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PubMed2003

Pregnant children and half-dead adults: modern living and the quickening life cycle in Botswana.

This paper utilizes ethnography and oral history to examine local perspectives on one aspect of the health transition, the female life cycle, in postcolonial Botswana. Botswana has undergone a remarkably rapid epidemiologic transition in recent decades, and it thus provides a unique context within which local actors analyze the interaction between biological and sociocultural change. Improvements in the standard of living have resulted in both an earlier onset for puberty in girls and an increased incidence of stroke among older women, thus refashioning the female life course. Local analysis and commentary on the shifting norms of women's bodies read this phenomenon alongside broader historical transformations. In the process they complicate basic assumptions in international health about the meanings of health and development.

Adult↗
PubMed2004

Is it time to reassess the categorization of disease burdens in low-income countries?

The classification of disease burdens is an important topic that receives little attention or debate. One common classification scheme, the broad cause grouping, is based on etiology and health transition theory and is mainly concerned with distinguishing communicable from noncommunicable diseases. This may be of limited utility to policymakers and planners. We propose a broad care needs framework to complement the broad cause grouping. This alternative scheme may be of equal or greater value to planners. We apply these schemes to disability-adjusted life year estimates for 2000 and to mortality data from Tanzania. The results suggest that a broad care needs approach could shift the priorities of health planners and policymakers and deserves further evaluation.

Chronic Disease↗
PubMed1999

Primordial prevention of coronary heart disease in India: challenges and opportunities.

Demographic shifts, lifestyle changes, and adverse effects of childhood nutrition portend an epidemic of coronary heart disease in the Indian subcontinent, which is currently experiencing health transition. Indian susceptibility includes atherogenic blood lipid levels and a metabolic complex of central obesity, glucose intolerance, hyperinsulinemia, and dyslipidemia due to insulin resistance. These characteristics are demonstrated dramatically in urban Indians and in Indian migrants to the west. Prime targets for effective strategies of primordial prevention include children and families in lower socio-economic classes now in transition. There is the greatest urgency in India for medical, political, and social action to prevent high risk in the first place, combating the tobacco trade, enlisting food and agriculture agencies, and promoting physical activity in the population. An empowered community with an enlightened policy can prevent the threatened epidemic.

Cardiovascular Diseases↗
PubMed2002

The smokescreen of culture: AIDS and the indigenous in Papua, Indonesia.

In health transition studies on AIDS, government activities typically have been accorded less importance than local cultural practices. Certain social and cultural values, theorists argue, prevent potentially at-risk individuals from taking effective precautions to prevent HIV infection during sexual intercourse. This paper shows how a focus on culture is inadequate to understanding the issue of risk when the AIDS epidemic occurs in a colonial context. A study conducted in 2001 in Papua (West Papua), eastern Indonesia, shows that ongoing colonial relationships between indigenous Papuans and in-migrant Indonesians create inequities in AIDS awareness. Rates of HIV infection in Papua are high, but indigenous Papuans have a low level of awareness. Drawing on a survey of condom use and the sex work industry, this paper shows that government values, and economic conditions, need to be scrutinized as closely as culture in order to provide effective AIDS prevention in Papua.

Acquired Immunodeficiency Syndrome↗
PubMed2005

The World Health Organization and the transition from "international" to "global" public health.

The term "global health" is rapidly replacing the older terminology of "international health." We describe the role of the World Health Organization (WHO) in both international and global health and in the transition from one to the other. We suggest that the term "global health" emerged as part of larger political and historical processes, in which WHO found its dominant role challenged and began to reposition itself within a shifting set of power alliances. Between 1948 and 1998, WHO moved from being the unquestioned leader of international health to being an organization in crisis, facing budget shortfalls and diminished status, especially given the growing influence of new and powerful players. We argue that WHO began to refashion itself as the coordinator, strategic planner, and leader of global health initiatives as a strategy of survival in response to this transformed international political context.

Communicable Disease Control↗
PubMed1999

Economic methods for measuring the quality of life associated with HIV infection.

