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Fulltext Sustainable development goals, universal health coverage and equity in health systems: the Orang Asli commons approach

Wong YS, Allotey P, Reidpath DD

Glob Health Epidemiol Genom, 2016;1:e12.
PMID: 29868204 DOI: 10.1017/gheg.2016.8

Universal health coverage is a key health target in the Sustainable Development Goals (SDGs) that has the means to link equitable social and economic development. As a concept firmly based on equity, it is widely accepted at international and national levels as important for populations to attain 'health for all' especially for marginalised groups. However, implementing universal coverage has been fraught with challenges and the increasing privatisation of health care provision adds to the challenge because it is being implemented in a health system that rests on a property regime that promotes inequality. This paper asks the question, 'What does an equitable health system look like?' rather than the usual 'How do you make the existing health system more equitable?' Using an ethnographic approach, the authors explored via interviews, focus group discussions and participant observation a health system that uses the commons approach such as which exists with indigenous peoples and found features that helped make the system intrinsically equitable. Based on these features, the paper proposes an alternative basis to organise universal health coverage that will better ensure equity in health systems and ultimately contribute to meeting the SDGs.
Fulltext Nine months a slave: when pregnancy is involuntary servitude to a foetus

Allotey-Reidpath KD, Allotey P, Reidpath DD

Reprod Health Matters, 2018 Dec;26(52):1451173.
PMID: 29651926 DOI: 10.1080/09688080.2018.1451173

Recent globally compiled evidence suggests that one-quarter of pregnancies end in abortions. However, abortions remain illegal in many countries, resulting in unsafe practices. Debates have largely stalled with the pro-life, pro-choice epithets. To provide further arguments in support of legalising abortion services, we argue that the state cannot demand of a woman that she maintains an unwanted pregnancy because that demand places her in a state of involuntary servitude. Involuntary servitude would put states in breach of international human rights law (Article 8 of International Covenant on Civil and Political Rights). Furthermore, we argue that the fact that a life may be forfeit when a woman withdraws her service is no basis for enforcing the servitude. We draw on the 13th Amendment of the US Constitution as an example to extend the argument and highlight the need to test involuntary servitude in international human rights law through mechanisms offered in the international periodic review of member states. This could provide a robust approach to support and strengthen access to safe abortion services.
Fulltext Gender bias in clinical case reports: A cross-sectional study of the "big five" medical journals

Allotey P, Allotey-Reidpath C, Reidpath DD

PLoS One, 2017;12(5):e0177386.
PMID: 28493948 DOI: 10.1371/journal.pone.0177386

BACKGROUND: Gender bias in medical journals can affect the science and the benefit to patients. It has never been investigated in clinical case reports. The oversight is important because of the role clinical case reports play in hypothesis generation and medical education. We investigated contemporary gender bias in case reports for the highest ranked journals in general and internal medicine.
METHODS: PubMed case reports data from 2011 to 2016 were extracted for the Annals of Internal Medicine, British Medical Journal, the Journal of the American Medical Association, The Lancet, and New England Journal of Medicine. The gender of the patients were identified and a text analysis of the Medical Subject Headings conducted.
RESULTS: A total of 2,742 case reports were downloaded and 2,582 (95.6%) reports contributed to the final analysis. A pooled analysis showed a statistically significant gender bias against female case reports (0.45; 95%CI: 0.43-0.47). The Annals of Internal Medicine was the only journal with a point estimate (non significant) in the direction of a bias against male patients. The text analysis identified no substantive difference in the focus of the case reports and no obvious explanation for the bias.
CONCLUSION: Gender bias, previously identified in clinical research and in clinical authorship, extends into the patients presented in clinical case reports. Whether it is driven by authors or editors is not clear, but it likely contributes to and supports an overall male bias of clinical medicine.
Shisha (waterpipe) smoking initiation among youth in Malaysia and global perspective: a scoping review (2006-2015)

Singh SK, Enzhong L, Reidpath DD, Allotey P

Public Health, 2017 Mar;144:78-85.
PMID: 28274388 DOI: 10.1016/j.puhe.2016.11.022

OBJECTIVE: To explore the initiating factors of waterpipe tobacco smoking (WTS) among youth.

