UN High-Level Meeting on Non-Communicable Diseases: addressing four questions

A case-control study of musculoskeletal impairment: association with socio-economic status, time use and quality of life in post-conflict Myanmar

Background

Musculoskeletal impairments (MSI) are a major global contributor to disability. Evidence suggests entrenched cyclical links between disability and poverty, although few data are available on the link of poverty with MSI specifically. More data are needed on the association of MSI with functioning, socio-economic status and quality of life, particularly in resource-poor settings where MSI is common.

Methods

We undertook a case-control study of the association between MSI and poverty, time use and quality of life in post-conflict Myanmar. Cases were recruited from two physical rehabilitation service-centres, prior to the receipt of any services. One age- (+/− 5 years of case’s age) and sex- matched control was recruited per case, from their home community. 108 cases and 104 controls were recruited between July – December 2015. Cases and controls underwent in-depth structured interviews and functional performance tests at multiple time points over a twelve-month period. The baseline characteristics of cases and controls are reported in this manuscript, using multivariate logistic regression analysis and various tests of association.

Results

89% of cases were male, 93% were lower limb amputees, and the vast majority had acquired MSI in adulthood. 69% were not working compared with 6% of controls (Odds Ratio 27.4, 95% Confidence Interval 10.6–70.7). Overall income, expenditure and assets were similar between cases and controls, with three-quarters of both living below the international LMIC poverty line. However, cases’ health expenditure was significantly higher than controls’ and associated with catastrophic health expenditure and an income gap for one fifth and two thirds of cases respectively. Quality of life scores were lower for cases than controls overall and in each sub-category of quality of life, and cases were far less likely to have participated in productive work the previous day than controls.

Conclusion

Adults with MSI in Myanmar who are not in receipt of rehabilitative services may be at increased risk of poverty and lower quality of life in relation to increased health needs and limited opportunities to participate in productive work. This study highlights the need for more comprehensive and appropriate support to persons with physical impairments in Myanmar.

Non-communicable disease (NCD) corners in public sector health facilities in Bangladesh: a qualitative study assessing challenges and opportunities for improving NCD services at the primary healthcare level

OBJECTIVE

To explore healthcare providers' perspective on non-communicable disease (NCD) prevention and management services provided through the NCD corners in Bangladesh and to examine challenges and opportunities for strengthening NCD services delivery at the primary healthcare level.

DESIGN

We used a grounded theory approach involving in-depth qualitative interviews with healthcare providers. We also used a health facility observation checklist to assess the NCD corners' service readiness. Furthermore, a stakeholder meeting with participants from the government, non-government organisations (NGOs), private sector, universities and news media was conducted.

SETTING

Twelve subdistrict health facilities, locally known as upazila health complex (UHC), across four administrative divisions.

PARTICIPANTS

Participants for the in-depth qualitative interviews were health service providers, namely upazila health and family planning officers (n=4), resident medical officers (n=6), medical doctors (n=4) and civil surgeons (n=1). Participants for the stakeholder meeting were health policy makers, health programme managers, researchers, academicians, NGO workers, private health practitioners and news media reporters.

RESULTS

Participants reported that diabetes, hypertension and chronic obstructive pulmonary disease were the major NCD-related problems. All participants acknowledged the governments' initiative to establish the NCD corners to support NCD service delivery. Participants thought the NCD corners have contributed substantially to increase NCD awareness, deliver NCD care and provide referral services. However, participants identified challenges including lack of specific guidelines and standard operating procedures; lack of trained human resources; inadequate laboratory facilities, logistics and medications; and poor recording and reporting systems.

CONCLUSION

The initiative taken by the Government of Bangladesh to set up the NCD corners at the primary healthcare level is appreciative. However, the NCD corners are still at nascent stage to provide prevention and management services for common NCDs. These findings need to be taken into consideration while expanding the NCD corners in other UHCs throughout the country.

Thyroid function and life expectancy with and without noncommunicable diseases: A population-based study

BACKGROUND

Variations in thyroid function within reference ranges are associated with increased risk of diseases and death. However, the impact of thyroid function on life expectancy (LE) with and without noncommunicable diseases (NCDs) remains unknown. We therefore aimed to investigate the association of thyroid function with total LE and LE with and without NCD among euthyroid individuals.

METHODS AND FINDINGS

The study was embedded in the Rotterdam Study, a prospective population-based study carried out in the Netherlands. In total, 7,644 participants without known thyroid disease and with thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels within reference ranges were eligible. NCDs were defined as presence of cardiovascular disease, diabetes mellitus type 2, or cancer. We used the demographic tool of multistate life tables to calculate LE estimates at the age of 50 years, using prevalence, incidence rates, and hazard ratios for three transitions (healthy to NCD, healthy to death, and NCD to death). The total LE and LE with and without NCD among TSH and FT4 tertiles were calculated separately in men and women. Analyses were adjusted for sociodemographic and cardiovascular risk factors. The mean (standard deviation) age of the participants was 64.5 (9.7) years, and 52.3% were women. Over a median follow-up of 8 years (interquartile range 2.7-9.9 years), 1,396 incident NCD events and 1,422 deaths occurred. Compared with those in the lowest TSH tertile, men and women in the highest TSH tertile were expected to live 1.5 years (95% confidence interval [CI] 0.8-2.3, p < 0.001) and 1.5 years (CI 0.8-2.2, p < 0.001) longer, respectively, of which 1.4 years (CI 0.5-2.3, p = 0.002) and 1.3 years (CI 0.3-2.1, p = 0.004) with NCD. Compared with those in the lowest FT4 tertile, the difference in LE for men and women in the highest FT4 tertile was -3.7 years (CI -5.1 to -2.2, p < 0.001) and -3.3 years (CI -4.7 to -1.9, p < 0.001), respectively, of which -1.8 years (CI -3.1 to -0.7, p = 0.003) and -2.0 years (CI -3.4 to -0.7, p = 0.003) without NCD. A limitation of the study is the observational design. Thus, the possibility of residual confounding cannot be entirely ruled out.

CONCLUSIONS

In this study, we found that people with low-normal thyroid function (i.e., highest tertile of TSH and lowest tertile of FT4 reference ranges) are expected to live more years with and without NCD than those with high-normal thyroid function (i.e., lowest tertile of TSH and highest tertile of FT4 reference ranges). These findings provide support for a re-evaluation of the current reference ranges of thyroid function.

Use of the Health Improvement Card by Chinese physical therapy students: A pilot study

This study investigated the perceptions of Chinese physical therapy students on use of the Health Improvement Card (HIC) as a clinical tool to assess lifestyle and prescribe health education to others. The biometrics and health indices/attributes/lifestyles of these students were also evaluated with self-administration of the HIC. After a tutorial on the HIC and its clinical application, physical therapy students (n = 82) from two Chinese universities, completed the Chinese translation of the HIC followed by a questionnaire on students’ perceptions of it. Second, they invited a friend/relative to complete the HIC. Then, they provided feedback on the HIC’s strengths and challenges related to its administration. The data were analyzed with descriptive statistics and content thematic analysis. Response rate of self-completed HICs was 100% (n = 82) and that of questionnaires was 99% (n = 81). Participants’ age range was 20–34 years; mean body mass index (BMI) was 23.9±5.4 for men and 20.5±2.6 kg/m² for women. Generally, participants had low-risk BMIs (82%) and blood pressures (BPs) (91%), moderate-risk dietary habits (90%), but fewer had low-risk exercise habits (41%). Of 81 friends/relatives who participated, 25% had high-risk exercise habits. Student participants concurred the HIC is useful in developing lifestyle education programs. Challenges included uncertainty about obtaining laboratory data, serving-size quantities and confidence to effect lifestyle change in others. Although students appeared receptive to assessing health and lifestyle behaviors using the HIC, they reported being unconfident to prescribe long-term effective lifestyle advice. We recommend introducing the HIC in physical therapy curricula as an effective way of sensitizing emerging physical therapists to their responsibility to assess health/attributes/lifestyle non-communicable diseases (NCDs) risk factors. Prescribing lifestyle education/counselling warrants greater curricular focus. Further research will establish how HIC data and information can be effectively used as a clinical assessment and education tool to target health and lifestyle, and track behavior change over time.

