A review of non-communicable disease in low- and middle-income countries

Exploring Acceptance of Digital Health Technologies for Managing Non-Communicable Diseases Among Older Adults: A Systematic Scoping Review

This review explores the acceptance of digital health (DH) technologies for managing non-communicable diseases (NCDs) among older adults (≥ 50 years), with an extended focus on artificial intelligence (AI)-powered conversational agents (CAs) as an emerging notable subset of DH. A systematic literature search was conducted in June 2024 using PubMed, Web of Science, Scopus, and ACM Digital Library. Eligible studies were empirical and published in English between January 2010 and May 2024. Covidence software facilitated screening and data extraction, adhering to PRISMA-ScR guidelines. The screening process finally yielded 20 studies. Extracted data from these selected studies included interventions, participant demographics, technology types, sample sizes, study designs and locations, technology acceptance measures, key outcomes, and methodological limitations. A narrative synthesis approach was used for analysis, revealing four key findings: (1) overall positive attitudes of older adults towards DH acceptance; (2) the Technology Acceptance Model (TAM) and the Unified Theory of Acceptance and Use of Technology (UTAUT) are the most frequently used standard frameworks for evaluating technology acceptance; (3) the key facilitators of technology acceptance include perceived usefulness, ease of use, social influence, and digital or e-health literacy, while barriers involve technical challenges, usability issues, and privacy concerns; (4) the acceptance of AI-based CAs for NCD management among older adults remains inadequately evaluated, possibly due to limited adaptation of established frameworks to specific healthcare contexts and technology innovations. This review significantly contributes to the DH field by providing a comprehensive analysis of technology acceptance for NCD management among older adults, extending beyond feasibility and usability. The findings offer stakeholders valuable insights into how to better integrate these technologies to improve health outcomes and quality of life for older adults. Protocol Registration: PROSPERO (Registration ID: CRD42024540035).

Physical activity promotes well-being: medical students' engagement and perspective. A cross-sectional study scoped through innovation and technology

Background

The role of physical activity (PA) in health promotion is further complimented by its disease preventive value. Future doctors' involvement and advocacy in diverse aspects of such significant role is still under evaluation.

Objectives

This study aimed to assess medical students' overall PA engagement and their perspective, and to identify whether their level of engagement affects their advocacy and promotion, while discussing related educational innovations and technological advances.

Methods

Through a cross-sectional observational study design, stratified sampling from third-, fourth-, and fifth-year medical students attending Nile University, Sudan, during the period from February to April 2020, were included. Descriptive data analysis was done using the SPSS software, and presented including, frequencies, cross-tabulation, Chi-square testing with 95% confidence level, and a P value, after data collection via a structured questionnaire adopting parts of the IPAQ. Study has been reported in line with the STROCSS criteria.

Results

Out of 188 students, 43% males and 57% females, less than half (91, 48.40%) participated in planned PA, and majority (156, 82.98%) agreed with its health-related significance. Few (57, 30.32%) considered academic load as a barrier, and only 20 (10.60%) were not actively promoting PA engagement to others. Most PA participants were males (57.14%), leaning toward group-based activity (54, 59.34%), making regular plans (51, 56.04%) and motivated by self-health promotion (86, 94.51%) (P < 0.05). Despite majority of students (82.98%) agreement on PA's benefits, nearly half (51.60%) do not engage, Similarly, overall advocacy for PA promotion in relation to specific people was not statistically significant (P = 0.21). Embedding PA into undergraduate curriculum, use of PA report cards, exercise prescription training and targeted mentoring, in addition to digital bracelets, smart phone applications and internet-based social media, had positive impact on PA participation and promotion.

Conclusion

Medical students' understanding of PA health related significance did not equate to increase engagement, despite active promotion. Curricular integration of PA should accompany recent innovative educational strategies to increase their participation and advocation. Future studies are needed to evaluate the role of technology-based and AI-driven PA in achieving this goal.

Economic burden of cardiovascular diseases among elderly patients in Iran: a case from a developing country

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of mortality and morbidity worldwide, particularly among the aging population. This study aims to evaluate the economic burden of CVDs among Iranians aged 60 years and older.

METHODS

A cost-of-illness study was conducted using a prevalence-based approach from a societal perspective. Cost analysis employed the bottom-up micro-costing method to assess direct medical and non-medical costs, while indirect costs were calculated using the human capital approach. Data were sourced from medical records of individuals aged 60 and older with CVDs registered in the hospital information systems of public and private hospitals in southeastern Iran. Additionally, structured face-to-face interviews were conducted with 160 caregivers or relatives serving as companions of elderly patients, using a structured questionnaire to gather data on healthcare utilization. Sensitivity analyses were performed, along with projections of the future economic burden of CVDs.

RESULTS

The annual total cost of CVDs among people aged 60 years and above in Iran was estimated at US$ 1,885,091,171.7 (about 1.88 billion), equivalent to 1.27% of the Iran's GDP in 2021. Direct medical costs accounted for 90.62% of the total, with 54.72% attributed to ambulatory care. The average cost of CVDs per patient was US$ 446.2. The results of two-way sensitivity analysis provided an estimated cost range between US$ 1.2 billion and US$ 2.7 billion. By 2030, the total cost of CVDs is projected to reach US$ 21 billion.

CONCLUSIONS

The elderly population with CVDs imposes a growing economic burden on Iran's healthcare system and society. This underscores the urgent need for effective and cost-effective interventions to prevent and manage CVDs in Iran.

Epidemiology of non-communicable diseases among professional drivers in LMICs: a systematic review and meta-analysis

This systematic review collected evidence on the burden of non-communicable diseases (NCDs) among professional drivers and reported on the most common factors that increase the risk of NCDs in this specific population in low- and middle-income countries (LMICs). The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We conducted a thorough search on PubMed/MEDLINE, EMBASE, Scopus, Global Health, Web of Science and Africa-wide information databases on 11 May 2023. We adapted the Joanna Briggs Institute (JBI) tool to assess the quality of the studies. We estimated the prevalence of hypertension, prediabetes, diabetes mellitus (DM), overweight and obesity among professional drivers using a random effect model to compute pooled and subgroup analyses. In addition, we conducted a narrative synthesis of the risk factors and recommendations presented in the included studies. Forty-one studies, including 48 414 study participants, met the criteria for inclusion. The pooled prevalence of hypertension, DM and obesity among professional drivers was 36.7% [95% confidence interval (CI): 31.8-41.6%], 15.2% (95% CI: 7.0-23.4%) and 27.2% (95% CI: 18.7-35.8%), respectively. Unsupportive environment, work stress, sedentary lifestyle, consumption of unhealthy foods and shift work were the most common modifiable risk factors reported. Our findings also show a significant burden of hypertension, DM and obesity among professional drivers in LMICs. The prevalence of DM and obesity was two- and three-fold higher than findings in general populations, respectively. Our findings indicate an urgent need for tailored interventions for different occupation-related risk factors for NCDs among professional drivers in LMICs.

Understanding barriers and facilitators to integrated HIV and hypertension care in South Africa

BACKGROUND

The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. This study aimed to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV in primary care clinics in Johannesburg, South Africa. Additionally, different stakeholder groups were included to identify discordant perceptions.

METHODS

Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by COM-B and the Theoretical Domains Framework were used to identify and compare determinants of hypertension care across stakeholder groups.

RESULTS

Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) and patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care.

CONCLUSIONS

The convergence of multi-stakeholder data highlight key areas for improvement, where tailored implementation strategies targeting motivations of clinic staff and capacity of patients may address challenges to hypertension screening, treatment, and management recognized across groups.

