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Lemp JM, Pengpid S, Buntup D, Sornpaisarn B, Peltzer K, Geldsetzer P, Probst C. Stakeholder-Informed Solutions To Address Barriers for Alcohol Screening and Brief Intervention in Thai Hypertension Care. J Prev (2022) 2024; 45:227-236. [PMID: 38148463 DOI: 10.1007/s10935-023-00763-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 12/28/2023]
Abstract
Premature deaths from NCDs disproportionately affect people in low- and middle-income countries. Since alcohol use is one of the most common causes of reversible hypertension, interventions targeting alcohol use may be a feasible and effective low-cost approach to synergistically reduce the prevalence of harmful drinking and high blood pressure. This study sought to identify key factors in successfully implementing alcohol use screening and brief intervention in hypertension care in Thailand. For this purpose, we surveyed participants (NRound 1 = 91, NRound 2 = 27) from three different groups of Thai stakeholders (policy- and decisionmakers, primary healthcare practitioners, and patients diagnosed with hypertension) in a two-round stakeholder elicitation. In round 1, we identified limited resources, lack of clear guidelines for lifestyle intervention, stigmatization, and inconsistent monitoring of patients' alcohol use as important barriers. In round 2, we sought to elicit solutions for the barriers identified in round 1. While stakeholders emphasized the need for adaptability to existing realities in Thai primary healthcare such as a high workload and limited digitization, they favorably evaluated a digital alcohol assessment tool with integrated, tailored advice for brief intervention as a potential scalable solution. Findings suggest that as one possible route to reduce the NCD burden caused by hypertension in Thailand, primary healthcare services may be enhanced by digital tools that support resource-effective, intuitive, and seamless delivery of alcohol screening and brief intervention.
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Affiliation(s)
- Julia M Lemp
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Supa Pengpid
- Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Doungjai Buntup
- ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand
| | - Bundit Sornpaisarn
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Faculty of Public Health, Mahidol University, Ratchathewi, Bangkok, Thailand
| | - Karl Peltzer
- Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Chan Zuckerberg Biohub - San Francisco, San Francisco, CA, USA
| | - Charlotte Probst
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany.
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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Lemp JM, Bommer C, Xie M, Michalik F, Jani A, Davies JI, Bärnighausen T, Vollmer S, Geldsetzer P. Quasi-experimental evaluation of a nationwide diabetes prevention programme. Nature 2023; 624:138-144. [PMID: 37968391 DOI: 10.1038/s41586-023-06756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/17/2023] [Indexed: 11/17/2023]
Abstract
Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.
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Affiliation(s)
- Julia M Lemp
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Christian Bommer
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Min Xie
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Felix Michalik
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Anant Jani
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- University of Oxford, Oxford, UK
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- Africa Health Research Institute, Somkhele, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA.
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA.
- Chan Zuckerberg Biohub-San Francisco, San Francisco, CA, USA.
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Llamosas-Falcón L, Rehm J, Bright S, Buckley C, Carr T, Kilian C, Lasserre AM, Lemp JM, Zhu Y, Probst C. The Relationship Between Alcohol Consumption, BMI, and Type 2 Diabetes: A Systematic Review and Dose-Response Meta-analysis. Diabetes Care 2023; 46:2076-2083. [PMID: 37890103 PMCID: PMC10620538 DOI: 10.2337/dc23-1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/26/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Moderate alcohol use may be associated with lower risk of type 2 diabetes mellitus (T2DM). Previous reviews have reached mixed conclusions. PURPOSE To quantify the dose-response relationship between alcohol consumption and T2DM, accounting for differential effects by sex and BMI. DATA SOURCES Medline, Embase, Web of Science, and one secondary data source. STUDY SELECTION Cohort studies on the relationship between alcohol use and T2DM. DATA EXTRACTION Fifty-five studies, and one secondary data source, were included with a combined sample size of 1,363,355 men and 1,290,628 women, with 89,983 and 57,974 individuals, respectively, diagnosed with T2DM. DATA SYNTHESIS Multivariate dose-response meta-analytic random-effect models were used. For women, a J-shaped relationship was found with a maximum risk reduction of 31% (relative risk [RR] 0.69, 95% CI 0.64-0.74) at an intake of 16 g of pure alcohol per day compared with lifetime abstainers. The protective association ceased above 49 g per day (RR 0.82, 95% CI 0.68-0.99). For men, no statistically significant relationship was identified. When results were stratified by BMI, the protective association was only found in overweight and obese women. LIMITATIONS Our analysis relied on aggregate data. We included some articles that determined exposure and cases via self-report, and the studies did not account for temporal variations in alcohol use. CONCLUSIONS The observed reduced risk seems to be specific to women in general and women with a BMI ≥25 kg/m2. Our findings allow for a more precise prediction of the sex-specific relationship between T2DM and alcohol use, as our results differ from those of previous studies.
