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1.
Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries-A Systematic Review.
Owolabi, MO, Yaria, JO, Daivadanam, M, Makanjuola, AI, Parker, G, Oldenburg, B, Vedanthan, R, Norris, S, Oguntoye, AR, Osundina, MA, et al
Diabetes care. 2018;(5):1097-1105
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Abstract
OBJECTIVE The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation. RESEARCH DESIGN AND METHODS Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences. RESULTS Most LMIC guidelines were inadequate in terms of applicability, clarity, and dissemination plan as well as socioeconomic and ethical-legal contextualization. LMIC guidelines targeted mainly health care providers, with only a few including patients (7%), payers (11%), and policy makers (18%) as their target audiences. Compared with HIC guidelines, the spectrum of DM clinical care addressed by LMIC guidelines was narrow. Most guidelines from the LMIC complied with less than half of the IOM standards, with 12% of the LMIC guidelines satisfying at least four IOM criteria as opposed to 60% of the HIC guidelines (P < 0.001). CONCLUSIONS A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.
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Risk factors for child pneumonia - focus on the Western Pacific Region.
Nguyen, TK, Tran, TH, Roberts, CL, Fox, GJ, Graham, SM, Marais, BJ
Paediatric respiratory reviews. 2017;:95-101
Abstract
Pneumonia is a major cause of disease and death in infants and young children (aged <5 years) globally, as it is in the World Health Organization Western Pacific region. A better understanding of the underlying risk factors associated with child pneumonia is important, since pragmatic primary prevention strategies are likely to achieve major reductions in pneumonia-associated morbidity and mortality in children. This review focuses on risk factors with high relevance to the Western Pacific region, including a lack of exclusive breastfeeding, cigarette smoke and air pollution exposure, malnutrition and conditions of poverty, as well as common co-morbidities. Case management and vaccination coverage have been considered elsewhere.
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Group-based microfinance for collective empowerment: a systematic review of health impacts.
Orton, L, Pennington, A, Nayak, S, Sowden, A, White, M, Whitehead, M
Bulletin of the World Health Organization. 2016;(9):694-704A
Abstract
OBJECTIVE To assess the impact on health-related outcomes, of group microfinance schemes based on collective empowerment. METHODS We searched the databases Social Sciences Citation Index, Embase, MEDLINE, MEDLINE In-Process, PsycINFO, Social Policy & Practice and Conference Proceedings Citation Index for articles published between 1 January 1980 and 29 February 2016. Articles reporting on health impacts associated with group-based microfinance were included in a narrative synthesis. FINDINGS We identified one cluster-randomized control trial and 22 quasi-experimental studies. All of the included interventions targeted poor women living in low- or middle-income countries. Some included a health-promotion component. The results of the higher quality studies indicated an association between membership of a microfinance scheme and improvements in the health of women and their children. The observed improvements included reduced maternal and infant mortality, better sexual health and, in some cases, lower levels of interpersonal violence. According to the results of the few studies in which changes in empowerment were measured, membership of the relatively large and well-established microfinance schemes generally led to increased empowerment but this did not necessarily translate into improved health outcomes. Qualitative evidence suggested that increased empowerment may have contributed to observed improvements in contraceptive use and mental well-being and reductions in the risk of violence from an intimate partner. CONCLUSION Membership of the larger, well-established group-based microfinance schemes is associated with improvements in some health outcomes. Future studies need to be designed to cope better with bias and to assess negative as well as positive social and health impacts.
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Access to Medications for Cardiovascular Diseases in Low- and Middle-Income Countries.
Wirtz, VJ, Kaplan, WA, Kwan, GF, Laing, RO
Circulation. 2016;(21):2076-85
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Abstract
Cardiovascular diseases (CVD) represent the highest burden of disease globally. Medicines are a critical intervention used to prevent and treat CVD. This review describes access to medication for CVD from a health system perspective and strategies that have been used to promote access, including providing medicines at lower cost, improving medication supply, ensuring medicine quality, promoting appropriate use, and managing intellectual property issues. Using key evidence in published and gray literature and systematic reviews, we summarize advances in access to cardiovascular medicines using the 5 health system dimensions of access: availability, affordability, accessibility, acceptability, and quality of medicines. There are multiple barriers to access of CVD medicines, particularly in low- and middle-income countries. Low availability of CVD medicines has been reported in public and private healthcare facilities. When patients lack insurance and pay out of pocket to purchase medicines, medicines can be unaffordable. Accessibility and acceptability are low for medicines used in secondary prevention; increasing use is positively related to country income. Fixed-dose combinations have shown a positive effect on adherence and intermediate outcome measures such as blood pressure and cholesterol. We have a new opportunity to improve access to CVD medicines by using strategies such as efficient procurement of low-cost, quality-assured generic medicines, development of fixed-dose combination medicines, and promotion of adherence through insurance schemes that waive copayment for long-term medications. Monitoring progress at all levels, institutional, regional, national, and international, is vital to identifying gaps in access and implementing adequate policies.
