Systematic review of cost-effectiveness studies of human papillomavirus (HPV) vaccination: 9-Valent vaccine,gender-neutral and multiple age cohort vaccination

BackgroundThe success of human papillomavirus (HPV) national immunization program depends on effective strategies in optimizing the uptake of HPV vaccine. Given the increasing number of economic evaluations, this review was conducted to update the economic evidence on HPV vaccination, by focusing on: (i) 9-valent vaccine compared to bi- or quadrivalent vaccine; (ii) gender-neutral vaccination compared to female only vaccination; and (iii) multiple age cohort immunization compared to single age cohort immunization.MethodsSearches were performed until June 2016 using 4 databases: PubMed; Embase; Cochrane Library; and LILACS. The combined WHO, Drummond and CHEERS checklist were used to evaluate the quality of included studies.ResultsThirty-four studies were included in the review and most of them were conducted in high-income countries. The inclusion of adolescent boys in vaccination program was found to be cost-effective if vaccine price and coverage was low. When coverage for female was above 75%, gender-neutral vaccination was less cost-effective than when targeting only girls aged 9–18 years. Current evidence does not show conclusive proof of greater cost-effectiveness of 9-valent vaccine compared to the older HPV vaccines as the price for 9-valent vaccine was still uncertain. Multicohort immunization strategy was cost-effective in the age range 9–14 years but the upper age limit at which vaccination was no longer cost-effective needs to be further investigated. Key influential parameters identified were duration of vaccine protection, vaccine price, coverage, and discounting rates.ConclusionsThese findings are expected to support policy-makers in making recommendations for HPV immunization programs on either switching to the 9-valent vaccine or inclusion of adolescent boys’ vaccination or extending the age of vaccination.     

What has been achieved in HIV prevention,treatment and care for people who inject drugs, 2010–2012? A review of the six highest burden countries

ObjectiveIn 2010 the international HIV/AIDS community called on countries to take action to prevent HIV transmission among people who inject drugs (PWID). To set a baseline we proposed an “accountability matrix”, focusing upon six countries accounting for half of the global population of PWID: China, Malaysia, Russia, Ukraine, Vietnam and the USA. Two years on, we review progress.DesignWe searched peer-reviewed literature, conducted online searches, and contacted experts for ‘grey’ literature. We limited searches to documents published since December 2009 and used decision rules endorsed in earlier reviews.ResultsPolicy shifts are increasing coverage of key interventions for PWID in China, Malaysia, Vietnam and Ukraine. Increases in PWID receiving antiretroviral treatment (ART) and opioid substitution treatment (OST) in both Vietnam and China, and a shift in Malaysia from a punitive law enforcement approach to evidence-based treatment are promising developments. The USA and Russia have had no advances on PWID access to needle and syringe programmes (NSP), OST or ART. There have also been policy setbacks in these countries, with Russia reaffirming its stance against OST and closing down access to information on methadone, and the USA reinstituting its Congressional ban on Federal funding for NSPs.ConclusionsPrevention of HIV infection and access to HIV treatment for PWID is possible. Whether countries with concentrated epidemics among PWID will meet goals of achieving universal access and eliminating new HIV infections remains unknown. As long as law enforcement responses counter public health responses, health-seeking behaviour and health service delivery will be limited.     

Prevalence of heart disease and stroke risk factors in persons with prehypertension in the United States, 1999-2000

BACKGROUND: Recent guidelines classify persons with above-optimal blood pressure (BP) but not clinical hypertension as having prehypertension. METHODS: Data were analyzed for 3488 persons aged 20 years and older with BP measured in the 1999-2000 National Health and Nutrition Examination Survey. The prevalence of risk factors-above-normal (> or =200 mg/dL [> or =5.17 mmol/L]) and high (> or =240 mg/dL [> or =6.21 mmol/L]) total cholesterol levels, diabetes mellitus, current smoker, and overweight or obesity-and the number of risk factors present were compared among BP groups (normotension, prehypertension, and hypertension). Multivariable logistic regression included age, sex, and race/ethnicity as covariates. RESULTS: Overall, 39% of persons were normotensive,31% were prehypertensive, and 29% were hypertensive. The age-adjusted prevalence of prehypertension was greater in men (39.0%) than in women (23.1%). African Americans aged 20 to 39 years had a higher prevalence of prehypertension (37.4%) than whites (32.2%) and Mexican Americans (30.9%), but their prevalence was lower at older ages because of a higher prevalence of hypertension. The probabilities of above-normal cholesterol levels, overweight/obesity, and diabetes mellitus were greater for persons with prehypertension vs normotension, whereas the probability of currently smoking was lower. Persons with prehypertension were 1.65 times more likely to have at least 1 other adverse risk factor than were those with normotension (P<.001). Among participants with prehypertension, there were no significant race/ethnic or sex differences in the likelihood of having at least 1 other risk factor. CONCLUSIONS: The greater prevalence of risk factors in persons with prehypertension vs normotension suggests the continued need for early clinical detection and intervention of prehypertension and comprehensive preventive and public health efforts.     

