Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

Background

In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home.

Methodology/Principal Findings

We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed “not necessary” by a household decision maker. Among the poorest women, “not necessary” was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended.

Conclusions

In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.     

Impact of Free Delivery Care on Health Facility Delivery and Insurance Coverage in Ghana’s Brong Ahafo Region

Background

Many sub-Saharan countries, including Ghana, have introduced policies to provide free medical care to pregnant women. The impact of these policies, particularly on access to health services among the poor, has not been evaluated using rigorous methods, and so the empirical basis for defending these policies is weak. In Ghana, a recent report also cast doubt on the current mechanism of delivering free care – the National Health Insurance Scheme. Longitudinal surveillance data from two randomized controlled trials conducted in the Brong Ahafo Region provided a unique opportunity to assess the impact of Ghana’s policies.

Methods

We used time-series methods to assess the impact of Ghana’s 2005 policy on free delivery care and its 2008 policy on free national health insurance for pregnant women. We estimated their impacts on facility delivery and insurance coverage, and on socioeconomic differentials in these outcomes after controlling for temporal trends and seasonality.

Results

Facility delivery has been increasing significantly over time. The 2005 and 2008 policies were associated with significant jumps in coverage of 2.3% (p = 0.015) and 7.5% (p<0.001), respectively after the policies were introduced. Health insurance coverage also jumped significantly (17.5%, p<0.001) after the 2008 policy. The increases in facility delivery and insurance were greatest among the poorest, leading to a decline in socioeconomic inequality in both outcomes.

Conclusion

Providing free care, particularly through free health insurance, has been effective in increasing facility delivery overall in the Brong Ahafo Region, and especially among the poor. This finding should be considered when evaluating the impact of the National Health Insurance Scheme and in supporting the continuation and expansion of free delivery care.     

Care-Seeking and Management of Common Childhood Illnesses in Tanzania – Results from the 2010 Demographic and Health Survey

Background

Malaria, pneumonia and diarrhoea continue to kill millions of children in Africa despite the available and effective treatments. Correct diagnosis and prompt treatment with effective drugs at the first option consulted for child care is crucial for preventing severe disease and death from these illnesses. Using the 2010 Demographic and Health Survey data, the present study aims to assess care-seeking and management of suspected malaria, pneumonia and diarrhoea at various health care facilities in Tanzania.

Methods

We analyzed data for 8176 children born within a 5 years period preceding the survey.The information was collected by interviewing 5519 women aged 15–49 years in 10,300 households selected from 475 sample points throughout Tanzania.

Results

The most common first option for child care was PHC facilities (54.8%), followed by private pharmacies (23.4%). These were more commonly utilized in rural compared to urban areas: 61.2% versus 34.5% for PHC facilities, and 26.5% versus 17.7% for pharmacies. Women in urban areas and those with higher level of education more commonly utilized higher level hospitals and private facilities as their first option for child care. Only one in four children with fever had received a blood test during the illness with lowest proportion being reported among children solely attended at PHC facilities. Use of abandoned antimalarial drugs for the treatment of suspected malaria was also observed in public health facilities and antibiotics use for diarrhoea treatment was high (49.0%).

Conclusions

PHC facilities and pharmacies most commonly provided sub-optimal care. These facilities were more commonly utilized as the first option for child care in rural areas and among the poor and non-educated families. These are groups with the highest child mortality, which calls for interventions’ targeting improvement of care at these facilities to further reduce child mortality from treatable illnesses in Tanzania.     

Cost-Effectiveness of the “Helping Babies Breathe” Program in a Missionary Hospital in Rural Tanzania

Objective

The Helping Babies Breathe” (HBB) program is an evidence-based curriculum in basic neonatal care and resuscitation, utilizing simulation-based training to educate large numbers of birth attendants in low-resource countries. We analyzed its cost-effectiveness at a faith-based Haydom Lutheran Hospital (HLH) in rural Tanzania.

