Getting ready for reduced donor dependency: the co-financing of family planning commodities.

Family planning (FP) programmes in low and lower-middle income countries are confronting the dual impact of reduced external donor commitments and stagnant or reduced domestic financing, worsened by economic consequences of the COVID-19 pandemic. Co-financing-a donor-government agreement to jointly fund aspects of a programme, with transition towards the government assuming increasing responsibility for total cost-can be a powerful tool to help build national ownership, fiscal sustainability and programme visibility. Using Gavi's successful co-financing model as reference, the current paper draws out a set of key considerations for developing policies on co-financing of FP commodities in resource-poor settings. Macroeconomic and contextual sensitivities must be incorporated while classifying countries and determining co-financing obligations-using the actual GNI per capita on a scale or sovereign credit ratings, in conjunction with programmatic indicators, may be preferred. It is also important for policies to allow sufficiently long time for countries to transition-dependent on the country context, may be up to 10 years as allowed under the US Agency for International Development FP graduation policy and flexibility to revisit the terms following externalities that can influence the fiscal space for health. Incentivizing new domestic financing to pay for co-financing dues is critical, so as not to displace government funding from related health or social sector programs. Pragmatic ways to ensure country compliance can include engaging both the ministries of health and finance as co-signatories to identify and address known administrative and fiscal challenges; establishing dedicated co-financing account with the finance ministry; and instituting a mutual monitoring mechanism. Lastly, the overall process of policymaking can benefit from an alignment of goals and interests of the key development partners.

Collectively achieving primary health care and educational goals through school-based platforms: financing solutions for intersectoral collaboration.

Despite abundant evidence demonstrating that improvements to health and education are positively correlated, and the importance of school-based platforms to achieve shared impacts, collaboration between ministries of health and education remains limited across low- and middle-income countries. Enhancing this collaboration is essential to realize mutually beneficial results, especially following the COVID-19 pandemic, which severely impacted health and education outcomes globally and highlighted the importance of resilient, domestically funded systems for delivering key social services including primary health care and education. We argue that the lack of an effective joint financing mechanism has hindered adoption of collaborative multisectoral approaches such as the WHO/UNESCO's Health Promoting Schools (HPS) model. HPS is well-positioned to organize, finance, and deliver primary health care and education services through a school-based platform and strategy. Case studies from several low- and middle-income countries highlight the need to expand limited inter-ministerial collaborations to achieve cross-sectoral benefits and ensure sustainability of HPS beyond the lifecycle of external partners' support. It is important to identify ways to widen the resource envelope for sector-specific activities and create efficiencies through mutually beneficial outcomes. This paper offers two pragmatic solutions: an inter-ministerial joint financing mechanism that starts with alignment of budgets but matures into a formal system for pooling funds, or a fixed-term co-financing mechanism that uses donor contributions to catalyze inter-ministerial collaborations. Achieving sustainability in these initiatives would require engaging the ministries of health, education, and finance; developing a common administrative, financial, and monitoring mechanism; and securing long-term commitment from all concerned stakeholders.

Increasing incidence of IV-drug use associated endocarditis in southern West Virginia and potential economic impact.

BACKGROUND: The opioid crisis has disproportionally affected Appalachia. One of the potentially lethal and costly complications associated with IV drug use is infective endocarditis (IE). The goal of this study was to assess the trend and costs of substance abuse associated IE admissions in Southern West Virginia. METHODS: This is a retrospective analysis of cost, incidence, and geographic patterns of all patients admitted over the last decade with concomitant drug abuse (cocaine, amphetamine, sedative, and other/mixed drug abuse) and IE in the largest tertiary care center for Southern West Virginia. A time series model was used to investigate the effect of drug use on the incidence of IE. RESULTS: A total of 462 patients were hospitalized with IE and concomitant illicit drug use. IE cases increased from 26 admissions in 2008 to 66 in 2015. Patterns of increases in mixed drug use (DRG most often associated with IV drug use in our center) mirrored increases in IE (P = 0.001). From 2008 to 2015, the total hospital charges were $17 306 464 on 462 cases of illicit drug associated IE. Only a fraction of the billed fees (22%) was collected ($3 829 701). CONCLUSIONS: The number of patients hospitalized with IE has dramatically increased over the last decade in a pattern that mirrors the increase in mixed drug use. The majority of payers were from underfunded state programs or private pay and thus, only 22% of the hospital charges were paid, leaving a hospital deficit of over $13 476 763 during the study period.

