Showing papers in "Bulletin of The World Health Organization in 2013"

The global burden of congenital toxoplasmosis: a systematic review

Abstract: OBJECTIVE: To estimate the global burden of congenital toxoplasmosis (CT), which results from infection of pregnant women with Toxoplasma gondii. METHODS: The authors systematically searched 9 major databases for published and unpublished sources and established direct contact with the authors of source materials. Searches were country-specific. To be included, studies had to report on the incidence of CT, on positivity to Toxoplasma-specific IgM in infants and pregnant women (including seroconversion results) or on positivity to Toxoplasma-specific IgG in the general population. Various modelling techniques were used, depending on the country-specific data available, to estimate the CT incidence and burden in each country. These data were then synthesized into an estimate of the global incidence of CT and of the global burden of CT in disability-adjusted life years (DALYs). FINDINGS: The global annual incidence of congenital toxoplasmosis was estimated to be 190 100 cases (95% credible interval, CI: 179 300-206 300). This was equivalent to a burden of 1.20 million DALYs (95% CI: 0.76-1.90). High burdens were seen in South America and in some Middle Eastern and low-income countries. CONCLUSION: Congenital toxoplasmosis poses a substantial burden of poor health globally. Toxoplasmosis should be included in future updates of the global burden of disease and the corresponding data should be used to support public health interventions to reduce disease burden.

Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis

Abstract: OBJECTIVE: To perform a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among untreated women with syphilis and women without syphilis. METHODS: PubMed, EMBASE and Cochrane Libraries were searched for literature assessing adverse pregnancy outcomes among untreated women with seroreactivity for Treponema pallidum infection and non-seroreactive women. Adverse pregnancy outcomes were fetal loss or stillbirth, neonatal death, prematurity or low birth weight, clinical evidence of syphilis and infant death. Random-effects meta-analyses were used to calculate pooled estimates of adverse pregnancy outcomes and, where appropriate, heterogeneity was explored in group-specific analyses. FINDINGS: Of the 3258 citations identified, only six, all case-control studies, were included in the analysis. Pooled estimates showed that among untreated pregnant women with syphilis, fetal loss and stillbirth were 21% more frequent, neonatal deaths were 9.3% more frequent and prematurity or low birth weight were 5.8% more frequent than among women without syphilis. Of the infants of mothers with untreated syphilis, 15% had clinical evidence of congenital syphilis. The single study that estimated infant death showed a 10% higher frequency among infants of mothers with syphilis. Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (66.5% [95% confidence interval, CI: 58.0-74.1]; I(2) = 91.8%; P < 0.001) and women without syphilis (14.3% [95% CI: 11.8-17.2]; I(2) = 95.9%; P < 0.001). CONCLUSION: Untreated maternal syphilis is associated with adverse pregnancy outcomes. These findings can inform policy decisions on resource allocation for the detection of syphilis and its timely treatment in pregnant women.

Mortality among people who inject drugs: a systematic review and meta-analysis

Abstract: OBJECTIVE: To systematically review cohort studies of mortality among people who inject drugs, examine mortality rates and causes of death in this group, and identify participant- and study-level variables associated with a higher risk of death. METHODS: Tailored search strings were used to search EMBASE, Medline and PsycINFO. The grey literature was identified through online grey literature databases. Experts were consulted to obtain additional studies and data. Random effects meta-analyses were performed to estimate pooled crude mortality rates (CMRs) and standardized mortality ratios (SMRs). FINDINGS: Sixty-seven cohorts of people who inject drugs were identified, 14 of them from low- and middle-income countries. The pooled CMR was 2.35 deaths per 100 person-years (95% confidence interval, CI: 2.12-2.58). SMRs were reported for 32 cohorts; the pooled SMR was 14.68 (95% CI: 13.01-16.35). Comparison of CMRs and the calculation of CMR ratios revealed mortality to be higher in low- and middle-income country cohorts, males and people who injected drugs that were positive for human immunodeficiency virus (HIV). It was also higher during off-treatment periods. Drug overdose and acquired immunodeficiency syndrome (AIDS) were the primary causes of death across cohorts. CONCLUSION: Compared with the general population, people who inject drugs have an elevated risk of death, although mortality rates vary across different settings. Any comprehensive approach to improving health outcomes in this group must include efforts to reduce HIV infection as well as other causes of death, particularly drug overdose.

Health financing for universal coverage and health system performance: concepts and implications for policy

Abstract: Unless the concept is clearly understood, "universal coverage" (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. This paper unpacks the definition of health financing for universal coverage as used in the World Health Organization's World health report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of UHC is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level.

Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis

Abstract: Objective To assess the effectiveness of interventions to improve the mental health of women in the perinatal period and to evaluate any effect on the health, growth and development of their offspring, in low- and middle-income (LAMI) countries. Methods Seven electronic bibliographic databases were systematically searched for papers published up to May 2012 describing controlled trials of interventions designed to improve mental health outcomes in women who were pregnant or had recently given birth. The main outcomes of interest were rates of common perinatal mental disorders (CPMDs), primarily postpartum depression or anxiety; measures of the quality of the mother–infant relationship; and measures of infant or child health, growth and cognitive development. Meta-analysis was conducted to obtain a summary measure of the clinical effectiveness of the interventions. Findings Thirteen trials representing 20 092 participants were identified. In all studies, supervised, non-specialist health and community workers delivered the interventions, which proved more beneficial than routine care for both mothers and children. The pooled effect size for maternal depression was −0.38 (95% confidence interval: −0.56 to −0.21; I 2 = 79.9%). Where assessed, benefits to the child included improved mother–infant interaction, better cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates. Conclusion In LAMI countries, the burden of CPMDs can be reduced through mental health interventions delivered by supervised non-specialists. Such interventions benefit both women and their children, but further studies are needed to understand how they can be scaled up in the highly diverse settings that exist in LAMI countries.

Universal health coverage and universal access

Abstract: Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda.1 Whether it is a means to an end or an end in itself and whether it is measureable are subjects of heated debate.2 In this issue of the Bulletin, Kutzin argues that universal health coverage not only leads to better health and to financial protection for households, but that it is valuable for its own sake.3 More recently, attention has shifted to just what the goal should be: whether universal coverage or universal access. This editorial focuses on this question. Universal health coverage is the goal that all people obtain the health services they need without risking financial hardship from unaffordable out-of-pocket payments.4 It involves coverage with good health services – from health promotion to prevention, treatment, rehabilitation and palliation – as well as coverage with a form of financial risk protection. A third feature is universality – coverage should be for everyone. Although many countries are far from attaining universal health coverage, all countries can take steps in this direction.3,4 Improving access is one such step. Universal health coverage is attained when people actually obtain the health services they need and benefit from financial risk protection. Access, on the other hand, is the opportunity or ability to do both of these things. Hence, universal health coverage is not possible without universal access, but the two are not the same. Access has three dimensions:5-8 Physical accessibility. This is understood as the availability of good health services within reasonable reach of those who need them and of opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain the services when they need them. Financial affordability. This is a measure of people’s ability to pay for services without financial hardship. It takes into account not only the price of the health services but also indirect and opportunity costs (e.g. the costs of transportation to and from facilities and of taking time away from work). Affordability is influenced by the wider health financing system and by household income. Acceptability. This captures people’s willingness to seek services. Acceptability is low when patients perceive services to be ineffective or when social and cultural factors such as language or the age, sex, ethnicity or religion of the health provider discourage them from seeking services. Services must be physically accessible, financially affordable and acceptable to patients if universal health coverage is to be attained. The requirement that services be physically accessible is fulfilled when these are available, of good quality and located close to people. Service readiness is said to exist when the inputs required to produce the services (e.g. buildings, equipment, health personnel, health products, technologies) are also available and of good quality. Financial affordability can be improved by reducing direct, out-of-pocket payments through insurance prepayments and pooling – e.g. the collection of government revenues and/or health insurance contributions to fund health services – or through demand-side stimuli such as conditional cash transfers and vouchers. Social and cultural accessibility can be enhanced by ensuring that health workers and the health system more generally treat all patients and their families with dignity and respect. Addressing the broader social determinants of health will also improve access to health services; differences in access in particular will be ameliorated by reducing poverty and income inequalities. Improvements in education will raise the average income, make health services more affordable and equip people with the awareness needed to demand and obtain the health services they need. Efforts to address these social determinants will help to reduce inequalities in income, service affordability and access to services, and this, in turn, will help to attenuate differences in health service coverage and in financial risk protection. These actions alone, however, will not guarantee that all people obtain the health services they need. Even if the services exist and people have access to them, they might not use them. They may be unaware, for instance, of having a condition requiring treatment (e.g. hypertension), of how health promotion or preventive services can benefit them, or of the availability of different types of health services or financial risk protection plans. Or they might not recognize that others’ health may be affected by their health-care decisions (e.g. if they fail to get treated for a communicable disease). In essence, universal health coverage is the obtainment of good health services de facto without fear of financial hardship. It cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable. Yet universal access, although necessary, is not sufficient. Coverage builds on access by ensuring actual receipt of services. Thus, universal health coverage and universal access to health services are complementary ideas. Without universal access, universal health coverage becomes an unreachable goal.