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Affiliation(s)
- Laura Llamosas-Falcón
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Clinical Psychology and Psychotherapy & Center of Clinical Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Dresden, Germany
- Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sophie Bright
- School of Health and Related Research (ScHARR), Faculty of Medicine, Dentistry & Health, University of Sheffield, Sheffield, U.K
| | - Charlotte Buckley
- Department of Automatic Control and Systems Engineering, University of Sheffield, Sheffield, U.K
| | - Tessa Carr
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Carolin Kilian
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Aurélie M. Lasserre
- Addiction Medicine, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Julia M. Lemp
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Yachen Zhu
- Alcohol Research Group, Public Health Institute, Emeryville, CA
| | - Charlotte Probst
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
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4
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Lemp JM, Bommer C, Xie M, Jani A, Davies JI, Bärnighausen T, Vollmer S, Geldsetzer P. Achieving behavior change at scale: Causal evidence from a national lifestyle intervention program for pre-diabetes in the UK. medRxiv 2023:2023.06.08.23291126. [PMID: 37398473 PMCID: PMC10312862 DOI: 10.1101/2023.06.08.23291126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
There remains widespread doubt among clinicians that mere lifestyle advice and counseling provided in routine care can achieve improvements in health. We aimed to determine the health effects of the largest behavior change program for pre-diabetes globally (the English Diabetes Prevention Programme) when implemented at scale in routine care. We exploited the threshold in glycated hemoglobin (HbA1c) used to decide on program eligibility by applying a regression discontinuity design, one of the most credible quasi-experimental strategies for causal inference, to electronic health data from approximately one-fifth of all primary care practices in England. Program referral led to significant improvements in patients' HbA1c and body mass index. This analysis provides causal, rather than associational, evidence that lifestyle advice and counseling implemented in a national health system can achieve important health improvements.
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Kilian C, Lemp JM, Probst C. Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States. Addict Behav 2023; 145:107765. [PMID: 37315509 DOI: 10.1016/j.addbeh.2023.107765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023]
Abstract
Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.
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Affiliation(s)
- Carolin Kilian
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada.
| | - Julia M Lemp
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada; Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Charlotte Probst
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada; Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Kilian C, Lemp JM, Llamosas-Falcón L, Carr T, Ye Y, Kerr WC, Mulia N, Puka K, Lasserre AM, Bright S, Rehm J, Probst C. Reducing alcohol use through alcohol control policies in the general population and population subgroups: a systematic review and meta-analysis. EClinicalMedicine 2023; 59:101996. [PMID: 37256096 PMCID: PMC10225668 DOI: 10.1016/j.eclinm.2023.101996] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/01/2023] Open
Abstract
We estimate the effects of alcohol taxation, minimum unit pricing (MUP), and restricted temporal availability on overall alcohol consumption and review their differential impact across sociodemographic groups. Web of Science, Medline, PsycInfo, Embase, and EconLit were searched on 08/12/2022 and 09/26/2022 for studies on newly introduced or changed alcohol policies published between 2000 and 2022 (Prospero registration: CRD42022339791). We combined data using random-effects meta-analyses. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 1887 reports, 36 were eligible. Doubling alcohol taxes or introducing MUP (Int$ 0.90/10 g of pure alcohol) reduced consumption by 10% (for taxation: 95% prediction intervals [PI]: -18.5%, -1.2%; for MUP: 95% PI: -28.2%, 5.8%), restricting alcohol sales by one day a week reduced consumption by 3.6% (95% PI: -7.2%, -0.1%). Substantial between-study heterogeneity contributes to high levels of uncertainty and must be considered in interpretation. Pricing policies resulted in greater consumption changes among low-income alcohol users, while results were inconclusive for other socioeconomic indicators, gender, and racial and ethnic groups. Research is needed on the differential impact of alcohol policies, particularly for groups bearing a disproportionate alcohol-attributable health burden. Funding Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Number R01AA028009.
