Methodology for estimating regional and global trends of child malnutrition. National policy development for cotrimoxazole prophylaxis in Malawi, Uganda and Zambia: the relationship between Context, Evidence and Links National, regional, and global levels and trends in maternal mortality between 1990 and 2015 with scenario-based projections to 2030: a systematic analysis by the United Nations Maternal Mortality Estimation Inter-Agency Group Cortisol reactivity and distress-induced emotional eating What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries. A complex breastfeeding promotion and support intervention in a developing country: study protocol for a randomized clinical trial Series: Pragmatic trials and real world evidence: Paper 1. Introduction. General practitioners’ views on the acceptability and applicability of a web-based intervention to reduce antibiotic prescribing for acute cough in multiple European countries: a qualitative study prior to a randomised trial A long-term study of a bicarbonate/lactate-based peritoneal dialysis solution--clinical benefits. The Bicarbonate/Lactate Study Group. Association of degree and timing of exposure to breastfeeding peer counseling services with breastfeeding duration. Slowing Down the Progression of Type 2 Diabetes: We Need Fair, Innovative, and Disruptive Action on Environmental and Policy Levels! Diagnostic accuracy of narrow-band imaging and pit pattern analysis significantly improved for less-experienced endoscopists after an expanded training program. The rise of assertive community interventions in South Africa: a randomized control trial assessing the impact of a modified assertive intervention on readmission rates; a three year follow-up Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer Prevalence of diabetes in Northern African countries: the case of Tunisia Trends of improved water and sanitation coverage around the globe between 1990 and 2010: inequality among countries and performance of official development assistance Roadmap to Achieve 25% Hypertension Control in Africa by 2025. Enhancing the comparability of costing methods: cross-country variability in the prices of non-traded inputs to health programmes A global representation of vitamin D status in healthy populations [L-acetylcarnitine treatment on fragile X patients hyperactive behaviour]. A new approach to multicultural item generation in the development of two obesity-specific measures: the Obesity and Weight Loss Quality of Life (OWLQOL) questionnaire and the Weight-Related Symptom Measure (WRSM). Antiepileptic drug treatment in a community health care setting in northern Ecuador: a prospective 12-month assessment Sudden cardiac death in low- and middle-income countries. Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries Can we predict arterial lactate from venous lactate in the ED? Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital [Exclusion diet in Crohn disease: a controlled, randomized study]. Fructooligosaccharides and Lactobacillus acidophilus modify bowel function and protein catabolites excreted by healthy humans. Cost of depression in Europe. The Nigerian antihypertensive adherence trial: a community-based randomized trial
BACKGROUND Child malnutrition is an important indicator for monitoring progress towards the Millennium Development Goals ( MDG ) . This paper describes the methodology developed by the World Health Organization ( WHO ) to derive global and regional trends of child stunting and underweight , and reports trends in prevalence and numbers affected for 1990 - 2005 . METHODS National prevalence data from 139 countries were extracted from the WHO Global Data base on Child Growth and Malnutrition . A total of 419 and 388 survey data points were available for underweight and stunting , respectively . To estimate trends we used linear mixed-effect models allowing for r and om effects at country level and for heterogeneous covariance structures . One model was fitted for each United Nation 's region using the logit transform of the prevalence and results back-transformed to the original scale . Best models were selected based on explicit statistical and graphical criteria . RESULTS During 1990 - 2000 global stunting and underweight prevalences declined from 34 % to 27 % and 27 % to 22 % , respectively . Large declines were achieved in Eastern and South-eastern Asia , while South- central Asia continued to suffer very high levels of malnutrition . Substantial improvements were also made in Latin America and the Caribbean , whereas in Africa numbers of stunted and underweight children increased from 40 to 45 , and 25 to 31 million , respectively . CONCLUSION Linear mixed-effect models made best use of all available information . Trends are uneven across regions , with some showing a need for more concerted and efficient interventions to meet the MDG of reducing levels of child malnutrition by half between 1990 and 2015 Background Several frameworks have been constructed to analyse the factors which influence and shape the uptake of evidence into policy processes in re source poor setting s , yet empirical analyses of health policy making in these setting s are relatively rare . National policy making for cotrimoxazole ( trimethoprim-sulfamethoxazole ) preventive therapy in developing countries offers a pertinent case for the application of a policy analysis lens . The provision of cotrimoxazole as a prophylaxis is an inexpensive and highly efficacious preventative intervention in HIV infected individuals , reducing both morbidity and mortality among adults and children with HIV/AIDS , yet evidence suggests that it has not been quickly or evenly scaled-up in re source poor setting s. Methods Comparative analysis was conducted in Malawi , Ug and a and Zambia , using the case study approach . We applied the ‘ RAPID ’ framework developed by the Overseas Development Institute ( ODI ) , and conducted a total of 47 in-depth interviews  across the three countries to examine the influence of context ( including the influence of donor agencies ) , evidence ( both local and international ) , and the links between research er , policy makers and those seeking to influence the policy process . Results Each area of analysis was found to have an influence on the creation of national policy on cotrimoxazole preventive therapy ( CPT ) in all three countries . In relation to context , the following were found to be influential : government structures and their focus , donor interest and involvement , healthcare infrastructure and other uses of cotrimoxazole and related drugs in the country . In terms of the nature of the evidence , we found that how policy makers perceived the strength of evidence behind international recommendations was crucial ( if evidence was considered weak then the recommendations were rejected ) . Further , local operational research results seem to have been taken up more quickly , while r and omised controlled trials ( the gold st and ard of clinical research ) was not necessarily translated into policy so swiftly . Finally the links between different research and policy actors were of critical importance , with overlaps between research er and policy maker networks crucial to facilitate knowledge transfer . Within these networks , in each country the policy development process relied on a powerful policy entrepreneur who helped get cotrimoxazole preventive therapy onto the policy agenda . Conclusions This analysis underscores the importance of considering national level variables in the explanation of the uptake of evidence into national policy setting s , and recognising how local policy makers interpret international evidence . Local priorities , the ways in which evidence was interpreted , and the nature of the links between policy makers and research ers could either drive or stall the policy process . Developing the underst and ing of these processes enables the explanation of the use ( or non-use ) of evidence in policy making , and potentially may help to shape future strategies to bridge the research -policy gaps and ultimately improve the uptake of evidence in decision making Summary Background Millennium Development Goal ( MDG ) 5 calls for a reduction of 75 % in the maternal mortality ratio ( MMR ) between 1990 and 2015 . We estimated levels and trends in maternal mortality for 183 countries to assess progress made . Based on MMR estimates for 2015 , we constructed scenario-based projections to highlight the accelerations needed to accomplish the Sustainable Development Goal ( SDG ) global target of less than 70 maternal deaths per 100,000 live births globally by 2030 . Methods We up date d the open access UN Maternal Mortality Estimation Inter-agency Group ( MMEIG ) data base . Based upon nationally-representative data for 171 countries , we generated estimates of maternal mortality and related indicators with uncertainty intervals using a Bayesian model , which extends and refines the previous UN MMEIG estimation approach . The model combines the rate of change implied by a multilevel regression model with a time series model to capture data -driven changes in country-specific MMRs , and includes a data model to adjust for systematic and r and om errors associated with different data sources . Results The global MMR declined from 385 deaths per 100,000 live births ( 80 % uncertainty interval ranges from 359 to 427 ) in 1990 to 216 ( 207 to 249 ) in 2015 , corresponding to a relative decline of 43.9 % ( 34.0 to 48.7 ) during the 25-year period , with 303,000 ( 291,000 to 349,000 ) maternal deaths globally in 2015 . Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1.8 % ( 0 to 3.1 ) in the Caribbean to 5.0 % ( 4.0 to 6.0 ) for Eastern Asia . Regional MMRs for 2015 range from 12 ( 11 to 14 ) for developed regions to 546 ( 511 to 652 ) for sub-Saharan Africa . Accelerated progress will be needed to achieve the SDG goal ; countries will need to reduce their MMRs at an annual rate of reduction of at least 7.5 % . Interpretation Despite global progress in reducing maternal mortality , immediate action is required to begin making progress towards the ambitious SDG 2030 target , and ultimately eliminating preventable maternal mortality . While the rates of reduction that are required to achieve country-specific SDG targets are ambitious for the great majority of high mortality countries , the experience and rates of change between 2000 and 2010 in selected countries – those with concerted efforts to reduce the MMR- provide inspiration as well as guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths . Funding Funding from grant R-155 - 000 - 146 - 112 from the National University of Singapore supported the research by LA and SZ . AG is the recipient of a National Institute of Child Health and Human Development , grant # T32-HD007275 . Funding also provided by USAID and HRP ( the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research , Development and Research Training in Human Reproduction ) Animal studies suggest a relationship between blunted HPA-axis stress reactivity and increased stress-induced food intake in chronically stressed animals . Such a relationship can potentially explain the underlying mechanisms of emotional eating in humans . However , no studies have experimentally tested the relationship between stress-induced cortisol responses and acute food intake in high and low emotional eaters . We studied these effects in 46 female students that were preselected on the basis of extremely high ( HEE ) or low ( LEE ) scores on an emotional eating question naire . Using a within subject design we measured the difference of actual food intake after a control or a stress task ( Trier Social Stress Test ) . The HEE and LEE groups did not differ in their cortisol stress reactivity but emotional eating significantly moderated the relationship between cortisol stress reactivity and the difference of food intake after stress vs control . Whereas HEE participants with a blunted cortisol stress response ate more food after distress than those with an elevated cortisol stress response , LEE participants showed no such relationship . These findings support the relevance of an animal based model on the relationship between a blunted cortisol stress response and increased stress-induced food intake for human high emotional eaters Prenatal and delivery care are critical both for maternal and newborn health . Using the Demographic and Health Surveys ( DHS ) data for thirty-two low-income countries across Asia , sub-Saharan Africa and Latin America , and employing a two-level r and om-intercept model , this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual- , household- and community-level characteristics on a woman 's decision to give birth at a health facility or at home . The results show that  prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions , with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility . These variations are more pronounced for Sub-Saharan Africa . The influence of the number of prenatal visits , maternal age and education , parity level , and economic status of the  birthing women on the place of delivery is found to vary across the three geographical regions . The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households . The strong influence of number of visits , household wealth , education and regional poverty on the site of delivery setting suggests that policies aim ed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction , enhancing the status of women , and increasing primary and secondary school enrollment rate among girls Background Breastfeeding has countless benefits to mothers , children and community at large , especially in developing countries . Studies from Lebanon report disappointingly low breastfeeding exclusivity and continuation rates . Evidence reveals that antenatal breastfeeding education , professional lactation support , and peer lay support are individually effective at increasing breastfeeding duration and exclusivity , particularly in low-income setting s. Given the complex nature of the breastfeeding ecosystem and its barriers in Lebanon , we hypothesize that a complex breastfeeding support intervention , which is centered on the three components mentioned above , would significantly increase breastfeeding rates . Methods / Design A multi-center r and omized controlled trial . Study population : 443 healthy pregnant women in their first trimester will be r and omized to control or intervention group . Intervention : A “ prenatal/postnatal ” professional and peer breastfeeding support package continuing till 6 months postpartum , guided by the Social Network and Social Support Theory . Control group will receive st and ard prenatal and postnatal care . Mothers will be followed up from early pregnancy till five years after delivery . Outcome measures : Total and exclusive breastfeeding rates , quality of life at 1 , 3 and 6 months postpartum , maternal breastfeeding knowledge and attitudes at 6 months postpartum , maternal exclusive breastfeeding rates of future infants up to five years from baseline , cost-benefit and cost-effectiveness analyses of the intervention . Statistical analysis : Descriptive and regression analysis will be conducted under the intention to treat basis using the most recent version of SPSS . Discussion Exclusive breastfeeding is a cost-effective