Human resources for health and universal health coverage: fostering equity and effective coverage

Abstract: Achieving universal health coverage (UHC) involves distributing resources, especially human resources for health (HRH), to match population needs. This paper explores the policy lessons on HRH from four countries that have achieved sustained improvements in UHC: Brazil, Ghana, Mexico and Thailand. Its purpose is to inform global policy and financial commitments on HRH in support of UHC. The paper reports on country experiences using an analytical framework that examines effective coverage in relation to the availability, accessibility, acceptability and quality (AAAQ) of HRH. The AAAQ dimensions make it possible to perform tracing analysis on HRH policy actions since 1990 in the four countries of interest in relation to national trends in workforce numbers and population mortality rates. The findings inform key principles for evidence-based decision-making on HRH in support of UHC. First, HRH are critical to the expansion of health service coverage and the package of benefits; second, HRH strategies in each of the AAAQ dimensions collectively support achievements in effective coverage; and third, success is achieved through partnerships involving health and non-health actors. Facing the unprecedented health and development challenges that affect all countries and transforming HRH evidence into policy and practice must be at the heart of UHC and the post-2015 development agenda. It is a political imperative requiring national commitment and leadership to maximize the impact of available financial and human resources, and improve healthy life expectancy, with the recognition that improvements in health care are enabled by a health workforce that is fit for purpose.

Measuring maternal health: focus on maternal morbidity

Abstract: A reduction in maternal mortality has traditionally been used as a critical measure of progress in improving maternal health. If a 75% reduction in maternal mortality between 1990 and 2015 – the target set under Millennium Development Goal 5 – is to be attained, we must redouble our efforts. In this endeavour, governments, policy-makers, donors, researchers, civil society and other stakeholders have come together in unprecedented fashion. Yet despite the fact that the maternal mortality ratio is considered one of the main indicators of a country’s status in the area of maternal health, the burden of maternal mortality is only a small fraction of the burden of maternal morbidity – the health problems borne by women during pregnancy and the postpartum period.

Community health workers for universal health-care coverage: from fragmentation to synergy

Abstract: To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs' contribution. The current drive towards universal health coverage (UHC) presents an opportunity to enhance people's access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs' skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress.

Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa.

Abstract: OBJECTIVE: To examine temporal trends in caesarean delivery rates in southern Asia and sub-Saharan Africa, by country and wealth quintile. METHODS: Cross-sectional data were extracted from the results of 80 Demographic and Health Surveys conducted in 26 countries in southern Asia or sub-Saharan Africa. Caesarean delivery rates were evaluated - as percentages of the deliveries that ended in live births - for each wealth quintile in each survey. The annual rates recorded for each country were then compared to see if they had increased over time. FINDINGS: Caesarean delivery rates had risen over time in all but 6 study countries but were consistently found to be lower than 5% in 18 of the countries and 10% or less in the other eight countries. Among the poorest 20% of the population, caesarean sections accounted for less than 1% and less than 2% of deliveries in 12 and 21 of the study countries, respectively. In each of 11 countries, the caesarean delivery rate in the poorest 40% of the population remained under 1%. In Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria, the rate remained under 1% in the poorest 80%. Compared with the 22 African study countries, the four study countries in southern Asia experienced a much greater rise in their caesarean delivery rates over time. However, the rates recorded among the poorest quintile in each of these countries consistently fell below 2%. CONCLUSION: Caesarean delivery rates among large sections of the population in sub-Saharan Africa are very low, probably because of poor access to such surgery.

Eliminating mother-to-child HIV transmission in South Africa

Abstract: PROBLEM: The World Health Organization has produced clear guidelines for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). However, ensuring that all PMTCT programme components are implemented to a high quality in all facilities presents challenges. APPROACH: Although South Africa initiated its PMTCT programme in 2002, later than most other countries, political support has increased since 2008. Operational research has received more attention and objective data have been used more effectively. LOCAL SETTING: In 2010, around 30% of all pregnant women in South Africa were HIV-positive and half of all deaths in children younger than 5 years were associated with the virus. RELEVANT CHANGES: Between 2008 and 2011, the estimated proportion of HIV-exposed infants younger than 2 months who underwent routine polymerase chain reaction (PCR) tests to detect early HIV transmission increased from 36.6% to 70.4%. The estimated HIV transmission rate decreased from 9.6% to 2.8%. Population-based surveys in 2010 and 2011 reported transmission rates of 3.5% and 2.7%, respectively. LESSONS LEARNT: Critical actions for improving programme outcomes included: ensuring rapid implementation of changes in PMTCT policy at the field level through training and guideline dissemination; ensuring good coordination with technical partners, such as international health agencies and international and local nongovernmental organizations; and making use of data and indicators on all aspects of the PMTCT programme. Enabling health-care staff at primary care facilities to initiate antiretroviral therapy and expanding laboratory services for measuring CD4+ T-cell counts and for PCR testing were also helpful.

