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

How integration of refugees into national health systems became a global priority: a qualitative policy analysis

BACKGROUND

Despite a long history of political discourse around refugee integration, it wasn't until 2016 that this issue emerged as a global political priority. Limited research has examined the evolution of policies of global actors around health service provision to refugees and how refugee integration into health systems came onto the global agenda. This study seeks to fill this gap.

METHODS

Drawing on a document review of 20 peer-reviewed articles, 46 global policies and reports, and 18 semi-structured interviews with actors representing various bilateral, multilateral and non-governmental organizations involved with refugee health policy and funding, we analyze factors that have shaped the global policy priority of integration. We use the Shiffman and Smith Policy Framework on determinants of political priority to organize our findings.

RESULTS

Several important factors generated global priority for refugee integration into national health systems. Employing the above-mentioned framework, actor power increased due to network expansion through collaborations between humanitarian and development actors. Ideas took hold through the framing of integration as a human rights and responsibility sharing. While political context was influenced through several global movements, it was ultimately the influx of Syrian refugees into Europe and the increasing securitization of the refugee crisis that led to key policies, and critically, global funding to support integration within refugee hosting nations. Finally, issue characteristics, namely the magnitude of the global refugee crisis, its protractedness and the increasing urbanicity of refugee inflows, led integration to emerge as a manageable solution.

CONCLUSION

The past decade has seen a substantial reframing of refugee integration, along with increased financing sources and increased collaboration, explains this shift towards their integration into health systems. However, despite the emergence of integration as a global political priority, the extent to which efforts around integration have translated into action at the national level remains uncertain.

Addressing chronic diseases: a comparative study of policies towards type-2 diabetes and hypertension in selected European countries

BACKGROUND

Type-2 diabetes (T2D) and hypertension (HTN) are two of the most prevalent non-communicable diseases (NCDs): they both cause a relevant number of premature deaths worldwide and heavily impact the national health systems. This study illustrates the impact of HTN and T2D in four European countries (Albania, Bulgaria, Greece and Spain) and compares their policies towards the monitoring and management of HTN and T2D and the prevention of NCDs as a whole. This analysis is conducted throughout the DigiCare4You Project (H2020)-which implements an innovative solution involving digital tools for the prevention and management of T2D and HTN.

METHODS

The analysis is implemented through desk research, and it is enriched with additional information directly provided by the local coordinators in the four countries, by filling specific semi-structured forms.

RESULTS

The countries exhibit significant differences in the prevalence of HTN and T2D and available policies and programs targeted to these two chronic conditions. Each country has implemented strategies for HTN and T2D, including prevention initiatives, therapeutic guidelines, educational programs and children's growth monitoring programs. However, patient education on proper disease management needs improvement in all countries, registries about patients affected by HTN and T2D are not always available, and not all countries promoted acts to contain the increasing rates of risk factors related to NCDs.

CONCLUSIONS

While political awareness of the risks associated with HTN, T2D and NCDs in general is growing, there is a collective need for countries to strengthen their policies for preventing and managing these chronic diseases.

Human resources challenges in the management of diabetes and hypertension in Mozambique

BACKGROUND

The major burden of non-communicable diseases (NCDs) globally occurs in low-and middle-income countries, where this trend is expected to increase dramatically over the coming years. The resultant change in demand for health care will imply significant adaptation in how NCD services are provided. This study aimed to explore self-reported training and competencies of healthcare providers, and the barriers they face in NCD services provision.

METHODS

A qualitative design was used to conduct this study. Data was collected through semi-structured interviews with government officials within the Mozambican Ministry of Health, district health authorities, health facility managers, and health providers at urban and rural health facilities of Maputo, in Mozambique. The data was then analyzed under three domains: provider´s capacity building, health system structuring, and policy.

RESULTS

A total of 24 interviews of the 26 planed with managers and healthcare providers at national, district, and health facility levels were completed. The domains analyzed enabled the identification and description of three themes. First, the majority of health training courses in Mozambique are oriented towards infectious diseases. Therefore, healthcare workers perceive that they need to consolidate and broaden their NCD-related knowledge or else have access to NCD-related in-service training to improve their capacity to manage patients with NCDs. Second, poor availability of diagnostic equipment, tools, supplies, and related medicines were identified as barriers to appropriate NCD care and management. Finally, insufficient NCD financing reflects the low level of prioritization felt by managers and healthcare providers.

CONCLUSION

There is a gap in human, financial, and material resources to respond to the country's health needs, which is more significant for NCDs as they currently compete against major infectious disease programming, which is better funded by external partners. Healthcare workers at the primary health care level of Mozambique's health system are inadequately skilled to provide NCD care and they lack the diagnostic equipment and tools to adequately provide such care. Any increase in global and national responses to the NCD challenge must include investments in human resources and appropriate equipment.

Progress and challenges in implementing non-communicable disease policies in Sudan

Non-communicable diseases (NCD) pose a substantial global public health challenge, representing the leading cause of morbidity and mortality worldwide. This study investigates the progress and challenges in implementing NCD policies in Sudan. Document analysis following the ready your materials, extract data, analyse data and distil your findings (READ) approach, was utilized to review published literature and reports. Data from the NCD Progress Monitor showed that the percentage of NCD-related mortality had increased from 32% in 2015 to 54% in 2022. Sudan's progress in implementing NCD policies has been slow and challenging; eight of the 19 NCD target indicators had never been fully achieved, and only five targets were fully achieved in the year 2022. However, these figures may be underestimated due to the lack of robust NCD information systems. Like many countries, Sudan faces challenges in implementing NCD policies, particularly those targeting healthy diets, medications and data management systems. This may be linked to the prolonged history of conflict, shortage of trained health personnel, limited resources and lack of robust NCD surveillance systems in the country. The ongoing devastating war and destruction of the healthcare system infrastructure in Sudan further intensified these challenges. Prioritizing NCD policies and programmes during the anticipated post-conflict health system reforms is crucial for enhancing NCD prevention and outcomes in Sudan.

