Mental Health in the Millennium Development Goals: Authors' Reply

Noncommunicable diseases and women's health Noncommunicable diseases (NCDs) --primarily cancer, cardiovascular disease, diabetes and chronic respiratory diseases--represent a major health, social, and economic burden that affects women globally, yet their impact on women in low- and middle-income countries (LMICs) has not been fully recognized. (1) NCDs cause premature death and disability among women of all socioeconomic strata worldwide. This burden is expected to increase substantially in the coming decades, especially in LMICs, because of a combination of factors, primarily the ageing of the population, improvements in maternal health in LMICs and a projected increase in smoking, obesity and other risk factors for NCDs among women. (2) Discussions surrounding the post-2015 development agenda provide an important and timely opportunity to realign policies and resources in trying to meet the complex and shifting health problems faced by women globally. The focus of the realignment should be on ensuring that health systems have the capacity to equitably provide health services to women throughout their lifecourse and on maximizing collective efforts to meet women's health needs in all settings, even the poorest. Achieving this will require strengthening the control of NCDs and integrating it into women's health frameworks and platforms, allocating resources optimally and promoting the development of health systems that serve the needs of women throughout all stages of life. (3) NCDs, communicable diseases and maternal conditions are interrelated in complex ways. One can lead to the other. For example, hormonal changes during pregnancy can induce the appearance of diabetes and hypertension. A pregnant woman who has diabetes, hypertension or infection with the human immunodeficiency virus (HIV) as an underlying condition is at greater risk of suffering complications during pregnancy and delivery than a woman who has none of these conditions. (4) Because of these interrelations, the limited availability and accessibility of NCD prevention and control services makes it even harder to make headway in addressing established global health priorities. Opportunities to prevent and treat NCDs and reduce their financial and social burden on women abound, but most of the time they are missed. NCDs develop over years; it takes frequent contact with the health system to detect them at an early stage. In many settings, maternal and reproductive health services are the only potential points of contact for the secondary prevention of NCDs. Health systems are ill-equipped to keep pace with changing patterns of disease and the need for an expanded range of health services for women of all ages. Many women who have some type of NCD also have HIV infection or a pregnancy-related health problem. Integration of NCD prevention and control efforts within existing health services is becoming increasingly necessary to bolster future progress in women's health and socioeconomic well-being and to safeguard the progress made so far in attaining the goals and targets set in the area of women's health and development. As a post-2015 framework that will sustain such progress develops, we must work towards capturing international attention and mobilizing resources to address current disease trends and the wide-ranging health needs of women in LMICs. These efforts should build upon existing health platforms and expand services to meet the health needs of women of all ages (e.g. human papillomavirus (HPV) vaccine programmes for adolescents and NCD screening for women of post-childbearing age). The poverty and gender divide Many of the women being targeted for interventions in the areas of sexual and reproductive health, maternal health and HIV-related problems are the ones who are affected by health inequities that increase their risk of getting and dying from NCDs. Women in all settings, regardless of resources, get NCDs; however, poor women, especially those who live in LMICs, are the least likely to have access to affordable diagnosis, management and treatment services. …

HIV infection, a communicable disease, and noncommunicable diseases (NCDs) are among the major health concerns worldwide. An estimated 33 million people live with HIV, two-thirds of them in sub-Saharan Africa, where three-fourths of all AIDS-related deaths occur.

