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As outlined in a blog on the making of the “Global Action Plan for healthy lives and well-being for all” published in June (http://g2h2.org/posts/still-not-amused/), the information on the GAP that are accessible on the WHO website (https://www.who.int/sdg/global-action-plan) have left us with many worries and unanswered questions. Today, and only two weeks ahead of its formal launch at an UNGA side event in New York, the final text of the GAP is still not available - and our questions and concerns remain unanswered. Instead of further coffee grounds reading, let us critically comment on the GAP once it is published, and let us critically watch its implementation, once the plan is in place.
The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.
The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.
Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall sh...
The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.
The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.
Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall shortage of mental health providers relative to need, primary care providers have been called upon to manage an increasing range of psychopathology. There is simultaneously a growing appreciation for the relationship between early life adversity and chronic physical illnesses: our sickest patients – whether encountered in the emergency department, primary care, specialty, or psychiatric settings -- are often those who have struggled with lifelong adversity. Engagement and adherence that can promote behavioral changes hinge upon mental health, and optimization of medical outcomes thus occur when mental health is integrated into evaluation and intervention. Minimizing the number of new providers, the number of transitions, the number of times one has to provide a medical (and trauma) history, are crucial for a trauma-informed medical system: continuity is key. Application of the program elements described by Schwarz and team can inform trauma-informed interventions that strive to support health equity world-wide.
Dear authors,
thank you for your initiative to discuss this (possible) source of bias in global health studies! I could't agree more and can only underscore that good and reliable research results will in the end benefit the work of everybody, including donor agencies.
thanks again and best regards,
Jan Peter
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Of note, the CCHF prevalence map used from WHO dated 2017 (4) identifies Pakistan as risk region with 5 – 49 cases of CCHF reported each year. Our laboratory performs clinical testing or CCHFV and reported 131 cases of CCHF in 2018. Testing is performed using a commercial assay from Altona Diagnostics, GmBH, and results are reported within 24 h of the specimen being received. This data indicates Pakistan is amongst the highest category of risk for CCHFV infections worldwide. Given that dengue fever is also prevalent in the same region and is part of differential diagnosis for CCHF in Pakistan, there is value in rapid diagnosis using a robust rapid RT-PCR assay in high risk cases even though it may be at an increased cost. Therefore, in CCHFV endemic regions having a rapid robust assay for diagnosis of acute infections is extremely important.
References
1. Mazzola LT, Kelly-Cirino C. Diagnostic tests for Crimean-Congo haemorrhagic fever: a widespread tickborne disease. BMJ Glob Health. 2019;4(Suppl 2):e001114.
2. Rai MA, Khanani MR, Warraich HJ, Hayat A, Ali SH. Crimean-Congo hemorrhagic fever in Pakistan. J Med Virol. 2008;80(6):1004-6.
3. Leblebicioglu H, Sunbul M, Memish ZA, Al-Tawfiq JA, Bodur H, Ozkul A, et al. Consensus report: Preventive measures for Crimean-Congo Hemorrhagic Fever during Eid-al-Adha festival. Int J Infect Dis. 2015;38:9-15.
4. WHO. Introduction to Crimean-Congo Haemorrhagic Fever. World Health Organization. Geneva, Switzerland2018. p. https://www.who.int/emergencies/diseases/crimean-congo-haemorrhagic-feve....
What the article does is discard the ethnic movement of the madhesi people (terai people) who have been marginalised in through out history. The dominant thinking is India blocked the movement of goods in to Nepal, but ehich is not true, it was the people who led a strike and prevented the flow of goods. By blaming external forces it can look away from the real issues. Also during riots and strikes transport companies are reluctant to send their vehicles in those areas since insurances do not cover if any mishaps occur.
A reputed journal publishing such baseless articles provides fuel to the fire and discards the historical domination of the Terai people.
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that...
