Communities In High-income Countries Research Articles

An innovation platform for diffusing public health practices across a global network

Hospitals and health systems in high-income countries (HIC) develop the capacities of peer healthcare organizations around the world by diffusing clinical, quality, and public health improvement practices in lower and middle-income countries (LMIC). In turn, these HIC healthcare institutions are exposed to innovative approaches developed and used by global communities to advance care despite resource constraints in the LMIC contexts. Attention has been growing in recent years to the potential these innovations can have to improve care delivery, lower costs, and drive quality within resource-constrained communities in HIC. Often referred to as “reverse innovations,” the identification, adaptation, and diffusion of these practices face challenges in uptake related to limited evidence, perceptions of poor quality or irrelevance, and a complicated regulatory and policy environment. This paper suggests the development of an approach to improve the capacity of the healthcare organizations in the HIC as well, based on lessons learned from diffusing practices in LMIC. It concludes with the need for a knowledge platform to support innovation diffusion in both directions.

The End Rheumatic Heart Disease in Australia Study of Epidemiology (ERASE) Project: data sources, case ascertainment and cohort profile.

PurposeAcute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist as public health issues in developing countries and among disadvantaged communities in high-income countries, with rates in Aboriginal and Torres Strait Islander peoples in Australia among the highest recorded globally. A robust evidence base is critical to support policy recommendations for eliminating RHD, but available data are fragmented and incomplete. The End RHD in Australia: Study of Epidemiology (ERASE) Project aims to provide a comprehensive database of ARF and RHD cases in Australia as a basis for improved monitoring and to assess prevention and treatment strategies. The objective of this paper is to describe the process for case ascertainment and profile of the study cohort.Patients and methodsThe ERASE database has been built using linked administrative data from RHD registers, inpatient hospitalizations, and death registry data from 2001 to 2017 (mid-year). Additional linked datasets are available. The longitudinal nature of the data is harnessed to estimate onset and assess the progression of the disease. To accommodate systematic limitations in diagnostic coding for RHD, hospital-only identified RHD has been determined using a purposefully developed prediction model.ResultsOf 132,053 patients for whom data were received, 42,064 are considered true cases of ARF or RHD in the study period. The patient population under 60 years in the compiled dataset is more than double the number of patients identified in ARF/RHD registers (12,907 versus 5049). Non-registered patients were more likely to be older, non-Indigenous, and at a later disease stage.ConclusionThe ERASE Project has created an unprecedented linked administrative database on ARF and RHD in Australia. These data provide a critical baseline for efforts to end ARF/RHD in Australia. The methodological work conducted to compile this database resulted in significant improvements in the robustness of epidemiological estimates and entails valuable lessons for ARF/RHD research globally.

Data gaps in adolescent fertility surveillance in middle-income countries in Latin America and South Eastern Europe: Barriers to evidence-based health promotion.

Adolescent health is a major global priority. Yet, as recently described by the World Health Organization (WHO), increased recognition of the importance of adolescent health rarely transforms into action. One challenge is lack of data, particularly on adolescent fertility. Adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families. Other important components of adolescent fertility include abortion, miscarriage, and stillbirth. Access to reliable, consistently-collected data to understand the scope and complexity of adolescent fertility is critical for designing strong research, developing meaningful policies, building effective programs, and evaluating success in these domains. Vital surveillance data can be challenging to obtain in general, and particularly in low- and middle-income countries and other under-resourced settings (including rural and indigenous communities in high-income countries). Definitions also vary, making comparisons over time and across locations challenging. Informed by the Adolescence and Motherhood Research project in Brazil and considering relevance to the Southern Eastern European (SEE) context, this article focuses on challenges in surveillance data for adolescent fertility for middle-income countries. Specifically, we review the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then we (3) consider implications of data gaps on this topic for selected middle-income countries in Latin America and SEE, and (4) propose next steps to improve adolescent fertility data for evidence-based health promotion in the middle-income country context.

The Global Spine Care Initiative: methodology, contributors, and disclosures

PurposeThe purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations.MethodsWorld Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative’s mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care.ResultsSixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest.ConclusionThe GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

What is the overall impact or effectiveness of visiting primary health care services in rural and remote communities in high-income countries? A systematic review

