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Gender norms: Characteristics of successful programmes targeting children, adolescents, and young adults

​Gender norms: Characteristics of successful programmes targeting children, adolescents, and young adults

Gender norms permeate in our communities’ culture and institutions as rules that govern beliefs about how individuals should behave and as perceptions of what most people in the community do. For instance, these norms are the ones behind masculinity requiring men to be tough and stoic, and proving the manliness through risky behaviours. Similarly, normative expressions of femininity encourage women's sexual passivity and deference to male partners for important health-related decisions. Under this normalization, it is common that a gender is favoured and that minorities are subject to isolation and poor quality or abusive health care, if any, for not conforming to a binary gender. Children, adolescents, and young adults are particularly vulnerable to the norms as they may lead to unequal breastfeeding or immunisation practices, or differential health-care seeking, among other problems that impact throughout the life up to adulthood. Given the importance early interventions in children, adolescents, and young adults, Levy and colleagues developed a systematic review to supplement the Lancet Series on Gender Norms and Health, to inform about the characteristics of successful programmes targeting these populations.

To provide the systematic review with robustness, the authors followed the PRISMA guidelines to identify health programmes with gender transformative intent that focused on the populations of interest. They included only programmes that rigorously measured health-related outcomes and that met at least one of the criteria of the Interagency Gender Working Group's definition of gender-transformative programming. Levy and colleagues identified and analysed 61 evaluations of gender-transformative programmes with different health focus that could also exemplify the Sustainable Development Goal principle of investing in areas that spark or catalyse diffusion of change. As a results, the authors suggested a potential model for accelerating the achievement of this Goal through 4 programmatic approaches: (1) using multisectoral action; (2) incorporating multilevel, multistakeholder involvement; (3) implementing diversified programming; and (4) fostering social participation and empowerment. The systematic review can be consulted at:

https://www.sciencedirect.com/science/article/pii/S2214109X19304954?via%3Dihub


Contact:

Salvador Camacho, Swiss TPH

salvador.camacho@swisstph.ch

12/02/2020 13:08
Under-funding of a magic bullet?

​Under-funding of a magic bullet?

Numerous research articles and documents produced by multilateral organisations such as WHO have highlighted the need for scaling-up community health worker (CHW) programmes. This, it is argued, is essential to the achievement of universal health coverage (UHC) for the most vulnerable populations and to enable preparedness to better respond to outbreaks of threatening infections, such as Ebola. Given the importance placed upon the strengthening of CHWs, it might be expected that development assistance has budgeted support for a much-needed scale-up. A study published this month in the WHO Bulletin by Lu et al entitled "Development assistance for community health workers in 114 low- and middle-income countries, 2007–2017". Investigated the extent and trend of development assistance for community health worker-related projects in low- and middle-income countries.

Using data extracted from the Organisation for Economic Co-operation and Development's (OECD) creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries between 2007–2017, the research team analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time. This revealed that in this period:

  • Total development assistance targeting CHW projects was around USD 5,298.02 million, accounting for only 2.5% of the total development assistance budget for health.

  • The top three donors to CHW strengthening and scale-up were the Global Fund, the government of Canada and the government of the United States of America. Together they provided a total of USD 4,350.08 million (82.1%) of these development assistance for CHW projects.

  • Sub-Saharan Africa received a total USD 3,717.93 million, the largest per capita assistance for CHW programmes over the study period.

  • Development assistance to CHW projects that focused on infectious diseases and child and maternal health received most funds during the study period.

The study concluded that the share of development assistance invested in the CHW projects was characterises as small and unstable, and in spite of being hailed as needing to be up-scaled, has received decreasing funding in recent years. Clearly, when so much is expected of CHWs, more strategic funding needs to be planned to strengthen these over-used and under supported human resources, if they are to reach their potential in the achievement of UHC and early detection and response to disease outbreaks to prevent epidemics.

The full article can be accessed here: https://www.who.int/bulletin/volumes/98/1/19-235499.pdf?ua=1


Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch

21/01/2020 09:21
Physicians’ brain drain. Why do the physicians go?

​Physicians' brain drain. Why do the physicians go?

It is well known that high-educated people from poor countries migrate to richer ones. For instance, the stock of highly skilled immigrants in member countries of the Organisation for Economic Co-operation and Development (OECD) has grown at a fast rate for the last decades. This migration also results from policies within the OECD countries aiming to attract specialised workforce from abroad. Medical doctors are among the most mobile of these migrants. However, medicine is also the sector that experiences the most serious labour shortages in certain regions and little is known about the dynamics of the migration flow.

This lack of knowledge keeps policymakers from taking mitigation strategies preventing physicians’ shortages. Researchers Botezat and Ramos from the Institute for Economic and Social Research and the University of Barcelona, correspondently, explored the new module on health worker migration from the OECD to examine the determinants of migration flows of foreign-trained physicians. The researchers explored data from Africa, Asia, and Europe covering elements such as GDP per capita of both origin and destination, school systems, employment rate, quality of life, language, among others.

While some of their findings may seem obvious at first sight, e.g. having a common language being an important factor for medical doctors to be willing to practice in another country; other findings may be surprising, e.g. greater health spending per capita in destination countries does not have a considerable effect on the number of migrant arrivals. Similarly, a high share of the population covered by health insurance is not necessarily an element favouring migration, but demography is. Countries with bigger shares of the elderly population have a bigger demand for health professionals, thus, higher migration. Physicians’ flows respond significantly to changes of the share of the elderly populations. 

This study contributes to a better understanding of the dynamics of medical doctors’ migration and the differences among the different origins. For example, African doctors are particularly attracted to destinations with higher wages and with low density of medical doctors, whereas Asian medical doctors prefer to migrate to countries with better school systems. The insights provided from Botezat, Ramos are relevant for policymakers intending to address the personnel shortages in both origin, and destiny countries, which is crucial also to achieve universal health care towards the sustainable development goals. The complete study is available at:

https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0536-0


Contact:

Salvador Camacho, Swiss TPH

salvador.camacho@swisstph.ch

16/01/2020 17:48
2019 Lancet Countdown Report on Health and Climate Change

​2019 Lancet Countdown Report on Health and Climate Change

Since the industrial revolution the rise in the combustion of fossil fuels has driven a 1°C temperature rise globally, which in turn, has had the effect of temperature rises as high as 3°C in some regions such as the north-west of Canada. In spite of widespread public concern, many of the indicators tracked in the 2019 Lancet Countdown Report on Health and Climate Change reflect a lack of effective action, which is apparent in a continued rise in carbon dioxide emissions throughout 2018. 

The report takes the position that children of today will experience a world that is more than four degrees warmer than the pre­industrial average. The 2015 Paris Agreement, in which almost 200 nations submitted plans to cut greenhouse gas emissions, set a target of "holding the increase in the global average temperature to well below 2°C above pre-industrial levels and pursuing efforts to limit the temperature increase to 1·5°C." At the time, it was acknowledged that this agreement was inadequate to meet essential goals and that additional radical changes were essential such as no longer using fossil fuels or releasing emissions, known as "net zero".

If the policies and practice of nations world-wide were aligned with the Paris Agreement, children born today would see the phase-out of all coal in the UK and Canada by their sixth and 11th birthdays; they would see France ban the sale of petrol and diesel cars by their 21st birthday; and they would be 31 years old by the time the world reaches net-zero in 2050. Current progress, however, is inadequate, and indicators published in the Lancet Countdown's 2019 report reflect the world struggling to cope with warming that is happening more rapidly than governments are able, or willing to respond. 

The prediction scenarios for the impact of climate change are, however, largely dependent on the effectiveness and extent of action taken and policies implemented. Recent data in the report show the consequences of climate change on human health and their worsening trends. For example, the global yield of major crops tracked since 1960 reveal downward trends that threaten food security, with infants often the worst affected by undernutrition. Air pollution resulting from combustion of fossil fuels affects brain development and damages vital organs such as the heart, lungs, the effects of which accumulate over the life course. Trends in climate suitability for vectors transmitting disease are particularly concerning, as illustrated by the rise in dengue, with nine of the ten most suitable years for transmission on record occurring since the year 2000.