Association of dietary phytochemical index with cardiometabolic risk factors

Objective(s): Cardio-metabolic risk factors are becoming a global health concern. To address this problem, one of the proposed ways is to focus on phytochemical-rich foods consumption. Therefore, we aimed to summarize the results of observational studies (cohorts, case-control, and cross-sectional) that investigated the association between dietary phytochemical index (PI) as a new index for evaluating phytochemical-rich food intake and various risk factors of cardio-metabolic disorders. Methods: We conducted a comprehensive systematic review through PubMed, Scopus, and Web of Science databases. The literature search was performed up to August 2021 with no publication year restriction on observational studies investigating the association between PI and cardiometabolic risk factors on adults and children. A random-effect meta-analysis was used. Results: Overall, 16 articles (cross-sectional, case-control, cohort) were eligible for this systematic review and 8 studies with 99771 participants were included in the meta-analysis. Random effect meta-analysis showed that adherence to higher dietary PI decrease the odds of abdominal obesity (OR: 0.73, 95% CI: 0.58, 0.88, I2: 84.90), generalized obesity (OR: 0.84, 95% CI: 0.69, 0.98, I2: 68.10), hypertriglyceridemia (OR: 0.81, 95% CI: 0.73, 0.89, I2: 0.00), hypertension (OR: 0.86, 95% CI: 0.73, 0.99, I2: 7.02), and MetS (OR: 0.79, 95% CI: 0.69, 0.88, I2: 84.90). However, results considering the associations between dietary PI with glycemic indices, and low high-density lipoprotein cholesterol (HDL-C) were not significant (p<0.05). Conclusion: Evidence showed adverse associations between dietary PI and some cardio-metabolic risk factors such as obesity, hypertriglyceridemia, hypertension and metabolic syndrome.

'It doesn't happen how you think, it is very complex!' Reconciling stakeholder priorities, evidence, and processes for zoonoses prioritisation in India

Background

Why do some zoonotic diseases receive priority from health policy decision-makers and planners whereas others receive little attention? By leveraging Shiffman and Smith's political prioritisation framework, our paper advances a political economy of disease prioritisation focusing on four key components: the strength of the actors involved in the prioritisation, the power of the ideas they use to portray the issue, the political contexts in which they operate, and the characteristics of the issue itself (e.g., overall burdens, severity, cost-effective interventions). These components afford a nuanced characterisation of how zoonotic diseases are prioritised for intervention and highlight the associated knowledge gaps affecting prioritisation outcomes. We apply this framework to the case of zoonoses management in India, specifically to identify the factors that shape disease prioritisation decision-making and outcomes.

Methods

We conducted 26 semi-structured interviews with national, state and district level health policymakers, disease managers and technical experts involved in disease surveillance and control in India.

Results

Our results show pluralistic interpretation of risks, exemplified by a disconnect between state and district level actors on priority diseases. The main factors identified as shaping prioritisation outcomes were related to the nature of the zoonoses problem (the complexity of the zoonotic disease, insufficient awareness and lack of evidence on disease burdens and impacts) as well as political, social, cultural and institutional environments (isolated departmental priorities, limited institutional authority, opaque funding mechanisms), and challenges in organisation leadership for cross-sectoral engagement.

Conclusion

The findings highlight a compartmentalised regulatory system for zoonoses where political, social, cultural, and media factors can influence disease management and prioritisation. A major policy window is the institutionalisation of One Health to increase the political priority for strengthening cross-sectoral engagement to address several challenges, including the creation of effective institutions to reconcile stakeholder priorities and prioritisation processes.

Dietary patterns and cardiometabolic health: Clinical evidence and mechanism

For centuries, the search for nutritional interventions to underpin cardiovascular treatment and prevention guidelines has contributed to the rapid development of the field of dietary patterns and cardiometabolic disease (CMD). Numerous studies have demonstrated that healthy dietary patterns with emphasis on food-based recommendations are the gold standard for extending lifespan and reducing the risks of CMD and mortality. Healthy dietary patterns include various permutations of energy restriction, macronutrients, and food intake patterns such as calorie restriction, intermittent fasting, Mediterranean diet, plant-based diets, etc. Early implementation of healthy dietary patterns in patients with CMD is encouraged, but an understanding of the mechanisms by which these patterns trigger cardiometabolic benefits remains incomplete. Hence, this review examined several dietary patterns that may improve cardiometabolic health, including restrictive dietary patterns, regional dietary patterns, and diets based on controlled macronutrients and food groups, summarizing cutting-edge evidence and potential mechanisms for CMD prevention and treatment. Particularly, considering individual differences in responses to dietary composition and nutritional changes in organ tissue diversity, we highlighted the critical role of individual gut microbiota in the crosstalk between diet and CMD and recommend a more precise and dynamic nutritional strategy for CMD by developing dietary patterns based on individual gut microbiota profiles.

From Local Action to Global Policy: A Comparative Policy Content Analysis of National Policies to Address Musculoskeletal Health to Inform Global Policy Development

BACKGROUND

Global policy to guide action on musculoskeletal (MSK) health is in a nascent phase. Lagging behind other non-communicable diseases (NCDs) there is currently little global policy to assist governments to develop national approaches to MSK health. Considering the importance of comparison and learning for global policy development, we aimed to perform a comparative analysis of national MSK policies to identify areas of innovation and draw common themes and principles that could guide MSK health policy.

METHODS

Multi-modal search strategy incorporating a systematic online search targeted at the 30 most populated nations; a call to networked experts; a specified question in a related eDelphi questionnaire; and snowballing methods. Extracted data were organised using an a priori framework adapted from the World Health Organization (WHO) Building Blocks and further inductive coding. Subsequently, texts were open coded and thematically analysed to derive specific sub-themes and principles underlying texts within each theme, serving as abstracted, transferable concepts for future global policy.

RESULTS

The search yielded 165 documents with 41 retained after removal of duplicates and exclusions. Only three documents were comprehensive national strategies addressing MSK health. The most common conditions addressed in the documents were pain (non-cancer), low back pain, occupational health, inflammatory conditions, and osteoarthritis. Across eight categories, we derived 47 sub-themes with transferable principles that could guide global policy for: service delivery; workforce; medicines and technologies; financing; data and information systems; leadership and governance; citizens, consumers and communities; and research and innovation.

CONCLUSION

There are few examples of national strategic policy to address MSK health; however, many countries are moving towards this by documenting the burden of disease and developing policies for MSK services. This review found a breadth of principles that can add to this existing work and may be adopted to develop comprehensive system-wide MSK health approaches at national and global levels.

A Comparative Study on Health Risks, Lifestyle Behaviors, Health Perceptions, and Health Seeking Patterns between Older and Younger Filipinos in the Rural Areas

Background

Worldwide trends in health risks, lifestyle behaviors, health perceptions, and health-seeking patterns suggest alarming disparities among individuals from low- and middle-income countries. Such international comparisons are particularly troubling for older individuals (≥ 60 years).

Objectives

This study aims to compare health risks, lifestyle behaviors, health perceptions, and health-seeking patterns between younger (<60) and older (≥60) Filipinos from rural communities in the Philippines.

Methods

A comparative cross-sectional study was employed with 863 younger and 427 older Filipinos. Data were analyzed using frequencies, chi-squares, and T-tests.

Results

Older participants were more likely to be single/widowed, ≤ high school education and had higher rates of hypertension, high cholesterol, diabetes, and depression. They reported poorer health status and went to the village health center when sick. Furthermore, they were less likely to drink alcohol and see a physician.

