Lancet Series Research Articles

PrEP: An Opportunity to Address Unmet Adolescent Health Needs.

* Abbreviations: PrEP — : preexposure prophylaxis SRH — : sexual and reproductive health STI — : sexually transmitted infection Kleinert stated in her 2007 Lancet series that “Adolescence is a time in life that harbours many risks and dangers, but also one that presents great opportunities for sustained health and wellbeing through education and preventive efforts.”1 In this issue of Pediatrics , Hosek and Henry-Reid2 reiterate this observation in their review of preexposure prophylaxis (PrEP) and prescribing among pediatric and adolescent health care providers and give some useful pointers on how providers can better use opportunities, particularly in offering oral PrEP to their adolescent clients. Their article also brings home a fact we all know but have had trouble admitting: adolescents by definition are discovering their sexuality and becoming sexual beings. With this come the “risks and dangers” that present as sexually transmitted infections (STIs), HIV, and unintended pregnancies.3 The unconditional acceptance that adolescents are engaging in sex as part of their behavioral, social, and physiologic transition to healthy adulthood is a first step in maximizing the opportunities we as providers can create, not only to protect but also to find ways to enhance sustained health and well-being.4 In their review of how to introduce oral PrEP as a novel and important prevention opportunity, Hosek and Henry-Reid2 provide tips and recommendations for how to go about offering … Address correspondence to Linda-Gail Bekker, MD, PhD, The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Anzio Rd, Observatory, Cape Town 7925, South Africa. E-mail: linda-gail.bekker{at}hiv-research.org.za

Longitudinal Caries Prevalence in a Comprehensive, Multi-Component, School-Based Prevention Program: An Open Cohort Study

Background: Unchanged in 30 years, the global prevalence of dental caries is >35% in low-, middle-, and high-income countries. As proposed in the Lancet Series on Oral Health, reducing the caries burden requires a radical change from care that is high-tech, high-cost, low-access, office-based, interventional, and delivered by dentists, to care that is low-tech, low-cost, high-access, community-based, preventive, and delivered by non-dentists. Here we report on one test of the latter, community-based prevention delivered by non-dentists. Methods: We conducted a 6-year prospective open cohort study in 33 U.S. public elementary schools, providing care to 6,927 children in communities with and without water fluoridation. Following a dental examination, dental hygienists provided twice-yearly prophylaxis, glass ionomer sealants, glass ionomer interim therapeutic restorations, fluoride varnish, toothbrushes, fluoride toothpaste, oral hygiene instruction, and referral to community dentists as needed. We used a two-phase school enrollment with six initial schools, and 27 later. To estimate the change in prevalence of untreated decay over time we fit regression models by using generalized estimating equations. Findings: The prevalence of untreated caries decreased from 39% at baseline to 18% in the initial six schools, and from 28% to 10% in the remaining 27 schools. The per-visit reduction in the odds of decay mainly occurred in subjects with untreated decay at baseline (adjusted odds ratio 0.79, 95% confidence interval 0.73, 0.85). Interpretation: These results support the hypothesis that community-based, comprehensive caries prevention reduces caries prevalence. The study also demonstrates the feasibility of low-tech, prevention-focused models of care. Funding Statement: Multiple governmental and non-governmental organizations supported this work. Declaration of Interests: The following organizations provided partial support for this work: National Institute of Minorities and Health Disparities, the Dental Service of Massachusetts – DentaQuest, Bingham Trust, the Massachusetts State Legislature, the American Dental Trade Alliance, Belizekian Trust and Noonan, and Bank of America Trust. In-kind support included: glass ionomer provided by GC America and toothbrushes, fluoride toothpaste, and fluoride varnish provided by Colgate Palmolive. None of the preceding organizations or individuals working with or for them had any input into trial design, patient recruitment, clinical care, data collection, analysis, interpretation, report writing, or any aspect of the study. All authors were either compensated by grant funding or were uncompensated for this work. No commercial entity compensated any of the authors for conducting the study or drafting the manuscript. Ethics Approval Statement: The Forsyth Institute, Boston, MA Investigational Review Board approved this study. Reporting follows STROBE guidelines. The authors previously reported the study rationale, calibration, selection of protocols, interventions, and six-month preliminary outcomes. Informed consent and assent was obtained from guardians.