Integrating emergency risk communication (ERC) into the public health system response: Systematic review of literature to aid formulation of the 2017 WHO Guideline for ERC policy and practice.

The World Health Organization (WHO) commissioned a systematic review of literature to facilitate evidence syntheses for the development of emergency risk communication (ERC) guidelines for its member states. The goal of this review was to integrate ERC best practices into governmental and non-governmental health systems for all emergencies of public health concern, by addressing three questions: (1) to identify best practices for the integration of ERC into national and international public health preparedness; (2) to identify mechanisms to establish effective intra-agency, inter-agency, and/or cross-jurisdictional information sharing; and (3) to identify methods to coordinate risk communication activities between responding agencies across organizations and levels of response. The review covered scientific and grey literature publications between January 2003 and February 2016, and searches were conducted in 17 English language electronic libraries besides Chinese, Portuguese and Spanish language databases. A mixed deductive-inductive process was used to synthesize findings across studies through identifying thematic areas. While 8,215 articles were initially retrieved, after a sequential screening process, the final evidence syntheses comprised of 21 articles for question (1) and 24 for questions (2) and (3) combined (due to overlap of themes). The confidence in findings was assessed by the Qualitative Evidence Syntheses (GRADE-CERQual) tool. PRISMA guidelines were followed to the extent possible given the limitations inherent to a review largely based on qualitative studies. The identified literature was very context-specific and referred to mechanisms, practices from the field, and recommendations that were derived from planning or response efforts implemented at the national or local levels in specific countries. Integration of ERC functions into public health emergency preparedness, planning and response activities was influenced by reforming components of the leadership structure when needed, modifying organizational factors, and nullifying restrictions (including amending laws/ regulations) that might have been an obstacle to the timely release of information. Exercises and trainings were recognized as effective strategies to identify the barriers and successes in this process of integration. Key elements to enhance information sharing and coordination across organizations included the creation of networks, task-forces and committees across disciplines, organizations and geographic areas. Engagement of local stakeholders was also important to guarantee the flow of information up and down the incident command system. On the whole, few empirical studies, especially from low- and middle-income countries, related to the WHO research questions, demonstrating the need for research in these areas. To facilitate an accurate identification of the gaps, the authors suggest integrating current findings with case studies across the WHO regions to better understand the specific evidence that is needed in practice across the multitude of ERC functions.

Personal vis-a-vis social responsibility for disparities in health status: An issue of justice.

Health inequities are disparities which can be avoided through rational actions on the part of policymakers. Such inequalities are unnecessary and unjust and may exist between and within nations, societies, and population groups. Social determinants such as wealth, income, occupation, education, gender, and racial/ethnic groups are the principal drivers of this inequality since they determine the health risks and preventive behaviors, access to, and affordability of health care. Within this framework, there is a debate on assigning a personal responsibility factor over and above societal responsibility to issues of ill health. One school of philosophy argues that when individuals are worse-off than others for no fault of their own, it is unjust, as opposed to health disparities that arise due to avoidable personal choices such as smoking and drug addiction for which there should (can) be a personal responsibility. Opposing thoughts have pointed out that the relative socioeconomic position of an individual dictates how his/her life may progress from education to working conditions and aging, susceptibility to diseases and infirmity, and the consequences thereof. The existence of a social gradient in health outcomes across populations throughout the world is a testimony to this truth. It has been emphasized that assuming personal responsibility for health in public policy-making can only have a peripheral place. Instead, the concept of individual responsibility should be promoted as a positive concept of enabling people to gain control over the determinants of health through conscious, informed, and healthy choices.

Observational studies and the difficult quest for causality: lessons from vaccine effectiveness and impact studies.

