Deconvolution of cancer cell states by the XDec-SM method.

Proper characterization of cancer cell states within the tumor microenvironment is a key to accurately identifying matching experimental models and the development of precision therapies. To reconstruct this information from bulk RNA-seq profiles, we developed the XDec Simplex Mapping (XDec-SM) reference-optional deconvolution method that maps tumors and the states of constituent cells onto a biologically interpretable low-dimensional space. The method identifies gene sets informative for deconvolution from relevant single-cell profiling data when such profiles are available. When applied to breast tumors in The Cancer Genome Atlas (TCGA), XDec-SM infers the identity of constituent cell types and their proportions. XDec-SM also infers cancer cells states within individual tumors that associate with DNA methylation patterns, driver somatic mutations, pathway activation and metabolic coupling between stromal and breast cancer cells. By projecting tumors, cancer cell lines, and PDX models onto the same map, we identify in vitro and in vivo models with matching cancer cell states. Map position is also predictive of therapy response, thus opening the prospects for precision therapy informed by experiments in model systems matched to tumors in vivo by cancer cell state.

A call from 40 public health scientists for an end to the continuing humanitarian and environmental catastrophe in Gaza.

An under-recognised aspect of the current humanitarian catastrophe in Gaza is the impact of the war on the environment and the associated risks for human health. This commentary contextualises these impacts against the background of human suffering produced by the overwhelming violence associated with the use of military force against the general population of Gaza. In calling for an immediate cessation to the violence, the authors draw attention to the urgent need to rebuild the health care system and restore the physical and human infrastructure that makes a liveable environment possible and promotes human health and well-being, especially for the most vulnerable in the population. Environmental remediation should therefore form one of the most important parts of international efforts to assist reconstruction, through which we hope Palestinians and Israelis will achieve lasting peace, health, and sustainable development, all as part of accepted international human rights obligations.

Migraine headache and other risk factors associated with glaucoma among the adult population living in Armenia: a case-control study.

PURPOSE: This study aimed to assess the association between migraine headache and glaucoma among the adult population living in Armenia. METHODS: This case-control study recruited 145 cases with glaucoma and 250 controls without glaucoma and other ocular disorders except refractive error from Optomed Canada Diagnostic Eye Center in Armenia. A structured questionnaire contained questions on socio-demographics, family history of glaucoma and stroke, ocular health, smoking, migraine, and obstructive sleep apnea. The Migraine Screening Questionnaire assessed possible migraine and the Berlin Questionnaire measured obstructive sleep apnea. RESULTS: The mean ages of cases and controls were 63.3 (SD = 12.3) and 39.5 (SD = 13.5), respectively. Females comprised 62.8% of cases and 69.1% of controls. A total of 17.8% of cases and 19.0% of controls had possible migraine. In the adjusted analysis older age (OR 1.17; 95% CI 1.12; 1.23), average/lower than average socio-economic status (OR 5.27; 95% CI 1.30; 21.3), and family history of glaucoma (OR 4.25; 95% CI 1.51; 11.9) were associated with high-tension glaucoma. CONCLUSION: Timely case detection of glaucoma among those with average/low socio-economic status and those with family history of glaucoma could prevent further progression of the disease. Further studies to explore the relationship between migraine headache and specific types of glaucoma may be worthwhile.

Associations Between Pro/Anti-Tobacco Media and Messaging Exposure and Knowledge and Support of Smoke-Free Policy Among Adults in Armenia and Georgia.