Noncommunicable diseases (NCDs) cause more than half of all deaths in low- and middle-income countries, claiming an estimated 29 million lives each year (of 36 million NCD deaths worldwide).1 About 30% of these deaths occur before the age of 60. Death and disability due to NCDs are rising in all regions of the world but most rapidly in sub-Saharan Africa, where the projected increases in NCDs will outpace reductions in infectious diseases (contributing to a rising “double-burden” of disease).2 In sub-Saharan Africa, women aged 15–49 are already dying from NCDs at a rate four times higher than women living in high-income countries.1 This burden of premature mortality and disability poses a threat to human, social and economic development. More than half of all tuberculosis deaths in India are attributed to tobacco, and over a quarter of new tuberculosis cases in countries with the highest burden are attributed to tobacco use and diabetes.3 Where public health systems are weak, payment for care can trap poor households in cycles of debt and illness. In India, for example, treatment for diabetes costs an affected person on average 15–25% of household earnings.4 A World Bank study showed that cardiovascular disease leads to catastrophic expenditure for 25% of Indian families and drives 10% of families into poverty.5 People with NCDs are also more likely to miss work, become unemployed or retire early.6 In view of such evidence, the World Economic Forum has ranked NCDs as among the top global threats to economic development.7 Scientists agree that a comprehensive package of primary prevention, health-care interventions and improved surveillance can substantially reduce the burden of NCDs.8,9 Building on this evidence, the 193 WHO Member States adopted a global strategy for the prevention and control of NCDs at the World Health Assembly in 2000. Subsequently, WHO has adopted the Framework Convention on Tobacco Control, the Global Strategy on Diet, Physical Activity and Health, and the Global Strategy to Reduce the Harmful Use of Alcohol. Tools are thus in place to reduce the burden of NCDs, enshrined in WHO’s 2008–2013 Action Plan for the implementation of the global strategy.10 Reducing the burden of NCDs is no longer just a technical issue, but a political problem.11 Health ministers and policy-makers in developing countries are aware of the burden and the existence of cost-effective interventions. Yet, thus far, donors and the international development community have been slow to respond, in part because NCDs are not among the Millennium Development Goals. Despite repeated donor commitments such as the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action, NCDs receive less than 3% of development assistance for health even though they cause more than one-third of all premature deaths.12 WHO’s Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases provides the roadmap for change.13 Since its adoption in 2008, a global movement has begun to emerge around its shared goals, led by leaders from developing countries. For example, the Doha Declaration on Noncommunicable Diseases and Injuries called for the integration of NCD prevention and control into the global development agenda. Discussions during the United Nations Economic and Social Council meeting in July 2009 led to a United Nations General Assembly Resolution in May 2010, requesting the United Nations convene a high-level meeting in September 2011 with the participation of heads of state and government.14 Just as the HIV/AIDS high-level meeting in 2001 marked a turning point in the HIV epidemic,15 this meeting provides an opportunity to raise the priority given to NCDs within the global development agenda. Preparations for the high-level meeting have already begun through regional consultations in all six WHO regions. These consultations have resulted in declarations or outcome documents that identify priorities for action against NCDs and outline the expectations of Member States. Based on the regional consultations, some of these expectations include: a greater commitment from policy-makers to NCD prevention; more effective mechanisms and monitoring of intersectoral action; greater accountability of non-health sectors; and scaling-up of WHO’s Action Plan. Ultimately the outcomes of the high-level meeting will depend on the expressed priorities of Member States. At the very least, the meeting should increase awareness of NCDs among policy-makers and achieve higher levels of political commitment. The involvement of the health profession is crucial to ensure that countries prepare well for the high-level meeting and focus their discussions on intensifying preventive action against NCDs and strengthening health-care interventions. If the health profession provides leadership and support to global and national initiatives to address NCDs, their active involvement will play a pivotal role in altering the course of the epidemic and averting millions of premature deaths.