Understanding Barriers and Facilitators to Integrated HIV and Hypertension Care in South Africa

Background The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. The objective of this study was to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV seeking treatment in primary care clinics in Johannesburg, South Africa. Methods Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by the Theoretical Domains Framework was used to identify and compare determinants of hypertension care across different stakeholder groups. Results Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) the patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care. Conclusions The convergence of multi-stakeholder data regarding barriers to hypertension screening, treatment, and management highlight key areas for improvement, where tailored implementation strategies may address challenges recognized by each stakeholder group.

Sociodemographic and geographic inequalities in diagnosis and treatment of older adults' chronic conditions in India: a nationally representative population-based study

CONTEXT

Expeditious diagnosis and treatment of chronic conditions are critical to control the burden of non-communicable disease in low- and middle-income countries. We aimed to estimate sociodemographic and geographic inequalities in diagnosis and treatment of chronic conditions among adults aged 45 + in India.

METHODS

We used 2017-18 nationally representative data to estimate prevalence of chronic conditions (hypertension, diabetes, lung disease, heart disease, stroke, arthritis, cholesterol, and neurological) reported as diagnosed and percentages of diagnosed conditions that were untreated by sociodemographic characteristics and state. We used concentration indices to measure socioeconomic inequalities in diagnosis and lack of treatment. Fully adjusted inequalities were estimated with multivariable probit and fractional regression models.

FINDINGS

About 46.1% (95% CI: 44.9 to 47.3) of adults aged 45 + reported a diagnosis of at least one chronic condition and 27.5% (95% CI: 26.2 to 28.7) of the reported conditions were untreated. The percentage untreated was highest for neurological conditions (53.2%; 95% CI: 50.1 to 59.6) and lowest for diabetes (10.1%; 95% CI: 8.4 to 11.5). Age- and sex-adjusted prevalence of any diagnosed condition was highest in the richest quartile (55.3%; 95% CI: 53.3 to 57.3) and lowest in the poorest (37.7%: 95% CI: 36.1 to 39.3). Conditional on reported diagnosis, the percentage of conditions untreated was highest in the poorest quartile (34.4%: 95% CI: 32.3 to 36.5) and lowest in the richest (21.1%: 95% CI: 19.2 to 23.1). Concentration indices confirmed these patterns. Multivariable models showed that the percentage of untreated conditions was 6.0 points higher (95% CI: 3.3 to 8.6) in the poorest quartile than in the richest. Between state variations in the prevalence of diagnosed conditions and their treatment were large.

CONCLUSIONS

Ensuring more equitable treatment of chronic conditions in India requires improved access for poorer, less educated, and rural older people who often remain untreated even once diagnosed.

M, Silambanan S, Kantipudi SJ, Sathianathan R, R. P. Development and Validation of Yoga Protocol for Patients with Depression

Background

Scientific evidence suggests that yoga is beneficial for treating mental health disorders. To the best of our knowledge, minimal studies have been done on the development of a yoga module for the specific clinical aspects of depression and there is no particular study on yoga protocol development for mild depression and moderate depression.

Purpose

The primary aim of this study is to develop specific yoga protocol modules for treating patients affected with mild and moderate depression.

Methods

Yoga protocols for treating mild and moderate depression were developed using classical yoga texts, previous literature, and with the help of yoga experts. 26 practices for mild depression and 35 practices for moderate depression were identified, each of which was scored as (a) not essential, (b) useful but not essential, and (c) essential, and content validity ratio (CVR) determined using Lawshe's formula for the validation.

Results

Expert's opinion revealed that 13 out of 28 practices and 12 out of 35 practices showed significant CVR (>0.60) for mild and moderate depression.

Conclusions

The yoga practices developed based on experts' opinion is the first step toward the development of a validated protocol for mild and moderate depression. This will be assessed for its effectiveness through a randomized controlled study to confirm the module's efficiency.

Electrophysiology practice in low- and middle-income countries: An updated review on access to care and health delivery

Concurrent with the epidemiological transition to cardiovascular diseases in low- and middle-income countries (LMICs), the burden of arrhythmias is increasing significantly. However, registries of electrophysiological disorders and their management in LMICs are limited. The advancement of telemedicine technology can play a distinctive role in providing accurate diagnoses in resource-limited settings. The estimated pacemaker implantation requirements (1 million per year) demand an alternate source of pacemakers, including reused permanent pacemakers and implantable cardioverter-defibrillators. In addition, the majority of supraventricular tachycardias and atrial fibrillation can be managed with radiofrequency ablation, which not only is cost-effective but is curative for most patients.

COVID-19 and Kidney Disease: Progress in Health Inequity From Low-Income Settings

The acute coronavirus disease-2019 (COVID-19) pandemic has had a significant impact on the incidence and prevalence of acute kidney injury and chronic kidney disease globally and in low-income settings. Chronic kidney disease increases the risk of developing COVID-19 and COVID-19 causes acute kidney injury directly or indirectly and is associated with high mortality in severe cases. Outcomes of COVID-19-associated kidney disease were not equitable globally owing to a lack of health infrastructure, challenges in diagnostic testing, and management of COVID-19 in low-income settings. COVID-19 also significantly impacted kidney transplant rates and mortality among kidney transplant recipients. Vaccine availability and uptake remains a significant challenge in low- and lower-middle-income countries compared with high-income countries. In this review, we explore the inequities in low- and lower-middle-income countries and highlight the progress made in the prevention, diagnosis, and management of patients with COVID-19 and kidney disease. We recommend further studies into the challenges, lessons learned, and progress made in the diagnosis, management, and treatment of patients with COVID-19-related kidney diseases and suggest ways to improve the care and management of patients with COVID-19 and kidney disease.

Barriers to the provision of non-communicable disease care in Zimbabwe: a qualitative study of primary health care nurses

BACKGROUND

Non-communicable diseases (NCDs) contribute significantly to the global disease burden, with low-and middle-income (LMICs) countries disproportionately affected. A significant knowledge gap in NCDs exacerbates the high burden, worsened by perennial health system challenges, including human and financial resources constraints. Primary health care workers play a crucial role in offering health care to most people in LMICs, and their views on the barriers to the provision of quality care for NCDs are critical. This study explored perceived barriers to providing NCDs care in primary health care facilities in Zimbabwe.

METHODS

In-depth, individual semi-structured interviews were conducted with general nurses in primary care facilities until data saturation was reached. We focused on diabetes, hypertension, and depression, the three most common conditions in primary care in Zimbabwe. We used thematic content analysis based on an interview guide developed following a situational analysis of NCDs care in Zimbabwe and views from patients with lived experiences.

RESULTS

Saturation was reached after interviewing 10 participants from five busy urban clinics. For all three NCDs, we identified four cross-cutting barriers, a) poor access to medication and functional equipment such as blood pressure machines, urinalysis strips; b) high cost of private care; c)poor working conditions; and d) poor awareness from both patients and the community which often resulted in the use of alternative potentially harmful remedies. Participants indicated that empowering communities could be an effective and low-cost approach to positive lifestyle changes and health-seeking behaviours. Participants indicated that the Friendship bench, a task-shifting programme working with trained community grandmothers, could provide a platform to introduce NCDs care at the community level. Also, creating community awareness and initiating screening at a community level through community health workers (CHWs) could reduce the workload on the clinic nursing staff.

