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Urbanization and mental health in developing countries: a research role for social scientists, public health professionals and social psychiatrists.

Urbanization in developing countries involves changes in social support and life events which have been shown to affect mental health; mainly depression and anxiety, particularly among low income women. Although depressive and anxiety disorders have a high prevalence and account for a large proportion of visits to primary health services there is little international health research in this field. The determinants, extent and outcome of the association between urbanization and mental health requires multi-disciplinary research by social scientists, social psychiatrists and public health professionals. An appreciation of different conceptual models and associated methods is required before effective research can begin. Other issues such as the avoidance of environmental determinism; the separation of macro-social and micro-social variables; the weakness of urban/rural comparisons of mental health; the role of rural to urban migration; the debates about cross-cultural psychiatry; and the policy-relevance of research, all need consideration in the development of research into this rapidly emerging, but relatively neglected problem.

Community Psychiatry↗

Contracting out of health services in developing countries.

Contracting out is emerging as a common policy issue in a number of developing countries. The theoretical case for contracting out suggests many advantages in combining public finance with private provision. However, practical difficulties such as those of ensuring that competition takes place between potential contractors, that competition leads to efficiency and that contracts and the process of contracting are effectively managed, suggest that such advantages may not always be realized. Most countries are likely only to contemplate restricted contracting of small-scale non-clinical services in the short term. Prerequisites of more extensive models appear to be the development of information systems and human resources to that end. Some urban areas of larger countries may have the existing preconditions for more successful large-scale contracting.

Contract Services↗

Coping with embedded mandibular wisdom teeth in developing countries.

Despite low incidence of embedded mandibular wisdom teeth (third molars) among dental patients in developing countries (less than 100/1,000), the unfavourable patients:dentist ratios, the limited resources and low levels of public awareness render them an important problem to operators in these countries. Since the effectiveness with which they are removed largely depends on the age with respect to the stage of root formation, bone resilience and relationship with adjacent anatomical structures, and the dexterity of the operator, whenever possible, early removal is recommended. To minimise occurrence of non-operative complications that are costly to manage, primary health care workers have a vital role to play in raising levels of awareness and early referral for further evaluation. In view of the risks involved in the removal of these teeth and the small number of trained oral surgeons, continuing education to the dental practitioners, could improve their efficiency in the management of this condition.

Developing Countries↗

Determinants of breastfeeding in developing countries: overview and policy implications.

Breastfeeding can play a major role in fertility regulation in developing countries. The effect of breastfeeding is enhanced when the incidence of breastfeeding is high and the duration extended. These factors are more likely to occur when suckling at the breast is frequent. Sociological and behavioral factors can also influence a woman's decision to initiate and terminate breastfeeding. The effects of urbanization, maternal education, and socioeconomic status act through the intervening variables of sociocultural factors, health services, employment status of women, and availability of breastmilk substitutes. Strategies to alter these intervening variables include educational campaigns and support groups for lactating women, changes in health services, availability of child care facilities near employment centers, and enforcement of the international code of marketing of breastmilk substitutes.

Breast Feeding↗

The problems of valve surgery in a developing country.

The management of young patients with valvular heart disease is a difficult problem in developing countries. At our Institution, 765 valves were operated upon in 523 patients over a period of two years. Rheumatic etiology was seen in 70% of the valves and 60% of all the valves were repaired. The hospital mortality and morbidity in the form of thromboembolic episodes were less in the repair group; 35 valves in 26 patients had to be reoperated upon for instability of the primary repair. Despite this high and early reoperation rate in the repair group and considering the higher mortality plus the problems of anticoagulation and limited durability of bioprostheses in the replacement group, conservation of the patient's own valve remains a better alternative in the long-term.

Adult↗

Paving the way for the introduction of new vaccines into developing countries.

The great advances in vaccine R&D over the last 20 years have not been paralleled by the regular introduction of new vaccines into the market thus far. This situation acquires more dramatic proportions in developing countries, where preventable infectious diseases still impose a major public health problem. Furthermore, most of the new developments are being conceived to target the market of industrialized countries and it is foreseeable that their introduction in low-to-middle income countries will be difficult if at any time possible. Strengthening their own capacities for R&D and production is likely to be the most reasonable avenue to ensure that new vaccines will become a sustainable reality for developing countries. Concerted efforts that draw together local capacities (industry and academy) with the experience of large global manufacturers, could have a major impact and provide a great example of an effective partnership to achieve this.

