From research to practice: the example of antenatal care in Thailand

The rationale for providing antenatal care is to screen predominantly healthy pregnant women to detect early signs of, or risk factors for, abnormal conditions or diseases and to follow this detection with effective and timely intervention. The recommended antenatal care programme in most developing countries is often the same as the programmes used in developed countries. However, in developing countries there is wide variation in the proportion of women who receive antenatal care. The WHO randomized trial of antenatal care and the WHO systematic review indicated that a model of care that provided fewer antenatal visits could be introduced into clinical practice without causing adverse consequences to the woman or the fetus. This new model of antenatal care is being implemented in Thailand. Action has been required at all levels of the health-care system, from consumers through to health professionals, the Ministry of Public Health and international organizations. The Thai experience is a good example of moving research findings into practice, and it should be replicated elsewhere to effectively manage other health problems.     

Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations

CONTEXT: The mortality numbers and rates of chronic disease are rising faster in developing than in developed countries. This article compares prevailing explanations of population chronic disease trends with theoretical and empirical models of population chronic disease epidemiology and assesses some economic consequences of the growth of chronic diseases in developing countries based on the experiences of developed countries. METHODS: Four decades of male mortality rates of cardiovascular and chronic noncommunicable diseases were regressed on changes in and levels of country income per capita, market integration, foreign direct investment, urbanization rates, and population aging in fifty-six countries for which comparative data were available. Neoclassical economic growth models were used to estimate the effect of the mortality rates of chronic noncommunicable diseases on economic growth in high-income OECD countries. FINDINGS: Processes of economic growth, market integration, foreign direct investment, and urbanization were significant determinants of long-term changes in mortality rates of heart disease and chronic noncommunicable disease, and the observed relationships with these social and economic factors were roughly three times stronger than the relationships with the population's aging. In low-income countries, higher levels of country income per capita, population urbanization, foreign direct investment, and market integration were associated with greater mortality rates of heart disease and chronic noncommunicable disease, less increased or sometimes reduced rates in middle-income countries, and decreased rates in high-income countries. Each 10 percent increase in the working-age mortality rates of chronic noncommunicable disease decreased economic growth rates by close to a half percent. CONCLUSIONS: Macrosocial and macroeconomic forces are major determinants of population rises in chronic disease mortality, and some prevailing demographic explanations, such as population aging, are incomplete on methodological, empirical, and policy grounds. Rising chronic disease mortality rates will significantly reduce economic growth in developing countries and further widen the health and economic gap between the developed and developing world.     

Oral health information systems--towards measuring progress in oral health promotion and disease prevention

This article describes the essential components of oral health information systems for the analysis of trends in oral disease and the evaluation of oral health programmes at the country, regional and global levels. Standard methodology for the collection of epidemiological data on oral health has been designed by WHO and used by countries worldwide for the surveillance of oral disease and health. Global, regional and national oral health databanks have highlighted the changing patterns of oral disease which primarily reflect changing risk profiles and the implementation of oral health programmes oriented towards disease prevention and health promotion. The WHO Oral Health Country/Area Profile Programme (CAPP) provides data on oral health from countries, as well as programme experiences and ideas targeted to oral health professionals, policy-makers, health planners, researchers and the general public. WHO has developed global and regional oral health databanks for surveillance, and international projects have designed oral health indicators for use in oral health information systems for assessing the quality of oral health care and surveillance systems. Modern oral health information systems are being developed within the framework of the WHO STEPwise approach to surveillance of noncommunicable, chronic disease, and data stored in the WHO Global InfoBase may allow advanced health systems research. Sound knowledge about progress made in prevention of oral and chronic disease and in health promotion may assist countries to implement effective public health programmes to the benefit of the poor and disadvantaged population groups worldwide.     

Injuries and noncommunicable diseases: emerging health problems of children in developing countries.

The present article identifies, for children living in developing countries, the major causes of ill-health that are inadequately covered by established health programmes. Injuries and noncommunicable diseases, notably asthma, epilepsy, dental caries, diabetes mellitus and rheumatic heart disease, are growing in significance. In countries where resources are scarce it is to be expected that increasing importance will be attached to the development and implementation of measures against these problems. Their control may benefit from the application of elements of programmes directed against infectious, nutritional and perinatal disorders, which continue to predominate.     