The effectiveness of policies for reducing dietary trans fat: a systematic review of the evidence

Abstract: OBJECTIVE: To systematically review evidence for the effectiveness of policies, including self-regulation, aimed at reducing industrially produced trans fatty acids (TFAs) in food. METHODS: The Medline, Embase and Cinahl databases were searched to identify peer-reviewed articles examining the effect of TFA policies. In addition, the first 20 pages of Google searches were examined for articles from the grey literature. A study was included if: (i) it was empirical and conducted in a "real-world" setting (i.e. modelling studies were excluded); (ii) it examined a TFA policy involving, for example, labelling, voluntary limits or bans; and (iii) it examined a policy's effect on TFA levels in food, people's diets, blood or breast milk. FINDINGS: Twenty-six articles met the inclusion criteria: 5 involved voluntary self-regulation; 8, labelling alone; 4, labelling and voluntary limits; 5, local bans and 4, national bans. Overall, the TFA content of food decreased with all types of policy intervention. In general, saturated fat levels increased or decreased, depending on the product type, and total fat content remained stable. National and local bans were most effective at eliminating TFAs from the food supply, whereas mandatory TFA labelling and voluntary TFA limits had a varying degree of success, which largely depended on food category. CONCLUSION: Policies aimed at restricting the TFA content of food were associated with significant reductions in TFA levels, without increasing total fat content. Such policies are feasible, achievable and likely to have an effect on public health.

Health systems and services: the role of acute care

Abstract: As populations continue to grow and age, there will be increasing demand for acute curative services responsive to life-threatening emergencies, acute exacerbation of chronic illnesses and many routine health problems that nevertheless require prompt action. Emergency interventions and services should be integrated with primary care and public health measures to complete and strengthen health systems. This paper focuses on acute care within that context. First, we draw on standard World Health Organization (WHO) terminology to propose working terms to define “acute care”. Second, we highlight the fragmentation of service delivery that results from not adopting the proposed definition. Third, we show the potential contribution of acute care to integrated health systems designed to reduce all-cause morbidity and mortality. Finally, we propose key steps to further the development of acute care that leaders, researchers and health workers, who are the people responsible for maintaining strong national health systems, should consider taking.

Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries

Abstract: Objective This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries It also explores design and implementation issues and the related challenges countries face Methods A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization's Regional Library of Medicine and Google Findings Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts All countries have set expenditure ceilings In general, systems were piloted before being implemented The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting Conclusion Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management

Multidrug-resistant tuberculosis in Belarus: the size of the problem and associated risk factors

Abstract: OBJECTIVE: To assess the problem of multidrug-resistant tuberculosis (MDR-TB) throughout Belarus and investigate the associated risk factors. METHODS: In a nationwide survey in 2010-2011, 1420 tuberculosis (TB) patients were screened and 934 new and 410 previously treated cases ofTB were found to meet the inclusion criteria. Isolates of Mycobacterium tuberculosis from each eligible patient were tested for susceptibility to anti-TB drugs. Sociobehavioural information was gathered in interviews based on a structured questionnaire. FINDINGS: MDR-TB was found in 32.3% and 75.6% of the new and previously treated patients, respectively, and, 11.9% of the 612 patients found to have MDR-TB had extensively drug-resistant TB (XDR-TB). A history of previous treatment for TB was the strongest independent risk factor for MDR-TB (odds ratio, OR: 6.1; 95% confidence interval, CI: 4.8-7.7). The other independent risk factors were human immunodeficiency virus (HIV) infection (OR: 2.2; 95% CI: 1.4-3.5), age < 35 years (OR: 1.4; 95% CI: 1.0-1.8), history of imprisonment (OR: 1.5; 95% CI: 1.1-2.0), disability sufficient to prevent work (OR: 1.9; 95% CI: 1.2-3.0), alcohol abuse (OR: 1.3; 95% CI: 1.0-1.8) and smoking (OR: 1.5; 95% CI: 1.1-2.0). CONCLUSION: MDR-TB is very common among TB patients throughout Belarus. The numerous risk factors identified for MDR-TB and the convergence of the epidemics of MDR-TB and HIV infection call not only for stronger collaboration between TB and HIV control programmes, but also for the implementation of innovative measures to accelerate the detection of TB resistance and improve treatment adherence.

Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment

Abstract: Objective To describe the Service Availability and Readiness Assessment (SARA) and the results of its implementation in six countries across three continents. Methods The SARA is a comprehensive approach for assessing and monitoring health service availability and the readiness of facilities to deliver health-care interventions, with a standardized set of indicators that cover all main programmes. Standardized data-collection instruments are used to gather information on a defined set of selected tracer items from public and private health facilities through a facility sample survey or census. Results from assessments in six countries are shown. Findings The results highlight important gaps in service delivery that are obstacles to universal access to health services. Considerable variation was found within and across countries in the distribution of health facility infrastructure and workforce and in the types of services offered. Weaknesses in laboratory diagnostic capacities and gaps in essential medicines and commodities were common across all countries. Conclusion The SARA fills an important information gap in monitoring health system performance and universal health coverage by providing objective and regular information on all major health programmes that feeds into country planning cycles.

