Geneva Health Forum Archive

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Social inequalities in overall and cause specific mortality in Seychelles.

Author(s) Silvia Stringhini1, Valentin Rousson2, Bharathi Viswanathan3, Jude Gedeon 4, Fred Paccaud 5, Pascal Bovet6.
Affiliation(s) 1IUMSP, CHUV, Lausanne, Switzerland, 2IUMSP, CHUV, Lausanne, Switzerland, 3Ministry of Health, Ministry of Health, Victoria, Seychelles, 4Ministry of Health, Ministry of Health, Victoria, Seychelles, 5IUMSP, CHUV, Lausanne, Switzerland, 6IUMSP, CHUV, Lausanne, Switzerland.
Country - ies of focus Seychelles
Relevant to the conference tracks Social Determinants and Human Rights
Summary Low socioeconomic status is associated with higher risk of overall and cause specific mortality in a country of the African Region.
Background Low socioeconomic status (SES) is consistently associated with higher mortality in high income countries. Only few studies have assessed this association in low and middle income countries, mainly because of sparse reliable mortality data.
Objectives This study explores SES differences in overall and cause-specific mortality in the Seychelles, a rapidly developing small island state.
Methodology All deaths have been medically certified for more than two decades. SES and other health risk factors were assessed in a total of 3246 participants from three independent population-based surveys conducted in 1989, 1994 and 2004. Vital status was ascertained using linkage with vital statistics. Occupational position was assessed using the same questions in the three surveys.
Results During a mean follow-up of 15.0 years (range 0-23 years), 523 participants died (overall mortality rate 10.8 per 1000 person-years). The main causes of death were cardiovascular disease (CVD) (219 deaths) and cancer (142 deaths). Participants in the low SES group had a larger mortality risk overall (HR=1.80; 95% CI: 1.24-2.62), CVD (HR=1.95; 1.04-3.65) and larger non-cancer/non-CVD (HR=2.14; 1.10-4.16) mortality compared to participants in the high SES group. Cancer mortality also tended to be patterned by SES (HR=1.44; 0.76-2.75). Major lifestyle-related risk factors (smoking, heavy drinking, obesity, diabetes, hypertension, hypercholesterolemia) explained 25%, 11% and 19% of the associations between low SES and all-cause, CVD, and non-cancer/non-CVD mortality, respectively.
Conclusion In this population-based study assessing social inequalities in mortality in the African region, low SES was strongly associated with overall, CVD and non-cancer/non-CVD mortality. Our findings support the view that the burden of non-communicable diseases may disproportionally affect the poor in low and middle income countries.

How well do we know the “users” of health interventions? The example of (non-)enrolment in voluntary community-based health insurance schemes in Mali.

Author(s) Alexander Schulze1.
Affiliation(s) 1Global Health, Novartis Foundation for Sustainable Development, Basel, Switzerland.
Country - ies of focus Mali
Relevant to the conference tracks Social Determinants and Human Rights
Summary For health interventions to be successful, not only the health system needs to be considered, but also the patients understood. However, often in health research this understanding is reduced to their socio-economic status.
The present empirical study, focusing on the reasons for (non-) enrolment in voluntary health insurance schemes in rural Mali, expands the analysis of household characteristics to sociocultural orientations and intra-familial structures, including decision-making patterns.
The results reveal that the socio-economic status of households does not explain membership in a health insurance scheme, whereas the attitudes heads and family decision making patterns clearly do.
Background Systematic, quantitative evidence on user characteristics of health interventions is mostly limited to socio-demographic features and economic status. Yet, as research in medical anthropology has revealed, the acceptance of health related innovations is not only dependent on these factors.The example of (non-)enrolment in voluntary health community-based insurance schemes in sub-Saharan Africa mirrors this research gap. These schemes are characterized by modest enrolments rates and do not tap their potential in an already limited catchment area. In order to increase their coverage, the reasons for (non-)enrolment need to be better understood.However, to date, research has focused on the supply side, i.e. features of the insurance schemes and their contracted providers. On the demand side, comparative studies of enrolled and non-enrolled households have mainly concentrated on their socioeconomic status.Three research gaps remain which are not unique to the analysis of community-based health insurance: 1) sociocultural features are not analyzed in a quantifiable manner as socio-economic characteristics are. 2) household and family structures and their decision making patterns are not considered. Thirdly, significant factors are not explained and related to each other.
Objectives The present empirical study aims to fill the following research gaps:1) to expand the analysis of household characteristics beyond households’ socio-economic status by also taking account of their sociocultural orientations and intra-familial structures, including decision-making patterns. The main hypothesis underlying this approach is that socio-economic differences have been overestimated regarding their importance in determining the uptake of innovations, i.e. in the presented case membership in health insurance schemes, whereas attitudes and values, such as openness to or mistrust of social innovations, have been underestimated.2) A further goal is to systematically bring together and interrelate influencing factors that are meaningful beyond statistical significance, in order to ultimately reveal different lifestyle patterns associated with membership in, or refusal to join, a health insurance scheme.3) A further aim of this study is to present an analytical framework that links the socio-economic characteristics of households with their sociocultural orientations as well as with household and family structures.
Methodology A mixed methods approach, with different instruments employed sequentially, was developed. The central rationale behind a mixed-methods approach of this type was the idea to use qualitative methods of data collection not only in the exploratory phase but also at a later stage, to enhance interpretation of results from quantitative statistical data analysis and to develop explanatory patterns.The core element of the mixed methods approach chosen was household surveys on lifestyle patterns and social protection strategies. A total of 600 heads of households were interviewed in two localities. Of these, in each locality 200 had no insurance, while 100 did have insurance. In a second survey round, half of these household heads were again interviewed about their social protection strategies. In each study area this round covered 100 households with insurance and 50 households with no insurance.Households were the focus of research for two reasons: on the one hand, they are the unit of membership in the community-based health insurance schemes being studied. On the other hand, households are important repositories of lifestyle patterns within society and have a great degree of influence on the activities of their members. This is manifested, for example, in the transmission of values between generations and in the sharing of resources. Moreover, households are units of decision-making in different areas of life.Comparison of two rural areas in Mali had been considered useful insofar as community-based health insurance schemes are being advocated for peasant populations, primarily in French-speaking Africa. Furthermore, the two localities differ in terms of climate and in socio-economic and sociocultural terms but have a very similar health insurance scheme. Comparison of two areas also made it possible to examine to what extent social differences exist in rural Mali.