The global impact of noncommunicable diseases: estimates and projections

With the aging of populations in developing countries there is both a demographic and an epidemiological transition which affects the impact of chronic degenerative diseases on the health status of the populations. Demographic transition takes place in countries where there are effective programmes of disease control which allow for survival during the early years of childhood and adolescence. This results in an increase in life expectancy which places larger proportions of the population in the age range (60 years and older) in which chronic degenerative diseases become the major determinants of health status. Epidemiological transition in diseases may also be brought about by shifts in social and economic patterns which favour detrimental changes in risk factors for the chronic degenerative diseases. Such changes may include health-related behaviour which augments dietary consumption of fats and alcohol, increases obesity, increases smoking and decreases physical activity. Such changes in risk-factor levels increase the prevalence of chronic degenerative diseases which manifest themselves at later ages, and for which early preventive actions could be cost-effective. In order to illustrate the impact of both demographic and risk-factor effects, analyses are made of the impact of increases in life expectancy on cause-specific mortality in both developing and developed countries. It is shown that there is great similarity in the effect of major noncommunicable diseases on the life expectancy of adults in both developed and developing countries. The major differences are seen to be in the proportions of deaths expected from such diseases as cancer, diabetes, heart disease, stroke and cirrhosis; but not in the distribution of age at death which is the better measure of disease impact. Demographic analyses, computing indirect estimates of mortality, also demonstrate that there are currently more chronic disease deaths in developing than developed countries and that as expectation of life increases in developing countries the global chronic disease burden will be greatly concentrated in the developing countries. Analyses of risk-factor reduction by feasible intervention strategies, e.g. smoking cessation campaigns, treatment of high blood pressure, using relationships between risk factors and diseases established in longitudinal studies carried out in developed countries, point out that the effect of risk-factor control in long-living populations can be hidden by the dependency of risk factors and various related causes of death, e.g. smoking has an impact on lung cancer, ischaemic heart disease and emphysema, but at different ages.(ABSTRACT TRUNCATED AT 400 WORDS)     

Prevention and control of haemoglobinopathies.

In many developing countries the haemoglobinopathies (thalassaemias and sickle-cell disorder) are so common that they provide a convenient model for working out a genetic approach to control of chronic childhood diseases. At present, about 250 million people (4.5% of the world population) carry a potentially pathological haemoglobinopathy gene. Each year about 300,000 infants are born with major haemoglobinopathies. Haemoglobinopathy control programmes, based on WHO approaches and recommendations, have been established in different countries in all WHO Regions and have been successful in management of the problem. Following WHO recommendations the health burden of hereditary anaemias could be significantly reduced. This article summarizes the presentations and discussion made at a joint WHO/TIF (Thalassaemia International Federation) meeting, held in Cyprus in April 1993, and reviews the experience of programmes in several countries for the control of haemoglobinopathies in the world.     

The campaign against sexually transmissible diseases and endemic treponematoses

From the moment WHO was established in 1948, the control of venereal diseases was felt to deserve highest priority, together with activities to control malaria and tuberculosis. International action was needed in view of the high morbidity and mortality from venereal diseases, their serious human and social consequences, and the prevalence of congenital syphilis and other sexually transmitted diseases (gonorrhoea, chancroid, venereal lymphogranulomatosis, granuloma inguinale). WHO immediately set up a global programme for the control of STDs and, with the participation of other agencies, especially UNICEF, furnished countries with assistance in the form of personnel, equipment and funds for the operation of programmes to assess the extent and impact of STDs and to plan and implement practical measure of control. The 1950s witnessed a steady and considerable decline in syphilis and gonorrhoea and many health authorities relaxed their control activities and efforts to maintain public awareness of the problem. In contrast to the prevailing optimism, WHO repeatedly stressed the possibility of a renewed upsurge of STDs. In the 1960s and 1970s, there was a sharp rise in STDs, both in the "classic" diseases (the five venereal diseases mentioned above) and also in the "second generation" STDs (chlamydial infection, genital herpes, human papillomavirus and other infections). Through its programme for the control of STDs, WHO put forward suitably designed control strategies, essentially based on information and education for health, screening for STDs, diagnosis and treatment of cases, contact tracing, and the training of health personnel. By the end of the 1970s, the bacterial, but not the viral STDs, had been contained in the industrialized countries. In many of the developing countries, STDs remained a priority public health problem, above all on account of the seriousness of their sequelae. In 1981, a new sexually transmitted disease-the acquired immunodeficiency syndrome (AIDS)-was identified. As of 1982, the WHO Programme on STDs organized meetings to define the extent of the problem, compare experience, promote and coordinate research and propose strategies for prevention. In 1987, WHO established a Global Programme on AIDS. It is clear that the control of STDs is now more than ever a priority. We have strategies for the prevention and control of STDs and the WHO Programme will continue to collaborate closely with countries in strengthening their national control programmes.(ABSTRACT TRUNCATED AT 400 WORDS)     

Integrated management of the sick child.