STUDY DESIGN: The analytic framework for this scoping review was performed using the methodology outlined by Arksey and O'Malley, which includes identification of the research question, study selection, charting the data, collating, summarizing and reporting the results that were primarily guided by the research question; 'what is known about the initiation of shisha smoking among youth?'

METHODS: Electronic databases such as Cochrane, MEDLINE and PsycINFO were used to search for relevant articles. Articles included were all in English and published within the year of 2006 to 2015. Inclusion criteria; i) age range of 10 to 29 years; ii) examined the reasons why youth started or tried WTS; iii) in full text. Therefore, 26 articles were included in this scoping review.

RESULTS: This review has identified and classified the initiating factors of WTS among youth in four subtopics: individual factors, interpersonal influences, cigarettes and alcohol use, and media influences. Individual factors and interpersonal influences played an important role in initiation factors of WTS among youth.

CONCLUSION: This study concludes that public health professionals within the Southeast Asia region need to promote innovative preventive measures through peer-to-peer led interventions that are also easily assessable on social media platforms. The public health messages need to address the misconceptions of risk associated to WTS use.
Chronic illness and sustainable careers: How individuals with multiple sclerosis negotiate work transitions in a middle-income country

Vijayasingham L, Jogulu U, Allotey P

Soc Sci Med, 2020 01;245:112699.
PMID: 31785425 DOI: 10.1016/j.socscimed.2019.112699

Reports of work change and transitions are common amongst individuals with chronic illnesses such as multiple sclerosis (MS). However, there is little research on the lived experience of these work transitions. The scarcity of this research is particularly evident within low-and-middle-income countries, where protection laws and resources such as anti-discrimination laws and reasonable work modifications may not exist or be well enforced. In this paper, we explore how and why individuals with MS seek and achieve work transitions in the structural context of Malaysia. We interviewed ten working individuals with MS (July-december 2015) using a joint hermeneutic phenomenology and constructivist grounded theory approach. Using a broad conceptual lens of 'sustainable careers', we examine their careers as a series of experiences, decisions, and events, paying attention to the influences of context, time, their personal levels of agency and sense of meaning. Participants described work transitions as early as within the first year of diagnosis, that were prompted by voluntary, involuntary and semi-voluntary reasons. Key aspects of the process of seeking new roles included an exploration of alternative roles and paths, and then acquiring, trialing/adapting and remaining engaged in their new roles. Participants identified the perception and experience of 'being unemployable', based on how their diagnosis and short-term symptoms were responded to by employers. Nevertheless, participants used various strategies and career resources to obtain and maintain meaningful work roles. However, success in obtaining or maintaining new roles were not equally achieved. This research draws attention to the cumulative economic disadvantage of a chronic illness diagnosis, even at milder and episodic stages. Furthermore, it reiterates the need for cohesive structural protection in low-and-middle-income countries to facilitate a more equal ability to remain economically resilient and capable of engaging in meaningful long-term careers when living with a chronic illness.
Doing gender better: can the UN step up?

Allotey P, Remme M, Lo S

Lancet, 2019 06 15;393(10189):2371-2373.
PMID: 31155269 DOI: 10.1016/S0140-6736(19)30988-2
Fulltext Pandemic response requires early and robust verification

Lehtimaki S, Allotey P, Schwalbe N

Lancet, 2021 Jul 10;398(10295):115.
PMID: 34181879 DOI: 10.1016/S0140-6736(21)01223-X
Fulltext Self care interventions to advance health and wellbeing: a conceptual framework to inform normative guidance

Narasimhan M, Allotey P, Hardon A

BMJ, 2019 Apr 01;365:l688.
PMID: 30936087 DOI: 10.1136/bmj.l688

Manjulaa Narasimhan and colleagues argue that there is a pressing need for a clearer conceptualisation of self care to support health policy
Fulltext Social sciences research in neglected tropical diseases 2: A bibliographic analysis