The report concludes that indicators provide evidence of worsening exposure, vulnerabilities, and impacts of climate change on health. Although these are present across a range of temperature and rainfall settings, with reductions in crop yields and increases in the vector capacity of a number of climate­ sensitive diseases, effects are felt most acutely by low- and middle-­income countries across the world. This in turn has potential economic and security consequences. 

The full report: The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate can be viewed here.


Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch

09/12/2019 11:01
HIV Outcomes Beyond Viral Suppression

​HIV Outcomes Beyond Viral Suppression

The starting point of the Lancet Series is that while viral suppression remains an essential goal, additional emphasis need to be placed on the broader health and wellbeing of people with HIV. Safreed-Harmon et al, in their article "Reorienting health systems to care for people with HIV beyond viral suppression" https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30334-0/fulltext argue that in the era of effective antiretroviral therapy (ART), health-related quality of life for people living with HIV should be given equal importance to the UNAIDS 90-90-90 targets; this is sometimes referred to as a "fourth 90". Given that people living with HIV have a disproportionately high incidence of major comorbidities and reduced HRQoL, the article reviews evidence concerning emerging challenges to the care of people living with HIV. Beyond viral suppression, it identifies four priority areas for action: 1) integrating HIV services with non-HIV services, 2) reducing HIV-related discrimination in health-care settings, 3) identifying indicators to monitor health systems' progress toward new goals, and 4) catalysing new forms of civil society engagement in the more broadly focused HIV response that is now needed worldwide. 

The article "Patient-reported outcomes to enhance person-centred HIV care" by Kall et al (https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30345-5/fulltext) explores the use of patient-reported outcomes (PROs) to improve the treatment and care of an ageing HIV positive population, with increasing comorbidities and a disproportionate burden of social problems. PROs, they article argues, have the potential to provide direct assessment of the impact of HIV treatment and care on patients' symptoms and quality of life, however, standards for PRO measures have yet to be developed.

In spite improved HIV treatment and care, stigma and discrimination remain persistent and key barriers to health-related quality of life. The article by Andersson "Stigma reduction interventions in people living with HIV to improve health-related quality of life" (https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30343-1/fulltext)reviews intervention studies assessing the effect of stigma on HRQoL. This unpacks the process of stigma and reviews global studies and their stigma measurement methods and tools.

Serwadda'a commentary "Beyond HIV viral suppression: an African perspective" (https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30349-2/fulltext) argues that African health care systems are too exclusively focused on achieving the UNAIDS 90-90-90 targets, and as a result, quality of care and HIV-related illnesses have not received adequate attention for improvement. Overall, this has not been addressed by community monitoring and advocacy as health consumer groups, where they exist in African nations are often under-resourced and unempowered.

Van den Berk et al's commentary "Improving HIV-related care through eHealth" (https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30348-0/fulltext) argues that with new smartphone technology, the use of information and communication technologies for health (eHealth) should advance from simple text messaging to the monitoring of patients and communication between patients and health-care providers. Development of applications connecting to electronic health records and use of artificial intelligence have the potential to transform HIV care beyond viral suppression in terms of comorbidity management, HRQoL, and patient-reported outcomes. The authors recommend that stakeholders in HIV medicine and eHealth strengthen their collaboration for achieving the triple aim of improving the experience of care from an individual perspective, improving the health of the population, and reducing the cost of care per capita.

The full series of articles published on 25 November 2019 can be accessed here.


Contact:
Kate Molesworth, Swiss TPH

kate.molesworth@swisstph.ch

09/12/2019 10:49
HIV self-testing acceptability among female sex workers

​HIV self-testing acceptability among female sex workers

In sub-Saharan Africa, the proportion of HIV infection in the general female population that is attributable to sex work is estimated to be between 13.6 and 22.1%. In spite of the overall reduction in new HIV infections in the general population, the prevalence and incidence of HIV among female sex workers remain extremely high. At the same time as being disproportionately affected by HIV infection, female sex workers are highly marginalised and least likely to take up voluntary counselling and testing (VCT) services, as they have to contend with multiple barriers to accessing services.
 
A recently published study by Napierala et al “HIV self-testing services for female sex workers, Malawi and Zimbabwe” in the Bulletin of the World Health Organisation, presents an assessment of the acceptability and accuracy of HIV self-testing among female sex workers. The two countries were selected as they present different contexts and approaches to HIV reduction among female sex workers. Zimbabwe has one of the few nationally scaled programmes for sex workers in Africa, which was established in 2009, but in Malawi, by contrast, there was relatively little programmatic focus on this key population until 2015, when dedicated services were introduced.
 
In order to refine systems for national scale-up through existing services, the study in Zimbabwe, made an assessment of the acceptability and accuracy of HIV self-testing among female sex workers. It assessed their preferences for HIV self-testing versus standard provider-delivered testing as well distribution preferences and support strategies. The study in Zimbabwe concluded that female sex workers were able to accurately self-test and found the method to be highly acceptable. Clinical follow-up was very high, with 99% of women who self-tested positive attending HIV services within the following 2–4 weeks. Furthermore, all the women interviewed reported that they would recommend self-testing to family and friends, and a further 81% reported that they would recommend self-testing to clients.
 
In Malawi, the study explored the context and needs of female sex workers for HIV self-testing and shaped a peer distribution model that was implemented to assess the uptake of self-testing kits and post-test support services. This identified three categories of female sex worker: bar-based, street-based and home-based. Street-based female sex workers were hard to reach for services, although, along with home-based workers, they were more independent and tended to have stronger support networks than bar-based workers. All female sex workers were highly mobile, following periodic transaction sex markets, although bar-based female sex workers were less so. As initial research indicated a preference for peer distributors of self-testing kits, implementation research tested this method. This revealed that users preferred self-testing under a peer distributor’s supervision, and in the case of illiterate women, that the test was carried out by the peer distributor. The study also revealed instances of harm associated with self-testing and disclosure, notably physical violence, mostly perpetrated by an established partner, in the context of pre-existing relationship violence. Some peer distributors reported experiencing social stigma, questioning of their credentials and low-level violence perpetrated by female sex workers and other community members.
 
Self-testing for HIV has been shown by Napierala et al to be acceptable and feasible for female sex workers in the two countries as they need, and often desire, frequent re-testing. It provides a step towards addressing inequities in access to HIV services and increasing the uptake of testing and timely access to treatment among female sex workers. In this way, self-testing has the potential to reduce morbidity and mortality among sex workers and transmission of the virus to clients and their partners, by enabling early awareness of infection, initiation of antiretroviral therapy and suppression of viral load.
 
The full study report, which - can be accessed here - provides a rich source of quantitative and ethnographic insights into the unmet needs of sex workers.

Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch


20/11/2019 17:11
A better cup to support breastfeeding in preterm children

​A better cup to support breastfeeding in preterm children

Breastfeeding is crucial to prevent deaths in children younger than five years old. It is estimated that a close to universal breastfeeding could prevent 823,000 deaths annually. However, breastfeeding can be a challenge for different reasons. For instance, children born prematurely, known as preterm, may face higher probabilities of having craniofacial anomalies affecting their suck-swallow-breathe mechanism, or being born to mothers who died of childbirth-related causes. Preterm children often require assistance for a short period to properly breastfeed until they develop their suck-swallow-breath mechanism. The WHO recommends hand expression of breast milk and the use of a small cup to feed new-borns facing feeding difficulties.

Even though a cup may seem too simple in comparison to nasogastric tubes, specialized bottles, and breast pumps, it is important to note that the sophisticated tools are impractical and unhygienic in settings that lack drinking water, electricity and other means to sanitize. It is not surprising that the systematic reviews find that cup compliance is challenging in high-income settings but high in low-income ones. Cup feeding preterm infants result in improved physiology and higher short-term and long-term breastfeeding rates after discharge.

