Potential uses of cost analyses in child survival programmes: evidence from Africa

How can analyses of costs and cost-effectiveness help internationalhealth care specialists to monitor service delivery, evaluateactivities, plan for improvements in programmes, and arrangefor adequate financing? Answers illustrated in this paper includecomparison of the average costs of specific services among localhealth care facilities for monitoring and supervision purposes;interpretation of total and average costs to increase programmeefficiency; consideration of the relative cost-effectivenessof various immunization strategies; projection of recurrentcosts to indicate the magnitude of future financing needs; and,derivation of information incidental to cost analyses, but essentialto programme operations and personnel management. Supportiveexamples include results from child survival programmes in Africa,with particular emphasis on evaluations of some national programmecomponents from the Combatting Childhood Communicable Diseases(CCCD) Project.     

Control of household air pollution for child survival: estimates for intervention impacts

Background

Exposure to household air pollution (HAP) from cooking with solid fuels affects 2.8 billion people in developing countries, including children and pregnant women. The aim of this review is to propose intervention estimates for child survival outcomes linked to HAP.

Methods

Systematic reviews with meta-analysis were conducted for ages 0-59 months, for child pneumonia, adverse pregnancy outcomes, stunting and all-cause mortality. Evidence for each outcome was assessed against Bradford-Hill viewpoints, and GRADE used for certainty about intervention effect size for which all odds ratios (OR) are presented as protective effects.

Results

Reviews found evidence linking HAP exposure with child ALRI, low birth weight (LBW), stillbirth, preterm birth, stunting and all-cause mortality. Most studies were observational and rated low/very low in GRADE despite strong causal evidence for some outcomes; only one randomised trial was eligible.Intervention effect (OR) estimates of 0.64 (95% CI: 0.55, 0.75) for ALRI, 0.71 (0.65, 0.79) for LBW and 0.66 (0.54, 0.81) for stillbirth are proposed, specific outcomes for which causal evidence was sufficient. Exposure-response evidence suggests this is a conservative estimate for ALRI risk reduction expected with sustained, low exposure. Statistically significant protective ORs were also found for stunting [OR=0.79 (0.70, 0.89)], and in one study of pre-term birth [OR=0.70 (0.54, 0.90)], indicating these outcomes would also likely be reduced. Five studies of all-cause mortality had an OR of 0.79 (0.70, 0.89), but heterogenity precludes a reliable estimate for mortality impact. Although interventions including clean fuels and improved solid fuel stoves are available and can deliver low exposure levels, significant challenges remain in achieving sustained use at scale among low-income households.

Conclusions

Reducing exposure to HAP could substantially reduce the risk of several child survival outcomes, including fatal pneumonia, and the proposed effects could be achieved by interventions delivering low exposures. Larger impacts are anticipated if WHO air quality guidelines are met. To achieve these benefits, clean fuels should be adopted where possible, and for other households the most effective solid fuel stoves promoted. To strengthen evidence, new studies with thorough exposure assessment are required, along with evaluation of the longer-term acceptance and impacts of interventions.

     

The process of changing national malaria treatment policy: lessons from country-level studies

Widespread resistance of Plasmodium falciparum parasites to commonly used antimalarials, such as chloroquine, has resulted in many endemic countries considering changing their malaria treatment policy. Identifying and understanding the key influences that affect decision-making, and factors that facilitate or undermine policy implementation, is critical for improving the policy process and guiding resource allocation during this process. A historical review of archival documents from Mala?i and data obtained from in-depth policy studies in four countries (Tanzania, South Africa, Kenya and Peru) that have changed malaria treatment policy provides important lessons about decision-making, the policy cycle and complex policy environment, while specifically identifying strategies successfully employed to facilitate policy-making and implementation. Findings from these country-level studies indicate that the process of malaria drug policy review should be institutionalized in endemic countries and based on systematically collected data. Key stakeholders need to be identified early and engaged in the process, while improved communication is needed on all levels. Although malaria drug policy change is often perceived to be a daunting task, using these and other proven strategies should assist endemic countries to tackle this challenge in a systematic fashion that ensures the development and implementation of the rational malaria drug policy.     

Global estimates of fatal work-related diseases

BACKGROUND: Work-related mortality is a relatively new concept which aims to widen occupational health and safety; to take into account not only recognized fatal occupational accidents and diseases but also other work-related deaths. Few countries in the world have a register for work-related diseases. METHODS: Estimates are calculated using baseline world mortality scenarios of all diseases for the year 2000 and attributable fractions made for work-related diseases in Finland, as adjusted. RESULTS: It is estimated that about 2 million work-related deaths take place annually. Men suffer two thirds of those deaths. The biggest groups of work-related diseases are cancers, circulatory diseases and communicable diseases. CONCLUSIONS: Information about work-related diseases is needed for prevention, as people in developed countries are working longer, and the age of retirement is being raised in many countries. As a result, workers are being exposed to different kinds of substances and working conditions for a longer time. In developing countries, work exposures may already start in infancy. Due to industrialization, workers in developing countries are facing new conditions with a lack of relevant knowledge and skills. With the help of information, nations can direct resources and skills for appropriate purposes such as regulatory measures on health and safety at work.     

