Reducing Blindness from Retinopathy of Prematurity (ROP) in Argentina Through Collaboration, Advocacy and Policy Implementation.

Retinopathy of prematurity (ROP) is a largely avoidable cause of blindness in children worldwide, requiring high-quality neonatal care, early detection and treatment. In middle-income countries throughout Latin America, Eastern Europe and South Asia, there has been a rise in ROP blindness due to a combination of increased survival of preterm infants, resource-scarce medical environments and lack of policies, training and human resources. However, Argentina is an example of country where rates of ROP blindness have declined and ROP programmes have been successfully and effectively embedded within the health and legal system. The purpose of this study is to describe the activities and stakeholders, including Ministry of Health (MoH) and UNICEF, involved in the process, from recognition of an epidemic of ROP blindness to the development of national guidelines, policies and legislation for control. Using a retrospective mixed methods case study design, data on rates of severe ROP was collected from 13 neonatal intensive care units from 1999 to 2012, and on the proportion of children blind from ROP in nine blind schools in seven provinces. Legislative document review, focus group discussions and key informant interviews were conducted with neonatologists, ophthalmologists, neonatal nurses, parents, MoH officials, clinical societies, legislators and UNICEF officials in seven provinces. Results are presented combining the stages heuristic policy framework and Shiffman including: agenda setting, policy formulation, implementation and evaluation. By 2012, ROP had declined as a cause of blindness in children in schools for the blind as had rates of severe ROP needing treatment in the NICUs visited. Multiple factors played a role in reducing blindness from ROP in Argentina and successfully coordinating its control including national advocacy, leadership, legislation and international collaboration. Lessons learned in Argentina can potentially be scaled to other LMICs in Latin America and beyond with further context-specific research.

Field Testing Project to Pilot World Health Organization Eye Health Indicators in Latin America.

PURPOSE: To develop and implement mechanisms to collect, report, and assess the World Health Organization (WHO) core eye health indicators in Chile, Honduras, Mexico, Peru, and Uruguay. METHODS: Simple templates for a situational analysis (of data collection and reporting processes), a national data collection strategy, and a national work plan to implement the core eye health indicators were developed. Public and private sector representatives from the ministries of health (MOHs), national vision committees, and national societies of ophthalmology of each country used these tools with 2013 baseline data to improve their data collection processes and collected 2015 data. Final analysis and cross-validation were performed using intraocular lens sales data and last observation carried forward imputation. RESULTS: Study tools were effectively implemented in all five countries and resulted in improved intersectoral stakeholder collaboration and communications, which improved the data collection and reporting processes. More complete and accurate data were reported by 2015 compared to the 2013 baseline. CONCLUSIONS: Multisectoral stakeholders, including national professional societies and national vision committees, should collaborate with MOHs to improve the quality of data that are reported to WHO. This study involved these stakeholders in the data collection processes to better understand the realities of indicator implementation, better manage their expectations, and improve data quality. WHO Member States across the globe can feasibly adapt the study tools and methodologies to strengthen their data collection processes. Overall, the reliability and validity of the indicators is hampered with limitations that prevent fully accurate data from being collected.

Cost and Expected Visual Effect of Interventions to Improve Follow-up After Cataract Surgery: Prospective Review of Early Cataract Outcomes and Grading (PRECOG) Study.

IMPORTANCE: Some experts recommend increasing low rates of follow-up after cataract surgery in low- and middle-income countries using various interventions. However, little is known about the cost and effect of such interventions. OBJECTIVE: To examine whether promoting follow-up after cataract surgery creates economic value. DESIGN, SETTING, AND PARTICIPANTS: The Prospective Review of Early Cataract Outcomes and Grading (PRECOG) is a cohort study with data from patients undergoing cataract surgery from January 19, 2010, to April 18, 2012. Final follow-up was completed on August 10, 2012. Data were collected before surgery, at discharge, and at follow-up at least 40 days after surgery from 27 centers in 8 countries in Asia, Africa, and Latin America. Each center enrolled 40 to 120 consecutive patients undergoing cataract surgery. If patients did not return to the hospital for the follow-up visit, hospitals could use telephone calls or transportation subsidies to increase follow-up rate. Data were analyzed from December 2013 to January 2016. MAIN OUTCOMES AND MEASURES: Cost of interventions (telephone calls and transportation subsidies) to increase follow-up at least 40 days after surgery, visual acuity (VA) in the eye undergoing cataract surgery, presence of complications, patient and facility costs per visit, and willingness to pay for treatment or glasses if needed. The maximum incremental cost of improving VA in 1 patient (incremental cost-effect ratio [ICER]) was calculated for spontaneous follow-up (compared with no follow-up) and follow-up with the telephone and transportation interventions. Expected ICERs were estimated including only those patients willing to pay. RESULTS: Among 2487 patients (1068 men [42.9%]; 1405 women [56.5%]; 14 missing [0.6%]; mean [SD] age, 68.4 [11.3] years), 2316 (93.1%) received follow-up, of whom 369 (16.0%) were seen in an outside facility or home and were in the cost-effectiveness analysis as unable to follow up. A grand mean (a mean of means of the different countries) of 56.3% of patients needed glasses, of whom 56.9% were willing to pay, and 1.6% had treatable complications, of whom 39.4% were willing to pay. Maximum proportions with improved VA (and corresponding ICERs) were 0.08 for no follow-up, 0.45 ($151.56) for spontaneous follow-up, 0.53 ($164.46) for a telephone intervention, and 0.53 ($133.07) for a transportation intervention. These results were most sensitive to the cost of follow-up. Expected proportions (ICERs) were 0.08, 0.27 ($232.69), 0.30 ($456.22), and 0.30 ($206.47), respectively. CONCLUSIONS AND RELEVANCE: Most patients benefiting from follow-up after cataract surgery returned spontaneously when requested at discharge. Use of telephone calls or transportation subsidies to increase follow-up in low- and middle-income countries may not be cost-effective.