Conclusion

There were significant differences in modifiable health risks and lifestyle behaviors and differences in health perceptions between younger and older cohorts of Filipinos living in rural areas in the Philippines. Our findings suggest the need to design separate health promotion interventions that target older and younger Filipinos' unique needs from rural communities.

The role of non-governmental organizations in strengthening healthcare systems in low- and middle-income countries: Lessons from Santé Diabète in Mali

Non-governmental organizations play a vital part in the achievement of the Sustainable Development Goals as defined by the United Nations. These Goals also include targets related to noncommunicable diseases. However, non-governmental organizations have played a limited role in this area despite such diseases causing the bulk of morbidity and mortality worldwide. Through their activities, non-governmental organizations should aim to strengthen health systems, yet they often only support these for a single disease. Mali, like many other low- and middle-income countries, is facing an increasing burden of diabetes and a health system not adapted to address this challenge. Santé Diabète, a non-governmental organization based in Mali since 2003, has been working specifically on diabetes, and has developed a wide range of activities to improve the national health system. This paper describes changes in the diabetes environment in Mali between 2004 and 2018 based on two health system assessments carried out using a Rapid Assessment Protocol. Over this period, the health system was strengthened with regard to financing and access to medical products. Leadership and governance, service delivery and health workforce were all improved but still partially rely on sustained support from Santé Diabète. The key lesson from this study is that to be effective in changing the management of noncommunicable diseases in a low- and middle-income country, non-governmental organizations need to play a variety of roles, many of which may change over time.

Chronic non-communicable diseases: Hainan prospective cohort study

PURPOSE

The Hainan Cohort was established to investigate the incidence, morbidity and mortality of non-communicable diseases and their risk factors in the community population.

PARTICIPANTS

The baseline investigation of the Hainan Cohort study was initiated in five main areas of Hainan, China, from June 2018 to October 2020. A multistage cluster random-sampling method was used to obtain samples from the general population. Baseline assessments included a questionnaire survey, physical examination, blood and urine sample collection, and laboratory measurements, and outdoor environmental data were obtained.

FINDINGS TO DATA

A total of 14 443 participants aged 35-74 years were recruited at baseline, with a participation rate of 90.1%. The mean age of the participants was 48.8 years; 51.8% were men, and 83.7% had a secondary school or higher education. The crude prevalence of diabetes, coronary heart disease, stroke, hypertension, hyperuricaemia, chronic bronchitis, pulmonary tuberculosis, asthma, cancer, chronic hepatitis and metabolic syndrome were 8.6%, 9.2%, 2.0%, 37.1%, 7.1%, 2.3%, 1.4%, 2.1%, 4.1%, 2.2% and 14.5%, respectively.

FUTURE PLANS

The Hainan Cohort is a dynamic cohort with no end date. All participants will be monitored annually for cause-specific mortality and morbidity until death. Long-term follow-up will be conducted every 5 years. The baseline population is considered to expand in the next wave of follow-up, depending on the availability of funding support.

What has been preventing the emergence of a broad social movement on diabetes (and NCDs)? Insights from the mobilisation of diabetes patients' associations in Bamako, Mali

Non-communicable diseases (NCDs) are among the leading causes of morbidity and mortality globally. While international strategies for their prevention and control call for greater civil society participation, many observers regret the lack of a broad social movement to address these diseases. This study focuses on diabetes patients' associations engaged from 1991 to 2014 in Bamako, Mali, and explores what factors influenced their capacity to build a collective national movement to address this disease and shape policy reforms in this area. Our findings show that the emergence of such a movement was limited by several constraints. The focus of diabetes patients' associations on technical biomedical issues silenced the daily embodied experience of patients and reduced the use of human-rights approaches. Moreover, few financial, material and social resources coupled with a fragmented base limited the scope and strength of claims made by patients' associations to obtain treatment at reduced coasts. Finally, modes of actions performed failed to challenge more structural inequalities and imbalances of power. Exacerbated by limited political opportunities, these constraints weakened the associations' ability to drive policy change on diabetes. They reflect some of the current weaknesses of the global mobilisation to address diabetes and NCDs.

Development of the Brazilian Version of a Pan-Canadian Behavior Change Program and Its Health and Fitness Outcomes

Chronic diseases are a major health problem worldwide, especially in lower-income jurisdictions. Considering this scenario, the World Health Organization has recently established, as a research priority, preventive interventions for populations from lower-income countries, such as the middle-income country of Brazil. The purpose of this article is to describe the components of a pan-Canadian lifestyle program adapted to Brazilians and to report its health and fitness outcomes. A 12-week program called ACCELERATION was translated and culturally adapted to Brazilians. A quasi-randomized controlled trial was designed, consisting of weekly emails and educational videos addressing risk factors for chronic disease. Health and fitness measures included body composition, cardiovascular variables, aerobic fitness, and muscular strength. The Brazilian experimental group showed maintenance in heart rate, blood pressure, and VO2max values while presenting an improvement of 3.3% in body fat percentage (p = 0.040, d = −0.325) and 5.1% in muscular strength (p = 0.039, d = 0.328). Overall, these results were similar to the Canadian intervention. Based on these findings, the Brazilian version of the program has the potential to contribute to the fight against chronic diseases in Brazil.

Management of type 1 diabetes in low- and middle-income countries: Comparative health system assessments in Kyrgyzstan, Mali, Peru and Tanzania

AIMS

To describe and compare the health system responses for type 1 diabetes in Kyrgyzstan, Mali, Peru and Tanzania.

METHODS

The Rapid Assessment Protocol for Insulin Access, a multi-level assessment of the health system, was implemented in Kyrgyzstan, Mali, Peru and Tanzania using document reviews, site visits and interviews to assess the delivery of care and access to insulin.

RESULTS

Despite the existence of noncommunicable or diabetes strategies and Universal Health Coverage policies including diabetes-related supplies, this has not necessarily translated into access to insulin or diabetes care for all. Insulin and related supplies were often unavailable and unaffordable. Across the four countries test strips and insulin, when paid for by the individual, represented respectively 48-82% and 25-36% of total costs. Care was mainly delivered at tertiary-level hospitals by specialists. Only Kyrgyzstan had data collection systems integrated into the Ministry of Health structure. In addition, issues with healthcare worker training and education and empowerment of people with diabetes were present in these health systems.

CONCLUSIONS

People with type 1 diabetes in these countries face different barriers, including the cost of insulin and care. Given the renewed attention to diabetes on the global health agenda tailored health system responses for type 1 diabetes are needed. Insulin should be prioritized as it is the foundation of type 1 diabetes care, but other elements of care and support need to be fostered by different actors.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Social, Economic, Technological, and Environmental Factors Affecting Cardiovascular Diseases: A Systematic Review and Thematic Analysis

Background

Today, cardiovascular disease (CVD) is the leading cause of mortality in both sexes. There are several risk factors for heart diseases; some controllable, others not. However, socioeconomic, technological, and environmental factors can impact CVD as well as exclusive risk factors. Accurate identification and assessment of these factors are often difficult. In the present systematic review, we aimed to explore factors affecting CVD.