Hypertension and Sudden Unexpected Deaths: An Autopsy Study of Four Hundred and Seventy-Seven Brought-in-Dead in a Tertiary Health Center

Introduction

Hypertension is an important and major public health concern globally. One of the major causes of sudden death worldwide is hypertension. This study is to present the morphological pattern of deaths at autopsy of those patients who were brought-in-dead (BID) and who had hypertensive heart disease (HHD) as the underlying illness.

Materials and Methods

This is a 6-year retrospective autopsy study of BID patients as a result of HHD seen at our department between January 1, 2010, and December 31, 2015. The autopsy findings and data retrieved were analyzed using IBM Statistical Package for Social Sciences version 20. Test for statistical significance was set at P < 0.05.

Results

A total of 477 deaths (44%) as a result of HHD were recorded out of the 1016 BID during the period under study. The age ranged from 21 to 92 years with a mean age of 52 ± 14.0 years and a male to female ratio of 1.8:1. The 5^th decade of life was the most common age group encountered. The most common cause of death was acute left ventricular failure (67.8%), and myocardial infarction was the least common (1.7%).

Conclusions

Acute left ventricular heart failure was the most common cause of sudden death as a result of hypertension and was followed by intracerebral hemorrhage. In the female gender, sudden deaths were most common in the 6^th decade and in the male gender most sudden deaths were seen in the 5^th decade.

Prevalence of prehypertension and hypertension and its risk factors in Iranian school children: a population-based study

OBJECTIVE

Because of the incidence of a childhood obesity epidemic and the widespread changes in people's lifestyle, the prevalence of high blood pressure in children is increasing. This study was conducted to determine the prevalence of prehypertension and hypertension and its risk factors in Iranian children.

METHODS

Using random cluster sampling in urban areas and census in rural areas, a total of 5620 schoolchildren aged 6-12 years living in Shahroud, Northeast of Iran, were studied. The prevalence of hypertension was determined on the basis of the fourth report of the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents by age, sex, and place of residence. The factors influencing blood pressure were studied using multivariate regression.

RESULTS

The prevalence of prehypertension was 7.44% and the prevalence of hypertension was 6.82%. The relative risk ratio (RRR) of prehypertension was 1.17 for BMI, 1.43 for female sex, and 3.71 for residence in rural areas; in addition, the RRR of hypertension was 1.22 for BMI, 6.64 for residence in rural areas, 1.69 for moderate economic status, and 1.89 for low economic status.

CONCLUSION

The prevalence of prehypertension and hypertension is significant in children and alarming in rural areas and requires urgent intervention. As factors such as high BMI, female sex, residence in rural areas, and moderate and low economic status are associated with increased risk of prehypertension and hypertension, it is recommended to conduct routine care programs at regular intervals in schools to prevent hypertension and its related complications.

Strengthening complex systems for chronic disease prevention: a systematic review

BACKGROUND

While frameworks exist for strengthening health care systems and public health systems, there are no practical frameworks to describe, assess and strengthen systems for chronic disease prevention (CDP) using complex systems approaches.

METHODS

A systematic and integrative review of peer reviewed literature was conducted to answer the following questions: How can systems for CDP be defined? What are key attributes of effective systems? How are complex systems approaches discussed? Search terms were identified and the Medline, SCOPUS, and Global Health databases were searched December 2017 and January 2018. Reference lists and selected journals were hand searched. A working definition for a system for CDP was developed to provide a guideline for inclusion. Key exclusion criteria were literature did not address the research questions or working definition; was published in a language other than English and before 2000; focused on specific chronic diseases and/or risk factors and not CDP broadly; concentrated on the health care sector and clinical services and/or health status and surveillance data; and described evaluations of setting specific actions such as policies, programs, interventions, approaches, projects, laws, or regulations. Selected literature (n = 141) was coded in terms of the extent to which the research questions and the working definition of systems for CDP were addressed. Data was then analysed and synthesized to determine key themes.

RESULTS

A revised definition of systems for CDP and seven attributes of effective systems for CDP are reported (collaborative capacity, health equity paradigm, leadership and governance, resources, implementation of desired actions, information and complex systems paradigm). A framework was developed to provide a foundation for describing, assessing and strengthening systems for CDP.

CONCLUSIONS

The results of this literature review provide a strong foundation for a framework to help strengthen systems for CDP. The framework consolidates not only well-established attributes of effective CDP but also highlights theoretical and practical insights from complex systems perspectives.

The process of prioritization of non-communicable diseases in the global health policy arena

Although non-communicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide, the global policy response has not been commensurate with their health, economic and social burden. This study examined factors facilitating and hampering the prioritization of NCDs on the United Nations (UN) health agenda. Shiffman and Smith's (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet 370: 1370-9.) political priority framework served as a structure for analysis of a review of NCD policy documents identified through the World Health Organization's (WHO) NCD Global Action Plan 2013-20, and complemented by 11 semi-structured interviews with key informants from different sectors. The results show that a cohesive policy community exists, and leaders are present, however, actor power does not extend beyond the health sector and the role of guiding institutions and civil society have only recently gained momentum. The framing of NCDs as four risk factors and four diseases does not necessarily resonate with experts from the larger policy community, but the economic argument seems to have enabled some traction to be gained. While many policy windows have occurred, their impact has been limited by the institutional constraints of the WHO. Credible indicators and effective interventions exist, but their applicability globally, especially in low- and middle-income countries, is questionable. To be effective, the NCD movement needs to expand beyond global health experts, foster civil society and develop a broader and more inclusive global governance structure. Applying the Shiffman and Smith framework for NCDs enabled different elements of how NCDs were able to get on the UN policy agenda to be disentangled. Much work has been done to frame the challenges and solutions, but implementation processes and their applicability remain challenging globally. NCD responses need to be adapted to local contexts, focus sufficiently on both prevention and management of disease, and have a stronger global governance structure.

The integrated health service model: the approach to restrain the vicious cycle to chronic diseases

BACKGROUND

In life time, nearly each person succumbs to some sort of chronic disease and many develop complicated chronic diseases. It is critical to focus on preventive services with a relatively high health impact and favorable cost effectiveness. During routine health facility visits, it is advisable to evaluate both symptomatic and asymptomatic patients for their needs of health promotion and disease prevention services. This necessitates the development of an integrated health service (IHS) approach that incorporates health promotion, disease prevention and curative services.

METHODS

There were two phases for the study. The first phase explored the degree of promotive and preventive health care delivery at the health centers and hospitals. Phase two, utilizing the Delphi strategy, centered on looking for agreement on the finding from phase 1 and on IHS approach. Delphi questions were created based on the results of phase 1, and the reply choices were tied to a five point Likert scale. Consensus was considered come to when 75% of the experts concurred on an issue. From that point, advance clarification and agreement was looked for by implies of a second-round assessment for scores between 50 and 75%. Agreement on proposed IHS model, application of case finding and Periodic Health Examination (PHE) approaches were also sought. This study focuses on finding from phase 2.

RESULT

Of the twenty experts, 90% (n = 18) agreed that the IHS framework shows the causal relationship of diseases and included plausible intervention approaches. Experts reached consensus (90%;n = 18) that case finding testing,screening patients for conditions other than the medical care they sought at a particular time, can be performed at health facilities. All experts (100%; n = 20) recommended conducting periodic health examinations in selected diseases for patients who are apparently not sick.

CONCLUSION

The Integrated Health Service (IHS) framework was agreed by experts to be a plausible method in describing the causal relationship of chronic non-communicable, communicable, and nutrition-related diseases. The framework can play a vital role by preventing the acquiring, progression, suffering or dying from diseases through restraining the vicious cycle of chronic diseases.

Effects of a health education intervention on hypertension-related knowledge, prevention and self-care practices in Nigerian retirees: a quasi-experimental study

BACKGROUND

Education is vital to increasing knowledge, improving prevention and self-care practices for hypertension in older adults. This study aimed to determine the effectiveness of a health education intervention in improving hypertension (HT) knowledge, prevention and self-care practices among retirees in Enugu State, South-east, Nigeria.

METHODS

In this quasi-experimental study, we enrolled 400 participants in Enugu and Nsukka cities in Enugu State, south-east Nigeria. Participants were assigned to the treatment and control groups. Participants in the intervention/treatment group (T-group) received the intervention provided by public health experts and nurses and participants in the control group (C-group) received health talk without the intervention. Data collected at baseline (before intervention), 16 weeks (4th month) and follow-up (5th month) included demographic variables, knowledge about hypertension, prevention and self-care practices. We used paired samples t-test, Chi-square test and one-way ANOVA repeated measures for data analyses.

