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The use and value of qualitative methods in health research in developing countries.

Qualitative and quantitative research methods for public health were integrated in the past. Work at the Polela Health Center and the Institute of Family and Community Health (South Africa) in the 1940's epitomized how true integration was possible. Since the 1950's the growth of disciplines and boundaries between them; the growing emphasis by funding agencies on quantitative research that yields results rapidly at low cost and the dominance of the medical profession in public health together resulted in a separation of approaches. Recently, recognition of the need for integrated approaches has reemerged but the capacity to conduct appropriate research in developing countries is weak and they have relied on importing both researchers and their methods. Examples are given (mainly using focus group methods) of how innovative integrated approaches in developing countries have been used to implement community diagnoses, understand factors affecting health service utilization and identify factors amenable to intervention. It is concluded that while qualitative methods are needed (and used) in developing countries, their use will only increase if appropriate training initiatives in developing countries are undertaken.

Cross-Cultural Comparison↗

Public investment in strengthening Veterinary Services and other food safety authorities: issues affecting developed and developing countries.

During the negotiation of the Agreement on the Application of Sanitary and Phytosanitary Measures (the SPS Agreement), there was clear recognition of the problems that developing countries would face in complying with the SPS Agreement. The agreement included provisions related to technical assistance and special differential treatment for developing countries. Both topics are discussed in the SPS Committee as a regular agenda item and have been subject to substantive consideration during both reviews of the SPS Agreement, in 1999 and latterly in 2005. The SPS Committee is currently considering proposals to make these provisions more precise, effective and operational. The Standards and Trade Development Facility (STDF) was formally established in mid-2002 by the Food and Agriculture Organization, World Organisation for Animal Health (OIE), World Bank, World Health Organization and World Trade Organization as a financing and coordinating mechanism. The STDF maintains a database which provides information on SPS-related technical assistance and capacity-building projects. From the limited data gathered, it would appear that the focus of the technical assistance provided so far has been knowledge transfer. Only a small minority of the projects reported deal with the strengthening of hard infrastructure such as laboratory facilities. It is also clear that in terms of the overall number and value of projects, animal health lags well behind the food safety sector. The World Bank estimates that annual expenditure by donor agencies on trade-related SPS programmes has been running at some USdollars 65 million to USdollars 70 million annually. However, there is under-reporting of technical cooperation activities in the STDF database.

Animals↗

Measuring health inequality among children in developing countries: does the choice of the indicator of economic status matter?

BACKGROUND: Currently, poor-rich inequalities in health in developing countries receive a lot of attention from both researchers and policy makers. Since measuring economic status in developing countries is often problematic, different indicators of wealth are used in different studies. Until now, there is a lack of evidence on the extent to which the use of different measures of economic status affects the observed magnitude of health inequalities. METHODS: This paper provides this empirical evidence for 10 developing countries, using the Demographic and Health Surveys data-set. We compared the World Bank asset index to three alternative wealth indices, all based on household assets. Under-5 mortality and measles immunisation coverage were the health outcomes studied. Poor-rich inequalities in under-5 mortality and measles immunisation coverage were measured using the Relative Index of Inequality. RESULTS: Comparing the World Bank index to the alternative indices, we found that (1) the relative position of households in the national wealth hierarchy varied to an important extent with the asset index used, (2) observed poor-rich inequalities in under-5 mortality and immunisation coverage often changed, in some cases to an important extent, and that (3) the size and direction of this change varied per country, index, and health indicator. CONCLUSION: Researchers and policy makers should be aware that the choice of the measure of economic status influences the observed magnitude of health inequalities, and that differences in health inequalities between countries or time periods, may be an artefact of different wealth measures used.

Journal Article↗

Effects of rapid increase in motorization levels on road fatality rates in some rich developing countries.

Road fatality rates in some rich developing countries (R.D.C.) are studied and compared with those of some industrialized countries (I.C.F.) during the fifties when their motorization levels and rates are comparable. It was found that fatalities per vehicle in both the R.D.C. and I.C.F. relate inversely to motorization levels (vehicles per population). It was also found that the power of the inverse relation correlates with motorization rates. Specifically, slow decrease in fatality rates are associated with rapid increases in motorization levels, the strength of the association being greater in the case of the R.D.C.

Accidents, Traffic↗

Vitamin K prophylaxis in less developed countries: policy issues and relevance to breastfeeding promotion.