BACKGROUND: Quality of life is measured as utilities for cost-effectiveness analyses. OBJECTIVE: To test the adequacy of three common utility elicitation methods for individuals with Human Immunodeficiency Virus (HIV) disease. MEASUREMENTS: HIV-positive participants (n = 75) rated three standardized health states (symptomatic HIV infection, minor AIDS defining illness, and major AIDS defining illness) with two utility elicitation methods (Standard Gamble [SG], and Time Trade-off [TTO]) and one value method (Visual Analog [VA]). Participants also rated their own health with one utility method (Health Utilities Index [HUI]) and one conventional quality of life method (Medical Outcomes Study--HIV Health Survey [MOS-HIV]). RESULTS: For all states, SG and TTO scores ranged from near 0.00 (equivalent to death) to 1.00 (best possible quality of life). Mean scores for symptomatic HIV were similar with the SG (0.80) and TTO (0.81) but higher than with the VA (0.70). Similar results were observed for minor AIDS defining illnesses (0.65, 0.65, 0.46 respectively) and major AIDS defining illnesses (0.42, 0.44, 0.25 respectively). Discrepant SG and TTO scores were observed in many individuals and were not explained by demographic characteristics. As expected, HUI scores of an individual's own health were related to the disease state. Four of ten MOS-HIV subscales (overall health, physical functioning, role functioning, and pain) were also related to disease state. HUI scores were correlated with the MOS-HIV score for overall health and for all MOS-HIV subscales except health transition. CONCLUSIONS: Mean utility scores for HIV-related health states elicited by the Standard Gamble and Time Trade-off were similar but a large degree of individual variation persists. Economic methods provide imprecise estimates of the quality of life associated with HIV infection.

Adult↗
PubMed2000

Compliance with antidepressant medication in the treatment of major depressive disorder in primary care: a randomized comparison of fluoxetine and a tricyclic antidepressant.

OBJECTIVE: Many claims have been made for superior compliance with selective serotonin reuptake inhibitors (SSRIs) compared with tricyclic antidepressants, but to date meta-analyses have not confirmed reduced dropouts in randomized controlled trials. The authors used a randomized study design to evaluate differential compliance with antidepressant medications in a primary care setting. METHOD: A total of 152 patients treated in 10 primary care practices in the United Kingdom were included in a randomized, open-label, parallel-group study of fluoxetine and dothiepin at therapeutic doses for 12 weeks. Compliance was assessed by using pill count, patient questionnaires, and the Medication Event Monitoring System. RESULTS: The level of compliance with fluoxetine was numerically higher than the level of compliance with dothiepin on all three primary outcome measures, although the differences were not significant. In a secondary analysis using data from the Medication Event Monitoring System, both a survival analysis for length of time without a gap in medicine taking and a derived compliance index showed a significant advantage to fluoxetine. Patients in the fluoxetine group reported superior response on the health transition scale of the 36-item Short-Form Health Survey Questionnaire and numerically greater improvement on the Hamilton Depression Rating Scale. In both treatment arms patients with a superior compliance index were more likely to have improved in Hamilton depression scale scores by the last study visit. CONCLUSIONS: This study supports recent meta-analyses of SSRIs versus tricyclic antidepressants in finding no significant differences in crude indices of compliance between fluoxetine and dothiepin, despite marked differences in side effect profile and dose regimen. However, both a survival analysis and a new measure that takes account of prolonged periods of noncompliance distinguished between the treatments and was associated with improvement in both groups.

Adolescent↗
PubMed1997

Prospective versus retrospective measurement of change in health status: a community based study in Geneva, Switzerland.

STUDY OBJECTIVES: To compare prospective and retrospective measurements of change in health status. DESIGN: Health status was measured using a French language version of the short form 36 (SF-36) health survey on two occasions one year apart--in 1992 and 1993. Differences in SF-36 scores measured prospectively were compared with the patients' single item retrospective evaluation of change in health (transition item). SETTING: This was a community based study among members of two health insurance plans in Geneva, Switzerland. PARTICIPANTS: Altogether 831 young adults (mean age 30 years at baseline). MAIN RESULTS: Health status remained stable on average during the study period. The retrospective rating correlated well with changes in health measured prospectively: those who said in 1993 that their current health was "much worse" than in 1992 experienced an average decrease of 1.06 SD on the eight SF-36 scales, while those who said that their health was "much better" recorded an average improvement of 0.43 SD. The associations between prospective and retrospective assessments of change were approximately linear for all scales but physical functioning. The transition item also discriminated between time periods: transition reported for 1991-92 did not correlate with changes recorded for 1992-93. Relative validity analyses indicated that the transition item was better suited to capture changes in general health than changes in purely physical or mental aspects of health. CONCLUSIONS: The concordance between retrospective and prospective measures of change in health suggests that both are sensitive, to some extent, to true changes in health status. Using both types of assessment may improve the reliability of measurements of change.

Adult↗
PubMed2002

Experiencing "change" from within: situating the transition to primary health care in a remote Australian context.

