Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey

Classification of patients with chronic disease by activation level using machine learning methods

Patient Activation Measure (PAM) measures the activation level of patients with chronic conditions and correlates well with patient adherence behavior, health outcomes, and healthcare costs. PAM is increasingly used in practice to identify patients needing more support from the care team. We define PAM levels 1 and 2 as low PAM and investigate the performance of eight machine learning methods (Logistic Regression, Lasso Regression, Ridge Regression, Random Forest, Gradient Boosted Trees, Support Vector Machines, Decision Trees, Neural Networks) to classify patients. Primary data collected from adult patients (n=431) with Diabetes Mellitus (DM) or Hypertension (HT) attending Family Health Centers in Istanbul, Turkey, is used to test the methods. [Formula: see text] of patients in the dataset have a low PAM level. Classification performance with several feature sets was analyzed to understand the relative importance of different types of information and provide insights. The most important features are found as whether the patient performs self-monitoring, smoking and exercise habits, education, and socio-economic status. The best performance was achieved with the Logistic Regression algorithm, with Area Under the Curve (AUC)=0.72 with the best performing feature set. Alternative feature sets with similar prediction performance are also presented. The prediction performance was inferior with an automated feature selection method, supporting the importance of using domain knowledge in machine learning.

Barriers Toward the National Program for Prevention and Control of Diabetes in Iran: A Qualitative Exploration

BACKGROUND

Despite the achievements of the national program for the prevention and control of diabetes (NPPCD) over the past two decades, the available evidence indicates a high prevalence of this disease in Iran. This qualitative study aims to investigate barriers to the NPPCD by pursuing the perspectives of relevant policy-makers, planners, and healthcare workers.

METHODS

A grounded theory approach was used to analyze participants' perceptions and experiences. Semi-structured interviews (n=23) and eight focus groups (n=109) were conducted with relevant policy-makers, planners, and healthcare workers in charge of Iran's national diabetes management program. Of the 132 participants, ages ranged from 25 to 56 years, and 53% were female. Constant comparative analysis of the data was conducted manually, and open, axial, and selective coding was applied to the data.

RESULTS

Two main themes emerged from data analysis: implementation barriers and inefficient policy-making/ planning. Insufficient financial resources, staff shortage and insufficient motivation, inadequate knowledge of some healthcare workers, and defects in the referral system were recognized as the NPPCD implementation barriers. Inappropriate program prioritizing, the lack of or poor intersectoral collaboration, and the lack of an effective evaluation system were the inefficient policy-making/planning problems.

CONCLUSION

Current results highlighted that inefficient policy-making and planning have led to several implementation problems. Moreover, the key strategies to promote this program are prioritizing the NPPCD, practical intersectoral collaboration, and utilizing a more efficient evaluation system to assess the program and staff performance.

Current gaps in management and timely referral of cardiorenal complications among people with type 2 diabetes mellitus in the Middle East and African countries: Expert recommendations

The upsurge of type 2 diabetes mellitus is a major public health concern in the Middle East and North Africa (MENA) and Africa (AFR) region, with cardiorenal complications (CRCs) being the predominant cause of premature morbidity and mortality. High prevalence of cardiometabolic risk factors, lack of awareness among patients and physicians, deficient infrastructure, and economic constraints lead to a cascade of CRCs at a significantly earlier age in MENA and AFR. In this review, we present consensus recommendations by experts in MENA and AFR, highlighting region-specific challenges and potential solutions for management of CRCs. Health professionals who understand sociocultural barriers can significantly increase patient awareness and encourage health-seeking behavior through simple educational tools. Increasing physician knowledge on early identification of CRCs and personalized treatment based on risk stratification, alongside optimum glycemic control, can mitigate therapeutic inertia. Early diagnosis of high-risk people with regular and systematic monitoring of cardiorenal parameters, development of region-specific care pathways for timely referral to specialists, followed by guideline-recommended care with novel antidiabetics are imperative. Adherence to guideline-recommended care can catalyze utilization of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists with demonstrated cardiorenal benefits-thus paving the way for overcoming care gaps in a cost-effective manner. Leveraging digital technology like electronic medical records can help generate real-world data and provide insights on voids in adoption of newer antidiabetic medications. A patient-centric approach, collaborative care among physicians from different specialties, alongside involvement of policy makers are key for improving patient outcomes and quality of care in MENA and AFR.

