal-comparative design, which was informed by Bronfenbrenner’s socioecological model, involved analysis of secondary data from the 2021 National Survey of Children’s Health (N=1416). Ordinal logistic regression analysis revealed that race and ethnicity moderated the relationship between socioeconomic status (caregiver educational and employment status …

Comparative Outcomes Of Coil Embolization And Surgical Clipping In Elderly Patients With Subarachnoid Hemorrhage: A Systematic Review And Meta-Analysis, Yohanna Idsabella Rossi, Gabriel Bolner, Jonathan Costa Dall'acqua, Fabiana Dolovitsch De Oliveira, Lucas V. Zacaria, Taís L. Denicol, Michel Frudit, Natália Vasconcellos De Oliveira Souza

Department of Neurology Faculty Papers

BACKGROUND AND OBJECTIVES: Elderly patients with subarachnoid hemorrhage (SAH) face a disproportionately high burden of morbidity and mortality. While endovascular coiling is often favored in this population, direct comparisons with surgical clipping are limited. We conducted a meta-analysis to compare outcomes of clipping versus coiling in SAH patients aged ≥ 60 years.

METHODS: A systematic search of PubMed, Embase, and Cochrane databases identified studies comparing the two treatments in this age group. The primary outcome was a composite of unfavorable outcomes (modified Rankin Scale [mRS] > 2 and mortality). Secondary outcomes included mortality, favorable outcome (mRS 0-2), rebleeding, and hospital length …

Breast Cancer Survival Rates And Determinants In Ethiopia: A Systematic Review And Meta-Analysis Of Longitudinal Studies, Abenezer M. Tafese, Meseker T. Fentie, Beminate L. Seifu, Angwach A. Asnake, Bikiltu D. Dirbaba, Abdisa G. Jara, Elsabeth Tizazu Asare, Brandon George

College of Population Health Faculty Papers

BACKGROUND: Breast cancer is the most common cancer and the leading cause of cancer mortality among women in Ethiopia, accounting for 32% of new cancer cases and 17.6% of cancer deaths. Despite its growing burden, comprehensive data on survival rates and contributing factors remain limited. This systematic review and meta-analysis aimed to synthesize existing data on breast cancer survival in Ethiopia and identify key determinants influencing outcomes.

METHODS: A comprehensive systematic search was conducted in PubMed, Web of Science, Scopus, Embase, and CINAHL to identify studies on breast cancer survival in Ethiopia published between January 2014 and August 2024. Eligible …

Trauma Resuscitation With Low-Titer Group O Whole Blood Or Products: Study Protocol For A Randomized Clinical Trial (The Troop Trial), Jan O Jansen, Claudia Pedroza, Luis Leon Novelo, Tianyao Hao, Gina R Dewildt, Charles F Coton, Kiran Mansoor, Shannon W Stephens, Marisa B Marques, James R Stubbs, Jillian R Richter, Henry E Wang, John B Holcomb, Stacia M Desantis

Faculty, Staff and Student Publications

Background: Hemorrhage is the most common cause of potentially preventable death after injury. Balanced transfusion with red blood cells, plasma, and platelets (component therapy, CT) has been shown to reduce mortality, and is the standard of care. Low-Titer Group O Whole Blood (LTOWB) is an attractive alternative to CT, but existing evidence comprises observational studies, and a small single center pilot randomized controlled trial, which evaluated a type of whole blood that is no longer in use. The aim of the "Trauma Resuscitation with Low-Titer Group O Whole Blood Or Products" (TROOP) trial is to compare the effectiveness and safety …

Adolescent Students’ Adaptability During The Covid-19 Pandemic Impacting Their Academic Preparedness In College: A Qualitative Exploration Of Resilience In Secondary School Disruptions, Nicole Tyanne Jameson

Dissertations

This study, conducted several years after the onset of the COVID-19 pandemic, takes a unique approach to investigating the long-term effects of the pandemic-induced disruptions on adolescents during secondary schooling and their academic preparedness in college. The study combined a descriptive qualitative analysis of academic routine data with quantifiable resilience scores, providing a comprehensive understanding of the challenges students faced, their adaptability and resilience, and the overall impact on their education journey into college. This comprehensive descriptive qualitative study utilizes triangulation of quantitative data and qualitative approaches to understand the subject matter thoroughly. The quantitative scores meticulously analyzed resiliency and …

Demographic Characteristics And Selected Personality Traits Of Women In Competitive Bodybuilding, Chloe A. Zeeuw

Master's Theses

This study investigated demographic characteristics and measures of personality (dimensions of performance perfectionism and five-factor model characteristics) in women in competitive bodybuilding between 18-25 years old. A total of 24 women completed an online survey which included a demographic questionnaire, the Five Factor Model Rating Form (FFMRF), and the Performance Perfectionism Scale for Sport (PPSS) inventories. Descriptive results for the FFMRF were Openness (18.17±3.12), Conscientiousness (25.58±3.33), Extraversion (19.96±3.46), Agreeableness (19.88±4.58), and Neuroticism (15.67±4.94), and for the PPS-S were Self-oriented performance perfectionism (20.96±3.53), Socially prescribed performance perfectionism (13.96±4.26), and Other-oriented performance perfectionism (10.54±4.23). Pearson’s correlation coefficients and Shapiro-Wilk tests revealed that …