Alcohol and alcohol-related harm in China: policy changes needed.

Abstract: In China, alcohol consumption is increasing faster than anywhere else in the world. A steady increase in alcohol production has also been observed in the country, together with a rise in alcohol-related harm. Despite these trends, China's policies on the sale and consumption of alcoholic beverages are weak compared with those of other countries in Asia. Weakest of all are its policies on taxation, drink driving laws, alcohol sale to minors and marketing licenses. The authors of this descriptive paper draw attention to the urgent need for public health professionals and government officials in China to prioritize population surveillance, research and interventions designed to reduce alcohol use disorders. They describe China's current alcohol policies and recent trends in alcohol-related harm and highlight the need for health officials to conduct a thorough policy review from a public health perspective, using as a model the World Health Organization's global strategy to reduce the harmful use of alcohol.

Breastfeeding policy: a globally comparative analysis.

Abstract: OBJECTIVE: To explore the extent to which national policies guaranteeing breastfeeding breaks to working women may facilitate breastfeeding. METHODS: An analysis was conducted of the number of countries that guarantee breastfeeding breaks, the daily number of hours guaranteed, and the duration of guarantees. To obtain current, detailed information on national policies, original legislation as well as secondary sources on 182 of the 193 Member States of the United Nations were examined. Regression analyses were conducted to test the association between national policy and rates of exclusive breastfeeding while controlling for national income level, level of urbanization, female percentage of the labour force and female literacy rate. FINDINGS: Breastfeeding breaks with pay are guaranteed in 130 countries (71%) and unpaid breaks are guaranteed in seven (4%). No policy on breastfeeding breaks exists in 45 countries (25%). In multivariate models, the guarantee of paid breastfeeding breaks for at least 6 months was associated with an increase of 8.86 percentage points in the rate of exclusive breastfeeding (P < 0.05). CONCLUSION: A greater percentage of women practise exclusive breastfeeding in countries where laws guarantee breastfeeding breaks at work. If these findings are confirmed in longitudinal studies, health outcomes could be improved by passing legislation on breastfeeding breaks in countries that do not yet ensure the right to breastfeed.

Viral suppression after 12 months of antiretroviral therapy in low- and middle-income countries: a systematic review

Abstract: OBJECTIVE: To establish estimates of viral suppression in low- and middle-income countries (LMICs) in patients who received antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection. METHODS: Data on viral suppression after 12 months of ART in LMICs were collected from articles published in 2003 to 2011 and from abstracts of conferences held between 2009 and 2011. Pooled proportions for on-treatment and intention-to-treat populations were used as summary estimates. Random-effects models were used for heterogeneous groups of studies (I² > 75%). FINDINGS: Overall, 49 studies covering 48 cohorts and 30 016 individuals met the inclusion criteria. With thresholds for suppression between 300 and 500 copies of viral ribonucleic acid (RNA) per ml of plasma, 84.3% (95% confidence interval, CI: 80.4-87.9) of the pooled on-treatment population and 70.5% (95% CI: 65.2-75.6) of the intention-to-treat population showed suppression. Use of different viral RNA thresholds changed the proportions showing suppression: to 84% and 76% of the on-treatment population with thresholds set above 300 and at or below 200 RNA copies per ml, respectively, and to 78%, 71% and 63% of the intention-to-treat population at thresholds set at 1000, 300 to 500, and 200 or fewer copies per ml, respectively. CONCLUSION: The pooled estimates of viral suppression recorded after 12 months of ART in LMICs provide benchmarks that other ART programmes can use to set realistic goals and perform predictive modelling. Evidence from this review suggests that the current international target - i.e. viral suppression in > 70% of the intention-to-treat population, with a threshold of 1000 copies per ml - should be revised upwards.

Differences by sex in the prevalence of diabetes mellitus, impaired fasting glycaemia and impaired glucose tolerance in sub-Saharan Africa: a systematic review and meta-analysis

Abstract: Objective To assess differences between men and women in the prevalence of diabetes mellitus, impaired fasting glycaemia and impaired glucose tolerance in sub-Saharan Africa. Methods In September 2011, the PubMed and Web of Science databases were searched for community-based, cross-sectional studies providing sex-specific prevalences of any of the three study conditions among adults living in parts of sub-Saharan Africa (i.e. in Eastern, Middle and Southern Africa according to the United Nations subregional classification for African countries). A random-effects model was then used to calculate and compare the odds of men and women having each condition. Findings In a meta-analysis of the 36 relevant, cross-sectional data sets that were identified, impaired fasting glycaemia was found to be more common in men than in women (OR: 1.56; 95% confidence interval, CI: 1.20–2.03), whereas impaired glucose tolerance was found to be less common in men than in women (OR: 0.84; 95% CI: 0.72–0.98). The prevalence of diabetes mellitus – which was generally similar in both sexes (OR: 1.01; 95% CI: 0.91–1.11) – was higher among the women in Southern Africa than among the men from the same subregion and lower among the women from Eastern and Middle Africa and from low-income countries of sub-Saharan Africa than among the corresponding men. Conclusion Compared with women in the same subregions, men in Eastern, Middle and Southern Africa were found to have a similar overall prevalence of diabetes mellitus but were more likely to have impaired fasting glycaemia and less likely to have impaired glucose tolerance.