CONTEXT: Despite high smoking rates, Armenia and Georgia recently adopted smoke-free policies (2022 and 2018). OBJECTIVE: We examined associations between exposure to pro-tobacco media (news opposing smoke-free policies; cigarette, e-cigarette, heated tobacco product [HTP] advertisements) and anti-tobacco media (media, community-based action) and (1) knowledge that the policies applied to alternative tobacco products (ATPs), and (2) support for the policies applying to ATPs and various settings. DESIGN: We analyzed 2022 survey data. SETTING: Data were from 28 communities in Armenia and Georgia. PARTICIPANTS: The sample comprised 1468 adults (31.6% past-month smokers). METHODS: We conducted multivariable regressions, controlling for country and sociodemographics. RESULTS: Participants were knowledgeable that the policy applied to ATPs (79.2%) and supportive of them applying to ATPs and various settings (means = 3.43 and 3.00; 1-4 = strongly support). Greater exposure to anti-tobacco media/community-based action correlated with more likely knowing that the policies applied to ATPs and greater support of the policies applying to various settings; HTP advertisement exposure correlated with less support of the policies applying to various settings. Less exposure to news opposing smoke-free policies and greater exposure to media supporting such policies correlated with greater support of the policies applying to ATPs. CONCLUSIONS: Media and community-based action may promote smoke-free policy knowledge and support. HTP advertisements may uniquely undermine smoke-free policies.

Correction: CTD: An information-theoretic algorithm to interpret sets of metabolomic and transcriptomic perturbations in the context of graphical models.

[This corrects the article DOI: 10.1371/journal.pcbi.1008550.].

CTD: An information-theoretic algorithm to interpret sets of metabolomic and transcriptomic perturbations in the context of graphical models.

We consider the following general family of algorithmic problems that arises in transcriptomics, metabolomics and other fields: given a weighted graph G and a subset of its nodes S, find subsets of S that show significant connectedness within G. A specific solution to this problem may be defined by devising a scoring function, the Maximum Clique problem being a classic example, where S includes all nodes in G and where the score is defined by the size of the largest subset of S fully connected within G. Major practical obstacles for the plethora of algorithms addressing this type of problem include computational efficiency and, particularly for more complex scores which take edge weights into account, the computational cost of permutation testing, a statistical procedure required to obtain a bound on the p-value for a connectedness score. To address these problems, we developed CTD, "Connect the Dots", a fast algorithm based on data compression that detects highly connected subsets within S. CTD provides information-theoretic upper bounds on p-values when S contains a small fraction of nodes in G without requiring computationally costly permutation testing. We apply the CTD algorithm to interpret multi-metabolite perturbations due to inborn errors of metabolism and multi-transcript perturbations associated with breast cancer in the context of disease-specific Gaussian Markov Random Field networks learned directly from respective molecular profiling data.

Addressing cancer prevention and control in Armenia: tobacco control and mHealth as key strategies.

This paper focuses on the particular challenges in cancer prevention and control (CPC) in low- and middle-income countries (LMICs). In particular, this paper extrapolates challenges and opportunities in Armenia, which has the 2nd highest rate of cancer-related deaths in the world, the 11th highest smoking prevalence among men globally, and an evolving health system infrastructure for non-communicable disease (NCD) prevention and control, including CPC. Despite significant progress in enhancing research capacity in Armenia over the past decade, additional efforts are needed, particularly in CPC-related research. Key opportunities are to advance tobacco control and utilization of mHealth. Public health training programs remain insufficient in the area of CPC, and in-country research expertise regarding CPC and related areas (e.g., tobacco control, mHealth, policy) is limited, particularly given the need to address the diverse and complex determinants of onset, prevention, and management of cancer. Moreover, critical gaps in research dissemination and knowledge translation from evidence to policy and practice continue to exist. Thus, public health infrastructure must be enhanced, in-country CPC leaders across various relevant disciplines must be further developed and supported, and medical and public health training must more fully integrate CPC and research dissemination and translation to inform policy and practice.

Health equity and COVID-19: global perspectives.

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

People-centred care versus clinic-based DOT for continuation phase TB treatment in Armenia: a cluster randomized trial.

