Financing mental health services in low- and middle-income countries

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.     

上海市初中生烟草认知对烟草易感性的影响

【目的】了解上海市初中学生烟草认知状况,探讨烟草易感性的影响因素。【方法】采用多阶段分层整群抽样方法,在上海市8个监测点抽取3155名初中生开展自填问卷调查。对数据加权后,采用SPSS 22.0统计软件中复杂调查数据分析程序进行分析。【结果】认为吸烟可以让人在社交场合更轻松、认为吸烟更有吸引力、肯定地认为开始吸烟后很难戒掉、肯定地认为二手烟烟雾对自己有害的比例分别为5.1%、8.2%、34.1%、83.2%。7.0%从未尝试使用过任何烟草制品的学生对烟草易感,男生的比例(8.6%)高于女生(5.4%)(P=0.005)。在家中、学校、乘坐公共交通工具时二手烟暴露者的烟草易感性高于非暴露者(P<0.05)。母亲吸烟(OR=2.567,95%CI:1.394~4.725)、好友吸烟(OR=2.596,95%CI:1.336~5.046)是烟草易感性的危险因素;认为吸烟者的吸引力比非吸烟者差(OR=0.281,95%CI:0.165~0.478)、过去30 d在媒体上接触到控烟信息(OR=0.606,95%CI:0.393~0.934)是烟草易感性的保护因素。【结论】建议综合考虑个体认知因素、社会环境因素的影响,以学校为基础探讨适宜的干预方法,降低从未使用烟草的青少年未来使用烟草的可能性。     

The ethics of health systems research in low- and middle-income countries: A call to action

The increasing conduct of health systems research (HSR) in low- and middle-income countries (LMICs) has not been matched by concurrent work to clarify the field's ethical dimensions. To begin to address this gap, a two-day workshop on the ethics of HSR in LMICs was convened at Johns Hopkins University in June 2013. Participants included health systems researchers, philosophers, lawyers, bioethicists and institutional review board members from Botswana, Uganda, the UK, USA and Zambia. Based on discussions from the workshop, the paper affirms that, while HSR in LMICs raises ethical issues in relation to constructs (i.e. consent, risk, equipoise) common to international clinical research, the nature of the issues that arise often differ between the two fields. Three salient features of HSR and the ethical considerations associated with each of them in LMICs are described to demonstrate this point. Recommendations for institutional review boards’ oversight of HSR in LMICs are presented. Finally, a call is made for further action to develop thinking and guidance around the ethics of HSR in resource-poor settings.     

Large-scale road safety programmes in low- and middle-income countries: An opportunity to generate evidence

The growing burden of road traffic injuries, which kill over 1.2 million people yearly, falls mostly on low- and middle-income countries (LMICs). Despite this, evidence generation on the effectiveness of road safety interventions in LMIC settings remains scarce. This paper explores a scientific approach for evaluating road safety programmes in LMICs and introduces such a road safety multi-country initiative, the Road Safety in 10 Countries Project (RS-10). By building on existing evaluation frameworks, we develop a scientific approach for evaluating large-scale road safety programmes in LMIC settings. This also draws on ‘13 lessons’ of large-scale programme evaluation: defining the evaluation scope; selecting study sites; maintaining objectivity; developing an impact model; utilising multiple data sources; using multiple analytic techniques; maximising external validity; ensuring an appropriate time frame; the importance of flexibility and a stepwise approach; continuous monitoring; providing feedback to implementers, policy-makers; promoting the uptake of evaluation results; and understanding evaluation costs. The use of relatively new approaches for evaluation of real-world programmes allows for the production of relevant knowledge. The RS-10 project affords an important opportunity to scientifically test these approaches for a real-world, large-scale road safety evaluation and generate new knowledge for the field of road safety.     

Agriculture and musculoskeletal disorders in low- and middle-income countries

Objectives: To systematically explore and summarize the risk factors of work-related musculoskeletal disorders (WMSDs) among the agricultural workers in low- and middle-income countries (LMIC). In addition, to identify and analyze the methodological flaws in the reviewed studies.

Methods: A comprehensive electronic literature search was conducted using PubMed, Medline, SCOPUS, CINAHL, Science Direct, Embase, Wiley Online Library, Google Scholar, and Web of Science databases. Three-phased screening process was undertaken to eliminate irrelevant publications. Assessment of methodological quality was done using a standardized assessment tool.

