The reported impact of non-communicable disease investment cases in 13 countries

Non-communicable diseases (NCDs) are a leading health and development challenge worldwide. Since 2015, WHO and the United Nations Development Programme have provided support to governments to develop national NCD investment cases to describe the socioeconomic dimensions of NCDs. To assess the impact of the investment cases, semistructured interviews and a structured process for gathering written feedback were conducted between July and October 2022 with key informants in 13 countries who had developed a national NCD investment case between 2015 and 2020. Investment cases describe: (1) the social and economic costs of NCDs, including their distribution and projections over time; (2) priority areas for scaled up action; (3) the cost and returns from investing in WHO-recommended measures to prevent and manage NCDs; and (4) the political dimensions of NCD responses. While no country had implemented all the recommendations set out in their investment case reports, actions and policy changes attributable to the investment cases were identified, across (1) governance; (2) financing; and (3) health service access and delivery. The pathways of these changes included: (1) stronger collaboration across government ministries and partners; (2) advocacy for NCD prevention and control; (3) grounding efforts in nationally owned data and evidence; (4) developing mutually embraced 'language' across health and finance; and (5) elevating the priority accorded to NCDs, by framing action as an investment rather than a cost. The assessment also identified barriers to progress on the investment case implementation, including the influence of some private sector entities on sectors other than health, the impact of the COVID-19 pandemic, and changes in senior political and technical government officials. The results suggest that national NCD investment cases can significantly contribute to catalysing the prevention and control of NCDs through strengthening governance, financing, and health service access and delivery.

Exploring educational inequalities in hypertension control, salt knowledge and awareness, and patient advice: insights from the WHO STEPS surveys of adults from nine Eastern European and Central Asian countries

OBJECTIVE

To inform strategies aimed at improving blood pressure (BP) control and reducing salt intake, we assessed educational inequalities in high blood pressure (HBP) awareness, treatment and control; physician's advice on salt reduction; and salt knowledge, perceptions and consumption behaviours in Eastern Europe and Central Asia.

DESIGN

Data were collected in cross-sectional, population-based nationally representative surveys, using a multi-stage clustered sampling design. Five HBP awareness, treatment and control categories were created from measured BP and hypertension medication use. Education and other variables were self-reported. Weighted multinomial mixed-effects regression models, adjusted for confounders, were used to assess differences across education categories.

SETTINGS

Nine Eastern European and Central Asian countries (Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan).

PARTICIPANTS

Nationally representative samples of 30 455 adults aged 25-65 years.

RESULTS

HBP awareness, treatment and control varied substantially by education. The coverage of physician's advice on salt was less frequent among participants with lower education, and those with untreated HBP or unaware of their HBP. The education gradient was evident in salt knowledge and perceptions of salt intake but not in salt consumption behaviours. Improved salt knowledge and perceptions were more prevalent among participants who received physician's advice on salt reduction.

CONCLUSIONS

There is a strong education gradient in HBP awareness, treatment and control as well as salt knowledge and perceived intake. Enhancements in public and patient knowledge and awareness of HBP and its risk factors targeting socio-economically disadvantaged groups are urgently needed to alleviate the growing HBP burden in low- and middle-income countries.

Suboptimal Intake of Fruits and Vegetables in Nine Selected Countries of the World Health Organization European Region

The objective of this study was to characterize fruit and vegetable consumption in 9 selected countries of the World Health Organization (WHO) European Region. We analyzed data on fruit and vegetable intake and participant sociodemographic characteristics for 30,455 adults in 9 Eastern European and Central Asian countries via standardized STEPS survey methodology. Fruit and vegetable consumption across all countries was suboptimal, with a high percentage of populations not meeting the WHO-recommended intake of at least 5 servings (400 g) per day. Strengthened implementation of evidence-based policies to increase intake of fruit and vegetables is needed to reduce the burden of and disparities in NCDs.

S02-5 Physical inactivity in nine Eastern European and Central Asian countries: results from the WHO STEPwise approach to NCD risk factor surveillance

Background

Physical inactivity is a major risk factor for noncommunicable diseases. This paper explores patterns of physical inactivity in Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Moldova, Tajikistan, Türkiye and Uzbekistan.

Methods

Nationally-representative data were collected through the WHO STEPwise survey of noncommunicable disease risk factors, which utilizes the Global Physical Activity Questionnaire (GPAQ) to estimate population physical inactivity.

Results

The prevalence of physical inactivity varied across the region, from 11.4 to 44.7%, and was higher among women than men in all countries except for Armenia, Belarus and Moldova. In most countries, the highest proportion of physical activity levels were registered during work time and appeared to vary according to the countries’ level of development. For both sexes and across all populations, time spent on leisure or recreational physical activity was low.

Conclusions

These results have important implications for policy, including actions to promote active travel and leisure-time physical activity as countries develop economically. Investments in workplace physical activity programmes and infrastructure are needed as populations transition to sedentary from more physically active occupations. The results reiterate the need for multisectoral policies, programmes and interventions to promote physical activity tailored to the local context.

Physical inactivity in nine European and Central Asian countries: an analysis of national population-based survey results

Background

Physical inactivity is a major risk factor for non-communicable diseases. However, recent and systematically obtained national-level data to guide policy responses are often lacking, especially in countries in Eastern Europe and Central Asia. This article describes physical inactivity patterns among adults in Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan.

Methods

Data were collected using the Global Physical Activity Questionnaire drawing nationally representative samples of adults in each country. The national prevalence of physical inactivity was calculated as well as the proportional contribution to total physical activity (PA) during work, transport and leisure-time. An adjusted logistic regression model was applied to analyze the association of age, gender, education, household status and income with physical inactivity.

Results

National prevalence of physical inactivity ranged from 10.1% to 43.6%. The highest proportion of PA was registered during work or in the household in most countries, whereas the lowest was during leisure-time in all countries. Physical inactivity was more likely with older age in eight countries, with female gender in three countries, and with living alone in three countries. There was no clear pattern of association with education and income.

Conclusion

Prevalence of physical inactivity is heterogeneous across the region. PA during leisure-time contributes minimally to total PA in all countries. Policies and programs that increase opportunities for active travel and leisure-time PA, especially for older adults, women and people living alone will be an essential part of strategies to increase overall population PA.

Estimating the impact of achieving Turkey's non-communicable disease policy targets: A macro-simulation modelling study

BACKGROUND

The Burden of non-communicable disease (NCDs) has continued to rise globally, particularly in low- and middle-income countries. In Turkey, NCDs account for 89% of all deaths, with nearly one in five deaths occurring before age 70. This study investigates the number of NCD deaths that could be prevented if Turkey met national and international targets for major modifiable NCD risk factors.

METHODS

Preventable deaths were estimated using the World Health Organization (WHO) 'Preventable Risk Integrated ModEl' (PRIME), by combining: 1) Baseline exposure data for risk factors, referenced from national surveillance and cohort studies; 2) Aetiological associations from published meta-analyses; and 3) Demographic and mortality statistics obtained from the Turkish Statistical Institute (TurkStat). Confidence intervals were estimated using Monte Carlo simulations.

FINDINGS

If Turkey met its NCD risk factor targets for reducing tobacco and salt consumption by 30%, and physical inactivity by 10% in 2017, an estimated 19,859 deaths (95%CI: 12,802 to 26,609) could have been prevented. Approximately two thirds of these preventable deaths were in men, and one in three were in adults below 75 years. A 30% relative reduction in the consumption of alcohol, tobacco, and salt, as well as physical inactivity, would prevent 180 (107 to 259); 4,786 (3,679 to 5,836); 13,112 (5,819 to 19,952); and 7,124 (5,053 to 9,212) deaths, respectively.