BACKGROUND: WHO's directly observed therapy (DOT) strategy for tuberculosis (TB) treatment depends upon a well-organized healthcare system. This study sought to evaluate the effectiveness of self-administered drug intake supported by a family member versus in-clinic DOT. METHODS: This open-label, nationally-representative stratified cluster randomized controlled non-inferiority trial with two parallel equal arms involved drug-susceptible pulmonary TB patients in the continuation treatment phase. We randomly assigned outpatient-TB-centres (52 clusters) to intervention and control arms. The intervention included an educational/counseling session to enhance treatment adherence; weekly visits to outpatient-TB-centres to receive medication, and daily SMS medication reminders and phone calls to track adherence and record side effects. Controls followed clinical DOT at Outpatient-TB-centres. Both groups participated in baseline and 4-5 months follow-up surveys. The trial's non-inferiority comparisons include: treatment success as the clinical (primary) outcome and medication adherence (self-reported), knowledge, depressive symptoms, stigma, quality of life, and social support as non-clinical (secondary) outcomes. RESULTS: Per-protocol analysis showed that the intervention (n = 187) and control (n = 198) arms achieved successful treatment outcome of 92.0 and 92.9%, respectively, indicating that the treatment success in the intervention group was non-inferior to DOT. Knowledge, depression, stigma, quality of life, and social support also showed non-inferiority, demonstrating substantial improvement over time for knowledge (change in the intervention = 1.05: 95%CL (0.49, 1.60); change in the control = 1.09: 95%CL (0.56, 1.64)), depression score (change in the intervention = - 3.56: 95%CL (- 4.99, - 2.13); change in the control = - 1.88: 95% CL (- 3.26, - 0.49)) and quality of life (change in the intervention = 5.01: 95%CL (- 0.64, 10.66); change in the control = 7.29: 95%CL (1.77, 12.81)). The intervention resulted in improved treatment adherence. CONCLUSIONS: This socially empowering alternative strategy might be a preferable alternative to DOT available to patients in Armenia and in other countries. Further research evaluating cost effectiveness of the intervention and generalizability of the results is warranted. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02082340, March 10, 2014.

Nurses role, importance and status in Armenia: A mixed method study.

AIM: To assess the perception of the nursing profession in Armenia from the perspective of multiple stakeholders, including nurses and the general public. BACKGROUND: Nurses' role perception is a complex phenomenon defined by multiple stakeholders. METHODS: The assessment used a convergent parallel mixed-methods design, with a dominant qualitative status. We conducted the qualitative phase through focus group discussions and in-depth interviews with 235 people and collected quantitative data in a cross-sectional telephone survey with 389 participants. RESULTS: The nursing profession has been influenced by medical hierarchy and subordination, and none of the participants recognized nursing as an autonomous health care profession. The quantitative survey findings were largely consistent with the qualitative results. Our findings highlighted empathy and compassion as inherent qualities of nurses in Armenia. CONCLUSION: To change opinions about the nursing profession and highlight nurses' meaningful contribution to the provision of health care services, it is important to develop a national definition of nursing and introduce higher educational opportunities for nurses in Armenia. IMPLICATIONS FOR NURSING MANAGEMENT: The paper highlights the importance of quality education for preparing highly competent nurse managers who can become role models in promoting nurses' roles in health care systems and improving the professional and public image of nursing.

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study.

BACKGROUND: Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health. METHODS: This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services. RESULTS: The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government's reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers' concern. CONCLUSION: The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

Predictors of Stunting Among Children Ages 0 to 59 Months in a Rural Region of Armenia.