Methods

Data about early neonatal mortality and fresh stillbirth rates were drawn from a linked observational study during one year before and one year after full implementation of the HBB program. Cost data were provided by the Tanzanian Ministry of Health and Social Welfare (MOHSW), the research department at HLH, and the manufacturer of the training material Lærdal Global Health.

Findings

Costs per life saved were USD 233, while they were USD 4.21 per life year gained. Costs for maintaining the program were USD 80 per life saved and USD 1.44 per life year gained. Costs per disease adjusted life year (DALY) averted ranged from International Dollars (ID; a virtual valuta corrected for purchasing power world-wide) 12 to 23, according to how DALYs were calculated.

Conclusion

The HBB program is a low-cost intervention. Implementation in a very rural faith-based hospital like HLH has been highly cost-effective. To facilitate further global implementation of HBB a cost-effectiveness analysis including government owned institutions, urban hospitals and district facilities is desirable for a more diverse analysis to explore cost-driving factors and predictors of enhanced cost-effectiveness.     

How Can Childbirth Care for the Rural Poor Be Improved? A Contribution from Spatial Modelling in Rural Tanzania

Introduction

Maternal and perinatal mortality remain a challenge in resource-limited countries, particularly among the rural poor. To save lives at birth health facility delivery is recommended. However, increasing coverage of institutional deliveries may not translate into mortality reduction if shortage of qualified staff and lack of enabling working conditions affect quality of services. In Tanzania childbirth care is available in all facilities; yet maternal and newborn mortality are high. The study aimed to assess in a high facility density rural context whether a health system organization with fewer delivery sites is feasible in terms of population access.

Methods

Data on health facilities’ location, staffing and delivery caseload were examined in Ludewa and Iringa Districts, Southern Tanzania. Geospatial raster and network analysis were performed to estimate access to obstetric services in walking time. The present geographical accessibility was compared to a theoretical scenario with a 40% reduction of delivery sites.

Results

About half of first-line health facilities had insufficient staff to offer full-time obstetric services (45.7% in Iringa and 78.8% in Ludewa District). Yearly delivery caseload at first-line health facilities was low, with less than 100 deliveries in 48/70 and 43/52 facilities in Iringa and Ludewa District respectively. Wide geographical overlaps of facility catchment areas were observed. In Iringa 54% of the population was within 1-hour walking distance from the nearest facility and 87.8% within 2 hours, in Ludewa, the percentages were 39.9% and 82.3%. With a 40% reduction of delivery sites, approximately 80% of population will still be within 2 hours’ walking time.

Conclusions

Our findings from spatial modelling in a high facility density context indicate that reducing delivery sites by 40% will decrease population access within 2 hours by 7%. Focused efforts on fewer delivery sites might assist strengthening delivery services in resource-limited settings.     

Why Do Women Deliver at Home? Multilevel Modeling of Ethiopian National Demographic and Health Survey Data

Background

Despite of the existing intensive efforts to improve maternal health in Ethiopia, the proportion of birth delivered at home remains high and is still the top priority among the national health threats.

Objective

The study aimed to examine effects of individual women and community-level factors of women’s decision on place of delivery in Ethiopia.

Methods

Data were obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design with rural-urban and regions as strata. The EDHS collected data from a big sample size but our study focused on a sample of 7,908 women whose most recent birth was within five years preceding 2011 and 576 communities in which the women were living in. The data were analyzed using a two-level mixed-effects logistic regression to determine fixed-effects of individual- and community-level factors and random-intercept of between-cluster characteristics.

Results

In the current study, 6980 out of 7908 deliveries (88.3%) took place at home. Lower educational levels (OR=2.74, 95%CI:1.84,4.70; p<0.0001), making no or only a limited number of ANC visits (OR=3.72,95%CI:2.85, 4.83; p<0.0001), non-exposure to media (OR=1.51, 95%CI 1.13, 2.01; p=0.004), higher parity (OR=2.68, 95%CI:1.96,3.68; p<0.0001), and perceived distance problem to reach health facilities (OR=1.29, 95%CI:1.03,1.62; p=0.022) were positively associated with home delivery. About 75% of the total variance in the odds of giving birth at home was accounted for the between-community differences of characteristics (ICC=0.75, p<0.0001). With regard to community-level characteristics, rural communities (OR=4.67, 95%CI:3.06,7.11; p<0.0001), pastoralist communities (OR=4.53, 95%CI:2.81,7.28; p<0.0001), communities with higher poverty levels (OR=1.49 95%CI:1.08,2.22; p=0.048), with lower levels of ANC utilization (OR=2.01, 95%CI:1.42,2.85; p<0.0001) and problem of distance to a health facility (OR=1.29, 95%CI:1.03,1.62; p=0.004) had a positive influence on women to give birth at home.