Developing Countries↗

Factors controlling the spread of HIV in heterosexual communities in developing countries: patterns of mixing between different age and sexual activity classes.

The paper describes the development and analysis of a mathematical model of the spread and demographic impact of HIV in heterosexual communities in developing countries. The model extends previous work in this area by the representation of patterns of mixing between and within different age and sexual activity classes in a two sex structure. Summary parameters are derived to represent different mixing patterns, ranging from assortative via random to disassortative, as are methods to ensure that particular mixing patterns between different age and sexual classes (stratified on the basis of rates of sexual partner change) meet constraints that balance the supply and demand for sexual partners as AIDS induced mortality influences the demographic structure of a population. Analyses of model behaviour rely on numerical methods due to the complexity of the mathematical framework, and sensitivity analyses are conducted to assess the significance of different assumptions and different parameter assignments. Simulated patterns of HIV spread across the two sexes and various age classes are compared with observed patterns in Uganda. The principle conclusion of the study is that the pattern of mixing between age and sexual activity classes, combined with the assumptions made to balance supply and demand between the sexes have a very major influence on the predicted pattern of HIV spread and the demographic impact of AIDS. The paper ends with a discussion of future needs in model development and data acquisition.

Acquired Immunodeficiency Syndrome↗

Clinical survey techniques to estimate prevalence and annual incidence of poliomyelitis in developing countries.

Recent epidemiological data suggest that poliomyelitis is a more important public health problem in developing countries than was originally suspected. Because of the availability of a cheap, effective, but labile oral vaccine, it is important that countries determine the incidence of poliomyelitis in order to determine the necessity and speed with which a vaccination programme should be introduced.Sequelae of poliomyelitis are distinctive and can be used to study the incidence of residual paralysis in children above the age of 5 years. Prevalence data for lameness due to poliomyelitis can then be translated into rates of annual incidence of paralytic disease. Lameness surveys can be efficiently done in schools and data are reliable as long as a similar search for lame children is done amongst children of the same age group who do not attend school but are in the geographical area served by the school. House-to-house surveys, while more time-consuming, are more reliable.

Adolescent↗

Recurrent costs in the health sector of developing countries.

Widespread concern exists about the recurrent cost problems faced in the health sector of developing countries, and about the difficulties likely to be faced in the 1990s and beyond in seeking to expand further the movement to primary health care. The article accepts that the problem is a real one, and seeks first to define and measure it, and to put together some of the evidence on the scale of the problem. Next, the analysis involves an examination of its causes, and hence its solutions, exploring in some detail issues of budgetary control, management decision making, project selection, and the prospects for mobilizing additional recurrent funds to, and within, the health sector. The article concludes by drawing attention to the complex aetiology of the recurrent cost problem, and offers a five-point plan of action if the problem is to be tackled seriously.

Capital Expenditures↗

The epidemiological features of heart failure in developing countries: a review of the literature.

Cardiovascular diseases are increasingly recognised as an important cause of morbidity and mortality in developing countries. This is due to the ageing of the population and better control of communicable disease and malnutrition. We review the published data on the epidemiology of heart failure in such countries. Rheumatic heart disease remains a major cause of heart failure in Africa and Asia, especially in the young. Hypertension is an important cause of heart failure especially in the African and African-American population. Chagas' disease is still a cause of heart failure in South America. However, as countries go through epidemiological transition and undergo socio-economic development, the epidemiology of heart failure becomes increasingly similar to that of Western Europe and North America with coronary artery disease being the single most common cause of heart failure. Preventive and public health strategies need to be specific to the local epidemiological characteristics.

Africa↗

Appliances and surgery for poliomyelitis in developing countries.

Death before maturity is the usual fate of the untreated crawling crippled child in developing countries. Most children with poliomyelitis, however, when upright and walking with supports or following surgery, are accepted by the community, educated by parents and relatives, and employable when they reach maturity. It is more economical to prevent 100 polio cases than to treat one hopelessly crippled child. It is often quicker to straighten 100 deformed limbs by simple subcutaneous surgeries than to treat a single patient with complicated procedures. It costs less for 100 crawling paralyzed children to walk in simple, locally made braces and clogs, than for 1 patient to be mobile in expensive imported appliances and boots. It is essential to educate or rehabilitate patients in addition to making them mobile. The final aim should be patients returned to their own village or town, accepted and integrated into their own communities, and earning their own living among their own friends. This chapter is discussed in further detail in both English and French in my Website, . This site also includes comprehensive information on both the manufacture of the simple appliances described and various surgical details. This information is also available on CD-ROM.

