Showing papers in "Bulletin of The World Health Organization in 2007"

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies

Abstract: Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study’s generalizability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control and cross-sectional studies. We convened a two-day workshop, in September 2004, with methodologists, researchers and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results and discussion sections of articles. Eighteen items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the web sites of PLoS Medicine, Annals of Internal Medicine and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.

Development of a WHO growth reference for school-aged children and adolescents

Abstract: Objective To construct growth curves for school-aged children and adolescents that accord with the WHO Child Growth Standards for preschool children and the body mass index (BMI) cut-offs for adults. Methods Data from the 1977 National Center for Health Statistics (NCHS)/WHO growth reference (1–24 years) were merged with data from the under-fives growth standards’ cross-sectional sample (18–71 months) to smooth the transition between the two samples. State-of-the-art statistical methods used to construct the WHO Child Growth Standards (0–5 years), i.e. the Box-Cox power exponential (BCPE) method with appropriate diagnostic tools for the selection of best models, were applied to this combined sample. Findings The merged data sets resulted in a smooth transition at 5 years for height-for-age, weight-for-age and BMI-for-age. For BMI-for-age across all centiles the magnitude of the difference between the two curves at age 5 years is mostly 0.0 kg/m² to 0.1 kg/m². At 19 years, the new BMI values at +1 standard deviation (SD) are 25.4 kg/m² for boys and 25.0 kg/m² for girls. These values are equivalent to the overweight cut-off for adults (> 25.0 kg/m²). Similarly, the +2 SD value (29.7 kg/m² for both sexes) compares closely with the cut-off for obesity (> 30.0 kg/m²). Conclusion The new curves are closely aligned with the WHO Child Growth Standards at 5 years, and the recommended adult cut-offs for overweight and obesity at 19 years. They fill the gap in growth curves and provide an appropriate reference for the 5 to 19 years age group. Bulletin of the World Health Organization 2007;85:660–667.

Elaboración de valores de referencia de la OMS para el crecimiento de escolares y adolescentes

Abstract: Introduction The need to develop an appropriate single growth reference for the screening, surveillance and monitoring of school-aged children and adolescents has been stirred by two contemporary events: the increasing public health concern over childhood obesity (1) and the April 2006 release of the WHO Child Growth Standards for preschool children based on a prescriptive approach. (2) As countries proceed with the implementation of growth standards for children under 5 years of age, the gap across all centiles between these standards and existing growth references for older children has become a matter of great concern. It is now widely accepted that using descriptive samples of populations that reflect a secular trend towards overweight and obesity to construct growth references results inadvertently in an undesirable upward skewness leading to an underestimation of overweight and obesity, and an overestimation of undernutrition. (3) The reference previously recommended by WHO for children above 5 years of age, i.e. the National Center for Health Statistics (NCHS)/WHO international growth reference, (4) has several drawbacks. (5) In particular, the body mass index-for-age reference, developed in 1991, (6) only starts at 9 years of age, groups data annually and covers a limited percentile range. Many countries pointed to the need to have body mass index (BMI) curves that start at 5 years and permit unrestricted calculation of percentile and z-score curves on a continuous age scale from 5 to 19 years. The need to harmonize growth assessment tools conceptually and pragmatically prompted an expert group meeting in January 2006 to evaluate the feasibility of developing a single international growth reference for school-aged children and adolescents. (7,8) The experts agreed that appropriate growth references for these age groups should be developed for clinical and public health applications. They also agreed that a multicentre study, similar to the one that led to the development of the WHO Child Growth Standards for 0 to 5 years, would not be feasible for older children, as it would not be possible to control the dynamics of their environment. Therefore, as an alternative, the experts suggested that a growth reference be constructed for this age group using existing historical data and discussed the criteria for selecting the data sets. WHO subsequently initiated a process to identify existing data sets from various countries. This process resulted in an initial identification of 115 candidate data sets from 45 countries, which were narrowed down to 34 data sets from 22 countries that met the inclusion criteria developed by the expert group. However, after further review, even these most promising studies showed great heterogeneity in methods and data quality, sample size, age categories, socioeconomic status of participating children and various other factors critical to growth curve construction. Therefore, it was unlikely that a growth reference constructed from these heterogeneous data sets would agree with the WHO Child Growth Standards at 5 years of age for the different anthropometric indicators needed (i.e. height-for-age, weight-for-age and BMI-for-age). In consequence, WHO proceeded to reconstruct the 1977 NCHS/WHO growth reference from 5 to 19 years, using the original sample (a non-obese sample with expected heights), supplemented with data from the WHO Child Growth Standards (to facilitate a smooth transition at 5 years), and applying the state-of-the-art statistical methods (9,10) used to develop standards for preschool children, that is, the Box-Cox power exponential (BCPE) method with appropriate diagnostic tools for the selection of best models. The purposes of this paper are to report the methods used to reconstruct the 1977 NCHS/WHO growth reference, to compare the resulting new curves (the 2007 WHO reference) with the 1977 NCHS/WHO charts, and to describe the transition at 5 years of age from the WHO standards for under-fives to these new curves for school-aged children and adolescents. …

The bottom billion: why are the poorest countries failing and what can be done about it

Abstract: Disadvantaged populations, such as the poor, pose a complex set of challenges to the process of economic development. While a girl child born in Japan in 2005 is expected to live for 86 years, deliver her child in a medical institution under skilled supervision and receive appropriate attention during her old age, her contemporary born in Angola, Lesotho, Sierra Leone, Swaziland, Zambia or Zimbabwe is expected to live for about 40 years, deliver her child at home without any skilled supervision and struggle to receive adequate care during old age if she survives that long. The child cannot be faulted for this diverse prospect of length and quality of life: countries that are home to such disadvantaged population groups are in extreme poverty and express their helplessness to rescue such groups. When countries are poor and small, their economies or governments are not in a position to respond effectively to diseases that predominantly affect their poor citizens. This inability to deal adequately with complex situations further impedes such countries’ growth. As a result, many low-income countries, where most of the world’s poor live, are drifting away, in developmental terms, from the rest of the world. On the other hand, the poor living in countries that are doing well economically face a different set of problems. Such people live alongside the rich and face similar market conditions due to increased globalization and monetization of economies. Possibilities to deal with the problems of poverty exist in better-off countries, but the poor often lack access to them. In such countries, the usefulness of economic growth lies in what it does to enhance people’s health and welfare. “Growth” has no meaning if millions of the poor lack access to basic amenities, such as health care. Whether developing or not, many low-income countries are caught in several traps which prevent them from prospering. To make things worse, the present global economy is unfavourable to the bottom billion people and the countries in which they live. Hence, it is much harder for disadvantaged countries to break out of the traps in which they find themselves. In this book, Paul Collier discusses four such traps that have previously received little attention. Interestingly, what many people would consider to be a source of prosperity – natural resources – is seen as a trap by the author. The other traps he discusses are conflict, being landlocked and surrounded by bad neighbours, and bad governance. The author claims that low-income, slow economic growth and high dependence on primary commodity exports are the key determinants of civil war, which is likely to continue longer if a country’s income is low. Civil war also tends to reduce a country’s economic growth by about 2.3% per annum. He notes that 73% of people among the bottom billion have been affected by civil war recently, 29% live in countries where natural wealth dominates the economy, 30% live in countries that are landlocked and resource-scarce and have bad neighbours, and 76% have lived through a prolonged period of bad governance and poor economic policies. The future progress of the bottom billion people is crucial for health and health system development. These are the people caught in the poverty/ill-health trap. Inequities in access to health care suffered by this group further disadvantage it. Conflicts, bad governance and lack of development clearly have an effect on the national health systems of the worst-affected countries. Breaking out of the traps discussed in the book is important for future health system development, and understanding these and other barriers to development is the essential first step. The book is a welcome contribution to health development literature and makes excellent reading for those who are concerned about poverty and the poor, and for those who tend to think that economic growth is the sum total of human welfare. The book powerfully describes the increasing income divisions between sections of populations; the difficulties that development agencies face in placing materials and staff in areas with maximum needs; governments’ inabilities and failures to deal with the situation; and investment failures in poor settings. The book also serves as a timely reminder for carrying out suitable policy and development responses. The author’s rich African experience is reflected in the valuable country examples provided, while the narrative style makes the book read well. A deliberately pessimistic view of the future prospects of the bottom billion is presented, but the book does provide some suggestions that the affected countries and the Group of Eight (G8) countries could adopt to improve the status quo. The book would have benefited from use of an analytical framework to better depict the evidence presented. ■