Vitamin K prophylaxis prevents hemorrhagic disease of the newborn. The present review estimates the potential magnitude of this problem in less developed countries, assessing the need for prophylaxis, along with its cost-effectiveness and feasibility. Late hemorrhagic disease, occurring between 2 and 12 weeks, often leads to death or permanent disability. Its median incidence in developed countries is 7 per 100,000 births. Incidences in less developed countries may be much higher. Three incidence scenarios are proposed and the corresponding losses of disability-adjusted life-years (DALYs) calculated. Under the intermediate scenario, late hemorrhagic disease accounts for 0.1% to 0.2% of DALYs lost to children less than 5 years of age. Assuming a cost of +1.00 per injection, each DALY saved would cost +133. Decisions on prophylaxis must be made on a national basis, considering mortality levels and causes, health budgets, and feasibility. Comparison with the impact of diseases prevented by breast-feeding shows that concern with hemorrhagic disease should not affect breast-feeding promotion efforts, although strategies for supplementing breast-fed infants must be explored.

Breast Feeding↗

Training of health workers for developing countries.

The training of health workers for developing countries should include emphasis on preventive as well as curative medicine. It should also include the inculcation of concern for the feelings and needs of patients including their own beliefs and practices relating to disease, time constraints in coming either alone or with young children for clinic visits and the limited funds available to them for purchase of medicine. They must also be given the chance to work in a well organized system and must be adequately remunerated.

Cultural Characteristics↗

[Obstetric-gynecologic problems in the developing countries].

The integrated health programmes in the developing countries give priority to the improvement of women's living conditions and of maternal and child health medical attention. The Authors, as specialists in Obstetrics and Gynecology active in an African country, present the most frequent pathological situations which, in their experience, can lead to the death of the pregnant woman. The social reality of the underdeveloped world and the high Total Fertility rates, due partly to the absence of a contraceptive culture, too often see the woman of reproductive age threatened by the complication deriving from abortion, ectopic pregnancy and labour. The obstetrician needs to know how to solve these emergencies and how to train the local personnel in order to guarantee as much as he can the essential obstetrical functions.

Child Health Services↗

Socioeconomic status and obesity in adult populations of developing countries: a review.

A landmark review of studies published prior to 1989 on socioeconomic status (SES) and obesity supported the view that obesity in the developing world would be essentially a disease of the socioeconomic elite. The present review, on studies conducted in adult populations from developing countries, published between 1989 and 2003, shows a different scenario for the relationship between SES and obesity. Although more studies are necessary to clarify the exact nature of this relationship, particularly among men, three main conclusions emerge from the studies reviewed: 1. Obesity in the developing world can no longer be considered solely a disease of groups with higher SES. 2. The burden of obesity in each developing country tends to shift towards the groups with lower SES as the country's gross national product (GNP) increases. 3. The shift of obesity towards women with low SES apparently occurs at an earlier stage of economic development than it does for men. The crossover to higher rates of obesity among women of low SES is found at a GNP per capita of about US$ 2500, the mid-point value for lower-middle-income economies. The results of this review reinforce the urgent need to: include obesity prevention as a relevant topic on the public health agenda in developing countries; improve the access of all social classes in these countries to reliable information on the determinants and consequences of obesity; and design and implement consistent public actions on the physical, economic, and sociocultural environment that make healthier choices concerning diet and physical activity feasible for all. A significant step in this direction was taken with the approval of the Global Strategy on Diet, Physical Activity and Health by the World Health Assembly in May 2004.

Adult↗

[Adult mortality in developing countries: a global overview].

"The article analyzes [selected] developing countries with reliable information on adult mortality between ages 15 and 65 years....A brief analysis of each country indicates the following aspects. Females maintained a more sustained and systematic decline of adult mortality than males. There are some countries that in spite of reasonable development, as Mexico, still have a great excess of male mortality in relation to other countries. Finally, some countries experienced a stagnation of the male mortality decline, while females continued benefiting from a decline of mortality." (SUMMARY IN ENG)

Adult↗

Helicobacter pylori infection in children with abdominal ailments in a developing country.

Helicobacter pylori commonly infects children in developing countries. To determine the frequency of this infection and its potential role in specific gastrointestinal entities, all patients requiring upper gastrointestinal endoscopy for the evaluation of abdominal ailments in a gastroenterology practice in Lima, Peru, were evaluated during a 1-year period. Gastric biopsies were obtained for each child and were stained with hematoxylin-eosin and Warthin-Starry stains. Of the 107 evaluable patients (mean age 7.4 years, 58% boys), 52 (49%) were infected. The infection rate increased with older patients (P = 0.004). Children with recurrent abdominal pain (P = 0.04), an endoscopic finding of nodular gastritis (P = 0.007), and a histologic finding of chronic active gastritis (P < 0.0001) were infected more commonly.