CONCLUSION

Our findings reflect those from other LMICs, with poor work conditions and resources shortages being salient barriers to optimal NCDs care at the facility level. Zimbabwe's primary health care system faces several challenges that call for exploring ways to alleviate worker fatigue through strengthened community-led care for NCDs. Empowering communities could improve awareness and positive lifestyle changes, thus optimising NCD care. Further, there is a need to optimise NCD care in urban Zimbabwe through a holistic and multisectoral approach to improve working conditions, basic clinical supplies and essential drugs, which are the significant challenges facing the country's health care sector. The Friendship Bench could be an ideal entry point for providing an integrated NCD care package for diabetes, hypertension and depression.

Epidemiological analysis of lower limb revascularization for peripheral arterial disease over 12 years on the public healthcare system in Brazil

Abstract Background Worldwide, peripheral arterial disease (PAD) is a disorder with high morbidity, affecting more than 200 million people. Objectives Our objective was to analyze surgical treatment for PAD provided on the Brazilian Public Healthcare System over 12 years using publicly available data. Methods The study was conducted with analysis of data available on the Brazilian Health Ministry’s database platform, assessing distributions of procedures and techniques over the years and their associated mortality and costs. Results A total of 129,424 procedures were analyzed (performed either for claudication or critical ischemia, proportion unknown). The vast majority of procedures were endovascular (65.49%) and this disproportion exhibited a rising trend (p<0.001). There were 3,306 in-hospital deaths (mortality of 2.55%), with lower mortality in the endovascular group (1.2% vs. 5.0%, p=0.008). The overall governmental expenditure on these procedures was U$ 238,010,096.51, and endovascular procedures were on average significantly more expensive than open surgery (U$ 1,932.27 vs. U$ 1,517.32; p=0.016). Conclusions Lower limb revascularizations were performed on the Brazilian Public Healthcare System with gradually increasing frequency from 2008 to 2019. Endovascular procedures were vastly more common and were associated with lower in-hospital mortality rates, but higher procedure costs.

Pharmacological Modulation of Immune Responses by Nutritional Components

The incidence of noncommunicable diseases (NCDs) has increased over the last few decades, and one of the major contributors to this is lifestyle, especially diet. High intake of saturated fatty acids and low intake of dietary fiber is linked to an increase in NCDs. Conversely, a low intake of saturated fatty acids and a high intake of dietary fiber seem to have a protective effect on general health. Several mechanisms have been identified that underlie this phenomenon. In this review, we focus on pharmacological receptors, including the aryl hydrocarbon receptor, binding partners of the retinoid X receptor, G-coupled protein receptors, and toll-like receptors, which can be activated by nutritional components and their metabolites. Depending on the nutritional component and the receptors involved, both proinflammatory and anti-inflammatory effects occur, leading to an altered immune response. These insights may provide opportunities for the prevention and treatment of NCDs and their inherent (sub)chronic inflammation. SIGNIFICANCE STATEMENT: This review summarizes the reported effects of nutritional components and their metabolites on the immune system through manipulation of specific (pharmacological) receptors, including the aryl hydrocarbon receptor, binding partners of the retinoid X receptor, G-coupled protein receptors, and toll-like receptors. Nutritional components, such as vitamins, fibers, and unsaturated fatty acids are able to resolve inflammation, whereas saturated fatty acids tend to exhibit proinflammatory effects. This may aid decision makers and scientists in developing strategies to decrease the incidence of noncommunicable diseases.

Anti-hypertensive medication access and affordability and their association with blood pressure control at a teaching hospital in Ghana

Introduction

many hypertensive patients require two or more anti-hypertensive drugs, but in low- and middle-income countries there may be challenges with medication access or affordability. The objective of this study was to determine accessibility and affordability of anti-hypertensive medicines and their association with blood pressure (BP) control among hypertensive patients attending the Korle-Bu teaching hospital (KBTH) polyclinic.

Methods

a cross-sectional study was conducted among 310 systematically sampled hypertensive patients attending the KBTH Polyclinic in Ghana. A structured questionnaire was used to obtain data on patient demographics and clinical characteristics, prices, availability and mode of payment of generic anti-hypertensive medicines.

Results

fifty-nine patients (19.4%) made out-of-pocket payments. At the private pharmacy and hospital, 123 (40.5%) and 77 patients (25.3%) respectively could not afford four anti-hypertensive medicines. Medicines availability at KBTH was 60%. Continuous access to BP drugs at KBTH was 14.8%. Overall access was 74.9% (SD ± 41.3). Out-of-pocket affordability of the medicines was positively correlated with BP control (R=0.12, p=0.037). Obtaining medicines via health insurance only was more likely to result in BP control than making any out-of-pocket payments (OR= 2.185; 95% CI, 1.215 - 3.927). Access at KBTH was more likely to result in BP control (OR=1.642; 95% C.I, 0.843 - 3.201).

Conclusion

there were access challenges although most patients obtained BP medication free. Out-of-pocket affordability is a challenge for some hypertensive patients. Access to affordable BP medication can improve BP control. These findings provide an impetus for urgently evaluating access to affordable anti-hypertensive medicines in other hospitals in Ghana.

Evaluation of a Meta-Analysis of Ambient Air Quality as a Risk Factor for Asthma Exacerbation

Background: An irreproducibility crisis currently afflicts a wide range of scientific disciplines, including public health and biomedical science. A study was undertaken to assess the reliability of a meta-analysis examining whether air quality components (carbon monoxide, particulate matter 10 µm and 2.5 µm (PM10 and PM2.5), sulfur dioxide, nitrogen dioxide and ozone) are risk factors for asthma exacerbation. Methods: The number of statistical tests and models were counted in 17 randomly selected base papers from 87 used in the meta-analysis. Confidence intervals from all 87 base papers were converted to p-values. p-value plots for each air component were constructed to evaluate the effect heterogeneity of the p-values. Results: The number of statistical tests possible in the 17 selected base papers was large, median = 15,360 (interquartile range = 1536–40,960), in comparison to results presented. Each p-value plot showed a two-component mixture with small p-values < 0.001 while other p-values appeared random (p-values > 0.05). Given potentially large numbers of statistical tests conducted in the 17 selected base papers, p-hacking cannot be ruled out as explanations for small p-values. Conclusions: Our interpretation of the meta-analysis is that random p-values indicating null associations are more plausible and the meta-analysis is unlikely to replicate in the absence of bias.

Cardiovascular Disease in the Indo-Caribbean Population: A Scoping Review

At the beginning of the 20th century, there was a shift in disease patterns from that of communicable disease to noncommunicable disease (NCD). As a result, cardiovascular disease (CVD) has emerged as a leading cause of morbidity and mortality worldwide. Its incidence and effect on various populations at a molecular level as well as clinical implications have been heavily studied; however, its role in morbidity and mortality in the Indo-Caribbean population is often overlooked. The Caribbean diaspora is a vibrant and heterogeneous culture, encompassing individuals with ancestries from across the world including the Indian subcontinent and Africa. Abundant research is consistently conducted on these populations, but limited research exists on how the interplay between genetics and environment translates to the manifestation of various diseases in the Indo-Caribbean population. This scoping review aims to identify and assess the current literature within the past 10 years conducted on CVD in Indo-Caribbeans in order to gain a thorough understanding of disease and management to improve health outcomes. Additionally, this review aimed to identify gaps in research that require further study to gain a better understanding of relevant variables affecting disease outcomes in the Indo-Caribbean population. Multiple health databases were queried, and the initial search yielded over 3,000 results. However, after screening with the inclusion and exclusion criteria established, the final search included less than 1% of the papers initially searched. This search yielded data that included treatment and management of myocardial infarction, hypertension, and atherosclerosis, but notably did not yield papers that discussed the relationship between social determinants of health and CVD in Indo-Caribbeans. Florida and New York are prominent states that have robust Indo-Caribbean populations; the lack of research renders these states vulnerable to improving health outcomes in these patients. The authors call for increased focus on this population in research studies and efforts to improve the quality of the data collected through stratification by ethnicity. Robust data may allow for improvement in the treatment and management of CVD in Indo-Caribbeans, which offers a more proactive rather than reactive approach to decreasing morbidity and mortality.