Conclusions

Not only individual characteristics of women, but also community-level factors determine women’s decision to deliver at home.     

High Awareness but Low Coverage of a Locally Produced Fortified Complementary Food in Abidjan,C?te d’Ivoire: Findings from a Cross-Sectional Survey

Poor complementary feeding practices among infants and young children in Côte d’Ivoire are major contributing factors to the country’s high burden of malnutrition. As part of a broad effort to address this issue, an affordable, nutritious, and locally produced fortified complementary food product was launched in the Côte d’Ivoire in 2011. The objective of the current research was to assess various levels of coverage of the program and to identify coverage barriers. A cross-sectional household survey was conducted among caregivers of children less than 2-years of age living in Abidjan, Côte d’Ivoire. Four measures of coverage were assessed: “message coverage” (i.e., has the caregiver ever heard of the product?), “contact coverage” (i.e., has the caregiver ever fed the child the product?), “partial coverage” (i.e., has the caregiver fed the child the product in the previous month?), and “effective coverage” (i.e., has the caregiver fed the child the product in the previous 7 days?). A total of 1,113 caregivers with children between 0 and 23 months of age were interviewed. Results showed high message coverage (85.0%), moderate contact coverage (37.8%), and poor partial and effective coverages (8.8% and 4.6%, respectively). Product awareness was lower among caregivers from poorer households, but partial and effective coverages were comparable in both poor and non-poor groups. Infant and young child feeding (IYCF) practices were generally poor and did not appear to have improved since previous assessments. In conclusion, the results from the present study indicate that availability on the market and high awareness among the target population is not sufficient to achieve high and effective coverage. With market-based delivery models, significant efforts are needed to improve demand. Moreover, given the high prevalence of malnutrition and poor IYCF practices, additional modes of delivering IYCF interventions and improving IYCF practices should be considered.     

Where,When and Why Do Tsetse Contact Humans? Answers from Studies in a National Park of Zimbabwe

Background

Sleeping sickness, also called human African trypanosomiasis, is transmitted by the tsetse, a blood-sucking fly confined to sub-Saharan Africa. The form of the disease in West and Central Africa is carried mainly by species of tsetse that inhabit riverine woodland and feed avidly on humans. In contrast, the vectors for the East and Southern African form of the disease are usually savannah species that feed mostly on wild and domestic animals and bite humans infrequently, mainly because the odours produced by humans can be repellent. Hence, it takes a long time to catch many savannah tsetse from people, which in turn means that studies of the nature of contact between savannah tsetse and humans, and the ways of minimizing it, have been largely neglected.

Methodology/Principal Findings

The savannah tsetse, Glossina morsitans morsitans and G. pallidipes, were caught from men in the Mana Pools National park of Zimbabwe. Mostly the catch consisted of young G. m. morsitans, with little food reserve. Catches were increased by 4–8 times if the men were walking, not stationary, and increased about ten times more if they rode on a truck at 10 km/h. Catches were unaffected if the men used deodorant or were baited with artificial ox odour, but declined by about 95% if the men were with an ox. Surprisingly, men pursuing their normal daily activities were bitten about as much when in or near buildings as when in woodland. Catches from oxen and a standard ox-like trap were poor indices of the number and physiological state of tsetse attacking men.

Conclusion/Significance

The search for new strategies to minimize the contact between humans and savannah tsetse should focus on that occurring in buildings and vehicles. There is a need to design a man-like trap to help to provide an index of sleeping sickness risk.     