Cups can be sanitized more conveniently than the bottles and require little effort from the infant to feed. There is no standard cup for feeding infants, however, the medical cup is commonly used for having fewer inconveniences as other cups that can cut the thin skin of the oral commissure of the infants, are too small for hand expression of breast milk, or are hard to manipulate to control the flow of milk during the feeding sessions. The cup feeding sessions must result in a good experience for both the child and the mother to ensure adherence to the support-phase.

To address the most common problems with feeding cups, a team of investigators from Seattle Children’s Hospital, PATH, and the University of Washington designed the original Neonatal Intuitive Feeding TechnologY (NIFTY) cup and tested it using a randomized crossover trial at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. This trial allowed the researcher to compare the Nifty’s cup benefits when compared to the commonly used medicine cup and to determine if this new cup could be associated with greater caregiver satisfaction and less spillage. The results from this interesting trial were published in the PLOS Journal and can be found at:

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223951


Contact:

Salvador Camacho, Swiss TPH

salvador.camacho@swisstph.ch

21/10/2019 09:59
Corporation’s use and misuse of evidence to influence health policy: a case study of sugar-sweetened beverage taxation.

​Corporation's use and misuse of evidence to influence health policy: a case study of sugar-sweetened beverage taxation

As a strategy to stop the increasing number of people developing non-communicable diseases, especially diabetes type 2, obesity, and related cardiovascular diseases, the governments implement or discuss taxing sugar-sweetened beverages because they are a major source of sugar in the diet. This taxation has strong evidence showing its efficacy in reducing not only sugar sweetened drinks consumption but also the so-called diet drinks.

The sugary drink taxes are commonly discussed through public consultations in which the beverage corporations have a saying before being in place. A study by Jonas Fooks and colleagues published in the journal “globalization and health”, examines the corporations’ use of agnogenic practices to influence the understanding of the tax and related policies, and their effects. Agnogenic practices refer to methods of representing, communicating, and producing scientific research and evidence to create ignorance or doubt irrespective of the strength of the underlying evidence. These practices range from questioning evidence by demanding higher standards of scientific proof to withholding clinical trial data so robust findings. 

Fooks and colleagues focused on the case of South Africa during the public consultations where the major beverage corporations presented responses to the South African National Treasury initiative to tax sugary drinks. The corporations claimed that the tax would trigger considerable damages to the economy and public health while achieving insignificant results in decreasing obesity and its comorbidities. After analysing these claims and the evidence presented to support them, Jonas Fooks and colleagues found several agnogenic practices. For example, misuse of raw data, observational selection, misstatement of key findings, omission of qualifying information, false attribution of focus, and presenting absence of evidence as evidence of absence, among others.

Given the severe impact of the non-communicable diseases and the role of the industry in tackling them, corporate agnogenesis represents a major problem for health actors and the general population. Addressing the global non-communicable disease epidemic requires fundamental changes in markets based on sound evidence and it is crucial that all stakeholders are aware of these practices not only to address them from the industry but also to avoid using them themselves.

The complete analysis can be consulted at:

https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0495-5


Contact:

Salvador Camacho, Swiss TPH

salvador.camacho@swisstph.ch

04/10/2019 12:51
World diabetes day and digital tools

​World diabetes day and digital tools

The number of people with diabetes is expected to rise to 522 million by 2030, which is why the International Diabetes Federation aims to raise awareness of the impact of this disease through the “world diabetes day”. The theme for 2019’s diabetes day is the same as in 2018: family and diabetes. The repetition is thought to emphasize the role of the family in the management, care, prevention, and education of this disease. Considering that every day more and more family members rely on the use of digital tools mostly web-based, for their everyday life, it makes sense to look at these tools to assist the families in these tasks.

Either to get in contact with other people, read the news or buying all kind of items, the internet presence and application are ubiquitous. The quantity of data that the internet can generate and store is so big that artificial intelligence (AI), i.e. the ability of computers to learn the associations within data to assist with classification, prediction, and optimisation, is seen as a game-changing tool that can greatly enhance public health. Consider diabetic foot ulcers and lower limb amputations that are among the most common and costly complications of diabetes, summing up to one-third of the direct cost of diabetes care. 25% of people with diabetes will develop a diabetic foot ulcer and will be admitted to a hospital, from them, one in five ulcers will result in amputation of the lower limb. The problem occurs due to the loss of sensation in the feet, which results in overstressing specific points of the feet, turning into an ulcer. One of the most effective preventions methods is the use of therapeutic footwear with special insoles to offload high plantar pressures. However, adherence is low. Considering the high prevalence of diabetes, AI could make a difference in the prevention of diabetic foot ulcers.

Caroline Abbott and colleagues designed a prospective, randomised study (proof-of-concept) to investigate the effectiveness of an intelligent insole system. The system was designed to measure and analyse static plantar pressure continuously during daily life activities and guide the patients to dynamic offloading the feet to prevent diabetic foot ulcers. The insole was armed with sensors that communicate to an alerting watch whenever a specific spot of the foot was being dangerously stressed so the patient could consciously offload it. With the use of this gadget, Abbott and colleagues reduced ulcer incidence by 86% in relation to the control group, suggesting that indeed, AI and its related digital tools can increase greatly the effectiveness of public health strategies.

More information on the World Diabetes Day can be consulted here.

The study by Abbott and colleagues can be consulted here.

Contact:

Salvador Camacho, Swiss TPH

salvador.camacho@swisstph.ch

02/10/2019 18:29
​Upcoming open online course, produced by the University of Basel and Swiss TPH

​Upcoming open onlinecourse, produced by the University of Basel and Swiss TPH

One Health: Connecting Humans, Animals and the Environment

If you’ve ever wondered whether doctors and veterinarians could work together more closely, join this course! We’ll show you that collaboration makes a lot of sense, saving more human and animal lives than either field ever could alone, and even saving money. You will learn theoretical foundations and hands-on practical methods for planning and implementing integrated approaches to health care. Enroll now here

The course starts September 30, 2019, and runs for 6 weeks

25/09/2019 17:14
The Lancet commission on malaria

​The Lancet commission on malaria

The global malaria community unsuccessfully tried to eradicate this disease in the mid-20th century. However, since 2000, considerable progress has taken place, which has motivated the reconsideration of malaria eradication. For example, both domestic and international yearly spending on malaria almost tripled, the number of countries with endemic malaria dropped from 106 to 86 and the worldwide incidence rate of the diseases decreased 36% whereas its annual death rate decreased 60%. Along with this remarkable progress, there has been also problems such as 55 countries experiencing an increase in cases between 2015 and 2017. With this in mind, the Lancet convened a commission to assess whether malaria eradication is feasible, affordable, and worthwhile.

A series of articles from the commission analyses topics such as the complexity of malaria biology, the cost of malaria eradication and its high dependency on managerial efficiency, the efficacy and cost of new tools, and the development assistance plateau since 2011. The Commission concludes its analysis with optimism stating that ‘malaria eradication by 2050 is a bold but attainable goal’. However, the commission estimates that to achieve this goal an additional investment of $2 billion per year is necessary, along with closer collaboration and a clearer definition of roles between the two apex organisations, WHO and the RBM Partnership to End Malaria. The conclusion also advocates for greater alignment of policies and investment strategies between The Global Fund to Fight AIDS, Tuberculosis and Malaria and the US President's Malaria Initiative, who are the two major malaria funders. The Commission also recommends the creation of an independent monitoring board for malaria eradication, which is crucial to increase accountability from all the actors involved.

Using different methods for analysis, the commission identifies opportunities and suggest specific actions to overcome the main challenges to achieve eradication by 2050. However, it also states that these actions are not enough without a higher ambition and vision to propel and sustain the community in the road to a malaria-free world. The commission on malaria is available here.