Methods

Multiple databases (MEDLINE, Scopus, ISI Web of Science, and Cochrane) and gray literature were searched. The included studies described at least one determinant of CVD. The framework method was applied to analyze the qualitative data.

Results

A total of 64 studies from 26 countries were included. The contextual determinants of CVD were categorized into 45 determinants, 15 factors, and 4 main social, economic, technological, and environmental categories. The 15 potentially reversible factors were identified as sociodemographic, violence, smoking, occupation, positive childhood experience, social inequalities, psychological distress, eating habits, neighborhood, family income, rapid technology, environmental pollution, living environments, noise, and disaster.

Conclusions

Devolution and more efficient health policies are required to achieve further sustained reduction in CVD mortality, increase life expectancy, and reduce its associated risk factors. Policymakers should fully address the value of social, economic, technological, and environmental factors. In fact, a prevention agenda should be developed and updated collaboratively in terms of the determinant factors.

Establishing political priority for global mental health: a qualitative policy analysis

Mental disorders represent the leading cause of disability worldwide, yet they remain a low global health priority. This paper uses a case study methodology and different data sources (35 interviews and documents) to analyse factors that have shaped the generation of political priority for global mental health over the past three decades (1990–2020) and their changes over time. The Shiffman and Smith framework on determinants of political priority for global health issues is used to organize data into themes: actor power, ideas, political context and issue characteristics. Global mental health has gained political attention, especially over the past decade, yet support remains limited. Findings reveal that actor power is undermined by a fragmented policy community, the absence of one guiding institution or coordination mechanism and little civil society mobilization. Public portrayal of the issue is divided, hampered by the absence of a common understanding by the community and by stigma. Some policy windows have been missed and a strong global governance structure is lacking. Credible indicators and evidence on simple cost-effective solutions, especially in low- and middle-income countries, are scarce. However, opportunities are arising, including an increasing number of leaders and grassroots organizations, multiple arguments for action and integrated solutions resonating with broader audiences, widening political support at the national level, an emerging global governance structure and an expanding evidence base on the scale of the problem and available solutions. The results point to three technical and four political challenges that advocates need to address to increase political support over the next decade.

Prevalence and Predicting Risk Factors of Polypharmacy in Azar Cohort Population

Background

As polypharmacy has some medically negative impacts, it has become a challenging issue for public health and affected people. Therefore, we decided to investigate the prevalence of polypharmacy and its predicting risk factors in the Azar cohort population.

Methods

In this cross-sectional population-based cohort study, the prevalence of polypharmacy was evaluated in 15,001 subjects who participated in the Azar cohort study. We measured demographic characteristics (age, gender, socioeconomic status, smoking status, marital status, and education level), physical activity level, body mass index (BMI), blood pressure, multimorbidity (coexistence of two or more chronic diseases (CDs)), and polypharmacy status (a daily intake of five or more medicines for a minimum of 90 days).

Results

Based on our results, 9.51% of the population had polypharmacy. The five most prescribed medications were drugs acting on the cardiovascular system (19.9%), central nervous system (16.7%), endocrine system (13.3%), NSAIDs (11.5%), and drugs used for musculoskeletal and joint diseases (11.4%). Being female, illiterate, and having the lowest tertile of physical activity level significantly increased the risk of polypharmacy. The risk of polypharmacy was 49.36 times higher in patients with four or more CDs than in those without.

Conclusions

Our study emphasized the importance of routine monitoring to evaluate polypharmacy among those aged 35 to 59 and the elderly. Physicians should carefully assess drug suitability, especially in multimorbid and obese patients, to prevent excessive polypharmacy and its potentially negative impacts.

Tracing the emergence of drowning prevention on the global health and development agenda: a policy analysis

Drowning has been a neglected health issue, largely absent from the global health and development discourse, until the UN General Assembly adopted its first resolution on global drowning prevention in 2021. This policy analysis examines the role of issue characteristics, actor power, ideas, and political contexts in the emergence of drowning prevention, and it also identifies opportunities for future actions. We identified three factors crucial to enhancing prioritisation: (1) methodological advancements in population-representative data and evidence for effective interventions; (2) reframing drowning prevention in health and sustainable development terms with an elevated focus on high burdens in low-income and middle-income contexts; and (3) political advocacy by a small coalition. Ensuring that the UN resolution on global drowning prevention is a catalyst for action requires positioning of drowning prevention within global health and sustainable development agendas; strengthening of capacity for multisectoral action; expansion of research measuring burden and identifying solutions in diverse contexts; and incorporation of inclusive global governance, commitments, and mechanisms that hold stakeholders to account.

Noncommunicable Diseases Prevention Policies and Their Implementation in Africa: A Systematic Review

Objectives: To synthesize the existing evidence on NCD policy equity, policy practices, and policy implementation gaps to prevent NCDs in African countries.

Methods: Following the PRISMA-Extension for equity-focused review guidelines, the authors systematically searched documentary evidence from seven databases (BMC, CINHAL Plus, Cochrane, Google Scholar, PubMed, Web of Science, and Scopus) to identify studies conducted and published on African countries between April 2013 and December 31, 2020.

Results: From identified 213 records, 21 studies were included in the final synthesis. Major results showed inadequate studies on NCD policy, unsatisfactory NCD-related policy development, poor policy implementation, lack of policy equity to combat NCDs, and lack of data recorded on NCDs’ prevalence, morbidity, and mortality.

Conclusion: The rigorous WHO-endorsed NCD policies and prevention strategies on the African continent might debar African policymakers and leaders from developing and implementing indigenous NCD-combating strategies. Continent-wide innovative and indigenous NCD-prevention policies and policy equity to effectively prevent, control, and manage NCDs must be developed by African scientists and policymakers.

Analyzing the Implementation of Policies and Guidelines for the Prevention and Management of Type 2 Diabetes at Primary Health Care Level in Nepal

Background

Nepal, in recent years, is witnessing an increasing problem of type 2 diabetes that has resulted significant premature deaths and disability. Prevention and management of non-communicable diseases (NCDs) including diabetes have been prioritized in the national policies and guidelines of the Nepal Government. However, research looking at the overview of the implementation of the existing policies and guidelines for diabetes prevention and control is scarce. Hence, this study reviewed diabetes related existing policies and its implementation process at the primary health care level in Nepal.

