Should deworming be included in antenatal packages in hookworm-endemic areas of developing countries?

BACKGROUND: WHO recommends antenatal (after the first trimester) deworming for pregnant women who live in areas where the prevalence of hookworm infection exceeds 20-30%. However, deworming has not been included in antenatal care packages in most developing countries. METHODS: A review of articles publishing original data identified primarily through Medline was conducted using subject heading terms and text words for "deworming", "pregnant women", "hookworm", "anthelminthic", "anthelmintic", "albendazole", "mebendazole", "pregnancy" and their combinations. Bibliographies of retrieved articles were scanned to identify any additional relevant documents. RESULTS: Five articles examined the benefits of antenatal deworming. All provided evidence favourable to deworming, in terms of both maternal and infant outcomes. Comparison of outcome measures could be improved with a more standardized approach to outcome ascertainment and reporting. CONCLUSION: The evidence base for the inclusion of deworming in antenatal care packages in hookworm-endemic areas is mostly observational in nature. Future research should be directed towards 1) strengthening the evidence base with empirical data from randomized controlled trials, and 2) furthering our understanding related to government uptake of the WHO policy on deworming.     

Are self-reports of health and morbidities in developing countries misleading? Evidence from India

Self-reported measures of poor health and morbidities from developing countries tend to be viewed with considerable skepticism. Examination of the social gradient in self-reported health and morbidity measures provides a useful test of the validity of self-reports of poor health and morbidities. The prevailing view, in part influenced by Amartya Sen, is that socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits because an individual's assessment of their health is directly contingent on their social experience. In this study, we tested whether the association between self-reported poor health/morbidities and socioeconomic status (SES) in India follows the expected direction or not. Cross-sectional logistic regression analyses were carried out on a nationally representative population-based sample from the 1998 to 1999 Indian National Family Health Survey (INFHS); and 1995–1996 and 2004 Indian National Sample Survey (INSS). Four binary outcomes were analyzed: any self-reported morbidity; self-reported sickness in the last 15 days; self-reported sickness in the past year; and poor self-rated health. In separate adjusted models, individuals with no education reported higher levels of any self-reported, self-reported sickness in the last 15 days, self-reported sickness in the last year, and poor self-rated health compared to those with most education. Contrary to the prevailing thesis, we find that the use of self-rated ill-health has face validity as assessed via its relationship to SES. A less dismissive and pessimistic view of health data obtained through self-reports seems warranted.     

Pesticide usage and health consequences for women in developing countries: out of sight, out of mind?

Pesticide exposures of women in developing countries are aggravated by economic policy changes associated with structural adjustment programs and globalization. Women in these countries, particularly in the agricultural sector, are increasingly exposed. Since they are concentrated in the most marginal positions in the formal and informal workforces, and production is organized in a gender-specific way, opportunities for women to control their exposures are limited. Data from developing countries show that: 1) women's exposures to pesticides are significantly higher than is recognized; 2) poisonings and other pesticide-related injuries are greatly underestimated for women; 3) for a given adverse outcome from exposure, the experience of that outcome is gender-discriminatory; 4) erroneous risk perception increases women's exposures. The hiatus in knowledge of gender-specific exposures and effects is related to gender biases in the nature of epidemiologic inquiry and in the literature, and the gendered nature of health workers' practices and surveillance. Recommendations are made for strong, independent organizations that provide opportunities for women to control their environments, and the factors affecting their health, as well as gender-sensitive research to address the particularities of women's pesticide exposures.     

Are doctors and nurses associated with coverage of essential health services in developing countries? A cross-sectional study

Background  

There is broad policy consensus that a shortage of doctors and nurses is a key constraint to increasing utilization of essential health services important for achieving the health Millennium Development Goals. However there is limited research on the quantitative links between health workers and service coverage rates. We examined the relationship between doctor and nurse concentrations and utilization rates of five essential health services in developing countries.     

The standard of care debate: can research in developing countries be both ethical and responsive to those countries' health needs?

To avoid exploitation of host communities, many commentators argue that subjects must receive the best methods available worldwide. Others worry that this requirement may block important research intended to improve health care, especially in developing countries.To resolve this dilemma, we propose a framework for the conditions under which it is acceptable to provide subjects with less than the best methods. Specifically, institutional review boards should assume a default of requiring the "worldwide best" methods, meaning the best methods available anywhere in the world, in all cases.However, institutional review boards should be willing to grant exceptions to this default for research studies that satisfy the following 4 conditions: (1) scientific necessity, (2) relevance for the host community, (3) sufficient host community benefit, and (4) subject and host community non-maleficence.     

