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Abstract Background Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. Methods A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. Results National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. Conclusions Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs.

In the United States (US), morbidity and mortality from pediatric asthma are increasing. We explored racial inequities using the Multiple Causes of Death Files of the US National Center for Health Statistics and the Wide-ranging Online Data for Epidemiologic Research (WONDER) for 1–14-year-olds from 1999 to 2018. We obtained mortality rates, Black:White mortality rate ratios (MRRs) and Annual Percent Change (APC). We tested for significance with 95% confidence intervals and joinpoint regression. Of 2,731 deaths from asthma, Blacks comprised 65.25% and 21.25% of the population. Black:White MRRs were 6.43 for 1–4, 7.54 for 5–9 and 6.88 for 10–14-year-olds of 6.88. The APC decline of −2.56 (p < 0.05) was significant among Whites but not Blacks. MRRs increased significantly from 4.23 in 2000 to16.57 in 2015 and declined to 6.69 in 2018. Among Black boys and girls, mortality rates were highest in Large Central Metropolitan areas. For Whites, rates were similar by urbanization in girls but were highest in Non-core, Non-metropolitan rural areas in boys. These descriptive data demonstrate statistically significant racial inequities in mortality from pediatric asthma in the US. They generate hypotheses, including, but not limited to, those related to under-resourced families and communities as well as economic and social marginalization. These and other plausible hypotheses require direct testing in analytic epidemiologic studies designed a priori to do so. In the meanwhile, efforts are necessary to strengthen community-driven initiatives and focus attention on inequitable systems, hierarchies, social structure and institutional practices. These include multifactorial interventions for individual, environmental and societal risk factors and educational efforts toward health-care providers and their patients about structural racism; these may combat, at least in part, vulnerabilities in US children and youth and improve racial inequities overall and from pediatric asthma. [ABSTRACT FROM AUTHOR]

Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60. In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit-risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis. ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials. Primary care providers should make individual decisions whether to prescribe ASA based on benefit-risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago. [ABSTRACT FROM AUTHOR]

In the treatment or secondary prevention of cardiovascular disease (CVD), there is general consensus that the absolute benefits of aspirin far outweigh the absolute risks. Despite evidence from randomized trials and their meta-analyses, older adults, defined as aged 65 years or older, are less likely to be prescribed aspirin than their middle-aged counterparts. In primary prevention, the optimal utilization of aspirin is widely debated. There is insufficient randomized evidence among apparently healthy participants at moderate to high risk of a first CVD event, so general guidelines seem premature. Among older adults, randomized data are even more sparse but trials are ongoing. Further, older adults commonly take multiple medications due to comorbidities, which may increase deleterious interactions and side effects. Older adults have higher risks of occlusive events as well as bleeding. All these considerations support the need for individual clinical judgments in prescribing aspirin in the context of therapeutic lifestyle changes and other adjunctive drug therapies. These include statins for lipids and usually multiple drugs to achieve control of high blood pressure. As regards aspirin, the clinician should weigh the absolute benefit on occlusion against the absolute risk of bleeding. These issues should be considered with each patient to facilitate an informed and person-centered individual clinical judgment. The use of aspirin in primary prevention is particularly attractive because the drug is generally over the counter and, for developing countries where CVD is becoming the leading cause of death, is extremely inexpensive. The more widespread use of aspirin in older adults with prior CVD will confer net benefits to risks and even larger net benefits to costs in the United States as well as other developed and developing countries. In primary prevention among older adults, individual clinical judgments should be made by the health-care professional and each of his or her patients. [ABSTRACT FROM AUTHOR]

Background: Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. Methods: A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. Results: National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. Conclusions: Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs. [ABSTRACT FROM AUTHOR]

Introduction: Longitudinal integrated clerkships (LICs) are an increasingly popular clerkship model that relies heavily on community-based preceptors. The availability of an engaged and prepared community-based faculty is crucial to the success of these programs. Teachers in these programs are often geographically separate from medical school campuses, are engaged in busy practices, and have limited time to devote to faculty development activities., Methods: We created a series of five brief faculty development podcasts directed towards community-based teachers in LICs from three US medical schools. Topics included encouraging continuity, bedside teaching, encouraging student ownership of patients, communicating and managing patient results between clinic days, and choosing the right patients for continuity. The podcasts were sent via a grouped text message just prior to preceptors' morning commute time. Pre- and postsurveys assessed the acceptability and effectiveness of the podcasts., Results: Among the 33 postintervention survey responders, 27 (81.8%) listened to at least three podcasts, 21 (63.6%) found them moderately or very helpful, 23 (69.7%) perceived that the podcasts altered their teaching style, 23 (69.7%) would likely or highly likely listen to further podcasts, and 18 (54.5%) would likely or highly likely recommend the podcasts to colleagues., Discussion: In a cohort of multispecialty faculty teaching in LICs, educational podcasts were well received and perceived by preceptors to impact their teaching style. Texting these podcasts to other community-based preceptors may offer an effective strategy for providing faculty development to busy clinicians., Competing Interests: None to report.