Assessment of cataract surgical outcomes in settings where follow-up is poor: PRECOG, a multicentre observational study.

BACKGROUND: Poor follow-up after cataract surgery in developing countries makes assessment of operative quality uncertain. We aimed to assess two strategies to measure visual outcome: recording the visual acuity of all patients 3 or fewer days postoperatively (early postoperative assessment), and recording that of only those patients who returned for the final follow-up examination after 40 or more days without additional prompting. METHODS: Each of 40 centres in ten countries in Asia, Africa, and Latin America recruited 40-120 consecutive surgical cataract patients. Operative-eye best-corrected visual acuity and uncorrected visual acuity were recorded before surgery, 3 or fewer days postoperatively, and 40 or more days postoperatively. Clinics logged whether each patient had returned for the final follow-up examination without additional prompting, had to be actively encouraged to return, or had to be examined at home. Visual outcome for each centre was defined as the proportion of patients with uncorrected visual acuity of 6/18 or better minus the proportion with uncorrected visual acuity of 6/60 or worse, and was calculated for each participating hospital with results from the early assessment of all patients and the late assessment of only those returning unprompted, with results from the final follow-up assessment for all patients used as the standard. FINDINGS: Of 3708 participants, 3441 (93%) had final follow-up vision data recorded 40 or more days after surgery, 1831 of whom (51% of the 3581 total participants for whom mode of follow-up was recorded) had returned to the clinic without additional prompting. Visual outcome by hospital from early postoperative and final follow-up assessment for all patients were highly correlated (Spearman's rs=0·74, p<0·0001). Visual outcome from final follow-up assessment for all patients and for only those who returned without additional prompting were also highly correlated (rs=0·86, p<0·0001), even for the 17 hospitals with unprompted return rates of less than 50% (rs=0·71, p=0·002). When we divided hospitals into top 25%, middle 50%, and bottom 25% by visual outcome, classification based on final follow-up assessment for all patients was the same as that based on early postoperative assessment for 27 (68%) of 40 centres, and the same as that based on data from patients who returned without additional prompting in 31 (84%) of 37 centres. Use of glasses to optimise vision at the time of the early and late examinations did not further improve the correlations. INTERPRETATION: Early vision assessment for all patients and follow-up assessment only for patients who return to the clinic without prompting are valid measures of operative quality in settings where follow-up is poor. FUNDING: ORBIS International, Fred Hollows Foundation, Helen Keller International, International Association for the Prevention of Blindness Latin American Office, Aravind Eye Care System.

Nutribusiness: an aspect of the political economy of persistent hunger.

The failure of nutrition programs to significantly impact on the prevalent hunger in underdeveloped countries is attributed to nutribusiness. This term conceptually links the activities of profit-motivated capitalist enterprises to the continuous generation of poverty and hunger. The actors are all part of a hierarchy dominated by multinational corporate interests and including bilateral and multilateral aid agencies, nutrition institutes, and nutrition professionals at various levels. Although many lower-level nutrition workers are unwittingly caught up in the system, most of the higher-level professionals are conscious of their roles, which they selfishly perform for personal advancement. The Philippine nutrition system is examined as an example of nutribusiness, albeit in a very obvious and extreme form. On the available evidence, the conclusion is drawn that in countries dominated by capitalist production, nutrition activities amount to nutribusiness. Consequently, the elimination and prevention of persistent hunger in underdeveloped countries must start with their disengagement from the world capitalist system and their pursuit of socialist transformation.