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Affiliation(s)
- Carolin Kilian
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Julia M. Lemp
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Laura Llamosas-Falcón
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tessa Carr
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Yu Ye
- Alcohol Research Group, Public Health Institute, Emeryville, CA, United States
| | - William C. Kerr
- Alcohol Research Group, Public Health Institute, Emeryville, CA, United States
| | - Nina Mulia
- Alcohol Research Group, Public Health Institute, Emeryville, CA, United States
| | - Klajdi Puka
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Aurélie M. Lasserre
- Addiction Medicine, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Sophie Bright
- School of Health and Related Research (ScHARR), Faculty of Medicine, Dentistry & Health, University of Sheffield, Sheffield, England, UK
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Dalla Lana School of Public Health & Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Program on Substance Abuse & WHO Collaborating Centre, Public Health Agency of Catalonia, Barcelona, Spain
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Charlotte Probst
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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7
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Lemp JM, Pengpid S, Buntup D, Bärnighausen TW, Geldsetzer P, Peltzer K, Rehm J, Sornpaisarn B, Probst C. Addressing alcohol use among blood pressure patients in Thai primary care: Lessons from a survey-based stakeholder consultation. Prev Med Rep 2022; 29:101954. [PMID: 36161118 PMCID: PMC9502666 DOI: 10.1016/j.pmedr.2022.101954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 08/12/2022] [Accepted: 08/14/2022] [Indexed: 11/20/2022] Open
Abstract
Alcohol use is a major risk factor for noncommunicable diseases in Thailand, and one of its pathways is high blood pressure. Given that brief intervention can effectively reduce hazardous alcohol consumption, this study aimed to investigate how hypertensive patients with concomitant alcohol use are identified and treated in Thai primary care settings and what this may mean for screening and lifestyle intervention strategies. In a cross-sectional, mixed-method design, we surveyed 91 participants from three different groups of Thai stakeholders: policy- and decisionmakers; healthcare practitioners; and patients diagnosed with hypertension. Data was collected between December 2020 and May 2021. Responses were analyzed descriptively and using open coding tools to identify current practices, barriers, facilitators, and implications for interventions. All stakeholder groups regarded alcohol use as an important driver of hypertension. While lifestyle interventions among hypertensive patients were perceived as beneficial, current lifestyle support was limited. Barriers included limited resources in primary healthcare facilities, lack of continuous monitoring or follow-up, missing tools or procedures for risk assessment and lifestyle intervention, and stigmatization of alcohol use. Our results suggest that although screening for lifestyle risk factors (including alcohol use) and lifestyle interventions are not yet sufficiently established, a wide range of stakeholders still recognize the potential of interventions targeted at hazardous alcohol use among hypertensive patients. Future interventions may establish standardized assessment tools, be tailored to high-risk groups, and include electronic or remote elements.
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Affiliation(s)
- Julia M. Lemp
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Supa Pengpid
- ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand
- Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa
| | - Doungjai Buntup
- ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand
| | - Till W. Bärnighausen
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Karl Peltzer
- Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Jürgen Rehm
- Institute of Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Bundit Sornpaisarn
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Faculty of Public Health, Mahidol University, Ratchathewi, Bangkok, Thailand
| | - Charlotte Probst
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Corresponding author at: Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
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8
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Theilmann M, Lemp JM, Winkler V, Manne-Goehler J, Marcus ME, Probst C, Lopez-Arboleda WA, Ebert C, Bommer C, Mathur M, Andall-Brereton G, Bahendeka SK, Bovet P, Farzadfar F, Ghasemi E, Mayige MT, Saeedi Moghaddam S, Mwangi KJ, Naderimagham S, Sturua L, Atun R, Davies JI, Bärnighausen T, Vollmer S, Geldsetzer P. Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries. BMJ 2022; 378:e067582. [PMID: 36041745 PMCID: PMC10471941 DOI: 10.1136/bmj-2021-067582] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries. DESIGN Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020. SETTING Population based survey data. PARTICIPANTS 1 231 068 individuals aged 15 years and older. MAIN OUTCOME MEASURES Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco). RESULTS The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age. CONCLUSIONS Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.