Coverage and Financial Risk Protection for Institutional Delivery: How Universal Is Provision of Maternal Health Care in India?

Background

India aims to achieve universal access to institutional delivery. We undertook this study to estimate the universality of institutional delivery care for pregnant women in Haryana state in India. To assess the coverage of institutional delivery, we analyze service coverage (coverage of public sector institutional delivery), population coverage (coverage among different districts and wealth quintiles of the population) and financial risk protection (catastrophic health expenditure and impoverishment as a result of out-of-pocket expenditure for delivery).

Methods

We analyzed cross-sectional data collected from a randomly selected sample of 12,191 women who had delivered a child in the last one year from the date of data collection in Haryana state. Five indicators were calculated to evaluate coverage and financial risk protection for institutional delivery—proportion of public sector deliveries, out-of-pocket expenditure, percentage of women who incurred no expenses, prevalence of catastrophic expenditure for institutional delivery and incidence of impoverishment due to out-of-pocket expenditure for delivery. These indicators were calculated for the public and private sectors for 5 wealth quintiles and 21 districts of the state.

Results

The coverage of institutional delivery in Haryana state was 82%, of which 65% took place in public sector facilities. Approximately 63% of the women reported no expenditure on delivery in the public sector. The mean out-of-pocket expenditures for delivery in the public and private sectors in Haryana were INR 771 (USD 14.2) and INR 12,479 (USD 229), respectively, which were catastrophic for 1.6% and 22% of households, respectively.

Conclusion

Our findings suggest that there is considerably high coverage of institutional delivery care in Haryana state, with significant financial risk protection in the public sector. However, coverage and financial risk protection for institutional delivery vary substantially across districts and among different socio-economic groups and must be strengthened. The success of the public sector in providing high coverage and financial risk protection in maternal health provides encouragement for the role that the public sector can play in universalizing health care.     

Is Knowledge Regarding Tuberculosis Associated with Stigmatising and Discriminating Attitudes of General Population towards Tuberculosis Patients? Findings from a Community Based Survey in 30 Districts of India

Background

Stigmatising and discriminating attitudes may discourage tuberculosis (TB) patients from actively seeking medical care, hide their disease status, and discontinue treatment. It is expected that appropriate knowledge regarding TB should remove stigmatising and discriminating attitudes. In this study we assessed the prevalence of stigmatising and discriminating attitudes towards TB patients among general population and their association with knowledge regarding TB.

Method

A cross-sectional knowledge, attitude and practice survey was conducted in 30 districts of India in January-March 2011. A total of 4562 respondents from general population were interviewed using semi-structured questionnaires which contained items to measure stigma, discrimination and knowledge on TB.

Result

Of the 4562 interviewed, 3823 were eligible for the current analysis. Of these, 73% (95% CI 71.4–74.2) had stigmatising and 98% (95% CI 97.4–98.3) had discriminating attitude towards TB patients. Only 17% (95% CI 15.6–18.0) of the respondents had appropriate knowledge regarding TB with even lower levels observed amongst females, rural areas and respondents from low income groups. Surprisingly stigmatising (adjusted OR 1.31 (0.78–2.18) and discriminating (adjusted OR 0.79 (0.43–1.44) attitudes were independent of knowledge regarding TB.

Conclusion

Stigmatising and discriminating attitudes towards TB patients remain high among the general population in India. Since these attitudes were independent of the knowledge regarding TB, it is possible that the current disseminated knowledge regarding TB which is mainly from a medical perspective may not be adequately addressing the factors that lead to stigma and discrimination towards TB patients. Therefore, there is an urgent need to review the messages and strategies currently used for disseminating knowledge regarding TB among general population and revise them appropriately. The disseminated knowledge should include medical, psycho-social and economic aspects of TB that not only informs people about medical aspects of TB disease, but also removes stigma and discrimination.     

Is Health Aid Reaching the Poor? Analysis of Household Data from Aid Recipient Countries

Objective

To determine the extent to which the narrowing of child mortality across wealth gradients has been related to foreign aid to the health sector in low- and middle-income countries.

