Global Assessment of Palliative Care Need: Serious Health-Related Suffering Measurement Methodology.

Inequities and gaps in palliative care access are a serious impediment to health systems especially low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions. In this paper, an updated methodology - SHS2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions. The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS. The discussion encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0.

Unmet Social Needs and Breast Cancer Screening Utilization and Stage at Presentation.

Importance: Unmet social needs in local populations may hinder the development of targeted cancer control interventions aimed at improving screening utilization and early-stage breast cancer diagnosis to ultimately improve breast cancer survival disparities. Objective: To evaluate if (1) city-funded screening mammography is associated with utilization of screening mammography, (2) unmet social needs are associated with utilization of screening mammography, and (3) unmet social needs are associated with later-stage disease at diagnosis. Design, Setting, and Participants: This cohort study included patients with stages I-IV invasive ductal or lobular carcinoma treated at an academic medical center (including both an underserved safety-net hospital [SNH] and a National Cancer Institute-designated academic cancer center [ACC]) from 2020 to 2023. Eligible patients were aged 18 years or older and able to consent. Data were analyzed between July 2023 and September 2023. Exposure: The Health Leads Social Needs Screening Toolkit, a screening tool that gathers information on the most common social need domains affecting patient health. Main Outcomes and Measures: Univariable and multivariable logistic regression was utilized to evaluate the following primary outcomes: (1) routine screening mammography and (2) American Joint Committee on Cancer 8th edition clinical stage at presentation. Results: Of the 322 women who completed the Health Leads Social Needs Screening Toolkit, 201 (62%) self-identified as Hispanic, 63 (19%) as non-Hispanic Black, and 63 (19%) as non-Hispanic White. Two hundred fifty-five (76%) patients with access to city-funded screening mammography completed a screening mammogram. Patients who presented to the SNH were more likely to present with late-stage disease compared with early-stage disease (15 of 48 [31%] vs 50 of 274 [18%]; P = .04). On multivariable logistic regression, not completing a screening mammography was associated with having an increasing number of unmet social needs (OR, 0.74; 95% CI, 0.55-0.99; P = .047) and an increasing age at diagnosis (OR, 0.92; 95% CI, 0.89-0.96; P < .001). Moreover, increasing unmet social needs was significantly associated with late-stage diagnosis above and beyond screening mammography (OR, 1.38; 95% CI, 1.01-1.89; P = .04). Conclusions and Relevance: In this cohort study, access to screening mammography did not translate to utilization of screening mammography, increasing unmet social needs were significantly associated with lower rates of screening mammography, and those with increasing unmet social needs were more likely to present with late-stage disease. This association transcended recruitment site (SNH vs ACC), indicating that patients in either hospital setting may benefit from unmet social needs screening to overcome access to care barriers associated with late-stage disease at diagnosis.

Health effects associated with exposure to intimate partner violence against women and childhood sexual abuse: a burden of proof study.

The health impacts of intimate partner violence against women and childhood sexual abuse are not fully understood. Here we conducted a systematic review by comprehensively searching seven electronic databases for literature on intimate partner violence-associated and childhood sexual abuse-associated health effects. Following the burden of proof methodology, we evaluated the evidence strength linking intimate partner violence and/or childhood sexual abuse to health outcomes supported by at least three studies. Results indicated a moderate association of intimate partner violence with major depressive disorder and with maternal abortion and miscarriage (63% and 35% increased risk, respectively). HIV/AIDS, anxiety disorders and self-harm exhibited weak associations with intimate partner violence. Fifteen outcomes were evaluated for their relationship to childhood sexual abuse, which was shown to be moderately associated with alcohol use disorders and with self-harm (45% and 35% increased risk, respectively). Associations between childhood sexual abuse and 11 additional health outcomes, such as asthma and type 2 diabetes mellitus, were found to be weak. Although our understanding remains limited by data scarcity, these health impacts are larger in magnitude and more extensive than previously reported. Renewed efforts on violence prevention and evidence-based approaches that promote healing and ensure access to care are necessary.