Although randomized placebo-controlled trials (RCT) are critical to establish efficacy of vaccines at the time of licensure, important remaining questions about vaccine effectiveness (VE)-used here to include individual-level measures and population-wide impact of vaccine programmes-can only be answered once the vaccine is in use, from observational studies. However, such studies are inherently at risk for bias. Using a causal framework and illustrating with examples, we review newer approaches to detecting and avoiding confounding and selection bias in three major classes of observational study design: cohort, case-control and ecological studies. Studies of influenza VE, especially in seniors, are an excellent demonstration of the challenges of detecting and reducing such bias, and so we use influenza VE as a running example. We take a fresh look at the time-trend studies often dismissed as 'ecological'. Such designs are the only observational study design that can measure the overall effect of a vaccination programme [indirect (herd) as well as direct effects], and are in fact already an important part of the evidence base for several vaccines currently in use. Despite the great strides towards more robust observational study designs, challenges lie ahead for evaluating best practices for achieving robust unbiased results from observational studies. This is critical for evaluation of national and global vaccine programme effectiveness.

Synbiotics for Prevention and Treatment of Atopic Dermatitis: A Meta-analysis of Randomized Clinical Trials.

IMPORTANCE: Atopic dermatitis (AD) is a highly prevalent condition that may be associated with an altered gastrointestinal microbiota that promotes an immune environment more susceptible to allergic disease. Synbiotics, a mixture of prebiotics and probiotics, have been used for the prevention and treatment of AD. OBJECTIVE: To investigate the efficacy of synbiotics for primary prevention and treatment of AD. DATA SOURCES: PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the CAB Abstracts Archive searchable database were searched from the inception of all databases to October 15, 2015, with no language restrictions. STUDY SELECTION: We included all published randomized clinical trials of synbiotics for prevention and/or treatment of AD. To be included, a publication needed to clearly define the intervention as oral administration of synbiotics (combination of probiotics and prebiotics) and must have included an assessment of AD disease severity, such as the Severity Scoring of Atopic Dermatitis (SCORAD) index, or the incidence of AD as an outcome measure. Only 8 of 257 initially identified studies (3%) met selection criteria. DATA EXTRACTION AND SYNTHESIS: Data extraction was independently done by multiple observers and cross-checked to avoid errors. The quality of the selected studies was critically examined following the Cochrane guidelines. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES: The primary outcomes were the SCORAD index (treatment studies) and the relative risk of AD (prevention studies). The hypothesis was formulated before data collection. RESULTS: A total of 257 abstracts were screened to identify 6 treatment studies (369 children enrolled; aged 0 months to 14 years) and 2 prevention studies (1320 children enrolled; up to age 6 months in one study and term neonates aged <3 days in the other). From the 6 treatment studies included for random-effects meta-analysis, the overall pooled change in SCORAD index in those treated with synbiotics at 8 weeks of treatment was -6.56 (95% CI, -11.43 to -1.68; P = .008). Heterogeneity was significant (I(2) = 77.1%; P = .001). Subgroup analysis showed that the beneficial effect was significant only when using mixed strains of bacteria (weighted mean difference, -7.32; 95% CI, -13.98 to -0.66; P = .03) and when used in children aged 1 year or older (weighted mean difference, -7.37; 95% CI, -14.66 to -0.07; P = .048). From the 2 prevention studies included, the pooled relative risk ratio of AD in those treated with synbiotics compared with placebo was 0.44 (95% CI, 0.11 to 1.83; P = .26). CONCLUSIONS AND RELEVANCE: This meta-analysis shows evidence that supports the use of synbiotics for the treatment of AD, particularly synbiotics with mixed strains of bacteria and for children aged 1 year or older. Further studies are needed to evaluate the effectiveness of synbiotics for primary prevention of AD.

Studying Policy Changes in Disaster Management in India: A Tale of Two Cyclones.