Increase value and reduce waste in research on psychological therapies

A seminal Lancet series focused on increasing value and reducing waste in biomedical research, providing a transferrable template to diagnose problems in research. Our goal was to document how some of these sources of waste apply to mental health and particularly psychological treatments research. We synthesize and critically evaluate empirical findings in relation to four major sources: i) defining research priorities; ii) research design, methods and analysis; iii) accessibility of research information; iv) accuracy and usability of research reports. We demonstrate that each source of waste considered is well-represented and amply documented within this field. We describe hype and insufficient consideration of what is known in defining research priorities, persistent risk of bias, particularly due to selective outcome reporting, for psychotherapy trials across mental disorders, intellectual and financial biases, direct and indirect evidence of publication bias, largely inexistent adoption of data sharing, issues of multiplicity and fragmentation of data and findings, and insufficient adoption of reporting guidelines.We expand on a few general solutions, including supporting meta-research, properly testing interventions to increase research quality, placing open science at the center of psychological treatment research and remaining vigilant particularly regarding the strains of research currently prioritized, such as experimental psychopathology.

Heat and health: a forthcoming Lancet Series

Heat and health: a forthcoming Lancet Series

An evaluation of the effectiveness of a community-based parenting empowerment program to improve nurturing care of young children in Kenya and Zambia

<p class="abstract"><strong>Background:</strong> Investing in parents and children during the critical period between birth and five years of a child’s life can have long-lasting benefits in the life of the child. Recently, the 2016 Lancet Series estimated that 250 million children aged less than five years in low- and middle-income countries (LMICs) are at risk of not reaching their developmental potential. Over 66 % of these, who live in sub-Saharan Africa and are at risk due to poor nutrition, exposure to poverty, high HIV prevalence as well as under stimulation in the home environment.</p><p class="abstract"><strong>Methods:</strong> The study will employ a cluster-randomized control trial design and will use a mixed-methods approach combining quantitative and qualitative methodologies <strong>(</strong>Concurrent Triangulation Design).<strong> </strong>This will be a two-arm study, where the first arm will participate in the parenting empowerment program implemented by the faith-based organizations, while the second (control) will not receive the parenting interventions. A total of 510 mother/primary caregiver-child dyads will be recruited into this study. We will estimate the causal effect of the intervention using mixed linear models and the Difference-in-Differences (DID) estimator.</p><p class="abstract"><strong>Conclusions: </strong> This implementation research will provide greater scientific rigor and a deeper process and outcome evaluation including measurement of child development outcomes. The findings will be useful for early childhood practitioners, multilateral stakeholders and funders as they provide information on the factors to consider in the implementation of high quality ECD interventions.</p><p class="abstract"><strong>Trial Registration: </strong>Ethical approval: ESRC P467/2018 and IRB No.00005948).</p>

Most Criticisms of the Pivotal Lancet Series on Low Back Pain Appear to Be Off the Mark

Most Criticisms of the Pivotal Lancet Series on Low Back Pain Appear to Be Off the Mark

'TEXT4MYBACK' - the development process of a self-management intervention delivered via text message for low back pain