A critical review of national diabetes prevention and control programs in 12 countries in Middle East

BACKGROUND

Diabetes mellitus has been known as one of the most significant systemic diseases with severe consequences and challenges to human health.

AIM

The primary aim of the current paper was to review the diabetes prevention programs in the Middle East countries, and secondary compare their goals and success rate and conclude possible upcoming strategies.

METHODS

All reports and documents regarding to diabetes prevention and control programs in the region were collected by searching Web of Science, PubMed, MEDLINE, Google Scholar, Scopus and EMBASE for articles up to 2020. The health policy triangle framework was used to analyze diabetes policies and programs. In the Middle East, a shift from rural to urban life, socioeconomic development, sedentary lifestyles, and high fat and sugary foods consumption led to increasing in obesity and diabetes rate, which have become a real challenge.

RESULTS

To decrease the burden of diabetes, preventive strategies with proper local socio-cultural context are needed. Evaluation of current policies and identifying stakeholders' views can help to improve the current strategies for the prevalence of diabetes and its complications.

CONCLUSIONS

It can provide local and global insight to evidence-informed decision-making for future policy reforms to enhance effectiveness of the program.

Aljaberi M. Correlation of Mortality Burdens of Cerebrovascular Disease and Diabetes Mellitus with Domestic Consumption of Soya and Palm Oils

BACKGROUND

Cerebrovascular diseases (CBVDs) and diabetes mellitus (DM) are interrelated and cumbersome global health burdens. However, the relationship between edible oils consumption and mortality burdens of CBVDs and DM has not yet been evaluated. This review aims to explore correlations between per capita mortality burdens of CBVDs and DM, as well as food consumption of palm or soya oils in 11 randomly selected countries in 2005, 2010, and 2016.

METHODS

After obtaining data on food consumption of palm and soya oils and mortality burdens of CBVDs and DM, correlations between the consumption of oils and mortality burdens of diseases were explored.

RESULTS

There was a positive correlation between the consumption of soya oil with the mortality burden of CBVDs in Australia, Switzerland, and Indonesia, as well as the mortality burden of DM in the USA. The consumption of palm oil had a positive correlation with the mortality burden of DM in Jordan only.

CONCLUSIONS

Food consumption of soya oil in several countries possibly contributes to the mortality burden of CBVDs or DM more than food consumption of palm oil, which could be a possible risk factor in the mortality burdens of CBVDs and DM.

Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research

BACKGROUND

Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes.

METHODS

A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data.

RESULTS

Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data.

CONCLUSION

We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO-academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.

Metabolic health in the Middle East and north Africa

The Middle East and north Africa are home to different populations with widely varying cultures, histories, and socioeconomic settings. Hence, their health status, health management, and access to appropriate health care differ accordingly. In this Review, we examine data on the historical and prospective status of metabolic diseases in this region including obesity, diabetes, hypertension, dyslipidaemia, and non-alcoholic fatty liver disease. Women in the Middle East and north Africa have the highest risk of metabolic diseases of all women globally, whereas men rank second of all men in this respect. Metabolic risk factors are responsible for more than 300 deaths per 100 000 individuals in this region, compared with a global mean of fewer than 250. Physical inactivity, especially in women, and an unhealthy diet (ie, low consumption of whole grains, nuts, and seafoods) stand out. More than one in every three women are obese in most countries of the region. Prevention programmes have not fully been achieved in most of these countries and the projected future is not optimistic. Comprehensive surveillance and monitoring of metabolic diseases, robust multisectoral systems that support primordial and primary preventions, continuous education of health-care providers, as well as collaboration between countries for joint projects in this region are urgently needed to overcome the paucity of data and to improve the metabolic health status of inhabitants in the Middle East and north Africa.