INTERPRETATION

Among major modifiable NCD risk factors, population-level reductions in salt intake and physical inactivity present the greatest opportunity for reducing NCD mortality in Turkey. These findings can help Turkey prioritise interventions to meet the Sustainable Development Goal target of reducing NCD mortality by one third, by 2030.

The perspectives of politicians on tobacco control in Turkey

Background

Tobacco use is a leading but preventable cause of non-communicable diseases and premature death. The legislature has a key role in setting tobacco control policies. Smoking trends are decreasing thanks to the introduction of effective tobacco control policies in Turkey and these policies may have been shaped by how politicians' interpreted social problems that were prominent during the development and implementation of tobacco regulations.

Aim

This paper explores the long-term national relationship between tobacco consumption, tobacco control policies and the associated political discourse in Turkey, considering the varying influences through national leadership on this important public health agenda. This relationship is studied by comparing a time series analysis of tobacco consumption trends with a policy analysis of the minutes of deliberations at the Grand National Assembly of Turkey (GNAT).

Methods

This study uses Bayesian time series analysis in order investigate whether the tobacco control policies and related activities influenced the annual per adult cigarette consumption in Turkey. We used a novel method to identify change points in tobacco trends and whether they correspond with key policy changes intended to alter usage after adjusting for the effect of other non-policy related covariates, such as the purchasing power. The policy analysis included an examination of the minutes of deliberations at the GNAT-which is the Turkish parliament and unicameral Turkish legislature-1 year before and 1 year after the break years associated with an increase or decrease in tobacco consumption.

Results and recommendations

Tobacco consumption increased with the encouragement of tobacco production and the entrance of multinational companies in the country in 1976 and 1993, respectively. The National Tobacco Law of 1996 and comprehensive amendments in 2008, including smoke-free public places and tax increases, appear to have helped reduce tobacco consumption in Turkey. The focus of Parliamentary discussions throughout this period changed, becoming less supportive of tobacco over time. However, throughout the period there remained discussions focussing on concerns around the implications for the economy and the privatization agenda, national agriculture and the welfare of farmers. Effective control appears to require certain political ingredients to be implemented: politicians who are well informed on tobacco control measures and understand the range of issues surrounding the policies (not only those directly health-related); and supportive public health information in the community. Evidence-based public health policy should be introduced to the politicians.

Cigarette prices and smoking prevalence after a tobacco tax increase--Turkey, 2008 and 2012

Raising the price of tobacco products has been shown to reduce tobacco consumption in the United States and other high-income countries, and evidence of this impact has been growing for low- and middle-income countries as well. Turkey is a middle-income country surveyed by the Global Adult Tobacco Survey (GATS) twice in a 4-year period, in 2008 and 2012. During this time, the country introduced a policy raising its Special Consumption Tax on Tobacco and implemented a comprehensive tobacco control program banning smoking in public places, banning advertising, and introducing graphic health warnings. The higher tobacco tax took effect in early 2010, allowing sufficient time for subsequent changes in prices and smoking to be observed by the time of the 2012 GATS. This report uses data from GATS Turkey to examine how cigarette prices changed after the 2010 tax increase, describe the temporally associated changes in smoking prevalence, and learn whether this smoking prevalence changed more in some demographic groups than others. From 2008 to 2012, the average price paid for cigarettes increased by 42.1%, cigarettes became less affordable, and smoking prevalence decreased by 14.6%. The largest reduction in smoking was observed among persons with lower socioeconomic status (SES), highlighting the potential role of tax policy in reducing health disparities across socioeconomic groups.

Global Health Professions Student Survey--Turkey: second-hand smoke exposure and opinions of medical students on anti-tobacco law

AIM

This study, as a part of "the Global Health Professions Student Survey" (GHPSS), aimed to assess medical students' tobacco use, exposure to second-hand tobacco smoke (SHS), and opinions as well as smoking policies at medical faculties in Turkey.

