Showing papers in "Bulletin of The World Health Organization in 2018"

The global burden of kidney disease and the sustainable development goals.

Abstract: Kidney disease has been described as the most neglected chronic disease. Reliable estimates of the global burden of kidney disease require more population-based studies, but specific risks occur across the socioeconomic spectrum from poverty to affluence, from malnutrition to obesity, in agrarian to post-industrial settings, and along the life course from newborns to older people. A range of communicable and noncommunicable diseases result in renal complications and many people who have kidney disease lack access to care. The causes, consequences and costs of kidney diseases have implications for public health policy in all countries. The risks of kidney disease are also influenced by ethnicity, gender, location and lifestyle. Increasing economic and health disparities, migration, demographic transition, unsafe working conditions and environmental threats, natural disasters and pollution may thwart attempts to reduce the morbidity and mortality from kidney disease. A multisectoral approach is needed to tackle the global burden of kidney disease. The sustainable development goals (SDGs) emphasize the importance of a multisectoral approach to health. We map the actions towards achieving all of the SDGs that have the potential to improve understanding, measurement, prevention and treatment of kidney disease in all age groups. These actions can also foster treatment innovations and reduce the burden of such disease in future generations.

Gender, health and the 2030 agenda for sustainable development

Abstract: Gender refers to the social relationships between males and females in terms of their roles, behaviours, activities, attributes and opportunities, and which are based on different levels of power. Gender interacts with, but is distinct from, the binary categories of biological sex. In this paper we consider how gender interacts with the 2030 agenda for sustainable development, including sustainable development goal (SDG) 3 and its targets for health and well-being, and the impact on health equity. We propose a conceptual framework for understanding the interactions between gender (SDG 5) and health (SDG 3) and 13 other SDGs, which influence health outcomes. We explore the empirical evidence for these interactions in relation to three domains of gender and health: gender as a social determinant of health; gender as a driver of health behaviours; and the gendered response of health systems. The paper highlights the complex relationship between health and gender, and how these domains interact with the broad 2030 agenda. Across all three domains (social determinants, health behaviours and health system), we find evidence of the links between gender, health and other SDGs. For example, education (SDG 4) has a measurable impact on health outcomes of women and children, while decent work (SDG 8) affects the rates of occupation-related morbidity and mortality, for both men and women. We propose concerted and collaborative actions across the interlinked SDGs to deliver health equity, health and well-being for all, as well as to enhance gender equality and women's empowerment. These proposals are summarized in an agenda for action.

Reducing the global burden of musculoskeletal conditions.

Abstract: Musculoskeletal conditions include more than 150 diagnoses that affect the locomotor system. These conditions are characterized by pain and reduced physical function, often leading to significant mental health decline, increased risk of developing other chronic health conditions and increased all-cause mortality.1 Many musculoskeletal conditions share risk factors common to other chronic health conditions, such as obesity, poor nutrition and a sedentary lifestyle. Musculoskeletal conditions account for the greatest proportion of persistent pain across geographies and ages.2 Back and neck pain, osteoarthritis, rheumatoid arthritis and fractures are among the most disabling musculoskeletal conditions and pose major threats to healthy ageing by limiting physical and mental capacities and functional ability. Although the prevalence of major musculoskeletal conditions increases with age, they are not just conditions of older age. Regional pain conditions, low back and neck pain, musculoskeletal injury sequelae and inflammatory arthritides commonly affect children, adolescents and middle-aged people during their formative and peak income-earning years, establishing trajectories of decline in intrinsic capacity in later years. While point prevalence estimates vary with respect to age and musculoskeletal condition, approximately one in three people worldwide live with a chronic, painful musculoskeletal condition. Notably, recent data suggest that one in two adult Americans live with a musculoskeletal condition, a prevalence comparable to that of cardiovascular and chronic respiratory diseases combined, which cost 213 billion United States dollars in 2011 (or 1.4% of gross domestic product).3 Data from lowand middle-income countries are fewer, yet comparable.4 Musculoskeletal health is critical for human function, enabling mobility, dexterity and the ability to work and actively participate in all aspects of life. Musculoskeletal health is therefore essential for maintaining economic, social and functional independence, as well as human capital across the life course. Impaired musculoskeletal health is responsible for the greatest loss of productive life years in the workforce compared with other noncommunicable diseases,5 commonly resulting in early retirement and reduced financial security. In subsistence communities and lowand middle-income economies, impaired musculoskeletal health has profound consequences on an individual’s ability to participate in social roles and in the prosperity of communities.4

Pandemic risk: how large are the expected losses?

Abstract: There is an unmet need for greater investment in preparedness against major epidemics and pandemics. The arguments in favour of such investment have been largely based on estimates of the losses in national incomes that might occur as the result of a major epidemic or pandemic. Recently, we extended the estimate to include the valuation of the lives lost as a result of pandemic-related increases in mortality. This produced markedly higher estimates of the full value of loss that might occur as the result of a future pandemic. We parametrized an exceedance probability function for a global influenza pandemic and estimated that the expected number of influenza-pandemic-related deaths is about 720 000 per year. We calculated that the expected annual losses from pandemic risk to be about 500 billion United States dollars - or 0.6% of global income - per year. This estimate falls within - but towards the lower end of - the Intergovernmental Panel on Climate Change's estimates of the value of the losses from global warming, which range from 0.2% to 2% of global income. The estimated percentage of annual national income represented by the expected value of losses varied by country income grouping: from a little over 0.3% in high-income countries to 1.6% in lower-middle-income countries. Most of the losses from influenza pandemics come from rare, severe events.

Revision of clinical case definitions: influenza-like illness and severe acute respiratory infection.

Abstract: The formulation of accurate clinical case definitions is an integral part of an effective process of public health surveillance. Although such definitions should, ideally, be based on a standardized and fixed collection of defining criteria, they often require revision to reflect new knowledge of the condition involved and improvements in diagnostic testing. Optimal case definitions also need to have a balance of sensitivity and specificity that reflects their intended use. After the 2009-2010 H1N1 influenza pandemic, the World Health Organization (WHO) initiated a technical consultation on global influenza surveillance. This prompted improvements in the sensitivity and specificity of the case definition for influenza - i.e. a respiratory disease that lacks uniquely defining symptomology. The revision process not only modified the definition of influenza-like illness, to include a simplified list of the criteria shown to be most predictive of influenza infection, but also clarified the language used for the definition, to enhance interpretability. To capture severe cases of influenza that required hospitalization, a new case definition was also developed for severe acute respiratory infection in all age groups. The new definitions have been found to capture more cases without compromising specificity. Despite the challenge still posed in the clinical separation of influenza from other respiratory infections, the global use of the new WHO case definitions should help determine global trends in the characteristics and transmission of influenza viruses and the associated disease burden.

Trends in catastrophic health expenditure in India: 1993 to 2014.

Abstract: Objective: To investigate trends in out-of-pocket health-care payments and catastrophic health expenditure in India by household age composition. Methods: We obtained data from four national consumer expenditure surveys and three health-care utilization surveys conducted between 1993 and 2014. Households were divided into five groups by age composition. We defined catastrophic health expenditure as out-of-pocket payments equalling or exceeding 10% of household expenditure. Factors associated with catastrophic expenditure were identified by multivariable analysis. Findings: Overall, the proportion of catastrophic health expenditure increased 1.47-fold between the 1993-1994 expenditure survey (12.4%) and the 2011-2012 expenditure survey (18.2%) and 2.24-fold between the 1995-1996 utilization survey (11.1%) and the 2014 utilization survey (24.9%). The proportion increased more in the poorest than the richest quintile: 3.00-fold versus 1.74-fold, respectively, across the utilization surveys. Catastrophic expenditure was commonest among households comprising only people aged 60 years or older: the adjusted odds ratio (aOR) was 3.26 (95% confidence interval, CI: 2.76-3.84) compared with households with no older people or children younger than 5 years. The risk was also increased among households with both older people and children (aOR: 2.58; 95% CI: 2.31-2.89), with a female head (aOR: 1.32; 95% CI: 1.19-1.47) and with a rural location (aOR: 1.27; 95% CI: 1.20-1.35). Conclusion: The proportion of households experiencing catastrophic health expenditure in India increased over the past two decades. Such expenditure was highest among households with older people. Financial protection mechanisms are needed for population groups at risk for catastrophic health expenditure.

