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Displaying 1-10 letters out of 472 published

  1. Association between sexually transmitted disease and church membership. A retrospective cohort study of two Danish religious minorities

    Korup and colleagues aimed to investigate the incidence of sexually transmitted diseases among Danish Seven-day Adventists (SDAs) and Danish Baptists as a proxy for cancers related to sexual behaviour. The authors use a retrospective cohort design with a cohort comprised of 3119 SDA females, 1856 SDA males, 2056 Baptist females and 1467 Baptist males and came with the conclusion that there is significant lower incidence of sexually transmittable diseases, mostly including human papillomavirus, which may partly explain the lower incidence of cancers of the cervix, rectum, anus, head and neck.

    It is not clear why the authors selected SDAs and Baptists in this study. I would suggest that the authors use a comparative case study method to get an in-depth examination of SDAs and Baptists, as well as Catholics, who are generally against the use of condoms in sexual relationships. It will be interesting to also understand whether the studied population is involved in oral sex and the types of prevention methods used. Another interesting area is to examine the prevalence among married couples, given that some countries have observed an increased incidence of STDs in married couples.

    Conflict of Interest:

    None declared

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  2. Traditional medicine used in childbirth and for childhood diarrhoea in Nigeria's Cross River State: interviews with traditional practitioners and a statewide cross-sectional study

    The authors of the study set out to explore factors associated with use of traditional medicine during childbirth and in management of childhood diarrhoea. They found out that 24.1% (1371/5686) of women reported using traditional medicine at childbirth; these women had less education, accessed antenatal care less, experienced more family violence and were less likely to have birth certificates for their children. 11.3% (615/5425) of young children with diarrhoea were taken to traditional medical practitioners; these children were less likely to receive BCG, to have birth certificates, to live in households with a more educated head, or to use fuel other than charcoal for cooking. Education showed a gradient with decreasing use of traditional medicine for childbirth and for childhood diarrhoea.

    I agree with the authors that less education and low income levels play a huge role in women's use of traditional medicine for child birth and in treating diarrhoea in children. However, the authors failed to mention other factors like gender relations and power dynamics which are very important factors in deciding whether child delivery should be done in the hospital or with the traditional birth attendance. It is also a factor that determines whether traditional medicine should be used for treating diarrhoea in children or not. Physical distance to the hospital in some instances is a major barrier and also the accessibility of health care providers in remote areas is a major factor. Cultural factors and knowledge transfer from one generation to another are important contributors. Choguya explained that African traditional medicine started a long time ago and this experience has sustained life without the addition of western medicine.

    Reference

    Choguya, NZ. Traditional birth attendants and policy ambivalence in Zimbabwe. Journal of Anthropology, 2014.

    Conflict of Interest:

    None declared

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  3. Access to improved water and its relationship with diarrhoea in Kathmandu Valley, Nepal: a cross-sectional study

    The authors set out to examine the relationship between diarrhoea and types of water sources, total quantity of water consumed and the quality of water consumed in fast growing highly populated urban areas in developing countries. They found that consumers of water from alternative sources have a higher prevalence of diarrhoea than those using clean water; those with limited access to water were at increased risk than those with full access. Consumers of alternative sources have lower risk of diarrhoea because they are aware of the fact that unconventional sources of water are contaminated and the water is not treated. There are higher incidences of diarrhoea among those with limited education, and higher incidences among people with low income. Concurrent with the findings of Shrestha and colleagues, unsafe drinking water is a major public health challenge in developing countries such as Nepal. I will compare the findings with Cameroon which is a developing country and has similar problems.