Contact:

Salvador Camacho, Swiss TPH

salvador.camacho@swisstph.ch

19/09/2019 13:32
The double burden of malnutrition at household level

​The double burden of malnutrition at household level

Two years ago the joint UNICEF-WHO-WB report on global child malnutrition[1] documented that most low- and middle-income countries are undergoing nutrition transition and experiencing the coexistence of overweight mothers and undernourished children in the same households. This is termed “the double burden of malnutrition at household level” (DBMHL) and its prevalence ranges from as low as 1.8% in Ethiopia to as high as 15.9% in Egypt. DBMHL is of particular concern, as it is an important promoter of the double burden of infectious and non-communicable diseases (NCDS).

The recent study by Anik et al “Double burden of malnutrition at household level: A comparative study among Bangladesh, Nepal, Pakistan, and Myanmar” explored the prevalence of DBMHL and its associated factors in the South Asian countries where there is a declining, but still high trend of child malnutrition at the same time as a significant increase in overweight and obesity among women. Using data extracted from the latest Demographic and Health Surveys (DHS), the study identified some 18,500 mother and child household pairs across the region with DBMHL.

Results revealed the highest prevalence of DBMHL to be in Myanmar (5.5%) and the lowest was in Nepal (1.5%) with 4.1% in Bangladesh and 3.9% in Pakistan. In all four countries, prevalence of DBMHL was found to be higher in urban areas than in rural areas. Households with no breastfeeding practice had a higher prevalence of DBMHL than the households that breastfed in Bangladesh (5.4% vs 3.0%), Nepal (3.2% vs 1.4%), Pakistan (5.7% vs 2.2%), and Myanmar (8.5% vs 3.3%). The association between breastfeeding and a reduced prevalence of DBMHL reflects the positive effect of the metabolic cost of breastfeeding on the weight loss of lactating mothers as well as the positive nutritional impact of breastfeeding on their children.

The study showed a positive association between higher wealth-index households and DBMHL, especially in Bangladesh and Pakistan. This is likely due to excessive intake of processed energy-dense foods and sodas in combination with a lack of physical exercise that are more common in middle and high income households compared with lower-income households in the two settings.

Older mothers were also found to be more closely associated with the increased risk of DBMHL than the younger mothers (in all study countries except Nepal) which reflects previous studies that showed women aged 30 years or older were overweight and obese in Bangladesh, Myanmar, and Pakistan. This is associated with increasingly sedentary lifestyles with increasing age in the three countries.

Regular media exposure was found to have a protective impact on DBMHL, indicating the potential benefits of multi-media approaches to behaviour change to support a balance between energy intake and expenditure in mothers, and optimal nutrition for foetal and child development. Although variation in findings between the four countries indicate the need for further research on the determinants of DBMHL, efforts towards the promotion and support of breastfeeding in combination with NCD reduction interventions, including positive nutrition and physical activity, appear to be key starting points.

The full article, published by PLOS One on August 16, 2019 can be accessed here: https://doi.org/10.1371/journal.pone.0221274


[1] Hayashi, C, et al. Joint Malnutrition Estimates 2017 Edition—Worldwide. UNICEF-WHO-WB; 2017: http://public.tableau.com/views/JointMalnutritionEstimates2017Edition-Wide/WB


Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch


02/09/2019 15:35
Evidence of falling use of modern contraception and rising abortion in sub-Saharan Africa with enactment of the US Mexico City Policy

Evidence of falling use of modern contraception and rising abortion in sub-Saharan Africa with enactment of the US Mexico City Policy ​

As the world's largest absolute donor of development assistance, the USA’s decisions regarding allocation of its global health resources have substantial impacts upon health services worldwide. Of particular concern the influence of US domestic abortion politics on the disbursement of foreign health funding. The Mexico City Policy introduced by the Reagan administration at the International Conference on Population in 1984 has influenced US family planning assistance ever since. This policy, which has been repeatedly rescinded and reinstated by presidents along partisan lines, prohibits NGOs that perform abortions or counsel women about abortion from receiving US federal funding.  

On the one hand, the policy's restrictions imply an intention g to reduce abortions, but on the other hand, if the policy also curtails the operations of organisations that provide family planning services, it could also limit the supply and use of modern contraception. This in turn may have the unintended consequence of increasing abortions because lower modern contraceptive use is associated with unintended pregnancies and demand for abortion. Many family planning and reproductive health organisations face a difficult choice between complying with the policy and maintaining US funding, or maintaining services that conflict with the policy and forfeiting US funding. Two of the largest international family planning organisations, International Planned Parenthood Federation and Marie Stopes International, have historically refused to sign the policy, sacrificing access to a substantial source of support.

A large-scale study published in the Lancet this month compared modern contraceptive uptake and abortion during periods of time when the policy was rescinded by William Clinton, reinstated by George W Bush, and rescinded again by Barack Obama. “USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy” by Brooks et al shows how a US policy intended to restrict federal funding for abortion services can lead to a rise in abortions in poor countries.

The study found that when the Mexico City Policy was in effect in 2001–08 (under George W. Bush’s reinstatement of the policy) abortion rates rose by approximately 40% compared with periods when the policy was repealed during 1995–2000 (under the Clinton administration) and 2009–14 (under Obama). The study showed that underlying the increase in abortion under restrictions imposed by the policy was a 14% reduction in modern contraceptive use, accompanied by a 12% increase in pregnancies. The study also revealed that the policy's effects reversed after each repeal, providing further evidence of the policy's role in the fall in modern contraceptive use, rise in pregnancy and abortion.

Access to safe and regulated abortion services is crucial for women's reproductive health, but it is also a highly emotive and political topic. This study is the first to show that enactment of the Mexico City Policy is followed by an increase in abortions, many of which are likely to be unsafe. However, this trend can be reversed with an improvement in the policy environment and adequate support for family planning organisations. The evidence generated by Brooks et al’s research is timely given that Donald Trump reinstated and expanded the policy in a Presidential Memorandum in 2017.

The full article can be accessed here.

Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch

19/08/2019 09:54
​Researchers develop intervention to eliminate schistosomiasis and draw lessons from persistent transmission and reinfection

​Researchers develop intervention to eliminate schistosomiasis and draw lessons from persistent transmission and reinfection

Schistosomiasis is a neglected tropical disease with considerable impact on global health. More than 200 million people are infected, mainly in sub-Saharan Africa. Researchers from Swiss TPH, the Natural History Museum London and partner institutions in Zanzibar developed an intervention aiming to eliminate schistosomiasis in Zanzibar, Tanzania. The researchers found that while schistosomiasis was eliminated as a public health problem in over 90% of the study regions, the transmission was not interrupted and reinfection occurred.

Schistosomiasis is a neglected tropical disease affecting more than 200 million people and putting in risk to around 800 million people. The global burden of the disease by 2016 was estimated at 1.86 million disability-adjusted life years, which caused a shift from the World Health Organisation to move from morbidity control towards elimination, i.e. elimination of schistosomiasis as a public health problem and interruption of transmission in selected areas by 2025.

Schistosomiasis is caused by blood flukes (parasitic flatworms) released by freshwater snails when they get in contact with human skin and penetrate it. That means that infection occurs when individuals, particularly children, are exposed to contaminated natural freshwater while swimming, bathing or washing. The risk of infection is higher in areas that lack clean water and sanitation. This parasitic disease, if left untreated, can lead to anaemia, severe damage of organs, infertility, cancer, and even death. The essential control of schistosomiasis is through mass drug administration (MDA) of praziquantel but this measure does not interrupt transmission because it does not impede the contamination of freshwater bodies. Therefore, it is necessary to investigate interventions to assist people in changing their behaviour to prevent water bodies' contamination and infection.

A group of scientists from Swiss TPH together with the Natural History Museum of London and partner institutions in Zanzibar, Tanzania conducted a 5-year cluster-randomised trial to assess the effect of different interventions for elimination of urogenital schistosomiasis in children aged 9-12 years from Zanzibar. The intervention was done on top of biannual MDA and it had one control and three arms, namely, a group with a preventive chemotherapy, a group with the preventive chemotherapy plus behaviour change interventions and the last group with the preventive chemotherapy plus snail control interventions.