BackgroundVisiting services address the problem of workforce deficit and access to effective primary health care services in isolated remote and rural locations. Little is known about their impact or effectiveness and thereby the extent to which they are helping to reduce the disparity in access and health outcomes between people living in remote areas compared with people living in urban regions of Australia. The objective of this study was to answer the question “What is the impact or effectiveness when different types of primary health care services visit, rather than reside in, rural and remote communities?”MethodWe conducted a systematic review of peer-reviewed literature from established databases. We also searched relevant websites for ‘grey’ literature and contacted several key informants to identify other relevant reference material. All papers were reviewed by at least two assessors according to agreed inclusion and exclusion criteria.ResultsInitially, 345 papers were identified and, from this selection, 17 papers were considered relevant for inclusion. Following full paper review, another ten papers were excluded leaving seven papers that provided some information about the impact or effectiveness of visiting services. The papers varied with regard to study design (ranging from cluster randomised controlled trials to a case study), research quality, and the strength of their conclusions. In relation to effectiveness or impact, results were mixed. There was a lack of consistent data regarding the features or characteristics of visiting services that enhance their effectiveness or impact. Almost invariably the evaluations assessed the service provided but only two papers mentioned any aspect of the visiting features within which service provision occurred such as who did the visiting and how often they visited.ConclusionsThere is currently an inadequate evidence base from which to make decisions about the effectiveness of visiting services or how visiting services should be structured in order to achieve better health outcomes for people living in remote and rural areas. Given this knowledge gap, we suggest that more rigorous evaluation of visiting services in meeting community health needs is required, and that evaluation should be guided by a number of salient principles.

Ethics and Community-Based Rehabilitation: Eight Ethical Questions from a Review of the Literature.

Purpose: This article reviews the literature regarding ethics and community-based rehabilitation (CBR) with the goal of identifying and analyzing ethical considerations associated with this approach. Method: We conducted a critical interpretive review of the academic literature related to CBR in low- and middle-income countries and to indigenous communities in high-income countries. Using an inductive analysis of the collected articles, we identified five key topic areas related to ethical considerations. We then critically appraised this literature and developed eight questions that reflect areas of ethical tension, uncertainty, or debate. Results: The five key topic areas are partnerships among stakeholders, respect for culture and local experience, empowerment, accountability, and fairness in programme design. The eight ethical questions are linked to these topics and associated with how CBR practices reflect commitments to equity, respect, inclusion, participation, and social justice. Conclusion: Continued engagement with ethical considerations associated with CBR can help to strengthen the foundations of this important and influential approach. It is crucial that all those involved in CBR projects, including physiotherapists, pay careful attention to the development of partnerships that, despite asymmetries among stakeholders, are respectful and effective.

Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data

WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. We analysed information about availability and costs of cardiovascular disease medicines (aspirin, β blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55). Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO's targets of 50% use of key medicines by 2025. Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

Respondent-driven sampling among gay and bisexual men: experiences from a New Zealand pilot study.

BackgroundRespondent-driven sampling (RDS) is a method of approximating random sampling of populations that are difficult to locate and engage in research such as gay, bisexual and other men who have sex with men (GBM). However, its effectiveness among established urban gay communities in high-income countries is largely unexplored outside North America. We conducted a pilot study of RDS among urban GBM in Auckland, New Zealand to assess its local applicability for sexual health research.FindingsPre-fieldwork formative assessment explored RDS suitability among local GBM. Highly-networked initial participants (“seeds”) and subsequent participants completed a questionnaire, took a rectal swab for chlamydia and gonorrhoea testing, and were asked to recruit up to three eligible peers over the subsequent 2 weeks using study coupons. Compensation was given for participating and for each peer enrolled. Feedback on the pilot was obtained through questionnaire items, participant follow-up, and a focus group. Nine seeds commenced recruitment, directly enrolling 10 participants (Wave One), who in turn enrolled a further three (Wave Two). Two of the 22 participants (9 %) had undiagnosed rectal chlamydia. The coupon redemption rate (23 %) was lower than the expected rate (33 %) for this population. Participants were motivated by altruism above financial incentives; however, time, transport and reluctance recruiting peers were perceived as barriers to enrolment.DiscussionSlow recruitment in our pilot study suggests that RDS might not be an effective or efficient method of sampling gay men in all high-income urban settings. However those who participated in the pilot were willing to provide anal swabs and information on their sexual behaviour, and also on the size of their GBM social network which is necessary to weight data in RDS. Refinements and adaptations such as reducing the transaction costs of taking part (e.g. offering online participation) could improve responses but these have their own drawbacks (higher set-up costs, difficulty collecting biological specimens).

Cardiovascular prevention model from Kenyan slums to migrants in the Netherlands.