Improving responsiveness of health systems to non-communicable diseases

The age at which children enter school represents a transitional period between early childhood and adolescence that involves increasing autonomy, interaction with peers, and exposure to environments outside the home. Although mortality is generally much lower in the 5 to 9 age group compared with infancy and early childhood, there are many preventable causes of mortality, morbidity, and disability that emerge in this age group, including injuries, noncommunicable diseases, and vaccine-preventable and highly treatable infections.1 Partly because of relatively low mortality rates and less frequent contacts with the health system, school-age children and younger adolescents ages 5 to 14 have been referred to as the “missing middle,” in that there is a dearth of robust data on key health indicators, morbidity burden, and cause-specific mortality in this group.2 Many health issues that have a high burden in early childhood can persist in older children, especially in low- and middle-income countries (LMIC), resource-constrained settings, and marginalized communities worldwide. Undernutrition and infections occurring in the context of poverty remain leading causes of morbidity and mortality in school-age children living in LMIC,3 whereas those children in higher-income settings are more likely to die due to injuries or noncommunicable disease (NCD). In addition, the prevalence of overweight and obesity in children and adolescents has increased steadily over the last few decades,4 though the rate of these increases varies widely among countries.5New risk factors relating to diet, lifestyle, mental health, injuries, and NCDs also become more prominent as children approach and enter adolescence, many of which can contribute to the development of chronic NCDs over the life course. Within this period, school-age children begin to establish healthy lifestyle habits (eg, diet, physical activity, avoidance of substance use), and are learning about sexual and reproductive health and rights, as well as the measures they can take to protect themselves and others. This represents a window of opportunity for educational interventions to support good health, optimal development, and well-being. A growing body of evidence suggests that school-based and digital platforms and delivery strategies are promising tools that aid in the delivery of health interventions to older children.The methodology and reviews described herein contributed to the portion of the upcoming 2022 Lancet Optimizing Child and Adolescent Health and Development Series6 related to school-age child and adolescent health interventions. This Lancet Series is the product of an ongoing academic collaboration involving global child health researchers worldwide, including many who are authors on articles within this supplement. The aim of the specific Lancet Series article citing this supplement is to provide a comprehensive overview of systematic reviews describing the most recent evidence for effective interventions to support maternal, newborn, child, and adolescent health and development from preconception through to 20 years of age.Figure 1 provides an overview of the key child health domains, and a breakdown of the intervention review topics addressing key risk factors covered by the articles included in this journal supplement. On the basis of work done in previous comprehensive overviews of interventions for child and adolescent health (eg, Disease Control Priorities, 3rd edition7; Lancet Adolescent Health Commission8), we identified a comprehensive set of key child health domains that represented priority areas for interventions to address modifiable risks for the major causes of child mortality and morbidity. The factors that informed which domains were covered in this supplement included: conditions with a high global burden of disease, conditions with disproportionate impacts on vulnerable and marginalized populations, potential to support improved human capital development across the life course, and pragmatic considerations including whether the topic had recently been covered elsewhere. In cases where the child health domain was deemed too broad in scope for a single review (eg, infectious diseases), the subtopics for individual reviews were also chosen on the basis of these factors. The age group of specific interest for these reviews was older school-age children (ages 5–9.9), though the period of early adolescence (ages 10–14.9) was also recognized as an important area of overlap and transition. The general outcomes of interest aligned with those chosen through consensus by the Lancet Series working group. These included, but were not limited to, mortality, severe morbidity, disability, growth and development, knowledge and behavior, and indicators of improved human capital development such as academic achievement.The methodological approaches taken, and child health domains covered in this supplement of reviews, was informed by a broad initial literature-scoping and evidence-mapping process to identify key health interventions and associated evidence for their effectiveness in the form of systematic reviews. This was done across all domains, from preconception and pregnancy to ages 0 to 20 to inform the 2022 Lancet Optimizing Child and Adolescent Health and Development Series.6 This involved leveraging existing large-scale intervention overviews (eg, Disease Control Priorities 3rd edition, Lancet Series) that had already highlighted existing effective interventions and the most recent systematic reviews detailing the evidence for their effectiveness. Additional targeted searches for newer interventions and systematic reviews in each domain were also conducted. Through this evidence-mapping process, we explored coverage and extent of LMIC-specific evidence across all child health domains to identify areas where school-age evidence was lacking and determined that there were significant gaps in existing evidence for intervention effectiveness in school-age children.We funneled the reviews identified during this initial scoping process that contained studies covering school-age children and adolescents into the individual reviews for each domain of child health covered in this supplement. We elected to conduct targeted overviews of systematic reviews if there was deemed to be a large body of existing evidence syntheses. In cases where there was a lack of evidence syntheses of intervention effectiveness for a given domain of school-age child health, conventional systematic reviews of primary literature (ie, experimental studies) were conducted. The general methodology for these 2 approaches are described below. See Table 1 and Fig 1 for a summary of the review methods used for each child health domain, and Fig 2 for a breakdown of the main methodology followed in each type of review.For those child health domains that encompassed a variety of intervention types addressing a wide range of risk factors and health conditions, and for which the initial scoping process identified a variety of existing systematic reviews of intervention effectiveness, an overview of systematic reviews was undertaken. This approach was taken to ensure comprehensiveness, reduce duplication of review efforts, and make the review process feasible.In addition to incorporating those relevant reviews previously identified in the initial literature-scoping and evidence-mapping exercise, tailored searches were executed in several databases (eg, Medline, Cochrane Database of Systematic Reviews, Campbell Library) to identify literature published up until the end of 2020. Evidence derived from Cochrane reviews and other high-quality systematic reviews that synthesized evidence from randomized controlled trials and quasi-experimental studies examining the effectiveness of interventions was prioritized for inclusion. A first pass of title and abstract screening for relevance was conducted, followed by a full text screening that was done by at least 2 reviewers against inclusion criteria. Two reviewers independently filled a standardized data abstraction form to capture review characteristics, the characteristics of included studies and interventions (eg, age coverage, country representation, delivery platform), and pooled-effect estimates (eg, risk ratios, odds ratios, mean differences, 95% confidence intervals) derived from meta-analyses where they were reported. The main outcomes of interest across the reviews included measures of child morbidity, mortality, development, academic achievement, and mental and physical