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1.
Pediatrics ; 145(5)2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32295817

RESUMO

BACKGROUND: Medicaid plays a critical role during the perinatal period, but pregnancy-related Medicaid eligibility only extends for 60 days post partum. In 2014, the Affordable Care Act's (ACA's) Medicaid expansions increased adult Medicaid eligibility to 138% of the federal poverty level in participating states, allowing eligible new mothers to remain covered after pregnancy-related coverage expires. We investigate the impact of ACA Medicaid expansions on insurance coverage among new mothers living in poverty. METHODS: We define new mothers living in poverty as women ages 19 to 44 with incomes below the federal poverty level who report giving birth in the past 12 months. We use 2010-2017 American Community Survey data and a difference-in-differences approach using parental Medicaid-eligibility thresholds to estimate the effect of ACA Medicaid expansions on insurance coverage among poor new mothers. RESULTS: A 100-percentage-point increase in parental Medicaid-eligibility is associated with an 8.8-percentage-point decrease (P < .001) in uninsurance, a 13.2-percentage-point increase (P < .001) in Medicaid coverage, and a 4.4-percentage-point decrease in private or other coverage (P = .001) among poor new mothers. The average increase in Medicaid eligibility is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states. However, in 2017, there were ∼142 000 remaining uninsured, poor new mothers. CONCLUSIONS: ACA Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among poor new mothers. Opportunities remain for expansion and nonexpansion states to increase insurance coverage among new mothers living in poverty.


Assuntos
Acesso aos Serviços de Saúde/economia , Cobertura do Seguro/economia , Medicaid/economia , Mães , Patient Protection and Affordable Care Act/economia , Pobreza/economia , Adulto , Feminino , Acesso aos Serviços de Saúde/tendências , Humanos , Lactente , Recém-Nascido , Cobertura do Seguro/tendências , Medicaid/tendências , Patient Protection and Affordable Care Act/tendências , Pobreza/tendências , Estados Unidos/epidemiologia , Adulto Jovem
3.
PLoS Med ; 17(3): e1003054, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32176692

RESUMO

BACKGROUND: Education and health are both constituents of human capital that enable people to earn higher wages and enhance people's capabilities. Human capabilities may lead to fulfilling lives by enabling people to achieve a valuable combination of human functionings-i.e., what people are able to do or be as a result of their capabilities. A better understanding of how these different human capabilities are produced together could point to opportunities to help jointly reduce the wide disparities in health and education across populations. METHODS AND FINDINGS: We use nationally and regionally representative individual-level data from Demographic and Health Surveys (DHS) for 55 low- and middle-income countries (LMICs) to examine patterns in human capabilities at the national and regional levels, between 2000 and 2017 (N = 1,657,194 children under age 5). We graphically analyze human capabilities, separately for each country, and propose a novel child-based Human Development Index (HDI) based on under-five survival, maternal educational attainment, and measures of a child's household wealth. We normalize the range of each component using data on the minimum and maximum values across countries (for national comparisons) or first-level administrative units within countries (for subnational comparisons). The scores that can be generated by the child-based HDI range from 0 to 1. We find considerable heterogeneity in child health across countries as well as within countries. At the national level, the child-based HDI ranged from 0.140 in Niger (with mean across first-level administrative units = 0.277 and standard deviation [SD] 0.114) to 0.755 in Albania (with mean across first-level administrative units = 0.603 and SD 0.089). There are improvements over time overall between the 2000s and 2010s, although this is not the case for all countries included in our study. In Cambodia, Malawi, and Nigeria, for instance, under-five survival improved over time at most levels of maternal education and wealth. In contrast, in the Philippines, we found relatively few changes in under-five survival across the development spectrum and over time. In these countries, the persistent location of geographical areas of poor child health across both the development spectrum and time may indicate within-country poverty traps. Limitations of our study include its descriptive nature, lack of information beyond first- and second-level administrative units, and limited generalizability beyond the countries analyzed. CONCLUSIONS: This study maps patterns and trends in human capabilities and is among the first, to our knowledge, to introduce a child-based HDI at the national and subnational level. Areas of chronic deprivation may indicate within-country poverty traps and require alternative policy approaches to improving child health in low-resource settings.