public health measure that has a significant impact on infant morbidity and mortality . In a country with limited healthcare re sources like Lebanon , developing an effective breastfeeding promotion and support intervention that is easily replicated across various setting s becomes a priority . If positive , the results of this study would provide a generalizable model to bolster breastfeeding promotion efforts and contribute to improved child health in Lebanon and the Middle East and North Africa ( MENA ) region . Trial registration Current Controlled Trials IS RCT This is the introductory paper in a series of eight papers . In this series , we integrate the theoretical design options with the practice of conducting pragmatic trials . For most new market-approved treatments , the clinical evidence is insufficient to fully guide physicians and policy makers in choosing the optimal treatment for their patients . Pragmatic trials can fill this gap , by providing evidence on the relative effectiveness of a treatment strategy in routine clinical practice , already in an early phase of development , while maintaining the strength of r and omized controlled trials . Selecting the setting , study population , mode of intervention , comparator , and outcome are crucial in design ing pragmatic trials . In combination with monitoring and data collection that does not change routine care , this will enable appropriate generalization to the target patient group in clinical practice . To benefit from the full potential of pragmatic trials , there is a need for guidance and tools in design ing these studies while ensuring operational feasibility . This paper introduces the concept of pragmatic trial design . The complex interplay between pragmatic design options , feasibility , stakeholder acceptability , validity , precision , and generalizability will be clarified . In this way , balanced design choices can be made in pragmatic trials with an optimal chance of success in practice Background Interventions to promote prudent antibiotic prescribing by general practitioners ( GPs ) have often only been developed for use in one country . We aim ed to develop an intervention which would be appropriate to implement in multiple European countries in order to offer greater benefit to practice whilst using fewer re sources . The INTRO ( INternet TRaining for antibiOtic use ) intervention needed to deliver training to GPs in the use of C-Reactive Protein ( CRP ) near patient tests to help diagnose acute cough and in communication skills to help explain prescribing decisions to patients . We explored GPs ’ views on the initial version of INTRO to test acceptability and potentially increase applicability for use in multiple countries before the start of a r and omised trial . Method 30 GPs from five countries ( Belgium , Engl and , the Netherl and s , Pol and and Spain ) , were interviewed using a “ think aloud ” approach . GPs were asked to work through the intervention and discuss their views on the content and format in relation to following the intervention in their own practice . GPs viewed the same intervention but versions were created in five language s. Data were coded using thematic analysis . Results GPs in all five countries reported the view that the intervention addressed an important topic , was broadly acceptable and feasible to use , and would be a useful tool to help improve clinical practice . However , GPs in the different countries identified aspects of the intervention that did not reflect their national culture or healthcare system . These included perceived differences in communication style used in the consultation , consultation length and the stage of illness at which patient typically presented . Conclusion An online intervention to support evidence -based use of antibiotics is acceptable and feasible to implement amongst GPs in multiple countries . However , tailoring of the intervention to suit national context s was necessary by adding local information and placing more emphasis on the fact that GPs could select the communication skills they wished to use in practice . Using think aloud methods to complement the development of interventions is a powerful method to identify regional context ual barriers to intervention implementation OBJECTIVE A bicarbonate/lactate peritoneal dialysis solution ( Bic/Lac ) has been developed based on in vitro and ex vivo data showing better preservation of cell function and correction of pain on infusion . DESIGN This was a r and omized , prospect i ve , controlled , open-label study comparing a new 25 mmol/L bicarbonate/15 mmol/L lactate with a st and ard 40 mmol/L lactate-buffered peritoneal dialysis solution ( Lac ) over a 12-month treatment period . SETTING 17 European nephrology centers . PATIENTS 106 ( 70 Bic/Lac and 36 Lac ) well-dialyzed continuous ambulatory peritoneal dialysis ( CAPD ) patients . INTERVENTIONS Dialysis adequacy and peritoneal equilibration test ( PET , week -4 , months 3 , 6 , and 12 ) ; 24-hour ultrafiltration ( week -4 , months 1 , 3 , and 6 ) ;  blood biochemistry  ( week -2 , day 0 , months 1 , 2 , 3,6 , 9 , and 12 ) ; and a  product acceptability question  naire ( months 1 and 6 ) . RESULTS 88 patients completed the first 6 months , and 44 the full year . The solutions were shown to be therapeutically equivalent with respect to plasma bicarbonate and peritoneal urea and creatinine clearances . Ultrafiltration in the Bic/Lac group increased significantly from baseline by about 150 mL/day for the whole of the 6-month treatment period ( p < 0.05 ) . The biochemistry profile , adverse events , and physical examination ( except body weight where there was a statistically significant increase in the Bic/Lac group ) results did not differ significantly between the two groups . Reduced pain/discomfort on infusion or an increased sense of well-being was reported by 41 % of patients on the Bic/Lac fluid . CONCLUSIONS The Bic/Lac solution is safe and effective in correcting uremic acidosis , provides relief of inflow pain/discomfort , and improves ultrafiltration and body weight R and omized trials conducted in developing countries have demonstrated that breastfeeding peer counseling increases rates of breastfeeding initiation and improves the duration of breastfeeding ( Morrow et al. 1999 ; Haider et al. 2000 ) . We are conducting a r and omized community trial , design ed to evaluate the effectiveness of an existing  community-based breastfeeding peer counseling program serving mostly low income Latinas ( i.e. , women from Spanish-speaking countries in Latin America or the Caribbean ) in Hartford , CT . Preliminary data from this on-going study previously have shown that subjects r and omized to receive breastfeeding peer counseling  have a median breastfeeding duration one month greater than their counterparts who did not receive breastfeeding peer counseling  ( 1.75 mo vs. 0.8 mo , P<0.05 ) ( Chapman et al. 2002 ) . The objectives of this analysis are to : a ) report on a process evaluation of the program , focusing on actual coverage of pre- , peri- , and postnatal services ; and b ) determine if differences in the degree and timing of the exposure to breastfeeding peer counseling services are associated with breastfeeding duration Over the past decades , we have observed an increase of prevalence of diabetes  in many countries along with significant differences in prevalence trends between countries worldwide ( 1 ) . In Europe and other Western countries , the prevalence rate reaches a plateau or has slowed down on the level of ∼8–10 % . In Asia , a continuous rise in prevalence has been monitored , similar to that in Africa , and an explosion of diabetes