Methods

Mortality and wealth data on 989,901 under-5 children from 957,674 households in 49 aid recipient countries in Africa, Asia, South America, and the Caribbean between 1993 and 2012 were used in the analysis. Declines in under-5 mortality in the four poorest wealth quantiles were compared to the decline among the wealthiest at varying levels of health aid per capita using fixed effects multivariable regression models and controlling for maternal education, urbanization, and domestic spending on health among recipient countries.

Results

Each additional dollar in total health aid per capita was associated with 5.7 fewer deaths per 10,000 child-years among children in the poorest relative to the wealthiest households (p<0.001). This was also true when measured in percent declines (1.90% faster decline in under-5 mortality among the poorest compared with the wealthiest with each dollar in total health aid, p = 0.008). The association was stronger when using health aid specifically for malaria than total health aid, 12.60% faster decline among the poorest compared with the wealthiest with each dollar in malaria aid, p = 0.001.

Conclusions

Foreign aid to the health sector is preferentially related to reductions in under-5 mortality among the poorest compared with the wealthiest. Health aid addressing malaria, which imposes a disproportionate burden among the poor, may explain the observed effect.     

From Where Are Tuberculosis Patients Accessing Treatment in India? Results from a Cross-Sectional Community Based Survey of 30 Districts

Background

Tuberculosis (TB) notification in India by the Revised National TB Control Programme (RNTCP) provides information on TB patients registered for treatment from the programme. There is limited information about the proportion of patients treated for TB outside RNTCP and where these patients access their treatment.

Objectives

To estimate the proportion of patients accessing TB treatment outside the RNTCP and to identify their basic demographic characteristics.

Methods

A cross sectional community-based survey in 30 districts. Patients were identified through a door-to-door survey and interviewed using a semi-structured questionnaire.

Results

Of the estimated 75,000 households enumerated, 73,249 households (97.6%) were visited. Of the 371,174 household members, 761 TB patients were identified (∼205 cases per 100,000 populations). Data were collected from 609 (80%) TB patients of which 331 [54% (95% CI: 42–66%)] were determined to be taking treatment ‘under DOTS/RNTCP’. The remaining 278 [46% (95% CI: 34–57%)] were on treatment from ‘outside DOTS/RNTCP’ sources and hence were unlikely to be part of the TB notification system. Patients who were accessing treatment from ‘outside DOTS/RNTCP’ were more likely to be patients from rural areas [adjusted Odds Ratio (aOR) 2.5, 95% CI (1.2–5.3)] and whose TB was diagnosed in a non-government health facility (aOR 14.0, 95% CI 7.9–24.9).

Conclusions

This community-based survey found that nearly half of self-reported TB patients were missed by TB notification system in these districts. The study highlights the need for 1) Reviewing and revising the scope of the TB notification system, 2) Strengthening and monitoring health care delivery systems with periodic assessment of the reach and utilisation of the RNTCP services especially among rural communities, 3) Advocacy, communication and social mobilisation activities focused at rural communities with low household incomes and 4) Inclusive involvement of all health-care providers, especially providers of poor rural communities.     

Is Social Capital a Determinant of Oral Health among Older Adults? Findings from the English Longitudinal Study of Ageing

There are a number of studies linking social capital to oral health among older adults, although the evidence base mainly relies on cross-sectional study designs. The possibility of reverse causality is seldom discussed, even though oral health problems could potentially lead to lower social participation. Furthermore, few studies clearly distinguish between the effects of different dimensions of social capital on oral health. The objective of the study was to examine the longitudinal associations between individual social capital and oral health among older adults. We analyzed longitudinal data from the 3^rd and 5^th waves of the English Longitudinal Study of Ageing (ELSA). Structural social capital was operationalized using measures of social participation, and volunteering. Number of close ties and perceived emotional support comprised the functional dimension of social capital. Oral health measures were having no natural teeth (edentate vs. dentate), self-rated oral health and oral health-related quality of life. Time-lag and autoregressive models were used to explore the longitudinal associations between social capital and oral health. We imputed all missing data, using multivariate imputation by chained equations. We found evidence of bi-directional longitudinal associations between self-rated oral health, volunteering and functional social capital. Functional social capital was a strong predictor of change in oral health-related quality of life – the adjusted odds ratio of reporting poor oral health-related quality of life was 1.75 (1.33–2.30) for older adults with low vs. high social support. However in the reverse direction, poor oral health-related quality of life was not associated with changes in social capital. This suggests that oral health may not be a determinant of social capital. In conclusion, social capital may be a determinant of subjective oral health among older adults rather than edentulousness, despite many cross-sectional studies on the latter.     

