Carla Makhlouf Obermeyer

Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND Young peoples health has emerged as a neglected yet pressing issue in global development. Changing patterns of young peoples health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10-24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors. METHODS The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories. FINDINGS The leading causes of death in 2013 for young people aged 10-14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15-19 years (14·2%) and 20-24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20-24 years (17·1%) and the fourth highest for girls aged 15-19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15-19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20-24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20-24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20-24 years. Alcohol and drug use in those aged 10-24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs. INTERPRETATION Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young peoples health risk factors and their determinants in health information systems. FUNDING Bill & Melinda Gates Foundation.

The Utilization of Testing and Counseling for HIV: A Review of the Social and Behavioral Evidence

Against the background of debates about expanding HIV testing and counseling, we summarize the evidence on the social and behavioral dimension of testing and its implications for programs. The discrepancy between acceptance of testing and returning for results and the difficulties of disclosure are examined in light of research on risk perceptions and the influence of gender and stigma. We also summarize the evidence on the provision of testing and counseling, the implementation of practices regarding confidentiality and consent, and the results of interventions. We demonstrate that social factors have a considerable impact on testing, show that the services linked to testing are key determinants of utilization, and consider the implications of these findings for HIV testing programs.

Facilitating HIV Disclosure Across Diverse Settings: A Review

HIV status disclosure is central to debates about HIV because of its potential for HIV prevention and its links to privacy and confidentiality as human-rights issues. Our review of the HIV-disclosure literature found that few people keep their status completely secret; disclosure tends to be iterative and to be higher in high-income countries; gender shapes disclosure motivations and reactions; involuntary disclosure and low levels of partner disclosure highlight the difficulties faced by health workers; the meaning and process of disclosure differ across settings; stigmatization increases fears of disclosure; and the ethical dilemmas resulting from competing values concerning confidentiality influence the extent to which disclosure can be facilitated. Our results suggest that structural changes, including making more services available, could facilitate HIV disclosure as much as individual approaches and counseling do.

The consequences of female circumcision for health and sexuality: An update on the evidence

This systematic review of published sources between 1997 and 2005 shows that female circumcision is associated with some health consequences but that no statistically significant associations are documented for a number of health conditions. This is in part a result of the difficulty of designing studies on the more extensive operations (infibulation). The findings of the analysis can be summarized as follows: statistically higher risks are documented for some but not all types of infections; the evidence regarding urinary symptoms is inconclusive; the evidence on obstetric and gynecological complications is mixed: increased risks have been reported for some complications of labour and delivery but not others, and for some symptoms such as abdominal pain and discharge, but not others such as infertility or increased mortality of mother or infant. Concerning sexuality, most of the existing studies suffer from conceptual and methodological shortcomings, and the available evidence does not support the hypotheses that circumcision destroys sexual function or precludes enjoyment of sexual relations. This review highlights the difficulties of research on the health and sexuality consequences of FGC, underscores the importance of distinguishing between more and less extensive operations, and emphasizes the need to go beyond simple inventories of physical harm or frequencies of sexual acts.This systematic review of published sources between 1997 and 2005 shows that female circumcision is associated with some health consequences but that no statistically significant associations are documented for a number of health conditions. This is in part a result of the difficulty of designing studies on the more extensive operations (infibulation). The findings of the analysis can be summarized as follows: statistically higher risks are documented for some but not all types of infections; the evidence regarding urinary symptoms is inconclusive; the evidence on obstetric and gynecological complications is mixed: increased risks have been reported for some complications of labour and delivery but not others, and for some symptoms such as abdominal pain and discharge, but not others such as infertility or increased mortality of mother or infant. Concerning sexuality, most of the existing studies suffer from conceptual and methodological shortcomings, and the available evidence does not support the hypotheses that circumcision destroys sexual function or precludes enjoyment of sexual relations. This review highlights the difficulties of research on the health and sexuality consequences of FGC, underscores the importance of distinguishing between more and less extensive operations, and emphasizes the need to go beyond simple inventories of physical harm or frequencies of sexual acts.

Menopause across cultures: a review of the evidence.

Objective: To review the cross‐cultural evidence on menopausal symptoms to assess the extent of variability in symptomatology and the relative weight of hormonal and social factors. Design: Literature review and critical summaries of available studies. Results: Symptoms related to menopause are found in all regions of the world, although everywhere large proportions of women go through menopause uneventfully. The evidence does not support that women in developing countries report fewer symptoms than in industrialized countries. There is a great diversity in symptom frequencies across countries, and the association of symptoms with menopausal status is weak. A number of symptoms thought to be part of menopause are in fact not specific to it, although the evidence does support the narrow estrogen hypothesis of a core of symptoms associated with estrogen decline, namely vasomotor and vaginal symptoms. Conclusions: The association between hormonal changes and menopause symptomatology is complex and mediated by sociocultural factors. (Menopause 2000;7:184‐192.

Culture, maternal health care, and women's status: a comparison of Morocco and Tunisia.

This report assesses the role of demographic, socioeconomic, and cultural factors in explaining differentials in maternal health-care use in North Africa. Analyses of the Demographic and Health Surveys for Morocco and Tunisia show substantial differences in the use of prenatal care and in the proportion of home compared with hospital births, both within and between the two countries. The findings raise the question of whether lower use rates are a reflection of the low status of women. The question is addressed first through a statistical analysis of the differences within the two countries in terms of the demographic, socioeconomic, and educational characteristics of individuals, and second, through a comparison of the social context, health-care systems, and population policies of the two countries. The findings are interpreted in light of field research on the cultural context of maternal health care.

Islam Women and Politics: The Demography of Arab Countries

This article examines three propositions that underlie many interpretations of the demography of Arab countries: that Arab countries do poorly in terms of demographic indicators that this is due to Islam and that the impact of Islam operates through the way in which it defines a low status for women. After reviewing the available data on fertility and health the article critically examines the claim that the high natality of Arab countries derives directly from religious doctrine or indirectly through Islams effect on the status of women. It argues that simplistic hypotheses linking Islam and the status of women cannot provide a satisfactory explanation for observed demographic patterns and that a better understanding of demographic change must include attention to the political context of fertility and health behavior. (SUMMARY IN FRE AND SPA) (EXCERPT)

Maternal health care utilization in Jordan: a study of patterns and determinants.

This article analyzes the patterns and determinants of maternal health care utilization in Jordan, using data from the Jordan Fertility and Family Health Survey of 1983. The study focuses on the 2,949 women who had a child in the five years preceding the survey. Through multivariate analyses of differentials in the utilization of prenatal care and health care at delivery, the study assesses the effect of sociodemographic factors, including residence, education, parity, and standard of living. The coverage of maternal health care in Jordan is discussed in relation to the overall organization of health services, the various providers of care, and the role of cultural factors.

HIV in the Middle East

Prevalence of HIV in the Middle East is low but there is no room for complacency

Women's views on consent, counseling and confidentiality in PMTCT: a mixed-methods study in four African countries

BackgroundAmbitious UN goals to reduce the mother-to-child transmission of HIV have not been met in much of Sub-Saharan Africa. This paper focuses on the quality of information provision and counseling and disclosure patterns in Burkina Faso, Kenya, Malawi and Uganda to identify how services can be improved to enable better PMTCT outcomes.MethodsOur mixed-methods study draws on data obtained through: (1) the MATCH (Multi-country African Testing and Counseling for HIV) studys main survey, conducted in 2008-09 among clients (N = 408) and providers at health facilities offering HIV Testing and Counseling (HTC) services; 2) semi-structured interviews with a sub-set of 63 HIV-positive women on their experiences of stigma, disclosure, post-test counseling and access to follow-up psycho-social support; (3) in-depth interviews with key informants and PMTCT healthcare workers; and (4) document study of national PMTCT policies and guidelines. We quantitatively examined differences in the quality of counseling by country and by HIV status using Fishers exact tests.ResultsThe majority of pregnant women attending antenatal care (80-90%) report that they were explained the meaning of the tests, explained how HIV can be transmitted, given advice on prevention, encouraged to refer their partners for testing, and given time to ask questions. Our qualitative findings reveal that some women found testing regimes to be coercive, while disclosure remains highly problematic. 79% of HIV-positive pregnant women reported that they generally keep their status secret; only 37% had disclosed to their husband.ConclusionTo achieve better PMTCT outcomes, the strategy of testing women in antenatal care (perceived as an exclusively female domain) when they are already pregnant needs to be rethought. When scaling up HIV testing programs, it is particularly important that issues of partner disclosure are taken seriously.