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Background: A variety of small mobile phone text-messaging interventions have indicated improvement in risk factors for cardiovascular disease (CVD). Yet the extent of this improvement and whether it impacts multiple risk factors together is uncertain. We aimed to conduct a systematic review and individual patient data (IPD) meta-analysis to investigate the effects of text-messaging interventions for CVD prevention. Methods: Electronic databases were searched to identify trials investigating a text-messaging intervention focusing on CVD prevention with the potential to modify at least two CVD risk factors in adults. The main outcome was blood pressure (BP). We conducted standard and IPD meta-analysis on pooled data. We accounted for clustering of patients within studies and the primary analysis used random-effects models. Sensitivity and subgroup analyses were performed. Results: Nine trials were included in the systematic review involving 3779 participants and 5 (n=2612) contributed data to the IPD meta-analysis. Standard meta-analysis showed that the weighted mean differences are as follows: systolic blood pressure (SBP), -4.13 mm Hg (95% CI -11.07 to 2.81, p<0.0001); diastolic blood pressure (DBP), -1.11 mm Hg (-1.91 to -0.31, p=0.002); and body mass index (BMI), -0.32 (-0.49 to -0.16, p=0.000). In the IPD meta-analysis, the mean difference are as follows: SBP, -1.3 mm Hg (-5.4 to 2.7, p=0.5236); DBP, -0.8 mm Hg (-2.5 to 1.0, p=0.3912); and BMI, -0.2 (-0.8 to 0.4, p=0.5200) in the random-effects model. The impact on other risk factors is described, but there were insufficient data to conduct meta-analyses. Conclusion: Mobile phone text-messaging interventions have modest impacts on BP and BMI. Simultaneous but small impacts on multiple risk factors are likely to be clinically relevant and improve outcome, but there are currently insufficient data in pooled analyses to examine the extent to which simultaneous reduction in multiple risk factors occurs.

BackgroundA variety of small mobile phone text-messaging interventions have indicated improvement in risk factors for cardiovascular disease (CVD). Yet the extent of this improvement and whether it impacts multiple risk factors together is uncertain. We aimed to conduct a systematic review and individual patient data (IPD) meta-analysis to investigate the effects of text-messaging interventions for CVD prevention.MethodsElectronic databases were searched to identify trials investigating a text-messaging intervention focusing on CVD prevention with the potential to modify at least two CVD risk factors in adults. The main outcome was blood pressure (BP). We conducted standard and IPD meta-analysis on pooled data. We accounted for clustering of patients within studies and the primary analysis used random-effects models. Sensitivity and subgroup analyses were performed.ResultsNine trials were included in the systematic review involving 3779 participants and 5 (n=2612) contributed data to the IPD meta-analysis. Standard meta-analysis showed that the weighted mean differences are as follows: systolic blood pressure (SBP), −4.13 mm Hg (95% CI −11.07 to 2.81, p<0.0001); diastolic blood pressure (DBP), −1.11 mm Hg (−1.91 to −0.31, p=0.002); and body mass index (BMI), −0.32 (−0.49 to −0.16, p=0.000). In the IPD meta-analysis, the mean difference are as follows: SBP, −1.3 mm Hg (−5.4 to 2.7, p=0.5236); DBP, −0.8 mm Hg (−2.5 to 1.0, p=0.3912); and BMI, −0.2 (−0.8 to 0.4, p=0.5200) in the random-effects model. The impact on other risk factors is described, but there were insufficient data to conduct meta-analyses.Conclusion

We aimed to estimate the impact of a Community-Based Health Insurance (CBHI) scheme on utilization of healthcare from medically trained providers (MTP) by informal workers. A quasi-experimental study was conducted where insured households were included in the intervention group and uninsured households in comparison group. In total 1,292 (646 insured and 646 uninsured) households were surveyed from Chandpur district comprising urban and rural areas after 1 year period of CBHI introduction. Matching of the characteristics of insured and uninsured groups was performed using a propensity score matching approach to minimize the observed baseline differences among the groups. Multilevel logistic regression model, with adjustment for individual and household characteristics was used for estimating association between healthcare utilization from the MTP and insurance enrolment. The utilization of healthcare from MTP was significantly higher in the insured group (50.7%) compared to the uninsured group (39.4%). The regression analysis demonstrated that the CBHI beneficiaries were 2.111 (95% CI: 1.458–3.079) times more likely to utilize healthcare from MTP.CBHI scheme increases the utilization of MTP among informal workers. Ensuring such healthcare for these workers and their dependents is a challenge in many low and middle income countries. The implementation and scale-up of CBHI schemes have the potential to address this challenge of universal health coverage.

Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the ‘implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers

Objectives: There is a growing need for efficient procedures for identification of emerging technologies by horizon scanning systems. We demonstrate the value of best-worst scaling (BWS) in exploring clinicians- views on emerging technologies that will impact outcomes in hepatocellular carcinoma (HCC) in the next 5 to 10 years. Methods: Clinicians in Asia, Europe, and the United States were surveyed and their views about eleven emerging technologies relevant to HCC were explored using BWS (case 1). This involved systematically presenting respondents with subsets of five technologies and asking them to identify those that will have the most and least impact on HCC within 5 to 10 years. Statistical analysis was based on sequential best-worst and analyzed using conditional logistic regression. Results: A total of 120 clinicians uniformly distributed across ten countries completed the survey (37 percent response rate). Respondents were predominately hepatologist (41 percent) who focused on HCC (65 percent) and had national influence in this field (39 percent). Respondents viewed molecular targeted therapy (p <.001) and early detection of HCC (p <.001) as having most potential, while improved surgical techniques (p <.001) and biopsy free HCC diagnostics (p <.001) were viewed upon negatively. Conclusions: We demonstrate that BWS could be an important research tool to facilitate horizon scanning and HTA more broadly. Our research demonstrates the value of including clinicians- preferences as a source of data in horizon scanning, but such methods could be used to incorporate the opinions of a broad array of stakeholders, including those in advocacy and public policy. © Copyright 2012 Cambridge University Press.

RIVM rapport:Dit rapport bevat de details van de scenario-analyse in de gelijktijdig verschijnende eerste Global Environment Outlook, onder auspicien van UNEP. Dit is een proeve van een wereldmilieuverkenning tot 2015 met een doorkijkje naar 2050. De studie is uitgevoerd ten behoeve van de tussenbalans van Agenda 21, vijf jaar na 'Rio' en tien jaar na 'Brundtland'. De scenario-analyse is gebaseerd op slechts een scenario, het Conventional Development scenario. Impliciet daarin is dat hoewel de gemiddelde welvaart stijgt, de verschillen in de wereld alleen maar toenemen. De analyse met behulp van gedetailleerde milieumodellen versterkt dat beeld. Het landbouwareaal breidt sterk uit om aan de toenemende vraag naar voedsel te voldoen, bij achterblijvende landbouwproductiviteit in Afrika en Azie. Van de natuurgebieden blijft niet veel over, en wat overblijft komt onder grote druk. De verhouding tussen beschikbaar en benodigd zoet water wordt ongunstiger, met sterke regionale verschillen. Handel in voedsel wordt een steeds belangrijker factor, zowel voor welvaart als voor de vraag waar op de wereld het milieu het meest belast wordt. De noodzakelijke transities op het gebied van gezondheid en demografische ontwikkelingen worden geillustreerd met case-studies over India, Mexico en Nederland. Milieubeheer zal gaandeweg een belangrijker factor worden bij het bevorderen van een gezonde levensverwachting in ontwikkelingslanden. Toekomstige generaties zullen steeds effectiever omspringen met energie, land en water. Maar hoewel het onderzochte scenario op dit punt tamelijk optimistisch is, zijn de veronderstelde efficiencyverbeteringen over het geheel genomen onvoldoende om de groei van de behoefte op te vangen. Aan de andere kant laten voorlopige berekeningen zien dat er technisch gesproken veel ruimte is om de druk op natuurlijke hulpbronnen te verminderen - aangenomen dat de politieke wil aanwezig is., This report documents the scenario analysis in UNEP's first Global Environment Outlook, published at the same time as the scenario analysis. This Outlook provides a pilot assessment of developments in the environment, both global and regional, between now and 2015, with a further projection to 2050. The study was carried out in support of the Agenda 21 interim evaluation, five years after 'Rio' and ten years after 'Brundtland'. The scenario analysis is based on only one scenario, Conventional Development. It features higher incomes and better health, but increasing regional inequalities. This pattern is reinforced by the analysis using detailed environmental models. Agricultural land use has to expand considerably in order to meet the growing demand for food, while agricultural productivity is not growing quickly enough in Africa and Asia. The little that remains of natural areas comes under heavy pressure. The ratio between water demand and availability becomes problematic in an increasing number of the world's catchment areas, although there are strong regional differences. Trade in food products becomes even more important than it is now, both for one's well-being and for the question on where the environmental pressures will occur. The necessary demographic and health transitions are illustrated with case studies for India, Mexico and the Netherlands. Protection of the environment will become an increasingly important factor in improving healthy life expectancy in developing countries. Future generations will be able to use energy, land and water more efficiently. Although the scenario analyzed in this study is rather optimistic in this respect. The assumed efficiency increases are by and large insufficient to meet the absolute growth in demand. On the other hand, there is technically speaking evidence given of considerable room for reducing the pressure on natural resources - assuming political determination, of course.