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that of urban areas and reported that rates of TB identified is 2.9 times higher in males compared with females. (1) The Multiple Indicator Cluster Survey from 2017 showed that 71.3% of people in urban areas have access to clean water versus 44.5% in rural areas. (2)
The differences between rural and urban areas matter, by any measure of health and development, which greatly influences DALYs. Of the raw data points, extracted from the 68 sources the paper reports that the Institute for Health Metrics and Evaluation used to create the DALYs portrayed in Table 2, only about 15% was from after 2009, which is when the majority of the publications used in this paper were from. Recent comprehensive surveys by the UN had not been updated by the data set, such as the Multiple Indicator Cluster Survey 2017 data, the TB Prevalence Survey 2015-2016, and the Socio-economic, Demographic, and Health survey 2014. (3) However, the publication included papers from 1998 to 2017 in their review. Interestingly, only 24 of the 26,179 data points used to develop the DALYs were from 2016, the year that Table 2 cites. (4)
The aid community has struggled with this paper’s conclusions about gaps in the evidence, as it is a daily battle. The amount of what is unknown versus known about public health nears a ratio of 99 to 1, with the UN, as in-country residential workers, having access to the majority of what is known about the population. When it comes to the amount of data that the UN has versus the NGOs working within the country or scientists visiting the DPRK, the UN has access to a much broader base of evidence than what is published, given its greater ability to negotiate for access. Accomplished researchers within the NGOs who work as aid workers have to make the choice to not publish any data about their work in the DPRK because of the political context. (5) Thus, the paper's argument that research and public health policies are not based on adequate evidence is a conclusion that seems out of touch with the realities on the ground. In more recent years, the DPRK government has shown greater openness to the idea of publishing their data, which is the basis for many UN publications and articles available today.
An interdisciplinary perspective to deconstruct the granularity of existing data will go a long way towards better community-centered public health initiatives, as it will unlock steps to navigating the political gridlock to achieve better public health outcomes. Despite the constraints of perspective this paper holds, it does generate more enthusiasm for others to get into the field. Ultimately, it is only by partnerships among the NGO community, international agencies, and scientists that we can catalyze progress towards addressing health in the DPRK.
The report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.
The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income co...
The report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.
The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income countries could indeed benefit from learning processes that engage service providers with the needs of service users. A relatively small number of studies have investigated the effectiveness of diabetes interventions involving CHWs in low- and middle-income countries (LMICs). These indicated positive outcomes in self-management, glucose control, and body mass index; however, these studies often lacked detailed characterisation of the role played by CHWs (4). The burgeoning epidemic of diabetes in LMICs demands context-specific research to assess the position of CHWs, and to shape opportunities for developing their role in diabetes management.
Adaptation of health interventions at the local level is key to making them relevant and acceptable to the communities they serve. In this area, diabetes management programmes can learn reciprocally from HIV intervention programmes, which have developed beyond reducing transmission, to chronic infection management, community engagement, and raising global awareness. The double burden of diabetes and infectious diseases such as HIV and tuberculosis, known to have interactions at the physiological as well as societal level, demands stronger health systems that can provide joined-up care. Previous studies have shown the central role of community-based individuals for outreach and mobilization in HIV interventions. They furthermore provide guidance on how to adapt interventions to their implementation sites, including the involvement of local staff in the adaptation process (5). Patients must also be stakeholders in the learning and adaptation process. We can anticipate that reciprocal learning approaches to health service development, both internationally and between disease-specific health programmes, will enhance services and strengthen resource-limited health systems.
References
1. van Olmen J, Delobelle P, Guwatudde D, Absetz P, Sanders D, Mölsted Alvesson H, et al. Using a cross-contextual reciprocal learning approach in a multisite implementation research project to improve self-management for type 2 diabetes. BMJ Glob Heal. 2018 Nov 26;3(6):e001068.