A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context

Abstract: Two decades after the Safe Motherhood campaign's 1987 launch in India, half a million women continue to die from pregnancy-related causes every year. Key health-care interventions can largely prevent these deaths, but their use is limited in developing countries, and is reported to vary between population groups. We reviewed the use of maternal health-care interventions in developing countries to assess the extent, strength and implications of evidence for variations according to women's place of residence and socioeconomic status. Studies with data on use of a skilled health worker at delivery, antenatal care in the first trimester of pregnancy and medical settings for delivery were assessed. We identified 30 eligible studies, 12 of which were of high or moderate quality, from 23 countries. Results of these studies showed wide variation in use of maternal health care. Methodological factors (e.g. inaccurate identification of population in need or range of potential confounders controlled for) played a part in this variation. Differences were also caused by factors related to health-care users (e.g. age, education, medical insurance, clinical risk factors) or to supply of health care (e.g. clinic availability, distance to facility), or by an interaction between such factors (e.g. perceived quality of care). Variation was usually framed by contextual issues relating to funding and organization of health care or social and cultural issues. These findings emphasize the need to investigate and assess context-specific causes of varying use of maternal health care, if safe motherhood is to become a reality in developing countries. Bulletin of the World Health Organization 2007;85:812-819.

The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries

Abstract: Objective To assess the availability and affordability of medicines used to treat cardiovascular disease, diabetes, chronic respiratory disease and glaucoma and to provide palliative cancer care in six low- and middle-income countries. Methods A survey of the availability and price of 32 medicines was conducted in a representative sample of public and private medicine outlets in four geographically defined areas in Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka. We analysed the percentage of these medicines available, the median price versus the international reference price (expressed as the median price ratio) and affordability in terms of the number of days’ wages it would cost the lowest-paid government worker to purchase one month of treatment. Findings In all countries < 7.5% of these 32 medicines were available in the public sector, except in Brazil, where 30% were available, and Sri Lanka, where 28% were available. Median price ratios varied substantially, from 0.09 for losartan in Sri Lanka to 30.44 for aspirin in Brazil. In the private sector in Malawi and Sri Lanka, the cost of innovator products (the pharmaceutical product first given marketing authorization) was three times more than generic medicines. One month of combination treatment for coronary heart disease cost 18.4 days’ wages in Malawi, 6.1 days’ wages in Nepal, 5.4 in Pakistan and 5.1 in Brazil; in Bangladesh the cost was 1.6 days’ wages and in Sri Lanka it was 1.5. The cost of one month of combination treatment for asthma ranged from 1.3 days’ wages in Bangladesh to 9.2 days’ wages in Malawi. The cost of a one-month course of intermediate-acting insulin ranged from 2.8 days’ wages in Brazil to 19.6 in Malawi. Conclusion Context-specific policies are required to improve access to essential medicines. Generic products should be promoted by educating professionals and consumers, by implementing appropriate policies and incentives, and by introducing market competition and/or price regulation. Improving governance and management efficiency, and assessing local supply options, may improve availability. Prices could be reduced by improving purchasing efficiency, eliminating taxes and regulating mark-ups.

Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries.

Abstract: OBJECTIVE: Progress towards the Millennium Development Goals for maternal health has been slow, and accelerated progress in scaling up professional delivery care is needed. This paper describes poor-rich inequalities in the use of maternity care and seeks to understand these inequalities through comparisons with other types of health care. METHODS: Demographic and Health Survey (DHS) data from 45 developing countries were used to describe poor-rich inequalities by wealth quintiles in maternity care (professional delivery care and antenatal care), full childhood immunization coverage and medical treatment for diarrhoea and acute respiratory infections (ARI). FINDINGS: Poor-rich inequalities in maternity care in general, and professional delivery care in particular, are much greater than those in immunization coverage or treatment for childhood illnesses. Public-sector inequalities make up a major part of the poor-rich inequalities in professional delivery attendance. Even delivery care provided by nurses and midwives favours the rich in most countries. Although poor-rich inequalities within both rural and urban areas are large, most births without professional delivery care occur among the rural poor. CONCLUSION: Poor-rich inequalities in professional delivery care are much larger than those in the other forms of care. Reducing poor-rich inequalities in professional delivery care is essential to achieving the MDGs for maternal health. The greatest improvements in professional delivery care can be made by increasing coverage among the rural poor. Problems with availability, accessibility and affordability, as well as the nature of the services and demand factors, appear to contribute to the larger poor-rich inequalities in delivery care. A concerted effort of equity-oriented policy and research is needed to address the huge poor-rich inequalities in maternity care.

Human papillomavirus and HPV vaccines: a review.

Abstract: Cervical cancer, the most common cancer affecting women in developing countries, is caused by persistent infection with "high-risk" genotypes of human papillomaviruses (HPV). The most common oncogenic HPV genotypes are 16 and 18, causing approximately 70% of all cervical cancers. Types 6 and 11 do not contribute to the incidence of high-grade dysplasias (precancerous lesions) or cervical cancer, but do cause laryngeal papillomas and most genital warts. HPV is highly transmissible, with peak incidence soon after the onset of sexual activity. A quadrivalent (types 6, 11, 16 and 18) HPV vaccine has recently been licensed in several countries following the determination that it has an acceptable benefit/risk profile. In large phase III trials, the vaccine prevented 100% of moderate and severe precancerous cervical lesions associated with types 16 or 18 among women with no previous infection with these types. A bivalent (types 16 and 18) vaccine has also undergone extensive evaluation and been licensed in at least one country. Both vaccines are prepared from non-infectious, DNA-free virus-like particles produced by recombinant technology and combined with an adjuvant. With three doses administered, they induce high levels of serum antibodies in virtually all vaccinated individuals. In women who have no evidence of past or current infection with the HPV genotypes in the vaccine, both vaccines show > 90% protection against persistent HPV infection for up to 5 years after vaccination, which is the longest reported follow-up so far. Vaccinating at an age before females are exposed to HPV would have the greatest impact. Since HPV vaccines do not eliminate the risk of cervical cancer, cervical screening will still be required to minimize cancer incidence. Tiered pricing for HPV vaccines, innovative financing mechanisms and multidisciplinary partnerships will be essential in order for the vaccines to reach populations in greatest need.