Global cost of correcting vision impairment from uncorrected refractive error

Objective

To estimate the global cost of establishing and operating the educational and refractive care facilities required to provide care to all individuals who currently have vision impairment resulting from uncorrected refractive error (URE).

Methods

The global cost of correcting URE was estimated using data on the population, the prevalence of URE and the number of existing refractive care practitioners in individual countries, the cost of establishing and operating educational programmes for practitioners and the cost of establishing and operating refractive care facilities. The assumptions made ensured that costs were not underestimated and an upper limit to the costs was derived using the most expensive extreme for each assumption.

Findings

There were an estimated 158 million cases of distance vision impairment and 544 million cases of near vision impairment caused by URE worldwide in 2007. Approximately 47 000 additional full-time functional clinical refractionists and 18 000 ophthalmic dispensers would be required to provide refractive care services for these individuals. The global cost of educating the additional personnel and of establishing, maintaining and operating the refractive care facilities needed was estimated to be around 20 000 million United States dollars (US$) and the upper-limit cost was US$ 28 000 million. The estimated loss in global gross domestic product due to distance vision impairment caused by URE was US$ 202 000 million annually.

Conclusion

The cost of establishing and operating the educational and refractive care facilities required to deal with vision impairment resulting from URE was a small proportion of the global loss in productivity associated with that vision impairment.     

Global estimates of fatal occupational accidents.

Data on occupational accidents are not available from all countries in the world. Furthermore, underreporting, limited coverage by reporting and compensation schemes, and non-harmonized accident recording and notification systems undermine efforts to obtain worldwide information on occupational accidents. This paper presents a method and new estimated global figures of fatal accidents at work by region. The fatal occupational accident rates reported to the International Labour Office are extended to the total employed workforce in countries and regions. For areas not covered by the reported information, rates from other countries that have similar or comparable conditions are applied. In 1994, an average estimated fatal occupational accident rate in the whole world was 14.0 per 100,000 workers, and the total estimated number of fatal occupational accidents was 335,000. The rates are different for individual countries and regions and for separate branches of economic activity. In conclusion, fatal occupational accident figures are higher than previously estimated. The new estimates can be gradually improved by obtaining and adding data from countries where information is not yet available. Sectoral estimates for at least key economic branches in individual countries would further increase the accuracy.     

A new method for imputing country-level estimates of hepatitis A virus endemicity levels in the Eastern Mediterranean region

Background

Few country-level estimates for hepatitis A virus (HAV) seroprevlance are available for the 23 countries in the Eastern Mediterranean region (EMRO) of the World Health Organization.

Methods

We used a three-stage approach to assign an HAV endemicity level to each country in North Africa and the Middle East based on the age at midpoint of population immunity. First, we conducted a systematic review to identify all age–seroprevalence studies conducted within the past 10 years. Second, for countries without first-stage evidence we searched for incidence data and older seroprevalence data. Third, for countries with no hepatitis A data, we estimated HAV endemicity based on socioeconomic and water indicators.

Results

This three-stage method allowed us to estimate country-specific endemicity levels for every country in EMRO even though first-stage evidence was only available for nine countries and for three countries only third-stage evidence was available. The region has a heterogeneous hepatitis A risk profile, with 13 countries having very high endemicity (an age at midpoint of population immunity in early childhood), three having high endemicity (late childhood), and seven having intermediate endemicity (early adulthood).

Conclusions

The three-stage estimation approach enables the creation of a complete country-level map of HAV risk in EMRO. Given the heterogeneity of HAV endemicity levels in the region and the likelihood of transitions to lower incidence rates and greater adult susceptibility in the near future, enhanced surveillance for hepatitis A would strengthen decisions about vaccination policy in the region.     

Global child survival initiatives and their relevance to the Latin American and Caribbean Region.

We review two series of papers published by The Lancet: the Child Survival Series (2003) and the Neonatal Survival Series (2005). Both series drew attention to the nearly 11 million annual deaths of children under the age of five years, and to the fact that almost 4 million of these deaths occur in the first month of life. We show that two thirds of these deaths could be prevented through universal coverage with existing, low-cost interventions that are failing to reach most children in the world. The series also highlighted the importance of reducing inequities both between and within countries. The relevance of these series to Latin America and the Caribbean is examined. Although substantial progress has been made in reducing mortality and improving coverage, two major challenges remain: how to improve the quality of health interventions, and how to reach the most disadvantaged children in the Latin American and Caribbean Region.     