Methods

This study involved two phases: Phase I: situation analyses through review of documents and Phase II: qualitative exploratory study. In phase I, four databases (Medline, Web of Science, Embase and PubMed) were systematically searched using key search terms related to diabetes care and policies between January 2000 and June 2021. Also, relevant gray literature was reviewed to understand the trajectory of policy development and its translation with regards to diabetes prevention and management at primary health care level in Nepal. Following the phase I, we conducted in-depth interviews (IDI) and key informant interviews (KII) with health care providers, policy makers, and managers (IDI = 13, and KII = 7) at peripheral and central levels in Kavrepalanchowk and Nuwakot districts of Nepal. The in-depth interviews were audio recorded, transcribed, and coded. The triangulation of data from document review and interviews was done and presented in themes.

Results

Four key themes were identified through triangulating findings from the document review and interviews including (i) limited implementation of policies into practices; (ii) lack of coordination among the different levels of service providers; (iii) lack of trained human resources for health and inadequate quality services at the primary health care level, and (iv) inadequate access and utilization of diabetes care services at primary health care level. Specifically, this study identified some key pertinent challenges to the implementation of policies and programs including inadequate resources, limited engagement of stakeholders in service design and delivery, lack of trained health care providers, lack of financial resources to strengthen peripheral health services, fragmented health governance, and weak reporting and monitoring systems.

Conclusion

This study revealed that the policies, plans, and strategies for prevention and management of NCDs in Nepal recognized the importance of diabetes prevention and control. However, a major gap remains with adequate and lack of clarity in terms of implementation of available policies, plans, strategies, and programs to address the problem of diabetes. We suggest the need for multisectoral approach (engaging both health and non-health sectors) at central as well as peripheral levels to strengthen the policies implementation process, building capacity of health care providers, ensuring adequate financial and non-financial resources, and improving quality of services at primary health care levels.

Exploring the role of social capital, self-efficacy and social contagion in shaping lifestyle and mental health among students representing the future healthcare workforce in Palestine: social cohort study protocol

INTRODUCTION

Non-communicable diseases (NCDs) and depression form an unhealthy mix. The project focuses on potentially effective psychosocial factors shaping health-related habits and mental health. The study is conducted among health domain students. Understanding what shapes their health will determine their quality of care. The study is implemented at An-Najah National University in Palestine. This zone of continuous conflict psychological stress is high and mental health problems are stigmatised.

METHODS AND ANALYSIS

Students who are enrolled in second and third year will be invited to fill in a baseline and two follow-up online questionnaires. The questionnaires will assess: health behaviours and outcomes (health-related habits, obesity and mental health), main predictors (social capital, social network, self-efficacy), confounders (general and sociodemographic characteristics) and effect modifiers (sense of coherence (SOC) and family SOC). Friendships within participating students will be identified by allowing students to name their friends from a pull-down menu of all students. Descriptive statistics and scores will describe participant's characteristics. The relationship between health behaviour, outcomes and main predictors will be examined by regression and structural equation models. Clustering of health behaviours and outcomes will be assessed by permutation tests. Their spread within the network of friends will be investigated by longitudinal generalised estimating equations.

DISCUSSION

The study will identify the prevalence of NCD-related health habits and mental health aspects in the future healthcare workforce in Palestine. It will be the first study to address the role of psychosocial factors for the targeted students. It has the potential to identify targets for promoting physical and mental health among these future professionals.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Ethikkommission Nordwest- und Zentralschweiz (EKNZ) in Switzerland and the Institutional Review Board Committee (IRBC) in Palestine. Participation in the study is voluntary and requires informed consent. The data management methodology ensures the confidentiality of the data. The outcomes of the study will be published as scientific papers. In addition, it will be presented in stakeholder conferences and to students at An-Najah National University.

Multimorbidity matters in low and middle-income countries

Multimorbidity is a complex challenge affecting individuals, families, caregivers, and health systems worldwide. The burden of multimorbidity is remarkable in low- and middle-income countries (LMICs) given the many existing challenges in these settings. Investigating multimorbidity in LMICs poses many challenges including the different conditions studied, and the restriction of data sources to relatively few countries, limiting comparability and representativeness. This has led to a paucity of evidence on multimorbidity prevalence and trends, disease clusters, and health outcomes, particularly longitudinal outcomes. In this paper, based on our experience of investigating multimorbidity in LMICs contexts, we discuss how the structure of the health system does not favor addressing multimorbidity, and how this is amplified by social and economic disparities and, more recently, by the COVID-19 pandemic. We argue that generating epidemiologic data around multimorbidity with similar methods and definition is essential to improve comparability, guide clinical decision-making and inform policies, research priorities, and local responses. We call for action on policy to refinance and prioritize primary care and integrated care as the center of multimorbidity.

Prevalence and determinants of hypertension in underrepresented indigenous populations of Nepal

Indigenous populations residing in low- and middle-income countries (LMICs) are highly underrepresented in medicine and public health research. Specifically, data on non-communicable diseases (NCDs) from indigenous populations remains scarce. Despite the increasing burden of NCDs in the Himalayan region, their prevalence in many indigenous populations remains understudied. The nationally representative public health surveys often do not include the indigenous communities, especially those that reside in rural areas or exist in small numbers. This observational cross-sectional survey study aimed to assess the prevalence of three NCD risk factors namely obesity, hypertension, and tachycardia and identify dietary and lifestyle variables associated with them across underrepresented indigenous populations of Nepal. A total of 311 individuals (53.3% women, 46.7% men) with mean age 43±15 years from 12 indigenous Nepali communities residing in rural (47.9%) or semi-urban (52.1%) areas volunteered to participate in this study. Univariate tests and multivariable logistic regressions were used to analyze the survey data. The mean systolic and diastolic blood pressures were 121.3±19.5 mmHg and 81.3±11.8 mmHg respectively. Overall, the prevalence of obesity and tachycardia was low (0.64% and 3.22%, respectively) but hypertension was prevalent at 23.8%. Hypertension was not significantly different across populations, but it was associated with age, BMI, and tobacco use, and collectively, these variables explained 13.9% variation in hypertension prevalence. Although we were unable to detect direct associations between individual determinants of hypertension identified in non-indigenous Nepalis, such as education levels, alcohol consumption, and smoking in this study, having one or more determinants increased the odds of hypertension in the indigenous participants. Furthermore, ~14% of the hypertensive individuals had none of the universally identified hypertension risk factors. The lack of association between previously identified risk factors for hypertension in these individuals indicates that the additional determinants of hypertension remain to be identified in indigenous Nepali populations.