The state of the international organ trade: a provisional picture based on integration of available information

Abstract: Organ transplantation is widely practised worldwide. The expansion of organ transplantation has led to a critical shortage of organs and the development of the organ trade. Many patients travel to areas where organs are obtainable through commercial transactions. Although the international organ trade is regarded as an important health policy issue, its current state remains obscure because of scarce data and the lack of efforts to synthesize available data. This paper is an attempt to integrate information about the current international organ trade and create a tentative global picture based on a systematic review of 309 media reports, journal articles and other documents. The international organ trade is described in terms of its forms, the organ-exporting countries, the organ-importing countries and its outcomes and consequences.

The high burden of injuries in South Africa

Abstract: Objective To estimate the magnitude and characteristics of the injury burden in South Africa within a global context. Methods The Actuarial Society of South Africa demographic and AIDS model (ASSA 2002) – calibrated to survey, census and adjusted vital registration data – was used to calculate the total number of deaths in 2000. Causes of death were determined from the National Injury Mortality Surveillance System profile. Injury death rates and years of life lost (YLL) were estimated using the Global Burden of Disease methodology. National years lived with disability (YLDs) were calculated by applying a ratio between YLLs and YLDs found in a local injury data source, the Cape Metropole Study. Mortality and disability-adjusted life years’ (DALYs) rates were compared with African and global estimates. Findings Interpersonal violence dominated the South African injury profile with age-standardized mortality rates at seven times the global rate. Injuries were the second-leading cause of loss of healthy life, accounting for 14.3% of all DALYs in South Africa in 2000. Road traffic injuries (RTIs) are the leading cause of injury in most regions of the world but South Africa has exceedingly high numbers – double the global rate. Conclusion Injuries are an important public health issue in South Africa. Social and economic determinants of violence, many a legacy of apartheid policies, must be addressed to reduce inequalities in society and build community cohesion. Multisectoral interventions to reduce traffic injuries are also needed. We highlight this heavy burden to stress the need for effective prevention programmes.

Association of physical activity and dietary behaviours in relation to the body mass index in a national sample of Iranian children and adolescents: CASPIAN Study

Abstract: OBJECTIVE: To examine the relation of dietary and physical activity (PA) patterns with the body mass index (BMI), and the associations between these patterns among children. METHODS: A representative sample of 21 111 school students aged 6-18 years was selected by multistage random cluster sampling from 23 provinces in the Islamic Republic of Iran. PA and dietary pattern were assessed by self-administered validated questionnaires. FINDINGS: Fruit and vegetables, dairy products and snacks (salty, fatty or sweet) had a similar consumption frequency of approximately twice a day. The type of fat most frequently consumed was hydrogenated solid fat (consumed by 73.8% of families). The PA level was significantly higher among boys than girls, in rural than in urban residents, and in intermediate students than high-school students. Among boys, the frequency of consumption of vegetables and plant proteins (R² = 0.46); and among girls, the frequency of consumption of dairy products and fruits, as well as high PA level had a significant inverse association with BMI (R² = 0.57). Among boys, the low frequency of consumption of fruits, the time spent on PA and the energy expenditure; and among girls, the time spent on PA and the energy expenditure, had significant relationships with overweight. When controlling for covariates, PA levels had significant relationships with the frequency of consumption of all food groups. CONCLUSION: Unhealthy lifestyles make Iranian young people prone to chronic diseases later in life. When examining their health benefits, the interrelationship of dietary and PA behaviours should be considered.

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies */Declaration De l'Initiative STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) : Recommandations Pour L'elaboration Des Rapports D'etudes Observationnelles/ Declaracion De la Iniciativa STOBE

Abstract: Introduction Many questions in medical research are investigated in observational studies (1) Much of the research into the cause of diseases relies on cohort, case-control or cross-sectional studies Observational studies also have a role in research into the benefits and harms of medical interventions (2) Randomized trials cannot answer all important questions about a given intervention For example, observational studies are more suitable to detect rare or late adverse effects of treatments, and are more likely to provide an indication of what is achieved in daily medical practice (3) Research should be reported transparently so that readers can follow what was planned, what was done, what was found, and what conclusions were drawn The credibility of research depends on a critical assessment by others of the strengths and weaknesses in study design, conduct and analysis Transparent reporting is also needed to judge whether and how results can be included in systematic reviews (4,5) However, in published observational research important information is often missing or unclear An analysis of epidemiological studies published in general medical and specialist journals found that the rationale behind the choice of potential confounding variables was often not reported (6) Only few reports of case-control studies in psychiatry explained the methods used to identify cases and controls (7) In a survey of longitudinal studies in stroke research, 17 of 49 articles (35%) did not specify the eligibility criteria (8) Others have argued that without sufficient clarity of reporting, the benefits of research might be achieved more slowly, (9) and that there is a need for guidance in reporting observational studies (10,11) Recommendations on the reporting of research can improve reporting quality The Consolidated Standards of Reporting Trials (CONSORT) Statement was developed in 1996 and revised five years later (12) Many medical journals supported this initiative, (13) which has helped to improve the quality of reports of randomized trials (14,15) Similar initiatives have followed for other research areas--eg for the reporting of meta-analyses of randomized trials (16) or diagnostic studies (17) We established a network of methodologists, researchers and journal editors to develop recommendations for the reporting of observational research: the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement Aims and use of the STROBE Statement The STROBE Statement is a checklist of items that should be addressed in articles reporting on the three main study designs of analytical epidemiology: cohort, case-control and cross-sectional studies The intention is solely to provide guidance on how to report observational research well: these recommendations are not prescriptions for designing or conducting studies Also, while clarity of reporting is a prerequisite to evaluation, the checklist is not an instrument to evaluate the quality of observational research Here we present the STROBE Statement and explain how it was developed In a detailed companion paper, the Explanation and Elaboration article, (18-20) we justify the inclusion of the different checklist items, and give methodological background and published examples of what we consider transparent reporting We strongly recommend using the STROBE checklist in conjunction with the explanatory article, which is available freely on the web sites of PLoS Medicine (wwwplosmedicineorg), Annals of Internal Medicine (wwwannalsorg) and Epidemiology (wwwepidemcom) Development of the STROBE Statement We established the STROBE Initiative in 2004, obtained funding for a workshop and set up a web site (wwwstrobestatementorg) We searched textbooks, bibliographic databases, reference lists and personal files for relevant material, including previous recommendations, empirical studies of reporting and articles describing relevant methodological research …

Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward

Abstract: OBJECTIVE: Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide - the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, we know little about their competence to manage common life-threatening obstetric complications. We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement. METHODS: The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II). FINDINGS: On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour - 46%; manual removal of placenta - 52%; bimanual uterine compression - 46%; immediate newborn care - 71%; and neonatal resuscitation - 55%. CONCLUSION: There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications. We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.

Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand

Abstract: OBJECTIVE: To estimate the incidence and describe the profile of catastrophic expenditures and impoverishment due to household out-of-pocket payments, comparing the periods before and after the introduction of universal health care coverage (UC). METHODS: Secondary data analyses of socioeconomic surveys on nationally representative households pre-UC in 2000 (n = 24 747) and post-UC in 2002 (n = 34 785) and 2004 (n = 34 843). FINDINGS: Households using inpatient care experienced catastrophic expenditures most often (31.0% in 2000, compared with 15.1% and 14.6% in 2002 and 2004, respectively). During the two post-UC periods, the incidence of catastrophic expenditures for inpatient services at private hospitals was 32.1% for 2002 and 27.8% for 2004. For those using inpatient care at district hospitals, the corresponding catastrophic expenditures figures were 6.5% and 7.3% in 2002 and 2004, respectively. The catastrophic expenditures incidence for outpatient services from private hospitals moved from 27.9% to 28.5% between 2002 and 2004. In 2000, before universal coverage was introduced, the percentages of Thai households who used private hospitals and faced catastrophic expenditures were 35.8% for inpatient care and 36.0% for outpatient care. Impoverishment increased for poor households because of payments for inpatient services by 84.0% in 2002, by 71.5% in 2004 and by 95.6% in 2000. The relative increase in out-of-pocket impoverishment was found in 98.8% to 100% of those who were poor following payments made to private hospitals, regardless of type of care. CONCLUSION: Households using inpatient services, especially at private hospitals, were more likely to face catastrophic expenditures and impoverishment from out-of-pocket payments. Use of services not covered by the UC benefit package and bypassing the designated providers (prohibited under the capitation contract model without proper referrals) are major causes of catastrophic expenditures and impoverishment.

True Outcomes for Patients on Antiretroviral Therapy Who Are "Lost to Follow-Up" in Malawi/Veritables Issues Du Traitement Antiretroviral Pour Les Patients Consideres Comme « Perdus De Vue » Au Malawi/Evolucion Real De Los Pacientes Sometidos a Terapia Antirretroviral Y Perdidos En El Seguimiento En Malawi

Abstract: Introduction Many resource-poor countries with HIV epidemics are scaling up antiretroviral therapy (ART) By December 2005, an estimated 13 million people from low-and middle-income countries had been placed on treatment; 810 000 of these were in sub-Saharan Africa (1) Treatment outcomes reported from various clinics in sub-Saharan Africa, Haiti, Asia and South America have been good, comparable with those observed in countries with higher incomes (2-7) Patient outcomes are usually categorized as patients alive and on treatment, stopped treatment, transferred to another facility, dead or "lost to follow-up" Depending on the facility, patients are classified as lost to follow-up if they have missed two or more consecutive clinic appointments (2) or have not been seen for at least 2 or 3 months (4-6) The proportion of patients lost to follow-up differs between clinics, ranging from 5% in programmes supported by Medecins Sans Frontieres (5) to 25% in western Kenya (4) In 18 ART-delivery programmes in Africa, Asia and South America, 15% of 4810 patients were lost to follow-up in the first year of ART, with the average being 12% in programmes with active follow-up and 19% in those with no active follow-up (7) To our knowledge, there ate no published data from resource-poor countries on the true outcome status of these patients Malawi--a small resource-poor country in southern Africa--has been engaged in ART scale-up for nearly 3 years By 31 March 2006, 46 702 patients had ever started receiving ART in 66 facilities in the public sector; of these, 33 891 (73%) were registered as alive, 5131 (11%) were dead, 4226 (9%) were lost to follow-up, 3140 (7%) had transferred to another facility and 314 (1%) had stopped therapy (8) We hypothesized that many patients lost to follow-up may have died, and therefore conducted a study in northern Malawi to investigate this problem Methods Details on the delivery and monitoring of ART in Malawi have been described previously (9) When patients start ART, their details are entered on master cards and an ART register Patients attend the ART clinic each month, at which time their outcome status is entered on the master card and they are given another month's supply of ART drugs if a patient is not seen in the clinic for three consecutive months, the patient is registered as a "defaulter" (an abbreviated term for "lost to follow-up") on the master card and also on the register Four public-sector ART facilities in the northern region of Malawi were selected for the study These included one central hospital and three peripheral hospitals (two district hospitals and one mission hospital) Provision of free ART was initiated at the central and mission hospitals in July 2004, and at the two district hospitals in January and June 2005 respectively For the period between the date when each facility started to provide free ART and 31 March 2006, we identified all patients indicated on the master cards and registers as a defaulter Using contact details, ART facility staff visited the patients' homes to try to ascertain their true outcome status If patients were traced to the home, they were asked whether they were still taking ART and if not, why they had stopped If the patient had died, the relatives were asked when the patient had died If the patient had moved away, relatives or friends were asked when they had moved Ethical approval for the study was granted by the Malawi National Health Sciences Research Committee Informed consent was obtained from patients being interviewed, and staff took care not to disclose that the patient was receiving ART when interviewing relatives or friends in the event of the patient's death or transfer Data were collected, on Structured forms, and analysis was carried out using Epi Info version 60 Patients from the central and the peripheral hospitals were compared: the [chi square] test with relative risks (RR) and 95% confidence intervals (CI) were used for characteristics and outcomes, and the student's t-test was used for time periods between start of ART, default and patient tracing, with differences at the level Of 0 …

Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003)

Abstract: Objective To evaluate the evolution in smoking indicators in the adult Brazilian population between 1989 and 2003. Methods We compared age-adjusted prevalence ratios and means for smoking indicators, stratified by age, sex and sociodemographic variables, obtained from two comparable household surveys that used probabilistic sampling of the Brazilian population aged > 18 years (n = 34 808 in 1989 and n = 5000 in 2003). Findings Between 1989 and 2003, there was a substantial decrease in the prevalence of smoking (from 34.8% to 22.4%; ageadjusted prevalence ratio, 0.65; 95% confidence interval, CI, 0.60–0.70) and a modest reduction in the mean number of cigarettes smoked per day (from 13.3 to 11.6; age-adjusted difference, –1.8; 95% CI, –2.6 – –1.0). Reductions in the prevalence and intensity of smoking were greater among males, younger age groups and higher socioeconomic strata. Conclusion The prevalence of smoking in the adult Brazilian population declined by 35% between 1989 and 2003, or an average of 2.5% per year. This exceptional reduction surpasses those seen in other countries that implemented wide-ranging and rigorous policies for controlling smoking during the same period. The more intense decline in smoking in younger age groups was consistent with the concentration of efforts of the Brazilian tobacco control programme to prevent the onset of smoking among youths and the total prohibition of cigarette advertising. We recommend the intensification of programme initiatives targeting women and less economically favoured population strata.