Subclinical Vascular Disease in Children With Human Immunodeficiency Virus in Uganda Is Associated With Intestinal Barrier Dysfunction

BACKGROUND

The risk of cardiovascular disease (CVD) and its mechanisms in children living with perinatally acquired HIV (PHIV) in sub-Saharan Africa has been understudied.

METHODS

Mean common carotid artery intima-media thickness (IMT) and pulse-wave velocity (PWV) were evaluated in 101 PHIV and 96 HIV-negative (HIV-) children. PHIV were on ART, with HIV-1 RNA levels ≤400 copies/mL. We measured plasma and cellular markers of monocyte activation, T-cell activation, oxidized lipids, and gut integrity.

RESULTS

Overall median (interquartile range, Q1-Q3) age was 13 (11-15) years and 52% were females. Groups were similar by age, sex, and BMI. Median ART duration was 10 (8-11) years. PHIV had higher waist-hip ratio, triglycerides, and insulin resistance (P ≤ .03). Median IMT was slightly thicker in PHIVs than HIV- children (1.05 vs 1.02 mm for mean IMT and 1.25 vs 1.21 mm for max IMT; P < .05), while PWV did not differ between groups (P = .06). In univariate analyses, lower BMI and oxidized LDL, and higher waist-hip ratio, hsCRP, and zonulin correlated with thicker IMT in PHIV (P ≤ .05). After adjustment for age, BMI, sex, CD4 cell count, triglycerides, and separately adding sCD163, sCD14, and hsCRP, higher levels of intestinal permeability as measured by zonulin remained associated with IMT (β = 0.03 and 0.02, respectively; P ≤ .03).

CONCLUSIONS

Our study shows that African PHIV have evidence of CVD risk and structural vascular changes despite viral suppression. Intestinal intestinal barrier dysfunction may be involved in the pathogenesis of subclinical vascular disease in this population.

Prevalence of non-communicable diseases and their risk factors in Papua New Guinea: A systematic review

INTRODUCTION

The mortality associated with non-communicable diseases has increased significantly in most countries in the World Health Organization Western Pacific Region over the last 20 years, as have the underlying risk factors. This study aimed to collate evidence on the prevalence of four major non-communicable diseases and their risk factors in Papua New Guinea in order to inform appropriate policy for their prevention and management.

METHODS

We performed a systematic review of Papua New Guinea-based population prevalence studies of cardiovascular diseases, type 2 diabetes mellitus, chronic respiratory diseases, and cancers, as well as non-communicable disease risk factors published before 2016. Five online databases were searched and screened against eligibility criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 57 articles were included in this review, most of which (n = 48) were published prior to 2000. Eleven articles reported on diabetes, six reported on chronic lung disease/asthma, two reported on cardiovascular diseases, and two reported cancer as the primary outcome, while the remaining 36 papers reported non-communicable disease risk factors.

CONCLUSION

This review demonstrated variations in the prevalence of non-communicable diseases (0%-19%) and their risk factors (0%-80.6%) attributed to the lifestyle and genetic diversity of the Papua New Guinea population. There is a strong suggestion that the prevalence of non-communicable diseases (particularly type 2 diabetes mellitus) and key non-communicable disease risk factors (hypertension, overweight, and obesity) has increased, but there is a lack of recent data. As such, there is an urgent need for new and up-to-date data in all areas of Papua New Guinea.

Disease burden metrics and the innovations of leading pharmaceutical companies: a global and regional comparative study

Background

The recent innovation activities of global top-tier pharmaceutical companies in accordance with global and regional health concerns were investigated in order to identify their innovations contributing to population health.

Methods

“Innovation activity” was defined as the number of drugs for which R&D activities have been reported within the last three years. Such activities were measured by collecting the data on drug developments and classifying them by developer company, phase of development, therapeutic use, and the country in which the development conducted. Subsequently, we examined and compared the correlations between the global innovation activities of the top 20 pharmaceutical companies and the disease burden measured in disability-adjusted life years (DALYs) by income level and region. In addition, this study analyzed the association between country-specific innovations and DALYs in the corresponding countries.

Results

At a global level, the innovation activities were not associated with global DALYs. However, when analyzed by income level, the innovation activities were associated with DALYs in high income and upper middle income countries while it was not associated with DALYs in low middle income and low income countries. In terms of region, correlations were found between the innovation activities and DALYs in the European region, the Americas, and the Western Pacific region whereas such correlations were not found in the African, Eastern Mediterranean, and South-East Asian regions. Similar to the analyses by income level and region, correlations between country-specific innovations and DALYs were only found in high income or high GDP countries. In addition, an empirical analysis of several cases including Canada, Germany, South Korea, and the United Kingdom revealed that pharmaceutical innovation is more closely related to market size than disease burden.

Conclusions

This study identified that discrepancies between pharmaceutical innovation and public health needs, i.e., disease burden values, have persisted until recently. To alleviate this imbalance, both public and private sectors should not only fulfill their respective roles and responsibilities regarding these issues, but also make strategic and collaborative efforts such as Product Development Partnerships (PDPs) directed toward public health improvement.

The crowding out effect of out-of-pocket medication expenses of two major non-communicable diseases in Pakistan

BACKGROUND

Elevated blood pressure (i.e. hypertension) and diabetes (BPD) are the two major noncommunicable diseases that expose households to high out-of-pocket treatment costs in low- and middle-income countries. Medication is the biggest share of BPD treatment expenses, and households with someone suffering from BPD may need to adjust consumption of other commodities to pay for essential BPD medicines. We assess how BPD medication expenditures are associated with crowding out of other household commodities in Pakistan.

METHODS

We analyze self-reported household consumption data from the nationally representative Pakistan Household Income and Expenditure Survey 2015-16. We estimate conditional Engel curves under the Quadratic Almost Ideal Demand System framework to examine the differences in average consumption shares between BPD medication-consuming and not-consuming households.

RESULTS

We find that BPD medication expenditures are associated with crowding out of food and crowding in of other medical expenditures for all households, but the magnitudes of crowding out and crowding in are larger for the poorer households. BPD medication spending is also associated with crowding out of education and personal care for middle-class and wealthier households.

CONCLUSIONS

Our results indicate that allocations for essential commodities, like food and education, are lower for BPD medication-consuming households and inform policies for preventive health promotions and affordable treatment for hypertension and diabetes.

Can Primary Medical Institutions Lead to Worse Health Status for Patients with Noncommunicable Diseases Compared with High-Level Hospitals? A Follow-Up Observation Study in China

The weak primary healthcare system in China brings challenges to the national strategy of primary medical institutions providing general health needs for patients with non-communicable diseases (NCDs). It is necessary to explore the potential discrepancies in health status for patients with NCDs if they go to primary medical institutions rather than high-level hospitals. Data was obtained from Surveillance of Health-seeking Behavior in Hubei Province. Respondents were investigated six times to collect information on health service utilization and health-related quality of life (HRQoL). Ninety-two hypertension patients who went to medical institutions of the same level were included. HRQoL was measured by the Chinese version of EQ-5D-3L. A multilevel growth curve model was applied to analyze whether provider level could influence HRQoL. The utility score and visual analogue scale (VAS) of patients varied insignificantly over six months (p > 0.05). A growth curve model showed that comorbidity was the only factor significantly influencing utility score (p = 0.019). Time and comorbidity were the only influencing factors of VAS (p < 0.05). Our findings indicated that the level of healthcare provider had no significant impact on the health status of patients with NCDs. As such, this study concludes that the primary healthcare system in China is qualified to be the health gatekeeper for NCDs patients.

Game dynamic model of optimal budget allocation under individual vaccination choice

Communicable diseases are leading cause of child mortality in developing and under-developed countries. Public health ministries in states and country allocate a considerable amount of budget every year for vaccination campaigns to control infections. Even third-party agencies such as Gates Foundation, UNDP, GAVI, World Bank, WHO also allocate huge funds to under-developed and developing countries for vaccination programs and disease eliminations. However, economic constraints and current disease prevalence are not enough driving factors for optimal decisions in budget allocations for vaccinations and controlling the disease. In a population under voluntary vaccination campaign, high vaccine coverage cannot be taken for granted, as individuals' free-riding behaviour plays a significant role in achieving the herd immunity level coverage. Individual-level vaccine exemptions and ignoring this important component by the policymakers are key determinants for failure of disease elimination program these days in many under-developed and developing countries. We integrate evolutionary game theory and compartmental model of disease transmission to analyze how individual vaccination choice influence the budget allocations and vice-versa. Our model illustrates that individuals' perceived risk plays an important role in optimal budget allocations to minimize infections. Analyses of our model indicate that the optimal distribution of third-party funds may be very different than usual, especially in multiple populations with contrasting demographic and economic profiles. These findings are certainly useful to public health policymakers and may help to quantify certain parameters in budget allocations to control vaccine-preventable diseases.

First Africa non-communicable disease research conference 2017: sharing evidence and identifying research priorities

Non-communicable diseases (NCDs) prevalence is rising fastest in lower income settings, and with more devastating outcomes compared to High Income Countries (HICs). While evidence is consistent on the growing health and economic consequences of NCDs in sub-Saharan Africa (SSA), specific efforts aimed at addressing NCD prevention and control remain less than optimum and country level progress of implementing evidence backed cost-effective NCD prevention approaches such as tobacco taxation and restrictions on marketing of unhealthy food and drinks is slow. Similarly, increasing interest to employ multi-sectoral approaches (MSA) in NCD prevention and policy is impeded by scarce knowledge on the mechanisms of MSA application in NCD prevention, their coordination, and potential successes in SSA. In recognition of the above gaps in NCD programming and interventions in Africa, the East Africa NCD alliance (EANCDA) in partnership with the African Population and Health Research Center (APHRC) organized a three-day NCDs conference in Nairobi. The conference entitled “First Africa Non-Communicable Disease Research Conference 2017: Sharing Evidence and Identifying Research Priorities” drew more than one hundred fifty participants and researchers from several institutions in Kenya, South Africa, Nigeria, Cameroon, Uganda, Tanzania, Rwanda, Burundi, Malawi, Belgium, USA and Canada. The sections that follow provide detailed overview of the conference, its objectives, a summary of the proceedings and recommendations on the African NCD research agenda to address NCD prevention efforts in Africa.

Consumption displacement in households with noncommunicable diseases in Bangladesh

The economic burden of noncommunicable diseases (NCDs), including treatment costs and income and productivity losses, is a growing concern in developing countries, where NCD medical expenditure may offset consumption of other essential commodities. This study examines the role of NCDs in household resource allocation in Bangladesh. We use the Bangladesh Household Income and Expenditure Survey (HIES) 2010 to obtain expenditure data on 11 household expenditure categories and 12 food expenditure sub-categories for 12,240 households. Household NCD status was determined through self-report of at least one of the six major NCDs within the household-heart disease, hypertension, diabetes, kidney diseases, asthma, and cancer. We estimated unadjusted and regression-adjusted differences in household expenditure shares between NCD and non-NCD households. We further investigated how consumption of different food sub-categories is related to NCD status, distinguishing between household economic levels. The medical expenditure share was estimated to be 59% higher for NCD households than non-NCD households, and NCD households had lower expenditure shares on food, clothing, hygiene, and energy. Regression results indicated that presence of NCDs was associated with lower relative expenditure on clothing and housing in all economic subgroups, and with lower expenditure on food among marginally poor households. Having an NCD was significantly associated with higher household spending on tobacco and higher-calorie foods such as sugar, beverages, meat, dairy, and fruit, and with lower spending on fish, vegetables, and legumes. The findings indicate a link between NCDs and the possibility of adverse economic effects on the household by highlighting the potential displacement effect on household consumption that might occur through higher medical expenditure and lower spending on essentials. The findings might also point to a need for raising awareness about the link between NCDs and diet in Bangladesh.

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.

Development of a Malawi Intensive care Mortality risk Evaluation (MIME) model, a prospective cohort study

INTRODUCTION

Intensive care medicine can contribute to population health in low-income countries by reducing premature mortality related to surgery, trauma, obstetrical and other medical emergencies. Quality improvement is guided by risk stratification models, which are developed primarily within high-income settings. Models validated for use in low-income countries are needed.

METHODS

This prospective cohort study consisted of 261 patients admitted to the intensive care unit (ICU) of Kamuzu Central Hospital in Malawi, from September 2016 to March 2018. The primary outcome was in-hospital mortality. We performed univariable analyses on putative predictors and included those with a significance of 0.15 in the Malawi Intensive care Mortality risk Evaluation model (MIME). Model discrimination was evaluated using the area under the curve.

RESULTS

Males made up 37.9% of the study sample and the mean age was 34.4 years. A majority (73.9%) were admitted to the ICU after a recent surgical procedure, and 59% came directly from the operating theater. In-hospital mortality was 60.5%. The MIME based on age, sex, admitting service, systolic pressure, altered mental status, and fever during the ICU course had a fairly good discrimination, with an AUC of 0.70 (95% CI 0.63-0.76).

CONCLUSIONS

The MIME has modest ability to predict in-hospital mortality in a Malawian ICU. Multicenter research is needed to validate the MIME and assess its clinical utility.

Promoting healthy eating in primary health care from the perspective of health professionals: a qualitative comparative study in the context of South America

BACKGROUND

Educational interventions designed to promote healthy eating are essential in primary health care. Nevertheless, given the nutrition controversies about what is healthy, the contradictions created by the media, and the situation of users with complex needs, the prioritization of the themes to be addressed in the services has scarcely been described in the planning process. This study aimed to identify the process of implementing the themes discussed by health professionals in nutrition education groups in two primary health care models.

METHODS

Our study followed a qualitative comparative approach. It included the systematic observation of nutrition education group meetings to identify the key messages addressed and semi-structured interviews with health professionals in São Paulo, Brazil, and in Bogotá, Colombia. We used thematic networks to classify the messages and the collective subject discourse technique to organize the information obtained from interviews. We observed 28 nutrition education groups in São Paulo, and 13 in Bogotá, and conducted 27 interviews with nutritionists in each city.