A global campaign to combat ageism.

Abstract: The World Health Organization (WHO) defines ageism as the stereotyping, prejudice and discrimination towards people on the basis of age.1 Ageism cuts across the life-course and stems from the perception that a person might be too old or too young to be or to do something. Ageism is highly prevalent;2,3 however, unlike other forms of discrimination, including sexism and racism, it is socially accepted and usually unchallenged, because of its largely implicit and subconscious nature.4,5 Children as young as 4 years are aware of their cultures’ age stereotypes.6 These stereotypes focus predominantly on the negative aspects of ageing, with older age typecast as an inevitable decline in physical and mental capacities and a period of dependency. Language and media, including films, television, popular music, print and social media, most often echo and reinforce these stereotypes, because ageist depictions tend to be the norm.7–9 As we get older, we experience ageism from others, but also from ourselves, because of the unconscious internalization of society’s negative attitudes and stereotypes towards older people. This helps to explain why older people often try to stay young, feel shame about getting older and limit what they think they can do instead of taking pride in the accomplishment of ageing. Perceived discrimination, whether based on race, gender or age, has negative health outcomes.10 Ageism has been shown to have significant impact on our participation in society, health and longevity. For example, evidence shows that those who hold negative attitudes on ageing have slower recovery from disability,11 live on average 7.5 years less than those who hold positive attitudes12 and are less likely to be socially integrated.13 Ageism also imposes barriers to the development of good policies on ageing and health as it influences the way problems are framed, the questions that are asked and the solutions that are offered. In this context, age is often understood as sufficient justification for treating people unequally and limiting their opportunities for meaningful contribution. Experience with sexism and racism has shown that changing social norms is possible and can result in more prosperous and equitable societies. Changing people’s understanding, social behaviours and political determination around age and ageing is possible and essential to foster healthy ageing, the ability for all people to live long and healthy lives and do what they have reason to value. Collective, concerted and coordinated global action is required to tackle ageism. Given the current demographic transition, with populations around the world ageing rapidly, we need to act now to generate a positive effect on individuals and society. In May 2016, the 194 WHO Member States called on the organization’s Director-General to develop, in cooperation with other partners, a global campaign to combat ageism.14 To be effective, the global campaign to combat ageism must tackle individual and social attitudes, stereotypes and behaviours towards people on the basis of their age, as well as the laws, policies and institutions that either perpetuate ageism or do little to stop it. To develop the campaign, WHO will build an evidence base on ageism and draw from evidence of what has worked for other public health campaigns, such as end violence against women15 and adopt healthier behaviours.16 Both campaigns have increased awareness, helped to rally public support and influenced change in individual behaviours and in international and national legislative and policy frameworks.17 Evidence suggests that certain conditions need to be met for a campaign to work. In addition to having clear goals and vision, a campaign needs to be evidence-based to understand the nature of the problem, who is affected and how, and which actions should be taken for which target audiences.18 The campaign’s approach should include actions that help to change attitudes and behaviours and to develop supportive policy and legal frameworks.19 A successful campaign should also be underpinned by a theory of change to anticipate possible routes towards change among target audiences, devise effective implementation strategies20 and facilitate evaluation.17 The campaign should be multisectoral and multilevel, as well as supportive of monitoring and evaluation. Finally, to ensure sustained action, the campaign should be supported through long-term funding.21 Ageism has received little attention in research and policy-making4,5 and the evidence base for global action is yet to be established. There is no global analysis on the magnitude of ageism, its determinants, consequences and what strategies and messages could work to address ageism. To develop the global campaign to combat ageism, WHO needs to find answers to six fundamental questions: (i) what is the global prevalence of ageism? (ii) what are the causes or determinants of ageism? (iii) what are the consequences of ageism at an individual and at a societal level? (iv) what strategies exist to effectively tackle ageism? (v) what are the available metrics to measure the different dimensions of ageism and its implicit and explicit expressions? (vi) What are the most effective ways of building public understanding and expanding thinking about age and ageing? To start answering these questions, in July 2017 WHO held a meeting with researchers from several universities to outline the methods for conducting a global set of systematic reviews on ageism. The evidence generated from those reviews will help to identify those strategies that are most likely to reduce ageism as well as those populations that should be targeted, either because they affect ageism or because they are affected by it. These reviews will support the development of a tool to measure ageism globally and help to identify key research A global campaign to combat ageism Alana Officer & Vânia de la Fuente-Núñez

Violence motivated by perception of sexual orientation and gender identity: a systematic review.

Abstract: Objective: To assess the prevalence of physical and sexual violence motivated by perception of sexual orientation and gender identity in sexual and gender minorities. Methods: We searched nine databases without language restrictions for peer-reviewed and grey literature published from 2000 to April 2016. We included studies with more than 50 participants that measured the prevalence of physical and sexual violence perceived as being motivated by sexual orientation and gender identity or gender expression. We excluded intimate partner violence and self-harm. Due to heterogeneity and the absence of confidence intervals in most studies, we made no meta-analysis. Findings: We included 76 articles from 50 countries. These covered 74 studies conducted between 1995 and 2014, including a total of 202 607 sexual and gender minority participants. The quality of data was relatively poor due to a lack of standardized measures and sometimes small and non-randomized samples. In studies where all sexual and gender minorities were analysed as one population, the prevalence of physical and sexual violence ranged from 6% (in a study including 240 people) to 25% (49/196 people) and 5.6% (28/504) to 11.4% (55/484), respectively. For transgender people the prevalence ranged from 11.8% (of a subsample of 34 people) to 68.2% (75/110) and 7.0% (in a study including 255 people) to 49.1% (54/110). Conclusion: More data are needed on the prevalence, risk factors and consequences of physical and sexual violence motivated by sexual orientation and gender identity in different geographical and cultural settings. National violence prevention policies and interventions should include sexual and gender minorities.