The household surveys were preceded by an exploratory phase including group and individual discussions, which primarily served to identify locally relevant categories of social differentiation. Following the household surveys, preliminary results were presented to representatives from the municipalities. These discussions brought out new points of view that were of use in further data collection and analysis. Following this, 20 group discussions and 24 individuals from selected families were interviewed in order to obtain insights into household and family decision-making patterns.

Results The results reveal that the socio-economic status of households does not explain membership in a community-based health insurance scheme, whereas the attitudes of household heads and family decision-making patterns clearly do. For instance, households of the lower socioeconomic tercile were even slightly more likely to be members than those of the middle tercile (p-value: 0.669; CI: .63-2.02; OR: 1.13).Households that are single households or are not part of a large family have greater freedom in decision-making. Moreover, heads of households with insurance appreciate different social changes (e.g. existence of new, formal organizations including community-based health insurance schemes), take on responsible roles in their communities and plan in a manner where the benefit is unsure or not immediately given, significantly more often than heads of uninsured households. For instance, those heads of household who only utter negative social changes are significantly less likely to be insured than those who also mention positive changes (p-value: 0.000; CI: .21-.57; OR: .35).Based on the results, a typology of households and their lifestyle patterns was empirically determined in both study areas. Each of the two study areas, two different household types were identified that are distinct not by their socio-economic status but by family structure and sociocultural orientation. The existence of different household types in both areas underscores the clear social differences that exist in rural Mali.
Conclusion The findings from this research on the reasons for (non-)enrolment of households in community-based health insurance schemes in rural Mali reveal that limiting the "users" of health interventions to their socio-economic status in many circumstances does not sufficiently explain why people "lack access to" or do not take up the services offered through health interventions.In order to better target potential users of health interventions and increase coverage, a more comprehensive but systematic analysis of their characteristics must be done. This includes socio-cultural features such as attitudes towards social innovations and change, leading values, consumption priorities as well as decision making patterns at household and family level.In other words, for health interventions to be successful, not only the heath system and its actors need to be considered, but also the patients. However, they must not be reduced to people living in poverty. Rather research must acknowledge that they are characterised by different livelihood patterns that expand beyond the issue of poverty.

Inequalities in health care utilization in Mexico.

Author(s) Christine Göppel1, Linus Grabenhenrich2, Peter Tinnemann3.
Affiliation(s) 1Institute of Social Medicine, Epidemiology and Health Economics, Charité Berlin, Berlin, Germany, 2Institute of Social Medicine, Epidemiology and Health Economics, Charité Berlin, Berlin, Germany, 3Institute of Social Medicine, Epidemiology and Health Economics, Charité Berlin, Berlin, Germany.
Country - ies of focus Mexico
Relevant to the conference tracks Social Determinants and Human Rights
Summary Mexico´s way towards Universal Health Coverage: Are the Mexican poor still at a disadvantage in health care utilization?
Background The cornerstone of the Mexican health reform towards Universal Health Coverage is the 2003 introduction of a voluntary Popular Health Insurance (Seguro Popular). It aims to ensure access to health care services for vulnerable population groups and to address inequities in health care utilization for those facing financial hardship through sickness.
Objectives To quantify the Mexican health reforms success we identified the characteristics of population subgroups that contribute attributably to disparities in health care utilization of older adults and evaluated socio-economic inequities considering the distribution of needs for health services across the income groups.
Methodology Data of the WHO “Study on global AGEing and adult health” (SAGE) Wave1, conducted 2009/10 in Mexico, was examined for determinants of health care utilization. The concentration curve and index of health care utilization were used to measure socioeconomic inequalities in health care utilization and standardized for health needs to assess inequities in health care utilization.
Results Among the SAGE Wave1 participants from Mexico, less than half of the population saw a doctor in the 12 months prior to the survey. Income is by far the strongest determinant of an older person´s probability of using health care services. Other associated factors are chronic conditions, rural residence and education of the household head respectively. Achieved access of health care services is concentrated on the richer quintiles of the population. Poor population subgroups use outpatient services less frequently, despite presenting worse health conditions. Pro-rich-inequalities in health care service utilization appear as a matter of inequity and reflect, at least partly,  inequitable distribution of health care services utilization.
Conclusion The study measures specific indicators of the Mexican health system performance as it moves towards Universal Health Coverage. Ongoing socio-economic inequalities in health care utilization are confirmed. No evidence is found that insurance coverage increases health care utilization among the elderly poor. Mexican health policy makers should address prevailing financial obstacles and improve policies to further promote equitable and sustainable access to health services.

Protecting the Health of International Labor Migrants through Intersectoral Action from a Source Country Perspective: The Philippines