Adolescent↗

Randomised placebo-controlled trials and HIV-infected pregnant women in developing countries. Ethical imperialism or unethical exploitation?

The maternal-fetal HIV transmission trials, conducted in developing countries in the 1990s, undoubtedly generated one of the most intense, high profile controversies in international research ethics. They sparked off a prolonged acrimonious and public debate and deeply divided the scientific community. They also provided an impetus for the revision of the Declaration of Helsinki--the most widely known guideline for international research. In this paper, I provide a brief summary of the context, outline the arguments for and against the controversial use of placebo controls, and focus on particular areas that I believe merit further discussion or clarification. On balance, I argue that the researchers failed in their duties to protect the best interests of their research subjects, and to promote distributive justice. I discuss the difficulties of obtaining valid consent in this research context, and argue that it is unethical to inform women of their HIV status without at least offering them prophylactic treatment for their unborn children. A global view of justice, which endorses international equity, cannot be squared with international research guidelines that allow 'local conditions' to define the scope of duty to the control group. Finally, I suggest that the heated debate reflects a tension, if not an outright war, between two conflicting meta-ethical systems, or incommensurable paradigms, that underpin scientific research involving human subjects.

Developing Countries↗

Intensive care needs of children with acute bacterial meningitis: a developing country perspective.

In view of very limited availability of paediatric intensive care (PIC) facilities in developing countries, it is important to define priorities and recognise children who might benefit most from PIC. The objective of this retrospective, descriptive analysis was to identify the clinical indicators for intensive care in children with acute bacterial meningitis (ABM). The study included 220 children aged between 1 month and 12 years with ABM admitted to the paediatric services of an urban, tertiary-care, teaching hospital in northern India from July 1993 to December 1996. Of these, 88 were transferred to the PICU by the primary physician, 59% were comatose (Glasgow coma score <8), 44% had raised intracranial pressure (ICP), 24% were in shock and 42% had respiratory distress/failure. Seizures occurred during their illness in 64 children, 34 of whom had refractory status epilepticus. Endotracheal intubation was needed in 29 and ventilatory support in 19 children. Most of the life support measures were required during the initial 48 hours. Nineteen (22%) children died, 16 of whom were comatose on admission. Multiple system involvement was associated with higher mortality. There were no deaths among the children who were not transferred to the PICU. Children with ABM who have a Glasgow coma score <8, clinical signs of raised ICP, refractory status epilepticus, shock and/or respiratory compromise should be prioritised to receive PIC.

Acute Disease↗

Is peritoneal dialysis adequate for hypercatabolic acute renal failure in developing countries?

BACKGROUND: Peritoneal dialysis (PD) is a therapeutic option for acute renal failure (ARF) in developing countries, despite concerns about inadequacy. Shorter and more efficient tidal peritoneal dialysis (TPD) was compared with continuous equilibrating peritoneal dialysis (CEPD) therapy in ARF by using their adequacies as accepted standards and analyzing the solute reduction indices (SRI). METHODS: A prospective, randomized crossover trial was performed in patients with mild to moderate hypercatabolic ARF who were assigned to CEPD and TPD therapy after an adequate washout period. Solute clearances (Kt/V, normalized creatinine clearances) were compared to NKF guidelines. Potassium and phosphate clearances, dextrose absorption, protein losses and costs were compared. Kt/V was compared to SRIdialysate, SRIKt/V. RESULTS: Eighty-seven patients with ARF received 236 sessions of dialysis (118 in each treatment). TPD resulted in higher clearances of solutes than CEPD (creatinine and urea clearances in mL/min of 9.94 +/- 2.93, 6.74 +/- 1.63 and 19.85 +/- 1.95, 10.63+/- 2.62, respectively, P=0.001). TPD and CEPD normalized creatinine clearances (L/week/1.73 m2 BSA) and Kt/V values were 68.5 +/- 4.43, 58.85 +/- 2.57 and 2.43 +/- 0.87, 1.80 +/- 0.32, respectively. CEPD did not meet standards of adequacy. TPD resulted in greater potassium and phosphate clearances, less dextrose absorption and was less expensive. CEPD resulted in less protein loss. Kt/V corresponded to SRIdialysate 0.88 +/- 0.12 (P=0.076). CONCLUSION: TPD produced higher solute clearances in less time with greater protein loss. CEPD just fell short to meet the dialysis adequacy standard. However, both TPD and CEPD are reasonable options for mild-moderate hypercatabolic ARF. Kt/V appropriately estimates solute removal in PD.