Diarrhoea, pneumonia, measles, malaria and malnutrition account for more than 70% of deaths and health facility visits among children under 5 years of age in developing countries. A number of programmes in WHO and UNICEF have developed an approach to the integrated management of the sick child, which is being coordinated by WHO''s Division for the Control of Diarrhoeal and Acute Respiratory Disease. Integrated clinical guidelines have been developed and a training course for health workers in outpatient (first level) health facilities has been completed. In addition to case management of these diseases, the course incorporates significant prevention of disease through promotion of breast-feeding, counselling to solve feeding problems, and immunization of sick children. Other materials to train and support health workers are also being developed: an inpatient case management training course, medical school curricular materials, a drug supply management course, and materials to support monitoring and reinforcement of skills after training. A planning guide for interventions to improve household management of childhood illness is also being developed. Since management of the sick child is a cost-effective health intervention, which has been estimated to have a large impact on the global burden of disease in developing countries, the completion of these materials and their wide implementation should have a substantial impact on child mortality.     

Benefits and costs of vaccination.

Vaccination programmes supported by the WHO and other organizations have dramatically reduced disease in developing countries, but there remains a need to extend coverage rates and expand the number of vaccines included. In industrialized countries, where paediatric vaccination is almost universal, there will be an increasing opportunity to protect against diseases which occur in later years.     

Introduction. Symposium: Obesity in developing countries: biological and ecological factors

Over the past decade there has been an increasing concern about the impact of chronic, noncommunicable diseases on the health of developing world populations. Traditionally, major causes of illness and death in developing countries have been linked to infectious diseases and undernutrition, and these are still major public health problems in several regions of the world. But recent projections indicate that in 20 y noncommunicable diseases will account for over 60% of the disease burden and mortality in the developing world. Obesity is recognized as an underlying risk factor for many of these chronic conditions. As in developed societies, the risk for obesity in developing countries is also strongly influenced by diet and lifestyle, which are changing dramatically as a result of the economic and nutrition transition. This symposium discusses key aspects of the phenomenon of obesity in the developing world and provides some specific examples from countries facing increasing prevalence of that condition.     

Veterinary diagnostic laboratories and their support role for Veterinary Services

National Veterinary Services administer a number of regulatory programmes, such as foreign animal disease (FAD) surveillance and exclusion of FADs, and certification of regions as free from disease. Laboratory testing is an important part of any surveillance or control programme. Most countries have a national laboratory which performs testing for FADs and provides support for national disease eradication and control programmes. State laboratories provide testing for surveillance programmes and export purposes, in addition to diagnosis of clinical cases. Many national and state laboratories are developing quality assurance programmes to assure the reliability of testing results. Veterinary Services are reliant on the diagnostic expertise of the laboratory system of that country to be able to respond to FAD introductions and to provide the surveillance programmes needed to detect the introduction of diseases and to certify freedom from disease.     

Trends in Diet, Nutritional Status, and Diet-related Noncommunicable Diseases in China and India: The Economic Costs of the Nutrition Transition

Undernutrition is being rapidly reduced in India and China. In both countries the diet is shifting toward higher fat and lower carbohydrate content. Distinct features are high intakes of foods from animal sources and edible oils in China, and high intakes of dairy and added sugar in India. The proportion of overweight is increasing very rapidly in China among all adults; in India the shift is most pronounced among urban residents and high-income rural residents. Hypertension and stroke are relatively higher in China and adult-onset diabetes is relatively higher in India. Established economic techniques were used to measure and project the costs of undernutrition and diet-related noncommunicable diseases in 1995 and 2025. Current WHO mortality projections of diet-related noncommunicable diseases, dietary and body composition survey data, and national data sets of hospital costs for healthcare, are used for the economic analyses. In 1995, China's costs of undernutrition and costs of diet-related noncommunicable diseases were of similar magnitude, but there will be a rapid increase in the costs and prevalence of diet-related noncommunicable diseases by 2025. By contrast with China, India's costs of undernutrition will continue to decline, but undernutrition costs did surpass overnutrition diet-related noncommunicable disease costs in 1995. India's rapid increase in diet-related noncommunicable diseases and their costs projects similar economic costs of undernutrition and overnutrition by 2025.     

Global policy and programme guidance on maternal nutrition: what exists, the mechanisms for providing it, and how to improve them?