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Affiliation(s)
- Michaela Theilmann
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Julia M Lemp
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Volker Winkler
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maja E. Marcus
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Charlotte Probst
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - Cara Ebert
- RWI — Leibniz Institute for Economic Research, Essen (Berlin Office), GermanyQuantitative Sciences Unit and Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Christian Bommer
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Maya Mathur
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- RWI — Leibniz Institute for Economic Research, Essen (Berlin Office), GermanyQuantitative Sciences Unit and Department of Pediatrics, Stanford University, Stanford, CA, USA
- Port of Spain, Trinidad and Tobago
- St Francis Hospital, Kampala, Uganda
- Ministry of Health, Victoria, Seychelles
- University Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- National Institute for Medical Research, Dar es Salaam, Tanzania
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
- Institute of Global Health, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
- Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Africa Health Research Institute, Somkhele, South Africa
- Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Glennis Andall-Brereton
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- RWI — Leibniz Institute for Economic Research, Essen (Berlin Office), GermanyQuantitative Sciences Unit and Department of Pediatrics, Stanford University, Stanford, CA, USA
- Port of Spain, Trinidad and Tobago
- St Francis Hospital, Kampala, Uganda
- Ministry of Health, Victoria, Seychelles
- University Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- National Institute for Medical Research, Dar es Salaam, Tanzania
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
- Institute of Global Health, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
- Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Africa Health Research Institute, Somkhele, South Africa
- Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | | | - Pascal Bovet
- Ministry of Health, Victoria, Seychelles
- University Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Ghasemi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mary T Mayige
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Sahar Saeedi Moghaddam
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kibachio J Mwangi
- Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
- Institute of Global Health, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
| | - Shohreh Naderimagham
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Lela Sturua
- Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Rifat Atun
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Justine I Davies
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Africa Health Research Institute, Somkhele, South Africa
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
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9
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Lemp JM, Nuthanapati MP, Bärnighausen TW, Vollmer S, Geldsetzer P, Jani A. Use of lifestyle interventions in primary care for individuals with newly diagnosed hypertension, hyperlipidaemia or obesity: a retrospective cohort study. J R Soc Med 2022; 115:289-299. [PMID: 35176215 PMCID: PMC9340092 DOI: 10.1177/01410768221077381] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Lifestyle interventions can be efficacious in reducing cardiovascular disease risk factors and are recommended as first-line interventions in England. However, recent information on the use of these interventions in primary care is lacking. We investigated for how many patients with newly diagnosed hypertension, hyperlipidaemia or obesity, lifestyle interventions were recorded in their primary care electronic health record. DESIGN A retrospective cohort study. SETTING English primary care, using UK Clinical Practice Research Datalink. PARTICIPANTS A total of 770,711 patients who were aged 18 years or older and received a new diagnosis of hypertension, hyperlipidaemia or obesity between 2010 and 2019. MAIN OUTCOME MEASURES Record of lifestyle intervention and/or medication in 12 months before to 12 months after initial diagnosis (2-year timeframe). RESULTS Analyses show varying results across conditions: While 55.6% (95% CI 54.9-56.4) of individuals with an initial diagnosis of hypertension were recorded as having lifestyle support (lifestyle intervention or signposting) within the 2-year timeframe, this number was reduced to 45.2% (95% CI 43.8-46.6) for hyperlipidaemia and 52.6% (95% CI 51.1-54.1) for obesity. For substantial proportions of individuals neither lifestyle support nor medication (hypertension: 12.2%, 95% CI 11.9-12.5; hyperlipidaemia: 32.2%, 95% CI 31.2-33.3; obesity: 43.9%, 95% CI 42.3-45.4) were recorded. Sensitivity analyses confirm that limited proportions of patients had lifestyle support recorded in their electronic health record before they were first prescribed medication (diagnosed and undiagnosed), ranging from 12.1% for hypertension to 19.7% for hyperlipidaemia, and 19.5% for obesity (23.4% if restricted to Orlistat). CONCLUSIONS Limited evidence of lifestyle support for individuals with cardiovascular risk factors (hypertension, hyperlipidaemia, obesity) recommended by national guidelines in England may stem from poor recording in electronic health records but may also represent missed opportunities. Given the link between progression to cardiovascular disease and modifiable lifestyle factors, early support for patients to manage their conditions through non-pharmaceutical interventions by establishing lifestyle modification as first-line treatment is crucial.