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Trends in obesity prevalence and disparities among low-income children in Oklahoma, 2005-2010.
Weedn, AE, Hale, JJ, Thompson, DM, Darden, PM
Childhood obesity (Print). 2014;(4):318-25
Abstract
BACKGROUND National WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children) data indicate a decrease in obesity prevalence among most low-income preschool-aged children. Though racial/ethnic disparities exist, studies examining obesity trends among various racial/ethnic groups are lacking. The aims of this study were to identify racial/ethnic disparities in obesity among low-income preschool children in Oklahoma and describe trends in obesity prevalence among four major racial/ethnic groups. METHODS Subjects included 218,486 children 2-4 years of age who participated in WIC in Oklahoma from 2005 to 2010. Logistic regression was performed to identify disparities and trends in obesity among American Indian, Hispanic, White, and African American children. RESULTS Racial/ethnic disparities in obesity were evident, with prevalence highest in Hispanics and lowest in African Americans. Obesity increased among girls for all racial/ethnic groups from 2005 to 2010 (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.01, 1.03). Among boys, obesity increased in African Americans (OR, 1.04; 95% CI, 1.01, 1.07), but remained stable in other racial/ethnic groups. CONCLUSIONS In Oklahoma, in contrast to recent national studies, obesity is increasing among certain groups of low-income preschool children. These findings suggest geographic diversity in obesity and that state-specific obesity surveillance is important to help target interventions to those at highest risk.
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Jumping the gun: the problematic discourse on socioeconomic status and cardiovascular health in India.
Subramanian, SV, Corsi, DJ, Subramanyam, MA, Smith, GD
International journal of epidemiology. 2013;(5):1410-26
Abstract
There has been an increased focus on non-communicable diseases (NCDs) in India, especially on cardiovascular diseases and associated risk factors. In this essay, we scrutinize the prevailing narrative that cardiovascular risk factors (CVRF) and cardiovascular disease (CVD) are no longer confined to the economically advantaged groups but are an increasing burden among the poor in India. We conducted a comprehensive review of studies reporting the association between socioeconomic status (SES) and CVRF, CVD, and CVD-related mortality in India. With the exception of smoking and low fruit and vegetable intake, the studies clearly suggest that CVRF/CVD is more prevalent among high SES groups in India than among the low SES groups. Although CVD-related mortality rates appear to be higher among the lower SES groups, the proportion of deaths from CVD-related causes was found to be greatest among higher SES groups. The studies on SES and CVRF/CVD also reveal a substantial discrepancy between the data presented and the authors' interpretations and conclusions, along with an unsubstantiated claim that a reversal in the positive SES-CVRF/CVD association has occurred or is occurring in India. We conclude our essay by emphasizing the need to prioritize public health policies that are focused on the health concerns of the majority of the Indian population. Resource allocation in the context of efforts to make health care in India free and universal should reflect the proportional burden of disease on different population groups if it is not to entrench inequity.
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Early-life conditions and older adult health in low- and middle-income countries: a review.
McEniry, M
Journal of developmental origins of health and disease. 2013;(1):10-29
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Abstract
Population aging and subsequent projected large increases in chronic conditions will be important health concerns in low- and middle-income countries. Although evidence is accumulating, little is known regarding the impact of poor early-life conditions on older adult (50 years and older) health in these settings. A systematic review of 1141 empirical studies was conducted to identify population-based and community studies in low- and middle-income countries, which examined associations between early-life conditions and older adult health. The resulting review of 20 studies revealed strong associations between (1) in utero/early infancy exposures (independent of other early life and adult conditions) and adult heart disease and diabetes; (2) poor nutrition during childhood and difficulties in adult cognition and diabetes; (3) specific childhood illnesses such as rheumatic fever and malaria and adult heart disease and mortality; (4) poor childhood health and adult functionality/disability and chronic diseases; (5) poor childhood socioeconomic status (SES) and adult mortality, functionality/disability and cognition; and (6) parental survival during childhood and adult functionality/disability and cognition. In several instances, associations remained strong even after controlling for adult SES and lifestyle. Although exact mechanisms cannot be identified, these studies reinforce to some extent the importance of early-life environment on health at older ages. Given the paucity of cohort data from the developing world to examine hypotheses of early-life conditions and older adult health, population-based studies are relevant in providing a broad perspective on the origins of adult health.