RESULTS

The mean age of the participants was 65.9 (± 8.9) years, the mean SBP and DBP were 136.5 (± 13.3) and 87.9 (± 9.1) respectively. More than half of the participants were (50.3%) were males, and the mean BMI was 23.9 (± 5.1) kg/m2. The paired comparison analysis showed that the mean HT knowledge score significantly increased in the T-group between baseline and 1 month (4th month) post-intervention compared to those in the C-group (P < 0.0001). Also, PA (P = 0.007), sleep pattern and quality (P = 0.003), substance use abstinence (P = 0.000), healthy diet (P = 0.000), and medication adherence (P = 0.000) improved significantly in the T-group compared to the control between baseline and 1 month after intervention. The repeated measures analyses showed statistically significant effects (between-groups analysis) for all outcomes with small to large effect sizes. Similarly, the repeated measures ANOVA analyses showed significant time-by-group interaction effects (within-groups) for all the outcomes with small to large effect sizes.

CONCLUSION

Community-based health education intervention targeted at older adults can increase HT knowledge, improve prevention and self-care practices of hypertension at the population level.

Socioeconomic Gradients and Distribution of Diabetes, Hypertension, and Obesity in India

IMPORTANCE

Cardiovascular disease and risk factors represent a major and increasing burden of death and disability in India, although socioeconomic aspects have been debated in recent years.

OBJECTIVE

To conduct a comprehensive equity analysis of the socioeconomic gradients and distribution of diabetes, hypertension, and obesity in India using the latest national data set.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of data originating from the fourth Indian National Family Health Survey collected from January 20, 2015, to December 4, 2016. The study population was based on a nationally representative cross-sectional sample of women aged 15 to 49 years and men aged 15 to 54 years in India, with a response rate of 97% and 92% among eligible women and men, respectively. Biomarker sampling of survey respondents captured height, weight, blood pressure, and random blood glucose levels. Markers of socioeconomic status (SES) were household wealth, education, and social caste. Descriptive analyses and logistic regression models that account for multistage survey design and sampling weights were estimated.

MAIN OUTCOMES AND MEASURES

Diabetes, hypertension, and obesity assessed by predetermined thresholds based on biomarker sampling or current medication were the primary outcomes.

RESULTS

The survey covered 757 958 individuals (weighted prevalence of 51.2% female). The overall prevalence of diabetes, hypertension, and obesity in the sample was 2.9%, 14.4% and 9.7%, respectively. Positive socioeconomic gradients were observed by household wealth, education, and social caste, and in a majority of states. The magnitude of the SES gradient was strongest for obesity (adjusted odds ratio for highest SES quintile vs lowest, 8.76; 95% CI, 7.70-9.95), followed by diabetes (adjusted odds ratio, 2.31; 95% CI, 1.88-2.85) and hypertension (adjusted odds ratio, 1.58; 95% CI, 1.45-1.72) (P < .001 for all associations). Analyses of the socioeconomic distribution indicated that between 70% and 90% of the population burden of diabetes, hypertension, and obesity was among the higher SES groups, and this figure was similar across states.

CONCLUSIONS AND RELEVANCE

Cardiovascular risk factors have an uneven distribution in India. Prevention and treatment strategies should reflect the distribution of the risk factor burden.

Improved control of non-communicable diseases (NCDs) requires an additional advanced concept for public health - a perspective from a middle-income country

A major consequence of all elements of the 'epidemiological transition' is the rapid emergence of non-communicable diseases (NCDs) in low- and middle-income countries. In contrast to the outcomes of the 'Alma Ata Conference for Primary Health Care', it has not yet been possible to introduce an equally powerful health policy for the prevention and control of NCDs. Major strategies so far are to advise individuals not to smoke and drink alcohol in excess. Additionally, 'healthy' nutrition and increased physical activity are also advocated. Policy for preventing and working against NCDs is now part of the Sustainable Development Goals, specifically target 3.4. So far, attempts to soften the influence of NCDs on the health of the people in low- and middle-income countries have been unsuccessful. It is argued here that additional concepts on how public health could operate against NCDs are needed.  Major risk factors for NCDs interfere with and alter complex steps within the human metabolism.  This paper explores how human metabolism works by assessing advances in molecular biology and research in genetics, epigenetics and gerontology. Recent developments in these scientific disciplines shed light on the complexity of how human health is maintained and diseases are invoked. Public health bodies should be aware, interested and possibly contribute to the aforementioned areas of interest, as far as NCDs are concerned, and translate major developments in a way, that could be useful in improving population health.

A review on diabetic foot challenges in Guyanese perspective

BACKGROUND

Diabetes mellitus signifies a major public health threat worldwide. Type 2 diabetes has been reported as the fourth leading cause of death and has affected 15.5% of the adult population in Guyana, South America. Diabetes has also led to major lower extremity amputation at the only referral public hospital in Guyana. Diabetic foot and related complications are known to be multifactorial.

CONCLUSION

In this review, we highlight the information on the diabetic foot and related complications with an emphasis on Guyanese background.

Catastrophic health expenditure among type 2 diabetes mellitus patients: A province-wide study in Shandong, China

AIMS/INTRODUCTION

Diabetes mellitus often causes high economic burden on the patients and their households. The present study aimed to assess the incidence and intensity of catastrophic health expenditure (CHE) relating to type 2 diabetes mellitus care, and to explore its determinants in China.

MATERIALS AND METHODS

A total of 1,948 type 2 diabetes patients were included in the analysis. CHE for type 2 diabetes mellitus was defined as out-of-pocket payments for diabetes care that were ≥40% of the non-food expenditure of a household. The Chi-square-test was used to identify the factors associated with CHE. Multivariate logistic regression was used to assess the effects of explanatory analysis variables.

RESULTS

The incidence of CHE for type 2 diabetes mellitus care was 13.8%. An association was observed between CHE incidence and household income level, and the poorest group was more likely to experience CHE as a result of diabetes mellitus care. The type 2 diabetes mellitus patients with complications were found to be more likely to experience CHE. Diabetes patients who experienced outpatient or inpatient services increased the likelihood of CHE, and those who experienced inpatient services were more likely to incur CHE.

CONCLUSIONS

Type 2 diabetes mellitus has a significantly catastrophic effect on patients and their households in China. Early screening for type 2 diabetes mellitus patients among the high-risk groups and effective management of the detected cases should be priorities to reduce the overall healthcare expenditure for type 2 diabetes mellitus.

Personal Activity Intelligence (PAI): A new standard in activity tracking for obtaining a healthy cardiorespiratory fitness level and low cardiovascular risk

Despite all the evidence of health benefits related to physical activity (PA) and cardiorespiratory fitness (CRF), low levels of PA have reached pandemic proportions, and inactivity is the fourth leading cause of death worldwide. Lack of time, and inability to self-manage are often cited as main barriers to getting adequate PA. Recently, a new personalized metric for PA tracking named Personal Activity Intelligence (PAI) was developed with the aim to make it easier to quantify how much PA per week is needed to reduce the risk of premature mortality from non-communicable diseases. PAI can be integrated in self-assessment heart rate devices and defines a weekly beneficial heart rate pattern during PA by considering the individual's sex, age, and resting and maximal heart rates. Among individuals ranging from the general population to subgroups of patients with cardiovascular disease (CVD), a PAI score ≥100 per week at baseline, an increase in PAI score, and a sustained high PAI score over time were found to delay premature death from CVD and all causes, regardless of whether or not the current PA recommendations were met. Importantly, a PAI score ≥100 at baseline, maintaining ≥100 PAIs and an increasing PAI score over time was associated with multiple years of life gained. Moreover, obtaining a weekly PAI ≥100 attenuated the deleterious association between CVD risk factor clustering and prolonged sitting time. PAI and objectively measured CRF (as indicated by VO_2peak) were positively associated in a graded fashion, and individuals with a PAI score between 100 and 150 had expected age and sex specific average VO_2peak values. A PAI score ≥100 was associated with higher VO_2peak in both men (4.1 mL·kg^-1·min^-1; 95% CI, 3.5 to 4.6) and women (2.9 mL·kg^-1·min^-1; 95% CI, 2.4 to 3.3), compared to the reference group of <100 PAI. The combined analysis of PAI, PA and VO_2peak demonstrated that a PAI score ≥100 was associated with high VO_2peak values regardless of meeting or not meeting the current PA recommendations. Collectively, these findings suggest that PAI has the potential to be a useful tool to motivate people to become and stay physically active by quantifying the amount of PA needed to produce significant health benefits.

