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.     

The requirements and challenges in preventing of road traffic injury in Iran. A qualitative study

Background  

Road traffic injuries (RTIs) are a major public health problem, especially in low- and middle-income countries. Among middle-income countries, Iran has one of the highest mortality rates from RTIs. Action is critical to combat this major public health problem. Stakeholders involved in RTI control are of key importance and their perceptions of barriers and facilitators are a vital source of knowledge. The aim of this study was to explore barriers to the prevention of RTIs and provide appropriate suggestions for prevention, based on the perceptions of stakeholders, victims and road-users as regards RTIs.     

Review of the epidemiological evidence for physical activity and health from low- and middle-income countries

Almost 80% of deaths from non-communicable diseases (NCDs) occur in low- and middle-income countries. Physical inactivity is a key risk factor for NCDs. Enhancing understanding of the scientific evidence linking physical activity and health in low- and middle-income countries is important for supporting national efforts to promote physical activity and reduce NCDs in these countries. A systematic review of three electronic databases was conducted in July 2013, including large population-based epidemiological studies with adult participants, conducted in low- and middle-income countries, and published in the past 30 years. Physical activity was consistently associated with a reduced risk of all-cause mortality, cardiovascular disease (CVD), diabetes and several types of cancer. Positive associations were also found between physical activity and body composition (including overweight and obesity), blood pressure, cholesterol, metabolic indices and bone mineral density. Overall, the results confirm that the epidemiological research into the health benefits of physical activity in low- and middle-income countries is consistent with previous research conducted in high-income countries. This summary of the available research can be used as an advocacy tool in low- and middle-income countries to support greater prominence of physical activity in NCD policies.     

Treatment of common mental disorders in primary care in low- and middle-income countries

Common mental disorders are responsible for up to 10% of the total global disease burden. The growing evidence base for the efficacy and cost-effectiveness of treatments for these disorders raises the possibility of delivering huge health and economic benefits. However, delivering these treatments in resource-constrained settings is challenging. At least one-third of all patients seen in primary care in low- and middle-income countries present with common mental disorders. The majority are not recognised or are ineffectively treated. To address this problem, WHO advocates integrating mental health in primary care. However, the limited evidence base has impeded efforts to develop such services.     

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.     

Economic evaluation of interventions to reduce road traffic injuries--a review of the literature with applications to low and middle-income countries

Road Traffic Injuries (RTIs) kill over one million people worldwide annually. This article takes the perspective of economic costs and benefits to review the impact of available road safety interventions in industrialized countries--and the potential effect of these interventions in low and middle-income countries, where RTIs pose an increasingly large public health problem. A comprehensive review of the literature on cost-benefits and cost-effectiveness studies related to road traffic injuries internationally, with comparisons of costs adjusted for inflation and exchange differentials was conducted. In the United States (U.S.), motor vehicle inspection laws resulted in annual savings of US $1.7 to $2.3 billion. The installation of seatbelts results in net savings of $162 per vehicle; with benefits outweighing costs by a factor ranging from 240 to 1727. Other cost effective interventions include mandatory seatbelt use, lowering speed limits, motorcycle helmet laws, and traffic calming devices such as speed bumps and road deviations. The dearth of similar economic evaluations of interventions for road traffic injuries in low and middle-income countries represents a serious research gap and hinders the implementation of effective strategies in those countries.     

The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives

It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals. In this systematic review we described and assessed the contributions of major primary care initiatives implemented in low- and middle-income countries in the past 30 years to a broad range of health system goals. The scope of the programs reviewed was substantial, with several interventions implemented on a national scale. We found that the majority of primary care programs had multiple components from health service delivery to financing reform to building community demand for health care. Although given this integration and the variable quality of the available research it was difficult to attribute effects to the primary care component alone, we found that primary care-focused health initiatives in low- and middle-income countries have improved access to health care, including among the poor, at reasonably low cost. There is also evidence that primary care programs have reduced child mortality and, in some cases, wealth-based disparities in mortality. Lastly, primary care has proven to be an effective platform for health system strengthening in several countries. Future research should focus on understanding how to optimize the delivery of primary care to improve health and achieve other health system objectives (e.g., responsiveness, efficiency) and to what extent models of care can be exported to different settings.     

2004—2006年云南省道路交通伤害的流行趋势

目的了解2004—2006年云南道路交通伤害流行特征,为制定道路交通伤害预防控制策略提供依据。方法分析来自云南省公安厅交通警察总队发布的2004—2006年的《云南省道路交通事故统计年报》,初步掌握云南省道路交通伤害的流行状况、事故原因及其变化趋势。结果2004—2006年云南省共发生道路交通伤害24711起。道路交通事故数、伤亡人数、人口死亡率、万车死亡率、里程死亡率均呈下降趋势,每起事故平均死亡人数呈上升趋势。肇事人员及伤亡人员男性多于女性,以21～45岁青壮年人群为主。乘客、行人和摩托车驾驶者也是道路交通伤害的主要受害者。结论云南省道路交通伤害呈下降趋势,但事故严重程度呈上升趋势。     

Economic barriers to better mental health practice and policy

Mental health systems in many countries are seriously under-developed, yet mental health problems not only have huge consequences for quality of life, but--particularly in low- and middle-income countries--contribute to continued economic burden and reinforce poverty. This paper discusses economic barriers to improving the availability, accessibility, efficiency and equity of mental health care in low- and middle-income countries. Six sets of barriers are identified: an information barrier, resource insufficiency, resource distribution, resource inappropriateness, resource inflexibility and resource timing. Overcoming these barriers will be a major task, although there is no shortage of suggestions for action. The paper discusses broadening the evidence base, improving mental health literacy, tackling stigma, improving financing mechanisms, prioritizing and protecting mental health care budgets, emphasizing mental health promotion through the development of resilience, exploring routes to improved equity, experimenting with new arrangements for purchasing and delivering services, improving coordination between agencies and professionals at both macro- and micro-levels, building alliances between public and private sectors, and training and mobilizing primary care services to improve identification and treatment of mental health problems.     

Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here?

E-health encompasses a diverse set of informatics tools that have been designed to improve public health and health care. Little information is available on the impacts of e-health programmes, particularly in low- and middle-income countries. We therefore conducted a scoping review of the published and non-published literature to identify data on the effects of e-health on health outcomes and costs. The emphasis was on the identification of unanswered questions for future research, particularly on topics relevant to low- and middle-income countries. Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low- and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients' self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low- and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low- and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.     

Alcohol control and urban livelihoods in developing countries: can public health aspirations and development goals be reconciled?

This commentary explores how household economic necessity and the public health aspirations set out in the WHO’s global strategy to reduce the harmful use of alcohol might be reconciled in the context of alcohol control in developing countries. The ‘ambiguity’ of alcohol’s role in social and economic development is clear, but, as yet, little progress has been made on how best to integrate alcohol control within development policies in low- and middle-income countries. Without this holistic thinking, alcohol control efforts are likely to be thwarted by liquor’s allure as an accessible micro-enterprise opportunity. Similarly, developmental efforts will be undermined by the severity of alcohol-related harms that now disproportionately affect middle-income countries. Drawing on the example of South Africa, this short commentary explores the complexities of controlling the supply of alcohol when its sale represents a major livelihood strategy amid conditions of high unemployment and constrained access to formal employment markets. The policy preference for closing illegal bars or shebeens in South Africa does not address the ‘causes of the causes’ of why people drink, and therefore why its sale continues to be an attractive livelihood choice. It also does little to provide alternative leisure or employment opportunities, which ultimately threatens the longer term sustainability of policy. We need to better appreciate why selling alcohol is a seductive business opportunity and the potential consequences of this for realising public health aspirations.     

2006-2008年全国伤害监测道路交通伤害病例分布特征分析

目的 了解中国道路交通伤害门(急)诊就诊病例的分布特点.方法 对2006-2008年因伤害首次在全国伤害监测系统哨点医院门(急)诊就诊的道路交通伤害病例进行描述性分析.结果 监测的3年中,道路交通伤害是门(急)诊就诊伤害病例的第二位伤害发生原因.其中男性(2006-2008年分别为64.63%、64.07%和64.38%)多于女性(分别为35.37%、35.93%和35.62%);病例构成居前三位的年龄组为30～44岁(分别为36.04%、34.82%和34.28%)、15～29岁(分别为30.74%、31.57%和30.13%)、45～64岁(分别为20.28%、20.70%和22.80%);道路交通伤害发生意图以非故意为主(分别为98.34%、99.07%和99.07%);伤害部位集中在头部(分别为35.21%、33.74%和35.77%)及下肢(分别为24.08%、24.54%和23.95%);伤害性质主要为挫(擦)伤(分别为56.47%、57.92%和58.89%)及骨折(分别为17.70%、15.84%和15.88%);伤害严重程度以轻度为主(分别为63.69%、67.24%和65.68%);伤害结局以病例在医院门(急)诊治疗后返家为主(分别为59.43%、63.76%和62.80%).结论 2006-2008年在门(急)诊就诊的道路交通伤害发生情况无明显变化,青壮年男性是道路交通伤害干预的重点人群.     

Evaluations of community mental health care in low- and middle-income countries: a 10-year review of the literature

Community-based models of providing mental health services are widely considered effective ways of serving individuals diagnosed with mental illness, but more comprehensive literature on these models in low- and middle-income countries is needed. This study is a systematic review of the effects of community-based models on health outcomes of adults with depression, schizophrenia, panic disorder, or bipolar disorders in middle- and low-income countries. PubMed, PsycINFO, and Cochrane Reviews were searched, returning 500 articles. The seventeen interventions included in this review in 14 countries show us that community-based mental health services can provide improvements in mental health outcomes, and the limited cost analyses suggest cost savings associated with community models of care. These findings are in line with much of the research on higher income countries. In addition, the studies also point to the gaps in the literature on costs, rural areas, bipolar disorders, and panic disorders, and note the need for further reviews of interventions targeting additional diseases, children, and adolescents as well as studies published in languages other than English. This review of the literature serves as a stepping stone for further research in community-based mental health services in low- and middle-income countries. The works reviewed here provide a base of knowledge that will assist us in taking the important next steps in program implementation and evaluation.     

The landscape in global tobacco control research: a guide to gaining a foothold

Smoking prevalence is shifting from more- to less-developed countries. In higher-income countries, smoking surveillance data, tailored treatments, public health campaigns, and research-based policy implementation have led to a decrease in tobacco use. In low- and middle-income countries, translating research into practice and policy is integral for tobacco control.We describe the landscape of existing resources, both financial and structural, to support global tobacco control research and strengthen research capacity in developing countries. We identify key organizations that support international efforts, provide examples of partnerships between developed and developing countries, and make recommendations for advancing global tobacco research.There is a need for increased commitment from organizations to support global tobacco control research.     

Road safety in less-motorized environments: future concerns

In the last three decades, the incidence of traffic crash fatalities and injuries has been reduced significantly in the high-income countries but not in the low- and middle-income countries. The traffic patterns in the former are not only different but are also less complex than those in the latter. Traffic in low-income countries comprises a much higher share of vulnerable road users and so vehicles, roads and the environment have to be designed for their safety. Solutions for such problems are not readily available and very innovative work needs to be done around the world to arrive at new policies and designs. In addition to crashworthiness of vehicles, transportation planning, exposure control, intelligent separation of non-motorized traffic on major roads, and traffic calming are likely to play a much more important role.     

WHO preferred product characteristics for monoclonal antibodies for passive immunization against respiratory syncytial virus (RSV) disease in infants – Key considerations for global use

World Health Organization (WHO) preferred product characteristics describe preferences for product attributes that would help optimize value and use to address global public health needs, with a particular focus on low- and middle-income countries. Having previously published preferred product characteristics for both maternal and paediatric respiratory syncytial virus (RSV) vaccines, WHO recently published preferred product characteristics for monoclonal antibodies to prevent severe RSV disease in infants. This article summarizes the key attributes from the preferred product characteristics and discusses key considerations for future access and use of preventive RSV monoclonal antibodies.     