Assuntos
Desenvolvimento Infantil , Saúde da Criança/tendências , Países em Desenvolvimento , Escolaridade , Disparidades nos Níveis de Saúde , Indicadores Básicos de Saúde , Determinantes Sociais da Saúde/tendências , Fatores Etários , Saúde da Criança/economia , Mortalidade da Criança/tendências , Pré-Escolar , Estudos Transversais , Países em Desenvolvimento/economia , Feminino , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Masculino , Determinação de Necessidades de Cuidados de Saúde/tendências , Pobreza/tendências , Estudos Retrospectivos , Determinantes Sociais da Saúde/economia
4.
Respir Res ; 20(1): 291, 2019 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-31864411

RESUMO

BACKGROUND: Low-resource settings are disproportionally burdened by chronic lung disease due to early childhood disadvantages and indoor/outdoor air pollution. However, data on the socioeconomic impact of respiratory diseases in these settings are largely lacking. Therefore, we aimed to estimate the chronic lung disease-related socioeconomic burden in diverse low-resource settings across the globe. To inform governmental and health policy, we focused on work productivity and activity impairment and its modifiable clinical and environmental risk factors. METHODS: We performed a cross-sectional, observational FRESH AIR study in Uganda, Vietnam, Kyrgyzstan, and Greece. We assessed the chronic lung disease-related socioeconomic burden using validated questionnaires among spirometry-diagnosed COPD and/or asthma patients (total N = 1040). Predictors for a higher burden were studied using multivariable linear regression models including demographics (e.g. age, gender), health parameters (breathlessness, comorbidities), and risk factors for chronic lung disease (smoking, solid fuel use). We applied identical models per country, which we subsequently meta-analyzed. RESULTS: Employed patients reported a median [IQR] overall work impairment due to chronic lung disease of 30% [1.8-51.7] and decreased productivity (presenteeism) of 20.0% [0.0-40.0]. Remarkably, work time missed (absenteeism) was 0.0% [0.0-16.7]. The total population reported 40.0% [20.0-60.0] impairment in daily activities. Breathlessness severity (MRC-scale) (B = 8.92, 95%CI = 7.47-10.36), smoking (B = 5.97, 95%CI = 1.73-10.22), and solid fuel use (B = 3.94, 95%CI = 0.56-7.31) were potentially modifiable risk factors for impairment. CONCLUSIONS: In low-resource settings, chronic lung disease-related absenteeism is relatively low compared to the substantial presenteeism and activity impairment. Possibly, given the lack of social security systems, relatively few people take days off work at the expense of decreased productivity. Breathlessness (MRC-score), smoking, and solid fuel use are potentially modifiable predictors for higher impairment. Results warrant increased awareness, preventive actions and clinical management of lung diseases in low-resource settings from health policymakers and healthcare workers.


Assuntos
Efeitos Psicossociais da Doença , Saúde Global/economia , Recursos em Saúde/economia , Pneumopatias/economia , Pobreza/economia , Classe Social , Adulto , Idoso , Doença Crônica , Estudos Transversais , Feminino , Saúde Global/tendências , Grécia/epidemiologia , Recursos em Saúde/tendências , Humanos , Quirguistão/epidemiologia , Pneumopatias/epidemiologia , Pneumopatias/terapia , Masculino , Pessoa de Meia-Idade , Pobreza/tendências , Uganda/epidemiologia , Vietnã/epidemiologia , Adulto Jovem
5.
Pediatrics ; 144(6)2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31676680

RESUMO

BACKGROUND: Disparities in health service use have been described across a range of sociodemographic factors. Patterns of PICU use have not been thoroughly assessed. METHODS: This was a population-level, retrospective analysis of admissions to the Cincinnati Children's Hospital Medical Center PICU between 2011 and 2016. Residential addresses of patients were geocoded and spatially joined to census tracts. Pediatric patients were eligible for inclusion if they resided within Hamilton County, Ohio. PICU admission and bed-day rates were calculated by using numerators of admissions and bed days, respectively, over a denominator of tract child population. Relationships between tract-level PICU use and child poverty were assessed by using Spearman's ρ and analysis of variance. Analyses were event based; children admitted multiple times were counted as discrete admissions. RESULTS: There were 4071 included admissions involving 3129 unique children contributing a total of 12 297 PICU bed days. Child poverty was positively associated with PICU admission rates (r = 0.59; P < .001) and bed-day rates (r = 0.47; P < .001). When tracts were grouped into quintiles based on child poverty rates, the PICU bed-day rate ranged from 23.4 days per 1000 children in the lowest poverty quintile to 81.9 days in the highest poverty quintile (P < .001). CONCLUSIONS: The association between poverty and poor health outcomes includes pediatric intensive care use. This association exists for children who grow up in poverty and around poverty. Future efforts should characterize the interplay between patient- and neighborhood-level risk factors and explore neighborhood-level interventions to improve child health.