The scientists eliminated urogenital schistosomiasis as a public health problem in more than 90% of the populations included in the study, however, the intervention did not manage to interrupt transmission/contamination and reinfection reoccurred. Nevertheless, valuable lessons can be learned from the trial as it can be noted in the published study here.

The complete study design can be consulted here.


Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch


24/07/2019 10:55
Community engagement in the Ebola response

​Community engagement in the Ebola response

A recent commentary by Melissa Parker and others, "Ebola, community engagement, and saving loved ones" reflects upon the much-discussed importance of community engagement in the control of Ebola outbreaks. Depending upon how individuals in a community are affected by an epidemic, they may not share the same opinions as their authorities or desire the approaches essential to collective action. The nature of community engagement may therefore create tension and those empowered by external agencies to implement control policy are at risk of being resented by their communities and even violence.

During the Ebola epidemic in Sierra Leone Parker et al observed how people were not prepared to give up their loved ones to official health care services and were convinced that protecting and assisting them was the right thing to do. In this way, relatives avoided public health authorities and evaded the instructions of their chief to report cases. Relatives of people exhibiting symptoms of Ebola infection took the sick into secluded forest locations, where they provided care themselves. Carers attempted to keep sick relatives hydrated and made protective clothing for themselves: Some of the sick survived and the dead were buried with the help of members of secret societies that are prevalent across the region, enabling their families could mourn them. These findings highlight that more people were probably infected with Ebola virus than official data indicate and that extensive unreported care was provided for those infected. For example, the authors found that while 58 Ebola cases were officially reported in Ribbi chiefdom, their research found a further 57 suspected cases, in just one village in the same chiefdom, only eight of which were referred to the chief or district authorities.

The article concludes that the most useful insight for Ebola policy is that in some contexts relatives will provide secret care for those they love and feel responsible for, regardless of regulations imposed by their immediate and national authorities: These realities present diverse challenges, particularly in identifying and working with those involved, but isolating relatives who believe themselves to be acting morally is likely to be counter-productive.

The commentary can be accessed at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31364-9/fulltext#back-bib3.

Further references on community approaches to Ebola can be found at: https://blogs.lse.ac.uk/africaatlse/2018/02/15/publicauthority-what-will-happen-when-there-is-another-epidemic-ebola-in-mathiane-sierra-leone/ (LSE PublicAuthority blog #PublicAuthority: What will happen when there is another epidemic? Ebola in Mathiane, Sierra Leone)

https://www.economist.com/middle-east-and-africa/2015/08/29/hail-to-the-chiefs (The Economist: Ebola in Sierra Leone. Hail to the chiefs. How local leaders helped to curb an epidemic.)

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(19)30044-1/fulltext (Trapido J. Ebola: public trust, intermediaries, and rumour in the DR Congo.Lancet Infect Dis. 11)


Contact:
Kate Molesworth, Swiss TPH | kate.molesworth@swisstph.ch


10/07/2019 10:52
Lancet Series on Gender Equality, Norms, and Health

Lancet Series on Gender Equality, Norms, and Health​

Evidence is accumulating that the traditional disregard for gender inequalities in health planning and intervention design, implementation, monitoring and evaluation weaken health outcomes in populations. The first of the five main articles in the Series, “Gender inequality and restrictive gender norms: framing the challenges to health“ by Heise et al, explores the relationships between gender inequalities, restrictive gender norms and health and wellbeing. Building upon the evidence base, it sets out a conceptual framework that shows how sexism and patriarchy intersect with other forms of discrimination, such as racism, classism and homophobia, to structure pathways to poor health. The article sets out evidence of the extensive consequences of these pathways, including how gender inequality and restrictive gender norms impact health through differential exposure, health-related behaviours and access to care, as well as how gender-biased health research and health-care systems reinforce and reproduce gender inequalities, with serious implications for health.


Using existing global, national, and subnational data, Weber et al in their article “Gender norms and health: insights from global survey data” present evidence that gender norms affect the health of females and males at all stages of the life course, in health sectors, and in all regions of the world. The authors present six case studies showing that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes.

Heymann et al in their article“Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms” present the results of a comprehensive review of the literature on rigorously evaluated programmes that aimed to reduce gender inequality and restrictive gender norms and improve health. Their review identified four mutually-reinforcing factors underpinning positive change: (1) multi-sectoral collaborative action, (2) multilevel, multi-stakeholder involvement, (3) diversified programming, and (4) social participation and empowerment. The team also examined whether laws and policies significantly affect gender-related health outcomes. This revealed that free primary education, paid maternity and parental leave significantly improve the health of mothers  and their children's. The article concludes by discussing examples of how improved governance can support gender-equitable laws, policies, and programmes, immediate next steps, and future research needs.

The need for concerted action and accountability on gender equality is clear: introduction of the 2030 Agenda for Sustainable Development and the Universal Health Coverage goals demand greater attention to the social determinants of health, including gender, for the purpose of enabling all people to reach their full potential. The last two articles in the series: by Hay et al “Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms” and by Gupta et al “Gender equality and gender norms: framing the opportunities for health” propose an agenda for action to systematically identify and address restrictive gender norms and gender inequalities in health systems as well as in broader settings including the corporate sector.

The five articles in the Lancet Series and further commentaries can be accessed here.


Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch

24/06/2019 16:28
How to disinvest in public health

How to disinvest in public health​

Aging populations, increase in chronic diseases and higher expectations of consumers are some of the main drivers increasing the cost of healthcare not only in Western countries but also in low and middle-income ones. More procedures, medications, and services are added to publicly funded health systems, which raises concerns about their sustainability. These concerns are aggravated by the fact that even if some new services are proved cost-effective, the existing ones are rarely verified to prove their cost-effectiveness. Health economists have suggested starting disinvestment strategies to address these concerns. Disinvestment is defined as the complete or partial withdrawal of resources from healthcare services that are considered as either unsafe, ineffective and/or inefficient, shifting those resources to more cost-effective health services.

Despite the logic of this suggestion, disinvestment can be an unpopular measure with little or no take-up. Deb Mitchel and colleagues investigate the response of health practitioners when confronted with a plan to disinvest from a health service that they previously provided to their patients at two Australian hospitals. This was a qualitative study with two data collection points: prior to and during a disinvestment phase of a multisite stepped wedge cluster randomized controlled trial that removed the weekend allied health service from twelve acute medical and surgical wards. The researchers focused on staff behaviour to understand its responses to disinvestment projects. Their results depict the way the responses from the personnel change over time, ranging from immediate negative reactions, looking for strategies to avoid the disinvestment project, to see it as an opportunity. The study from Mitchel and colleagues provides valuable insights on how to manage disinvestments to increase the cost-effectiveness while avoiding disincentives for clinicians and affected healthcare professionals.

The study with the response phases found by the researchers and relevant recommendations can be found here.

17/06/2019 13:07
Trained dogs identify people with malaria parasites by their odour

Trained dogs identify people with malaria parasites by their odour 

Millions of lives saved and global rates dropping by 60 percent are some of the arguments to consider the fight against malaria as one of the biggest successes of the 21st century. Nevertheless, The Global Fund remarks that the fight is not over because malaria is on the rise in endemic places and new tools are needed to get the malaria response back on track. There are huge efforts to do so. For instance, the malaria vaccine is currently being tested in humans through pilot programmes in three African countries (Malawi, Ghana and Kenya). The aim of these pilots is to generate evidence and experience to inform policy recommendations on the broader use of the vaccine.

However, the vaccine is part of the holistic malaria control and it should be complemented by the already recommended measures for prevention, such as the use of insecticide-treated bed nets, indoor spraying with insecticides, and the timely use of malaria testing and treatment. Timely testing for malaria has been particularly challenging and a non-invasive method probably would turn malaria elimination simpler. That is why Claire Guest and colleagues trained dogs to identify people with malaria parasites by their odour.