Early implementation of WHO recommendations for the retention of health workers in remote and rural areas.

Abstract: The maldistribution of health workers between urban and rural areas is a policy concern in virtually all countries. It prevents equitable access to health services, can contribute to increased health-care costs and underutilization of health professional skills in urban areas, and is a barrier to universal health coverage. To address this long-standing concern, the World Health Organization (WHO) has issued global recommendations to improve the rural recruitment and retention of the health workforce. This paper presents experiences with local and regional adaptation and adoption of WHO recommendations. It highlights challenges and lessons learnt in implementation in two countries - the Lao People's Democratic Republic and South Africa - and provides a broader perspective in two regions - Asia and Europe. At country level, the use of the recommendations facilitated a more structured and focused policy dialogue, which resulted in the development and adoption of more relevant and evidence-based policies. At regional level, the recommendations sparked a more sustained effort for cross-country policy assessment and joint learning. There is a need for impact assessment and evaluation that focus on the links between the rural availability of health workers and universal health coverage. The effects of any health-financing reforms on incentive structures for health workers will also have to be assessed if the central role of more equitably distributed health workers in achieving universal health coverage is to be supported.

No physical health without mental health: lessons unlearned?

Abstract: Dr Brock Chisholm, the first Director-General of the World Health Organization (WHO), was a psychiatrist and shepherded the notion that mental and physical health were intimately linked. He famously stated that “without mental health there can be no true physical health”.1 Half a century later, we have strong evidence elucidating the bidirectional relationship between mental illnesses – specifically depression and anxiety – and physical health outcomes. However, policy continues to lag behind the evidence in this regard, as demonstrated by our global noncommunicable disease response. Over a decade ago, the World Health Assembly adopted a global strategy for the prevention and control of noncommunicable disease. At the time, these were limited to the following four illness types: cardiovascular disease, diabetes, respiratory illness and cancers. Such a categorization would set a precedent for the exclusion of mental illnesses from all future WHO discussions on noncommunicable diseases. It is not surprising then, that in the 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases mental illnesses were relegated to a footnote, with the justification that they do not share risk factors with the other four types of illnesses.2 We take issue with this viewpoint, as mental illnesses are themselves risk factors that affect the incidence and prognosis of diseases traditionally classified as “noncommunicable”. Patients with type II diabetes mellitus, for example, are twice as likely to experience depression as the general population,3 and those patients with diabetes who are depressed have greater difficulty with self-care.4 Patients suffering from mental illness are twice as likely to smoke cigarettes as other people, and in patients with chronic obstructive pulmonary disease mental illness is linked to poorer clinical outcomes.5,6 Up to 50% of cancer patients suffer from a mental illness, especially depression and anxiety,7 and treating symptoms of depression in cancer patients may improve survival time.8 Similarly, in patients who are depressed, the risk of having a heart attack is more than twice as high as in the general population;9 further, depression increases the risk of death in patients with cardiac disease.10 Moreover, treating the symptoms of depression after a heart attack has been shown to lower both mortality and re-hospitalization rates.11 In light of this evidence, how can we possibly address the burgeoning epidemic of noncommunicable diseases without tackling co-morbid mental illnesses? Mental illnesses were declared a regional priority in Africa during the WHO African Region Ministerial Consultation on Noncommunicable Diseases, held in Brazzaville, Congo, in April 2011. Later that month the WHO’s African Member States and India reiterated this priority at the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, held in Moscow, Russia.12 As a result, mental illnesses were featured prominently in the preambles of the Moscow Declaration, as well as in the political declaration issued by the United Nations General Assembly at the high-level meeting on noncommunicable diseases held in New York City in September 2011.13 Despite this progress, however, mental illnesses received no mention at all in the resolution on noncommunicable diseases that WHO’s Member States adopted during the 130th session of WHO’s Executive Board.14 Mental illnesses were also omitted from WHO’s proposed monitoring framework, indicators and voluntary targets for the prevention and control of noncommunicable diseases, which was released in November 2012.15 The 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases will be revised over the coming year, and the WHO’s Executive Board and World Health Assembly are preparing their deliberations for 2013. During this critical time we urge Member States to recognize the importance of co-morbid mental illnesses as amplifiers of the burden of other noncommunicable diseases. To this end, we call on Member States to assess and monitor co-morbid mental illnesses in primary care settings, prioritize the training of professionals in mental health care, and, critically, incorporate mental health interventions within chronic disease programs as part of a vigorous global response to noncommunicable diseases. We now know that addressing mental illnesses in primary care settings will delay progression, improve survival outcomes, and reduce the health care costs of other noncommunicable diseases. The time has now come to do away with the artificial divisions between mental and physical health, as WHO’s first Director-General championed so many decades ago.