Purpose: To systematically develop a bank of text messages designed to provide a lifestyle-focused intervention for people with low back pain seeking care from pharmacists. The intervention is based on the provision of advice, motivation, and behaviour change support. Methods: The iterative development process consisted of 3 phases: (i) Concept development phase: this first phase consisted of a pre-development meeting with researchers, consumer advocates and clinicians with specific knowledge of low back pain. The key domains considered to be important for this patient demographic, the sources of content for the key messages and the volume and timing of messages considered acceptable were identified in two 2-hour workshops. (ii) Content development phase: the second phase was completed by a team of writers and based on recent evidence (Lancet Series on Low Back Pain; the NICE guidelines for low back pain; Chartered Society of Physiotherapy consumer information; and the Manage your pain consumer guide developed by Musculoskeletal Australia). Six domains were identified: exercise, education, mood, sleep, use of care and medication. Moreover, each of them had one of three aims: education, motivation or behavioural change. (iii) Writing phase: a bank with 86 draft messages was developed and each message was meant to convey one of the six domains. The theoretical basis of the messages was the behaviour change technique, which included: provision of information and encouragement; prompting about consequences, intention formation, monitoring self-behaviour, and barrier identification; advice about setting graded tasks; and strategies aimed at relapse prevention and the use of prompting and cues. Results: After the bank was developed, all the messages were reviewed by a researcher with expertise in behavioural change and text messages. This was followed by 2 other review phases: (i) Expert review phase: the expert review panel members were identified by the investigators as key opinion leaders and clinicians in the field of low back pain. The review panel comprised a multidisciplinary team including researchers, pharmacists, physiotherapists, GP’s, nurses and clinical psychologist. Each of them reviewed 15 messages, scored them using a 5-item psychometric scale according to the appropriateness of content and likely clinical effectiveness and provided recommendations for improvement. This process ensured that every message was reviewed by a minimum of 2 experts and had an average from 2-10 points. It was established that those messages which received a sum score inferior than 8 points by any reviewer would be changed and improved according to the reviewers’ comments to maximize their quality and likelihood of effectiveness. After that, 29 messages, representing 34% of the bank of drafts, were modified accordingly. The mean score of the bank of messages was of 8.3/10 points. (ii) Consumer review phase: consumers with low back pain were identified by Musculoskeletal Australia and invited to review 15 messages. 12 consumers reviewed and scored the messages using a 5-item psychometric scale according to the utility and understanding of the text content and language acceptability. This process ensured that every message was reviewed by a minimum of 2 consumers and had an average from 3-15 points. They were also asked to provide recommendations for improvement. It was established that those messages receiving a sum score inferior than 12 points by any reviewer would be changed and improved even if their sum score was above 12. There were 36 messages, representing 42% of the bank of drafts, modified accordingly. The mean score of the bank of messages was of 12.5/15 points. Conclusions: A final bank of 86 text messages designed to support lifestyle-focused intervention for patients with low back pain has been developed through a multistep iterative process. The description of this process can provide a scientific support for future development of text message interventions within the musculoskeletal field of research.

Improving Health Systems Response Through Women's Self-Help Groups in India: Repeated Cross-Sectional, Quasi-Experimental Study