Results: Eighteen cross-sectional studies were included in the narrative synthesis. Based on the median score of 38%, nine publications were classified as having higher methodological quality. Eight countries were represented in this review, mainly the South East Asia countries. Majority of the participants were rice farmers. Most common risk factors associated with WMSDs were physical factors (n = 10), followed by individual (n = 6) and psychosocial (n = 5) risk factors. A majority of the studies investigated the risk factors for spinal region. Several methodological weaknesses were noticed in the studies concerning outcome definition, assessment of potential confounders, generalizability, selection bias, information bias, and statistical analysis. Extensive heterogeneity across the studies prevented statistical pooling.

Conclusions: The common anatomical region evaluated was the spine and the most reported risk factors were physical risk factors. Future researches in the LMIC should focus on conducting longitudinal studies that could infer temporality. Researchers should give more attention in defining the study population, evaluating the exposure and outcome in an unbiased way, and in executing reliable statistical analysis.     

Misunderstandings and ambiguities in strategic purchasing in low- and middle-income countries

Strategic purchasing is branded as an approach that is necessary for progress towards universal health coverage. While we agree that publicly purchased health services should respond to society's needs and patient expectations, and thus generally endorse strategic purchasing, here we would like to explore two emerging concerns within current discussions in low- and middle-income countries. First, there exists a great deal of misunderstanding and conceptual unclarity, within practitioner groups, around the concept of strategic purchasing and what instruments it incorporates. Second, there is a growing trend to regularly fuse strategic purchasing into a performance-based financing (PBF) discourse in ways that increasingly blur their distinctive properties and policy orientations, while perhaps too easily obfuscating potential tensions. We believe the discourse on strategic purchasing would benefit from better conceptual clarity by dissociating and prioritising its two objectives, namely: priority should be given to needs-based allocation of resources, while rewarding performance is a subsequent concern. We argue there is a need for a more thoroughgoing conceptual and empirical re-examination of strategic purchasing's priorities, its link with PBF, as well as for a wider evidence-base on what strategic purchasing tools exist and which are most appropriate for diverse contexts.     

Examining anger as a predictor of drug use among multiethnic middle school students

Background:  Anger, a component of negative affect, has previously been associated with increased drug use primarily among white high school–aged students. However, few studies have examined these associations over time, and fewer have examined them among younger adolescents and students of color. Affective factors may play a greater role in drug use for girls relative to boys; yet, little is known regarding differences in associations between affect and drug use by gender.
Methods:  The current study used data from the control condition (N = 2025) of a drug and violence preventive intervention trial to examine the association between self-reported anger levels among multiethnic urban adolescents in the sixth grade and their use of cigarettes, alcohol, and marijuana use 1 year later. Potential gender differences were examined as well.
Results:  Multivariate generalized estimating equations models found anger to be significantly associated with increases in smoking, drinking, and marijuana use. There were no significant gender differences found for any of the drug use outcomes.
Conclusions:  Results are consistent with studies conducted on primarily white high school youth, where anger had a small but significant effect on drug use over time. The findings also suggest that drug prevention programs should include emotion regulation skills, such as anger management, in addition to drug resistance skills.     

National legislation on school smoking restrictions in eight European countries

OBJECTIVE: To review and compare national legislation addressing smoking at school in eight European countries during the late 1990s. DESIGN: The data are from the EC-funded Control of Adolescent Smoking (CAS) study in eight European countries. The information on national legislation was gathered during the period 1998-1999, through a review of scientific and official documents and interviews with key informants in each country. RESULTS: Four of the participating countries (Austria, French-speaking Belgium, Finland and Norway) had legislation specifically restricting smoking at school, while the remaining countries (Denmark, North Rhein Westphalia region of Germany, Scotland and Wales in the UK) did not have such legislation in place. In those countries with legislation in place, smoking among students aged 15 years and younger was not permitted. The position with regard to teacher smoking varied considerably among countries, but with the exception of Finland, there was no legislation regulating outdoor smoking by teachers during school hours. CONCLUSIONS: The findings suggest that there were inconsistencies within countries in terms of legislation that had been developed and the enforcement, compliance and monitoring practices that were in place. Further work is required to develop and resource such mechanisms, although it may be possible to build on existing practice, such as increasing the involvement of school health services, school inspectorate services or working through health promoting school networks already established in many countries.     