Association between deficient and insufficient 25(OH)D serum concentrations and cardiometabolic risk factors: Findings of a population-based study with older adults of southern Brazil

To investigate the association between deficient and insufficient serum concentrations of 25(OH)D and cardiometabolic risk factors (CMRF), considering that both conditions are important predictors of cardiovascular disease and diabetes mellitus. A cross-sectional study with a subsample of 526 older adults (63-93 years old) who participated in the second wave of the population-based longitudinal study EpiFloripa Idoso. The CMRF analyzed were abdominal obesity, high fasting glucose, high blood pressure, high triglycerides and high LDL-cholesterol. The exposure variable was 25(OH)D serum concentration (≤20 ng/mL = deficient; 21-29 ng/mL = insufficient, ≥30-<100 ng/mL = sufficient). The prevalences of 25(OH)D deficiency and insufficiency were estimated at 21.9% and 43.7%, respectively. The adjusted OR of prevalence of the abdominal obesity (OR 1.99;1.12-3.54), high blood pressure (OR 2.58;1.35-4.94) and high LDL-cholesterol (OR 2.73;1.63-4.6) were higher among those with deficient serum concentration of 25(OH)D. Participants with insufficient serum concentrations of 25(OH)D also presented higher adjusted OR of prevalence for abdominal obesity (OR 2.14;1.31-3.48). No significant adjusted association was found between 25(OH)D with the outcomes high fasting glucose and high triglycerides. Significant effect modification/interaction by age was also observed in the tested associations for abdominal obesity (P < 0.001), blood pressure (P < 0.001) and LDL-cholesterol (P < 0.001), in which deficient and insufficient 25(OH)D values were associated with higher values of these FRCM. 25(OH)D serum concentrations between 30 and 100 ng/mL can contribute to preventing and controlling CMRF such as abdominal obesity, high blood pressure and high LDL-cholesterol. The understanding this particular interaction may indicate ways to prevent/control cardiometabolic outcomes, health problems common in the older adults.

How to Dampen the Surge of Non-Communicable Diseases in Southeast Asia: Insights from a Systematic Review and Meta-Analysis

Non-communicable diseases (NCDs), such as diabetes, cancer, cardiovascular diseases and chronic respiratory diseases, have overtaken infectious diseases as the number one cause of death worldwide. The rise of these diseases is especially grave in Southeast Asia, where existing research however falls short on offering guidance on how policy can best prevent and control NCDs in the region. Additionally, low- and middle-income countries in Southeast Asia cannot directly incorporate lessons drawn from interventions in richer countries, since health system capacities and human and financial resources are thoroughly different. Preventive interventions, thus, need to correspond to local capacities and require contextual solutions. In this article, we provide a systematic review of a wide scope of NCD interventions conducted in Southeast Asia to inform about existing intervention designs and to derive sound evidence of their effectiveness. Our literature search results in 51 studies from five Southeast Asian countries from which we can extract 204 estimates. We sort the studies into six intervention categories and analyse them with respect to 23 different health and behavioural outcomes. While we find positive and significant average effects across all six types of interventions, we also document evidence of substantial publication bias. Using a meta-regression approach in which we correct for the publication bias, we instead fail to confirm positive average effects for some interventions. Especially dietary and physical activity interventions fail to achieve improvements in analysed health outcomes, while programs focusing on smoking cessation, on the take-up of preventive screening activities or educating patients on how to cope with NCDs achieve sizeable effects. We also present evidence that the size of the effect differs with the participants’ characteristics as well as with design features of the intervention. For local policymakers, the results provide important knowledge on how to address the increasing NCD burden in the coming years.

Getting to the root of the problem: the international and domestic politics of junk food industry regulation in Latin America

In response to non-communicable diseases (NCDs) in Latin America, governments have introduced impressive prevention programmes However, the purpose of this article is to better explain why several governments have yet to address arguably the 'root of the problem': i.e. implementing effective regulatory policies restricting the food industries' ability to market and sale their products. Introducing a political science analytical framework merging international relations and domestic politics theory, this article claims that most governments have failed to achieve this process because of their reluctance to transfer their beliefs in human rights to health from the area of NCD prevention to regulation, thus achieving what the author refer to as 'normative transferability'. The research design for this study entailed a documentary analysis of 44 qualitative primary and secondary documentary data sources (combined), i.e. articles, books, policy reports and the usage of these data sources for a comparative case study analysis of Chile, Brazil and Mexico. These qualitative data sources were also used to illustrate the potential efficacy of the author's proposed analytical framework, developed from the political science and public policy literature. Quantitative epidemiological data from the World Health Organization global health observatory were used to provide a contextual backdrop of the obesity and diabetes situation in these countries. Comparing these three countries, Chile was the only one capable of achieving 'normative transferability' due to a strong linkage between activists, supportive institutions and policy advocates within government viewing regulatory policy as a human right to protection from aggressive industry marketing and sales tactics. To better understand differences between nations in achieving normative transferability processes and effective NCD regulatory policy outcomes, political scientists and public health scholars should work together to develop alternative analytical frameworks in the commercial determinants of health.

Identifying opportunities to engage communities with social mobilisation activities to tackle NCDs in El Salvador in the context of the global COVID-19 pandemic

BACKGROUND

Social mobilisation is potentially a key tool in the prevention of non-communicable diseases (NCDs) in fragile settings. This formative study addressed existing and potential social mobilisation mechanisms seeking behaviour to tackle NCDs in El Salvador, with an emphasis on the implications in the context of the current COVID-19 pandemic.

METHODS

We conducted 19 semi-structured interviews with health workers, government officials, NGO leaders, and community members. Interviews addressed mechanisms for social mobilisation which existed prior to COVID-19, the ways in which these mechanisms tackled NCDs, the impact of COVID-19 on social mobilisation activities and new, emerging mechanisms for social mobilisation in the wake of the COVID-19 pandemic.

RESULTS

Findings indicate a growing awareness of NCDs within communities, with social mobilisation activities seen as valuable in tackling NCDs. However, major barriers to NCD prevention and treatment provision remain, with COVID-19 constraining many possible social mobilisation activities, leaving NCD patients with less support. Factors linked with effective social mobilisation of communities for NCD prevention included strong engagement of community health teams within community structures and the delivery of NCD prevention and management messages through community meetings with trusted health professionals or community members. There are gender differences in the experience of NCDs and women were generally more engaged with social mobilisation activities than men. In the context of COVID-19, traditional forms of social mobilisation were challenged, and new, virtual forms emerged. However, these new forms of engagement did not benefit all, especially those in hard-to-reach rural areas. In these contexts, specific traditional forms of mobilisation such as through radio (where possible) and trusted community leaders - became increasingly important.

CONCLUSIONS

New mechanisms of fostering social mobilisation include virtual connectors such as mobile phones, which enable mobilisation through platforms such as WhatsApp, Facebook and Twitter. However, traditional forms of social mobilisation hold value for those without access to such technology. Therefore, a combination of new and traditional mechanisms for social mobilisation hold potential for the future development of social mobilisation strategies in El Salvador and, as appropriate, in other fragile health contexts.

An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries

BACKGROUND

Noncommunicable diseases (NCDs), including mental health, have become a major concern in low- and middle-income countries. Despite increased attention to them over the past decade, progress toward addressing NCDs has been slow. A lack of bold policy commitments has been suggested as one of the contributors to limited progress in NCD prevention and management. However, the policies of key global actors (bilateral, multilateral, and not-for-profit organisations) have been understudied.

