What is QOL in children and adolescents with physical disabilities? A thematic synthesis of pediatric QOL literature.

PURPOSE: Many neuromotor conditions affect children from a young age through to adulthood, impacting their quality of life (QOL). For QOL to be accurately measured in these children, pediatric QOL must first be conceptualized. Some theoretical models and definitions have been proposed to understand QOL, but they were not developed for the pediatric population. The purpose of this review is to build on existing frameworks of QOL and develop a framework and definition of pediatric QOL for measurement purposes, by integrating the findings of multiple qualitative studies involving children and adolescents with physical disabilities. METHODS: A systematic search was conducted on four databases. Inclusion criteria were qualitative studies with participants with common neurological and neuromuscular conditions. The content of studies had to involve the lived experiences of children and adolescents with disabilities. Thematic synthesis was conducted. RESULTS: 48 studies were included. Results generated a schema of the causes and the mitigators of QOL. This  consisted of casual indicators of QOL, mitigators, and components of QOL. Themes under QOL included thoughts and feelings, fitting in, self-image, about the future, and independence. A new framework and definition of pediatric QOL were proposed. CONCLUSIONS: In conclusion, pediatric QOL for children with disabilities is formed by their thoughts and feelings, being accepted by society, being able to forge an identity that is beyond their disability, having autonomy, and having a hope for the future. The resulting QOL framework proposed here can also aid future development of QOL measures in children with physical disabilities.

Explaining Why Farmers Grow Tobacco: Evidence From Malawi, Kenya, and Zambia.

INTRODUCTION: Tobacco production continues to increase in low- and middle-income countries creating complications for tobacco control efforts. There is the need to understand and address the global tobacco leaf supply as a means of decreasing tobacco consumption and improving farmers livelihoods in line with Article 17 of the WHO Framework Convention on Tobacco Control. This study aims to understand the reasons why farmers grow tobacco and identify factors that influence these reasons. METHODS: Primary survey data (N = 1770) collected in Kenya, Malawi, and Zambia in the 2013-2014 farming season. Data analysis uses both descriptive and multinomial logistical regression methods. RESULTS: Majority of farmers started and are currently growing tobacco because they believed it was the only economically viable crop. Compared with Malawi, farmers in Kenya and Zambia have a 0.2 and 0.4 lower probability of growing tobacco, respectively because they perceive it as the only economically viable crop, but a 0.04 and 0.2 higher probability of growing tobacco, respectively because they believe it is highly lucrative. There are district/county differences in the reasons provided with some districts having a majority of the farmers citing the existence of a ready market or incentives from the tobacco industry. Statistically significant factors influencing these reasons are the educational level and age of the household head, land allocated to tobacco and debts. CONCLUSION: There is the need to address the unique features of each district to increase successful uptake of alternative livelihoods. One consistent finding is that farmers' perceived economic viability contributes to tobacco growing. IMPLICATIONS: This study finds that perceived economic viability of tobacco is the dominant factor in the decisions to grow tobacco by smallholder farmers in Malawi, Kenya, and Zambia. There is the need to more deeply understand what contributes to farmers' perceived viability of a crop. Understanding and addressing these factors may increase the successful uptake of alternative livelihoods to tobacco. Furthermore, this study demonstrates that a one-size fits all alternative livelihood intervention is less likely to be effective as each district has unique features affecting farmers' decisions on growing tobacco.

Government policy and agricultural production: a scoping review to inform research and policy on healthy agricultural commodities.

Unhealthy foods and tobacco remain the leading causes of non-communicable disease (NCDs). These are key agricultural commodities for many countries, and NCD prevention policy needs to consider how to influence production towards healthier options. There has been little scholarship to bridge the agriculture with the public health literature that seeks to address the supply of healthy commodities. This scoping review synthesizes the literature on government agricultural policy and production in order to 1) present a typology of policies used to influence agricultural production, 2) to provide a preliminary overview of the ways that impact is assessed in this literature, and 3) to bring this literature into conversation with the literature on food and tobacco supply.This review analyzes the literature on government agricultural policy and production. Articles written in English and published between January 1997 and April 2018 (20-year range) were included. Only quantitative evaluations were included. Studies that collected qualitative data to supplement the quantitative analysis were also included. One hundred and three articles were included for data extraction. The following information was extracted: article details (e.g., author, title, journal), policy details (e.g., policy tools, goals, context), methods used to evaluate the policy (e.g., outcomes evaluated, sample size, limitations), and study findings. Fifty four studies examined the impact of policy on agricultural production. The remaining articles assessed land allocation (n = 25) (e.g., crop diversification, acreage expansion), efficiency (n = 23), rates of employment including on- and off-farm employment (n = 18), and farm income (n = 17) among others. Input supports, output supports and technical support had an impact on production, income and other outcomes. Although there were important exceptions, largely attributed to farm level allocation of labour or resources. Financial supports were most commonly evaluated including cash subsidies, credit, and tax benefits. This type of support resulted in an equal number of studies reporting increased production as those with no effects.This review provides initial extrapolative insights from the general literature on the impact of government policies on agricultural production. This review can inform dialogue between the health and agricultural sector and evaluative research on policy for alternatives to tobacco production and unhealthy food supply.