Undernutrition in one form or another affects the majority of women of reproductive age in most developing countries. However, there are few or no effective programmes trying to solve maternal undernutrition problems. The purpose of the paper is to examine global policy and programme guidance mechanisms for nutrition, what their content is with regard to maternal nutrition in particular, as well as how these might be improved. Almost all countries have committed themselves politically to ensuring the right of pregnant and lactating women to good nutrition through the Convention on the Elimination of all Forms of Discrimination Against Women. Despite this, the World Health Organization (WHO) has not endorsed any policy commitments with regard to maternal nutrition. The only policy guidance coming from the various technical departments of WHO relates to the control of maternal anaemia. There is no policy or programme guidance concerning issues of maternal thinness, weight gain during pregnancy and/or low birthweight prevention. Few if any countries have maternal nutrition programmes beyond those for maternal anaemia, and most of those are not effective. The lack of importance given to maternal nutrition is related in part to a weakness of evidence, related to the difficulty of getting ethical clearance, as well as a generalised tendency to downplay the importance of those interventions found to be efficacious. No priority has been given to implementing existing policy and programme guidance for the control of maternal anaemia largely because of a lack of any dedicated funding, linked to a lack of Millennium Development Goals indicator status. This is partly due to the poor evidence base, as well as to the common belief that maternal anaemia programmes were not effective, even if efficacious. The process of providing evidence-based policy and programme guidance to member states is currently being revamped and strengthened by the Department of Nutrition for Health and Development of WHO through the Nutrition Guidance Expert Advisory Group processes. How and if programme guidance, as well as policy commitment for improved maternal nutrition, will be strengthened through the Nutrition Guidance Expert Advisory Group process is as yet unclear. The global movement to increase investment in programmes aimed at maternal and child undernutrition called Scaling Up Nutrition offers an opportunity to build developing country experience with efforts to improve nutrition during pregnancy and lactation. All member states are being encouraged by the World Health Assembly to scale-up efforts to improve maternal infant and young child nutrition. Hopefully Ministries of Health in countries most affected by maternal and child undernutrition will take leadership in the development of such plans, and ensure that the control of anaemia during pregnancy is given a great priority among these actions, as well as building programme experience with improved nutrition during pregnancy and lactation. For this to happen it is essential that donor support is assured, even if only to spearhead a few flagship countries.     

Expanded programme on immunization

The Expanded Programme on Immunization (EPI) was established in 1974 to develop and expand immunization programmes throughout the world. In 1977, the goal was set to make immunization against diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis available to every child in the world by 1990. Problems encountered by the Programme have included: lack of public and governmental awareness of the scope and seriousness of the target diseases; ineffective programme management; inadequate equipment and skills for vaccine storage and handling; and insufficient means for monitoring programme impact as reflected by increasing immunization coverage levels and decreasing incidence of the target diseases. When the EPI was initiated in 1974, fewer than 5% of children in developing countries were receiving a third dose of DPT and poliomyelitis vaccines in their first year of life. These coverage levels have now surpassed 50% in developing countries, and millions of cases of the target disease have been prevented. Over 700,000 measles deaths were prevented by immunization in developing countries in 1987, and an increasing number of neonatal tetanus deaths is now being prevented by maternal immunization and improved childbirth conditions. Poliomyelitis immunization efforts have been so successful that the Pan American Health Organization is leading a drive to eradicate poliomyelitis from the Americas by 1990. The successes of the Programme represent a major public health achievement, but much remains to be done.(ABSTRACT TRUNCATED AT 250 WORDS)     

The determinants of compliance with an early intervention programme for high-risk babies in India

BACKGROUND: Early intervention is known to improve outcomes for babies at risk for growth and developmental problems. Such programmes usually have a prolonged course and require frequent contacts with the service providers. As a consequence of poverty, illiteracy and lack of communication facilities in developing countries, treatment adherence can suffer. METHODS: The present study is an analysis of a clinic-based early intervention programme for high-risk babies in a developing society in Goa, India. A sample of 152 neonates and their parents were offered an early intervention programme and followed up until their first birthday. The primary outcome under study was the uptake of the programme. Various socio-demographic, programmatic and infant-related variables that could affect compliance were examined. RESULTS: Compliance with the intervention programme was only moderate, with 59.2% of infants brought for three or more sessions. Higher maternal educational levels and proximity of the place of residence of the family to the early intervention clinic were significantly associated with better compliance. CONCLUSIONS: Early intervention programmes that go into homes have a greater chance of reaching high-risk infants, compared with those provided at a distant centre. Better-educated mothers are more likely to be convinced about the benefits of such inputs. The authors conclude with recommendations for future practice and research.     

The treatment of epilepsy in developing countries: where do we go from here?

