Alessandro R Demaio

Exploring knowledge, attitudes and practices related to diabetes in Mongolia: a national population-based survey

BackgroundNon-communicable diseases (NCDs) are now the leading causes of mortality in Mongolia, and diabetes, in particular, is a growing public health threat. Mongolia is a nation undergoing rapid and widespread epidemiological transition and urbanisation: a process that is expected to continue in coming decades and is likely to increase the diabetes burden. To better inform policy and public-health responses to the impact of the growth in NCDs, a national NCD Knowledge, Attitudes and Practices survey was implemented in Mongolia in 2010; a section of which focused on diabetes.MethodsThis survey was a nationally-representative, household-based questionnaire conducted by field-workers. Households were selected using a multi-stage, cluster sampling technique, with one participant (aged 15–64) selected from each of the 3540 households. Questions explored demographic and administrative parameters, as well as knowledge attitudes and practices around NCDs and their risk factors.ResultsThis research suggests low levels of diabetes-related health knowledge in Mongolia. Up to fifty percent of Mongolian sub-populations, and one in five of the total population, had never heard the term diabetes prior to surveying. This research also highlights a high level of misunderstanding around the symptomatology and natural progression of diabetes; for example, one-third of Mongolians were unaware that the disease could be prevented through lifestyle changes. Further, this study suggests that a low proportion of Mongolians have received counseling or health education about diabetes, with lowest access to such services for the urban poor and least educated sub-populations.ConclusionsThis research suggests a low prevalence of diabetes-related health-knowledge among Mongolians. In this light, health-education should be part of any national strategy on diabetes.

Prevalence of rheumatoid arthritis in low– and middle–income countries: A systematic review and analysis

Background Rheumatoid arthritis (RA) is an autoimmune disorder that affects the small joints of the body. It is one of the leading causes of chronic morbidity in high–income countries, but little is known about the burden of this disease in low– and middle–income countries (LMIC). Methods The aim of this study was to estimate the prevalence of RA in six of the World Health Organizations (WHO) regions that harbour LMIC by identifying all relevant studies in those regions. To accomplish this aim various bibliographic databases were searched: PubMed, EMBASE, Global Health, LILACS and the Chinese databases CNKI and WanFang. Studies were selected based on pre–defined inclusion criteria, including a definition of RA based on the 1987 revision of the American College of Rheumatology (ACR) definition. Results Meta–estimates of regional RA prevalence rates for countries of low or middle income were 0.40% (95% CI: 0.23–0.57%) for Southeast Asian, 0.37% (95% CI: 0.23–0.51%) for Eastern Mediterranean, 0.62% (95% CI: 0.47–0.77%) for European, 1.25% (95% CI: 0.64–1.86%) for American and 0.42% (95% CI: 0.30–0.53%) for Western Pacific regions. A formal meta–analysis could not be performed for the sub–Saharan African region due to limited data. Male prevalence of RA in LMIC was 0.16% (95% CI: 0.11–0.20%) while the prevalence in women reached 0.75% (95% CI: 0.60–0.90%). This difference between males and females was statistically significant (P < 0.0001). The prevalence of RA did not differ significantly between urban and rural settings (P = 0.353). These prevalence estimates represent 2.60 (95% CI: 1.85–3.34%) million male sufferers and 12.21 (95% CI: 9.78–14.67%) million female sufferers in LMIC in the year 2000, and 3.16 (95% CI: 2.25–4.05%) million affected males and 14.87 (95% CI: 11.91–17.86%) million affected females in LMIC in the year 2010. Conclusion Given that majority of the world’s population resides in LMIC, the number of affected people is substantial, with a projection to increase in the coming years. Therefore, policy makers and health–care providers need to plan to address a significant disease burden both socially and economically.

Appropriate health promotion for Australian Aboriginal and Torres Strait Islander communities: crucial for closing the gap

Health promotion for Australian Aboriginal and Torres Strait Islander communities and their people has generally had limited efficacy and poor sustainability. It has largely failed to recognise and appreciate the importance of local cultures and continues to have minimal emphasis on capacity building, community empowerment and local ownership. Culturally Appropriate Health Promotion is a framework of principles developed in 2008 with the World Health Organization and the Global Alliance for Health Promotion. It serves as a guide for community-focused health promotion practice to be built on and shaped by the respect for understanding and utilisation of local knowledge and culture. Culturally Appropriate Health Promotion is not about targeting, intervening or responding. Rather, it encourages health programme planners and policymakers to have a greater understanding, respect, a sense of empowerment and collaboration with communities, and their sociocultural environment to improve health. This commentary aims to examine and apply the eight principles of Culturally Appropriate Health Promotion to the Australian Aboriginal and Torres Strait Islander context. It proposes a widespread adoption of the framework for a more respectful, collaborative, locally suitable and therefore appropriate approach to Australian Aboriginal and Torres Strait Islander health promotion.

Urbanization and the prevalence of schizophrenia in China between 1990 and 2010

Among the environmental risk factors for schizophrenia, evidence supports a role of urbanicity (1–3). In recent decades, urbanization has been occurring at a massive scale in low- and middle-income countries (4,5). It is therefore of global public health importance to explore how rapid urbanization might have affected the burden of schizophrenia in growing economies, with China being a prime example. Epidemiological evidence in China has improved over the past two decades and Chinese academic journals have become accessible in electronic databases (6). Moreover, China recently underwent urbanization and economic development at an unprecedented scale: 26.4% of its 1.1 billion inhabitants lived in urban areas in 1990, rising to 49.2-49.7% of 1.3 billion in 2010 (4,7). We may expect a significant increase of schizophrenia burden in China as a result. To explore this, we conducted a systematic review of the Chinese and English literature, through China National Knowledge Infrastructure, Wanfang and PubMed, for the years from 1990 to 2010. Only studies that had applied a case definition based on DSM-III or IV, ICD-9 or 10, or Chinese Classification of Mental Disorders (CCMD-2, 2R or 3) were retained. Based on pre-defined minimum quality criteria, 42 prevalence studies were selected. They were mostly large population-based studies, typically using a two-stage data collection design in which trained assessors performed an initial screening and psychiatrists followed up with a detailed evaluation. Direct contact was made with the corresponding authors of 13 studies to obtain any missing information. Geographically, the retained studies covered 21 of mainland China’s 31 provinces, municipalities and autonomous regions. Bayesian methods were applied to predict maximum likelihood for point prevalence and lifetime prevalence in urban and rural China in the years 1990, 2000 and 2010. The analyses of the 42 studies combined information from 2,284,957 people, 10,506 of whom were diagnosed with schizophrenia in their lifetime. In urban areas, the point prevalence (≥15 years) of the disorder was 0.32% (95% CI: 0.29-0.36) in 1990, 0.47% (95% CI: 0.44-0.50) in 2000, and 0.68% (95% CI: 0.57-0.81) in 2010. In contrast, in rural areas, the corresponding estimates were 0.37% (95% CI: 0.33-0.42), 0.36% (95% CI: 0.35-0.38), and 0.35% (95% CI: 0.33-0.38). Lifetime prevalence (≥15 years) in urban China was 0.39% (95% CI: 0.37-0.41) in 1990, 0.57% (95% CI: 0.55-0.59) in 2000, and 0.83% (95% CI: 0.75-0.91) in 2010. The corresponding estimates for rural areas were 0.37% (95% CI: 0.34-0.40), 0.43% (95% CI: 0.42-0.44), and 0.50% (95% CI: 0.47-0.53). Applying these prevalence estimates to the corresponding population of China, there were 3.09 (95% CI: 2.87-3.32) million persons affected during their lifetime in the year 1990. Twenty-seven percent of the cases were from urban areas, which corresponds to the overall proportion of urban residents in China in the same year (26.4%). By 2010, the number of persons affected with schizophrenia rose to 7.16 (95% CI: 6.57-7.75) million, a 132% increase, while the total population of China only increased by 18% during this period (4). Moreover, the contribution of expected cases from urban areas to the overall burden increased from 27% in 1990 to 62% in 2010, well above the proportion of urban residents in China in 2010 (49.2-49.7%). This study helps to establish the universality of urbanicity as a risk factor and the extent to which it affects the burden of schizophrenia in a large country that underwent rapid urbanization. As schizophrenia prevalence was found to be similar in rural and urban China at the beginning of industrialization (late 1980s) (8), our findings suggest that the mechanisms driving the risks of illness in urban areas are likely to be associated with modern urban lifestyles. The lower rates of schizophrenia found when China was less industrialized are consistent with studies that reported lower rates of the illness in low- and middle-income countries (3). This analysis has broad implications. Many populous parts of the world, particularly in low- and middle-income countries, are undergoing urbanization at a scale and rate that took Western countries centuries to achieve (9). Global urbanization may therefore result in an increased global prevalence of schizophrenia through mechanisms that need to be further explored.

Primary Health Care: a strategic framework for the prevention and control of chronic non-communicable disease.

In 2014, chronic, non-communicable diseases (NCDs) represent the leading causes of global mortality and disability. Government-level concern, and resulting policy changes, are manifesting. However, there continues to be a paucity of guiding frameworks for legislative measures. The surge of NCDs will require strong and effective governance responses, particularly in low and middle-income countries. Simultaneously following the 2008 World Health Report, there has recently been renewed interest in Primary Health Care (PHC) and its core principles. With this, has come strengthened support for revitalizing this approach, which aims for equitable and cost-effective population-health attainment. In this light and reflecting recent major global reports, declarations and events, we propose and critique a PHC approach to NCDs, highlighting PHC, with its core themes, as a valuable guiding framework for health promotion and policy addressing this group of diseases.In 2014, chronic, non-communicable diseases (NCDs) represent the leading causes of global mortality and disability. Government-level concern, and resulting policy changes, are manifesting. However, there continues to be a paucity of guiding frameworks for legislative measures. The surge of NCDs will require strong and effective governance responses, particularly in low and middle-income countries. Simultaneously following the 2008 World Health Report, there has recently been renewed interest in Primary Health Care (PHC) and its core principles. With this, has come strengthened support for revitalizing this approach, which aims for equitable and cost-effective population-health attainment. In this light and reflecting recent major global reports, declarations and events, we propose and critique a PHC approach to NCDs, highlighting PHC, with its core themes, as a valuable guiding framework for health promotion and policy addressing this group of diseases.

Hypertension and hypertension-related disease in Mongolia; findings of a national knowledge, attitudes and practices study

BackgroundMongolia has a high and increasing burden of hypertension and related disease, with cardiovascular diseases among the leading causes of death. Yet little is known about the knowledge, attitudes and practices of the Mongolian population with regards to blood pressure. With this in mind, a national Non-Communicable Diseases knowledge, attitudes and practices survey on blood pressure was implemented in late 2010. This paper reports on the findings of this research.MethodsUsing a multi-stage, random cluster sampling method 3450 participant households were selected from across Mongolia. This survey was interviewer-administered and included demographic and socio-economic questions. Sample size was calculated using methods aligned with the World Health Organization STEPS surveys.ResultsOne fifth of participants reported having never heard the term ‘blood pressure’. This absence of health knowledge was significantly higher in men, and particularly younger men. The majority of participants recognised high blood pressure to be a threat to health, with a higher level of risk awareness among urban individuals. Education level and older age were generally associated with a heightened knowledge and risk perception. Roughly seven in ten participants were aware of the relationship between salt and blood pressure. Exploring barriers to screening, participants rated a ‘lack of perceived importance’ as the main deterring factor among fellow Mongolians and overall, participants perceived medication and exercise as the only interventions to be moderately effective at preventing high blood pressure.ConclusionRural populations; younger populations; men; and less educated populations, all with lower levels of knowledge and risk perception regarding hypertension, present those most vulnerable to it and the related health outcomes. This research intimates major health knowledge gaps in sub-populations within Mongolia, regarding health-risks related to hypertension.

Open access: academic publishing and its implications for knowledge equity in Kenya

Traditional, subscription-based scientific publishing has its limitations: often, articles are inaccessible to the majority of researchers in low- and middle-income countries (LMICs), where journal subscriptions or one-time access fees are cost-prohibitive. Open access (OA) publishing, in which journals provide online access to articles free of charge, breaks this barrier and allows unrestricted access to scientific and scholarly information to researchers all over the globe. At the same time, one major limitation to OA is a high publishing cost that is placed on authors. Following recent developments to OA publishing policies in the UK and even LMICs, this article highlights the current status and future challenges of OA in Africa. We place particular emphasis on Kenya, where multidisciplinary efforts to improve access have been established. We note that these efforts in Kenya can be further strengthened and potentially replicated in other African countries, with the goal of elevating the visibility of African research and improving access for African researchers to global research, and, ultimately, bring social and economic benefits to the region. We (1) offer recommendations for overcoming the challenges of implementing OA in Africa and (2) call for urgent action by African governments to follow the suit of high-income countries like the UK and Australia, mandating OA for publicly-funded research in their region and supporting future research into how OA might bring social and economic benefits to Africa.