Costs, contracts and the narrative of prosperity: an economic analysis of smallholder tobacco farming livelihoods in Kenya.

BACKGROUND: The tobacco industry has used the alleged negative impacts on economic livelihoods for tobacco farmers as a narrative to oppose tobacco control measures in low/middle-income countries. However, rigorous empirical evidence to support or refute this claim remains scarce. Accordingly, we assess how much money households earn from selling tobacco, and the costs they incur to produce the crop, including labour inputs. We also evaluate farmers' decision to operate under contract directly with tobacco manufacturers and tobacco leaf-buying companies or to operate as independent farmers. METHODS: A stratified random sampling method was used to implement a nationally representative household-level economic survey of 585 farmers across the three main tobacco growing regions in Kenya. The survey was augmented with focus group discussions in all three regions to refine and enrich the context of the findings. RESULTS: Both contract and independent farmers experience small profit margins per acre, with contract farmers operating at a loss. Even when family labour is excluded from the calculation, income levels remain low, particularly considering the typically large households. Generally, tobacco farmers enter into contracts with tobacco companies because they have a 'guaranteed' buyer for their tobacco leaf and receive the necessary agricultural inputs (fertiliser, seeds, herbicides and so on) without paying cash up-front. CONCLUSIONS: Tobacco farming households enter into contract with tobacco companies to realise perceived economic benefits. The narrative that tobacco farming is a lucrative economic undertaking for smallholder farmers, however, is inaccurate in the context of Kenya.

Further validation of the Preference-Based Stroke Index three months after stroke.

OBJECTIVE: To estimate the construct validity of the Preference-Based Stroke Index and its value added over a generic measure, the EuroQol-5D-3L at three months after stroke. DESIGN: This is a secondary analysis of an existing inception cohort. Pearson correlation coefficients were estimated to test construct validity and Generalized Estimating Equation analysis was conducted to compare the strength of the correlations of the Preference-Based Stroke Index and EuroQol-5D-3L with other measures. SETTING: Community. SUBJECTS: Participants (n = 488) with confirmed diagnosis of stroke hospitalized within 72 hours. MAIN MEASURES: Health-related quality of life was measured using Preference-Based Stroke Index and EuroQol-5D-3L. For validation purposes, the Stroke Impact Scale, Short Form-36 V1, Walking Speed, Two-Minute Walk Test, Berg Balance Scale, and the Mini-Mental State Examination were used. The Barthel Index and Canadian Neurological Scale were used to define known groups. RESULTS: Preference-Based Stroke Index correlated moderately with the EuroQol-5D-3L (r = 0.73), Walking Speed (r = 0.68), Two-Minute Walk Test (r = 0.73), and Berg Balance Scale (r = 0.70) and strongly with Stroke Impact Scale Activities of Daily Living (r = 0.80). Correlations were significantly higher for the Preference-Based Stroke Index than EuroQol-5D-3L. Participants with mild stroke had a higher mean Preference-Based Stroke Index score (77.9 ± 20.6) than participants with severe stroke (62.8 ± 20.3). Participants with functional independence had higher Preference-Based Stroke Index (85.7 ± 11.9) than those dependent for activities of daily living (60.8 ± 19.7). CONCLUSION: Preference-Based Stroke Index demonstrated significantly higher construct validity compared to the EuroQol-5D-3L at three months post stroke and can discriminate among known groups.

Costs, revenues and profits: an economic analysis of smallholder tobacco farmer livelihoods in Malawi.

BACKGROUND: The preservation of the economic livelihood of tobacco farmers is a common argument used to oppose tobacco control measures. However, little empirical evidence exists about these livelihoods. We seek to evaluate the economic livelihoods of individual tobacco farmers in Malawi, including how much money they earn from selling tobacco, and the costs they incur to produce the crop, including labour inputs. We also evaluate farmers' decisions to contract directly with firms that buy their crops. METHODS: We designed and implemented an economic survey of 685 tobacco farmers, including both independent and contract farmers, across the 6 main tobacco-growing districts. We augmented the survey with focus group discussions with subsets of respondents from each region to refine our inquiries. RESULTS: Contract farmers cultivating tobacco in Malawi as their main economic livelihoods are typically operating at margins that place their households well below national poverty thresholds, while independent farmers are typically operating at a loss. Even when labour is excluded from the calculation of income less costs, farmers' gross margins place most households in the bottom income decile of the overall population. Tobacco farmers appear to contract principally as a means to obtain credit, which is consistently reported to be difficult to obtain. CONCLUSIONS: The tobacco industry narrative that tobacco farming is a lucrative economic endeavour for smallholder farmers is demonstrably inaccurate in the context of Malawi. From the perspective of these farmers, tobacco farming is an economically challenging livelihood for most.

Disentangling regional trade agreements, trade flows and tobacco affordability in sub-Saharan Africa.

BACKGROUND: In principle, trade and investment agreements are meant to boost economic growth. However, the removal of trade barriers and the provision of investment incentives to attract foreign direct investments may facilitate increased trade in and/or more efficient production of commodities considered harmful to health such as tobacco. We analyze existing evidence on trade and investment liberalization and its relationship to tobacco trade in Sub-Saharan African countries. METHODS: We compare tobacco trading patterns to foreign direct investments made by tobacco companies. We estimate and compare changes in the Konjunkturforschungsstelle (KOF) Economic Globalization measure, relative price measure and cigarette prices. RESULTS: Preferential regional trade agreements appear to have encouraged the consolidation of cigarette production, which has shaped trading patterns of tobacco leaf. Since 2002, British American Tobacco has invested in tobacco manufacturing facilities in Nigeria, Kenya and South Africa strategically located to serve different regions in Africa. Following this, British America Tobacco closed factories in Ghana, Rwanda, Uganda, Mauritius and Angola. At the same time, Malawi and Tanzania exported a large percentage of tobacco leaf to European countries. After 2010, there was an increase in tobacco exports from Malawi and Zambia to China, which may be a result of preferential trade agreements the EU and China have with these countries. Economic liberalization has been accompanied by greater cigarette affordability for the countries included in our analysis. However, only excise taxes and income have an effect on cigarette prices within the region. CONCLUSIONS: These results suggest that the changing economic structures of international trade and investment are likely heightening the efficiency and effectiveness of the tobacco industry. As tobacco control advocates consider supply-side tobacco control interventions, they must consider carefully the effects of these economic agreements and whether there are ways to mitigate them.

Shifting from tobacco growing to alternatives in Malawi? A qualitative analysis of policy and perspectives.

Tobacco is the primary export commodity in Malawi and an important contributor to foreign earnings. The entrenchment of tobacco interests within government has partly explained why Malawi has lagged in its efforts to address the health consequences of tobacco and has been a vocal opponent of global tobacco control. Despite the extensive historical and entrenched relationship between the economy of Malawi and tobacco production, there have been important shifts at the highest policy levels towards the need to explore diversification in the agricultural sector. There is explicit recognition that alternatives to tobacco production must be pursued. This study provides an analysis of the policies and perspectives that characterize contemporary government approaches to tobacco and alternatives in Malawi by interviewing key government officials working on tobacco policy and reviewing recent policy documents. This research finds that there is openness and movement towards reducing tobacco growing in Malaw, including efforts to reduce tobacco dependency. Rather than a singular tobacco policy discourse in the country, there is a somewhat conflictual set of policies and perspectives on the future of tobacco in Malawi. Informing these policies and perspectives is the interplay between the economics of agricultural production (tobacco vs other crops), global markets (ranging from the ability to generate export earnings to the inability to compete with wealthier countries' non-tobacco crop subsidies) and the lack of developed supply and value chains other than those created by the transnational tobacco industry. The implications for government policy supporting a move away from tobacco dependence are not straightforward: there is a need to fill the supply chain gap for alternative crops, which requires not only strong intersectoral support within the country (and some challenge to the residual pro-tobacco narratives) but also international support.

Why Do Farmers Grow Tobacco? A Qualitative Exploration of Farmers Perspectives in Indonesia and Philippines.

Tobacco supply remains a pressing challenge to tobacco control. Tobacco remains a dominant cash crop in many low- and middle-income countries, despite the evidence suggesting that it is not as profitable as industry claims and is harmful to health and the environment. In order to implement successful and sustainable alternative livelihood interventions, it is important to understand why farmers continue to grow tobacco. This study explores this question from the perspective of farmers in Indonesia and Philippines. This study was informed by interpretive description methodology. Data was collected through focus group discussions (FGDs) (n = 7) with farmers (n = ~60). The FGDs were audio recorded, transcribed verbatim, and then translated into English. An inductive thematic analysis of the data was conducted to identify and categorize the reason provided by participants. We identified two overarching themes: (1) perceived viability (profitability, ready market, and environmental factors) and (2) financial context. Financial context included lumpsum payments and access to financial loans and credit facilities in light of their lack of capital. These results highlight that, in addition to identifying viable alternatives to tobacco, institutional factors such as improved access to credit and well-developed supply chains are key to the successful uptake of alternative livelihoods.