True outcomes for patients on antiretroviral therapy who are "lost to follow-up" in Malawi

Abstract: PROBLEM: In many resource-poor countries that are scaling up antiretroviral therapy (ART), 5-25% of patients are reported as "lost to follow-up". This figure is 9% in Malawi. There is no published information about the true outcome status of these patients. APPROACH: In four facilities in northern Malawi, ART registers and master cards were used to identify patients who had not attended the facility for 3 months or more and were thus registered as "lost to follow-up". Clinic staff attempted to trace these patients and ascertain their true outcome status. LOCAL SETTING: Of 253 patients identified as "lost to follow-up", 127 (50%) were dead, 58% of these having died within 3 months of their last clinic visit. Of the 58 patients (23%) found to be alive, 21 were still receiving ART and 37 had stopped treatment (high transport costs being the main reason for 13 patients). Sixty-eight patients (27%) could not be traced, most commonly because of an incorrect address in the register. Fewer patients were alive and more patients could not be traced from the central hospital compared with the peripheral hospitals. RELEVANT CHANGES:Better documentation of patients’ addresses and prompt follow-up of patients who are late for their appointments are required. LESSONS LEARNED: ART clinics in resource-poor countries should ensure that patients’ addresses are correct and comprehensive. Clinics should also undertake contact tracing as soon as possible in the event of non-attendance, consider facilitating access to ART clinics and take loss to follow-up into consideration when assessing death rates.

Population-Based Evidence of a Strong Decline in the Prevalence of Smokers in Brazil (1989-2003)/preuves Dans la Population D'une Forte Baisse De la Prevalence Du Tabagisme Au Bresil (1989-2003)/evidencia Poblacional De Una Fuerte Disminucion De la Prevalencia del Tabacluismo En El Brasil (1989-2003)

Abstract: Introduction The adverse effects of tobacco smoking on health have been known since at least the 1950s (1,2) Even the large multinational cigarette companies, who previously denied the problem and questioned the validity of scientific studies, now explicitly admit that tobacco smoking has adverse consequences There is scientific evidence that even nonsmokers exposed to tobacco smoke ("passive smokers') have a greater incidence of cancer, cardiovascular disease and respiratory disease (3) As well as being a risk factor for a variety of diseases, smoking is characterized by chemical dependence, and falls into a model of chronic disease with a long-term natural history and with periods of recurrence and remission (4) The accumulation of knowledge on the risks of tobacco smoking has not been enough to reduce worldwide consumption In fact, tobacco consumption in developing countries has been increasing at an alarming rate as a result of sophisticated global promotion strategies developed by multinational cigarette companies Favoured by the liberalization of commerce brought about by globalization, such companies are promoting the rapid transfer of the burden of tobacco consumption from rich to poor countries (5) In 1999, smoking already accounted for four million deaths per year worldwide, and half of these occurred in developing countries At current trends, the number of deaths attributed to smoking will double by 2020, and seven of every ten tobacco-related deaths will take place in developing countries (6) In light of the adverse effects of smoking and the evidence for increased consumption of tobacco, especially in developing countries, the World Health Assembly has approved several wide-ranging resolutions to contain the global demand for tobacco These culminated in 1999 with the sanction of the Framework Convention on Tobacco Control, a set of multisectoral actions aimed at reducing the demand for, and consequent health effects of, tobacco in the world (7) Despite being the second-largest producer of tobacco in the world, Brazil has a notable record of initiatives aimed at combating smoking The origin of such initiatives dates back to the 1970s, when scientific medical societies began to work towards enlightening the Brazilian population about health hazards associated with smoking, at the same time pressuring the Ministry of Health to assume responsibility for controlling the problem (8) However, coordinated and persistent initiatives did not begin until 1989, when the Ministry of Health assigned the coordination of a national tobacco control programme to its cancer institute The initiatives in this programme gained in strength, organization and scope throughout the years, evolving from a campaign-oriented character in the early 1990s to a set of coordinated nationwide measures These involved educating the population and pressuring government agencies and Congress to adopt fiscal measures to increase the price of cigarettes and to approve laws prohibiting the advertising of tobacco products and smoking in public places A complete description of the strategies and actions performed by the Brazilian tobacco control programme between 1989 and 2003 can be found elsewhere (9) The absence to date of repeated and comparable national surveys on smoking in Brazil has prevented the adequate evaluation of the results of the Brazilian tobacco control programme Indirect evidence for the programme's success can be deduced based on the declining trend in cigarette commercialization in the country, and comparisons between the prevalence of smoking in large Brazilian cities in the early 2000s and that reported in the only national survey of smoking available at the time, which was conducted in 1989 (10) The availability of the results of a second national smoking survey carried out in 2003 allows us to assess changes in the prevalence and intensity of smoking in Brazil during a period marked by the creation of a notable body of measures for containing tobacco consumption …

Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe

Abstract: OBJECTIVE: To assess the impact of routine antenatal HIV testing for preventing mother-to-child transmission of HIV (PMTCT) in urban Zimbabwe. METHODS: Community counsellors were trained in routine HIV testing policy using a specific training module from June 2005 through November 2005. Key outcomes during the first 6 months of routine testing were compared with the prior 6-month "opt-in" period, and clients were interviewed. FINDINGS: Of the 4551 women presenting for antenatal care during the first 6 months of routine HIV testing, 4547 (99.9%) were tested for HIV compared with 3058 (65%) of 4700 women during the last 6 months of the opt-in testing (P < 0.001), with a corresponding increase in the numbers of HIV-infected women identified antenatally (926 compared with 513, P < 0.001). During routine testing, more HIV-infected women collected results compared to the opt-in testing (908 compared with 487, P < 0.001) resulting in a significant increase in deliveries by HIV-infected women (256 compared with 186, P = 0.001); more mother/infant pairs received antiretroviral prophylaxis (n = 256) compared to the opt-in testing (n = 185); and more mother/infant pairs followed up at clinics (105 compared with 49, P = 0.002). Women were satisfied with counselling services and most (89%) stated that offering routine testing is helpful. HIV-infected women reported low levels of spousal abuse and other adverse social consequences. CONCLUSION: Routine antenatal HIV testing should be implemented at all sites in Zimbabwe to maximize the public health impact of PMTCT.