Assuntos
Disparidades em Assistência à Saúde/economia , Unidades de Terapia Intensiva Pediátrica/economia , Admissão do Paciente/economia , Pobreza/economia , Características de Residência , Criança , Pré-Escolar , Feminino , Disparidades em Assistência à Saúde/tendências , Humanos , Unidades de Terapia Intensiva Pediátrica/tendências , Masculino , Ohio/epidemiologia , Admissão do Paciente/tendências , Pobreza/tendências , Estudos Retrospectivos
6.
Pediatrics ; 144(6)2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31748253

RESUMO

BACKGROUND: Prenatal and infancy home-visiting by nurses is promoted as a means of improving maternal life-course, but evidence of long-term effects is limited. We hypothesized that nurse-visitation would lead to long-term reductions in public-benefit costs, maternal substance abuse and depression, and that cost-savings would be greater for mothers with initially higher psychological resources. METHODS: We conducted an 18-year follow-up of 618 out of 742 low-income, primarily African-American mothers with no previous live births enrolled in an randomized clinical trial of prenatal and infancy home visiting by nurses. We compared nurse-visited and control-group women for public-benefit costs, rates of substance abuse and depression, and examined possible mediators of intervention effects. RESULTS: Nurse-visited women, compared with controls, incurred $17 310 less in public benefit costs (P = .03), an effect more pronounced for women with higher psychological resources ($28 847, P = .01). These savings compare with program costs of $12 578. There were no program effects on substance abuseor depression. Nurse-visited women were more likely to be married from child age 2 through 18 (19.2% vs 14.8%, P = .04), and those with higher psychological resources had 4.64 fewer cumulative years rearing subsequent children after the birth of the first child (P = .03). Pregnancy planning was a significant mediator of program effects on public benefit costs. CONCLUSIONS: Through child age 18, the program reduced public-benefit costs, an effect more pronounced for mothers with higher psychological resources and mediated by subsequent pregnancy planning. There were no effects on maternal substance abuse and depression.


Assuntos
Serviços de Assistência Domiciliar/tendências , Visita Domiciliar/tendências , Saúde Materna/tendências , Mães , Enfermeiros de Saúde Comunitária/tendências , Cuidado Pré-Natal/tendências , Adulto , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Mães/psicologia , Pobreza/tendências , Gravidez , Cuidado Pré-Natal/métodos , Cuidado Pré-Natal/psicologia , Fatores de Tempo
7.
Pediatrics ; 144(6)2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31748254

RESUMO

OBJECTIVES: Given earlier effects found in randomized clinical trials of the Nurse-Family Partnership, we examined whether this program would improve 18-year-old first-born youths' cognition, academic achievement, and behavior and whether effects on cognitive-related outcomes would be greater for youth born to mothers with limited psychological resources (LPR) and on arrests and convictions among females. METHODS: We enrolled 742 pregnant, low-income women with no previous live births and randomly assigned them to receive either free transportation for prenatal care plus child development screening and referral (control; n = 514) or prenatal and infant home nurse visit (NV) plus transportation and screening (n = 228). Assessments were completed on 629 18-year-old first-born offspring to evaluate these primary outcomes: (1) cognitive-related abilities (nonverbal intelligence, receptive language, and math achievement) and (2) behavioral health (internalizing behavioral problems, substance use and abuse, sexually transmitted infections, HIV risk, arrests, convictions, and gang membership). RESULTS: Compared with control-group counterparts, NV youth born to mothers with LPR had better receptive language (effect size = 0.24; 95% confidence interval [CI]: 0.00 to 0.47; P = .05), math achievement (effect size = 0.38; 95% CI: 0.14 to 0.61; P = .002), and a number of secondary cognitive-related outcomes. NV females, as a trend, had fewer convictions (incidence ratio = 0.47; 95% CI: 0.20 to 1.11; P = .08). There were no intervention effects on other behaviors. CONCLUSIONS: The program improved the cognitive-related skills of 18-year-olds born to mothers with LPR and, as a trend, reduced female convictions but produced no other effects on youth behavioral health.


