Disparities in the change of cervical cancer mortality rate between urban and rural Chiang Mai in the era of universal health care and the Thai national screening program.

BACKGROUND: The Ministry of Public Health of Thailand established universal health coverage (UHC) in 2002, which also included national-level screening for cervical cancer in 2005. This study examined the changes in mortality of cervical cancer in rural and urban areas in Chiang Mai Province of northern Thailand during the era of UHC and the immediately preceding period. METHODS: Data of cervical cancer patients in Chiang Mai in northern Thailand, who died from 1998 through 2012, were used to calculate the change in age-standardized rates of mortality (ASMR) using a joinpoint regression model and to calculate estimated annual percent changes (APC). The change in mortality rate by age groups along with changes by geographic area of residence were determined. RESULTS: Among the 1177 patients who died from cervical cancer, 13(1%), 713 (61%) and 451 (38%) were in the young age group (aged < 30), the screening target group (aged 30-59) and the elderly group (aged ≥60), respectively. The mortality rate among women aged 30-59 significantly declined by 3% per year from 2003 through 2012 (p < 0.001). By area of residence, the mortality rate in women targeted by the screening program significantly decreased in urban areas but remained stable in more rural areas, APC of - 7.6 (95% CI: - 12.1 to - 2.8) and APC of 3.7 (95% CI: - 2.1 to 9.9), respectively. CONCLUSION: The UHC and national cervical cancer screening program in Thai women may have contributed to the reduction of the mortality rate of cervical cancer in the screening target age group. However, this reduction was primarily in urban areas of Chiang Mai, and there was no significant impact on mortality in more rural areas. These results suggest that the reasons for this disparity need to be further explored to equitably increase access to cervical cancer services of the UHC.

"Why did our baby die soon after birth?"-Lessons on neonatal death in rural Cambodia from the perspective of caregivers.

INTRODUCTION: Neonatal deaths represent around half the deaths of children less than five-years old in Cambodia. The process from live birth to neonatal death has not been well described. This study aimed to identify problems in health care service which hamper the reduction of preventable neonatal deaths in rural Cambodia. METHODS: This study adopted a method of qualitative case study design using narrative data from the verbal autopsy standard. Eighty and forty villages were randomly selected from Kampong Cham and Svay Rieng provinces, respectively. All households in the target villages were visited between January and February 2017. Family caregivers were asked to describe their experiences on births and neonatal deaths between 2015 and 2016. Information on the process from birth to death was extracted with open coding, categorized, and summarized into several groups which represent potential problems in health services. RESULTS: Among a total of 4,142 children born in 2015 and 2016, 35 neonatal deaths were identified. Of these deaths, 74% occurred within one week of birth, and 57% were due to low-birth weight. Narrative data showed that three factors should be improved, 1) the unavailability of a health-care professional, 2) barriers in the referral system, and 3) lack of knowledge and skill to manage major causes of neonatal deaths. CONCLUSION: The current health system has limitations to achieve further reduction of neonatal deaths in rural Cambodia. The mere deployment of midwives at fixed service points such as health centers could not solve the problems occurring in rural communities. Community engagement revisiting the principle of primary health care, as well as health system transformation, is the key to the solution and potential breakthrough for the future.

Effects of a Household Air Pollution Intervention with Liquefied Petroleum Gas on Cardiopulmonary Outcomes in Peru. A Randomized Controlled Trial.

Rationale: Approximately 40% of people worldwide are exposed to household air pollution (HAP) from the burning of biomass fuels. Previous efforts to document health benefits of HAP mitigation have been stymied by an inability to lower emissions to target levels. Objectives: We sought to determine if a household air pollution intervention with liquefied petroleum gas (LPG) improved cardiopulmonary health outcomes in adult women living in a resource-poor setting in Peru. Methods: We conducted a randomized controlled field trial in 180 women aged 25-64 years living in rural Puno, Peru. Intervention women received an LPG stove, continuous fuel delivery for 1 year, education, and behavioral messaging, whereas control women were asked to continue their usual cooking practices. We assessed for stove use adherence using temperature loggers installed in both LPG and biomass stoves of intervention households. Measurements and Main Results: We measured blood pressure, peak expiratory flow (PEF), and respiratory symptoms using the St. George's Respiratory Questionnaire at baseline and at 3-4 visits after randomization. Intervention women used their LPG stove exclusively for 98% of days. We did not find differences in average postrandomization systolic blood pressure (intervention - control 0.7 mm Hg; 95% confidence interval, -2.1 to 3.4), diastolic blood pressure (0.3 mm Hg; -1.5 to 2.0), prebronchodilator peak expiratory flow/height2 (0.14 L/s/m2; -0.02 to 0.29), postbronchodilator peak expiratory flow/height2 (0.11 L/s/m2; -0.05 to 0.27), or St. George's Respiratory Questionnaire total score (-1.4; -3.9 to 1.2) over 1 year in intention-to-treat analysis. There were no reported harms related to the intervention. Conclusions: We did not find evidence of a difference in blood pressure, lung function, or respiratory symptoms during the year-long intervention with LPG. Clinical trial registered with www.clinicaltrials.gov (NCT02994680).

Rural Counties With Majority Black Or Indigenous Populations Suffer The Highest Rates Of Premature Death In The US.

Despite well-documented health disparities by rurality and race/ethnicity, research investigating racial/ethnic health differences among US rural residents is limited. We used county-level data to measure and compare premature death rates in rural counties by each county's majority racial/ethnic group. Premature death rates were significantly higher in rural counties with a majority of non-Hispanic black or American Indian/Alaska Native (AI/AN) residents than in rural counties with a majority of non-Hispanic white residents. After we adjusted for community-level covariates, differences in premature death remained significant in counties with a majority of AI/AN residents but not those with a majority of non-Hispanic black residents. This study highlights the particular vulnerability of non-Hispanic black and AI/AN rural communities to high rates of premature mortality. Policies to improve rural health should focus on these racially diverse communities, addressing economic vitality and current and historical political context to mitigate health inequities and the harmful health effects of neglecting social determinants of health.

Can integration reduce inequity in healthcare utilization? Evidence and hurdles in China.

BACKGROUND: Integration of medical insurance schemes has been prioritized as one of the key strategies to address inequity in China's health system. The first pilot attempt to integrate started in 2003 and later expanded nationwide. This study aims to assess its intended impact on inequity in inpatient service utilization and identify the main determinants contributing to its ineffectiveness. METHODS: A total of 49,365 respondents in the pilot integrated area and 77,165 respondents in the non-integration area were extracted from the Fifth National Health Services Survey. A comparative analysis was conducted between two types of areas. We calculate a concentration index (CI) and horizontal inequity index (HI) in inpatient service utilization and decompose the two indices. RESULTS: Insurance integration played a positive role in reducing inequality in inpatient service utilization to some extent. A 13.23% lower in HI, a decrease in unmet inpatient care and financial barriers to inpatient care in the pilot integrated area compared with the non-integration area; decomposition analysis showed that the Urban-Rural Residents Basic Medical Insurance, a type of integrated insurance, contributed 37.49% to reducing inequality in inpatient service utilization. However, it still could not offset the strong negative effect of income and other insurance schemes that have increased inequality. CONCLUSIONS: The earlier pilot attempt for integrating medical insurance was not enough to counteract the influence of factors which increased the inequality in inpatient service utilization. Further efforts to address the inequality should focus on widening access to financing, upgrading the risk pool, reducing gaps within and between insurance schemes, and providing broader chronic disease benefit packages. Social policies that target the needs of the poor with coordinated efforts from various levels and agencies of the government are urgently needed.

Grand multiparity in rural Cameroon: prevalence and adverse maternal and fetal delivery outcomes.

BACKGROUND: Grand multiparity is a major public health concern especially among developing countries and has been associated with higher risk of adverse maternal and fetal outcomes compared with women of lesser parity. There is a dearth of evidence on this subject in Cameroon, especially in the rural areas. We therefore carried out this study to document the prevalence and maternal and fetal delivery outcomes of grand multiparity in a rural Cameroonian setting. METHODS: We conducted a retrospective chart review of delivery records from two health facilities (the Oku District Hospital and Kevu Integrated Health Centre) in the Oku Health District over a period of eight years. Data was entered into and analyzed using Epi-Info version 7.0.8.3. The Chi-squared or Fisher's exact test was used to compare categorical variables. The threshold of statistical significance was set at 5%. RESULTS: A total of 1755 delivery records met our inclusion criteria. The overall prevalence of grand multiparity was 27.0%. We found no significant difference in the rate of selected maternal and fetal delivery outcomes between grand multiparous women and those with lesser parity (p-value> 0.05). However, grand multiparous women were less likely to develop second-fourth degree perineal tears compared to their counterparts with lesser parity (odds ratio = 0.3, 95% confidence interval = 0.2-0.7, p = 0.001). CONCLUSION: Our study depicts a high prevalence of grand multiparous delivery in this rural community. With the exception of severe perineal tear, grand multipara and their babies are as likely to develop adverse delivery outcomes as their counterparts with lesser parity. There is also the need to enhance existing government policies on reproductive health in rural areas.

Does the National Rural Health Mission improve the health of tribal women? Perspectives of husbands in Maharashtra, India.

OBJECTIVES: This study examined the health status of tribal women and, in particular, their maternal health. This study also explored the utilization of the Janani Suraksha Yojana (JSY) scheme, the tribal motherhood scheme and the human development scheme among pregnant women. The performance of accredited social health activist (ASHA) workers was also investigated. To fulfil the study objectives, husbands and key informants were interviewed. STUDY DESIGN: This was a cross-sectional, community-based study. METHODS: Both qualitative and quantitative methods were used for data collection. For the quantitative analysis, 385 men, aged 15-49 years, whose wives had given birth in the last 2 years, were recruited using multistage sampling. To study the qualitative aspects of the maternal health situation, 15 interviews were conducted with key informants, and four focus group discussions were conducted with a mixed-age group of men. The key informants included the dais (midwives/traditional birth attendants) and ASHAs in the villages studied. RESULTS: The results revealed that less than half of women delivered in health facilities, but nearly 60% of births were attended by skilled medical personnel. The utilization rates for full antenatal care (ANC) and postnatal care were 70% and 50%, respectively. Nearly 60% of men had heard about the JSY scheme; however, only 57% reported that their wives had benefited from the JSY scheme. The mean amount of money received was ₹700 ($US 11) for the most recent birth. For men whose wives did not receive the benefits of JSY, 24% reported that their wives were not eligible for the scheme, and the majority (75%) reported that they were not aware of the JSY scheme. CONCLUSIONS: The basic community-level issues of limited medical workforce and medical equipment should be urgently addressed. Moreover, full ANC and institutional health facilities for delivery should be provided to tribal women. When implementing National Rural Health Mission strategies, understanding the local community-driven traditional and cultural factors is important.

Pathways to diabetic care at hospitals in rural Eastern Uganda: a cross sectional study.

BACKGROUND: Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals. METHODS: Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another. RESULTS: Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals' diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another. CONCLUSIONS: Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.

Medicina convencional frente a medicina tradicional: preferencias de uso en una comunidad rural del Ecuador / Conventional medicine versus traditional medicine: preferences for use in a rural community in Ecuador

Objetivo: Analizar las preferencias del tratamiento convencional, frente al tratamiento con plantas medicinales en una comunidad rural del Ecuador. Métodos: Se realizó una investigación cuantitativa, no experimental, descriptiva, transversal. Se aplicó un cuestionario de 22 preguntas a 49 informantes, uno por cada hogar de la comunidad. Se cumplieron todas las consideraciones éticas en la obtención y manejo de la información. Resultados: Estas personas tienen una concepción de causalidad para diferenciar las enfermedades físicas de otras de origen sobrenatural, cuya curación corresponde exclusivamente a la medicina tradicional. Reconocen la efectividad de la medicina convencional para tratar problemas agudos de tipo somático y traumático, así como también, para curar y prevenir complicaciones de enfermedades crónicas. Sin embargo, en dolores viscerales la población prefiere el tratamiento con plantas medicinales, por su mayor accesibilidad y rapidez de acción. Conclusiones: La medicina convencional es elegida en la mayoría de los problemas físicos de salud, no obstante, se valora a la medicina tradicional para tratar problemas de origen sobrenatural y se promueve el respeto por las cosmovisiones del proceso salud enfermedad.

The impact of rural-urban community settings on cognitive decline: results from a nationally-representative sample of seniors in China.

BACKGROUND: Aging and rural-urban disparities are two major social problems in today's ever-developing China. Much of the existing literature has supported a negative association between adverse community setting with the cognitive functioning of seniors, but very few studies have empirically investigated the impact of rural-urban community settings on cognitive decline in the late life course of the population in developing countries. METHODS: Data of seniors aged 65 or above (n = 1709) within CHARLS (The China Health and Retirement Longitudinal Study, a sister study of HRS), a nationally representative longitudinal cohort (2011-2015) in China, were analyzed using a multilevel modeling (MLM) of time within individuals, and individual within communities. Cognitive impairment was assessed with an adapted Chinese version of Mini-Mental State Examination. RESULTS: Urban community setting showed a significant protective effect (ß = - 1.978, p < .000) on cognitive impairment in simple linear regression, and the MLM results showed it also had a significant lower cognitive impairment baseline (ß = - 2.278, p < .000). However, the curvature rate of cognitive decline was faster in urban community setting indicated by a positive interaction between the quadratic time term and urban community setting on cognitive impairment (ß = 0.320, p < .05). A full model adjusting other individual SES factors was built after model fitness comparison, and the education factor accounted for most of the within and between community setting variance. CONCLUSIONS: The findings suggest that urban community setting in one's late-life course has a better initial cognitive status but a potentially faster decline rate in China, and this particular pattern of senior cognitive decline emphasize the importance of more specific preventive measures. Meanwhile, a more holistic perspective should be adopted while construct a risk factor model of community environment on cognitive function, and the influence at society level needs to be further explored in future research.

Self-reported use of family physician, chiropractor and physiotherapy services among adult Canadians with chronic back disorders: an observational study.

BACKGROUND: Chronic back disorders (CBD) are prevalent, costly, and among the most common reasons for seeking primary care; however, little is known regarding the comparative use of family physician, chiropractic, and physiotherapy services among people with CBD in Canada. Elucidating these differences may identify potential gaps in access to care and inform the development of strategies to improve access. The research objectives were to investigate patterns of health care use and to profile factors associated with self-reported use of family physicians, chiropractors, and physiotherapists among adult Canadians with CBD. METHODS: The combined 2009 and 2010 Canadian Community Health Surveys conducted by Statistics Canada were used to investigate self-reported health care use among adults with CBD. This complex survey employs population weights and bootstrapping to be representative of the Canadian population. Following descriptive analyses, we used multiple logistic regression to profile self-reported health care use while statistically controlling for possible confounding effects. RESULTS: The majority of adult respondents with CBD sought care only with a family physician (53.8%), with 20.9% and 16.2% seeking care with combined family physician/chiropractor or family physician/physiotherapist, respectively. Few respondents sought care only with a chiropractor (2.5%) or physiotherapist (1.0%). After adjustment, differential patterns of utilization (p < 0.05) were evident between provider groups with respect to age, gender, socioeconomic status, rural/urban residence, functional limitations, and presence of co-morbidities. CONCLUSIONS: This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations.

Assessing the effects of the percentage of chronic disease in households on health payment-induced poverty in Shaanxi Province, China.

BACKGROUND: Chronic disease has become one of the leading causes of poverty in China, which posed heavy economic burden on individuals, households and society, and accounts for an estimated 80% of deaths and 70% of disability-adjusted life-years lost now in China. This study aims to assess the effect of chronic diseases on health payment-induced poverty in Shaanxi Province, China. METHODS: The data was from the 5th National Health Survey of Shaanxi Province, which was part of China's National Health Service Survey (NHSS) conducted in 2013. Totally, 20,700 households were selected for analysis. We used poverty headcount, poverty gap and mean positive poverty gap to assess the incidence, depth and intensity of poverty before and after health payment, respectively. Logistic regression models were further undertaken to evaluate the influence of percentage of chronic patients in households on the health payment-induced poverty with the control of other covariates. RESULTS: In rural areas, the incidence of poverty increased 31.90% before and after health payment in the household group when the percentage of chronic patients in the households was 0, and the poverty gap rose from 932.77 CNY to 1253.85 CNY (50.56% increased). In the group when the percentage of chronic patients in the households was 1-40% and 41-50%, the poverty gap increased 76.78 and 89.29%, respectively. In the group when the percentage of chronic patients in the households was 51~ 100%, the increase of poverty headcount and poverty gap was 49.89 and 46.24%. In the logistic model, we found that the proportion of chronic patients in the households was closely related with the health payment-induced poverty. The percentage of chronic disease in the households increased by 1 %, the incidence of poverty increased by 1.01 times. On the other hand, the male household head and the household's head with higher educational lever were seen as protective factors for impoverishment. CONCLUSIONS: With the percentage of chronic patients in the households growing, the health payment-induced poverty increases sharply. Furthermore, the households members with more chronic diseases in rural areas were more likely to suffer poverty than those in urban areas. Our analysis emphasizes the need to protect households from the impoverishment of chronic diseases, and our findings will provide suggestions for further healthcare reforms in China and guidance for vulnerable groups.

The spillover effect of midwife attrition from the Nigerian midwives service scheme.

BACKGROUND: The Nigerian Midwives Service Scheme (MSS) increased use of antenatal services at rural public sector clinics. However, it is unclear if women who would not have otherwise sought care, or those who would have sought care in rural private sector clinics caused this change. Additionally, it is also unclear if the reported midwife attrition was associated with a spillover of the scheme's effect on urban areas. We sought to answer these two questions using data from two nationally representative surveys. METHODS: We used an interrupted time series model to assess trends in the use of obstetric (i.e. antenatal and delivery) services among rural and urban respondents in the 2008 and 2013 Nigerian demographic and health surveys. RESULTS: We found that the MSS led to a 5-percentage point increase in the use of antenatal services at rural public sector clinics, corroborating findings from a previous study. This change was driven by women who would not have sought care otherwise. We also found that there was a 4-percentage point increase in the use of delivery services at urban public sector clinics, and a concurrent 4-percentage point decrease in urban home deliveries. These changes are most likely explained by midwives' attrition and exemplify a spillover of the scheme's effect. CONCLUSION: Midwife attrition from the Nigerian MSS was associated with a spillover of the scheme's effect on the use of delivery services, on urban areas.

Effectiveness of a campaign to implement chlorhexidine use for newborns in rural Haiti.

BACKGROUND: Chlorhexidine topical cord application is recommended to prevent umbilical cord infections in newborns delivered at home in low-resource settings. A community campaign introducing chlorhexidine for the first time in Haiti was developed. Traditional birth attendants (TBAs) were identified as implementers since they typically cut newborns' cords. TBAs were trained to apply chlorhexidine to the cord and demonstrate this procedure to the mother. Concurrently TBAs explained reasons for using chlorhexidine exclusively instead of traditional cord care practices. The campaign's effectiveness was evaluated 7-10 days post-delivery using a survey administered by community health workers (CHWs) to 198 mothers. RESULTS: Nearly all mothers heard about chlorhexidine use and applied it as instructed. Most mothers did not initially report using traditional cord care practices. With further probing, the majority reported covering the cord but few applied an unhygienic substance. No serious cord infections were reported. CONCLUSION: The campaign was highly successful in reaching mothers and achieving chlorhexidine use. In this study, the concomitant use of traditional cloth coverings or bindings of the cord did not appear harmful; however more research is needed in this area. This campaign provides a model for implementing chlorhexidine use, especially where trained TBAs and CHWs are present.

Dietary deficiency of vitamin A among rural children: A community-based survey using a food-frequency questionnaire.

BACKGROUND: Overt vitamin A deficiency has been controlled in most parts of India, but prevalence of subclinical deficiency may still be high, which may enhance susceptibility to infections, reduce growth potential and also lead to higher mortality. We aimed to: (i) assess the consumption pattern of vitamin A-rich foods in children 1-5 years of age in rural Jammu; and (ii) estimate the dietary deficiency of vitamin A leading to risk of subclinical vitamin A deficiency in cluster- villages of the study area. METHODS: In 2011, we conducted a survey of 750 children by selecting 50 from each of the 1 5 clusters. The Helen Keller International's Food-Frequency Questionnaire (HKI-FFQ) modified to the local context was used to assess past week's intake for 28 food-items, including vitamin A-rich foods. RESULTS: The study revealed that plant sources such as amaranth, carrots, etc. and animal sources such as eggs and butter were the major sources of vitamin A in the study population. Consumption of amaranth (2.7 days/week) and carrots (1.7 days/week) was moderate but that of animal foods rich in vitamin A was low to negligible (1.1 day/week for eggs and 0.2 day/week for liver and fish combined). The majority (80%) of the cluster-villages manifested inadequate intake of vitamin A-rich foods, thereby making subclinical vitamin A deficiency a public health problem for the whole area. Faulty diets, improper breastfeeding practices, low coverage of vitamin A supplementation and high prevalence of undernutrition could be related to the observed subclinical deficiency. CONCLUSION: Dietary diversification by including both plant and animal sources of vitamin A in adequate amounts along with improved breastfeeding, better implementation of mega-dose vitamin A supplementation and minimizing undernutrition may help in lowering subclinical vitamin A deficiency. The HKI-FFQ may be used as a proxy indicator of vitamin A intake/status for identifying pockets at risk of subclinical vitamin A deficiency in resource-constrained settings.

Discrepancies in the use of chemotherapy and artificial nutrition near the end of life for hospitalised patients with metastatic gastric or oesophageal cancer. A countrywide, register-based study.

AIM: To evaluate the frequency and the factors associated with the use of chemotherapy and artificial nutrition near the end of life in hospitalised patients with metastatic oesophageal or gastric cancer. METHODS: Nationwide, register-based study, including all hospitalised adults (≥20 years) who died with metastatic oesophageal or gastric cancer between 2010 and 2013, in France. Chemotherapy and artificial nutrition during the final weeks of life were considered as primary outcomes. RESULTS: A total of 4031 patients with oesophageal cancer and 10,423 patients with gastric cancer were included. While the proportion of patients receiving chemotherapy decreased from 35.9% during the 3rd month before death to 7.9% in the final week (p < 0.001 for trend), the use of artificial nutrition rose from 9.6% to 16.0% of patients. During the last week before death, patients with stomach cancer were more likely to receive chemotherapy (adjusted odds ratio (aOR) = 1.35, 95% CI = 1.17-1.56) but less likely to receive artificial nutrition (aOR = 0.80, 95%CI = 0.73-0.88) than patients with cancer of the oesophagus. The adjusted rates of chemotherapy use during the last week of life varied from 1.6% in rural hospitals to 11.2% in comprehensive cancer centres, while the adjusted probability to receive artificial nutrition varied from 12.1% in private for-profit clinics up to 19.9% in rehabilitation care facilities (p < 0.001). CONCLUSIONS: Our study shows that in hospitalised patients with metastatic oesophageal or gastric cancer, the use of chemotherapy decreases while the use of artificial nutrition increases as death approaches. This raises important questions, as clinical guidelines clearly recommend to limit the use of artificial nutrition in contexts of limited life expectancy.

Anaemia in hospitalised preschool children from a rural area in Mozambique: a case control study in search for aetiological agents.

BACKGROUND: Young children bear the world's highest prevalence of anaemia, the majority of which is of multifactorial aetiology, which in turn hampers its successful prevention. Even moderate degrees of anaemia are associated with increased mortality and morbidity. Despite this evidence, there is a lack of effective preventive programs and absence of consensus in the safety of iron supplementation in malaria areas, which reflects the poor understanding of the contribution of different aetiologies to anaemia. In order to reduce the anaemia burden in the most vulnerable population, a study to determine the aetiology of anaemia among pre-school Mozambican children was performed. METHODS: We undertook a case-control study of 443 preschool hospitalized children with anaemia (haemoglobin concentration <11 g/dl) and 289 community controls without anaemia. Inclusion criteria were: age 1-59 months, no blood transfusion in the previous month, residence in the study area and signed informed consent. Both univariable and multivariable logistic regression analyses were performed to identify factors associated with anaemia and adjusted attributable fractions (AAF) were estimated when appropriate. RESULTS: Malaria (adjusted odds ratio (AOR) = 8.39, p < 0.0001; AAF = 37%), underweight (AOR = 8.10, p < 0.0001; AAF = 43%), prealbumin deficiency (AOR = 7.11, p < 0.0001; AAF = 77%), albumin deficiency (AOR = 4.29, p = 0.0012; AAF = 30%), HIV (AOR = 5.73, p = 0.0060; AAF = 18%), and iron deficiency (AOR = 4.05, p < 0.0001; AAF = 53%) were associated with anaemia. Vitamin A deficiency and α-thalassaemia were frequent (69% and 64%, respectively in cases) but not independently related to anaemia. Bacteraemia (odds ratio (OR) = 8.49, p = 0.004), Parvovirus-B19 (OR = 6.05, p = 0.017) and Epstein-Barr virus (OR = 2.10, p = 0.0015) infections were related to anaemia only in the unadjusted analysis. Neither vitamin B12 deficiency nor intestinal parasites were associated with anaemia. Folate deficiency was not observed. CONCLUSIONS: Undernutrition, iron deficiency, malaria, and HIV are main factors related to anaemia in hospitalised Mozambican preschool children. Effective programs and strategies for the prevention and management of these conditions need to be reinforced. Specifically, prevention of iron deficiency that accounted in this study for more than half of anaemia cases would have a high impact in reducing the burden of anaemia in children living under similar conditions. However this deficiency, a common preventable and treatable condition, remains neglected by the international public health community.

Assessment of health system challenges and opportunities for possible integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region, Ethiopia: a qualitative study.

BACKGROUND: The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem in low and middle income countries. However, despite the known synergy between the two disease conditions, services for TB and DM have separately been provided. The objective of this study was to explore health system challenges and opportunities for possible integration of DM and TB services. METHODS: This was a descriptive qualitative study which was conducted in South-Eastern Amhara Region, Ethiopia. Study participants included health workers (HWs), program managers and other stakeholders involved in TB and DM prevention and control activities. Purposive sampling was applied to select respondents. In order to capture diversity of opinions among participants, maximum variation sampling strategy was applied in the recruitment of study subjects. Data were collected by conducting four focus group discussions and 12 in-depth interviews. Collected data were transcribed verbatim and were thematically analyzed using NVivo 10 software program. RESULT: A total of 44 (12 in-depth interviews and 32 focus group discussion) participants were included in the study. The study participants identified a number of health system challenges and opportunities affecting the integration of TB-DM services. The main themes identified were: 1. Unavailability of system for continuity of DM care. 2. Inadequate knowledge and skills of health workers. 3. Frequent stockouts of DM supplies. 4. Patient's inability to pay for DM services. 5. Poor DM data management. 6. Less attention given to DM care. 7. Presence of a well-established TB control program up to the community level. 8. High level of interest and readiness among HWs, program managers and leaders at different levels of the health care delivery system. CONCLUSION: The study provided insights into potential health systems challenges and opportunities that need to be considered in the integration of TB-DM services. Piloting TB and DM integrated services in selected HFs of the study area is needed to assess feasibility for possible full scale integration of services for the two comorbid conditions.