Estimating mortality and causes of death in Turkey: methods, results and policy implications

BACKGROUND: Cause-specific mortality statistics are primary evidence for health policy formulation, programme evaluation, and epidemiological research. In Turkey, a partially functioning vital registration system in urban areas yields fragmentary evidence on levels and causes of mortality. This article discusses the application of innovative methods to develop national mortality estimates in Turkey, and their implications for national health development policies. METHODS: Child mortality levels from the Demography and Health Survey (DHS) were applied to model life tables to estimate age-specific death rates. Reported causes of death from urban areas were adjusted using re-distribution algorithms from the Global Burden of Disease (GBD) Study. Rural cause structure was estimated from epidemiological models. Local epidemiological data was used to adjust model-based estimates. RESULTS: Life expectancy at birth in 2000 was estimated to be 67.7 years (males) and 71.9 years (females), about 8-10 years lower than in Western Europe. Leading causes of death include major vascular diseases (ischaemic heart disease, stroke) causing 35-38% of deaths, chronic obstructive lung disease and lung cancer in men, but also perinatal causes, lower respiratory infections and diarrhoeal diseases. Injuries cause about 6-8% of deaths, although this may be an underestimate. CONCLUSIONS: Mortality estimates are uncertain in Turkey, given the poor quality of death registration systems. Application of burden of disease methods suggests that there has been progress along the epidemiological transition. Key health development strategies for Turkey include improved access to communicable disease control technologies, and urgent attention to the development of a reliable, nationally representative health information system.     

Short- and long-term protective efficacy against clade 2.3.4.4 H5N2 highly pathogenic avian influenza virus following prime-boost vaccination in turkeys

Highly pathogenic avian influenza virus (HPAIV) infections are frequently associated with systemic disease and high mortality in domestic poultry, particularly in chickens and turkeys. Clade 2.3.4.4 represents a genetic cluster within the Asian HPAIV H5 Goose/Guangdong lineage that has transmitted through migratory birds and spread throughout the world. In 2014, clade 2.3.4.4 strains entered the U.S. via the Pacific flyway, reassorted with local strains of the North American lineage, and produced novel HPAIV strains of the H5N1, H5N2, and H5N8 subtypes. By 2015, the H5N2 HPAIVs disseminated eastwards within the continental U.S. and Canada and infected commercial poultry, causing the largest animal health outbreak in recent history in the U.S. The outbreak was controlled by traditional mass depopulation methods, but the outbreak was of such magnitude that it led to the consideration of alternative control measures, including vaccination. In this regard, little information is available on the long-term protection of turkeys vaccinated against avian influenza. In this report, a vaccination study was carried out in turkeys using 3 prime-boost approaches with a combination of 2 different vaccines, an alphavirus-based replicon vaccine and an adjuvanted-inactivated reverse genetics vaccine. Vaccine efficacy was assessed at 6 and 16 weeks of age following challenge with a prototypic novel clade 2.3.4.4 H5N2 HPAIV. All three vaccines protocols were protective with significantly reduced virus shedding and mortality after challenge at 6 weeks of age. In contrast, significant variations were seen in 16-week old turkeys after challenge: priming with the alphavirus-based replicon followed by boost with the adjuvanted-inactivated vaccine conferred the best protection, whereas the alphavirus-based replicon vaccine given twice provided the least protection. Our study highlights the importance of studying not only different vaccine platforms but also vaccination strategies to maximize protection against HPAIV especially with regards to the longevity of vaccine-induced immune response.     

The effect of health transformation policies on the resident physicians' perception of the medical profession in Turkey

Although the new changes in the health system in Turkey has resulted in positive implications with respect to the groups that use the healthcare services, it has been singled out for criticism by the professional associations because of its erosive consequences particularly for the medical profession as a whole. The purpose of this study is to explain how the health transformation policies and practices influenced the working conditions and perceptions of the resident physicians in Turkey with regard to the medical profession. A qualitative research design was employed, and the data was collected through document analysis and focus group interview. The common findings highlight that the new practices have had an aggravated effect on the working conditions of the resident physicians, which has resulted in several contentious issues. These include the increased workload, insufficient training and development, economic and social conditions and a heightened number of violent acts against physicians. Negatively, these influence the motivation of the physicians and their perception of the medical profession. This finding suggests that the medical profession is able to be studied as an appropriate case for the phenomenon of deprofessionalization. Copyright © 2016 John Wiley & Sons, Ltd.     

Subclinical infections with Crimean-Congo hemorrhagic fever virus, Turkey

To investigate Crimean-Congo hemorrhagic fever virus in Turkey, we conducted a seroepidemiologic survey during January-April 2009. Seroprevalence of infection was 10% in a sample from an outbreak region and increased with patient age, indicating that the virus had been previously present in Turkey. We also estimated that 88% of infections were subclinical.     

Evaluation of the quality of early childhood classrooms in Turkey

The purpose of this study was to examine the quality of two types of Turkish early childhood education programs: private and public preschools. ¹ 1. The term preschool is used to address the educational settings visited, which are preparatory classes starting one year before primary schools. Three public and three private preschools in a district of Istanbul were randomly selected. The quality of preschools was assessed using the Early Childhood Environment Rating Scale developed by Harms et al. The preschools were visited by the researcher and were observed for a nine‐hour school day. Observations indicate that activities such as daily routines, parent–teacher interactions, personal and professional needs are more appropriately handled by private preschool teachers than public preschool teachers. Shortcomings exist in both types of preschools in their physical class arrangements, authoritarian teacher child interactions, poor teacher–student ratio, and emphasis on structured and paper–pencil activities. Results suggest the need for Turkish preschool programs to be more child and family centered.     