Prevalence of schizophrenia in China between 1990 and 2010

Background Dramatic development and changes in lifestyle in many low and middle–income countries (LMIC) over the past three decades may have affected mental health of their populations. Being the largest country and having the most striking record of development, industrialization and urbanization, China provides an important opportunity for studying the nature and magnitude of possible effects. Methods We reviewed CNKI, WanFang and PubMed databases for epidemiological studies of schizophrenia in mainland China published between 1990 and 2010. We identified 42 studies that reported schizophrenia prevalence using internationally recognized diagnostic criteria, with breakdown by rural and urban residency. The analysis involved a total of 2 284 957 persons, with 10 506 diagnosed with schizophrenia. Bayesian methods were used to estimate the probability of case of schizophrenia (“prevalence”) by type of residency in different years. Findings In urban China, lifetime prevalence was 0.39% (0.37–0.41%) in 1990, 0.57% (0.55–0.59%) in 2000 and 0.83% (0.75–0.91%) in 2010. In rural areas, the corresponding rates were 0.37% (0.34–0.40%), 0.43% (0.42–0.44%) and 0.50% (0.47–0.53%). In 1990 there were 3.09 (2.87–3.32) million people in China affected with schizophrenia during their lifetime. The number of cases rose to 7.16 (6.57–7.75) million in 2010, a 132% increase, while the total population increased by 18%. The contribution of cases from urban areas to the overall burden increased from 27% in 1990 to 62% in 2010. Conclusions The prevalence of schizophrenia in China has more than doubled between 1990 and 2010, with rates being particularly high in the most developed areas of modern China. This has broad implications, as the ongoing development in LMIC countries may be increasing the global prevalence of schizophrenia.

Complementary and alternative medicine use among diabetic patients in Africa: a Kenyan perspective

Complementary and alternative medicine (CAM) use is common among patients with chronic diseases in developing countries. The rising use of CAM in the management of diabetes is an emerging public health concern given the potential adverse effects, drug interactions and benefits associated with its use. Herbal medicine, dietary supplements, prayers and relaxation techniques are some of the most frequently used CAM modalities in Kenya. Cited reasons for CAM use as adjuvant therapy include dissatisfaction and inaccessibility of allopathic medicine, and recommendations by family and friends. This article explores the pattern of CAM use in Kenya and other developing countries. It also identifies some constraints to proper CAM control, and offers suggestions on what can be done to ensure safe and regulated CAM use.

Protocol for a national, mixed-methods knowledge, attitudes and practices survey on non-communicable diseases

BackgroundMongolia is undergoing rapid epidemiological transition with increasing urbanisation and economic development. The lifestyle and health of Mongolians are changing as a result, shown by the 2005 and 2009 STEPS surveys (World Health Organizations STEPwise Approach to Chronic Disease Risk Factor Surveillance) that described a growing burden of Non-Communicable Diseases and injuries (NCDs).This study aimed to assess, describe and explore the knowledge, attitudes and practices of the Mongolian adult population around NCDs in order to better understand the drivers and therefore develop more appropriate solutions to this growing disease burden. In addition, it aimed to provide data for the evaluation of current public health programs and to assist in building effective, evidence-based health policy.Methods/designThis national survey consisted of both quantitative and qualitative methods. A quantitative household-based questionnaire was conducted using a nationally representative sample of 3854 rural and urban households. Participants were selected using a multi-stage cluster sampling technique in 42 regions across Mongolia, including rural and urban sites. Permanent residents of sampled households were eligible for recruitment, if aged between 15-64 years. This quantitative arm was then complemented and triangulated with a qualitative component: twelve focus group discussions focusing on diet, exercise and alcohol consumption. Discussions took place in six sites across the country, facilitated by local, trained health workers. These six sites were chosen to reflect major Mongolian cultural and social groups.DiscussionKAP surveys are well represented in the literature, but studies that aim to explore the knowledge, attitudes and practices of a population around NCDs remain scarce. This is despite the growing number of national epidemiological surveys, such as STEPS, which aim to quantify the burden of these diseases but do not explore the level of population-based awareness, understanding, risk-perception and possible motivation for change. Therefore this paper will contribute to building a knowledge base of NCD KAP survey methodology for future use in epidemiology and research worldwide.