OBJECTIVES: The prevalence of stunting in Armenia more than doubled since the 1990 s. This study aimed to investigate the prevalence and the predictors of stunting among children younger than 5 years in a rural region of Armenia, Talin, targeted by the World Vision (WV) nutrition interventions. METHODS: Anthropometric measurements were conducted among a large representative sample of children 0 to 59 months old to identify the prevalence of stunting. Children identified as stunted were included in a case-control study as cases and compared with normally growing controls randomly selected from the same pool of children. The mothers of cases and controls were interviewed. Logistic regression analysis was applied to identify the predictors of stunting. RESULTS: Of 739 measured children, 101 (13.7%) were undernourished, including 94 (12.7%) who were stunted. The fitted logistic regression model identified 7 independent predictors of stunting, of which 4 were protective: mother's height, child's birth length, number of child's hand washings per day, and the full set of WV interventions carried out in the community; whereas 3 were risk factors, that is, never/rarely using soap during hand washing, being the fourth or later child in the family, and family size. CONCLUSIONS: The study findings suggest that although WV nutrition interventions have shown impact, there is also a nonnutritional pathway of child stunting in rural Armenia. Thus, antistunting interventions should include sanitation and hygienic measures along with adequate perinatal care and maternal and child nutrition to further reduce childhood stunting, ensuring long-term health benefits for children not only in rural Armenia but also in rural communities in other low/middle-income countries.

Prevalence and determinants of anaemia among children aged 0-59 months in a rural region of Armenia: a case-control study.

OBJECTIVE: Despite the trend of increasing prevalence of childhood anaemia in Armenia, no studies exploring its risk factors have been conducted in the country. The present study aimed to investigate the prevalence and determinants of childhood anaemia in rural Armenia. DESIGN: Blood Hb level was measured among a representative sample of children using the HemoCue Hb201+ analyser. The revealed cases with anaemia were compared with randomly selected non-anaemic controls. Mothers of cases and controls were interviewed. Logistic and linear regression models were fitted to identify the risk factors of anaemia and low Hb level, respectively. SETTING: Talin communities, Aragatsotn Province, Armenia. SUBJECTS: Children under 5 years of age in Talin region. RESULTS: Of the 729 studied children, 32·4% were anaemic with 14·7% having moderate/severe anaemia. Infants were the most affected group with 51·1% being anaemic before 6 months and 67·9% at 6-12 months of age. Fitted regression models identified the following predictors of anaemia: younger age, male gender, shorter birth length, anaemia during pregnancy, lower meal frequency per day, lack of meat in the diet, using dung cakes for heating and living in a community that received an incomplete set of nutrition interventions. CONCLUSIONS: The study identified several modifiable risk factors that could be targeted to reduce childhood anaemia in rural Armenia and, possibly, in rural areas in other low-/middle-income countries. The suggested interventions include prevention and treatment of anaemia during pregnancy, provision of adequate complementary feeding to children with inclusion of meat in their daily diet and reduction of their exposure to biomass fuel smoke.

Risk factors for children's blood lead levels in metal mining and smelting communities in Armenia: a cross-sectional study.

BACKGROUND: Children's exposure to lead poses a significant risk for neurobehavioral consequences. Existing studies documented lead contamination in residential soil in mining and smelting communities in Armenia. This study aimed to assess blood lead levels (BLL) in children living in three communities in Armenia adjacent to metal mining and smelting industries, and related risk factors. METHODS: This cross-sectional study included 159 children born from 2007 to 2009 and living in Alaverdi and Akhtala communities and Erebuni district in Yerevan - the capital city. The BLL was measured with a portable LeadCare II Blood Lead Analyzer; a survey was conducted with primary caregivers. RESULTS: Overall Geometric Mean (GM) of BLL was 6.0 µg/dl: 6.8 for Akhtala, 6.4 for Alaverdi and 5.1 for Yerevan. In the sample 68.6 % of children had BLL above CDC defined reference level of 5 µg/dl: 83.8 % in Akhtala, 72.5 % in Alaverdi, and 52.8 % in Yerevan. Caregiver's lower education, dusting furniture less than daily, and housing distance from toxic source(s) were risk factors for higher BLL. Additional analysis for separate communities demonstrated interaction between housing distance from toxic source(s) and type of window in Erebuni district of Yerevan. CONCLUSIONS: The study demonstrated that children in three communities adjacent to metal mining and smelting industries were exposed to lead. Investigation of the risk factors suggested that in addition to promoting safe industrial practices at the national level, community-specific interventions could be implemented in low- and middle-income countries to reduce BLL among children.