RESULTS

The messages identified were grouped into four global themes: feeding habits, life cycle, disease, and "being a multiplier". The process of implementing the themes, understood as identification, selection, consultation, and application of themes, is intermediated by social representations of the health professionals about service requirements, training and professional performance, and the relationship with users. Two notions shape these representations: Control, although the time and the physical space dedicated to health services are restricted to the disease in São Paulo, in Bogotá only limited health promotion is provided; and specificity, which is portrayed as therapeutic support within a more educational model in São Paulo and as health promotion training courses within a prescriptive model in Bogotá.

CONCLUSIONS

Understanding the process of implementing the themes discussed in nutrition education groups can reveal mechanisms that support the approach to themes on healthy eating, including communicative and educational adaptations of health professionals. This study contributes to the discussion about educational models in health care and their effects on the qualifications of health professionals within the service, especially those included in the context of low- and middle-income settings.

The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review

BACKGROUND

The evidence on the economic burden of cardiovascular disease (CVD) in low- and middle- income countries (LMICs) remains scarce. We conducted a comprehensive systematic review to establish the magnitude and knowledge gaps in relation to the economic burden of CVD and hypertension on households, health systems and the society.

METHODS

We included studies using primary or secondary data to produce original economic estimates of the impact of CVD. We searched sixteen electronic databases from 1990 onwards without language restrictions. We appraised the quality of included studies using a seven-question assessment tool.

RESULTS

Eighty-three studies met the inclusion criteria, most of which were single centre retrospective cost studies conducted in secondary care settings. Studies in China, Brazil, India and Mexico contributed together 50% of the total number of economic estimates identified. The quality of the included studies was generally low. Reporting transparency, particularly for cost data sources and results, was poor. The costs per episode for hypertension and generic CVD were fairly homogeneous across studies; ranging between $500 and $1500. In contrast, for coronary heart disease (CHD) and stroke cost estimates were generally higher and more heterogeneous, with several estimates in excess of $5000 per episode. The economic perspective and scope of the study appeared to impact cost estimates for hypertension and generic CVD considerably less than estimates for stroke and CHD. Most studies reported monthly costs for hypertension treatment around $22. Average monthly treatment costs for stroke and CHD ranged between $300 and $1000, however variability across estimates was high. In most LMICs both the annual cost of care and the cost of an acute episode exceed many times the total health expenditure per capita.

CONCLUSIONS

The existing evidence on the economic burden of CVD in LMICs does not appear aligned with policy priorities in terms of research volume, pathologies studied and methodological quality. Not only is more economic research needed to fill the existing gaps, but research quality needs to be drastically improved. More broadly, national-level studies with appropriate sample sizes and adequate incorporation of indirect costs need to replace small-scale, institutional, retrospective cost studies.

Effectiveness of an Integrated Approach to HIV and Hypertension Care in Rural South Africa: Controlled Interrupted Time-Series Analysis

Supplemental Digital Content is Available in the Text.

Background:

South Africa faces a dual burden of HIV/AIDS and noncommunicable diseases. In 2011, a pilot integrated chronic disease management (ICDM) model was introduced by the National Health Department into selected primary health care (PHC) facilities. The objective of this study was to assess the effectiveness of the ICDM model in controlling patients' CD4 counts (>350 cells/mm³) and blood pressure [BP (<140/90 mm Hg)] in PHC facilities in the Bushbuckridge municipality, South Africa.

Methods:

A controlled interrupted time-series study was conducted using the data from patients' clinical records collected multiple times before and after the ICDM model was initiated in PHC facilities in Bushbuckridge. Patients ≥18 years were recruited by proportionate sampling from the pilot (n = 435) and comparing (n = 443) PHC facilities from 2011 to 2013. Health outcomes for patients were retrieved from facility records for 30 months. We performed controlled segmented regression to model the monthly averages of individuals' propensity scores using autoregressive moving average model at 5% significance level.

Results:

The pilot facilities had 6% greater likelihood of controlling patients' CD4 counts than the comparison facilities (coefficient = 0.057; 95% confidence interval: 0.056 to 0.058; P < 0.001). Compared with the comparison facilities, the pilot facilities had 1.0% greater likelihood of controlling patients' BP (coefficient = 0.010; 95% confidence interval: 0.003 to 0.016; P = 0.002).

Conclusions:

Application of the model had a small effect in controlling patients' CD4 counts and BP, but showed no overall clinical benefit for the patients; hence, the need to more extensively leverage the HIV program for hypertension treatment.

Burden of disease attributable to vitamin A deficiency in Iranian population aged less than five years: findings from the global burden of disease study 2010

BACKGROUND

Vitamin A deficiency (VAD) is considered as one of the most serious public health concerns in developing countriesand the leading cause of mortality in under-five-year-old children.A large number of young children and pregnant women especially in low-income, non-industrialized communities are more susceptible to VAD. This study aims to report the burden of disease (BOD) attributable to VAD in Iranian population aged less than 5 years by using data of the Global Burden of Disease (GBD) study 2010.

METHODS

The GBD 2010 study calculated the proportion of deaths, years of life lost (YLLs), and years lived with disability (YLDs) and disability-adjusted life years (DALYs) attributable to VAD by using the comparative risk assessment (CRA). VAD defined as low serum retinol concentrations (plasma retinol concentration < 0.70 umole/L) among children aged less than five. The VAD outcomes consisted of mortality due to diarrhea, measles, malaria, neglected infectious diseases, morbidity due to malaria (children < 5 years), low birth weight and other perinatal conditions. Uncertainty in the estimates is presented as 95% uncertainty interval (UI).

RESULTS

In 1990, there were 371 (95% UI: 166,665) DALYs due to VAD per 100,000 under five-year-old Iranian children in both sexes. The DALYs rate had a downward trend throughout the following years and reached to 76 (95% UI: 33-139)in 2010.The DALYs in children aged under 5 years was 378 (95% UI: 153-747) years for boys and 363 (95% UI: 148-692) years for girls in 1990 which fell to 79 (95% UI: 32-149) and 73 (95% UI: 29-138) in boys and girls in 2010, respectively. The rates of YLDs attributable to VAD changed in both sexes from 87(95% UI: 34-162) in 1990 to 46 (95% UI: 17-69) in 2010. The highest rate of YLDs attributed to VAD was observed in children aged 1-4. On the other hand, the YLLs were mostly in the 0-1-year-oldchildren in all years except 2010.

CONCLUSION

It was found that DALYs attributable to VAD in 1990, followed by a considerable reduction rate after a period of two decades, in 2010. Additional studies on the burden of diseases particularly at sub-national level with more accurate data are recommended.

Measurement and decomposition of socioeconomic inequality in single and multimorbidity in older adults in China and Ghana: results from the WHO study on global AGEing and adult health (SAGE)

BACKGROUND

Globally people are living longer and enduring non-communicable diseases (NCDs) many of which co-occur as multimorbidity. Demographic and socioeconomic factors are determinants of inequalities and inequities in health. There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana.

METHODS

The data source is the World Health Organization Study on Global AGEing and Adult Health (SAGE) Wave 1 (2007-2010). Nationally representative cross-sectional data collected from adults in China (n = 11,814) and Ghana (n = 4,050) are analysed. Country populations are ranked by a socioeconomic index based on ownership of household assets. The study uses a decomposed concentration index (CI) of single and multiple NCD morbidity (multimorbidity) covering arthritis, diabetes, angina, stroke, asthma, depression, chronic lung disease and hypertension. The CI quantifies the extent of overall inequality on each morbidity measure. The decomposition utilises a regression-based approach to examine individual contributions of demographic and socioeconomic factors, or determinants, to the overall inequality.