prevalence can be observed in the Arabic region . Surprisingly , in each of the countries , there is a significant number of people who do not develop  diabetes  during their lives despite living unhealthy lifestyles in similar environments — in Europe , an estimated 10 % of the population ( 2 ) . These people might be the secret answer to successful individual diabetes prevention , but we still do not underst and the detailed mechanisms of why some people develop diabetes— and why others do not . What we can do is observe individual lifestyle and environment as determinants for the development or prevention of diabetes and the respective risk factors including genetic susceptibility . The interplay between these determinants , influencing the probability of the individual staying healthy or how a person learns or chooses a healthy lifestyle , will define success in diabetes prevention ( 3 ) . Innovative actions are needed to slow down the progression of type 2 diabetes . The purpose of this article is to offer innovative policy and environmental strategic activities design ed to enable sustainable diabetes prevention with scalability on national level . # # # Why Do We Need Environmental and Policy Changes in Diabetes Prevention ? Diabetes prevention is a success story , but it generates new challenges . Throughout the past 15 years , a number of r and omized controlled trials have sought to test various interventions to prevent diabetes ( 4 ) . The results are overwhelmingly positive on an individual level , with a significant relative diabetes risk reduction attributed to lifestyle and pharmacological intervention ( 5 BACKGROUND Previous reports assessing diagnostic skill using narrow-b and imaging ( NBI ) and pit pattern analysis for colorectal polyps involved only highly experienced endoscopists . OBJECTIVE To evaluate diagnostic skills of  less-experienced endoscopists ( LEE group ) for differentiation of diminutive colorectal polyps by using NBI and pit pattern analysis with and without magnification after an exp and ed training program . DESIGN Prospect i ve study . PATIENTS This study involved 32 patients with 44 colorectal polyps ( 27 adenomas and 17 hyperplastic polyps ) of < or = 5 mm that were identified and analyzed by using conventional colonoscopy as well as non-magnification and magnification NBI and chromoendoscopy followed by endoscopic removal for histopathological analysis . INTERVENTION Before a training course , 220 endoscopic images were distributed in r and omized order to residents with no prior endoscopy experience ( NEE group ) and to the LEE group , who had performed colonoscopies for more than 5 years but had never used NBI . The 220 images were also distributed to highly experienced endoscopists ( HEE group ) who had routinely used NBI for more than 5 years . The images were distributed to the NEE and LEE groups again after a training class . Magnification NBI and chromoendoscopy images were assessed by using the Sano and Kudo classification systems , respectively . MAIN OUTCOME MEASUREMENTS Diagnostic accuracy and interobserver agreement for each endoscopic modality in each group . RESULTS Diagnostic accuracy was significantly higher , and kappa ( kappa ) values improved in the LEE group for NBI with high magnification after exp and ed training . Diagnostic accuracy and kappa values when using high-magnification NBI were highest among endoscopic techniques for the LEE group after such training and the HEE group ( accuracy 90 % vs 93 % ; kappa = 0.79 vs 0.85 , respectively ) . LIMITATIONS Study involved only polyps of < or = 5 mm . CONCLUSION Using high-magnification NBI increased the differential diagnostic skill of the LEE group after exp and ed training so that it was equivalent to that of the HEE group Background Many countries have over the last few years incorporated mental health assertive interventions in an attempt to address the repercussions of deinstitutionalization . Recent publications have failed to duplicate the positive outcomes reported initially which has cast doubt on the future of these interventions . We previously reported on 29 patients from a developing country who completed 12 months in an assertive intervention which was a modified version of the international assertive community treatment model .  We demonstrated reduction in readmission rates as well as improvements in social functioning compared to patients from the control group . The obvious question was , however , if these outcomes could be sustained for longer periods of time . This study aims to determine if modified assertive interventions in an under-re source d setting can successfully maintain reductions in hospitalizations . Methods Patients suffering from schizophrenia who met a modified version of Weidens ’ high frequency criteria were r and omized into two groups . One group received a modified assertive intervention based on the international assertive community treatment model . The other group received st and ard care according to the model of service delivery in this region . Data was collected after 36 months , comparing readmissions and days spent in hospital . Results The results demonstrated significant differences between the groups . Patients in the intervention group had significantly less readmissions ( p = 0.007 ) and spent less days in hospital compared to the patients in the control group ( p = 0.013 ) . Conclusion Modified assertive interventions may be successful in reducing readmissions and days spent in hospital in developing countries where st and ard care services are less comprehensive . These interventions can be tailored in such a way to meet service needs and still remain affordable and feasible within the context of an under-re source d setting The authors examined the impact of the laparoscopic approach on the early outcome of resected colon carcinomas . The role of laparoscopic techniques in the treatment of colon carcinomas is question able . Previous studies have suggested technical feasibility of surgical resections of these cancers by laparoscopic means and have implied a benefit to laparoscopic technique for patients undergoing colorectal resections . A prospect i ve , r and omized study was conducted comparing  laparoscopic assisted colectomy ( LAC ) open colectomy ( OC ) for colon cancer . We present the preliminary results in relation to the short-term outcome and judge the feasibility of the laparoscopic procedure to as a way of performing accurate oncologic resection and staging . Benefit has been demonstrated with LAC in this setting . Passing flatus , oral intake , and discharge from hospital occurred earlier in LAC- than OC-treated patients The mean operative time was significantly longer in the LAC group than in the OC group . The overall morbidity was significantly lower in the LAC group . No significant differences were observed between both groups in the number of lymph nodes removed or the pathological stage following the Astler-Coller modification of the Dukes classification . The laparoscopic approach improves the short-term outcome of segmental colectomies for colon cancer . However , the further follow-up of these patients will allow us to answer in the near future whether or not the LAC may influence the long-term outcome Background Although diabetes is recognized as an emerging disease in African and Middle East , few population -based surveys have been conducted in this region . We performed a national survey to estimate the prevalence of type 2 diabetes ( T2D ) and to evaluate the relationship between this diagnosis , demographic and socioeconomic variables . Methods The study was conducted on a r and om sample of 6580 households ( 940 in each region ) . 