Background: Maternal, newborn and child health (MNCH) interventions with women's self-help groups (SHGs) can improve its outcomes in rural communities through addressing health system barriers, and empowering women. We assessed the effect of large-scale implementation of health interventions integrated within SHGs compared with standard group settings, on group advocacy, women's self-determination, and norms around health care service delivery. Methods: Using a pre-post quasi-experimental design, 33 geographic blocks were divided into two groups: intervention and comparison. SHG women in comparison blocks received the usual microcredit program, and SHG members in intervention blocks received additional participatory training around MNCH issues through a community mobilizer who led at least one health meeting a month. Two cross-sectional surveys in 2013 (N= 2407) and 2016 (N=2974) were conducted among eligible women (i.e., 18-49 years, married, SHG member and had a live birth within 12 months). The outcomes in the study were: collective agency to negotiate with health center/workers, women's self-advocacy with health workers, self-confidence in accessing health services, and services from health workers including respectful care. Outcome effects were assessed using difference-in-differences (DID) methods. Findings: Of the 5089 women interviewed across the two-time points, the mean age was 26 (±4·7) years. The intervention improved women's collective agency to demand for services and improved key healthcare system related factors: self-advocacy with local health facility (DID: 16 percentage points[pp], p<0·001); improved health workers' response in providing: respectful care (DID: 3pp, p=0·035), getting appropriate referrals from frontline health workers (DID: 6pp, p=0·009), receiving help during emergencies (DID: 10pp, p=0·005); and postnatal care (DID:14pp, p<0·001). Interpretation: Self-help groups are important community institutions enabling poor women and their households to access finance and social services. Health interventions layered within these institutions enable women's participatory learning, collectivization, and ability to connect with health care providers in meaningful ways. Funding: This evaluation study was funded to Population Council by the Bill and Melinda Gates Foundation (#OPP1141832) and Project Concern International (061C-XX1ZZ-140700). The Population Council had designed and conducted the study on their own. The funders had no role in study design, data collection, data analysis or interpretation and decision to publish. Further, the paper was developed in support of The Lancet Series on Gender Equality, Norms and Health. We thank The Lancet Series leadership, and the Bill and Melinda Gates Foundation and the UAE government for their support to the publication of this paper as a supplemental paper to the Series. Declaration of Interest: None declared. Ethical Approval: All study procedures were reviewed and approved by the Institutional Review Board of the Population Council.

Stillbirth rate in Bhutan: a retrospective facility-based study

Introduction: Stillbirth is an important public health concern; yet there is no reliable stillbirth rate for Bhutan. Hence the aim of this study was to estimate the stillbirth rate for Bhutan.&#x0D; Methods: A retrospective study was carried out for live and stillbirths recorded in delivery registers of all 253 health facilities across the country for a period of one year commencing 1st January till 31st December 2015.&#x0D; Results: There were a total of 11,126 live births and 108 stillbirths documented in delivery registers. The stillbirth rate from this data set was 10 per 1000 live births.&#x0D; Conclusions: The stillbirth rate for Bhutan from this study is 10 per 1000 live births lower than 16 per 1000 live births estimated in Lancet Series 2015. In order to find the true burden of stillbirths in the country, a surveillance may be instituted which can facilitate the prevention efforts while at the same time enable to strengthen information system.

Offline: The fetishisation of “global”