OBJECTIVE: The mainstay of India's disaster management policy until the early 2000s had been relief and rescue operations. The Odisha Super Cyclone (1999) with 10,000 deaths and US $3 billion economic damage provided a rude awakening. Recognizing the importance of preemptive preparedness, the government initiated systematic steps to implement a national framework interlinking economic, environmental, and overall developmental issues for efficient response to and mitigation of disasters. METHODS: We attempted a critical analysis of this paradigm shift in India's disaster management policy through the prism of 2 cyclones, 14 years apart in time. RESULTS: With improved preparedness and response measures, the death toll in 2013 Cyclone Phailin was 0.5% and the economic loss was about one-third of that during 1999. Concomitant improvements in the technological expertise of the early warning system, an integrated approach at all levels of administration including joint planning with major nongovernmental organizations, and improved community participation were identified as game-changers. An unbelievable 1 million people were evacuated to safety. CONCLUSIONS: Our essay aims to highlight key steps in this success and calls for futuristic approaches like insurance programs and gender-sensitive recovery plans. With thorough scrutiny, India's model may well stand to be replicated in resource-restricted settings.

The Use of Social Media by State Health Departments in the US: Analyzing Health Communication Through Facebook.

The use of social media as a powerful health communication tool is an area of current research interest. Our objective was to describe use of Facebook by State Health Departments (SHDs) in US, and their relationship with CDC's Behavioral Risk Factor Surveillance System (BRFSS) data. Facebook pages of 34 SHDs were studied over a 200 day period, coding 2597 posts into 19 broad health communication categories. Mean number of Facebook posts per SHD was 76.4 (range 34-133); most frequent topic areas included healthy living (12%), communicable diseases (9%), vaccines and immunization (7%), emergency preparedness and response (7%), infant and child health (5%), smoking and tobacco use (5%), and miscellaneous (32%). Through web-based interactive graphics (Google motion charts), we contrasted Facebook posts with CDC's BRFSS data on adult nutrition and physical activity, vaccination, smoking, adolescent health and road traffic accidents. Our research finds an apparent disconnect between content provided on Facebook by SHDs and the health conditions that affect their populations. Acknowledging the severe limitations in funding and human resources faced by the SHDs, our research attempts to present the factual situation in embracing a vastly popular social media platform for health communication. We believe there is a need for research exploring methods to balance the demands and resources.

Comparison of two contraceptive pills containing drospirenone and 20 µg or 30 µg ethinyl estradiol for polycystic ovary syndrome.

OBJECTIVE: To compare the effects of 30 µg and 20 µg ethinyl estradiol (EE) among women with polycystic ovary syndrome (PCOS). METHODS: In a randomized study, patients with PCOS, a history of six or fewer menstrual cycles in the previous 12 months, and abnormal body hair growth were enrolled at a center in Kolkata, India, between May 1, 2012, and January 31, 2014. Participants were randomly assigned (1:1) using a computer-generated randomization table to receive an oral contraceptive pill containing 3mg drospirenone and either 30 µg EE or 20 µg EE. Patients were followed up after 6 and 12 months. The primary outcome was the absolute change in the free androgen index. Participants were masked to group assignment but investigators were not. Analyses were by intention to treat. RESULTS: Overall, 112 patients were enrolled. At 6 months, the free androgen index had decreased by 4.96±6.01 among patients receiving 30 µg (n=55) and by 4.81±6.03 among those receiving 20 µg (n=57; P=0.89). At 12 months, the decrease from baseline was 5.23±5.79 with 30 µg and 4.99±5.86 with 20 µg (P=0.82). CONCLUSION: Among patients with PCOS, an oral contraceptive pill containing 20 µg EE has similar effects on androgen levels to those of a pill containing 30 µg. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2012/04/002571.

Persistent Distress after Water Contamination.

Background: A chemical spill contaminated the public water supply of Charleston, West Virginia in January 2014 for at least a week. Psychological distress is common after disasters. Methods: We surveyed the exposed population to assess psychological distress during and three months after the incident. We inquired about stressors that might predict distress, adequacy of communication from public officials, and use of the water supply and perceptions of its safety three months after the incident. Results: Twenty six percent of interviewees had persistent symptoms of distress. Female sex, negative household experiences during the episode (especially having someone sick), and poor perception of communication increased odds of persistent distress. Households of respondents without persistent distress were significantly more likely to report drinking tap water (RR=1.95) than those with persistent distress. Conclusions: Distress in Charleston area residents persisted and may have resulted in continuing mistrust of the water supply.