7700 subjects adults 35–70 years old were included in the analyses .  T2D was assessed on the basis of a question naire and fasting blood glucose level according to the WHO criteria . Access to health care and diabetes management  were also assessed . Results Overall , the prevalence of T2D was 15.1 % . There were sharp urban vs. rural contrasts , the prevalence of diabetes being twice higher in urban area . However , the ratio urban/rural varied from 3 in the less developed region to 1.6 in the most developed ones . A sharp increase of prevalence of T2D with economic level of the household was observed . For both genders those with a family history of T2D were much more at risk of T2D than those without . Awareness increase with age , economic level and were higher amongst those with family history of T2D . Drugs were supplied by primary health care centers for 57.7 % with a difference according to gender , 48.9 % for men vs. 66.0 % women ( p < 0.001 ) and area , 53.3 % on urban area vs. 75.2 % on rural one ( p < 0.001 ) . Conclusions Through its capacity to provide the data on the burden of diabetes in the context of the epidemiological transition that North Africa is facing , this survey will not only be valuable source for health care planners in Tunisia , but will also serve as an important research for the study of diabetes in the region where data is scarce . In this context , NCDs emerge as an intersectoral challenge and their social determinants requiring social , food and environmental health policy ABSTRACT Background : As the Millennium Development Goals ended , and were replaced by the Sustainable Development Goals , efforts have been made to evaluate the achievements and performance of official development assistance ( ODA ) in the health sector . In this study , we explore trends in the expansion of water and sanitation coverage in developing countries and the performance of ODA .  Design : We explored ine quality across developing countries by income level , and investigated how ODA for water and sanitation was committed by country , region , and income level . Changes in ine quality were tested via slope changes by investigating the interaction of year and income level with a likelihood ratio test . A r and om effects model was applied according to the results of the Hausman test . Results : The slope of the linear trend between economic level and sanitation coverage has declined over time . However , a r and om effects model suggested that the change in slope across years was not significant ( e.g. for the slope change between 2000 and 2010 : likelihood ratio χ2 = 2.49 , probability > χ2 = 0.1146 ) . A similar pro-rich pattern across developing countries and a non-significant change in the slope associated with different economic levels were demonstrated for water coverage . Our analysis shows that the ine quality of water and sanitation coverage among countries across the world has not been addressed effectively during the past decade . Our findings demonstrate that the countries with the least coverage persistently received far less ODA per capita than did countries with much more extensive water and sanitation coverage , suggesting that ODA for water and sanitation is poorly targeted . Conclusion : The most deprived countries should receive more attention for water and sanitation improvements from the world health community . A strong political commitment to ODA targeting the countries with the least coverage is needed at the global level BACKGROUND The Pan-African Society of Cardiology ( PASCAR ) has identified hypertension as the highest area of priority action to reduce heart disease and stroke on the continent . OBJECTIVES The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection , treatment and control of hypertension and cardiovascular health in sub-Saharan Africa ( SSA ) by the year 2025 . METHODS Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension . In 2014 , experts in different fields , including physicians and nonphysicians , were invited to join . Via face-to-face meetings and teleconferences , the consortium made a situation analysis , set a goal , identified roadblocks and solutions to the management of hypertension and customized the World Heart Federation roadmap to Africa . RESULTS Hypertension is a major crisis on the continent but very few r and omized controlled trials have been conducted on its management . Also , only 25.8 % of the countries have developed or adopted guidelines for management of hypertension . Other major roadblocks are either government and health-system related or health care professional or patient related . The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25 % control of hypertension in Africa by 2025 . CONCLUSIONS Hypertension affects millions of people in SSA and if left untreated , is a major cause of heart disease and stroke . Very few SSA countries have a clear hypertension policy . This PASCAR roadmap identifies practical and effective solutions that would improve detection , treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national setting Background National and international policy makers have been increasing their focus on developing strategies to enable poor countries achieve the millennium development goals . This requires information on the costs of different types of health interventions and the re sources needed to scale them up , either singly or in combinations . Cost data also guides decisions about the most appropriate mix of interventions in different setting s , in view of the increasing , but still limited , re sources available to improve health . Many cost and cost-effectiveness studies include only the costs incurred at the point of delivery to beneficiaries , omitting those incurred at other levels of the system such as administration , media , training and overall management . The few studies that have measured them directly suggest that they can sometimes account for a substantial proportion of total costs , so that their omission can result in biased estimates of the re sources needed to run a programme or the relative cost-effectiveness of different choices . However , prices of different inputs used in the production of health interventions can vary substantially within a country . Basing cost estimates on a single price observation runs the risk that the results are based on an outlier observation rather than the typical costs of the input . Methods We first explore the determinants of the observed variation in the  prices  of selected  " non-traded " intermediate inputs to health programmes – printed matter and media advertising , and water and electricity – accounting for variation within and across countries . We then use the estimated relationship to impute average prices for countries where limited data are available with uncertainty intervals . Results Prices vary across countries with GDP per capita and a number of determinants of supply and dem and . Media and printing were inelastic with respect to GDP per capita , with a positive correlation , while the utilities had a surprisingly negative relationship . All equations had relatively good fits with the data . Conclusion While the preferred option is to derive costs from a r and om sample of prices in each setting , this option is often not available to analysts . In this case , we suggest that the approach described in this paper could represent a better option than basing policy recommendations on results that are built on the basis of a single , or a few , price observations Purpose This paper visualizes the available data on vitamin D status on a global map , examines the existing heterogeneities in vitamin D status and identifies research gaps . Methods A graphical illustration of global vitamin D status was developed based on a systematic review of the worldwide literature published between 1990 and 2011 . Studies were eligible if they included sample s of r and omly selected males and females from the general population and assessed  circulating 25-hydroxyvitamin D [ 25(OH)D ] levels .  