Epilepsy is the most common serious neurological disorder and is one of the world's most prevalent noncommunicable diseases. As the understanding of its physical and social burden has increased it has moved higher up the world health agenda. Over four-fifths of the 50 million people with epilepsy are thought to be in developing countries; much of this condition results from preventable causes. Around 90% of people with epilepsy in developing countries are not receiving appropriate treatment. Consequently, people with epilepsy continue to be stigmatized and have a lower quality of life than people with other chronic illnesses. However, bridging the treatment gap and reducing the burden of epilepsy is not straightforward and faces many constraints. Cultural attitudes, a lack of prioritization, poor health system infrastructure, and inadequate supplies of antiepileptic drugs all conspire to hinder appropriate treatment. Nevertheless, there have been successful attempts to provide treatment, which have shown the importance of community-based approaches and also indicate that provision for sustained intervention over the long term is necessary in any treatment programme. Approaches being adopted in the demonstration projects of the Global Campaign Against Epilepsy--implemented by the International League Against Epilepsy, the International Bureau for Epilepsy, and the World Health Organization--may provide further advances. Much remains to be done but it is hoped that current efforts will lead to better treatment of people with epilepsy in developing countries.     

National Immunization Technical Advisory Groups (NITAGs): Guidance for their establishment and strengthening

The majority of industrialized and some developing countries have formally established national technical advisory bodies to guide immunization policies; other countries are working towards or contemplating the establishment of such bodies. These advisory bodies are often referred to as National Immunization Technical Advisory Groups (NITAGs). A NITAG is a technical resource supplying guidance to national policy makers and programme managers to enable them to make evidence-based immunization related policy and program decisions. The focus of this paper is to: (1) review the value and functions of a NITAG; (2) provide directions and identify issues for countries to consider when establishing or improving the functioning of a NITAG; and (3) outline potential WHO and partners’ roles and activities in support of the establishment and strengthening of NITAGs.     

Cerebrovascular disease in the community: results of a WHO Collaborative Study

In a cooperative study coordinated by WHO, stroke was registered between 1971 and 1974 in 17 centres both in developing and developed countries. A common operating protocol was used to obtain comparable data. Age-adjusted incidence of stroke shows moderate geographical variations, cerebrovascular accidents being common in all the contrasting populations studied in various parts of the world. Data were also obtained on the types of management of stroke patients, their survival rates, and functional prognosis. Control of hypertension, although known to be effective in the prevention of stroke, seemed to be insufficient in most countries. It is concluded that stroke registers may be used as a source of information for the planning and implementation of stroke control programmes in the community.     

The global burden of oral diseases and risks to oral health

This paper outlines the burden of oral diseases worldwide and describes the influence of major sociobehavioural risk factors in oral health. Despite great improvements in the oral health of populations in several countries, global problems still persist. The burden of oral disease is particularly high for the disadvantaged and poor population groups in both developing and developed countries. Oral diseases such as dental caries, periodontal disease, tooth loss, oral mucosal lesions and oropharyngeal cancers, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)-related oral disease and orodental trauma are major public health problems worldwide and poor oral health has a profound effect on general health and quality of life. The diversity in oral disease patterns and development trends across countries and regions reflects distinct risk profiles and the establishment of preventive oral health care programmes. The important role of sociobehavioural and environmental factors in oral health and disease has been shown in a large number of socioepidemiological surveys. In addition to poor living conditions, the major risk factors relate to unhealthy lifestyles (i.e. poor diet, nutrition and oral hygiene and use of tobacco and alcohol), and limited availability and accessibility of oral health services. Several oral diseases are linked to noncommunicable chronic diseases primarily because of common risk factors. Moreover, general diseases often have oral manifestations (e.g. diabetes or HIV/AIDS). Worldwide strengthening of public health programmes through the implementation of effective measures for the prevention of oral disease and promotion of oral health is urgently needed. The challenges of improving oral health are particularly great in developing countries.     

Nutritional surveillance

The concept of nutritional surveillance is derived from disease surveillance, and means “to watch over nutrition, in order to make decisions that lead to improvements in nutrition in populations”. Three distinct objectives have been defined for surveillance systems, primarily in relation to problems of malnutrition in developing countries: to aid long-term planning in health and development; to provide input for programme management and evaluation; and to give timely warning of the need for intervention to prevent critical deteriorations in food consumption. Decisions affecting nutrition are made at various administrative levels, and the uses of different types of nutritional surveillance information can be related to national policies, development programmes, public health and nutrition programmes, and timely warning and intervention programmes. The information should answer specific questions, for example concerning the nutritional status and trends of particular population groups.