Last week, the UK Government, WHO, and OECD came together to host the first Global Ministerial Mental Health Summit. The gathering, under the banner of “Equality for mental health in the 21st century”, felt a genuinely momentous event. Matt Hancock, Britain's Conservative Secretary of State for Health and Social Care, spoke about “a bold and ambitious statement of intent”. Mental health was “a defining challenge of our age”. As machines take over what, in the past, have been considered cognitive tasks, human beings will be left to rely ever more on their emotional skills and abilities. Mental health will therefore be central to a country's future economic wellbeing. Simon Stevens, Chief Executive of the National Health Service, called mental health “an unfinished revolution”. An array of health ministers from Europe, Africa, and Asia pledged their support for this new global health initiative. The Netherlands Government announced that it would hold the second Global Summit in Amsterdam in October, 2019—the theme, emergency settings. The Lancet Commission on Global Mental Health and Sustainable Development, co-chaired by Vikram Patel and Shekhar Saxena, was launched at the Summit. The Commission builds on a 2007 Lancet Series on Global Mental Health, also led by Vikram and Shekhar, which made the case for greater investments in mental health services. That Series led to the creation of a Movement for Global Mental Health. A decade of campaigning has made mental health a core priority for the international health community. The Lancet Commission's goal is to accelerate action on mental health. But it does so not by repeating old messages. Instead, the Commission aims for a radical reappraisal of mental health. It situates mental health as foundational for sustainable development. It defines mental health as a continuum rather than a binary. As Vikram Patel noted, when we talk about mental health, “we are talking about ourselves”. The Commission sought to contextualise mental health as a product of the political, economic, social, and environmental circumstances of communities. And the Commission argued that mental health is “a fundamental human right”. Charlene Sunkel, who leads the Movement for Global Mental Health, called for the Commission to be used as a tool for advocacy. Grace Gatera, a member of Young Leaders for the Lancet Commission, described her two attempts at suicide, “to escape the darkness”. “Young people are suffering”, she said. “Young people are now.” The Commission looks forward to a time when discrimination against those with mental health conditions will end, when political leaders recognise and act on the mental health needs of their peoples, and when communities are empowered to demand the attention and services they need. But I left the Summit with nagging doubts. Doubts not about the importance of mental health to sustainable development, nor about the ambitious messages of the Lancet Commission. But doubts about the fetishisation of the “global”. Global summits. Global campaigns. Global actions. What is this idea of the “global”? Irene Agyepong, director of health services for Accra, Ghana, gave the annual Academy of Medical Sciences/Lancet International Health Lecture 2 days before the Summit. She asked whether universal health coverage (UHC), the global health community's latest priority, would be a “breakthrough or great white elephant?” By white elephant, she meant, “a curse if the resources to maintain a commitment of such magnitude were not forthcoming”. Her experience was that abstract global calls often ignore local country contexts. “History matters”, she argued. She told the story of Ghana's quest for UHC—colonisation, independence, self-rule, four Republics interspersed by military coups, the emergence of multiparty democracy, and the eventual creation of the Ghana Health Service and National Health Insurance. The trajectory towards UHC cannot be taken for granted, she warned. If grand global goals are to be realised, country demand, ownership, leadership, institutions, ideas, interests, and resources are essential. The principle global goal should be to catalyse human capacity building in countries. Global commitments mean little unless they take account of the domestic challenges faced by country policy makers. Above all, she urged global health leaders to “resist the gold rush lure of fix-all, global technological magic bullets”. A bracing admonition.

Asking Different Questions: A Call to Action for Research to Improve the Quality of Care for Every Woman, Every Child.

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents different research questions drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on right care, which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Adapting the Quality Maternal and Newborn Care (QMNC) Framework to evaluate models of antenatal care: A pilot study.

BackgroundRecent evidence indicates that continuity models of maternity care result in improved clinical and psychosocial outcomes, but their causal mechanisms are poorly understood. The recent Lancet Series on Midwifery’s Quality Maternal and Newborn Care Framework describes five components of quality care and their associated characteristics. As an initial step in developing this Framework into an evaluation toolkit, we transformed its components and characteristics into a topic guide to assess stakeholder perceptions and experiences of care provided and received. The main purpose of this study was to assess the feasibility of this process.MethodsWe conducted twelve focus groups in two Scottish health board areas with 13 pregnant women, 18 new mothers, 26 midwives and 12 obstetricians who had experience of a range of different models of maternity care. Transcripts were analysed using a six-phase approach of thematic analysis. We mapped the identified themes and sub-themes back to the Framework.ResultsThe emerging themes and sub-themes demonstrated the feasibility of using the QMNC framework as a data collection tool, and as a lens for analysing the data. Of the four emerging themes, only Organisation Culture / Work Structure’ mapped directly to a single Framework component. The others—‘Relationships’; ‘Information and support’; and ‘Uncertainty’–mapped to between two and five components, illustrating the interconnectedness of the Framework’s components. Some negative sub-themes mirrored positive Framework characteristics of care. Some re-phrasing and re-ordering of the topic guides in later focus groups ensured we could cover all aspects of the Framework adequately.ConclusionAdapting the Quality Maternal and Newborn Care Framework enabled us to focus on aspects of care which worked well and which didn’t work well for these key stakeholders. Identifying ‘what works for whom and why’ in different models of care is a necessary step in reinforcing and replicating the most effective models of care.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents different research questions drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on right care, which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child.