Two different age categories were selected : children and adolescents ( 1–18 years ) and adults ( > 18 years ) . Studies were chosen to represent a country based on a hierarchical set of criteria . Results In total , 200 studies from 46 countries met the inclusion criteria , most coming from Europe . Forty-two of these studies ( 21 % ) were classified as representative . In children , gaps in data were identified in large parts of Africa , Central and South America , Europe , and most of the Asia/Pacific region . In adults , there was lack of information in Central America , much of South America and Africa . Large regions were identified for which the mean 25(OH)D levels were below 50 nmol/L. Conclusions This study provides an overview of 25(OH)D levels around the globe . It reveals large gaps in information in children and adolescents and smaller but important gaps in adults . In view of the importance of vitamin D to musculoskeletal growth , development , and preservation , and of its potential importance in other tissues , we strongly encourage new research to clearly define 25(OH)D status around the world Hyperactivity is a significant problem for almost all young males affected by fragile X syndrome ( FXS ) , the most common inherited disease causing mental retardation . Therapeutical approaches are actually based on Central Nervous System ( CNS ) stimulants lacking a well defined rationale and efficacy while they further decrease the patient 's limited attention span . A pilot study on 17 fragile X male treated with L-acetylcarnitine ( LAC ) over one year , showed a significant reduction of their hyperactivity behaviour tested by the Conners Abbreviated Parent-Teacher Question naire . LAC use in FXS patients derives from the hypothesis that the biochemical and physiological properties this substance has may preserve brain activity . LAC is a small , hydrosoluble molecule that easily diffuses in the extracellular space and enters any cell in the nervous system through specific transporters . Different cerebral areas use this molecule differently to metabolize glucose and lipids to provide for ATP and neurotrasmitters synthesis . The acetyl group LAC carriers represents a key metabolic signaling element possibly mediating its effect in the CNS . The exogenous administration of LAC may affect brain activity in FXS by : I ) modulation of fuel partitioning for energy production , which at the mithocondrial level is associated with the Kreb 's cycle metabolic role in neurotransmitter synthesis ; II ) remodelling of lipid membrane in terms of LAC actively determining the production of polyunsaturated fatty acids ; III ) preferential effect on the attention component of the cholinergic system which relies on its peculiar modality of communication in the CNS . Based on the above premises an explorative , double-blind , placebo controlled , multicenter study is ongoing . A total population of 160 children from nine European centers will be enrolled . The objective of this study is to determine the effect of LAC on the hyperactive behaviour of FXS children as evaluated by the administration of the Conners Abbreviated Parent Question naire BACKGROUND Being overweight or obese has substantial effects on individuals ' perceptions of their health and quality of life ( QoL ) . Generic measures often miss important QoL information , and existing obesity-specific instruments have shortcomings with respect to cross-cultural input , application to differing levels of severity , conceptual clarity , and patient burden . OBJECTIVE This study aim ed to develop culturally sensitive measures of QoL and symptoms in overweight or obese persons , both those trying to lose weight and those not trying to lose weight . METHODS Currently accepted criteria and guidelines for question naire development were streamlined and augmented to include cross-cultural input from 5 European countries and the United States . The preliminary pool of items was created based on qualitative interviews conducted in the United States , followed by an early check of item translatability and preharmonization across all language s. Ten additional qualitative in-country interviews were then conducted to produce further culture-specific items . This was followed by 2 forward and 1 backward translation , plus cognitive debriefing interviews in each country . Finally , an exp and ed international harmonization meeting was held to ensure inclusion of appropriate new items and their acceptability across all 6 cultures . RESULTS The procedures described result ed in development of the 41-item Obesity and Weight Loss Quality of Life question naire and the 20-item Weight-Related Symptom Measure . These question naires are subject to further psychometric validation . CONCLUSIONS Augmentation of the initial item-generation and international harmonization steps of question naire development through integration of cross-cultural input allowed greater validity of cross-cultural content while meeting time , budget , and re source constraints The results of a prospect i ve assessment of antiepileptic drug treatment carried out over a 12-month period , in the context of existing community health care in a rural area of a developing country ( a highl and region of northern Ecuador ) , are reported . A house to house survey defined all patients in the area with a history of epileptic seizures , and 192 patients with active epilepsy were recruited into the programme . These patients were r and omised to treatment with carbamazepine or phenobarbital  , and 139 completed the assessment . Treatment was carried out by health visitors and rural doctors , monitored by a team of neurologists , and st and ard treatment regimens were used . Treatment was effective in controlling seizures , 53 % of the patients were rendered entirely seizure free in the second 6 months of therapy , and a further 14 % had a 50 % or more reduction in seizures . These results were similar to those reported in hospital based studies in developed countries . No significant differences were found between the efficacy and safety of phenobarbital or carbamazepine . Antiepileptic drug levels were monitored during the study , and ranges similar to those found in developed countries were recorded . Compliance was good . In view of the successful treatment in this community control programme , we would recommend that community programmes for the control of epilepsy in rural setting s should be given a higher priority in the planning of health care provision than is commonly the case . Finally , the programme afforded the opportunity to study the efficacy of treatment in patients with chronic long-st and ing epilepsy , who had not been previously treated , and the results of this treatment were good Cardiovascular disease , and the incidence of sudden cardiac death ( SCD ) , will increase significantly in low- and middle-income countries ( LMIC ) . Thus , SCD threatens to become a global public health problem . We present a summary of the current research that has investigated the epidemiology of SCD in LMIC . Few studies of SCD in LMIC exist , and they are of variable method ological quality . Risk factors for SCD are described , taking into account recent global burden of disease and risk factor statistics . We describe 1 proposal for a community-based , prospect i ve , multiple- source methodology for SCD monitoring and surveillance that can be implemented in LMIC . Further research into the epidemiology of SCD in LMIC , using st and ardized methodology , would allow investigators and policy makers to determine the regions , communities , and individuals most at need for SCD prevention . Focusing on SCD and its prevention in LMIC should be a priority for the global health community Background Little is known about the process of knowledge translation in low- and middle-income countries . We studied policymaking processes in Mozambique , South Africa and Zimbabwe to underst and the factors affecting the use of research evidence in national policy development , with a particular focus on the findings from r and omized control trials ( RCTs ) . We examined two cases : the use of magnesium sulphate ( MgSO4 ) in the treatment of eclampsia in pregnancy ( a clinical case ) ; and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control ( a public health case ) . Methods We used a qualitative case- study methodology to explore the policy making process . We carried out key informants interviews with a range of research and policy stakeholders in each country , review ed documents and developed timelines of key events . Using an iterative approach , we undertook a thematic analysis of the data . Findings Prior experience of particular interventions , local champions , stakeholders and international networks , and the involvement of research ers in policy development were important in knowledge translation for both case studies . Key differences across the two case studies included the nature of the evidence , with clear evidence of efficacy for MgSO4 and ongoing debate regarding the efficacy of bed nets compared with spraying ; local research er involvement in international evidence production , which was stronger for MgSO4 than for malaria vector control ; and a long-st and ing culture of evidence -based health care within obstetrics . Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO4 , and regional networks and political interests for malaria control . In contrast to treatment policies for eclampsia , a diverse group of stakeholders with varied interests , differing in their use and interpretation of evidence , was involved in malaria policy decisions in the three countries . Conclusion Translating research knowledge into policy is a complex and context sensitive process . Research ers aim ing to enhance knowledge translation need to be aware of factors influencing the dem and for different types of research ; interact and work closely with key policy stakeholders , networks and local champions ; and acknowledge the roles of important interest groups OBJECTIVE We aim ed to generate equation to predict arterial lactate ( a-Lac ) using venous lactate ( v-Lac ) and other lab data . METHODS A prospect i ve cross-sectional study was conducted on emergency patients in the emergency department for 6 months at a general hospital in Tokyo , Japan . We collected  arterial and venous gas analysis data . Patients were eligible for entry into the study if an arterial blood gas analysis was required for appropriate diagnostic care by the treating physician . Univariate linear regression analysis was conducted to generate an equation to calculate a-Lac incorporating only v-Lac . A multivariate forward stepwise logistic regression model ( p-value of 0.05 for entry , 0.1 for removal ) was used to generate an equation including v-Lac and other potentially relevant variables . Bl and -Altman plot was drawn and the two equations were compared for model fitting using R-squares . RESULTS Seventy-two arterial sample s from 72 participants ( 61 % male ; mean age , 58.2 years ) were included in the study . An initial regression equation was derived from univariate linear regression analysis : " ( a-Lac ) = -0.259 + ( v-Lac ) × 0.996 " . Subsequent multivariate forward stepwise logistic regression analysis , incorporating v-Lac and Po2 , generated the following equation:"(a-Lac ) = -0.469+(venous Po2 ) × 0.005 + ( v-Lac ) × 0.997 " . Calculated R-squares by single and multiple regression were 0.94 and 0.96 , respectively . CONCLUSION v-Lac estimates showed a high correlation with arterial values and our data provide two clinical ly useful equations to calculate a-Lac from v-Lac data . Considering clinical flexibility , " Lac = -0.259 + v-Lac × 0.996 " might be more useful while avoiding a time-consuming and invasive procedure Objective To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies . Design Retrospective medical record review of hospital admissions during 2005 in eight countries . Setting Ministries of Health of Egypt , Jordan , Kenya , Morocco , Tunisia , Sudan , South Africa and Yemen ; the World Health Organisation ( WHO ) Eastern Mediterranean and African Regions ( EMRO and AFRO ) , and WHO Patient Safety . Participants Convenience sample of 26 hospitals from which 15 548 patient records were r and omly sample d. Main outcome measures Two stage screening . Initial screening based on 18 explicit criteria . Records that screened positive were then review ed by a senior physician for determination of adverse event , its preventability , and the result ing disability . Results Of the 15 548 records review ed , 8.2 % showed at least one adverse event , with a range of 2.5 % to 18.4 % per country . Of these events , 83 % were judged to be preventable , while about 30 % were associated with death of the patient . About 34 % adverse events were from therapeutic errors in relatively non-complex clinical situations . Inadequate training and supervision of clinical staff or the failure to follow policies or protocol s contributed to most events . Conclusions Unsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied , and hence should be a high priority public health problem . Many other developing and transitional economies will probably share similar rates of harm and similar contributory factors . The convenience sampling of hospitals might limit the interpretation of results , but the identified adverse event rates show an estimate that should stimulate and facilitate the urgent institution of appropriate remedial action and also to trigger more research . Prevention of these adverse events will be complex and involves improving basic clinical processes and does not simply depend on the provision of more re sources In a controlled study patients with Crohn 's disease received an exclusion diet or an diet low in refined carbohydrates and rich in fiber .  