Acute Kidney Injury↗

Referral and previous care of children with meningitis in Nigeria: implications for the presentation and outcome of meningitis in developing countries.

There is a paucity of data on the referral of children with meningitis in developing countries, and on the relationship of presentation and outcome to previous care. Referral and previous care were investigated in 281 post-neonatal children treated in two tertiary centres. Data were obtained through the review of referral notes from orthodox health facilities, interview of parents/guardians and review of admission notes. Forty-four (16%) children were facility-referred and 81 (29%) self-referred from orthodox facilities while 156 (55%) were self-referred without previous care in these facilities. The facility-referrals (n=44) included 19 (43%) with meningitis on treatment, 13 (30%) with suspected meningitis and 12 (27%) with unsuspected meningitis. Twenty-two (50%) were referred because of deterioration, partial response or non-response to treatment, 5 (11%) on request by the parents, 9 (21%) on the suspicion of meningitis or other neurological disorder and 7 (16%) for mixed reasons. No reason was given in 1 case of meningitis on treatment. Among the 19 children referred with meningitis on treatment, only 1 was referred within 24 h of diagnosis, a confirmatory lumbar puncture was done only in 7, and only 10 of 18 (no data in 1 case) were on reasonably appropriate antibiotic regimens. Previous care in orthodox facilities was significantly associated with delayed presentation (>3 days of illness, p<0.001), partial treatment (p<0.001), lack of typical signs (p<0.05), severe illness (p<0.01), and adverse outcome (death or recovery with neurological sequelae, p<0.05). Limited recognition of the possibility of meningitis in acutely ill children and an inadequate referral practice may account for these effects. A clear delineation of referral needs might reduce the magnitude of these problems.

Child, Preschool↗

Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials.

BACKGROUND: Zinc deficiency is prevalent in children in developing countries. Supplemental zinc provides therapeutic benefits in diarrhea. OBJECTIVE: We sought to measure the effect of supplemental zinc given with oral rehydration therapy during recovery from acute or persistent diarrhea. DESIGN: We conducted pooled analyses including all available published and unpublished randomized controlled trials of the effects of supplementary oral zinc in children aged <5 y with acute or persistent diarrhea. We used Cox survival regression analysis to evaluate the overall effect of zinc on continuation of diarrhea and possible differential effects in subgroups divided by sex, age, weight-for-height, and initial plasma zinc concentration. Dichotomous outcomes were analyzed by logistic regression. To assess the effects of excluding studies without original data from the pooled analyses, effect-size was estimated for all studies by using random-effects models. RESULTS: Zinc-supplemented children had a 15% lower probability of continuing diarrhea on a given day (95% CI: 5%, 24%) in the acute-diarrhea trials and a 24% lower probability of continuing diarrhea (95% CI: 9%, 37%) and a 42% lower rate of treatment failure or death (95% CI: 10%, 63%) in the persistent-diarrhea trials. In none of the subgroup analyses were the 2 subgroups of each pair significantly different from each other; however, in persistent diarrhea there tended to be a greater effect in subjects aged <12 mo, who were male, or who had wasting or lower baseline plasma zinc concentrations. CONCLUSION: Zinc supplementation reduces the duration and severity of acute and persistent diarrhea.

Acute Disease↗

Cancer pain management in developing countries: a mosaic of complex issues resulting in inadequate analgesia.

Cancer pain is often undertreated even in developed countries with abundant resources and easy access to oral, parenteral, and transdermal opioids. The problems in developing nations are more complex, and as a result, these medications are not available to the vast majority of patients in Latin and South America, Eastern Europe, Asia, and Africa. Some of the reasons for this are reviewed, with India cited as a case example. In spite of serious efforts by the World Health Organization and other bodies to make oral opioids available and to educate government officials and physicians, little progress has been made in relieving pain in cancer patients in the developing world. Novel approaches that address fundamental concerns regarding opioid availability in these countries are desperately needed. One such approach, which is currently under development, is presented in this manuscript. This has the potential to make opioids available to patients in rural areas, improve compliance in the poorly educated patient, reduce the number of follow-up visits necessary for medication refills, and reduce the risk that opioids will be diverted to illicit channels. The potential for relieving cancer pain and the magnitude of this problem worldwide make it imperative that innovative approaches be tailored to the complex social issues and limited resources common to developing nations.

Developing Countries↗