Impact of a national helminth control programme on infection and morbidity in Ugandan schoolchildren

Abstract: OBJECTIVE: We aimed to assess the health impact of a national control programme targeting schistosomiasis and intestinal nematodes in Uganda, which has provided population-based anthelmintic chemotherapy since 2003. METHODS: We conducted longitudinal surveys on infection status, haemoglobin concentration and clinical morbidity in 1871 randomly selected schoolchildren from 37 schools in eight districts across Uganda at three time points - before chemotherapy and after one year and two years of annual mass chemotherapy. FINDINGS: Mass treatment with praziquantel and albendazole led to a significant decrease in the intensity of Schistosoma mansoni - 70% (95% confidence interval (CI): 66-73%) after one year and 82% (95% CI: 80-85%) after two years of treatment. Intensity of hookworm infection also decreased (75% and 93%; unadjusted). There was a significant increase in haemoglobin concentration after one (0.135 g/dL (95% CI: 0.126-0.144)) and two years (0.303 g/dL (95% CI: 0.293-0.312)) of treatment, and a significant decrease in signs of early clinical morbidity. The impact of intervention on S. mansoni prevalence and intensity was similar to that predicted by mathematical models of the impact of chemotherapy on human schistosomiasis. Improvements in haemoglobin concentration were greatest among children who were anaemic or harbouring heavy S. mansoni infection at baseline. CONCLUSION: Anthelmintic treatment delivered as part of a national helminth control programme can decrease infection and morbidity among schoolchildren and improve haemoglobin concentration.

Standard deviation of anthropometric Z-scores as a data quality assessment tool using the 2006 WHO growth standards: a cross country analysis.

Abstract: OBJECTIVE: Height- and weight-based anthropometric indicators are used worldwide to characterize the nutritional status of populations. Based on the 1978 WHO/National Center for Health Statistics (NCHS) growth reference, the World Health Organization has previously indicated that the standard deviation (SD) of Z-scores of these indicators is relatively constant across populations, irrespective of nutritional status. As such, the SD of Z-scores can be used as quality indicators for anthropometric data. In 2006, WHO published new growth standards. Here, we aim to assess whether the SD of height- and weight-based Z-score indicators from the 2006 WHO growth standards can still be used to assess data quality. METHODS: We examined data on children aged 0-59 months from 51 Demographic and Health Surveys (DHS) in 34 developing countries. We used 2006 growth standards to assign height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), weight-for-height Z-scores (WHZ) and body-mass-index-for-age Z-scores (BMIZ). We also did a stratified analysis by age group. FINDINGS: The SD for all four indicators were independent of their respective mean Z-scores across countries. Overall, the 5th and 95th percentiles of the SD were 1.35 and 1.95 for HAZ, 1.17 and 1.46 for WAZ, 1.08 and 1.50 for WHZ and 1.08 and 1.55 for BMIZ. CONCLUSION: Our results concur with the WHO assertion that SD is in a relatively small range for each indicator irrespective of where the Z-score mean lies, and support the use of SD as a quality indicator for anthropometric data. However, the ranges of SDs for all four indicators analysed were consistently wider than those published previously by WHO.

Global health diplomacy: the need for new perspectives, strategic approaches and skills in global health

Abstract: Introduction "In the past"--said Robert Cooper, one of Europe's pre-eminent diplomats--"it was enough for a nation to look after itself. Today it is no longer sufficient." (1) This is particularly true in the health arena, There is an increasing range of health issues that transcend national boundaries and require action on the global forces that determine the health of people. The broad political, social and economic implications of health issues have brought more diplomats into the health arena and more public health experts into the world of diplomacy. Simple classifications of policy and politics--domestic and foreign, hard and soft, or high and low--no longer apply. (2) Diplomacy is frequently referred to as the art and practice of conducting negotiations. (3) It is usually still understood to mean the conduct of international relations through the intervention of professional diplomats from ministries of foreign affairs with regard to issues of "hard power", initially war and peace, and--as countries compete economically--economics and trade. But in recent years there has also been an increase in the number of international agreements on "soft issues", such as the environment and health; it is now recognized that some of these issues have significant "hard" ramifications on national economies. The term "global health diplomacy" aims to capture these multi-level and multi-actor negotiation processes that shape and manage the global policy environment for health. Global health diplomacy is at the coal-face of global health governance --it is where the compromises are found and the agreements are reached, in multilateral venues, new alliances and in bilateral agreements. It is a world to which outsiders find it difficult to relate, where the art of diplomacy juggles with the science of public health and concrete national interest balances with the abstract collective concern of the larger international community in the face of intensive lobbying and advocacy. No longer do diplomats just talk to other diplomats--they need to interact with the private sector, nongovernmental organizations, scientists, activists and the media, to name but a few, since all these actors are part and parcel of the negotiating process. Global health diplomacy is gaining in importance and its negotiators should be well prepared. Some countries have added a full-time health attache to their diplomatic staff in recognition of the importance and complexity of global health deliberations; others have added diplomats to the staff of international health departments. Their common challenge is to navigate a complex system in which issues in domestic and foreign policy intertwine the lines of power and constantly influence change, and where increasingly rapid decisions and skilful negotiations are required in the face of outbreaks of disease, security threats or other issues. Missions to the United Nations and international organizations--for example, in New York and Geneva--increasingly need to deal with health issues, as do the classical bilateral embassies. An important part of global health diplomacy still takes place within the World Health Organization; indeed it has recently gained new momentum through the negotiation during the past five years of the Framework Convention on Tobacco Control and the International Health Regulations. But the venue of global health diplomacy has shifted to include other spaces of negotiation and influence, and the number of organizations dealing with health has increased exponentially. At all levels we are witnessing a diversification of actors, the most illustrative development being the growth of public--private partnerships and platforms around a multitude of health issues, all clamouring for attention and funds. It is clear that the profound change underway requires new mechanisms and new skills for global health diplomacy. Yet an informal survey by the authors of staff of the international departments of health in countries that belong to the Organisation for Economic Co-operation and Development (OECD), in Latin America and of health attaches in Geneva has confirmed that many do not feel well prepared for the challenges that confront them. …

A balanced scorecard for health services in Afghanistan

Abstract: The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13 843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context.

Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia

Abstract: Problem In Cambodia, care for people with HIV/AIDS (prevalence 1.9%) is expanding, but care for people with type II diabetes (prevalence 5–10%), arterial hypertension and other treatable chronic diseases remains very limited. Approach We describe the experience and outcomes of offering integrated care for HIV/AIDS, diabetes and hypertension within the setting of chronic disease clinics. Local setting Chronic disease clinics were set up in the provincial referral hospitals of Siem Reap and Takeo, 2 provincial capitals in Cambodia. Relevant changes At 24 months of care, 87.7% of all HIV/AIDS patients were alive and in active follow–up. For diabetes patients, this proportion was 71%. Of the HIV/AIDS patients, 9.3% had died and 3% were lost to follow-up, while for diabetes this included 3 (0.1%) deaths and 28.9% lost to follow-up. Of all diabetes patients who stayed more than 3 months in the cohort, 90% were still in follow-up at 24 months. Lessons learned Over the first three years, the chronic disease clinics have demonstrated the feasibility of integrating care for HIV/AIDS with non-communicable chronic diseases in Cambodia. Adherence support strategies proved to be complementary, resulting in good outcomes. Services were well accepted by patients, and this has had a positive effect on HIV/AIDS-related stigma. This experience shows how care for HIV/AIDS patients can act as an impetus to tackle other common chronic diseases.