Dimensions of suffering and the need for palliative care: experiences and expectations of patients living with cancer and diabetes and their caregivers in Mexico - a qualitative study.

OBJECTIVES: Over 40 million people in low-income and middle-income countries (LMICs) experience serious health-related suffering (SHS) annually and require palliative care. Patient and caregiver experiences of SHS in LMICs are understudied despite their importance in guiding palliative care provision. Diabetes and cancer are the second-leading and third-leading causes of death in Mexico, causing a significant SHS burden on patients, families and health systems. This study examines SHS and palliative care from the point of view of patients with cancer and diabetes and their caregivers. DESIGN: A qualitative descriptive study based on in-depth telephone interviews was conducted between August 2021 and February 2022. Data were analysed through inductive thematic analysis. PARTICIPANTS: Overall, 20 patients with end-stage cancer, 13 patients with diabetes and 35 family caregivers were interviewed individually. SETTING: Participants were recruited from two family medicine clinics and a pain clinic in Mexico City. RESULTS: Seven themes emerged: (1) suffering as a multifaceted phenomenon, (2) diversity in perceptions of suffering, (3) different coping strategies, (4) need and perceived importance of relief from suffering, (5) barriers to accessing services to relieve suffering, (6) demand for the health sector's active and humane role in addressing suffering and (7) preferences and need for comprehensive care for relief from suffering. The primary coping strategies included family companionship, protective buffering and faith-based support. Participants lacked knowledge of palliative care. They expressed the importance of relief from suffering, viewing it as the health sector's responsibility and requesting more humane, personalised care and access to medicines and pain clinics. CONCLUSIONS: The multifaceted nature of SHS highlights the health system's responsibility to provide high-quality palliative care. Policies to enhance access to palliative care should integrate it into primary care, redesigning services towards patient and caregiver biopsychosocial and spiritual needs and ensuring access to medicines and competent health personnel.

Palliative care need in the Eastern Mediterranean Region and human resource requirements for effective response.

Integration of palliative care into health care systems is considered an ethical responsibility, yet no country in the Eastern Mediterranean Region (EaMReg) has achieved integration. Data on palliative care need and cost are crucial forEaMReg health care planners and implementers in the region. Using data from the Lancet Commission on Palliative Care and Pain Relief, we estimated the number of people in each EaMReg country who needed palliative care in 2015 and their degree of access. In three countries, we estimated the number of days during which an encounter for palliative care was needed at each level of the health care system. This enabled calculation of the number of full-time equivalents (FTEs) of clinical and non-clinical staff members needed at each level to administer the essential package of palliative care recommended by WHO. In 2015, 3.2 million people in the EaMReg needed palliative care, yet most lacked access to it. The most common types of suffering were pain, fatigue, weakness, anxiety or worry, and depressed mood. To provide safe, effective palliative care at all levels of health care systems, between 5.4 and 11.1 FTEs of trained and supervised community health workers per 100,000 population would be needed in addition to 1.0-1.9 FTEs of doctors, 2.2-4.3 FTEs of nurses, and 1.4-2.9 FTEs of social workers. Data from our study enables design of palliative care services to meet the specific needs of each EaMReg country and to calculate the cost or cost savings.

Non-pharmaceutical interventions to combat COVID-19 in the Americas described through daily sub-national data.

This dataset covers national and subnational non-pharmaceutical interventions (NPI) to combat the COVID-19 pandemic in the Americas. Prior to the development of a vaccine, NPI were governments' primary tools to mitigate the spread of COVID-19. Variation in subnational responses to COVID-19 is high and is salient for health outcomes. This dataset captures governments' dynamic, varied NPI to combat COVID-19 for 80% of Latin America's population from each country's first case through December 2021. These daily data encompass all national and subnational units in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru. The dataset includes individual and aggregate indices of nine NPI: school closures, work suspensions, public event cancellations, public transport suspensions, information campaigns, local travel restrictions, international travel controls, stay-at-home orders, and restrictions on the size of gatherings. We also collected data on mask mandates as a separate indicator. Local country-teams drew from multiple data sources, resulting in high-quality, reliable data. The dataset thus allows for consistent, meaningful comparisons of NPI within and across countries during the pandemic.