Increased risk for multidrug-resistant tuberculosis in migratory workers, Armenia.

To understand use of tuberculosis (TB) services for migrant workers, we conducted a cross-sectional census of 95 migrant workers with TB from Armenia by using medical record reviews and face-to-face interviews. Prolonged time between diagnosis and treatment, treatment interruption, and treatment defaults caused by migrant work might increase the risk for multidrug-resistant TB.

The prevalence of and major risk factors associated with diabetic retinopathy in Gegharkunik province of Armenia: cross-sectional study.

BACKGROUND: Diabetic retinopathy (DR) is one of the leading causes of blindness in adults in industrialized countries and the emerging cause of blindness in developing countries. The objective of this study was to describe the prevalence of DR and risk factors associated with it among diabetic patients. METHODS: The analytical cross-sectional survey and eye screenings were carried out among 625 diabetic patients from urban and rural areas of Gegharkunik region. DR was assessed by dilated ophthalmoscopy and defined based on the WHO International Classification of Diseases. The survey instrument, included questions about demographics, disease history, health status, medication use and healthy lifestyle. Descriptive statistics and logistic regression were used to analyze the data. RESULTS: The prevalence of DR in the sample was 36.2%. A total of 90.2% of patients with DR had non-proliferative, while 9.8% had proliferative DR. In bivariate analysis, age, diabetes duration, being under insulin treatment, blood glucose level, having non-communicable diseases were significantly associated with DR. In the adjusted analysis being under insulin treatment (OR = 3.24; 95% CI: 1.56-6.75), diabetes duration (OR = 1.23; 95% CI: 1.16-1.31) and age (OR = 1.05; 95% CI: 1.02-1.08) were independently associated with DR. CONCLUSION: Earlier diagnosis of diabetes and DR can help to control some of these factors and prevent further complications and vision loss. Population-based educational programs on diabetes and diabetic retinopathy and continuous medical education on diabetes management can improve diabetes care and self-management and prevent eye complications.

Visual impairment and depression among socially vulnerable older adults in Armenia.

OBJECTIVES: Visual impairment in older adults is a major public health problem. Untreated visual impairment might negatively impact physical and psychological health. This study assessed the association between visual impairment and depression among socially vulnerable older adults (those aged 50 and above) in Armenia. METHOD: The survey and eye screenings were carried out among 339 participants who were the residents of retirement homes and single older adults in the households. The study team used Golovin-Sivtsev chart and cycloplegic skiascopy to measure visual impairment and Center for Epidemiologic Studies Depression scale to measure depression. RESULTS: The prevalence of visual impairment in the sample was 13.3%. Almost 24.0% of participants reported depression symptoms. Participants living in the retirement homes had substantially higher rates of visual impairment (21.5%) and depression (28.0%) than those living in households (9.3% and 15.0%, respectively). The odds of having depression were higher among those with visual impairment compared to those without after adjusting for confounders (OR = 2.75; 95% CI: 1.29-5.87). Having at least one non-communicable disease was associated with depression (OR = 2.47; 95% CI: 1.28-4.75). Living in the retirement home was marginally significantly associated with having depression. Other confounders included age, gender, education, physical activity, and smoking. CONCLUSION: Visual impairment was significantly associated with depression in socially vulnerable older adults in Armenia. Timely eye screenings in similar population groups could lead to early detection of visual impairment and prevention of visual loss and associated mental health problems.

Progress towards universal health coverage in BRICS: translating economic growth into better health.