Determinants of reduced child stunting in Cambodia: analysis of pooled data from three Demographic and Health Surveys

Abstract: OBJECTIVE: To assess how changes in socioeconomic and public health determinants may have contributed to the reduction in stunting prevalence seen among Cambodian children from 2000 to 2010. METHODS: A nationally representative sample of 10 366 children younger than 5 years was obtained from pooled data of cross-sectional surveys conducted in Cambodia in 2000, 2005, and 2010. The authors used a multivariate hierarchical logistic model to examine the association between the prevalence of childhood stunting over time and certain determinants. They estimated those changes in the prevalence of stunting in 2010 that could have been achieved through further improvements in public health indicators. FINDINGS: Child stunting was associated with the child's sex and age, type of birth, maternal height, maternal body mass index, previous birth intervals, number of household members, household wealth index score, access to improved sanitation facilities, presence of diarrhoea, parents' education, maternal tobacco use and mother's birth during the Khmer Rouge famine. The reduction in stunting prevalence during the past decade was attributable to improvements in household wealth, sanitation, parental education, birth spacing and maternal tobacco use. The prevalence of stunting would have been further reduced by scaling up the coverage of improved sanitation facilities, extending birth intervals, and eradicating maternal tobacco use. CONCLUSION: Child stunting in Cambodia has decreased owing to socioeconomic development and public health improvements. Effective policy interventions for sanitation, birth spacing and maternal tobacco use, as well as equitable economic growth and education, are the keys to further improvement in child nutrition.

A comprehensive health labour market framework for universal health coverage

Abstract: In many developed and developing countries, progress towards attaining UHC is hindered by the lack of a health workforce large enough and with the proper skills to deliver quality services to the entire population. Several factors accentuate the problems associated with health worker shortages, especially in low- and middle-income countries: maldistribution and migration of the workforce, inappropriate training, poor supervision, unregulated dual practice, imbalances in skill-mix composition, and reduced productivity and performance.1 Such problems are, however, not limited to low- and middle-income countries; many high-income countries are likely to face severe shortages of health workers because of budget cuts for social services resulting from the global economic downturn. The ageing of the population puts further pressure on health systems by increasing the demand for health care. Moreover, the changing dynamics of workforce migration, such as the increased exodus of workers from one developing country to another, pose a challenge for global health labour markets.2

Untapped potential of health impact assessment

Abstract: The World Health Organization has promoted health impact assessment (HIA) for over 20 years. At the 2012 United Nations Conference on Sustainable Development (Rio+20), HIA was discussed as a critical method for linking health to "green economy" and "institutional framework" strategies for sustainable development. In countries having a high human development index (HDI), HIA has been added to the overall assessment suite that typically includes potential environmental and social impacts, but it is rarely required as part of the environmental and social impact assessment for large development projects. When they are performed, project-driven HIAs are governed by a combination of project proponent and multilateral lender performance standards rather than host country requirements. Not surprisingly, in low-HDI countries HIA is missing from the programme and policy arena in the absence of an external project driver. Major drivers of global change (e.g. population growth and urbanization, growing pressure on natural resources and climate change) inordinately affect low- and medium-HDI countries; however, in such countries HIA is conspicuously absent. If the cloak of HIA invisibility is to be removed, it must be shown that HIA is useful and beneficial and, hence, an essential component of the 21st century's sustainable development agenda. We analyse where and how HIA can become fully integrated into the impact assessment suite and argue that the impact of HIA must not remain obscure.

Sexual health in older women.

Abstract: However, the sexual health of the older members of these aging populations is often overlooked in aca-demic and media discourse.The subject of sexuality in older people remains largely taboo in many cultures, yet older women the world over are known to have sexual desire and to engage in sexual activity ( Fig. 1).

Smoking-related deaths averted due to three years of policy progress

Abstract: OBJECTIVE: To evaluate the global impact of adopting highest-level MPOWER tobacco control policies in different countries and territories from 2007 to 2010. METHODS: Policy effect sizes based on previously-validated SimSmoke models were applied to determine the reduction in the number of smokers as a result of policy adoption during this period. Based on previous research suggesting that half of all smokers die from smoking, we also derived the estimated smoking-attributable deaths (SADs) averted due to MPOWER policy implementation. The results from use of this simple yet powerful method are consistent with those predicted by using previously validated SimSmoke models. FINDINGS: In total, 41 countries adopted at least one highest-level MPOWER policy between 2007 and 2010. As a result of all policies adopted during this period, the number of smokers is estimated to have dropped by 14.8 million, with a total of 7.4 million SADs averted. The largest number of SADs was averted as a result of increased cigarette taxes (3.5 million), smoke-free air laws (2.5 million), health warnings (700 000), cessation treatments (380 000), and bans on tobacco marketing (306 000). CONCLUSION: From 2007 to 2010, 41 countries and territories took action that will collectively prevent nearly 7.5 million smoking-related deaths globally. These findings demonstrate the magnitude of the actions already taken by countries and underscore the potential for millions of additional lives to be saved with continued adoption of MPOWER policies.