Determinants of womens participation in cervical cancer screening trial, Maharashtra, India

Abstract: Objective To determine the factors associated with participation in cervical cancer screening and follow-up treatment in the context of a randomized controlled trial. The trial was initiated to evaluate the efficacy and cost effectiveness of visual inspection with acetic acid, cytological screening and testing for human papillomavirus in reducing the incidence of and mortality from cervical cancer in Maharashtra, India. Methods Between October 1999 and November 2003 women aged 30–59 years were randomized to receive one of the three tests or to a control group. Participation was analysed for all three intervention arms. The differences between those who were screened versus those who were not was analysed according to the sociodemographic characteristics of the 100 800 eligible women invited for screening. Those who were treated versus those who were not were analysed according to the sociodemographic characteristics of the 932 women diagnosed with high-grade lesions. Participation in screening and compliance with treatment were also analysed according to the type of test used. Findings Compared with women who were not tested, screened women were younger (aged 30–39), better educated and had ever used contraception. A higher proportion of screened women were married and a lower proportion had never been pregnant. Of the 932 women diagnosed with high-grade lesions or invasive cancer, 85.3% (795) received treatment. Women with higher levels of education, who had had fewer pregnancies and those who were married were more likely to comply with treatment. There were no differences in rates of screening or compliance with treatment when results were analysed by the test received. Conclusion Irrespective of the test being used, good participation levels for cervical cancer screening can be achieved in rural areas of developing countries by using appropriate strategies to deliver services. Communication methods and delivery strategies aimed at encouraging older, less-educated women, who have less contact with reproductive services, are needed to further increase screening uptake. Bulletin of the World Health Organization 2007;85:264-272.

Offering Integrated Care for HIV/AIDS, Diabetes and Hypertension within Chronic Disease Clinics in Cambodia/Offre De Soins Integree a L'intention Des Personnes Vivant Avec le VIH/sida, Un Diabete Ou De L'hypertension Par Les Dispensaires Cambodgiens Specialises Dans Les Maladies Chroniques/ Atencion Integrada Contra El VIH/SIDA, la Diabetes Y la Hipertension En Dispensarios De Enfermedades Cronicas De Camboya

Abstract: Introduction At the end of 2004, there were an estimated 100 000 people living with HIV/ AIDS in Cambodia, of whom approximately 25 000 were estimated to urgently require care and treatment with highly active antiretroviral therapy (HAART). (1,2) Cambodia is struggling with a growing burden of chronic diseases. A survey done in 2005 estimated that between 5% and 11% of all adults had type II diabetes and the prevalence of impaired glucose intolerance was between 10% and 15%. The same survey showed that between 12% and 25% of the population screened could be classified as being hypertensive. (3) These results are consistent with growing evidence that diabetes and other non-communicable diseases represent a significant and growing part of the disease burden in low-income countries. (4,5) In 2002, Medecins Sans Frontieres (MSF) and the Cambodian Ministry of Health established chronic disease clinics to integrate HIV/AIDS care with the management of diabetes and hypertension in two provincial capitals, Takeo and Siem Reap. This paper describes the approach and outcomes of this strategy. Context Siem Reap and Takeo are both predominantly rural provinces, although the urban population of Siem Reap town is increasing rapidly due to growing tourism around the Angkor Wat temple complex. Both locations were selected for this pilot programme because they are large provincial centres with referral hospital capacity to expand activities. Furthermore, adequate care for the target diseases at these sites was lacking. HAART began to be provided in Cambodia in 2001. By the end of 2005, 12 355 people were on treatment through programmes run jointly by the Ministry of Health and nongovernmental organizations (NGOs). Chronic diseases are largely neglected in developing countries. (6) In Cambodia, medical care for diseases such as diabetes, arterial hypertension and epilepsy was not generally included in the reconstruction of the health care system over the past 15 years. Most diabetics receive only limited medication at referral hospital outpatient departments or when they arrive with severe hyperglycaemia at emergency wards; they are rarely referred to long-term care once they are discharged. Some drugs to treat arterial hypertension are available at hospitals and health centres, but these are usually provided for only two weeks. Rationale for the chronic disease clinics The rationale to combine care of HIV/ AIDS, diabetes and hypertension was based on three assumptions. First, the availability of antiretroviral treatment in developing countries is transforming HIV/AIDS into a chronic disease, as has been the experience elsewhere. (7) It was anticipated that in this resource-poor context, efficiency gains could be attained through the establishment of a multidisciplinary chronic disease care team that would use a common approach to respond to the needs of chronic disease patients, especially in providing continuity of care, long-term adherence support and social support. Second, in Cambodian society as elsewhere, the stigma attached to HIV/ AIDS presents a barrier to care. By providing care for seropositive clients and patients with other chronic diseases within the same facility, it was hoped that facility-related stigma could be reduced. Third, it was considered important that the care delivery model should reflect epidemiological realities. Although at the clinics' inception reliable epidemiological data on diabetes and other chronic diseases was lacking, these illnesses were recognized to contribute an increasing share of the total burden of disease in Cambodia. Diabetes was given a specific priority, since it was seen by many health workers as a frequent problem. The provision of systematic and continuous care for chronic diseases was encouraged by both the Ministry of Health and local WHO representatives, who were involved in the final design of this pilot health care delivery model. …

Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance

Abstract: Objective To identify barriers to successful tuberculosis (TB) treatment in Tomsk, Siberia, by analysing individual and programmatic risk factors for non-adherence, default and the acquisition of multidrug resistance in a TB treatment cohort in the Russian Federation. Methods We conducted a retrospective cohort study of consecutively enrolled, newly detected, smear and/or culture-positive adult TB patients initiating therapy in a DOTS programme in Tomsk between 1 January and 31 December 2001. Findings Substance abuse was strongly associated with non-adherence [adjusted odds ratio (OR): 7.3; 95% confidence interval (CI): 2.89–18.46] and with default (adjusted OR: 11.2; 95% CI: 2.55–49.17). Although non-adherence was associated with poor treatment outcomes (OR: 2.4; 95% CI: 1.1–5.5), it was not associated with the acquisition of multi-drug resistance during the course of therapy. Patients who began treatment in the hospital setting or who were hospitalized later during their treatment course had a substantially higher risk of developing multidrug-resistant TB than those who were treated as outpatients (adjusted HRs: 6.34; 95% CI: 1.35–29.72 and 6.26; 95% CI: 1.02–38.35 respectively). Conclusion In this cohort of Russian TB patients, substance abuse was a strong predictor of non-adherence and default. DOTS programmes may benefit from incorporating measures to diagnose and treat alcohol misuse within the medical management of patients undergoing TB therapy. Multidrug-resistant TB occurred among adherent patients who had been hospitalized in the course of their therapy. This raises the possibility that treatment for drug-sensitive disease unmasked a pre-existing population of drugresistant organisms, or that these patients were reinfected with a drug-resistant strain of TB. Bulletin of the World Health Organization 2007;85:703–711.