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Affiliation(s)
- Julia M Lemp
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, 69120 Heidelberg, Germany
| | - Meghana Prasad Nuthanapati
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, 37073 Göttingen, Germany
| | - Till W Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, 69120 Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA 02115, USA.,Africa Health Research Institute, Somkhele, Mtubatuba, 3935, South Africa
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, 37073 Göttingen, Germany
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, 69120 Heidelberg, Germany.,Division of Primary Care and Population Health, Stanford University, Stanford, CA 94305, USA
| | - Anant Jani
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, 69120 Heidelberg, Germany.,Oxford Martin School, Oxford University, Oxford OX1 3BD, UK
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10
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Marcus ME, Manne-Goehler J, Theilmann M, Farzadfar F, Moghaddam SS, Keykhaei M, Hajebi A, Tschida S, Lemp JM, Aryal KK, Dunn M, Houehanou C, Bahendeka S, Rohloff P, Atun R, Bärnighausen TW, Geldsetzer P, Ramirez-Zea M, Chopra V, Heisler M, Davies JI, Huffman MD, Vollmer S, Flood D. Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data. Lancet Glob Health 2022; 10:e369-e379. [PMID: 35180420 PMCID: PMC8896912 DOI: 10.1016/s2214-109x(21)00551-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/05/2021] [Accepted: 11/16/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND In the prevention of cardiovascular disease, a WHO target is that at least 50% of eligible people use statins. Robust evidence is needed to monitor progress towards this target in low-income and middle-income countries (LMICs), where most cardiovascular disease deaths occur. The objectives of this study were to benchmark statin use in LMICs and to investigate country-level and individual-level characteristics associated with statin use. METHODS We did a cross-sectional analysis of pooled, individual-level data from nationally representative health surveys done in 41 LMICs between 2013 and 2019. Our sample consisted of non-pregnant adults aged 40-69 years. We prioritised WHO Stepwise Approach to Surveillance (STEPS) surveys because these are WHO's recommended method for population monitoring of non-communicable disease targets. For countries in which no STEPS survey was available, a systematic search was done to identify other surveys. We included surveys that were done in an LMIC as classified by the World Bank in the survey year; were done in 2013 or later; were nationally representative; had individual-level data available; and asked questions on statin use and previous history of cardiovascular disease. Primary outcomes were the proportion of eligible individuals self-reporting use of statins for the primary and secondary prevention of cardiovascular disease. Eligibility for statin therapy for primary prevention was defined among individuals with a history of diagnosed diabetes or a 10-year cardiovascular disease risk of at least 20%. Eligibility for statin therapy for secondary prevention was defined among individuals with a history of self-reported cardiovascular disease. At the country level, we estimated statin use by per-capita health spending, per-capita income, burden of cardiovascular diseases, and commitment to non-communicable disease policy. At the individual level, we used modified Poisson regression models to assess statin use alongside individual-level characteristics of age, sex, education, and rural versus urban residence. Countries were weighted in proportion to their population size in pooled analyses. FINDINGS The final pooled sample included 116 449 non-pregnant individuals. 