Bridging the gaps between research,policy and practice in low- and middle-income countries: a survey of researchers

Background

Many international statements have urged researchers, policy-makers and health care providers to collaborate in efforts to bridge the gaps between research, policy and practice in low- and middle-income countries. We surveyed researchers in 10 countries about their involvement in such efforts.

Methods

We surveyed 308 researchers who conducted research on one of four clinical areas relevant to the Millennium Development Goals (prevention of malaria, care of women seeking contraception, care of children with diarrhea and care of patients with tuberculosis) in each of 10 low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania). We focused on their engagement in three promising bridging activities and examined system-level, organizational and individual correlates of these activities.

Results

Less than half of the researchers surveyed reported that they engaged in one or more of the three promising bridging activities: 27% provided systematic reviews of the research literature to their target audiences, 40% provided access to a searchable database of research products on their topic, and 43% established or maintained long-term partnerships related to their topic with representatives of the target audience. Three factors emerged as statistically significant predictors of respondents’ engagement in these activities: the existence of structures and processes to link researchers and their target audiences predicted both the provision of access to a database (odds ratio [OR] 2.62, 95% CI 1.30–5.27) and the establishment or maintenance of partnerships (OR 2.65, 95% CI 1.25–5.64); stability in their contacts predicted the provision of systematic reviews (OR 2.88, 95% CI 1.35–6.13); and having managers and public (government) policy-makers among their target audiences predicted the provision of both systematic reviews (OR 4.57, 95% CI 1.78–11.72) and access to a database (OR 2.55, 95% CI 1.20–5.43).

Interpretation

Our findings suggest potential areas for improvement in light of the bridging strategies targeted at health care providers that have been found to be effective in some contexts and the factors that appear to increase the prospects for using research in policy-making.The need to bridge the gaps between research, policy and practice appears to be a global phenomenon. Three recent, highly visible resolutions — the Mexico Action Statement on Health Research in 2004 (58 countries),¹ the related World Health Assembly resolution in 2005 (193 countries)² and the Bamako Call to Action on Research for Health in 2008 (53 countries) ³ — urged researchers, policy-makers and health care providers to collaborate in efforts to bridge these gaps. These efforts can range from bringing research-based evidence to the attention of those who could use it, to making research-based evidence available so that it can be readily retrieved when needed.We are not aware of a survey having been conducted in a range of low- and middle-income countries about researchers’ bridging activities related to specific high-priority health topics. Researchers and research organizations have been surveyed about their bridging activities in single high-income countries such as Canada.^4–6 Guideline-producing organizations and health technology assessment agencies have also been surveyed about their bridging activities;⁷ only in one case was the focus on bridging activities in low- and middle-income countries.⁸ Select research funding agencies have been studied in low- and middle-income countries.⁹ Yet the Millennium Development Goals and the goals of many countries call for topic-focused efforts to bridge the gaps between research, policy and practice.We studied efforts to bridge the gaps between research, policy and practice in 10 low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania). In this article, we describe the findings from a survey of researchers in these countries who conducted research in one of four clinical areas relevant to the Millennium Development Goals: prevention of malaria (Ghana, Laos, Senegal and Tanzania), care of women seeking contraception (China, Kazakhstan, Laos and Mexico), care of children with diarrhea (Ghana, India, Pakistan and Senegal) and care of patients with tuberculosis (China, India, Iran and Mexico). In a related article, we describe the findings from a survey of health care providers in these countries who were practising in one of these clinical areas about their awareness of, access to and use of research-based evidence in these clinical areas and the influence of such evidence on their professional practice.¹⁰The challenges associated with documenting such efforts include cross-country differences in the capacity to conduct surveys of researchers; the visibility of researchers depending on their alignment with priorities of government, development agencies, research funding agencies and industry (and hence their likelihood of being identified to participate in these surveys); and researchers’ familiarity with and attitudes toward the bridging activities asked about in these surveys.     

Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: a systematic review

Background

Recent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union (FSU) suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, we conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data.

Methods and Findings

A comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, Joint United Nations Programme on HIV/AIDS (UNAIDS)–classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3–60.6); low-prevalence countries, 14.4 (95% CI 13.8–14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0–10.2). Significant differences in ORs for HIV infection among MSM in were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2–8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8–24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3–13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7–25.2) where it was not. By region, the OR for MSM in the Americas was 33.3 (95% CI 32.3–34.2); 18.7 (95% CI 17.7–19.7) for Asia; 3.8 (95% CI 3.3–4.3) for Africa; and 1.3 (95% CI 1.1–1.6) for the low- and middle-income countries of Europe.

Conclusions

MSM have a markedly greater risk of being infected with HIV compared with general population samples from low- and middle-income countries in the Americas, Asia, and Africa. ORs for HIV infection in MSM are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium–high prevalence settings. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.     

The Uptake of Integrated Perinatal Prevention of Mother-to-Child HIV Transmission Programs in Low- and Middle-Income Countries: A Systematic Review

Background

The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries.

Methods and Findings

We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30–100%) and 81% (range 26–100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22–99%) and 60% (range 19–100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44–100%) of infants were tested for HIV and 11% (range 3–18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis.

Conclusion

The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.     

Low socioeconomic status is associated with prolonged times to assessment and treatment, sepsis and infectious death in pediatric Fever in el salvador

Background

Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality.

Method

This prospective cohort study included children aged 0–16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented.

Findings

Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0–20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0–3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09–8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03–1.81; P = 0.031) and in families with an annual household income InterpretationIlliteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.     

Inadequate Knowledge of Neonatal Danger Signs among Recently Delivered Women in Southwestern Rural Uganda: A Community Survey

Background

Early detection of neonatal illness is an important step towards improving newborn survival. Every year an estimated 3.07 million children die during their first month of life and about one-third of these deaths occur during the first 24 hours. Ninety-eight percent of all neonatal deaths occur in low- and middle-income countries like Uganda. Inadequate progress has been made globally to reduce the amount of neonatal deaths that would be required to meet Millennium Development Goal 4. Poor knowledge of newborn danger signs delays care seeking. The aim of this study was to explore the knowledge of key newborn danger signs among mothers in southwestern Uganda.

Methods

Results from a community survey of 765 recently delivered women were analyzed using univariate and multivariate logistic regressions. Six key danger signs were identified, and spontaneous responses were categorized, tabulated, and analyzed.

Results

Knowledge of at least one key danger sign was significantly associated with being birth prepared (adjusted OR 1.7, 95% CI 1.2–2.3). Birth preparedness consisted of saving money, identifying transportation, identifying a skilled birth attendant and buying a delivery kit or materials. Overall, respondents had a poor knowledge of key newborn danger signs: 58.2% could identify one and 14.8% could identify two. We found no association between women attending the recommended number of antenatal care visits and their knowledge of danger signs (adjusted OR 1.0, 95% CI 0.8–1.4), or between women using a skilled birth attendant at delivery and their knowledge of danger signs (adjusted OR 1.2, 95% CI 0.9–1.7).

Conclusions

Our findings indicate the need to enhance education of mothers in antenatal care as well as those discharged from health facilities after delivery. Further promotion of birth preparedness is encouraged as part of the continuum of maternal care.     

Geographical representativeness of published and ongoing randomized controlled trials. The example of: Tobacco consumption and HIV infection

Background

The challenge for evidence-based healthcare is to reduce mortality and the burden of diseases. This study aimed to compare where research is conducted to where research is needed for 2 public health priorities: tobacco consumption and HIV infection.

Methods

We identified randomized controlled trials (RCTs) included in Cochrane systematic reviews published between 1997 and 2007 and registered ongoing RCTs identified in January 2009 through the World Health Organization''s International Clinical Trials Registry Platform (WHO-ICTRP) evaluating interventions aimed at reducing or stopping tobacco use and treating or preventing HIV infection. We used the WHO and World Bank reports to classify the countries by income level, as well as map the global burden of disease and mortality attributable to tobacco use and HIV infection to the countries where the trials performed.

Results

We evaluated 740 RCTs included in systematic reviews and 346 ongoing RCTs. For tobacco use, 4% of RCTs included in systematic reviews and 2% of ongoing trials were performed in low- and middle-income countries, even though these countries represented 70% of the mortality related to tobacco use. For HIV infection, 31% of RCTs included in systematic reviews and 33% of ongoing trials were performed in low- and middle-income countries, even though these countries represented 99% of the mortality related to HIV infection.

Conclusions

Our results highlight an important underrepresentation of low- and middle-income countries in currently available evidence (RCTs included in systematic reviews) and awaiting evidence (registered ongoing RCTs) for reducing or stopping tobacco use and treating or preventing HIV infection.     

Effect of point-of-care computer reminders on physician behaviour: a systematic review

Background

The opportunity to improve care using computer reminders is one of the main incentives for implementing sophisticated clinical information systems. We conducted a systematic review to quantify the expected magnitude of improvements in processes of care from computer reminders delivered to clinicians during their routine activities.

Methods

We searched the MEDLINE, Embase and CINAHL databases (to July 2008) and scanned the bibliographies of retrieved articles. We included studies in our review if they used a randomized or quasi-randomized design to evaluate improvements in processes or outcomes of care from computer reminders delivered to physicians during routine electronic ordering or charting activities.

Results

Among the 28 trials (reporting 32 comparisons) included in our study, we found that computer reminders improved adherence to processes of care by a median of 4.2% (interquartile range [IQR] 0.8%–18.8%). Using the best outcome from each study, we found that the median improvement was 5.6% (IQR 2.0%–19.2%). A minority of studies reported larger effects; however, no study characteristic or reminder feature significantly predicted the magnitude of effect except in one institution, where a well-developed, “homegrown” clinical information system achieved larger improvements than in all other studies (median 16.8% [IQR 8.7%–26.0%] v. 3.0% [IQR 0.5%–11.5%]; p = 0.04). A trend toward larger improvements was seen for reminders that required users to enter a response (median 12.9% [IQR 2.7%–22.8%] v. 2.7% [IQR 0.6%–5.6%]; p = 0.09).

Interpretation

Computer reminders produced much smaller improvements than those generally expected from the implementation of computerized order entry and electronic medical record systems. Further research is required to identify features of reminder systems consistently associated with clinically worthwhile improvements.Computerized systems for entering orders and electronic medical records represent two of the most widely recommended improvements in health care.¹ These systems offer the opportunity to improve practice by delivering reminders to clinicians at the point of care. Such reminders range from simple prescribing alerts to more sophisticated support for decision-making.Previous reviews have classified all computer reminders together, including computer-generated paper reminders and email alerts sent to providers, along with reminders generated at the point of care.^2–5 They have also typically reported the proportion of studies with results that were on balance “positive.”^2–4 We conducted a systematic review to quantify the expected magnitude of improvements in processes of care from computer reminders delivered to physicians during their routine electronic ordering or charting activities.     

Preterm Birth and Childhood Wheezing Disorders: A Systematic Review and Meta-Analysis

Background

Accumulating evidence implicates early life factors in the aetiology of non-communicable diseases, including asthma/wheezing disorders. We undertook a systematic review investigating risks of asthma/wheezing disorders in children born preterm, including the increasing numbers who, as a result of advances in neonatal care, now survive very preterm birth.

Methods and Findings

Two reviewers independently searched seven online databases for contemporaneous (1 January 1995–23 September 2013) epidemiological studies investigating the association between preterm birth and asthma/wheezing disorders. Additional studies were identified through reference and citation searches, and contacting international experts. Quality appraisal was undertaken using the Effective Public Health Practice Project instrument. We pooled unadjusted and adjusted effect estimates using random-effects meta-analysis, investigated “dose–response” associations, and undertook subgroup, sensitivity, and meta-regression analyses to assess the robustness of associations. We identified 42 eligible studies from six continents. Twelve were excluded for population overlap, leaving 30 unique studies involving 1,543,639 children. Preterm birth was associated with an increased risk of wheezing disorders in unadjusted (13.7% versus 8.3%; odds ratio [OR] 1.71, 95% CI 1.57–1.87; 26 studies including 1,500,916 children) and adjusted analyses (OR 1.46, 95% CI 1.29–1.65; 17 studies including 874,710 children). The risk was particularly high among children born very preterm (<32 wk gestation; unadjusted: OR 3.00, 95% CI 2.61–3.44; adjusted: OR 2.81, 95% CI 2.55–3.12). Findings were most pronounced for studies with low risk of bias and were consistent across sensitivity analyses. The estimated population-attributable risk of preterm birth for childhood wheezing disorders was ≥3.1%.Key limitations related to the paucity of data from low- and middle-income countries, and risk of residual confounding.