Abdominal Pain↗

Training needs and services for elderly care in developing countries: models from Romania, Barbados and Kuwait.

Developing countries are facing multiple problems in establishing and funding sociomedical services for the elderly. This study outlines the need for such services especially in the transitional stage of urbanization, changes in the structure and role of families, and the inadequate resources for establishing community-based elderly care programs. The study focuses on the analysis of human resource needs for training of the different categories of health workers, both educational degree and non-degree training for elderly care programs. It proposes an integrated approach for short-term training of physicians, nurses, and social workers. This concept was accepted and adopted by the Expert Group Meeting of the International Institute on Aging in Malta, 1989. The study also presents applications of this model in Romania, Barbados, and Kuwait.

Aged↗

Pre-eclampsia and the HELLP syndrome still cause maternal mortality in The Netherlands and other developed countries; can we reduce it?

Maternal mortality in developed countries does not seem to have decreased during the past decade, despite good prenatal care. Hypertensive disorders of pregnancy are the main cause of maternal mortality in most countries. In more than half of these cases, the HELLP syndrome is involved. In this article attention is drawn again to the life-threatening complications that might occur in cases of pre- eclampsia and the HELLP syndrome. Two case histories with fatal outcomes are described to provide extra emphasis. The literature indicates that some cases of maternal mortality might be avoidable. From a review of the literature, suggestions and recommendations are made about how to achieve a decrease in maternal mortality from pre-eclampsia/the HELLP syndrome. The most important are the making of an early, correct diagnosis, anticipating the possibilities of serious complications, and, if necessary, early referral to a regional centre with special expertise.

Adult↗

Aspects of stress among traditionally living people in a developing country.

Stress situations are present in a developing country, and a few of the common problems usually seen by a GP are briefly described. Causes of emotional stress include: (a) interpersonal differences between family members, neighbours, etc.; (b) differences with ancestral spirits; (c) going against accepted traditional taboos; (d) differences with traditional leaders, chiefs, traditional healers (inyangas) and people who cast spells. The clinical presentation includes (a) conversion syndrome (hysteria); (b) headache; (c) inexplicable pains; (d) 'something moving up and down in one's body; (e) palpitations; (f) pain in the heart; (g) symptoms of depression; and (h) frank psychosis. Diagnosis may be difficult and is usually by exclusion. Gaining the confidence of the patient is important; ignorance of the patient's language and customs puts the doctor at a disadvantage. Where symptoms are of long standing, treatment is difficult, prognosis poor, and most cases need to be referred to a psychiatrist.

Black or African American↗

[Combined vaccines in veterinary medicine in the developing countries].

It is in the interest of developing countries to have combined vaccines in veterinary medicine, not so much because they reduce production costs, but rather because they increase convenience and efficacy concerning the logistics of prophylactic projects in the field, thus lowering the cost of these projects. Their drawbacks are basically due to the biological compatibility of immunogens (possible immunosuppression by some viruses) and to the interaction of the various components when mixed, or when lyophilization is carried out. Some examples of such associations of vaccines are: (1) cattle plague + pleuropneumonia and possibly anthrax, (2) anthrax + blackleg, (3) sheeppox + anthrax, (4) pleuropneumonia + blackleg, (5) Newcastle disease + fowlpox + fowl typhoid, (6) fowl typhoid + chicken pasteurellosis. Practical results have been most positive and include the eradication of cattle plague - a major scourge of almost all of the African continent - and control over peripneumonia as a first step towards its eradication.

Africa↗

Problems and pitfalls in developing countries.

Despite major challenges, in the last decade several epilepsy centers in the developing world have successfully implemented epilepsy surgery programs and produced results comparable to those from developed countries. If the program is to have a lasting impact, it would be essential to work with and educate the local professionals and public about the recent advances in the treatment of epilepsies. The epilepsy surgery centers in developing countries should initially restrict their surgical candidates to patients with mesial temporal lobe epilepsy and those with circumscribed potentially epileptogenic lesions in whom the epileptogenic zone can be unquestionably localized by using locally available relatively inexpensive and noninvasive technologies, and in whom an excellent postoperative outcome can be guaranteed. It is important for such epilepsy center to assess its capabilities and limitations regularly and adopt a stepwise progressive approach to increasing levels of complex presurgical evaluation and surgical treatment strategies.

Developing Countries↗

Human aflatoxicosis in developing countries: a review of toxicology, exposure, potential health consequences, and interventions.