Recognizing Noncommunicable Diseases as a Global Health Security Threat

Abstract: Protecting health against potential risks such as epidemiological risks that determine disease outbreaks and pandemics, safety risks associated with poor quality of care and financial risks derived from paying for care, will ensure health security.1 However, health security can have different meanings. Health security can be understood as securing health at the individual, national and global levels, but may also be understood as the effect of health on security. The latter is a traditional approach that focuses mainly on national security and the protection of sovereignty, borders, people, and private interests and property.2 The discrepancy in meanings has caused confusion and mistrust between and among Member States.3 In this paper, we discuss securing health from noncommunicable disease at the individual, national and global levels. A recent Lancet editorial noted that noncommunicable diseases are not garnering the attention they deserve and suggested that such diseases should be considered as a global health security issue.4 A Lancet editorial discussing the 2007 World Health Report called for leadership from the World Health Organization (WHO) to ensure that global health security is achieved.5 The impact of noncommunicable diseases on public health is well known. In 2010, 34.5 million out of a total of 52.84 million deaths were attributed to noncommunicable diseases, and most of these occured in lowand middle-income countries.6 In 2011, the General Assembly adopted a resolution on the prevention and control of noncommunicable diseases. This political declaration was largely an acknowledgement of the burden of noncommunicable diseases and the role of governments and other stakeholders in preventing and managing this burden. Noncommunicable diseases have also been included in the sustainable development goals with a specific target.7 Despite many efforts by WHO and the international community, however, funding for the prevention and control of noncommunicable diseases has lagged. Of the total 37.6 billion United States dollars (US$) in development assistance for health for 2016, 29.4% was allocated to maternal, newborn and child health, 25.4% to human immunodeficiency virus (HIV), 6.6% to malaria, 4% to tuberculosis and 1.7% to noncommunicable diseases.8 The scarce funding for noncommunicable diseases is a possible indicator of their low priority on the global health agenda. Here we argue that this situation is in part due to the failure to recognize noncommunicable diseases as a global health security threat. For example, in contrast with noncommunicable diseases, HIV, an epidemic of global significance, has attracted considerable funding. The security concerns associated with HIV were so pressing that the issue reached the United Nations Security Council. HIV is considered a national security threat because of the impact on strategically important population groups, such as soldiers and peacekeepers and because of its potential to destabilize states. Noncommunicable diseases can affect personal security in many ways: they are chronic conditions and therefore have a long-lasting impact on health and on the perception of one’s personal security and well-being. Evidence suggests that noncommunicable diseases contribute to personal poverty, because of their chronic nature, their impact on productivity and their direct and indirect costs. However, it is the scale of the premature mortality due to noncommunicable diseases, with its impact on individuals and families, that mainly threatens personal security. The WHO Global status report on noncommunicable diseases 2014 showed that in 2012, 42% of all deaths caused by noncommunicable diseases occurred before the age of 70 years and 82% were in lowand middle-income countries.9 Noncommunicable diseases clearly have an impact on individuals; however, they also represent an economic burden to governments, and therefore are a health security challenge at the national level. The global dimension of noncommunicable diseases as a health security issue refers to the health of all the people and efforts to reduce health inequity. The Lancet Commission on Global Health 2035 foresees that the threat of pandemics, antimicrobial resistance and noncommunicable diseases will represent the greatest threats to global public health in the future.10 Antimicrobial resistance and pandemics have a high priority status in the global agenda and their threat to global health security is largely unquestioned. The West African Ebola outbreak prompted the creation of a global health security agenda. Interestingly, the initiative did not come from the public health community, but from the highest political levels. In 2014, the United States of America, with initially 40 partners from around the world, launched the global health security agenda with the aim to prevent, detect and respond to infectious disease threats globally.11 The urge for a rapid response to infectious diseases is not surprising, as fear of contagion is strong; noncommunicable diseases do not pose such a threat and are therefore not perceived as threatening.12 We propose that the magnitude of the epidemic of noncommunicable diseases, their increasing prevalence, global costs, potential to overwhelm the response capacity of low-income countries and their contribution to the inequality of health, make noncommunicable diseases a global health security threat. For example, the increased Recognizing noncommunicable diseases as a global health security threat Amrita Saha & George Alleyne

Prevalence of asymptomatic Zika virus infection: a systematic review.

Abstract: Objective To conduct a systematic review to estimate the prevalence of asymptomatic Zika virus infection in the general population and in specific population groups. Methods We searched PubMed®, Embase® and LILACS online databases from inception to 26 January 2018. We included observational epidemiological studies where laboratory testing was used to confirm positive exposure of participants to Zika virus and in which Zika virus symptom status was also recorded. We excluded studies in which having symptoms of Zika virus was a criterion for inclusion. The main outcome assessed was percentage of all Zika virus-positive participants who were asymptomatic. We used a quality-effects approach and the double arcsine transformation for the meta-analysis. Findings We assessed 753 studies for inclusion, of which 23 were included in the meta-analysis, totalling 11 305 Zika virus-positive participants. The high degree of heterogeneity in the studies (I2 = 99%) suggests that the pooled prevalence of asymptomatic Zika virus-positive participants was probably not a robust estimate. Analysis based on subgroups of the population (general population, returned travellers, blood donors, adults with Guillain-Barre syndrome, pregnant women and babies with microcephaly) was not able to explain the heterogeneity. Funnel and Doi plots showed major asymmetry, suggesting selection bias or true heterogeneity. Conclusion Better-quality research is needed, using standardized methods, to determine the true prevalence of asymptomatic Zika virus and whether it varies between populations or over time.

Catastrophic health spending in Europe: equity and policy implications of different calculation methods.

Abstract: Objective To investigate the equity and policy implications of different methods of calculating catastrophic health spending. Methods We used routinely collected data from recent household budget surveys in 14 European countries. We calculated the incidence of catastrophic health spending and its distribution across consumption quintiles using four methods. We compared the budget share method, which is used to monitor universal health coverage (UHC) in the sustainable development goals (SDGs), with three other well established methods: actual food spending; partial normative food spending; and normative spending on food, housing and utilities. Findings Country estimates of the incidence of catastrophic health spending were generally similar using the normative spending on food, housing and utilities method and the budget share method at the 10% threshold of a household’s ability to pay. The former method found that catastrophic spending was concentrated in the poorest quintile in all countries, whereas with the budget share method catastrophic spending was largely experienced by richer households. This is because the threshold for catastrophic health spending in the budget share method is the same for all households, while the other methods generated effective thresholds that varied across households. The normative spending on food, housing and utilities method was the only one that produced an effective threshold that rose smoothly with total household expenditure. Conclusion The budget share method used in the SDGs overestimates financial hardship among rich households and underestimates hardship among poor households. This raises concerns about the ability of the SDG process to generate appropriate guidance for policy on UHC.

Policy implications of big data in the health sector.

Abstract: Over the last decade, there has been growing enthusiasm for data analytics as well as growing appreciation of the potential usefulness of so-called big data in transforming personal care, clinical care and public health, and related research. Both the public and private health sectors are investing in the technologies and analytical capabilities needed to unlock the full value of big data. For governments that are interested in using such data, a natural starting point is to link national health-care data sets, to facilitate in-depth analysis of the performance and utilization of health services. At the institutional level, the analysis of electronic health records may greatly expand the capacity to generate new knowledge by creating an observational evidence base to help resolve clinical questions.1 Analysis of big data is already proving critical in building accurate models of disease progression and providing personalized medicine in clinical practice. It has also facilitated the evaluation of the impact of health policies and improved the efficiency of clinical trials.2 By encouraging patients to participate in their own care, delivering personalized information and integrating medicine with behavioural determinants of health, the integration of electronic health records with personal data from other sources, e.g. medical devices, wearable devices, sensors and tools based on virtual reality, could also be very beneficial.3 The value of health research based on non-traditional data streams from Internet-based applications, platforms, e.g. social media and services, e.g. email and online purchasing, has already been demonstrated. For example, during the Zika virus outbreak in 2015, analyses of reports in the online media helped to supplement existing information, close knowledge gaps and allow researchers to estimate transmission dynamics and plan response measures that extended beyond vector suppression.4 Big data ecosystem

Fiscal policy to improve diets and prevent noncommunicable diseases: from recommendations to action.

Abstract: The World Health Organization has recommended that Member States consider taxing energy-dense beverages and foods and/or subsidizing nutrient-rich foods to improve diets and prevent noncommunicable diseases. Numerous countries have either implemented taxes on energy-dense beverages and foods or are considering the implementation of such taxes. However, several major challenges to the implementation of fiscal policies to improve diets and prevent noncommunicable diseases remain. Some of these challenges relate to the cross-sectoral nature of the relevant interventions. For example, as health and economic policy-makers have different administrative concerns, performance indicators and priorities, they often consider different forms of evidence in their decision-making. In this paper, we describe the evidence base for diet-related interventions based on fiscal policies and consider the key questions that need to be asked by both health and economic policy-makers. From the health sector's perspective, there is most evidence for the impact of taxes and subsidies on diets, with less evidence on their impacts on body weight or health. We highlight the importance of scope, the role of industry, the use of revenue and regressive taxes in informing policy decisions.

Antibiotic stewardship interventions in hospitals in low-and middle-income countries: a systematic review.