Based on the evidence showing that people infected with malaria parasites produce a body odour that is detected by mosquitoes, which use this information to feed on asymptomatic malaria-infected individuals, the researchers hypothesised that dogs with their advanced sense of smell could be trained to detect people with the disease. With the support of Bill & Melinda Gates Foundation, Guest and colleagues trained dogs and assessed their diagnostics accuracy using a blinded study. The specificity and the sensitivity of the trained dogs met the thresholds recommended by the World Health Organization for malaria diagnostics. The results from the researchers open the possibility to use dogs to overcome specific barriers in malaria detection such as detecting individuals infected with malaria at ports of entry in countries or regions that are either free of malaria or approaching elimination. The study was published online by The Lancet ahead of the printed version and can be found here.


Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

27/05/2019 16:48
Creating and sustaining health research capacity in conflict-affected areas.

​Creating and sustaining health research capacity in conflict-affected areas

Building and sustaining research capacity has been continuously promoted as the best strategy to overcome health disparities worldwide. Yet, health research capacity is disproportionately located in the global north where most academic papers are produced and published, and where most implementation is done. This is due to several reasons such as low and middle-income countries (LMICs) lacking human and financial resources, or low training capability/capacity for domestic researchers. This situation undermines the capacity of the health systems from LMICs to continuously learn preventing them to become communities producing scientific knowledge to address both global and local concerns.

For countries in conflict, it is even less common if not impossible to build research capacity or to put it in place although these countries are the ones that could benefit the most. Research in areas with conflicts is conducted mostly by non-governmental organisations under financial and human resources constraints, within an environment full of barriers such as political pressures, instability, undervaluing research, and ethical challenges. This affects not only the quality and quantity of the research but also its impact on policies. Besides, health research in LMICs affected by armed conflict is often fragmented, under-developed, or driven by researchers and research agendas from the global North due to large-funders' interests, perception about the local capacity to absorb resources, and risk appetite.

With this in mind, Gemma Bowsher and colleagues carried a narrative review examining the current literature on health research capacity strengthening (sometimes referred to as research capacity building) in LMICs to support the undertaking of future capacity strengthening programmes in conflict settings. Their review covered peer-reviewed articles published from 1990 to 2018 and grey literature from the World Health Organization (WHO) Global Health Observatory (GHO), Reliefweb and the Social Science Relief Network, among other sources. The authors clearly identified the main factors influencing research capacity strengthening and they broke it into several categories and by the type of influence, i.e. either positive or negative.

By highlighting the challenges to research capacity strengthening in conflict-countries, as well as examples of good practice, the authors make the case for the need for support and attention to this vital practice. Bowsher and colleagues also manage to inform effectively about the enablers and deterrents of research capacity strengthening with the aim of building and sustaining research capacity in these settings that need it the most. Their article can be found here.

17/05/2019 15:25
WHO Guideline: recommendations on digital interventions for health system strengthening

​WHO Guideline: recommendations on digital interventions for health system strengthening


Digital health interventions have demonstrated positive impacts in global health such as increasing the quality of care offered at the community level, improving service utilization, quality of care and information, reducing supply stock-outs, among others advantages. It is thought that digital health interventions can overcome the challenges that currently limit the achievements of health systems. The World Health Assembly Resolution on Digital Health approved unanimously in 2018 by all the Member States of the World Health Organisation (WHO), is a proof of the collective recognition of the value of digital health to contribute to achieving universal health coverage (UHC) and ultimately sustainable developments goals (SDGs). Digital health is a broad “umbrella term” defined as the use of digital technologies for health. Within digital health, there is a subset of specific concepts, such as “eHealth” -the use of information and communications technology in support of health and health-related fields, and mobile health or mHealth, defined as the use of mobile wireless technologies for health. Digital health also covers emerging areas such as the use of big-data, genomics and artificial intelligence.

Due to its perceived advantages, digital health is a strong and common practice to address health needs from all kind of stakeholders, ranging from medical practitioners and community health workers to international aid agencies. However, the enthusiasm for digital health implementations have brought along a wide assortment of short-term implementations and an extensive diversification of digital tools, including software and programming languages, as well as a lack of evaluations to assess their benefits and harms. To help to overcome these concerns, the WHO has created the first Digital Health guideline with recommendations based on critical evaluations of evidence on digital health interventions and their impact on health system improvements. The evaluations cover benefits, harms, acceptability, feasibility, resource use and equity considerations. The guide also includes a comparison of the digital interventions against their non-digital alternatives with the aim of providing health policy-makers and stakeholders with recommendations and implementation to support their decisions and actions.

It is important to note that although this is a digital health guideline, the document makes the case that “health interventions are not a substitute for functioning health systems, and that there are significant limitations to what digital health is able to address. Digital health interventions should complement and enhance health systems functions…but will not replace the fundamental components needed by health systems…” This approach makes the guideline a valuable document for both enthusiastic supporters and critics of digital health interventions. The guideline covers context delimitation, evidence and recommendations, and research and implementation considerations. The electronic version also contains two web supplements. The guideline can be consulted and downloaded at this link.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

24/04/2019 08:28
Assessing the measurement tools of quality to improve maternal and newborn care

Assessing the measurement tools of quality to improve maternal and newborn care ​

While there has been a marked increase globally in skilled birth attendance and institutional deliveries, only a few countries met their Millennium Development Goals (MDGs) of reducing the maternal mortality ratio and infant mortality rate. The quality of maternity services including antenatal and postnatal care that determine the extent of preventable maternal and neonatal morbidity and mortality remain poor in many country settings, where preventable birth injury and death occur in spite of skilled attendance and facility-based deliveries.  By the end of the MDGs era, it was evident that an increase in institutional births and skilled birth attendance alone were not effective in reducing maternal mortality ratios and infant mortality rates. Quality health care during pregnancy and childbirth have since received substantial attention as essential to improving health outcomes for women and their newborns. This is reflected in the Sustainable Development Goals (SDGs) and the 2016–30 Global Strategy for Women's, Children's, and Adolescents' Health.

WHO responded in 2016 with a substantial framework and global standards for quality maternal and new-born care. As the figure below illustrates, this comprises eight domains for improving the provision and experience of care. Each domain of the framework has specific standards describing what is expected to be provided to achieve high-quality care around the time of childbirth.  These are elaborated by 31 statements of priorities for measurably improving quality of care, organised into 352 quality measures for assessing, measuring and monitoring the quality of care as specified in the quality statement. The WHO standards are used to guide national and facility level quality improvements, such as creating national standards of care, measuring the quality of care, providing benchmarks for ensuring high-quality services at the facility level, and informing health facility audits.

Understanding the extent to which existing tools can be used to measure quality is therefore imperative. A recent study assessed the effectiveness of large-scale facility assessment tools currently used to measure quality of maternal and newborn care.
 
At a time when quality of maternal and newborn care are receiving considerable global attention, understanding, the extent to which existing tools effectively measure quality is essential. A recent study by Brizuela et al “Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools” assessed the effectiveness of large-scale facility assessment tools currently used to measure quality of maternal and newborn care.This review is the first assessment and comparison of the ability of widely used facility assessment tools to measure quality of maternal and new-born care according to WHO's standards.
 
The study revealed there to be no unified global tool available that can capture the comprehensive list of indicators for maternal and newborn health set out by WHO. The full report that can be accessed here details specific quality assessment tools that were assessed and rates their performance. It concluded that current tools have substantial limitations such that they fail to explore adequately input and process quality measures, health information systems and patient experience of care.

The study concludes that improved guidance and simplified recommendations are needed to operationalise and prioritise WHO’s standards on quality of maternal and neonatal care. The authors call for better coordination of the different agencies leading multicounty surveys to reduce inconsistencies and enable a more precise and standardised approach to measurement of quality of maternal and newborn health care, including a more accessible way in which countries can understand and use the data generated to practically improve services.

