Hrev_master Abstract People living with HIV (PLHIV) require a focus on their qual- ity of life to prevent deterioration. This study aims to establish a spiritual-based palliative nursing model to enhance the quality of life for PLHIV. A cross-sectional study of 225 PLHIV receiving treatment at Said Sukanto Hospital, Jakarta. Data, including demographic, disease, psychological, spiritual, support, services, spiritual-based palliative care, spiritual meaning in illness experi- ence, and quality of life variables, were collected using a researcher-modified questionnaire. Data were analyzed using descriptive and structural analysis through Partial Least Square Equation Modeling (SEM-PLS). The outer model demonstrated construct validity (λ > 0.5) and high reliability (composite reliabil- ity > 0.7). The inner model exhibited moderate power (R2 > 0.33) and predictive relevance (1.009). Goodness-of-fit indicators (RMS Theta = 0.072, NFI = 0.971, SRMR = 0.098) confirmed the model’s suitability. Hypothesis testing indicated the significance of all variables (p<0.05). The findings support the application of a spiritual-based palliative nursing model to enhance the quality of life for PLHIV. This model offers a holistic approach encompass- ing physical, psychological, social, and spiritual well-being, pro- viding a comprehensive framework for healthcare providers and policymakers to improve care for PLHIV. Introduction HIV remains a significant global public health problem and has claimed 40.1 million lives. By 2021, 650,000 people will die of HIV-related causes, and 1.5 million people will acquire HIV.1 Scientists continue to fight against it. The discovery of anti-retro- viral therapy (ART), while not a cure for HIV, has been able to prevent new viruses from being produced in newly infected cells.2 Moreover, with increasing access to effective HIV prevention, diagnosis, treatment, and care, including for opportunistic infec- tions, HIV infection has become a chronic health condition that can be managed. This shift has enabled people living with HIV (PLHIV) to lead long and healthy lives, focusing on the quality of life.3,4 The facts show that most HIV patients (63.7%) have a poor quality of life.5 Research results in Iran concluded that most PLHIV have low quality of life scores.6,7 In Nigeria, the average score for the quality of life for PLHIV is low in the domain of social and environmental relations, and in China, other studies have shown a decrease in the quality of life for PLHIV in the physical health domain.8 The low quality of life underlines the policy formulation by the Ministry of Health of the Republic of Indonesia regarding Palliative Care. This policy is based on the Healthcare in Low-resource Settings 2023; volume 11:11737 Development of a spiritual-based palliative care model for the quality of life of people with HIV/AIDS Rohman Rohman,1,2 Nursalam Nursalam,2 Tintin Sukartini,2 Hamidah Hamidah,3 Supatmi Supatmi,4 Diah Priyantini,4 Daviq Ayatulloh,5 Miciko Umeda1 1Faculty of Nursing, Universitas Muhammadiyah Jakarta, Jakarta; 2Faculty of Nursing, Universitas Airlangga, Surabaya; 3Faculty of Medicine and Health, Universitas Muhammadiyah Jakarta, Jakarta; 4Faculty of Health Science, Universitas Muhammadiyah Surabaya, Surabaya; 5Faculty of Health Science, Universitas Gresik, Gresik, Indonesia Correspondence: Rohman Rohman, Faculty of Nursing, Universitas Muhammadiyah Jakarta, Jakarta, Indonesia; Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia. E-mail: rohman1azzam@gmail.com Key word: palliative; PLHIV; quality of life; spiritual meaning. Contributions: RR, NN, TS, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; HH, methodology, visualization, writing – review and editing; ss, resources, investigation, and writing – review and editing; DP, formal analysis, validation, writing – review and editing; DA, resources, supervision, and writing – review and edit- ing; MU, resources, investigation, and writing – review and editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from the Health Research Ethics Commission, Faculty of Nursing, Universitas Airlangga, based on ethical certifi- cate 2742-KEPK. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgments: we would like to be thankful to all the partici- pants for their valuable contributions to this study. Received: 16 September 2023. Accepted: 14 November 2023. Early access: 17 November 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11737 doi:10.4081/hls.2023.11737 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 114] [Healthcare in Low-resource Settings 2023; 11:11737] Non -co mmerc ial us e o nly consideration that cases of incurable diseases are increasing and aims to improve health services for clients with such diseases, including palliative care.9 Palliative care aims to enhance the quality of life of patients and their families, encompassing physical, psychosocial, and spir- itual aspects.10 However, in practice, palliative care for PLHIV has predominantly focused on managing physical and psychological symptoms like pain, shortness of breath, anorexia, constipation, nausea, fatigue, delirium, anxiety, and depression.11 It identifies the current shortcoming, emphasizing that palliative care for PLHIV tends to treat physical symptoms but hasn’t paid sufficient atten- tion to spiritual aspects. A spiritual-based palliative care approach can help individuals remain calm when facing problems and endure suffering,12 serving as a key to overcoming difficulties,13 and increasing resilience when experiencing sadness. It allows individuals to be more accepting,14 serving as a resource in dealing with life events that cause stress and helping them accept reality more realistically. This research aimed to develop a spiritual-based palliative care model to improve the quality of life for PLHIV. Materials and Methods Research design The research employed an explanatory research design. This approach aimed to analyze the factors that influenced the quality of life of PLHIV using a cross-sectional method. It delved into how demographic, disease, psychological, spiritual, support, and ser- vice system factors impacted the ability to find spiritual meaning in the experience of illness and the overall quality of life for PLHIV. The research was conducted at Said Sukanto Hospital, Jakarta, which was chosen due to its specialization in treating PLHIV patients. Study participants Sample size determination followed the rule of thumb, which suggested a sample size of 5 to 10 times the number of indicators (observed variables). As there were 27 indicators in this study, the minimum sample size was 5 x 27, which equaled 135 samples. Therefore, the researchers included 225 respondents, all of whom were HIV patients. The sampling technique used nonprobability sampling with a purposive sampling method. The criteria for selecting participants were PLHIV patients undergoing hospital- ization, aged 21 years or older, possessing a competent level of consciousness, being able to read and write, having good hearing and vision, and not being in critical condition or suffering from many opportunistic infections. Variable, instrument and data collection Independent variables encompassed demographic factors (age, gender, education, occupation, religion, economic status, and mar- ital status), which were measured using a patient demographic data questionnaire containing personal information. Disease factors (early diagnosis, opportunistic infections, and ARV adherence) were assessed using the WHOQOL-HIV BREF questionnaire and the Morisky Medication Adherence Scale/MMAS. Psychological factors (anxiety and depression) were gauged with the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI-II), respectively. Spiritual factors (personal beliefs, religious practices, and spiritual satisfaction) were assessed using the PLHIV-focused Spiritual Questionnaire developed by Nursalam.15 Support system factors (family support, caregivers, peer groups, and religious communities) employed a questionnaire modified by the researcher. Service factors (nursing services, service availability, access to services, and the health team) were also measured using a questionnaire modified by the researcher. The spiritual-based palliative care variable was evaluated with a questionnaire designed by the researcher, which incorporated elements of spiri- tual well-being to enhance patient outcomes during treatment and in life. The dependent variable, consisting of spiritual meaning in the experience of illness (symptoms of pain and loss), was assessed with a researcher-modified questionnaire. The quality of life for PLHIV (covering physical aspects, psychological aspects, level of independence, social relations, environmental