Abstract: Objective To review the effectiveness of antibiotic stewardship interventions in hospitals in low- and middle-income countries. Methods We searched MEDLINE®, Embase®, Cochrane Central Register of Controlled Trials and regional indexes for studies of interventions to improve appropriate prescribing and use of antibiotics for hospitalized patients in low- and middle-income countries. We included controlled trials, controlled before-and-after studies and interrupted time-series studies published up to December 2017. We report prescribing, clinical and microbiological outcomes using a narrative approach. Findings We screened 7342 original titles and abstracts, assessed 241 full-text articles and included 27 studies from 2 low-income and 11 middle-income countries. We found a medium (11 studies) or high risk (13 studies) of bias. Generally, all types of interventions (structural, persuasive and enabling) and intervention bundles were reported to improve prescribing and clinical outcomes. However, the studied interventions and reported outcomes varied widely. The most frequent intervention was procalcitonin-guided antibiotic treatment (8 of 27 studies, all randomized controlled trials). The intervention was associated with a relative risk for patients receiving antibiotics ranging between 0.40 and 0.87. Conclusion The majority of studies reported a positive effect of hospital antibiotic stewardship interventions. However, we cannot draw general conclusions about the effectiveness of such interventions in low- and middle-income countries because of low study quality, heterogeneity of interventions and outcomes, and under-representation of certain settings. To strengthen the evidence base, action needs to be taken to address these shortcomings.

A life-course approach to health: synergy with sustainable development goals.

Abstract: A life-course approach to health encompasses strategies across individuals' lives that optimize their functional ability (taking into account the interdependence of individual, social, environmental, temporal and intergenerational factors), thereby enabling well-being and the realization of rights. The approach is a perfect fit with efforts to achieve universal health coverage and meet the sustainable development goals (SDGs). Properly applied, a life-course approach can increase the effectiveness of the former and help realize the vision of the latter, especially in ensuring health and well-being for all at all ages. Its implementation requires a shared understanding by individuals and societies of how health is shaped by multiple factors throughout life and across generations. Most studies have focused on noncommunicable disease and ageing populations in high-income countries and on epidemiological, theoretical and clinical issues. The aim of this article is to show how the life-course approach to health can be extended to all age groups, health topics and countries by building on a synthesis of existing scientific evidence, experience in different countries and advances in health strategies and programmes. A conceptual framework for the approach is presented along with implications for implementation in the areas of: (i) policy and investment; (ii) health services and systems; (iii) local, multisectoral and multistakeholder action; and (iv) measurement, monitoring and research. The SDGs provide a unique context for applying a holistic, multisectoral approach to achieving transformative outcomes for people, prosperity and the environment. A life-course approach can reinforce these efforts, particularly given its emphasis on rights and equity.

Untreated depression and tuberculosis treatment outcomes, quality of life and disability, Ethiopia

Abstract: Objective To investigate the association between comorbid depression and tuberculosis treatment outcomes, quality of life and disability in Ethiopia. Methods The study involved 648 consecutive adults treated for tuberculosis at 14 primary health-care facilities. All were assessed at treatment initiation (i.e. baseline) and after 2 and 6 months. We defined probable depression as a score of 10 or above on the nine-item Patient Health Questionnaire. Data on treatment default, failure and success and on death were obtained from tuberculosis registers. Quality of life was assessed using a visual analogue scale and we calculated disability scores using the World Health Organization's Disability Assessment Scale. Using multivariate Poisson regression analysis, we estimated the association between probable depression at baseline and treatment outcomes and death. Results Untreated depression at baseline was independently associated with tuberculosis treatment default (adjusted risk ratio, aRR: 9.09; 95% confidence interval, CI: 6.72 to 12.30), death (aRR: 2.99; 95% CI: 1.54 to 5.78), greater disability (β: 0.83; 95% CI: 0.67 to 0.99) and poorer quality of life (β: -0.07; 95% CI: -0.07 to -0.06) at 6 months. Participants with probable depression had a lower mean quality-of-life score than those without (5.0 versus 6.0, respectively; P < 0.001) and a higher median disability score (22.0 versus 14.0, respectively; P < 0.001) at 6 months. Conclusion Untreated depression in people with tuberculosis was associated with worse treatment outcomes, poorer quality of life and greater disability. Health workers should be given the support needed to provide depression care for people with tuberculosis.

Complex determinants of inappropriate use of antibiotics.

Abstract: Inappropriate use of antibiotics in humans and agriculture is one of the drivers1 of the emergence of antimicrobial resistance. The prevalence of penicillinresistant pneumococci, macrolideresistant Streptococcus pneumoniae and S. pyogenes strongly correlates with total antibiotic use in outpatients.2 Such inappropriate use is the result of complex interactions between demand for and supply of antibiotics. The use of antibiotics in the retail sector, for example in pharmacies and drugstores, the healthcare sector and in farms involves both professional and unqualified personnel from various sectors. These personnel operate within their country-specific regulatory environments and have different economic incentives. In the retail sector, there are several challenges on the demand for antibiotics. Prevalence of non-prescription antibiotics is high in some countries, such as in Bangladesh, Brazil and Sudan. In these countries, the prevalence of antimicrobial resistance is higher in communities who use non-prescription antibiotics more frequently.3 Among Hispanic households in New York, United States of America (USA), self-medication with antibiotics is a common choice for fever, respiratory and gastrointestinal conditions.4 A systematic review of adult individuals in households of lowand middle-income countries covering 34 studies shows high prevalence (39%) of antimicrobial self-medication.5 Half of these studies focus on non-prescription antibiotics while the remainder is about the use of anti-malarial and other medicines. Main sources of self-medication antibiotics were found to be pharmacies, drugstores and leftover or borrowed drugs. Antibiotics sold in drugstores and provided by non-qualified personnel exacerbate inappropriate use. Common inappropriate use by households includes not completing the course or taking an insufficient dose, taking antibiotics for the wrong indications, such as viral infection and inflammation, and sharing antibiotics. The antibiotics most commonly used inappropriately to treat flu or common cold symptoms are ampicillin, tetracycline, metronidazole, ceftriaxone, kanamycin and cotrimoxazole.5 Health-care markets, understood as the interface between demand and supply, are imperfect, because professionals have more technical information than patients; this is also known as asymmetry of information.6 Health professionals who prescribe or dispense antibiotics, when motivated by financial incentives, can induce demand through the unnecessary use of antibiotics. In South Asian countries, common challenges on the supply side in the retail sector7 are poor quality dispensing, particularly by unqualified providers, and inadequate labelling and counselling. Other challenges include insufficient clinical history taking and sale of antibiotics that have no proper dosage or are clinically inappropriate.8 Common sources of poor counselling are unqualified drug sellers, patients using old prescriptions and word of mouth from friends. In the Australian health-care sector, there are gaps such as the prescribing knowledge among junior doctors, the lack of awareness on the limited use of restricted antibiotic classes9 and antibiotics are often prescribed in the absence of a laboratory sensitivity test. In Peru, poor knowledge of local resistance rates and profiles leads to inappropriate prescribing, and patient demand for antibiotics further complicate the problem.10 A study across 17 European countries shows that a 1% increase in doctor-to-population density is associated with 0.52% to 0.86% increase in outpatient use of antibiotics, and that a fee-for-service incentivises higher use than the capitation payment method.11 Foodborne transmission of antimicrobial-resistant bacteria from animals to people is well documented.12,13 For instance, the emergence of fluoroquinolone-resistant Campylobacter has been attributed to the consumption of poultry meat in the USA which has led to banning the use of fluoroquinolones in poultry.14 In the agricultural sector, veterinarian prescriptions in some countries are influenced by their training, published literature, experience, sensitivity tests, risk of resistance and ease of administration.15 Another study carried out in 25 European countries showed that about a half (44.3%) of the 3004 veterinarians who participated in the study seldom collect samples for laboratory bacterial diagnosis before prescription, while 37.8% frequently undertook the test.16 In Cambodia, a study has shown that farmers have limited understanding of the action and indication for antibiotics.17 Farmers also had a low level of risk perception about the implications of antimicrobial resistance in livestock and a lack of concern about potential links between antibiotic use in farming and resistance in humans. In contrast, German farmers have a high level of awareness on the links between antimicrobial resistance in humans and animals and the need for prudent antibiotic prescribing.18 In some countries, the high cost of animal feed that contains antibiotics pushes farmers to use active pharmaceutical ingredients mixes with animal feed, with no quality control over the homogeneity of antibiotics in the feed.