Challenges in the implementation of primary health care reforms: a qualitative analysis of stakeholders' views in Turkey

OBJECTIVES

This study aims to assess the implementation of the Family Medicine Programme (FMP), which has taken place in Turkey from 2005 to 2010 as a set of comprehensive primary health care (PHC) reforms and involved changes in professional organisation (eg, family medicine specialisation) and service provision (eg, patients' registration list). Our particular interest is to identify the challenges and limitations that PHC physicians and academicians have encountered in the implementation of the FMP which could have influenced the delivery of care and utilisation of services.

DESIGN

We applied the framework method to analyse data obtained through semi-structured interviews conducted in the field. This qualitative approach involved the categorisation of raw data into a predefined framework, which comprised challenges and limitations identified in the literature, and the emergence of a new framework, whose categories corresponded to challenges and limitations identified through thematic analysis of our data.

SETTING

PHC centres and academic departments from five Turkish provinces.

PARTICIPANTS

PHC physicians and academicians involved in training and/or research were invited to participate. 20 participants agreed to take part and, due to schedule limitations, 15 participants (seven PHC physicians and eight academicians) completed the interviews.

RESULTS

Shortcomings in the planning of the reforms, inadequate commitment to integration of PHC in the system and collateral effects of a market model in healthcare emerged as limitations to successful FMP implementation. Uncertainty about care quality and physicians' ethical values as well as perceptions of organisational injustice among healthcare workers were contributing challenges.

CONCLUSIONS

A systems thinking approach in the FMP design and implementation could help foresee and address these limitations. In decentralisation processes, such as FMP, shared governance by including PHC stakeholders in policy-making and planning could alleviate misalignment of interests and positively affect PHC performance, for example, by removing barriers to gatekeeping implementation.

Ottawa charter framework as a guide for type 2 diabetes prevention and control in Iran

The growth of T2DM in Iran is predicted to be even greater than the global trend. So a new public health movement to effectively prevent and manage T2DM is required more than ever. The solution has lain in the heart of the Ottawa Charter, the first international conference on health promotion more than 30 years ago. The charter contains five useful actions to facilitate the process of diseases prevention and control: 1) building healthy public policy, 2) creating supportive environments, 3) strengthening community action, 4) developing personal skills, and 5) reorienting health care services toward promotion of health. The charter articulates health in all policies and their frameworks. The aim of this review is to examine how the five actions have been implemented in Iran and can serve as a guide to prevent and control diabetes. Several national case studies will be examined to illustrate the challenges facing Iran's health system. It enables the identification and sharing of best practice between countries.

Family physicians' views on their role in the management of childhood obesity: a mixed methods study from Turkey

BACKGROUND

Childhood obesity (CO) is a high priority issue due to its serious health consequences and its rapid increase.

OBJECTIVES

To examine the views of primary care physicians (family physicians, FPs) in Turkey regarding their role in the management of CO and the barriers they perceive.

METHODS

Mixed methods approach. Data was collected in two major counties of Istanbul between February and May 2014. All Family Health Centres (FHCs) in the region were visited, and 180/284 FPs (63.4%) agreed to complete a structured questionnaire (22 questions). Of those, 48 FPs agreed to participate in in-depth interviews that were taken until saturation was 25. Quantitative data were analysed using descriptive statistics. For qualitative data, content analysis was applied to identify the themes.

RESULTS

Most of the FPs (93.3%) agreed that they have a role in managing CO. Almost all FPs (98.3%) agreed that for the 0-4-year-olds height and weight measures should be taken. However, only 67.6% recommended this for children aged 5-15 years. The most common barriers in the management of CO were reported as lack of time (68.9%) and FHCs not being utilized for the care of children aged 5-15 years old (53.3%) in Turkey. In-depth interviews showed that FPs tend to limit their role to identifying the problem and making the family aware of it.

CONCLUSION

Although FPs recognize primary healthcare as an appropriate setting for managing CO, they have concerns about being involved in the treatment.

Dementia Primary Prevention Policies and Strategies and Their Local Implementation: A Scoping Review Using England as a Case Study

BACKGROUND

Understanding the policy context and how policy is implemented at the local and clinical level is an important precursor to developing preventive strategies focusing on dementia risk reduction in primary healthcare settings.