9229 individuals reported a previous history of cardiovascular disease (7·9% [95% CI 7·4-8·3] of the population-weighted sample). Among those without a previous history of cardiovascular disease, 8453 were eligible for a statin for primary prevention of cardiovascular disease (9·7% [95% CI 9·3-10·1] of the population-weighted sample). For primary prevention of cardiovascular disease, statin use was 8·0% (95% CI 6·9-9·3) and for secondary prevention statin use was 21·9% (20·0-24·0). The WHO target that at least 50% of eligible individuals receive statin therapy to prevent cardiovascular disease was achieved by no region or income group. Statin use was less common in countries with lower health spending. At the individual level, there was generally higher statin use among women (primary prevention only, risk ratio [RR] 1·83 [95% CI 1·22-2·76), and individuals who were older (primary prevention, 60-69 years, RR 1·86 [1·04-3·33]; secondary prevention, 50-59 years RR 1·71 [1·35-2·18]; and 60-69 years RR 2·09 [1·65-2·65]), more educated (primary prevention, RR 1·61 [1·09-2·37]; secondary prevention, RR 1·28 [0·97-1·69]), and lived in urban areas (secondary prevention only, RR 0·82 [0·66-1·00]). INTERPRETATION In a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future. FUNDING National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation, and National Institute of Diabetes and Digestive and Kidney Diseases. TRANSLATION For the Spanish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Maja E Marcus
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Harvard Medical School, Boston, MA, USA; Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michaela Theilmann
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Saeedi Moghaddam
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Keykhaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirali Hajebi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Scott Tschida
- Center for Indigenous Health Research, Wuqu' Kawoq, Tecpán, Guatemala
| | - Julia M Lemp
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany
| | - Krishna K Aryal
- Public Health Promotion and Development Organization, Kathmandu, Nepal
| | - Matthew Dunn
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Corine Houehanou
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | - Silver Bahendeka
- Department of Internal Medicine, MKPGMS Uganda Martyrs University, Kampala, Uganda; Saint Francis Hospital Nsambya, Kampala, Uganda
| | - Peter Rohloff
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Indigenous Health Research, Wuqu' Kawoq, Tecpán, Guatemala
| | - Rifat Atun
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Till W Bärnighausen
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA; Heidelberg Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany; Africa Health Research Institute, Somkhele, South Africa
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany; Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Michele Heisler
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Justine I Davies
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK; Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark D Huffman
- Department of Medicine and Global Health Center, Washington University in St Louis, St Louis, MO, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany.
| | - David Flood
- Center for Indigenous Health Research, Wuqu' Kawoq, Tecpán, Guatemala; Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA; INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala.
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11
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Abstract
Education involving active engagement in the arts, herein called arts education, is often believed to foster the development of desirable personality traits and skills in children and adolescents. Yet the impact of arts education on personality development has rarely been systematically investigated. In the current article, we reviewed the literature on personality change through arts education. We identified 36 suitable experimental and quasi-experimental studies. Evidence from these studies tentatively suggests that arts-education programs can foster personality traits such as extraversion and conscientiousness but not self-esteem. In addition, the effects of arts education appeared to be stronger in early and middle childhood than in preadolescence and early adolescence. However, the evidence for the effectiveness of arts education was very limited among the few included true experiments. Furthermore, the reviewed studies were heterogenous and subject to content-related, methodological, and statistical limitations. Thus, the current evidence base is inconclusive as to the effects of arts education on personality development. By identifying potential effects of arts education and limitations of past research, our review serves as a call for more research and guidepost for future studies on arts education and personality change.