Associations between Depression and Diabetes in the Community: Do Symptom Dimensions Matter? Results from the Gutenberg Health Study

Objectives

While a bidirectional relationship between diabetes and depression has been established, there is little knowledge if the associations are due to somatic-affective or cognitive-affective dimensions of depression.

Research Design and Methods

In a population-based, representative survey of 15.010 participants we therefore studied the associations of the two dimensions of depression with diabetes and health care utilization among depressed and diabetic participants. Depression was assessed by the Patient Health Questionnaire PHQ-9.

Results

We found a linear and consistent association between the intensity of depression and the presence of diabetes increasing from 6.9% in no or minimal depression to 7.6% in mild, 9% in moderate and 10.5% in severe depression. There was a strong positive association between somatic-affective symptoms but not with cognitive-affective symptoms and diabetes. Depression and diabetes were both independently related to somatic health care utilisation.

Conclusions

Diabetes and depression are associated, and the association is primarily driven by the somatic-affective component of depression. The main limitation of our study pertains to the cross-sectional data acquisition. Further longitudinal work on the relationship of obesity and diabetes should differentiate the somatic and the cognitive symptoms of depression.     

Is Spousal Violence Being “Vertically Transmitted” through Victims? Findings from the Pakistan Demographic and Health Survey 2012-13

Introduction

Violence against women is regarded as a major violation of human rights, and several socio-behavioral aspects among victims have been identified as important determinants of spousal violence experience. Pakistani nationally representative contextual evidence is scarce in this regard. We aimed to estimate prevalence of spousal violence, and explore its association with intergenerational transfer, and attitudinal acceptance of violence, among Pakistani ever-married women.

Materials and Methods

Data of 3,687 ever-married women from Pakistan Demographic and Health Survey, 2012-13 was used to perform secondary analysis. Logistic regression analyses were conducted. Association between the different forms of spousal violence and the independent variables: intergenerational transfer of spousal violence (mother also beaten up by father); and attitudinal acceptance of spousal violence (beating is justifies if wife argues with husband) were reported as Odds ratios with 95% confidence intervals (CI).

Results

Overall, more than a third (n=1344, 37.9%)of ever-married women reported that they experienced spousal violence. Almost 68% (n=539) of the women who reported that their mothers were also beaten up by their fathers, were victims of spousal violence; and almost 47% (n=603) of the women who agreed that beating was justified if the wife argues with her husband, also suffered spousal violence. Intergenerational transfer (OR =5.71, 95%CI 4.40-7.41, p-value <0.01), and attitudinal acceptance (OR =1.66, 95%CI 1.27-2.15, p-value <0.01) were significantly associated with experience of physical violence even after adjusting for respondents’ age at marriage, education level, wealth index, parity, employment status, and empowerment status.

Conclusions

Spousal violence continues to haunt the lives of women in Pakistan, and is being transmitted as a learned behavior from mothers to daughters who tend to accept such violation of human rights. Girl children from such unfortunate homes may continue to transmit such behaviors, and thus may be targeted for future anti-domestic violence efforts.     

Mental Disorders in Megacities: Findings from the S?o Paulo Megacity Mental Health Survey,Brazil

Background

World population growth is projected to be concentrated in megacities, with increases in social inequality and urbanization-associated stress. São Paulo Metropolitan Area (SPMA) provides a forewarning of the burden of mental disorders in urban settings in developing world. The aim of this study is to estimate prevalence, severity, and treatment of recently active DSM-IV mental disorders. We examined socio-demographic correlates, aspects of urban living such as internal migration, exposure to violence, and neighborhood-level social deprivation with 12-month mental disorders.