well-being. The extracted data were then matched among reviewers to check for errors and ensure consistency, and then consolidated into a single table for inclusion in the article. The AMSTAR 2 tool12 was used for review quality assessment, and was also conducted in duplicate, with any disagreements in ratings resolved by consensus or the involvement of a third reviewer.If for a given domain the initial evidence-mapping exercise revealed that the existing evidence-synthesis literature was lacking for the school-age group, we proceeded with a conventional systematic review of primary literature. All systematic reviews were reported in accordance with the reporting guidance provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.13Search strategies were developed using the population, intervention, control, and outcomes methodology, relevant medical subject headings terms, and keywords derived from the scoping search. The search terms were adapted for use in other bibliographic databases in combination with database-specific filters for controlled trials, where these were available. Searches for the individual, domain-specific reviews were conducted in a variety of databases, including but not limited to: PubMed, Embase, Medline, PsycINFO, Ovid SP, The Cochrane Library, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, and the World Health Organization regional databases. Evidence derived from LMIC was prioritized for synthesis, though evidence from high-income countries (HIC) settings was leveraged to highlight whether effective interventions exist in cases where LMIC evidence was sparse. Gray literature searches and additional hand searching were conducted in Google Scholar and reference lists of relevant articles, book chapters, and reviews.After removal of duplicate studies, a multistage screening process was performed to select studies that met the eligibility criteria. Each title and abstract was assessed by at least 1 reviewer, who excluded those that were deemed irrelevant. At the full-text review stage, at least 2 reviewers assessed all full texts. Any disagreements in inclusion decisions were resolved by discussion and, where necessary, by consulting a third reviewer. At this stage, reasons for exclusion were documented. The methods section of each individual review in this supplement describes their selection and eligibility criteria, which differed depending on the child health domain being assessed. Data from included studies were independently extracted and coded by 2 review authors using standardized, previously piloted data extraction forms, which sought general study characteristics, details of the population, intervention, comparison groups, and quantitative outcome data. Data extraction forms were matched and checked, and if necessary, a third review author was consulted in the event of any disagreements to establish consensus.Assessment of risk of bias for included studies was conducted according to criteria and tools outlined in the Cochrane Effective Practice and Organization of Care guidelines14 for randomized trials, nonrandomized trials, controlled before–after, interrupted time series, and the Cochrane Handbook for Systematic Reviews of Interventions.15 Assessments were conducted independently by 2 review authors; scores were compared, and a final risk of bias judgement was reported for the included studies of each systematic review. Randomized trials were assessed using the Cochrane Risk of Bias tool15 across the following domains: randomization process, deviations from the intended interventions (blinding of personnel, participants, and outcome assessment), missing outcome data, outcome measurement, the selection of the reported result, disclosure of funding, and conflicts of interest. Studies were assigned an overall risk of bias judgement accordingly (low risk, high risk, or some concerns/medium risk). Quasi-experimental study designs were assessed using the Risk of Bias Tool for Nonrandomized Studies of Interventions (ROBINS-I) tool.15,16 Studies were assessed according to the following domains: bias because of confounding, bias in selection of study participants, bias in classification of interventions, bias because of deviations from intended interventions, bias because of missing data, bias in measurement of outcomes, and bias in selection of the reported result. Each study was assigned an overall risk of bias judgement (low, moderate, serious, and critical risk).Meta-analyses were conducted where possible using Review Manager 5.4 software.17 Randomized controlled trials and cluster-randomized controlled trials were analyzed separately from quasi-experimental study designs. To mitigate heterogeneity within included studies, a random-effects meta-analysis was used for pooled outcomes. For those situations where meta-analysis was not possible, data on the effect of interventions from individual studies was tabulated and reported, and a narrative synthesis was conducted for each key intervention domain.Where there were a sufficient quantity of comparable studies (in both interventions and outcome), a summary of the intervention effect and a measure of quality for key outcomes were produced using the Grading of Recommendations Assessment, Development and Evaluation approach.18 The Grading of Recommendations Assessment, Development and Evaluation approach considers 5 domains (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of the body of evidence for each outcome. The evidence was downgraded from “high quality” by 1 level for serious (or by 2 levels for very serious) limitations, depending on assessments for risk of bias, indirectness of evidence, serious inconsistency, imprecision of effect estimates, or potential publication bias.The aim of the authors of this supplement of reviews is to comprehensively assess the available evidence for the effectiveness of interventions to improve health and well-being in school-age children and adolescents. The initial literature-scoping and evidence-mapping process, followed by the different review approaches taken, has helped to maximize the scope covered across this set of reviews, and has allowed us to provide the most comprehensive assessment of the state of the published literature covering interventions for school-age children and adolescents. The individual reviews in this supplement have also highlighted child health domain-specific gaps in the evidence for both primary literature in the school-age group, and gaps in existing evidence syntheses.It is important to note that, for the reviews within this supplement, the descriptions of intervention effects are meant to provide an overview of what is currently known in terms of evidence for effectiveness, and do not imply that other interventions were ineffective simply because there was an evidence gap. Given the limited space and large scope, it was only possible to provide the highlights of specific comparisons and outcomes in each of the results sections. Comprehensive tables of study characteristics, outcomes, and effect estimates are provided in both the main articles and appendices.Although we were specifically interested in focusing on LMIC research, this was only feasible for a few review topics (eg, sexual and reproductive health and rights, neglected tropical diseases) because of a dearth of literature. Instead of being used to attempt to generalize their effectiveness to LMIC settings, evidence from intervention effectiveness in HIC settings are included and described to establish that effective interventions do indeed exist and may differ in their impact between settings. This approach has previously been used in the context of adolescent health interventions.19 This evidence from HIC could act as a starting point for future research and implementation in various LMIC settings, with program components tailored to local contexts.In the case of those reviews taking the overview of systematic reviews approach, we were limited to including only those primary studies already included in systematic reviews and could not cover each subdomain in depth. Thus, we were unable to identify and include those primary studies that may not have been included in systematic reviews because of studies not being identified in review authors’ database searches, not meeting their inclusion criteria, or falling out of the time frame of the review. Furthermore, some systematic reviews of primary literature were unable to perform meta-analyses because of high heterogeneity or a lack of high-quality evidence from randomized trials, which makes synthesizing the existing evidence more difficult.

Reproductive health needs to be front and centre in development

Information about mental health systems is essential for mental health planning to reduce the burden of neuropsychiatric disorders. Unfortunately, many low- and middle-income countries lack systematic information on their mental health systems. The objectives, scope, structure, and contents of mental health assessment and monitoring instruments commonly used in high-income countries may not be appropriate for use in middle- and low-income countries. The World Health Organization (WHO) has recently developed the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), a comprehensive assessment tool for mental health systems designed for middle- and low-income countries. WHO-AIMS was developed through an iterative process that included input from in-country and international experts on the clarity, content, validity, and feasibility of the instrument, as well as a pilot trial. The resulting instrument, WHO-AIMS 2.2, consists of six domains: policy and legislative framework, mental health services, mental health in primary care, human resources, public information and links with other sectors, and monitoring and research. These domains address the ten recommendations of the World Health Report 2001 through 28 facets and 155 items. All six domains need to be assessed to form a basic, yet broad, picture of a mental health system, with a focus on health sector activities. WHO-AIMS provides essential information for mental health policy and service delivery. Countries will be able to develop information-based mental health policy and plans with clear baseline information and targets. Moreover, they will be able to monitor progress in implementing reform policies, providing community services, and involving consumers, families, and other stakeholders in mental health promotion, prevention, care and rehabilitation. This article provides an overview of the rationale, development process, and potential uses and benefits of WHO-AIMS.