OBJECTIVE

Using England as a case study, we review policies and strategies relevant to dementia prevention from the national to local level and how these are translated into primary healthcare services.

METHODS

We conducted a scoping review covering: 1) identification of national, regional, and local policies and strategies that include dementia prevention; 2) identification of national guidelines for implementing dementia prevention at the clinical level; and 3) evaluation of the implementation of these at the clinical level.

RESULTS

Dementia prevention is addressed in national policy, and this filters through to regional and local levels. Focus on dementia prevention is limited and variable. Reference to modifiable risk factors is associated with other non-communicable diseases, placing less emphasis on factors more dementia specific. Evidence of implementation of dementia prevention policies at the clinical level is limited and inconsistent. Available evidence suggests messages about dementia prevention may best be delivered through primary healthcare services such as the National Health Service (NHS) Health Check.

CONCLUSION

The limitations identified in this review could be addressed through development of a national policy focused specifically on dementia prevention. This could provide a platform for increasing knowledge and understanding among the general population and healthcare professionals. It would be important for such a policy to cover the full range of modifiable risk factors relevant to dementia.

How primary care reforms influenced health indicators in Manisa district in Turkey: Lessons for general practitioners

Background: Turkish health reforms began in 2003 and brought some significant changes in primary care services. Few studies in Turkey compare the shift from health centres (HC) to family physicians (FP) approach, which was initiated by reforms.

Objectives: This study compares health status indicators during the HC period before reforms (2003–2007) and the FP period after reforms (2008–2012) in Turkey.

Methods: This study encompasses time series data consisting of the results of a 10-year assessment (2003–2012) in Manisa district. All the data were obtained electronically and by month. The intersection points of the regression curves of these two periods and the beta coefficients were compared using segmented linear regression analysis.

Results: The mean number of follow-up per person/year during the HC period in infants (10.5), pregnant women (6.6) and women (1.8) was significantly higher than the mean number of follow-up during the FP period in infants (6.7), pregnant women (5.6) and women (0.9). Rates of BCG and measles vaccinations were significantly higher during the FP period; however, rates of HBV and DPT were same. The mean number of outpatient services per person/year during the FP period (3.3) was significantly higher than HC period (2.8). Within non-communicable diseases, no difference was detected for hypertension prevalence. Within communicable diseases, there was no difference for rabies suspected bites but acute haemorrhagic gastroenteritis significantly decreased. The infant mortality rate and under five-year child mortality rate significantly increased during the FP period.

Conclusion: Primary care services should be reorganized and integrated with public health services.

An evaluation of cause-of-death trends from recent decades based on registered deaths in Turkey

OBJECTIVES

Although cause-of-death analyses are very important to define public health policy priorities and to evaluate health programs, there is very limited knowledge about mortality profiles and trends in Turkey. The aim of this study was to measure the trends in mortality within three broad cause-of-death groups and their distribution by age groups and gender and to describe the changes of leading causes of death between 1980 and 2013 in Turkey.

STUDY DESIGN

Descriptive study.

METHODS

In the study, data on the number of deaths by year, gender, age and cause was obtained from the Turkish Statistical Institute. The causes of death were classified as group I: communicable, maternal, perinatal, and nutritional conditions; group II: non-communicable diseases (NCDs); and group III: injuries. Unknown or ill-defined causes of death were distributed within group I and group II. The percentage distribution of the cause-of-death groups by gender and age groups between 1980 and 2013 was identified. Age-standardized mortality rates (ASMRs) per 100,000 of broad causes-of-death groups were calculated using European Standard Population 1976 between 1980 and 2008. Changes in mortality rates per hundred were calculated using the formula ([the rate of last year of the period-the rate of the first year of the period]/the rate of the first year of the period). Gender and age-specific data were analyzed using the Joinpoint software to examine trends and significant changes in trends of mortality rates.

RESULTS

Crude death rates for group I, group II, and group III were 157.3, 147.2, and 21.4 per 100,000 in 1980 and 35.3, 377.5, and 15.8 in 2008 for males; 161.8, 120.2, and 5.8 in 1980 and 38.6, 318.4, and 6.4 in 2008 for females, respectively. ASMRs for group I, group II, and group III were 146.3, 394.3, and 29.3 per 100,000 in 1980 and 49.7, 723.6, and 18.8 in 2008 for males; 138.0, 291.5, and 7.6 per 100,000 in 1980 and 47.7, 478.8, and 7.2 in 2008 for females, respectively. The mortality rates of group I for almost all age groups particularly below 5 years of age decreased significantly.

