Editorials Public awareness campaigns can help overcome some of these issues, while also promoting active and healthy lifestyles. Outreach programmes also are a valuable supplement to clinic based services for older women. Community based activities, including support groups and volunteer health promoters, hold special promise since they can maximise the interest and resources of the elderly themselves as well as the wider community. No matter which interventions are selected, expanding services for older women will place new demands on healthcare providers. Providers should receive pre-service and refresher training to learn how to counsel women and treat common health problems. Equally important, educational programmes should
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United Nations Population Fund. The state of the world population 2002. New York: UNFPA, 2002. www.unfpa.org/swp/swpmain.htm (accessed 4 Apr 2003). Population Action International. A world of difference: sexual and reproductive health and risks—the PAI report card 2001. Washington, DC: PAI, 2001. Ross JA and Winfrey WL. Unmet need for contraception in the developing world and former Soviet Union: an updated estimate. Int Fam Plann Perspect 2002;28:138-43. Bonita R. Women, ageing, and health: achieving health across the life span. 2nd ed. Geneva: World Health Organization, 1998. Kols AJ. Older women. In: Reproductive health outlook. Seattle: PATH, 2002. www.rho.org/html/older_women.htm (accessed 4 Apr 2003). Kane P. Priorities for reproductive health: assessing need in the older population in the Asia-Pacific region. Medscape Women’s Health 2001;6(4). www.medscape.com/viewarticle/408946 (accessed 4 Apr 2003).
aim to change providers’ attitudes so that they value older clients. Following the lead of international agencies and local programmes, the global health community must work to address the health needs of older women, especially in the world’s poorest countries. Christopher Elias president (celias@path.org)
Jacqueline Sherris strategic program leader, reproductive health Program for Appropriate Technology in Health, 1455 NW Leary Way, Seattle, WA 98107, USA
Competing interests: None declared.
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Senanayake P. Women and reproductive health in a graying world. Int J Gynaecol Obstet 2000;70:59-67. 8 Jejeebhoy S, Koenig M, Elias C. Community interaction in studies of gynaecological morbidity: experiences in Egypt, India and Uganda. In: Jejeebhoy S, Koenig M, Elias C, eds. Reproductive tract infections and other gynaecological disorders. Cambridge: Cambridge University Press, 2003. 9 WHO Department of Reproductive Health and Research. Improving access to quality care in family planning. Medical eligibility criteria for contraceptive use. 2nd ed. Geneva: WHO, 2000. (WHO/RHR/00.02.) 10 Gelfand MM. Sexuality among older women. J Womens Health Gend Based Med 2000;9(suppl 1):s15-20. 11 Sherris J, Herdman C. Preventing cervical cancer in low-resource settings. Outlook 2001;18(1):1-8. www.path.org/files/eol18_1.pdf (accessed 4 Apr 2003). 12 Kols AJ. Breast cancer: increasing incidence, limited options. Outlook 2002;19:1-8. www.path.org/files/eol19_4.pdf (accessed 4 Apr 2003).
Balancing benefits and harms in health care We need to get better evidence about harms
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hould kids be plastered with sunscreen this summer? Is this likely to be more beneficial than harmful? How would we know? For example, sunscreen use has been associated with overexposure to the sun, perhaps because of overconfidence in its abilities.1 2 Might there also be a potential risk of developing contact allergies, skin irritation, and rare but severe adverse effects? People making a decision about whether or not to use sunscreen need reliable evidence on the balance of benefits and harms. The same is true of all healthcare interventions, and unfortunately reliable evidence on harms is often lacking. Great progress has been made in obtaining reliable evidence on the beneficial effects of interventions, but developments in the identification, interpretation, and reporting of harmful effects is more challenging. Randomised controlled trials are the best way to evaluate small to moderate effects of healthcare interventions, and much of the evidence for benefits from treatment comes from such studies. However, they are not always suitable to evaluate harms, and this was made clear during a recent meeting jointly organised by the Cochrane Collaboration and BMJ Knowledge in London. There are various problems with randomised controlled trials in relation to harms and some of these problems affect systematic reviews too. Firstly, trialists may know which benefits to assess but may be unaware of potential harms of the interventions they are testing. Identifying unexpected harms is difficult when the 12 JULY 2003
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delay between the intervention and the onset of side effects is long or when a cumulative exposure is necessary to trigger the harms. Harms may be measured or grouped differently among trials, making it almost impossible to summarise, aggregate, or interpret the evidence in meaningful ways. The debate about the potentially serious cardiovascular effects of cyclooxygenase-2 (COX 2) inhibitors illustrates some of these problems. Serious cardiovascular effects associated with the use of COX 2 inhibitors have been identified recently3 4 because they were not systematically searched for in previous trials.5 All this can lead to harmful drugs continuing to be used for many years before a warning is raised. Problems exist with detection also. Rare harms may turn out to be more common than anticipated once flagged, but providing effective and balanced information to doctors and the public may be a complex and lengthy process. Even if the information is collected it might not be reported or indexed consistently well.6 Adverse effects can also be confused with the symptoms of the condition being treated. People taking analgesics for headache may develop analgesic induced headaches.7 Until this was discovered people with migraine might have thought their condition was getting worse, increased the amount of analgesics they took to compensate, and found themselves being exposed to even more of a harmful treatment. Raising the alarm about a potential harm can also do more bad than good if the quality of the evidence or 65