health, and spiritual- ity) was measured using the WHOQOL-HIV BREF. The research instruments were previously validated for their reliability and validity, using a 4-point Likert scale: strongly agree = 4, agree = 3, disagree = 2, and strongly disagree = 1. All instruments were tested for validity and reliability on 40 PLHIV, obtaining a calculated r value of 0.270 – 0.991 (r table 0.257) and reliability with Cronbach’s Alpha 0.714 – 0.974 (Cronbach’s Alpha > 0.6), con- firming their validity and reliability. Data analysis The analysis used the PLS (Partial Least Square) approach. PLS allowed for structural equation modeling with relatively small sample sizes and did not require multivariate normal assumptions. The PLS model specification in path analysis encompassed three types of relationships: the inner model, outer model, and weight relation. Results As per the data presented in Table 1, it is evident that the observed demographic factors showed the following results: 37.3% of the respondents were in the age range of 26-35 years, 74.2% were male, 51.1% had completed high school, and 64.9% worked as private employees. The majority of the respondents practiced the Muslim faith (92.4%), were married (43.6%), and had an income status of 54.2% below the regional minimum wage. Based on the results of the outer loading values, it is evident that the outer loading values for all latent variables exhibit a result of λ ≥ 0.5 and a statistical T value ≥ 1.96. Variables with valid mea- surements include demographic factors, disease factors, psycho- logical factors, spiritual factors, support system factors, health ser- vice factors, spiritual meaning in the experience of illness, and quality of life for PLHIV (Figure 1). Based on the data processing results presented in Table 2, an evaluation of the structural model (inner model) was conducted to assess its validity. The test results indicate that when the T-statis- tics value is ≥ T-table (1.96) or the p-value is < the significant alpha level of 5% or 0.05, it is considered to have a significant influence of the independent variables on the dependent variable. The research findings reveal that several variables, including X1 (demographic factors), X2 (disease factors), X3 (psychological factors), X4 (spiritual factors), and spiritually based palliative care (Y1), along with the spiritual meaning of the illness experience (Y2), play a significant role. Notably, X4, representing spiritual factors, serves as one of the latent variables in this research, signi- fying the level of spirituality among PLHIV, which is manifested through their attitudes and behaviors. This includes components related to personal beliefs, religious practices, and spiritual satis- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2023; 11:11737] [page 115] Non -co mmerc ial us e o nly faction. It is evident that spiritual factors have a noteworthy impact on enhancing the quality of life for PLHIV, as indicated by the T- statistics value of 5.054 (less than 1.96) and a p-value of 0.040 (greater than 0.05). The research model’s path analysis identifies the most influen- tial path as originating from X7 (spiritual-based palliative care), which subsequently impacts both Y1 (spiritual meaning of illness experience) and Y2 (quality of life of PLHIV). The path analysis reveals an original sample value of 0.791 with a p-value of 0.000. According to the model fit image provided above, the RMS Theta value is 0.072, which is less than 0.102, and the NFI value is 0.971, exceeding the threshold of 0.9. Therefore, based on these two model assessments, the model meets the criteria for model fit. Similarly, the SRMR (Standardized Root Mean Square) value is 0.098, slightly below 0.10. Consequently, the model is deemed to be a good fit for the research data (Table 3). Discussion The research results demonstrate that all hypotheses signifi- cantly influence the independent and dependent variables. Spiritual-based palliative care is a developmental model studied to enhance the quality of life in PLHIV. The palliative approach was initially aimed at improving the quality of life for clients and fam- ilies facing life-threatening illnesses through the prevention, assessment, and treatment of pain, as well as other physical and psychosocial issues.7,16,17 In this study, palliative care was com- bined with spirituality