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Influence of poverty and infection on asthma in Latin America.
Cooper, PJ, Rodrigues, LC, Barreto, ML
Current opinion in allergy and clinical immunology. 2012;(2):171-8
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Abstract
PURPOSE OF REVIEW Asthma in Latin America is a growing public health problem and seems to be most prevalent and cause most morbidity among poor urban populations. This article will review the findings of recent human studies of the associations of asthma prevalence in Latin America with factors associated with poverty and inequality including childhood infections, stress, environment, nutrition and diet. RECENT FINDINGS Most asthma in childhood in Latin America is nonatopic and has been associated with exposures related to environmental dirt, diet and psychosocial distress. These factors are strongly linked to poverty and inequality. Interestingly, infections with bacterial, viral and parasitic pathogens in childhood appear to attenuate atopy in childhood but have no effect on asthma symptoms. There are biologically plausible mechanisms by which dirt exposures (e.g. endotoxin and other microbial products and nonmicrobial irritants), diet and obesity and psychosocial stress may cause airways inflammation. SUMMARY Most childhood asthma in Latin America is nonatopic for which important risk factors are those of poverty including poor hygiene (i.e. dirt), poor diet and obesity and psychosocial stress. There is evidence that exposures to infections in early childhood reduce atopy but not asthma. Research is needed to identify causes of nonatopic asthma that may be suitable for primary prevention or other public health intervention strategies for asthma in Latin America.
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Childhood adversities of populations living in low-income countries: prevalence, characteristics, and mental health consequences.
Benjet, C
Current opinion in psychiatry. 2010;(4):356-62
Abstract
PURPOSE OF REVIEW Although an association between childhood adversity and psychiatric disorder has been documented, most research has centered upon those living in developed countries and the types of adversities those populations experience. Most of the world's youth, however, live in the poorest countries and face additional types of adversity for which limited data are available. The aim of this review is to synthesize recently published research and policy documents regarding the prevalence, characteristics, and mental health consequences of childhood adversity in low-income countries. RECENT FINDINGS Many youth in low-income countries are exposed to war-related violence, are orphaned by AIDS, work long hours in dangerous conditions, and, among girls in Africa, undergo female genital mutilation. These children have more posttraumatic stress disorder and depression than unexposed youth. Family violence, discrimination, and poverty may exacerbate the effects of war-related trauma and AIDS orphanhood upon mental health. CONCLUSION Research on the psychological consequences of childhood adversity in low-income countries is increasing, but is limited by the range of mental health outcomes evaluated and by small nonrepresentative samples. Further research is warranted to inform child advocacy and to guide public policy and the actions of nongovernmental agencies involved in the protection and welfare of children.
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Household impacts of AIDS: using a life course approach to identify effective, poverty-reducing interventions for prevention, treatment and care.
Loewenson, R, Hadingham, J, Whiteside, A
AIDS care. 2009;(8):1032-41
Abstract
A life course approach was used to assess household level impacts and inform interventions around HIV risk and AIDS vulnerability across seven major age-related stages of life. Our focus was sub-Saharan Africa. We provided a qualitative review of evidence from published literature, particularly multicountry reviews on impacts of AIDS, on determinants of risk and vulnerability, and reports of large surveys. Areas of potential stress from birth to old age in households affected by AIDS, and interventions for dealing with these specific stresses were identified. While specific interventions for HIV are important at different stages, achieving survival and development outcomes demands a wider set of health, social security and development interventions. One way to determine the priorities amongst these actions is to give weighting to interventions that address factors that have latent impacts later in life, which interrupt accumulating risk, or that change pathways to reduce the risk of both immediate and later stress. This qualitative review suggested that interventions, important for life cycle transitions in generalised epidemics where HIV risk and AIDS vulnerability is high, lie within and outside the health sector, and suggested examples of such interventions.