RIVM rapport:This report documents the scenario analysis in UNEP's first Global Environment Outlook, published at the same time as the scenario analysis. This Outlook provides a pilot assessment of developments in the environment, both global and regional, between now and 2015, with a further projection to 2050. The study was carried out in support of the Agenda 21 interim evaluation, five years after 'Rio' and ten years after 'Brundtland'. The scenario analysis is based on only one scenario, Conventional Development. It features higher incomes and better health, but increasing regional inequalities. This pattern is reinforced by the analysis using detailed environmental models. Agricultural land use has to expand considerably in order to meet the growing demand for food, while agricultural productivity is not growing quickly enough in Africa and Asia. The little that remains of natural areas comes under heavy pressure. The ratio between water demand and availability becomes problematic in an increasing number of the world's catchment areas, although there are strong regional differences. Trade in food products becomes even more important than it is now, both for one's well-being and for the question on where the environmental pressures will occur. The necessary demographic and health transitions are illustrated with case studies for India, Mexico and the Netherlands. Protection of the environment will become an increasingly important factor in improving healthy life expectancy in developing countries. Future generations will be able to use energy, land and water more efficiently. Although the scenario analyzed in this study is rather optimistic in this respect. The assumed efficiency increases are by and large insufficient to meet the absolute growth in demand. On the other hand, there is technically speaking evidence given of considerable room for reducing the pressure on natural resources - assuming political determination, of course., Dit rapport bevat de details van de scenario-analyse in de gelijktijdig verschijnende eerste Global Environment Outlook, onder auspicien van UNEP. Dit is een proeve van een wereldmilieuverkenning tot 2015 met een doorkijkje naar 2050. De studie is uitgevoerd ten behoeve van de tussenbalans van Agenda 21, vijf jaar na 'Rio' en tien jaar na 'Brundtland'. De scenario-analyse is gebaseerd op slechts een scenario, het Conventional Development scenario. Impliciet daarin is dat hoewel de gemiddelde welvaart stijgt, de verschillen in de wereld alleen maar toenemen. De analyse met behulp van gedetailleerde milieumodellen versterkt dat beeld. Het landbouwareaal breidt sterk uit om aan de toenemende vraag naar voedsel te voldoen, bij achterblijvende landbouwproductiviteit in Afrika en Azie. Van de natuurgebieden blijft niet veel over, en wat overblijft komt onder grote druk. De verhouding tussen beschikbaar en benodigd zoet water wordt ongunstiger, met sterke regionale verschillen. Handel in voedsel wordt een steeds belangrijker factor, zowel voor welvaart als voor de vraag waar op de wereld het milieu het meest belast wordt. De noodzakelijke transities op het gebied van gezondheid en demografische ontwikkelingen worden geillustreerd met case-studies over India, Mexico en Nederland. Milieubeheer zal gaandeweg een belangrijker factor worden bij het bevorderen van een gezonde levensverwachting in ontwikkelingslanden. Toekomstige generaties zullen steeds effectiever omspringen met energie, land en water. Maar hoewel het onderzochte scenario op dit punt tamelijk optimistisch is, zijn de veronderstelde efficiencyverbeteringen over het geheel genomen onvoldoende om de groei van de behoefte op te vangen. Aan de andere kant laten voorlopige berekeningen zien dat er technisch gesproken veel ruimte is om de druk op natuurlijke hulpbronnen te verminderen - aangenomen dat de politieke wil aanwezig is.