A total of 26 patients was observed for 1 year . The exclusion diet was not significantly superior to the st and ard diet with respect to the clinical course ( Crohn 's disease activity index according to Best or van Hees ) or laboratory parameters of inflammatory activity . During dietary counselling relapses were infrequent and symptoms improved in both dietary groups The objective of this experiment was to determine whether supplementation with fructooligosaccharides ( FOS ) and ( or ) Lactobacillus acidophilus ( LAC ) affected bowel function and fermentative end-product concentrations in feces of healthy humans . Subjects ( n = 68 ) were enrolled in a r and omized , double-blind , placebo-controlled , parallel study design . After a 4-wk baseline period , subjects consumed one of the following treatments twice daily for 4 wk : 1 ) 3 g sucrose + 80 mg cornstarch ; 2 ) 3 g FOS + 80 mg cornstarch ; 3 ) 3 g sucrose + 1 x 10(9 ) colony-forming units ( cfu ) LAC ; or 4 ) 3 g FOS + 1 x 10(9 ) cfu LAC . Subjects completed 7-d bowel function forms and 3-d dietary records before collection of fresh stool sample s at wk 4 , 6 and 8 . Statistical analyses were performed on differences from baseline using the General Linear Models procedure of SAS . Fructooligosaccharides decreased fecal ammonia ( P = 0.07 ) and isovalerate ( P = 0.12 ) concentrations at wk 6 . At wk 8 , FOS tended ( P = 0.11 ) to increase fecal putrescine concentrations . Lactobacillus decreased fecal organic matter percentage at wk 6 ( P < 0.05 ) and 8 ( P = 0.07 ) . At wk 6 and 8 , LAC increased ( P < 0.05 ) fecal 2-methylindole , total indole , and total indole and phenol concentrations . At wk 8 , LAC decreased fecal agmatine ( P = 0.08 ) and phenylethylamine ( P < 0.05 ) concentrations . In conclusion , FOS and LAC modified several metabolites associated with gut health , with FOS tending to be beneficial ( decreased fecal protein catabolites ) and LAC being negative ( increased fecal protein catabolites ) BACKGROUND Depression is one of the most disabling diseases , and causes a significant burden both to the individual and to society . WHO data suggests that depression causes 6 % of the burden of all diseases in Europe in terms of disability adjusted life years ( DALYs ) . Yet , the knowledge of the economic impact of depression has been relatively little research ed in Europe . AIMS OF THE STUDY The present study aims at estimating the total cost of depression  in Europe based on published epidemiologic and economic evidence . METHODS A model was developed to combine epidemiological and economic data on depression in Europe to estimate the cost . The model was populated with data collected from extensive literature review s of the epidemiology and economic burden of depression in Europe . The cost data was calculated as annual cost per patient , and epidemiologic data was reported as 12-month prevalence estimates . National and international statistics for the model were retrieved from the OECD and Eurostat data bases . The aggregated annual cost estimates were presented in Euro for 2004 . RESULTS In 28 countries with a population of 466 million , at least 21 million were affected by depression . The total annual cost of depression in Europe was estimated at Euro 118 billion in 2004 , which corresponds to a cost of Euro 253 per inhabitant . Direct costs alone totalled dollar 42 billion , comprised of outpatient care ( Euro 22 billion ) , drug cost ( Euro 9 billion ) and hospitalization ( Euro 10 billion ) . Indirect costs due to morbidity and mortality were estimated at Euro 76 billion . This makes depression the most costly brain disorder in Europe , accounting for 33 % of the total cost . The cost of depression corresponds to 1 % of the total economy of Europe ( GDP ) . DISCUSSION Our cost results are in good agreement with previous research findings . The cost estimates in the present study are based on model simulations for countries where no data was available . The predictability of our model is limited to the accuracy of the input data employed . As there is no earlier cost-of-illness study conducted on depression in Europe , it is , however , difficult to evaluate the validity of our results for individual countries and thus further research is needed . CONCLUSION The cost of depression poses a significant economic burden to European society . The simulation model employed shows good predictability of the cost of depression in Europe and is a novel approach to estimate the cost-of-illness in Europe . IMPLICATION S FOR HEALTH CARE PROVISION AND POLICIES : Health and social care policy and commissioning must be evidence -based . The empirical results from this study confirm previous findings , that depression is a major concern to the economic welfare in Europe which has consequences to both healthcare providers and policy makers . One important way to stop this explosion in cost is through increased research efforts in the field . Moreover , better detection , prevention , treatment and patient management are imperatives to reduce the burden of depression and its costs . Mental healthcare policies and better access to healthcare for mentally ill are other challenges to improve for Europe . IMPLICATION S FOR FURTHER RESEARCH This study has identified several research gaps which are of interest for future research . In order to better underst and the impact of depression to European society long-term prospect i ve epidemiology and cost-of-illness studies are needed . In particular data is lacking for Central European countries . On the basis of our findings , further economic evaluations of treatments for depression are necessary in order to ensure a cost-effective use of European healthcare budgets Background : Research in industrialized countries has demonstrated that a key factor limiting the control of hypertension is poor patient adherence and that the most successful interventions for long-term adherence employ multiple strategies . Very little data exist on this question in low-income countries , wherein medication-taking behavior may be less well developed . Method : We conducted a treatment adherence trial of 544 patients [ mean age ∼63 years , mean blood pressure ( BP ) ∼168/92 mmHg ] with previously untreated hypertension in urban and rural Nigeria . Eligible participants were r and omized to one of two arms : clinic management only , or clinic management and home visits . Both interventions included three elements : a community based , nurse-led treatment program with physician backup ; facilitation of clinic visits and health education ; and the use of diuretics and a & bgr ; blocker as needed . After initial diagnosis , the management protocol was implemented by a nurse with physician backup . Participants were evaluated monthly for 6 months . Results : Medication adherence was assessed with pill count and urine testing . Drop-out rates , by treatment group , ranged from 12 to 28 % . Among participants who completed the 6-month trial , overall adherence was high ( ∼77 % of participants took > 98 % of prescribed pills ) . Adherence did not differ by treatment arm , but was better at the rural than the urban site and among those with higher baseline BP . Hypertension control ( BP < 140/90 mmHg ) was achieved in approximately 66 % of participants at 6 months . Conclusion : This community-based intervention confirms relatively modest default rates compared with industrialized societies , and suggests that medication adherence can be high in developing world setting s in clinic attenders
While we found relatively good st and ards of reporting the study ’s question , population , interventions , comparators and conclusions , the overall reporting was poor , and evidence of unfamiliarity with international guidelines was evident ( i.e. absence of incremental analysis , of discounting long-term costs and effects ) .
Analysis or description of place-to-place variability was infrequent .
Use and acceptance of health economic evaluations ( HEEs ) has been much greater in developed than in developing nations .
Nevertheless , while developing countries lag behind in the development of HEE methods , they could benefit from the progress made in other countries and concentrate on ways in which existing methods can be used or would need to be modified to fulfill their specific needs .
HEEs , as context -specific tools , are not easily generalizable from setting to setting .
Existing studies regarding generalizability and transferability of HEEs have primarily been conducted in developed countries .
Therefore , a legitimate question for policy makers in Latin America and the Caribbean region ( LAC ) is to what extent HEEs conducted in industrialized economies and in LAC are generalizable to LAC ( trans-regional ) and to other LAC countries ( intra-regional ) , respectively .