Caregiver Perceptions, Knowledge, And Likelihood To Intervene With Suicidal Youth, Amber L. Willwerth

All-Inclusive List of Electronic Theses and Dissertations

This study utilized an online survey to target primary caregivers of a child aged 5-18. The survey highlighted factors regarding caregiver involvement in suicide prevention efforts, such as their knowledge, comfort and confidence intervening with a youth experiencing suicidality, and barriers to doing so. It was found that caregivers who had experienced suicide prevention training reported higher levels of comfort and confidence intervening with their own child and another child than those who had not, as well as lower levels of worry. Higher levels of education were also found to predict lower levels of worry, suggesting that further training and …

Kenyan Dietitians’ Knowledge Of Ketogenic Dietary Therapies For Drug-Resistant Epilepsy, Pauline Samia, Violet Naanyu, Perry Ndila, Helen Cross, Richard Idro, Paul Boon, Jo Wilmshurst, Stanley Luchters

Paediatrics and Child Health, East Africa

Background: Ketogenic dietary therapy (KDT) has been proven to be efficacious for people with drug-resistant epilepsy. However, it is rarely utilized in low-resource settings. Due to the complexity of implementation, dietitians play a crucial role in managing KDT.

Methods: We conducted a cross-sectional survey of 253 out of the 1,000 registered dietitians. We assessed their knowledge of and interest in further training in KDT.

Results: Most participants were female (78%), with a median age of 33 years (IQR=28–38). A total of 171 (67.6%) reported knowledge of KDT. However, only 13 respondents (7.6%) answered all five knowledge-specific questions correctly. A …

Mental Health Service Utilization Among Arab/Middle Eastern In The Us: Structural Disparities, Digital Access, And Stigma-Related Barriers., Fatima M. Aldarweesh

Electronic Theses and Dissertations

Arab Middle Eastern (AME) United States (US) college-attending students are more susceptible to disproportionate mental health problems and underutilization of mental healthcare services due to cultural, structural, and psychosocial barriers. The study examines mental health service utilization and mental health outcomes among AME, particularly focusing on the impact of structural, cultural, and psychosocial determinants grounded in Andersen and Aday’s Health Services research model and Corrigan’s stigma framework. The three interconnected aims use secondary nationally representative data from the Healthy Minds Study (HMS) 2019-2024. The study was analyzed using logistic regression and generalized structural equation modeling across three aims to identify …

Engaging In Movement At Work: Exploring Engagement And Physical Activity., Spencer A. Cavan

Electronic Theses and Dissertations

High levels of employee engagement provide organizations competitive advantages such as increased customer satisfaction, profits, and employee productivity. Despite potential benefits, the number of engaged employees is declining and organizations need to find innovative ways to enhance engagement. Emerging evidence suggests workplace physical activity may generate organizational benefits extending beyond health improvement. Therefore, the purpose of this study was to investigate perceptions of engagement among employees participating in a physical activity intervention at work. A qualitative design, guided by phenomenology, examined perceptions of workplace physical activity and perceived levels of engagement, as well as constraints related to involvement among university …

Navigating Childhood Asthma Care In Kenya: Barriers Identified By Children And Their Caregivers, Joan Ahimbisibwe, Roselyter Riang’A, Angela Migowa, Samuel Otido

Paediatrics and Child Health, East Africa

Background: Asthma is one of the most common chronic conditions in children, with significant morbidity and mortality, especially in Africa. Achieving adequate asthma control in children remains challenging because of gaps between standard recommended management strategies and actual treatment practices. This study explored barriers to asthma management as perceived by children and their caregivers in a private tertiary care setting in Kenya.

Methods: An exploratory phenomenological qualitative study was conducted at Aga Khan University Hospital (AKUH), Nairobi. Children aged 6–18 years with a confirmed diagnosis of asthma and their caregivers were recruited. The participants had been receiving treatment for at …

Dissecting The Heterogeneous Effects Of Opioid Prescribing Limit Laws On Pediatric Mortality: A Multidimensional And Negative Binomial Modeling Approach, Francine R. Vega

Dissertations and Theses (Open Access)

Opioid prescribing for children and adolescents continues to be a significant health crisis in the United States. Early naïve exposure to opioid prescriptions has been linked to later misuse, opioid use disorder, and death. In response to the crisis, many states have implemented opioid prescribing limit laws (OPLLs) aimed at reducing exposure to opioids. These laws vary widely in their approach, including differences in dosage restrictions, prescription duration limits, informed consent requirements, educational provisions, and whether they offer explicit protections specifically for minors. Despite their widespread adoption, there is limited understanding of how heterogeneity in legal regulations affects outcomes for …

Rethinking Health Systems Responsiveness In Low–And Middle-Income Countries, Meesha Iqbal

Dissertations and Theses (Open Access)

Health systems responsiveness (HSR) refers to a health system’s ability to meet legitimate non-health expectations of the population. Traditionally, HSR has been conceptualized across eight domains: respect for dignity, autonomy, confidentiality, prompt attention to health needs, availability of basic amenities, choice of provider, access to social support networks, and clarity of communication. However, as the expectations of populations in high-income countries (HICs) and low- and middle-income countries (L&MICs) differ significantly due to diverse social and cultural contexts, the conceptualization of HSR also varies. We conducted a systematic review of literature to adapt and contextualize the HSR framework for L&MICs based …