Reidpath DD, Allotey P, Pokhrel S

Health Res Policy Syst, 2011 Jan 06;9:1.
PMID: 21210997 DOI: 10.1186/1478-4505-9-1

BACKGROUND: There are strong arguments for social science and interdisciplinary research in the neglected tropical diseases. These diseases represent a rich and dynamic interplay between vector, host, and pathogen which occurs within social, physical and biological contexts. The overwhelming sense, however, is that neglected tropical diseases research is a biomedical endeavour largely excluding the social sciences. The purpose of this review is to provide a baseline for discussing the quantum and nature of the science that is being conducted, and the extent to which the social sciences are a part of that.
METHODS: A bibliographic analysis was conducted of neglected tropical diseases related research papers published over the past 10 years in biomedical and social sciences. The analysis had textual and bibliometric facets, and focussed on chikungunya, dengue, visceral leishmaniasis, and onchocerciasis.
RESULTS: There is substantial variation in the number of publications associated with each disease. The proportion of the research that is social science based appears remarkably consistent (<4%). A textual analysis, however, reveals a degree of misclassification by the abstracting service where a surprising proportion of the "social sciences" research was pure clinical research. Much of the social sciences research also tends to be "hand maiden" research focused on the implementation of biomedical solutions.
CONCLUSION: There is little evidence that scientists pay any attention to the complex social, cultural, biological, and environmental dynamic involved in human pathogenesis. There is little investigator driven social science and a poor presence of interdisciplinary science. The research needs more sophisticated funders and priority setters who are not beguiled by uncritical biomedical promises.
Fulltext Work Change in Multiple Sclerosis as Motivated by the Pursuit of Illness-Work-Life Balance: A Qualitative Study

Vijayasingham L, Jogulu U, Allotey P

Mult Scler Int, 2017;2017:8010912.
PMID: 29348937 DOI: 10.1155/2017/8010912

Individuals with multiple sclerosis have a tendency to make early decisions for work change, even in reversible, episodic, or mild disease stages. To better understand how a multiple sclerosis (MS) diagnosis influences perceptions of work and motivations for work changes, we conducted a hermeneutic phenomenology study to explore the work lives of ten individuals with MS in Malaysia. The interpretive analysis and cumulative narratives depict an overarching change in their concept of ideal work and life aspirations and how participants make preemptive work changes to manage illness-work-life futures in subjectively meaningful ways. Discussions on their integrated pursuit of finding dynamic and subjective illness-work-life balance include reconciling the problem of hard work and stress on disease activity and progress, making positive lifestyle changes as health management behaviour, and the motivational influence of their own life and family roles: the consideration of their spouses, parents, and children. At an action level, work change was seen as moral and necessary for the management of illness futures. Our findings contribute insights on how individual perceptions and holistic life management decisions contribute to on-going and disrupted work trajectories, which can inform practice and policy on early interventions to support continued employment.
Cultural imperatives and the ethics of verbal autopsies in rural Ghana

Aborigo RA, Allotey P, Tindana P, Azongo D, Debpuur C

Glob Health Action, 2013 Jan;6(1):18570.
PMID: 28140962 DOI: 10.3402/gha.v6i0.18570