Assuntos
Cognição/fisiologia , Comportamentos de Risco à Saúde/fisiologia , Serviços de Assistência Domiciliar/tendências , Visita Domiciliar/tendências , Enfermeiros de Saúde Comunitária/tendências , Cuidado Pré-Natal/tendências , Adolescente , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Pobreza/tendências , Gravidez , Cuidado Pré-Natal/métodos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
8.
Psychiatry Res ; 280: 112525, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31445423

RESUMO

Acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) are developed from exposure to traumatic events including war, interpersonal violence and natural disasters. We investigated prevalence and trauma-related information in patients from an outpatient psychiatric unit in Brazil among 2014-2017. A prevalence of ASD/PTSD of 40.8% was found in 179 patients. Female, Caucasian, married, mostly educated during 10-12 years long and employed patients composed a main profile. The presence of any previous trauma in adulthood and childhood were related to ASD/PTSD with longer follow-up time. This study provides evidence of stress-related disorders in a heterogeneous environment.


Assuntos
Ambulatório Hospitalar/economia , Pobreza/economia , Transtornos de Estresse Pós-Traumáticos/economia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Traumático Agudo/economia , Transtornos de Estresse Traumático Agudo/epidemiologia , Adulto , Brasil/epidemiologia , Feminino , Seguimentos , Humanos , Renda/tendências , Masculino , Pessoa de Meia-Idade , Ambulatório Hospitalar/tendências , Pacientes Ambulatoriais/psicologia , Pobreza/psicologia , Pobreza/tendências , Prevalência , Transtornos de Estresse Pós-Traumáticos/psicologia , Transtornos de Estresse Traumático Agudo/psicologia , Fatores de Tempo , Violência/economia , Violência/psicologia , Violência/tendências
9.
Pediatrics ; 144(2)2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31292218

RESUMO

BACKGROUND AND OBJECTIVE: Children with special health care needs (SHCNs) have significant medical and educational expenses affecting household finances. Housing instability can be detrimental to family well-being. Our objective was to evaluate housing instability in households of children with and without SHCNs. METHODS: Cross-sectional surveys (2013-2017) in English and Spanish of caregivers with children <4 years old were conducted at 5 hospitals. The children with SHCN screener and caregiver report of child Supplemental Security Income (SSI) receipt were used to categorize children into the following groups: (1) no SHCNs, (2) SHCNs and no SSI, or (3) SHCNs and receiving SSI. Housing instability was determined by positive endorsement of ≥1 adverse circumstance: behind on rent or mortgage, or moving twice or more in the past year, or homelessness in the child's lifetime. Analyses used multivariable logistic regression models, adjusting for demographics and housing subsidies. RESULTS: Of 14 188 children, 80% had no SHCNs, 16% had SHCNs and no SSI, and 4% had SHCNs and received SSI. Compared with the no-SHCNs group, the SHCNs-no-SSI group but not the SHCN-receiving-SSI group experienced significantly greater adjusted odds of being behind on rent or mortgage (adjusted odds ratio [aOR] 1.28 [95% confidence interval (CI) 1.14-1.44]; P < .001), multiple moves (aOR 1.29 [95% CI 1.05-1.59]; P = .01), and homelessness (aOR 1.44 [95% CI 1.20-1.72]; P < .001). CONCLUSIONS: Families of children with SHCNs are at risk for housing instability. Child SSI receipt decreased the risk of housing instability among families of children with SHCNs. Protecting families of young children with SHCNs from housing instability is an important investment.


