Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis.

Objective: To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa. Methods: We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model. Findings: We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I 2 = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I 2 = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher. Conclusion: Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.

Economic and social drivers of antibiotic dispensing practices among community pharmacies in Nepal.

OBJECTIVE: To assess economic and social drivers of dispensing antibiotics without prescription by community pharmacies in Nepal. METHOD: A survey was conducted among 111 pharmacy owners and managers in five districts. Information on demographic and economic characteristics of the pharmacies (e.g. revenue and profits from antibiotics) and their inclination to sell antibiotics without a physician's prescription under various scenarios (e.g. diarrhoea in a child) was collected. Univariate analysis was conducted to assess the demographic and economic characteristics. Bivariate analysis was conducted to examine the relationship between dispensing antibiotics without prescription and economic and social factors. RESULTS: Azithromycin and amoxicillin were the most commonly dispensed antibiotics. The proportions of pharmacies reporting that they would 'most likely' or 'likely' dispense antibiotics without prescription to adult patients ranged from 36.9% (sore throat) to 67.6% (cough). The proportions for paediatric patients ranged from 62.2% (sore throat) to 80.2% (cough or diarrhoea). There was no consistent relationship between the likelihood of dispensing antibiotics and revenues, profits or the number of patients. Instead, dispensing behaviour was influenced by the pressure from the patient; the respondents were more likely to dispense antibiotics when the patient specifically asked for 'an antibiotic' rather than for 'a medicine', and 68.5% respondents ranked 'customer satisfaction' as the most important factor motivating their work. CONCLUSIONS: In Nepal, inappropriate sale of antibiotics by community pharmacists is high, particularly for paediatric patients. Additional research is needed to establish key drivers of this behaviour and to help design effective approaches to reducing AMR.

The Effect of Reframing the Goals of Family Planning Programs from Limiting Fertility to Birth Spacing: Evidence from Pakistan.

Contraceptive prevalence in Pakistan has plateaued near 34 percent for over a decade, suggesting that fertility levels are likely to stay high unless effective interventions are designed. We evaluate the Family Advancement for Life and Health 2007-2012 (FALAH), a family planning project implemented in 31 districts of Pakistan. Deviating from previous programs, FALAH emphasized birth spacing-as opposed to limiting family size-as the primary purpose of contraceptive use. We use Pakistan Demographic and Health Survey to evaluate FALAH's impact on continuous and binary measures of birth intervals. To estimate the causal effects of the project, we compare the outcomes for multiple children born to the same mother before and after the project. We find that FALAH increased interbirth intervals by 2.4 months on average and reduced the proportion of short birth intervals by approximately 7.1 percentage points. This finding suggests that birth spacing as a goal of contraceptive use may resonate better with Pakistani couples than limiting family size. The project's effects were more pronounced for women with high education, in rural areas, and in the middle of the wealth distribution.

Livestock ownership and anaemia in Sub-Saharan African households.

OBJECTIVE: To determine the association between livestock ownership and Hb concentration of women of child-bearing age (WCBA) and preschool-aged children in Sub-Saharan Africa (SSA). DESIGN: A prospective analysis of publicly available cross-sectional data, using linear and logistic regressions controlling for potential confounders. SETTING: Twenty-eight countries in SSA. PARTICIPANTS: 162 305 WCBA and 118 607 children aged 6-59 months. RESULTS: More than half of WCBA (62·5 %) and children (58 %) belonged to households that owned livestock. The average altitude-adjusted blood Hb concentration for WCBA and children was 12.23 and 10·24 g/dL, respectively. In adjusted models, higher number of livestock owned was associated with lower Hb concentration for children but not for WCBA. The magnitude of the association for children was small, with one additional unit of livestock owned reducing Hb concentration by 0·001 g/dL. Higher numbers of cattle, cows and bulls, sheep, and goats were associated with lower Hb concentration for both groups. The number of certain categories of livestock owned was associated with the consumption of relevant foods by children. There was no association between the consumption of animal-source foods and Hb concentration or between livestock ownership and diarrhoeal diseases or fever among children. CONCLUSIONS: Livestock ownership in SSA had a net negative association with the Hb concentration of children and no association with that of WCBA. The results highlight the need for research aimed at clarifying the mechanisms linking livestock ownership and nutritional status, and identifying entry points for leveraging livestock ownership to improve the health of women and children in SSA.