Author(s) Ramon Lorenzo Luis Guinto1
Affiliation(s) 1None, None, Manila, Philippines.
Country - ies of focus Philippines
Relevant to the conference tracks Social Determinants and Human Rights
Summary This source-country perspective study examines how intersectoral action can be harnessed to protect the health of international labor migrants. With nearly 10% of its citizens living overseas, the Philippines, with its decades-long history of institutionalized labor migration, has established structures and processes that ensure migrants' rights and welfare. While best practices exist, there is room for improving intersect oral action to  address migrants' health, such as strengthening the Department of Health's coordinating role, developing monitoring and evaluation mechanisms, and emphasizing health in bilateral labor agreements with destination countries.
Background With nearly 10% of its citizens living overseas, the Philippines has been a key provider of migrant labor force to over 200 countries in hundreds of occupational categories and employment arrangements, in addition to a sizeable number of immigrants. The progressive growth of international migration of Filipinos has been significantly attributed to a wide institutionalized network of government organizations with respective legal mandates and programs. The country’s international labor migrants have greatly contributed to the growth of the country’s gross domestic product especially in recent decades. While much has been documented about the social and economic dimensions of international migration in the Philippines, little is known about the health of Filipino workers overseas – and the structures and mechanisms that govern migration health. Furthermore, much of the available migration health literature analyse the situation in destination countries, so a source country perspective is of critical importance and usefulness for developing sound migration health policy in today’s increasingly mobile world.
Objectives Since both migration in general and migration health in particular are complex issues that require action across a wide range of stakeholders, this study will examine how intersectoral action can be harnessed to protect the health of migrants, particularly international labor migrants. While most studies looked at destination countries, this study will present experience and lessons in addressing migration health from a source country such as the Philippines. In this study, policies, programs, institutions, and mechanisms that support the health of "Overseas Filipino Workers" or OFWs will be mapped and described. As a result of this situational analysis, challenges and opportunities in the Philippines approach to migration health will be identified, and priorities and activities that the government and other stakeholders can undertake in order to advance the health of Filipino migrants overseas will then be proposed.
Methodology In order to guide the direction of this qualitative analysis of migration health governance in the Philippines, a conceptual framework was developed, which provided a strong emphasis on the principle of intersectoral action for health. An extensive desk review of relevant literature, including existing policies, was initially conducted. This was followed by a multi-stakeholder analysis using key informant interviews and focused group discussions as primary methods of data collection. Various organizations that represent various stakeholder groups (government, private sector, civil society, and intergovernmental organizations located in the Philippines) were pre-identified according to the findings of the literature review and served as key sources of information. During the interviews and group discussions, a discussion guide was used to ask the participants about key themes that reflect the different phases of the whole migration process (pre-departure, travel, interception, destination, and return) as well as the migration health action points articulated in the World Health Assembly resolution 61.17 on the health of migrants: monitoring migrants’ health, existence of policy-legal frameworks, building migrant-sensitive health systems, and participating in local and international partnerships and networks. Data gathered from both literature review and multi-stakeholder analysis were individually analyzed and then triangulated.
Results There exist a limited number of studies that have been conducted to assess the health needs of Filipino migrants overseas. However, much of the available grey literature indicate mental health problems as a common cause of illness among OFWs, while HIV-AIDs is becoming a growing concern, especially among returnees. Such a dearth of robust information is indicative of a weak information system that is supposed to monitor the health status and needs of migrants. In terms of policy-legal frameworks, the Philippines has instituted a number of laws that protect the rights and welfare of international labor migrants, which also cover some health-related aspects. Meanwhile, most of the existing migration health services are provided during the pre-departure phase of the migration process (i.e. pre-departure medical assessment). On the other hand, there is a limited amount of health supportive services that address the health needs of returning Filipinos. The Philippines is also a signatory to a number of international frameworks that commit to advancing migrants’ health, both at the international and regional levels. Interestingly, government institutions that craft policies, regulate actors, and provide services related to migration health lie outside of the health sector (i.e. labor), while at present, the Department of Health plays a minimal role (i.e. implementing quarantine among returnees suspected with contagious disease). While no concrete or clear mechanism exists to coordinate migration health-related efforts, there are some interactions occurring between various government agencies in order to implement certain functions.
Conclusion The existing structures and mechanisms that protect and ensure the health rights of Filipino labor can provide the template for a more concerted whole-of-government approach to migration health. While certain migration health policies and services do exist, there remain gaps in some key action areas recommended by the WHA resolution, especially in terms of monitoring migrants’ health and establishing migrant-sensitive health systems. The Department of Health should therefore assume a greater coordinating and technical role to support the migration health-related functions already performed by various non-health government agencies and other stakeholders. Furthermore, as international labor migrants interface with health systems of destination countries, source countries such as the Philippines should strengthen their diplomatic functions so they can negotiate for better provision and protection of health for their citizens residing overseas. Finally, the cause of advancing the health of international labor migrants offers an opportunity for governments, most especially countries that serve as sources of international workforce, to implement meaningful intersectoral action for health.

Measuring community perception of Healthcare Delivery Systems: A Tool Developmental Process.

Author(s) Nur Ezdiani Mohamed1, Jabrullah Ab Hamid2, Samsiah Awang3, Farrah Ong Abdullah 4, Zurriyati Ya'kub 5, Low Lee Lan6, Lin Naing7
Affiliation(s) 1Health Care Quality Research Division, Institute fo Health Systems Research, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia, 2Health Care Services Research, Institute fo Health Systems Research, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia, 3Health Care Quality Research Division, Institute fo Health Systems Research, Ministry of Health Malaysia, Subang Jaya, Selangor, Malaysia, 4Health Outcome Research Division, Institute fo Health Systems Research, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia, 5Information Communication Technology Division, Institute fo Health Systems Research, Ministry of Health Malaysia, Rawang, Selangor, Malaysia, 6Health Care Services Research, Institute fo Health Systems Research, Ministry of Health Malaysia, Subang Jaya, Selangor, Malaysia, 7Institute of Medicine, University of Brunei Darussalam (UBS), Brunei-Muara, Brunei, Brunei.
Country - ies of focus Malaysia
Relevant to the conference tracks Social Determinants and Human Rights
Summary This study is to develop a tool to measure users' satisfaction on the healthcare delivery service.The tool (questionnaire) to measure patient satisfaction was adopted based on Health-seeking behaviour models by Susanna et al. (2003), with regard to this study context. Items were derived from the literature (published and grey), findings from the FGD (focus group discussion), in-depth interviews, and from expert-opinion.Exploratory factor analysis classified the items/domains into five.

The validated questionnaire can be used to measure perception towards healthcare system in the Malaysian context. It can be further tailored to needs.