Contact
Dr Kate Molesworth
kate.molesworth@swisstph.ch


15/04/2019 12:14
TB case detection by prison peer educators

​TB case detection by prison peer educators

Prisoners worldwide are one of the most at- risks groups for acquiring TB, and are up to 30 times more likely to be infected than the general population. Despite the well-documented high risk of this population, people in detention are commonly missed or not reached by awareness campaigns, testing and treatment services, which perpetuate their vulnerability to illness and premature mortality.

Two critical and challenging elements in the global response to TB are early detection and adherence to treatment, which are more challenging for people in detention due to the nature of the prison environment. For instance, prisons commonly face resource scarcity and a shortage of health personnel, as well as poor living conditions, poor nutrition, overcrowded spaces, and stressful surroundings. This translates into inadequate health infrastructure, lack of awareness about tuberculosis, and health inequalities in accessing diagnosis and treatment, making traditional detection approaches such as microscope-based diagnosis (sputum smear) or chest X-rays, inaccessible.  


A study in Ethiopia by Adane and colleagues in resource-limited prisons in the regions of Amhara and Tigray aimed to contribute to developing alternative tools and approaches to improve inmates’ access to diagnostic services. A cluster-randomised controlled trial tested the effects of peer education to as a cost-effective method to increase case detection. In the intervention prisons peer educators received a 3-day training in the detection of TB cases, and provided education to all other prison inmates about TB prevention and control every two weeks for one year. They also actively searched for symptomatic prison inmates and conducted routine symptom-based tuberculosis screening. A set of control prisons continued with their existing passive case finding system for comparison. The study found that involving trained inmates as peer educators significantly improved the case detection rate of TB. These results are relevant not only for low-income countries but also from prisons or similar settings that face scarcity of resources. The full research report can be found here.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

01/04/2019 09:38
Diabetes and TB: convergence of two epidemics

Diabetes and TB: convergence of two epidemics

This year, the theme of World TB Day: “It’s Time” emphasised the urgency for action on commitments made by global leaders to fight the disease, as the dedicated World Health Organisation site sets out. Global efforts to address TB are estimated to have saved approximately 54 million lives per year since 2000. However, there is still a lot left to do beyond World TB Day (March 24th) to reduce the negative health, social and economic consequences of the disease, particularly in terms of its interaction with non-communicable diseases (NCDs) that are rising rapidly in low- and middle-income countries.


Diabetes is estimated by WHO to triple a person's risk of developing TB and it is estimated that about 15% of TB cases globally may be linked to diabetes. A recently published systematic review and meta-analysis by Noubiap and colleagues of data from 2·3 million patients with TB from 50 countries explored the relationship between diabetes and TB. The research team found that it is not clear yet whether diabetes increases vulnerability to TB infection, or if TB triggers the onset of diabetes. However, it is evident that the two conditions occur together and that the incremental prevalence of diabetes hinders TB control. This study highlights the need more in-depth research on this topic to inform policymakers to ensure adequate planning and service delivery of integrated disease programmes. The meta-analysis of Jean Jacques Noubiap and colleagues can be found here and a WHO factsheet “Tuberculosis and Diabetes” on the dual epidemic can be accessed here.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

01/04/2019 09:30
Incorporating NCDs into facility-based surveillance systems

​Incorporating NCDs into facility-based surveillance systems

Mozambique is a low-income country that faces endemic diseases such as malaria, tuberculosis, and HIV and neglected infectious diseases that account for 57% of all deaths. But like many countries it is experiencing a rise in NCDs that has not been quantified as health facility surveillance systems have been focused on CDs. In an article published this month, a group of researchers report on an intervention designed to adapt data collection tools to include NCDs in the Mozambique health information system (HIS). Mocumbi et al (2019) collected data on the prevalence of selected NCDs in a general hospital serving nearly 800,000 people, based on the WHO Global Action Plan and Brazzaville Declaration for NCD prevention and control: arterial hypertension, diabetes, stroke, chronic respiratory diseases, mental illness and cancers.

Registration books used for consultations were adapted by replacing age group with the exact patient’s age, adding an extra column for gender, and using the observations column to register the immediate outcome (discharge, transfer or death). To respond to the better awareness of NCD prevalence, staff were trained on the diagnosis and treatment of the selected NCDs.




The study detected the selected NCDs among 7.2% (6,423) of the 89,381 patients in the sample. Of the NCD diagnoses sample, the distribution of diseases was found to be dominated by diabetes in 6,289 patients (78%) and stroke 2,994 (66 %); followed by arterial hypertension in 2,397 patients (37%), mental illness 1,497 (23%) and asthma 1,495 (23%); with a lower prevalence of chronic obstructive pulmonary disease 61 (0.95%) and cancers among 46 patients (0.72%). The data show that many patients were diagnosed with more than one NCD.

This research provides a simple model to incorporate NCD surveillance into existing health facility mechanisms in low-resource settings and can be effectively used to design better strategies and actions to tackle the double burden by maximizing resources.

The full article by Mocumbi et al (2019) “Incorporating selected non-communicable diseases into facility-based surveillance systems from a resource-limited setting in Africa” can be accessed here.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

20/02/2019 13:44
Global Syndemic of Obesity, Undernutrition, and Climate Change

​Global Syndemic of Obesity, Undernutrition, and Climate Change

Obesity continues to increase in prevalence in almost all countries and is an important risk factor for poor health and mortality. The condition is widely regarded to be an individual’s responsibility, and a result of poor choices and behaviours. However, the Lancet Commission argues that this position is no longer acceptable as there are “deep systemic problems” underlying the syndemic of obesity, undernutrition and climate change. For instance, the current food system requires agriculture to generate products that need large amounts of energy and at the same time generate methane and pollution that impact on climate change. Current food systems also favour cheap food, which is linked to malnutrition.

Therefore, a total rethink of the way we eat, produce, consume, move, and in general, how we interact with our environment is crucial. Our food systems, transportation, buildings, and of course, health facilities need to be designed or re-designed in a holistic way to blend into the planet in the less aggressive way. This would not only reduce their negative impact on the wellbeing of people and the planet but also would help to achieve a sustainable and healthier economic grow.

The global syndemic commission successfully incorporates the concept of obesity into a holistic approach beyond individual diseases. It facilitates understanding of the underlying human-made drivers and existing feedback loops that lead to malnutrition in all its forms—obesity, undernutrition, and nutrient deficiency—and climate change. The commission discusses the interactions between climate change and its effects on health, considering also food insecurity and the way climate change affects it.

The analysis and recommendations presented by the Global Syndemic Commission are highly relevant considering the predicted population growth, and the accompanying rising need for food production, transport, and housing among others.

The series of articles from the Lancet Commission Report: Global Syndemic of Obesity can be found here.

Contact:

Salvador Camacho, Swiss TPU | salvador.camacho@swisstph.ch

12/02/2019 16:22
World Cancer Day on February 4th, 2019

World Cancer Day on February 4th, 2019

The Union for International Cancer Control (UICC) represents the world’s major cancer societies, ministries of health and patient groups and includes influential policy makers, researchers and experts in cancer prevention and control. Working closely with key international UN agencies including the World Health Organization (WHO), UICC takes the lead in convening, capacity building and advocacy initiatives to reduce the global cancer burden through delivering the targets of the World Cancer Declaration to ensure cancer control continues to be a priority in the world health and development agenda.


The 2013 World Cancer Declaration that can be accessed here: https://www.uicc.org/sites/main/files/private/UICC_WCD_Declaration_Refresh_Screen_FA.pdf has the overarching goal of major reductions in premature deaths from cancer, and improvements in quality of life and cancer survival rates. It has 9 targets to be reached by 2025.



To support focussed and effective action, a set of tools has been developed for free use online at https://www.worldcancerday.org/materials?#4,9. These provide guides and templates for individuals and groups to customise their own communication materials to contribute to the ‘I Am and I Will’ campaign. As the pictures below show, templates are offered in a number of languages.