Conclusions

There is compelling evidence that preterm birth—particularly very preterm birth—increases the risk of asthma. Given the projected global increases in children surviving preterm births, research now needs to focus on understanding underlying mechanisms, and then to translate these insights into the development of preventive interventions.

Review Registration

PROSPERO CRD42013004965 Please see later in the article for the Editors'' Summary     

Addressing Women's Non-Maternal Healthcare Financing in Developing Countries: What Can We Learn from the Experiences of Rural Indian Women?

Background and Objectives

This paper focuses on the inadequate attention on women''s non-maternal healthcare in low- and middle-income countries. The study assessed the purchase of and financial access to non-maternal healthcare. It also scoped for mainstreaming household financial resources in this regard to suggest for alternatives.

Methods

A household survey through multi-stage stratified sampling in the state of Orissa interviewed rural women above 15 years who were neither pregnant nor had any pregnancy-related outcome six weeks preceding the survey. The questions explored on the processes, determinants and outcomes of health seeking for non-maternal ailments. The outcome measures were healthcare access, cost of care and financial access. The independent variables for bivariate and multivariate analyses were contextual factors, health seeking and financing pattern.

Results

The survey obtained a response rate of 98.64% and among 800 women, 43.8% had no schooling and 51% were above 60 years. Each woman reported at least one episode of non-maternal ailment; financial constraints prevented 68% from receiving timely and complete care. Distress coping measures (e.g. borrowings) dominated the financing source (67.9%) followed by community–based measures (32.1%). Only 6% had financial risk-protection; financial risk of not obtaining care doubled for women aged over 60 years (OR 2.00, 95% CI 0.84–4.80), seeking outpatient consultation (OR 2.01, 95% CI 0.89–4.81), facing unfavourable household response (OR 2.04, 95% CI 1.09–3.83), and lacking other financial alternatives (OR 2.13, 95% CI 1.11–4.07). When it comes to timely mobilization of funds and healthcare seeking, 90% (714) of the households preferred maternal care to non-maternal healthcare.

Conclusion

The existing financing options enable sub-optimal purchase of women''s non-maternal healthcare. Though dominant, household economy extends inadequate attention in this regard owing to its unfavourable approach towards non-maternal healthcare and limited financial capacity and support from other financial resources.     

Frequency and Risk Factors for Under- and Over-Treatment in Stroke Prevention for Patients with Non-Valvular Atrial Fibrillation in General Practice

Objective

To determine adequacy of antithrombotic treatment in patients with non-valvular atrial fibrillation. To determine risk factors for under- and over-treatment.

Design

Retrospective, cross-sectional study of electronic health records from 36 general practitioners in 2008.

Setting

General practice in the Netherlands.

Subjects

Primary care physicians (n = 36) and patients (n = 981) aged 65 years and over.

Main Outcome Measures

Rates of adequate, under and over-treatment, risk factors for under and over-treatment.

Results

Of the 981 included patients with a mean of age 78, 18% received no antithrombotic treatment (under-treatment), 13% received antiplatelet drugs and 69% received oral anticoagulation (OAC). Further, 43% of the included patients were treated adequately, 26% were under-treated, and 31% were over-treated. Patients with a previous ischaemic stroke were at high risk for under-treatment (OR 2.4, CI 1.6–3.5), whereas those with contraindications for OAC were at high risk for over-treatment (OR 37.0, CI 18.1–79.9). Age over 75 (OR 0.2, CI: 0.1–0.3]), diabetes (OR 0.1, CI: 0.1–0.3), heart failure (OR 0.2, CI: 0.1–0.3), hypertension (OR 0.1, CI: 0.1–0.2) and previous ischaemic stroke (OR 0.04, CI: 0.02–0.11) protected against over-treatment.

Conclusions

In general practice, CHADS₂-criteria are being used, but the antithrombotic treatment of patients with atrial fibrillation frequently deviates from guidelines on this topic. Patients with previous stroke are at high risk of not being prescribed OAC. Contraindications for OAC, however, seem to be frequently overlooked.     