as an active and positive process involving the search for activities that restore a person’s sense of coherence, internal wholeness, and inner peace. Therefore, a palliative model combined with spirituality can enhance the quality of life in PLHIV patients. Based on the overall results of the study, it can be observed that in the development of a spiritual-based palliative care model for quality of life in PLHIV, the best path is from service factors to spiritual-based palliative care, ultimately leading to the path of the ability to find the spiritual meaning in the experience of illness, which affects the quality of life in PLHIV patients. This indicates that the quality of spiritual-based palliative care and services is the most dominant factor contributing to the improvement of the qual- ity of life for PLHIV. Therefore, in its development, it should be studied how to enhance both of these factors.18,19 Spiritual-based palliative care is the most significant factor in improving the quality of life of PLHIV patients, which includes indicators of symptom management, spiritual support, and end-of- life care.20 This spiritual-based palliative care can help individuals remain calm when facing problems and endure suffering due to their illness.21 Psychologically, PLHIV often experiences low self- confidence, prolonged stress, anxiety, and depression, and spiritu- ally, they may undergo a crisis of faith due to feelings of guilt and sin, as well as a sense of approaching death.14 The quality of life for PLHIV is greatly influenced by spiritu- ality, as it serves as an essential contributor to well-being in improving their quality of life. Spirituality acts as a bridge between decisions and meaningfulness in life.22 According to Bornet et al. (2017),23 treatment is based on spiritual abilities, including the ability to determine the meaning of life and engage in worship according to one’s religious beliefs. PLHIV often recognize their illness as a test from God to assess their faith, leading them to strengthen their beliefs, which ultimately impacts their quality of life. When illness strikes, a person’s spiritual health can aid in Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Figure 1. Research outer loading value. Table 1. Characteristics of research respondents (n=225). Indicator F % Age 17-25 Years 16 7.2 26-35 Years 84 37.3 36-45 Years 73 32.4 46-55 Years 52 23.1 Gender Man 167 74.2 Woman 58 25.8 Education No school 4 1.8 Elementary school 33 14.7 Junior high school 52 23.1 Senior high school 115 51.1 University 21 9.3 Work Doesn't work 56 24.9 Private employees 146 64.9 Businessman 23 10.2 Religion Islam 208 92.4 Protestant 14 6.2 Catholic 2 0.9 Buddha 1 0.5 Economic Status < Regional minimum wage 122 54.2 ≥ Regional minimum wage 103 45.8 Marital status Not married yet 71 31.5 Marry 98 43.6 Divorced 48 21.3 Death divorce 8 3.6 [page 116] [Healthcare in Low-resource Settings 2023; 11:11737] Non -co mmerc ial us e o nly recovery because they believe their efforts will be successful.23 This helps PLHIV endure difficult times and not give up on their illness. Quality of life is associated with spirituality, which involves drawing closer to God by adapting one’s lifestyle accord- ing to God’s commands, establishing a spiritual and social net- work, and maintaining an optimistic spirit. Combining palliative care with spirituality can motivate individuals to gain religious and spiritual experiences, achieve physical health, and alleviate self- anxiety, ultimately leading to a higher quality of life.24,25 Recommendations for improving the quality of life of PLHIV in developing a spiritual-based palliative care model have theoreti- cal and practical implications. The spiritual-based palliative care model contributes to strengthening and developing existing theo- ries, such as the theory of palliative care and spiritual well-being. It shows that demographic factors, disease factors, psychological fac- tors, spiritual factors, support system factors, spiritual-based pallia- tive care, and service system factors directly influence the ability to find spiritual meaning in the experience of illness, thus improving the quality of life for PLHIV.26 The application of a spiritual-based palliative care model in improving the quality of life for PLHIV will provide nurses with guidance on the need for spiritual studies to