Determination of dietary habits as a risk factor of cardiovascular heart disease in Turkish adolescents

Summary Background To investigate dietary habits and evaluate these with regard to cardiovascular risk status in Turkish adolescents aged 12–19 years. Methods A total of 300 adolescents, 135 males and 165 females aged between 12 and 19, were included in the study. Dietary intake was determined by using 3–day food records (including 1 weekend day). Adolescents smoking habits and familial chronic diseases were recorded. The values obtained for energy and nutrient intakes were compared with RDA and DRI and recommendations given by AHA. Results The mean energy intakes of male and female subjects were 1964 ± 723 kcal and 1804 ± 486 kcal respectively. According to NHANES III, age–standardized (CDC: Centers for Disease Control and Prevention) prevalence of overweight indicated that 20.7% among male and 17.5% among female adolescents were at risk for becoming overweight. The prevalence of premature CHD family history was found to be 9.6% for males and 11.5 % for females. The prevalence of current smoking was found to be 22.2 % for males and 18.2 % for females. In addition, 29.6% of the males and 37.6% of the females were physically inactive (p < 0.05); however, male adolescents (48.2%) were significantly more likely than female adolescents (52.1 %) to report sufficient moderate physical activity (p < 0.05). The dietary fiber intake was slightly below the recommended intake of 10 g per 1000 kcal. Compared to the AHA averages, these adolescents had significantly higher intake of total fat, saturated fat, sodium and dietary cholesterol and lower intake of polyunsaturated fat, monounsaturated fat and dietary fiber. The Turkish adolescents also had higher amounts of energy from fat. The mean percentage of energy from fat was 34.2 ± 6% TE for males and 35.2 ± 6.8 % TE for females; saturated fat was 11.8 ± 6.8 % TE for males and 12.1 ± 8.9 for females. The intake of fat and saturated fat was higher than the AHA recommendations. The polyunsaturated to saturated fat ratio was 0.4 ± 0.2 and reflected a high saturated fat (12.0 ± 7.7% TE) and low polyunsaturated fat (5.5 ± 3.9 % TE) diet. In addition, the percentage of adolescents who did not meet 66% of RDA for vitamin E, B6, and folates and the recommendation for RDA dietary fiber is presented. Approximately, 80% of adolescents failed to meet the dietary recommendation of the AHA for polyunsaturated fatty acids, and about 26.7% reported a cholesterol intake higher than 100 mg/1000 kcal. Conclusion It can be said that fiber, total fat, saturated fatty acid, cholesterol and sodium intake of Turkish adolescents are found to be high; however, their vitamin E, vitamin B6 and folate intake are found to be low compared to AHA recommendations. Turkish adolescents fruit and vegetable intake are also found to be low.     

Malaria: knowledge and behaviour in an endemic rural area of Turkey

This cross-sectional study was conducted to determine the knowledge and behaviour of people in the Sanliurfa province of Turkey regarding the prevention of malaria. A modified 30-cluster sampling method based on the traditional Expanded Programme for Immunization coverage surveys was employed to select a representative sample from 210 households. A questionnaire that focused on sociodemographic characteristics, knowledge and behaviour of malaria prevention, treatment-seeking behaviour and the use of antimalarials was applied. Eighty-nine percent of respondents knew at least one of the classical symptoms of malaria, and fever and chills were the most commonly reported symptoms (78.6%). Of the people interviewed, 33% believed that malaria can be acquired from dirty water, by changing place of residence, by working in cotton or tomato fields, or from malaria patients' belongings. None of the respondents knew how mosquitoes acquire the parasite. Twenty-five percent of respondents believed that elimination of breeding sites was one way to prevent malaria, and 8% identified the use of bednets. Fifty-five percent of respondents reported protective behaviours that are not directly associated with malaria transmission. Almost 47% of respondents reported that they completed their antimalarials, and only 21% of respondents indicated that they would seek treatment for febrile disease from physicians or a malaria unit. Understanding community perceptions of aetiology, symptom identification and treatment of malaria is an important step towards disease control.     

Obstetric outcomes of adolescent pregnancies in Turkey

Pregnancy in adolescence has been and continues to be a problem in public health. The purpose of this study was to investigate obstetric outcomes of adolescent pregnancies in Samsun, Turkey. A cross-sectional study was conducted between January 1 and December 31, 2004, at 3 hospitals in Samsun, Turkey. Of the 10,100 women who gave birth during this period, 357 (3.5%) were 18 years of age or younger; these patients were included in the study. Participants with a history of any chronic disease were excluded. Data were provided as median values (minmax) and percentages. In this study, the rate of birth for females 18 years or younger was found to be 35 per 1000. The median age of participants was 18 (14–18) years. The prevalence of cesarean section was calculated at 55.7%. Prevalences of lowbirthweight infants, preterm delivery, and eclampsia/preeclampsia were recorded as 44 (12.3%), 34 (9.5%), and 30 (8.4%) cases, respectively. Although the stillbirth rate was determined to be 1.7%, no congenital deformity was noted in infants, and none of the mothers died. The cephalopelvic disproportion rate was 5.9%, and only 2 adolescents experienced abruptio placentae. To reduce the occurrence of adolescent childbearing, pregnancy intentions must be assessed in multiple ways. Information/education may provide benefit to those female adolescents with inconsistent pregnancy intentions.