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Affiliation(s)
| | - Julia M Lemp
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg
| | - Beatrice Rammstedt
- Department of Survey Design and Methodology, GESIS - Leibniz Institute for the Social Sciences, Mannheim
| | - Clemens M Lechner
- Department of Survey Design and Methodology, GESIS - Leibniz Institute for the Social Sciences, Mannheim
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12
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Kirschbaum TK, Theilmann M, Sudharsanan N, Manne-Goehler J, Lemp JM, De Neve JW, Marcus ME, Ebert C, Chen S, Aryal KK, Bahendeka SK, Norov B, Damasceno A, Dorobantu M, Farzadfar F, Fattahi N, Gurung MS, Guwatudde D, Labadarios D, Lunet N, Rayzan E, Saeedi Moghaddam S, Webster J, Davies JI, Atun R, Vollmer S, Bärnighausen T, Jaacks LM, Geldsetzer P. Targeting Hypertension Screening in Low- and Middle-Income Countries: A Cross-Sectional Analysis of 1.2 Million Adults in 56 Countries. J Am Heart Assoc 2021; 10:e021063. [PMID: 34212779 PMCID: PMC8403275 DOI: 10.1161/jaha.121.021063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background As screening programs in low‐ and middle‐income countries (LMICs) often do not have the resources to screen the entire population, there is frequently a need to target such efforts to easily identifiable priority groups. This study aimed to determine (1) how hypertension prevalence in LMICs varies by age, sex, body mass index, and smoking status, and (2) the ability of different combinations of these variables to accurately predict hypertension. Methods and Results We analyzed individual‐level, nationally representative data from 1 170 629 participants in 56 LMICs, of whom 220 636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or reporting to be taking blood pressure–lowering medication. The shape of the positive association of hypertension with age and body mass index varied across world regions. We used logistic regression and random forest models to compute the area under the receiver operating characteristic curve in each country for different combinations of age, body mass index, sex, and smoking status. The area under the receiver operating characteristic curve for the model with all 4 predictors ranged from 0.64 to 0.85 between countries, with a country‐level mean of 0.76 across LMICs globally. The mean absolute increase in the area under the receiver operating characteristic curve from the model including only age to the model including all 4 predictors was 0.05. Conclusions Adding body mass index, sex, and smoking status to age led to only a minor increase in the ability to distinguish between adults with and without hypertension compared with using age alone. Hypertension screening programs in LMICs could use age as the primary variable to target their efforts.
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Affiliation(s)
- Tabea K Kirschbaum
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany
| | - Michaela Theilmann
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany
| | - Nikkil Sudharsanan
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases Massachusetts General HospitalHarvard Medical School Boston MA
| | - Julia M Lemp
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany
| | - Maja E Marcus
- Department of Economics and Centre for Modern Indian Studies University of Goettingen Germany
| | - Cara Ebert
- RWI-Leibniz Institute for Economic Research Berlin Germany
| | - Simiao Chen
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany.,Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Krishna K Aryal
- Monitoring Evaluation and Operational Research Project Abt Associates Kathmandu Nepal
| | | | | | | | - Maria Dorobantu
- Cardiology Department Emergency Hospital of Bucharest Romania
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center Endocrinology and Metabolism Population Sciences Institute Tehran University of Medical Sciences Tehran Iran
| | - Nima Fattahi
- Non-Communicable Diseases Research Center Endocrinology and Metabolism Population Sciences Institute Tehran University of Medical Sciences Tehran Iran
| | - Mongal S Gurung
- Health Research and Epidemiology Unit Policy and Planning Division Ministry of Health Thimphu Bhutan
| | - David Guwatudde
- Department of Epidemiology and Biostatistics School of Public Health Makerere University Kampala Uganda
| | - Demetre Labadarios
- Faculty of Medicine and Health Sciences Stellenbosch University Stellenbosch South Africa
| | - Nuno Lunet
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica Faculdade de Medicina da Universidade do Porto Porto Portugal
| | - Elham Rayzan
- Non-Communicable Diseases Research Center Endocrinology and Metabolism Population Sciences Institute Tehran University of Medical Sciences Tehran Iran
| | - Sahar Saeedi Moghaddam
- Endocrinology and Metabolism Research Center Endocrinology and Metabolism Clinical Sciences Institute Tehran University of Medical Sciences Tehran Iran
| | - Jacqui Webster
- The George Institute for Global HealthUniversity of New South Wales Sydney Australia
| | - Justine I Davies
- Institute of Applied Health Research University of Birmingham United Kingdom.,Centre for Global Surgery Department of Global Health Stellenbosch University Cape Town South Africa.,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit Faculty of Health Sciences School of Public Health University of the Witwatersrand Johannesburg South Africa
| | - Rifat Atun
- Department of Global Health and Population Harvard T.H. Chan School of Public Health Boston MA
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies University of Goettingen Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany.,Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Lindsay M Jaacks