Physician Care Patterns and Adherence to Postpartum Glucose Testing after Gestational Diabetes Mellitus in Oregon

Objective

This study examines obstetrician/gynecologists and family medicine physicians'' reported care patterns, attitudes and beliefs and predictors of adherence to postpartum testing in women with a history of gestational diabetes mellitus.

Research Design and Methods

In November–December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician/gynecologists and family medicine from a population of 2171.

Results

Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69–7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65–11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing.

Conclusions

Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.     

The Impact of Clinical Social Franchising on Health Services in Low- and Middle-Income Countries: A Systematic Review

Background

The private sector plays a large role in health services delivery in low- and middle-income countries; yet significant gaps remain in the quality and accessibility of private sector services. Clinical social franchising, which applies the commercial franchising model to achieve social goals and improve health care, is increasingly used in developing countries to respond to these limitations. Despite the growth of this approach, limited evidence documents the effect of social franchising on improving health care quality and access.

Objectives and Methods

We examined peer-reviewed and grey literature to evaluate the effect of social franchising on health care quality, equity, cost-effectiveness, and health outcomes. We included all studies of clinical social franchise programs located in low- and middle-income countries. We assessed study bias using the WHO-Johns Hopkins Rigour Scale and used narrative synthesis to evaluate the findings.

Results

Of 113 identified articles, 23 were included in this review; these evaluated a small sample of franchises globally and focused on reproductive health franchises. Results varied widely across outcomes and programs. Social franchising was positively associated with increased client volume and client satisfaction. The findings on health care utilization and health impact were mixed; some studies find that franchises significantly outperform other models of health care, while others show franchises are equivalent to or worse than other private or public clinics. In two areas, cost-effectiveness and equity, social franchises were generally found to have poorer outcomes.

Conclusions

Our review indicates that social franchising may strengthen some elements of private sector health care. However, gaps in the evidence remain. Additional research should include: further documentation of the effect of social franchising, evaluating the equity and cost-effectiveness of this intervention, and assessing the role of franchising within the context of the greater healthcare delivery system.     

Stevens-Johnson Syndrome Associated with Drugs and Vaccines in Children: A Case-Control Study

Objective

Stevens-Johnson Syndrome (SJS) is one of the most severe muco-cutaneous diseases and its occurrence is often attributed to drug use. The aim of the present study is to quantify the risk of SJS in association with drug and vaccine use in children.

Methods

A multicenter surveillance of children hospitalized through the emergency departments for acute conditions of interest is currently ongoing in Italy. Cases with a diagnosis of SJS were retrieved from all admissions. Parents were interviewed on child’s use of drugs and vaccines preceding the onset of symptoms that led to the hospitalization. We compared the use of drugs and vaccines in cases with the corresponding use in a control group of children hospitalized for acute neurological conditions.

Results

Twenty-nine children with a diagnosis of SJS and 1,362 with neurological disorders were hospitalized between 1^st November 1999 and 31^st October 2012. Cases were more frequently exposed to drugs (79% vs 58% in the control group; adjusted OR 2.4; 95% CI 1.0–6.1). Anticonvulsants presented the highest adjusted OR: 26.8 (95% CI 8.4–86.0). Significantly elevated risks were also estimated for antibiotics use (adjusted OR 3.3; 95% CI 1.5–7.2), corticosteroids (adjusted OR 4.2; 95% CI 1.8–9.9) and paracetamol (adjusted OR 3.2; 95% CI 1.5–6.9). No increased risk was estimated for vaccines (adjusted OR: 0.9; 95% CI 0.3–2.8).

Discussion

Our study provides additional evidence on the etiologic role of drugs and vaccines in the occurrence of SJS in children.     

Maternal and Perinatal Outcomes of Twin Pregnancy in 23 Low- and Middle-Income Countries

Background

Twin pregnancies in low- and middle-income countries (LMICs) pose a high risk to mothers and newborns due to inherent biological risks and scarcity of health resources. We conducted a secondary analysis of the WHO Global Survey dataset to analyze maternal and perinatal outcomes in twin pregnancies and factors associated with perinatal morbidity and mortality in twins.

Methods

We examined maternal and neonatal characteristics in twin deliveries in 23 LMICs and conducted multi-level logistic regression to determine the association between twins and adverse maternal and perinatal outcomes.

Results

279,425 mothers gave birth to 276,187 (98.8%) singletons and 6,476 (1.2%) twins. Odds of severe adverse maternal outcomes (death, blood transfusion, ICU admission or hysterectomy) (AOR 1.85, 95% CI 1.60–2.14) and perinatal mortality (AOR 2.46, 95% CI 1.40–4.35) in twin pregnancies were higher, however early neonatal death (AOR 2.50, 95% CI 0.95–6.62) and stillbirth (AOR 1.22, 95% CI 0.58–2.57) did not reach significance. Amongst twins alone, maternal age <18, poor education and antenatal care, nulliparity, vaginal bleeding, non-cephalic presentations, birth weight discordance >15%, born second, preterm birth and low birthweight were associated with perinatal mortality. Marriage and caesarean section were protective.

Conclusions

Twin pregnancy is a significant risk factor for maternal and perinatal morbidity and mortality in low-resource settings; maternal risk and access to safe caesarean section may determine safest mode of delivery in LMICs. Improving obstetric care in twin pregnancies, particularly timely access to safe caesarean section, is required to reduce risk to mother and baby.     

Effective Linkages of Continuum of Care for Improving Neonatal,Perinatal, and Maternal Mortality: A Systematic Review and Meta-Analysis

Background

Continuum of care has the potential to improve maternal, newborn, and child health (MNCH) by ensuring care for mothers and children. Continuum of care in MNCH is widely accepted as comprising sequential time (from pre-pregnancy to motherhood and childhood) and space dimensions (from community-family care to clinical care). However, it is unclear which linkages of care could have a greater effect on MNCH outcomes. The objective of the present study is to assess the effectiveness of different continuum of care linkages for reducing neonatal, perinatal, and maternal mortality in low- and middle-income countries.

Methods

We searched for randomized and quasi-randomized controlled trials that addressed two or more linkages of continuum of care and attempted to increase mothers’ uptake of antenatal care, skilled birth attendance, and postnatal care. The outcome variables were neonatal, perinatal, and maternal mortality.

Results

Out of the 7,142 retrieved articles, we selected 19 as eligible for the final analysis. Of these studies, 13 used packages of intervention that linked antenatal care, skilled birth attendance, and postnatal care. One study each used packages that linked antenatal care and skilled birth attendance or skilled birth attendance and postnatal care. Four studies used an intervention package that linked antenatal care and postnatal care. Among the packages that linked antenatal care, skilled birth attendance, and postnatal care, a significant reduction was observed in combined neonatal, perinatal, and maternal mortality risks (RR 0.83; 95% CI 0.77 to 0.89, I² 79%). Furthermore, this linkage reduced combined neonatal, perinatal, and maternal mortality when integrating the continuum of care space dimension (RR 0.85; 95% CI 0.77 to 0.93, I² 81%).

Conclusions

Our review suggests that continuous uptake of antenatal care, skilled birth attendance, and postnatal care is necessary to improve MNCH outcomes in low- and middle-income countries. The review was conclusive for the reduction of neonatal and perinatal deaths. Although maternal deaths were not significantly reduced, composite measures of all mortality were. Thus, the evidence is sufficient to scale up this intervention package for the improvement of MNCH outcomes.     

Physical Activity Patterns and Factors Related to Exercise during Pregnancy: A Cross Sectional Study

Objective

To assess the physical activity levels of pregnant women and to examine the characteristics associated with the practice of exercise and the activities of daily living during pregnancy.

Methods

For this cross-sectional study, 1,279 women were recruited within 72 hours postpartum. They were interviewed about their socio-demographic data and obstetric history and were administered self-report questionnaires about exercise and daily physical activities during pregnancy. Data on the current pregnancy, labor, delivery, and newborn outcomes were collected from participants’ medical records. To analyze factors related to the practice of exercise, we used the student t-test, X², and odds ratio (OR), with a corresponding 95% confident interval (CI), followed by a multiple logistic regression. The significance level was 5%.