The Physiology of Optimizing Health with a Focus on Exercise as Medicine

Physical inactivity is one of the leading health problems in the world. Strong epidemiological and clinical evidence demonstrates that exercise decreases the risk of more than 35 different disorders and that exercise should be prescribed as medicine for many chronic diseases. The physiology and molecular biology of exercise suggests that exercise activates multiple signaling pathways of major health importance. An anti-inflammatory environment is produced with each bout of exercise, and long-term anti-inflammatory effects are mediated via an effect on abdominal adiposity. There is, however, a need to close the gap between knowledge and practice and assure that basic research is translated, implemented, and anchored in society, leading to change of praxis and political statements. In order to make more people move, we need a true translational perspective on exercise as medicine, from molecular and physiological events to infrastructure and architecture, with direct implications for clinical practice and public health.

Regional differences and spatial patterns of health status of the member states in the "Belt and Road" Initiative

The strategy of the "Belt and Road" initiative aims not only to promote the cooperation and the development of economic trade, but also to boost the integration and development in multiple fields-especially in the field of health. This paper explores the health levels of member-states in the Belt and Road initiative from the perspective of regional differences and spatial patterns. Data from the 68 member-states in the Belt and Road initiative were selected from the statistical data on disease and socioeconomics in all countries from the 2015 publication by the World Bank and the World Health Organization. Health indicators that can reflect health levels of member states were selected. Moran's I and Getis-Ord Gi* were used to analyze the spatial clustering and hot/cold spots of the health status. After that a novel spatial statistical method "geographical detector" was used to analysis the spatial stratified heterogeneity of the selected health indicators. The result showed that the health level of the member states fluctuated around the world average and varied greatly within the member states. The health status of the member states showed spatial clustering, and the q-statistics of the geographical detector confirmed that the health status demonstrated statistically significant spatial heterogeneity for different continent the member states reside. In general, member states in Europe and Oceania demonstrated higher health status, while those in South Asia, Southeast Asia, Africa and part of Middle East have lower health status. In particular, special attention should be paid to control communicable diseases in African member states. Different regions and member states face different kinds of health threats in various degrees. Member states should strengthen health cooperation between themselves and work closely with other countries to make the "belt and road" a healthy road.

Primary care and multimorbidity in six Latin American and Caribbean countries

Objectives

To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments.

Methods

Cross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care.

Results

The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams.

Conclusions

Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

Earth Observation: Investigating Noncommunicable Diseases from Space

The United Nations has called on all nations to take immediate actions to fight noncommunicable diseases (NCDs), which have become an increasingly significant burden to public health systems around the world. NCDs tend to be more common in developed countries but are also becoming of growing concern in low- and middle-income countries. Earth observation (EO) technologies have been used in many infectious disease studies but have been less commonly employed in NCD studies. This review discusses the roles that EO data and technologies can play in NCD research, including ( a) integrating natural and built environment factors into NCD research, ( b) explaining individual-environment interactions, ( c) scaling up local studies and interventions, ( d) providing repeated measurements for longitudinal studies including cohorts, and ( e) advancing methodologies in NCD research. Such extensions hold great potential for overcoming the challenges of inaccurate and infrequent measurements of environmental exposure at the level of both the individual and the population, which is of great importance to NCD research, practice, and policy.

Tobacco and Alcohol Use Among Youth in Low and Middle Income Countries: A Multi-Country Analysis on the Influence of Structural and Micro-Level Factors

BACKGROUND

The transition from adolescence to adulthood is a critical life phase as it is during this period that substance use and disorders typically emerge and escalate. Globally, few studies have examined the prevalence and correlates of alcohol and tobacco use among youth (ages 15-24). This study seeks to bridge this gap by assessing the influence of structural and micro-level factors on tobacco and alcohol use among youth in Low- and Middle-income countries (LMICs).

METHODS

Data are drawn from the Multiple Indicator Cluster Surveys (MICS) conducted in 29 countries or regions in Eastern Europe, Latin America, Asia and Africa between 2010 and 2015. Analyses focus on lifetime prevalence and age of onset for tobacco and alcohol use.

RESULTS

Descriptive analyses highlight regional variations in the prevalence and age of onset of tobacco and alcohol use: tobacco use is more concentrated among youth in Eastern Europe but alcohol use is generalized across the regions. Using multi-level analyses, we find statistically significant main effects for age, gender, educational attainment, rural residence, marital status and exposure to mass media on tobacco and alcohol use outcomes as well as interaction effects for age, gender and education on tobacco and alcohol use outcomes. Conclusions/importance: These findings highlight the need for structural interventions to control tobacco social marketing, and for gender considerations in tobacco and alcohol use prevention programs and policies.

Reasons to stop drinking alcohol among patients with rheumatoid arthritis in Sweden: a mixed-methods study

OBJECTIVES

The aims were to identify patients with rheumatoid arthritis (RA) who had stopped drinking alcohol and compare them with patients drinking alcohol, and to explore reasons for stopping drinking alcohol.

DESIGN

A sequential explanatory mixed methods design was used.

SETTING

Six rheumatology clinics in Southern Sweden Better Anti-Rheumatic FarmacOTherapy cohort.

PARTICIPANTS

A total of 1509 patients completed the questions about alcohol and were included in the study. 86 of these had stopped drinking alcohol and 72 responded to the open question and their answers were analysed with qualitative content analysis.

OUTCOME MEASURES

The quantitative data were from a cross-sectional survey assessing disease severity, physical function (Health Assessment Questionnaire, HAQ) and health-related quality of life (EuroQol five dimensions, EQ5D), pain, fatigue, patient global assessment (PatGA) and lifestyle factors, for example, alcohol. The questions assessing alcohol included an open question 'Why have you stopped drinking alcohol?'

RESULTS

The patients who stopped drinking alcohol were older (median (min-max) 69 (36-90) vs 66 (23-95), p=0.011), had worse HAQ (1.00 (0-2.75) vs 0.50 (0-3.00), p<0.001), worse EQ5D (0.69 (-0.02-1.00) vs 0.76 (-0.58-1.00), p<0.001) worse PatGA (5 (0-10) vs 3 (0-10), p<0.001), more pain (5 (0-10) vs 3 (0-10), p<0.001) and more fatigue (6 (0-10) vs 4 (0-10), p<0.001 compared with patients drinking alcohol. The qualitative content analysis revealed five categories describing reasons for patients with RA to stop drinking alcohol: illness and treatment; health and well-being; work and family; faith and belief; and dependences and abuse.

CONCLUSIONS

The patients who had stopped drinking had worse physical functioning and higher levels in pain-related variables. Most stopped drinking due to their illness or a desire to improve health.

The epidemiology of cancer in the United Arab Emirates: A systematic review

OBJECTIVE

We conducted a systematic review to explore the United Arab Emirates (UAE)'s cancer-specific epidemiological profiles.

METHODS

We followed the standardized methods for conducting and reporting systematic reviews. We employed a highly sensitive and extensive strategy to identify all studies on the prevalence and incidence of cancer in the UAE, searching electronic databases and the grey literature. We assessed the methodological quality of the studies, summarized them, and qualitatively analyzed their results.

RESULTS

We included 4 retrospective studies published between 2003 and 2011, reporting data gathered between 1982 and 2004. The majority of the data were collected from national cancer registries and addressed adult Emiratis and certain cancer types. All included studies employed validated procedures for diagnostic confirmation. The overall age-standardized cancer rates were 70.1 and 74.2 per 100,000 in males and females, respectively. Lung, gastric, and prostate cancer ranked as the top 3 types in Emirati males; while breast, cervical, and thyroid cancer were the top 3 types in Emirati females. Men exhibited higher rates of lung and stomach cancers compared with women. The majority of the studies were of acceptable methodological quality.

CONCLUSIONS

Our findings highlight the need for high-quality future research and systematic cancer data collection and registration to provide reliable data on the current incidence of cancer. We hope that our findings guide the tailoring of interventions aimed at curbing cancer rates in the UAE.

Costs associated with management of non-communicable diseases in the Arab Region: a scoping review

BACKGROUND

Global mortality rates resulting from non-communicable diseases (NCDs) are reaching alarming levels, especially in low- and middle-income countries, imposing a considerable burden on individuals and health systems as a whole. This scoping review aims at synthesizing the existing literature evaluating the cost associated with the management and treatment of major NCDs across all Arab countries; at evaluating the quality of these studies; and at identifying the gap in existing literature.

METHODS

A systematic search was conducted using Medline electronic database to retrieve articles evaluating costs associated with management of NCDs in Arab countries, published in English between January 2000 and April 2016. 55 studies met the eligibility criteria and were independently screened by two reviewers who extracted/calculated the following information: country, theme (management of NCD, treatment/medication, or procedure), study design, setting, population/sample size, publication year, year for cost data cost conversion (US$), costing approach, costing perspective, type of costs, source of information and quality evaluation using the Newcastle-Ottawa Scale (NOS).

RESULTS

The reviewed articles covered 16 countries in the Arab region. Most of the studies were observational with a retrospective or prospective design, with a relatively low to very low quality score. Our synthesis revealed that NCDs' management costs in the Arab region are high; however, there is a large variation in the methods used to quantify the costs of NCDs in these countries, making it difficult to conduct any type of comparisons.

CONCLUSIONS

The findings revealed that data on the direct costs of NCDs remains limited by the paucity of this type of evidence and the generally low quality of studies published in this area. There is a need for future studies, of improved and harmonized methodology, as such evidence is key for decision-makers and directs health care planning.

Investigative Study on Nitric Oxide Production in Human Dermal Fibroblast Cells under Normal and High Glucose Conditions

Diabetic foot ulcers (DFU) are a major health problem associated with diabetes mellitus. Impaired nitric oxide (NO) production has been shown to be a major contributor to the dysregulation of healing in DFU. The level of impairment is not known primarily due to challenges with measuring NO. Herein, we report the actual level of NO produced by human dermal fibroblasts cultured under normal and high glucose conditions. Fibroblasts produce the extracellular matrix, which facilitate the migration of keratinocytes to close wounds. The results show that NO production was significantly higher in normal glucose compared to high glucose conditions. The real-time NO detected was compared to the nitrite present in the culture media and there was a direct correlation between real-time NO and nitrite in normal glucose conditions. However, real-time NO detection and nitrite measurement did not correlate under high glucose conditions. The inducible nitric oxide synthase (iNOS) enzyme responsible for NO production was upregulated in normal and high glucose conditions and the proliferation rate of fibroblasts was not statistically different in all the treatment groups. Relying only on nitrite to assess NO production is not an accurate determinant of the NO present in the wound bed in pathological states such as diabetes mellitus.

Prevalence of underweight, overweight and obesity and their associated risk factors in Nepalese adults: Data from a Nationwide Survey, 2016

Introduction

Over the past few decades, the total population of Nepal has increased substantially with rapid urbanization, changing lifestyle and disease patterns. There is anecdotal evidence that non-communicable diseases (NCDs) and associated risk factors are becoming key public health challenges. Using nationally representative survey data, we estimated the prevalence of underweight, overweight and obesity among Nepalese adults and explored socio-demographic factors associated with these conditions.

Materials and methods

We used the Nepal Demographic Health Survey 2016 data. Sample selection was based on stratified two-stage cluster sampling in rural areas and three stages in urban areas. Weight and height were measured in all adult women and men. Body mass index (BMI) was calculated using Asian specific BMI cut-points.

Results

A total of 13,542 adults aged 18 years and above (women 58.19%) had their weight and height measured. The mean (±SD) age was 40.63±16.82 years (men 42.75±17.27, women 39.15±16.34); 41.13% had no formal education and 60.97% lived in urban areas. Overall, 17.27% (95% CI: 16.64–17.91) were underweight; 31.16% (95% CI: 30.38–31.94) overweight/obese. The prevalence of both underweight (women 18.30% and men 15.83%, p<0.001) and overweight/obesity (women 32.87% and men 28.77%, p<0.001) was higher among women. The older adults (≥65 years) (aOR: 2.40, 95% CI: 1.92–2.99, p<0.001) and the adults of poorest wealth quintile (aOR: 2.05, 95% CI: 1.62–2.59, p<0.001) were more likely to be underweight. The younger age adults (36–45 years) (aOR: 3.05, 95% CI: 2.61–3.57, p<0.001) and women (aOR: 1.53, 95% CI 1.39–1.68, p<0.001) were more likely to be overweight or obese. Also, all adults were twice likely to overweight/obese (p<0.001). No significant difference was observed for overweight/obesity by ecological regions and place of residence (urban vs. rural).

Conclusion

These findings confirm co-existence of double burden of underweight and overweight/obesity among Nepalese adults. These conditions are associated with increased risk of developing NCDs. Therefore, effective public health intervention approaches emphasizing improved primary health care systems for NCDs prevention and care and using multi-sectoral approach, is essential.

Transgenerational and intergenerational epigenetic inheritance in allergic diseases

It has become clear that early life (including in utero exposures) is a key window of vulnerability during which environmental exposures can alter developmental trajectories and initiate allergic disease development. However, recent evidence suggests that there might be additional windows of vulnerability to environmental exposures in the parental generation before conception or even in previous generations. There is evidence suggesting that information of prior exposures can be transferred across generations, and experimental animal models suggest that such transmission can be conveyed through epigenetic mechanisms. Although the molecular mechanisms of intergenerational and transgenerationational epigenetic transmission have yet to be determined, the realization that environment before conception can alter the risks of allergic diseases has profound implications for the development of public health interventions to prevent disease. Future research in both experimental models and in multigenerational human cohorts is needed to better understand the role of intergenerational and transgenerational effects in patients with asthma and allergic disease. This will provide the knowledge basis for a new approach to efficient intervention strategies aimed at reducing the major public health challenge of these conditions.

Perceived Neighbourhood Problems over Time and Associations with Adiposity

There is growing interest in understanding which aspects of the local environment influence obesity. Using data from the longitudinal West of Scotland Twenty-07 study (n = 2040) we examined associations between residents’ self-reported neighbourhood problems, measured over a 13-year period, and nurse-measured body weight and size (body mass index, waist circumference, waist–hip ratio) and percentage body fat. We also explored whether particular measures such as abdominal obesity, postulated as a marker for stress, were more strongly related to neighbourhood conditions. Using life course models adjusted for sex, cohort, household social class, and health behaviours, we found that the accumulation of perceived neighbourhood problems was associated with percentage body fat. In cross-sectional analyses, the strongest relationships were found for contemporaneous measures of neighbourhood conditions and adiposity. When analyses were conducted separately by gender, perceived neighbourhood stressors were strongly associated with central obesity measures (waist circumference, waist–hip ratio) among both men and women. Our findings indicate that chronic neighbourhood stressors are associated with obesity. Neighbourhood environments are modifiable, and efforts should be directed towards improving deleterious local environments to reduce the prevalence of obesity.

Perceptions of Kenyan adults on access to medicines for non-communicable diseases: A qualitative study

In Kenya, noncommunicable diseases (NCDs) account for 27% of all deaths. Adult Kenyans have an 18% chance of dying prematurely from cancers, diabetes, cardiovascular diseases or chronic respiratory diseases. A Novartis Access Initiative is making medicines available to treat cardiovascular diseases, diabetes, chronic respiratory diseases, and breast cancer in 30 countries, including Kenya. Little is known about patients’ perceptions of access to medicines for NCDs in Kenya. The study objective was to understand patients’ perceptions of access to medicines; as well as barriers and facilitators at the household, community, and healthcare system level. A baseline qualitative study was conducted in eight of 47 counties as part of an evaluation of the Novartis Access Initiative in Kenya. The 84 patients interviewed through a household survey had been diagnosed and treated for an NCD. Although medicines at government facilities were free or cheaper than those sold in private pharmacies, the availability of medicines presented a constant challenge. Patients often resorted to private pharmacies, where NCD medicines cost more than at public facilities. Participants with an NCD took their health seriously and strove to get the medicines, even under difficult circumstances. Buying NCD medicines put a strain on the household budget, especially for the lower-income participants. Some actions to overcome affordability barriers included: borrowing money, selling assets, seeking help from relatives, taking on extra work, buying partial dosages, leaving without the medicines, or resorting to non-medical alternatives. In conclusion, access to NCD medicines is a major challenge for most adults in Kenya. As a result, they engage in complex interactions between public, private facilities and pharmacies to overcome the barriers. The government should ensure well-stocked public sector pharmacies and subsidize prices of medicines for lower-income patients. Integration of industry-led access to medicine programs may help governments to obtain low cost supplies.