Background There are quite a number of tools measuring users’ satisfaction on the healthcare delivery service, yet little is known on how to measure their perception as well as discriminating the factors pertinent in choosing their provider.
Objectives The study was carried out to develop a tool that can measure users' perception and satisfaction on the healthcare delivery services.
Methodology A triangulation of three different sources (published literature; qualitative feedback from community and panel experts; and reviews on local theses and administrative data) was used to identify factors related to health seeking behaviour as well as factors that concerned the users in evaluating a provider both in term of local context and from other regions. A self-administrated survey was done on 347 randomly selected adult individuals exited from out- and in-patient area in health facilities; both public and private.
Results Acceptable internal reliability consistency coefficients (Cronbach’s α) ranged from 0.78 to 0.91. As for the Perception section; The Principal Component Analyses (PCA) classified five domains, corresponding to: (1) clinical resources (4 items), (2) supportive resources (12 items), (3) opportunity to meet doctors (5 items), (4) during/after meeting the healthcare provider/doctor (10 items), and (5) treatment charge (1 item). For the Factors Influencing Decision Making it was short-listed to 17 items, alpha 0.89.
Conclusion The validated questionnaire demonstrated good psychometric properties. It can be used to measure perception on the health care delivery systems as well as distinguishing factors influencing the provider choice in Malaysian context. Further refinement is encouraged.

Sickle Cell Disease and Intervention preparedness among the Messiria people, Western Sudan.

Author(s) Dina Nagodra1, Oladele Akogun2.
Affiliation(s) 1Department of Voluntary Agencies, Khartoum State Ministry of Health, Omdurman, Sudan, 2Public Health, Parasitology, Common Heritage Foundation, Yola, Nigeria.
Country - ies of focus Sudan
Relevant to the conference tracks Social Determinants and Human Rights
Summary Introduction: An exploratory study of the knowledge and practices of the Messiria people about Sickle Cell Disease (SCD).
Methodology: Ethnographic tools and 401 structured household surveys.
Results: The cited prevalence of SCD is 28% with mortality of 20%. About 90% marry their patrilateral parallel cousin resulting in 48% bearing affected children. The communal treatment burden is US $217,138 per crisis. There is no policy regarding the SCD dilemma in Sudan. Almost 79% would accept prenuptial screening and 69% would decline a marriage offer with the prospective SCD spouse. Conclusion: There is a need to provide the foundation for planning a community-directed genetic counseling and prenuptial screening against SCD.
Background Sickle Cell Disease (SCD) is a very common health problem in Africa. It is associated with hemoglobin disorders which may be reduced by balancing disease management with prevention (or behavior change) programs. Promotion of pre-marital screening in areas where it is highly prevalent and discouraging marriages between sickle cell trait partners is a major prevention strategy for reducing the prevalence of the disease. Sickle Cell Anemia (SCA) is one of the major types of anemia, especially in Western Sudan where it is a major public health concern among the Messiria ethnic group. Parents of such children are resign to their fate and to the frequent hospital admissions with their attendant cost. Although an understanding of local knowledge, beliefs and practices is generally considered important, very little effort has been directed to this aspect of SCD management. The present study is to provide information on the local knowledge, attitude and practices about the SCD situation among the Messiria people of Western Sudan in order to understand the local perception of the problem and burden of the disease as well as preparedness to challenge it. Such understanding will be helpful in developing a locally appropriate and community-sustained intervention strategy.
Objectives The main objective of this study is to apply a mixed research methodology for documenting local perception of the burden of the disease and intervention-seeking practices about Sickle Cell Trait and Sickle Cell Disease in a typical Western Sudan community.
The specific objectives of the study are:
i. To describe and document community knowledge, attitude and practice about and towards the prevention and treatment of Sickle Cell Disease.
ii. To assess the cultural and biological burden of the disease (perceived, empirical, social and economic) at the household, community and government sphere of influence.
iii. To assess community preparedness to participate in preventive approaches towards alleviating the problem of SCD (adoption of preventive Hb electrophoresis technique; and denying marriages with Sickle Cell Trait Partner).
iv. To review and analyze current policy on SCD treatment, prevention and control in the State.
Methodology The study was carried out between June 2012 and February 2013 among eight Messiria communities in Southern Kordofan State, Western Sudan. A mixed methodology combining quantitative household survey with social research techniques was used. A thematic design matrix was developed after critical thinking and brainstorming. This approach would yield measurable indicators and variables, identify the source of information and verify the analysis technique for each of them. The study was designed in three stages with each stage preceding and providing information for the subsequent stage. Data tools prepared and pretested.The study comprised of:
1. Unstructured interviews with Health personnel and local opinion leaders about the problem.
2. Household surveys.
3. In-depth interviews with affected, non - affected, FG discussions
The Messiria population is around 507,000, which could be 4 times more but no documented data is available in Sudan. Therefore; 507,000 constituted the study population and the required sample size was 2488 which was equivalent to 401 households. Systematic stratified random sampling method was used. About 11 rohot (pools of water) camps were included in the study and 5 or 6 different camps may be found around each rahat (pool of water). Every camp around each rahat was included in the study and every odd number of household from Messiria Humr community in a camp was selected in the study. Informed Voluntary Consent was taken from every participant and Ethical Clearance was obtained from the University and Locality department.

Data were analysed in the following manner:
1. Selection and baseline data collection: through observation, in-depth interviews, focus group discussion and structured questionnaires analyzed.
2. Assessing community preparedness towards preventive techniques through structured questionnaires interviews analyzed.
3. Estimating disease burden physically, economically and socially and documenting a policy based on current strategy and anticipated outcomes through in-depth interviews and quantitative data collection and analysis.
These were then used for reviewing the local and government policy about the disease.
The qualitative data collected were transcribed appropriately and written notes in English and Arabic were compared for quality. A coding theme was prepared and analysed manually. Quantitative data was entered in Epidata and analysed through IBM SPSS. Analysis was guided by the research questions and objectives using the indicators.

Results Messiria community is divided into two main divisions, Humr and Zurug. Sickle Cell Anemia (SCA) is locally referred to as aldabas. The social worker perceives that the word aldabas means swelling which is the most obvious sign in children with SCA.
About 79% of Messiria Humr regarded aldabas (swelling of hands and feet commonly observed in children) as the most dreadful of the first three principal community health problems, affecting 49% of households with 5745 aldabas sufferers. The cited prevalence of aldabas is about 28% with male to female ratio of 1:3 (P value 0.000) and mortality of 20%; yet, no policy is established regarding SCD dilemma in Sudan. Nine of every 10 Messiria are married to their paternal uncle’s son or daughter. Culture imposes patrilateral parallel marriage as a means of preserving ancestral kinship and wealth of livestock within the family resulting in 48% bearing one or more children with aldabas. However, only 24% consider aldabas to be hereditary and 89% prefer Government health facilities for treatment. Records indicate that SCD accounted for 441 children hospital admissions per year. Estimation of the exact full cost of care and national economic burden due to SCD in Sudan is unfeasible as no such studies have been done and SCA children may be admitted more than once in a month. The burden of aldabas treatment on the Messiria community is US $217,138 per crisis with a mean of US $135 per admission compelling 27% to sacrifice their education. Care not directly related to SCD is unknown and quite higher if the additional contributions of sickle cell disease associated with reduced quality of life, uncompensated care, lost productivity and premature mortality is considered. Almost 79% would accept prenuptial screening to determine SCD status of their partner, and 69% willing would decline a marriage offer if the prospective spouse is confirmed to be inflicted with SCD or is a carrier.
"There is no any ongoing community effort or Government assistance regarding aldabas affected patients or children. The affected child often named SICKLER is neglected / ignored and never given adequate management and are repeatedly admitted, 3 to 4 times every month. It is very painful to lose 7 children in a family due to SCD. These are very precious babies and they are lost without even having understood the disease properly by the parents." Community Leader Interview.
Conclusion Sickle cell anemia disease or aldabas is regarded as the primary health problem among the Messiria people of Western Sudan with a perceived prevalence of 28% and a health burden of $135/ hospital admission (or communal burden of US$217,138). The disease is so well entrenched within the culture that there is a causation theory, beliefs and practices surrounding it. Although the people do not appreciate the association between the practice of patrilineal marriage and aldabas, 83% would accept prenuptial screening to determine their proposed spouse’ sickle cell status and 69% would decline a marriage offer to a prospective spouse with confirmed sickle cell disease or carrier. Healthy marriage Program (Premarital screening) introduced in 2004 in Saudi Arabia resulted in decreasing consanguineous marriage from being 89.6% in 2004 to 62% in 2007. The average cost of treating one person with Sickle cell Anemia in Sudan is US $2695 whereas screening with Hemoglobin Electrophoresis done prior to marriage may cost around US $7.30. Large differences in estimated approximate cost of treating and preventing SCD in Sudan should open up a way for Control and Prevention Programme for SCD similar to Healthy Marriage Programme. The fact that 92%, particularly youths and adults, were eager to participate in community intervention against the disease provides a unique opportunity to commence a community-driven approach to awareness-raising, prenuptial screening and counseling among the Messiria. Community directed intervention (CDI) approaches (made popular by the African programme for onchocerciasis control (APOC) and currently used for the increasing access to culturally appropriate intervention services) are most likely to change the current status of sickle cell disease among the Messiria if introduced at the earliest possibility. The CDI approach that has been made popular in the control of Malaria in nomads in Nigeria can be adopted to control SCD in nomads in Sudan.
In the absence of SCD Policy a Control or Prevention Programme (CDI) can be approached to optimise results with prolonged sustainability.

Breast cancer screening for everyone.

Author(s) Patrick Brander1, Marius Besson2, Béatrice Arzel3
Affiliation(s) 1Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 2Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 3Fondation genevoise de dépistage du cancer du sein, Fondation genevoise de dépistage du cancer du sein, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Social Determinants and Human Rights
Summary As breast cancer is the most prevalent cancer in women, a screening program has been developed in the canton of Geneva since 1999. The University Hospital’s CAMSCO service (Consultation ambulatoire mobile de soins Communautaires) is devoted to people living in precarious conditions which includes mainly undocumented migrants and women working in the domestic’s fields, those without health insurance, and inclusive of those aged over 50 years old. Since 2006 a collaboration between the cantonal breast cancer screening program and the CAMSCO was developed allowing for these undocumented women to have access to information in their own language and also mammography screening. Since 2008 280 women have had mammography screening.
What challenges does your project address and why is it of importance? Access to health systems for undocumented migrants in Switzerland is difficult and differs greatly between cantons. Some swiss cantons have organized a system to allow these people to have access to primary care and preventive medicine. Breast cancer screening is recommended by international guidelines and should, as such, be offered to every women between 50 and 74 years old.
How have you addressed these challenges? Do you see a solution? A collaboration between the CAMSCO and the “Geneva Breast Screening program” has been developed since 2006, allowing the undocumented women between 50 and 74 years old and living in Geneva to be offered mammography screening. This program is financially supported by public funds and the mammography itself is paid 90% by patients’ insurance with a 10% (19.15.-swiss francs) contribution by the patient. The exception is disadvantaged women, for whom this amount is supported by screening program through private funds.
How do you know whether you have made a difference? Due to this collaboration 280 migrants women without health insurance had access to mammography screening. Their number has been about stable since 2010 averaging 65 for each year.
Have you or the project mobilized others and if so, who, why and how? The project has mobilized the Geneva hospital gynecology service as they do the mammography and assure that any anomaly is investigated and treated as needed. Medical doctors working in the Geneva hospital primary care service are also encouraged to plan mammography for their undocumented migrants as indicated
When your donor funding runs out how will your idea continue to live? Our collaboration may be funded by public funds, as it is already in part. Otherwise, it could only be funded by patients themselves, which is impossible.