RESULTS

In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China (single morbidity CI = -0.0365: 95% CI = -0.0689,-0.0040; multimorbidity CI = -0.0801: 95% CI = -0.1233,-0.0368;). In Ghana inequalities were significant and more highly concentrated among the rich (single morbidity CI = 0.1182; 95% CI = 0.0697, 0.1668; multimorbidity CI = 0.1453: 95% CI = 0.0794, 0.2083). In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multimorbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multimorbidity.

CONCLUSIONS

The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions.

Cardiometabolic diseases of civilization: history and maturation of an evolving global threat. An update and call to action

Despite striking extensions of lifespan, leading causes of death in most countries now constitute chronic, degenerative diseases which outpace the capacity of health systems. Cardiovascular disease is the most common cause of death in both developed and undeveloped countries. In America, nearly half of the adult population has at least one chronic disease, and polypharmacy is commonplace. Prevalence of ideal cardiovascular health has not meaningfully improved over the past two decades. The fall in cardiovascular deaths in Western countries, half due to a fall in risk factors and half due to improved treatments, have plateaued, and this reversal is due to the dual epidemics of obesity and diabetes type 2. High burdens of cardiovascular risk factors are also evident globally. Undeveloped nations bear the burdens of both infectious diseases and high childhood death rates. Unacceptable rates of morbidity and mortality arise from insufficient resources to improve sanitation, pure water, and hygiene, ultimately linked to poverty and disparities. Simultaneously, about 80% of cardiovascular deaths now occur in low- and middle-income nations. For these reasons, risk factors for noncommunicable diseases, including poverty, health illiteracy, and lack of adherence, must be targeted with unprecedented vigor worldwide. Key messages In developed and relatively wealthy countries, chronic "degenerative" diseases have attained crisis proportions that threaten to reverse health gains made within the past decades. Although poverty, disparities, and poor sanitation still cause unnecessary death and despair in developing nations, they are now also burdened with increasing cardiovascular mortality. Poor adherence and low levels of health literacy contribute to the high background levels of cardiovascular risk.

Cardiovascular disease and hypertension in sub-Saharan Africa: burden, risk and interventions

Cardiovascular disease, including stroke, heart failure and kidney disease, has been common in sub-Saharan Africa for many years, and rapid urbanization is causing an upsurge of ischaemic heart disease and metabolic disorders. At least two-thirds of cardiovascular deaths now occur in low- and middle-income countries, bringing a double burden of disease to poor and developing world economies. High blood pressure (or hypertension) is by far the commonest underlying risk factor for cardiovascular disease. Its prevention, detection, treatment and control in sub-Saharan Africa are haphazard and suboptimal. This is due to a combination of lack of resources and health-care systems, non-existent effective preventive strategies at a population level, lack of sustainable drug therapy, and barriers to complete compliance with prescribed medications. The economic impact for loss of productive years of life and the need to divert scarce resources to tertiary care are substantial.

Oxidative stress, type 2 diabetes and vitamin D: past, present and future

Oxidative stress refers to an imbalance between potentially harmful free radicals and the body's mechanisms to efficiently detoxify them in favor of the free radicals. Consequently, excess free radicals can attack and damage a wide range of biomolecules including proteins, lipids and nucleic acids. Antioxidant mechanisms of the body are under the influence of genetic and environmental (including dietary) factors. Diabetes is one of the most common metabolic disorders around the world. A huge body of evidence indicates a role for oxidative stress in development of many human diseases including diabetes. In this article, the latest information on the possible links of oxidative stress with diabetes development, control and complications as well as the newest results of antioxidant supplementation trials is reviewed. In addition, the possible role of vitamin D, as a newly recognized antioxidant in diabetes is discussed. Finally, concluding remarks on pivotal issues and future studies are presented.

Development and evaluation of the Andhra Pradesh Children and Parent Study Physical Activity Questionnaire (APCAPS-PAQ): a cross-sectional study

Background

There is limited availability of context-specific physical activity questionnaires in low and middle income countries. The aim of this study was to develop and examine the validity of a new Indian physical activity questionnaire, the Andhra Pradesh Children and Parent Study Physical Activity Questionnaire (APCAPS-PAQ).

Methods

The current study was conducted with the cohort from the Hyderabad DXA Study (n = 2321), recruited in 2009-2010. Criterion validity (n = 245) was examined by comparing the APCAPS-PAQ to a combined heart rate and motion sensor worn for 8 days. Construct validity (n = 2321) was assessed with linear regression, comparing APCAPS-PAQ against BMI, percent body fat, and pulse rate.

Results

The APCAPS-PAQ criterion validity was variable depending on the PA intensity groups (ρ = 0.26, 0.07, 0.39; к = 0.14, 0.04, 0.16 for sedentary, light, moderate/vigorous physical activity (MVPA) respectively). Sedentary and light intensity activities from the questionnaire were underestimated when compared to the criterion data while MVPA in APCAPS-PAQ was overestimated. Higher time spent in sedentary activity in APCAPS-PAQ was associated with higher BMI and percent body fat, suggesting construct validity.

Conclusions

The APCAPS-PAQ validity is comparable to other physical activity questionnaires. This tool is able to assess sedentary behavior, moderate/vigorous activity and physical activity energy expenditure on a group level with reasonable validity. This new questionnaire may be used for ranking individuals according to their sedentary time and physical activity in southern India.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2706-9) contains supplementary material, which is available to authorized users.

Influences on eating: a qualitative study of adolescents in a periurban area in Lima, Peru

Background

Peruvian adolescents are at high nutritional risk, facing issues such as overweight and obesity, anemia, and pregnancy during a period of development. Research seeking to understand contextual factors that influence eating habits to inform the development of public health interventions is lacking in this population. This study aimed to understand socio-cultural influences on eating among adolescents in periurban Lima, Peru using qualitative methods.

Methods

Semi-structured interviews and pile sort activities were conducted with 14 adolescents 15–17 years. The interview was designed to elicit information on influences on eating habits at four levels: individual (intrapersonal), social environmental (interpersonal), physical environmental (community settings), and macrosystem (societal). The pile sort activity required adolescents to place cards with food images into groups and then to describe the characteristics of the foods placed in each group. Content analysis was used to identify predominant themes of influencing factors in interviews. Multidimensional scaling and hierarchical clustering analysis was completed with pile sort data.

Results

Individual influences on behavior included lack of financial resources to purchase food and concerns about body image. Nutrition-related knowledge also played a role; participants noted the importance of foods such as beans for anemia prevention. At the social environmental level, parents promoted healthy eating by providing advice on food selection and home-cooked meals. The physical environment also influenced intake, with foods available in schools being predominantly low-nutrient energy-dense. Macrosystem influences were evident, as adolescents used the Internet for nutrition information, which they viewed as credible.

Conclusions

To address nutrition-related issues such as obesity and iron-deficiency anemia in Peruvian adolescents, further research is warranted to elucidate the roles of certain factors shaping behavior, particularly that of family, cited numerous times as having a positive influence. Addressing nutrition-related issues such as obesity and iron-deficiency anemia in this population requires consideration of the effect of social and environmental factors in the context of adolescent lifestyles on behavior. Nutrition education messages for adolescents should consider the cultural perceptions and importance of particular foods, taking into account the diverse factors that influence eating behaviors.

