Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings.
Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.
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Community-Oriented Primary Health Care for Improving Maternal, Newborn, and Child Health
Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta
Article
Dementia Caregiver Interventions
Laura N. Gitlin
The number of people living with dementia worldwide is estimated to be 55 million and is expected to increase to 78 million by 2030 andover 150 million by 2050. Families—defined broadly as relatives, fictive kin, neighbors, friends, relatives, and spouses—provide most of the long-term care throughout the disease trajectory. Family caregiving is a global phenomenon. Low- to middle-income countries in Latin America, Africa, and Asia are experiencing the most rapid increases in dementia, with the burden of care being particularly acute for extremely low-resourced families in these regions of the world.
Compared to caregiving for individuals with serious illnesses but who are not cognitively impaired, caregivers of people living with dementia provide more assistance with all aspects of care, oversee complex clinical symptoms, and must at some point in the disease process provide constant vigilance and extensive hands-on and physical care. The economic outlay of dementia caregiving is another differentiator, with families incurring approximately 70% of care costs. As care responsibilities increase with disease progression, caregivers need a wide range of supportive services to help them stay healthy themselves and also manage the complexities of the disease process and their elongated care responsibilities.
In response, a robust body of intervention studies has evolved during the past half-century. Although most research has emanated from the United States, research is emerging from other countries that either adapt and test existing evidence-based U.S. programs or develop and evaluate new intervention approaches tailored to the specific country and cultural group.
An appraisal of this expansive and growing research offers a “glass half full” and “glass half empty” perspective as to the level and depth of the evidence. On one hand and taken as a whole, this vast corpus of research has yielded evidence for a wide range of strategies, approaches, interventions, and programs demonstrating varying levels of effectiveness in supporting caregivers by increasing mastery and reducing depressive symptoms and care burdens. On the other hand, more methodological rigor in studies is needed along with the testing of interventions with diverse family caregivers that considers strength-based approaches (vs. symptom reduction only) and a wider range of outcomes such as supporting resilience, adaptation, and positive affect.
Despite evidence for many supportive approaches for caregivers, interventions with some level of evidence have not been widely disseminated, embedded in practice settings, nor sustained. Few families worldwide have access to proven supportive programs; few health professionals are aware of the evidence base; and most agencies, community-based programs, and health care systems do not have the infrastructure, staff capacities, or both to identify caregivers and provide disease education, support, care coordination, skills training, and other needed strategies shown to be helpful to families. This persistent “family care gap” between what is known to be effective and what is practiced in health care systems is one of the defining characteristics of this field of inquiry.
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Health and Health Care Access Among Diverse Groups of Elders in the United States: An Intersectionality Approach
Sadaf Arefi Milani and Kyriakos S. Markides
Great interest has been shown in recent years about the influence of diversity on access to health care and health status, especially over the life course. Substantial interest has been shown in diversity by race/ethnicity, gender, socioeconomic status, and also sexual orientation and rurality. A life course perspective whereby life conditions earlier in life influence health care access and health status later in life, with increasing application of an intersectionality perspective, is crucial to understanding how statuses delineated by social class, race/ethnicity, gender, sexual orientation, and age interact to influence later life outcomes. Application of intersectionality to the study of aging and health is relatively recent, in conjunction with the increasingly popular cumulative advantage/disadvantage life course perspective, promises to lead to significant advances in the field of diversity, aging, and health in the United States and elsewhere.
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Homelessness and Vaccination Strategies: Problems and Potential Solutions to Vaccinate Vulnerable Populations
Elena Mitevska, Priyanka Gill, and Monty Ghosh
People experiencing homelessness (PEH) are at a higher risk of vaccine-preventable illnesses. They have higher rates of chronic illnesses that predispose them to communicable diseases, and this is compounded by poor access to sanitation. While vaccination is especially important in PEH, they tend to have lower rates of vaccine uptake compared to the general population. Factors impacting this discrepancy include difficulty accessing vaccines and public health programs, lack of access to primary care services, and distrust of the health care system. Despite this, there is evidence to suggest that many PEH are accepting of vaccinations and are willing to get vaccinated provided the right approach and interactions. Understanding client-specific barriers along with education and counseling are key to improving vaccine uptake in PEH, and programs targeted specifically at PEH can improve vaccine uptake and ultimately the health of PEH.