HIV Treatment vs Prevention Debate must Reconcile the Post-MDG Development Agenda Focus on Social Determinants and Human Rights

Author(s) Nabeel M K1
Affiliation(s) 1Education, Research, and Evidence-informed Advocacy, Public Health Organizations, New Delhi, India.
Country - ies of focus Global, India
Relevant to the conference tracks Advocacy and Communication
Summary With recent scientific advances in HIV, an old debate based on the treatment-prevention dichotomy is re-emerging. One side appeals that resources must now be diverted from conventional prevention strategies towards early treatment as it can prevent new infections. The other side argues, among other reasons, that treatment can realistically reach only a small subsection of those in need of it. Therefore investments in prevention need to be furthered in order to effectively contain HIV. This paper analyses the HIV prevention vs. treatment debate in the context of a post-2015 development agenda, particularly in light of Social Determinants and Human Rights.
Background With the global flat-lining of resources for HIV, there are appeals to prioritize based on reasonable resource allocation decisions and a search for high impact interventions that maximize ‘benefit’. In this context, and with recent scientific advances in HIV on the preventive benefits of Anti-retroviral Therapy (ART), an old debate based on the treatment-prevention dichotomy is re-emerging. One argument is that resources must now divert from conventional prevention strategies towards early treatment as it can prevent new infections. The other side argues that treatment can only realistically reach a small subsection of those in need so prevention investments need to be furthered in order to effectively contain HIV. Amidst the treatment vs. prevention debate, with the backdrop of the global financial crunch, concerns emerge as to how the goals of zero new infections and zero AIDS related death can be achieved as agreed upon by member states at the United Nations High Level Meeting in June 2011. Incidentally, the Millennium Development Goals of which halting and reversing the HIV epidemic is a key target, will soon give way to a new development agenda in the post-2015 period.
Objectives Public health professionals and national governments face this ethical challenge – whether to take the side of treatment or prevention. This paper aims to address the resource allocation dilemma arising from the choice whether to prefer HIV prevention or treatment in programs run by governments, by comparing the merits and demerits of the two positions from a public health point of view. It explores different theories and approaches which could be used for the analysis. Apart from this primary objective, the paper aims to feed into the post-2015 development agenda by proposing an integrated approach to several interconnected challenges encompassing not only HIV, but Social Determinants of Health, Human Rights, and Equitable health.
Methodology The main aspect of the methodology used in this analysis is to compare and contrast the two divergent positions:Position 1: With the evidence on “Treatment as Prevention” to divert scarce resources from prevention towards treatment: Position 2: Re-allocating funds from prevention budget to treatment is faulty as strengthening prevention is the way forward.The approach for analysis is to examine the following dimensions:i. Merits and Demerits of the two positions

ii. Problems in subscribing to either of the two

iii. Possibility of an alternative position

iv. Lessons from the past in related areas

Within this broad framework, the analytic methodology adopts a systems approach with an understanding that interconnected challenges need integrated solutions. Political and contextual factors, especially those related to power differences get too little attention in many of our discourses especially the ‘high theories’ (Arras J, 2010). In the process, individuals and groups with different types of vulnerabilities based on factors like gender, poverty and race tend to be disproportionately skewed in their respective risk-benefit equations. By ignoring the political and contextual factors related to power imbalances, people with different vulnerabilities tend to receive more harm than others. (Bertomeu M, 2009). Feminist approaches try to address this gap by adopting a bottom-up approach as opposed to some of the traditional theories that are top-down, abstract, and deductive in nature (Arras J, 2010; and Beauchamp TL, 2009). Accordingly, people who are otherwise oppressed or devalued in society are considered in discourses about policy options (Sherwin S, 1999). Moreover, critiques have pointed out the inappropriateness of using theories and approaches which were originally designed in the context of clinical ethics or research ethics for the purpose of public health ethics. (Baylis F, 2008, and Kenny N, 2010). Hence, we need an systems approach to research methodology not only considering health systems, but also integrating Social Determinants of Health, Human Rights, and Equity.

Results Even after three decades of responding to HIV, prevention programming continues to be ‘largely deficient’ (Bertozzi SM, 2008). Hence some proponents of the test and treat strategy, citing recent evidence, argue for the diversion of resources towards scaling up Antiretroviral Therapy (ART) as a strategy for HIV prevention. Yet, conventional prevention modalities continue to be the most inexpensive options. One of the arguments against conventional programs among sex workers is that condom use is not universal. It is often pointed out that sex workers tend to agree to transactional sex without condoms if there is a premium in the payment over and above what they get for sex with condom. However studies have identified the factors that make women vulnerable to such compromises (de la Torre A, 2010). Hence, prevention programs must broaden to influence structural determinants that make women vulnerable rather than totally denouncing behavioral and non-biomedical modes of HIV prevention. Studies also report that people who are treatment optimistic or who believe that ART can reduce the viral load and hence HIV transmissibility, tend to indulge more in risky sexual behaviour (Brennan DJ, 2010). This is especially profound when we consider education levels and other factors like power relations in the provider-patient relationship. The results of the detailed (not included here due to space constraints) analysis did not favor one over the other in the treatment vs. prevention debate. However, the analysis led to an alternative position where it is demonstrated that the treatment-prevention dichotomy is in fact irrelevant in the context of recent scientific advances that profess the very concept of “Treatment as Prevention”. By opting for an integrated continuum model, HIV programs can still have treatment as one of the options in a combination prevention strategy. By doing so, HIV programs demolish the water-tight compartments of treatment and prevention, thereby leading to a more realistic path towards the goals of zero new infections, zero AIDS related deaths, and zero discrimination. This approach is crucial to uphold the rights and interests of those who are marginalized in society due to different socio-political, economic and cultural factors. In the absence of a holistic approach relevant to the local contextual factors, issues of the marginalized will skip the frameworks created for monitoring and evaluation of programs; and hence remain unaddressed.
Conclusion Analysis of the two conflicting positions has demonstrated both advantages as well as disadvantages of these positions. Any bias towards treatment or prevention in a public health scenario tends to overlook some issue or the other and is faced predominantly by the oppressed or otherwise less-valued groups of people in the society. It is in this context that this paper argues to strengthen the prevention-treatment-care continuum. This has been proposed earlier, before the recent advances that led to calls for ‘test and treat’ strategy based on the premise of ‘treatment is prevention’ (de Loenzien M 2009; and Simon V, 2006). Further within this broader continuum model, a continuum of prevention is also identified: one which takes into consideration not only the uninfected, but also infected persons at different clinical stages ranging from asymptomatic individuals to those who clinically require ART and other advanced forms of care (Simon V, 2006). HIV policies and programs in some developing countries have taken this model to higher holistic levels by including palliative care in the continuum model. At the same time, they have acknowledged the need to address other larger issues like poverty, gender-based power differences, and other health issues - especially reproductive health issues, which are also determinants of success in HIV control programs (de Loenzien M 2009). Thus we can see that by over-emphasizing a medicalized model through a test and treat strategy, national HIV programs will be missing crucial opportunities in addressing larger human development issues. Even within the domain of health, an HIV prevention strategy predominated by early ART alone ignores the interconnected challenges including other sexually transmitted diseases and the social factors that determine many diseases which are disproportionately prevalent among poor and socially marginalized sections of society (Reading JL, 2009). Success in HIV prevention programs has been shown to be associated with measures to address gender disparities, counter stigma and discrimination and mobilize affected communities (Merson MH, 2008). A continuum approach or an integrated one has also been shown to provide a human rights framework for examining state responsibility with respect to obligations towards a wide range of people whose lives are infected and affected by HIV (Walker E, 2007). In the move from MDGs to post-2015 agenda, such integrated approaches must guide us.