    Waterborne diseases such as diarrheal diseases are very prevalent in Cameroon especially among children of less than five years [1]. Every year, 6000 children of under-five die of diarrhoea in Cameroon [2]. With the growth of the urban areas and the depletion of the forest, the existing water supply coverage is insufficient to the urban population and the people at the periphery of the urban cities do not have available clean drinking water [3]. The uneven distribution of water has caused a huge problem to access to clean water and only those who can pay for it have access. As a result, most of the population turn to alternative sources of water such as wells, rivers and lakes for safe water, which is often polluted with faeces, household and industrial waste. With the consumption of polluted water, the incidence of diarrheal disease is on the rise as compared to those who have access to clean water. Cameron is gifted with freshwater sources but only approximate 40% of the population has access to clean water [4]. In the urban town of Douala and Yaound, only 13 liters of water per person per day is available for consumers and for every 30 inhabitants only one connection is available. Over the years there has been a gradual reduction of public standpipes from 1,776 in 1987 to 126 in 2002 in these cities [5]. Today there are spotted public standpipes. Polluted water is not the only factor responsible for the rise of incidence of diarrhoea; methods of water transportation, storage and improper hand washing are contributing factors. Socio-economic factors such as low level of education and low income levels are also contributing factors. Statistics show that the poverty level in Cameroon was 37.5% and urban poverty was 9% in 2014 [6]. The literacy level was 68% [7]. These figures confirm the fact that low income and education are contributing factors to diarrhoea. I agree with the author that clean water supply is an important strategy of prevention of diarrhoea in developing countries such as Nepal and Cameroon.

    References

    1. Yongsi HBN. Suffering for Water, Suffering from Water: Access to Drinking-water and Associated Health Risks in Cameroon. J HEALTH POPUL NUTR, October 2010.

    2. UNICEF, WHO, GAVI Alliance. Cameroon to protect its children against leading cause of severe diarrhoea. 2014. Available online at: http://www.gavi.org/Library/News/Press-releases/2014/Cameroon-to-protect- its-children-against-leading-cause-of-severe-diarrhoea/

    3. Ako AA, Shimada J, Eyong GET, Fantong WY. Access to potable water and sanitation in Cameroon within the context of Millennium Development Goals (MDGS), March 2010. 61 (5) 1317-1339.

    4. Fung O. Water shortage in Cameroon poses a serious health threat to the Cameroon population. 2013. Available online at: http://www.foretiafoundation.org/portfolio/water-shortage-in-cameroon- poses-a-serious-health-threat-to-the-cameroonian-population/

    5. OK Clean Water Project. Facts about Cameroon & Canada. 2016. Available online at: http://www.okcleanwaterproject.org/index.php?p=page&page_id=facts-about- cameroon.836

    6. World Bank. Overview, 2016. Available online at: http://www.worldbank.org/en/country/cameroon/overview

    7. Fortune of Africa. Economy of Cameroon, 2014. Available online at: http://fortuneofafrica.com/cameroon/2014/01/24/economy-of-cameroon/

    Conflict of Interest:

    None declared

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  4. RE: Factors influencing the inclusion of complementary and alternative medicine (CAM) in undergraduate medical education

    In this article KR Smith makes three important points in the conclusion. Firstly, that it may be useful for the General Medical Council to clarify the extent to which Complementary and Alternative Medicine (CAM) should be incorporated into the curriculum. Secondly, he suggests that current CAM education appears to exist primarily as a means of educating future doctors on the modalities that their patients may use or request. And thirdly, he observes that some forms of pedagogy arguably risk students assimilating CAM advocacy in an uncritical fashion. These conclusions are pertinent in a country such as Kenya where a large proportion of the population use CAM partly due to culture and tradition and partly due to inability to afford conventional medicine. At the same time the teaching of complementary and alternative medicine to health professionals is far from fully developed with varying curriculum content and teaching and learning methods on the one hand, and the ongoing debate on CAM integration in health care, on the other. There is also acknowledgement of the changes which may need to be effected in order to improve medical education with regard to CAM which in turn will have effect its full inclusion safety and the efficacy in the healthcare system. It is true that guidance from the regulatory authority in relation to teaching CAM in health professional schools will be necessary. However, in addition this should be in the context of a structured needs assessment incorporating key stakeholders including input of conventional medical practitioners, CAM practitioners, the faculty, students, and the community (the consumers of CAM). I also agree with the author that CAM education should address more than preparing the future health service practitioners to respond to patient requests. The students need to be prepared to critically think and engage CAM practitioners and literature as well as also be prepared to make informed to choice on the benefits of CAM for their own personal consumption self-awareness and self-care. Thus, apart from lectures and other didactic approaches opportunities to experience CAM personally, particularly mind-body approaches and stress management, as part of self-care should provide to student opportunity for experiential learning. The students who learn the fundamentals of self-awareness and self-care will also be better able to teach their patients to care for themselves. Therefore medical education should include opportunities to experience CAM approaches, such as meditation and relaxation therapy, for students who personally may benefit from these approaches during their stressful journey through health professionals training. The faculty will also understand first-hand the importance of experiential learning and how this initiative in CAM could actually advance learning in terms of broader issues, such as improved patient-provider communication, and heightened student and faculty self-awareness and self-care while also addressing personal biases in clinical interactions, personal health and wellness, or training in mind-body interventions.

    Conflict of Interest:

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  5. RE: Community-Linked Maternal Death Review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

    As the author stated, maternal mortality remains high and existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system, particularly in the sub-Saharan region. Health and Demographic Surveillance System (HDSS) sites provide data on vital events and a sampling frame and base population for community-based research in countries where vital registration systems are non-existent or weak (UNFPA, 2014). An HDSS collects and monitors the demographic and health characteristics of a population living in a well-defined geographic area. The process starts with a baseline census followed by regular update of key demographic events (birth, death, and migration) and health events through systematic data collection. The author shows advantages of Health System Survey sites as a platform for research and research capacity building and in providing evidence- based interventions for health development. However, the Community-Linked Maternal Death Review (CLMDR) on its own could not predict accurate verbal autopsy information through a prospective cohort study without case controls and multinomial regression models. The design of the CLMDR which partnered with the community and health facility stakeholders to identify and review maternal deaths and to generate actions to prevent future deaths is a crucial strategy to mould the bottom-up-approach in strengthening health systems. The author has presented the CLMDR process involving four stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews and involving both community and facility representatives.

    I propose that this process should be tailored to each context and should target men, women, youth and influential decision- makers. I further propose the inclusion of two additional stages consisting of training of community members and integration of the community as the focal point (CFP) in providing reliable information. These two stages are appropriate approaches for use in rural areas, where due to lack of health education, not all information related to pregnancy risk factors are recorded.

    References

    * UNFPA. The State of the World's Midwifery 2014. A Universal Pathway. A Woman's Right to Health. New York: UNFPA, 2014.

    * UNDESA. World Population Prospects: The 2012 Revision. 2012. Available online at: http://esa.un.org/wpp/ unpp/panel_indicators.htm

    * Saving Mothers, Giving Life. Making Pregnancy and Childbirth Safer in Uganda and Zambia. Annual Report. Washington DC: US?AID, 2013.

    * Jacob Annamma, text book of midwifery and gynecological nursing, 5rd, Jaypee, DELHI, 2012.

    Conflict of Interest:

    None declared

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  6. Re: Are depression and poor sexual health neglected comorbidities? Evidence from a population sample

    Several methodological concerns make the results of this study [1] questionable. To begin with, while it was loosely mentioned in the methods section that binary and ordinal logistic regression were deployed, it was never referred specifically which one was used in which analyses. There are at least two issues in this regard: (1) if ordinal logistic regression was used, then was the proportional odds assumption met? Findings (odds ratios [OR]) from Table 3, and those from the supplementary table, indicate that this assumption was not probably met; and (2) if multiple logistic (logistic regression repeated on every possible combination of two outcome variables, such as 'treated for depression' vs. 'no' groups, and 'depressive symptoms' vs. 'no' groups) regression was used, then the total probability could add up to more than 1. Since the ORs were similar, as the author clarified, it would have been more reasonable to add both the treated and non-treated depression groups together.

