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.
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.
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 miscar...
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.
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...
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.
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 reque...
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.
My affiliation institution reported in the article "Do
patterns of mental healthcare predict treatment failure in young people
with schizophrenia? Evidence from an Italian population-based cohort
study" published in BMJ Open is incomplete. The second affiliation is as follows:
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 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.
Efforts to reduce sugar intake among children are required as
intakes are much higher than recommended. Sweetened drinks are one of the
main sources of dietary sugars, particularly for children and adolescents,
and sugar intakes are around 2-3 times more than recommended by the
Scientific Advisory Committee on Nutrition. That said, juices and
smoothies make a nutritionally valuable contribution to children's diets
as the...
Efforts to reduce sugar intake among children are required as
intakes are much higher than recommended. Sweetened drinks are one of the
main sources of dietary sugars, particularly for children and adolescents,
and sugar intakes are around 2-3 times more than recommended by the
Scientific Advisory Committee on Nutrition. That said, juices and
smoothies make a nutritionally valuable contribution to children's diets
as they count as one of their 5-a-day. The National Diet and Nutrition
Survey revealed that only 10% of boys and 7% of girls aged 11 - 18 years
met the 5-a-day recommendation. The Government's latest advice is that
juices and smoothies should be limited to a combined total of one small
(150ml) glass per day and to keep them to mealtimes to reduce the risk of
tooth decay.
In determining the sugar content of the drinks surveyed, the authors
themselves have used the clearly labelled amounts of sugars present in
products. One of the suggestions in the paper to tackle unacceptably high
sugar intakes is that the food industry stops adding unnecessary sugar to
sweeten drinks. Pure fruit juices and fruit juice smoothies are made from
whole fruit, crushed fruit and fruit purees, and are not permitted to
contain added sweeteners or to dilute the naturally-occurring sugar
content contributed by the fruit with water. Reducing the sugar content
of these products is only possible by using lower sugar variants of fruits
or vegetables. Fruit juice-based drinks, such as squashes and cordials,
may include additional ingredients such as sugars, sweeteners and added
water, which must be declared in the ingredients list. Reducing the sugar
content of these products is possible, and some manufacturers have taken
steps by replacing all or some of the added sugars with artificial
sweeteners.
References
Scientific Advisory Committee on Nutrition. Carbohydrates and Health.
The London: TSO, 2015.
National Diet and Nutrition Survey. Results from Years 1, 2, 3 and 4
(combined) of the Rolling Programme (2008/2009 - 2011/2012). A survey
carried out on behalf of Public Health England and the Food Standards
Agency. London: TSO, 2014.
Sundstrom et al. examined the association between marital status and
dementia in adults by a 10-year cohort study [1]. The authors handled
2,288,489 induviduals, and 31,572 dementia individuals were observed.
Marital status was classified into married, single, divorced or widowed,
and the incidence of dementia was monitored. Cox regression showed that
significant increase in hazard ratios of single, divorced and widowed...
Sundstrom et al. examined the association between marital status and
dementia in adults by a 10-year cohort study [1]. The authors handled
2,288,489 induviduals, and 31,572 dementia individuals were observed.
Marital status was classified into married, single, divorced or widowed,
and the incidence of dementia was monitored. Cox regression showed that
significant increase in hazard ratios of single, divorced and widowed
against married individuals were observed both in men and women, which was
also recognized in young-old and middle-old individuals. The authors
concluded that living alone, non-married, was a risk for dementia. I have some concerns in their study.
First, St John and Montgomery determined that self-rated health (SRH)
in cognitively intact older adults could predict dementia, but SRH in
older adults with cognitive impairment could not predict dementia by a
prospective cohort study with multinomial regression models [2]. This
means that SRH monitoring is effective to prevent dementia in individuals
without cognitive impairment, and SRH monitoring in combination with the
screening for early cognitive impairment in individuals living alone is
strongly recommended.
Relating to the first query, I previously reported that male, having
disease, physical complaints, depressive state, lower levels of education
and being divorced resulted a risk for poor self-rated health [3]. Taken
together, inter-relationship among marital status, self-rated heath and
dementia should be considered simultaneously.