determine interventions that fulfill spiritual support in collabora- tion with religious volunteers. The model can also be used to enhance the health status, motivation, enthusiasm, and belief of PLHIV in their recovery by emphasizing spiritual meaning. Conclusions The development of a spiritual-based palliative care model has been demonstrated to significantly influence the spiritual meaning of the experience of illness and the quality of life among PLHIV. This model encompasses various factors, including demographic factors (age, gender, education, occupation, religion, economic sta- tus, and marital status), disease factors (early diagnosis, oppor- tunistic infections, and ARV adherence), psychological factors (anxiety and depression), spiritual factors (personal beliefs, reli- gious practices, and spiritual satisfaction), support system factors (family support, caregivers, peer groups, and religious communi- ties), and service factors (nursing care, service availability, access to services, and healthcare teams). These factors serve as mediat- ing elements in the development of this model. The study’s results indicate that the future benefits of this model include making sig- nificant contributions to improving the quality of life for PLHIV through spiritually-based palliative care. Nurses and other health- care professionals can apply interventions to provide care for PLHIV. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 2. Research hypothesis testing results. Hypothesis Original sample T Statistics P Significance (O) (|O/STDEV|) X1 Demographic factor -> X7 Spiritual based palliative care 0.523 10.859 0.004 Significant X1 Demographic factor -> Y1 Spiritual meaning in the experience of illness 0.418 7.623 0.045 Significant X2 Disease Factor -> X7 Spiritual-based palliative care 0.494 9.825 0.041 Significant X2 Disease Factor -> Y1 Spiritual meaning in the experience of illness 0.415 6.873 0.038 Significant X3 Psychological Factors -> X7 Spiritual-based palliative care 0.469 8.496 0.014 Significant X3 Psychological Factors -> Y1 Spiritual meaning in the experience of illness 0.404 5.243 0.048 Significant X4 Spiritual Factor -> X7 Spiritual based palliative care 0.416 7.313 0.048 Significant X4 Spiritual Factor -> Y1 Spiritual meaning in the experience of illness 0.401 5.054 0.040 Significant X5 Support System Factor -> X7 Spiritual-based palliative care 0.655 14.176 0.000 Significant X5 Support System Factor -> Y1 Spiritual meaning in the experience of illness 0.492 9.341 0.001 Significant X6 Service system factor -> X7 Spiritual-based palliative care 0.675 16.705 0.000 Significant X6 Service system factor -> Y1 Spiritual meaning in the experience of illness 0.481 9.160 0.000 Significant X7 Spiritual-based palliative care -> Y1 Spiritual meaning in the experience of illness 0.888 26.397 0.000 Significant Y1 Spiritual meaning in the experience of illness -> Y2 Quality of Life 0.753 16.647 0.000 Significant Table 3. Results of model fit testing research. Saturated model Estimated model SRMR 0.101 0.098 d_ULS 8.313 8.313 d_G 4.903 4.903 Chi-Square 2215.232 2215.232 NFI 0.971 0.971 rms Theta 0.072 [Healthcare in Low-resource Settings 2023; 11:11737] [page 117] Non -co mmerc ial us e o nly References 1. Tarigan YN, Woodman RJ, Miller ER, Wisaksana R, Wignall FS, Ward PR. Changes in the HIV continuum of care following expanded access to HIV testing and treatment in Indonesia: a retrospective population-based cohort study. PLoS One 2020;15:e0239041. 2. Misgina KH, Weldu MG, Gebremariam TH, Weledehaweria NB, Alema HB, Gebregiorgis YS, et al. Predictors of mortality among adult people living with HIV/AIDS on antiretroviral therapy at Suhul Hospital, Tigrai, Northern Ethiopia: a retro- spective follow-up study. J Heal Popul Nutr 2019;38:1-10. 3. Sari PI, Martawinarti RTSN, Lataima NS, Berhimpong VM. The Quality of Life of Patients with HIV/AIDS Undergoing Antiretroviral Therapy: A Systematic Review. J Ners 2019;14:50-4. 4. Ekstrand ML, Heylen E, Mazur A, et al. The role of HIV stig- ma in ART adherence and quality of life among rural women living with HIV in India. AIDS Behav 2018;22:3859-68. 5. Yan H, Li X, Li J, et al. Association between perceived HIV stigma, social support, resilience, self-esteem, and depressive symptoms among HIV-positive men who have sex with men (MSM) in Nanjing, China. AIDS Care 2019;31:1069-76. 