What impact does antenatal and postnatal care have on neonatal deaths in low- and lower-middle-income countries? Evidence from Bangladesh

We investigated the contribution of antenatal and postnatal care in reducing the risk of neonatal deaths in Bangladesh. The effects of these services were examined using adjusted Cox regression models and secondary data with 7,314 live-born infants. We observed that neonatal mortality was significantly decreased for newborns whose mothers' attended antenatal care services but postnatal care did not show any effect. Health promotion programs offering antenatal care in Bangladesh and other low- and lower-middle-income countries may build awareness about these practices. Further research is required to examine the reasons for the lack of impact of postnatal care on mortality.     

Achieving universal health insurance in Korea: a model for other developing countries?

As developing countries explore alternative methods to provide universal health insurance coverage, one potential model is South Korea. In twelve years (from 1977 to 1989), Korea was able to achieve universal health insurance coverage first by mandating employer based health insurance coverage for medium and large firms and then by establishing regional health insurance systems for small firms, farmers and the self-employed. A government medical aid insurance program was instituted for low income citizens. The specifics of the plan and some of the issues encountered in implementing the plan may be of interest to developing countries who want to achieve universal health insurance while maintaining a significant role for the private sector.     

What socioeconomic factors are associated with different levels of antenatal care visits in Bangladesh? A behavioral model

We identify the socioeconomic determinants of three levels of antenatal care (ANC) visits (no, intermediate [1–3], and recommended [≥4]) in Bangladesh using a behavior model framework for health care utilization. Using multinomial logistic regression, we found that different levels of visits had different determinants; for example, media exposure increased the likelihood of intermediate compared with no visits while desire for pregnancy increased the likelihood of recommended compared with intermediate visits. We therefore highlight that ANC policies or interventions should be target-group specific because determinants differ depending on level of ANC visits.     

‘Why take chances?’ Advice on alcohol intake to pregnant and non-pregnant women in four Nordic countries

In this article we explore the construction of risk in government guidelines on alcohol intake during and before pregnancy in four Nordic countries given that there is no sound evidence linking a low level of alcohol intake during pregnancy to foetal harm. In the article we draw on two sources of data to examine the rationale behind the advice given to pregnant women: health education materials and other government documents, such as guidelines for professionals. We found that in all the four countries the government guidelines advised pregnant women to completely abstain from alcohol consumption, but there was some variation between the countries in the advice for non-pregnant women. The guidance in the four countries also differed in the extent to which they discussed the lack of evidence behind the abstinence advice and the precautionary approach on which the advice was based. In all the four countries the printed and widely circulated health education materials did not explain that the abstinence advice was not based on actual evidence of harm but on a precautionary approach. The other government documents adopted varying strategies for justifying the abstinence advice including not offering information about the uncertainty of the knowledge base, implying that there was evidence that low alcohol consumption was harmful to the foetus, acknowledging that a safe level of alcohol intake during pregnancy could not be specified and explaining the precautionary approach to risk. In this article we argue that the shift from ‘estimation of risk’ to the ‘precautionary principle’ is a part of a wider socio-cultural push towards broader employment of the precautionary principle as a strategy to manage uncertainty, and in the context of pregnancy, it is a part of the symbolic struggle to protect the purity of the foetus and construct the ‘perfect mother’.     

Measuring women’s expectations of childbirth care services in a developing country: development and validation of scales

Aim

To describe the development of an instrument for measuring women’s expectations of different aspects of childbirth care services in Zahedan, Iran.

Subjects and methods

Qualitative research was conducted with 24 mothers, 21 of whom gave birth at home and 4 of whom gave birth in the hospital, to identify women’s expectations of childbirth care services. Four scales, preference for and opposition to the hospital and home, were designed. The questionnaires were administered to a representative sample of mothers who had planned home or hospital births within the past 6?months. Then, psychometric analyses were used to assess the validity and reliability of the scales.

Results

The reliability analysis of the scales showed satisfactory results (Cronbach’s alpha ranged from 0.91 to 0.97). The results of the scale content validity index (S-CVI) suggested good construct validity (ranging from 94 to 98). The result of the known group comparison showed that the scales and sub-scales distinguished well between sub-groups of mothers whose places of delivery differed (planned home or hospital birth). The factor analysis of preference for hospital yielded three factors: perceived safety, enjoyment of development and financial accessibility. The sub-scale of opposition to home included perceived risk, policies and perceived health status.

Conclusion

The scale can be used by managers and policymakers to adjust services in accord with the views and expectations of mothers to increase the utilisation of services.     

Audit of therapeutic interventions in inpatient children using two scores: are they evidence-based in developing countries?