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents "different research questions" drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on "right care," which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

The virtual special section of active transport papers from the 2017 active living research conference

Since 2004, the Active Living Research (ALR) Conference has focused on advancing knowledge and practice related to the creation of communities that increase opportunities for physical activity. Communities designed for active living are better for health, economic vitality, and environmental sustainability. The Annual ALR Conference serves as a premier venue for cross-disciplinary learning, as over 30 disciplines are represented among participants. This commentary serves as an introduction to a virtual Special Section of Journal of Transport and Health that includes several of the best transport-related studies that were presented at ALR 2017. The theme of the 2017 ALR Conference, Active Living across the Life Span, placed emphasis on the importance of promoting physical activity from childhood through mature adulthood and offered solutions for achieving this goal. The theme challenged attendees to consider the myriad needs across age cohorts and the ways that community design, policies, and programs affect opportunities for active living. The conference highlighted the importance of policy-relevant research and facilitated cross-sector exchange among scientists, practitioners, and policymakers to create and sustain active living environments where residents can grow, live, and thrive at any age. Jana Lyncott from the AARP Public Policy Institute delivered the Keynote Address on creating environments for active and engaged living for all ages. The presentation provided examples from communities across the United States that are promoting livability and fostering healthy, active, and engaged lifestyles. The presentation highlighted AARP's Livability Index, which scores neighborhoods and communities for the services and amenities that have a significant impact on residents. The featured panel included Drs. Adrian Bauman, NiCole Keith, and David Bann and focused on the challenges of integrating equity perspectives in research on active living across the lifespan. Dr. Bauman, from Australia, shared lessons from his research on middle-age-to-older adults and his international collaborations. Dr. Keith, from the United States, described the effort to ensure disadvantaged populations were given high priority in developing the multi-sector strategies of the US National Physical Activity Plan. Dr. Bann, from the UK, presented findings on active living across the lifespan from a large, long-term birth cohort study. The second panel featured Deputy Commissioner Adetokunbo 'Toks' Omishakin, (Tennessee Department of Transportation), Councillor Kristyn Wong-Tam (City of Toronto, Canada), and Otis Johnson (Former Mayor of Savannah, Georgia) and provided local and state examples of active transportation and lessons learned. A clear takeaway from the keynote and panelists was the need to integrate and apply life-course research and practice/policy lessons learned to most effectively create activity-supportive cities. The concept of active living includes physical activity for all purposes, including transport, recreation, occupation, and household. Active transport continues to be a dominant theme at ALR Conferences, and the link between transport and health outcomes is rising on research and policy agendas internationally, as shown by extensive coverage in Journal of Transport and Health and the 2016 Lancet Series on Urban Design, Transport, and Health. In the Lancet Series, Giles-Corti and colleagues (2016) reviewed a wide range of physical, mental, and social health problems linked with motorized transport. Stevenson and colleagues (2016) reported models that revealed a shift of just 10% of motorized trips to active modes could produce important reductions in mortality in cities as diverse as Copenhagen and Delhi. Thus, as co-chairs of the ALR 2017 Conference we want to thank Dr. Jennifer Mindell, Editor-in-Chief of Journal of Transport and Health, for facilitating this virtual special section of papers that will further advance evidence on active transport and health.

Stillbirth: moving from advocacy to action.