2006－2013年全国伤害监测系统中儿童道路交通伤害病例变化趋势及现况特征分析

目的 了解中国儿童道路交通伤害门/急诊病例变化趋势及现况特征,为制定相关干预措施和政策提供依据.方法 利用2006-2013年全国伤害监测系统(NISS)数据,分析儿童道路交通伤害病例变化趋势及人口学、伤害事件和临床等现况特征.结果 2006-2013年NISS儿童道路交通伤害病例数量呈上升趋势,一直居儿童非故意伤害发生原因的第二位,但占儿童非故意伤害病例总数的比例呈下降趋势.2013年儿童道路交通伤害男女性别比值为1.82,17岁年龄段占10.86％;机动车车祸病例占66.44％,7、8月、周末和17:00-18:00时为高发期,65.42％的伤害是发生在驾乘交通工具时;伤害性质73.53％为挫伤/朦伤,伤害部位33.81％为头部,轻病例占76.42％,伤者74.86％的就医结局为治疗后回家.结论 儿童道路交通伤害问题不容忽视,中学高年级男生和学龄前男童是儿童道路交通伤害干预的重点人群,应针对不同年龄和性别儿童开展道路交通安全教育.     

Role of the private sector in the provision of immunization services in low- and middle-income countries

The authors conducted a literature review on the role of the private sector in low- and middle-income countries. The review indicated that relatively few studies have researched the role of the private sector in immunization service delivery in these countries. The studies suggest that the private sector is playing different roles and functions according to economic development levels, the governance structure and the general presence of the private sector in the health sector. In some countries, generally low-income countries, the private for-profit sector is contributing to immunization service delivery and helping to improve access to traditional EPI vaccines. In other countries, particularly middle-income countries, the private for-profit sector often acts to facilitate early adoption of new vaccines and technologies before introduction and generalization by the public sector. The not-for-profit sector plays an important role in extending access to traditional EPI vaccines, particularly in low-income countries. Not-for-profit facilities are situated in rural as well as urban areas and are more likely to be coordinated with public services than the private for-profit sector. Although numerous studies on non-governmental organizations (NGOs) suggest that the extent of NGO provision of immunization services in low- and middle-income countries is substantial, the contribution of this sector is poorly documented, leading to a lack of recognition of its role at national and global levels. Studies on quality of immunization service provision at private health facilities suggest that it is sometimes inadequate and needs to be monitored. Although some articles on public-private collaboration exist, little was found on the extent to which governments are effectively interacting with and regulating the private sector. The review revealed many geographical and thematic gaps in the literature on the role and regulation of the private sector in the delivery of immunization services in low- and middle-income countries.     

浙江省5县（市）医院急诊交通伤监测结果分析

目的分析浙江省道路交通伤害情况，为今后开展相关干预提供依据。方法运用浙江省5县（市）的15所医院的医院急诊伤害监测数据进行分析。结果2004-2005年共登记伤害患者23167例，交通伤病例5312例，占22．93％。监测的交通伤患者男女性别比为1．54：1，平均年龄（37．8±16．4）岁。道路交通伤害患者职业前3位分别是农／渔业劳动者、农民工和工人。伤害发生的主要地点为街道／城区（62．31％）和城际间公路（32．94％），男女性别间差异有统计学意义（P〈0．0001）；交通伤发生时活动主要为休闲和工作（包括去工作的路上），男女性间差异有统计学意义（P〈0．0001）；伤害严重程度以中等程度和轻微浅表伤为主，随着年龄的增长，轻微浅表伤其构成逐渐降低，中等程度伤害其构成逐渐升高（P〈0．0001）；2．81％的交通伤患者在伤害发生之前有饮酒行为。结论道路交通伤害的发生存在其一定规律，浙江省应充分利用医院急诊伤害监测系统，使其成为浙江省获取道路交通伤害发生情况的重要信息来源之一。