RIVM rapport:Achtergrond en doelstelling: de toepassing van een generiek fertiliteitsmodel, beschreven op basis van de Indiase situatie. Het model bestaat uit vier onderdelen. Het deel waarin de toestand is beschreven berekent de fertiliteitsratio en de factoren die dit direct bepalen zoals onderscheiden door Bongaarts en Potter: huwelijkse leeftijd, gebruik van anticonceptiva, abortus provocatus en post-partum amenorroe. Het druksysteem beschrijft de causale krachten: levensverwachting, scholingsniveau van vrouwen, bruto nationaal produkt, en populatiegroei. Het impactsysteem beschrijft de ontwikkeling van het aantal geboorten, dat, tezamen met geprojecteerde en/of gesimuleerde sterftecijfers, de geschatte populatiegroei bepaalt. Het sturingsgedeelte bevat vier beleidsvelden: beleid in relatie tot abortus, scholingsbeleid, anticonceptieprogramma's en massacommunicatie. Resultaten: De toegepaste scenarios gebruiken een aantal trajecten in het model die het volgende aantonen: a. Een verdere verlaging van de vruchtbaarheid zonder een expliciete bevolkingspolitiek is mogelijk, als gevolg van de aanname dat de diffusie van methoden zich zal continueren en de voorkeur voor zonen zal afnemen. De daling zal echter meer tijd nodig hebben om het vervangingsniveau te halen. Deze verandering zal zich dan op micro-niveau voltrekken. b. In het geval van tegenvallende economische groei zijn er expliciete bevolkingsstrategieen mogelijk met betrekking tot het moment van kinderen krijgen. Er is een afgenomen effectiviteit van methoden, die slechts partieel door informatieve programma's is te compenseren. c. De daling van het aantal kinderen per vrouw zal doorzetten en kent in sommige gebieden een versnelling. Sommige scenario's tonen dat het vervangingsniveau binnen twee decennia bereikt kan worden. Onder ongunstiger omstandigheden kan het diffusieproces zich nog steeds voltrekken, maar het gewenste kinderaantal zal boven het vervangingsniveau blijven liggen. Conclusies: De relatie tussen fertil, Background and purpose: This report on fertility change in India presents the results of a project on integrated population modelling initiated by the National Institute of Public Health and Environment (RIVM) and the Population Research Centre of the University of Groningen as part of RIVM's contributions to UNEP's global environmental outlook. A generic fertility module has been designed and applied to the Indian situation. Methodology: The model includes four sections on the systems: state, pressure, impact and response/steering. The state system encompasses the total fertility rate and its proximate determinants distinguished by Bongaarts and Potter: marriage, contraceptive use, induced abortion and postpartum infecundability. The pressure system describes the driving forces behind fertility changes, comprising the following variables: life expectancy, female education, gross national product and (current) population growth. The impact system describes the number of births, which together with the number of deaths from the health module, generates estimated population figures. The response/steering system includes: abortion policy, education policy, family planning allocation and mass communication. Results: The scenarios applies a number of possible fertility trajectories within the fertility model, showing that: a. Further fertility decline without explicit population policies is possible because of the assumed continuation of the diffusion process and changing son-preference: it takes longer. The decline is a consequence of changes at the micro-level: changes in reproductive attitudes in relation to son-preference and the demand for family planning methods. b. For the scenarios assuming less economic development, explicit policies are possible for increasing the possibilities of child spacing. There is a reduced use-effectiveness of child-spacing methods which can only partially be compensated by increased information and health education. c. Fertility declin

RIVM rapport:Het rapport beschrijft de menselijke fertiliteit en de veranderingen daarvan in de tijd in relatie tot sociale, economische en culturele processen. Het aantal kinderen per vrouw is een biologisch proces, dat gestuurd wordt door sociale, economische, culturele en milieufactoren. De effecten van deze factoren op de vruchtbaarheid worden bepaald door een verzameling intermediaire variabelen ('proximate variables'). De relatie tussen deze intermediaire variabelen en vruchtbaarheid is bekend en vormt de kern van het fertiliteitsmodel. Ongeacht de beperkingen inherent aan modelleren en ten gevolge van lacunes in kennis kan het fertiliteitsmodel als geintegreerd onderdeel van het TARGETS-model een nuttig instrument voor het verkennen van mogelijke toekomstige ontwikkelingen en het ontwikkelen van duurzame beleidsstrategieen zijn., In this report we address human fertility and its evolution over time in relation to socio-economic development. Human fertility is a biological process that is governed by social, economic, cultural and environmental variables. The effects for these on fertility levels are mediated by a set of proximate variables. The relation between these proximate variables and fertility is well understood and forms the core of the fertility model presented in this report. Notwithstanding a few limitations, the fertility model as integrated part of the TARGETS framework can be a helpful guide for the analysis of the complex interlinked processes and for the development of sustainable population policies.

RIVM rapport:Abstract niet beschikbaar, In order to assess the impact of an anthropogenic climate change on the transmission of malaria, an integrated assessment model has been developed. In this integrated model, the direct effects of a change in temperature and precipitation on the transmission potential of a mosquito population are assessed by means of the vectorial capacity (defined as the number of potentially infective contacts inflicted by the mosquito population per infectious person per day) and the related critical mosquito density (the minimum number of mosquitoes needed to maintain malaria at an endemic level). The simulation results indicate a worldwide increase of potential malaria risk and an extension of the areas conductive to malaria transmission. In non-malarious areas the risk of introduction of malaria associated with imported cases of malaria increases to some extent as a result of the increasing importance of modern transport systems (e.g. air travel) in introducing malaria into receptive areas. However, sound interpretation of the change in malaria risk as simulated must be performed within the framework of local conditions and socio-economic developments.

RIVM rapport:A conceptual framework for UNEP's reporting functions is proposed, aimed at supporting strategic environmental policy development. To this end information should be provided about the past, current and future state of the environment as a function of demographic and socio-economic developments. The policy relevance of the existing global environmental reporting functions may be improved considerably by introducing three new elements: (1) the application of integrated conceptual frameworks and computer models to allow for the analysis of the dynamic linkages between different environmental changes, between environment and development, and for early warning purposes and prognosis ; (2) a framework of appropriate indicators related to the pressure on the environment, the state-of-the-environment, the resulting impacts on functions of the environment and the societal response ; for these indicators to be policy-relevant appropriate reference values should be selected and developed ; (3) networks of experts and expert institutions for assessment and consensus building on key environmental issues. This report focuses on the first two elements. Consensus building on reference values is necessary for appreciation of reported indicators. The Pressure-State-Impact-Response framework is used as an organizing principle for indicators in the environmental management cycle., Deze studie ontwikkelt een kader voor de rapportage-functies van UNEP, met als doel het ondersteunen van de ontwikkeling van strategisch milieubeleid. Daartoe is informatie nodig over de huidige, historische en toekomstige toestand van het milieu als functie van demografische, sociale en economische ontwikkelingen. De beleidsrelevantie van de bestaande milieurapportage-lijnen kan aanzienlijk worden verbeterd door drie nieuwe elementen te introduceren: (1) toepassing van geintegreerde conceptuele kaders en computermodellen voor de analyse van dynamische verbanden tussen verschillende veranderingen in het milieu, tussen milieu en ontwikkeling en voor prognose ; (2) een kader van geschikte indicatoren voor druk op het milieu, milieutoestand, veranderingen in functies van het milieu (impacts) en de maatschappelijke reactie op milieuveranderingen ; om deze indicatoren beleidsrelevant te doen zijn, moeten referentiewaarden worden geselecteerd of ontwikkeld; (3) netwerken van experts of expert-instituten voor milieu-evaluatie en consensus-vorming over de belangrijkste milieuthema's. Dit rapport is geconcentreerd op de eerste twee elementen. Consensusvorming over referentiewaarden is belangrijk om de te rapporteren indicatoren te kunnen beoordelen. De indeling in Pressure-State-Impact-Response wordt gehanteerd om de verzameling indicatoren te structureren binnen de beleidslevencyclus.

RIVM rapport:Abstract niet beschikbaar, In all stages of the development of societies, the objective of health policy has been to promote health, as measured by an increase in life expectancy. Not until the past two decades has an awareness grown that resources to be invested in health are limited and that the increase in survival may mean an increase in years spent in health but also in years spent with disease as the additional effect of socio-economic development and medical technology. This appreciation has created a need for an integrated approach to determine the positive and negative effects of socio-economic and technological advances on the level of health and disease in population as a whole. The purpose of this report is to explore the usefulness of the sustainable development concept, as used in environmental modelling research, in the search for a more comprehensive health policy approach. The application of sustainable development concepts for a comprehensive approach to health policy is a worthwhile enterprise as one can account for the role of health determinants, the beneficial and negative effects of preventive and curative care, as well as the limits to the necessary resources for health and the overall effects of economic development. Two important issues in the development of the model are the framing of an integrated methodology to allow for the inclusion of various sets of determinants and disease-specific subsidiary-models as well as the collection of global and regional data for model validation.