METHODS

This study aimed to map the key global actors investing in action regarding NCDs and review their policies to examine the articulation of priorities regarding NCDs. Narrative synthesis of 70 documents and 31 policy papers was completed, and related to data collated from the Global Health Data Visualisation Tool.

RESULTS

In 2019 41% of development assistance for health committed to NCDs came from private philanthropies, while that for other global health priorities from this source was just 20%. Through a range of channels, bilateral donors were the other major source of NCD funding (contributing 41% of NCD funding). The UK and the US were the largest bilateral investors in NCDs, each contributing 8%. However, NCDs are still under-prioritised within bilateral portfolios - receiving just 0.48% of US funding and 1.66% of the UK. NGOs were the key channels of funding for NCDs, spending 48% of the funds from donors in 2019. The reviewed literature generally focused on NCD policies of WHO, with policies of multilateral and bilateral donors given limited attention. The analysis of policies indicated a limited prioritisation of NCDs in policy documents. NCDs are framed in the policies as a barrier to economic growth, poverty reduction, and health system sustainability. Bilateral donors prioritise prevention, while multilateral actors offer policy options for NCD prevention and care. Even where stated as a priority, however, funding allocations are not aligned.

CONCLUSION

The growing threat of NCDs and their drivers are increasingly recognised. However, global actors' policy priorities and funding allocations need to align better to address these NCD threats. Given the level of their investment and engagement, more research is needed into the role of private philanthropies and NGOs in this area.

A global perspective on the issue of access to insulin

The discovery of insulin in 1921 changed the prognosis for people with type 1 diabetes. A century later, availability and affordability of insulin remain a challenge in many parts of the globe. Using the WHO's framework on understanding the life cycle of medicines, this review details the global and national challenges that affect patients' abilities to access and afford insulin. Current research and development in diabetes has seen some innovations, but none of these have truly been game-changing. Currently, three multinational companies control over 95% of global insulin supply. The inclusion of insulin on the WHO's Prequalification Programme is an opportunity to facilitate entry of new companies into the market. Many governments lack policies on the selection, procurement, supply, pricing and reimbursement of insulin. Moreover, mark-ups in the supply chain also affect the final price to the consumer. Whilst expenses related to diabetes are mostly covered by insurance in high-income countries, many patients from low- and middle-income countries have to pay out of their own pockets. The organisation of diabetes management within the healthcare system also affects patient access to insulin. The challenges affecting access to insulin are complex and require a wide range of solutions. Given that 2021 marks the centenary of the discovery of insulin, there is need for global advocacy to ensure that the benefits of insulin and innovations in diabetes care reach all individuals living with diabetes.

Global Perspectives on Improving Chronic Disease Prevention and Management in Diverse Settings

The Centers for Disease Control and Prevention (CDC) define chronic diseases as conditions that last 1 year or more and that require ongoing medical attention or limit activities of daily living, or both (1). Chronic diseases may be influenced by a combination of genetics, lifestyle and social behaviors, health care system factors, community influences, and environmental determinants of health (2). These risk factors often coexist and interact with each other. Therefore, a better understanding of determinants of chronic diseases such as tobacco use, unhealthy eating, and physical inactivity stands to benefit from effective strategies for improving primary, secondary, and tertiary disease prevention and management in diverse global settings (3). Strategies to prevent and manage chronic disease outcomes such as diabetes and cardiovascular diseases (CVDs) have global commonalities (4-7). The impact of chronic diseases is disproportionately evident in Black and Brown communities (8,9). Chronic disease prevention and management typically focus on behavioral interventions such as healthy eating, increased physical activity, and cessation of unhealthy practices such as tobacco and alcohol use (10-15). In 2020, the COVID-19 pandemic added to the fact that chronic diseases disproportionately affect low-resource communities, where many Black and Brown populations live (16,17). COVID-19 demonstrated that chronic disease disparities actually present as preexisting conditions in Black and Brown communities, who are disproportionately affected by COVID-19 outcomes. Although most of the articles in this Preventing Chronic Disease (PCD) collection were published before the pandemic, the insights they present, combined with the racial and ethnic data on the burden of COVID-19 thus far, support this reality. Many researchers and public health practitioners often consider the need to sufficiently address the relationships between chronic diseases and social, behavioral, and community factors (18). Global lessons in the prevention and management of chronic diseases, therefore, can help researchers and practitioners benefit from the shared lessons and experience derived from research and interventions conducted in different parts of the world. There are more than 7 billion people worldwide, who speak diverse languages and who have different nationalities, identities, and health systems. Yet, if we share challenges and opportunities for chronic disease prevention and management, many of the global adversities to improving health and well-being can be ameliorated, which is the purpose of this collection. The authors in this collection share lessons that represent experiences in diverse contexts across countries and regions of the world.

Framing global discourses on non-communicable diseases: a scoping review

Background

The choices that policymakers make are shaped by how their problems are framed. At last, non-communicable diseases (NCDs) have risen high on the global policy agenda, but there are many disputed issues. First, what are they? Their name refers not to what they are but what they are not. Second, where do their boundaries lie? What diseases are included? Third, should we view their causes as mainly biomedical, behavioural, or social, or a combination? Our failure to resolve these issues has been invoked as a reason for our limited progress in developing and implementing effective remedies. In this scoping review, we ask “What is known from the existing literature about how NCDs are framed in the global policy discourses?” We answer it by reviewing the frames employed in policy and academic discourses.

Methods

We searched nine electronic databases for articles published since inception to 31 May 2019. We also reviewed websites of eight international organisations to identify global NCDs policies. We extracted data and synthesised findings to identify key thematic frames.

Results

We included 36 articles and nine policy documents on global NCDs policies. We identified five discursive domains that have been used and where there are differing perspectives. These are: “Expanding the NCDs frame to include mental health and air pollution”; “NCDs and their determinants”; “A rights-based approach to NCDs”; “Approaches to achieving policy coherence in NCDs globally”; and “NCDs as part of Sustainable Socio-economic Development”. We further identified 12 frames within the five discursive domains.

Conclusions

This scoping review identifies issues that remain unresolved and points to a need for alignment of perspectives among global health policy actors, as well as synergies with those working on mental health, maternal health, and child health. The current COVID-19 pandemic warrants greater consideration of its impact on global NCDs policies. Future global strategies for NCDs need to consider explicitly how NCDs are framed in a changing global health discourse and ensure adequate alignment with implementation and global health issues. There is a need for global strategies to recognise the pertinent role of actors in shaping policy discourses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05958-0.

Using routine health information data for research in low- and middle-income countries: a systematic review

BACKGROUND

Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications.

METHODS

Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form.

RESULTS

We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored.

