The aim of universal health coverage (UHC) is to ensure that all individuals in a country have access to quality healthcare services and do not suffer financial hardship in using these services. However, progress toward attaining UHC has been slow, particularly in sub-Saharan Africa. The use of information and communication technologies for healthcare, known as eHealth, can facilitate access to quality healthcare at minimal cost. eHealth systems also provide the information needed to monitor progress toward UHC. However, in most countries, eHealth systems are sometimes non-functional and do not serve programmatic purposes. Therefore, it is crucial to implement strategies to strengthen eHealth systems to support UHC. This perspective piece proposes a conceptual framework for strengthening eHealth systems to attain UHC goals and to help guide UHC and eHealth strategy development.

As funding for malaria control increased considerably over the past 10 years resulting in the expanded coverage of malaria control interventions, so did the need to measure the impact of these investments on malaria morbidity and mortality. Members of the Roll Back Malaria (RBM) Partnership undertook impact evaluations of malaria control programs at a time when there was little guidance in terms of the process for conducting an impact evaluation of a national-level malaria control program. The President's Malaria Initiative (PMI), as a member of the RBM Partnership, has provided financial and technical support for impact evaluations in 13 countries to date. On the basis of these experiences, PMI and its partners have developed a streamlined process for conducting the evaluations with a set of lessons learned and recommendations. Chief among these are: to ensure country ownership and involvement in the evaluations; to engage stakeholders throughout the process; to coordinate evaluations among interested partners to avoid duplication of efforts; to tailor the evaluation to the particular country context; to develop a standard methodology for the evaluations and a streamlined process for completion within a reasonable time; and to develop tailored dissemination products on the evaluation for a broad range of stakeholders. These key lessons learned and resulting recommendations will guide future impact evaluations of malaria control programs and other health programs.

Additional targeted research and customized training programs could spearhead strategies for elimination of the disparities in prevalence and control of high BP between African Americans and the remainder of the US general population. | This report presents findings of an ad hoc working group assembled by the National Heart, Lung, and Blood Institute (NHLBI) to assess research needs to improve prevention, treatment and control of hypertension among African Americans. Non-Hispanic Blacks (African American and Black will be used for US and international studies, respectively) tend to have an earlier onset, higher prevalence, and disproportionately high risk of complications for hypertension compared to non-Hispanic Whites and Mexican Americans.1

INTRODUCTION: This study evaluated recent trends in the prevalence of coronary heart disease in the U.S. population aged ≥40 years. METHODS: A total of 21,472 adults aged ≥40 years from the 2001-2012 National Health and Nutrition Examination Survey were included in the analysis. The analysis was conducted in 2015. Coronary heart disease included myocardial infarction, angina, and any other type of coronary heart disease, which were defined as a history of medical diagnosis of these specific conditions. Angina was also defined as currently taking anti-angina medication or having Rose Angina Questionnaire responses that scored with a Grade ≥1. Trends from 2001 to 2012 were analyzed overall, within demographic subgroups, and by major coronary heart disease risk factors. RESULTS: Between 2001 and 2012, the overall prevalence of coronary heart disease significantly decreased from 10.3% to 8.0% (p-trend<0.05). The prevalence of angina significantly decreased from 7.8% to 5.5% and myocardial infarction prevalence decreased from 5.5% to 4.7% (p-trend <0.05 for both groups). Overall coronary heart disease prevalence significantly decreased among women, adults aged >60 years, non-Hispanic whites, non-Hispanic blacks, adults who did not complete high school, adults with more than a high school education, and adults who had health insurance (p-trend <0.05 for all groups). CONCLUSIONS: The overall prevalence of coronary heart disease including angina and myocardial infarction decreased significantly over the 12-year survey period. However, this reduction was seen mainly among persons without established coronary heart disease risk factors. There was no change in coronary heart disease prevalence among those with specific coronary heart disease risk factors.

OBJECTIVE: Universal coverage with insecticide-treated bed nets is a cornerstone of modern malaria control. Mozambique has developed a novel bed net allocation strategy, where the number of bed nets allocated per household is calculated on the basis of household composition and assumptions about who sleeps with whom. We set out to evaluate the performance of the novel allocation strategy. METHODS: 1,994 households were visited during household surveys following two universal coverage bed net distribution campaigns in Sofala and Nampula Provinces in 2010-2013. Each sleeping space was observed for the presence of a bed net, and the sleeping patterns for each household were recorded. The observed coverage and efficiency were compared to a simulated coverage and efficiency had conventional allocation strategies been used. A composite indicator, the product of coverage and efficiency, was calculated. Observed sleeping patterns were compared with the sleeping pattern assumptions. RESULTS: In households reached by the campaign, 93% (95% CI: 93-94%) of sleeping spaces in Sofala and 84% (82-86%) in Nampula were covered by campaign bed nets. The achieved efficiency was high, with 92% (91-93%) of distributed bed nets in Sofala and 93% (91-95%) in Nampula covering a sleeping space. Using the composite indicator, the novel allocation strategy outperformed all conventional strategies in Sofala and was tied for best in Nampula. The sleeping pattern assumptions were completely satisfied in 66% of households in Sofala and 56% of households in Nampula. The most common violation of the sleeping pattern assumptions was that male children 3-10 years of age tended not to share sleeping spaces with female children 3-10 or 10-16 years of age. CONCLUSIONS: The sleeping pattern assumptions underlying the novel bed net allocation strategy are generally valid, and net allocation using these assumptions can achieve high coverage and compare favorably with conventional allocation strategies.

BACKGROUND: In 2011, Uganda's Ministry of Health switched policy from presumptive treatment of malaria to recommending parasitological diagnosis prior to treatment, resulting in an expansion of diagnostic services at all levels of public health facilities including hospitals. Despite this change, anti-malarial drugs are often prescribed even when test results are negative. Presented is data on anti-malarial prescription practices among hospitalized children who underwent diagnostic testing after adoption of new treatment guidelines. METHODS: Anti-malarial prescription practices were collected as part of an inpatient malaria surveillance program generating high quality data among children admitted for any reason at government hospitals in six districts. A standardized medical record form was used to collect detailed patient information including presenting symptoms and signs, laboratory test results, admission and final diagnoses, treatments administered, and final outcome upon discharge. RESULTS: Between July 2011 and December 2013, 58,095 children were admitted to the six hospitals (hospital range 3294-20,426).A total of 56,282 (96.9 %) patients were tested for malaria, of which 26,072 (46.3 %) tested positive (hospital range 5.9-57.3 %). Among those testing positive, only 84 (0.3 %) were first tested after admission and 295 of 30,389 (1.0 %) patients who tested negative at admission later tested positive. Of 30,210 children with only negative test results, 11,977 (39.6 %) were prescribed an anti-malarial (hospital range 14.5-53.6 %). The proportion of children with a negative test result who were prescribed an anti-malarial fluctuated over time and did not show a significant trend at any site with the exception of one hospital where a steady decline was observed. Among those with only negative test results, children 6-12 months of age (aOR 3.78; p < 0.001) and those greater than 12 months of age (aOR 4.89; p < 0.001) were more likely to be prescribed an anti-malarial compared to children less than 6 months of age. Children with findings suggestive of severe malaria were also more likely to be prescribed an anti-malarial after a negative test result (aOR 1.98; p < 0.001). CONCLUSIONS: Despite high testing rates for malaria at all sites, prescription of anti-malarials to patients with negative test results remained high, with the exception of one site where a steady decline occurred.

Anemia in children under 5 years of age, defined by the World Health Organization as a hemoglobin concentration < 11 g/dL, is a global public health problem. According to the 2006 Demographic Health Survey, the prevalence of anemia among children under five in Uganda was 72% in 2006. The 2009 Uganda Malaria Indicator Survey was conducted in late 2009 and revealed that over 60% of children less than 5 years of age were anemic and that over half of children tested positive for malaria via a rapid diagnostic test. Children with concomitant malaria infection, and in households without any type of mosquito net were more likely to be anemic, confirming that children under 5 years, are vulnerable to both the threat of malaria and anemia and the beneficial effect of malaria prevention tools. However, prevention and treatment of other factors associated with the etiology of anemia (e.g., iron deficiency) are likely necessary to combat the toll of anemia in Uganda.

BACKGROUND: Malaria is the leading cause of death in Mozambique in children under five years old. In 2009, Mozambique developed a novel bed net distribution model to increase coverage, based on assumptions about sleeping patterns. The coverage and impact of a bed net distribution campaign using this model in four districts in Sofala Province, Mozambique was evaluated. METHODS: Paired household, cross-sectional surveys were conducted one month after the 2010 distribution of 140,000 bed nets and again 14 months after the campaign in 2011. During household visits, malaria blood smears were performed and haemoglobin levels were assessed on children under five and data on bed net ownership, access and use were collected; these indicators were analysed at individual, household and community levels. Logistic regression was used to evaluate predictors of malaria infection and anaemia. RESULTS: The campaign reached 98% (95% CI: 97-99%) of households registered during the precampaign listing, with 81% (95% CI: 77-85%) of sleeping spaces covered by campaign bed nets and 85% (95% CI: 81-88%) of the population sleeping in a sleeping space with a campaign bed net designated for the sleeping space. One year after the campaign, 65% (95% CI: 57-72%) of sleeping spaces were observed to have hanging bed nets. The proportion of sleeping spaces for which bed nets were reported used four or more times per week was 65% (95% CI: 56-74%) in the wet season and 60% (95% CI: 52-68%) in the dry season. Malaria parasitaemia prevalence in children under five years old was 47% (95% CI: 40-54%) in 2010 and 36% (95% CI: 27-45%) in 2011. Individual-level malaria infection and anaemia were significantly associated with community-level use of bed nets. CONCLUSIONS: The campaign using the novel distribution model achieved high coverage, although usage was not uniformly high. A significant decrease in malaria parasitaemia prevalence a year after the campaign was not observed, but community-level use of bed nets was significantly associated with a reduced risk for malaria infection and anaemia in children under five.

The primary source of malaria surveillance data in Uganda is the Health Management Information System (HMIS), which does not require laboratory confirmation of reported malaria cases. To improve data quality, an enhanced inpatient malaria surveillance system (EIMSS) was implemented with emphasis on malaria testing of all children admitted in select hospitals. Data were compared between the HMIS and the EIMSS at four hospitals over a period of 12 months. After the implementation of the EIMSS, over 96% of admitted children under 5 years of age underwent laboratory testing for malaria. The HMIS significantly overreported the proportion of children under 5 years of age admitted with malaria (average absolute difference = 19%, range = 8-27% across the four hospitals) compared with the EIMSS. To improve the quality of the HMIS data for malaria surveillance, the National Malaria Control Program should, in addition to increasing malaria testing rates, focus on linking laboratory test results to reported malaria cases.

The aim of this study is to describe trends in the awareness, treatment, and control of hypertension; mean blood pressure; and the classification of blood pressure among US adults 2003 to 2012. Using data from the National Health and Nutrition Examination Survey 2003 to 2012, a total of 9255 adult participants aged ≥18 years were identified as having hypertension, defined as measured blood pressure ≥140/90 mm Hg or taking prescription medication for hypertension. Awareness and treatment among hypertensive adults were ascertained via an interviewer administered questionnaire. Controlled hypertension among hypertensive adults was defined as systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg. Blood pressure was categorized as optimal blood pressure, prehypertension, and stage I and stage II hypertension. Between 2003 and 2012, the percentage of adults with controlled hypertension increased (P-trend <0.01). Hypertensive adults with optimal blood pressure and with prehypertension increased from 13% to 19% and 27% to 33%, respectively (P-trend <0.01 for both groups). Among hypertensive adults who were taking antihypertensive medication, uncontrolled hypertension decreased from 38% to 30% (P-trend <0.01). Similarly, a decrease in mean systolic blood pressure was observed (P-trend <0.01); however, mean diastolic blood pressure remained unchanged. The trend in the control of blood pressure has improved among hypertensive adults resulting in a higher percentage with blood pressure at the optimal or prehypertension level and a lower percentage in stage I and stage II hypertension. Overall, mean systolic blood pressure decreased as did the prevalence of uncontrolled hypertension among the treated hypertensive population.

BACKGROUND: Clear and consistent definitions of hypertension and hypertension control are crucial to guide diagnosis, treatment, and surveillance. A variety of surveillance definitions are in frequent use, resulting in variation of reported hypertension prevalence and control, even when based on the same data set. METHODS AND RESULTS: To assess the variety of published surveillance definitions and rates, we performed a literature search for studies and reports that used National Health and Nutrition Examination Surveys (NHANES) data from at least as recent as the 2003 to 2004 survey cycle. We identified 19 studies that used various criteria for defining hypertension and hypertension control, as well as different parameters for age adjustment and inclusion of subpopulations. This resulted in variation of reported age-standardized hypertension prevalence from 28.9% to 32.1% and hypertension control from 35.1% to 64%. We then assessed the effects of varying the definitions of hypertension and hypertension control, parameters for age adjustment, and inclusion of subpopulations on NHANES data from both 2007 to 2008 (n=5645) and 2005 to 2008 (n=10 365). We propose standard surveillance definitions and age-adjustment parameters for hypertension and hypertension control. By using our recommended approach with NHANES 2007 to 2008 data, the age-standardized prevalence of hypertension in the United States was 29.8% (SE, 0.62%) and the rate of hypertension control was 45.8% (SE, 4.03%). CONCLUSIONS: Surveillance definitions of hypertension and hypertension control vary in the literature. We present standard definitions of hypertension prevalence and control among adults and standard parameters for age-adjustment and population composition that will enable meaningful population comparisons and monitoring of trends.

OBJECTIVE: This report presents estimates for the period 2001-2008 of means and selected percentiles of systolic and diastolic blood pressure by sex, race or ethnicity, age, and hypertension status in adults aged 18 and over. METHODS: Demographic characteristics were collected during a personal interview, and blood pressures were measured during a physician examination. All estimates were calculated using the mean of up to three measurements. The final analytic sample consisted of 19,921 adults aged 18 and over with complete data. Examined sample weights and sample design variables were used to calculate nationally representative estimates and standard error estimates that account for the complex design, using SAS and SUDAAN statistical software. RESULTS: Mean systolic blood pressure was 122 mm Hg for all adults aged 18 and over; it was 116 mm Hg for normotensive adults, 130 mm Hg for treated hypertensive adults, and 146 mm Hg for untreated hypertensive adults. Mean diastolic blood pressure was 71 mm Hg for all adults 18 and over; it was 69 mm Hg for normotensive adults, 75 mm Hg for treated hypertensive adults, and 85 mm Hg for untreated hypertensive adults. There was a trend of increasing systolic blood pressure with increasing age. A more curvilinear trend was seen in diastolic blood pressure, with increasing then decreasing means with age in both men and women. Men had higher mean systolic and diastolic pressures than women. There were some differences in mean blood pressure by race or ethnicity, with non-Hispanic black adults having higher mean systolic and diastolic blood pressures than non-Hispanic white and Mexican-American adults, but these differences were not consistent after stratification by hypertension status and sex. CONCLUSIONS: These estimates of the distribution of blood pressure may be useful for policy makers who are considering ways to achieve a downward shift in the population distribution of blood pressure with the goal of reducing morbidity and mortality related to hypertension.

OBJECTIVES: This study assesses (1) the prevalence of ever having a blood test for cholesterol, (2) current practices of following advice from a health care professional to manage high cholesterol, and (3) the association between total serum cholesterol level and following the advice. METHODS: A total of 17,260 adults aged 20 and older participated in the interview and medical examination in National Health and Nutrition Examination Survey (1999-2006). Cholesterol management was examined among adults previously diagnosed with high cholesterol who were advised to change their lifestyles through low-fat diets, weight loss, or exercise and/or to take medications. Five analytic groups were defined: (1) Those taking medications only, (2) those making one or more lifestyle changes, (3) those making one or two lifestyle changes and taking medications, (4) those making three lifestyle changes and taking medications, and (5) those not following any advice. RESULTS: Between 69% and 80% of adults advised to lower cholesterol reported following advice to control their cholesterol. Adults on medication only and adults with lifestyle changes and medication were more likely to have cholesterol level below 240 mg/dL compared with adults with lifestyle changes only (medication only: odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3-5.8); one or two lifestyle changes and medication: OR, 4.1; 95% CI, 3.1-5.4; three lifestyle changes and medication: OR, 4.3; 95% CI, 3.0-6.2; referent: one or two or three lifestyle changes). CONCLUSION: The combination of medication and lifestyle changes was more strongly associated with decreasing cholesterol compared with making one or more lifestyle changes without medication use.

KEY FINDINGS: Data from the National Health and Nutrition Examination Survey There was no significant change in the prevalence of high blood pressure among U.S. adults from 1999-2000 to 2007-2008. This was true for men and women, all age groups, and for non-Hispanic white, non-Hispanic black, and Mexican-American adults. Among U.S. adults with high blood pressure, the percentage that was aware of the condition increased from 69.6% in 1999-2000 to 80.6% in 2007-2008. Among U.S. adults with high blood pressure, the percentage who were taking medication to lower their blood pressure increased from 1999-2000 through 2007-2008. The control of blood pressure increased among U.S. adults with high blood pressure from 1999-2000 through 2007-2008. Increases in control occurred for all subgroups of the population.

AIM: To evaluate the effects of HMG-CoA reductase inhibitor (statin) treatment on serum inflammatory markers using data from the National Health and Nutrition Examination Survey (NHANES 1999-2004). METHODS AND RESULTS: A total of 9,128 individuals aged 40 and older participated in the NHANES. The inflammatory markers studied were white blood cell counts (WBC), high sensitivity C-reactive protein (CRP) and ferritin. Other covariables were: age, gender, race/ethnicity, body mass index, prescription or nonprescription medication use within the previous 30 days (statins, anti-inflammatory drugs, antibiotics). Four analytic groups for drug use were defined: Statin users; AI/Antibiotic users (use of either anti-inflammatory or antibiotic drugs); Combination group (use of both Statins and anti-inflammatory or antibiotic drugs), and a Non-use group (taking none of the listed drugs). The mean CRP level was significantly lower in the Statin use group than the Non-use group (0.3 mg/dL, 95%CI: 0.3-0.3 and 0.4 mg/dL, 95%CI: 0.4-0.5). In multivariable regression modeling, the Statin use group had significantly lower predicted mean WBC (Beta Coeff: -0.2, p < 0.05) and CRP (Beta Coeff: -0.1, p < 0.01) values than the Non-use group. CONCLUSIONS: Treatment with statins was significantly associated with decreased WBC and CRP levels in this large population-based sample.

Eliminating health disparities among different segments of the population is one of two overarching goals of both Healthy People 2010 and 2020 (1). Race/ethnicity differences in health care and chronic diseases have been well documented (2,3). Hypertension, hypercholesterolemia, and diabetes are all chronic conditions associated with cardiovascular disease, the leading cause of death in the United States. The co-occurrence of these three chronic conditions by race/ethnicity has been less frequently documented. In addition, reliance on only self-reported diagnosis results in an underestimate of the prevalence of these conditions. The objective of this report is to compare the prevalence of diagnosed and undiagnosed hypertension, hypercholesterolemia, and diabetes among three racial/ethnic groups and the prevalence of co-morbidity of these conditions for U.S. adults.

The global health community is interested in the health impact of the billions of dollars invested to fight malaria in Africa. A recent publication used trends in malaria cases and deaths based on health facility records to evaluate the impact of malaria control efforts in Rwanda and Ethiopia. Although the authors demonstrate the use of facility-based data to estimate the impact of malaria control efforts, they also illustrate several pitfalls of such analyses that should be avoided, minimized, or actively acknowledged. A critique of this analysis is presented because many country programmes and donors are interested in evaluating programmatic impact with facility-based data. Key concerns related to: 1) clarifying the objective of the analysis; 2) data validity; 3) data representativeness; 4) the exploration of trends in factors that could influence malaria rates and thus confound the relationship between intervention scale-up and the observed changes in malaria outcomes; 5) the analytic approaches, including small numbers of patient outcomes, selective reporting of results, and choice of statistical and modeling methods; and 6) internal inconsistency on the strength and interpretation of the data. In conclusion, evaluations of malaria burden reduction using facility-based data could be very helpful, but those data should be collected, analysed, and interpreted with care, transparency, and a full recognition of their limitations.