Depression and anxiety are among the most common mental health conditions globally that impact the lifestyle of affected individuals. Mental conditions and chronic diseases are linked to each other bidirectionally. Depression and anxiety with comorbid chronic conditions are often neglected or under-screened and possess challenges in treatment. This study aimed to know the frequency and determinants of depression and anxiety along with the severity level among common chronic communicable and non-communicable diseases. We enrolled 200 healthy controls and 800 cases with equal number (n = 400) of patients with communicable and non-communicable diseases. Depression and anxiety were screened through Hamilton's rating scale for depression and anxiety separately. We also measured the determinants of severe depression among patients with chronic diseases. Data was analyzed through SPSS version 23. We found higher frequency of depression (31% vs 11%; p=<0.001) and anxiety (13.25% vs 6%; p = 0.021) among cases as compared to healthy controls respectively. We found higher levels of depression among participants with non-communicable diseases as compared to communicable diseases (37.25% vs 24.75%; p < 0.05) respectively. Moreover, there was a higher frequency of anxiety in participants with communicable diseases as compared to those with non-communicable diseases, but the difference was non-significant (14% vs 12.5% p = 0.081). Among non-communicable diseases the highest percentage was found among individuals with cancer (67%), followed by diabetes (38%), cardiovascular diseases (33%) and respiratory disorders (11%). Among participants with communicable diseases, the highest percentage of depression was found in patients with Tuberculosis (29%) followed by HIV/AIDS (28%), Long COVID-19 (25%) and Hepatitis B/C (17%). There is a significantly higher percentage of depression and anxiety among participants with chronic diseases. It calls for a comprehensive approach to patient care that incorporates mental health as a fundamental aspect of the treatment and management of chronic diseases. Understanding the predictors of severe depression across different chronic conditions helps in stratifying patients who may benefit most from integrated psychiatric and psychological interventions.

Mental health problem is one of the growing major public health issues in the Asia Pacific region. It contributes to the high number of Disability Adjusted Life Years (DALYs), morbidity and mortality in the region. It is expected that leading mental health problems will occur in the low-and middle-income countries (LMICs) and majority of the countries which comes under this category are in the Asia Pacific region. In addition, mental health problem hamper the achievement of Millennium Development Goals (MDGs), particularly MDG 1, MDG 4 and MDG 5. The most common mental health problems in the region are depression, anxiety, posttraumatic stress disorder, suicidal behaviour and substance abuse disorder. Several modifiable and non-modifiable risk factors were identified for the cause of these major mental health issues. Interventions, programmes and policies need to be designed in order to curb mental health problems at all levels.