The incidence of stillbirth in high-income countries has progressively declined over the past 50 years, but has plateaued in many (Lawn et al., Lancet 2016;387:587–603). Stillbirth continues to be a vexing problem, often relegated to the shadows out of a sense of guilt and shame among patients, their families, and obstetric providers. For far too long, efforts to address stillbirth have been meager. The recent Lancet series on stillbirth, along with the BJOG themed issue on stillbirth, bring into stark relief the extent of the problem of stillbirth worldwide. Such efforts have led to meaningful reductions in stillbirth, even in some high-income countries. In this commentary from the Stillbirth Advocacy Working Group (Ateva et al. BJOG 2018;1058–60), the authors bring into sharp focus the need for increased research on stillbirth, with an emphasis on awareness, bereavement, voice, and leadership. Key to this effort will be a uniform definition of stillbirth. The wide variety of definitions makes comparing data difficult, and the lack of a common language only further hampers progress. Adopting a common set of definitions and outcomes, as advocated through the CROWN initiative (Khan et al. BJOG 2016;123(S3):103–4), would be a major step in addressing this problem. Additionally, the authors highlight that the majority of stillbirths occur in low- and middle-income countries, but even high-income countries with low rates can improve. We applaud the authors and wholeheartedly endorse all of their points and goals. In order to truly reduce the rate of stillbirths we must marshal advocates, political will, and considerable resources; however, in addition to the ‘10 000-foot view’ put forth in this commentary, and in prior worldwide programmes, focusing on clinical and public health research efforts on specific interventions to prevent stillbirth is crucial. Such efforts should emphasise precise policies, algorithms, and bundles targeting conditions known to cause or contribute to stillbirth. The opportunity is greatest in low-resource settings with relatively high stillbirth rates. Many stillbirths can be prevented using current knowledge through improved access to better prenatal and intrapartum care and safe cesarean delivery. Of course, a lack of resources in settings with many other priorities remains a barrier. Research efforts are more complex in high-income countries that enjoy relatively lower rates of stillbirth and have already implemented many evidence-based strategies. Accordingly, it makes sense to focus on the subset of conditions with the best opportunities for prevention. A recent US study identified 25% of such cases (Page et al. Obstet Gynecol 2018;131:336–43). Future efforts should concentrate on more precise methods to screen for stillbirth risk and on specific strategies to prevent them. Continued advocacy efforts such as those promoted by the Stillbirth Advocacy Working Group will help to lift the veil from stillbirth; however, until there is political will from governments and funding agencies with a focused effort to fund interventional trials aimed at preventing stillbirth, far too many families will continue to suffer this scourge. Now is the time to bring stillbirth out of the shadows and into the light, and make real progress in addressing this tragedy. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Low back pain: a call for action

Low back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population.1 Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series,2,3 is a call for action on this global problem of low back pain.

Low back pain: a major global challenge

Low back pain is a major problem throughout the world and it is getting worse—largely because of the ageing and increasing world population. 1 GBD 2016 Disease and Injury Incidence and Prevalence CollaboratorsGlobal, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017; 390: 1211-1259 Summary Full Text Full Text PDF PubMed Scopus (4135) Google Scholar It affects all age groups and is generally associated with sedentary occupations, smoking, obesity, and low socioeconomic status. 2 Hartvigsen J Hancock MJ Kongsted A et al. What low back pain is and why we need to pay attention. Lancet. 2018; (published online March 21.)http://dx.doi.org/10.1016/S0140-6736(18)30480-X Summary Full Text Full Text PDF PubMed Scopus (1564) Google Scholar Years lived with disability caused by low back pain have increased by more than 50% since 1990, especially in low-income and middle-income countries (LMICs). 1 GBD 2016 Disease and Injury Incidence and Prevalence CollaboratorsGlobal, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017; 390: 1211-1259 Summary Full Text Full Text PDF PubMed Scopus (4135) Google Scholar , 2 Hartvigsen J Hancock MJ Kongsted A et al. What low back pain is and why we need to pay attention. Lancet. 2018; (published online March 21.)http://dx.doi.org/10.1016/S0140-6736(18)30480-X Summary Full Text Full Text PDF PubMed Scopus (1564) Google Scholar Disability related to low back pain is projected to increase most in LMICs where resources are limited, access to quality health care is generally poor, and lifestyle changes and shifts towards more sedentary work for some mean the risks will only increase. What low back pain is and why we need to pay attentionLow back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Full-Text PDF Prevention and treatment of low back pain: evidence, challenges, and promising directionsMany clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. Full-Text PDF Low back pain: a call for actionLow back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population.1 Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series,2,3 is a call for action on this global problem of low back pain. Full-Text PDF