Setting international standards for verbal autopsy

Abstract: In many countries most deaths occur at home. Such countries often have civil registration systems that are limited or non-existent and therefore most deaths go unrecorded. Countries that cannot record the number of people who die or why they die cannot realize the full potential of their health systems. Health systems need reliable numbers and causes of death to function properly. But in these circumstances – in the absence of a complete picture of the population’s health – there are tools and techniques that can be used to obtain a fairly accurate representation of mortality trends. It takes a long time for countries to achieve a fully functioning civil registration system with medical certification of cause of death. In the meantime, more and more countries are using verbal autopsies (VA) to meet the information needs of their health systems.1 Verbal autopsy is a method of ascertaining probable causes of a death based on an interview with primary caregivers about the signs, symptoms and circumstances preceding that death. Different institutions have been researching and developing all aspects of the verbal autopsy process over the past two decades. We have also been working on this process, particularly to improve the questionnaire and the methods of analysing the resulting information. However, this has been a largely uncoordinated effort and one that has not reached consensus on what to cover in the interview and how to analyse the results, despite previous attempts to promote standard tools.2–4 The main consequence of this failure to agree on a standard approach is that now we cannot compare results from different countries. Currently, 36 Demographic Surveillance Sites (DSS) in 20 countries, the Sample Registration System (SRS) sites in India, and the Disease Surveillance Points (DSP) in China regularly use VA on a large scale, primarily to assess the causes-of-death structure of a defined population.1 Despite such a widespread use of verbal autopsy, we are unable to assess how consistent and reliable the data are. We are also unable to replicate procedures used to assign cause of death. Because verbal autopsy data sets are not widely shared, it is impossible to independently assess the quality of the assignment. Really useful validation studies are rare and verbal autopsy research is often done on small and non-representative samples of the population. The Millennium Development Goals (MDG) have put pressure on countries to track their progress in terms of population health. But to track that progress, countries need reliable numbers. In other words, they need a strong empirical basis for cause-specific mortality data. This is essential for evaluating the impact of disease control programmes and major global health initiatives. One way of dealing with incomplete information is to use models of mortality patterns. But cause-of-death information predicted by such models is not suitable for monitoring progress on what works and what does not.5 That leaves verbal autopsy as the only practical option in these countries and one that will play a key role in tracking progress towards the MDGs. Agreement on a core set of verbal autopsy tools (including technical standards and guidelines for their use) and their widespread adoption is needed now. To tackle this challenge, WHO led an expert group of researchers, data users, and other stakeholders, with sponsorship from the Health Metrics Network (HMN), in developing the necessary standards. The expert group systematically reviewed, debated, and condensed the accumulated experience and evidence from the most widely-used and validated procedures. This synthesis was done to achieve a high degree of consistency and comparability across verbal autopsy data sets. WHO has now published the results of this collaboration as: Verbal autopsy standards: ascertaining and attributing cause of death. The new standards include: Verbal autopsy questionnaires for three age groups (under four weeks; four weeks to 14 years; and 15 years and above); Cause-of-death certification and coding resources consistent with the International Classification of Diseases and Related health Problems, tenth revision (ICD-10); and A cause-of-death list for verbal autopsy prepared according to the ICD-10. The content is freely available on the WHO web site (www.who.int) and will be distributed in print; and incorporated into HMN’s resource kit. This is an important publication, but it is not the last word on verbal autopsy methods. Research is needed to validate these standard core procedures in several countries with different patterns of mortality. Other areas of research include further development of items included in questionnaires, and automated methods for assigning causes of death from verbal autopsy that remove human bias, while producing replicable and valid results.6 Operational issues need addressing: sampling methods and size when using verbal autopsy tools in research demographic surveillance sites; sample or sentinel registration; censuses; and household surveys. Research is also required when adapting these questionnaires to specific situations in different countries, taking into account relevant cultural, epidemiological and administrative considerations. WHO is working with partners to do this research and develop guidelines on these issues. With time, this guidance and experience will better inform the users of verbal autopsy, and improve the comparability and consistency of its results. For the present, we urge that these new international consensus standards become the foundation of verbal autopsy practices wherever possible. ■

Adverse birth outcomes in United Republic of Tanzania: impact and prevention of maternal risk factors

Abstract: OBJECTIVE: To determine risk factors for poor birth outcome and their population attributable fractions. METHODS: 1688 women who attended for antenatal care were recruited into a prospective study of the effectiveness of syphilis screening and treatment. All women were screened and treated for syphilis and other reproductive tract infections (RTIs) during pregnancy and followed to delivery to measure the incidence of stillbirth, intrauterine growth retardation (IUGR), low birth weight (LBW) and preterm live birth. FINDINGS: At delivery, 2.7% of 1536 women experienced a stillbirth, 12% of live births were preterm and 8% were LBW. Stillbirth was independently associated with a past history of stillbirth, short maternal stature and anaemia. LBW was associated with short maternal stature, ethnicity, occupation, gravidity and maternal malaria whereas preterm birth was associated with occupation, age of sexual debut, untreated bacterial vaginosis and maternal malaria. IUGR was associated with gravidity, maternal malaria, short stature, and delivering a female infant. In the women who had been screened and treated for syphilis, in between 20 and 34% of women with each outcome was estimated to be attributable to malaria, and 63% of stillbirths were estimated as being attributable to maternal anaemia. Screening and treatment of RTIs was effective and no association was seen between treated RTIs and adverse pregnancy outcomes. CONCLUSION: Maternal malaria and anaemia continue to be significant causes of adverse pregnancy outcome in sub-Saharan Africa. Providing reproductive health services that include treatment of RTIs and prevention of malaria and maternal anaemia to reduce adverse birth outcomes remains a priority.

Delivery settings and caesarean section rates in China

Abstract: Objective To quantify the influence of increasing use of health-care services on rising rates of caesarean section in China. Methods We used data from a population-based survey conducted by the United Nations Population Fund during September 2003 in 30 selected counties in three regions of China. The study sample (derived from birth history schedule) consisted of 3803 births to mothers aged less than 40 years between 1993 and 2002. Multiple logistic regression models were used to estimate the effect of health-care factors on the odds of a caesarean section, controlling for time and selected variables. Findings Institutional births increased from 53.5% in 1993–1994 to 82.2% in 2001–2002, while the corresponding increase in births by caesarean section was from 8.9% to 24.8%, respectively. Decomposition analysis showed that 69% of the increase in rates of caesarean section was driven by the increase in births within institutions. The adjusted odds of a caesarean section were 4.6 times (95% confidence interval, CI: 3.4–11.8) higher for recent births. The adjusted odds were also significantly higher for mothers who had at least one antenatal ultrasound test. Rates of caesarean section in secondary-level facilities markedly increased over the last decade to the same levels as in major hospitals (P < 0.001). Conclusion The upsurge in rates of births by caesarean section in this population cannot be fully explained by increases in institutional births alone, but is likely to be driven by medical practice within secondary-level hospitals and women’s demand for the procedure.