Multisectoral approach to the delivery of health care in Jamaica

Examines the need for better integration of the public health sector with other sectors in the society. Critically examines the health status of the Jamaican population, the socio-economic environment and the development of health policy between 1950 and 1983. Five areas were researched for intersectoral co-ordination: Basic Services Programme for children jointly sponsored by UNICEF, PAHO and Government of Jamaica; the Pesticides Advisory Committee concerned with utilization of chemical and pesticides as it relates to plant protection, food storage and public health; the Nutrition Advisory Council which co-ordinates the development of food and nutrition policies; methods used for the efficient delivery of water; and methods used in the process of collaboration between the Ministries of Health and Education as attempts are made to include health concepts in school curricula and programmes. Concludes that almost all the projects and activities investigated have not performed as expected. Recommendations include the following: 1) clear goals and task specifications before the execution of any project or programme; 2) a common understanding and expectation of desired goals and objectives; 3) paying greater attention to the incorporation of potential beneficiaries into the planning and design stages of programmes. (Au)

Food consumption patterns in St. James - abstract

A household survey was conducted in March 1982 using a stratified random sample the population in 3 ecological zones: urban (U), Rural Lowland (RL, <1000 feet), and Rural Upland (RU, >1000 feet). Households with 10 acres of land and children over 3 years were excluded. This paper examines the patterns of food consumption and assesses the adequacy of the household's consumption by use of 24-hour recall conducted by trained Community Health Aides. One hundred and three different items were reported from the 301 households in the U (N = 82), RL (N = 118), RU (N = 101) zones. Fifteen items used by at least 15 percent of the sample contributed 80.8 percent and 68.7 percent to total calories and protein respectively, in the parish, Cereals contributed 32.3 percent, 36.5 percent and 30.5 percent to total calories while root crops contributed 12.7 percent, 15.0 percent and 33.2 percent in U, RL and RU respectively. The average househeld calorie satisfaction was not significantly different for the 3 zones (106 percent), 104 percent, 110 percent) nor the proportion of households with < 80 percent calorie satisfaction. The mean protein energy per cent was 13.7 ñ 2.3 for urban, 11.7 ñ 2.8 and 10.8 ñ 2.8 for the RL and RU zones respectively (p<.001). Households spending > J$3.00/2000Kcal were 63.4 percent in urban, 55.9 percent and 56.4 percent in RL and RU zones. The average weekly food expenditure per person was J$17.2 ñ 9.1, J$13.4 ñ 7.5 and J$14.6 ñ 7.2 (p<0.5): expressed as percentage of total expenditure: 52.7 percent, 66.2 percent, and 75.3 percent, in the U, RL and RU zones (p<.01). Elasticity of demand for calories consumption was negative in the urban area (r bar to second power = 0.360; p<.001) and positive in the combined rural zones (r bar to second power = 0.502, p<.001). Certain implications are suggested byu the data: 1. Very few food items can be used to construct a food basket which could be monitored once or twice yearly. 1. The urban dwellers consumed more "luxury" items hence more expensive calories than the rural dwellers. 3. Increased income has different effects on calorie consumption depending on income class and geographical location (AU)

Political constraints to nutritional improvement: the case of Guyana.

The processes generating malnutrition are examined with particular reference to Guyana. The theoretical framework includes the concept of limiting factors, which in this case means that the failure to alter a critical variable will prevent nutritional improvement, despite intervention in other variables. Among important factors found to cause malnutrition age low national production, inequitable income distribution, and maladaptive cultural practices. These are located in the economy of the country and in the institutions and ideas which support that economy. Power and politics therefore fundamentally affect nutritional outcome; and imperialist control of underdeveloped economies makes international relations an indispensible consideration. It is concluded that for Guyana the political process is the limiting factor which must be altered before significant nutritional improvement can occur.

The nutritional significance of root and tuber crop development as staples in the Caribbean community.

The competition between cereals and root crops as CARICOM staples is described. The move to substitute locally grown food for imported wheat is shown to favor root crop development in the region. Against this background, traditional nutrition-prompted objections to wheat substitution by root crops are examined. Evidence is cited to show the essential adequacy of protein in root crops, except plantain and cassava and for all humans except perhaps some infants. The low protein in cassava and plantain, it is proposed, can be easily overcome in the process of local root crop development. Finally, it is argued that there exists the potential to obtain cheap calories from root crops. This and the generation of economic activity among small farmers, concomitant with root crop development, are seen as possible indicators of good nutrition for the region in the future.

The nutritional significance of root and tuber crop development as staples in the Caribbean community

The competition between cereals and root crops as CARICOM staples is described. The move to substitute locally grown food for imported wheat is shown to favor root crop development in the region. Against this background, traditional nutrition-promoted objections to wheat substitution by root crops are examined. Evidence is cited to show the essential adequacy of protein in root crops, except platain and cassava and for all humans except perhaps some infants. The low protein in cassava and plantain, it is proposed, can be easily overcome in the process of local root crop development. Finally, it is argued that there exists the potential to obtain cheap calories from root crops. This and the generation of economic activity among small farmers, concomitant with root crop development, are seen as possible indicators of good nutrition for the region in the future