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Intervention Approaches for Osteoarthritis
Susan Hughes, Cheryl Der Ananian, and Andrew DeMott
Osteoarthritis (OA) currently affects 32.5 million people in the United States at a cost of $136.8 billion. The available literature on the epidemiology of OA shows that the number of people affected will increase exponentially by the year 2040, affecting 78.4 million people. There is an abundance of evidence that self-management and physical activity (PA) approaches improve multiple outcomes for individuals with arthritis. However, these programs are not widely accessible to the population that can benefit from them across the United States. Two national organizations—the arthritis program of the Centers for Disease Control and Prevention (CDC) and the Administration on Community Living (ACL)—have established similar, but distinct, criteria for the review of evidence-based programs and seek to promote their dissemination. The CDC arthritis program has reviewed the evidence bases of arthritis-appropriate, evidence-based intervention programs and classified them as self-management or PA approaches. These “recognized” programs are recommended for national dissemination by the CDC. The ACL has also recognized several of the same programs by using its own criteria and classified them as Self-Management or Falls Prevention approaches. The different review criteria used by these two national public organizations present significant challenges for investigators who design interventions. The situation is further compounded by an investment in funding that hugely supports the discovery of interventions as opposed to the dissemination of interventions that have demonstrated efficacy. The National Public Health Agenda for Osteoarthritis: 2020 Update presents a blueprint that includes nine strategies for improving public health outcomes among persons with OA. These recommendations should be considered by interventionists in the future when developing programs. Other areas that can substantially benefit from further research include weight management and weight loss, injury prevention, technology-based interventions, addressing comorbid conditions, and understanding program mechanisms of action. Finally, underscoring all of these approaches and common to them is the need to enroll underserved populations to improve health equity. Underserved populations disproportionately include African Americans, Hispanics, persons with low socioeconomic status, and persons who live in rural areas of the United States. Policy recommendations to render future approaches to improving health outcomes for persons with OA are (a) to increase funding for the dissemination of programs that demonstrated efficacy and effectiveness, (b) to increase the transparency of the review and funding processes across public agencies, and (c) to nurture, broker, and provide sustainable funding streams to maintain evidence-based programming for all persons with OA across the United States.
Article
Menopause
Funmilola M. OlaOlorun and Wen Shen
Menopause is the natural senescence of ovarian hormonal production, and it eventually occurs in every woman. The age at which menopause occurs varies between cultures and ethnicities. Menopause can also be the result of medical or surgical interventions, in which case it can occur at a much younger age. Primary symptoms, as well as attitudes toward menopause, also vary between cultures. Presently, the gold standard for treatment of menopause symptoms is hormone therapy; however, many other options have also been shown to be efficacious, and active research is ongoing to develop better and safer treatments.
In a high-resource setting, the sequelae/physiologic changes associated with menopause can impact a woman’s physical and mental health for the rest of her life. In addition to “hot flashes,” other less well-known conditions include heart disease, osteoporosis, metabolic syndrome, depression, and cognitive decline. In the United States, cardiac disease is the leading cause of mortality in women over the age of 65. The growing understanding of the physiology of menopause is beginning to inform strategies either to prevent or to attenuate these common health conditions. As the baby boomers age, the distribution of age cohorts will increase the burden of disease toward post-reproductive women. In addition to providing appropriate medical care, public health efforts must focus on this population due to the financial impact of this age cohort of women.
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Prevention of Suicide
Danuta Wasserman
Around 700,000 people take their lives each year worldwide. Suicide accounts for approximately 1.3% of all deaths and therefore represents a major public health problem. The global age-standardized suicide rate is 9 per 100,000 population, yet there are large variations among genders, ages, countries, and world regions. The stress–vulnerability model of suicidal behaviors has been proposed to explain how a diathesis, developed through the influence of genetic and neurodevelopmental factors in relation to perinatal, postnatal, and life experiences, interacts with different risk and protective factors that either decrease or enhance the individual’s level of resilience to stress and suicidal risk. Public health suicide prevention strategies include suicide means restriction, reducing harmful substance use, promoting responsible media reporting, public-awareness campaigns, gatekeeper trainings, school-based interventions, crisis helplines, and postvention. Mental health strategies comprise identification, treatment, and rehabilitation of persons in distress and at risk for suicide. Multicomponent strategies that use a combination of evidence-based methods from public and mental health sectors are recommended. Future work should aim at enhancing the quality of epidemiological data, improving the research on protective and ideation-to-action factors, expanding the quantity and quality of data coming from low- and middle-income countries, and evaluating the cost-effectiveness of different suicide prevention strategies.
Article
Using Lifestyle Interventions to Reduce Alzheimer’s Risk in African Americans
Robert L. Newton, Jr., George W. Rebok, Andrew McLeod, and Owen Carmichael
Currently, there are no pharmacological interventions that have been shown to reduce the risk of developing dementias such as Alzheimer’s disease. However, it is recognized that modifiable behaviors are associated with increased risk of developing dementias. Lifestyle interventions are designed to assist participants in changing these modifiable behaviors. Typical behaviors targeted include dietary intake, sleep patterns, and social, cognitive, and physical activities. It is hypothesized that these effects occur through physiological and biological pathways. African Americans have a high risk of developing dementias, and altering lifestyle behaviors may be effective for reducing risk in this population. Identifying these interventions is important, as effective interventions for a majority non-Hispanic White population do not necessarily translate into effective interventions for African Americans.