Cardiovascular diseases (CVD) are the main cause of morbidity and mortality worldwide. As prevention and treatment of CVD often requires active screening and lifelong follow up it is a challenge for health systems both in high-income and low and middle-income countries to deliver adequate care to those in need, with efficient use of resources.We developed a health service model for primary prevention of CVD suitable for implementation in the Nairobi slums, based on best practices from public health and the private sectors. The model consists of four key intervention elements focusing on increasing awareness, incentives for promoting access to screening and treatment, and improvement of long-term adherence to prescribed medications. More than 5,000 slum dwellers aged ≥35 years and above have been screened in the study resulting in more than 1000 diagnosed with hypertension and referred to the clinic.Some marginalized groups in high-income countries like African migrants in the Netherlands also have low rates of awareness, treatment and control of hypertension as the slum population in Nairobi. The parallel between both groups is that they have a combination of risky lifestyle, are prone to chronic diseases such as hypertension, have limited knowledge about hypertension and its complications, and a tendency to stay away from clinics partly due to cultural beliefs in alternative forms of treatment, and lack of trust in health providers. Based on these similarities it was suggested by several policymakers that the model from Nairobi can be applied to other vulnerable populations such as African migrants in high-income countries. The model can be contextualized to the local situation by adapting the key steps of the model to the local settings.The involvement and support of African communities’ infrastructures and health care staff is crucial, and the most important enabler for successful implementation of the model in migrant communities in high-income countries. Once these stakeholders have expressed their interest, the impact of the adapted intervention can be measured through an implementation research approach including collection of costs from health care providers’ perspective and health effects in the target population, similar to the study design for Nairobi.Electronic supplementary materialThe online version of this article (doi:10.1186/s12992-015-0095-y) contains supplementary material, which is available to authorized users.

International Women's Day 2014: women's health equity is progress for all.

International Women's Day 2014: women's health equity is progress for all.

Microbial ‘Old Friends’, immunoregulation and stress resilience

Chronic inflammatory diseases (autoimmunity, allergy and inflammatory bowel diseases) are increasing in prevalence in urban communities in high-income countries. One important factor is reduced exposure to immunoregulation-inducing macro- and microorganisms and microbiota that accompanied mammalian evolution (the hygiene hypothesis or ‘Old Friends’ mechanism). Reduced exposure to these organisms predisposes to poor regulation of inflammation. But inflammation is equally relevant to psychiatric disorders. Inflammatory mediators modulate brain development, cognition and mood, and accompany low socioeconomic status and some cases of depression in developed countries. The risk of all these conditions (chronic inflammatory and psychiatric) is increased in urban versus rural communities, and increased in immigrants, particularly if they move from a low- to a high-income country during infancy, and often the prevalence increases further in second generation immigrants, suggesting that critical exposures modulating disease risk occur during pregnancy and infancy. Diminished exposure to immunoregulation-inducing Old Friends in the perinatal period may enhance the consequences of psychosocial stressors, which induce increased levels of inflammatory mediators, modulate the microbiota and increase the risk for developing all known psychiatric conditions. In later life, the detrimental effects of psychosocial stressors may be exaggerated when the stress occurs against a background of reduced immunoregulation, so that more inflammation (and therefore more psychiatric symptoms) result from any given level of psychosocial stress. This interaction between immunoregulatory deficits and psychosocial stressors may lead to reduced stress resilience in modern urban communities. This concept suggests novel interpretations of recent epidemiology, and novel approaches to the increasing burden of psychiatric disease.

South Asians and Cardiovascular Risk

Case presentation: A 36-year-old nonsmoking, normotensive South Asian man presented to the emergency department of a community hospital with retrosternal chest pain of &60 minutes’ duration. His 12-lead ECG demonstrated 10 mm of ST-segment elevation in leads V2 through V6, and he received fibrinolytic therapy within 90 minutes of symptom onset. His pain resolved, but his ST segments only partially normalized; he had a peak creatine kinase of 4564 IU/L, and he showed signs of early heart failure. LDL cholesterol was 135 mg/dL, HDL 32 mg/dL, triglycerides 20 mg/dL, and total cholesterol 206 mg/dL; his body mass index (BMI) was 24 kg/m2. Cardiac catheterization demonstrated severe and diffuse triple-vessel disease, including occlusion of the proximal left anterior descending artery, as well as moderate left ventricular dysfunction. While in the hospital, he was diagnosed with new-onset type 2 diabetes mellitus and subsequently underwent uncomplicated coronary bypass surgery. South Asians are individuals whose ethnic roots originate from the Indian subcontinent, a large geographic area that includes India, Pakistan, Sri Lanka, Nepal, and Bangladesh. Collectively, South Asians represent one fifth of the global population. In North America, more than 2 million South Asians reside in the United States and almost 1 million in Canada. It is important to recognize that the term “South Asian” refers to a heterogeneous population, with important differences in diet, culture, and lifestyle among different South Asian populations and religions. Multiple studies of migrant South Asian populations have, however, confirmed a 3- to 5-fold increase in the risk for myocardial infarction and cardiovascular death as compared with other ethnic groups.1–3 In an analysis of age-standardized coronary heart disease (CHD) mortality in Canada over a 15-year period, South Asians had the highest CHD mortality compared with individuals of Chinese and European descent.4 In …