Background

The evidence base of clinical interventions in paediatric hospitals of developing countries has not been formally assessed. We performed this study to determine the proportion of evidence-based therapeutic interventions in a paediatric referral hospital of a developing country

Methods

The medical records of 167 patients admitted in one-month period were revised. Primary diagnosis and primary therapeutic interventions were determined for each patient. A systematic search was performed to assess the level of evidence for each intervention. Therapeutic interventions were classified using the Ellis score and the Oxford Centre for Evidence Based Medicine Levels of Evidence

Results

Any dehydration due to diarrhoea (59 cases) and pneumonia (42 cases) were the most frequent diagnoses. Based on Ellis score, level I evidence supported the primary therapeutic intervention in 21%, level II in 73% and level III in 6% cases. Using the Oxford classification 16%, 8%, 1% and 75% therapeutic interventions corresponded to grades A, B, C, and D recommendations, respectively. Overall, according to Ellis score, 94% interventions were evidence based. However, out of the total, 75% interventions were based on expert opinion or basic sciences. Most children with mild to moderate dehydration (52 cases) were inappropriately treated with slow intravenous fluids, and most children with non-complicated community acquired pneumonia (42 cases) received intravenous antibiotics

Conclusions

Most interventions were inappropriate, despite the availability of effective therapy for several of them. Diarrhoeal dehydration and community acquired pneumonia were the most common diagnoses and were inappropriately managed. Existing effective interventions for dehydration and pneumonia need to be put into practice at referral hospitals of developing countries. For the remaining problems, there is the need to conduct appropriate clinical studies. Caution must be taken when assigning the level of evidence supporting therapeutic interventions, as commonly used classifications may be misleading     

Gaps in transitional care: what are the perceptions of adolescents,parents and providers?

Background Several studies have investigated preferences and experiences of adolescents with different chronic conditions and their parents. Some have included the provider's perspective. Studies comparing the three perspectives on satisfaction with (transitional) care for different chronic conditions, however, are lacking. The main aim of this paper was to explore differences and similarities in perspectives between adolescents with chronic conditions, their parents and providers on transitional care. A secondary aim was to explore the extent to which such perspectives are disease‐specific. Methods This quantitative study included 127 adolescents with juvenile rheumatoid arthritis (JRA), neuromuscular disorder with chronic ventilation (NMD), or diabetes Type I; 166 parents; and 19 care providers. To assess the experiences and perceptions of adolescents and parents on transitional care, we used the ‘Mind the Gap’ instrument. The survey for providers included a checklist of shortcomings in transitional care. Results Adolescents rate current care significantly worse than parents on opportunities to make their own decisions and be seen without parents present. Adolescents also rated providers' current social skills lower than parents. Adolescents are more satisfied than their parents about transitional care process aspects such as co‐ordination and communication between providers, but both groups indicated that the care process offers most room for improvement. Providers reported other aspects such as adolescents' lack of responsibility with regard to self‐care and parents' difficulties with ceding control to their children. When looking at the three disease groups – JRA, NMD, diabetes, we found only small differences. According to providers, shortcomings in the care process with respect to guidelines, protocols and co‐ordination are most prevalent. Conclusion Adolescents, parents and providers all report that there is room for improvement with regard to aspects of the care delivery process in transitional care. With respect to disease‐specific issues we only found small differences.     

Role of primary care providers in a pandemic – conflicting views and future opportunities

In pandemic situations, primary care providers may be involved in a variety of roles related to disease surveillance, diagnosis and treatment, prevention, and patient education. This commentary describes the contextual factors that may influence primary care providers’ perspectives on their pandemic roles and responsibilities. These factors include the natural evolution of the pandemic situation, with early uncertainty affecting decision-making and communication; the variation in typical practice patterns and clinical expertise across and within primary care providers; and the lack of representation of practicing primary care providers in pandemic planning and decision-making bodies.     

Ethical oversight of public health research: can rules and IRBs make a difference in developing countries?

Controversies in the conduct of international research continue to pose challenges for the system of ethical review, particularly for developing countries. Although the concept of vulnerability is key to addressing these challenges, ethical review has typically ignored the agency of vulnerable participants and groups in determining what kind of review process is needed. Concurrent with developments shaping the new public health that seek to operationalize empowerment of communities by placing them as initiators and organizers of their own health, ethical review of public health research must find ways to recognize the agency of vulnerable individuals, groups, and communities in the review process if it is to address effectively the ethical dilemmas currently evident in collaborative international research.     

Environmental health practices,constraints and possible interventions in peri-urban settlements in developing countries – a review of Kampala,Uganda

Like most cities in developing countries, Uganda's capital city, Kampala, is experiencing urbanisation leading to an increase in population, and rapid development of peri-urban (informal) settlements. More than 60% of the city's population resides in these settlements which have the lowest basic service levels (sanitation, water supply, solid waste collection, stormwater and greywater disposal). A review of earlier studies on infrastructure development and sustainability within Kampala's peri-urban settlements, field surveys in a typical peri-urban settlement in the city (Bwaise III Parish), and structured interviews with key personnel from the National Water and Sewerage Corporation (NWSC), Kampala City Council (KCC), and the National Environment Management Authority (NEMA) were undertaken. Findings on current environmental health practices as well as perspectives of local communities and interviewed institutions on problems, constraints and possible solutions to basic service provision are presented. The implications of these viewpoints for possible environmental health interventions are presented.     