CONCLUSION

This study indicates that Turkey is at an advanced stage in the epidemiological transition, with the majority of the causes of death from NCDs. Considering the regional differences, it is necessary to carry out studies on the specific details of epidemiological transition and the social determinants of deaths in Turkey.

Use of Healthcare Services by Patients with Non-Communicable Diseases in Nepal: A Qualitative Study with Healthcare Providers

INTRODUCTION

The healthcare systems in many Low-and Middle-Income Countries (LMICs) like Nepal have long focused on preventing and treating infectious diseases. Little is known about their preparedness to address the increasing prevalence of Non-Communicable Diseases (NCDs).

AIM

This study aimed to investigate the use of healthcare services by patients with NCDs in Nepal.

MATERIALS AND METHODS

Nine healthcare providers (including health assistants, pharmacy assistants, nurse, specialised nurse, practicing pharmacists, chief hospital pharmacist, doctors and specialised doctor) from Pokhara, Nepal, were recruited using purposive sampling. In depth interviews about the magnitude of NCDs, first point of care, screening and diagnosis, prevention and management, follow-up, and healthcare system responses to NCD burden were conducted. Data were thematically analysed with a deductive approach.

RESULTS

Although the healthcare system in Nepal is still primarily focused on communicable infectious diseases, healthcare providers are aware of the increasing burden of NCDs and NCD risk factors. The first points of care for patients with NCDs are government primary healthcare facilities and private pharmacies. NCDs are often diagnosed late and opportunistically. NCD prevention and treatment is unaffordable for many people. There are no government sponsored NCD screening programs.

CONCLUSION

There are problems associated with screening, diagnosis, treatment and follow-up of patients with NCDs in Nepal. Healthcare providers believe that the current healthcare system in Nepal is inadequate to address the growing problem of NCDs. The health system of Nepal will face challenges to incorporate programs to prevent and treat NCDs in addition to the pre-existing communicable diseases.

Changes in primary care provision in Turkey: A comparison of 1993 and 2012

Since the early 1990s, the primary care system in Turkey has undergone fundamental changes. In the first decade of the millennium family doctor scheme was introduced to the Turkish primary care sector and the name of the primary care doctors (PCDs) changed from "general practitioner" (GP) to "family doctor" (FD). This study aims to give an insight into those changes and to compare the service profiles of PCDs in 1993 and 2012. Data, based on cross sectional surveys among Turkish doctors working in primary care are derived from the 1993 European GP Task Profile study (n=199) and the 2012 Quality and Costs of Primary Care in Europe (QUALICOPC) study (n=299). The study focuses on the changes in the primary care service provision based on selected aspects such as the first contact of care, preventive care, and the knowledge exchange and collaboration with other health professionals. Compared to GPs in 1993, FDs in 2012 reported that their involvement in treatment of chronic diseases, first contact care, antenatal and child health care have increased. FDs have more contact with other primary healthcare workers but their contact with hospital consultants have decreased. Overall, the services provided by PCDs seem to be expanded. However, the quality of care given by FDs and its effects on health indicators are needed to be explored by further studies.

Predicting the health impact of lowering salt consumption in Turkey using the DYNAMO health impact assessment tool

OBJECTIVE

To estimate the impact of three daily salt consumption scenarios on the prevalence and incidence of ischaemic heart disease (IHD) and cerebrovascular disease in 2025 in the Turkish population aged ≥30 years using the DYNAMO Health Impact Assessment tool.

STUDY DESIGN

Statistical disease modelling study.