Results

Compared to the pre-pregnancy period, the prevalence of physical activity among participants was lower throughout pregnancy (20.1%) (p = 0.01). Half of the women interrupted practicing physical exercise due to pregnancy. The lowest prevalence of exercise was observed in the first (13.6%) and third trimesters (13.4%). Less than half of women received exercise guidance during prenatal care meetings (47.4%). Walking was the most commonly reported exercise, followed by water aerobics. Factors positively associated with exercise practice were higher educational level (OR= 1.82; CI 95% 1.28–2.60), primiparity (OR=1.49; CI 95% 1.07–2.07), exercising before pregnancy (OR= 6.45; CI 95% 4.64–8.96), and exercise guidance during prenatal care (OR=2.54; CI 95% 1.80–3.57). Mildly intense exercise and domestic activities were most frequently reported among pregnant women. There were no differences in maternal and perinatal outcomes between active and sedentary pregnant women.

Conclusion

The findings indicate that promoting physical activity remains a priority in public health policy, and women of childbearing age, especially those planning a pregnancy, should be encouraged to adopt an exercise routine or maintain an active lifestyle during pregnancy in order to avoid sedentary- and obesity-associated risks.     

Inappropriate Drugs in Elderly Patients with Severe Cognitive Impairment: Results from the Shelter Study

Background

It has been estimated that Nursing Home (NH) residents with impaired cognitive status receive an average of seven to eight drugs daily. The aim of this study was to determine prevalence and factors associated with use of inappropriate drugs in elderly patients with severe cognitive impairment living in NH in Europe.

Methods

Cross-sectional data from a sample of 1449 NH residents with severe cognitive impairment, participating in the Services and Health for Elderly in Long TERm care (SHELTER) study were analysed. Inappropriate drug use was defined as the use of drugs classified as rarely or never appropriate in patients with severe cognitive impairment based on the Holmes criteria published in 2008.

Results

Mean age of participating residents was 84.2±8.9 years, 1087 (75.0%) were women. Inappropriate drug use was observed in 643 (44.9%) residents. Most commonly used inappropriate drugs were lipid-lowering agents (9.9%), antiplatelet agents (excluding Acetylsalicylic Acid – ASA –) (9.9%), acetylcholinesterase, inhibitors (7.2%) and antispasmodics (6.9%). Inappropriate drug use was directly associated with specific diseases including diabetes (OR 1.64; 95% CI 1.21–2.24), heart failure (OR 1.48; 95% CI 1.04–2.09), stroke (OR 1.43; 95% CI 1.06–1.93), and recent hospitalization (OR 1.69; 95% CI 1.20–2.39). An inverse relation was shown between inappropriate drug use and presence of a geriatrician in the facility (OR 0.55; 95% CI 0.39–0.77).

Conclusion

Use of inappropriate drugs is common among older EU NH residents. Determinants of inappropriate drug use include comorbidities and recent hospitalization. Presence of a geriatrician in the facility staff is associated with a reduced rate of use of these medications.     

Global Cardiovascular Research Output,Citations, and Collaborations: A Time-Trend,Bibliometric Analysis (1999–2008)

Introduction

Health research is one mechanism to improve population-level health and should generally match the health needs of populations. However, there have been limited data to assess the trends in national-level cardiovascular research output, even as cardiovascular disease [CVD] has become the leading cause of morbidity and mortality worldwide.

Materials and Methods

We performed a time trends analysis of cardiovascular research publications (1999–2008) downloaded from Web of Knowledge using a iteratively-tested cardiovascular bibliometric filter with >90% precision and recall. We evaluated cardiovascular research publications, five-year running actual citation indices [ACIs], and degree of international collaboration measured through the ratio of the fractional count of addresses from one country against all addresses for each publication.

Results and Discussion

Global cardiovascular publication volume increased from 40 661 publications in 1999 to 55 284 publications in 2008, which represents a 36% increase. The proportion of cardiovascular publications from high-income, Organization for Economic Cooperation and Development [OECD] countries declined from 93% to 84% of the total share over the study period. High-income, OECD countries generally had higher fractional counts, which suggest less international collaboration, than lower income countries from 1999–2008. There was an inverse relationship between cardiovascular publications and age-standardized CVD morbidity and mortality rates, but a direct, curvilinear relationship between cardiovascular publications and Human Development Index from 1999–2008.

Conclusions

Cardiovascular health research output has increased substantially in the past decade, with a greater share of citations being published from low- and middle-income countries. However, low- and middle-income countries with the higher burdens of cardiovascular disease continue to have lower research output than high-income countries, and thus require targeted research investments to improve cardiovascular health.