Increase of catastrophic and impoverishing health expenditures in Mexico associated to policy changes and the COVID-19 pandemic.

Background: In 2003, the Mexican Congress approved a major reform to provide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020. Methods: We performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expenditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state. Results: The percentage of households without health insurance almost doubled from 8.8% (three million households) in 2018 to 16.5% (5.8 million households) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting mostly central and southern states (range = -1.0% to 194.4%). Conclusions: The discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico.

Harnessing progress in radiotherapy for global cancer control.

The pace of technological innovation over the past three decades has transformed the field of radiotherapy into one of the most technologically intense disciplines in medicine. However, the global barriers to access this highly effective treatment are complex and extend beyond technological limitations. Here, we review the technological advancement and current status of radiotherapy and discuss the efforts of the global radiation oncology community to formulate a more integrative 'diagonal approach' in which the agendas of science-driven advances in individual outcomes and the sociotechnological task of global cancer control can be aligned to bring the benefit of this proven therapy to patients with cancer everywhere.

Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption.

2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.

Bridging gaps to universal palliative care access in Chile: serious health-related suffering and the cost of expanding the package of care services.

Background: The Lancet Commission on Palliative Care (PC) and Pain Relief quantified the burden of serious health-related suffering (SHS), proposing an Essential Package of PC (EPPC) to narrow the global PC divide. We applied the EPPC framework to analyze PC access in Chile, identify gaps in coverage, and provide recommendations to improve PC access. Methods: Total SHS and population in need of PC was estimated using official 2019 government data. We differentiated between cancer and non-cancer related SHS given guaranteed Chilean PC coverage for cancer. We calculated differences between the Chilean PC package and the Lancet Commission EPPC to estimate the cost of expanding to achieve national coverage of palliative care. Findings: In 2019, nearly 105,000 decedent and non-decedent Chileans experienced SHS with a lower-bound estimate of 12.1 million days and an upper-bound estimate of 42.4 million days of SHS. Each individual experienced between 116 and 520 days of SHS per year. People living with a cancer diagnosis had PC access with financial protection, accounting for almost 42% of patients in need. People with non-cancer diagnoses-about 61 thousand patients-lacked PC coverage. Expanding coverage of the EPPC for all patients in need would cost just above $123 million USD, equivalent to 0.47% of Chilean National Health Expenditure. Interpretation: Achieving universal PC access is urgent and feasible for Chile, classified as a high-income country. Expanding PC services and coverage to the EPPC standard are affordable and critical health system responses to ensuring financial protection for patients with SHS. In Chile, this requires closing large gaps in PC coverage pertaining to patients with non-cancer conditions and treatment of symptoms that go beyond pain. Our research provides an empirical approach for applying the Lancet Commission SHS framework to estimate the cost of achieving national universal PC access anchored in a package of health care services. Funding: This research was partially funded by the Chilean Government through the Fondo Nacional de Ciencia y Tecnología (Fondecyt Regular) grant number 1201721, the U.S. Cancer Pain Relief Committee grant AWD-003806 awarded to the University of Miami and by the University of Miami Institute for Advanced Study of the Americas. We acknowledge NIH/NCI award P30CA008748.

Burden of overweight and obesity in Mexico from 1990 to 2021.

BACKGROUND: Overweight and obesity (OW/OB) represent a serious challenge in Mexico, with effects on health, society and economy. Demographic, epidemiological, nutritional, social and economic factors have exacerbated this problem. OBJECTIVE: To analyze mortality and years of healthy life lost in Mexico due to OW/OB in the 1990-2021 period. MATERIAL AND METHODS: The Global Burden of Disease and Risk Factors 2021 study was used to analyze data on elevated body mass index (BMI) as a risk factor and its evolution in Mexico. RESULTS: In 2021, 118 thousand deaths attributable to high BMI were recorded, which accounted for 10.6% of total deaths and more than 4.2 million disability-adjusted life years lost. CONCLUSIONS: The obesogenic environment, influenced by social determinants of health, has had a significant impact on mortality, burden of disease, and economic costs. Addressing OW/OB requires multisector interventions to strengthen the Mexican health system.