METHODS

DYNAMO health impact assessment was populated using data from Turkey to estimate the prevalence and incidence of IHD and cerebrovascular disease in 2025. TurkSTAT data were used for demographic data, and national surveys were used for salt consumption and disease-specific burden. Three salt consumption scenarios were modelled: (1) reference scenario: mean salt consumption stays the same from 2012-2013 until 2025; (2) gradual decline: daily salt intake reduces steadily by 0.47 g per year by lowering salt intake from bread by 50% and from table salt by 40% by 2025; and (3) World Health Organization (WHO) advice: daily salt intake of 5 g per day from 2013 until 2025.

RESULTS

The gradual decline scenario would lead to a decrease in the prevalence of IHD and cerebrovascular disease by 0.3% and 0.2%, respectively, and a decrease in the incidence by 0.6 and 0.4 per 1000, respectively. Following WHO's advice would lead to a decrease in the prevalence of IHD and cerebrovascular disease by 0.8% and 0.5%, respectively, and a decrease in the incidence by 1.0 and 0.7 per 1000, respectively.

CONCLUSION

This model indicates that Turkey can lower its future cardiovascular disease burden by following the gradual decline scenario. Following WHO's advice would achieve an even greater benefit.

Policies and Programs for Prevention and Control of Diabetes in Iran: A Document Analysis

Trend analysis in 2005 to 2011 showed high growth in diabetes prevalence in Iran. Considering the high prevalence of diabetes in the country and likely to increase its prevalence in the future, the analysis of diabetes-related policies and programs is very important and effective in the prevention and control of diabetes. Therefore, the aim of the study was an analysis of policies and programs related to prevention and control of diabetes in Iran in 2014.

This study was a policy analysis using deductive thematic content analysis of key documents. The health policy triangle framework was used in the data analysis. PubMed and ScienceDirect databases were searched to find relevant studies and documents. Also, hand searching was conducted among references of the identified studies. MAXQDA 10 software was used to organize and analyze data.

The main reasons to take into consideration diabetes in Iran can be World Health Organization (WHO) report in 1989, and high prevalence of diabetes in the country. The major challenges in implementing the diabetes program include difficulty in referral levels of the program, lack of coordination between the private sector and the public sector and the limitations of reporting system in the specialized levels of the program.

Besides strengthening referral system, the government should allocate more funds to the program and more importance to the educational programs for the public. Also, Non-Governmental Organizations (NGOs) and the private sector should involve in the formulation and implementation of the prevention and control programs of diabetes in the future.

Research capacity and training needs for non-communicable diseases in the public health arena in Turkey

Background

The aim of this study is to define the research capacity and training needs for professionals working on non-communicable diseases (NCDs) in the public health arena in Turkey.

Methods

This study was part of a comparative cross-national research capacity-building project taking place across Turkey and the Mediterranean Middle East (RESCAP-Med, funded by the EU). Identification of research capacity and training needs took place in three stages. The first stage involved mapping health institutions engaged in NCD research, based on a comprehensive literature review. The second stage entailed in-depth interviews with key informants (KIs) with an overview of research capacity in public health and the training needs of their staff. The third stage required interviewing junior researchers, identified by KIs in stage two, to evaluate their perceptions of their own training needs. The approach we have taken was based upon a method devised by Hennessy&Hicks. In total, 55 junior researchers identified by 10 KIs were invited to participate, of whom 46 researchers agreed to take part (84%). The specific disciplines in public health identified in advance by RESCAP-MED for training were: advanced epidemiology, health economics, environmental health, medical sociology-anthropology, and health policy.

Results

The initial literature review showed considerable research on NCDs, but concentrated in a few areas of NCD research. The main problems listed by KIs were inadequate opportunities for specialization due to heavy teaching workloads, the lack of incentives to pursue research, a lack of financial resources even when interest existed, and insufficient institutional mechanisms for dialogue between policy makers and researchers over national research priorities. Among junior researchers, there was widespread competence in basic epidemiological skills, but an awareness of gaps in knowledge of more advanced epidemiological skills, and the opportunities to acquire these skills were lacking. Self-assessed competencies in each of the four other disciplines considered revealed greater training needs, especially regarding familiarity with the qualitative research skills for medical anthropology/sociology.

Conclusions

In Turkey there are considerable strengths to build upon. But a combination of institutional disincentives for research, and the lack of opportunities for the rising generation of researchers to acquire advanced training skills.