CONCLUSIONS

Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

The process of building the priority of neglected tropical diseases: A global policy analysis

The global burden attributed to Neglected Tropical Diseases (NTDs) is 47.9 million Disability-Adjusted Life Years (DALYs). These diseases predominantly affect disadvantaged populations. Priority for NTDs has grown in recent years, which is observed by their inclusion in the sustainable development goals (SDGs). This study analyzed the process that allowed these diseases to be included on the global health policy agenda. This global policy analysis used the Shiffman and Smith framework to understand the determinants of global health political priority for NTDs. The framework comprises four categories: actor power, ideas, political contexts, and issue characteristics. Global documents and World Health Assembly (WHA) resolutions were examined, key-informant interviews were conducted, and academic publications were reviewed to understand the four categories that comprise the framework. A total of 37 global policy documents, 15 WHA resolutions, and 38 academic publications were examined. Twelve semi-structured interviews were conducted with individuals representing different sectors within the NTD community who have been involved in raising the priority of these diseases. This study found that several factors helped better position NTDs in the global health agenda. These include the leadership of actors that mobilized the global health community, the creation of a label combining these diseases as a group to represent a larger disease burden, the presence of mechanisms aligning the NTD community, and the agreement on ways to present the NTD burden and potential solutions. The process of building the priority of NTDs in the global health agenda shows that several determinants led to positive outcomes, but these diseases continue to have low priority at the global level which requires the implementation of actions to increase their global priority. These include sustaining the commitment of current actors and engaging new ones; increasing the attention given to diseases formerly categorized as "tool-deficient", including zoonotic NTDs; continue leveraging on policy windows and creating favorable policy moments to sustain commitment, as well as setting realistic targets. Findings from this study can help develop strategies to build the momentum and drive actions to implement the goals of the new Roadmap for NTDs in the pathway to universal health coverage (UHC) and sustainable development.

Adapting and implementing training, guidelines and treatment cards to improve primary care-based hypertension and diabetes management in a fragile context: results of a feasibility study in Sierra Leone

Background

Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention.

Methods

A mixed-method approach was used for the assessment, including 51 semi-structured interviews, review of routine treatment cards (retrieved for newly registered hypertensive and diabetic patients from June 2018 to March 2019 followed up for three months) and mentoring data, and observation of training. Thematic analysis was used for qualitative data and descriptive trend analysis and t-test was used for quantitative data, wherever appropriate.

Results

A Technical Working Group, established at district and national level, helped to adapt and develop the context-specific desktop guidelines for clinical management and lifestyle interventions and associated training curriculum and modules for community health officers (CHOs). Following a four-day training of CHOs, focusing on communication skills, diagnosis and management of hypertension and diabetes, and thanks to a CHO-based mentorship strategy, there was observed improvement of NCD knowledge and care processes regarding diagnosis, treatment, lifestyle education and follow up. The intervention significantly improved the average diastolic blood pressure of hypertensive patients (n = 50) three months into treatment (98 mmHg at baseline vs. 86 mmHg in Month 3, P = 0.001). However, health systems barriers typical of fragile settings, such as cost of transport and medication for patients and lack of supply of medications and treatment equipment in facilities, hindered the optimal delivery of care for hypertensive and diabetic patients.

Conclusion

Our study suggests the potential feasibility of this approach to strengthening primary care delivery of NCDs in fragile contexts. However, the approach needs to be built into routine supervision and pre-service training to be sustained. Key barriers in the health system and at community level also need to be addressed.

Governing Noncommunicable Diseases Through Political Rationality and Technologies of Government: A Discourse Analysis

In the last two decades, global action to address noncommunicable diseases (NCDs) has accelerated, but policy adoption and implementation at the national level has been inadequate. This analysis examines the role of rationalities of governing, or governmentality, in national-level adoption of global recommendations. Critical discourse analysis was conducted using 49 formal institutional and organizational documents obtained through snowball sampling methodology. Text were coded using a framework of five forms of governmentality and analyzed to describe the order of discourse which has emerged within the global NCD policy domain. The dominant political rationality used to frame NCDs is rooted in risk governmentality. Recommendations for tobacco control and prevention of harmful alcohol use rely on a governmentality of police mixed with discipline. The promotion of physical activity relies heavily on disciplinary governmentality, and the prevention of unhealthy diet mixed disciplinary measures, discipline, and neoliberal governmentalities. To translate global NCD prevention and control strategies to national action, acceptability for the political rationalities embodied in policy options must be nurtured as new norms, procedures, and institutions appropriate to the political rationalities of specific interventions are developed.

Assessment and prioritization of the WHO "best buys" and other recommended interventions for the prevention and control of non-communicable diseases in Iran

BACKGROUND

The WHO's "best buys" and other recommended interventions are a menu of policy options and cost-effective interventions for the prevention and control of major noncommunicable diseases (NCDs). The menu has six objectives, implementing which by member states is expected to promote the achievement of the nine NCD targets by 2025. In line with their context, countries can select from the menu of best buys and other recommended interventions. Iran adopted its national action plan on NCDs, 2015, including global as well as some specific goals and targets. This study had two objectives: analyzing the gaps to reach the national targets on NCDs; and prioritizing the best buys and other recommended interventions based on multi-criteria decision-making (MCDA) method for the context of Iran.

METHODS

This is a mixed-methods study. We used qualitative textual evidence (documentary content analysis) and MCDA for prioritization of interventions based on five criteria, including a number of people to be potentially affected by the intervention, cost-effectiveness of the intervention, attributable burden (DALY per 100,000), hospitalization and variations among income levels. Data related to five criteria for each intervention were extracted from national studies and relevant international organizations. The weight of each criterion determines based on the opinions of national experts.

RESULTS

Out of 105 actions and interventions recommended by WHO, only 12 of them were not on the national agenda in Iran, while the six missed interventions were related to objective number 4. Only one of the best buys Group's interventions was not targeted (vaccination against human papillomavirus, two doses of 9-13-year-old girls), for which arrangements are being made for the implementation. Encouraging and educating healthy dietary habits and increasing public awareness about the side effects of smoking and exposure to second-hand smoke, e.g., through mass media campaigns, are among the interventions in need of serious prioritization. The priority of interventions was independently calculated in the area of risk factors and clinical preventive interventions.

CONCLUSION

Due to limited resources, low and middle-income countries (LMICs) need to identify and prioritize more cost-effective and more equitable interventions to combat the NCD epidemic. Based on our findings, we advocate more investment in the mass and social media campaigns to promote a healthy diet, avoid tobacco use, as well as the inclusion of some effective clinical preventive interventions into the national action plan, along the long pathway to tackle NCDs and ultimately reach sustainable health development in Iran. The use of the MCDA approach assisted us in formulating a simultaneous use of efficiency and equity, and other indices for prioritizing the interventions.

Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases.