LOW BIRTH WEIGHTS IN VIETNAM

Guidelines for low birth weight: a literature review comparing national guidelines in Vietnam with WHO guidelines

Review article

Line M Pederson

 

Background

This study was prompted by the persisting high prevalence of low birth weight (LBW) in Vietnam. LBW, defined as an infant weighing less than 2500g, is a leading cause of perinatal (22 weeks of gestation to 7 days postpartum) and neonatal (within 28 days postpartum) deaths globally. It contributes indirectly, through maternal factors, and directly, through postpartum factors, to 40-60% of newborn mortality.[1] LBW is the most important criteria for determining both immediate and long-term outcomes of neonates and infants. This includes chance of survival, healthy growth and freedom from morbidities.[2]

Vietnam is part of the WHO Western Pacific Region (WPR). Neonatal deaths in the WPR region contribute to the highest proportion (56%) of the under-five mortality compared to other WHO regions.[3] In Vietnam specifically, neonatal deaths account for 55% of the under-five mortality.[4]

Nutrition has a major impact on LBW and associated infant morbidity and mortality.[5-7] Nutritional factors are related to the biological processes that affect the fetus in utero and the mother’s physiology.[8, 9] The most important maternal risk factors[10] increasing risk of LBW are: body mass index (BMI) at conception[7, 8, 11-16], stature[17, 18], nutrition (including suboptimal gestational weight gain[10, 11, 19]), intake of micronutrients (iron[20, 21] and iodine deficiency[22]), maternal age (age <18[23-27], age >35[28, 29]) and cultural food habits and behaviours.[30, 31]

Maternal pre-partum health status, immediate care of the LBW infant and exclusive breastfeeding (EBF) for 6 months are crucial to reducing the burden of LBW.[32] Guidelines are important as they act as a tool for quality assurance, facilitating improved quality of care provided by informed healthcare workers.[33]

Methods

A Quick Scoping Review was performed to evaluate existing knowledge of LBW. This involved a rapid review of literature on LBW risk factors. Guidelines were obtained from the WHO website, Vietnamese government website, online and through formal email correspondence with the WHO WPR Reproductive, Maternal, Newborn, Child and Adolescent Health team to ensure the most recent guidelines were included.

An extensive literature search was then conducted to identify barriers to proper implementation of LBW guidelines in Vietnam. Bibliographic databases (Pubmed, ProQuest, Cochrane Library, Google Scholar, WHO and UNICEF) were searched using combinations of keywords including low birth weight, guidelines, barriers, attitude, beliefs, maternal health/nutrition, health services utilisation, satisfaction and quality of care. Additional articles were identified and retrieved by reviewing the reference list of relevant articles, while further reports and materials from organisations and governments were identified manually and found online.

Only English language papers published between 2000 and 2016 were included. Articles pertaining to women with co-morbidities were excluded, as separate sets of guidelines often exist for these women. Besides the WHO guidelines, only studies relating to Vietnam were included. Furthermore, only studies related to antenatal care (ANC), perinatal care, postnatal care (PNC) and breastfeeding practices were included, with a focus on LBW. The critical evaluation of studies included looking at the study methodology, perceived objectivity, study provenance, research evidence, and the contribution of the study to the literature.

The review was conducted by the author from February to June 2016 as part of a master’s thesis. Subsequently, the Ministry of Health (MoH) Vietnam has launched The National Guideline on nutrition for pregnant women and lactating mothers, acting as a practical step for effective implementation of the National Nutrition strategy 2011-2020 with a vision toward 2030. The WHO has since updated their recommendations on newborn health, but no significant changes occurred with regards to the included guidelines.

Results

Variance between WHO guidelines and national guidelines in Vietnam

Differences between the WHO’s guidelines and national guidelines in Vietnam were analysed to identify whether Vietnam follows the evidence-based guidelines proposed by the WHO, and to determine whether both sets of guidelines are appropriate considering the national context. As shown in Table 1 below, national guidelines in Vietnam are largely in agreement with WHO guidelines. However, significant disagreements exist, and are highlighted in the table.

Barriers to guideline implementation in Vietnam

1. Health sector

Structural components, including health facilities,[43] staff[44, 45] and basic equipment for reproductive health care,[46] are lacking mostly in rural areas. The Joint Annual Health Review 2015 conducted by the MoH Vietnam and Health Partnership Group suggested that restricted health financing may impede improvement.[47] Health funds are allocated via input indicators (number of beds and staff). Thus, rural areas are faced with smaller hospitals and fewer staff. At a commune and district level, less funding is relatively available, and investments are rather made in high-tech equipment such as ultrasound.[47]

A study by Eriksson et al. involving 412 primary health care practitioners found availability of national guidelines for reproductive health care similar across hospitals (67%) and community health centres (70%) in northern Vietnam.[48] However, in a study by Trevisanuto et al. conducted in South/South Central Vietnam, only half of clinical practitioners from provincial level hospitals deemed written guidelines ‘very important’.[49] Despite a limited sample size (n=54) including a mix of professional backgrounds (nurses, midwives, doctors), the majority of the sample were considered local experts in neonatal infections. Though content of national guidelines was considered relevant by such professionals, they were rarely used.[50] Furthermore, Eriksson et al found no association between level of knowledge of neonatal care and access to guidelines.[48] This suggests limited knowledge and utilisation of guidelines despite availability.[48] Thus, a need for stronger implementation strategies and/or more context appropriate guidelines is necessary.

In-service and competency-based training as well as the quality of health workers’ performance is also unequally distributed between urban and rural areas[46-48, 51-57], particularly for infant feeding practices.[57-61] This is primarily due to working conditions and the lack of compensation for time spent on training, in addition to a paucity of career development opportunities.[46, 50, 52] In contrast, one study by Eriksson et al., found relatively high knowledge scores on LBW care and early breastfeeding among health workers[48] which could contribute to reducing LBW morbidity and mortality.

Structural components, including health facilities [43], staff[44, 45] and basic equipment for reproductive health care[46], are lacking mostly in rural areas. The Joint Annual Health Review 2015 conducted by MoH Vietnam and Health Partnership Group suggested that impedance to improvement stems from restricted health financing.[47] Health funds are allocated via input indicators (number of beds and staff). Thus, rural areas are faced with smaller hospitals and fewer staff. At a commune and district level, less funding is relatively available, and investments are rather made in high-tech equipment such as ultrasound.[47]

2. Mothers and cultural factors

Another cultural factor often overlooked is the occurrence of home births, particularly in rural areas.[40, 43] Homebirths are preferred by patients given lower costs and travel. However, they are also related to a higher prevalence of LBW and neonatal mortality.[67, 68] Such births are often chosen to avoid embarrassment and stigmatisation in cases of non-marital status or lack of knowledge. Furthermore, the convenience of local family support[69] or adherence to cultural traditions favour home births in rural areas.[55, 69] In contrast, urban mothers tend to over-use technology, with a strong preference for birth via caesarean section (CS)[53, 67, 68]. CS has been associated with poorer rates[55, 70, 71] and durations of EBF,[68, 72] thus having negative consequences for breastfeeding practices.

EBF and lactation mechanisms are often poorly understood and under-appreciated amongst mothers, relatives and lay persons.[59, 70, 71, 73-76] An example is the low value placed on colostrum – a vital dietary component for the LBW infant.[59, 71, 72, 77-80] Whilst women traditionally follow postpartum rituals passed on from grandmothers and other surrounding mothers[57, 58, 73], these breastfeeding practices may be dangerous and suboptimal due to feeding of water [71, 78] and the perception that breastmilk is insufficient in quantity and quality.[59, 71, 77, 78] Such practices may increase the risk of poor postnatal outcomes,[57-60, 73, 80] as the LBW infant does not receive vital nutrients from colostrum that stimulate the development of the infant’s digestive system, antibodies and white blood cells.[71]

Two different scenarios were found for breastfeeding in Vietnam. For rural areas, women with high education tend to breastfeed longer than women with lower education. On the contrary, highly educated women in urban areas tend to breastfeed for a shorter duration and non-exclusively.[68, 72, 76] Thus, higher educational level improves breastfeeding practices in rural areas, but presents as a barrier in urban areas. This may be due to exposure to mass media and infant formula advertisements, amongst other reasons yet to be explored.[71, 81, 82]

Despite guideline discouragement,[40] pre-lacteal feeds[57, 59, 71, 73-75] and complementary feeding[83, 84] are often given before the 6 months of exclusive breastfeeding ends. Interestingly, the cultural preference for sons has caused a disparity between breastfeeding practices in male and female infants. Due to the belief that breastfeeding is inferior to formula milk, males are breastfed less often.[68, 85] This is often a belief carried by the whole family and undermines the importance of EBF, meaning that emphasis must be placed on familial involvement and education to encourage breastfeeding practices and prevent morbidity and mortality due to LBW.[79, 80, 86]

3. Inconsistent and confounding policies for LBW prevention and care

The International Code of Marketing of Breastmilk Substitutes is enacted in Vietnam.[87] However, implementation has been challenging,[88-90] and the International Baby Food Action Network along with the WHO and UNICEF have identified common violations, such as biased/inaccurate advertisements, improper labelling and promotion of complementary infant foods.[91, 92] Health workers are often approached by formula companies to promote complementary foods from which they receive commission.[55, 58, 71, 93] Such practices have adverse consequences on promotion of healthy infant feeding practices[58, 60, 71, 76, 93, 94], thus hindering breastfeeding practices and the health and survival of LBW infants.

Confounding policies regarding maternity leave are also contributing to suboptimal LBW prevention and care. Since 2012, maternity leave has been 4-6 months, which is longer than the recommended 14 weeks proposed by the International Labor Organisation.[95] However, the unpaid nature of maternity leave has been found to be a barrier to EBF. [84, 93] Casual or temporary workers find it necessary to return to work given financial responsibilities, thus necessitating complementary infant foods.[59, 71, 73, 74, 77, 79]

Discussion

As evident from this study, developing coherent guidelines and aligning strategies preventing LBW is difficult at national and international levels. Even more challenging is implementation of such guidelines in countries with high prevalence of LBW and neonatal morbidity and mortality. Appropriate evidence-based guidelines have the potential to promote beneficial interventions and discourage ineffective medical practice.[96] Their appropriateness for prevention and management of LBW infants in Vietnam will therefore be discussed.

Appropriate cut-off for referral of LBW

Different cut-offs for referral of LBW infants were found in two current WHO WPR documents: a 2000g cut-off and a 1500g cut-off in the WHO WPR Action Plan 2014-2020[37] and the WHO WPR EENC guide (2014),[97, 98] respectively. This demonstrates intra-organisation disparity. The 2000g cut-off in Vietnam seems to be more appropriate, due to the seemingly lower risk of mortality associated with the 2000g threshold when compared to 1500g. On the other hand, a 1500g cut-off may be more easily adaptable to the context given high ANC coverage in Vietnam. However, high coverage does not always mean high quality of care.[98] Thus, rather than debating between cut-off values, focus should remain on intensifying quality care for LBW infants whilst reducing unnecessary CS as recommended by the WHO WPR Action Plan.[37]

Qualifying as an LBW infant might not necessarily increase risk of mortality – a phenomenon known as the LBW paradox.[99, 100] In Vietnam, factors such as high altitude may be a risk factor for LBW, but not necessarily for mortality.[99, 100] Knowledge of the predominant distribution (weight distribution of term births) and the residual distribution (percentage of small and preterm births) is essential in gaining insight into the gestational-age characteristics. Epidemiological data is needed to provide a better basis to judge the appropriateness of cut-off values.

Appropriate number and timing of ANC visits

Despite the WHO recommending 4 ANC visits,[35] the exact timing of ANC visits has been debated.[101] Current recommendations are based on a large WHO ANC randomized trial comparing the standard model of ANC (12 visits) with the new ANC model (4 visits). No differences in maternal and perinatal outcomes were found between the two models.[102] A systematic review of studies from developed and developing countries provided similar findings

where good perinatal outcomes persisted despite reduced ANC visits.[103] However, it proposed that in a setting of low ANC coverage, visits should not be reduced without close monitoring of foetal and neonatal outcomes.[103]

There is no current documentation of 3 visits being equal to or better than 4. One argument for increasing the number of ANC visits from 3 to 4 would be the relatively high contribution of neonatal mortality to under-5 mortality in Vietnam. One-third of neonatal deaths are estimated to be caused by prematurity,[104] including a proportion of LBW infants, for which higher frequency of ANC visits could be beneficial. Further supporting arguments include the relatively high maternal malnutrition rates that could be potentially addressed through increased counselling by clinicians. Increasing visitation might facilitate breastfeeding education and allow healthcare providers to detect and counsel women at risk of prematurity and LBW. However, this requires further investigation.

Nevertheless, recommending 4 ANC visits comes with increased societal costs as well as costs to the mother via transportation and loss of working hours for mothers without access to free reproductive health services. This potentially increases disparities between urban and rural areas where socioeconomic standing differs. Therefore, changes in policy and practice should be closely monitored. Outcomes including monitoring of customer (mother) and provider (healthcare worker) satisfaction should be monitored alongside trends in peri- and post-partum morbidity and mortality.

Appropriate number and timing of PNC visits

A Cochrane review conducted by Yonemoto et al. found no strong evidence on the association between number and timing of home-visits and improvements in neonatal and maternal mortality.[105] However, the review found 4 studies with evidence suggesting that home visits may encourage women to participate in EBF. An association between home visits and increased maternal satisfaction with postnatal care was also described, which suggests that PNC is beneficial in alleviating the burden of LBW. Unlike the WHO, the MoH in Vietnam does not recommend a PNC visit at 7-14 days. Considering the high neonatal mortality within the first week of life,[106, 107] the low rate of EBF, the importance of managing potential infections and educating mothers in nutrition/feeding practices for LBW infants, recommending a PNC visit at 7-14 days could be appropriate. This should be considered only after evaluating the availability of resources and assessing morbidity and mortality risk within the first week of life. To date, it remains unknown if a PNC visit at 7-14 days is appropriate in Vietnam. Furthermore, the current Vietnamese PNC schedule articulates well with the Expanded Programme on Immunisation.[108] Similar to ANC, the focus should be on content and quality of care to facilitate optimal breastfeeding practices as opposed to increasing PNC visits, which may incur economic and consumer costs.

Discussion of strengths and limitations

While based on secondary data and guidelines supplied by key stakeholders, it is assumed that the retrieved guidelines represent the current state of guidelines for LBW and associated barriers and implementation. However, a literature review is dependent on the current state of research. The reviewed research into LBW is limited, especially with regards to guidelines in Vietnam, which sometimes display contradiction. Small sample sizes in the individual studies reviewed may have further limited the validity, reliability and generalisability of this study. Larger and prospective studies of current practice and potential improvements are recommended, but with a focus on the actual users of current guidelines, such as first-line healthcare workers and the women, before, during and after birth. Persistently high rates of neonatal morbidity and mortality in Vietnam call for future studies to address relatively simple questions, including the discrepancy between available guidelines regarding ANC frequency and the threshold of referral.

Conclusion

Guidelines on ANC, perinatal care, PNC and breastfeeding for LBW infants weighing between 1500-2500g were available and accessible in Vietnam. Structural factors, including culture, infrastructure and economy, appeared to be major barriers to implementation and acceptance of guidelines.

The appropriateness of LBW guidelines requires

further research. In the context of relatively high neonatal mortality, four ANC visits in Vietnam might be more appropriate than three. In line with recommendations by the WHO, breastfeeding and skin-to-skin contact were found appropriate for Vietnam given their potential to reduce the burden of LBW morbidity and mortality in low-resource settings. The internal institutional alignment and coherence of guidelines, particularly the cut-off for referral of LBW infants, should also be monitored to ensure healthcare workers are appropriately informed of practices and the complications of nonadherence. Further studies comparing divergent WHO guidelines, local guidelines and local cultural norms and traditions are recommended.

 

 

Acknowledgements

The author would like to thank her supervisor Professor Ib Bygbjerg, Priya Mannava, and Dr. Ashraful (Neeloy) Alam for their guidance, advice and support.

Declarations

The materials used and analysed during the current study are available from the author upon reasonable request.

Conflicts of interest

None declared

Correspondence

linemp89@gmail.com

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MENTAL ILLNESS IN REFUGEES : WHAT CAN BE DONE?

Mental illness in refugees fleeing conflict and persecution: what can be done?

Review article

John Koh

 

Introduction

The United Nations Refugee Agency estimates that there are currently 22.5 million refugees worldwide, most of whom are fleeing conflict and persecution in their homeland. A further 28,300 more are displaced from their homes every day.[1] There is a large body of evidence that suggests a correlation between psychopathology and exposure to armed conflict and targeted persecution. While needs such as physical health, safety, food and shelter often take precedence over psychological concerns, the sheer scarcity of mental health services means that most refugees who develop mental illness will never receive appropriate care.[2] This adversely affects overall psychosocial wellbeing and has demonstrable long-term implications on refugee mental health.[3] This paper seeks to examine the factors that contribute to mental illness in refugees fleeing conflict and persecution, identify refugee subpopulations at high risk of long-term mental health issues, and provide evidence-based recommendations by reviewing the literature on interventions.

Common mental illnessess among refugees exposed to conflict and persecution

Psychological disturbance is a common consequence of exposure to traumatic events. However, a disturbance may only be classified as a ‘mental disorder’ if it continues to inflict psychological distress over an extended period of time and causes dysfunction in daily life. The degree of the disorder will vary according to the level of exposure to potentially traumatic events (PTEs) and other ongoing stressors.[4]

The most common mental illness among refugees exposed to violence and persecution is Post-Traumatic Stress Disorder (PTSD), where sufferers experience flashbacks of traumatic experiences, as well as heightened levels of anxiety and reactivity to sensory stimuli. The rate of PTSD in refugees can be up to ten times more than the general population.[5] Refugees exposed to PTEs also had an overall rate of 30.8% for depression, with some populations reporting rates as high as 85.5%.[6] Furthermore, a survey of over 16,000 war-affected refugees found prevalence rates of unspecified anxiety disorders between 20 and 88%.[3]

Other mental conditions include psychosis (9-16%) and somatization disorders, which often manifest as chronic pain or other medically unexplained somatic complaints. Most refugees have several co-morbidities in addition to their primary psychopathology. For example, a Danish study showed that virtually all war-refugees who sought psychiatric treatment at the Competence Center for Transcultural Psychiatry in Copenhagen had depression, pain and somatic complaints in addition to PTSD.[7]

In the absence of proper health services, many refugees afflicted by mental illness turn to substance and alcohol abuse, in turn, creating an addiction problem.[8] Research involving 64 refugees with PTSD showed that most had suicidal ideations and half had a history of suicide attempts.[9]

The diagnosis of mental disorders among refugees is often impeded by language barriers and cultural variance in its manifestations and conceptualisation. In some cultures, mental illness is stigmatised, leading to the suppression of verbal and emotional expressions of distress.[10] For example, among Rohingya refugees, psychological distress is expressed idiomatically and often attributed to spirit possession.[11] Somali refugees conceptualize mental illness as Murug, Waali and Gini – sadness, craziness due to spirits and craziness due to trauma. These terms did not exist in pre-war Somalia, however have come to fruition in recent years.[12] Understanding these cultural differences, in contrast to Western conceptualizations of mental disorders, and having a degree of cultural competence can prove helpful to clinicians working with traumatized refugees and in devising appropriate interventions.[3]

Factors associated with mental illness

1. Direct exposure to violence

Refugees exposed directly to violence are predisposed to mental illness. This violence can come in the form of witnessing shooting and bombardment, the destruction of their homes and significant loss of life such as the injury or death of friends and family.[13] Violence can also be targeted directly at individuals. Persecution for racial, religious or other reasons are prime examples. Being subject to torture as a means of persecution is one of the strongest contributing factors to the development of PTSD in refugees.[6] Often times, the victimised individuals find the sheer atrocity of the actions inflicted on them to be incomprehensible, and may assign supernatural or religious meaning to their experiences or mental illness. In other cases, they are unable to conceptualise their experience within their traditional framework for handling crises, leading to distress, depression, anxiety, guilt or shame.[14] In understanding the impact of PTEs and targeted violence on refugee mental health, it is important to take into account the traditional interpretive frameworks used to comprehend trauma and mental illnesses.

2. Gender and sexual orientation

Female refugees are known to have higher rates of both depression and PTSD than their male counterparts, as well as a greater propensity to rely on psychotropic drugs post-migration.[15] Women are particularly vulnerable due to pre-migration trauma such as sexual or gender-based violence during war as well as ongoing stressors.[16] Post-migration stressors include safety concerns in refugee camps as well as discrimination following resettlement in a different country.[5] Cultural differences in internalised gender roles may also explain why male and female refugees are affected differently by post-migration stress. Blight and colleagues found that while job occupancy was important to the mental health of male refugees in Sweden, job occupancy and living in an urban environment appeared to adversely affect the mental health of female refugees.[17] However, research on this topic is limited.[15]

Refugees who are lesbian, gay, bisexual, transgender or intersex also have higher rates of mental illness.[16] Although acts of violence towards LGBTI individuals may increase during times of conflict, many LGBTI refugees have endured years of persecution at the hands of their families or communities. This abuse includes beatings, corrective rape and honour killings.[18] War can exacerbate pre-existing mental illnesses and prompt many LGBTI refugees to flee from their communities.

3. Socioeconomic background and educational status

Refugees from relatively higher socioeconomic and educational statuses in their countries of origin had poorer mental health outcomes.[2] Researchers had previously assumed that these factors would act as a buffer against mental illness, but found that greater social and intellectual status prior to displacement resulted in greater distress and depression when those statuses were reduced to nought.[19] Previously affluent refugees often lose their possessions and homes as a result of persecution and war, while the well-educated found that their degrees and prior work experience were not recognised in the countries they resettled in.

Long-term mental health issues in refugee sub-populations

Even many years after traumatic events and resettlement, mental illness may continue to persist in refugee populations.[3] Vietnamese refugees exposed to 3 or more traumatic events continued to have a 12% risk of mental illness 10 years after resettlement.[20] Furthermore, refugees resettled in western countries continued to exhibit rates of PTSD that are ten times higher than the general population(s).[21] These are consequences of long-term non-treatment,[21] pre-migration trauma and unresolved post-migration stressors.

Refugees who are subject to protracted periods of detention represent a sub-population that is particularly prone to long-term mental health issues. Living conditions and further exposure to violence and PTEs while in detention often re-traumatise refugees.[22, 23] Following detention, adults experience a threefold increase in mental illness, while a tenfold increase was observed in children.[23] The deprivation of freedom of movement and independence following escape from collective violence and persecution is known to be a major post-migration stressor for refugees.[11] Even several years after resettlement and release from detention, refugees continued to experience high levels of PTSD, anxiety and depression, which they associated with feelings of insecurity and injustice resulting from their experiences in detention.[24] Longer periods of detention were associated with greater degrees of long-term psychological disturbance following follow-up with refugee children in Sweden indicated a gradual improvement in mental illness over time, children who had been exposed to violence and conflict displayed persisting psychological disturbances. This was similarly observed in Cambodian refugees over a 12-year period, with specific regard to PTSD.[27] The most common types of PTEs experienced by children during times of conflict include funerals, witnessing armed conflict and seeing injured or dead strangers and family members.[28] Adult refugees who experienced PTEs as children had worse long-term mental health. Indeed, the extent of childhood PTEs was found to be more strongly related to mental illness than the degree of exposure to more recent violence and human rights violations.[29] This suggests that child refugees fleeing conflict have a high risk of long-term mental illness, which may persist even into adulthood.

Recommended interventions

There remains a pressing need for diagnostic tools to conduct large-scale screening for mental illness in refugees. This is essential for early intervention, to prevent deterioration of mental health and to halt the progression to long-term mental illness. The Kessler Psychological Distress Scale (K10) has shown potential as a screening instrument for mental illness, particularly PTSD.[30] However, it may have limited effectiveness in culturally diverse populations,[31] likely due to interpretative complications. Nevertheless, until further research into transcultural diagnostic tools, K10, used in conjunction with other conventional instruments such as PTSD-8, has utility in initial screening for mental illness.[30] The effective translation of these diagnostic tools into the primary languages used by large and potentially diverse refugee populations, while taking into consideration cultural and linguistic nuances, is an intervention that must be explored. Collaboration between healthcare professionals, interpreters and ‘culture brokers’ is crucial for this intervention to be successful and for the subsequent treatment of diagnosed mental illnesses.[5]

Where there is access to psychiatric services, Narrative Exposure Therapy (NET), which helps individuals contextualise their experiences of persecution and violence, has been shown to alleviate mental illness in refugees from a diverse range of backgrounds and with varying traumatic experiences.[32, 33] Psychopharmacological treatments involving antidepressants and antipsychotics are also known to be effective.[34] However, due to a lack of data, no specific pharmacological regimens can be recommended at this juncture.[35] Nevertheless, if available and deemed appropriate by a clinician, pharmacological interventions should be used in conjunction with psychotherapy. For instance, Sertraline used with Trauma-Focused Cognitive Behavioural Therapy (TFCBT) is known to be efficacious in the treatment of PTSD.[7] In addition, clinicians should take into account cultural variations in the conceptualisation and expression of psychological distress when conducting conventional psychotherapy.

Although more research needs to be done to develop precise, culturally-adapted therapeutic interventions, the Delphi Method has been proven to be useful in creating mental health interventions for culturally diverse groups and Iraqi refugees in Australia.[10] It is a type of consensus method which allows a panel of mental health experts to devise comprehensive mental health interventions through multiple rounds of anonymous input and feedback. This method should be adopted and tested with other refugee populations and may prove successful in creating refined interventions.

In low-resource settings, mental health interventions may need to be community-based, delivering mental health support within schools, peer-systems and families, rather than between individuals and mental health professionals.[36] This is especially important for refugee children exposed to violence and traumatic events. One of the primary protective factors against long-term mental illness in trauma-exposed refugee children is stable social support in schools.[37] With a shortage of mental health professionals equipped to deal with this specific type of trauma, community-based aid workers can successfully be trained in mental health first aid and provide initial assistance to refugees.[38] The World Health Organisation’s scalable psychological interventions, such as Problem Management Plus (PM+), can be delivered face-to-face, in a group sessions, or with a smartphone by non-professionals.[39] Healthcare institutions may serve as training-providers for government or non-government organisations (NGOs) which are providing the community-based care.

Electronic-mental health interventions are another promising way of reaching refugees who do not have access to mental health professionals or are afraid of stigmatisation. Although there is limited research in low-resource settings, internet-delivered Cognitive Behavioural Therapy was found to significantly improve PTSD in war-traumatised Arab individuals.[39] The internet and development of new technology can allow clinicians to administer psychotherapy without being there in-person, such as via video-call.

It is essential that these psychological interventions take place as soon as mental illness is diagnosed or an individual is determined to be at risk. Untreated mental illness can lead to long-term issues following resettlement or further deterioration of mental health following repatriation, whether voluntary or involuntary.[40] Mental illness may persist for many years, and successful resettlement may not necessarily lead to the resolution of pre-existing mental disorders. There is therefore a need for longitudinal interventions to help refugees through the stages of resettlement and acculturation.[41] This involves making mental healthcare accessible and affordable locally in the countries they are resettled in, so that continued care in the form of psychotherapy and/or medication is readily available. Discharge from care or a decreased frequency of checkups can be considered once a pre-existing mental illness is resolved and deemed unlikely to recur.

Social interventions are necessary to address ongoing stressors, particularly for refugees in the process of resettlement or confined in closed camps for extended periods. Social interventions must address socioeconomic concerns which are commonly associated with long-term depression, such as the lack of gainful employment.[3] The present nature of detention, including its re-traumatising effects, level of safety, extent of restriction of movement and overall duration needs to be addressed as well. Social interventions for refugee mental illness falls in grey area between healthcare and politics, therefore requiring significant dialogue between both healthcare professionals and policymakers. Potential interventions would include job opportunities, recognition of academic accreditations, social support for resettlement and legislation pertaining to the harmful duration and conditions of detention.

 

Conclusion

Refugees fleeing conflict and persecution are prone to developing mental illness, which if left untreated can have long-term implications on psychosocial wellbeing. There is presently a major lack of resources being allocated to refugee mental health. Research pertaining to culturally-adapted diagnostic tools and transcultural psychotherapy is only just beginning to emerge. This paper examined the factors associated with mental illness in refugees exposed to PTEs, as well as identified refugee subpopulations at a high risk of long-term mental health problems. The literature regarding psychiatric interventions was then reviewed and recommendations were made based on the evidence gathered. Areas where further research is required, or where current research is limited, were noted. Social interventions were addressed as well but may be potentially limited by non-medical factors (e.g. political and economic concerns). Assessing the practicality of social or socioeconomic interventions would likely fall outside the purview of medical literature and was therefore not attempted. Further research into methods for alleviating mental illness in traumatised refugees is still desperately needed.

 

Acknowledgements

None

Photo credit

Image 1: public domain, accessed from https://www.shutterstock.com/image-photo/syrian-refugees-families-who-came-kobani-353855087?src=zFmLNzGPxpTxDnsWrgrieA-1-23

Conflicts of interest

None declared

Correspondance

kohmyj2@gmail.com

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Depression

Poor mental health: the relationship between poverty and mental health in low and middle income countries

Review article

Salwa Sayeed & Damindri Fernando

 

Introduction

The World Health Organization (WHO) defines mental health as a state of well-being which allows an individual to work and contribute meaningfully to their community whilst coping with the normal stresses of life.[1] Mental illness, on the other hand, is defined as disorders characterised by combinations of abnormal behaviour, thoughts, emotions and interpersonal relationships.[2] Mental illness currently carries an immense global burden of disease, estimated to contribute 32.4% of years lived with disability (YLD) and 13.0% of disability-adjusted life-years (DALYs). This places mental illness as an indisputable, global first by years of life lost (YLL) and on par with cardiovascular disease burden by DALYs.[3]

Notably, in low to middle-income countries (LMIC) with a gross national income (GNI) per capita of <$12,236 ,[4] the WHO estimates depressive disorders to be the second leading cause of years lived with disability.[5] Schizophrenia, bipolar disorder, alcohol use disorder and anxiety disorders are also in the top 10 causes of disability due to health-related conditions in LMIC.[6] Strikingly, 80% of sufferers of mental illness reside in LMIC.[7]

Whilst the relationship between poverty and mental illness in industrialised nations has been well-established, the same correlation in LMIC is yet to be established by the literature. This is due to the following reasons: 1. The impact of third factor variables interacting with poverty and mental health, including barriers to mental health services,[8] 2. The way poverty and mental health cyclically cause and impact one-another, 3. Controversy surrounding the best instrument to measure poverty,[9] 4. Lack of research in the area.[10]

Nonetheless, an understanding of poverty as a mental health determinant in these regions is valuable for its ability to inform and direct global mental health policies and interventions. If a causal link between poverty and mental health is established, then there would be health benefits in reducing income inequality. However if such a relationship is disproved, resources could be re-directed into changing health knowledge, preferences and behaviour.[11] This review aims to summarise the literature on whether a causal link between poverty and mental illness can be drawn and thus provide direction for future areas of research in this field.

As the literature on poverty and mental illnesses is primarily on common mental disorders, this review focuses on the same. Regarding definitions of poverty, there are various parameters that can be used including: consumption poverty, highest level of education attained, yearly income, food insecurity and financial stress.[12] As each study cited uses its own measurements, this review does not provide an overarching definition of poverty.

Theories

In the interface between poverty and mental health, two main theories have been proposed. Firstly, the ‘social causation theory’ highlights that poverty is a risk factor for mental illness through various mechanisms of social exclusion, stress, deprivation, malnutrition, increased obstetrics risk, violence and trauma.[13] On the other hand, the ‘social drift (or social selection) theory’ suggests vice versa, that mental illness can cause impoverished conditions through low employment, low productivity and stigma. Nevertheless, it is likely that both pathways are at play in mental illness.[14]

Poverty and mental illness

A 2003 article by Patel and Kleinman et al. reviewed the association between poverty and common mental health disorders in six LMIC through English-language journals and global mental health reports published since 1990.[10] Most studies showed a robust association between poverty and common mental disorders, particularly asserting that they interact in a vicious cycle. The most strongly associated measure of poverty was low levels of education. The contribution of low level education to increasing hopelessness, insecurity, rapid social change and limited opportunities ultimately increases mental illness development risk. Contrastingly, actual income was less implicated as a risk. However, the article did not find causal associations between poverty measurements. That is, most LMIC populations living in poverty do not develop mental illness. These findings called for further longitudinal research.[10]

Another study done by Das et al. (2007) revisited the relationship using survey data from five LMIC: Bosnia and Herzegovina, Indonesia, Mexico, India and Tonga.[15] Contrasting the findings of Patel & Kleinman et al. (2003), the study found that the relationship between consumption poverty and mental illness was poor while the strongest factors were widow-hood and poor physical health. It was hypothesised that the differences in the poverty-mental health relationship between developing and developed LMIC could be attributed to two causes. The first being the flexibility of work hours and attendance in LMIC in the informal sector (primary industries, self-employment), allowing individuals with mental illness opportunity to maintain employment. The second, larger village and family support systems lowering the risk of developing mental illness and insuring against poverty development.[15]

Other additional findings of the report were that life changes – either positive or negative – had bigger, long-term impacts on mental health. Thus, Das et al. (2007) argued that public mental health interventions in LMIC should focus on individuals experiencing upheaval and adverse life changes.[15]

However, a critique of Das et al. (2007) by Corrigall et al. (2008) expanded on certain limitations of the study.[16] Firstly, it argued that the effect of downstream variables, such as age and poor health, is statistically larger than upstream variables, such as poverty. This is primarily because upstream variables exert their effect through downstream factors, resulting in poverty being less associated with mental illness. Secondly, the use of household expenditure (i.e. consumption poverty) as the measure of poverty could be misguided as the measure can be confounded with household debt. This itself has been found to be independently associated with poverty.[17] Thirdly, their study contradicts the vast majority of community-based epidemiological studies that had been conducted in low, middle and high-income countries. Lastly, it was not clear whether a multivariate regression was performed.[16]

In order to combat these issues, Lund et al. (2010) conducted a systematic review of the epidemiological literature in LMIC, using a variety of poverty measures.[8] 79% of the 115 studies reviewed showed positive associations between different poverty measures and common mental disorders. However, there were differences in impact depending on the measure studied. Income, unemployment and consumption were less associated with CMD, whilst education, socio-economic status, food insecurity, housing, social class, financial stress were strongly and consistently associated. Lund et al. (2010) mentioned that such differences could account for the weak association between poverty and mental illness in LMIC as suggested by previous studies.[8]

Lund et al. (2010) also noted that most of the 115 studies used in the reviews were cross-sectional. Thus, conclusions about the original cause in the interface between mental illness and poverty could not be drawn. It did, nevertheless, confirm that poverty and mental health most likely interact in a vicious cycle, as originally hypothesised.[8] Individuals living in poverty are at risk of mental illness through high stressors, social exclusion, reduced social capital, malnutrition, increased risk for violence and trauma, and obstetrics risk. Concurrently, individuals with mental illness are inclined to be in poverty due to stigma surrounding mental illness, lost employment, school dropout and reduced social support.[8]

In summary, the relationship between poverty and mental illness is complex and varied. Whilst a strong correlation between poverty and mental illness exists, there is also evidence to suggest the vice-versa – mental illness resulting in poverty. Hence, both social drift and social causation pathways are relevant in understanding poverty and mental health in LMIC.

 

Limitations and further areas of research

The limitations within the current body of literature indicates a wide scope for further research and improvement.

One of the most significant limitations of the literature thus far is accepting and validating definitions of poverty. The definition of ‘poverty’ has historically been controversial as it is imbued with socio-political ideological baggage. The lack of rigorous reporting of poverty indicators, and lack of consequent justification of the measures utilized based on current theoretical understanding in the field is concerning in this context. It impairs critical assessment and comparison across studies and consequently, future studies should focus on clearly defining variables with validated measures to be used.[9]

In addition to more stringent quality of reporting, qualitative studies that reflect lived experiences would be a helpful contribution to this field as it may better capture the contextual differences across different developing countries as well as contribute to development of theoretical causality.[8]

Given the complex interplay of factors that inform mental health outcomes in the context of multiple deprivation, further research is required to ascertain the strength of association amongst these factors. The ultimate goal is to identify those that may be protective in nature. Longitudinal epidemiological studies are required to establish direction of causality.[8] Despite schizophrenia and bipolar disorders belonging to the top causes of disability in LIMC, there has been little effort to evaluate how these conditions uniquely interact with various determinants of poverty across an individual’s lifespan.[6, 18]

Further research is also required in evaluating the interventions targeting poverty and mental health in LMIC. Despite a clear positive trend between mental health interventions and improved economic outcomes in LMIC, the feasibility and efficacy in scaling up these interventions is unclear with macroeconomic costs involved in implementation and subsequent impact to be determined.[14]

 

Conclusion

In reviewing the literature, it becomes clear that both the social drift and social causation theories are central to our understanding of the dynamic relationship between mental illness and poverty in LMIC. Of the measures examined, poverty, education, socio-economic status, food insecurity, housing, social class, financial stress were the most strongly associated with CMD, whilst income, employment and consumption did not having as significant an impact.[8] Whilst correlations between poverty factors and mental illness have been established, causation has not. In this regard, longitudinal studies are important in establishing causality, with focus on the recognition of protective factors and time points for intervention in resource poor settings.[13] As the degree of impact on mental illness is influenced by which poverty indicator is used, rigorous reporting of studies is critical to establish the framework which future studies will utilise to ultimately influence the development of effective policy.

 

Acknowledgements

None

Conflicts of interest

None declared

Correspondence

salwasayeed70@hotmail.com

References

1. World Health Organisation. Mental health: state of well-being 2014 [updated 2014; cited 2018. Available from: http://www.who.int/features/factfiles/mental_health/en/

2. World Health Organisation. Mental Disorders 2017 [Available from: http://www.who.int/en/news-room/fact-sheets/detail/mental-disorders.

3. Vigo D, Thronicraft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry. 2016 3(2):171-8.

4. World Bank Development Team. 2017. [cited 2018]. Available from: http://blogs.worldbank.org/opendata/edutech/new-country-classifications-income-level-2017-2018.

5. World Health Organisation. Global Health Estimates 2015: Disease burden by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva: World Health Organisation; 2016.

6. Rathod S, Pinniti N, Irfan M, Gorczynski P, Rathod P, Gega L, et al. Mental Health Service Provision in Low-and Middle-Income Countries. Health Services Insights. 2017;10.

7. World Health Organisation. Disease and Injury Regional Estimates for 2004. Geneva, Switzerland: World Health Organisation 2008.

8. Lund C, Breen A, Fisher A, Kakuma R, Corrigall J, Joska J, et al. Poverty and common mental disorders in low and middle income countries: A systematic review. Social Science & Medicine. 2010;71:517-28.

9. Cooper S, Lund C, Kaukma R. The measurement of poverty in psychiatric epidemiology in LMICs: critical review and recommendations. Social Psychiatry and Psychiatric Epidemiology. 2012;47.

10. Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization. 2003;81:609-15.

11. Hanandita W, Tampubolon W. Does poverty reduce mental health? An instrumental variable analysis. Social Science & Medicine. 2014;113:59-67.

12. Howe L, Galobardes B, Matijasevich A, Gordon D, Johnston D, Onwujekwe O, et al. Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper. International Journal of Epidemiology. 2012;41(3):871-86.

13. Li C, Jiang S, Yin X. Understanding the Relationship between Poverty and Children’s Mental Health in Poverty-Stricken Area of China: Social Causation or Social Selection? Journal of Child and Family Studies. 2017;27:1186-92.

14. Lund C, De Silva M, Plagerson S, Cooper S, Chisholm D, Das J, et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. The Lancet. 2011;378:1502-14.

15. Das J, Do Q, Friedman J, McKenzie D, Scott K. Mental health and poverty in developing countries: Revisiting the relationship. Social Science & Medicine. 2007;65(3):467-80.

16. Corrigall J, Lund C, Patel V, Plagerson S, Funk MK. Poverty and mental illness: Fact or fiction? A commentary on Das, Do, Friedman, McKenzie & Scott. Social Science & Medicine. 2008;66:2061-3.

17. Araya R, Lewis G, Rojas G, Fritsch R. Education and income: which is more important for mental health? Journal of Epidemiology and Community health. 2003;57:501-5.

18. Lund C. Poverty and mental health: Towards a research agenda for low and middle-income countries. Commentary on Tampubolon and. Social Science & Medicine. 2014;111:134e6

ENVIRONMENTAL ISSUES

State of emergency: a call to action on environmental issues

Feature article

Ike Schwartz

Modifiable environmental factors account for almost a quarter of global deaths.[1] Climate change and associated environmental issues such as air pollution severely impact on the health of communities around the globe, and today’s medical students have a unique choice between leading forward-thinking preventative action or managing the future health consequences of inaction. Given this stark choice, why aren’t globally minded medical students more interested in advocating for what the WHO director-general has called the ‘defining global health issue of our time’ ?[2]

A cause that affects us all

The effects of environmental degradation on human health are wide and deleterious. Many of the most pressing global health issues of our time, ranging from food availability to water quality, malaria prevalence to cardiovascular and respiratory disease rates, are being increasingly exacerbated by the global effects of anthropogenic climate change,[3] and dealing with this problem is a matter of urgency.

Individual organisations dealing with such problems receive funding, publicity and support from medical students and their organisations around the world. While these efforts are nevertheless worthwhile, greater consideration must be given to the climatic and environmental causes that intensify these issues.

Climate change is an existential threat to humanity, but its causes are the result of profound injustices mimicking global patterns of inequality such as health resource disparity and the burden of communicable disease; whilst wealthy nations account for the vast majority of global consumption and emissions, climatic consequences impact most heavily on impoverished populations least equipped to deal with such issues.[4] Far from guiltless, Australia has the highest per capita material footprint of any country in the world on consumption-based measures of resource use.[5] In comparison, though each of Bangladesh’s citizens consumes only half the resources of the global average, it will see a loss of 17 percent of its land mass by 2050 on current estimates of sea level rise, creating approximately 20 million climate refugees.[6] Such stark inequity should evoke an immediate response from global health groups, especially in Australia, but currently seems to generate far less discussion than comparative global health issues.

In addition to such massive inequities, environmental issues exist that can be felt concretely throughout the developed world, albeit to a lesser extent. For example, one of the environmental issues most directly affecting human health is air pollution, an issue intrinsically linked with climate change in many ways. Greenhouse gases including carbon dioxide and air pollutants such as particulate matter, sulphur and nitrogen oxides, largely all stem from fossil fuel combustion. Particulates aggravate climatic effects by absorbing sunlight and altering precipitation patterns, and changes to the climate in turn prolong air circulation of pollutants through alteration of natural removal processes.[7] The atmosphere over inhabited locations commonly contains tens of thousands of particles per millilitre, capable of penetrating deep into the lungs and inducing alveolar inflammation, which can exacerbate lung disease and lead to increased blood coagulability, cardiovascular disease and ischaemic stroke.[8] Evidence also suggests such air pollution can impact on perinatal outcomes such as birth weight.[9] Current guidelines rely, often unsuccessfully, on keeping pollution below ‘safe thresholds’, when evidence suggests there may in fact be no lower limit under which no health effects are observed.[10]

Such devastating environmental issues require attention from populations around the world, and communities of medical students are well placed to lead immediate and necessary action on their health implications.

Ineffective Leadership

Historically, governments and other institutions above the level of the community have been heavily relied upon to take leadership on environmental issues. However, current systems for environmental protection are failing to meet the needs of the present and future global population.

Air pollution management is one such example. On the 30th October, 2018, the World Health Organisation will hold its first Global Conference on Air Pollution and Health, featuring a “call for urgent action” aimed at encouraging policymakers to produce more progressive solutions to a growing crisis of air quality.[11] While undoubtedly a worthy effort, this action comes too late for the estimated 103.1 million disability-adjusted life years accounted for by outdoor ambient air pollution in 2015 – a measure of years of healthy life lost. Within that figure is 4.2 million premature deaths and similar numbers of people likely died as a result of air pollution in 2016 and 2017.[12]

History would have us believe that international collaborative efforts are doomed to a large extent to be reactive, rather than preventative, on environmental issues. While global cooperation has had moments of marked success, such as the 1989 Montreal protocol which was able to successfully phase out use of ozone depleting chlorofluorocarbons,[13] international law pertaining to issues such as water use, chemicals, and the climate is often incomplete and ineffective.[14] A contemporary example of this is the 2015 Paris Agreement. While this agreement marks a significant achievement in international environmental collaboration, its aims of “keeping a global temperature rise this century well below 2 degrees Celsius… and pursuing efforts to limit further to 1.5 degrees” appear to be ambitious yet completely unachievable based on current action. [15] Present voluntary national contributions imply warming will in fact reach 2.6-3.1 degrees Celsius this century, and commitments would have to be substantially strengthened for prevention of disastrous interference with the global climate.[16]

While governments and international organisations may play an important role in environmental protection, these structures cannot be solely relied on to instigate prompt and effective change on this time-sensitive issue. Medical students and doctors must recognise this fact, and commit to educating themselves and creating action in absence of support from these institutions.

Community level organisation, and hope for a healthier future

Medical students and doctors occupy a unique space in the public eye, and must utilise this privilege to advocate for those who do not. Climate change, and all its ugly associated symptoms, is a health issue, a humanitarian issue and a moral issue. It is imperative that we, as members of the medical community, take a stand now and fight for the health of our communities and planet, or we risk vast and irreparable damage.

Action on such issues not only prevents climatic and environmental disaster, but has a range of co-benefits. For example, creating sustainable cities through urban management strategies reduces greenhouse gas emissions, but also provides health benefits to residents through improved cooling and reduced air pollution.[17] Research even suggests that the co-benefits of many climate mitigation policies provide enough cost reduction for them to have a net economic benefit, as well as the obvious climate and health advantages.[18]

Though truly lasting environmental sustainability may only be achievable through a systemic shift in the way we value natural resources and the environment, individuals and groups can create essential change that impacts on broader society.

Environmental advocacy groups, for example, have been historically effective in creating change on a range of issues. Massive community response was instrumental in preventing the development of the Jabiluka uranium mine in 1998, when up to 14000 young people, including tertiary students organised by the National Union of Students, joined with Aboriginal action groups to run one of the most successful environmental campaigns in Australia’s history.[19] In 2017, the ongoing national campaign against the proposed Adani Carmichael coal mine, which would be the largest coal mine in Australia and was called a “public health disaster” by The Lancet saw two health professionals arrested for protesting out of concern for the health impacts of the mine.[20-22]

A variety of strategies exist for medical students to become active in this space. Medical students are perfectly capable of lobbying elected representatives, organising or participating in public forums that discuss the interaction between environmental and health issues, or joining action groups. Becoming educated on these topics and spreading information empowers individuals to agitate for larger change. Using existing student groups such as medical societies to hold corporations to account for the environmental consequences of their production through boycotts and promotion can be an incredibly effective way to make change at a local level, and ensuring that student groups themselves are aware of their own carbon and waste footprint is a method of creating awareness and encouraging personal investment in the environment. Getting involved in local environmental groups can be as simple as searching for the environmental issues most relevant in your area and sending someone an email or attending a community meeting. Even individual actions such as turning off the lights or opting for the bike can be empowering and contribute to the efforts of millions of others attempting to reduce their carbon footprint.

Medical student organisations should be actively seeking collaboration with other community groups that lead change in this area. For instance, collaboration with First Nations peoples is an essential and oft-neglected component of any successful environmental strategy, and it is imperative that well-meaning groups provide a platform for Indigenous voices and knowledge to be included in any discussion involving the natural environment. In Australia, Aboriginal and Torres Strait Islander peoples successfully and sustainably thrived in a diverse range of ecosystems for tens of thousands of years, and Western ignorance of the strategies that facilitated these populations is a tragedy whose effects are perennially experienced in today’s bushfires, soil degradation crises, and ecological extinctions.[23] Medical students should take responsibility for building relationships with First Nations Peoples, for health and social reasons as much as environmental. Indigenous community leaders are often the most passionate advocates for environmental protection, and open discussion and collaboration provides unique opportunities for community driven change as well as opening channels for discussion of other complex Indigenous health issues.

Strong, inclusive, community action creates change, and climate change is a truly global issue providing an opportunity for the medical profession to collaborate with and inspire other groups with leadership and initiative. Environmental health groups already operate in Australia and worldwide, and they need the support and initiative that the next generation of doctors and medical students can provide. Students and doctors have a responsibility to fulfil the expectations of social conscience the community has of us. If we don’t take urgent action, we can’t expect that anyone else will.

 

Acknowledgements

The author would like to thank Georgia Behrens for her help in making important revisions to the first draft.

Photo credits

Image 1: public domain, accessed from https://pixnio.com/es/diverso/humo-tecnologia-toxico-contaminacion-del-aire-clima-fabrica

Image 2: Frontline Action on Coal. Medical doctors and health professionals arrested whilst highlighting devastating health risks of Adani’s mega coal mine [Internet]. 2017 [cited 20 May 2018]. Available from: https://www.frontlineaction.org/_doctors_risk_arrest_to_stopadani

Conflicts of interest

None declared

Correspondence

schwartzike@gmail.com

References

1. WHO. Preventing Disease Through Healthy Environments [Internet]. Geneva: World Health Organisation; 2016 [cited 2018 May 27]. Available from: http://www.who.int/quantifying_ehimpacts/publications/preventing-disease/en/.

2. Chan M. WHO Director-General addresses Human Rights Council on climate change [Internet]. Geneva: World Health Organisation; 2016 [updated 2018; cited 2018 Mar 29].

Available from: http://www.who.int/dg/speeches/2016/human-rights-council/en/.

3. Grasso M, Manera M, Chiabai A, Markandya A. The Health Effects of Climate Change: A Survey of Recent Quantitative Research. International Journal of Environmental Research and Public Health. 2012;9(5):1523-47.

4. Campbell-Lendrum D, Corvalán C. Climate Change and Developing-Country Cities: Implications For Environmental Health and Equity. Journal of Urban Health. 2007;84(1):109-17.

5. Wiedmann TO, Schandl H, Lenzen M, Moran D, Suh S, West J, et al. The material footprint of nations. Proceedings of the National Academy of Sciences. 2015;112(20):6271.

6. Bayes A. Who takes responsibility for the climate refugees? International Journal of Climate Change Strategies and Management. 2017;10(1):5-26.

7. Fiore AM, Naik V, Leibensperger EM. Air quality and climate connections. Journal of the Air & Waste Management Association (1995). 2015;65(6):645-85.

8. Seaton A, Godden D, MacNee W, Donaldson K. Particulate air pollution and acute health effects. The Lancet. 1995;345(8943):176-8.

9. Fleischer NL, Merialdi M, van Donkelaar A, Vadillo-Ortega F, Martin RV, Betran AP, et al. Outdoor Air Pollution, Preterm Birth, and Low Birth Weight: Analysis of the World Health Organization Global Survey on Maternal and Perinatal Health. Environmental Health Perspectives. 2014;122(4):425-30.

10. Chow JC. Health Effects of Fine Particulate Air Pollution: Lines that Connect. Journal of the Air & Waste Management Association. 2006;56(6):707-8.

11. WHO. WHO’s First Global Conference on Air Pollution and Health, 30 October – 1 November 2018 [Internet]. Geneva: World Health Organisation; 2017 [updated 2018; cited 2018 Mar 27]. Available from: http://www.who.int/airpollution/events/conference/en/.

12. Cohen AJ, Brauer M, Burnett R, Anderson HR, Frostad J, Estep K, et al. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. The Lancet. 2017;389(10082):1907-18.

13. Spurgeon D. ‘Surprising success’ of the Montreal Protocol. Nature. 1997;389:219.

14. Conca K. An unfinished foundation : the United Nations and global environmental governance: New York : Oxford University Press; 2015.

15. UNFCCC. The Paris Agreement [Internet]. Bonn: United Nations Framework Convention on Climate Change; 2014 [updated 2018; cited 2018 26 Nov]. Available from: http://unfccc.int/paris_agreement/items/9485.php.

16. Rogelj J, den Elzen M, Höhne N, Fransen T, Fekete H, Winkler H, et al. Paris Agreement climate proposals need a boost to keep warming well below 2 °C. Nature. 2016;534:631.

17. Harlan SL, Ruddell DM. Climate change and health in cities: impacts of heat and air pollution and potential co-benefits from mitigation and adaptation. Current Opinion in Environmental Sustainability. 2011;3(3):126-34.

18. Bollen J, Guay B, Jamet S, Corfee-Morlot J. Co-benefits of climate change mitigation policies: literature review and new results. OECD Publishing; 2009.

19. Branagan M. The Australian movement against uranium mining: Its rationale and evolution. International Journal of Rural Law and Policy. 2014(1):1-12.

20. Osborne R. Adani’s Carmichael Coal Mine and Health: Fact Sheet [Internet]. Adelaide: Doctros for the Environment Australia; 2017 [Available from: https://www.dea.org.au/adanis-carmichael-coal-mine-and-health/.

21. McCall C. Australia’s new coal mine plan: a “public health disaster”. The Lancet. 2017;389(10069):588.

22. Cooke S, Selvey L. Professionals ready to stand up for health of Australians [Internet]. Pyrmont: Fairfax Media; 2018 [cited 2018 May 28]. Available from: https://www.illawarramercury.com.au/story/5165529/professionals-ready-to-stand-up-for-health-of-australians/.

23. Pascoe B. Dark Emu: Black Seeds : Agriculture Or Accident? Broome: Magabala Books; 2014.

Drug Control in Australia: Where to Next?

Review

Abstract

Substance use and associated disorders are increasingly recognised as a global health issue. As attitudes towards drug use disorders evolve, varying drug control policies worldwide are called into question. Nations such as the United States of America utilise the criminal justice system to place sanctions on those contravening drug control policy, which often results in cycles of incarceration, further drug use, and poverty. In contrast, Portugal has revolutionised its approach to drug control since the turn of the century by decriminalising all drugs to great effect. In view of this wide spectrum of attitudes towards drug control, the future of Australia’s approach to drug control policy is examined. 

 

Introduction

The International Classification of Diseases defines substance use disorders as “continuing drug consumption despite severe adverse consequences”.[1] A report by the office of National Drug Control Policy in 2010 outlined the detriments of substance use disorders using a biopsychosocial paradigm (Figure 1).[1, 2]

Figure 1: The biopsychosocial adverse outcomes related to substance use disorders [1, 2]

Substance use disorders are managed through three main drug policy approaches: decriminalisation, criminalisation, and harm minimisation. Decriminalisation involves prohibiting and regulating drugs but excluding sanctions from criminal law jurisdiction, whereas criminalisation is the attribution of criminal offences to drug-related activities.[3, 4] Harm minimisation strives to decrease adverse consequences without aiming to reduce consumption.[1] Substance use disorders are perpetuated by social stigma and thus the political context is a key determinant of long-term health outcomes.[3]

Benefits and detriments of different policy approaches

Criminalisation of drugs, and the subsequent incarceration of drug users, provides the immediate benefit of removing the individual from an environment that exacerbates their drug use, and prevents the community from being threatened by drug-affected behaviour. Additionally, incarceration allows the government to demonstrate the work being done to tackle drugs in a manner that is tangible and easily understood by the general public. However, punitive drug law enforcement alone may fail to address or even worsen health complications of drug use. It can marginalise populations at risk of poorer health and increase barriers to seeking health services, as illustrated by the growing epidemic of HIV/AIDS and hepatitis C amongst injecting drug users.[5] Moreover, drug law enforcement has minimal impact on the drug market itself, although there is some evidence that it may alleviate a degree of associated harm.[1, 6]

Advantages of the harm minimisation approach include curbing the progression of the HIV/AIDs epidemic through safe needle programs and deterring criminal behaviours.[1, 7] This is achieved through demand and supply reduction, prevention campaigns, and improved access to treatment and harm reduction.[8] Critiques of this approach include maintaining demand for the illicit drug market, and ineffectively addressing all biopsychosocial facets of substance use disorders.[8]

The main benefit of decriminalisation is that it reframes drug use as a public health problem, which allows for reallocation of funds from drug-related criminal justice proceedings and the prison system to rehabilitation services focusing on long-term health outcomes.[3] This, coupled with a shift in criminal justice focus to high-level drug offenders, ultimately results in less drug use and better long-term health outcomes.[3] Decriminalisation addresses substance use disorders in a biopsychosocial context and identifies it as a key public health issue, both key steps in arresting the perpetuation of stigma which only serves to isolate drug users from health services.[3] Criticisms of decriminalisation include potential for increased accessibility to drugs and a cheaper street value, which could result in increased uptake of drug use.[9]

In 2009, Antonio Costa, the executive director of the United Nations Office on Drugs and Crime, affirmed that “drug use should be treated as an illness in need of medical help”, and appealed for universal access to drug treatment.[2] In 2011, the Global Commission on Drug Policy emphasised that it was time to “end the criminalization, marginalization and stigmatization of people who use drugs but who do no harm to others”.[1] The World Health Organization and the United Nations echoed this view in their joint statement published in June 2017, stating that to ignore such a call to “[review] and [repeal] punitive laws….[including] drug use or possession of drugs for personal use” would be to “[violate] the most fundamental human rights protected in international treaties and in national laws and constitutions”.[10] This strong stance against discrimination in health care settings reflects the global shift in attitudes towards drug policy, from incarceration to rehabilitation of drug offenders. 

Drug control approaches worldwide

Criminalisation: the United States

The United States (US) has a strong stance of criminalisation towards illicit drugs and has a low threshold to prosecute drug offenders.[3] Its prison population has increased by almost 800% since 1980, in marked disproportion to its population growth, with 47% of all inmates imprisoned for drug-related crimes, and many with drug use disorders.[3] In 2010 alone, US $80 billion was spent on continuing incarceration of inmates.[3] Drug users, possessors and traffickers are treated equally in this criminal system, with mandatory minimum prison sentences.[3]

Without adequate rehabilitation services or emphasis on drug use and use disorders as a public health issue, the high rates of recidivism are unsurprising, often resulting in a cycle of criminality, incarceration and poverty, with subsequent economic burden on the community.[3] This is an issue fuelled by media sensationalism, portraying

Where drug courts – legal committees which redirect non-violent drug offenders from incarceration to treatment – have been trialled in the US, they have proven to decrease crime rates (7-14%) and recidivism (up to 35%), and improving rehabilitation uptake, treatment outcomes and stability of the family unit.[2] Such models are estimated to reduce health care costs related to substance use disorders by US $4 for every US $1 spent.[2]

While marijuana is considered illicit under US federal law, states are able to make independent laws, which are only disregarded in cases concerning juveniles, cross-border trafficking, or organised crime.[9, 11] Presently, over half of American states have legalised medicinal marijuana, and eight have further allowed recreational use.[9] Given the relatively recent legalisation of marijuana, data on its impact on usage patterns is currently conflicting, and more time is required for reliable assessment.[9] Studies have indicated that diversion of black market marijuana from legalised to criminalised states is likely to decrease marijuana prices, although the degree and impact of this is uncertain.[12, 13] Notably, there are significant economic benefits associated with the legalisation of marijuana.[9] In Colorado, where recreational marijuana use is legal, marijuana tax and licensing fees have been implemented, together generating over US $70 million in the first year alone.[9] This revenue was subsequently funnelled into school construction and youth and substance use programs).[9]

Criminalisation: Central Asia

Central Asian countries, such as Tajikistan, Kazakhstan, and Uzbekistan, have adopted an increasingly stringent approach to drugs.[14] In the year following the September 11 attacks, these countries received US $187.5 million from the US government to improve border control, counter-terrorism measures and counter-narcotics initiatives.[14] Between 2004 and 2007, a strong criminal justice-based approach was further reinforced in Central Asia with funding from international agencies, other foreign governments and national budgets directed to legal action against drug use.[14]

Further, national campaigns in Central Asia often label drug users as evil, increasing the stigma and discrimination which perpetuates cycles of drug use.[15] Little or no rehabilitation or treatment is available for substance users, with such countries preferring a model of criminalisation and incarceration.[14] For example, opioid substitution treatment is prohibited in Tajikistan and Turkmenistan, minimally available in Uzbekistan and Kyrgyzstan, and non-existent in Kazakhstan.[14] The lack of treatment for drug users and increasing accessibility of opiates has resulted in a growing HIV epidemic in Central Asian prison systems with poor long-term health outcomes.[14]

Decriminalisation: Portugal

Prior to 2001, drug use was criminalised in Portugal, yet rates of heroin use and drug trafficking continued to increase.[3] Consequently, the Portuguese government drafted a law decriminalising all drugs purchased, possessed or consumed for personal use. This law also had a public health focus towards rehabilitating those with substance use disorders, and a punitive focus towards high-level drug trafficking. This involves a committee of two medically-trained persons and one legally-trained person, deciding first whether an offence is protected by this law, and then whether the offender is suffering from a drug use disorder.[3] This law only aimed to decriminalise low-level drug offences; strict laws remain against high-level offenders and drug traffickers who propagate this vicious cycle and endanger the general community.[16]

After this law was passed, Portugal reduced its burden on the criminal-justice system, allowing more funding allocation towards public health endeavours, including prevention campaigns, treatment, and facilities.[17] Treatment uptake consequently increased, resulting in decreasing rates of drug-associated illnesses.[4, 18] During the four years following decriminalisation in 2000 to 2006, there was a significant decrease in the incidence of new cases of HIV/AIDS amongst drug users in Portugal, from almost 1400 to 400 persons.[18] Decreased rates of new hepatitis B and C infections have also been evident, attributed to the improved treatment and rehabilitation programs afforded by decriminalisation.[17, 18] Moreover, absolute numbers of drug-related deaths by each prohibited substance decreased; the total number of drug-related deaths decreased from 400 in 1999 to 290 in 2006.[18]

Importantly, while some speculated that decriminalisation would lead to lower prices of drugs and subsequent higher rates of usage, the cost of drugs did not decrease.[19] In fact, the rates of cannabis and cocaine use after decriminalisation have been three times lower than before.[18] Further, data extrapolations have predicted lower lifetime prevalence rates of drug use for almost all drug categories post-decriminalisation.[18]

Decriminalisation: West Africa

West African countries must contend with both international drug cartels and the growing transit of illicit substances to Europe and North America. Consequently, local consumption of illicit substances has increased, especially among younger persons, with significant economic, health and social consequences.[20] While data is scarce, in 2008 it was estimated there were 1.8 million intravenous drug users in Sub-Saharan Africa, of whom 12% were thought to be living with HIV.[20, 21]

In 2014, the West Africa Commission on Drugs published a declaration specifically stating that “criminalisation of drug use worsens health and social problems, puts huge pressures on the criminal justice system and incites corruption”, and that “drug use must be regarded primarily as a public health problem”, mirroring the movements of Portugal.[20] Despite these recommendations, there is currently no evidence that any West African countries have been successful in implementing drug decriminalisation policies.

Drug policy in Australia and the way forward

In 1985, the Australian Government adopted an official national drug policy of harm minimisation.[1] In the 2002-03 financial year, the Australian Government allocated $3.2 billion to managing illicit drugs, 75% of which was spent on drug law enforcement, aiming to decrease drug and drug-related crime, and improve public health and safety.[1, 16] Despite this investment, a staggering 400 Australians die yearly from heroin overdose, and most areas have a demand for substitution products far out-weighing the supply, notwithstanding the costly co-payment.[1] The methadone substitution program and syringe exchange services available in Australia have made an impact, yet with a growing affected population and the root cause unaddressed, the need is largely unmet.[1] Harm minimisation still perpetuates discrimination and marginalisation of drug users, instead, decriminalisation can reduce stigma and is essential to better health outcomes.[3]

The Australia21 report, published in 2012, was effective in initiating a debate on drug reform. The report not only illustrated the harmful effects of criminalising possession and personal use on drug-dependent individuals in an Australian context, but also highlighted the potential health benefits of some currently illicit drugs.[1, 8] This report left Australians to decide which legal system would allow for better biopsychosocial health and economic stability for the community with respect to those consuming drugs – rehabilitation or incarceration.

Australia should act to follow countries like Portugal that have prospered from revolutionising drug policy with respect to low-level offences and reform to decriminalise all drugs. As supported by the Global Commission on Drug Policy, a move towards decriminalisation of low-level drug offenses in Australia would allow for decreased economic burden on the criminal justice system, reallocation of funds to drug rehabilitation programs, and a sharpened focus on the illegality of high-level drug trafficking offenses.[3] Viewing drug use as a public health problem is the key first step to reducing stigma and consequently improving access to treatment and long-term health outcomes.

Conclusion

Criminalisation marginalises those afflicted with drug use disorders, who are already burdened with significant health, social and economic disadvantage. Where there is demand, there is supply, and tackling drug use disorders with criminal law is simply too late to create a meaningful impact on the individual or society at large. Poverty breeds poverty; while incarceration may remove the immediate threat from society, it does nothing to address the root cause.

Substance use disorders are a medical condition and public health problem, not a moral choice. Epitomised by Portugal, decriminalisation of drugs and rehabilitation fortifies a community, not just immediately, but with long-term positive effects in the workforce and crime rates, spanning generations. Substance use disorders, therefore, need to be reframed from a criminal, punitive problem, to one befitting the biopsychosocial model of health. Fortunately, throughout the world this is increasingly becoming the case.

Raquel Maggacis

Raquel Maggacis is a final year medical student at the University of Queensland. She has a keen passion for public health endeavours and hopes to one day intertwine this with a career as a medical physician.

Acknowledgements

Sophie Lim, Vector Associate Editor 

Conflict of Interest

None declared

Correspondance

raquel.maggacis@uqconnect.edu.au 

References

  1. Wodak AD. The need and direction for drug law reform in Australia. The Medical Journal of Australia. 2012;197(6):312-3.
  2. Madras BK. Office of National Drug Control Policy: a scientist in drug policy in Washington, DC. Ann N Y Acad Sci. 2010;1187:370-402.
  3. Sapp CE. Rehabilitate or incarcerate? A comparative analysis of the United States’ sentencing laws on low-level drug offenders and Portugal’s decriminalization of low-level drug offenses. Cardozo Journal of International & Comparative Law. 2014;23(1):63-97.
  4. Félix S, Portugal P, Tavares A. Going after the Addiction, Not the Addicted: The Impact of Drug Decriminalization in Portugal. IDEAS Working Paper Series from RePEc. 2017.
  5. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global drug control policy. CMAJ. 2005;172(5):655-6.
  6. Mazerolle L, Soole DW, Rombouts S. Street-level drug law enforcement: A meta-analytical review⋆. Journal of Experimental Criminology. 2006;2(4):409-35.
  7. Webster IW. Managing legal and medical complexities in caring for people with drug and alcohol problems: a call for change. Med J Aust. 2016;204(4):141-2.
  8. The prohibition of illicit drugs is killing and criminalising our children and we are all letting it happen. [press release]. Canberra2012.
  9. Homel PB, Rick. Marijuana legalisation in the United States: An Australian perspective. Canberra: Australian Institute of Criminology; 2017 June 2017.
  10. Joint United Nations statement on ending discrimination in health care settings [press release]. World Health Organisation2017.
  11. Adler J. Symposium Marijuana, Federal Power, and the States: Introduction. Case Western Reserve Law Review. 2015;65(3):505-12.
  12. Caulkins JP, Bond BM. Marijuana Price Gradients. Journal of Drug Issues. 2012;42(1):28-45.
  13. Hall W, Weier M. Assessing the public health impacts of legalizing recreational cannabis use in the USA. Clin Pharmacol Ther. 2015;97(6):607-15.
  14. Latypov A. Understanding post 9/11 drug control policy and politics in Central Asia. Int J Drug Policy. 2009;20(5):387-91.
  15. Wolfe D. Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union. Int J Drug Policy. 2007;18(4):246-54.
  16. Willis K. Measuring the effectiveness of drug law enforcement. Trends and Issues in Crime and Criminal Justice. 2011;406(1):1-7.
  17. Hughes CE, Stevens A. What Can We Learn From The Portuguese Decriminalization of Illicit Drugs? British Journal of Criminology. 2010;50(6):999-1022.
  18. Greenwald G. Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies. Washington, DC: Cato Institute; 2009.
  19. Felix S, Portugal P. Drug decriminalization and the price of illicit drugs. Int J Drug Policy. 2017;39:121-9.
  20. Drugs WACo. Not Just in Transit: Drugs, the State and Society in West Africa. West Africa Commission on Drugs; 2014.
  21. Mathers BMD, Louisa; Phillips, Benjamin; Wiessing, Lucas; Hickman, Matthew; Strathdee, Steffanie A; Wodak, Alex; Panda, Samiran; Tyndall, Mark; Toufik, Abdalla; Mattick, Richard P. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet. 2008;372(9651):1733-45.

 

Sugar tax – A Sweet Solution for Obesity?

Review

Abstract

Background

The rising prevalence of obesity and obesity-related illnesses parallels the increase in sugar consumption across the globe. To limit consumption of sugar and tackle obesity, the World Health Organization has recommended that member states implement a tax on sugar. Such a tax is envisioned to reduce sugar consumption at a societal level, generate stable revenue for governments, and drive product reformulation. However, at present there is insufficient evidence to suggest any beneficial effect of a sugar tax on the incidence and prevalence of obesity.

Aim

This review examines the effectiveness of a sugar tax as an obesity prevention strategy.

Methods

A qualitative review of modelling and observational studies investigating the link between sugar tax and obesity, and conducted over the past ten years, was carried out. 

Findings

Modelling studies suggest that a tax on high-sugar foods and beverages is likely to have beneficial effects on obesity as increased price of taxed items leads to reduced consumption. However, observational studies suggest little benefit of a sugar tax on actual obesity rates in a population. Taxes in combination with other policy and regulatory approaches, for example health food subsidies and education campaigns, might be more effective than a tax on its own.

Conclusion

A tax on sugar is likely to be a step in the right direction as it would raise public awareness of the negative health effects of excess sugar and de-normalise consumption of excess sugar.

 

Introduction

The obesity epidemic

Over the past few decades, overweight and obesity have risen to epidemic proportions all over the globe. In 2014, more than 1.9 billion adults were overweight and 600 million were obese.[1] In 2013, 42 million children under the age of five were either overweight or obese, and this is predicted to increase to 70 million by 2025.[2] The growing prevalence of childhood obesity is particularly alarming given that it is a predisposing factor for lifelong obesity.[3] Obesity, defined as having a body mass index (BMI) greater than or equal to 30, is a major risk factor for non-communicable diseases such as cardiovascular disease, diabetes, cancer, and mental illness.[4] Since non-communicable diseases were responsible for 68% of all deaths in 2012, [5] it is apparent that the health burden of obesity is high.

Obesity is a complex heterogenous disease that arises from an interplay between our genes and the environment we live in. Highly energy-dense diets combined with a lack of adequate physical activity leads to a positive caloric balance and hence weight gain in genetically susceptible individuals. Our diet and physical activity are increasingly shaped and driven by broader social, cultural, economic, and political landscapes that are often beyond individual control and awareness.[6] The modern obesogenic environment, which provides easy access to calorie-rich processed food and encourages sedentary lifestyle, is mismatched to human physiology that evolved to survive in an environment of food scarcity.[7] At a population level, obesity can be viewed as a manifestation of a global economic system that currently prioritises wealth creation over health creation.[8]

Obesity’s sweet tooth

In recent decades, the rising prevalence of obesity has closely paralleled the burgeoning consumption of sugar all over the world.[9] Sugar is recognised as one of the biggest risk factors for obesity,[10-15] and the leading source of sugar in the diet is sugar sweetened beverages (SSBs).[15] Therefore, the current review will focus on SSBs as a proxy for sugar and the discussion about policies aimed at limiting sugar intake (i.e. sugar taxes), will predominantly revolve around SSBs.

SSBs are non-alcoholic beverages with added sugar and include soft drinks, fruit drinks, sports drinks, energy drinks, iced tea and coffee, and lemonade. SSBs are becoming increasingly popular in low- and middle-income countries, with Latin America and Asia leading the world in consumption.[16] The worldwide impact of SSBs on the burden of adiposity-related cardiovascular disease, cancer, and diabetes is estimated at a total of 8.5 million (95% CI: 2.8 – 19.2) disability-adjusted life years (DALYs) [17].

Limiting the intake of free sugars to less than 10% of total daily energy consumption is strongly recommended by the World Health Organisation and the US Dietary Guidelines Advisory Committee.[18, 19] For every additional serving of SSB per day, the likelihood of a child becoming obese increases by 60% over the course of two years.[20] The energy obtained from SSBs is added to an individual’s total energy intake rather than displacing other sources of calories due to the poor satiating properties of sugar in liquid form.[21] The net increase in calorie consumption is likely to contribute to an increase in body mass. Given the high burden of obesity-related illnesses on healthcare systems [17] and the strong evidence linking excess consumption of SSBs to obesity in children and adults,[15, 22] a reduction in SSB consumption is warranted. A decrease in consumption is especially pertinent as the major SSB consumers are children, adolescents and poorly educated individuals from lower socio-economic strata of society who may be less aware of the harmful effects of added sugar.[10]

Sugar tax as an obesity prevention strategy?

Population health interventions aimed at curbing the consumption of excess sugar are pertinent to curtail the obesity epidemic. Price is one of the key factors influencing food purchasing behaviour. People tend to reduce consumption of unhealthy foods in response to increased prices of such products.[23] To discourage purchase of SSBs and address the growing burden of obesity, countries such as France, Mexico, the UK, and Hungary, and several jurisdictions in the USA, have implemented a tax on sugar.[10] Following implementation of a €0.11 per 1.5 L excise tax on SSBs, which translated to a 6% price increase, France saw a 6.7% decline in demand for cola in the first two years.[24] SSBs are a sensible target for a sugar tax as they have a high calorie density with no additional nutritional value [10, 25] and can be clearly defined for policy implementation.[2]

A number of assumptions underscore the success of an SSB tax [26]: first, the tax must be passed onto consumers, leading to an increase in cost; second, SSBs follow the law of demand; and finally, the tax leads to a significant net reduction in energy intake despite substitution by consumers, for example by increasing consumption of fruit juices with comparable caloric content.[27] While a tax on sugary drinks may not be the silver bullet for obesity on its own, it has the potential to slow the epidemic. For this reason, recommendations to implement diet-related taxes should be taken seriously.[28, 29]

The success of an SSB tax as an obesity prevention strategy remains controversial. The plethora of studies investigating the link between sugar taxation and obesity prevention demonstrate conflicting results. There is currently no consensus regarding the best approach to implement a sugar tax. Furthermore, existing meta-analyses on the topic show inconsistent findings and are unable to include many primary studies in their analysis owing to methodological inconsistencies.

 Methods

Electronic databases (PubMed and Web of Science) were searched for relevant journal articles between 1 January 2007 and 1 July 2017. The year 2007 was chosen to ensure included studies were relevant to modern dietary habits and practices.

The following search strategy was used: (tax* OR price* OR economic* OR financial*) AND (sugar OR sweetened OR beverage* OR drink*) AND (intake OR consumption OR demand OR sale* OR diet OR weight OR overweight OR obes* OR body mass index OR BMI).

Searches were limited to articles published in English. Relevant articles were also identified by searching the reference lists of included studies. Abstracts were assessed for suitability of inclusion. Studies that were found to be suitable were read in full and their salient features reported here.

Economic feasibility of a sugar tax

Consumers do not bear the full costs of their decisions when it comes to high-calorie foods and beverages.[30] It is estimated that an individual with a BMI between 30 and 35 will accumulate 30% higher medical costs than a normal weight individual;[31] this increases to 50% in individuals with a BMI greater than 35.[32] In Canada, obesity-related healthcare costs are close to $6 billion [33] whereas in Australia this figure is close to $10.7 billion.[34] In addition to direct healthcare costs, there are indirect costs to the community associated with absenteeism and obesity-related premature death.[35]

A number of modelling studies have reported substantial healthcare cost savings and stable revenue streams from a tax on sugar.[14, 36-38] For example, annual healthcare cost savings of $23.6 billion (95% CI: 9.33 – 54.9) and annual revenue of $12.5 billion (95% CI: 8.92 – 14.1) have been predicted for a tax of $0.01 per ounce of sugar in the United States (US).[39] Importantly, a sugar tax combined with a fruit and vegetable subsidy is deemed to be poverty neutral,[37] an important consideration given the significantly higher relative cost of fresh produce,[40] especially in rural and remote communities. The revenue generated from an SSB tax can be used to cover the healthcare costs of obesity, support subsidies on healthy food options, and fund public and school education campaigns promoting childhood nutrition and obesity prevention.

Effectiveness of a sugar tax for preventing obesity

Of various taxes on “unhealthy” foods, a tax on sugar was modelled to have the biggest health gain in the Australian population, equating to 270,000 DALYs (95% CI: 250,000 – 290,000) averted.[37] The effect of a sugar tax on BMI was found to be modest, equating to a BMI reduction of 0.1 in males and 0.06 in females, and a decline in obesity prevalence of 2.7% in males and 1.2% in females [36]. In a study modelling the German population, a 20% SSB tax was shown to reduce the prevalence of obesity by 4% in males aged 20 to 29.[41] Similarly, a modelling study by Cancer Research UK estimated that a 20% tax on SSBs could prevent 3.7 million people from becoming obese by 2025. Significant, albeit small, inverse associations between SSB taxes and weight gain have been reported by other modelling studies.[15] These could represent important changes over time and alter the prevalence of obesity at a population level.[42] Importantly, reductions in energy consumption were more pronounced in low- and middle-income groups.[38, 41, 43]

One of the biggest limitations of these studies is that they are population models.[37] They rely on national data which may be outdated and assume a linear relationship between weight changes and energy consumption without accounting for substitution behaviour by consumers and often relies on self-reported data.[41] The substitution effect is an obvious confounder in studies that do not classify fruit juices as SSBs, despite juices often containing more sugar than soft drinks.[14] Another limitation of modelling studies is the lack of information on long-term SSB price elasticity that is specific to geographic and economic subgroups.[14]

Six months after implementation of an SSB excise tax ($0.01 per ounce), consumption of SSBs decreased in Berkeley, California (–21%) and increased in comparable neighbouring cities that did not levy a sugar tax (+4%). Of the 124 people who reported changing drinking habits as a result of the tax, 82% reported drinking SSBs less frequently and 40% reported drinking smaller sizes because of the tax.[44] Similarly, following introduction of an SSB tax (1 peso/litre) by the Mexican government, the purchase of SSBs declined by an average of 6% during the first year of the tax and this decline was greater in low income groups.[45] The average Mexican purchased 4.2 litres less taxed beverages than expected during the first year, however, purchase of untaxed beverages increased by 13 litres on average.[45] Whether the increased consumption of untaxed beverages compensated for the reduced caloric intake due to the decline in taxed beverages was unable to be determined, so the effect of the sugar tax on net caloric intake remains to be seen. Given their short time frame, these observational studies provide no indication of the effect of a sugar tax on actual obesity rates in a population.

Similarly, surveys investigating consumers’ purchasing behaviour may not necessarily predict their actual purchasing habits.[46] This is critical in light of the fact that a 20% tax on SSBs did not result in an appreciable reduction in consumers’ likelihood to buy SSBs, despite their perception that they were more expensive.[46] Notwithstanding these pitfalls, a review of cross-sectional and longitudinal studies investigating the impact of sugar taxes on weight gain found several studies that demonstrated an inverse association between price increase of SSBs and point prevalence of overweight and obesity.[13] However, the magnitude of change reported in these studies was small.[13]

Outlook

Reduced consumption of sugar by virtue of an SSB tax may not necessarily translate to decreased body weight, particularly if unhealthy alternatives still exist. A tax on SSBs will only be effective in reducing obesity when there is no substitution with another untaxed high-calorie food or beverage.[47] A tax on sugar-rich foods (e.g. confectionary) in conjunction with a tax on SSBs would reduce the likelihood of substitution and therefore increase the effectiveness of the public health intervention. Taxes on high-fat foods will need to be considered in the future as adjuncts to the sugar tax. Given the complexity of taxing foods high in sugar and fat, and limited research on their effectiveness, this requires further study.

In addition to reducing calorie intake through a sugar tax, other aspects of the obesogenic environment that require monitoring and regulation include food labelling, food portions, food advertisements, and plain packaging. A sugar tax on its own is unlikely to be the panacea for obesity prevention. It is widely accepted that taxes have the potential to reduce sugar consumption, drive production reformulation, and generate substantial revenue for governments.[16] While it appears plausible that reduced sugar consumption and product reformulation would be beneficial to tackle obesity, whether this is actually the case remains to be seen. To address the obesity epidemic, a number of other population level policy measures, including advertising restriction, reformulation targets, health star rating systems, promotion of healthy transport choices, and sustained high-impact education campaigns are warranted.[48]

While the effect of sugar taxes on SSB consumption and obesity have been carried out in some low- and middle-income groups,[38, 41, 43] there is a paucity of literature from developing nations on the impact of decreasing SSB consumption on obesity rates. This is pertinent given that low- and middle-income nations are disproportionately impacted by obesity and related non-communicable diseases.

Conclusion

Obesity and obesity-related diseases are a significant burden on healthcare systems around the world. The global prevalence of obesity has increased and excess consumption of sugar, in particular SSBs, is one of the strongest drivers of that increase. To curb the obesity epidemic, a number of countries have adopted various forms of sugar taxes. While theoretically and economically sound, a sugar tax on its own might be insufficient to curb the obesity epidemic. However, a tax on sugar is likely to be a step in the right direction as it would raise public awareness of the adverse health effects of excess sugar and de-normalise excess consumption. A tax on SSBs can also encourage industry to reformulate its products with lower sugar levels. Taxes in combination with other policy and regulatory approaches, for example subsidies to healthy foods, graphic warning labels, and awareness campaigns, might be more effective to curb the obesity epidemic than a tax on its own. A sustained, focussed, and multi-pronged public health intervention worked in the past against Big Tobacco. There is no reason to believe that similar perseverance will not work against Big Sugar.

Saiuj Bhat

Saiuj is a first year medical student at the University of Western Australia with a passion for understanding the social and commercial determinants of health. He also has an interest in tissue engineering, in particular organoid technology, and the promising that holds for many aspects of medicine in the future. He graduated last year with Honours in pharmacology.

Conflicts of interest

None declared

Correspondance

saiujbhat59@hotmail.com

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Dengue in the Pacific Islands

Review

Abstract

Without a fully effective vaccine, prophylactic measures, or sufficient treatment options, dengue has emerged as a significant global health threat. The Pacific Islands are particularly susceptible to dengue as they provide favourable conditions for the Aedes mosquito population, the vector responsible for spreading the virus. Strong public health protocols with an emphasis on vector control are considered to be the best way to combat dengue in this region. However, for a variety of social, economic, environmental and political factors, vector surveillance and control mechanisms are failing. This review seeks to provide an overview on the emergence of dengue in the Pacific Islands, why this region is susceptible due to virus and vector factors, and what has been done and can be done in the future to contain the dengue threat in this region.

 

Introduction

Dengue virus is a vector-borne disease primarily spread by the Aedes mosquito population; it is one of the most significant infectious diseases that remains without definitive prevention or treatment options. Due to a variety of environmental and social factors, the Pacific Islands are particularly susceptible to dengue and other arbovirus.[1, 2] This has significant associated morbidity, mortality and economic cost, particularly when patients contract ‘severe dengue’.[1-3] A diagnosis of dengue can be based on clinical signs and/or laboratory diagnosis, whilst a diagnosis of ‘severe dengue’ is based on serious complications including plasma leakage, severe haemorrhage or severe organ impairment.[3] These clinical manifestations and complications of dengue can cause severe illness, particularly in susceptible patient groups including children.[3]

Treatment options are limited particularly in resource poor settings, and thus preventing dengue and recognising outbreaks is critical.[3] Dengvaxia, a world-first dengue vaccine, has recently been approved for use in endemic settings, with the World Health Organization recommending high-risk nations implement it as part of their vaccination program.[4-6] However, the vaccine has variable levels of efficacy, and is not yet considered a cost-effective solution.[5, 6] Whilst dengue remains a growing threat, the Pacific Island region must urgently develop alternative cost-effective diagnostic, detection, treatment and prevention strategies.[4, 7, 8]

Methods

The intended focus of this literature review was dengue in the Pacific Island region. An Ovid MEDLINE search was conducted combining the search terms “Dengue”, “Aedes” and “Pacific”. Grey literature and data was also sourced from the World Health Organization (WHO) and other non-profit organisations. Additional resources were identified through analysing the articles retrieved through these searches.

Epidemiology

Prevalence

Dengue has been reported in several Pacific Island nations since the 1950s, but in the past decade the incidence has grown exponentially.[1, 9] Whilst in 2000 there was only 50 reported cases per 1000 people, by 2012 this had grown to 350 per 1000.[1] It is difficult to determine reliable data on the endemic levels of dengue in the Pacific Islands, as this depends on accurate and timely reporting to the Pacific Public Health Surveillance Network, still under development.[2] However, whilst dengue is not endemic in all Pacific Islands, it is emerging in previously untouched islands including the Solomon Islands and Papua New Guinea.[9] From 2016 to 2017 alone, there has been an unusual increase in dengue illness reported in the Solomon Islands, Vanuatu, Fiji and Palau.[10] With this growth, some reports indicate that the vast majority of the Pacific Island population will be infected at some point in their lives.[1] In Samoa, one study showed 96% of the population tested positive for IgG antibodies, indicating prior infection.[11] With 89% of 18-25 year olds testing positive, this demonstrated that most Samoans first contracted dengue during childhood, when dengue illness is more likely to be fatal.[7, 11]

Outbreaks

Dengue typically follows an epidemic pattern with 1 of the 4 serotypes causing outbreaks across the Pacific every three to five years. However, the number of outbreaks of concurrent serotypes has been growing.[2] After an outbreak of a single serotype, this strain of the virus tends to circulate throughout the region until the next outbreak of a different strain occurs.[12] A single outbreak can affect a large portion of the population, with the 2009 outbreaks affecting 14 Pacific nations.[13] During such outbreaks, complications increase, placing a burden on hospital resources, with 4% of the Federated States of Micronesia’s population requiring hospitalisation during the Kosrae state outbreak.[14] The frequency of outbreaks appears to be increasing,[4] though this may be due to improved surveillance.

The virus

Dengue virus (DENV) is a single-stranded, positive-sense RNA virus of the Flavivirus genus.[15] There are four serotypes DENV-1 to DENV-4. Though they only share 65% of their genomes, their clinical syndromes are nearly identical, and they all occupy the same ecological niche.[16, 17] Dengue epidemics usually result from introduction of a single serotype from hyper-endemic countries, which will remain dominant in the region for several years.[12,18,19] However, in 2012, outbreaks of all four DENV serotypes were noted in a single year [20]. Each DENV serotype has caused outbreaks or been prevalent in the Pacific Islands at various times (Table 1).

Table 1: Dengue Serotypes and Epidemiology

DENV Serotype Notable related epidemiology and outbreaks
DENV-1 The most prominent serotype in 2012-2013, causing the largest-ever documented outbreak affecting New Caledonia.[21]
DENV-2 Caused recent outbreaks in Tuvalu and a current outbreak in Samoa.[10, 22]
DENV-3 After 18 years of absence, has recently become the dominant serotype in the Pacific islands causing five ongoing outbreaks [23].
DENV-4 Caused one outbreak since 2012, is rare in the Pacific Islands [10].

 

Repeated infection of DENV of the same serotype is associated with increase risk of progressing to severe dengue, which is associated with higher morbidity and mortality if left untreated.[24] Those living in endemic areas such as the Pacific Islands are at an increased risk of being reinfected and thus complications are more common.

The Vector

Dengue, zika, chikungunya and other arboviruses are transmitted to humans through the bites of infected Aedes mosquitoes.[25] Aedes aegypti is the primary vector in the Pacific Islands and is widespread across the region except for Futuna and other isolated islands.[26,27] Aedes aegypti is associated with human migration and urbanisation, enabling it to be dominant in the region, however, Aedes albopictus, Aedes polynesiensis and nine other potential vectors have also been identified in the Pacific Islands.[27, 28]

Aedes mosquitoes begin their transmission cycle upon acquiring the dengue virus from the blood of a viraemic person; the virus then replicates in mosquito midgut epithelium before shedding its progeny into the haemocoel, which then disseminates into secondary target tissues such as salivary glands.[29] During the next feeding event, the mosquito transmits the virus to the host through saliva.[29,30] Aedes aegypti is capable of repeatedly transmitting the virus through this process irrespective of its number of hosts.[30]

The introduction of Aedes aegypti into different islands has been spurred by human migration; there have been intense population migrations in the Pacific Islands since European colonization.[31] Though the first dengue epidemic in the Pacific Islands was reported in the 1880s, descriptions of Aedes aegypti didn’t emerge until the 1960s in Fiji and Tonga.[20, 32, 33] Aedes aegypti then spread during World War II, when travel between the Pacific Islands and Asia, Europe, and America became more frequent.[34] Recent studies have now identified genetic variability in nine locations across Fiji, New Caledonia, Tonga and French Polynesia, suggesting a link between human migration and Aedes aegypti populations, possibly related to island isolation and environmental conditions.[25]

Several factors influence the transmission of DENV from mosquitoes to humans, including climate.[30] Higher temperatures enable the virus to replicate in higher concentrations, enhancing the vectors’ risk for pathogen transmission and contributing to the high prevalence of dengue infection in the tropical Pacific Islands[30] Globally, climate-induced variations in modelled Aedes aegypti populations were strongly correlated to historical dengue cases between 1958 to 1995.[35] Recent research from New Caledonia, where dengue spread by Aedes aegypti is a major public health problem, showed that the epidemic dynamics of dengue were predominantly driven by climate in the last forty years.[36] Another study found a positive correlation between dengue infection and El Nino southern oscillation in ten countries, with evidence of infection spreading from larger islands to smaller surrounding islands.[37] It is predicted that global warming will increase the latitudinal and altitudinal distribution of Aedes aegypti and subsequently DENV.[38,39]

Dengue Surveillance Methods

Dengue surveillance and tracking is essential to enable timely epidemic responses.[8] Though representatives from the Pacific Islands believe there is adequate surveillance infrastructure and systems, governments have not emphasised prevention. These systems must be strengthened to more accurately track dengue epidemiological data [8, 40]. Given financial difficulties, this may be better accomplished through alternative mechanisms.

One such alternative is the transport of serum and blood samples internationally.[41] When a new serotype emerges in one Pacific country, this is often followed by outbreaks in neighbouring countries [42]; using blood samples to identify emerging serotypes enables surveillance of viral spread across the region. Filter paper (FP)-dried blood spots have minimal health risk and so are not bound by dangerous goods regulations present in several Pacific nations [43]. Blood spiked with cultured DENV can be blotted on FP-cards and the serotype determined using reverse-transcriptase polymerase chain reaction.[44]. The serotype and genotype of DENV can be identified using FP-dried serum even after being transported over thousands of kilometres at tropical temperatures.[41] This method of surveillance particularly useful in the Pacific Islands, where samples may need to be transported over long distances.

Another method to monitor dengue levels is the use of international travellers as ‘sentinels’, so that the risk of dengue infection can be estimated through proxies who travelled to particular areas.[45] Patterns of local dengue incidence in the Pacific Islands were shown to be closely correlated with patterns of dengue incidence imported from the Pacific to New Zealand.[46] However, this method is more commonly retrospective and cannot provide an indication of outbreaks. A combination of both methods could be implemented to cheaply and effectively improve dengue surveillance in the regions.

Dengue Prevention and Control, Now and in the Future

Strategies and Policies

Many nations have been attempting to meet the WHO infectious disease strategy objectives (Figure 1) by implementing policies that address vector surveillance, health education for vector control and dengue prevention, and emergency response capacity.[8] However, an urgent policy review to combat dengue is needed, with a focus on emphasising dengue in climate change and environmental medicine policies.[48] It is also essential that dengue is classed as a notifiable disease across all Pacific Islands through legislation.[48]

Figure 1: Outline of the World Health Organization Infectious Disease Strategy [47]

A Dengue Vaccine

Although several live-attenuated dengue vaccines are undergoing phase III clinical trials, currently Dengvaxia (CYD-TDV) is the only vaccine that is licensed and registered for use in individuals aged 9-45 years and living in dengue endemic areas.[40] Modelling has shown that Dengvaxia would only have the highest net benefit and be most cost-effective if the majority of the population is vaccinated in dengue-endemic nations.[52] The WHO has recommended that nations with a high burden of disease, defined as seroprevalence >70% in 9 year-olds, introduce the vaccine.[4, 1] However, many nations worldwide are still debating this, and Dengvaxia is not currently licensed for use in Pacific Island nations.[5, 51]

From the two major phase III clinical trials for Dengvaxia, overall vaccine efficacy against severe dengue was 79%, however, this varied by serotype, age at vaccination, and previous dengue infection.[52] For those with a previous dengue infection, vaccination efficacy was 78%, however, it was only 38% for those with no prior infection.[52] In fact, a study has shown that Dengvaxia can also increase the risk of hospitalisation when seronegative individuals are vaccinated and later experience natural secondary dengue infection.[51] The pooled efficacy for those older than 9 years old was higher than those under 9 years of age, who have a higher risk of severe dengue (66% vs 44%).[3, 52] Finally, in terms of serotype, vaccine efficacy was shown to be higher against serotypes 3 (72%) and 4 (77%) than for serotypes 1 (55%) and 2 (43%).[52]

Further study is ongoing to determine whether dengue illness and hospitalisation has reduced in nations that have implemented Dengvaxia.[53, 54] However, with varying efficacy, and questions regarding long-term safety and cost-effectiveness, it is predicted that vaccination will only be possible in the Pacific Islands if it is priced competitively.[53, 54] Thus, for the time being, vector control will remain the focus of dengue control strategy in the Pacific Islands, with the aim of integrating vaccination once it is more efficacious and cost-effective.[55] At present, it is far more affordable and effective to combat dengue by improving vector control mechanisms, and vaccination will be most useful as an adjunct if appropriate for specific nations.

Vector Control: Currently Used Methods

Vector control currently offers the best option for preventing dengue, but delivery of prevention programmes in the Pacific Islands is often inefficient, ineffective or both.[7] Several mechanisms exist in various Pacific Islands to control outbreaks once they occur, however some of the most common efforts, such as pesticide spraying, have limited effectiveness.[56]

Factors that increase the risk of dengue transmission have included poor household drainage and hygiene problems, issues that can be addressed by health education programs to build a ‘prevention attitude’ among Pacific residents.[57, 58] However, it is believed that improving health education, awareness campaigns and technical support is necessary to ensure successful vector control.[8] Environmental factors such as buckets of stagnant water, allowing mosquitoes to breed, and host larvae and pupae, are other key risk factor which could be targeted through education campaigns.[59] Chemical treatment of breeding sites, insecticide spraying and biological control by introducing predators are mechanisms already utilised by some Pacific Islands which could be further implemented for vector control in the future.[60]

Vector Control: Innovative Approaches

Novel vector-based approaches aimed at controlling dengue include the use of obligate intracellular bacterium Wolbachia pipientis,[61] which interferes with reproduction in over 40% of insect species.[62] Although Wolbachia does not occur naturally in Aedes aegypti species, transinfection has been shown to be successful.[63] Recent studies in Cairns, Australia have shown stable transinfection of natural A. aegypti populations with the wMel strain of Wolbachia, rising to near-fixation within a matter of months and remaining established in those field sites unaided.[64] The antiviral activity of wMel has shown to be highly effective in laboratory studies even one year after field release.[65] The evidence supports the long-term stability of Wolbachia against the dengue virus, however, the effects on reduction of human disease in dengue-endemic regions is yet to be established, this is currently under investigation in Indonesia and Vietnam.[61]

Another promising vector control method is the sterile insect technique (SIT), which has historically been successful against a multitude of agricultural pests.[66] In the 1960s, large-scale SIT programs enabled the elimination of A. aegypti from 23 American countries.[67] SIT has recently re-emerged as a vector control strategy due to innovative technological advances including genetic modification of mosquitoes.[68] Using SIT, Cuba has come close to the eradication of A. aegypti [69] and Singapore has kept levels of the mosquitoes down for more than 30 years.[70] Though neither of these methods is currently used widely in Pacific Islands, these innovative strategies are potential cost-effective vector reduction methods.

Emergency Response Capacity

There is a significant need to grow emergency-response and outbreak-response to combat dengue.[8] Currently, the WHO and Red Cross manage the majority of outbreak control, both logistically and financially[14, 71] The Pacific Public Health Surveillance Network has provided some support in capacity building, and multiagency response teams have successfully been implemented during some outbreaks, but there remains a need to engage Pacific Directors and Ministers of Health to help prepare these multidisciplinary response teams for future outbreaks.[2, 14]

Conclusion

Dengue remains a significant threat in the Pacific Islands, with prevalence levels and the number of outbreaks continuing to increase. Until Dengvaxia or another dengue vaccine has a proven cost-effective public health benefit beyond the currently calculated values, it is unlikely to be deployed in Pacific Islands.[5, 51] The best hope for containing dengue is by improving region-wide surveillance and cost-effective, sustainable vector control mechanisms [6-8]. This requires Pacific Island governments to integrate dengue prevention into their environmental and public health policy, and work to improve vector surveillance and control methods, which may involve implementing innovative approaches [8, 48]. Another area that requires significant improvement is outbreak response, and upskilling all Pacific doctors to appropriately respond to dengue outbreaks [8, 60]. Ultimately, until the objectives outlined by the WHO are addressed, dengue will remain a growing challenge in the Pacific Islands.[7, 47] These islands must engage with the growing body of organisations working in the region to develop new and innovative surveillance and control approaches and combat dengue in the future.[7]

Madeleine Marsland and Dunya Tomic

Madeleine is a fourth year medical student who is interested in global health and research. She combines these interests in her role as Chief of Editorials and Publications for the Pacific Medical Students’ Association, and is also undertaking research with the Department of Anatomy and Developmental Biology at Monash University. She hopes to pursue global health research and policy.

Dunya is a fourth year medical student at Monash University with a particular interest in clinical research and medical ethics. She hopes to one day combine this with a career as a physician.

Conflicts of interest

None declared

Correspondance

dtom4@student.monash.edu

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  54. Flasche S, Jit M, Rodríguez-Barraquer I, Coudeville L, Recker M, Koelle K et al. The Long-Term Safety, Public Health Impact, and Cost-Effectiveness of Routine Vaccination with a Recombinant, Live-Attenuated Dengue Vaccine (Dengvaxia): A Model Comparison Study. PLOS Medicine. 2016;13(11):e1002181.
  55. Background Paper on Dengue Vaccines [Internet]. 1st ed. SAGE Working Group on Dengue Vaccines and WHO Secretariat; 2016 [cited 3 April 2017]. Available from: http://www.who.int/immunization/sage/meetings/2016/april/1_Background_Paper_Dengue_Vaccines_2016_03_17.pdf
  56. Masahiro U, Sengebau-Kinzio M, Nakamura K, Ridep E, Watanabe M, Takano T. Household risk factors associated with dengue-like illness, Republic of Palau, 2000-2001. BioScience Trends. 2007;1(1):33 – 37.
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  58. Morrow GBowen K. Accounting for health in climate change policies: a case study of Fiji. Global Health Action. 2014;7(1):23550.
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  62. Zug R, Koehncke A, Hammerstein P. Epidemiology in evolutionary time: the case of Wolbachia horizontal transmission between arthropod host species. J Evol Biol. 2012 Nov;25(11):2149-60.
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PrEP-Related Health Promotion for Aboriginal and Torres Strait Islander Gay and Bisexual Men

Volume 11 Issue 1
Review
a peer-reviewed article

Abstract

Aboriginal and Torres Strait Islander peoples experience significantly poorer health compared to the general Australian population. This health inequality is highlighted in comparisons between Indigenous and non-Indigenous sexual health. Pre-exposure prophylaxis (PrEP) is a new HIV prevention technology that protects gay and bisexual men. Social, economic, cultural and historical barriers may exist that prevent Aboriginal and Torres Strait Islander gay and bisexual men from accessing PrEP, and therefore widen the sexual health inequality that already exists.