The neglected burden of caregiving in low- and middle-income countries

BackgroundThe number of persons with disability worldwide is estimated at more than one billion, and low- and middle-income countries (LMIC's) have particularly high prevalence. The consequences of disability have garnered growing attention, but the burden of caregiving for persons with disease or disability remains largely unquantified especially in LMIC's.ObjectiveThe goal of this paper is to report the results of a review of literature on caregiving in LMIC's, describing the characteristics of caregivers and of persons with disease or disability for whom care is provided, and the burden of caregiving in several domains.MethodsWe reviewed electronically available literature up to March 2012. Data were extracted pertaining to the following categories: caregiver demographics, caregiving activities, psychological burden, social burden, financial burden, physical burden, and time burden.ResultsOur review demonstrates that there is considerable and neglected burden on caregivers in LMIC's in physical, psychological, social, time, and financial realms. Existing literature is limited by the small volume of published research available on this topic, diverse methodologies, and lack of consensus on how to define and measure caregiver burden. However the evidence is clear that there are adverse consequences that arise as a result of the role of caregiver in this setting.ConclusionsIn light of the mounting evidence of the significant burden placed on caregivers of persons with disease and disability, it is imperative that the opportunity be taken to ensure that evidence informs best practice and policy in order to provide the support and services necessary to make an impact.     

Cancer control capacity in 50 low- and middle-income countries

Within the World Health Organization-International Atomic Energy Agency (WHO-IAEA) collaboration for delivery of technical assistance to its Member States, the National Cancer Control Programme/Plan (NCCP) Core Capacity Self-Assessment Tool has been used to obtain a simple and quick qualitative overview of national cancer control planning and on-going activities. The NCCP tool was applied in 50 Member States, which were classified as low- and middle-income countries in 2012. Results show that half of these countries reported having officially endorsed an NCCP and 42% were in the process of preparing or updating one. Overall, the most relevant cancer control interventions reported to be partially developed or well established in most countries were related to the cancer prevention, early detection of cervical and breast cancers, as well as diagnosis and treatment of curable cancers. Contrarily, patient's rehabilitation, psychosocial support, human papilloma virus vaccination, breast cancer screening with mammography and control of occupational carcinogens were noted as being in early development phases. The availability of crucial resources to support interventions was perceived to be the highest in upper middle-income countries. These findings highlight specific areas where WHO, IAEA and partners could strengthen collaboration with countries to leverage on-going interventions and improve availability of resources.     

Density of tobacco retail outlets near schools and smoking behaviour among secondary school students

Objective: To investigate whether the density of tobacco retail outlets near schools in Victoria, Australia, is associated with adolescent smoking behaviour. Methods: Cross‐sectional survey data of 2,044 secondary school students aged 12–17 years was combined with tobacco outlet audit data. Associations between students' self‐reported tobacco use and the density of tobacco outlets near schools was examined using multilevel logistic and negative binomial regression models, with cigarette price at local milk bars and key socio‐demographic and school‐related variables included as covariates. Results: Increased tobacco retail outlet density was associated with a significant increase in the number of cigarettes smoked in the previous seven days among students who smoked in the past month (IRR=1.13; 95% CI 1.02–1.26), but not the odds of smoking in the past month in the larger sample (OR=1.06; 95% CI 0.90–1.24), after controlling for local mean price of cigarettes and socio‐demographic and school‐related variables. Conclusions and implications: This study suggests there is a positive association between tobacco retail outlet density and cigarette consumption among adolescent smokers, but not smoking prevalence, in the Australian context. There is value in considering policy measures that restrict the supply of tobacco retail outlets in school neighbourhoods as a means of reducing youth cigarette consumption.     

