A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries.

BACKGROUND: Treatments for mental health problems in childhood and adolescence have advanced in the last 15 years. Despite advances in research, most of the evidence on effective interventions comes from high-income countries, while evidence is scarce in low- and middle-income countries (LMICs), where 90% of world's children and adolescents live. The aim of this review was to identify evidence-based interventions tested in LMICs to treat or prevent child and adolescent mental health problems. METHODS: We conducted a systematic review of seven major electronic databases, from January 2007 to July 2019. We included randomised or non-randomised clinical trials that evaluated interventions for children or adolescents aged 6 to 18 years living in LMICs and who had, or were at risk of developing, one or more mental health problems. Results were grouped according to the studied conditions. Due to the heterogeneity of conditions, interventions and outcomes, we performed a narrative synthesis. The review was registered at PROSPERO under the number CRD42019129376. FINDINGS: Of 127,466 references found through our search strategy, 107 studies were included in narrative synthesis after the eligibility verification processes. Nineteen different conditions and nine types of interventions were addressed by studies included in the review. Over 1/3 of studied interventions were superior to comparators, with psychoeducation and psychotherapy having the highest proportion of positive results. One-third of studies were classified as presenting low risk of bias. INTERPRETATION: This review shows that different interventions have been effective in LMICs and have the potential to close the mental health care gap among children and adolescents in low-resource settings.

Income and out-of-pocket health expenditure in living arrangements of families with older adults in Brazil.

The main objective of this study was to characterize household sociodemographic and economic patterns of different living arrangements of families with older adults in Brazil and their relationship with income and out-of-pocket health expenditure. Data were extracted from the 2008-2009 Brazilian Household Budget Survey (POF, in Portuguese) database of the Brazilian Institute of Geography and Statistics. Families with older adults represented 28% of all families, being smaller and having higher average income when compared to families without older adults. Older adults were head of the household in 85% of the families, with income based mainly on social protection policies. The families with older adult or couple as head of the household had significantly higher average monthly income. The proportion of out-of-pocket health expenditure per income quintile per capita was higher for families with one older adult or couple as head of the household, when compared to families without older adult as head of the household and even more in families without older adults at all. These findings allow the identification of potential positive impacts on the quality of life of families with older adults in Brazil. The higher household income of families with older adults is a consequence of the expansion of inclusive social protection policies for this population in the 2000s in Brazil, especially for families with lower average income levels, representing 4/5 of this population. The economic and political crisis in the 2010s have probably reduced these families' relative advantage, and this study will compare with results of the next survey.

Effective/cost effective interventions of child mental health problems in low- and middle-income countries (LAMIC): Systematic review.

BACKGROUND: This systematic review protocol aims to examine the evidence of effectiveness and cost-effectiveness of interventions for children and adolescents with, or at risk of developing mental disorders in low- and middle-income countries (LAMICs). METHODS: We will search Medline Ovid, EMBASE Ovid, PsycINFO Ovid, CINAHL, LILACS, BDENF and IBECS. We will include randomised and non-randomised controlled trials, economic modelling studies and economic evaluations. Participants are 6 to 18 year-old children and adolescents who live in a LAMIC and who present with, or are at high risk of developing, one or more of the conditions: depression, anxiety, behavioural disorders, eating disorders, psychosis, substance abuse, autism and intellectual disabilities as defined by the DSM-V. Interventions which address suicide, self-harm will also be included, if identified during the extraction process. We will include in person or e-health interventions which have some evidence of effectiveness (in relation to clinical and/or functional outcomes) and which have been delivered to young people in LAMICs. We will consider a wide range of delivery channels (e.g., in person, web-based or virtual, phone), different practitioners (healthcare practitioners, teachers, lay health care providers) and sectors (i.e., primary, secondary and tertiary health care, education, guardianship councils). In the pilot of screening procedures, 5% of all references will be screened by two reviewers. Divergences will be resolved by one expert in mental health research. Reviewers will be retrained afterwards to ensure reliability. The remaining 95% will be screened by one reviewer. Covidence web-based tool will be used to perform screening of references and full text paper, and data extraction. RESULTS: The protocol of this systematic review will be disseminated in a peer-reviewed journal and presented at relevant conferences. The results will be presented descriptively and, if possible, meta-analysis will be conducted. Ethical approval is not needed for anonymised secondary data. CONCLUSION: the systematic review could help health specialists and other professionals to identify evidence-based strategies to deal with child and adolescents with mental health conditions.

Income and out-of-pocket health expenditure in living arrangements of families with older adults in Brazil / Renda e gastos diretos em saúde de acordo com diferentes arranjos de moradia em famílias com idosos no Brasil / Ingresos y gastos personales en salud dentro de hogares familiares conviviendo con ancianos en Brasil

Abstract: The main objective of this study was to characterize household sociodemographic and economic patterns of different living arrangements of families with older adults in Brazil and their relationship with income and out-of-pocket health expenditure. Data were extracted from the 2008-2009 Brazilian Household Budget Survey (POF, in Portuguese) database of the Brazilian Institute of Geography and Statistics. Families with older adults represented 28% of all families, being smaller and having higher average income when compared to families without older adults. Older adults were head of the household in 85% of the families, with income based mainly on social protection policies. The families with older adult or couple as head of the household had significantly higher average monthly income. The proportion of out-of-pocket health expenditure per income quintile per capita was higher for families with one older adult or couple as head of the household, when compared to families without older adult as head of the household and even more in families without older adults at all. These findings allow the identification of potential positive impacts on the quality of life of families with older adults in Brazil. The higher household income of families with older adults is a consequence of the expansion of inclusive social protection policies for this population in the 2000s in Brazil, especially for families with lower average income levels, representing 4/5 of this population. The economic and political crisis in the 2010s have probably reduced these families' relative advantage, and this study will compare with results of the next survey.

Resumo: O estudo teve como principal objetivo caracterizar os padrões domiciliares sociodemográficos e econômicos em diferentes arranjos de moradia em famílias com idosos no Brasil e a associação com renda e gastos diretos em saúde. Os dados foram extraídos da base de dados da Pesquisa de Orçamentos Familiares (POF) de 2008/2009 do Instituto Brasileiro de Geografia e Estatística. As famílias com idosos representavam 28% do total, eram menores e tinha uma média de renda mais elevada, comparado a famílias sem idosos. Os adultos idosos eram chefes de família em 85% do total, e com renda originária principalmente das políticas de proteção social. As famílias chefiadas por um adulto ou casal idoso tinham média de renda mensal mais elevada. A proporção de gastos diretos em saúde de acordo com o quintil de renda per capita era mais alta em famílias chefiadas com um adulto ou casal idoso, comparado a famílias com um idoso não chefe de domicílio, e mais ainda em famílias sem idosos. Os achados permitem a identificação de impactos positivos potenciais sobre a qualidade de vida de famílias com idosos no Brasil. A renda domiciliar mais alta das famílias com idosos é consequência da expansão das políticas inclusivas de políticas de proteção social para idosos no Brasil nos anos 2000, especialmente para famílias com renda mais baixa, que representam 80% dessa população. É provável que a crise econômica e política dos anos 2010 tenha reduzido a vantagem relativa dessas famílias, e o estudo atual permitirá comparações com os resultados da próxima POF.

Resumen: El objetivo principal de este estudio fue caracterizar los patrones sociodemográficos y económicos de los hogares en los que conviven familias con ancianos en Brasil, y su relación con los ingresos y gastos personales en salud. Los datos se extrajeron de la base de datos de la Encuesta de Presupuestos Familiares (POF, por sus siglas en portugués) en 2008-2009 del Instituto Brasileño de Geografía y Estadística. Las familias con ancianos representaron un 28% de todas las familias, eran pequeñas y contaban con ingresos promedio altos, cuando se compararon con las familias sin ancianos en el hogar. Los ancianos eran los cabeza de familia en un 85% de las familias, con ingresos basados principalmente en políticas de protección social. Las familias con ancianos o parejas de ancianos cabezas del hogar contaban con un promedio de ingresos significativamente más alto. La proporción de gasto personal en salud por quintil de ingresos per cápita fue mayor en las familias con una pareja o un anciano como cabeza de familia, cuando se comparó con las familias sin ancianos cabeza de familia, e incluso mayor respecto a las familias sin ancianos en el hogar. Estos resultados permitieron la identificación de potenciales impactos positivos en la calidad de vida de las familias con ancianos en Brasil. Los ingresos más altos por hogar de familias con ancianos son una consecuencia de la expansión de la protección social inclusiva en Brasil durante la primera década del 2000, especialmente para familias con niveles promedio más bajos de ingresos, representando un 4/5 de esta población. La crisis política y económica a partir del año 2010 ha reducido probablemente la ventaja relativa de estas familias, lo que permitirá comparaciones entre este estudio y los resultados de posteriores.

Simple but not simpler: a systematic review of Markov models for economic evaluation of cervical cancer screening.

The aim of this study was to critically evaluate the quality of the models used in economic evaluations of screening strategies for cervical cancer prevention. We systematically searched multiple databases, selecting model-based full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses) of cervical cancer screening strategies. Two independent reviewers screened articles for relevance and performed data extraction. Methodological assessment of the quality of the models utilized formal checklists, and a qualitative narrative synthesis was performed. Thirty-eight articles were reviewed. The majority of the studies were conducted in high-income countries (82%, n=31). The Pap test was the most used screening strategy investigated, which was present in 86% (n=33) of the studies. Half of the studies (n=19) used a previously published Markov model. The deterministic sensitivity analysis was performed in 92% (n=35) of the studies. The mean number of properly reported checklist items was 9 out of the maximum possible 18. Items that were better reported included the statement of decision problem, the description of the strategies/comparators, the statement of time horizon, and information regarding the disease states. Compliance with some items of the checklist was poor. The Markov models for economic evaluation of screening strategies for cervical cancer varied in quality. The following points require improvement: 1) assessment of methodological, structural, heterogeneity, and parameter uncertainties; 2) model type and cycle length justification; 3) methods to account for heterogeneity; and 4) report of consistency evaluation (through calibration and validation methods).

Simple but not simpler: a systematic review of Markov models for economic evaluation of cervical cancer screening

The aim of this study was to critically evaluate the quality of the models used in economic evaluations of screening strategies for cervical cancer prevention. We systematically searched multiple databases, selecting model-based full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses) of cervical cancer screening strategies. Two independent reviewers screened articles for relevance and performed data extraction. Methodological assessment of the quality of the models utilized formal checklists, and a qualitative narrative synthesis was performed. Thirty-eight articles were reviewed. The majority of the studies were conducted in high-income countries (82%, n=31). The Pap test was the most used screening strategy investigated, which was present in 86% (n=33) of the studies. Half of the studies (n=19) used a previously published Markov model. The deterministic sensitivity analysis was performed in 92% (n=35) of the studies. The mean number of properly reported checklist items was 9 out of the maximum possible 18. Items that were better reported included the statement of decision problem, the description of the strategies/comparators, the statement of time horizon, and information regarding the disease states. Compliance with some items of the checklist was poor. The Markov models for economic evaluation of screening strategies for cervical cancer varied in quality. The following points require improvement: 1) assessment of methodological, structural, heterogeneity, and parameter uncertainties; 2) model type and cycle length justification; 3) methods to account for heterogeneity; and 4) report of consistency evaluation (through calibration and validation methods).

Potentially inappropriate medications among elderly Brazilian outpatients.

CONTEXT AND OBJECTIVES In Brazil, few studies have investigated the prevalence of potentially inappropriate medications (PIMs) among elderly outpatients. This study aimed to determine the prevalence of PIMs prescribed for elderly outpatients, identify the PIMs most commonly involved, and investigate whether age, sex and number of medications are related to prescription of such medications. DESIGN AND SETTING Observational descriptive study developed in the Geriatrics Service of the Central Institute of Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil. METHODS Prescriptions issued to 1,270 elderly patients (≥ 60 years) were gathered from a database. These prescriptions had been written by geriatricians at a tertiary-level university hospital in São Paulo, Brazil, between February and May 2008. The prescriptions were divided according to sex and age group (60-69, 70-79 and ≥ 80). The Beers criteria were used to evaluate PIMs. RESULTS Most of the sample comprised women (77%) and the mean age was 80.1 years. The mean prevalence of PIM prescriptions was 26.9%. Female sex and number of medications prescribed were associated with prescription of PIMs. The chance of having a PIM prescription was lower among patients ≥ 70 years. CONCLUSION The greater prevalence of PIMs was correlated with female sex. The chance of having a PIM prescription was lower among patients ≥ 70 years and became greater with increasing numbers of medications prescribed (≥ 7).

Potentially inappropriate medications among elderly Brazilian outpatients / Medicamentos potencialmente inapropriados em pacientes idosos ambulatoriais brasileiros

In Brazil, few studies have investigated the prevalence of potentially inappropriate medications (PIMs) among elderly outpatients. This study aimed to determine the prevalence of PIMs prescribed for elderly outpatients, identify the PIMs most commonly involved, and investigate whether age, sex and number of medications are related to prescription of such medications.

Observational descriptive study developed in the Geriatrics Service of the Central Institute of Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.

Prescriptions issued to 1,270 elderly patients (≥ 60 years) were gathered from a database. These prescriptions had been written by geriatricians at a tertiary-level university hospital in São Paulo, Brazil, between February and May 2008. The prescriptions were divided according to sex and age group (60-69, 70-79 and ≥ 80). The Beers criteria were used to evaluate PIMs.

Most of the sample comprised women (77%) and the mean age was 80.1 years. The mean prevalence of PIM prescriptions was 26.9%. Female sex and number of medications prescribed were associated with prescription of PIMs. The chance of having a PIM prescription was lower among patients ≥ 70 years.

The greater prevalence of PIMs was correlated with female sex. The chance of having a PIM prescription was lower among patients ≥ 70 years and became greater with increasing numbers of medications prescribed (≥ 7). .

No Brasil, poucos estudos investigaram a prevalência de prescrição de medicamentos potencialmente inapropriados (MPIs) para idosos em ambulatório. Este estudo visa determinar a prevalência de MPIs prescritos para idosos no ambulatório, identificar os mais comumente envolvidos e verificar se a idade, o sexo e o número de medicamentos estão relacionados à prescrição de tais medicamentos.

Estudo descritivo observacional, desenvolvido no Serviço de Geriatria do Instituto Central do Hospital das Clínicas (HC) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brasil.

Foram coletadas prescrições de 1.270 pacientes idosos (≥ 60 anos) em banco de dados. As prescrições foram realizadas por geriatras de hospital universitário de atenção terciária em São Paulo, Brasil, entre fevereiro e maio de 2008. As prescrições foram divididas de acordo com o sexo e faixa etária (60-69; 70-79 e ≥80). Os critérios de Beers foram utilizados para a avaliação de MPIs.

A maior parte da casuística foi composta por mulheres (77%) e a média de idade foi de 80,1 anos. A prevalência média de prescrição de MPIs foi de 26,9%. O sexo feminino e o número de medicamentos prescritos foram associados à prescrição de MPIs. A chance de prescrição de um MPI foi menor em pacientes com ≥70 anos.

A maior prevalência de MPIs encontrada foi correlacionada ao sexo feminino. A chance de pr...

Potentially inappropriate medication prescribed to elderly outpatients at a general medicine unit / Medicamentos potencialmente inapropriados prescritos a pacientes idosos ambulatoriais de clínica médica

Objective: To determine the prevalence of potentially inappropriate medications prescribed for elderly outpatients; identify the PIMs most commonly involved; and to investigate whether age and sex besides the number of medications are related to prescription of such medications. Methods: Prescriptions issued to 1,800 elderly patients (greater than or equal to 60 years) were gathered from a database. These prescriptions had been written by general physicians at a tertiary-level university hospital in São Paulo, Brazil, between February and May 2008. Only one prescription per patient was considered. The prescriptions were divided according to sex and age group (60-69, 70-79 and greater than or equal to 80). The Beers criteria (2003 version) were used to evaluate potentially inappropriate medications. Results: Most of the sample comprised women (66.6%) and the mean age was 71.3 years. The mean prevalence of potentially inappropriate medications prescriptions was 37.6%. The 60-69 age group presented highest prevalence (49.9%). The potentially inappropriate medications most prescribed to the women were carisoprodol, amitriptyline, and fluoxetine, and for the men were amitriptyline, carisoprodol, fluoxetine and clonidine. Female sex (p < 0.001; OR = 2.0) and number of medications prescribed (p < 0.001) were associated with prescription of potentially inappropriate medications. The chance of having a PIM prescription was lower among patients greater than or equal to 80 years (OR = 0.7). The mean number of medications prescribed was 7.1, considering both sexes and all age groups. The mean number of medications per patient was greater among females (p < 0.001), and this result did not depend on age group (p = 0.285).

Objetivo: Determinar a prevalência de medicamentos potencialmente inapropriados em idosos ambulatoriais; identificar os mais comumente envolvidos; e verificar se a idade e o sexo do paciente, além do número de medicamentos, estão relacionados à prescrição de medicamentos potencialmente inapropriados. Métodos: Foram coletadas prescrições de 1.800 pacientes idosos (maior ou igual a 60 anos) em banco de dados. As prescrições foram realizadas por clínicos gerais de hospital universitário de atenção terciária em São Paulo entre Fevereiro e Maio de 2008; foi considerada apenas uma prescrição por paciente. As prescrições foram divididas de acordo com o sexo e faixa etária (60-69; 70-79 e maior ou igual a 80). Os critérios de Beers versão 2003 foram utilizados para a avaliação de medicamentos potencialmente inapropriados. Resultados: A maior parte da casuística foi composta por mulheres (66,6%) e a média de idade foi de 71,3 anos. A prevalência média de prescrição de MPIs foi de 37,6%, sendo que a faixa etária de 60-69 anos apresentou a maior prevalência (49,9%). Os medicamentos potencialmente inapropriados mais prescritos para as mulheres foram o carisoprodol, a amitriptilina e a fluoxetina e, para os homens, foram a amitriptilina, o carisoprodol, a fluoxetina e a clonidina. O sexo feminino (p < 0,001; RC = 2,0) e o número de medicamentos prescritos (p < 0,001) foram associados à prescrição de medicamentos potencialmente inapropriados. A chance de prescrição de um medicamento potencialmente inapropriado foi menor em pacientes com maior ou igual a 80 anos (RC = 0,7). A média de medicamentos prescritos foi 7,1, considerando ambos os sexos e todas as faixas etárias. A média do número de medicamentos por paciente foi maior no sexo feminino (p < 0,001), sendo que esse resultado não dependeu da faixa etária (p = 0,285).

Potentially inappropriate medication prescribed to elderly outpatients at a general medicine unit.

OBJECTIVE: To establish the prevalence of potentially inappropriate medications prescribed for elderly patients, to identify the most commonly involved drugs, and to investigate whether age, sex and number of medications were related with the prescription of these drugs. METHODS: Prescriptions for 1,800 elderly patients (≥ 60 years) were gathered from a database. These prescriptions were written by general physicians at a tertiary level university hospital in the city of Sao Paulo, Brazil, from February to May 2008. Only one prescription per patient was considered. The prescriptions were classified according to sex and age (60-69, 70-79 and ≥ 80). The Beers criteria (2003 version) were used to evaluate potentially inappropriate medications. RESULTS: Most of the sample comprised women (66.6%) with a mean age of 71.3 years. The mean prevalence of potentially inappropriate medication prescriptions was 37.6%. The 60-69 age group presented the highest prevalence (49.9%). The most frequently prescribed potentially inappropriate medications to women were carisoprodol, amitriptyline, and fluoxetine; amitriptyline, carisoprodol, fluoxetine and clonidine were prescribed more often to men. The female sex (p<0.001; OR=2.0) and number of medications prescribed (p<0.001) were associated with prescription of potentially inappropriate medications. The chance of having a prescription of these drugs was lower among patients aged over 80 years (OR=0.7). The mean number of prescribed medications for both sexes and all age groups was 7.1. The mean number of medications per patient was higher among females (p<0.001); this result was not age-dependent (p=0.285). CONCLUSION: The prevalence of potentially inappropriate medications was similar to previously reported values in the literature and was correlated with the female sex. The chance of having a potentially inappropriate medication prescription was lower among patients aged over 80 years. The chance of having a potentially inappropriate medications prescription increased proportionally with the number of medications prescribed (≥ 5).