The transition to primary health care (PHC) is often described in an idealized manner, which either ignores or obscures the experiences associated with its implementation at the local level. By adopting an anthropological perspective, this article highlights some of these experiences and the context within which they occur for one health care organisation in remote Western Australia. It specifically focuses on problems associated with economic rationalism, managerialism, and the inherently fragmented character of health service organisations. Such issues must be allowed to inform idealized PHC models in order to make them more applicable and attuned to local needs and realities.

Efficiency, Organizational↗
PubMed1997

Health state utilities in knee replacement surgery: the development and evaluation of McKnee.

OBJECTIVE: 1. To develop McKnee, a classification system and direct utility measure for health states associated with knee replacement (KR) surgery. 2. To apply McKnee in a before-after study of KR surgery to: (i) gain experience with McKnee in an elderly population; (ii) confirm the practicality and usefulness of the McKnee system; (iii) assess self-health utility one week before and 3 mo after surgery; (iv) evaluate the stability of 3 clinical marker health states describing mild, moderate, and severe knee disability; (v) compare self-health utility scores with Short Form 36 (SF-36). METHODS: 1. Instrument development: The McKnee modified Health Utilities Index was developed and used to describe self-health and clinical marker health states: the clinical validity of the clinical marker states was evaluated by 5 clinicians involved in the care off KR patients. 2. Instrument evaluation: McKnee and the SF-36 were administered to 48 patients with osteoarthritis one week before and 3 mo after KR surgery. RESULTS: Before-after study: McKnee was feasible and acceptable in the older patient group studied (mean age in years, SD: 69.9, 8.6). No change in self-health utility (mean, SD) was observed at 3 mo postsurgery: before -0.78, 0.17; after -0.78, 0.21. On the SF-36, only the change scores for pain and health transition were statistically significant. Utilities (mean, SD) for the clinical marker health states were: mild -0.80, 0.20; moderate -0.55, 0.28; and severe -0.48, 0.31. The clinical marker mean utility scores were stable between the baseline and 3 mo assessment, but the intraclass correlation coefficients for individual scores were low. CONCLUSION: McKnee provides a preference based measure of health related quality of life that can be used to obtain and interpret clinically the knee disability utility scorers needed for cost-utility studies and medical decision-making models about KR surgery. The McKnee system provides a practical and useful method for classifying knee disability health states and obtaining direct measurements of utility scores for selected health states.

Aged↗
PubMed1998

The nutrition transition and its health implications in lower-income countries.

OBJECTIVE: This article reviews information on the rapid changes in diet, activity and body composition that lower- and middle-income countries are undergoing and then examines some of the potential health implications of this transition. DESIGN AND SETTING: Data came from numerous countries and also from national food balance (FAOSTAT) and World Bank sources. Nationally representative and nationwide surveys are used. The nationally representative Russian Longitudinal Monitoring Surveys from 1992-96 and the nationwide China Health and Nutrition Survey from 1989-93 are examined in detail. RESULTS: Rapid changes in the structure of diet, in particular associated with urbanization, are documented. In addition, large changes in occupation types are documented. These are linked with rapid increases in adult obesity in Latin America and Asia. Some of the potential implications for adult health are noted. CONCLUSIONS: The rapid changes in diet, activity and obesity that are facing billions of residents of lower- and middle-income countries are cause for great concern. Linked with these changes will be a rapid increase in chronic diseases. Little to date has been done at the national level to address these problems.

Adult↗
PubMed1998

Educational attainment and transitions in functional status among older Taiwanese.

Despite considerable research examining the influence of socioeconomic status on health, few studies have considered this relationship as it pertains to older adults in non-Western societies. We attempt to ascertain the influence of education on changes in physical functioning in a rapidly developing country. Data come from the 1989 Survey of Health and Living Status of the Elderly in Taiwan and a follow-up interview in 1993 (N = 4,049, age = 60+). Individuals are conceptualized to be in a state of functional independence or functional limitation at the time of origin, based on their ability to perform three physical functioning tasks. The outcome at the follow-up interview is categorized as functionally independent, limited, or dead, allowing for six probabilities, one from each state of origin to each outcome. These are calculated using a multinomial logit model, controlling for other factors often thought to be associated with health transitions. High levels of educational attainment result in a decreased incidence of functional limitation for those originating in a state of independence. Contrary to expectations, however, education has little influence on those who originate functionally limited. Thus, higher education plays a substantial role in primary prevention of morbidity, delaying the onset of disability, but other factors are more important once limitations begin. We speculate on the reasons behind these findings, including that the results may be culturally dependent.

Activities of Daily Living↗
PubMed2006

Lessons in ethnonephrology.

Only recently has the nephrology community moved beyond a fairly singular focus on terminal kidney failure to embrace population-based studies of earlier stages of disease, its markers and risk factors, and of interventions. Observations in developing countries, and in minority, migrant, and disadvantaged groups in westernized countries, have promoted these developments. We are only beginning to interpret renal disease in the context of public health history, social and health transitions, changing population demography, and competing mortality. Its intimate relationships to other health issues are being progressively exposed. Perspectives on the multideterminant etiology of most disease and the pedestrian nature of most risk factors are maturing. We are challenged to reconcile epidemiologic patterns with morphology in diseased renal tissue, and to consider structural markers, such as nephron number and glomerular size, as determinants of disease susceptibility. New work force models are mandated for population-based studies and intervention programs. Intervention programs need to be integrated with other chronic disease initiatives and nested in a matrix of systematic primary care, and although flexible to changing needs, must be sustained over the long term. Cross-disciplinary collaboration is essential in designing those programs, and in promoting them to health-care funders. Substantial expansion and restructuring of the discipline is needed for the nephrology community to participate effectively in those processes.

Developing Countries↗
PubMed2000

The burden of psoriasis: a study concerning health-related quality of life among Norwegian adult patients with psoriasis compared with general population norms.

BACKGROUND: The reduction of disability caused by psoriasis is an important issue in dermatology. It is thus important to assess the patients' appraisal of their health-related quality of life. OBJECTIVE: The aim of the present study was to assess health-related quality of life among patients with psoriasis and to compare these estimates with population norms. METHODS: The samples comprised 283 patients and 2323 control subjects representative of the general Norwegian population. Health-related quality of life was assessed by means of the SF-36. RESULTS: Both demographic and clinical variables, such as age, gender, educational level, hospital setting, comorbidity, and physical symptoms, affected the different SF-36 scales among the patients. After adjustments had been made for age, gender, and educational level, it was seen that psoriasis patients reported significantly lower scores than the normal controls on all scales. The greatest difference was found on the role emotional scale. The smallest difference was found on the health transition scale. CONCLUSION: These results show that psoriasis patients report poorer health-related quality of life than the general population. Therefore patient care of psoriasis must give attention to the impact of the disease on different life domains.

Adult↗
PubMed2001

Temporal trends and ethnic variations in amenable mortality in Singapore 1965-1994: the impact of health care in transition.

BACKGROUND: Amenable mortality is used to assess the effects of health care services on gains in mortality outcomes. Possibly differing patterns of trends in amenable mortality may be expected in economically less developed countries, which have undergone rapid epidemiological transition and recent reforms in health care systems, but such studies are scarce. This study was set up to examine the trends in amenable mortality in Singapore from 1965 to 1994; to estimate the relative impact of medical care and primary preventive policy measures in terms of gains in mortality outcomes; to examine ethnic differences in amenable mortality among Chinese, Malays and Indians. METHODS: Age-standardized mortality rates were calculated for 16 amenable causes of death in Singapore for six 5-year periods (1965-1969,..., 1990-1994), and for each of the three main ethnic groups for three periods (1989-1991, 1992-1994, 1995- 1997). Amenable mortality rates were divided into those which can be reduced by timely therapeutic care for 'treatable' conditions (e.g. asthma and appendicitis), or by primary preventive measures for 'preventable' conditions (e.g. lung cancer and motor vehicle injury). RESULTS: Amenable mortality was higher in males (age-standardized rate 109.7 per 100 000 population) than in females (age-standardized rate 60.7 per 100 000 population). Amenable mortality declined by 1.77% a year in males and 1.72% a year in females. By comparison, the average yearly decline in non-amenable mortality was 0.91% in males and 1.17% in females. The decline in amenable mortality was largely due to 'treatable' causes rather than a decline in mortality due to 'preventable' causes of death. Amenable mortality was lowest for Chinese and highest for Malays. Over the recent 9-year period from 1989 to 1997, amenable mortality declined more in Chinese than in Malays and Indians. However, Indian females showed by far the sharpest decline, whereas Indian males, by contrast, showed an increase in amenable mortality, due to both treatable and preventable causes. CONCLUSIONS: In line with findings from European countries, amenable mortality in Singapore declined more than non-amenable mortality. There were more significant gains in mortality outcomes from medical care interventions than from primary preventive policy measures. Gender and ethnic differences in amenable mortality were also observed, highlighting issues of socioeconomic equities to be addressed in the financing and delivery of health care.

Adolescent↗