Introduction

Aboriginal and Torres Strait Islander (hereafter ‘Indigenous’) peoples living in Australia have significantly poorer health than non-Indigenous Australians,[1] inextricably linked to a history of disempowerment and oppression through colonialism.[2, 3] Indigenous Australians are often identified as a priority population for public health interventions due to their generally lower health status.[4] Discrepancies between Indigenous and non-Indigenous sexual health have been re-contextualised as a human rights issue to draw awareness and urgency to the matter of inequity of sexual health between Indigenous and non-Indigenous Australians.[5]

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HIV and Indigenous Australians

Human immunodeficiency virus (HIV) is a retroviral infection that is both blood-borne and sexually transmissible. HIV exhibits epidemiological differences between Indigenous and non-Indigenous Australians. Sexual contact between men is responsible for 75% of HIV notifications for non-Indigenous Australians, compared to only 51% of HIV notifications amongst Indigenous peoples.[6] Twenty-one percent of Indigenous HIV notifications are attributable to injecting drug use and 16% to heterosexual contact.[6,7] Worryingly, since 2011, the age-standardised rate of Indigenous HIV notifications has been steadily rising despite nationwide slowing of HIV notifications in the general population.[8] In 2015, the age-standardised rate of new HIV notifications in Indigenous people was more than double that of non-Indigenous people (6.8 per 100,000 vs 3.1 per 100,000).[6]

Men who have sex with men (MSM) are at elevated risk of becoming infected with HIV compared to the general population. It is unclear how many Indigenous Australians identify as gay or bisexual, and many Indigenous MSM may not identify as gay or bisexual, sometimes due to stigma.[9] A survey of Indigenous youth aged 16 to 29 found 6% of male respondents identified as gay, 2% as bisexual, and a small but significant number as transgender.[10]

Indigenous gay and bisexual men (GBM) and other MSM may be at increased risk of contracting HIV compared to non-Indigenous GBM. Indigenous peoples experience higher rates of sexually transmitted infections (STIs), namely gonorrhoea and chlamydia, particularly in remote areas.[6] The presence of an STI predisposes individuals to HIV infection.[7] Furthermore, Indigenous GBM report higher rates of risky sexual behaviours compared to non-Indigenous GBM.[11, 12]  Rates of unprotected anal intercourse with casual partners are higher in Indigenous GBM compared to non-Indigenous, a known risk factor for HIV infection.[13] Likewise, illicit drug use before or during group sex was reported at higher rates in Indigenous GBM compared to non-Indigenous GBM.[11, 14] Coupled with the worrying epidemiological pattern of HIV notifications among injecting drug users and heterosexual people, these elevated rates of risk factors among Indigenous people could increase the risk of HIV transmission for Australia’s Indigenous peoples.[11]  Indeed, steady increases in Indigenous HIV notifications and an elevated age-standardised rate of Indigenous HIV notifications are causes for concern (Figure 1).[6]

 

Figure 1. The age-standardised rate of new HIV notifications by Indigenous status. 

A pill a day to prevent HIV

Antiretroviral (ARV) medications have been used since the 1990s as an effective treatment for HIV. More recently, at-risk individuals have used ARVs as an effective HIV prevention method.[15] At-risk individuals can take one pill daily containing two antiretroviral medications, preventing replication of the virus within the body so that viral exposure is not seroconverted, thus preventing HIV infection.[16] Randomised control trials have found that ARVs taken as pre-exposure prophylaxis (PrEP) can prevent 40-99% of HIV infections when taken more than four times a week.[17-21] PrEP implementation trials are currently being run in New South Wales, Queensland, Victoria, South Australia, and the Australian Capital Territory. These trials are supported and funded by state health departments, allowing free or heavily discounted access to expensive drugs that cannot be accessed as PrEP via the Australian Pharmaceutical Benefits Scheme (PBS).[22]

In New South Wales, the Kirby Institute runs the Expanded PrEP Implementation in Communities (EPIC) trial in conjunction with NSW Health. After a year of recruitment, over 5000 at-risk individuals have been enrolled and given access to PrEP. Most of these participants are GBM, identified as being at high risk of HIV exposure.[13] This represents a major expansion from a small pilot study to a large demonstration trial.

Are Indigenous gay and bisexual men accessing PrEP?

Studies in the United States (US) have found that identified priority populations, including Black (African-American) men who have sex with men, may have difficulty in accessing PrEP compared to the general population. This may be due to lack of awareness about PrEP,[23] stigma,[24] poor healthcare coverage,[3] or lack of culturally-appropriate services providing access.[25] Indeed, Black men who have sex with men in the US were successfully recruited, engaged and retained in PrEP programs that employed “culturally-tailored techniques”.[26]

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Research shows that in order to target interventions like PrEP to Indigenous communities, culturally-appropriate services owned and governed by the community are in the best position to deliver positive health outcomes.[27-29] Likewise, health promotion materials should be designed and produced by the community for the community, and should avoid blocks of text and overly technical terminology.[30] Therefore, Aboriginal community-controlled health services (ACCHSs) may be best placed to help promote and educate PrEP to at-risk members of the community, facilitating referral to specialised sexual health clinics for assessment and preventative methods that may or may not include PrEP. ACCHSs provide holistic care, and are well equipped to focus on prevention and primary healthcare.[31] ACCHSs are considered manifestations of self-determination and autonomy for Indigenous communities.[29, 32]

Self-determination in Indigenous Australian health services

The United Nations has identified ACCHSs as best practice models of self-determination,[29] and the United Nations Declaration on the Rights of Indigenous Peoples advocates for the right of all peoples, especially Indigenous, to be able to “freely determine their political status and freely pursue their economic, social and cultural development”.[33] However, self-determination in healthcare alone cannot improve health outcomes. Secure, long-term funding coupled with equitable partnerships between Aboriginal community-controlled and mainstream health services is required to address the gap between Indigenous and non-Indigenous health.[29, 32] Facilitating community empowerment reduces the rates of HIV and STIs in female sex workers (FSWs) in low- and middle-income countries.[34, 35] Community empowerment in Australian FSWs during the initial years of the HIV epidemic was essential in enshrining effective HIV prevention focused on universal condom use among FSWs.[36] This case study could be applicable to the Indigenous population, and similar community empowerment in the form of well-funded ACCHSs may allow the gap between Indigenous and non-Indigenous health.

Furthermore, Aboriginal Sexual Health Workers administer culturally-appropriate health services throughout Australia, increasing the involvement of Indigenous people in the healthcare workforce.[28, 37] However, Indigenous peoples need to be consulted and involved in the decision-making process and not just in the delivery of health services.[38, 39]

Conclusion

PrEP is touted as a crucial part of the HIV eradication strategy throughout the world. However, efforts to prevent HIV transmission may be hampered by a failure to engage priority populations, including Aboriginal and Torres Strait Islander Australians. PrEP implementation projects such as EPIC need to ensure adequate coverage of at-risk Indigenous peoples through culturally-appropriate health promotion and security of access to medication. This would be facilitated through the involvement of Indigenous Australians in the decision-making process. Further research will explore PrEP-related health promotion to Indigenous peoples and communities, and attempt to identify any gaps or facilitators.

Alec Hope

Alec is a 4th year medical student at the University of New South Wales who is conducting qualitative research into the health promotion of PrEP to Aboriginal and Torres Strait Islander gay and bisexual men. Alec’s research interests include immunology, sexual health, and health inequality. He is looking forward to completing his last two years of medical school in Wagga Wagga.

Acknowledgements

Dr Bridget Haire, The Kirby Institute

b.haire@unsw.edu.au

Conflict of Interest

None declared

Correspondence

alecjulianhope@gmail.com

References

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  18. Eisingerich AB, Wheelock A, Gomez GB, Garnett GP, Dybul MR, Piot PK. Attitudes and Acceptance of Oral and Parenteral HIV Preexposure Prophylaxis among Potential User Groups: A Multinational Study. PLoS One. 2012;7(1):e28238.
  19. Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral Preexposure Prophylaxis for Heterosexual HIV Transmission in Botswana. New England Journal of Medicine. 2012;367(5):423-34.
  20. Molina J-M, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection. New England Journal of Medicine. 2015;373(23):2237-46.
  21. McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. The Lancet. 2015;387(10013):53-60.
  22. Winsor B. Three ways to get PrEP in Australia. SBS Sexuality [Internet]. 2017. Available from: http://www.sbs.com.au/topics/sexuality/agenda/article/2016/08/30/three-ways-get-prep-australia.
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Mental Illness Following Disasters in Low Income Countries

Volume 11 Issue 1
Review
a peer reviewed article

Abstract

Disasters test the capacity of health infrastructure to act in a well-coordinated and adaptable manner, due to the unique nature of each event. While immediate provision of healthcare focuses on the physical consequences, the long term mental health ramifications of such events are often forgotten, and services are ill-equipped to deal with the mental illnesses arising from them. The inherent challenges to the public health response are compounded by the limitations experienced by Low to Middle Income Countries (LMIC). These countries may lack the fiscal resources to fund such interventions and have unstable socio-political environments, which may further complicate disaster response. It is by consideration of these limitations, risk factors specific to such countries, and cultural sensitivity then that effective, long-standing mental health interventions can be implemented. This paper will review the predisposing factors to mental illness development following disaster, particularly in respect to at-risk subpopulations, the impact of socio-political climate and low GDP on disaster response, and the development of effective, culturally-specific interventions. The intersection between low national GDP and poor mental health infrastructure often translates to poorer mental health outcomes following disaster. Women, people of low educational status and low income are especially predisposed to development of mental illness. Common mental health disorders include Post Traumatic Stress Disorder, depression and anxiety

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Introduction

In Low and Middle Income Countries (LMIC), mental health care considerations of disaster survivors have taken a proverbial back seat, as the establishment of basic needs take priority.[1] Unfortunately, overwhelming evidence of causality between natural disasters and mental health issues has confirmed that provision of culture-specific mental health care is an integral part of the public health response following massive loss of life and injury to minimise long-term recovery ramifications, and a lack of these services negatively impacts survivors.[2]

Psychosocial and mental health support programmes are increasingly being recognised as a crucial component of the humanitarian response to disasters.[3] However, disaster response coordination is notoriously complicated with numerous factors to consider, and lack of funding and resources in low income countries further limits health responses.[4] This paper will examine the predisposing factors to the development of mental illness in those affected by disaster in LMIC, and suggests potential preventative actions.

Common mental health disorders arising from disasters

Poor mental health in the immediate aftermath following disasters is to be expected in most survivors, the degree of suffering is affected by the nature of the experience, support networks, coping skills and the community response.[4] This suffering includes distress –situations in which the individual feels anger, fear, sadness or shame – emotional dysregulation, or emotional numbing, however these typically resolve without long-term consequences.[5] It is when they are sustained, and impact on daily functioning, that they are defined as a ‘mental illness’. The most common of these are the anxiety disorders, particularly Post Traumatic Stress Disorder (PTSD), in which the individual experiences heightened arousal, avoidance of triggers, and flashback episodes.[5] Other mood disorders commonly experienced include abnormal grief reactions and depression.

Due to the decreased utilisation of health services, particularly mental health services around the world and especially in Low to Middle Income Countries (LMIC), individuals may attempt to self-medicate with alcohol and other substances.[4] This may lead to substance use disorders as a way to deal with stressors, by avoiding or displacing difficult emotions associated with disasters. This is especially common in patients with a history of substance use disorder in remission, as relapse is common following stressful events.

Somatisation disorders also show increased incidence following disasters; a way for survivors to express emotional distress.[2] They are more likely to occur in individuals with other concurrent mental health diagnoses, such as PTSD. Various cultures approach emotional distress as irrational, and thus there are a number of culture-specific disorders that manifest in this way.[3] These include Latah, a condition originating in Southeast Asia in which individuals have an abnormal startle reaction; Koro, significant anxiety surrounding recession of genitalia; or Susto, a cultural variation of panic attacks originating in Latin America.[6] Knowledge and sensitivity surrounding these diagnoses may dramatically increase utilisation and efficacy of mental health programs in disaster areas.

Predisposing factors to mental health disorder diagnosis

There is a complex interplay between social dynamics and mental health diagnoses, and alteration for cultural context is an important consideration for any mental health intervention to be effective. Disasters have the potential to have a greater impact than initially considered because of the fear regarding the loss of long-held traditions that define the culture and community of those affected.[7]

Gender

Of people impacted by disaster in LMIC, females have been shown to have a higher overall likelihood of developing mental health disorders, particularly depression.[8, 9] Recognition of the specific cultural challenges that females face following a disaster may reduce the impact of events on their recovery. Females in LMIC often occupy roles of household responsibility, and women may therefore feel guilty regarding their lack of ability to tend to basic domestic tasks. Practical consideration may also mitigate some impact of the trauma; though shelters often offer gender-segregated areas, nursing mothers may be reluctant to feed in public spaces. Women may suffer additional mental strain or sexual harassment if they are obliged to use public toilet services, or if they are seen in wet clothing in traditionally modest countries. These considerations must be kept in mind for established relief facilities to be effective, particularly in the case of foreign aid provision.

Low income

The correlation between low income in LMIC and increased propensity towards poor mental health may be explained by the ‘reserve capacity model’.[5] This model states that as individuals have increasing background worries – for instance uncertainty regarding income and food shortages – their capacity to deal with additional stressors, as in the case of disaster, diminishes accordingly. It is well established that those of low Socio-Economic Status (SES) have poorer mental health, and often have the least access to services, either because lack of funding or locational difficulties.[10] Recognising low SES as a risk factor for the development of mental illness following disaster may allow more targeted relief efforts to be initiated.

Formal education

Education and financial stability may also influence recovery and disease development.[10] One of the key areas preventing development of LMIC is the lack of formal education of its citizens. This may also influence coping capacity following a disaster. On a practical level, educated individuals have an increased ability to cope with documentation demands, applications and resource seeking. This accordingly reduces the stress and impact of coping following disasters. Similarly, financial status may impact individuals at every stage of disasters. Those with lower incomes may have poorer quality of life and less safe dwellings, and are thus most predisposed to damage in the event of disasters.[11] Additionally, poor financial reserves may make it difficult to repair houses, and thus affects post-disaster recovery as well as the reserve capacity of individuals.

At-risk subpopulations

Children

Children are amongst the most vulnerable groups to disasters.[12] Negative long-term effects on paediatric wellbeing include increased incidence of PTSD, depression, and life dissatisfaction. Children may lose one or both parents due to disasters, potentially leaving them without a primary caregiver in areas with inadequate infrastructure such as education to meet their needs.

Such events have been showed to have a deleterious impact on school performance, particularly in young males.[13] In countries where education level has a direct correlation with lifetime health quality, lack of access to education may drastically alter an individual’s life course, as well as the overall poverty level of the affected country. Schools, if still operational, may provide invaluable facilities for mental health support for students following natural disaster events in LMIC. Schools provide a relatively stable environment for observation and continued support, and they may bring a sense of normalcy back to areas ravaged by disaster.[14]

Aid workers

A specific challenge is to assess and care for the first responders and aid workers who assist in relief work following a disaster. All rescue workers have a higher risk of chronic distress following exposure to an incident; although several elements, such as years of experience, perceived locus of control and social support; may mitigate development of disease.[15] These factors are important as responders are often foreign aid workers, operating without existing infrastructure and in unfamiliar environments devoid of a support network. Though they are often briefed beforehand and may receive training to prevent long-term mental health consequences, such workers are often volunteers with minimal experience. There is also some degree of stoicism amongst these volunteers, as their degree of suffering is judged to be far less than that of the people they are assisting.

Specific considerations in LMIC

The impact of disasters in LMIC appears to be far greater, in part due to the fragility of their existing infrastructure, and the lack of significant financial reserves to rebuild and support affected communities.[3] It is expected that encroaching urbanisation and industrialisation of developing counties will increase the incidence of disasters – both man-made and natural – and that developing countries will be most affected in terms of number and severity. It has been shown that the risk of PTSD also rises proportionate to increase in severity and frequency of such events.[15]

Several factors worsen the impact of disasters. Houses are often of inferior build quality, which reduces the ability to withstand severe forces.[7] Slums and communities experiencing poverty are also likely to be built in disaster-prone areas such as flood plains because their inhabitants are unable to obtain property in safer areas.

In the immediate aftermath of these events, LMIC may struggle to adequately treat the problems of their citizens due to limited training and capacity of healthcare and aid professionals.[10] The World Health Organization has recognised the role of unskilled aid workers in assessing mental health conditions and have devised a framework to use in these circumstances.[16] Untrained or poorly-organised humanitarian aid and destruction of primary infrastructure may also constitute secondary stressors following natural disasters and may compound the initial trauma of the event. Improper, or lack of, information dissemination may lead to anxiety and depression about food distribution, with negatively impacts on community wellbeing.[3]

Determinants of effectiveness of public health responses

One of the difficulties surrounding mental health disaster response is the changeable nature of the assistance required. Systems required in the immediate aftermath to aid those dealing with loss, physical impairment and adaptation to a different way of life are vastly different as some people return to their original occupations and homes.[3] Pre-disaster planning should involve a multidisciplinary team of healthcare professionals, infrastructure experts and politicians to create lasting policies that are effective and easily implemented.