Assessment of the multi-sectoral approach to tobacco control policies in South Africa and Togo

Background

Tobacco use is the world’s leading preventable cause of illness and death and the most important risk factor for non-communicable diseases (NCDs), particularly cardiovascular and chronic respiratory diseases (heart attack, stroke, congestive obstructive pulmonary disease, and lung cancer). Tobacco control is one of the World Health Organization’s “best-buys” interventions to prevent NCDs. This study assessed the use of a multi-sectoral approach (MSA) in developing and implementing tobacco control policies in South Africa and Togo.

Methods

This two-country case study consisted of a document review of tobacco control policies and of key informant interviews (N = 56) about the content, context, stakeholders, and strategies employed throughout policy formulation and implementation in South Africa and Togo. To guide our analysis, we used the Comprehensive Framework for Multi-Sectoral Approach to Health Policy, which is built around four major constructs of context, content, stakeholders and strategies.

Results

The findings show that the formulation of tobacco control policies in both countries was driven locally by the political, historical, social and economic contexts, and globally by the adoption WHO Framework Convention on Tobacco Control (FCTC). In both countries, the health department led policy formulation and implementation. The stakeholders involved in South Africa were more diverse, proactive and dynamic than those in Togo, whereas the strategies employed were more straightforward in Togo than in South Africa. The extent of understanding and use of MSA in both countries consisted of an inter-sectoral action for health, whereby the health department strove to collaborate with other sectors within and outside the government. Consequently, information sharing was identified as the main outcome of the interactions between institutions and interest groups within and across three critical sectors of the state, namely the public (government), the private and the civil society.

Conclusion

Tobacco control policies in South Africa and Togo were formulated and implemented from an inter-sectoral approach perspective, which relied heavily on information transfer between stakeholders and less on collaborative problem-solving approach. Incorporation of multiple stakeholders allowed both countries to formulate policies to meet FCTC goals for tobacco control and NCD reduction.

Healthcare choices in Mumbai slums: A cross-sectional study

Background: Informal urban settlements, known as slums, are the home for a large proportion of the world population. Healthcare in these environments is extremely complex, driven by poverty, environmental challenges, and poor access to formal health infrastructures. This study investigated healthcare challenges faced and choices made by slum dwellers in Mumbai, India. Methods: Structured interviews with 549 slum dwellers from 13 slum areas in Mumbai, India, were conducted in order to obtain a population profile of health-related socio-economic and lifestyle factors, disease history and healthcare access. Statistical tools such as multinomial logistic regression were used to examine the association between such factors and health choices. Results: Private providers (or a mixture of public and private) were seen to be preferred by the study population for most health conditions (62% - 90% health consultations), apart from pregnancy (43% health consultations). Community-based services were also preferred to more remote options. Stark differences in healthcare access were observed between well-known conditions, such as minor injuries, pulmonary conditions, and pregnancy and emerging challenges, such as hypertension and diabetes. A number of socio-economic and lifestyle factors were found to be associated with health-related decisions, including choice of provider and expenditure. Conclusions: Better planning and coordination of health services, across public and private providers, is required to address mortality and morbidity in slum communities in India. This study provides insights into the complex landscape of diseases and health providers that slum dwellers navigate when accessing healthcare. Findings suggest that integrated services and public-private partnerships could help address demand for affordable community-based care and progress towards the target of universal health coverage.

Barriers to healthy dietary choice amongst students in Sri Lanka as perceived by school principals and staff

Summary

Sri Lanka has experienced a massive demographic, environmental, economic and social transition in recent decades. Over this period of time the country has undergone rapid urbanization leading to accompanying shifts in lifestyle and it suffers a double burden of under- and over-nutrition. Current programmes in the country focus on improving the dietary behaviour of secondary school students. The purpose of this study was to investigate principal's perceptions on barriers to healthy dietary choice among pupils within a socio-ecological framework. Focus groups (n = 11) were carried out with school principals and staff (n = 55) in two rural districts of Sri Lanka. Principals identified a number of barriers to healthy dietary choice by students, which could be found at a number of levels of influence of a socio-ecological framework: (i) structural level barriers included educational and agricultural policies, (ii) living and working level barriers included employment opportunities and local food production, (iii) social and community level barriers included traditions and social/cultural beliefs and (iv) individual level barriers included knowledge and preference. Findings from this study suggest that the barriers to healthy dietary choice amongst secondary school students in Sri Lanka occur at many levels supporting the use of multifactorial programmes to promote healthy eating. Only from understanding these barriers and finding ways to counter them can we hope to reduce the double burden of under- and over-nutrition the country is currently suffering.

Alcohol use and abuse: a cross-sectional study among Italian adolescents

INTRODUCTION

Alcohol is recognized as one of four major risk factors for non-communicable diseases. Exposure to alcoholic beverages during the adolescence has been linked to increased heavier drinking habits: obviously, the age of alcohol initiation resulted an important determinant of alcohol dependence. The aim of this study is to analyze knowledge, attitudes and practices in alcohol habit of adolescent population.

METHODS

943 students from 13 schools (middle and upper secondary schools) of the Bari district were enrolled in the study: in each school one class for each age was randomly selected. The research was carried out by an anonymous, self-administered questionnaire which investigated alcohol consumption, knowledge of alcohol consumption of parents and knowledge of the law regulating alcohol consumption.

RESULTS

34.8% (328) have never consumed alcoholic drinks while 65.2% (615) declare the use of alcohol; the average age of alcohol initiation was 12.2 years. 35.7% (329/921) of mothers and 36.6% (335/915) of fathers drink alcohol only on special occasions. 17.9% (168/939) considered that alcohol could be free sale at all while 16.4% (154/939) reported that sale is forbidden for children under 14.

CONCLUSIONS

The higher prevalence of alcohol habits and the poor knowledge on alcohol law seemed to indicated the need of improving public health efforts in the prevention of alcohol consumption among Italian adolescents.

Impact of the National Population Register in Improving the Health Information System of Malignant Diseases in Kosova

Introduction

Malignant diseases are serious socio-medical problem, being that they cause grave problems in terms of health, social and economic perspective to an individual, in particular, and society in general. A proper reporting and monitoring system enables adequate calculation of indicators and evidence based decision making.

Aim

The study aims to examine the appearance of malignancies diagnosed and reported in Kosovo for a three years period: 2012, 2013, and 2014 by its modalities such as by the years of appearance, gender, age, and most frequent types of malignancies.

Material and methods

The study is a retrospective cohort research whereas source data we used are reports of malignant diseases from National Cancer Register (NCR) in the Health Information System (HIS) at the National Institute of Public Health of Kosova (NIPHK).

Results and discussions

In Kosova during years 2012, 2013 and 2014 a total of 7437 cases of malignant diseases were reported; in 2012 were 31%, in 2013 were 24.3%, and during 2014 higher number of cases were reported, 3320 or 44.6%. During the reporting period, the appearance of malignant diseases in both sexes is about equal, with a light predominance of male cases with 50.8% (or 3780 cases), while by age group were represented with the elderly, from ages 50 to 79 years with 5111 cases or 68.8% of total malignancies.

Conclusion

The highest number of malignant diseases was reported during year 2014 due to better reporting through HIS and NCR. Malignancies attacked both genders equally, whereas the most common types of malignancies were: melanoma and other malignant neoplasms of the skin, malignant diseases of the respiratory and intrathoracic organs, digestive tract, breast and female genital tract. The most affected the older ones.

Tuberculosis non-communicable disease comorbidity and multimorbidity in public primary care patients in South Africa

BACKGROUND

 Little is known about the prevalence of non-communicable disease (NCD) multimorbidity among tuberculosis (TB) patients in Africa.Aim and setting: The aim of this study was to assess the prevalence of NCD multimorbidity, its pattern and impact on adverse health outcomes among patients with TB in public primary care in three selected districts of South Africa.