Assuntos
Necessidades e Demandas de Serviços de Saúde/tendências , Serviços de Saúde para Pessoas com Deficiência/tendências , Habitação , Pobreza/tendências , Pré-Escolar , Estudos Transversais , Feminino , Necessidades e Demandas de Serviços de Saúde/economia , Serviços de Saúde para Pessoas com Deficiência/economia , Habitação/economia , Humanos , Renda/tendências , Lactente , Masculino , Pobreza/economia
10.
World Neurosurg ; 130: e822-e830, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31295603

RESUMO

OBJECTIVE: In 2015, the Lancet Commission on Global Surgery highlighted the disparities in surgical care worldwide. The aim of the present study was to investigate the research productivity of low-income countries (LICs) and low- to middle-income countries (LMICs) in selected journals representing the worldwide neurosurgical data and their ability to report and communicate globally the existing differences between high-income countries (HICs) and LMICs. METHODS: We performed a retrospective bibliometric analysis using PubMed and Scopus databases to record all the reports from 2015 to 2017 by investigators affiliated with neurosurgical departments in LICs and LMICs. RESULTS: A total of 8459 reports by investigators self-identified as members of neurosurgery departments worldwide were identified. Of these, 6708 reports were included in accordance with our method in the final analysis. The systematic search resulted in 459 studies reported by LICs and LMICs. Of these, 334 reports were included for the full text evaluation. Of the 6708 reports, 303 (4.52%) had been reported with an LMIC affiliation and only 31 (0.46%) with an LIC. The leading countries were India with 182 (54.5% among LMICs and LICs; 2.71% overall), followed by Egypt at 66 (19.76% among the LMICs and LICs; 0.98% overall), with a large difference compared with other countries such as Uganda at 9 (2.69% among the LMICs and LICs) and Tunisia and Pakistan at 8 each (2.4% among the LMICs and LICs). A few reports studies had been generated by collaboration with HIC neurosurgeons. CONCLUSIONS: Our results have shown that research studies from LMICs are underrepresented. Understanding and discussing the reasons for this underrepresentation are necessary to start addressing the disparities in neurosurgical research and care capacity. Future engagements from international journals, more partnership collaboration from HICs, and tailored funding to support investigators, collaborations, and networks could be of help.


Assuntos
Bibliometria , Análise de Dados , Países em Desenvolvimento/economia , Procedimentos Neurocirúrgicos/economia , Pobreza/economia , Relatório de Pesquisa , Humanos , Procedimentos Neurocirúrgicos/tendências , Pobreza/tendências , Relatório de Pesquisa/tendências , Estudos Retrospectivos
11.
Am J Public Health ; 109(7): 1015-1021, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31095413

RESUMO

Objectives. To explore the effect of the Affordable Care Act (ACA) on disparities in access to health care based on disability status, as well as age, income, race, and ethnicity. Methods. In this study, I used logistic regression to analyze nationally representative data from 128 000 respondents to the US National Health Interview Survey from 2008 to 2010 and 2015 to 2017. Outcome variables were uninsurance over the previous 12 months, delayed or forgone health care for reasons of cost, and having a regular provider at a doctor's office or health clinic. Results. Over the period when the ACA was implemented, large existing disparities in access to health care were reduced for people with certain types of disabilities, young adults aged 19 to 25 years, and low-income families. Conclusions. The ACA improved overall access to health care and reduced some disparities, but substantial disparities persist. Disability status remains associated with much greater risk of delayed or forgone care, and mental health disability is associated with greater likelihood of uninsurance. Public Health Implications. The ACA partially achieved its goals and must not be weakened or rolled back. Further policy efforts are needed to address the remaining disparities.


Assuntos
Pessoas com Deficiência/estatística & dados numéricos , Disparidades em Assistência à Saúde/tendências , Cobertura do Seguro/tendências , Patient Protection and Affordable Care Act , Feminino , Acesso aos Serviços de Saúde/tendências , Humanos , Masculino , Visita a Consultório Médico/tendências , Pobreza/tendências , Estados Unidos
12.
Pediatrics ; 143(6)2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31088893