ANTECEDENTES: El sobrepeso y la obesidad constituyen un grave desafío en México, con efectos en la salud, sociedad y economía. Factores demográficos, epidemiológicos, nutricionales, sociales y económicos han agravado esta problemática. OBJETIVO: Analizar la mortalidad y los años de vida saludable perdidos en México por sobrepeso y obesidad en el período de 1990 a 2021. MATERIAL Y MÉTODOS: Se utilizó el Global Burden of Disease 2021 para analizar los datos sobre índice de masa corporal elevado como factor de riesgo y su evolución en México. RESULTADOS: En 2021 se registraron 118 mil muertes atribuibles a índice de masa corporal elevado, que representaron 10.6 % del total de muertes y más de 4.2 millones de años de vida perdidos ajustados por discapacidad. CONCLUSIONES: El ambiente obesogénico, influido por determinantes sociales, ha tenido un impacto significativo en la mortalidad, la carga de enfermedad y los costos económicos. Abordar el sobrepeso y la obesidad requiere intervenciones multisectoriales para fortalecer el sistema de salud mexicano.

Prevention of violence against children in the home: an overview of reviews protocol.

BACKGROUND: Violence against children (VAC) in the home, or by household members, is a widespread problem with devastating and costly consequences for individuals and societies. In the past two decades, much research has been dedicated to the prevention of VAC in the home, in particular, in low- and- middle-income countries, but there are few systematic examinations of the growing body of literature. We present a protocol for an overview of reviews to synthesize the evidence from recent reviews on the effectiveness and characteristics of both universal and selective interventions to prevent VAC in the home or by household members. METHODS: We will conduct an overview of reviews of quantitative studies of universal and selective interventions to prevent VAC in the home published after 2000. Our outcomes will be VAC in the home (e.g., physical, sexual, or psychological violence or neglect) and drivers or direct risk factors for VAC (e.g., beliefs or attitudes towards VAC, parenting stress). We will search for reviews in multiple databases using controlled vocabularies and keywords. We will use the AMSTAR 2 to assess the quality of reviews and will extract information on outcomes, main results, and geographic distribution of primary studies, among other data. We will conduct a narrative synthesis of the findings. DISCUSSION: The proposed overview will provide timely evidence on effective strategies to prevent VAC in the home and will identify the key strengths and limitations of the current body of evidence on this topic. In doing so, we will inform future research, policy, and practice aimed at building effective strategies to prevent VAC globally. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022304784.

Can You Hear Us Now? Equity in Global Advocacy for Palliative Care.

Evidence-based advocacy underpins the sustainable delivery of quality, publicly guaranteed, and universally available palliative care. More than 60 million people in low- and middle-income countries (LMICs) have no or extremely limited access to either palliative care services or essential palliative care medicines (e.g., opioids) on the World Health Organization Model List. Indeed, only 12% of the global palliative care need is currently being met. Palliative care advocacy works to bring this global public health inequity to light. Despite their expertise, palliative care practitioners in LMICs are rarely invited to health policymaking tables - even in their own countries - and are underrepresented in the academic literature produced largely in the high-income world. In this paper, palliative care experts from Bangladesh, Colombia, Egypt, Sudan, Uganda, and Zambia affiliated with the International Association for Hospice & Palliative Care Advocacy Focal Point Program articulate the urgent need for evidence-based advocacy, focusing on significant barriers such as urban/rural divides, cancer-centeredness, service delivery gaps, opioid formulary limitations, public policy, and education deficits. Their advocacy is situated in the context of an emerging global health narrative that stipulates palliative care provision as an ethical obligation of all health systems. To support advocacy efforts, palliative care evaluation and indicator data should assess the extent to which LMIC practitioners lead and participate in global and regional advocacy. This goal entails investment in transnational advocacy initiatives, research investments in palliative care access and cost-effective models in LMICs, and capacity building for a global community of practice to capture the attention of policymakers at all levels of health system governance.