Background Due to a paucity of statistics from vital registration systems in developing countries, the verbal autopsy (VA) approach has been used to obtain cause-specific mortality data by interviewing lay respondents on the signs and symptoms experienced by the deceased prior to death. In societies where the culture of mourning is adhered to, the use of VA could clash with traditional norms, thus warranting ethical consideration by researchers. Objective The study was designed to explore the ethics and cultural context of collecting VA information through a demographic and health surveillance system in the Kassena-Nankana District (KND) of Ghana. Study Design Data were collected through qualitative in-depth interviews (IDIs) with four field staff involved in the routine conduct of VAs, four physicians who code VAs, 20 selected respondents to the VA tool, and eight opinion leaders in the KND. The interviews were supplemented with observation by the researchers and with the field notes of field workers. Interviews were audio-recorded, and local language versions transcribed into English. Thematic analysis was performed using QSR NVivo 8 software. Results The data indicate that cultural sensitivities in VA procedures at both the individual and family levels need greater consideration not only for ethical reasons but also to ensure the quality of the data. Discussions of some deaths are culturally prohibited and therefore lead to refusal of interviews. Families were also concerned about the confidentiality of information because of the potential of blame for the death. VA teams do not necessarily engage in culturally appropriate bereavement practices such as the presentation of tokens. The desire by families for feedback on the cause of death, which is currently not provided by researchers, was frequently expressed. Finally, no standard exists on the culturally acceptable time interval between death and VA interviews. Conclusion Ethical issues need to be given greater consideration in the collection of cause of death data, and this can be achieved through the establishment of processes that allow active engagement with communities, authorities of civil registrations, and Institutional Review Boards to take greater account of local contexts.
Fulltext Community-based blood pressure measurement by non-health workers using electronic devices: a validation study

Reidpath DD, Ling ML, Yasin S, Rajagobal K, Allotey P

Glob Health Action, 2012;5:14876.
PMID: 22761601 DOI: 10.3402/gha.v5i0.14876

INTRODUCTION: Population monitoring and screening of blood pressure is an important part of any population health strategy. Qualified health workers are expensive and often unavailable for screening. Non-health workers with electronic blood pressure monitors are increasingly used in community-based research. This approach is unvalidated. In a poor, urban community we compared blood pressure measurements taken by non-health workers using electronic devices against qualified health workers using mercury sphygmomanometers.
METHOD: Fifty-six adult volunteers participated in the research. Data were collected by five qualified health workers, and six non-health workers. Participants were randomly allocated to have their blood pressure measured on four consecutive occasions by alternating a qualified health worker with a non-health worker. Descriptive statistics and graphs, and mixed effects linear models to account for the repeated measurement were used in the analysis.
RESULTS: Blood pressure readings by non-health workers were more reliable than those taken by qualified health workers. There was no significant difference between the readings taken by qualified health workers and those taken by non-health workers for systolic blood pressure. Non-health workers were, on average, 5-7 mmHg lower in their measures of blood pressure than the qualified health workers (95%HPD: -2.9 to -10.0) for diastolic blood pressure.
CONCLUSION: The results provide empirical evidence that supports the practice of non-health workers using electronic devices for BP measurement in community-based research and screening. Non-health workers recorded blood pressures that differed from qualified health workers by no more than 10 mmHg. The approach is promising, but more research is needed to establish the generalisability of the results.
KEYWORDS: Malaysia; blood pressure; community workers; hypertension; measurement; screening
Study site: urban, low-income community, of the Klang Valley near Kuala Lumpur, Malaysia
Device: Mercury sphygmomanometers (Spirit brand, model number CK-101C), electronic, automatic blood pressure monitors (Omron brand model HEM-7203)
15 years of APOC--a lifetime of public health evidence

Allotey P, Amazigo U, Adjei S, Seddoh A, Lusamba-Dikassa PS

Lancet, 2012 Oct 20;380(9851):1361-3.
PMID: 23084441 DOI: 10.1016/S0140-6736(12)60723-5
Fulltext The fallacy of the equity-efficiency trade off: rethinking the efficient health system

Reidpath DD, Olafsdottir AE, Pokhrel S, Allotey P

BMC Public Health, 2012;12 Suppl 1:S3.
PMID: 22992346 DOI: 10.1186/1471-2458-12-S1-S3

In the health systems literature one can see discussions about the trade off between the equity achievable by the system and its efficiency. Essentially it is argued that as greater health equity is achieved, so the level of efficiency will diminish. This argument is borrowed from economics literature on market efficiency. In the application of the economic argument to health, however, serious errors have been made, because it is quite reasonable to talk of both health equity being a desirable output of a health system, and the efficient production of that output. In this article we discuss notions of efficiency, and the equity-efficiency trade off, before considering the implications of this for health systems.
Fulltext Behaviour Change in Public Health: Evidence and Implications