Childbearing, Unintended Pregnancy and Contraceptive Use among South Asian Married Female Adolescents

Author(s) S. M. Mostafa Kamal1, Che Hashim Hassan2,
Affiliation(s) 1Department of Mathematics, Islamic University, Kushtia-7003, Afghanistan, Unit for the Enhancement of Academic Performance, University of Malaya, Kuala Lumpur, Malaysia, 3
Country - ies of focus Bangladesh
Relevant to the conference tracks Social Determinants and Human Rights
Summary This study examined the childbearing status, unintended pregnancy and contraceptive use among married female adolescents of four South Asian countries using the nationally representative survey data. Findings show that, the initiation of childbearing ranges from 57% in Pakistan to 67% in Nepal. The incidence of unintended pregnancy was more frequent in Nepalese adolescents. The use rate of contraceptive methods was highest in Bangladesh and lowest in India. The reproductive behaviour of female adolescents are significantly associated with education, working status, place of residence and standard of living indices, although the associations are not always consistent across countries.
Background Despite global declines in the rate of early childbearing, reproductive behaviour of adolescents remains a persistent challenge in many developing countries.
Objectives This study endeavours to examine childbearing, unintended pregnancy and contraceptive use among married adolescents in four South Asian countries: Bangladesh, India, Nepal and Pakistan.
Methodology Data for this study have drawn from the most recent and nationally representative Demographic and Health Survey (DHS) conducted between 2005 and 2011. The analysis focused on the married female adolescents of age ranging from 15 to 19. The prevalence of initiation of childbearing, intention status of the most recent pregnancy, current use of any contraceptive methods were assessed by simple cross tabulation, while binary logistic regression models were constructed to examine the socioeconomic and country impacts on each of the outcome measures. The sample was made nationally representative by using the weight factor in the survey data. Data were analysed by IBM SPSS v21 (SPSS Inc., Chicago, IL, USA).
Results The mean age at first marriage was significantly lowest among adolescents in Bangladesh (15.1±1.7), followed by India (15.5±1.8), Pakistan (15.7±1.7) and Nepal (15.9±1.5) respectively. In Bangladesh, two-thirds (66.1%) of the adolescents initiated childbearing, of whom 53.4% were already a mother 12.7% were pregnant for the first time. The corresponding figures for India, Nepal and Pakistan were 57.8%, 67.6% and 56.7% respectively. The incidence of unintended pregnancy was more frequent in Nepalese adolescents (32.4%), followed by Bangladesh (25.2%), India (17.3%) and Pakistan (13.1%). The use rate of any and modern contraceptive methods was highest in Bangladesh (47.1% and 42.4%), followed by Nepal (21.0% and 17.1%), India (13.0% and 6.9%) and Pakistan (6.7% and 4.2%). The multivariate binary logistic regression analyses yielded quantitatively important and reliable estimates of the reproductive behaviour of adolescents. The analyses suggest that reproductive behaviours of female adolescents are significantly associated with their level of education, working status, place of residence and standard of living indices, although the associations are not always consistent across countries. Furthermore, the likelihood of initiation of childbearing was significantly higher among female adolescents of Bangladesh than other three South Asian countries. Unintended pregnancy was significantly higher in Nepalese adolescents. Meanwhile, the adolescents of India, Nepal and Pakistan were less likely to use any contraceptive methods than those of Bangladesh.
Conclusion Early initiation of childbearing, unintended pregnancies and lower use rate of any contraceptive methods among married female adolescents are common in the four South Asian countries. Programmes and policy initiatives should focus on the enforcement of the legal age at first marriage and education retention as this may reduce early practices of child marriage in South Asian countries. Providing door-step delivery services of effective family planning methods is important to reduce unintended pregnancy among married female adolescents.

The Effect of Unintended Pregnancy on Maternal Health Care Service Utilisation in South Asia.