METHODS

The study was conducted in 2010 as a school-based survey of third-year students in 12 medical schools. GHPSS uses a standardised methodology for selecting schools (probability proportional to student enrolment size) and data processing. In total, data from 1,217 of third year medical students were analysed.

RESULTS

Prevalence of current tobacco use among participating students was 28.5%. Exposure to SHS in the last seven days was 46.9% at home, and 42.2% in other places. Among smokers, over 7 in 10 students reported smoking on medical school premises during the past 30 days and the past year.

CONCLUSION

Medical students' exposure to SHS is common and smoking on medical school premises/buildings constitutes a problem. Turkey passed an anti-tobacco law in 2008, yet enforcement of the law must be stronger. In addition, medical schools must evaluate, and likely revise their education curricula to better prepare medical students to advocate tobacco control.

Effect of policy changes on cigarette sales: the case of Turkey

BACKGROUND

In 1996, Turkey made tobacco control a health priority. The tobacco control effort was extended in July 2009 with the expansion of the smoke-free law to include all enclosed workplaces and public places and, in January 2010, with a 20% increase in the Special Consumption Tax on Tobacco.

METHODS

Sales data were averaged, by month, for the period January 2005 through June 2009 to establish an 'expected' monthly sales pattern. This was the period when no new tobacco control measures were implemented. The overall monthly average was then calculated for the same period. The expected monthly sales pattern was then graphed against the overall monthly sales average to delineate a seasonal sales pattern that was used to evaluate the divergence of actual monthly sales from the 'expected' pattern.

RESULTS

A distinct seasonal pattern was found with sales above average from May through August. Comparison of actual cigarette sales to the 'expected' monthly sales pattern following the implementation of the expanded smoke-free law in July resulted in a 5.2% decrease. Cigarettes sales decreased by 13.6% following the January 2010 Special Consumption Tax. Since the implementation of the expanded smoke-free law in July 2009 and the tax increase in January 2010, cigarette sales in Turkey decreased by 10.7%.

CONCLUSION

The effect of recent Turkish tobacco control policies could contribute to a reduction in the number of premature deaths related to tobacco use. Evidence has shown that periodic tax increases and strong enforcement of all tobacco control policies are essential to further decrease tobacco consumption.

Linking Global Youth Tobacco Survey (GYTS) data to tobacco control policy in Turkey--2003 and 2009

OBJECTIVE

The purpose of this paper is to use data from the Global Youth Tobacco Survey (GYTS) conducted in Turkey in 2003 and 2009 to examine changes in tobacco use and important tobacco control measures.

METHODS

The GYTS were conducted in grades 7-9 in 2003 and 7-10 in 2009 in Turkey. Data in this paper are limited to 13 to 15 year old students. A total of 15,957 students from 202 schools participated in 2003 and 5,054 students from 69 schools participated in 2009. The overall response rate was 92.1% in 2003 and 87.5% in 2009.

RESULTS

Between 2003 and 2009 current cigarette smoking did not change significantly for either boys (9.4% to 10.2%) or girls (3.5% to 5.3%). Current cigarette smoking was higher among boys than girls in 2003 and in 2009. In 2009, half of students reported they had been exposed to second hand smoking (SHS) at home and 80% reported they had been exposed to SHS in public places. Three in ten students reported they had been exposed to pro-tobacco advertising in newspapers or magazines; one in ten had an object with a cigarette brand logo on it; and 7% had been offered free cigarettes by a cigarette company representative. Two-thirds of current cigarette smokers reported that they wanted to stop smoking; and almost two-thirds had been taught in school in the past year about the dangers of smoking.

CONCLUSION

Passing and implementing the Law No. 4207 on Prevention of Hazards of Tobacco Products, ratifying the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), raising tax on tobacco, and requiring pictorial warning labels were important steps forward for tobacco control in Turkey. However, as to the tobacco control much work yet to be accomplished including developing an effective enforcement plan for all tobacco control efforts.