- Department of Global Health and Population Harvard T.H. Chan School of Public Health Boston MA.,Public Health Foundation of India New Delhi India.,Global Academy of Agriculture and Food Security The University of Edinburgh Midlothian United Kingdom
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany.,Division of Primary Care and Population Health Department of Medicine Stanford University Stanford CA
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13
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Geldsetzer P, Lemp JM. Cervical Cancer Screening in Low- and Middle-Income Countries-Reply. JAMA 2021; 325:790-791. [PMID: 33620399 DOI: 10.1001/jama.2020.25217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Pascal Geldsetzer
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Julia M Lemp
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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14
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Lemp JM, De Neve JW, Bussmann H, Chen S, Manne-Goehler J, Theilmann M, Marcus ME, Ebert C, Probst C, Tsabedze-Sibanyoni L, Sturua L, Kibachio JM, Moghaddam SS, Martins JS, Houinato D, Houehanou C, Gurung MS, Gathecha G, Farzadfar F, Dryden-Peterson S, Davies JI, Atun R, Vollmer S, Bärnighausen T, Geldsetzer P. Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries. JAMA 2020; 324:1532-1542. [PMID: 33079153 PMCID: PMC7576410 DOI: 10.1001/jama.2020.16244] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022]
Abstract
Importance The World Health Organization is developing a global strategy to eliminate cervical cancer, with goals for screening prevalence among women aged 30 through 49 years. However, evidence on prevalence levels of cervical cancer screening in low- and middle-income countries (LMICs) is sparse. Objective To determine lifetime cervical cancer screening prevalence in LMICs and its variation across and within world regions and countries. Design, Setting, and Participants Analysis of cross-sectional nationally representative household surveys carried out in 55 LMICs from 2005 through 2018. The median response rate across surveys was 93.8% (range, 64.0%-99.3%). The population-based sample consisted of 1 136 289 women aged 15 years or older, of whom 6885 (0.6%) had missing information for the survey question on cervical cancer screening. Exposures World region, country; countries' economic, social, and health system characteristics; and individuals' sociodemographic characteristics. Main Outcomes and Measures Self-report of having ever had a screening test for cervical cancer. Results Of the 1 129 404 women included in the analysis, 542 475 were aged 30 through 49 years. A country-level median of 43.6% (interquartile range [IQR], 13.9%-77.3%; range, 0.3%-97.4%) of women aged 30 through 49 years self-reported to have ever been screened, with countries in Latin America and the Caribbean having the highest prevalence (country-level median, 84.6%; IQR, 65.7%-91.1%; range, 11.7%-97.4%) and those in sub-Saharan Africa the lowest prevalence (country-level median, 16.9%; IQR, 3.7%-31.0%; range, 0.9%-50.8%). There was large variation in the self-reported lifetime prevalence of cervical cancer screening among countries within regions and among countries with similar levels of per capita gross domestic product and total health expenditure. Within countries, women who lived in rural areas, had low educational attainment, or had low household wealth were generally least likely to self-report ever having been screened. Conclusions and Relevance In this cross-sectional study of data collected in 55 low- and middle-income countries from 2005 through 2018, there was wide variation between countries in the self-reported lifetime prevalence of cervical cancer screening. However, the median prevalence was only 44%, supporting the need to increase the rate of screening.
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Affiliation(s)
- Julia M. Lemp
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Hermann Bussmann
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simiao Chen
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michaela Theilmann
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Maja-Emilia Marcus
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Cara Ebert
- RWI–Leibniz Institute for Economic Research, Essen (Berlin office), Germany
| | - Charlotte Probst
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | | | - Lela Sturua
- Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Joseph M. Kibachio
- Division of Non-Communicable Diseases, Kenya Ministry of Health, Nairobi, Kenya
- Institute of Global Health, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
| | - Sahar Saeedi Moghaddam
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Joao S. Martins
- Faculty of Medicine and Health Sciences, Universidade Nacional Timor Lorosa’e, Rua Jacinto Candido, Dili, Timor-Leste
| | - Dismand Houinato
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | - Corine Houehanou
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | - Mongal S. Gurung
- Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan
| | - Gladwell Gathecha
- Division of Non-Communicable Diseases, Kenya Ministry of Health, Nairobi, Kenya
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Scott Dryden-Peterson
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Botswana Harvard AIDS Institute, Gaborone, Botswana
| | - Justine I. Davies
- MRC/Wits Rural Public Health and Health Transitions Research Unit, University of Witwatersrand School of Public Health, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rifat Atun
- Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Global Health and Social Medicine at the Harvard Medical School, Boston, Massachusetts
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Africa Health Research Institute, Somkhele, South Africa
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
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