Canada's efforts to ensure the health and wellbeing of Indigenous peoples

Canada's efforts to ensure the health and wellbeing of Indigenous peoples

Cindy Blackstock: advocate for First Nations children

She has been called “Canada's Martin Luther King”, the “conscience of the nation”, and a “national hero”, but Cindy Blackstock bristles at the accolades. “The only reason my job exists is because racism against First Nations children has been used as a cost-saving measure. I don't want that job to exist—now or ever.” Blackstock is the Executive Director of the First Nations Child and Family Caring Society of Canada, a charity that, for 20 years, has lobbied for First Nations children to have equitable access to health and social welfare services. Canada's time to actBeavers, ice hockey, maple syrup, Mounted Police, peace-keeping. These things conjure Canada in the minds of many. Others will add health to the list, for Canada's public health-care system is one of the oldest and most celebrated in the world and because Canada has ministered to global humanitarian, migration, and medical crises for decades. While Canadian values of solidarity, inclusivity, and diplomacy have found much expression in matters of health, there are clear signs that all of the world now “needs more Canada”. Full-Text PDF Challenges in health equity for Indigenous peoples in CanadaCanada's health-care system, like the country itself, is a complex entity. As the two papers in The Lancet's Series on Canada1,2 make clear, the country's health-care landscape is made up of multiple people, places, and policies with often overlapping—and sometimes conflicting—jurisdictions, priorities, paradigms, and practices. These complexities are rooted in Canada's fairly young colonial history that resulted in a nation comprised of a majority of settler and recent immigrants and their descendants, alongside a steady resurgence of Indigenous populations of First Nations, Inuit, and Métis peoples that are growing in numbers, political acumen, and agency. Full-Text PDF Canada and global health: accelerate leadership nowCanada's celebration in 2017 of 150 years as a nation is a ripe time for reflection on both its own universal health system and the country's global commitments towards universal health coverage (UHC) as articulated in the Sustainable Development Goals (SDGs).1,2 The recognition in the prairie province of Saskatchewan that farmers should not have to sell the farm to pay for their family's health care was the principled pivot point that triggered Canada's march towards UHC in the 1960s. Although it took nearly a century for the Canadian confederation, established in 1867, to achieve UHC, over these past 50 years, from a global perspective, Canada's universal health-care system is viewed as being among the world's best. Full-Text PDF Canada's efforts to ensure the health and wellbeing of Indigenous peoplesIn September, 2017, Prime Minister Justin Trudeau stood before the UN General Assembly and acknowledged that the “failure of successive Canadian governments to respect the rights of Indigenous peoples in Canada is our great shame.”1 For generations, First Nations, Inuit, and Métis peoples in Canada were denied the right to self-determination and subjected to laws, policies, and practices based on domination and assimilation. Indigenous peoples lost control over their own lives. Full-Text PDF Canada's vision for global health and gender equalityA global shift is happening. I see it wherever I go—coffee shops to cabinet meetings to international conferences. We have achieved a critical mass of activists and allies around the world who are fighting for women's rights. The message is clear: the world is ready to make real progress on gender equality, and improve the lives of women and girls. Full-Text PDF Canada's universal health-care system: achieving its potentialAccess to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Full-Text PDF Canada's global health role: supporting equity and global citizenship as a middle powerCanada's history of nation building, combined with its status as a so-called middle power in international affairs, has been translated into an approach to global health that is focused on equity and global citizenship. Canada has often aspired to be a socially progressive force abroad, using alliance building and collective action to exert influence beyond that expected from a country with moderate financial and military resources. Conversely, when Canada has primarily used economic self-interest to define its global role, the country's perceived leadership in global health has diminished. Full-Text PDF