METHODS

 In a cross-sectional survey, new TB and TB retreatment patients were interviewed, and medical records assessed in consecutive sampling within 1 month of anti-TB treatment. The sample included 4207 (54.5% men and 45.5% women) TB patients from 42 primary care clinics in three districts. Multimorbidity was measured as the simultaneous presence of two or more of 10 chronic conditions, including myocardial infarction or angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, dyslipidaemia, malignant neoplasms, tobacco and alcohol-use disorder.

RESULTS

 The prevalence of comorbidity (with one NCD) was 26.9% and multimorbidity (with two or more NCDs) was 25.3%. We identified three patterns of multimorbidity: (1) cardio-metabolic disorders; (2) respiratory disorders, arthritis and cancer; and (3) substance-use disorders. The likelihood of multimorbidity was higher in older age, among men, and was lower in those with higher education and socio-economic status. The prevalence of physical health decreased, and common mental disorders and post-traumatic stress disorder increased with an increase in the number of chronic conditions.

CONCLUSION

 High NCD comorbidity and multimorbidity were found among TB patients predicted by socio-economic disparity.

Economic growth and obesity in South African adults: an ecological analysis between 1994 and 2014

Background

To assess the trend associations between South Africa's economic growth using various economic growth indicators (EGIs) with adult obesity prevalence over a specified period of time. Data for obesity levels reported were obtained from national surveys conducted in South African adults in 1998, 2003 and 2012. EGIs incorporated in the current analysis were obtained from the World Bank and IHS Global insight databases. Obesity prevalence is presented by gender, urbanisation level and ethnicity. EGIs congruent to the time points where obesity data are available are presented. Unadjusted time trend plots were applied to assess associations between obesity prevalence and EGIs by gender, urbanisation level and ethnicity. Females present higher levels of obesity relative to males for all time points. For both males and females, an overall increase in prevalence was observed in both rural and urban settings over-time, with urban dwellers presenting higher obesity levels. An overall increase in Gross Domestic Product (GDP) per capita and Household Final Consumption Expenditure (HFCE) per capita was observed. The Gini coefficient for all ethnicities except the White population increased between 1998 and 2003 but declined by 2012. Overtime per capita GDP and HFCE increased with increasing obesity prevalence in both genders. The trend association between the Gini coefficient for all ethnicities and obesity prevalence was similar for both genders in that as the Gini coefficient increased obesity prevalence declined, and when the coefficient decreased obesity prevalence increased. Trend associations exist between South Africa's economic growth and adult obesity.

Feasibility study of a targeted self-management intervention for reducing stroke risk factors in a high-risk population in Uganda

INTRODUCTION

Stroke remains a global concern due to increasing lifespan, patterns of industrialization, adoption of harmful western diets, and an increasing prevalence of risk factors such as hypertension, obesity, and diabetes. We investigated an adopted novel self-management intervention, TargetEd mAnageMent Intervention (TEAM) to reduce modifiable stroke risk factors in Uganda.

METHODS

A six-month, uncontrolled, prospective pilot study to establish feasibility, acceptability and preliminary efficacy of TEAM in Ugandans at high risk for stroke was conducted. The primary outcome was change in systolic BP from baseline to 24-week follow-up. Secondary outcomes included change in diastolic BP, serum cholesterol, high and low density lipoprotein (HDL, LDL) and triglycerides.

RESULTS

Mean (SD) baseline systolic BP was 162.9 (±25.6) mmHg while mean (SD) baseline diastolic BP was 99.1 (±13.8) mmHg. There was a significant reduction in mean baseline blood pressure of 163/98.8mmHg to blood pressure of 147.8/88.0mmHg at 24weeks, P=0.023. There were also significant reductions in the serum total cholesterol levels at 24weeks with P=0.001.

CONCLUSION

Targeted training in self-management (TEAM) adapted to the Ugandan setting is feasible, highly acceptable to participants and appears to be associated with reduced blood pressure, improved lipid profiles and improved glucose control in diabetics.

Cost-effectiveness of a complex workplace dietary intervention: an economic evaluation of the Food Choice at Work study

OBJECTIVE

To evaluate the costs, benefits and cost-effectiveness of complex workplace dietary interventions, involving nutrition education and system-level dietary modification, from the perspective of healthcare providers and employers.

DESIGN

Single-study economic evaluation of a cluster-controlled trial (Food Choice at Work (FCW) study) with 1-year follow-up.

SETTING

Four multinational manufacturing workplaces in Cork, Ireland.

PARTICIPANTS

517 randomly selected employees (18-65 years) from four workplaces.

INTERVENTIONS

Cost data were obtained from the FCW study. Nutrition education included individual nutrition consultations, nutrition information (traffic light menu labelling, posters, leaflets and emails) and presentations. System-level dietary modification included menu modification (restriction of fat, sugar and salt), increase in fibre, fruit discounts, strategic positioning of healthier alternatives and portion size control. The combined intervention included nutrition education and system-level dietary modification. No intervention was implemented in the control.

OUTCOMES

The primary outcome was an improvement in health-related quality of life, measured using the EuroQoL 5 Dimensions 5 Levels questionnaire. The secondary outcome measure was reduction in absenteeism, which is measured in monetary amounts. Probabilistic sensitivity analysis (Monte Carlo simulation) assessed parameter uncertainty.

RESULTS

The system-level intervention dominated the education and combined interventions. When compared with the control, the incremental cost-effectiveness ratio (€101.37/quality-adjusted life-year) is less than the nationally accepted ceiling ratio, so the system-level intervention can be considered cost-effective. The cost-effectiveness acceptability curve indicates there is some decision uncertainty surrounding this, arising from uncertainty surrounding the differences in effectiveness. These results are reiterated when the secondary outcome measure is considered in a cost-benefit analysis, whereby the system-level intervention yields the highest net benefit (€56.56 per employee).

CONCLUSIONS

System-level dietary modification alone offers the most value per improving employee health-related quality of life and generating net benefit for employers by reducing absenteeism. While system-level dietary modification strategies are potentially sustainable obesity prevention interventions, future research should include long-term outcomes to determine if improvements in outcomes persist.

TRIAL REGISTRATION NUMBER

ISRCTN35108237; Post-results.

The socioeconomic distribution of non-communicable diseases in Europe: findings from the European Social Survey (2014) special module on the social determinants of health

Background

A range of non-communicable diseases (NCDs) has been found to follow a social pattern whereby socioeconomic status predicts either a higher or lower risk of disease. Comprehensive evidence on the socioeconomic distribution of NCDs across Europe, however, has been limited.

Methods

Using cross-sectional 2014 European Social Survey data from 20 countries, this paper examines socioeconomic inequalities in 14 self-reported NCDs separately for women and men: heart/circulatory problems, high blood pressure, back pain, arm/hand pain, foot/leg pain, allergies, breathing problems, stomach/digestion problems, skin conditions, diabetes, severe headaches, cancer, obesity and depression. Using education to measure socioeconomic status, age-controlled adjusted risk ratios were calculated and separately compared a lower and medium education group with a high education group.

Results

At the pooled European level, a social gradient in health was observed for 10 NCDs: depression, diabetes, obesity, heart/circulation problems, hand/arm pain, high blood pressure, breathing problems, severe headaches, foot/leg pain and cancer. An inverse social gradient was observed for allergies. Social gradients were observed among both genders, but a greater number of inequalities were observed among women. Country-specific analyses show that inequalities in NCDs are present everywhere across Europe and that inequalities exist to different extents for each of the conditions.

Conclusion

This study provides the most up-to-date overview of socioeconomic inequalities for a large number of NCDs across 20 European countries for both women and men. Future investigations should further consider the diseases, and their associated determinants, for which socioeconomic differences are the greatest.