Author(s) S. M. Mostafa Kamal1, Che Hashim Hassan2.
Affiliation(s) 1Department of Mathematics, Islamic University, Kushtia-7003, Bangladesh, 2Unit for the Enhancement of Academic Performance, University of Malaya, Kuala Lumpur, Malaysia 3.
Country - ies of focus Bangladesh
Relevant to the conference tracks Social Determinants and Human Rights
Summary This study examines the effect of unintended pregnancy on maternal health care services utilization among women of four South Asian countries using nationally representative survey data conducted between 2005 and 2011. The prevalence of unintended pregnancy ranges from 25% in India to 32% in Bangladesh. Overall, the Indian women sought more skilled services for maternity care than the women of other study countries. The multivariable binary logistic regression yielded that, except for Pakistan, the women with unintended pregnancy were significantly less likely to seek skilled maternal health care services than women who reported that their last child was planned/wanted.
Background Of the estimated annual 210 million pregnancies occurring worldwide, approximately two-fifths are unintended which include mistimed and unwanted pregnancies, out of which 22% end in unsafe and illegal abortions. Unintended pregnancy is a major cause of unsafe abortion. Ninety-five percent of unsafe abortions occur in the developing countries. Worldwide, unsafe abortion accounts for approximately 13% of the total maternal deaths. Millions more suffer long-term life threatening complications caused by unsafe abortion. The pernicious consequences due to unintended pregnancies are well documented. Evidences show that unintended childbearing can cause adverse health outcomes such as depression, anxiety, poor psychological well-being, poor utilization of antenatal care services, low use of supplements, vaccination and nutrition. However, most of these findings are from developed countries. Such evidence is limited in developing countries.
Objectives This study aims to examine the effect of unintended pregnancy on maternal health care service utilization among women of four South Asian countries: Bangladesh, India, Nepal and Pakistan.
Methodology Data used in this study were collected by the most recent and nationally representative Demographic and Health Survey (DHS) conducted in Bangladesh, India, Nepal and Pakistan. The surveys are based on a two-stage stratified sample of households. It accumulated information from married women of reproductive age inclusive of rural and urban areas. The survey obtained various information related to demographic and health issues including fertility, marriage, use of family planning methods, pregnancy intention status, maternal and child health, use of maternal and health care services etc. The surveys collected information of live births that occurred in the five years preceding the survey.Outcome measures.The outcome measures of the study are: (i) skilled antenatal care (ANC) seeking; (ii) adequate ANC (≥4 ANC) visits; (iii) seeking assistance from skilled birth assistants (SBA); and (iv) delivery at facility place. The skilled MHCS has been defined as receiving care from a medically-trained services provider. The facility for childbirth includes a medically equipped health care service centre.Exposure variables.Along with the principal exposure variable ‘unintended pregnancy’, we additionally included socioeconomic and demographic variables which may influence the utilization of MHCS. The list, definitions and measurement of the covariates included for analysis are provided in Table 1.

Statistical analyses.

Both bivariate and multivariable statistical analyses were adopted in this study. Differences of the use of MHCS according to the desirability of pregnancy and other socioeconomic factors were assessed by chi-square (χ2) tests. To assess the net effects of the exposure variables on the outcome measures, four different multivariable binary logistic models were designed for outcome interests. The checking of multi co-linearity results in its non-existence. The results of the logistic regression analyses are presented by odds ratios (ORs) with 95% confidence intervals (CIs). The level of significance was set at 0.10. The statistical analyses were performed by IBM SPSS v21 (SPSS Inc., Chicago, IL, USA).

Results Prevalence of unintended pregnancy.The prevalence of unintended pregnancy was highest in Bangladesh (32%), followed by Pakistan (30%), Nepal (30%) and India (25%). The prevalence of unintended pregnancy differed significantly by place of residence, age at first marriage, maternal age, birth order and wealth index.Prevalence and differentials of MHCS utilisation.A slightly over half of the Bangladeshi women (51.8%) visited at least once for ANC services. The corresponding figures for women in India, Nepal and Pakistan were respectively 76%, 58.3% and 64.8%. The proportion of women who received adequate ANC services was highest in Nepal (50.1%), followed by India (37.3%), Pakistan (28.8%) and Bangladesh (23.9%). Exactly half of the Nepalese women received adequate ANC services. Seeking assistance from SBA was reported to be highest among women of India (46.7%), followed by Pakistan (39.2%), Nepal (36.0%) and Bangladesh (27.7%) respectively. The prevalence of delivery at hospital was highest among Indian women (38.7%), followed by Nepal (45.3%), Pakistan (34.6%) and Bangladesh (24.9%). Pregnancy desireability exhibited a significant difference in the use of four indicators of MHCS. Except in Pakistan, the prevalence of use of MHCS was lowest among those who reported their last child as unwanted.

Results of multivariate regression

The multivariate logistic regression analysis reveals that, when other variables were controlled for, except for Pakistan, the women, experiencing unintended pregnancy were significantly reluctant to seek skilled MHCS than women with wanted pregnancy. For instance, the women of Bangladesh who opined that their last child was unintended, the risk of seeking ANC, SBA and use of facility place for delivery decreased by the factors 0.85 (95% CI=(0.75-0.96), 0.87 (95% CI=0.77-0.99), 0.86 (95% CI=0.76-0.98) respectively as compared to that those with wanted pregnancy. Almost similar results were obtained for India and Nepal. Surprisingly, the Pakistani women experiencing unintended pregnancy were more likely to seek ANC services, but were less likely to go for delivery at hospital than those whose last child was reported as wanted. The other variables that showed to have significant effect on the utilization of MHCS for the study countries are maternal age, age at first marriage, birth order, women’s education, pregnancy termination and wealth index.

Conclusion Overall, the study results provide important insights into the association of unintended pregnancy with four indicators of MHCS utilization. To our knowledge, this study is the first multi-country study of the association of pregnancy intention status and use of maternity care services. All of these outcomes have been previously associated with a variety of factors, including place of residence, education, and standard of living index or wealth quintiles. However, study findings reveal a high prevalence of unintended pregnancy in the study countries which adds another layer of vulnerability over and above these background characteristics on MHCS utilisation. In the study countries, unintended pregnancy is not only a concern from the perspective of fertility, but is also a cause for concern from the point of view of public health, particularly regarding the use of MHCS. Therefore, greater attention is required to curb the high levels of unintended pregnancies in South Asia. Family planning programmes can play a vital role in averting unintended births and in reducing the burden of unintended pregnancy. Improving access to quality contraception may be an important intervention. Awareness should be created as to the long term benefits of using skilled MHCS through information, education and communication (IEC) programmes.