Knowledge integration in One Health policy formulation, implementation and evaluation.

Abstract: The One Health concept covers the interrelationship between human, animal and environmental health and requires multistakeholder collaboration across many cultural, disciplinary, institutional and sectoral boundaries. Yet, the implementation of the One Health approach appears hampered by shortcomings in the global framework for health governance. Knowledge integration approaches, at all stages of policy development, could help to address these shortcomings. The identification of key objectives, the resolving of trade-offs and the creation of a common vision and a common direction can be supported by multicriteria analyses. Evidence-based decision-making and transformation of observations into narratives detailing how situations emerge and might unfold in the future can be achieved by systems thinking. Finally, transdisciplinary approaches can be used both to improve the effectiveness of existing systems and to develop novel networks for collective action. To strengthen One Health governance, we propose that knowledge integration becomes a key feature of all stages in the development of related policies. We suggest several ways in which such integration could be promoted.

Lead poisoning outbreak among opium users in the Islamic Republic of Iran, 2016-2017.

Abstract: Objective To describe an outbreak of lead poisoning among opium users in the Islamic Republic of Iran and estimate the number of affected people in the country. Methods We used data from the country's largest poison treatment centre to illustrate the epidemiology of an outbreak of lead poisoning in oral opium users. We describe the government's referral and treatment guidelines in response to the outbreak. Based on the number of individuals treated and previous studies on the prevalence of oral opium use we estimated the total number of people at risk of lead-contaminated opium nationwide. Findings In February 2016, we noticed a steep increase in the numbers of oral opium users referred to our poison treatment centre with abdominal pain, anaemia and constipation. Numbers peaked in June 2016 but the outbreak was ongoing in August 2017. The mean blood lead level in a sample of 80 patients was 140.3 µg/dL (standard deviation: 122.6). Analysis of an illegal opium sample showed 3.55 mg lead in 1 g opium. Treatment was exposure reduction with opioid substitutes and laxatives, or chelation therapy if indicated. Over 7 months, 4294 poison cases were seen at main referral hospitals in Tehran out of an estimated 31 914 oral opium users in the city. We estimate more than 260 000 out of 773 800 users nationwide remain untreated and at risk of poisoning. Conclusion Lead-contaminated opium and heroin that has transited through the Iranian markets is a global risk and highlights a need for better monitoring of illegal drug supplies.

Measuring health inequalities in the context of sustainable development goals.

Abstract: Transforming our world: the 2030 agenda for sustainable development promotes the improvement of health equity, which entails ongoing monitoring of health inequalities. The World Health Organization has developed a multistep approach to health inequality monitoring consisting of: (i) determining the scope of monitoring; (ii) obtaining data; (iii) analysing data; (iv) reporting results; and (v) implementing changes. Technical considerations at each step have implications for the results and conclusions of monitoring and subsequent remedial actions. This paper presents some technical considerations for developing or strengthening health inequality monitoring, with the aim of encouraging more robust, systematic and transparent practices. We discuss key aspects of measuring health inequalities that are relevant to steps (i) and (iii). We highlight considerations related to the selection, measurement and categorization of dimensions of health inequality, as well as disaggregation of health data and calculation of summary measures of inequality. Inequality monitoring is linked to health and non-health aspects of the 2030 agenda for sustainable development, and strong health inequality monitoring practices can help to inform equity-oriented policy directives.

Classification of patient-safety incidents in primary care.

Abstract: Primary care lags behind secondary care in the reporting of, and learning from, incidents that put patient safety at risk. In primary care, there is no universally agreed approach to classifying the severity of harm arising from such patient-safety incidents. This lack of an agreed approach limits learning that could lead to the prevention of injury to patients. In a review of research on patient safety in primary care, we identified 21 existing approaches to the classification of harm severity. Using the World Health Organization's (WHO's) International Classification for Patient Safety as a reference, we undertook a framework analysis of these approaches. We then developed a new system for the classification of harm severity. To assess and classify harm, most existing approaches use measures of symptom duration (11/21), symptom severity (11/21) and/or the level of intervention required to manage the harm (14/21). However, few of these approaches account for the deleterious effects of hospitalization or the psychological stress that may be experienced by patients and/or their relatives. The new classification system we developed builds on WHO's International Classification for Patient Safety and takes account not only of hospitalization and psychological stress but also of so-called near misses and uncertain outcomes. The constructs we have outlined have the potential to be applied internationally, across primary-care settings, to improve both the detection and prevention of incidents that cause the most severe harm to patients.

The Minamata Convention and the phase down of dental amalgam

Abstract: Oral health is a neglected area of global health, although oral disease is one of the most common public health issues worldwide.1 Despite advances in modern dentistry, untreated dental caries in permanent teeth was reported as the most prevalent of the 328 conditions assessed in 2016 Global Burden of Disease Study.2 The restorative model for managing dental caries was developed in the 1900s, alongside dental amalgam as one of the restorative materials commonly used to treat dental caries. Together they still provide the backbone of oral health services in most countries today. A shift away from the restorative model and the widespread use of dental amalgam was perhaps unimaginable even a decade ago, despite the World Health Organization (WHO) calling for oral health to be incorporated into policies for the integrated prevention and treatment of chronic noncommunicable and communicable diseases, and into maternal and child health policies.3 The Minamata Convention on Mercury (2013) is an international legally binding treaty that aims to protect the human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds.4 The convention addresses mercury-added products, including dental amalgam, which is made of approximately 50% of elemental mercury by weight, and proposes nine measures to phase down the use of dental amalgam (Box 1). These measures show the interconnected and interdependent nature of phasing down dental amalgam, and reinforce the need for a multipronged approach as called for by WHO. The implementation of the convention and its provision for dental amalgam can catalyse the shift away from the restorative model of care and the use of mechanically retained filling materials, such as dental amalgam, towards preventive and minimal intervention dentistry that predominantly uses adhesive dental materials. Implementation will also provide an opportunity to strengthen oral health promotion and oral disease prevention within an integrated, people-centred model of health services (Box 1).

Antimicrobial resistance in livestock and poor quality veterinary medicines.

Abstract: Every year, antimicrobial resistance causes the death of around 700 000 people, and this number is expected to rise to an estimated 10 million deaths annually by 2050.1 Antimicrobial resistance has the potential to affect almost all sustainable development goals (SDGs), particularly those targeting poverty, hunger, health and economic growth. Although the reduction and eradication of antimicrobial resistance is not included as an individual SDG, paragraph 26 of Transforming our world: the 2030 agenda for sustainable development states: “We will equally accelerate the pace of progress made in fighting malaria, [human immunodeficiency virus/acquired immunodeficiency syndrome], tuberculosis, hepatitis, Ebola and other communicable diseases and epidemics, including by addressing growing antimicrobial resistance and the problem of unattended diseases affecting developing countries.”2 There is concern about how antimicrobial resistance emergence in livestock will impact SDG 3, i.e. ensuring healthy lives and promoting wellbeing for all, at all ages.3 With meat production set to increase from 200 million tons to 470 million tons by 2050,4 it is likely that farmers will rely even more on antibiotics to prophylactically prevent disease in their livestock to meet this expected demand. The high proportion of poor-quality veterinary medicine for therapeutic use in livestock compounds the problem of antibiotic overuse, particularly in lowand middle-income countries. The annual market in Africa for substandard and non-registered veterinary medicine is estimated to be 400 million United States dollars,5 equal to that of the officially registered, quality-assured veterinary drug market.6 Numerous cases of antimicrobial resistance in humans have been traced to resistant microbes suspected of originating in livestock,7,8 which is particularly concerning as infected livestock can be asymptomatic.8 Transmission of resistant bacteria from livestock to humans can occur through the consumption of meat, direct contact with colonized animals or manure spread in the environment.7 The strongest correlation between interspecies pathogen transmission is observed in countries with policies to reduce agricultural antibiotic use. When the glycopeptide avoparcin was banned across the European Union in the late 1990s, the prevalence of vanco mycin-resistant enterococci in biological samples from both poultry and humans decreased.9 While research on drug resistance, including the role of poor quality medicine, has increased in recent years, the scientific community has not incorporated the impact of poor-quality veterinary medicine into the overall picture of antimicrobial resistance. Poor-quality medicines that provide subtherapeutic doses of active pharmaceutical ingredient, whether due to inadequate amounts of pharmaceutical, ineffective release, presence of impurities or degradation of compounds, are believed to contribute to antimicrobial resistance by exposing microbes to a level of antibiotic that will not effectively kill the whole microbial population.10 Poor-quality veterinary medicine as a contributor to antimicrobial resistance has been mentioned anecdotally in the literature, but systematic studies are lacking. Given the widespread use of antibiotics in animal husbandry and the persistent problems of drug quality in lowand middle-income countries, this is a significant oversight that could lead to long-term challenges. Increased frequency of antibiotic use in livestock, particularly at subtherapeutic doses due to issues with administration and/ or drug quality, can allow resistant microbes to flourish. While poor-quality veterinary medicine is presumed to impact antimicrobial resistance, there are no robust studies that can act as an evidence base for developing sound policies.

The sustainable development goals as a framework to combat health-sector corruption.

Abstract: Corruption is diverse in its forms and embedded in health systems worldwide. Health-sector corruption directly impedes progress towards universal health coverage by inhibiting people’s access to quality health services and to safe and effective medicines, and undermining systems for financial risk protection. Corruption is also a cross-cutting theme in the United Nations’ sustainable development goals (SDGs) which aim to improve population health, promote justice and strong institutions and advance sustainable human development. To address health-sector corruption, we need to identify how it happens, collect evidence on its impact and develop frameworks to assess the potential risks and put in place protective measures. We propose that the SDGs can be leveraged to develop a new approach to anti-corruption governance in the health sector. The aim will be to address coordination across the jurisdictions of different countries and foster partnerships among stakeholders to adopt coherent policies and anti-corruption best practices at all levels. Combating corruption requires a focused and invigorated political will, better advocacy and stronger institutions. There is no single solution to the problem. Nevertheless, a commitment to controlling corruption via the SDGs will better ensure the integrity of global health and human development now and beyond 2030.

Praziquantel for the treatment of schistosomiasis during human pregnancy.

Abstract: In 2014, an estimated 40 million women of reproductive age were infected with Schistosoma haematobium, S. japonicum and/or S. mansoni. In both 2003 and 2006, the World Health Organization (WHO) recommended that all schistosome-infected pregnant and breastfeeding women be offered treatment, with praziquantel, either individually or during treatment campaigns. In 2006, WHO also stated the need for randomized controlled trials to assess the safety and efficacy of such treatment. Some countries have yet to follow the recommendation on treatment and many programme managers and pregnant women in other countries remain reluctant to follow the recommended approach. Since 2006, two randomized controlled trials on the use of praziquantel during pregnancy have been conducted: one against S. mansoni in Uganda and the other against S. japonicum in the Philippines. In these trials, praziquantel treatment of pregnant women had no significant effect on birth weight, appeared safe and caused minimal side-effects that were similar to those seen in treated non-pregnant subjects. Having summarized the encouraging data, on efficacy, pharmacokinetics and safety, from these two trials and reviewed the safety data from non-interventional human studies, we recommend that all countries include pregnant women in praziquantel treatment campaigns. We identify the barriers to the treatment of pregnant women, in countries that already include such women in individual treatments and mass drug administration campaigns, and discuss ways to address these barriers.

Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review.

Abstract: Objective To review interventions improving eye-care services for schoolchildren in low- and middle-income countries. Methods We searched online databases (CINAHL, Embase®, ERIC, MEDLINE®, ProQuest, PubMed® and Web of ScienceTM) for articles published between January 2000 and May 2018. Eligible studies evaluated the delivery of school-based eye-care programmes, reporting results in terms of spectacle compliance rates, quality of screening or attitude changes. We considered studies to be ineligible if no follow-up data were reported. Two authors screened titles, abstracts and full-text articles, and we extracted data from eligible full-text articles using the availability, accessibility, acceptability and quality rights-based conceptual framework. Findings Of 24 559 publications screened, 48 articles from 13 countries met the inclusion criteria. Factors involved in the successful provision of school-based eye-care interventions included communication between health services and schools, the willingness of schools to schedule sufficient time, and the support of principals, staff and parents. Several studies found that where the numbers of eye-care specialists are insufficient, training teachers in vision screening enables the provision of a good-quality and cost-effective service. As well as the cost of spectacles, barriers to seeking eye-care included poor literacy, misconceptions and lack of eye health knowledge among parents. Conclusion The provision of school-based eye-care programmes has great potential to reduce ocular morbidity and developmental delays caused by childhood vision impairment and blindness. Policy-based support, while also attempting to reduce misconceptions and stigma among children and their parents, is crucial for continued access.

Qualitative evidence to improve guidelines and health decision-making.

Abstract: 79 As governments are developing schemes for universal health coverage (UHC) and progressing towards the sustainable development goals (SDGs), they need relevant and context-sensitive evidence to support different policies and interventions. Decision-makers are increasingly using qualitative evidence to understand various socioeconomic contexts, health systems and communities. This type of evidence is useful to assess the needs, values, perceptions and experiences of stakeholders, including policymakers, providers, communities and patients, and is thus crucial for complex health decision-making. For instance, during the development of the World Health Organization (WHO) Recommendations on antenatal care for a positive pregnancy experience,1 qualitative evidence was used to understand what women want, need and value during pregnancy and antenatal care.2 The findings of two qualitative evidence syntheses helped to identify factors that influence access to antenatal care for women3 and provision of good-quality services by health-care providers.4 The findings also contributed to informing the acceptability of the recommendations and their implementation considerations. Qualitative evidence syntheses, which combine and analyse evidence from individual qualitative studies, have emerged as a key approach to inform guideline development and address implementation considerations in diverse country settings and complex health systems.5 By extending beyond the evidence on benefits and harms provided by effectiveness reviews, qualitative evidence syntheses clarify the interplay between stakeholders, health systems and context. They are fundamental to understand the values and preferences of end-users, to assess the acceptability and feasibility of health and social interventions, and to explore the effects of different interventions on equity.5 WHO, as a producer of clinical, public health and health system guidelines, increasingly uses qualitative evidence syntheses to ensure that its recommendations reflect the needs of its audience and the varied contexts where recommended interventions will be implemented. Beyond global guidance, qualitative evidence is invaluable for national and local decision-makers and practitioners to understand factors influencing the implementation and scale-up of health policies and programmes. For instance, policy-makers require evidence on factors that influence vaccination coverage, satisfaction and retention of health-care workers or quality of care in health facilities. Qualitative data have proven essential in planning, developing and implementing health policies and interventions, including in lowand middle-income countries, for example to prevent and treat malaria during pregnancy6 or to promote respectful maternity care in country programmes.7 Qualitative evidence also helps policymakers and programme managers to make decisions about how to adapt a given WHO guideline and how to prioritize specific recommendations for implementation. Yet, despite the relevance of findings from qualitative evidence syntheses, there is limited guidance on how to assess and use this evidence in policy and practice. To address this need, the Alliance for Health Policy and Systems Research and the WHO Department of Reproductive Health and Research have supported the development of a new approach called GRADE-CERQual (Grading of Recommendations Assessment, Development and EvaluationConfidence in the evidence from reviews of qualitative research). The GRADECERQual approach is used to describe how much confidence decision-makers and other users can place in findings from qualitative evidence syntheses by transparently assessing methodological limitations, coherence, adequacy and relevance.8,9 The approach is similar to GRADE, which is widely used to assess how much confidence to place in review findings on the effectiveness of health interventions. New guidance on how to apply the GRADE-CERQual approach is now available as a special series of articles to support stakeholders conducting reviews of qualitative research and using their findings to inform decision-making.8 The articles explain the approach step-by-step and why and how the approach was developed. This guidance also provides information on how to make an overall assessment of confidence and how to present key findings and confidence assessments. The GRADE-CERQual approach was developed as a global public good to advance research methods and promote the uptake of qualitative findings in decision-making within and beyond the health sector. This guidance is also aligned with a global movement towards the generation and use of a wide array of evidence in policy-making.10,11 Finally, this approach is important to better understand complex policies and programmes across contexts and to inform system-wide interventions relevant to UHC and the SDGs. As such, WHO aims to innovate and test methods to improve the development, adaptation and use of its guidelines, and to support countries towards greater use of evidence in health decision-making. ■ Qualitative evidence to improve guidelines and health decision-making Etienne V Langlois, Özge Tunçalp, Susan L Norris, Ian Askew & Abdul Ghaffar

Medicines quality assurance to fight antimicrobial resistance.

Abstract: Medicines quality assurance to fight antimicrobial resistance Jude Nwokike, Aubrey Clark & Phillip P Nguyen a The Promoting the Quality of Medicines Program, US Pharmacopeial Convention, 12601 Twinbrook Parkway, Rockville, Maryland, 20852, USA. b United States Pharmacopeial Convention, International Public Policy and Regulatory Affairs, Rockville, USA. Correspondence to Aubrey Clark (email: aubrey.clark@usp.org). (Submitted: 29 June 2017 – Revised version received: 1 November 2017 – Accepted: 2 November 2017 – Published online: 1 December 2017) Antimicrobial resistance is increasingly the focus of global attention. The adoption of resolution 68.7 at the 68th World Health Assembly 1 was pivotal in the ongoing fight against antimicrobial resistance, as the resolution urges Member States to develop national action plans to fight antimicrobial resistance by 2017. To date, 67 Member States, out of 194, have already developed such plans, while 62 others are in the process of doing so. 2 These national plans describe national efforts to combat resistance through strategies and interventions that often include strengthening surveillance of priority pathogens, increasing research efforts and optimizing the use of antimicrobials, among others.

Multicontaminant air pollution in Chinese cities.

Abstract: Objective To investigate multicontaminant air pollution in Chinese cities, to quantify the urban population affected and to explore the relationship between air pollution and urban population size. Methods We obtained data for 155 cities with 276 million inhabitants for 2014 from China's air quality monitoring network on concentrations of fine particulate matter measuring under 2.5 μm (PM2.5), coarse particulate matter measuring 2.5 to 10 μm (PM10), nitrogen dioxide (NO2), sulfur dioxide (SO2) and ozone (O3). Concentrations were considered as high, if they exceeded World Health Organization (WHO) guideline limits. Findings Overall, 51% (142 million) of the study population was exposed to mean annual multicontaminant concentrations above WHO limits - east China and the megacities were worst affected. High daily levels of four-contaminant mixtures of PM2.5, PM10, SO2 and O3 and PM2.5, PM10, SO2 and NO2 occurred on up to 110 days in 2014 in many cities, mainly in Shandong and Hebei Provinces. High daily levels of PM2.5, PM10 and SO2 occurred on over 146 days in 110 cities, mainly in east and central China. High daily levels of mixtures of PM2.5 and PM10, PM2.5 and SO2, and PM10 and SO2 occurred on over 146 days in 145 cities, mainly in east China. Surprisingly, multicontaminant air pollution was less frequent in cities with populations over 10 million than in smaller cities. Conclusion Multicontaminant air pollution was common in Chinese cities. A shift from single-contaminant to multicontaminant evaluations of the health effects of air pollution is needed. China should implement protective measures during future urbanization.

Involving male partners in maternity care in Burkina Faso: a randomized controlled trial

Abstract: To determine whether an intervention to involve the male partners of pregnant women in maternity care influenced care-seeking, healthy breastfeeding and contraceptive practices after childbirth in urban Burkina Faso. In a non-blinded, multicentre, parallel-group, superiority trial, 1144 women were assigned by simple randomization to two study arms: 583 entered the intervention arm and 561 entered the control arm. All women were cohabiting with a male partner and had a low-risk pregnancy. Recruitment took place at 20 to 36 weeks' gestation at five primary health centres in Bobo-Dioulasso. The intervention comprised three educational sessions: (i) an interactive group session during pregnancy with male partners only, to discuss their role; (ii) a counselling session during pregnancy for individual couples; and (iii) a postnatal couple counselling session. The control group received routine care only. We followed up participants at 3 and 8 months postpartum. The follow-up rate was over 96% at both times. In the intervention arm, 74% (432/583) of couples or men attended at least two study sessions. Attendance at two or more outpatient postnatal care consultations was more frequent in the intervention than the control group (risk difference, RD: 11.7%; 95% confidence interval, CI: 6.0 to 17.5), as was exclusive breastfeeding 3 months postpartum (RD: 11.4%; 95% CI: 5.8 to 17.2) and effective modern contraception use 8 months postpartum (RD: 6.4%; 95% CI: 0.5 to 12.3). Involving men as supportive partners in maternity care was associated with better adherence to recommended healthy practices after childbirth. Determiner si une intervention visant a faire participer le compagnon des femmes enceintes aux soins de maternite a permis d'influencer le recours aux soins, l'allaitement et les pratiques contraceptives apres l'accouchement dans une ville du Burkina Faso. Dans le cadre d'un essai de superiorite en groupes paralleles, multicentrique, non aveugle, 1144 femmes ont ete reparties par randomisation simple en deux groupes d'etude: 583 dans le groupe experimental et 561 dans le groupe temoin. Toutes les femmes vivaient avec un compagnon et avaient une grossesse a faible risque. Leur recrutement a eu lieu entre 20 et 36 semaines de grossesse dans cinq centres de soins primaires de Bobo-Dioulasso. L'intervention comprenait trois seances pedagogiques: (i) une seance de groupe interactive pendant la grossesse, avec les compagnons uniquement, afin de discuter de leur role; (ii) une seance de conseil pendant la grossesse pour les couples; et (iii) une seance de conseil postnatale pour les couples. Le groupe temoin a beneficie uniquement de la prise en charge habituelle. Nous avons suivi les participants a 3 et 8 mois apres l'accouchement. Le taux de suivi etait superieur a 96% aux deux visites de suivi. Dans le groupe experimental, 74% (432/583) des couples ou des hommes avaient assiste a au moins deux des seances prevues. La presence a deux consultations postnatales externes ou plus etait plus frequente dans le groupe experimental que dans le groupe temoin (difference de risques, DR: 11,7%; intervalle de confiance de 95%, IC: 6,0 a 17,5), comme l'allaitement exclusif 3 mois apres l'accouchement (DR: 11,4%; IC 95%: 5,8 a 17,2) et l'utilisation de moyens de contraception modernes efficaces 8 mois apres l'accouchement (DR: 6,4%; IC 95%: 0,5 a 12,3). La participation et l'accompagnement des hommes aux soins de maternite etaient associes a un meilleur suivi des pratiques recommandees apres l'accouchement. Determinar si una intervencion para involucrar a las parejas masculinas de las mujeres embarazadas en la atencion de la maternidad influyo en la busqueda de atencion, la lactancia materna saludable y las practicas anticonceptivas despues del parto en una zona urbana de Burkina Faso. En un ensayo preponderado, no cegado, multicentrico, de grupos paralelos, se asigno a 1144 mujeres aleatorias a dos grupos del estudio: 583 entraron en el grupo de intervencion y 561 entraron en el grupo de control. Todas las mujeres convivian con una pareja masculina y tenian un embarazo de bajo riesgo. La seleccion tuvo lugar entre las semanas 20 y 36 de gestacion en cinco centros de salud primarios en Bobo-Dioulasso. La intervencion conto con tres sesiones educativas: (i) una sesion grupal interactiva durante el embarazo solo con las parejas masculinas, para hablar sobre su papel; (ii) una sesion de asesoramiento durante el embarazo para parejas individuales; y (iii) una sesion de consejeria posnatal en pareja. El grupo de control recibio solo atencion rutinaria. Seguimos a los participantes a los 3 y 8 meses despues del parto. La tasa de seguimiento fue superior al 96% en dos visitas. En el grupo de intervencion, el 74% (432/583) de parejas u hombres asistieron al menos a dos sesiones de estudio. La asistencia a dos o mas consultas de atencion posnatal para pacientes ambulatorios fue mas frecuente en el grupo de intervencion que el grupo de control (diferencia de riesgo, RD: De 1,7% a 95% en el intervalo de confianza, IC: De 6,0 a 17,5), en la lactancia materna exclusiva 3 meses despues del parto (RD: De 11,4% a 95% IC: De 5,8 a 17,2) en anticonceptivos modernos efectivos 8 meses despues del parto (RD: De 6,4% a 95% IC: De 0,5 a 12,3). Involucrar a los hombres como apoyo en la atencion de maternidad se asocio con una mejor adherencia a las practicas recomendadas de salud despues del parto. تحديد ما إذا كان التدخل لإشراك الشركاء الذكور للنساء الحوامل في رعاية الأمومة، قد أثر على طلب الرعاية الصحية والرضاعة الطبيعية وممارسات منع الحمل بعد الولادة في المناطق الحضرية في بوركينا فاصو. في تجربة متفوقة غير مغشاة، متعددة المراكز، في مجموعات متوازية، تم اختيار 1144 امرأة بطريقة عشوائية بسيطة للمشاركة في فرعي الدراسة: 583 منهن انضممن لفرع التدخل، بينما انضم 561 منهن لفرع التحكم. كانت كل السيدات تعيشن مع شريك من الذكور، وكانت احتمالات الحمل منخفضة الخطورة. وتمت الاختيارات في الفترة من 20 إلى 36 أسبوعا من الحمل في خمسة مراكز صحية أولية في بوبو ديولاسو. وتألف التدخل من ثلاث جلسات تعليمية: (أ) جلسة جماعية تفاعلية أثناء الحمل مع الشركاء الذكور فقط، لمناقشة دورهم؛ و(ب) جلسة المشورة خلال فترة الحمل لكل زوجين على حدة؛ و(ج) جلسة المشورة للزوجين بعد الولادة. لم تحصل مجموعة التحكم إلا على الرعاية الروتينية المعتادة فقط. وقمنا بمتابعة المشاركين بعد مرور 3 و8 أشهر من الولادة. كان معدل المتابعة أكثر من 96٪ في كلتا المرتين. بالنسبة لفرع التدخل ، حضر 74٪ (432/583) من الزوجين أو الرجال جلستين دراسيتين على الأقل. وكان الحضور في اثنتين أو أكثر من استشارات رعاية ما بعد الولادة في العيادات الخارجية، أمرا متكرر الحدوث بشكل أكبر في مجموعة التدخل أكثر منه في مجموعة التحكم (فرق المخاطر: 11.7٪؛ فاصل الثقة 95٪، 6.0 إلى 17.5)، كما كانت الرضاعة الطبيعية الحصرية لمدة 3 أشهر بعد الولادة (فرق المخاطر: 11.4٪؛ فاصل الثقة 95٪: 5.8 إلى 17.2)، واستخدام وسائل منع الحمل الحديثة الفعالة لمدة 8 أشهر بعد الولادة (فرق المخاطر 6.4٪؛ فاصل الثقة 95٪: 0.5 إلى 12.3). ارتبط إشراك الرجال باعتبارهم شركاء داعمين في رعاية الأمومة بمستوى أفضل من الالتزام بالممارسات الصحية الموصى بها بعد الولادة. 在布基纳法索 (Burkina Faso) 城市地区，确定孕产期保健中孕产妇男性伴侣的干预是否会影响分娩后的就医行为、健康的母乳喂养和避孕行为。. 在一个采用非盲法、多中心、平行组的优势试验中，将 1144 名女性简单随机分为两个研究组：583 名分入干预组，561 名分入控制组。所有女性都与男性伴侣同居并且妊娠风险低。在博博迪乌拉索 (Bobo-Dioulasso) 五个主要的健康中心进行招募，共招募了妊娠期在 20 至 36 周的被试者。干预包含三个不同层次的教育型会谈：(i) 在妊娠期间仅与男性伴侣进行互动式小组会谈以讨论其职责；(ii) 在妊娠期间对每一对夫妇进行咨询会谈；以及 (iii) 产后夫妇咨询会谈。控制组仅接受常规护理。我们分别在产后第 3 个月和第 8 个月对参与者的情况进行了随访。. 两次的随访率均超过 96%。在干预组中，74% (432/583) 的夫妇或男性参与了至少两次的学习会谈。干预组参与两次或以上的门诊产后保健咨询的频率高于控制组（风险差异：11.7%；95% 置信区间，CI：6.0 至 17.5)，如在产后 3 个月进行纯母乳喂养（风险差异：11.4；95% 置信区间，CI：5.8 至 17.2）以及产后 8 个月有效的现代避孕方法（风险差异：6.4%；95% 置信区间，CI：0.5 至 12.3)。. 让男性作为支持伴侣参与到孕产期保健中关系到孕妇分娩后更好地遵循推荐的健康习惯。. Определить, повлияло ли вмешательство путем вовлечения мужчин, являющихся партнерами беременных женщин, в систему охраны материнства на активное обращение за медицинской помощью, на приверженность здоровым практикам грудного вскармливания и на использование контрацепции после родов в городских районах Буркина-Фасо. В открытом многоцентровом параллельном групповом исследовании эффективности 1144 женщины были разделены путем простой рандомизации на две группы: 583 вошли в группу вмешательства, 561 — в контрольную группу. Все женщины сожительствовали с мужчиной-партнером и имели низкий риск осложнений при беременности. Участниц набирали на сроке беременности от 20 до 36 недель в пяти центрах первичной медико-санитарной помощи в Бобо-Диуласо. Вмешательство состояло из трех образовательных занятий: (i) интерактивное групповое занятие во время беременности только с партнерами-мужчинами для обсуждения их роли; (ii) консультирование пар во время беременности; (iii) консультирование пар после родов. Контрольная группа получала стандартную медицинскую помощь. Участники проходили последующее наблюдение через 3 и 8 месяцев после родов. Доля пациентов, оставшихся под наблюдением, составляла более 96% в обоих случаях. В группе вмешательства 74% (432/583) пар или мужчин посетили не менее двух занятий в рамках исследования. Посещение двух или более амбулаторных консультаций по послеродовому уходу было более частым в группе вмешательства, чем в контрольной группе (разность рисков, РР: 11,7; 95%-й ДИ: от 6,0 до 17,5), а также исключительно грудное вскармливание через 3 месяца после родов (РР: 11,4; 95%-й ДИ: от 5,8 до 17,2) и эффективное использование современных контрацептивов через 8 месяцев после родов (РР: 6,4; 95%-й ДИ: от 0,5 до 12,3). Вовлечение мужчин в качестве партнерской поддержки в систему охраны материнства было связано с лучшей приверженностью рекомендованным здоровым практикам после родов.