Prevalence of tobacco use among students aged 13-15 years in Health Ministers' Council/Gulf Cooperation Council Member States, 2001-2004

BACKGROUND: This article examines differences and similarities in adolescent tobacco use among Member States of the Health Ministers' Council for the Gulf Cooperation Council (HMC/GCC) using Global Youth Tobacco Survey (GYTS) data. METHODS: Nationally representative samples of students in grades associated with ages 13-15 in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen. Schools were selected proportional to enrollment size, classes were randomly selected within participating schools, and all students in selected classes were eligible to participate. RESULTS: GYTS results confirmed that boys are significantly more likely than girls to smoke cigarettes or use shisha (water pipe). Students had higher rates of tobacco use than adults in Bahrain, Oman, and United Arab Emirates. For boys and girls, shisha use was higher than cigarette smoking in almost all countries. Susceptibility to initiate smoking among never smokers was higher than current cigarette smoking in all countries. Exposure to secondhand smoke in public places was greater than 30%, direct protobacco advertising exposure was greater than 70% on billboards and in newspapers, and more than 10% of students were influenced by indirect advertising. Finally, less than half of the students were taught in school about the dangers of tobacco use in the past year. CONCLUSIONS: For boys and girls, high prevalence of cigarette smoking, high prevalence of shisha use, and high susceptibility of never smokers to initiate smoking in the next year are troubling indicators for the future of chronic disease and tobacco-related mortality in the Member States of the HMC/GCC.     

Academic performance and substance use: findings from a state survey of public high school students

BACKGROUND: Previous investigations have shown that low academic achievers are more likely to smoke cigarettes, drink alcohol, and use marijuana and other illicit drugs. This study investigated the relationship between academic performance and substance use among public high school students in Mississippi. METHODS: The sampling frame for the 2003 Mississippi Youth Risk Behavior Survey was obtained from the Mississippi Department of Education. A 2-stage cluster sample design produced a representative sample of Mississippi students in grades 9-12 who attended public schools. During the spring 2003, 34 of the 45 sampled schools (75.6%) participated. RESULTS: A total of 1488 from the 1672 sampled students (89.0%) completed an 87-item questionnaire (overall response rate 67.3%). Low academic performance (students with mostly Cs or below) during the 12 months preceding the survey was more prevalent among males, non-Hispanic blacks, frequent smokers, binge drinkers, and marijuana users. Logistic regression identified gender, race, frequent smoking, and marijuana use as statistically significant factors associated with increased odds for low academic performance. Adjusted odds ratios were 1.2 for binge drinkers versus other students to 2.6 for non-Hispanic black students versus non-Hispanic white students. CONCLUSIONS: The present findings highlight the extensive use of cigarettes, alcohol, and marijuana among Mississippi public high school students. Because poor academic achievers are more prevalent among students who participate in these substance-use behaviors, multifaceted approaches that encourage high levels of academic performance, while dissuading student involvement in risky/problem behaviors, may both improve low levels of academic achievement and reduce behaviors that contribute to poor health in adulthood.     

Using pneumococcal carriage studies to monitor vaccine impact in low- and middle-income countries

Pneumococcal disease is a leading cause of childhood mortality, globally. The pneumococcal conjugate vaccine (PCV) has been introduced to many countries worldwide. However there are few studies evaluating PCV impacts in low- and middle-income countries (LMIC) because measuring the impact of PCV on pneumococcal disease in LMICs is challenging. We review the role of pneumococcal carriage studies for the evaluation of PCVs in LMICs and discuss optimal methods for conducting these studies. Fifteen carriage studies from 13 LMICs quantified the effects of PCV on carriage, and identified replacement carriage serotypes in the post-PCV era. Ten studies reported on the indirect effects of PCV on carriage. Results can be used to inform cost-effectiveness evaluations, guide policy decisions on dosing and product, and monitor equity in program implementation. Critically, we highlight gaps in our understanding of serotype replacement disease in LMICs and identify priorities for research to address this gap.     

衢州市中学生吸烟状况及其影响因素分析

  目的  了解贵州省贵阳市中学生烟草使用现状及控烟知识情况,为今后开展干预措施提供依据。  方法  于2015年5 — 6月采用分层整群抽样方法,在贵阳市抽取14所中学3 847名中学生,使用2013年中国青少年烟草流行调查问卷进行调查。  结果  贵阳市中学生尝试吸烟率为40.4 %,现在吸烟率为17.1 %,经常吸卷烟率为5.7 %。男生尝试吸烟率（54.5 %）、现在吸烟率（28.5 %）及经常吸卷烟率（10.9 %）均高于女生的27.3 %、6.5 %、0.9 %（均P < 0.05）。性别、地区、饮酒、学校类型是贵阳市中学生尝试吸烟、现在吸烟及经常吸卷烟的主要影响因素。贵阳市中学生烟草广告及促销暴露率高,控烟信息覆盖率低。  结论  贵阳市中学生烟草使用情况严峻,卫生计生及教育部门应加强控烟宣传,同时结合青少年身心发育特点及影响因素制定针对性的干预措施。     