The prevalence of type 2 diabetes among older people in Africa: a systematic review

Little information is available on the prevalence of diabetes in people aged 55 years or older living on the African continent. We did a systematic review of the prevalence of type 2 diabetes in studies reported from Jan 1, 2000, to June 30, 2015, to provide accurate data for monitoring future trends. We did a comprehensive literature search using an African search filter and extracted and synthesised data from full papers. Among 1473 identified citations, 41 studies providing 49 separate data contributions involving 16 086 individuals met the inclusion criteria. The overall prevalence of diabetes was 13·7% (95% CI 11·3-16·3) and was higher in studies based on the oral glucose tolerance test (23·9%, 17·7-30·7, 12 contributions with 3415 participants) than fasting blood glucose criteria (10·9%, 8·9-13·0, 37 contributions with 12 671 participants; p<0·001). Prevalence was also higher in non-STEPS than in STEPS studies (17·1%, 95% CI 13·6-20·9) vs 9·6%, 6·6-13·0, p=0·003) and in urban than in rural settings (19·7%, 15·0-24·9 vs 7·9%, 4·6-12·0, p=0·0002), but did not differ significantly across age groups, sex, sample size, year of publication, region, or population coverage. These data highlight the need to reduce diabetes risk factors and implement adequate management strategies. In addition, they suggest that uniform diagnostic methods should be used across African countries and elsewhere to enable assessment of trends in diabetes prevalence and the success of diabetes prevention strategies. A collaborative initiative is required between key international and national diabetes and geriatric organisations to improve diabetes care for the older population in Africa and worldwide.

The "expert patient" approach for non-communicable disease management in low and middle income settings: When the reality confronts the rhetoric

This paper seeks to explore the relevance between the Western “expert patient” rhetoric and the reality of non-communicable diseases (NCDs) control and management in low and middle income settings from the health sociological perspective. It firstly sets up a conceptual framework of the “expert patient” or the patient self-management approach, showing the rhetoric of the initiative in the developed countries. Then by examining the situation of NCDs control and management in low income settings, the paper tries to evaluate the possibilities of implementing the “expert patient” approach in these countries. Kober and Van Damme's study on the relevance of the “expert patient” for an HIV/AIDS program in low income settings is critically studied to show the relevance of the developed countries' rhetoric of the “expert patient” approach for the reality of developing countries. In addition, the MoPoTsyo diabetes peer educator program is analyzed to show the challenges faced by the low income countries in implementing patient self-management programs. Finally, applications of the expert patient approach in China are discussed as well, to remind us of the possible difficulties in introducing it into rural settings.

Is violence a disease? Situating violence prevention in public health policy and practice

The paper provides a review of some of the thoughts, ideas, and opinions that pervade the public health literature concerning how to classify or conceptualise violence. It is argued that violence transcends classic distinctions between communicable and non-communicable diseases, distinguishes itself from the discipline of injury control, and is influenced by wider, social determinants. Through a discussion of these varied perspectives it is concluded that a fourth revolution in public health is needed - a 'change in scope' revolution - that recognizes the influence of social justice, economics, and globalization in the aetiology of premature death and ill health, into which violence fits. However, rather than be shackled by debates of definition or classification, it is important that public health acknowledges the role it can play in preventing violence through policy and practice, and takes unified action.

Health Care Coverage Decision Making in Low- and Middle-Income Countries: Experiences from 25 Coverage Schemes

Lessons learned by countries that have successfully implemented coverage schemes for health services may be valuable for other countries, especially low- and middle-income countries (LMICs), which likewise are seeking to provide/expand coverage. The research team surveyed experts in population health management from LMICs for information on characteristics of health care coverage schemes and factors that influenced decision-making processes. The level of coverage provided by the different schemes varied. Nearly all the health care coverage schemes involved various representatives and stakeholders in their decision-making processes. Maternal and child health, cardiovascular diseases, cancer, and HIV were among the highest priorities guiding coverage development decisions. Evidence used to inform coverage decisions included medical literature, regional and global epidemiology, and coverage policies of other coverage schemes. Funding was the most commonly reported reason for restricting coverage. This exploratory study provides an overview of health care coverage schemes from participating LMICs and contributes to the scarce evidence base on coverage decision making. Sharing knowledge and experiences among LMICs can support efforts to establish systems for accessible, affordable, and equitable health care.

The projection of burden of disease in Islamic Republic of Iran to 2025

Objective

Iran as a developing country is in the transition phase, which might have a big impact on the Burden of Disease and Injury (BOD). This study aims to estimate Burden of Disease and Injury (BOD) in Iran up to 2025 due to four broad cause groups using Disability-Adjusted Life Year (DALY).

Methods

The impacts of demographic and epidemiological changes on BOD (DemBOD and EpiBOD) were assessed separately. We estimated DemBOD in nine scenarios, using different projections for life expectancy and total fertility rate. EpiBOD was modeled in two scenarios as a proportion of DemBOD, based on the extracted parameters from an international study.

Findings

The BOD is projected to increase from 14.3 million in 2003 to 19.4 million in 2025 (95% uncertainty interval: 16.8, 21.9), which shows an overall increase of 35.3%. Non-communicable diseases (12.7 million DALY, 66.0%), injuries (4.6 million DALY, 24.0%), and communicable diseases, except HIV/AIDS (1.8 million DALY, 9%) will be the leading causes of losing healthy life. Under the most likely scenario, the maximum increase in disease burden due to DemBOD is projected to be observed in HIV/AIDS and Non-communicable diseases (63.9 and 62.4%, respectively) and due to EpiBOD in HIV/AIDS (319.5%).

Conclusion

It seems that in the following decades, BOD will have a sharp increase in Iran, mainly due to DemBOD. It seems that communicable diseases (except HIV/AIDS) will have less contribution, and especially non-communicable diseases will play a more significant role.

Reforms and emerging noncommunicable disease: some challenges facing a conflict-ridden country--the case of the Syrian Arab Republic

The past year witnessed considerable turbulence in the Arab world-in this case, Syria, a lower middle-income country with a record of a strong public health infrastructure. This paper explores the current challenges facing its health system from reforms, civil strife and international sanctions all of which we argue have serious implications for population health. The health sector in Syria was little known, and until recently, it was well integrated to provide preventive and specialized care when needed. Regionally, it was one of the few countries ready and capable of addressing the challenges of demographic and epidemiologic transition with a long-standing emphasis on primary care and prevention, unlike most countries of the region. This context has changed dramatically through the recent implementation of reforms and the current civil war. Changes to financing, management and the delivery of health service placed access to services in jeopardy, but now, these are compounded by the destruction from an intractable and violent conflict and international sanctions. This paper explores some of the combined effects of reforms, conflict and sanctions on population health.

Spanish-speaking patients' engagement in interactive voice response (IVR) support calls for chronic disease self-management: data from three countries

We measured Spanish-speaking patients' engagement in Interactive Voice Response (IVR) calls using data from self-management support studies in Honduras, Mexico and the US. A total of 268 patients with diabetes or hypertension participated in 6-12 weeks of weekly IVR follow-up. Participants had an average of 6.1 years of education, and 73% of them were women. After 2443 person-weeks of follow-up, patients had completed 1494 IVR assessments. The call completion rates were higher in the US (75%) than in Honduras (59%) or Mexico (61%; P < 0.001). Patients participating with an informal caregiver were more likely to complete calls (adjusted odds ratio 1.5; P = 0.03) while patients reporting fair or poor health at enrolment were less likely (adjusted odds ratio 0.59; P = 0.02). Satisfaction rates were high, with 98% of patients reporting that the system was easy to use, and 86% reporting that the calls helped them a great deal in managing their health problems. IVR self-management support is feasible among Spanish-speaking patients with chronic disease, including those living in less-developed countries. Involving informal caregivers may increase patient engagement.