What do consumers and healthcare providers in West Virginia think of long-term care?

In recent years, the media has portrayed long-term care in a negative light, with exposè news stories on skilled nursing facilities, personal care homes, and hospitals that provide long-term care. There have been few positive news stories to counter the negative ones, and there is concern that the public perception of long-term care is inaccurate. The authors conducted the following study to evaluate how the West Virginia consumer perceives and defines long-term care and if there is a difference in that perception as compared with healthcare workers' perceptions and definitions of long-term care. The results of the study indicate that the respondents' education level, not occupation, has the most significant influence on respondents' definitions and perceptions of long-term care. Respondents felt that although media articles are informative, they are not accurate, and that long-term care is a needed service they would consider both for themselves and for a loved one. The results of the study suggest that current marketing strategies employed by nursing homes are working, as respondents largely believe that long-term care is provided in nursing homes and that they would likely seek care there if needed.     

Insertional pain and other IUD insertion-related rare events for breastfeeding and non-breastfeeding women — a decade's experience in developing countries

The possible effect of breastfeeding on intrauterine device (IUD) insertion events was investigated. Analysis included a total of 6493 women who enrolled in multicenter IUD clinical trials over a ten-year period. Findings indicate that breastfeeding exerts a protective effect on the incidence of moderate to severe insertional pain and reduces the need for cervical dilatation to facilitate insertion. The pain protection effect was most evident in breastfeeding women who were still in lactational amenorrhea. Subjects with amenorrhea, both breastfeeding and non-breastfeeding, had a significantly lower incidence of pain at IUD insertion than the corresponding menstruating subjects. This effect may be related to a higher secretion of beta-endorphin in the breastfeeding and lactational amenorrheic subjects.

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Resumen Se investigaron en este estudio los posibles efectos del amamantamiento sobre la inserción de dispositivos intrauterinos (DIU). El estudio comprendió 6493 mujeres que participaron en ensayos clínicos en diversos centros durante un período de diez años. Los resultados indican que el amamantamiento ejerce un efecto protector contra la aparición de dolores moderados a fuertes en el momento de la inserción y reduce la necesidad de dilatar el cuello del útero para facilitar la inserción. Este efecto de protección contra el dolor predominó entre las mujeres que amamantaban y se hallaban aún en amenorrea de lactación. Las mujeres con amenorrea, tanto las que amamantaban como las que no lo hacían, señalaron un nivel de dolor significativamente menor en el momento de inserción del DIU que aquéllas cuyo ciclo menstrual se había reanudado. Este efecto puede estar relacionado con una mayor secreción de -endorfina en las mujeres en período de amamantamiento o de amenorrea de lactación.

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Resumé Cette étude présente les effets possibles de l'allaitement au sein sur des phénomènes liés à l'insertion de dispositifs intra-utérins (DIU). La recherche portait 6493 femmes inscrites dans plusieurs centres pour participer à des essais cliniques pendant une période de dix ans. On a constaté que l'allaitement au sein a un effet protecteur contre l'apparition de douleurs modérées à fortes au moment de l'insertion et qu'il réduit la nécessité de dilater le col utérin en vue de faciliter l'insertion. Cet effet de protection contre les douleurs prédominait chez les femmes qui allaitaient et se trouvaient encore en aménorrhéc de lactation. Les douleurs au moment de l'insertion étaient significativement moins fréquentes au moment de la pose du DIU chez celles qui, allaitant ou non, étaient encore en période d'aménorrhée, que chez celles dont le cycle menstruel avait repris. Cet effet peut être lié à une sécrétion plus abondante de -endorphine chez les femmes en période d'allaitement ou d'aménorrhée de lactation.

     

Pulmonary embolus and maternal mortality in the antenatal period--evidence of a trend?

An analysis of pulmonary embolus mortality data was undertaken to investigate a putative change in maternal mortality due to pulmonary embolism in the antenatal period of pregnancy. A comparison was made of mortality due to pulmonary embolus for pregnant and non-pregnant women of reproductive age in England and Wales in the four triennia from 1976. During this period the antenatal pulmonary embolus mortality rate remained unchanged, whereas a statistically significant decline in non-pregnancy related pulmonary embolus mortality was observed. A comparison of the mortality trends between the two groups found the difference to be statistically highly significant. These findings strongly suggest that, over the twelve years investigated, women in the antenatal period of pregnancy have not benefited from the reduced risk of death from pulmonary embolus enjoyed by their non-pregnant counterparts.