Implementation of school policies to prevent youth tobacco use in Alabama

BACKGROUND: Public health professionals must monitor the effectiveness of school policies and programs to prevent youth initiation, promote quitting, and eliminate secondhand smoke. This analysis of school tobacco policies was preliminary to release of a state tobacco prevention and control plan for 2010‐2015. METHODS: University health educators collaborated with the state health agency to review policies of 33 school systems in 5 Metropolitan Statistical Areas and 9 public health areas. Authors developed a systematic approach of 8 steps useful to rate implementation of school tobacco control and prevention policies and discuss implications for health education program planning. RESULTS: Thirty school policies prohibited possession and use of tobacco by students, faculty and campus visitors, and 26 of 33 specified disciplinary measures following violations. Only 4 public education agencies included 3 of the 6 elements of a model tobacco prevention and control policy as suggested by the state public health agency. None featured all 6 elements. None specified establishing school‐community partnerships for tobacco prevention and control. CONCLUSIONS: Preparing smoke‐free youth requires implementing and evaluating tobacco education in grades K‐12 including use of model guidelines from federal agencies and professional organizations. Determining the focus of existing school tobacco policies is an initial step to encourage adoption of comprehensive policies to reduce youth use of tobacco. Youth health advocates may act together with school administrators and legislators to strengthen policies to be consistent with model guidelines for tobacco prevention and control.     

Effect of oral contraception on anemia in 12 low- and middle-income countries

Context

In low- and middle-income countries, anemia is a major public health issue in women of reproductive age for a series of factors including iron deficiency.

Understanding the Association Between Authoritative Parenting and Adolescent Smoking

Background: Research on adolescent cigarette smoking has attempted to measure the role of parents in preventing smoking experimentation and uptake. However, aspects of parental influence have often been limited to parental smoking behavior or antismoking socialization. Only a limited number of studies considered the hypothesis that the influence of parenting on adolescent current cigarette smoking may extend beyond parental behavior and antismoking socialization to consider broader measures of the parent–child relationship, such as parenting style. Methods: The sample was nationally representative and included 17,287 high school students nationwide. Data were used to categorize the parenting style—authoritative, permissive, autocratic, and unengaged—experienced by each respondent. Logistic regression analysis was used to assess the association between parenting style and adolescent current cigarette smoking. Results: Authoritative parenting was associated with a reduction in the odds of adolescent current cigarette smoking (OR: 0.74, 99% CI: 0.58, 0.95). When authoritative parenting is simultaneously considered with believing parents’ opinions about smoking are important, authoritative parenting was no longer a significant correlate of adolescent current cigarette smoking, while believing parents’ opinions about smoking are important was associated with a 45% (99% CI: 0.48, 0.64) reduction in the odds of adolescent current cigarette smoking. Authoritative parenting was associated with a more than three-fold increase (OR: 3.65, 99% CI: 2.87, 4.66) in the odds of believing parents’ opinions about smoking are important. Discussion: Interventions may want to educate parents about authoritative parenting, which includes the importance of having appropriate and routine conversations with their children, requiring chores, and implementing general rules and boundaries.     

Do state expenditures on tobacco control programs decrease use of tobacco products among college students?

The objective of this paper is to investigate the effects of state tobacco control program expenditures on individual‐level tobacco use behaviors among young adults. Data come from the 1997, 1999 and 2001 waves of the Harvard School of Public Health College Alcohol Study (CAS). Our findings indicate that a higher level of state spending on tobacco control programs in the prior year is associated with a statistically significant increase in the probability that current daily smokers report at least one attempt to quit smoking in the past year. We also find evidence that higher state expenditures on tobacco control programs in the prior year are associated with reductions in the prevalence of daily smoking and 30‐day cigar use among college students. We do not find any statistically significant association between state tobacco control program expenditures and the number of attempts to quit smoking among those with at least one attempt, or on the prevalence of smokeless tobacco use in the past month. Copyright © 2010 John Wiley & Sons, Ltd.