    Another very crucial thing missing was adjusting for confounders other than age. There are several studies published showing potential confounders, and simply saying 'not to 'over-adjust'' is surely not sufficient justification. Adjusting for a few potential confounders does not comprise 'over-adjustment', which was defined as adjusting for an intermediate variable in the exposure-outcome pathway [2]. The concern that other potential confounders were not adjusted for, p-hacking [3], could not be ruled out. Addition of the results after adjusting for other potential confounders is mandated.

    The inference that 'treatment for depression was associated with reporting 2 or more sexual partners without condoms' implies the treatment was harmful in terms of sexual risk behaviour, or previously treated (and potentially cured, since the methods section says the two depression groups were mutually exclusive implying the 'treated for depression' group was cured while the 'depressive symptoms' group was still having depressive symptoms) individuals were more likely to have sexual risk behaviours. None of these sounds sound from clinical perspectives. Would it not be more plausible to say past (and current, if both the depression groups were merged together) depressive symptoms are associated with sexual risk behavior?

    Minor concerns include age-range of the participants. In sexual risk behaviour studies, it is more plausible to include sexually-active participants as used in previous studies [4,5]. Also, why the analyses were stratified by gender was not justified while there are existing literature on gendered distribution of depression, and sexual risk behaviours, and gender difference in their association [5].

    References:

    1. Field N, Prah P, Mercer CH, Rait G, King M, Cassell JA, Tanton C, Heath L, Mitchell KR, Clifton S, Datta J. Are depression and poor sexual health neglected comorbidities? Evidence from a population sample. BMJ Open, 2016 Mar 1;6(3):e010521.

    2. Schisterman EF, Cole SR, Platt RW. Overadjustment bias and unnecessary adjustment in epidemiologic studies. Epidemiology (Cambridge, Mass.), 2009 Jul;20(4):488.

    3. Bruns SB, Ioannidis JP. p-Curve and p-Hacking in Observational Research. PloS One, 2016 Feb 17;11(2):e0149144.

    4. Chen Y, Wu J, Yi Q, Huang G, Wong T. Depression associated with sexually transmitted infection in Canada. Sexually transmitted infections, 2008 Dec 1;84(7):535-40.

    5. Islam N, Laugen C. Gender differences in depression and condom use among sexually active Canadians. Journal of affective disorders, 2015 Mar 15;174:511-5.

    Conflict of Interest:

    None declared

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  7. Practices of no net benefit

    The phenomenon of "overdiagnosis" is currently attracting the interest of health professionals, researchers, and governments. However, Ghanuouni and colleagues suggest that the definition of the phenomenon is not clearly understood. A major problem with the term is that it is imprecise. This is reflected by the public's varying attempts to define overdiagnosis: their responses spanned four themes and 15 subthemes. However, we believe that the term itself is inappropriate and misleading.

    The definition of "overdiagnosis" used by the authors, "the diagnosis of disease which would never have become clinically apparent in a person's lifetime (i.e. causing neither symptoms nor death)", is currently largely accepted. However, as the authors acknowledge, this definition and the term itself both emphasise the possible harms of a diagnosis.

    A diagnosis in isolation might cause a patient distress or other psychological harm, but the potential for physical harm and waste of finite resources occurs through inappropriate testing, which reveals the diagnosis, and inappropriate treatment of diagnoses that do not need it. An inappropriate test can harm a patient through a direct adverse reaction (e.g. contrast nephropathy) or harm indirectly, by diverting resources from necessary interventions. Inappropriate treatment can cause harm by the same mechanisms and by medicalizing the patient.

    Focusing on the term "overdiagnosis" distracts from the two activities that can cause patient harm and waste resources: testing and treating. We prefer the term 'practices of no net benefit'. "Practices" refers to medical practices (tests or treatments) and "no net benefit" implies that the tests or treatments may result in some benefits, but their harms outweigh those benefits. Identifying and reducing practices of no net benefit will prevent the diagnosis of diseases that might never become clinically apparent and reduce the frequency with which net harmful treatments are offered to patients.

    Some of the subjects in the study reported by Ghanuouni and colleagues - those who defined "overdiagnosis" as "too many tests" or "overtreatment" - seem to have understood this. Perhaps the public are more aware of the problems than they are given credit for.

    Conflict of Interest:

    None declared

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  8. Weekly miscarriage rates in a community based prospective cohort study in rural western Kenya, Dellicour S. et al, April 16 2016

    The objective of the study was to estimate the background rate and cumulative probability of miscarriage in rural western Kenya using a population based prospective cohort study.

    The authors sought to identify pregnancies early from the general population by asking all consenting women 15-49 to respond to questions and take a pregnancy test. Some of the limitations of the study regarding ascertainment of miscarriage less than 12 weeks was indeed very difficult due to the cultural realities mentioned by the authors. The authors stated that the recruitment of participants and data collection from them was undertaken by trained community based staff and it is not clear whether these community based staff were from the community or not.

    In my view the involvement of female community health workers who are in a similar age group and therefore peers to the respondents would improve the accuracy and ascertainment of miscarriage below 12 weeks and thus address some of the limitations of the study mentioned by authors.

    It is also conceivable that data collection by peers might be able to identify induced abortions as the respondents might be more likely to offer this information to peers rather than strangers given the fact that induced abortion is illegal expect if the life of the mother is in danger. This would also reduce the gestational age identification of pregnancy.

    It would be therefore advisable to include the reporting of miscarriages in community health workers' household reporting tool.

    The authors report that risk factors are known by the study population and the risk factors mentioned appeared to be quite scientific and does not seem to include cultural risk factors, and hence a qualitative approach to collecting this information could add the perspectives of the community.

    The high pregnancy test acceptance rate is a testimony to the rapport that the study team has with the local community and therefore the respondents. This is a lesson that other researchers may learn from: that the relationship within the study team and study population improves the response rate, as reported in this study.

    It is important for a study to be done on the causes of miscarriage since most cases went unreported as has been outlined by this study.

    Conflict of Interest:

    None declared

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  9. Impact of health insurance status changes on healthcare utilization patterns: a longitudinal cohort study in South Korea

    The study design is robust and appropriate in determining whether changes in health insurance status were associated with healthcare utilization.

    The study findings that health insurance beneficiaries with a coverage level lower than Medical Aid showed lower healthcare utilization, as measured by the number of hospitalizations and days spent in hospital per year, is replicable in other developing nations.

    However, I would like to highlight a few factors which might also contribute to variation among health insurance beneficiaries with different coverage level. In the context of liberalized economies such as Kenya, the difference in costing of medical services by different healthcare providers, and the proportion of the total cover for outpatients may also contribute to lower healthcare utilization.

    Conflict of Interest:

    None declared

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  10. Long-term financing needs for HIV control in sub-Saharan Africa in 2015-2050: a modeling study

    The authors of the article presented a very thoughtful estimate of the present value of current and future funding needed for HIV treatment and prevention in nine sub-Saharan African (SSA) countries that account for 70% of HIV burden in Africa under different scenarios of intervention scale-up.

    The objectives of the study were to analyze the gaps between current expenditures and funding obligation, and discuss the policy implications of future financing needs. The authors used most up-to-date cost, cost effectiveness, coverage and epidemiological data to estimate funding needed for HIV treatment and prevention in the nine sub-Saharan African countries.

    However, I want to add that for HIV to be controlled in SSA, it is not all about the amount of finances needed that translate to HIV control in sub-Saharan Africa in 2015-2050 but also favorable contextual factors like cultural, environmental, social and political factors. Health care financing in SSA has been constrained, not only in terms of the volume of funds available, but also by the fragility of the underlying governance structures that have not adequately addressed efficiency of resource allocation and use (Stephen Musau, 2010). Finances have been pumped in the health systems to control HIV but its prevalence has still increased.

    Conflict of Interest:

    None declared

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