Aflatoxins are well recognized as a cause of liver cancer, but they have additional important toxic effects. In farm and laboratory animals, chronic exposure to aflatoxins compromises immunity and interferes with protein metabolism and multiple micronutrients that are critical to health. These effects have not been widely studied in humans, but the available information indicates that at least some of the effects observed in animals also occur in humans. The prevalence and level of human exposure to aflatoxins on a global scale have been reviewed, and the resulting conclusion was that approximately 4.5 billion persons living in developing countries are chronically exposed to largely uncontrolled amounts of the toxin. A limited amount of information shows that, at least in those locations where it has been studied, the existing aflatoxin exposure results in changes in nutrition and immunity. The aflatoxin exposure and the toxic affects of aflatoxins on immunity and nutrition combine to negatively affect health factors (including HIV infection) that account for >40% of the burden of disease in developing countries where a short lifespan is prevalent. Food systems and economics render developed-country approaches to the management of aflatoxins impractical in developing-country settings, but the strategy of using food additives to protect farm animals from the toxin may also provide effective and economical new approaches to protecting human populations.

Aflatoxins↗

Designing a prehospital system for a developing country: estimated cost and benefits.

Many of the costs associated with prehospital care in developed countries are covered in budgets for fire suppression, police services, and the like. Determining these costs is therefore difficult. The costs and benefits of developing a prehospital care system for Kuala Lumpur, Malaysia, which now has essentially no emergency medical services (EMS) system, were estimated. Prehospital therapies that have been suggested to decrease mortality were identified. A minimal prehospital system was designed to deliver these treatments in Kuala Lumpur. The potential benefit of these therapies was calculated by using statistics from the United States corrected for demographic differences between the United States and Malaysia. Costs were extrapolated from the current operating budget of the Malaysian Red Crescent Society. Primary dysrhythmias are responsible for almost all potentially survivable cardiac arrests. A system designed to deliver a defibrillator to 85% of arrests within 6 minutes would require an estimated 48 ambulances. Kuala Lumpur has approximately 120 prehospital arrhythmic deaths per year. A 6% resuscitation rate was chosen for the denominator, resulting in seven survivors. Half of these would be expected to have significant neurological damage. Ambulances cost $53,000 (US dollars) to operate per year in Kuala Lumpur; 48 ambulances would cost a total of $2.5 million. Demographic factors and traffic problems would significantly increase the cost per patient. Other therapies, including medications, airway management, and trauma care, were discounted because both their additional cost and their benefit are small. Transport of patients (including trauma) is now performed by police or private vehicle and would probably take longer by ambulance. A prehospital system for Kuala Lumpur would cost approximately $2.5 million per year. It might save seven lives, three of which would be marred by significant neurological injury. Developing countries would do well to consider alternatives to a North American EMS model.

Arrhythmias, Cardiac↗

Dioxins and related compounds in human breast milk collected around open dumping sites in Asian developing countries: bovine milk as a potential source.

In this study, concentrations of dioxins and related compounds (DRCs)--such as polychlorinated dibenzo- p-dioxins, polychlorinated dibenzofurans, and coplanar polychlorinated biphenyls--were found in human breast milk from women living near dumping sites of municipal waste and reference sites in India, Cambodia, Vietnam, and the Philippines during 1999 to 2000. DRCs were detected in all human breast milk samples analyzed, demonstrating that residents in these Asian developing countries have been exposed to these contaminants. In India, the concentrations of DRCs in human breast milk from women living near the investigated dumping site were notably higher than those from women living near reference sites and from women in other Asian developing countries. Toxic equivalent quantity (TEQ) levels of DRCs were comparable with or higher than those reported in the general populations of developed countries since 1990. In contrast, levels of these contaminants in human breast milk in women from Cambodia and Vietnam were not significantly different between milk from women living near the dumping and reference sites. These results indicate that significant pollution sources for DRCs are present in Indian dumping sites and that residents there have been exposed to relatively higher levels of these contaminants. TEQ levels in human breast milk from the dumping site in India tended to decrease with an increase in the number of previous deliveries by mothers, whereas no significant relationship was observed in Cambodia, Vietnam, or the Philippines. This suggests that mothers who have been exposed to relatively high levels of DRCs transfer greater amounts of these contaminants to the first infant than later ones through breast-feeding, which in turn implies that the first children of these mothers might be at higher risk from DRCs. When the residue levels of DRCs in bovine milk collected from the Indian dumping site and reference sites were examined, TEQ levels in bovine milk from the dumping site were higher than those from reference sites. This result suggests that bovine milk is a potential source of DRCs for residents living near the dumping site in India. To our knowledge, this is the first comprehensive study on exposure to DRCs of residents living in proximity to open dumping sites of municipal waste in Asian developing countries.

Adolescent↗