RESUMO

BACKGROUND AND OBJECTIVES: Pregnancy, infancy, and toddlerhood are sensitive times in which families are particularly vulnerable to household food insecurity and when disparities in child obesity emerge. Understanding obesity-promoting infant-feeding beliefs, styles, and practices in the context of food insecurity could better inform both food insecurity and child obesity prevention interventions and policy guidelines. METHODS: We performed purposive sampling of low-income Hispanic mothers (n = 100) with infants in the first 2 years of life, all of whom were participants in a randomized controlled trial of an early child obesity prevention intervention called the Starting Early Program. Bilingual English-Spanish interviewers conducted semistructured qualitative interviews, which were audio recorded, transcribed, and translated. By using the constant comparative method, transcripts were coded through an iterative process of textual analysis until thematic saturation was reached. RESULTS: Three key themes emerged: (1) contributors to financial strain included difficulty meeting basic needs, job instability, and high vulnerability specific to pregnancy, infancy, and immigration status; (2) effects on infant feeding included decreased breastfeeding due to perceived poor maternal diet, high stress, and limiting of healthy foods; and (3) coping strategies included both home- and community-level strategies. CONCLUSIONS: Stakeholders in programs and policies to prevent poverty-related disparities in child obesity should consider and address the broader context by which food insecurity is associated with contributing beliefs, styles, and practices. Potential strategies include addressing misconceptions about maternal diet and breast milk adequacy, stress management, building social support networks, and connecting to supplemental nutrition assistance programs.


Assuntos
Aleitamento Materno/economia , Abastecimento de Alimentos/economia , Hispano-Americanos , Mães , Obesidade Pediátrica/economia , Pobreza/economia , Adulto , Aleitamento Materno/tendências , Pré-Escolar , Feminino , Hospitais Públicos/economia , Hospitais Públicos/tendências , Humanos , Lactente , Masculino , Obesidade Pediátrica/epidemiologia , Obesidade Pediátrica/prevenção & controle , Pobreza/tendências , Gravidez
13.
Matern Child Health J ; 23(8): 1048-1070, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30915627

RESUMO

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36-55%), 24% (95% CI 17-32%), and 1.4% (95% CI 1.2-1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.


Assuntos
Episiotomia/normas , Parto , Períneo/lesões , Pobreza/tendências , Ferimentos e Lesões/etiologia , Adulto , Parto Obstétrico/métodos , Parto Obstétrico/normas , Países em Desenvolvimento , Episiotomia/métodos , Episiotomia/tendências , Feminino , Humanos , Períneo/cirurgia , Gravidez , Fatores de Risco , Ferimentos e Lesões/complicações , Ferimentos e Lesões/cirurgia
14.
PLoS Med ; 16(3): e1002775, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30925157

RESUMO

BACKGROUND: In 2015, approximately 42,000 women died as a result of hypertensive disorders of pregnancy worldwide; over 99% of these deaths occurred in low- and middle-income countries. The aim of this paper is to describe the incidence and characteristics of eclampsia and related complications from hypertensive disorders of pregnancy across 10 low- and middle-income geographical regions in 8 countries, in relation to magnesium sulfate availability. METHODS AND FINDINGS: This is a secondary analysis of a stepped-wedge cluster randomised controlled trial undertaken in sub-Saharan Africa, India, and Haiti. This trial implemented a novel vital sign device and training package in routine maternity care with the aim of reducing a composite outcome of maternal mortality and morbidity. Institutional-level consent was obtained, and all women presenting for maternity care were eligible for inclusion. Data on eclampsia, stroke, admission to intensive care with a hypertensive disorder of pregnancy, and maternal death from a hypertensive disorder of pregnancy were prospectively collected from routine data sources and active case finding, together with data on perinatal outcomes in women with these outcomes. In 536,233 deliveries between 1 April 2016 and 30 November 2017, there were 2,692 women with eclampsia (0.5%). In total 6.9% (n = 186; 3.47/10,000 deliveries) of women with eclampsia died, and a further 51 died from other complications of hypertensive disorders of pregnancy (0.95/10,000). After planned adjustments, the implementation of the CRADLE intervention was not associated with any significant change in the rates of eclampsia, stroke, or maternal death or intensive care admission with a hypertensive disorder of pregnancy. Nearly 1 in 5 (17.9%) women with eclampsia, stroke, or a hypertensive disorder of pregnancy causing intensive care admission or maternal death experienced a stillbirth or neonatal death. A third of eclampsia cases (33.2%; n = 894) occurred in women under 20 years of age, 60.0% in women aged 20-34 years (n = 1,616), and 6.8% (n = 182) in women aged 35 years or over. Rates of eclampsia varied approximately 7-fold between sites (range 19.6/10,000 in Zambia Centre 1 to 142.0/10,000 in Sierra Leone). Over half (55.1%) of first eclamptic fits occurred in a health-care facility, with the remainder in the community. Place of first fit varied substantially between sites (from 5.9% in the central referral facility in Sierra Leone to 85% in Uganda Centre 2). On average, magnesium sulfate was available in 74.7% of facilities (range 25% in Haiti to 100% in Sierra Leone and Zimbabwe). There was no detectable association between magnesium sulfate availability and the rate of eclampsia across sites (p = 0.12). This analysis may have been influenced by the selection of predominantly urban and peri-urban settings, and by collection of only monthly data on availability of magnesium sulfate, and is limited by the lack of demographic data in the population of women delivering in the trial areas. CONCLUSIONS: The large variation in eclampsia and maternal and neonatal fatality from hypertensive disorders of pregnancy between countries emphasises that inequality and inequity persist in healthcare for women with hypertensive disorders of pregnancy. Alongside the growing interest in improving community detection and health education for these disorders, efforts to improve quality of care within healthcare facilities are key. Strategies to prevent eclampsia should be informed by local data. TRIAL REGISTRATION: ISRCTN: 41244132.