Tobacco use among institutionalized adolescents in Turkey: does social environment affect the risk?

OBJECTIVES

The study aimed to estimate smoking prevalence and associated risk factors among Turkish adolescents residing in orphanages and to investigate whether "institutionalization" (i.e., factors leading to institutionalization and/or those present in the institutional environment) makes adolescents more prone "to try" and/or "continue" smoking.

METHODS

An institution-based survey was conducted in all orphanages in Turkey and included 6,220 adolescents. Effects of institutionalization on smoking were further evaluated based on comparisons with external data obtained from an earlier survey of non-institutionalized Turkish students.

RESULTS

Of the participants: 57% had ever smoked cigarettes; 29.3% were current cigarette smokers; and exposure to secondhand smoke (SHS) was above 80.0%. Compared to non-institutionalized adolescents, institutionalized adolescents seem to be more prone to start and continue smoking; have higher access to tobacco; know less about the health hazards of smoking; and have higher prevalence of addiction, especially among girls.

CONCLUSIONS

Smoking prevalence among institutionalized adolescents is quite high; they have an environment favoring smoking and the gender gap in smoking rates is closing. An effective tobacco-control program based on evidence, tailored to the specific needs, and combined with a motivating environment is required to decrease tobacco consumption among institutionalized youngsters.

Experience of workplace violence during medical speciality training in Turkey

AIMS

To determine the type, extent and effects of workplace violence among residents during postgraduate speciality training in various departments of medical schools in Turkey.

METHODS

A cross-sectional survey was conducted in seven medical schools representing all geographical regions of Turkey. All physicians in speciality training in the selected medical schools were asked to complete a semi-structured 'violence questionnaire' addressing the type (emotional, physical and sexual) and extent of violence experienced, the perpetrators of the violence and the victim's reactions to the experience.

RESULTS

A total of 1712 residents out of 2442 completed the questionnaire. In all, 68% indicated they had experienced some form of workplace violence, 67% had experienced verbal violence, 16% had experienced physical violence and 3% had experienced sexual violence. The victims' most prevalent reactions to violence included being deeply disturbed but feeling they had to cope with it for the sake of their career (39%), being distressed (26%) but considering that such events are common in all occupations and discounting it and being confused and bewildered and unsure how to respond (19%). The most frequently named perpetrators of verbal violence were relatives/friends of patients (36%) and academic staff (36%), followed by other residents/senior residents (21%), patients (20%), heads of department (13%) and non-medical hospital staff (6%).

CONCLUSIONS

Physicians in speciality training in medical schools in Turkey are subject to significant verbal, physical or sexual violence. Precautions to prevent such exposure are urgently needed.

Tobacco use among youth and related characteristics, Turkey

OBJECTIVES

To provide nationally representative data on smoking prevalence of Turkish adolescents; to examine their knowledge, attitude and exposure to tobacco.

METHODS

A school-based representative survey of adolescents (13-15 years) was conducted within the frame of Global Youth Tobacco Survey (GYTS). 15957 students were selected using a two-stage cluster sampling method and completed an internationally standardized questionnaire on tobacco use and related factors.

RESULTS

About one-third of students had already experienced smoking and 10% were current smokers. Rate of exposure to passive smoking was high both in current smokers (89.0%) and never smokers (79.2%). More than one-third of current smokers had intended to quit. Susceptibility to initiate smoking was fairly high among never smokers, especially in boys (9.1% versus 5.8%). Considerable proportions of both never, and current smokers had positive attitude toward tobacco use. Half of the students had no school curriculum about the effects of tobacco use.

CONCLUSIONS

Smoking prevalence among Turkish adolescents is alarmingly high and the gender gap is closing. A relevant legislation is a must for success in tobacco control but should be combined by other effective prevention and cessation programs.