Finally, the authors concluded that social relationship should be
considered as a risk factor for dementia. Kuiper et al. conducted a
systematic review with a meta-analysis, and social relationship factors
including a lack of social interaction were associated with incident
dementia [4]. Marital status and other information on social network
should be evaluated simultaneously for the risk of dementia.
References
1. Sundstrom A, Westerlund O, Kotyrlo E. Marital status and risk of
dementia: a nationwide population-based prospective study from Sweden. BMJ
Open, 2016;6:e008565.
2. St John P, Montgomery P. Does self-rated health predict dementia?
J Geriatr Psychiatry Neurol, 2013;26:41-50.
3. Kawada T, Suzuki S. Marital status and self-rated health in rural
inhabitants in Japan: a cross-sectional study. J Divorce Remarriage,
2011;52:48-54.
4. Kuiper JS, Zuidersma M, Oude Voshaar RC, et al. Social
relationships and risk of dementia: A systematic review and meta-analysis
of longitudinal cohort studies. Ageing Res Rev, 2015;22:39-57.
I wish to provide some perspective from epidemiology with regard to a
recent study that appeared in your journal. First, this study is the
first population-based study to look at the relationship between MS and
retinopathy in a North Chinese population, but the study did not mention
why it uses Shenyang people as the study population. Second, the author
provided numerous studies on MS, DM. But the stereo fundus photography...
I wish to provide some perspective from epidemiology with regard to a
recent study that appeared in your journal. First, this study is the
first population-based study to look at the relationship between MS and
retinopathy in a North Chinese population, but the study did not mention
why it uses Shenyang people as the study population. Second, the author
provided numerous studies on MS, DM. But the stereo fundus photography was
not mentioned in the introduction, which is used to detect retinopathy.
Third, logistic regression analyses for retinopathy were only adjusted for
age, gender, drinking, smoking and health conditions (BMI, HbA1c, duration
of diabetes, SBP, DBP), but there are more important factors that
influence people's retinopathy, such as demo-socioeconomic status,
occupations and other health conditions. Such factors also should be taken
into account. Fourth, the tables and figures were clearly presented - however, the P
-value did not show in the Table 2. It is better to add the P-value so as
to show how significant it is. Fifth, diabetes status was defined
according to self-reported physician diagnosis or the use of antidiabetic
agents. Nevertheless, the type of diabetes was not investigated.
In summary, there are some limitations to this study. I hope this
letter can point them out, which could help future similar studies.
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.
...
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 miscar...
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...
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 reque...
My affiliation institution reported in the article "Do patterns of mental healthcare predict treatment failure in young people with schizophrenia? Evidence from an Italian population-based cohort study" published in BMJ Open is incomplete. The second affiliation is as follows:
Istituto Auxologico Italiano, Milan, Italy.
Conflict of Interest:
None declared
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...
Barthold Vonen should have both affiliations 5 and 6. For number 5 it should not stand CMO only Nordland Hospital Trust, Bod?, Norway
Efforts to reduce sugar intake among children are required as intakes are much higher than recommended. Sweetened drinks are one of the main sources of dietary sugars, particularly for children and adolescents, and sugar intakes are around 2-3 times more than recommended by the Scientific Advisory Committee on Nutrition. That said, juices and smoothies make a nutritionally valuable contribution to children's diets as the...
Sundstrom et al. examined the association between marital status and dementia in adults by a 10-year cohort study [1]. The authors handled 2,288,489 induviduals, and 31,572 dementia individuals were observed. Marital status was classified into married, single, divorced or widowed, and the incidence of dementia was monitored. Cox regression showed that significant increase in hazard ratios of single, divorced and widowed...
I wish to provide some perspective from epidemiology with regard to a recent study that appeared in your journal. First, this study is the first population-based study to look at the relationship between MS and retinopathy in a North Chinese population, but the study did not mention why it uses Shenyang people as the study population. Second, the author provided numerous studies on MS, DM. But the stereo fundus photography...
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