Gaps In Primary Care And Health System Performance In Six Latin American And Caribbean Countries

The rapid demographic and epidemiological transitions occurring in Latin America and the Caribbean have led to high levels of noncommunicable diseases in the region. In addition to reduced risk factors for chronic conditions, a strong health system for managing chronic conditions is vital. This study assessed the extent to which populations in six Latin American and Caribbean countries receive high-quality primary care, and it examined the relationship between experiences with care and perceptions of health system performance. We applied a validated survey on access, use, and satisfaction with health care services to nationally representative samples of the populations of Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama. Respondents reported considerable gaps in the ways in which primary care is organized, financed, and delivered. Nearly half reported using the emergency department for a condition they considered treatable in a primary care setting. Reports of more primary care problems were associated with worse perceptions of health system performance and quality and less receipt of preventive care. Urgent attention to primary care performance is required as the region's population continues to age at an unprecedented rate.

The complications of treating chronic obstructive pulmonary disease in low income countries of sub-Saharan Africa

INTRODUCTION

In most low and middle-income countries, chronic obstructive pulmonary disease (COPD) is on the rise. Areas covered: Unfortunately, COPD is a neglected disease in these countries. Taking sub-Saharan Africa as an example, in rural areas, COPD is even unknown regarding public awareness and public health planning. Programs for the management of COPD are poorly developed, and the quality of care is often of a low standard. Inhaled medication is often not available or not affordable. Tobacco smoking is the most common encountered risk factor for COPD. However, in sub-Saharan Africa, household air pollution is another major risk factor for the development of COPD. Communities are also exposed to a variety of other risk factors, such as low birth weight, malnutrition, severe childhood respiratory infections, occupational exposures, outdoor pollution, human-immunodeficiency virus and tuberculosis. All these factors contribute to the high burden of poor respiratory health in sub-Saharan Africa. Expert commentary: A silent growing epidemic of COPD seems to be unravelling. Therefore, prevention and intervention programs must involve all the stakeholders and start as early as possible. More research is needed to describe, define and inform treatment approaches, and natural history of biomass-related COPD.

In Vitro Antioxidant Potential and Effect of a Glutathione-Enhancer Dietary Supplement on Selected Rat Liver Cytochrome P450 Enzyme Activity

BACKGROUND

There is considerable evidence that many people take dietary supplements including those of herbal origin as an alternative therapy to improve their health. One such supplement, with an amalgam of constituents, is CellGevity®. However, the effect of this dietary supplement on drug-metabolizing enzymes is poorly understood, as it has not been studied extensively. Therefore, we investigated the effect of CellGevity dietary supplement on selected rat liver microsomal cytochrome P450 (CYP) enzymes, the most common drug-metabolizing enzymes. We also determined the total antioxidant potential of this dietary supplement in vitro.

METHODS

To determine the antioxidant potential of CellGevity dietary supplement, 2,2-diphenyl-2-picryl-hydrazyl (DPPH), total phenolic, and flavonoid assays were used after initial preparation of a solution form of the supplement (low dose, LD; 4 mg/kg and high dose, HD; 8 mg/kg). Rats received oral administration of these doses of the supplement for 7 days, after which the effect of the supplement on selected liver CYP enzymes was assessed using probe substrates and spectroscopic and high-performance liquid chromatographic methods. Rats which received daily administration of 80 mg/kg of phenobarbitone and distilled water served as positive and negative controls, respectively.

RESULTS

The IC₅₀ value of the supplement 0.34 ± 0.07 mg/ml compared to 0.076 ± 0.03 mg/ml of the BHT (positive control). The total phenolic content of the supplement at a concentration of 2.5 mg/ml was 34.97 g gallic acid equivalent (GAE)/100 g while its total flavonoid content at a concentration of 2.5 mg/ml was 6 g quercetin equivalent (QE)/100 g. The supplement significantly inhibited rat CYP2B1/2B2 (LDT 92.4%; HDT 100%), CYP3A4 (LDT 81.2%; HDT 71.7%), and CYP2C9 (LDT 21.7%; HDT 28.5%) while it had no significant inhibitory effect on CYPs 1A1/1A2, CYP1A2, and CYP2D6.

CONCLUSION

CellGevity dietary supplement possesses moderate antioxidant activity in vitro and has an inhibitory effect on selected rat liver CYP enzymes, suggesting its potential interaction with drugs metabolized by CYP enzymes.

Healthcare choices in Mumbai slums: A cross-sectional study

Background: Informal urban settlements, known as slums, are the home for a large proportion of the world population. Healthcare in these environments is extremely complex, driven by poverty, environmental challenges, and poor access to formal health infrastructures. This study investigated healthcare challenges faced and choices made by slum dwellers in Mumbai, India. Methods: Structured interviews with 549 slum dwellers from 13 slum areas in Mumbai, India, were conducted in order to obtain a population profile of health-related socio-economic and lifestyle factors, disease history and healthcare access. Statistical tools such as multinomial logistic regression were used to examine the association between such factors and health choices. Results: Private providers (or a mixture of public and private) were seen to be preferred by the study population for most health conditions (62% - 90% health consultations), apart from pregnancy (43% health consultations). Community-based services were also preferred to more remote options. Stark differences in healthcare access were observed between well-known conditions, such as minor injuries, pulmonary conditions, and pregnancy and emerging challenges, such as hypertension and diabetes. A number of socio-economic and lifestyle factors were found to be associated with health-related decisions, including choice of provider and expenditure. Conclusions: Better planning and coordination of health services, across public and private providers, is required to address mortality and morbidity in slum communities in India. This study provides insights into the complex landscape of diseases and health providers that slum dwellers navigate when accessing healthcare. Findings suggest that integrated services and public-private partnerships could help address demand for affordable community-based care and progress towards the target of universal health coverage.

Development and Evaluation of a Hematology-Oriented Clinical Research Training Program in Latin America

The objectives of the study were to describe the development of a patient-oriented clinical research training program in a low- or middle-income country (LMIC) setting, to describe perceived benefits of the program and barriers to application, and to make recommendations for future training programs. The program was developed by the American Society of Hematology in collaboration with Latin American stakeholders and clinical researchers. Session types were didactic, small group, and one-on-one faculty/participant dyad formats. Outcomes were assessed by quantitative surveys of trainees and qualitative feedback from both trainees and faculty members. The program is an annual 2-day course specifically for Latin American hematologists. Through course evaluations, all trainees described that the didactic sessions were relevant. All session types were useful for gaining knowledge and skills, particularly one-on-one meetings. The potential for networking was highly valued. Barriers to trainee applications were the concerns that skill level, proposed research program, and knowledge of English were not sufficiently strong to warrant acceptance into the course, and financial costs of attendance. We have described the development and initial evaluation of a clinical research training program in a LMIC setting. We learned several valuable lessons that are applicable to other research training programs.

Gender-Related Differences and Short-Term Outcome of Stroke: Results from a Hospital-Based Registry in Sub-Saharan Africa

BACKGROUND

Studies suggest that sex differences have an impact on patients with stroke, but existing data in Africa remain inconclusive about this inference.

OBJECTIVES

To study sex differences in terms of the clinical profile and short-term outcome of stroke in the Douala General Hospital, Cameroon.

METHODS

A hospital-based prospective cohort study was carried out in a tertiary care hospital over an 8-year period, which included all patients admitted for confirmed acute stroke. Information about the history of stroke with emphasis on clinical profile and outcome was collected. Descriptive statistics, t test, and chi square test were used for comparisons, while the Kaplan-Meier curve was used for survival rate analysis.

RESULTS

Of the 818 patients included, 455 (55.6%) were male patients. When compared to males, female patients are more likely to experience a stroke at an older age (mean age 62.3 ± 14.1 vs. 58.4 ± 12.9 years, p < 0.001), to be unmarried, to remain unemployed, and to have higher rates of cardio-embolic stroke (p = 0.049), body mass index (p = 0.031), altered levels of consciousness at presentation (p = 0.005), higher mean HDL cholesterol levels (p = 0.001), and in-hospital complications (p = 0.011), especially urinary tract infections (p = 0.018). Males were more likely to have health insurance, to smoke, to consume alcohol (p < 0.001), and to have higher rates of dysarthria (p = 0.004), higher mean uric acid (p = 0.013), and creatinine (p < 0.001) concentrations. Ischemic and hemorrhagic strokes were more prevalent in men (p = 0.003). There are no sex differences in terms of stroke severity, length-of-hospital stay, case fatality, and functional outcome on admission.

CONCLUSIONS

Sex differences exist in the clinical profile of stroke but not in the outcome. Knowledge of these differences could help influence stroke prevention, thereby improving stroke burden in Africa.