Pokhrel S, Anokye NK, Reidpath DD, Allotey P

Biomed Res Int, 2015;2015:598672.
PMID: 26380284 DOI: 10.1155/2015/598672
Fulltext A latent trait approach to measuring HIV/AIDS related stigma in healthcare professionals: application of mokken scaling technique

Ahmadi K, Reidpath DD, Allotey P, Hassali MAA

BMC Med Educ, 2016 May 30;16:155.
PMID: 27240562 DOI: 10.1186/s12909-016-0676-3

BACKGROUND: The attitudes of healthcare professionals towards HIV positive patients and high risk groups are central to the quality of care and therefore to the management of HIV/AIDS related stigma in health settings. Extant HIV/AIDS stigma scales that measure stigmatising attitudes towards people living with HIV/AIDS have been developed using scaling techniques such as principal component analysis. This approach has resulted in instruments that are often long. Mokken scale analysis is a nonparametric hierarchical scaling technique that can be used to develop unidimensional cumulative scales. This technique is advantageous over the other approaches; as the scales are usually shorter, while retaining acceptable psychometric properties. Moreover, Mokken scales also make no distributional assumptions about the underlying data, other than that the data are capable of being ordered by item and by person. In this study we aimed at developing a precise and concise measure of HIV/AIDS related stigma among health care professionals, using Mokken scale analysis.
METHODS: We carried out a cross sectional survey of healthcare students at the Monash University campuses in Malaysia and Australia. The survey consisted of demographic questions and an initial item pool of twenty five potential questions for inclusion in an HIV stigma scale.
RESULTS: We analysed the data using the mokken package in the R statistical environment providing a 9-item scale with high reliability, validity and acceptable psychometric properties, measuring and ranking the HIV/AIDS related stigmatising attitudes.
CONCLUSION: Mokken scaling procedure not only produced a comprehensive hierarchical scale that could accurately order a person along HIV/AIDS stigmatising attitude, but also demonstrated a unidimensional and reliable measurement tool which could be used in future studies. The principal component analysis confirmed the accuracy of the Mokken scale analysis in correctly detecting the unidimensionality of this scale. We recommend future works to study the generalisability of this scale in a new population.
Fulltext The Lancet Commission on Gender and Global Health

Hawkes S, Allotey P, Elhadj AS, Clark J, Horton R

Lancet, 2020 08 22;396(10250):521-522.
PMID: 32763153 DOI: 10.1016/S0140-6736(20)31547-6
Fulltext Challenges for Diagnostic Clarity for Post-stroke Cognitive Impairment and Behavioural Issues in Middle-Income Countries: Case Studies From Malaysia

Yap KH, Warren N, Allotey P, Reidpath D

Front Neurol, 2021;12:628876.
PMID: 34149589 DOI: 10.3389/fneur.2021.628876

Following stroke, individuals require ongoing screening, diagnosis and monitoring for cognitive impairment. Services and policies around these vary widely between settings, and reports from many countries highlight persistent under-diagnosis of cognitive impairment in the months and years after stroke. Missed and delayed diagnosis of post-stroke cognitive impairment, including dementia, are important factors in shaping the experiences of people so affected and their family members, especially in low- and middle-income countries. Drawing upon ethnographic research conducted in Malaysia, this article draws upon three case studies to examine the continued health-seeking behaviour after the appearance of salient cognitive and behavioural symptoms that occurred after stroke. Findings highlight the challenges in getting formal diagnostic clarity for cognitive and behavioural symptoms in a rural setting within a middle-income country. No study participants sought help for memory or cognitive problems, partly due to limited lay awareness of cognitive impairment but more significantly due to health service factors. Despite their elevated risk for dementia, participants were not monitored for cognitive impairment during any follow-up care in various health facilities. Furthermore, caregivers' attempts to seek help when behavioural issues became untenable were met with multiple health system barriers. The journey was complicated by the meanings attached to the reactions towards cognitive symptoms at the community level. We suggest that strategies seek to increase the awareness of post-stroke cognitive and behavioural symptoms, and incorporate clear treatment pathways into the long-term care plans of community-dwelling stroke survivors.
Chronic disease profiles of subjective memory complaints: a latent class analysis of older people in a rural Malaysian community