Assuntos
Eclampsia/economia , Eclampsia/epidemiologia , Pobreza/tendências , Adolescente , Adulto , África ao Sul do Saara/epidemiologia , Análise por Conglomerados , Eclampsia/diagnóstico , Feminino , Haiti/epidemiologia , Humanos , Incidência , Índia/epidemiologia , Gravidez , Estudos Prospectivos , Adulto Jovem
15.
Psychiatry Res ; 279: 172-179, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30922607

RESUMO

The interplay between objective and subjective measures of economic hardship on influencing mental health has not been explored during a period of enduring recession. The present study aims to fill this gap by investigating the relationship between income and economic difficulties in evoking major depression and suicidality in Greece, while taking into consideration gender differences. A random and representative sample of 2188 adults participated in a telephone survey in 2013 (response rate = 81%). Major depression and suicidality were assessed with the pertinent modules of SCID-IV; while financial difficulties were measured by the Index of Personal Economic Distress. Information on confounder variables was also gleaned. Income exerted an independent effect on major depression (OR = 0.37, 95%CI = 0.22-0.63), which was more pronounced among men than women. On the contrary, financial difficulties exerted a strong and independent effect on depression (OR = 1.16, 95%CI = 1.13-1.2). Income was found to bear a strong association with suicidality only among men; whereas financial difficulties were unrelated in both genders. Subjective and objective indices of economic hardship exert a differential impact on mental health outcomes amid recession. Gender-sensitive policies and interventions should be geared towards softening the social effects of the recession in the country.


Assuntos
Transtorno Depressivo Maior/economia , Transtorno Depressivo Maior/psicologia , Recessão Econômica/tendências , Ideação Suicida , Suicídio/economia , Suicídio/psicologia , Adulto , Estudos Transversais , Transtorno Depressivo Maior/epidemiologia , Feminino , Grécia/epidemiologia , Humanos , Renda/tendências , Masculino , Pessoa de Meia-Idade , Pobreza/economia , Pobreza/psicologia , Pobreza/tendências , Suicídio/tendências , Adulto Jovem
16.
PLoS Med ; 16(3): e1002751, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30822339

RESUMO

BACKGROUND: The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach. METHODS AND FINDINGS: We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given ("treated"), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%-9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%-5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%-78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys. CONCLUSIONS: The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured.


Assuntos
Assistência à Saúde/economia , Diabetes Mellitus/economia , Diabetes Mellitus/epidemiologia , Necessidades e Demandas de Serviços de Saúde/economia , Inquéritos Epidemiológicos/economia , Pobreza/economia , Adolescente , Adulto , Estudos Transversais , Assistência à Saúde/tendências , Diabetes Mellitus/terapia , Feminino , Necessidades e Demandas de Serviços de Saúde/tendências , Inquéritos Epidemiológicos/tendências , Humanos , Renda/tendências , Masculino , Pessoa de Meia-Idade , Pobreza/tendências , Adulto Jovem
17.
Compr Psychiatry ; 90: 52-64, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30711814