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--represent some of the world's fastest growing large economies and nearly 40% of the world's population. Over the last two decades, BRICS have undertaken health-system reforms to make progress towards universal health coverage. This paper discusses three key aspects of these reforms: the role of government in financing health; the underlying motivation behind the reforms; and the value of the lessons learnt for non-BRICS countries. Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. There is a reliance on direct expenditures in China and India and a substantial presence of private insurance in Brazil and South Africa. The Brazilian health reforms resulted from a political movement that made health a constitutional right, whereas those in China, India, the Russian Federation and South Africa were an attempt to improve the performance of the public system and reduce inequities in access. The move towards universal health coverage has been slow. In China and India, the reforms have not adequately addressed the issue of out-of-pocket payments. Negotiations between national and subnational entities have often been challenging but Brazil has been able to achieve good coordination between federal and state entities via a constitutional delineation of responsibility. In the Russian Federation, poor coordination has led to the fragmented pooling and inefficient use of resources. In mixed health systems it is essential to harness both public and private sector resources.

Le Brésil, la Fédération de Russie, l'Inde, la Chine et l'Afrique du Sud ­ les pays connus sous le nom de BRICS ­ représentent quelques-unes des grandes économies ayant connu la croissance la plus rapide dans le monde et près de 40% de la population mondiale. Au cours des 2 dernières décennies, le groupe BRICS a engagé des réformes de son système de santé pour atteindre la couverture de santé universelle. Cet article aborde les 3 aspects clés de ces réformes: le rôle du gouvernement dans le financement de la santé; la motivation profonde derrière ces réformes; et la valeur des leçons tirées pour les pays non-BRICS. Bien que les gouvernements nationaux jouent un rôle majeur dans ces réformes, le financement privé constitue une part importante des dépenses de santé dans le groupe BRICS. Il existe une dépendance à l'égard des dépenses directes en Chine et en Inde et à l'égard d'une présence importante des assurances privées au Brésil et en Afrique du Sud. Les réformes de la santé du Brésil ont fait suite à un mouvement politique qui a fait de la santé un droit constitutionnel, alors que les réformes en Chine, en Inde, en Fédération de Russie et en Afrique du Sud ont représenté des tentatives visant à améliorer la performance du système public et à réduire les inégalités de l'accès aux soins. Les progrès vers la couverture de santé universelle ont été lents. En Chine et en Inde, les réformes n'ont pas abordé suffisamment le problème des paiements restants à charge. Les négociations entre les entités nationales et infranationales ont souvent été difficiles, mais le Brésil a pu parvenir à une coordination adéquate entre les entités fédérales et étatiques grâce à une délimitation constitutionnelle des responsabilités. Dans la Fédération de Russie, le manque de coordination a entraîné un regroupement fragmenté et une utilisation inefficace des ressources. Dans les systèmes de santé à financement mixte, il est essentiel de maîtriser à la fois les ressources des 2 secteurs: public et privé.

Brasil, la Federación de Rusia, India, China y Sudáfrica, los países conocidos como BRICS, son algunas de las grandes economías que más rápidamente están creciendo y representan casi el 40% de la población mundial. A lo largo de las últimas dos décadas, los BRICS han emprendido reformas en los sistemas sanitarios para avanzar hacia una cobertura universal de salud. Este artículo analiza tres aspectos clave de estas reformas: el papel del gobierno a la hora de financiar la salud, los motivos subyacentes de las reformas y el valor de las lecciones aprendidas de otros países distintos a los BRICS. Aunque los gobiernos nacionales tienen un papel destacado en las reformas, la financiación privada constituye una parte importante de los gastos sanitarios en estos países. Hay una dependencia de los gastos directos en China e India y una presencia significativa de seguros privados en Brasil y Sudáfrica. Las reformas sanitarias brasileñas tuvieron como resultado un movimiento político que hizo de la salud un derecho constitucional, mientras que las de China, India, la Federación de Rusia y Sudáfrica fueron un intento de mejorar el rendimiento del sistema público y reducir las desigualdades del acceso a este. El avance hacia la cobertura universal de la salud ha sido lento. En China e India, las reformas no han abordado adecuadamente el problema de los pagos directos. A menudo, las negociaciones entre las entidades nacionales y subnacionales han sido difíciles, pero Brasil ha sido capaz de lograr una buena coordinación entre las entidades federales y estatales a través de una descripción constitucional de la responsabilidad. En la Federación de Rusia, una mala coordinación ha tenido como resultado una mancomunación fragmentada y el uso ineficaz de los recursos. En los sistemas sanitarios mixtos, es fundamental emplear recursos tanto del sector público como del privado.