Yap KH, Warren N, Allotey P, Reidpath DD

Aging Ment Health, 2020 05;24(5):709-716.
PMID: 30588848 DOI: 10.1080/13607863.2018.1550632

Background: Subjective memory complaints (SMC) are common in the elderly and have been suggested as the first subtle sign of decline which can predict dementia. Cognitive decline is thought to be related to inflammatory processes similarly found in other chronic diseases and conditions such as stroke, heart disease and arthritis. This study aimed to examine the association of SMC with chronic diseases and the profile of these health conditions reported by a group of older adults.Methods: Data from a cross-sectional survey conducted from August 2013 and March 2014 was drawn from 6179 individuals aged 56 years and above. Multivariable logistic regression analyses were used to examine SMC's relationship with individual chronic diseases (asthma, kidney disease, heart disease, stroke, arthritis, hypertension and diabetes) and multimorbidity. Latent class analysis (LCA) was used to identify the profile of health conditions. The effect of SMC was estimated in a multinomial logistic regression as part of the latent class model.Results: SMC was statistically significant in its association with asthma, stroke, heart disease, arthritis and multimorbidity in the fully controlled multivariable logistic regression models. Three health profiles were identified: low comorbidity (n = 4136, low rates in all health conditions), arthritis group (n = 860) and diabetes and hypertension group (n = 1183). SMC was associated with arthritis group (OR = 2.04, 95% CI = 1.51-2.75) and diabetes and hypertension group (OR = 1.22, 95% CI = 1.03-1.46).Conclusion: Adapting a combination of analytical approaches allows a better understanding in the assessment of SMC's relationship with chronic diseases and the patterns of distribution of these health conditions.
Understandings of stroke in rural Malaysia: ethnographic insights

Yap KH, Warren N, Allotey P, Reidpath DD

Disabil Rehabil, 2021 02;43(3):345-353.
PMID: 31169419 DOI: 10.1080/09638288.2019.1624841

BACKGROUND: Stroke is a public health concern in Malaysia but local beliefs and lay understandings of stroke have not been examined before. Explanatory models provide a way for people to make sense of their illness and influence health seeking behaviors, in a locally relevant way.
METHODS: Drawing on ethnographic research from rural Malaysia, this descriptive article explores ethnic Malaysian-Chinese stroke survivors' lay understandings of stroke. Eighteen community-dwelling stroke survivors aged 50-83 took part in the study.
RESULTS: Causation of stroke was derived from cultural, biomedical and social sources. Participants also drew simultaneously from both biomedical and traditional explanations of stroke to develop their own understanding of etiology. Similarities with biomedical causation and other studies from different cultures were found. Participants' typically focused on the more immediate effects of stroke and often do not attribute causation and association with their comorbid conditions which are also risk factors of stroke.
CONCLUSION: Lack of knowledge about stroke and its symptoms was evident in participants' account. Findings emphasize the importance of knowledge based health interventions, especially in health education strategies for stroke survivors to reduce delays to diagnosis and potentially improve health outcomes post-stroke. Implications for rehabilitation Stroke survivors often form explanatory models of stroke that draw from both biomedical and traditional explanations of stroke. Understanding how people derive lay understandings of stroke can contribute towards developing the goals and activities that facilitate recovery and rehabilitation in similar settings. Health practitioners in the community should strengthen communication regarding the identification, etiology and risk factors of stroke with stroke survivors and their carers to improve compliance to medication, exercise and diet for better recovery. Sustained health education which is culturally relevant is recommended. Communication should also include non-physical impact of stroke (such as cognitive deficits and emotional difficulties) as the stroke survivors were unlikely to relate such symptoms to stroke.

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