Nutritional intervention: a key to child survival

In a collaborative relationship, researchers from the Cebu Institute of Medicine and from the United States have carried out a series of longitudinal studies of breast feeding and infant growth in a rural Philippine community. On the basis of our findings, we have conducted field experiments designed to have mothers improve their infants' diets using locally available food. Contingent reinforcement strategies were used successfully to get mothers to change their behavior and beliefs about infant feeding practices. The use of reinforcements resulted in improved diets and very high rates of continuation of participation in the field experiments. We believe that this is a highly productive and cost effective way to approach the problem of gaining cooperation and continued involvement in a nutrition intervention effort.     

The struggle for survival of the child discharged from intensive care

Pediatric intensive care units have significantly reduced childhood morbidity and mortality, and have generated a group of children with special care needs. The common sense family care they receive at home however has not been trained to attend to them, interfering in their quality of life and causing frequent returns to hospital. To know about discharge from intensive care is to go beyond survival and to also offer a better quality of life. To this end we developed an epidemiological method in two public health care facilities in Rio de Janeiro, to investigate the time and number of hospitalizations and type and quantity of diagnosis between 1994-1999, with children aged from 29 days to 12 years. The results show that 6.3% (85) of 1355 hospitalized children were considered with special care needs, with 9 hospitalizations of up to 60 days. To each hospitalization can be added one or two basic diagnoses revealing chronic conditions.     

Estimating the mortality cost of AIDS: do estimates of earnings differ?

The future earnings of male Texans dying of AIDS in 1987 were estimated using: national earnings profiles; earnings derived from occupations listed on death certificates; and earnings reported by persons with AIDS who responded to a survey. Mortality cost estimates using the two sources of actual earnings differed by a modest amount in comparison to the estimate using national earnings profiles.     

Women's education, child welfare and child survival: a review of the evidence

This paper reviews recent evidence concerning the relative importance of women's education for child health, especially child survival in the Third World. Important regional patterns are uncovered, and particular attention is paid to discussion of the weaker associations observed in sub-Saharan Africa.     

PM2.5对慢性阻塞性肺疾病发生发展影响及药物治疗研究进展

  目的  研究穿心莲内酯对香烟烟雾熏染小鼠的保护作用,为慢性阻塞性肺疾病（COPD）的预防治疗提供依据;  方法  采用随机数字表法将40只小鼠分为对照组（A）、香烟烟雾组（B）、生理盐水组（C）、穿心莲内酯组（D）。除对照组小鼠正常饲养外,其他3组采用浓度为300 mg/m³香烟烟雾熏染,1天2次,每次1 h,每周5天,共熏染12周,生理盐水组和穿心莲内酯组在每周的最后一天分别注射生理盐水和穿心莲内酯。测定各组小鼠的平均内衬间隔（MLI）和平均肺泡面积（MAA）、血清和支气管肺泡灌洗液（BALF）中的IL-6和IL-8、BALF中的基质金属蛋白酶9（MMP-9）,并进行IL-6、IL-8与MMP-9的相关性分析。  结果  香烟烟雾组MLI、MAA、IL-6、IL-8、MMP-9明显 > 对照组。与香烟烟雾组比较,穿心莲内酯组MLI和MAA减小,IL-6、IL-8、MMP-9明显下降。IL-6、IL-8与MMP-9显著相关。  结论  穿心莲内酯通过抗炎降低MMP-9的产生以拮抗香烟烟雾对小鼠的肺损伤。     

Beneficial effects of a woman-focused development programme on child survival: evidence from rural Bangladesh

This paper reports results from a prospective study of the impact of a woman-focused development programme on child survival in Matlab, a rural area of Bangladesh. The programme was targeted to households owning less than 50 decimals of land and members selling more than 100 days of labour for living in a year. Programme components included formation of women's groups for saving and credit, training on skill development, functional literacy including legal and social awareness, and technical and marketing support to projects undertaken with the loan money from the organization. A total of 13,549 children born alive during 1988-97 in the study area were included in the study. Hazards of mortality during pre- and post-intervention periods were compared among the programme participants and non-participants controlling the effects of other relevant variables. There has been a substantial reduction in mortality during the post-intervention period; however, the reduction was much greater for infants whose mothers participated in the development programme compared to infants of non-participant mothers from similar socioeconomic background. In a relative sense, there has been a 52% reduction of the pre-intervention level hazard of death of children during infancy of participant mothers compared to 31% reduction for the infants of non-participant mothers from similar socioeconomic background. There had also been a substantial reduction in hazard of death during childhood (1-4 year age group), however, the reduction was statistically similar for all groups of children irrespective of their mothers' participation in the development programmes.     

Expanding Medicaid coverage for pregnant women: estimates of the impact and cost

An estimated 361,000 pregnant women are expected to be newly eligible for Medicaid coverage when all states raise the income ceiling for such coverage to 100 percent of the federal poverty level by 1990, as Congress has mandated. According to a methodology for projecting the effects of recent congressional changes in the Medicaid program, about 64 percent of these women would be otherwise uninsured, at least for maternity care, and the rest would have some insurance, so Medicaid would be the payer of last resort. Congress has also given states the option to cover pregnant women with incomes from 100 to 185 percent of poverty. If all states were to do so, another 552,000 women would become eligible, 29 percent of whom would otherwise have no insurance coverage for maternity care. The estimate of newly eligible women with incomes below 185 percent of poverty represents 24 percent of the 3.8 million women who give birth in the United States each year. Under the 100-percent-of-poverty ceiling, the estimated number of poor women eligible for coverage ranges from 4,000 or fewer in 18 states and the District of Columbia to 41,000 in California and Texas. At 185 percent of poverty, the number ranges from 4,000 or fewer in 11 states and the District of Columbia to more than 90,000 in California and Texas. Eight states have already elected to extend Medicaid coverage to the 185-percent-of-poverty ceiling.(ABSTRACT TRUNCATED AT 250 WORDS)     

Total body protein in healthy adolescent girls: validation of estimates derived from simpler measures with neutron activation analysis

BACKGROUND: Little recent and accurate information about body protein content in healthy adolescent girls is available. OBJECTIVE: The objective was to assess the total body nitrogen (TBN) and total body protein (TBPr) contents of fat-free mass (P:FFM) in a group of healthy adolescent girls and to validate previously published TBN prediction equations. DESIGN: TBN was measured with in vivo neutron activation analysis (TBNNAA). Bone mineral density and FFM were measured with dual-energy X-ray absorptiometry (FFMDXA), total body water and FFM were measured with bioimpedance analysis, and FFM was assessed by measuring skinfold thicknesses in 51 girls with a mean (+/- SD) age of 14.7 +/- 0.7 y. The validity of the TBN prediction equations was assessed with Bland-Altman analysis. RESULTS: TBNNAA in our adolescent group was higher (1.49 kg) than values reported in earlier studies of women (1.25 and 1.31 kg), and P:FFM was slightly higher (23%) than that documented in adults (19-21%). Previously published TBN equations showed either systematic bias or wide limits of agreement. CONCLUSION: A predictive equation derived from the present study population based on FFMDXA improves the prediction of TBN for groups of young girls but may not be helpful for individuals in clinical settings.     

Up-to-date and precise estimates of cancer patient survival: model-based period analysis

Monitoring of progress in cancer patient survival by cancer registries should be as up-to-date as possible. Period analysis has been shown to provide more up-to-date survival estimates than do traditional methods of survival analysis. However, there is a trade-off between up-to-dateness and the precision of period estimates, in that increasing the up-to-dateness of survival estimates by restricting the analysis to a relatively short, recent time period, such as the most recent calendar year for which cancer registry data are available, goes along with a loss of precision. The authors propose a model-based approach to maximize the up-to-dateness of period estimates at minimal loss of precision. The approach is illustrated for monitoring of 5-year relative survival of patients diagnosed with one of 20 common forms of cancer in Finland between 1953 and 2002 by use of data from the nationwide Finnish Cancer Registry. It is shown that the model-based approach provides survival estimates that are as up-to-date as the most up-to-date conventional period estimates and at the same time much more precise than the latter. The modeling approach may further enhance the use of period analysis for deriving up-to-date cancer survival rates.     

Mother protection,child survival: narrative perspectives on child mental health services underutilization

In the United States, increased national attention has generated a wealth of public health and epidemiologic research examining disparities in African American children’s mental health services utilization. Research has not yet been extended to examining the social structural mechanisms that keep these disparities stable and in place. Drawing from a larger urban ethnographic field study exploring the ‘everyday’ of health and illness within and across African American families living in an inner city public housing community, in this article I document the narratives of four African American mothers to illustrate how social structural mechanisms shape their decisions to seek or not mental health services for their children. I frame mothers’ decisions in terms of everyday violence, drawing attention to the institutionalized injustices that are normalized and rendered invisible because of their routine pervasiveness. I conclude with a discussion of integrating structural interventions to modify or reduce disparities in African American children’s mental health services utilization.