Disparities in the availability, accessibility and quality of mental healthcare due to ethnicity are well-documented. This may be due to language barriers, fears regarding insurance and monetary constraints, geographical difficulties (especially in rural communities), mental health stigma and lack of education.[7] Addressing these barriers may increase uptake of such services and reduce the incidence of mental health-related decrease in quality of life for those most at risk.

Solutions include the validation and normalisation of distress reactions, so individuals feel they are experiencing legitimate reactions, rather than moments of weakness.[7] It is important to recognise the role of communities and to establish programs which value interdependence rather than independence in such situations. Promoting community action and initiatives will increase community resilience and realisation of the true impact of shared events.

Cultural competence and sensitivity in foreign aid workers is essential to effective integration of support services, as well as the recognition that cultural competence is an ongoing learning process rather than an end-state.[16] It is important to identify the causes of potential stigma and mistrust in order to properly engage minorities in healthcare. Rituals and traditions from the cultures of those affected may also be utilised and integrated into care solutions, thus using innovative interventions to circumvent such difficulties. Finally, it is critical that aid workers and all stakeholders advocate, facilitate and conduct research into the incidence of mental illness and effective treatment solutions for mental illness in affected populations to increase efficacy of interventions in the future.[1]

Disaster-derived mental illness: a contemporary perspective

Disasters today are often man-made, as in the case of conflict. There is scarce research into the impact of such political conflict in LMIC. Of the research exists, it has been shown that women and people with a past history of mental illness have the greatest risk of developing mental disorders post-event.[17] Higher levels of constant political terror – measured on a scale that stratified countries according to the frequency of politically-motivated crises – directly correlated with higher rates of PTSD and depression.[18] Resource limitation directly impacts on the quality and quantity of care provided because LMIC must allocate fiscal resources frugally. They often chose to apportion money only to the most severely-affected populations, where the greatest benefit would be attained. This, in addition to the deterioration of healthcare services in wartime, culminates in a dearth of services for all but the most severely affected.

The current global political climate, with the rise of nationalism and the unprecedented numbers of people displaced by conflict worldwide, also raise a number of considerations with respect to disaster preparedness.[19] There are more people displaced by conflict than ever before, seeking relocation in countries with greater stability and economic opportunity. The mental health of refugees is also influenced by the circumstances in the country of their resettlement. For example, a study of Latino and Asian refugees arriving in America found that those who experienced discrimination, unemployment or who experienced uncertainty due to unpredictable health insurance had lower self-rated mental health.[19] These post-settlement factors had a greater impact on their mental health than pre-settlement trauma, including war-related trauma.[19] This reflects the detrimental effect of hostile attitudes from the host country towards displaced individuals, and should be considered in the provision of mental health services for these affected communities.

The impact of political instability on disaster responses in LMIC was also demonstrated following the earthquake in Nepal’s Gorkha region. Nepal has a GDP of only $20 billion USD, and an extremely limited capacity to fund disaster relief operations. Political instability and slow constitutional development following abolition of the region’s monarchy has prevented ratification of rigorous governance surrounding disaster prevention efforts, such as building codes, which may have reduced the impact of such an event.

Conclusion

Considerations regarding the provision of mental health support to people in LMIC following disasters rely on a complex interplay between existing culture, socio-political climate and financial constraints hindering relief and prevention efforts. This review has identified that potential avenues for improvement of mental health services in disaster responses include: identification of most at-risk subpopulations including low SES; active integration of cultural sensitivity in in the provision of mental health support; and measures to address barriers in uptake of care. Though further research is needed into the impacts of disaster in LMIC, governments must actively engage in policy development before these events occur and learn from previous experiences to protect their citizens from long-term mental health implications of disasters.

Rose Brazilek

Rose Brazilek is a PhD candidate studying through the Australian Centre for Blood Disease at the Alfred Hospital. She has a keen interest in translational medical research and blood disorders. In the future, she hopes to specialise in haematology with a special interest in thrombosis and haemostasis.

Acknowledgements

None

Conflict of Interest

None declared

Correspondence

rose.brazilek1@monash.edu

References

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  15. Marmar CR, Weiss DS, Metzler TJ, Delucchi KL, Best SR, Wentworth KA. Longitudinal Course and Predictors of Continuing Distress Following Critical Incident Exposure in Emergency Services Personnel. The Journal of Nervous and Mental Disease.187(1):15-22.
  16. Zhang Y, Baik SH. Race/Ethnicity, disability, and medication adherence among medicare beneficiaries with heart failure. Journal of general internal medicine. 2014;29(4):602-7.
  17. Ostadtaghizadeh A, Soleimani SV, Ardalan A. Health Consequences and Management of Explosive Events. Health in Emergencies and Disasters Quarterly.1(2):71-8.
  18. Charlson FJ SZ, Degenhardt L, Chey T, Silove D, Marnane C. Conflict in Libya on Population Mental Health: PTSD and Depression Prevalence and Mental Health Service Requirements. PLoS ONE.7(7):e40593.
  19. Kim I. Beyond Trauma: Post-resettlement Factors and Mental Health Outcomes Among Latino and Asian Refugees in the United States. Journal of Immigrant and Minority Health.18(4):740-8.

 

Factors that Contribute to the Reduced Rates of Cervical Cancer Screening in Australian Migrant Women – a Literature Review

Volume 11 Issue 1
Review
a peer reviewed article

Abstract

AIM: This literature review presents factors that have led to decreased cervical cancer screening rates in Australian migrant women. It also evaluates past interventions that have been implemented to solve this issue in screening.

METHODS: A wide range of peer reviewed articles from databases such as CINAHL and SCOPUS were analysed to determine factors that have led to migrant women having a lower cervical cancer screening rate in comparison to the general Australian population. This review also analysed the reference lists from these articles. 

RESULTS: The factors that have led to this reduction in screening rates include cultural differences, limited acculturation, modesty, and logistical issues. Specific cultural issues such as female genital mutilation and the use of Ayurvedic medicine in certain ethnic groups may also contribute. There have been interventions aimed at increasing screening rates, including ethnic media campaigns and education of health professionals, such as doctors and nurses who work in these communities. However, their effectiveness is uncertain due to a lack of evaluation after implementation.

CONCLUSION: Whilst research has provided a basic understanding of the reasons that have contributed to the difference in screening between these two populations, there have been insufficient strategies applied to remedy it. Moreover, there has been inadequate appraisal of current interventions and discussion of the cultural appropriateness of current programs.

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Introduction

This year, the Australian government has renewed the National Cervical Cancer Screening Program (NCSP) to incorporate updated screening protocols in accordance to new research. Hence, it is important to assess the value of the previous screening protocols in underscreened populations such as Australia’s migrant women. From 2012-2013, 58.2% of the target population partook in the NCSP and since the introduction of organised cervical cancer screening in Australia, cervical cancer mortality has fallen by 44% (95% CI 0.51-0.62).[1,2,3] Whilst migrant women have benefited from screening, the results have not been as favourable in comparison to the general population. The incidence of cervical cancer is higher in migrant women from countries with higher incidence of cervical cancer, including Sub-Saharan Africa, Central America, South East Asia and Melanesia.[1]

Consequently, this paper will examine relevant literature since the current NCSP’s introduction in 1991. It will analyse the factors that have caused lower screening rates in migrants, at the level of both the individual and the health system. It will also analyse past and future interventions that may reduce these disparities evident in the rates of cervical cancer screening in Australian migrant women.

Methods

This literature review used various online databases to source information. It concentrated on articles that surveyed Australian migrant women, however some larger international studies were also used to provide global context. CINAHL was searched with keywords “cervical cancer AND migrant women”, and SCOPUS was searched with the key words “cervical cancer AND migrant AND Australia”. Only peer reviewed journal articles were used, and opinion papers were excluded in the search. Relevant articles since 1991 were analysed, from the implementation of the NCSP in Australia. Additionally, reference lists of relevant articles were examined using similar inclusion criteria.

What is a pap smear?

Pap smears are the recommended primary screening tool for cervical cancer by the NCSP. During the procedure, the doctor collects a cytological sample from the ectocervical and endocervical canal of the uterus, which is then analysed to see if any pre-cancerous or cancerous changes are present. If a cytological abnormality is identified, the patient will then be referred for colposcopy.[4] Pap smears are routinely used in general practice and account for approximately 1.7 of 100 consultations.[5] Disease incidence and burden is reduced in Australia through organised screening for cervical cancer. A key strategy lies in general practitioners instigating accessible screening, recall systems and opportunistic screening in their practice.[6]

Factors that prevent regular screening

Lack of Knowledge

Prior to living in Australia, many migrant women from developing countries had never heard of cervical cancer screening or understood the risk factors associated with the disease.[7] This is the result of a lack of organised screening programs in countries such as Ghana and Vietnam, as their health systems lack the appropriate human resources and infrastructure to support such programs.[8,9,10] Hence, Australian general practitioners are key in providing health education to new migrant women about the NCSP. A qualitative study of 21 West African women in Australia showed that they became informed about pap smears via public health campaigns and from antenatal care during pregnancy in Australia. After this initial point of contact, they had their first pap smear after their pregnancy and then received reminders every two years.[8] Although migrant women of reproductive age were educated through these campaigns, post-menopausal women who have a greater risk of cancer with age were neglected.[11]

Even with health education on cervical cancer, it appears that migrant women still have a misconstrued understanding about the NCSP or why they require a pap smear.[8,12] The surveyed West African migrant women believed that they did not require a pap smear without a family history of cervical cancer.[8] Thai and Chinese migrant women also had misconceptions about the risk factors of cervical cancer which included promiscuous behaviour, karma or having a sexual partner who had unhygienic genitalia.[7,13] Some Chinese migrant women did not understand the role of pap smears as a screening tool and none of the surveyed women were aware of the role of Human Papillomavirus (HPV) in cervical cancer.[7] Furthermore, these migrant women believed they did not require a pap smear as they were asymptomatic, had no family history and only had one sexual partner.[7,8]

Cultural Factors

Language is a common barrier for women from non-English speaking backgrounds (NESB). Migrant women have a strong preference to see a doctor who speaks their native language, regardless of their English proficiency, as it allows for clearer articulation of their concerns, particularly regarding intimate procedures.[7] However, a study of migrant women from NESB portrayed that 75.1% of the surveyed women would prefer female health providers to male practitioners to conduct their pap smear, and only 36.4% would travel a large distance to see a doctor who spoke their own language.[14] Another study of Thai immigrant women analysed that 61% would prefer a female general practitioner to perform the pap smear due to embarrassment.[13] This implied that modesty was important to migrant women from a NESB, especially as the newer migrant population often were from very conservative cultures in the discussion of sexual and reproductive health is surrounded by stigma.[8] Additionally, cultural beliefs about maintaining purity may also affect cervical cancer screening, with Assyrian migrants believing that unmarried women should not have pap smears as premarital sex is prohibited.[15] Throughout the literature, it appears that migrant women feel vulnerable and embarrassed during their pap smears and would ideally prefer a female doctor who spoke their language to assist them.[7,8,12]

Moreover, there are factors that are culturally specific, such as female genital mutilation (FGM) and the use of Ayurvedic medicine. Approximately 130 million females worldwide have experienced FGM, mainly in Asia, the Middle East and Africa.[16] Migrant women with FGM may not wish to undergo pap smears due to pain, both physical and psychological, and the reminder of the initial traumatic experience.[8] Ayurvedic medicine is practised throughout Asia. A study of Thai women in Brisbane showed these women saw a variety of alternative medical practitioners; including naturopaths, chiropractors, herbalists and traditional Chinese healers; both in Australia and Thailand.[13] As these women would often rely on these traditional methods for medical care, they were less likely to present to their general practitioner for ailments and thus have a reduced chance of undertaking opportunistic cervical cancer screening.

Finally, the time since migration to Australia is directly proportional to a woman’s probability of having regular pap smears.[7] As acculturation occurs, the individuals becomes more integrated into the Australian community and start to adopt health preventative behaviours.[13] Single migrants or those who are married to other migrants took the longest time to adjust to the health system. On the other hand, migrants who married an Australian or had a catalytic health event, such as the birth of a child, had a faster trajectory to health acculturation.[12]

Other Factors

Various factors further contribute to the lower participation of migrant women in cervical cancer screening. Several migrant women from Asia and the Middle East hold a fatalistic view of health and believe that screening is superfluous, as they have no control over their destiny.[19] Migrant women from Yugoslavian and West African communities describe their fear of their results and do not wish to start looking for problems that did not exist.[8,20] Similar to women in the general population, Chinese Australian women describe how previous negative experiences have deterred them from having regular pap smears.[7] Additionally, they may simply forget or have logistical barriers that prevent regular pap smears, such as lack of transportation or childcare.[7,20]

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Interventions

From 2002 to 2011, the Australian Research Council (ARC) spent 7.8% of their funding for people-related research on the migrant population; insufficient considering migrants comprise over a quarter of the Australian population.[21,22] Moreover, the lack of funding for migrant research does not allow for the provision of strongly evidence-based interventions into migrant health, especially as data is not available as to the amount of ARC funding allocated specifically to cervical cancer screening.[22] Nonetheless, using available Australian data supplemented with some international publications, the following conclusions can be drawn about the effectiveness of past interventions and discussion of what is required for future success.

Educational Campaigns

Migrant women state that they largely receive information about cervical cancer from health professionals and public media campaigns. Therefore, the lack of awareness about pap smears must be targeted in both health and community settings; through general practice, migrant resource centres and community centres.[8] General practitioners play a key role in advocating for cervical cancer screening in consultations and through reminder letters, as migrant women who have never had a pap smear may not be comfortable asking for the test.[7,8,23] Similarly, the use of nurses in community, refugees health, women’s health, and child and family health is key in facilitating discussions regarding cancer screening amongst the migrant population.[8]

The Ethnic Communities Council of Queensland (ECCG) created the Pilot Cancer Screening Education Program (PCSEP) which identified cervical cancer screening levels in various migrant populations before and after their program. In this program, 76% of participants participated in cervical cancer screening and this increased to 91% after the PCSEP.[24] Yet as this result was not statistically significant, we cannot confirm that this target program would be successful in increasing cervical cancer screening rates in migrant populations.

Cultural Sensitivity

As cultural factors play a key role in the decreased screening rate amongst migrant women, it is essential for Australian doctors to undertake cultural sensitivity training. This may improve understanding of factors affecting women from certain cultures such as modesty and fatalistic views of health.[7] This will allow health practitioners to appropriately tailor their consultations and the way that they promote cervical cancer screening with their migrant patients.

There may also be reduced rates of cancer screening referrals from migrant doctors to patients of their own nationality. A study of Korean American doctors showed that there were reduced referral rates of colorectal cancer screening for their Korean patients. This was because they understood the cultural sensitivities surrounding cancer screening and perceived that compliance would be lower amongst their Korean patients.[25] It is key for doctors providing carer to patients of the same nationality to undergo training in cancer screening. The significance of bilingual health practitioners cannot be underestimated, as migrants prefer to see practitioners of the same nationality.[7,23] In the Vietnamese community, information sessions for bilingual practitioners about cervical cancer has been documented, but the effectiveness of this intervention has not been assessed.[23]

Use of ethnic media

Previous interventions have used ethnic media as a health promotion strategy to increase cervical cancer screening in various migrant populations.[23,26] Between 1991 and 1994, Pap Test Victoria conducted three sets of interventions in ethnic media outlets for over 12 migrant groups including Vietnamese, Chinese, Arabic and Turkish populations. During these interventions, the respective ethnic media outlets conducted live interviews, paid announcements and competitions with prizes. These three interventions led to an increase in screening compliance by 6.7% (95% CI 4.4-9.2).[26] As ethnic media can be utilised for health promotion and appears to be an effective method of increasing screening uptake, funding should be allocated for a nationwide ethnic media campaign on cervical screening.

 Conclusion

Lower rates of cervical cancer screening in migrant women is a multifaceted issue. Factors contributing to these lower rates include lack of knowledge, cultural differences, limited acculturation and logistical issues. While research has been undertaken to understand the cause of the decreased participation of migrant women in regular pap smears, there have not been sufficient evidence-based interventions to address the issue. Although the government has redesigned the NCSP to reflect current medical research, there has been little evaluation of the cultural appropriateness of the current NCSP and the effectiveness of previous interventions to increase participation amongst the migrant population. The renewal of the NCSP should parallel the increased number of research projects that occurred during its initial implementation, as this is necessary to provide updated information on cervical cancer screening to migrant women. This will then allow for the application of evidence-based interventions to increase pap smear rates in this underscreened population.

Archana Nagendiram

Archana is a fourth year medical student from James Cook University with interests in global health and women’s health.

Acknowledgements

None

Conflict of Interest

None declared

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