Good physical and mental health, achievements in school and work, and the ability to empathize with and help other people have their roots in early childhood. Experiences in the first years of life shape what we become—physically, emotionally, and socially. Evidence-based strategies to promote children's development are available and can be feasibly integrated into health, nutrition, education, social, and child protection programs. Three areas are critical foundations for healthy child development: stable, responsive, and nurturing caregiving with opportunities to learn; safe, supportive physical environments; and appropriate nutrition. A stable and engaged family environment in which parents show interest and encourage their child's development and learning is the most important of the foundations. Such supportive human relationships promote and protect a child's physical and mental health, behavior, and learning across his or her lifetime.1 Today, the global community is charting the agenda for sustainable development beyond 2015. It is facing the challenge of responding to a rapidly changing environment in which the proportion of young people making up the world's population is growing quickly, in particular in Africa, Asia, and the Middle East, in which basic literacy and numeracy skills are no longer sufficient to compete in an ever faster evolving workplace, and in which a good education is paramount for self-realization and life satisfaction.2 It is against this background that, now more than ever, every individual should have the right to attain their full development potential. Good health and education are critical ingredients for individuals to progress and for societies to reduce inequities. In this regard, the WHO Commission on Social Determinants of Health singled out investment in early child development as a powerful equalizer.3 In the past decades, considerable progress has been made toward Millennium Development Goal 4 on reducing child mortality. The number of deaths among children younger than 5 years has declined from 12 million in 1990 to 6.6 million in 2012, a reduction of almost 50%. Nevertheless, about a quarter of all children under five, or 162 million children, are stunted, 56% of them living in Asia and 36% in Africa.4 Depression, anxiety, psychological distress, sexual violence, domestic violence, and escalating rates of substance use are a reality for too many families. Evidence suggests that close to a third of all children under five, or 200 million children, do not attain their full development capacity. The health sector has a unique responsibility, because it has the greatest reach to children and their families during critical time periods that affect child development. The first window of opportunity is during pregnancy, birth, and in early childhood, the first 1000 days, when essential interventions for health, nutrition, and psychosocial development have a great impact. The second window of opportunity is during adolescence, an ideal time to help young people prepare for future parenthood and facilitate their access to effective preconception care. WHO is committed to early child development through an approach that binds together many areas of the organization: reproductive, maternal, newborn, child, and adolescent health; nutrition; mental health and substance abuse management; violence and injury prevention; environmental health; and social determinants of health. The intervention that weaves as a red thread through all these initiatives is Care for Development.5 Care for Development strengthens caregiver–child interactions and helps families be sensitive to children's needs and respond appropriately. Through simple activities, such as play and communication, it promotes children's growth and development and helps reduce mental stress and illness, particularly in women. As messages and counseling activities are fully aligned to those for infant and young child feeding, the Care for Development intervention can be fully integrated in nutrition and health interventions, making the critical link for healthy growth and development. While we have the means to make a difference, this volume of Annals of the New York Academy of Sciences clearly illustrates that much more has to be learned about effective implementation models, their cost and impact. The multisectoral factors that influence child development need to be better addressed and documented through synergy of programs and policies. The foundations for early child development that can be built through the health sector need to be sustained in preschool and primary education, and complemented with additional measures, such as cash transfers and social protection safety nets, in particular for those who are most deprived. More is needed to stimulate multisectoral partnerships and investment in large-scale, national programs that integrate critical elements for early child development, in particular in low-income and middle-income countries. The time is right for action. Global leaders are committing to the goals of A Promise Renewed, with the aim to end preventable neonatal and child deaths by 2035.6 Global action plans have been developed for reaching every mother, every newborn,7 and every child8 with essential interventions and quality health care. These provide a revitalized and strong programmatic foundation for integrated health, nutrition, and development interventions. As WHO, we intend to fully capitalize on these opportunities and work with member states and partners to ensure that every child has the best possible opportunity to realize its full development potential.

Objective-Persons with severe mental illness have higher rates of chronic general medical illness compared with the general population.Similarly, compared with the general population, incarcerated persons have higher rates of chronic medical illness; however, there is little information about the synergy between severe mental illness and incarceration and the general medical problems of consumers.To address this gap in the literature this study addresses the following question: are consumers with a history of incarceration at greater risk of general medical problems compared with consumers without such a history?Methods-Administrative data were used to compare the medical problems of 3,690 persons with severe mental illness with a history of incarceration and 2,042 persons with severe mental illness with no such history.Results-Consumers with a history of incarceration were more likely than those with no such history to have infectious, blood, and skin diseases and a history of injury.Furthermore, when analyses controlled for gender, race, age, and substance use disorders, consumers with an incarceration history were 40% more likely to have any general medical problem and 30% more likely to have multiple medical problems.Conclusions-The findings presented here call for better communication among local public health and mental health providers and jails and better integration of primary care and behavioral health care among community mental health providers.Also, research on evidence-based interventions designed to divert persons with severe mental illness from the criminal justice system and facilitate community reentry for persons with severe mental illness who are released from jails and prisons should be accelerated.