6. Lu H, Sheng W, Liao S, et al. The changes and the predictors of suicide ideation and suicide attempt among HIV-positive patients at 6-12 months post diagnosis: A longitudinal study. J Adv Nurs 2019;75:573-84. 7. Satriawibawa IWE, Dewi K, Wati K, et al. Factors associated with anxiety in children and adolescents with HIV infection. Int J HIV-Relat Prob 2022;21(2). 8. Prasetyanti DK, Nikmah AN, Tantriyani K. The Effect of Health Promotion Through Audio Visual Media About HIV AIDS On Housewives Knowledge. Str J Ilm Kesehat 2021;10:1272-9. 9. Fuspita Y, Yona S, Waluyo A. HIV testing of housewives with HIV in Lampung, Indonesia: A qualitative study. Enfermería Clínica 2019;29:879-84. 10. Hasanah H, Sulistiadi W. HIV/AIDS Infection among Housewives in Asia: A Systematic Review. Promot Popul Ment Heal Well-Being 2019;219-28. 11. Mekonnen N, Abdulkadir M, Shumetie E, et al. Incidence and predictors of loss to follow-up among HIV infected adults after initiation of first line anti-retroviral therapy at University of Gondar comprehensive specialized Hospital Northwest Ethiopia, 2018: retrospective follow up study. BMC Res Notes 2019;12:1-7. 12. Nursalam N, Sukartini T, Mafula D, Priyantini D. DREAMS Partnership: Pemberdayaan Perempuan untuk Meningkatkan Upaya Promotif, Preventif dan Resilience HIV/AIDS pada Remaja Putri dan Ibu Rumah Tangga di Kabupaten Tulungagung [DREAMS Partnership: Empowering Women to Improve HIV/AIDS Promotive, Preventive. Community Reinf Dev J 2022;1:7-17. 13. Nursalam N, Sukartini T, Priyantini D, et al. Risk factors for psychological impact and social stigma among people facing COVID 19: A systematic review. Syst Rev Pharm 2020;11:1022-8. 14. Dahlui M, Azahar N, Bulgiba A, et al. HIV/AIDS related stig- ma and discrimination against PLWHA in Nigerian population. PLoS One. 2015;10:e0143749. 15. Rohman, Nursalam, Sukartini T, Abdullah RA. The relation- ship between knowledge and spirituality with the prevention behavior of infection transmission in PLWHA. Indian J Public Heal Res Dev 2019;10:2817-22. 16. Johnson SM, Naidoo AV. A psychoeducational approach for prevention of burnout among teachers dealing with HIV/AIDS in South Africa. AIDS Care - Psychol Socio-Medical Asp AIDS/HIV 2017;29:73-8. 17. Motumma A, Negesa L, Hunduma G, Abdeta T. Prevalence and associated factors of common mental disorders among adult patients attending HIV follow up service in Harar town, Eastern Ethiopia: A cross-sectional study. BMC Psychol. 2019;7:11. 18. Wyatt GE, Gómez CA, Hamilton AB, et al. The intersection of gender and ethnicity in HIV risk, interventions, and preven- tion: New frontiers for psychology. Am Psychol 2013;68:247- 60. 19. Van Velthoven MHMMT, Brusamento S, Majeed A, Car J. Scope and effectiveness of mobile phone messaging for HIV/AIDS care: A systematic review. Psychol Health Med 2013;18:182-202. 20. Logie C, James L, Tharao W, Loutfy M. Associations between HIV-Related stigma, racial discrimination, gender discrimina- tion, and depression among hiv-positive african, caribbean, and black women in Ontario, Canada. AIDS Patient Care STDS 2013;27:114-22. 21. Rueda S, Mitra S, Chen S, et al. Examining the associations between HIV-related stigma and health outcomes in people liv- ing with HIV/AIDS: a series of meta-analyses. BMJ Open 2016;6:e011453. 22. Garett R, Smith J, Chiu J, Young SD. HIV/AIDS stigma among a sample of primarily African-American and Latino men who have sex with men social media users. AIDS Care 2016;28:731-5. 23. Bornet MA, Rubli Truchard E, Rochat E, et al. Factors associ- ated with quality of life in elderly hospitalised patients under- going post-acute rehabilitation: a cross-sectional analytical study in Switzerland. BMJ Open 2017;7:e018600. 24. Mahathir M, Wiarsih W, Permatasari H. How Do People Living with HIV Acquire HIV Related Information: A Qualitative Evaluation of Jakarta Setting. J Ners 2020;15:126- 34. 25. Martawinarti RTSN, Nursalam N, Wahyudi AS. Lived Experience of People Living with HIV/AIDS Undergoing Antiretroviral Therapy: A Qualitative Study. J Ners 2020;15:157-63. 26. Rooney AS, Moore RC, Paolillo EW, et al. Depression and aging with HIV: associations with health-related quality of life and positive psychological factors. J Affect Disord 2019;251:1-7. [page 118] [Healthcare in Low-resource Settings 2023; 11:11737] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly