[The impact of social economic factors and family dietary intake on health of children and adolescents].

The impact of social economic factors, digitalization, sanctions and quality of family diet is manifested in increasing effect of these factors on lifestyle, environment and health of children and adolescents. The surrounding reality affects their organism in formative way due to digitalization of various areas of activity. The consequences of pandemic, announced new sanctions of Western countries, environmental pollution and digitalization of life result in deterioration of life conditions and population health. The analysis of family diet of children and adolescents testifies negative tendency to deterioration of health of children in all age groups. This is becoming a predominant factor negatively impacting quality of human potential: population health, abilities to master and implement professional skills, individual culture level and education, etc. The children from low-income families find oneself in group of special risk. Their diet usually does not meet approved physiological and medical biological standards. In conditions of sanction pressure from Western countries the poor households include even more often average family, even with one child. The birth of children very often diminish possibility of liveable existence of members of such families and decreases standard of living of household as a whole. The most vulnerable group become poor and low-income families where three or more juvenile children are brought up. The Western sanctions have disastrous effect on household incomes, aggravate problems of poverty, especially in large families. The investigation and comparative analysis of key characteristics of families diet, social economic factors affecting health of children and adolescents in the context of digitalization, demonstrated the need in reducing negative impact on their health and changing diet to more balanced and diversified one.

The antibiotic resistance and risk heterogeneity between urban and rural rivers in a pharmaceutical industry dominated city in China: The importance of social-economic factors.

Rivers are important environmental sources of human exposure to antibiotic resistance. Many factors can change antibiotic resistance in rivers, including bacterial communities, human activities, and environmental factors. However, the systematic comparison of the differences in antibiotics resistance and risks between urban rivers (URs) and rural rivers (RRs) in a pharmaceutical industry dominated city is still rare. In this study, Shijiazhuang City (China) was selected as an example to compare the differences in antibiotics resistance and risks between URs and RRs. The results showed higher concentrations of total quinolones (QNs) antibiotics in both water and sediment samples collected from URs than those from RRs. The subtypes and abundances of antibiotic resistance genes (ARGs) in URs were significantly higher than those in RRs, and most emerging ARGs (including OXA-type, GES-type, MCR-type, and tet(X)) were only detected in URs. The ARGs were mainly influenced by QNs in URs and social-economic factors (SEs) in RRs. The composition of the bacterial community was significantly different between URs and RRs. The abundance of antibiotic-resistant pathogenic bacteria (ARPBs) and virulence factors (VFs) were higher in URs than those in RRs. Therein, 371 and 326 pathogen types were detected in URs and RRs, respectively. Most emerging ARGs showed a significantly positive correlation with priority ARPBs. Variance partitioning analysis revealed that SEs were the main driving factors of ARGs (80 %) and microbial communities (92 %) both in URs and RRs. Structural equation models indicated that antibiotics (QNs) and microbial communities were the most direct influence of ARGs in URs and RRs, respectively. The cumulative resistance risk of QNs was high in URs, but relatively low in RRs. Enrofloxacin and flumequine posed the highest risk in water and sediment, respectively. This study could help us to better manage and control the risk of antibiotic resistance in different rivers.

Non-linear relations between life expectancy, socio-economic, and air pollution factors: a global assessment with spatial disparities.

Influential factors of socio-economic and air pollution on life expectancy (LE) show complexity. The investigations of non-linear functions of LE, socio-economic, and air pollution factors have not been largely conducted, and spatial and temporal differences of the linear or non-linear relations between LE and the influential factors have been obscured across countries in the world. In this study, the non-linear relations between LE and factors of per capita gross national income (GNIpc), urban population rate (UPR), and fine-particulate (PM2.5) were estimated from 2000 to 2015 by using a generalized additive model (GAM). The collected data included the 219 countries and regions with sufficient data and covers the period 2000-2015. The results demonstrate that at the global level, the GNIpc plays a stable and significant non-linear role in LE, while the non-linear relationships between UPR, PM2.5, and LE are not significant. The temporal variation was further investigated that the non-linear effect of PM2.5 on LE is gradually strengthened, and the non-linear effect of UPR on LE shows a weakened trend. However, GNIpc always plays a significantly non-linear role in the LE level. Furthermore, the spatial difference in the non-linear relations among different continents is detected. In sum, it cannot be ignored the non-linear effects of socio-economic and air pollution factors on LE at a global scale and across different continents.

Exploring the spatial-temporal distribution and evolution of population aging and social-economic indicators in China.

BACKGROUND: China is one of the world's fastest-aging countries. Population aging and social-economic development show close relations. This study aims to illustrate the spatial-temporal distribution and movement of gravity centers of population aging and social-economic factors and thier spatial interaction across the provinces in China. METHODS: Factors of elderly population rate (EPR), elderly dependency ratio (EDR), per capita gross regional product (GRPpc), and urban population rate (UPR) were collected. Distribution patterns were detected by using global spatial autocorrelation, Kernel density estimation, and coefficient of variation. Further, Arc GIS software was used to find the gravity centers and their movement trends yearly from 2002 to 2018. The spatial interaction between the variables was investigated based on bivariate spatial autocorrelation analysis. RESULTS: The results showed a larger variety of global spatial autocorrelation indexed by Moran's I and stable trends of dispersion degree without obvious convergence in EPR and EDR. Furthermore, the gravity centers of the proportion of EPR and EDR moved northeastward. In contrast, the economic and urbanization factors showed a southwestward movement, which exhibited an reverse trend compared to population aging indicators. Moreover, the movement rates of EPR and EDR (15.12 and 18.75 km/year, respectively) were higher than that of GRPpc (13.79 km/year) and UPR (6.89 km/year) annually during the study period. Further, the bivariate spatial autocorrelation variation is in line with the movement trends of gravity centers which showed a polarization trend of population aging and social-economic factors that the difference between southwest and northeast directions and exhibited a tendency to expand in China. CONCLUSIONS: In sum, our findings revealed the difference in spatio-temporal distribution and variation between population aging and social-economic factors in China. It further indicates that the opposite movements of gravity centers and the change of the BiLISA in space which may result in the increase of the economic burden of the elderly care in northern China. Hence, future development policy should focus on the social-economic growth and distribution of old-aged supporting resources, especially in northern China.

Spatial patterns and social-economic influential factors of population aging: A global assessment from 1990 to 2010.

The world's population is aging rapidly. In this paper, three population aging indicators were collected to represent the elderly population, the oldest-old population, and centenarians. The spatial patterns of three population aging indicators and the influencing social-economic factors and their spatial spillover effects in the world from 1990 to 2010 were investigated. The empirical strategy was based on application of spatial autocorrelation methods and spatial error modeling. The results revealed the significant positive spatial autocorrelation as well as the obvious spatial disparities and clusters of the aging indicators in the world. Furthermore, spatial spillover effects of population aging indicators were detected with positive influence of several social-economic factors (e.g., per capita GNI, urbanization rate, and life expectancy) not only of population aging in a country itself, but in its neighboring counties. In sum, these findings indicated that population aging are a spatio-temporal process, and the spatial spillover effects from neighbors also vary among these indicators, which should be considered into the differentiated policies in response to the challenge of an aging society.

Enteroparasitoses e aspectos socioeconômicos em pacientes alcoolistas / Intestinal parasites and socioeconomic aspects of alcoholic patients

Introdução: as enteroparasitoses constituem um problema de saúde pública que atinge as populações mais vulneráveis. O alcoolismo é um problema que afeta milhões de pessoas em todo o mundo, apresenta efeitos nocivos à saúde dos indivíduos e predispõe à infecção por S. stercoralis e às formas mais graves da estrongiloidíase. Objetivo: avaliar a prevalência da infecção das enteroparasitoses, bem como fatores socioeconômicos e sanitários de pacientes alcoolistas atendidos em um centro de tratamento especializado em Salvador, Bahia. Metodologia: trata-se de um estudo transversal, realizado com pacientes alcoolistas (n=277), do sexo masculino, atendidos em um centro de tratamento entre julho de 2014 e junho de 2017. O estudo foi realizado através da aplicação de um questionário estruturado para obtenção de dados socioeconômicos, demográficos e sanitários, sendo solicitadas, ainda, pelo menos duas amostras de fezes em dias alternados. O diagnóstico parasitológico foi realizado pelos métodos de sedimentação espontânea, Baermann-Moraes e cultura em placa de ágar. Resultados: a média de idade dos pacientes inclusos foi de 44,8 ± 9,5 anos. Verificouse que 35,7% dos pacientes estavam infectados com algum enteroparasito e, desses, 30,3% eram monoparasitados. Os parasitos mais frequentes foram S. stercoralis, Endolimax nana e ancilostomídeos, correspondendo 16,6%, 11,2% e 5,8%, respectivamente. Conclusão: dessa forma, S. stercoralis foi o parasito mais frequente, e a associação entre a infecção por esse parasito e o alcoolismo pode levar à estrongiloidíase grave. A elevada frequência de enteroparasitoses nesses pacientes, principalmente por protozoários, deve-se à ausência de higiene pessoal, pois esses indivíduos são suscetíveis à infecção oral fecal. A implementação de medidas de saneamento básico e de campanhas de conscientização para prevenção de infecções parasitárias é imprescindível para a saúde das populações mais vulneráveis.

Introduction: intestinal parasitoses are a public health issue that notably affects vulnerable populations. Alcoholism is a problem that affects millions worldwide by causing damaging effects to the health of individuals as it predisposes them to that infection through stercralisàs and more evolved forms of strongyloidiasis. Objective: evaluate the prevalence of intestinal parasite infections as well as socioeconomic and sanitation factors in a population of alcoholic patients at a specialized treatment facility in Salvador, Bahia. Methodology: this cross-sectional study was carried out with male alcoholic patients (n=277) at a treatment facility from July/2014 to June/2017. The research data were collected through a structured questionnaire aimed to obtain socioeconomic, demographic and sanitation information. Stool tests were ordered in alternate days. The parasitological diagnosis was based on methods of spontaneous sedimentation, Baermann-Moraes and Agar plate growth medium. Results: the patients' average age was 44,8 ± 9,5 years. A total of 35% of the patients was infected with a type of enteroparasite, of whom 30,3% was mono-infected. The most commonly found parasites were S. stercoralis, Endolimax nana and hookworm, corresponding to 16,6%, 11,2% e 5,8%, respectively. Conclusion: as such, S. Stercoralis was the most frequent parasite in this population and the association between the infection by this parasite and alcoholism may lead to severe strongyloidiasis. The high rates of enteroparasitism in those patients, particularly protozoa, are due to the lack of adequate personal hygiene, given those individuals are prone to acquire infections transmitted through the oral fecal route. An implementation of public health sanitation measures and the launch of public awareness campaigns in order to prevent parasite infections are vital to the health of vulnerable populations.

[The Analysis of Social Economic Factors Impact on Epidemic Situation with Tuberculosis in Regions of the Russian Federation].

The article presents original multi-factorial linear regression models developed on the basis of panel structure of data. The distribution of the regions of the Russian Federation according tuberculosis burden was implemented using cluster analysis technique. The evaluation of degree of impact of analyzed factors to epidemic process was implemented using Pratt metric. In overall, approximately 100,000 records from 78 regions of the Russian Federation were processed. four regional clusters were marked out differentiating by level of morbidity, prevalence and mortality of tuberculosis. The diversity of social economic factors impacting the main indices of epidemic process is reducing as its intensity increases. If in the first cluster 7 factors impacted on morbidity and 4 factors -- on mortality, then in the fourth cluster only 1 factor impacted morbidity and 2 -- on mortality. At that, intensity of their impact on epidemic process increased significantly. So, for example, the role of such factor as "Area of housing per capita" in decreasing of tuberculosis morbidity among regions of the 4th cluster assessed in 79%, and among regions of 1st cluster only in 17%. The study results demonstrated that modern techniques of machine learning permit to develop models for quantification assessing of impact of social economic conditions of a particular region on activity of epidemic process of tuberculosis.

Conhecimentos, vivências e crenças no campo sexual: um estudo com alunos do ensino médio com perfis socioeconômicos diferenciados / Knowledge, experiences and beliefs in the sexual field: a study of 1 and 2 year high school students from different socioeconomic backgrounds / Conocimiento, experiencias y creencias en la esfera sexual: un estudio de estudiantes de 1º y 2º año de la escuela secundaria, con diferentes perfiles socioeconómicos

O objetivo neste estudo foi analisar conhecimentos, vivências e crenças no campo sexual de estudantes do 1º e 2º anos do ensino médio,com perfis socioeconômicos diferenciados. Trata-se de uma investigação transversal, descritiva e analítica, com amostragem por conveniência.Aplicou-se questionário estruturado a 258 alunos de Belo Horizonte-MG, de escolas classificadas em A, B2 e C1, segundo critério de classificação econômica. Os resultados mostraram que o nível socioeconômico foi relevante na diferenciação entre os alunos das três escolas, no que serefere à iniciação sexual e a diversos conhecimentos...

The objective of this study was to analyze knowledge, experiences and beliefs in the sexual reproductive field of prevention of Sexually TransmittedDiseases (STDs) in students enrolled in the 1st and 2nd years of high school from different socioeconomic backgrounds. This was a descriptiveand analytical cross-sectional investigation of a convenience sample of 258 students in Belo Horizonte - MG, in schools classified as A, B2 and C1,according to economic status criterion. Results showed that socioeconomic position was relevant to differences between students enrolled at thethree schools as to initiation of sexual intercourse and knowledge...

El objetivo de este estudio fue analizar los conocimientos, las experiencias y creencias en la esfera sexual de alumnos con diferentes perfiles socioeconómicos de 1º y 2º año del secundario. Investigación transversal, descriptiva y analítica con muestreo por conveniencia. Se aplicó un cuestionario estructurado a 258 alumnos de Belo Horizonte - MG, de escuelas clasificadas como A, B2 y C1, según el criterio de clasificación económica.Los resultados mostraron que, en relación a la iniciación sexual y otros conocimientos...

Factores asociados al uso adecuado de la citología cérvico-uterina por mujeres de cartagena (Colombia) / Factors associated to the adequate use of pap smears by women in cartagena (Colombia) / Fatores associados ao uso adequado da citologia cérvico-uterina por mulheres de cartagena (Colombia)

Objetivo: Determinar los factores asociados al uso de la citología en mujeres de la ciudad de Cartagena. Metodología: Se realizó un estudio analítico de corte transversal, en una población de referencia de 237.751 mujeres. Se solicitó consentimiento informado a cada participante de acuerdo a las normas éticas nacionales e internacionales Fueron incluidas mujeres del área urbana de la ciudad de Cartagena, seleccionadas mediante un muestreo polietápico. Se aplicó una encuesta socio-demográfica y el apartado relacionado con cáncer de cuello uterino de la Encuesta Nacional de Demografía y Salud (ENDS - 2010). A los datos se aplicó estadística descriptiva e inferencial. Resultados: Participaron 915 mujeres con una edad promedio de 40 años (DE = 12,9 años). La prevalencia de uso de la citología fue del 85,9%; solo el 39,8% (313) cumple el esquema propuesto por la norma técnica nacional. Las variables que explican el uso adecuado de la citología por parte de las mujeres de Cartagena son: ser mayor de 29 años (OR: 2,1 - IC: 1,3-3,4), reclamar el resultado (OR: 2,5 - IC: 1,1-5,7), tener un resultado anormal (OR: 0,5 - IC: 0,2-0,9) y pertenecer al régimen subsidiado o no tener afiliación en salud (OR: 0,5 - IC: 0,4-0,8). Conclusiones: Los factores asociados al uso de la citología en mujeres de la ciudad de Cartagena, de acuerdo al esquema propuesto por la norma técnica nacional, se explica por factores demográficos, económicos y sociosanitarios.

Objective: To determine factors associated with the use of cytology in women in the city of Cartagena. Methods: A cross-sectional analytical study, with a population of 237,751 women was carried out. Informed consent was requested from each participant as national and international ethic norms request. Women from the urban area of the city of Cartagena were included, selected through multistage sampling. A social-demographic survey and the section related to cervical cancer in the National Demographic and Health Survey (ENDS - 2010) was used. Descriptive and inferential statistics analysis were applied to the data. Results: A total of 915 women with an average age of 40 years (SD = 12.9 years) participated. The prevalence of cytology was 85.9%, only 39.8% (313) which meets the scheme proposed by the national standard. The variables explaining the proper use of cytology by women from Cartagena are: be over 29 years old (OR: 2.1 - CI: 1.3-3.4), pick up the result of the test (OR: 2.5 - CI: 1.1-5.7), have an abnormal result (OR: 0.5 CI 0.2 to 0.9) and belong to the subsidized health care coverage or not having health care coverage (OR: 0.5 - CI: 0.4-0.8). Conclusions: Factors associated with the use of cytology in women in the city of Cartagena according to the scheme proposed by the national standard is explained by, demographic, economical and social health factors.

Objetivo: Determinar os fatores associados ao uso da citologia em mulheres da cidade de Cartagena. Metodologia: Realizou se um estudo analítico de corte transversal, em uma povoação de referencia de 237.751 mulheres. Solicitou se consentimento informado a cada participante de acordo às normas éticas nacionais e internacionais Foram incluídas mulheres da área urbana da cidade de Cartagena, selecionadas mediante uma amostragem polietápico (Nesta as unidades que finalmente compõem a amostragem se determinam em etapas sucessivas). Aplicou-se uma enquete sócia - demográfica e o apartado relacionado com câncer de colo uterino da Enquete Nacional de Demografia e Saúde (ENDS - 2010). Aos dados se aplicou estadística descritiva e inferencial. Resultados: Participaram 915 mulheres com uma idade média de 40 anos (DE = 12,9 anos). A prevalência de uso da citologia foi do 85,9%; só 39,8% (313) faz o esquema proposto pela norma técnica nacional. As variáveis que explicam o uso adequado da citologia por parte das mulheres de Cartagena são: ser maior de 29 anos (OR: 2,1 - IC: 1,3-3,4), reclamar o resultado (OR: 2,5 - IC: 1,1-5,7), ter um resultado anormal (OR: 0,5 - IC: 0,2-0,9) e pertencer ao regime subsidiado ou não ter afiliação e saúde (OR: 0,5 - IC: 0,4-0,8). Conclusões: Os fatores associados ao uso da citología em mulheres da cidade de Cartagena, de acordo ao esquema proposto pela norma técnica nacional, se explicam por fatores demográficos, econômicos e sócio -sanitários.

The effectiveness of interventions in workplace health promotion as to maintain the working capacity of health care personal.

BACKGROUND: The increasing proportion of elderly people with respective care requirements and within the total population stands against aging personnel and staff reduction in the field of health care where employees are exposed to high load factors. Health promotion interventions may be a possibility to improve work situations and behavior. METHODS: A systematic literature search is conducted in 32 databases limited to English and German publications since 1990. Moreover, internet-searches are performed and the reference lists of identified articles are scanned. The selection of literature was done by two reviewers independently according to inclusion and exclusion criteria. Data extraction and tables of evidence are verified by a second expert just like the assessment of risk of bias by means of the Cochrane Collaboration's tool. RESULTS: We identified eleven intervention studies and two systematic reviews. There were three randomized controlled trials (RCT) and one controlled trial without randomization (CCT) on the improvement of physical health, four RCT and two CCT on the improvement of psychological health and one RCT on both. Study duration ranged from four weeks to two years and the number of participants included from 20 to 345, with a median of 56. Interventions and populations were predominantly heterogeneous. In three studies intervention for the improvement of physical health resulted in less complaints and increased strength and flexibility with statistically significant differences between groups. Regarding psychological health interventions lead to significantly decreased intake of analgesics, better stress management, coping with workload, communication skills and advanced training. DISCUSSION: Taking into consideration the small to very small sample sizes, other methodological flaws like a high potential of bias and poor quality of reporting the validity of the results has to be considered as limited. Due to the heterogeneity of health interventions, study populations with differing job specializations and different lengths of study durations and follow-up periods, the comparison of results would not make sense. CONCLUSIONS: Further research is necessary with larger sample sizes, with a sufficient study duration and follow-up, with a lower risk of bias, by considering of relevant quality criteria and with better reporting in publications.

Individual health services.

BACKGROUND: The German statutory health insurance (GKV) reimburses all health care services that are deemed sufficient, appropriate, and efficient. According to the German Medical Association (BÄK), individual health services (IGeL) are services that are not under liability of the GKV, medically necessary or recommendable or at least justifiable. They have to be explicitly requested by the patient and have to be paid out of pocket. RESEARCH QUESTIONS: The following questions regarding IGeL in the outpatient health care of GKV insurants are addressed in the present report: What is the empirical evidence regarding offers, utilization, practice, acceptance, and the relation between physician and patient, as well as the economic relevance of IGeL?What ethical, social, and legal aspects are related to IGeL? FOR TWO OF THE MOST COMMON IGEL, THE SCREENING FOR GLAUCOMA AND THE SCREENING FOR OVARIAN AND ENDOMETRIAL CANCER BY VAGINAL ULTRASOUND (VUS), THE FOLLOWING QUESTIONS ARE ADDRESSED: What is the evidence for the clinical effectiveness?Are there sub-populations for whom screening might be beneficial? METHODS: The evaluation is divided into two parts. For the first part a systematic literature review of primary studies and publications concerning ethical, social and legal aspects is performed. In the second part, rapid assessments of the clinical effectiveness for the two examples, glaucoma and VUS screening, are prepared. Therefore, in a first step, HTA-reports and systematic reviews are searched, followed by a search for original studies published after the end of the research period of the most recent HTA-report included. RESULTS: 29 studies were included for the first question. Between 19 and 53% of GKV members receive IGeL offers, of which three-quarters are realised. 16 to 19% of the insurants ask actively for IGeL. Intraocular tension measurement is the most common single IGeL service, accounting for up to 40% of the offers. It is followed by ultrasound assessments with up to 25% of the offers. Cancer screening and blood or laboratory services are also frequent and represent a major proportion of the demand. The ethical, social, and legal aspects discussed in the context of IGeL concern eight subject areas: autonomous patient decisions versus obtrusion,commercialization of medicine, duty of patient information, benefit, evidence, and (quality) control, role and relation of physicians and patients,relation to the GKV, social inequality,formally correct performance. For glaucoma screening, no randomized controlled trial (RCT) is identified that shows a patient relevant benefit. For VUS three RCT are included. However, they do not yet present mortality data concerning screened and non-screened persons. VUS screening shows a high degree of over-diagnosis in turn leading to invasive interventions. To diagnose one invasive carcinoma, 30 to 35 surgical procedures are necessary. CONCLUSION: IGeL are a relevant factor in the German statutory health care system. To provide more transparency, the requests for evidence-based and independent patient information should be considered. Whether official positive and negative-lists could be an appropriate instrument to give guidance to patients and physicians, should be examined. Generally, IGeL must be seen in the broader context of the discussions about the future design and development of the German health care system.

Prevention of alcohol misuse among children, youths and young adults.

BACKGROUND: Despite many activities to prevent risky alcohol consumption among adolescents and young adults there is an increase of alcohol intoxications in the group of ten to twenty year old juveniles. OBJECTIVES: This report gives an overview about the recent literature as well as the German federal prevention system regarding activities concerning behavioral and policy prevention of risky alcohol consumption among children, adolescents and young adults. Furthermore, effective components of prevention activities are identified and the efficiency and efficacy of ongoing prevention programs is evaluated. METHODS: A systematic literature review is done in 34 databases using Bool'sche combinations of the key words alcohol, prevention, treatment, children, adolescents and young adults. RESULTS: 401 studies were found and 59 studies were selected for the health technology assessment (HTA). Most of the studies are done in USA, nine in Germany. A family strengthening program, personalized computer based intervention at schools, colleges and universities, brief motivational interventions and policy elements like increase of prices and taxes proved effective. DISCUSSION: Among the 59 studies there are three meta-analyses, 15 reviews, 17 randomized controlled trials (RCT) and 18 cohort studies. Despite the overall high quality of the study design, many of them have methodological weaknesses (missing randomization, missing or too short follow-ups, not clearly defined measurement parameters). The transferability of US-results to the German context is problematic. Only a few prevention activities reach a sustainable reduction of frequency and/or amount of alcohol consumption. CONCLUSION: The HTA-report shows the need to develop specific and target group focused prevention activities for the German situation. Essential for that is the definition of target goals (reduction of consumption, change of behaviour) as well as the definition and empirical validation of risky alcohol consumption. The efficacy of prevention activities should be proven before they are launched. At present activities for the reduction or prevention of risky alcohol consumption are not sufficiently evaluated in Germany concerning their sustainable efficacy.

Informative value of Patient Reported Outcomes (PRO) in Health Technology Assessment (HTA).

BACKGROUND: "Patient-Reported Outcome" (PRO) is used as an umbrella term for different concepts for measuring subjectively perceived health status e. g. as treatment effects. Their common characteristic is, that the appraisal of the health status is reported by the patient himself. In order to describe the informative value of PRO in Health Technology Assessment (HTA) first an overview of concepts, classifications and methods of measurement is given. The overview is complemented by an empirical analysis of clinical trials and HTA-reports on rheumatoid arthritis and breast cancer in order to report on type, frequency and consequences of PRO used in these documents. METHODS: For both issues systematic reviews of the literature have been performed. The search for methodological literature covers the publication period from 1990 to 2009, the search for clinical trials of rheumatoid arthritis and breast cancer covers the period 2005 to 2009. Both searches were performed in the medical databases of the German Institute of Medical Documentation and Information (DIMDI). The search for HTA-reports and methodological papers of HTA-agencies was performed in the CRD-Databases (CRD = Centre for Reviews and Dissemination) and by handsearching the websites of INAHTA member agencies (INAHTA = International Network of Agencies for Health Technology Assessment). For all issues specific inclusion and exclusion criteria were defined. The methodological quality of randomized controlled trials (RCT) was assessed by a modified version of the Cochrane Risk of Bias Tool. For the methodological part information extraction from the literature is structured by the report's chapters, for the empirical part data extraction sheets were constructed. All information is summarized in a qualitative manner. RESULTS: Concerning the methodological issues the literature search retrieved 158 documents (87 documents related to definition or classification, 125 documents related to operationalisation of PRO). For the empirical analyses 225 RCT (rheumatoid arthritis: 77; breast cancer: 148) and 40 HTA-reports and method papers were found. The analysis of the methodological literature confirms the role of PRO as an umbrella term for a variety of different concepts. The newest classification system facilitates the description of PRO measures by construct, target population and the method of measurement. Steps of operationalisation involve defining a conceptual framework, instrument development, exploration of measurement properties or, possibly, the modification of existing instruments. Seven out of 59 RCT analysing the effects of antibody therapy for rheumatoid arthritis define PRO as the primary endpoint, 38 trials utilize composite measures (ACR, DAS) and ten trials report clinical or radiological parameters as the primary endpoint. Six out of 123 chemotherapy trials for breast cancer define PRO as the primary endpoint, while 98 trials report clinical endpoints (survival, tumour response, progression) in their primary analyses. Discrepancies in the number of trials result from inaccurate specifications of endpoints in the publications. This distribution is reflected in the HTA-reports: while almost all reports on rheumatoid arthritis refer to PRO, this is only the case in about half of the reports on breast cancer. CONCLUSIONS: As definition and classification of PRO are concerned, coherent concepts are found in the literature. Their operationalisation and implementation must be guided by scientific principles. The type and frequency of PRO used in clinical trials largely depend on the disease analysed. The HTA-community seems to pursue the utilization of PRO proactively - in case of missing data the need for further research is stated.

Effectiveness of programmes as part of primary prevention demonstrated on the example of cardiovascular diseases and the metabolic syndrome.

BACKGROUND: The HTA-report (HTA = Health Technology Assessment) deals with the primary prevention of cardiovascular diseases and diabetes mellitus type 2. In 2009 approximately 356,000 people died in Germany due to cardiovascular diseases. According to estimations about 6.3 million people are suffering from diabetes mellitus type 2. The interventions that are subsidized by the public health insurance are mainly focused on sufficient physical activities, healthy nutrition, stress management and the reduction of the consumption of addictive drugs and luxury food. OBJECTIVES: Which lifestyle-related measures and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are effective? To what extent will the health status be improved by these offers? To what extent will existing health resources and skills be strengthened by these offers? Are there any differences regarding the effectiveness among the interventions with respect to different settings or subgroups? Which lifestyle-related interventions and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are sustainable and cost-effective? Which outcome parameters are in the view of the contributors decisive for the evaluation of the effectiveness? In the view of the contributor are there different values between the outcome parameters? In the view of the payers and other actors are there different values between the outcome parameters? Which ethical and juridical factors have to be considered? Which social and/or socio-economic parameters influence the use of the services and effectiveness? METHODS: A systematic literature research is done in 35 databases. For the period 2005 to 2010, reviews, epidemiological and clinical studies as well as economical evaluations which deal with primary prevention programmes regarding cardiovascular diseases or the metabolic syndrome are included. RESULTS: 44 publications meet the inclusion criteria. These studies confirm the effectiveness of the primary prevention programmes. Physical activity programs seem to have a stronger effect than nutrition programmes. Psychological programmes prove as well effectiveness, if they include cognitive behaviour therapy. The identified economical studies indicate that programmes for cardiovascular prevention can be conducted cost-effectively. Interventions that focus on the general population turn out to be particularly cost-effective and sustainable. DISCUSSION: There is a wide range of primary preventive effective lifestyle-related interventions with high evidence. The outcomes and results are consistent with the recommendations of the two identified evidence-based guidelines regarding the recommendations on lifestyle and healthy nutrition. Furthermore, the cost-effectiveness of primary prevention services is proven. With regard to the economical studies it is however worth noting that this result is based on very few publications. The transferability has to be critically assessed as the studies mainly originate from the American health system. CONCLUSION: On the whole a comprehensive setting approach with educative, somatic, psychosocial and activity therapeutic components is recommended. The sustainability of a prevention intervention must be ensured from programme to programme. Long-term studies are necessary to make valid statements regarding the sustainable effectiveness: There is an essential deficit in the current practiced evaluation of the use of primary prevention services provided by the health insurance - mainly regarding the comprehensive setting approach - regarding the evidence-based evaluation of the prescribed preventive interventions. With regard to the ethical, social and economical evaluation the research situation is deficient. The situation has to be particularly analyzed for the socially deprived and one has to respond to their specific needs for prevention.

Over-, under- and misuse of pain treatment in Germany.

BACKGROUND: The HTA-report (Health Technology Assessment) deals with over- and undertreatment of pain therapy. Especially in Germany chronic pain is a common reason for the loss of working hours and early retirement. In addition to a reduction in quality of life for the affected persons, chronic pain is therefore also an enormous economic burden for society. OBJECTIVES: Which diseases are in particular relevant regarding pain therapy?What is the social-medical care situation regarding pain facilities in Germany?What is the social-medical care situation in pain therapy when comparing on international level?Which effects, costs or cost-effects can be seen on the micro-, meso- and macro level with regard to pain therapy?Among which social-medical services in pain therapy is there is an over- or undertreatment with regard to the micro-, meso- and macro level?Which medical and organisational aspects that have an effect on the costs and/or cost-effectiveness have to be particularly taken into account with regard to pain treatment/chronic pain?What is the influence of the individual patient's needs (micro level) in different situations of pain (e. g. palliative situation) on the meso- and macro level?Which social-medical and ethical aspects for an adequate treatment of chronic pain on each level have to be specially taken into account?Is the consideration of these aspects appropriate to avoid over- or undertreatment?Are juridical questions included in every day care of chronic pain patients, mainly in palliative care?On which level can appropriate interventions prevent over- or undertreatment? METHODS: A systematic literature research is done in 35 databases. In the HTA, reviews, epidemiological and clinical studies and economic evaluations are included which report about pain therapy and in particular palliative care in the years 2005 till 2010. RESULTS: 47 studies meet the inclusion criteria. An undertreatment of acupuncture, over- and misuse with regard to opiate prescription and an overuse regarding unspecific chest pain and chronic low back pain (LBP) can be observed. The results show the benefit and the cost-effectiveness of interdisciplinary as well as multi-professional approaches, multimodal pain therapy and cross-sectoral integrated medical care. Only rough values can be determined about the care situation regarding the supply of pain therapeutic and palliative medical facilities as the data are completely insufficient. DISCUSSION: Due to the broad research question the HTA-report contains inevitably different outcomes and study designs which partially differ qualitatively very strong from each other. In the field of palliative care hospices for in-patients and palliative wards as well as hospices for out-patients are becoming more and more important. Palliative care is a basic right of all terminally ill persons. CONCLUSION: Despite the relatively high number of studies in Germany the HTA-report shows a massive lack in health care research. Based on the studies a further expansion of out-patient pain and palliative care is recommended. Further training for all involved professional groups must be improved. An independent empirical analysis is necessary to determine over or undertreatment in pain care.

Anemia em crianças e fatores associados em região urbana / Factors associated to anemia in infants residents of an urban region / Factores asociados a la anemia en ninos de una zona urbana

O objetivo com esta pesquisa foi identificar a frequência da anemia em crianças do município de Vespasiano-MG e sua associação com variáveis socioeconômicas, demográficas e biológicas. Foram avaliados 556 bebês e pré-escolares na faixa etária de 6 a 24 meses entre maio e julho de 2007. A hemoglobina sanguínea foi determinada por punção digital, pelo método da cianometahemoglobina. Também foi aplicado um questionário às mães para a obtenção de variáveis biológicas, socioeconômicas e demográficas. Considerou-se anemia a concentração de Hb <11,0g/dL, segundo Organização Mundial da Saúde (OMS). A frequência de anemia na população estudada foi de 37,9%. Foi possível verificar que as variáveis que tiveram associação independente com a anemia foram: baixa escolaridade materna (< 8 anos de estudo) (RP=1,37; 1,11-1,70); esgoto escoado a céu aberto ou em fossa (RP=1,51; 1,21-1,87); criança possuir pelo menos um irmãomenor de 5 anos (RP=1,43; 1,16-1,76); faixa etária entre 6 e 12 meses incompletos (RP=1,36; 1,11-1,67); e sexo masculino(RP=1,25; 1,03-1,54). A frequência de anemia encontrada foi caracterizada como problema de saúde pública, agravada nos subgrupos da população de baixos recursos socioeconômicos. Esses resultados alertam para a necessidade de avaliação de políticas de intervenção implementadas. A instituição de mecanismos contínuos de vigilância alimentar e nutricional faz-se urgente no município avaliado, permitindo uma intervenção precoce no problema.

The objective of this study was to investigate the frequency of anemia in children and their association with socioeconomic, demographic and biological variables. Between May and July 2007 mothers of infants and preschoolers aged 6 to 24 months were invited to participate in the study. Hemoglobin (Hb) level was assessed on site by fingerprick blood tests using the cyanmethemoglobin method. Additionally, mothers were asked to answer a social economic, biological and demographic questionnaire. The frequency of anemia in the 556 children examined was 37.9%. The results show that anemia was associated with the following variables: mother’s schooling less than 8 years (PR=1.37;CI95% 1.11–1.70), open sewers or cesspit nearby (PR=1.51; 1.21–1.87), the child has at least one sibling younger than five years old (PR=1.43; 1.16–1.76), children from 6 to 12 months of age (PR=1.36; 1.11 – 1.67) and of the male sex (PR=1.25; 1.03–1.54). The frequency of anemia detected in young children represents a public health problem aggravated in low income families. These results highlight the need to re-evaluate the current intervention policy. The implementation of continuous food security mechanisms and nutrition are urgently recommended in the area under study are mechanisms which will enable an early response to the problem of anemia.

El objetivo de este estudio fue identificar la frecuencia de anemia en los niños en la ciudad de Vespasiano-MG y su asociación con las variables socioeconómicas, demográficas y biológicas. Se evaluaron 556 bebés y niños entre 6 y 24 meses de mayo a julio de 2007. La hemoglobina de la sangre se determinó mediante punción digital por el métodode cianometahemoglobina. También se aplicó una encuesta a las madres para obtener las características biológicas, socioeconómicas y demográficas. La concentración de Hb <11,0 g / dl, según la Organización Mundial de la Salud, está considerada como anemia. La frecuencia de anemia en la población objeto de estudio fue de 37,9%. Las variables asociadas a la anemia fueron: baja educación materna (menos de 8 años de estudio) (PR = 1,37, 1,11 a 1,70), aguasresiduales a cielo abierto o en fosa séptica ( PR = 1,51, 1,21 a 1,87), niños con por lo menos un hermano con menos de5 años (RP = 1,43, 1,16 a 1,76), edades comprendidas entre 6 y 12 meses incompletos ( PR = 1,36, 1,11 a 1,67) y varones (RP = 1,25, 1,03 a 1,54). La frecuencia de tal anemia se considera un problema de salud pública que se agrava en lossubgrupos de la población de bajos recursos socioeconómicos. Estos resultados enfatizan la necesidad de evaluar las políticas aplicadas. Se recomienda establecer con urgencia mecanismos contínuos de vigilancia alimentaria y nutricionalen la ciudad ojeto de estudio para darle una rápida respuesta al serio problema de la anemia.