A Randomized Controlled Trial of a Community-Based Nutrition Education Program for Low-Income Parents

ObjectiveAssess effectiveness of the Expanded Food and Nutrition Education Program on nutrition behaviors post-education and longitudinally.DesignSwitching replications randomized experimental design. Participants randomly assigned to immediate education (IE) or delayed education (DE). Participants in IE received intervention the first 8 weeks, and those in DE the second 8 weeks, with no intervention during alternate periods. Data were collected in 3 repeated measures.ParticipantsParents (n = 168 randomized; n = 134 completed) of children in 2 Head Start and 6 low-income schools.InterventionEight weekly workshops, based on Eating Right is Basic-Enhanced adapted to incorporate dialogue approach with experiential learning.Main Outcome MeasuresTen-item self-reported behavior checklist on nutrition, food resource management, food safety, and food security; responses on a 5-point scale reporting frequency of behavior.AnalysisChi-square, analysis of variance, and multiple regression.ResultsGroups were demographically similar. Both groups reported improved behaviors pre- to post-education (P < .05). There was no significant difference between groups at Time 1 (T1) or DE control period (T1 vs T2). Changed IE behavior was retained T2 to T3. A multiple regression model of overall change, controlling for T1 score and educator, showed significant improvement (n = 134, β = 5.72, P < .001).Conclusions and ImplicationsPositive outcomes were supported by this experimental study in a usual program context, with reported behavior changes retained at least 2 months.     

Veterans’ perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

ObjectivesDrawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.MethodsWe interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.ResultsParticipants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers’ fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.ConclusionOur findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.Practice ImplicationsWe discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers’ burnout.     

Gender Comparisons of Unhealthy Weight-control Behaviors Among Sixth-Graders

ObjectiveTo examine gender differences in unhealthy weight-control behaviors (UWCB) and identify key psychosocial and demographic correlates of UWCB among sixth-graders.MethodsA cross-sectional survey was completed by 146 boys and 153 girls at a middle school. Secondary data analyses included bivariate tests and multivariable logistic regression.ResultsForty-seven percent of participants reported 1 or more UWCB, with no differences by gender (P = .75). Factors common to boys and girls included: lower global self-esteem; lower body-esteem; and greater negative parental modeling among participants who engaged in UWCB compared to those who did not. However, multivariable models revealed gender differences. Among boys, body mass index, negative parental modeling, and global self-esteem retained statistically significant associations with UWCB after controlling for other variables in the model, whereas race and weight-related body-esteem remained significant for girls.Conclusions and ImplicationsThis research highlights the need for gender-specific UWCB prevention programs implemented in late childhood and early adolescence.     

Adverse childhood experiences and self-reported liver disease: new insights into the causal pathway

OBJECTIVE: To examine the relationship of adverse childhood experiences (ACEs), including abuse, neglect, and forms of household dysfunction, to the risk of liver disease by assessing the role of risk behaviors, such as substance abuse and high-risk sexual activity, as mediators of the ACEs-liver disease relationship. METHODS: Retrospective cohort study data were collected from 17 337 adult health plan members through a survey. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACEs-liver disease relationship and the impact of the mediators in this relationship. RESULTS: Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). The number of ACEs (ACE score) had a graded relationship to liver disease (P<.001). Compared with persons with no ACEs, the adjusted odds ratio of ever having liver disease among persons with 6 or more ACEs was 2.6 (P<.001). The ACE score also had a strong graded relationship to risk behaviors for liver disease. The strength of the ACEs-liver disease association was reduced 38% to 50% by adjustment for these risk behaviors, suggesting they are mediators of this relationship. CONCLUSIONS: The ACE score showed a graded relationship to the risk of liver disease that appears to be mediated substantially by behaviors that increase the risk of viral and alcohol-induced liver disease. Understanding the effect of ACEs on the risk of liver disease and development of these behaviors provides insight into causal pathways, which may prove useful in the prevention of liver disease.