Kate Molesworth, Swiss Swiss TPH | kate.molesworth@swisstph.ch

29/01/2019 14:29
UCL–Lancet Commission on Migration and Health: the health of a world on the move

​UCL–Lancet Commission on Migration and Health: the health of a world on the move

The UCL–Lancet Commission on Migration and Health, in light of current emotive political debate, sets out evidence for cooperation and action on what has become one of the most pressing issues of our time. It takes the position that migration and health are intricately linked and key to sustainable development. It challenges some of the myths around migration to provide evidence of the multiple factors that might be beneficial or detrimental to individuals and systems along the migration journey from point of origin, through transit, destination, and return. It documents the devastating impacts of forced migration, especially on girls and women, but also the overall benefits to the health of individuals and populations that planned, economic migration can generate. Articles include:

  • Systematic reviews and meta-analyses of 1) global patterns of mortality in international migrants. 2) health impacts of parental migration on left-behind children and adolescents.

  • The unmet needs of refugees and internally displaced people.

  • Migration, health and human rights.

  • Advancing health in migration governance, and migration in health governance

  • The role of the Global Compact for Migration for children and adolescents on the move.


The Commission report, which can be accessed here: https://www.thelancet.com/commissions/migration-health sets out a research agenda to better ensure and address the health of migrants. Using a health perspective the Commission shows that migration policies can be both ethical and feasible calls for governments, international agencies, and professionals to promote health in global mobility.

24/01/2019 17:57
Effectiveness of HIV self-testing and same day ART

​Effectiveness of HIV self-testing and same day ART

Yesterday Dr Niklaus Labhardt presented at the Swiss TPH its joint study with Solidarmed in Lesotho on the effect of offering same-day ART to individuals who test HIV positive at home, versus health facility referral on linkage to care and viral suppression (reduction of the function and replication of HIV using antiretroviral therapy (ART). Participants were 278 individuals aged 18 years or older who tested HIV positive at home and had not previously taken ART. Half (n = 138) were randomly assigned to be offered same-day home-based ART initiation and subsequent follow-up intervals of 1.5, 3, 6, 9, and 12 months after treatment initiation at the health facility or to receive usual care (n = 140) with referral to the nearest health facility for preparatory counselling followed by ART initiation and monthly follow-up visits.

Results showed that in the same-day treatment group, 134 (97.8%) indicated readiness to start ART that day and 2 (1.5%) within the next few days. These were given a 1-month supply of ART. At 3 months, 69% (94 people) in same-day group versus 43% (59) in the usual health facility care group had linked to care – a difference of 26 %.  At 12 months, 50% (69) in the same-day group versus 34% (47) in usual care group achieved viral suppression.

The study that can be accessed in full here concludes that among adults in the high HIV prevalence setting of rural Lesotho, offering same-day home-based ART initiation to individuals who tested positive during home-based HIV testing, compared with usual care and standard clinic referral, significantly increased linkage to care at 3 months and HIV viral suppression at 12 months. These findings support the practice of offering same-day ART initiation during home-based HIV testing.

A short interview by the first author can be viewed here.

28/11/2018 09:47
GBD 2017: A fragile world

​GBD 2017: A fragile world

The results of GBD 2017, published this month, explode the comforting trend of gradual improvement and instead show plateauing mortality rates on a background of faltering and uneven progress, era-defining epidemics, and dramatic health worker shortages. Instead of the progress updates we have become accustomed to, GBD 2017 comes as an urgent warning signal from a fragile and fragmented world.

The 2017 study reports that the previous trend of decreasing global adult mortality rates has plateaued, and in some cases, mortality rates have increased. Conflict and violence have become two of the fastest growing causes of death globally (increasing by 118% between 2007 and 2017). Epidemics such as opioid dependence, non-communicable diseases, depression and dengue fever have become more severe. Opioid dependence has grown to an unprecedented scale, with 4 million new cases in 2017 and 110,000 deaths. Non-communicable diseases accounted for 73% of all global deaths in 2017, with over half (28·8 million) attributable to just four risk factors: high blood pressure, smoking, high blood glucose, and high body-mass index. Obesity prevalence has risen in almost every country in the world, leading to more than a million deaths from type 2 diabetes, half a million deaths from diabetes-related chronic kidney disease, and 180,000 deaths related to non-alcoholic steatohepatitis - a type of fatty liver disease, characterized by inflammation with fat accumulation in the liver, associated with obesity and diabetes. In 2017, depressive disorders became the third leading cause of years lived with disability, after low back pain and headache disorders, and deaths from dengue fever, a disease often associated with struggling development and urbanisation, increased substantially in most tropical and subtropical countries, rising from 24,500 deaths globally in 2007 to 40,500 in 2017.

The improvement in sex-specific disaggregation of data in GBD 2017 reveals areas where the gendered aspects of health, often overlooked, need to  be addressed. Estimates show that substantial differences in health for men and women that underlie the overall headline figures are still pervasive. Whereas deaths among adult men remain stagnant in many parts of the world, in some areas, mortality has increased: women are living longer, but with more years spent in poor health. The greatest sex differences in health outcomes: substance use disorders, transport injuries, and self-harm and interpersonal violence, are socially driven, suggesting that more attention and action are needed are needed in response to underlying factors.

For the first time in the history of the GBD study, estimates of health worker density have been included. These show that the global shortage and unequal distribution of health workers requires urgent attention in order not to undermine reaching the Sustainable Development Goals (SDGs). The report estimates that in 2017 only half of all countries had the health-care workers required to deliver quality health care (The standard estimated to be 30 physicians, 100 nurses or midwives, and five pharmacists per 10,000 people). Although many European countries have highly-resourced health workforces, countries across sub-Saharan Africa, southeast Asia, south Asia, and some countries in Oceania were estimated to have the greatest shortfalls.

Alarmingly, the GBD 2017 report estimates that no country is on track to meet all of WHO's health-related SDGs by 2030. Under-five mortality, neonatal mortality, maternal mortality, and malaria indicators had the most countries with at least 95% probability of success. However, for many other targets, including child malnutrition and violence reduction goals, no country in the world has attained the pace of change that is required for these goals to be met.

GBD 2017 is disturbing. Not only do the amalgamated global figures show a worrying slowdown in progress, but the data reveal exactly how patchy progress has been. The report provides a reminder that without vigilance and constant effort, progress can easily be reversed. But the GBD is also an encouragement to think differently in this time of crisis. By cataloguing inequalities in health-care delivery and patterns of disease geography, the new version of the GBD presents an opportunity to move away from the generic application of UHC, towards a more tailored approach to UHC. The shock of GBD 2017 should be used to galvanise national governments and international agencies to amplify their efforts to avoid the loss of hard-won gains and also to adopt fresh and effective approaches to growing threats.

View the full article here.

27/11/2018 14:05
World Diabetes Day 2018-19: Focus on family

​World Diabetes Day 2018-19: Focus on family


The theme of WDD on Wednesday 14 November 2018 is “Diabetes Concerns Every Family” and aims to build towards a month of awareness-raising of the impact that diabetes has on the family and to promote the role of the family in the identification, management, care, prevention and education of the condition.

A number of resources are available to enable schools, health facilities and places of work to participate in this year’s awareness-raising campaign and for individuals to take messages home to their families.

The International Diabetes Federation WDD 2018 campaign Toolkit, is available in English, French and Spanish. It provides guidance and resources to support the detection, prevention and management of diabetes, with a special emphasis on spotting diabetes warning signs within the family. Current figures are provided as well as future projections of the diabetes pandemic.

As well as providing support for organisers of events, the Toolkit guides readers to engaging and participate through various channels of social media.

The Toolkit can be accessed here.

A number of posters are available in different languages, free for download that can easily be printed and posted in our places of work. They can be accessed here.

12/11/2018 19:55
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