Breastfeeding rates in central and western China in 2010: implications for child and population health

Abstract: OBJECTIVE: To describe breastfeeding practices in rural China using globally recommended indicators and to compare them with practices in neighbouring countries and large emerging economies. METHODS: A community-based, cross-sectional survey of 2354 children younger than 2 years in 26 poor, rural counties in 12 central and western provinces was conducted. Associations between indicators of infant and young child feeding and socioeconomic, demographic and health service variables were explored and rates were compared with the most recent data from China and other nations. FINDINGS: Overall, 98.3% of infants had been breastfed. However, only 59.4% had initiated breastfeeding early (i.e. within 1 hour of birth); only 55.5% and 9.4% had continued breastfeeding for 1 and 2 years, respectively, and only 28.7% of infants younger than 6 months had been exclusively breastfed. Early initiation of breastfeeding was positively associated with at least five antenatal clinic visits (adjusted odds ratio, aOR: 3.48; P < 0.001) and negatively associated with delivery by Caesarean (aOR: 0.53; P < 0.001) or in a referral-level facility (aOR: 0.6; P = 0.014). Exclusive breastfeeding among children younger than 6 months was positively associated with delivery in a referral-level facility (aOR: 2.22; P < 0.05). Breastfeeding was not associated with maternal age or education, ethnicity or household wealth. Surveyed rates of exclusive and continued breastfeeding were mostly lower than in other nations. CONCLUSION: Despite efforts to promote breastfeeding in China, rates are very low. A commitment to improve infant and young child feeding is needed to reduce mortality and morbidity.

Trends in smoking and lung cancer mortality in Japan, by birth cohort, 1949-2010

Abstract: OBJECTIVE: To determine smoking trends in Japan in comparison with lung cancer mortality. METHODS: Age-specific smoking prevalence among cohorts born between 1897 and 1985 were determined for the period 1949-2010. The percentages of the cohorts born between 1893 and 1979 who initiated smoking early (e.g. before the age of 20 years) were determined. The results were compared against lung cancer mortality rates in people aged 40-84 years belonging to cohorts born between 1868 and 1968. FINDINGS: In males, smoking prevalence was generally high, particularly among those born before the late 1950s, and early initiation was fairly uncommon. Early initiation was most common among recent birth cohorts of males, who showed relatively low prevalences of smoking. In females, the prevalence of smoking was generally low and early initiation was very uncommon, particularly among those born in the late 1930s and before the late 1940s, respectively. Recent cohorts of females showed relatively high prevalences of smoking and relatively high percentages of early initiation. In both sexes, lung cancer mortality was generally low but increased over the study period. CONCLUSION: Lung cancer mortality in Japanese males was relatively low given the high prevalence of smoking, perhaps because early initiation was fairly uncommon. Over the last four decades, however, early initiation of smoking has become more common in both sexes. The adverse effect this is likely to have on lung cancer mortality rates has probably not been observed because of the long time lag.

The epidemiology of child homicides in South Africa

Abstract: Objective To describe age- and sex-specific rates of child homicide in South Africa. Methods A cross-sectional mortuary-based study was conducted in a national sample of 38 medicolegal laboratories operating in 2009. These were sampled in inverse proportion to the number that were operational in each of three strata defined by autopsy volume: 1499 annual autopsies. Child homicide data were collected from mortuary files, autopsy reports and police interviews. Cause of death, evidence of abuse and neglect or of sexual assault, perpetrator characteristics and circumstances surrounding the death were investigated. Findings An estimated 1018 (95% confidence interval, CI: 843–1187) child homicides occurred in 2009, for a rate of 5.5 (95% CI: 4.6–6.4) homicides per 100 000 children younger than 18 years. The homicide rate was much higher in boys (6.9 per 100 000; 95% CI: 5.6–8.3) than in girls (3.9 per 100 000; 95% CI: 3.2–4.7). Child abuse and neglect had preceded nearly half (44.5%) of all homicides, but three times more often among girls than among boys. In children aged 15 to 17 years, the homicide rate among boys (21.7 per 100 000; 95% CI: 14.2–29.2) was nearly five times higher than the homicide rate among girls (4.6 per 100 000; 95% CI: 2.4–6.8). Conclusion South Africa's child homicide rate is more than twice the global estimate. Since a background of child abuse and neglect is common, improvement of parenting skills should be part of primary prevention efforts.