Clearing the air: improving smoke-free policy compliance at the national oncology hospital in Armenia.

BACKGROUND: Smoke-free policies shown to reduce population exposure to secondhand smoke (SHS) are the norm in hospitals in many countries around the world. Armenia, a transition economy in the South Caucasus, has one of the highest male smoking rates in the European region. Although smoking in healthcare facilities has been banned since 2005, compliance with this ban has been poor due to lack of implementation and enforcement mechanisms and social acceptability of smoking. The study aimed to develop and test a model intervention to address the lack of compliance with the de jure smoking ban. The national oncology hospital was chosen as the intervention site. METHODS: This study used employee surveys and objective measurements of respirable particles (PM2.5) and air nicotine as markers of indoor air pollution before and after the intervention. The intervention developed in partnership with the hospital staff included an awareness campaign on SHS hazards, creation of no-smoking environment and building institutional capacity through training of nursing personnel on basics of tobacco control. The survey analysis included paired t-test and McNemar's test. The log-transformed air nicotine and PM2.5 data were analyzed using paired t-test. RESULTS: The survey showed significant improvement in the perceived quality of indoor air, reduced worksite exposure to SHS and increased employees' awareness of the smoke-free policy. The number of employees reporting compliance with the hospital smoke-free policy increased from 36.0% to 71.9% (p < 0.001). The overall indoor PM2.5 concentration decreased from 222 µg/m3 GM (95% CI = 216-229) to 112 µg/m3 GM (95% CI = 99-127). The overall air nicotine level reduced from 0.59 µg/ m3 GM (95% CI = 0.38-0.91) to 0.48 µg/ m3 GM (95% CI = 0.25-0.93). CONCLUSIONS: The three-faceted intervention developed and implemented in partnership with the hospital administration and staff was effective in reducing worksite SHS exposure in the hospital. This model can facilitate a tangible improvement in compliance with smoke-free policies as the first step toward a smoke-free hospital and serve as a model for similar settings in transition countries such Armenia that have failed to implement the adopted smoke-free policies.

Estimated prevalence and predictors of undernutrition among children aged 5-17 months in Yerevan, Armenia.

OBJECTIVE: Child undernutrition is a serious public health problem in many low- and middle-income countries. Data on child undernutrition prevalence and its risk factors in Armenia are limited. The present study aimed to estimate the prevalence and explore the predictors of undernutrition among children aged 5-17 months in Yerevan. DESIGN: The study was cross-sectional and employed a review of the ambulatory charts of children selected through a multistage cluster sampling. This phase was followed by a case-control study. The cases were undernourished children identified during the record review and randomly matched with normally growing controls of the same age and gender from the same pool of records. Mothers of cases and controls participated in a telephone interview. The study used conditional logistic regression analysis. SETTING: Yerevan, Armenia. SUBJECTS: Children aged 5-17 months residing in Yerevan, Armenia. RESULTS: Review of 570 ambulatory charts suggested the prevalence of stunting, underweight and wasting among 5-17-month-old children in Yerevan to be 17·9 %, 7·3 % and 3·1 %, respectively. The case-control study of eighty-nine matched pairs identified four significant predictors of child undernutrition: family's socio-economic status score (P = 0·030), child's length at birth (P = 0·027), duration of predominant breast-feeding (P = 0·046) and food diversity score (P = 0·039). CONCLUSIONS: The factors determining growth patterns of children in Yerevan are mostly behavioral and environmental, hence modifiable. Reducing poverty and inequalities in food availability, promoting breast-feeding and adequate complementary feeding, and ensuring optimal care before, during and after pregnancy are likely to help reduce child undernutrition in Yerevan, Armenia and societies with similar public health concerns.