RESUMO

In the United States, over 40% of youth under the age of 18 live at or near the federal poverty line. Several decades of research have established clear links between exposure to child poverty and the development of psychopathology, yet the mechanisms that convey this risk remain unclear. We review research in developmental science and other allied disciplines that identify self-regulation as a critical factor that may influence the development of psychopathology after exposure to poverty. We then connect this work with neurobiological research in an effort to further inform these associations. We propose a starting framework focused on the neural correlates of self-regulation, and discuss recent work relating poverty to alterations in brain regions related to self-regulation. We close this review by highlighting important considerations for future research on poverty/socioeconomic status, neurobiology, self-regulation, and the risks related to the development of negative mental health outcomes.


Assuntos
Encéfalo/diagnóstico por imagem , Pobreza/economia , Pobreza/psicologia , Autocontrole/psicologia , Criança , Pré-Escolar , Família/psicologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Neurobiologia , Pobreza/tendências , Psicopatologia , Fatores de Risco , Classe Social , Estados Unidos/epidemiologia
18.
Clin Pharmacol Ther ; 105(6): 1378-1385, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30771252

RESUMO

Despite recent advances in recognizing and reducing the risk of drug-drug interactions (DDIs) in developed countries, there are still significant challenges in managing DDIs in low-income countries (LICs) worldwide. In the treatment of major infectious diseases in these regions, multiple factors contribute to ineffective management of DDIs that lead to loss of efficacy or increased risk of adverse events to patients. Some of these difficulties, however, can be overcome. This review aims to evaluate the inherent complexities of DDI management in LICs from pharmacological standpoints and illustrate the unique barriers to effective management of DDIs, such as the challenges of co-infection and treatment settings. A better understanding of comprehensive drug-related properties, population-specific attributes, such as physiological changes associated with infectious diseases, and the use of modeling and simulation techniques are discussed, as they can facilitate the implementation of optimal treatments for infectious diseases at the individual patient level.


Assuntos
Anti-Infecciosos/uso terapêutico , Doenças Transmissíveis/tratamento farmacológico , Doenças Transmissíveis/economia , Interações Medicamentosas/fisiologia , Pobreza/economia , Anti-Infecciosos/economia , Anti-Infecciosos/metabolismo , Antituberculosos/economia , Antituberculosos/metabolismo , Antituberculosos/uso terapêutico , Doenças Transmissíveis/metabolismo , Humanos , Pobreza/tendências , Resultado do Tratamento , Tuberculose/tratamento farmacológico , Tuberculose/economia , Tuberculose/metabolismo
19.
BMC Geriatr ; 19(1): 4, 2019 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-30616586

RESUMO

BACKGROUND: Socioeconomic level of residential environment was found to influence cognitive performance. However, individuals from the same place of residence may be affected differently. We aim to investigate for the first time the influence of individual activity space on the association between neighborhood socioeconomic status (NSES) and the risk of dementia. METHODS: In the frame of the Three-City cohort, a French population-based study, we followed longitudinally (12 years) 7009 participants aged over 65. The activity space (i.e., the spatial area through which a person moves daily) was defined using two questions from Lawton's Instrumental Activities of Daily Living scale ("Goes shopping independently","Travels alone"), and one question about mobility restriction. The survival analysis was performed using a Cox marginal model that takes into account intra-neighborhood correlations and includes a large number of potential confounders. RESULTS: Among people with a limited activity space (n = 772, 11%), risk of dementia is increased in subjects living in a deprived area (characterized by high GINI index or low median income) compared to those living in more favored. CONCLUSION: This study shows that the individual activity space modifies the association between NSES and the risk of dementia providing a more complete picture of residential inequalities. If confirmed in different populations, these findings suggest that people with limited activity space and living in a deprived neighborhood are particularly at risk and should be targeted for prevention.


Assuntos
Atividades Cotidianas , Demência/epidemiologia , Planejamento Ambiental , Características de Residência , Classe Social , Meio Social , Atividades Cotidianas/psicologia , Idoso , Idoso de 80 Anos ou mais , Cidades/epidemiologia , Estudos de Coortes , Demência/economia , Demência/psicologia , Planejamento Ambiental/economia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pobreza/economia , Pobreza/tendências , Fatores de Risco , Fatores Socioeconômicos
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