Global Health

BackgroundThere is a significant treatment gap in provision of effective treatment for people with mental disorders globally. In some Low and Middle Income Countries (LMICs) this gap is 90% or more in terms of untreated cases. Clinical practice guidelines (CPGs) are one tool to improve health care provision. The aim of this review is to examine studies of the effectiveness of evidence-based CPG implementation across physical and mental health care, to inform mental healthcare provision in low and middle income countries (LMICs), and to identify transferable lessons from other non-communicable diseases to mental health.MethodsA systematic literature review employing narrative synthesis and utilising the tools developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group was conducted. Experimental studies of CPG implementation relating to non-communicable diseases, including mental disorders, in LMICs were retrieved and synthesised.ResultsFew (six) studies were identified. Four cluster randomised controlled trials (RCTs) related to the introduction of CPGs for non-communicable diseases in physical health; one cluster-RCT included CPGs for both a non-communicable disease in physical health and mental health, and one uncontrolled before and after study described the introduction of a CPG for mental health. All of the included studies adopted multi-faceted CPG implementation strategies and used education as part of this strategy. Components of the multi-faceted strategies were sometimes poorly described. Results of the studies included generally show statistically significant improvement on some, but not all, outcomes.ConclusionEvidence for the effectiveness of interventions to improve uptake of, and compliance with, evidence-based CPGs in LMICs for mental disorders and for other non-communicable diseases is at present limited. The sparse literature does, however, suggest that multifaceted CPG implementation strategies that involve an educational component may be an effective way of improving guideline adherence and therefore of improving clinical outcomes. Further work is needed to examine cost-effectiveness of CPG implementation strategies in LMICs and to draw conclusions on the transferability of implementation experience in physical health care to mental health practice settings. Strategies to ensure that CPGs are developed with clear guidance for implementation, and with explicit, methods to evaluate them should be a priority for mental health researchers and for international agencies.

Because of the urbanization, demographic transition and influence of globalization, the lifestyle of people in many of the low and middle income countries (LMIC) is changing; heading to unhealthy dietary habit, physical inactivity and use of cigarette and alcohol.The lifestyle changes on the background of earlier malnutrition, inevitably leads to central obesity.This with the stressful situation caused by the competitive environment catalyzes the surge of Non Communicable Diseases (NCDs).Reports showed that the burden of NCDs in LMICs is on the rise.As a result, NCDs are responsible for two-thirds of the world's deaths-80% in low-and middle-income countries.In sub-Saharan Africa, NCDs contribute a third of the disability-adjusted life year burden.However, resources allocated to prevent and treat NCDs in LMICs are none or little (1).Until recently, communicable diseases remained the sole priority for health policy though they do not constitute the major contributor to the burden of disease in terms of disability-adjusted life years or mortality in any region of the world apart from sub-Saharan Africa (2, 3).Though essential to reduce the future disease burden, prevention interventions will do little for those people who have already developed NCDs, and who are essentially being used to validate investments that will come too late to help them.While working on limiting the number of future NCD patients, an important duty is to ensure that people with NCDs receive quality care today.Investing to improve primary care to shoulder NCD services-the main entry point to health services for most people in resource-limited settingshas the potential to overcome some of these problems (4).From the successful experience gained in delivering interventions for communicable diseases such as HIV, tuberculosis

Human Immunodeficiency Virus (HIV) and Non Communicable Diseases (NCD) are now the major chronic diseases of public health concern, especially in low- and middle-income countries. This joint burden has major adverse effects on the quality of life of an affected individual; causes premature death; creates adverse economic effects on families in general. The purpose of this paper is to highlight extent of the problem and various approaches that can address the threat posed by NCD among people living with HIV based on evidence and best practices in health interventions. The paper is based on the non-systematic review of policies, programs, health interventions and published research articles. In addition, recommendations of expert consultations and workshops organized in various countries were also reviewed. Review indicates that there are emerging developments to bridge the gap between the NCD and HIV, however, no focused strategy is available to address NCD in PLHIV. Some of the key suggested approaches are; build evidence for planning and management of NCD in PLHIV, increase allocation of financial resources for investigation and treatment of common NCDs in PLHIV, strengthening governance structure for improved efficiency and effectiveness of systems to address NCD in HIV and non-HIV services, reconfiguration of primary health care, routine screening of PLHIV for NCD and promoting healthy lifestyle to reduce PLHIV’s susceptibility to NCD, multi-/ inter-sectoral cooperation, public private partnership and community participation for sustained efforts. Although context-specific factors vary from place to place, the feasibility and cost-effectiveness of different approaches tackling NCD in PLHIV is needed.