Acceptability of mobile-phone reminders for routine childhood vaccination appointments in Nigeria - a systematic review and meta-analysis.

BACKGROUND: Mobile-phone reminders have gained traction among policymakers as a way to improve childhood vaccination coverage and timeliness. However, there is limited evidence on the acceptability of mobile-phone reminders among patients and caregivers. This systematic review and meta-analysis aimed to evaluate the ownership of mobile-phone device and the willingness to receive mobile-phone reminders among mothers/caregivers utilizing routine childhood immunization services in Nigeria. METHOD: MEDLINE, Scopus, CINAHL, CNKI, AJOL (African Journal Online), and Web of Science were systematically searched for studies on the acceptability of mobile-phone reminders for routine immunization appointments among mothers/caregivers in Nigeria. Studies were assessed for methodological quality using the Newcastle Ottawa Scale and JBI critical appraisal checklists. Meta-analysis was conducted using random-effects model to generate pooled estimates (proportion) of mothers who owned at least one mobile phone and proportion of mothers willing to receive mobile-phone reminders. RESULTS: Sixteen studies (13 cross-sectional and three interventional) involving a total of 9923 mothers across 15 states and the Federal Capital Territory Abuja met inclusion criteria. Pooled estimates showed that the proportion of mothers who owned at least one mobile phone was 96.4% (95% CI = 94.1-98.2%; I2 = 96.3%) while the proportion of mothers willing to receive mobile-phone reminders was 86.0% (95% CI = 79.8-91.3%, I2 = 98.4%). Most mothers preferred to receive text message reminders at least 24 h before the routine immunization appointment day, and in the morning hours. Approximately 52.8% of the mothers preferred to receive reminders in English, the country's official language. CONCLUSION: Current evidence suggests a high acceptability for mobile-phone reminder interventions to improve routine childhood immunization coverage and timeliness. Further studies, however, are needed to better understand unique regional preferences and assess the operational costs, long-term effects, and risks of this intervention. SYSTEMATIC REVIEW PROTOCOL REGISTRATION: PROSPERO CRD42021234183.

Content of antenatal care and perception about services provided by primary hospitals in Nepal: a convergent mixed methods study.

BACKGROUND: Nepal has made significant strides in maternal and neonatal mortality over the last three decades. However, poor quality of care can threaten the gains, as maternal and newborn services are particularly sensitive to quality of care. Our study aimed to understand current gaps in the process and the outcome dimensions of the quality of antenatal care (ANC), particularly at the sub-national level. We assessed these dimensions of the quality of ANC in 17 primary, public hospitals across Nepal. We also assessed the variation in the ANC process across the patients' socio-economic gradient. METHODS: We used a convergent mixed methods approach, whereby we triangulated qualitative and quantitative data. In the quantitative component, we observed interactions between providers (17 hospitals from all 7 provinces) and 198 women seeking ANC and recorded the tasks the providers performed, using the Service Provision Assessments protocol available from the Demographic and Health Survey program. The main outcome variable was the number of tasks performed by the provider during an ANC consultation. The tasks ranged from identifying potential signs of danger to providing counseling. We analyzed the resulting data descriptively and assessed the relationship between the number of tasks performed and users' characteristics. In the qualitative component, we synthesized users' and providers' narratives on perceptions of the overall quality of care obtained through focus group discussions and in-depth interviews. RESULTS: Out of the 59 tasks recommended by the World Health Organization, providers performed only 22 tasks (37.3%) on average. The number of tasks performed varied significantly across provinces, with users in province 3 receiving significantly higher quality care than those in other provinces. Educated women were treated better than those with no education. Users and providers agreed that the overall quality of care was inadequate, although providers mentioned that the current quality was the best they could provide given the constraints they faced. CONCLUSION: The quality of ANC in Nepal's primary hospitals is poor and inequitable across education and geographic gradients. While current efforts, such as the provision of 24/7 birthing centers, can mitigate gaps in service availability, additional equipment, infrastructure and human resources will be needed to improve quality. Providers also need additional training focused on treating patients from different backgrounds equally. Our study also points to the need for additional research, both to document the quality of care more objectively and to establish key determinants of quality to inform policy.

Child-level double burden of malnutrition in the MENA and LAC regions: Prevalence and social determinants.

Although the prevalence of obesity has rapidly increased in the low- and middle-income countries of the Middle East and North Africa (MENA) and Latin America and the Caribbean (LAC) regions, child undernutrition remains a public-health challenge. We examined region-specific sociodemographic determinants of this double burden of malnutrition, specifically, the co-occurrence of child stunting and overweight, using Demographic and Health Survey and Multiple Indicator Cluster Survey data (2003-2016) from 11 countries in the MENA (n = 118,585) and 13 countries in the LAC (n = 77,824) regions. We used multiple logistic regressions to model region-specific associations of maternal education and household wealth with child nutritional outcomes (6-59 months). The prevalence of stunting, overweight, and their co-occurrence was 24%, 10%, and 4.3% in children in the MENA region, respectively, and 19%, 5%, and 0.5% in children in the LAC region, respectively. In both regions, higher maternal education and household wealth were significantly associated with lower odds of stunting and higher odds of overweight. As compared with the poorest wealth quintiles, decreased odds of co-occurring stunting and overweight were observed among children from the second, third, and fourth wealth quintiles in the LAC region. In the MENA region, this association was only statistically significant for the second wealth quintile. In both regions, double burden was not statistically significantly associated with maternal education. The social patterning of co-occurring stunting and overweight in children varied across the two regions, indicating potential differences in the underlying aetiology of the double burden across regions and stages of the nutrition transition.

Understanding challenges to malaria elimination in Nepal: a qualitative study with an embedded capacity-building exercise.

BACKGROUND: The Nepalese Government has made significant progress toward the elimination of malaria. However, given the surge in the prevalence of non-communicable diseases, such as diabetes and hypertension, and the localized nature of malaria prevalence, malaria elimination will remain a challenge. In the current study, the authors sought to understand local perceptions on threats to malaria elimination in three endemic districts. METHODS: The authors conducted a capacity-building exercise embedded within a qualitative study. The study component aimed to understand how local policymakers and actors perceive challenges in malaria elimination. For them to be able to articulate the challenges, however, an understanding of malaria elimination in the context of a broader health system in Nepal would be required. The capacity-building component, thus, involved providing that knowledge. RESULTS: Although the prevalence of malaria is high in the three districts where the study was conducted, there are significant gaps in human resources, diagnosis and treatment, and the provision of indoor residual spraying and long-lasting insecticide treated nets. More importantly, the authors' experience suggests that it may be possible to capitalize on local expertise in order to identify gaps in malaria elimination at a sub-national level by building in a capacity-building exercise within a study. CONCLUSIONS: Locals in three malaria-endemic districts of Nepal perceive that there are significant gaps in human resources, diagnosis and treatment, the provision of insecticide treated nets, and indoor residual spraying.

Readmission Rates and Skilled Nursing Facility Utilization After Major Inpatient Surgery.

BACKGROUND: There is widespread interest in reducing use of postacute care (ie, care after hospital discharge) following major surgery, provided that such reductions do not worsen quality outcomes such as readmission rates. OBJECTIVES: To describe the association between changes in skilled nursing facility (SNF) use and changes in readmission rates after surgery. RESEARCH DESIGN: This was a observational study. SUBJECTS: Fee-for-service Medicare beneficiaries undergoing coronary artery bypass grafting (CABG) or total hip replacement (THR) from 2008 to 2013. MEASURES: Primary exposure was risk-adjusted SNF use initiated 0-2 days after hospital discharge, and the primary outcome was risk-adjusted readmission rates from 3 to 30 days after discharge. RESULTS: Among 176,994 patients who underwent CABG at 804 hospitals and 233,955 patients who underwent THR at 1220 hospitals, hospital-level SNF utilization increased after CABG (16.4%-19.0%, P=0.001) and THR (40.8%-45.5%, P<0.001), from 2008 to 2013. Hospital readmission rates decreased for CABG (14.7%-12.7%, P<0.001) but did not change for THR (4.9%-4.8%, P=0.55), from 2008 to 2013. However, there was wide variation in hospital-level change in readmission rates. After adjusting for hospital characteristics and baseline readmission rates, there was no statistically significant association between change in SNF use and change in readmission rates (0.017 and 0.011 percentage point increase in SNF use for every one percentage point increase in readmission rates for CABG and THR respectively, P=0.58 and 0.32). CONCLUSIONS: Changes in use of postacute care after THR and CABG have not been associated with changes in readmission rates.

Urbanicity Gradients Are Associated with the Household- and Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa.

BACKGROUND: The nutrition transition is advancing throughout sub-Saharan Africa (SSA). However, the nutritional risk across urbanicity gradients associated with this transition is not clear. OBJECTIVES: We aimed to determine 1) the extent to which overweight and anemia in women of childbearing age (WCBA) and stunting in preschool-age children (PSC) are spatially correlated within countries of SSA; and 2) the association of urbanicity with the individual-level nutritional double burden (i.e., concurrent overweight and anemia within an individual WCBA), the household-level double burden (i.e., overweight WCBA and stunted PSC in the same household), and the 3 components of these double burdens (i.e., overweight, anemia, and stunting). METHODS: We used Demographic and Health Surveys (DHS) data for 30 countries in SSA from 2006-2012. We calculated overweight [body mass index (BMI; in kg/m(2)) ≥25] and anemia (hemoglobin concentration <120 g/L) in WCBA, and stunting in PSC aged 12-59 mo (height-for-age z score <-2). We used population density, measured using a high-resolution population distribution dataset, to define gradients of urbanicity. We used geolocated DHS data to calculate cluster-level mean population densities and the Moran's I statistic to assess spatial autocorrelation. RESULTS: Cluster-level BMI values and hemoglobin concentrations for WCBA were spatially correlated. The odds of overweight in WCBA were higher in periurban and urban areas than in rural areas (periurban, OR: 1.08; 95% CI: 1.01, 1.16; urban, OR: 1.26; 95% CI: 1.18, 1.36), as were the odds of stunting in PSC in periurban areas (OR: 1.13; 95% CI: 1.06, 1.22). The odds of both double burden conditions were higher in periurban and urban areas than in rural areas (individual-level-periurban, OR: 1.18; 95% CI: 1.05, 1.33; urban, OR: 1.43; 95% CI: 1.27, 1.61; household-level-periurban, OR: 1.24; 95% CI: 1.06, 1.44; urban, OR: 1.24; 95% CI: 1.06, 1.46). CONCLUSION: Urban and periurban areas in SSA may be particularly vulnerable to the nutritional double burden compared with rural areas. Clearly differentiating urban environments is important for assessing changing patterns of nutritional risk associated with the nutrition transition in SSA.

Open Defecation, Livestock Ownership, and Child Nutritional Status in India.

South Asian children are among the most severely malnourished worldwide. One prominent hypothesis is that open defecation in the local area exposes children to human fecal pathogens that can cause diarrhea and malnutrition. Much of the existing research uses district-level measures of open defecation, which could mask important local-area variation. A second hypothesis is that animal fecal matter is a major source of exposure. This analysis tested these dual hypotheses using census data collected from 949 villages in Tamil Nadu, India, and a survey conducted in a random sample of 5,000 households in the same area. The final analytic sample consisted of 2,561 children aged 0-10 years. We estimated the association between the measures of village- and household-level open defecation, household livestock ownership, and child height-for-age Z-scores in a regression framework, controlling for potential confounders. Results revealed that village- and household-level open defecations are negatively associated with child height. There was an estimated difference of approximately 0.5 height-for-age Z-score between children living in villages with no open defecation and children in villages where all households practiced open defecation (P = 0.001) and a 0.2 Z-score difference between children living in households that practiced open defecation and those living in households that did not (P = 0.001). Livestock ownership was not associated with child height. Overall, the findings provide evidence on the centrality of open defecation in explaining persistent child malnutrition in India and the higher risk of exposure to human fecal pathogens compared with animal feces in the south Indian context.

Setting research priorities for global pandemic preparedness: An international consensus and comparison with ChatGPT's output.

Background: In this priority-setting exercise, we sought to identify leading research priorities needed for strengthening future pandemic preparedness and response across countries. Methods: The International Society of Global Health (ISoGH) used the Child Health and Nutrition Research Initiative (CHNRI) method to identify research priorities for future pandemic preparedness. Eighty experts in global health, translational and clinical research identified 163 research ideas, of which 42 experts then scored based on five pre-defined criteria. We calculated intermediate criterion-specific scores and overall research priority scores from the mean of individual scores for each research idea. We used a bootstrap (n = 1000) to compute the 95% confidence intervals. Results: Key priorities included strengthening health systems, rapid vaccine and treatment production, improving international cooperation, and enhancing surveillance efficiency. Other priorities included learning from the coronavirus disease 2019 (COVID-19) pandemic, managing supply chains, identifying planning gaps, and promoting equitable interventions. We compared this CHNRI-based outcome with the 14 research priorities generated and ranked by ChatGPT, encountering both striking similarities and clear differences. Conclusions: Priority setting processes based on human crowdsourcing - such as the CHNRI method - and the output provided by ChatGPT are both valuable, as they complement and strengthen each other. The priorities identified by ChatGPT were more grounded in theory, while those identified by CHNRI were guided by recent practical experiences. Addressing these priorities, along with improvements in health planning, equitable community-based interventions, and the capacity of primary health care, is vital for better pandemic preparedness and response in many settings.

Parental disability and children's educational, labor market and marital outcomes: Evidence from Nepal.

BACKGROUND: The extent to which parental disability affects children's educational, employment, and marital outcomes in low-income countries is poorly understood, limiting the countries' efforts to design and implement disability-inclusive policies. OBJECTIVE: To assess the association between parental disability and children's education, employment, and marital outcomes in Nepal, and variations in these associations by sex. METHOD: Using a nationally representative 15% sample of the 2011 census, we examine the relationship between parental disability and children's outcomes in a regression framework, controlling for potential confounders. We also test if the associations vary by the individual's sex. RESULTS: Father's disability is not associated with any of the outcomes for boys except enrolment status. However, for girls, it is associated also with lower chances of being at the appropriate grade and higher chances of being employed. Mother's disability is associated with lower chances of being at the appropriate grade, lower educational attainment, higher chances of being employed, and earlier marriage for boys. For girls, it is associated only with lower chances of being at the appropriate grade and being employed. CONCLUSIONS: Adverse effects of parental disability can last across generations in a low-income setting and can vary by the individual's sex. Further research is needed to ascertain causal pathways and intervening mechanisms.

The affordable care act and do-not-resuscitate orders: Differences by race and ethnicity.

BACKGROUND: The Affordable Care Act (ACA) created new payment rules that provided reimbursement for physicians to engage in advance care planning (ACP) conversations with patients. This reimbursement policy has the potential to increase ACP participation, including among racial and ethnic minority groups that have had lower ACP participation. OBJECTIVES: To examine whether the ACP payment rules were associated with an increase in use of do-not-resuscitate (DNR) orders, particularly among racial and ethnic minority groups, among patients diagnosed with heart failure (HF) in California. METHODS: The California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data Set was used to identify a cohort of elderly patients with a principal diagnosis of HF. This study included 432,520 hospital admissions of patients over the age of 65 with a primary diagnosis of HF between 2012 and 2018. DNR status was identified using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision, codes. RESULTS: There was a small increase in the utilization of DNR orders overall after the ACA reimbursement policy, but the change was not significantly different for all racial and ethnic groups when compared to white non-Hispanic patients. CONCLUSIONS: ACP payment rules provided in the ACA were associated with increased utilization of DNR, but the effect was not significantly different for racial and ethnic minorities hospitalized with HF in CA. Additional efforts are needed to increase ACP participation among racial and ethnic minorities.

Validity of ICD codes to identify do-not-resuscitate orders among older adults with heart failure: A single center study.

BACKGROUND: Observational research on the advance care planning (ACP) process is limited by a lack of easily accessible ACP variables in many large datasets. The objective of this study was to determine whether International Classification of Disease (ICD) codes for do-not-resuscitate (DNR) orders are valid proxies for the presence of a DNR recorded in the electronic medical record (EMR). METHODS: We studied 5,016 patients over the age of 65 who were admitted to a large, mid-Atlantic medical center with a primary diagnosis of heart failure. DNR orders were identified in billing records from ICD-9 and ICD-10 codes. DNR orders were also identified in the EMR by a manual search of physician notes. Sensitivity, specificity, positive predictive value and negative predictive value were calculated as well as measures of agreement and disagreement. In addition, estimates of associations with mortality and costs were calculated using the DNR documented in EMR and the DNR proxy identified in ICD codes. RESULTS: Relative to the gold standard of the EMR, DNR orders identified in ICD codes had an estimated sensitivity of 84.6%, specificity of 96.6%, positive predictive value of 90.5%, and negative predictive value of 94.3%. The estimated kappa statistic was 0.83, although McNemar's test suggested there was some systematic disagreement between the DNR from ICD codes and the EMR. CONCLUSIONS: ICD codes appear to provide a reasonable proxy for DNR orders among hospitalized older adults with heart failure. Further research is necessary to determine if billing codes can identify DNR orders in other populations.

Perceptions of key stakeholders on taxes on tobacco and alcohol products in Nepal.

BACKGROUND: Non-communicable diseases (NCDs) are on the rise in Nepal. Consumption of alcohol and tobacco products remains high. Taxes on these products are significantly below the rate recommended by the WHO. In an effort to understand the reasons behind the slow progress towards the adoption of higher health taxes to curb NCDs, we documented the perceptions of key stakeholders on health taxes, including perceived barriers and facilitators to adopting higher health taxes. METHODS: We conducted 45 in-depth interviews with individuals comprising government officials; producers, wholesale distributors and sellers of alcohol and tobacco products; and consumers and representatives from civil society organisations. We conducted a thematic analysis of the resulting data. RESULTS: Respondents from alcohol and tobacco industries are not supportive of higher health taxes. They argued that higher taxes can increase illicit trade and worsen inequality. Strikingly, several government officials shared the industries' concerns, arguing that health taxes have limited potential to reduce consumption of alcohol and tobacco products to help curb NCDs. In terms of barriers to adoption of higher health taxes, several local government representatives opined that close ties between industries and politicians at the federal level is a major hindrance. CONCLUSIONS: In order to adopt higher health taxes, the government will need to counter the false narrative pushed by alcohol and tobacco industries on the negative economic effects of such taxes. Health taxes earmarked for NCDs need to reflect the amount of revenue raised, reoriented towards prevention efforts and communicated clearly to the public.

Cost-Savings of Do Not Resuscitate Orders Among Elderly Patients With Heart Failure in the United States.

Do-not-resuscitate (DNR) orders should preclude the use of cardiopulmonary resuscitation and may be associated with patient outcomes for patients hospitalized with heart failure (HF). This study examined the association between DNR and costs, mortality, and length of stay. The study cohort was a national sample of 700 922 hospital admissions of patients aged >65 with a primary diagnosis of HF. Elderly HF patients who died with a DNR had cost-savings of $5640 ( P < 0.001). Patients with a DNR order were 8.9% points more likely to die before discharge than patients without ( P < 0.001), and patients who died with a DNR had a significantly shorter hospital stay by 1.51 days ( P < 0.001). DNR orders among elderly patients with HF are associated with cost-savings, as well as a higher mortality and shorter length of stay. In addition to primary benefits, advance care planning may aid in containing costs of care at end of life for HF.

Protocol for a randomized controlled trial on community education and surveillance on antibiotics use among young children in Nepal.

Background: Antimicrobial resistance (AMR) is one of the top ten threats to global health. There exists limited empirical evidence on effective approaches to address this threat. In low- and middle-income countries (LMICs), one of the primary drivers of AMR is easy access to antibiotics without prescriptions, in particular from community pharmacies. Interventions to reduce non-prescribed use of antibiotics and surveillance systems to track such usage are critically needed. This protocol describes a study that aims to test the effect of an educational intervention targeted to parents of young children on non-prescribed antibiotics consumption in Nepal and to track such consumption using a phone-based application. Methods: The study is a clustered randomized controlled trial, in which we randomly assign 40 urban wards of Kathmandu Valley to either treatment group or control group, and randomly select 24 households in each ward. Households in the treatment group will receive an education intervention consisting of an "AMR pitch" (an in-person interaction that lasts up to an hour) by community nurses, videos and text messages on AMR every two weeks, and a brochure. We will conduct a survey at baseline with the parents of children ages 6 months to 10 years and track consumption of antibiotics and health care use among these children for a period of 6 months using a phone-based application. Conclusion: While the study will primarily inform future policy and programmatic efforts to reduce AMR in Nepal, the study-both the education intervention and the surveillance system-can serve as a prototype for tackling AMR in other similar settings.

Framing health taxes: learning from low- and middle-income countries.

Health taxes are effective policy instruments to save lives, raise government revenues and improve equity. Health taxes, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy. Yet, little is known about which frames resonate in which settings and how framing can most effectively advance or limit policies. To fill this gap, we conducted qualitative research in 2022, including focus group discussions, in-depth interviews, document reviews and media analysis on the political economy of health taxes across eight low-income and middle-income countries. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Findings suggest that no single frame dominates; in fact, a plurality of different frames exist and shape discourse and policymaking. There was no clear trade-off between health and economic framing of health tax policy proposals, nor a straightforward way to handle concerns around earmarking. Understanding how to best position health taxes can empower health policymakers with more persuasive framings for health taxes and can support them to develop broader coalitions to advance health taxes. These insights can improve efforts to advance health taxes by better appreciating political economy factors and constraining corporate power, ultimately leading to improved population-level health.

Women's extreme seclusion during menstruation and children's health in Nepal.

There is limited empirical evidence from low-income countries on the effects of women's seclusion during menstruation on children's health. The objective of the current study was to examine the association between women's extreme seclusion during menstruation and their children's nutritional status and health in Nepal. Using nationally representative data from the 2019 Multiple Indicator Cluster Survey, we examined the relationship between mother's exposure to extreme forms of seclusion during menstruation and anthropometric measures of nutritional status and health outcomes among children ages 5-59 months (n = 6,301). We analyzed the data in a regression framework, controlling for potential confounders, including province fixed effects. We assessed extreme seclusion during menstruation based on women's exposure to chhaupadi, a practice in which women are forced to stay away from home-in separate huts or animal sheds-during menstruation and childbirth. Mothers' exposure to extreme seclusion during menstruation was associated with 0.18 standard deviation lower height-for-age z-scores (HAZ) (p = 0.046) and 0.20 standard deviation lower weight-for-age z-scores (WAZ) (p = 0.007) among children. Analysis by the place of seclusion showed that the negative association was stronger when women stayed in animal sheds-0.28 SD for HAZ (p = 0.007) and 0.32 SD for WAZ (p<0.001)-than when they stayed in separate huts. Extreme seclusion was associated with higher incidence of acute respiratory symptoms but not with incidence of diarrhea, irrespective of the place of seclusion. Women's extreme seclusion during menstruation in Nepal has profound implications on the physical health of their children. Additional research is needed to ascertain potential mechanisms.