Methods and Results

A representative cross-sectional household sample of 5,037 adults was interviewed face-to-face using the WHO Composite International Diagnostic Interview (CIDI), to generate diagnoses of DSM-IV mental disorders within 12 months of interview, disorder severity, and treatment. Administrative data on neighborhood social deprivation were gathered. Multiple logistic regression was used to evaluate individual and contextual correlates of disorders, severity, and treatment. Around thirty percent of respondents reported a 12-month disorder, with an even distribution across severity levels. Anxiety disorders were the most common disorders (affecting 19.9%), followed by mood (11%), impulse-control (4.3%), and substance use (3.6%) disorders. Exposure to crime was associated with all four types of disorder. Migrants had low prevalence of all four types compared to stable residents. High urbanicity was associated with impulse-control disorders and high social deprivation with substance use disorders. Vulnerable subgroups were observed: women and migrant men living in most deprived areas. Only one-third of serious cases had received treatment in the previous year.

Discussion

Adults living in São Paulo megacity had prevalence of mental disorders at greater levels than similar surveys conducted in other areas of the world. Integration of mental health promotion and care into the rapidly expanding Brazilian primary health system should be strengthened. This strategy might become a model for poorly resourced and highly populated developing countries.     

Is Using the Strengths and Difficulties Questionnaire in a Community Sample the Optimal Way to Assess Mental Health Functioning?

An important characteristic of a screening tool is its discriminant ability or the measure’s accuracy to distinguish between those with and without mental health problems. The current study examined the inter-rater agreement and screening concordance of the parent and teacher versions of SDQ at scale, subscale and item-levels, with the view of identifying the items that have the most informant discrepancies; and determining whether the concordance between parent and teacher reports on some items has the potential to influence decision making. Cross-sectional data from parent and teacher reports of the mental health functioning of a community sample of 299 students with and without disabilities from 75 different primary schools in Perth, Western Australia were analysed. The study found that: a) Intraclass correlations between parent and teacher ratings of children’s mental health using the SDQ at person level was fair on individual child level; b) The SDQ only demonstrated clinical utility when there was agreement between teacher and parent reports using the possible or 90% dichotomisation system; and c) Three individual items had positive likelihood ratio scores indicating clinical utility. Of note was the finding that the negative likelihood ratio or likelihood of disregarding the absence of a condition when both parents and teachers rate the item as absent was not significant. Taken together, these findings suggest that the SDQ is not optimised for use in community samples and that further psychometric evaluation of the SDQ in this context is clearly warranted.     

High Urinary Tungsten Concentration Is Associated with Stroke in the National Health and Nutrition Examination Survey 1999–2010

Background

In recent years there has been an exponential increase in tungsten demand, potentially increasing human exposure to the metal. Currently, the toxicology of tungsten is poorly understood, but mounting evidence suggests that both the elemental metal and its alloys have cytotoxic effects. Here, we investigate the association between tungsten and cardiovascular disease (CVD) or stroke using six waves of the National Health and Nutrition Examination Survey (NHANES).

Methods

We investigated associations using crude and adjusted logistic regression models in a cohort of 8614 adults (18–74 years) with 193 reported stroke diagnoses and 428 reported diagnoses of CVD. We also stratified our data to characterize associations in a subset of younger individuals (18–50 years).

Results

Elevated tungsten concentrations were strongly associated with an increase in the prevalence of stroke, independent of typical risk factors (Odds Ratio (OR): 1.66, 95% Confidence Interval (95% CI): 1.17, 2.34). The association between tungsten and stroke in the young age category was still evident (OR: 2.17, 95% CI: 1.33, 3.53).

Conclusion

This study represents the most comprehensive analysis of the human health effects of tungsten to date. Individuals with higher urinary tungsten concentrations have double the odds of reported stroke. We hypothesize that the pathological pathway resulting from tungsten exposure may involve oxidative stress.