2. Egbujie BA, Delobelle PA, Levitt N, Puoane T, Sanders D, van Wyk B. Role of community health workers in type 2 diabetes mellitus self-management: A scoping review. PLoS One 2018;13(6):e0198424.
3. Silverman J, Krieger J, Sayre G, Nelson K. The Value of Community Health Workers in Diabetes Management in Low-Income Populations: A Qualitative Study. J Community Health. 2018 Oct 1;43(5):842–7.
4. Alaofè H, Asaolu I, Ehiri J, Moretz H, Asuzu C, Balogun M, et al. Community Health Workers in Diabetes Prevention and Management in Developing Countries. Ann Glob Heal. 2017 May 1;83(3–4):661–75.
5. Kevany S, Khumalo-Sakutukwa G, Murima O, Chingono A, Modiba P, Gray G, et al. Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: evaluating findings from Project Accept (HPTN 043). BMC Public Health. 2012 Jun 20;12:459.
Recently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
We would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.9...
Recently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
We would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.91 (1.30-2.79)), but not in boys (RR 0.84 (0.61-1.17))5.
WHO established a collaboration where four groups (the Institute for Disease Modelling, GSK Vaccines, Imperial College London and the Swiss Tropical and Public Health Institute) modelled the expected public health impact of introducing the RTS,S/AS01 vaccine. Based on the measured vaccine efficacy against clinical malaria, the models estimated that per 100,000 fully vaccinated children in a four-dose schedule, 484 deaths would be averted6. However, if the RTS,S/AS01 mortality results5 were representative, fully vaccinating 100,000 children in a four dose schedule would cause 464 additional deaths: Stratified by sex, 100,000 fully vaccinated boys would result in 252 fewer deaths, whereas 100,000 fully vaccinated girls would result in 1182 additional deaths.
The modelled results are in line with the general perception that vaccines only have one effect: prevention of the target disease. However, increasing evidence suggest that non-live vaccines may have negative non-specific effects despite protection against the target disease. The RTS,S/AS01 results fits the pattern previously observed perfectly: the negative non-specific effects of non-live vaccines are particularly pronounced in females.
Nonetheless, the RTS,S/AS01 vaccine is now being introduced as a four-dose schedule in Ghana, Kenya and Malawi as part of the WHO malaria vaccine pilot programme targeting 720,000 children. Policymakers may feel confident about this decision given the effect on clinical malaria and the modelled mortality data. However, based on the empirical mortality data, and the fact that they fit into an already established pattern of mortality effects on non-live vaccines, we fear that this introduction of RTS,S/AS01 may lead to unnecessary female deaths. Discrepancies between modelled and real-life data must be taken seriously. No model is better than the data and assumptions used. Therefore, empirical data should rank higher.
References
1. Colbourn T, Prost A, Seward N. Making the world a simpler place: the modeller’s temptation to seek alternative trial results. BMJ Global Health 2018;3(5) doi: 10.1136/bmjgh-2018-001194
2. RTS.S Clinical Trials Partnership. Efficacy and safety of RTS,S/AS01 malaria vaccine with or without a booster dose in infants and children in Africa: final results of a phase 3, individually randomised, controlled trial. Lancet 2015;386(9988):31-45. doi: 10.1016/S0140-6736(15)60721-8
3. Aaby P, Rodrigues A, Kofoed P-E, et al. RTS,S/AS01 malaria vaccine and child mortality. The Lancet 2015;386(10005):1735-36. doi: 10.1016/S0140-6736(15)00693-5
4. Benn CS, Netea MG, Selin LK, et al. A small jab - a big effect: nonspecific immunomodulation by vaccines. Trends in immunology 2013;34(9):431-9. doi: 10.1016/j.it.2013.04.004
5. Klein SL, Shann F, Moss WJ, et al. RTS,S Malaria Vaccine and Increased Mortality in Girls. mBio 2016;7(2) doi: 10.1128/mBio.00514-16
6. Penny MA, Verity R, Bever CA, et al. Public health impact and cost-effectiveness of the RTS,S/AS01 malaria vaccine: a systematic comparison of predictions from four mathematical models. The Lancet 2016;387(10016):367-75. doi: 10.1016/s0140-6736(15)00725-4
Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.
India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)
This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to...
Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.
India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)
This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to unlocking the potential of the plain packaging policy. The tobacco industry, which made almost a trillion dollars in 2016, in India alone (Statista, 2018), is a big forex earner for most low and middle income countries, and there is a need for future policies to focus on giving societies who provide labor for the system an alternative way of means.
References
McNeill A, Gravely S, Hitchman SC, Bauld L, Hammond D, Hartmann-Boyce J (2017). Tobacco packaging design for reducing tobacco use. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.: CD011244.DOI: 10.1002/14651858.CD011244.pub2.
Steven J. G. (2016): The Australian experience following plain packaging: the impact on tobacco branding, Society for the study of addiction,
Eckhardt, J., Holden, C., & Callard, C. D. (2016) Tobacco Control and the World Trade Organization: Mapping Member States’ Positions after the Framework Convention on Tobacco Control. Tobacco Control. pp. 692-698. ISSN 1468-3318
Statista: tobacco industry statistics & facts. https://www.statista.com/topics/1593/tobacco/ 27 October 2018
Many countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
There is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access...
Many countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
There is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access to services, lack of necessary knowledge about contraceptive methods, social opposition to their use, and health concerns about possible side effects.
The finding that ‘providing a behavioral nudge in combination with a voucher for free postpartum contraceptive increases take- up of modern methods’ is, in my view, an important finding, particularly for program planners particularly in Sub-Saharan Africa and other developing countries where there is heavy burden of HIV.
It is key, therefore, to consider this study’s finding of providing both behavioral nudges and some promise of free modern contraceptive methods, especially for women living with HIV as a strategy to improve both PMTCT and the health, human rights and well-being of women.
References:
• John B. Casterline; Steven W. Sinding; Unmet Need for Family Planning in Developing Countries and Implications for Population Policy; wiley online library; (2004);
• Sexual and Reproductive Health, World Contraception Day 2018 report,WHO (http://www.who.int/reproductivehealth/topics/family_planning/world-contr... (retrieved, 3rd November 2018)
As outlined in a blog on the making of the “Global Action Plan for healthy lives and well-being for all” published in June (http://g2h2.org/posts/still-not-amused/), the information on the GAP that are accessible on the WHO website (https://www.who.int/sdg/global-action-plan) have left us with many worries and unanswered questions. Today, and only two weeks ahead of its formal launch at an UNGA side event in New York, the final text of the GAP is still not available - and our questions and concerns remain unanswered. Instead of further coffee grounds reading, let us critically comment on the GAP once it is published, and let us critically watch its implementation, once the plan is in place.
The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.
The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.
Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall sh...
Show MoreDear authors,
thank you for your initiative to discuss this (possible) source of bias in global health studies! I could't agree more and can only underscore that good and reliable research results will in the end benefit the work of everybody, including donor agencies.
thanks again and best regards,
Jan Peter
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Of note, the CCHF prevale...
Show MoreWhat the article does is discard the ethnic movement of the madhesi people (terai people) who have been marginalised in through out history. The dominant thinking is India blocked the movement of goods in to Nepal, but ehich is not true, it was the people who led a strike and prevented the flow of goods. By blaming external forces it can look away from the real issues. Also during riots and strikes transport companies are reluctant to send their vehicles in those areas since insurances do not cover if any mishaps occur.
A reputed journal publishing such baseless articles provides fuel to the fire and discards the historical domination of the Terai people.
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that...
Show MoreThe report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.
The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income co...
Show MoreRecently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
Show MoreWe would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.9...
Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.
India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)
This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to...
Show MoreMany countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
Show MoreThere is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access...
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