Environmental arsenic toxicity in West Bengal, India: A brief policy review.

High-level arsenic contamination of drinking water in West Bengal (WB), India is a grave public health concern, with 26 million people remaining affected. Two decades of research has provided detailed information on multiple aspects of exposure assessment and risk characterization. However, policy paralysis due to lack of finances and lack of any administrative coordination between the Central and State Governments has hampered the implementation of long-term solutions. Household- and community-level arsenic removal units have provided some relief to the suffering population. In view of the increased funding through the 12th Five-Year Plan period, it is the responsibility of the authorities to implement piped water supply schemes with single-point treatment facilities as the permanent solution to this three-decade-long crisis. Incorporating research evidence into policy and focusing on behavior change communication would be crucial to that end.

Correction: Self-Reported Household Impacts of Large-Scale Chemical Contamination of the Public Water Supply, Charleston, West Virginia, USA.

[This corrects the article DOI: 10.1371/journal.pone.0126744.].

Self-reported household impacts of large-scale chemical contamination of the public water supply, Charleston, West Virginia, USA.

A January 2014 industrial accident contaminated the public water supply of approximately 300,000 homes in and near Charleston, West Virginia (USA) with low levels of a strongly-smelling substance consisting principally of 4-methylcyclohexane methanol (MCHM). The ensuing state of emergency closed schools and businesses. Hundreds of people sought medical care for symptoms they related to the incident. We surveyed 498 households by telephone to assess the episode's health and economic impact as well as public perception of risk communication by responsible officials. Thirty two percent of households (159/498) reported someone with illness believed to be related to the chemical spill, chiefly dermatological or gastrointestinal symptoms. Respondents experienced more frequent symptoms of psychological distress during and within 30 days of the emergency than 90 days later. Sixty-seven respondent households (13%) had someone miss work because of the crisis, missing a median of 3 days of work. Of 443 households reporting extra expenses due to the crisis, 46% spent less than $100, while 10% spent over $500 (estimated average about $206). More than 80% (401/485) households learned of the spill the same day it occurred. More than 2/3 of households complied fully with "do not use" orders that were issued; only 8% reported drinking water against advice. Household assessments of official communications varied by source, with local officials receiving an average "B" rating, whereas some federal and water company communication received a "D" grade. More than 90% of households obtained safe water from distribution centers or stores during the emergency. We conclude that the spill had major economic impact with substantial numbers of individuals reporting incident-related illnesses and psychological distress. Authorities were successful supplying emergency drinking water, but less so with risk communication.

Social determinants of good hand-washing practice (GHP) among adolescents in a rural Indian community.

A cross-sectional study was conducted in 5 randomly selected villages to assess prevalence of good hand-washing practice (GHP) among adolescents, and describe the social determinants. The prevalence of adolescent GHP was 32.1% (95% CI = 27.1, 37.1). Logistic regression established 5 significant positive predictors-maternal GHP, presence of sanitary latrine, availability of soap at hand-washing locations, in-house water supply, and higher per capita income. Our research provides a scope for better understanding of the socioeconomic determinants of GHP in a rural Indian setting, and may find implications in the Total Sanitation Campaign launched by Government of India.

Comparative study of the therapeutic effects of oral contraceptive pills containing desogestrel, cyproterone acetate, and drospirenone in patients with polycystic ovary syndrome.

OBJECTIVE: To compare the effects of oral contraceptive pills containing desogestrel, cyproterone acetate, and drospirenone, in polycystic ovary syndrome (PCOS), after 6 and 12 months of therapy. DESIGN: Double-blind randomized controlled trial. SETTING: Gynecologic clinic of the first author. PATIENT(S): Women (n = 171) with PCOS (Androgen Excess Society criteria, 2006). INTERVENTION(S): The three-arm trial involved 58, 56, and 57 cases in desogestrel, cyproterone acetate, and drospirenone groups, respectively. Body mass index, abdominal circumference, hirsutism score (modified Ferriman Galwey), acne and acanthosis nigricans scores, and blood pressure were noted. Blood levels of total T, sex hormone-binding globulin, fasting glucose, and fasting insulin were measured. Free androgen index, glucose-insulin ratio, and homeostasis model assessment-insulin resistance were calculated. Follow-up was after 6 and 12 months of treatment. MAIN OUTCOME MEASURE(S): Primarily, absolute change in the Free Androgen Index score between the three groups and, secondarily, changes in the clinical and other hormonal and biochemical parameters were studied. RESULT(S): Six months of treatment showed similar effects. After 12 months, cyproterone acetate significantly decreased the modified Ferriman Galwey score (change = -5.29) compared with both desogestrel (change = -1.69) and drospirenone (change = -2.12); cyproterone acetate significantly increased sex hormone-binding globulin (change = 142.91) compared with desogestrel (change = 99.53); drospirenone significantly increased sex hormone-binding globulin (change = 131.52) compared with desogestrel; and cyproterone acetate significantly decreased the Free Androgen Index (change = -10.57) compared with desogestrel (change = -5.58). CONCLUSION(S): No difference in effects after 6 months. At 12 months, cyproterone acetate showed the strongest antiandrogen activities. Effects on metabolic parameters were identical. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2010/091/000332.

Exploring the quality of life (QOL) in the Indian software industry: a public health viewpoint.

OBJECTIVES: Our objectives were to describe the QOL and its determinants among software professionals of Kolkata, and to compare the same according to information technology (IT) and IT-enabled services (ITeS) sub-sectors. METHODS: An institution-based cross-sectional study was conducted among software professionals of Kolkata applying a two-stage stratified random sampling technique. The WHO QOL BREF questionnaire was administered along with a list of pertinent variables. RESULTS: Overall, the analysis for 338 software professionals (177 IT and 161 ITeS) clearly demonstrated significant differences between mean scores of these two sectors for each of the six outcome domains of WHO QOL BREF. Multilevel multivariate analysis outlined 13 significant predictors of QOL-four positive (age, regular fitness regimes, foreign placements and changing companies frequently) and the rest of the nine, negative (multiple sex partners, multiple addictions, extended working hours, night-shift duties, income, expenditure, carrying office work home, current illness and ITeS company type). CONCLUSIONS: Our study helps in obtaining a clear understanding of the multifaceted risk factors prevailing in this sector, the majority of which can be effectively addressed by specific health promotional interventions. A dedicated health policy is mandated at both government and company levels.

Prevalence and risk of metabolic syndrome in adolescent Indian girls with polycystic ovary syndrome using the 2009 'joint interim criteria'.

AIM: Our objective was to study the prevalence and risk of metabolic syndrome (MS) among adolescent Indian girls with polycystic ovary syndrome (PCOS), compared to those without, as per the recent 'joint interim statement' criteria. We also aimed to compare the selected study parameters across PCOS adolescents with and without MS. MATERIAL & METHODS: Cross-sectional data of 96 adolescent girls were retrospectively analyzed applying the 2009 'joint interim criteria' for MS. Fifty-one of them were diagnosed with PCOS as per the Androgen excess society criteria 2006. The remaining 45 adolescent girls (no androgen excess manifestations and regular cycles) formed the comparison group. RESULTS: The prevalence of MS among adolescents with PCOS (60.78%; 95% CI = 50.78%, 70.78%) was significantly more compared to those without (P = 0.002). The odds ratio of MS among PCOS adolescents was 4.26 (95% CI = 1.79, 10.15). Only the mean waist circumference differed significantly between the PCOS and non-PCOS groups (P = 0.046). Interestingly, the contrast between the MS and non-MS subgroups of the PCOS adolescent sample produced significant differences in body mass index, waist circumference, blood pressure and biochemical parameters such as fasting plasma glucose, high-density lipoprotein-cholesterol and triglyceride levels. CONCLUSION: Adolescent Indian girls with PCOS were reported to have 4.26 times more chances of developing MS compared to those without. Waist circumference was found to be the cheapest and simplest significant marker of MS. The study underlines the need for routine screening of MS among adolescent girls suffering from PCOS to reduce future co-morbidities.